Treatment of Joint Position Sense – Physiotherapy

Published: 02nd February 2009
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A previous article has identified the importance of joint position sense and here we move on to considering the assessment of a deficit and what the physiotherapist is likely to do about it. The physio will very likely concentrate on the problems the patient has most commonly after trauma or illness, namely muscle weakness, loss of joint mobility and pain. Once these are responding to treatment the physiotherapist will consider whether proprioceptive treatment is required. Complete rehabilitation of the patient to their normal activities, whether sporting or functional, cannot occur without retraining the body's nervous and joint systems to accurately receive, interpret and act on proprioceptive inputs.

Proprioception is very important in the arm as the arm's function is to place the hand in front of the eyes so we can watch while we do something. Precise, controlled movement must have an accurate and effective feedback mechanism to monitor the performance and correct the action to achieve the desired result. Our hands and vision working together are a key part of being able to manipulate objects and get things done. We need to know where our arm is at all times if we are going to be able to use it. I am touch typing, or trying to, a job for which I need to know where my fingers are very precisely, without looking at them most of the time.

To test the proprioception of the arm the physiotherapist asks the patient to shut their eyes and explains they are going to place the affected arm in a particular position. Then the patient is asked to place their unaffected arm in the same position as the affected one, mirroring the position as closely as they can. When a person with normal joint position sense performs this test they are able to mimic the position of the other arm very closely. The results will tell the physiotherapist whether the patient has any significant deficit in their ability to understand the position of their arm.

Proprioception has a different function in the lower body as the pelvis and the lower limbs are adapted for weight bearing and locomotion. A loss of joint position sense in the legs can be very disabling as it interferes with our ability to balance and walk. This is illustrated very clearly by a patient of mine who had multiple sclerosis and who told me that he had trouble managing in the dark.

I'm sure you can relate to the story the patient told me, it may well have happened to you at some time. Going into a toilet he turned to shut and lock the door, but then because it so automatic he turned the light on. He did not initially notice that the light was already on so it went off straight away, depriving him of the feedback from his eyes that he needed to stay upright. Because his legs were not providing the information due to his condition he did not know where his legs were or what they were doing. He fell over immediately, indicating the importance of joint position sense.

Physiotherapists test patients' joint position sense routinely on assessing a patient after trauma or neurological illness. Getting the patient to mirror the position of the good leg with the affected leg can be used if the problem is profound or the patient is in bed. More practical ways of testing use weight bearing positions, starting with checking the gait which might give an indication of any losses of the joint position sense. Less dramatic limitations can show up with balance testing, starting with standing with the feet together and moving on to standing on one leg and balancing with the eyes shut.

Physiotherapy treatment to increase joint position sense includes steadily more challenging work for the limb whilst carefully watching with eyes. As the patient improves they are taught to rely more and more on the information flowing in from the ligaments, muscles and joints to correct their movements. Weight bearing through the joint can increase the position sense and this is used to progress the treatment, teaching the brain pathways to reinforce the patterns for coordinated movement. Continued improvement is possible by continuing the exercises given by the physiotherapist but there may be some long term restriction.

Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Kent.

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