Wednesday, May 20, 2020

Proprioception: The Sixth Sense

By: Nicole Lovett, DPT, OCS


Imagine walking across a room and without warning, the lights go out, and suddenly,  you fall down.  Or you reach into your pocket to grab a quarter and when you look down to see, your hand is empty.   What would life be like if you had to look down at your feet every time you took a step?  Luckily for most of us, this is not the case; we have the ability to sense where we are and where other things are as part of our 6th sense.  But in rare cases, there is the absence of proprioception, which can occur when a fetus is just developing.  The absence of proprioception occurs when a mutated gene makes the Piezo2 receptor non-functioning. The Piezo2 receptor is an important receptor that integrates mechanical and thermal cues in vertebra mechanoreceptors. (1)  Without it, an individual has no proprioception.  Separate from genetic factors, proprioception can be affected when someone suffers an ankle sprain, an ACL tear, an Achilles rupture, a lumbar muscle strain, or in someone who is afflicted with a neurological disorder.

What is Proprioception?

Proprioception, also called kinesthesia, is the body’s ability to sense its location, movements, and actions in space.   Proprioceptors are specialized nerves that facilitate neurological and physiological responses.    The proprioceptors are sensory and can be found in the inner ear, muscles, skin, joints, tendons, and other tissues.  This is how the brain receives information about the body’s position and to perform certain tasks like, catch a ball, reach for a glass out of the cupboard, or walk in the dark.

How do you test for Proprioception?

There are a variety of ways to test for proprioception. Some tests include:
-     Romberg Test
-     Field Sobriety Test
-     Thumb Finding Test
-     Sequential Finger Touching, or Distal Proprioception Test

Also, the Single-Leg Stance Balance Test with eyes closed would be appropriate to assess proprioception. (2)  These particular tests determine a patient’s ability to sense, move, and act or react. It is a safety-related issue that includes balance and awareness to determine treatment plans that will prevent potential injuries during day-to-day activities.

Single limb stance
 Simply stated, the single-leg stance balance tests for proprioception. With the patient’s eyes closed for 30 seconds, the individual must maintain his or her position for the duration.

Normative data
Age (years)         Eyes closed
20-49                  24-29 sec
50-59                  21 sec
60-69                  10 sec
70-79                  4 sec

How do you train Proprioception?

Once the assessment is complete and altered proprioception is detected, training is essential. When a soft tissue injury occurs, receptor activity is lost. With a loss of receptor activity, proprioception is affected. This is why that during the rehabilitation process, it is imperative to restore receptor activity.   This is done through proprioceptive training in order to re-activate the receptors in the soft tissues. To challenge the receptors one can vary the surface they are standing on or vary the speed of the task or multi-task.  Furthermore, there are three key areas of proprioception input, the cervical spine, pelvic girdle and the sole of the foot.  When training proprioception, pay close attention to alignment in these areas to better improve your outcomes. Improving proprioception will improve a patient’s motor skills, balance, and muscle strength.   Below are three exercises to focus on the three key areas: the sole of the foot, the pelvic girdle and the cervical spine.

Cone pickups on the grass to challenge the lower
extremity and sole of the foot

Deep cervical flexor swiss ball isometrics to challenge the cervical spine

Swiss ball marching to challenge the pelvic girdle

Nicole Lovett is a physical therapist working at Kaiser Permanente. She is a movement science fellowship graduate, Movement Links certified clinician and instructor, and has taught movement concepts in the Loma Linda Residency.

1. Chesler AT, Szczot M, Bharucha-Goebel D, et al. The role of PIEZO2in human mechanosensation. N Engl J Med. 2016;375:1355-1364. DOI:10.1056/NEJMoa1602812.

2. Bohannon RW, Larkin PA, Cook AC, et al. Decrease in timed balance test scores with aging. Physical Therapy. 1984;(64)7:1067-1070.

Wednesday, April 15, 2020

F.M.P. (Yah you know me)

By David, Kurihara, DPT, OCS, SCS, FAAOMPT

One of the more challenging things we do as a clinicians involves our clinical reasoning and how it guides the prioritization of treatment.  In other words, making sense of the information we gather in our examination and implementing an effective and logical intervention plan. 

To this day, I still have cases where I fall off the track or get lost in the plethora of information.  When that happens, the picture becomes muddled and the case complexity automatically doubles. 

To keep me on the right path, I like to use a very useful tool adapted by Phil Page and Clare Frank called the Functional Management Progression (FMP).  I have it in my head constantly and it guides me in terms of progressing and prioritizing appropriate interventions. The pyramid is broken down into four main categories. 

1) Normalization of dysfunctional structures (base of pyramid)
2) Correction of muscle/movement balance (mid-bottom pyramid)
3) Increasing proprioception and facilitate subcortical pathways (mid-top pyramid)
4) Improving endurance in coordinated movement (top of pyramid)

*within each category are specific impairments

Functional Management Progression - adapted from Phil Page and Clare Frank

This is a powerful tool and there are many ways to utilize it.  For most cases, my personal preference is to use it like a ‘ladder’.  I will try to climb the pyramid all the way to the top where ‘skill/functional activity’ is sitting (which is usually the goal).   As I climb each level, I’ll try to address any impairment the patient might have within that specific level.  I usually won’t advance levels until the impairment at the current level is resolved.

This is especially helpful when you have what I like to call “impairment overload”.  It’s when you gather so much data in the subjective/objective exam that you don’t know what to do with it or where to start.  The easy way out is to have a “shotgun” approach to blindly treat every impairment.  That approach may sometimes produce results, however, there is no “progress control” and the reasoning of what helped or not is lacking.  It’s always nice to have a system in place. 



13 year-old female with chief complaints of:

1) Right lateral hip clicking/pain with every step x 4 years. Insidious onset.
2) Left anterior- posterior hip pain (“locking/weird feeling”) x 4 years. Insidious onset.  Has episodes every 1-2 months until 1 month ago got 3 episodes in a span of 2 weeks.  Symptoms occur with putting on pants, getting in/out of car, turning while feet planted.  Pain lasts 3 days. Plays judo and golf regularly for years.

1) Posture: BL pes planus (functional), BL genu valgus, BL femoral IR (worse on left)
2) Gait: excessive femoral IR worse on right (with clicking laterally in left hip)
3) PROM: hyperflexible all joints (especially hips)
 4) Wobbly/incoordinated SL squat on left > right
 5) Golf swing: over-rotation with shoulder, trunk and hips
5) MMT: 3/5 (inhibited--poor initiation) BL glute max, ER and medius


13 year-old female with BL hip pain secondary to multidirectional excessive mobility driven from inherent joint laxity and poor phasic muscle stability.

Day 1

It would have been fair (and obvious to most) to start strengthening her hips due to the glaring strength deficit.  However, using the FMP, I started on the bottom of the pyramid and opted to normalize her faulty posture and pain deficits (as much as possible). 

Posture re-ed: Neutral legs in standing (tripod foot position), sitting (no crossing legs), sleeping on side (pillow)

Postural Re-Education in standing, sitting, sleeping

Gait re-ed: Verbal cueing for reducing right femoral IR during gait resolved her right hip clicking

Gait Re-Education out of excess Femoral IR

Day 2

Patient experienced no clicking in the right hip with “mindful” hip position and no symptoms in left hip with putting on pants, twisting in closed chain or getting in/out of car.  Patient was “mindful” about centration of joints with sleeping, sitting, standing and walking and often catches herself in bad positions, but quickly re-corrects.

*** Addressing the static postural deficits proved to be helpful as she was standing, sitting and sleeping in poor positions and creating a ‘stretch weakness’ within her muscles and de-centration of joint position.  If that was not corrected, strengthening exercises may not have been as successful.

Furthermore, her words of being more “mindful” was a huge positive in that it told me that she was understanding the building blocks of motor control/awareness, which is a nice prerequisite for creating muscle balance.

Continuing to climb up the pyramid, there was no need to address her joint mobility or muscle length as she was hypermobile and flexible.  Those levels were skipped and we advanced to motor function/proprioception activities (with an overlapping of ‘muscle performance’).  I wanted to dial-up her “phasic” motor chain to increase stability in her joints.

Illustration of clinical reasoning using the FMP for Day 2

Brügger band squat, sidestep and leg opening, SL with TB

Top line: Brügger band squat// Bottom left: Brügger band sidestepping// Bottom middle: Brügger leg opening// Bottom right: Single leg stance with TB

*** The faster I can get a patient off the table, the better.  It would have been fine to start her in open chain exercises but it was a clinical decision I made to get her in closed chain immediately.  I felt that her motor awareness was excellent and the exercises we put her in could facilitate the right muscles even better than in open chain.

Day 3

Still no symptoms with all aggravating factors and able to return to full Judo and Golf without problems.  She liked the exercises as it helped her feel “good” in her legs.

We now arrived at the top of the pyramid and addressed the functional activities and skills she’d been doing regularly (judo/golf).  I could tell she felt a difference in her body with the exercises so I decided to advance her to a more functionally difficult regimen (specifically, dynamic single leg stability and closed chain hip rotation control to mimic judo and golf mechanics)

Illustration of clinical reasoning using the FMP for Day 3

SL squat with TB, SL airplanes

Left: Single leg Squat with TB// Right: Single Leg Airplanes

***.  We also tightened up her golf swing with leg and trunk positional cues to not over rotate (skill).

Again, you can utilize the pyramid to your liking based on your patient case or preferred way of thinking.  It’s probably better if you do, that way you know you’re thinking criticallyJ

David Kurihara is a board-certified specialist in Ortho­pedic Physical Therapy (OCS) and Sports Physical Therapy (SCS) and a fellow in the American Academy of Orthopedic Manual Physical Therapy (FAAOMPT).
He completed the Southern California Kaiser Permanente Orthopedic Residency Program in 2005, Manual Therapy Fellowship in 2006, Sports Residency in 2007 and Movement Science Fellowship in 2009.
David served on the clinical faculty for Kaiser Orthopedic Residency (2010-15), and Sports Fellowship (2008-15) and has been instructing various continuing education and residency classes since 2009. He currently resides in Honolulu and is part of Queen's Medical Center Sports Medicine team.

Friday, March 13, 2020

Evidence Based Therapeutic Exercise for Cervical Spine Disorders

Summary of key points from seminar by Dr Deborah Falla, BPhty(Hons), PhD.
University of Birmingham

Common forward head position with shortened sternocleidomastoid (SCM)- Source: 

Neck Pain
-       Relatively common complaint.
-       Affects 70% of individuals at some time in their lives
-       Annual Prevalence of neck pain 30-50%         
-       Tends to be persistent and recurrent disorder
-       85% of people can expect some degree of ongoing pain for many years after their first episode.
-       Most concerning is the recurrence.  Recurrences are partially attributed to ongoing dysfunction of the neuromuscular system (motor control) Carroll et al, Spine, 2008
-       When pain & Injury occur, the strategies used by the CNS to control movement and/or posture can be substantially compromised.

Clinical Implication:  Not only treat & reduce pain, but to prevent further episodes.

Common findings with neck pain
1.   Reduced force output and maintenance of force output.
2.   Reduced Deep neck flexor (DNF) activity (longus colli and capitus that is responsible for cranio-cervical (CC) flexion and support of the cervical spine) with subsequent increased compensatory SCM activity.
a.   co-contraction of SCM & Splenius
b.   SCM activity increased regardless of the severity/ intensity of the symptoms

Slide from D. Falla seminar

Injected saline solution to upper traps resulting in immediate pain.

Slide from D. Falla seminar

1.   Reduced directional specificity
2.   Reduced Semispinalis cervicis activity
3.   Poor postural endurance
4.   Structural changes present over time with chronicity ( > 3months)
- muscle fiber transformation from Type 1 to Type 2   (Uhlig et al, 1995)
- Increased fatty infiltration
Occurs soon following neck trauma, but not immediately, Andrey et al, 1998, Hallgren et al 1994, McPartland et al 1997, Kristjansson 2004, Elliott et al 2006
Use this window of time following neck trauma to minimize the secondary structural adaptations

Clinical Implication:
Changes are primarily in motor control.  However, if alterations in motor control is sustained beyond the acute pain phase, its effects may contribute to chronicity of neck pain & structural changes. 
Motor control training must be initiated in early rehab.

Deep neck flexor training using Bio-Feedback

Key Rehab Principles for Cervical Spinal Pain & Therapeutic Exercise Program
For both rehabilitation and prevention of recurrences.

1st phase - Motor control to target the deep postural muscles
2nd phase - Introduce higher load strength & endurance training. 

-       Need for Selectivity and specificity of exercise
-       Target & activate Deep Neck Flexors (DNF) with low load specific exercises.
-       Retrain endurance capacity of DNF
-       Retrain the patterns of activation of deep & superficial neck muscles
-       Co-contraction exercises (DNF and extensors)
-       Re-ed the use of muscles in posture & ADL
-       Address strength & endurance for functional requirements

Re-education of co-activation of deep cervical flexors/extensors using developmental position- prone 3 month position 

Re-education of deep neck flexors using isometrics

Reflexive activation of deep cervical muscles using a theraband

Long term efficacy for neck specific exercise.  Landén Ludvigsson et al., Eur J Pain, 2015

-       Participation in a neck-specific exercise intervention, in contrast to general physical activity, was the only factor that consistently indicated higher odds of treatment success.
-       At 12 months, patients in the neck-specific exercise intervention had up to 5.3x higher relief of disability reduction, and 3.9x higher odds of pain reduction compared to those in the physical activity group.

Clare Frank is the founder of Movement Links, Inc, a company borne out of a desire to enhance clinicians’ understanding of the movement system. She is the program director of Azusa Pacific University Advanced Fellowship in Movement & Performance and clinical faculty of Kaiser Permanente Spine Rehab Fellowship.  Clare is a lifelong learner, implementor and advocate for the movement system.

Key References:

Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain. Phys Ther. 2007;87(4):408-17.

Jull G. Whiplash, Headache, and Neck Pain, Research-based Directions for Physical Therapies. Elsevier Health Sciences; 2008.

Neck pain: combining exercise and manual therapy for your neck and upper back leads to quicker reductions in pain. J Orthop Sports Phys Ther. 2013;43(3):128.

Sremakaew M, Jull G, Treleaven J, Barbero M, Falla D, Uthaikhup S. Effects of local treatment with and without sensorimotor and balance exercise in individuals with neck pain: protocol for a randomized controlled trial. BMC Musculoskelet Disord. 2018;19(1):48.

Thursday, February 27, 2020

Does what we “say” to our patients impact how our patients move and recover?

Image from Canva

The answer may seem obvious. Yes! What we say does have an impact.  But let us take a closer look at how this plays out clinically.  As part of our clinical education, we learn what to say or what not to say.  I remember learning how to perform a posture exam; with a few mutterings and inflections like “oh,” “wow,” “hmm,” and occasionally “uh.”  I realized for the sake of learning, I was just rattling off impairments left and right.  Never was there not a “forward head posture with a kyphotic thoracic spine with rounded shoulders and bilateral abducted, downwardly and medially rotated scapula, etc.”  As one can see, the list of predicted impairments goes on and on. Plenty of information for us to dictate to our mentors, write down and test, making for a lengthy yet thorough examination.  At some point, a patient might ask “Are you going to explain what that means,” “Is it bad?” or just have a worried expression on their face.  Of course, we would say “all will be explained at the end of the examination.” 

Enter the DIMs vs SIMs conundrum we just created for the patient.  Here’s a brief explanation of DIMs and SIMs from Butler and Mosely’s Explain Pain: Supercharged.1 DIM stands for “Danger in Me.”  This simply put is your brain’s way of concluding that there is sufficient evidence of danger to create pain.  Conversely, when we find enough evidence to indicate that things are safe, we will not protect using pain, and all is well.  This is called “Safety in Me.”  DIMs and SIMs in short.  As people, we look for the evidence in the things we hear, see, smell, touch, taste, do, and say; our thoughts, beliefs, places we go, people in our lives, and things happening in our bodies.  

Explain Pain, Supercharged

Returning to our clinical example, we can see how we have added to our patient’s interpretation of DIMs / SIMs just by doing our work. The practice of doing our postural assessment and only highlighting what is not ideal can lead to the patient creating DIMs about their condition.  Instead of calling out “excess lumbar lordosis and anterior pelvic tilt”, we may make the following alternative statements:
-       “Your shoulders stack really nicely above your pelvis.  We may benefit from working on the balance of muscles around your pelvis and hips.”
-       “This alignment can be changed with some training.”

In this way, the patient knows they have to do some work but it is not negative.

Communication about alignment

The question for the clinician then becomes, do you ever think about how you do your work and how it is perceived by your patient?

Therapeutic alliance is best defined as the relationship between the provider and patient.8  A warm, friendly, and reassuring interaction has been shown to improve outcomes instead of an impersonal or uncertain interaction.2  The two main factors to create a therapeutic alliance are the patient’s ability to forge a bond and the clinician’s ability to present themselves as caring and sensitive in the treatment encounter.5  Remembering our patient example, it is imperative to think about the words we use to explain and cue our patients to put them at ease with our process of examination and intervention. Some phrases that I utilize are,
- “Yes I have seen this before and this is fixable”
- “you are saveable”
- “help me understand.”

These interactions are especially important when we are trying create a relationship that educates, inspires and empowers them to change how they move.  

Now that we have established it is important what the patient thinks of us, does it then matter what the clinician thinks?

Let’s examine this question.  According to Cook et al 2013, therapeutic equipoise is simply defined as the clinicians expectations and treatment approach preferences.3  So now we have to consider not only the thoughts and perceptions of our patients, but also that of ourselves.4  Because of this, clinicians will favor different treatment approaches and provide interventions enthusiastically and with the expectation of certain success; thus impacting our clinical outcomes.6  To come back to our patient example, it comes down to what we say, how we say it, and also how much we believe in it.  All of these variables will have an effect on our interventions and outcomes.  The next time you’re in clinic and you try that movement correction to externally rotate and elevate the scapula during shoulder elevation and it does not change their symptoms, stick with it and do not lose that enthusiasm; if you keep trying and explain your rationale for what you are attempting to do for your patient, they might surprise you and “move without making it hurt.”  Teaching and learning new movements can be tough for both clinician and patient.  With some practice in how we work and how our patients perceive our words and cues, we can create the right formula to link the movements.

Choosing our words and cues wisely is important because health care professionals have an influence on what patients take from our encounters.  Darlow et al, in his study in 2013, explored the formation and impact of attitudes and beliefs among people experiencing low back pain. Participants in the study were often given messages by their that the spine needed to be protected.  The explanatory model that insufficient muscle strength results in a more fragile spine can be impactful.  Example statements by participants were: “Basically, all I’ve been told to do by my physios is to work on my core,” or “I’ve been tested by various different physios and Pilates, and apparently my core is ridiculously weak.”

Image from Canva

 Conversely, other clinicians in the study provided education about the importance of movement with positivity and with reassurance.  The impact of this message became quite powerful for a participant with a 6-year history of episodic back pain.  “I feel that I should keep moving and keep doing things as much as possible…I mean going to bed definitely doesn’t help it.  So, I’ll keep active.”  Another participant reported: “Lots of reassurance from the [doctor]…made me feel like, “don’t panic, this is OK, you’ll be fine.  It’s not the start of something thing awful.”7

Bottom line: what we say and how we say it can have a profound effect on our patient’s confidence and anxiety levels.  It’s not always easy, though. Sometimes the right words or cues are hard to find.  We may not get the desired outcome the first or fifth time when learning a new approach.  Learning, changing and growing is difficult, especially during our busy work schedules. Stay present and think about your communication to your patients because the more you practice, the easier it gets to help those movements link!

Ernie Linares is a board-certified Clinical Specialist (OCS) in Orthopaedic Physical Therapy and a Fellow of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT). He is also a Movement Links and Dynamic Neuromuscular Stabilization (DNS) certified practitioner. He currently works as a clinical specialist at the Kaiser Permanente Woodland Hills facility and as Guest Lecturer in the Physical Therapy Department at California State University, Northridge. Ernie also serves on the American Board of Physical Therapy Residency and Fellowship Education as an Accreditation Services Committee Member.

1.    Moseley, G. L., & Butler, D. S. (2017). Explain pain supercharged. The clinician’s handbook. Painos. Australia: Noigroup publication. Liite1(1), 1.
2.    Di Blasi, Z., Harkness, E., Ernst, E., Georgiou, A., & Kleijnen, J. (2001). Influence of context effects on health outcomes: a systematic review. The Lancet357(9258), 757-762.
3.    Cook, C., Learman, K., Showalter, C., Kabbaz, V., & O'Halloran, B. (2013). Early use of thrust manipulation versus non-thrust manipulation: a randomized clinical trial. Manual therapy18(3), 191-198.
4.    Cook, C., & Sheets, C. (2011). Clinical equipoise and personal equipoise: two necessary ingredients for reducing bias in manual therapy trials. Journal of Manual & Manipulative Therapy19(1), 55-57.
5.    Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy93(4), 470-478.
6.    Witt, C. M., Martins, F., Willich, S. N., & Schützler, L. (2012). Can I help you? Physicians' expectations as predictor for treatment outcome. European Journal of Pain16(10), 1455-1466.
7.    Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine11(6), 527-534.
8.    Kegerreis, S. (2010). Mechanisms and Management Of Pain For The Physical Therapist. journal of Orthopaedic & Sports Physical40(10), 668-669.