Test–retest reliability of a knee joint position sense measurement method in sitting and prone position

The Effect of Muscle Fatigue on the Knee Proprioception: A Systematic Review

This study aimed to systematically review and summarise the evidence about the effect of muscle fatigue on the knee proprioception of trained and non-trained individuals. A search in PubMed, Scopus, Web of Science and EBSCO databases and Google Scholar was conducted using the expression: "fatigue" AND ("proprioception" OR "position sense" OR "repositioning" OR "kinesthesia" OR "detection of passive motion" OR "force sense" OR "sense of resistance") AND "knee". Forty-two studies were included. Regarding joint-position sense, higher repositioning errors were reported after local and general protocols. Kinesthesia seems to be more affected when fatigue is induced locally, and force sense when assessed at higher target forces and after eccentric protocols. Muscle fatigue, both induced locally or generally, has a negative impact on the knee proprioception.

Effectiveness of a sensorimotor exercise program on proprioception, balance, muscle strength, functional mobility and risk of falls in older people

Introduction

Sensory systems provide the necessary information for a motor response to be provided. In this sense, the objective of this study is to evaluate the effectiveness of a sensorimotor exercise program on proprioceptive acuity, balance, muscle strength, functional mobility and risk of falls in institutionalized elderly.

Methodology

56 participants (84.6 ± 8.4 years) were randomly distributed between the control (CG, n = 28) and intervention groups (IG, n = 28). The CG performed a protocol based on warm-up, muscle strengthening and warm down and the IG performed the same intervention, with the addition of sensorimotor exercises. Joint Position Sensation (JPS) was evaluated in both limbs at angles of 20° and 45°, balance, functional mobility, fear of falling in the elderly and muscle strength of quadriceps, hamstrings, adductors and abductors in both limbs, before and after the 12 weeks of intervention.

Results

Both groups showed gains in muscle strength. When analyzing functionality through Timed Up and Go (TUG), before and after for each group separately, both showed a significant difference (CG p = 0.002; IG p < 0.001). For the Short Physical Performance Battery (SPPB) variable, there were significant differences in IG in balance (p < 0.001), gait speed time (s) (p = 0.004) and sit-to-stand (p = 0.002). In JPS, significant differences were recorded for Absolute Error 45° Non-Dominant (p = 0.045) and Relative Error 45° Non-Dominant (p = 0.045) in the CG and Relative Error 45° Non-Dominant for IG (p = 0.018). In the Falls Efficacy Scale International (FES-I) variable there were significant improvements in the CG (p = 0.006) and in the GI (p = 0.002). However, only IG showed significant improvements (p = 0.013) for Activities-Specific Balance Confident (ABC) in a comparison between before and after the 12-week research period. When comparing the differences verified with the intervention between CG and IG, only balance SPPB (p < 0.001) and sit-to-stand SPPB (p = 0.022) showed significant values.

Conclusion

He effectiveness of sensorimotor exercises provides balance gain in the elderly (p < 0.001) and positively impacts their confidence (p = 0.013) when performing their duties. It is concluded that the protocol presented in its different levels of difficulty is effective and important for the quality of life of the institutionalized sedentary elderly.

Sensorimotor function and standing balance in older adults with transtibial limb loss

BACKGROUND

Limited research has focused on older prosthesis users despite the expected compounded effects of age and amputation on sensorimotor function, balance, and falls. This study compared sensorimotor factors and standing balance between older individuals with and without transtibial amputation, hypothesizing that prosthesis users would demonstrate worse sensorimotor function. Secondarily we assessed the relationship between standing balance and somatosensation in prosthesis users.

METHODS

Thirteen persons with unilateral transtibial amputation (71.7 years) and 10 able-bodied controls (71.7 years) participated in this cross-sectional observational study. Passive joint range-of-motion, muscle strength, proprioception (joint position sense), tactile sensitivity, and standing balance (center-of-pressure sway) were compared between groups. A multiple linear regression analysis assessed the relationship between proprioception and balance (without vision) in prosthesis users.

FINDINGS

Our hypotheses were generally not supported, with the only differences being reduced joint range-of-motion and strength in prosthesis users (with large effect sizes), but comparable sensation and balance. Notably, prosthesis users demonstrated better proprioception than controls as reflected through better joint position sense when the limb was non-weight bearing. Worse amputated limb proprioception was associated with better standing balance in prosthesis users.

INTERPRETATION

Older prosthesis users have impaired passive joint motion and muscle strength compared to controls that could challenge their ability to position and control the amputated limb to avoid falls during daily activities. However, their better amputated limb proprioception might help counteract those limitations by leveraging sensory feedback from the suspended limb. The relationship between amputated limb proprioception and standing balance suggests a nuanced relationship that warrants further study.

Evaluation of Knee Position Sense in Children with Motor Disabilities and Children with Typical Development: A Cross-Sectional Study

BACKGROUND

In children with motor disabilities, knee position during walking is often of concern in rehabilitation. This study aimed to investigate knee joint position sense. Thirty-seven children with Cerebral Palsy (CP), 21 with Myelomeningocele (MMC), 19 with Arthrogryposis (AMC), and 42 TD children participated in the study. Knee joint position sense, i.e., the difference between the criterion angle and the reproduced angle (JPS-error), was assessed in sitting while 3D motion capture was recorded at flexed knee 70 (Knee70), 45 (Knee45), and 20 (Knee20) degrees, and after three seconds at maintained criterion angle (CAM) and maintained reproduced angle (RAM). No differences were found between the groups in JPS-error, CAM, and RAM. At Knee70, CAM differed between the right and left legs in the TD group (p = 0.014) and RAM in the MMC group (p = 0.021). In the CP group, CAM was greater than RAM at Knee70 in the left leg (p = 0.002), at Knee45 in both legs (p = 0.004, p = 0.025), and at Knee20 in the right leg (p = 0.038). Difficulties in maintaining the knee position at CAM in the CP group sheds light on the need for complementary judgments of limb proprioception in space to explore the potential influence on knee position during walking.

Functional outcomes after anterior cruciate ligament reconstruction: unravelling the role of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries

BACKGROUND

Numerous individual, temporal, injury- and surgery-specific factors impact the functional capacity during rehabilitation, return to sports (RTS), and re-injury prevention after an anterior cruciate ligament (ACL) reconstruction.

PURPOSE

This multicentre cohort study evaluated the isolated and interactive contributions of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries as to inertial sensor-assessed motor function after ACL reconstructions in multiple linear mixed model regressions.

METHODS

Anonymized data were retrieved from a nationwide German registry. In this cohort study, patients with an acute unilateral ACL rupture, with or without concomitant ipsilateral knee injuries, and having passed an arthroscopically assisted anatomic reconstruction were included. Potential predictors were age [years], gender/sex, time since reconstruction [days], time between injury and reconstruction [days], concomitant intra-articular injuries (isolated ACL tear, meniscal tear, lateral ligament, unhappy triad), graft type (hamstrings, patellar, or quadriceps tendon autograft), and pain during each measurement (visual analogue scale 0-10 cm). Repeated inertial motion unit-assessments of a comprehensive battery of classic functional RTS test were performed in the course of the rehabilitation and return to sports: Joint position sense/kinesthesia (Angle reproduction error [degrees]), Dynamic Balance Composite score [cm] of the Y-Balance test), drop jumps (Knee displacement [cm]), Vertical hop (Hopping height [mm]), Speedy jumps (Duration [seconds]), Side hops (Number of hops [n]), single leg hop for distance (hopping distance [cm]). Repeated measures multiple linear mixed models investigated the impact and nesting interaction of the potential predictors on the functional outcomes.

RESULTS

Data from 1441 persons (mean age 29.4, SD 11.8 years; 592 female, 849 male) were included. Most had an isolated ACL rupture: n = 938 (65.1%). Minor shares showed lateral ligament involvement: n = 70 (4.9%), meniscal tear: n = 414 (28.7%), or even unhappy triad: n = 15 (1%). Several predictors such as time between injury and reconstruction, time since reconstruction (estimates for n_days ranged from + .05 (i.e., an increase of the hopping distance of 0.05 cm per day since reconstruction occurs) for single leg hop for distance to + 0.17 for vertical hopping height; p < 0.001), age, gender, pain, graft type (patellar tendon graft: estimates between + 0.21 for Y-balance and + 0.48 for vertical hop performance; p < 0.001), and concomitant injuries contribute to the individual courses of functional abilities of the reconstructed side after ACL reconstruction. The unimpaired side was mostly influenced by sex, age, the time between injury and reconstruction (estimates between - 0.0033 (side hops) and + 0.10 (vertical hopping height), p < 0.001)), and time since reconstruction.

CONCLUSIONS

Time since reconstruction, time between injury and reconstruction, age, gender, pain, graft type, and concomitant injuries are not independent but nested interrelating predictors of functional outcomes after anterior cruciate ligament reconstruction. It might not be enough to assess them isolated; the knowledge on their interactive contribution to motor function is helpful for the management of the reconstruction (earlier reconstructions should be preferred) deficit-oriented function-based rehabilitation (time- and function based rehabilitation instead of solely a time- or function based approach) and individualized return to sports strategies.

Test-Retest Reliability of a Passive Joint Position Sense Test After ACL Reconstruction: Influence of Direction, Target Angle, Limb, and Outcome Measures

Background:

The joint position sense (JPS) is an element of proprioception and defined as an individual’s ability to recognize joint position in space. The JPS is assessed by measuring the acuity of reproducing a predetermined target angle. The quality of psychometric properties of knee JPS tests after anterior cruciate ligament reconstruction (ACLR) is uncertain.

Purpose/Hypothesis:

The purpose of this study was to evaluate the test-retest reliability of a passive knee JPS test in patients who underwent ACLR. We hypothesized that the passive JPS test would produce reliable absolute error, constant error, and variable error estimates after ACLR.

Study Design:

Descriptive laboratory study.

Methods:

Nineteen male participants (mean age, 26.3 ± 4.4 years) who had undergone unilateral ACLR within the previous 12 months completed 2 sessions of bilateral passive knee JPS evaluation. JPS testing was conducted in both the flexion (starting angle, 0°) and the extension (starting angle, 90°) directions in the sitting position. The absolute error, constant error, and variable error of the JPS test in both directions were calculated at 2 target angles (30° and 60° of flexion) by using the angle reproduction method for the ipsilateral knee. The standard error of measurement (SEM), smallest real difference (SRD), and intraclass correlation coefficients (ICCs) with 95% Cis were calculated.

Results:

ICCs were higher for the JPS constant error (operated and nonoperated knee, 0.43-0.86 and 0.32-0.91, respectively) compared with the absolute error (0.18-0.59 and 0.09-0.86, respectively) and the variable error (0.07-0.63 and 0.09-0.73, respectively). The constant error of the 90°-60° extension test showed moderate to excellent reliability for the operated knee (ICC, 0.86 [95% CI, 0.64-0.94]; SEM, 1.63°; SRD, 4.53°), and good to excellent reliability for the nonoperated knee (ICC, 0.91 [95% CI, 0.76-0.96]; SEM, 1.53°; SRD, 4.24°).

Conclusion:

The test-retest reliability of the passive knee JPS tests after ACLR varied depending on the test angle, direction, and outcome measure (absolute error, constant error, or variable error). The constant error appeared to be a more reliable outcome measure than the absolute error and the variable error, mainly during the 90°-60° extension test.

Clinical Relevance:

As constant errors have been found reliable during the 90°-60° extension test, investigating these errors—in addition to absolute and variable errors—to reflect bias in passive JPS scores after ACLR is warranted.

A Randomized, Double-Blind Placebo Control Study on the Effect of a Blood Flow Restriction by an Inflatable Cuff Worn around the Arm on the Wrist Joint Position Sense in Healthy Recreational Athletes

The number of blood flow restriction (BFR) training practitioners is rapidly increasing, so understanding the safety issues associated with limb occlusion is strongly needed. The present study determined the effect of BFR by an inflatable cuff worn around the arm on the wrist joint position sense (JPS) in healthy recreational athletes. In the prospective randomized, double-blind placebo control study, sixty healthy right-handed recreational athletes aged x = 22.93 ± 1.26 years were assigned to groups of equal size and gender rates: BFR, placebo, and control. The active wrist JPS was assessed in two separate sessions using an isokinetic dynamometer. The first assessment was performed with no cuffs. In the second session, a cuff with a standardized pressure was worn on the examined limb in the BFR group. In the placebo group, the cuff was uninflated. A between-session comparison in each group of collected angular errors expressed in degrees was carried out. The angular error in the BFR group was larger during the second measurement than the first one (p = 0.011-0.336). On the contrary, in the placebo (p = 0.241-0.948) and control (p = 0.093-0.904) groups, the error value in the second session was comparable or smaller. It was determined that BFR by an inflatable cuff around the arm impairs the wrist position sense. Hence, BFR training should be performed with caution.

Reliability of the active knee joint position sense test and influence of limb dominance and sex

The output of a sensorimotor performance can be measured with the joint position sense (JPS) test. However, investigations of leg dominance, sex and quality measures on this test are limited. Therefore, these potential influencing factors as well as reliability and consistency measures were evaluated for angular reproduction performance and neuromuscular activity during the active knee JPS test in healthy participants. Twenty healthy participants (10 males; 10 females; age 29 ± 8 years; height 165 ± 39 cm; body mass 69 ± 13 kg) performed a seated knee JPS test with a target angle of 50°. Measurements were conducted in two sessions separated by two weeks and consisted of two blocks of continuous angular reproduction (three minutes each block). The difference between reproduced and target angle was identified as angular error measured by an electrogoniometer. During reproduction, the neuromuscular activity of the quadriceps muscle was assessed by surface electromyography. Neuromuscular activity was normalized to submaximal voluntary contraction (subMVC) and displayed per muscle and movement phase. Differences between leg dominance and sex were calculated using Friedman-test (α = 0.05). Reliability measures including intraclass correlation coefficient (ICC), Bland-Altman analysis (bias ± limits of agreement (LoA)) and minimal detectable change (MDC) were analysed. No significant differences between leg dominance and sex were found in angular error and neuromuscular activity. Angular error demonstrated inter-session ICC scores of 0.424 with a bias of 2.4° (± 2.4° LoA) as well as MDC of 6.8° and moderate intra-session ICC (0.723) with a bias of 1.4° (± 1.65° LoA) as well as MDC of 4.7°. Neuromuscular activity for all muscles and movement phases illustrated inter-session ICC ranging from 0.432 to 0.809 with biases between - 2.5 and 13.6% subMVC and MDC from 13.4 to 63.9% subMVC. Intra-session ICC ranged from 0.705 to 0.987 with biases of - 7.7 to 2.4% subMVC and MDC of 2.7 to 46.5% subMVC. Leg dominance and sex seem not to influence angular reproduction performance and neuromuscular activity. Poor to excellent relative reliability paired with an acceptable consistency confirm findings of previous studies. Comparisons to pathological populations should be conducted with caution.

Supervised, Heavy Resistance Training Is Tolerated and Potentially Beneficial in Women with Knee Pain and Knee Joint Hypermobility: A Case Series

Introduction

Adults with generalised joint hypermobility including knee joint hypermobility (GJHk) report more knee joint symptoms when compared to adults without GJHk. There is no consensus on best practice for symptom management. For instance, controversy exists regarding the appropriateness and safety of heavy resistance training as an intervention for this specific group. This case series aims to describe a supervised, progressive heavy resistance training program in adults with GJHk and knee pain, the tolerability of the intervention, and the outcomes of knee pain, knee-related quality of life, muscle strength, proprioception, and patellar tendon stiffness through a 12-week period.

Materials and Methods

Adults with GJHk and knee pain were recruited to perform supervised, progressive heavy resistance training twice a week for 12 weeks. The main outcome was the tolerability of the intervention. Secondary outcomes were knee pain during a self-nominated activity (VASNA); Knee injury and Osteoarthritis Outcome Score (KOOS); Tampa Scale of Kinesiophobia (TSK); maximal quadriceps voluntary isometric contraction and rate of torque development; 5 repetition maximum strength in five different leg exercises; single leg hop for distance; knee proprioception and patellar tendon stiffness.

Results

In total, 16 women (24.2 years, SD 2.5) completed at least 21/24 training sessions. No major adverse events were observed. On average, VASNA decreased by 32.5 mm (95% CI 21.4-43.6), in addition to improvements in KOOS and TSK scores. These improvements were supported by an increase in all measures of lower extremity muscle strength, knee proprioception, and patellar tendon stiffness.

Conclusion

Supervised heavy resistance training seems to be well tolerated and potentially beneficial in young women with GJHk and knee pain.

Effects of compression garment on muscular efficacy, proprioception, and recovery after exercise-induced muscle fatigue onset for people who exercise regularly

Fatigue is a major cause of exercise-induced muscle damage (EIMD). Compression garments (CGs) can aid post-exercise recovery, therefore, this study explored the effects of CGs on muscular efficacy, proprioception, and recovery after exercise-induced muscle fatigue in people who exercise regularly. Twelve healthy participants who exercised regularly were enrolled in this study. Each participant completed an exercise-induced muscle fatigue test while wearing a randomly assigned lower-body CG or sports pants (SP); after at least 7 days, the participant repeated the test while wearing the other garment. The dependent variables were muscle efficacy, proprioception (displacements of center of pressure/COP, and absolute error), and fatigue recovery (muscle oxygen saturation/SmO₂, deoxygenation and reoxygenation rate, and subjective muscle soreness). A two-way repeated measure analysis of variance was conducted to determine the effect of garment type. The results indicated that relative to SP use, CG use can promote muscle efficacy, proprioception in ML displacement of COP, and fatigue recovery. Higher deoxygenation and reoxygenation rates were observed with CG use than with SP use. For CG use, SmO₂ quickly returned to baseline value after 10 min of rest and was maintained at a high level until after 1 h of rest, whereas for SP use, SmO₂ increased with time after fatigue onset. ML displacement of COP quickly returned to baseline value after 10 min of rest and subsequently decreased until after 1 hour of rest. Relative to SP use, CG use was associated with a significantly lower ML displacement after 20 min of rest. In conclusion, proprioception and SmO₂ recovery was achieved after 10 min of rest; however, at least 24 h may be required for recovery pertaining to muscle efficacy and soreness regardless of CG or SP use.

Knee proprioceptive function and physical performance of patients with patellofemoral pain: A matched case-control study

BACKGROUND

Patients with patellofemoral pain (PFP) present pain, functional limitation, and alteration in knee proprioception.

PURPOSE

To compare the knee joint position sense and lower extremity functionality between patients with PFP and controls. Secondarily, investigate the relationship between proprioceptive acuity and physical performance.

METHODS

This is a matched case-control study including 48 patients with PFP and 48 healthy individuals matched by age, sex, weight, height, and limb dominance. The proprioceptive evaluation was performed using the joint position sense test (absolute error and relative error) and functionality was assessed using the Single-Leg Triple-Hop test and the Y-Balance Test. The groups were compared using the independent student's T-test. Proprioceptive acuity and physical performance correlations were determined by Pearson correlation coefficient.

RESULTS

Participants were on average 31 years old and 62.5% were men. There was no statistically difference for absolute and relative angular error between groups. Patients presented lower relative reached distance on the anterior direction of the Y-Balance Test than controls [patients=58.6 (6.6) % versus controls=61.7 (5.9) %, p=.020]. No differences between groups were found for other functional measures. Significant correlation was found between absolute angular error and anterior component at 60° (r=0.225, p=.028) and relative angular error at 60° with the posterolateral component of the Y- Balance Test (r=0.231, p=.024).

CONCLUSION

Proprioceptive acuity of patients with PFP was not reduced. The anterior direction of the Y-Balance Test was impaired compared to matched controls. Proprioceptive sense is related to dynamic balance but not to jump ability.

Proprioceptive Training for Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: There is increased interest in proprioceptive training for knee osteoarthritis (KOA). However, little consensus supports the effectiveness of this intervention.

Objective: This meta-analysis aimed to assess the effects of proprioceptive training on symptoms, function, and proprioception in people with KOA.

Methods: The PubMed, Cochrane Library, Web of Science, and EMBASE databases were systematically searched from the inception dates to April 16, 2021 for relevant randomized controlled trials (RCTs). Data were pooled by calculating the standardized mean differences (SMDs) and 95% confidence intervals (CIs). A random-effects model was used for the analyses.

Results: A total of 24 RCTs involving 1,275 participants were included in our analysis. This study indicated that compared to no intervention, proprioceptive training significantly improved pain, stiffness, physical function, joint position sense (JPS), muscle strength, mobility, and knee ROM (P < 0.05) in people with KOA. When compared to other non-proprioceptive training, proprioceptive training provided better results in terms of JPS (SMD = −1.28, 95%CI: [−1.64, −0.92], I² = 0%, P < 0.00001) and mobility (timed walk over spongy surface) (SMD = −0.76, 95%CI: [−1.33, −0.18], I² = 64%, P = 0.01), and other results are similar. When proprioceptive training plus other non-proprioceptive training compared to other non-proprioceptive training, the two groups showed similar outcomes, but there was a greater improvement for JPS (SMD = −1.54, 95%CI: [−2.74, −0.34], I² = 79%, P = 0.01), physical function (SMD = −0.34, 95%CI: [−0.56, −0.12], I² = 0%, P = 0.003), and knee ROM (P < 0.05) in the proprioceptive training plus other non-proprioceptive training group. When proprioceptive training plus conventional physiotherapy compared against conventional physiotherapy, the two groups demonstrated similar outcomes, but there was a significant improvement for JPS (SMD = −0.95, 95%CI: [−1.73, −0.18], I² = 78%, P = 0.02) in the proprioceptive training plus conventional physiotherapy group.

Conclusions: Proprioceptive training is safe and effective in treating KOA. There is some evidence that proprioceptive training combined with general non-proprioceptive training or conventional physiotherapy appears to be more effective and should be considered as part of the rehabilitation program. However, given that the majority of current studies investigated the short-term effect of these proprioceptive training programs, more large-scale and well-designed studies with long-term follow up are needed to determine the long-term effects of these proprioceptive training regimes in KOA.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/#recordDetails, PROSPERO, identifier: CRD42021240587.

The effect of static stretching of agonist and antagonist muscles on knee joint position sense

Background/Aims

Proprioception acuity is important in sports activities and stretching is widely used in warm-up programmes. The main objective of this study was to evaluate if a warm-up programme with and without stretching flexors and extensors muscles could affect knee joint position sense.

Methods

The effects of different stretching regimens on joint position sense were examined. A total of 12 semi-professional football players completed four warm-up sessions over 4 weeks: standard warm-up programme; standard warm-up programme with quadriceps stretching; standard warm-up programme with hamstring stretching; and standard warm-up programme with stretching of both quadriceps and hamstrings. Open kinetic chain knee joint position sense was estimated from the ability to reproduce the three target angles (20°, 45° and 60° knee flexion) in the dominant limb before and after the intervention.

Results

In the absolute angular error, there was a statistically significant three-way interaction between the warm-up programme, target angle and time (F (6, 54)=6.88, P=0.001). Findings of post-hoc analysis demonstrated that there was a statistically significant difference between the pre- and post-stretching of hamstrings for the target angles of 20° (4.70 vs 1.57, P=0.01), 45° (1.70 vs 4.50, P=0.02), and 60° (1.93 vs 4.20, P=0.02). In the relative angular error, interaction of time by the warm-up programme was significant (F (3, 27)=3.41, P=0.03).

Conclusions

The warm-up programme with static stretching of hamstrings had a negative effect on open kinetic chain knee joint position sense during the flexion to extension repositioning task, which may not only have a negative effect on performance of athletes as a part of warm-up exercises, but may also lead to further injuries.

Effects of variable frequencies of kinesthesia, balance and agility exercise program in adults with knee osteoarthritis: study protocol for a randomized controlled trial

Background

Knee osteoarthritis (OA) is a common painful and disabling condition that affects older individuals. Proprioceptive training programs in the form of kinesthesia, balance and agility (KBA) exercises have been reported to be beneficial for individuals with knee OA. However, the most optimal training dosage of KBA exercises is still unclear. The aim of this study is to determine the effects of different frequencies of KBA training (i.e., twice-weekly or thrice-weekly) in adults with knee OA.

Methods

A single (assessor) blind, three-arm parallel, multi-center randomized controlled trial will be conducted. One hundred twenty adults with knee OA will be recruited from four tertiary hospitals in Northwestern Nigeria and randomly assigned into one of three intervention groups; twice-weekly KBA (n = 40), thrice-weekly KBA (n = 40), and conventional physiotherapy (n = 40) in the ratio of 1:1:1. Participants in the conventional physiotherapy group will receive two sessions of brief patient education, and sixteen sessions of ultrasound therapy, and stretching and strengthening exercises for 8 weeks. Participants in the two different KBA groups will receive KBA training according to the designed sessions for 8 weeks in addition to the conventional physiotherapy program. All groups will be assessed pre-intervention, immediately post-intervention and at 3 months, 4 months, and 6 months post-randomization. The primary outcome will be physical function (Ibadan Knee and Hip Osteoarthritis Outcome Measure) whereas the secondary outcomes will be pain intensity (Visual Analogue Scale for pain), knee stability (Knee Outcome Survey-Activities of Daily Living Scale), proprioception (electronic goniometer), and quality of life (Osteoarthritis Knee and Hip Quality of Life Questionnaire).

Discussion

The findings of this study may provide evidence on the effectiveness of KBA exercise training and the ideal number of sessions needed to achieve the highest effectiveness in adults with knee OA.

Trial registration

Pan African Clinical Trials Registry (PACTR201810713260138). Registered on 28 November 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05386-3.

Lower limb joint position sense and prospective hamstring injury

BACKGROUND

The hamstrings remain the most injured muscle group within the Australian Football League (AFL).

OBJECTIVE

To investigate preseason measures of hip and knee joint position sense (JPS) and prospective hamstring injury in AFL players.

DESIGN

Prospective cohort study.

METHODS

A total of 116 AFL players were recruited for this study. JPS was assessed with 3-D sensors using mono-articular hip (45° flexion and 0°) and knee (90° and 45° flexion) joint reproduction tests conducted in the preseason. Hamstring injury data were collected prospectively in the following AFL season. Wilcoxon-signed rank tests were used to assess between the subsequently injured and uninjured limbs. Mann-Whitney U tests were used to assess between group differences and odds ratio (OR) were used to predict players at risk of hamstring injury.

RESULTS

Eight players with JPS data sustained a season hamstring injury and 108 players did not. JPS was not significantly different between the subsequently injured and uninjured limbs (all P values > 0.05). No significant differences for any JPS measure were found between the subsequently injured and uninjured players (all p's > 0.05). ORs did not achieve significance for AE (2.7, p = 0.21) or for RMSE (OR = 1.9, p = 0.44).

CONCLUSION

Lower limb JPS measures were not predictive of hamstring injury in AFL players.

Comparison of the Position-Matching and Position-Reproducing Tasks to Detect Deficits in Knee Position Sense After Reconstruction of the Anterior Cruciate Ligament

CONTEXT

Deficits in knee position sense following reconstruction of the anterior cruciate ligament (ACL) can delay an athlete's return to sport participation and increase the risk of reinjury. Deficits in position sense postreconstruction have been evaluated using either a position-reproducing or position-matching task.

OBJECTIVE

The aim of our study was to combine both to determine which assessment would be more effective to identify deficits in knee position sense.

DESIGN

Longitudinal laboratory-based study.

PARTICIPANTS

Eleven athletes (6 men and 5 women; mean age, 20.5 [1.2] y), who had undergone ACL reconstruction with an ipsilateral hamstring autograft, and 12 age-matched controls.

INTERVENTIONS

Position sense was evaluated at 6 and 12 months postreconstruction and once for the control group. In addition, peak isokinetic knee extension and flexion strength, at 60°/s and 180°/s, was assessed for the ACL reconstruction group to evaluate possible influences of muscle strength on knee joint position sense.

MAIN OUTCOME MEASURES

The variables include the angular differences between the reference limb and indicator limb, and peak torque values of isokinetic knee extension and flexion.

RESULTS

Significant matching differences were identified at 6 months postsurgery on the position-matching task, but not at 12 months postsurgery. No significant between-group and within-subject differences were identified on the position-reproducing task. No significant matching errors were identified for the control group. There was no correlation between errors in position sense and maximum isokinetic strength.

CONCLUSION

The position-matching task is more sensitive than the position-reproducing task to identify deficits in knee position sense over the first year following ACL reconstruction surgery.

Effects of Innovative Land-based Proprioceptive Training on Knee Joint Position Sense and Function in Athletes with Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Background: Proprioceptive deficits are one of the most important challenges after anterior cruciate ligament reconstruction (ACLR). Objectives: The current study aimed to investigate the effects of incorporating innovative land-based proprioceptive training into the conventional accelerated land-based rehabilitation protocol, as compared to the conventional accelerated land-based rehabilitation protocol alone, on knee function and joint position sense in male athletes after ACLR. Methods: Thirty male athletes with ACLR were randomly assigned to two rehabilitation groups. The conventional therapy (CT) group (n = 15) received conventional rehabilitation for six weeks, and the proprioception training (PT) group (n = 15) received the same conventional rehabilitation in addition to 12 sessions of innovative land-based proprioceptive training. Outcomes included joint position sense (JPS) errors, International Knee Documentation Committee (IKDC) form, and Visual Analog Scale (VAS). Results: There were significant differences in absolute errors (AE) (FAE = 56.81, P < 0.001) and variable errors (VE) (FVE = 60.95, P < 0.001) between the two groups. No significant differences were found in constant error (CE), VAS, and IKDC score between the two groups (P > 0.05). Both groups showed significant changes in terms of AE, VE, VAS, and IKDC after the intervention (P < 0.05). Percent changes after the intervention for AE, VE, CE, VAS, and IKDC were greater in the PT group than in the CT group, which were 70.19%, 69.22%, 66.20%, 38.50%, and 39.61%, respectively. Conclusions: Innovative land-based proprioceptive training incorporated into the conventional accelerated rehabilitation protocol offers the improvement of proprioception efficiency for individuals with ACL reconstruction, and therefore, it could be useful for clinicians when designing rehabilitation protocols to ensure the optimal engagement of proprioception.

The influence of sports practice, dominance and gender on the knee joint position sense

BACKGROUND

Physical activity, muscle fatigue or age have been suggested as factors that positively or negatively influence the knee joint position sense (KJPS). However, conflicting results about the influence of sports practice, limb dominance and gender are found in the literature. This study aimed to assess the influence of sports practice, limb dominance and gender on the KJPS of soccer players and untrained individuals.

METHODOLOGY

Sixty subjects participated in this study: 29 soccer players (SPs) and 31 untrained participants (UPs). KJPS was tested in a seated position, for the target angles of 20° and 45° of knee flexion, through an open kinetic chain technique and active repositioning method. Intergroup analysis was performed to compare KJPS between SPs and UPs and between gender, and intragroup analysis was performed to compare proprioceptive acuity between dominant and non-dominant limbs.

RESULTS

Knee repositioning errors were lower in SPs than in the UPs. Repositioning errors of the dominant and non-dominant limb were not significantly different in SPs (P > 0.05), but in UPs the dominant limb showed significantly lower repositioning errors, both for 20° (P = 0.046) and 45° target (P = 0.036). There were no gender differences in the KJPS in both groups (P > 0.05).

CONCLUSIONS

Proprioceptive acuity is higher in trained than in untrained participants. Dominance seems not to influence KJPS of SPs, but in UPs the dominant limb showed a higher accuracy. There were no differences in KJPS related to gender. These results suggest that sports practice, but neither gender nor limb dominance, may positively influence proprioceptive acuity.

Effects of 2 Different External Loads on Joint Position Sense and the Relationship Between Muscle Strength and Force Sense

CONTEXT

Joint position sense (JPS) tests of proprioception lack ecological validity because the testing conditions are so different from the normal function that they can contribute little to understanding the role proprioception plays in daily and sporting activities.

OBJECTIVE

To evaluate the effect of low and high external load on the knee JPS and to investigate the relationship between maximum voluntary isometric contraction and force sense (FS).

DESIGN

Experimental study.

SETTING

Research laboratory.

PARTICIPANTS

A total of 47 volunteers with no history of knee pathology.

INTERVENTIONS

Three active JPS tests performed with no load, low load, and high load were compared at the 45° target angle. For isometric FS test, 50% load was used. For isotonic low load and high load JPS tests, 30% and 70% loads were applied, respectively.

MAIN OUTCOME MEASURES

To analyze obtained data set 2-way multiple analysis of variance, repeated measures of analysis of variance, paired sample t test, and the Pearson correlation coefficient were used.

RESULTS

JPS was not affected by gender (male and female) and activity levels (sedentary, recreational, and trained). Results of the repeated measure of analysis of variance demonstrated the significant main effect of loads (P = .001). Significant differences were found between no load, low load, and high load JPS (P = .001). A positive and significant correlation was found between maximum voluntary isometric contraction and FS error values (r = .41, P = .001).

CONCLUSIONS

The results suggest that as the load level increases, the knee JPS improves. Knee JPS assessed under external load may be a more appropriate alternative to the nature of the sport. Those with higher muscle strength have a worse FS.

Immediate effects of neurodynamic nerve gliding versus static stretching on hamstring neuromechanical properties

PURPOSE

We investigated the immediate effects of neurodynamic nerve gliding (ND) on hamstring flexibility, viscoelasticity, and mechanosensitivity, compared with traditional static stretching (ST).

METHODS

Twenty-two physically active men aged 21.9 ± 1.9 years were divided randomly into two equal intervention groups using ST or ND. An isokinetic dynamometer was used to measure the active knee joint position sense, perform passive knee extension, record the passive extension range of motion (ROM) and the passive-resistive torque of hamstrings. Stiffness was determined from the slope of the passive torque-angle relationship. A stress relaxation test (SRT) was performed to analyze the viscoelastic behavior of the hamstrings. The passive straight leg raise (SLR) test was used to evaluate hamstring flexibility.

RESULTS

A significant interaction was observed for ROM and passive ultimate stiffness, reflected by an increase in these indicators after ND but not after SD. SLR increased significantly in both groups. After ST, a significantly faster initial stress relaxation was observed over the first 4 s. than after ND. There was no significant change in the active knee joint position sense.

CONCLUSIONS

ND provided a slightly greater increase in hamstring extensibility and passive stiffness, possibly by decreasing nerve tension and increasing strain in connective tissues than ST. The ST mostly affected the viscoelastic behavior of the hamstrings, but neither intervention had a significant impact on proprioception.

The effect of 8 weeks proprioception training without visual input on single-limb standing balance time in deaf students: A randomized controlled trial

INTRODUCTION

The aim of this study was to determine the effects of 8 weeks proprioception training without visual input on the proprioception of the knee and ankle and single standing balance time in deaf students.

METHODS

Twenty male deaf students participated in this study and were randomly assigned into control (n = 10) and experimental (n = 10) groups. Subjects' proprioception was measured using an electrogoniometer. In addition, balance performance was evaluated through single-limb standing performance test under four sensory conditions (condition 1: eyes open on one leg; condition 2: eyes closed on one leg; condition 3: eyes open on foam; condition 4: eyes closed on foam).

RESULTS

The findings showed that proprioception training without visual input induced meaningful, significant effects in knee and ankle proprioception (p ≤ 0.001), and single-limb standing time of deaf students at condition 1 (p ≤ 0.03) and 2 (p ≤ 0.001). However, training programs did not have any significant effects on single-limb standing time in conditions 3 (p ≤ 0.41) and 4(p ≤ 0.22).

CONCLUSIONS

Proprioception training without visual input improves proprioception of ankle, knee and single-limb standing balance time in deaf students.

Assessing the concurrent validity and reliability of an iPhone application for the measurement of range of motion and joint position sense in knee and ankle joints of young adults

OBJECTIVE

To analyze the concurrent validity and reliability of an iPhone application for assessing range of motion (ROM) and joint position sense (JPS) in ankle and knee joints.

DESIGN

Cross-sectional study.

SETTING

Sport laboratory.

PARTICIPANTS

Twenty healthy and physically active volunteers.

INTERVENTIONS

All participants performed a ROM and a JPS test in ankle and knee joints, which were simultaneously evaluated with photo-analysis and the iPhone application.

MAIN OUTCOMES MEASURES

A total of 80 angles were obtained with the iPhone app and the photo-analysis and compared for concurrent validity. Reliability was evaluated through re-scoring of images with the iPhone app by two different testers.

RESULTS

Very high correlation was observed between both methods for ankle and knee ROM and knee JPS (r > 0.90), and high correlation for ankle JPS (r = 0.71-0.90), while Bland-Altman plots showed absolute agreement for all the variables. Inter- and intra-tester reliability was perfect for all the variables (ICC > 0.81), except for the inter-tester reliability of ankle JPS, which was substantial (ICC = 0.61-0.81).

CONCLUSIONS

This new iPhone application is valid and reliable for measuring ankle and knee ROM and JPS, although special attention is needed during ankle evaluation to avoid errors.

Effects of knee orthoses on kinesthetic awareness and balance in healthy individuals

Introduction

Conflicting evidence exists regarding the effects of knee orthoses on proprioception. One belief is that pressure applied by orthoses heightens kinesthetic awareness and that this affects balance. This study aimed to investigate the effects of two different orthosis designs on kinesthetic awareness and balance in healthy individuals.

Methods

Twenty individuals (13 women) participated in this case series study. Each was tested wearing 1/no orthosis, 2/soft elastic orthosis and 3/non-elastic jointed orthosis. Pressure under orthoses was recorded. Kinesthetic awareness was investigated by testing joint position sense and threshold to detection of passive motion. Balance was tested using a modified sensory organization test.

Results

Non-elastic jointed orthoses applied the greatest pressure to the knee. With non-elastic jointed orthoses, threshold to detection of passive motion was significantly poorer for pooled results (p = 0.02) and when the start position of the knee was 70° (mean threshold = 0.6°, 0.6°, 0.7° for no-orthosis, elastic and jointed-orthoses; p = 0.03). No major differences were observed in JPS or balance and correlation between proprioception and balance was poor.

Conclusions

There may be a limit to the amount of pressure that should be applied to the knee joint by an orthosis. Exceeding this limit may compromise kinesthetic awareness.

Effect of Force Sense to Active Joint Position Sense and Relationships between Active Joint Position Sense, Force Sense, Jumping and Muscle Strength

We aimed to investigate the effect of external load on the joint position sense (JPS) accuracy and its relation to the target jump height. The present study also aimed to explore the relationship between force sense (FS) and maximum voluntary isometric contraction (MVIC). Participants' MVIC levels were determined during the 45-degree knee extension task. Then, participants were asked to execute a knee JPS task with external load (EL-JPS) and with no-load (EL-JPS). To assess jumping accuracy participants were instructed to jump with their 50% of maximum jump height. Results indicated that EL-JPS error values were lower than NL-JPS. EL-JPS was correlated to jumping errors. However, the relationship between NL-JPS and jumping errors was not significant. A significant correlation was found between MVIC and FS errors.

KNEE PROPRIOCEPTION MAY BE ALTERED BY TREATMENT IN ATHLETES SUFFERING FROM DELAYED ONSET MUSCLE SORENESS

Delayed onset muscle soreness (DOMS) is a very common musculoskeletal problem in athletes involved in extreme competitions. The aim of this study is to compare the effect of diathermy, sham diathermy and massage on the knee proprioception of athletes treated for DOMS. Forty athletes were enrolled after the second day of a demanding ski mountaineering race. They were randomly assigned to four groups: no treatment [Formula: see text], massage [Formula: see text], diathermy [Formula: see text], and sham diathermy [Formula: see text]. The knee reposition error was measured after the treatments in order to assess knee proprioception. Significant differences between the diathermy and sham diathermy groups were found ([Formula: see text]) with an absolute effect size of [Formula: see text]. No other significant differences were found among groups. This means that diathermy has a negative impact on joint proprioception and can be explained by the spindle desensitization consequent to deeper tissue heating. This information can be important in the DOMS management of athletes, since an altered proprioception may interfere with the athlete’s performance and can increase the risk of injury.

Proprioceptive Training and Outcomes of Patients With Knee Osteoarthritis: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To describe the effects of proprioceptive training on pain, stiffness, function, and functional test outcomes among patients with knee osteoarthritis (OA).

DATA SOURCES

All studies completed from 1946 to 2017 were obtained from 4 databases (PubMed, MEDLINE, CINAHL, and SPORTDiscus).

STUDY SELECTION

Three reviewers independently identified appropriate studies and extracted data.

DATA EXTRACTION

Methodologic quality and level of evidence were assessed using the Physiotherapy Evidence Database scale and Oxford Centre for Evidence-Based Medicine guidelines. The standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated for pain, stiffness, function, and functional test outcomes.

DATA SYNTHESIS

Seven randomized controlled trials involving 558 patients with knee OA met the inclusion criteria. The selected studies had Physiotherapy Evidence Database scores of 6 to 8. All randomized controlled trials had an Oxford Centre for Evidence-Based Medicine level of evidence of 2. Meta-analysis of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale (SMD = -0.56; 95% CI = -1.06, -0.07; P = .026), function subscale (SMD = -0.40; 95% CI = -0.59, -0.21; P < .001), and non-WOMAC walking speed test (SMD = -1.07; 95% CI = -2.12, -0.01; P = .048) revealed that proprioceptive training had significant treatment effects. Proprioceptive training was not associated with reductions in WOMAC stiffness subscale scores and did not improve non-WOMAC get-up-and-go scores.

CONCLUSIONS

Proprioceptive training effectively promoted pain relief and completion of functional daily activity among patients with knee OA and should be included in rehabilitation programs. Stiffness and other mobility measures were unchanged after proprioceptive training. Modified proprioceptive training programs are needed to target stiffness and improve additional physical function domains.

Delayed effects of a 20-min crushed ice application on knee joint position sense assessed by a functional task during a re-warming period

Delayed effects of a 20-min crushed ice application on knee joint position sense assessed by a functional task during a re-warming period.

INTRODUCTION

The effect of cryotherapy on joint positioning presents conflicting debates as to whether individuals are at an increased risk of injury when returning to play following cryotherapy application at the lower limb.

OBJECTIVES

The aim of this study was to investigate whether a 20 min application of crushed ice at the knee affects knee joint kinematics immediately post and up to 20 mins post ice removal, during a small knee bend.

METHOD

17 healthy male participants took part in the study performing a functional task. Using three-dimensional motion analysis (Qualisys Medical AB Gothenburg, Sweden), kinematics of the knee were measured during a weight bearing functional task pre and immediately post, 5, 10, 15 and 20 min post cryotherapy intervention. Skin surface temperature (T_sk) cooling was measured via infrared non-contact thermal imaging (Flir Systems, Danderyd, Sweden) over the anterior and medial aspect of the knee.

RESULTS

Results demonstrated significant reductions in the ability to accurately replicate knee joint positioning. A significant increase (P ≧ 0.05) in rotational movement in the transverse plane occurred, 20 min post ice removal.

DISCUSSION

A 20-min application of crushed ice to the anterior aspect of the non-dominant knee has an adverse effect on knee joint repositioning and dynamic stability, 20 min after ice is removed. In consideration of returning a land-based athlete to dynamic functional activities, post cryotherapeutic intervention at the knee, clinicians should consider these findings due to the potential increase risk of injury.

Test–retest reliability of wrist joint position sense in healthy adults in a clinical setting

Introduction

Proprioceptive assessments of the wrist inform clinical decision making. In wrist rehabilitation, joint position sense has emerged as one way of assessing conscious proprioception with varying methods and minimal psychometric analysis reported. The purpose of this study was to standardise the wrist joint position sense test method for clinical use and to determine its test–retest reliability in a healthy population.

Methods

Four wrist positions (20° and 45° flexion, 20° and 45° extension) were measured twice in a random order, by a single rater, using a universal goniometer on the same day. The absolute error in degrees between each position and reposition was calculated. For relative reliability analysis, the intraclass correlation coefficient (3,1) was calculated. For absolute reliability the standard error of the measurement was calculated and Bland–Altman plots visually inspected.

Results

Fifty-five healthy volunteers (mean age 31.1 SD±10.25 years) were assessed. The mean absolute error, summarised for all positions for test and retest, was 3.98°. The intraclass correlation coefficients were poor to fair (0.07–0.47), and standard error of the measurement was 2° (rounded) for all positions. The limits of agreement were fairly narrow, and the Bland–Altman plots showed random distribution of errors for each position, therefore the measurement error was clinically acceptable.

Conclusions

The active wrist joint position sense test using goniometry demonstrated poor to fair test–retest reliability and acceptable measurement error in healthy volunteers. The wrist joint position sense angle of 20° flexion was the most reliable.

The Effects of Cryotherapy on Knee Joint Position Sense and Force Production Sense in Healthy Individuals

The proprioceptive information received from mechanoreceptors is potentially responsible for controlling the joint position and force differentiation. However, it is unknown whether cryotherapy influences this complex mechanism. Previously reported results are not universally conclusive and sometimes even contradictory. The main objective of this study was to investigate the impact of local cryotherapy on knee joint position sense (JPS) and force production sense (FPS). The study group consisted of 55 healthy participants (age: 21 ± 2 years, body height: 171.2 ± 9 cm, body mass: 63.3 ± 12 kg, BMI: 21.5 ± 2.6). Local cooling was achieved with the use of gel-packs cooled to -2 ± 2.5°C and applied simultaneously over the knee joint and the quadriceps femoris muscle for 20 minutes. JPS and FPS were evaluated using the Biodex System 4 Pro apparatus. Repeated measures analysis of variance (ANOVA) did not show any statistically significant changes of the JPS and FPS under application of cryotherapy for all analyzed variables: the JPS’s absolute error (p = 0.976), its relative error (p = 0.295), and its variable error (p = 0.489); the FPS’s absolute error (p = 0.688), its relative error (p = 0.193), and its variable error (p = 0.123). The results indicate that local cooling does not affect proprioceptive acuity of the healthy knee joint. They also suggest that local limited cooling before physical activity at low velocity did not present health or injury risk in this particular study group.

Early self-managed focal sensorimotor rehabilitative training enhances functional mobility and sensorimotor function in patients following total knee replacement: a controlled clinical trial

OBJECTIVE

To assess the effects of early self-managed focal sensorimotor training compared to functional exercise training after total knee replacement on functional mobility and sensorimotor function.

DESIGN

A single-blind controlled clinical trial.

SETTING

University Hospital of Rion, Greece.

SUBJECTS

A total of 52 participants following total knee replacement.

OUTCOME MEASURES

The primary outcome was the Timed Up and Go Test and the secondary outcomes were balance, joint position error, the Knee Outcome Survey Activities of Daily Living Scale, and pain. Patients were assessed on three separate occasions (presurgery, 8 weeks post surgery, and 14 weeks post surgery).

INTERVENTION

Participants were randomized to either focal sensorimotor exercise training (experimental group) or functional exercise training (control group). Both groups received a 12-week home-based programme prescribed for 3-5 sessions/week (35-45 minutes).

RESULTS

Consistently greater improvements ( F_2,98 = 4.3 to 24.8; P < 0.05) in group mean scores favour the experimental group compared to the control group: Timed Up and Go (7.8 ± 2.9 seconds vs. 4.6 ± 2.6 seconds); balance (2.1 ± 0.9° vs. 0.7 ± 1.2°); joint position error (13.8 ± 7.3° vs. 6.2 ± 9.1°); Knee Outcome Survey Activities of Daily Living Scale (44.2 ± 11.3 vs. 26.1 ± 11.4); and pain (5.9 ± 1.3 cm vs. 4.6 ± 1.1 cm). Patterns of improvement for the experimental group over time were represented by a relative effect size range of 1.3-6.5.

CONCLUSIONS

Overall, the magnitude of improvements in functional mobility and sensorimotor function endorses using focal sensorimotor training as an effective mode of rehabilitation following knee replacement.

The influence of below-knee compression garments on knee-joint proprioception

OBJECTIVE

The purpose of the study was to assess the influence of below-knee compression garments on proprioception accuracy under, information processing constraints designed to cause high or low conscious attention to the task.

METHODS

In a counterbalanced, single-blinded, crossover trial, 44 healthy participants (26 male/18 female) with a mean age of 22.7±6.9 years performed an active joint repositioning task using their nondominant and their dominant leg, with and without below-knee compression and with and without conducting a secondary task.

RESULTS

Analysis of variance revealed no main effect of leg dominance and no interactions (p's>0.05). However, a main effect was evident for both compression (F_{1, 43}=84.23, p<0.001, ηp²=0.665) and secondary task (F_{1, 43}=4.391, p=0.04, ηp²=0.093).

CONCLUSIONS

The study is the first to evaluate the effects of a belowknee compression garment on knee proprioception under differential information processing constraints. We conclude that proprioception accuracy of the knee joint is significantly enhanced post application of below-knee compression garments and when a secondary task is conducted concurrently with active joint repositioning. The findings suggest that below-knee compression garments may improve proprioception of the knee, regardless of leg dominance, and that secondary tasks that direct attention away from proprioceptive judgments may also improve proprioception, regardless of the presence of compression. Clinical implications are discussed with respect to proprioception in modern.sports and rehabilitation settings.

Knee position sense: does the time interval at the target angle affect position accuracy?

[Purpose] This study examined whether the interval at the target angle during knee joint position sense (JPS) affected reposition accuracy, and evaluated the consequence of this factor on test-retest reliability. [Subjects and Methods] Twenty healthy subjects participated in this study. Reposition ability was measured after the knee was placed at a target angle (ranging from 40° to 60°) for intervals of 3, 6, 9, and 12 seconds, in randomized order. Two trials were performed for each condition. The measurement was repeated after a week. The absolute error (AE) of each trial and average AE under each condition within the two measures were used for data analysis. [Results] No significant difference was found in comparing the AE or the average AE during all trials and between the two measures. Fair-to-good reliability was found for the AE results of all trials under the conditions of 3, 6, and 12 seconds. Poor reliability was found with time interval of 9 seconds. [Conclusion] The length of time needed to memorize the target angle during knee JPS test might affect test reliability. Practitioners can use this information when collecting JPS data.

An exploratory study into the effects of a 20 minute crushed ice application on knee joint position sense during a small knee bend

OBJECTIVES

The effect of cryotherapy on joint positioning presents conflicting debates as to whether individuals are at an increased risk of injury when returning to play or activity immediately following cryotherapy application at the knee. The aim of this study was to investigate whether a 20 min application of crushed ice at the knee immediately affects knee joint position sense during a small knee bend.

DESIGN

Pre- and post-intervention.

SETTING

University movement analysis laboratory.

PARTICIPANTS

Eleven healthy male participants.

MAIN OUTCOME MEASURES

Kinematics of the knee were measured during a weight bearing functional task pre and post cryotherapy intervention using three-dimensional motion analysis (Qualisys Medical AB Gothenburg, Sweden). Tissue cooling was measured via a digital thermometer at the knee.

RESULTS

Results demonstrated significant reductions in the ability to accurately replicate knee joint positioning in both sagittal (P = .035) and coronal (P = .011) planes during the descent phase of a small knee bend following cryotherapy.

CONCLUSION

In conclusion a 20 min application of crushed ice to the knee has an adverse effect on knee joint repositioning. Team doctors, clinicians, therapists and athletes should consider these findings when deciding to return an athlete to functional weight bearing tasks immediately following ice application at the knee, due to the potential increase risk of injury.

Effects of hip abductor muscle fatigue on gait control and hip position sense in healthy older adults

We experimentally investigated whether unilateral hip abductor muscle fatigue affected gait control and hip position sense in older adults. Hip abductor muscles were fatigued unilaterally in side-lying position in 17 healthy older adults (mean age 73.2 SD 7.7 years). Hip joint position sense was assessed by an active-active repositioning test while standing and was expressed as absolute and relative errors. Participants walked on a treadmill at their preferred walking speed, while 3D linear accelerations were collected by an inertial sensor at the lower back. Gait parameters, including step and stride time, local divergence exponents and harmonic ratio were quantified. In fatigued gait, stride time variability and step-to-step asymmetry in the frontal plane were significantly increased. Also a significantly slower mediolateral trunk movement in fatigued leg late stance toward the non-fatigued leg was observed. Despite these temporal and symmetry changes, gait stability in terms of the local divergence exponents was not affected by fatigue. Hip position sense was also affected by fatigue, as indicated by an increased relative error of 0.7° (SD 0.08) toward abduction. In conclusion, negative effects of fatigue on gait variability, step-to-step symmetry, mediolateral trunk velocity control and hip position sense indicate the importance of hip abductor muscles for gait control.

Reliability and measurement precision of concentric-to-isometric and eccentric-to-isometric knee active joint position sense tests in uninjured physically active adults

OBJECTIVES

Proprioception is important because it is used by the central nervous system to mediate muscle control of joint stability, posture, and movement. Knee active joint position sense (AJPS) is one representation of knee proprioception. The purpose of this study was to establish the intra-tester, inter-session, test-retest reliability of concentric-to-isometric (seated knee extension; prone knee flexion) and eccentric-to-isometric (seated knee flexion; prone knee extension) knee AJPS tests in uninjured adults.

DESIGN

Descriptive.

SETTING

University laboratory.

PARTICIPANTS

Six males, six females (age 26.2 ± 5.7 years; height 171.1 ± 9.6 cm; mass 71.1 ± 16.6 kg).

MAIN OUTCOME MEASURES

Mean absolute error (AE; °); intraclass correlation coefficient (ICC) (2,1); standard error of measurement (SEM; °).

RESULTS

Mean AE ranged from 3.18° to 5.97° across tests. The ICCs and SEMs were: seated knee extension 0.13, 1.3°; prone knee flexion 0.51, 1.2°; seated knee flexion 0.31, 1.7°; prone knee extension 0.87, 1.4°.

CONCLUSIONS

The prone knee flexion and prone knee extension tests demonstrated moderate to good reliability. Prone knee flexion and prone knee extension AJPS tests may be useful in cross-sectional studies estimating how proprioception contributes to knee functional joint stability or prospective studies estimating the role of proprioception in the onset of knee injury.

Joint-position sense is altered by football pre-participation warm-up exercise and match induced fatigue

BACKGROUND

The demands to which football players are exposed during the match may augment the risk of injury by decreasing the sense of joint position. This study aimed to assess the effect of pre-participation warm-up and fatigue induced by an official football match on the knee-joint-position sense of football players.

METHODS

Fourteen semi-professional male football players (mean age: 25.9±4.6 years old) volunteered in this study. The main outcome measures were rate of perceived exertion and knee-joint-position sense assessed at rest, immediately after a standard warm-up (duration 25 min), and immediately after a competitive football match (90 minutes duration).

RESULTS

Perceived exertion increased significantly from rest to the other assessments (rest: 8.6±2.0; after warm-up: 12.1±2.1; after football match: 18.5±1.3; p<0.001). Compared to rest, absolute angular error decreased significantly after the warm-up (4.1°±2.2° vs. 2.0°±1.0°; p=0.0045). After the match, absolute angular error (8.7°±3.8°) increased significantly comparatively to both rest (p=0.001) and the end of warm-up (p<0.001). Relative error showed directional bias with an underestimation of the target position, which was higher after the football match compared to both rest (p<0.001) and after warm-up (p<0.001).

CONCLUSIONS

The results indicate that knee-joint-position sense acuity was increased by pre-participation warm-up exercise and was decreased by football match-induced fatigue.

CLINICAL RELEVANCE

Warm-up exercises could contribute to knee injury prevention, whereas the deleterious effect of match-induced fatigue on the sensorimotor system could ultimately contribute to knee instability and injury.

Reproducibility of a knee and hip proprioception test in healthy older adults

BACKGROUND

Proprioception can be assessed by measuring joint position sense (JPS). Most studies have focused on JPS of the knee joint while literature for other joints especially for hip JPS is scarce. Although some studies have evaluated proprioception of the knee joint, the reproducibility of methods has rarely been investigated.

AIMS

To estimate intrasession reliability and agreement of an active-active JPS test for hip flexion/abduction and knee flexion in healthy older adults.

METHODS

Nineteen healthy older adults participated in this study. The proprioception of the hip (flexion and abduction) and knee (flexion) were assessed in both legs using the "active-active" reproduction technique. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and limits of agreement (LOA) were estimated for relative angular error (RE), absolute angular error (AE), and variable angular error (VE).

RESULTS

Reliability of our JPS test was substantial to almost perfect for the RE for both joints and legs (ICC values ranging from 0.75 to 0.93). We also found that the ICC values for AE were substantial for knee flexion and hip abduction of the left and right leg. The ICC results of VE showed poor reliability for hip and knee joints. SEM and LOA values for hip abduction were generally lower than for hip and knee flexion, indicating lower measurement error or more precise scores for the proprioception test of hip abduction.

CONCLUSION(S)

Proprioceptive acuity of the knee and hip joints in healthy older adults can be reliably assessed with an active-active procedure in a standing position with respect to relative and absolute error.

Effect of blocked vision treadmill training on knee joint proprioception of patients with chronic stroke

[Purpose] The purpose of this study was to compare the effect of treadmill training with the eyes closed and eyes open on the joint position sense of chronic stroke patients. [Subjects and Methods] Thirty patients with chronic stroke participated in this study. Patients performed the timed up and go test and were assigned to one of two treadmill training groups with and without visual deprivation. The treadmill gait training for each group lasted 40 minutes, and sessions were held 3 times a week for 4 weeks. The knee joint proprioception was measured using the Biodex System Pro 3 before and after the intervention. [Results] The knee joint proprioception of the treadmill training with blocked vision group showed more significant improvement after the treadmill training sessions than that of the eyes open group. [Conclusion] This study demonstrated that treadmill training with blocked vision may be useful for the proprioceptive sensory rehabilitation of patients with chronic stroke.

The effects of cryotherapy on proprioception system

Proprioception plays an important role in the complex mechanism of joint control. Contemporary sport activities impose extremely high physical demands on athletes. Winter sports are played in areas with excessively low temperatures. Moreover, many athletes are subjected to treatments that involve local lowering of the body temperature before, during, and after physical activity. This work reviews the current knowledge regarding the influence of local cryotherapy on the proprioception system. The reviewed literature identified several tests that evaluate different aspects of proprioception. There is no universally agreed protocol, or clear set of criteria for test conditions. The outcomes of different tests and assessments of cryotherapy procedures using different cold modalities are poorly correlated. In general, the published results on the mechanism of cryotherapy effects on proprioception are not uniquely conclusive and are frequently contradictory. Additional high-quality research is required to explicitly answer the following questions: (1) whether local cryotherapy influences all aspects of proprioception; (2) whether the current methods of evaluation are adequate for the exploration of the relationship between cryotherapy and proprioception; and (3) whether the application of local cryotherapy is safe for athletes regarding proprioception. The review clearly showed that there is no comprehensive model relating cryotherapy and proprioception.

Does knee joint proprioception alter following medial patellofemoral ligament reconstruction?

BACKGROUND

This study firstly aimed to determine whether proprioception deficits, as measured by joint position sense (JPS), occur in people following recurrent patellar dislocations. Secondly, to determine whether JPS changes following medial patellofemoral ligament reconstruction (MPFL) reconstruction for patellar instability.

METHODS

Thirty people following recurrent patellar dislocation were recruited. Pre-operative JPS was assessed using the passive angle reproduction test. Through this, an assessor moved a participant's limb to a target position. This was returned to neutral, before finally moving the limb again, whilst requiring the participant to indicate when they thought the target angle was reached. The actual angular error (AAE) was calculated as the difference between the perceived angle and target angle. Clinical outcomes included the Kujala Patellofemoral Disorder Score, the International Knee Documentation Committee (IKDC) form, pain, knee motion, extensor muscle strength and frequency of patellar dislocation. Outcomes were assessed pre-operative, 6 weeks, 3 and 12 months.

RESULTS

Mean AAE was 2.2° (inner range) to 3.9° (mid-range); this was not clinically significant. There was no statistically significant difference between the baseline-and-6 week, 6 week-and-3 month or baseline-and-12 month AAE measures (p=0.38 to 1.00). There was a statistically significant improvement in functional outcomes as measured by the Kujala score, IKDC form, reduced pain and increased extension strength from baseline to 12 months (p<0.01).

CONCLUSIONS

Following recurrent patellar dislocation, patients exhibit minimal deficits in JPS. Whilst MPFL reconstruction significantly improved clinical and functional outcomes for this population, this operation did not significantly alter JPS during the first post-operative year.

A systematic review to determine the reliability of knee joint position sense assessment measures

BACKGROUND

The assessment of joint position sense (JPS) is the most widely used measurement of knee proprioceptive capability within the literature. However, it remains unclear what the most reliable method is to assess this. The purpose of this study was to determine the intra- and inter-rater reliability of the various methods used to assess knee JPS.

METHODS

A systematic review of published and unpublished literature sources was conducted up to June 2012. All studies principally assessing the reliability (intra- or inter-rater) or reproducibility of a JPS of the knee were included. The methodological quality of each study was reviewed using the Critical Appraisal Skills Programme tool.

RESULTS

A total of 18 studies were eligible, assessing the reliability of JPS with 456 knees. The reliability of four methods of JPS has been recorded: position replication using a model, image recorded angulation, electrogoniometry and dynamometry/angular motion chair. Intra-rater reliability was good for the assessment of JPS using photographs and digital images, and replicating knee position using a paper model, this was good but variable when electrogoniometry was used, and moderate but variable when assessed using dynamometry/angle motion chairs. The assessment of JPS by image recorded angulation, electrogoniometry and dynamometry/angular motion chair has demonstrated good inter-rater reliability.

CONCLUSIONS

Whilst JPS methods appear to have variable reliability, the four assessment methods should be further assessed with pathological populations such as those following patellar dislocation or anterior cruciate ligament rupture. This will better facilitate the generalisability of JPS assessment methods to inform clinical practice.

Do people with benign joint hypermobility syndrome (BJHS) have reduced joint proprioception? A systematic review and meta-analysis

Joint proprioceptive deficit is documented in a variety of musculoskeletal conditions including osteoarthritis, ligament and meniscal injuries, and individuals with increased joint hypermobility, such as those with Ehlers-Danlos. No systematic reviews have assessed joint proprioception in people with benign joint hypermobility syndrome (BJHS). This study addresses this to determine whether people with BJHS exhibit reduced joint proprioception, and, if so, whether this is evident in all age groups. The search strategy was conducted on 31st January 2013. The published literature was assessed using the databases: AMED, CINAHL, MEDLINE, EMBASE, PubMed and the Cochrane Library. Unpublished literature and trial registries were assessed including: OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials, the UK National Research Register Archive. All studies comparing the proprioceptive capability of people with and without BJHS were included. Study methodological quality was assessed using the CASP appraisal tool. Meta-analysis techniques were used when study homogeneity permitted. Five studies including 254 people were identified. People with BJHS demonstrated statistically significantly poorer lower limb joint position sense (JPS) (p < 0.001) and threshold detection to movement (p < 0.001) than those without BJHS. The evidence for upper limb proprioceptive difference was less clear, with no statistically significant difference between the cohorts for shoulder JPS (p = 0.10), but a statistically significant difference in finger JPS (p < 0.001). One study which assessed childhood BJHS reported reduced knee proprioceptive capability in those with BJHS (p < 0.001). To conclude, lower limb joint proprioception is reduced in those with BJHS compared to non-BJHS cohorts, whilst unclear in the upper limb.

Effectiveness of proprioceptive exercises for ankle ligament injury in adults: a systematic literature and meta-analysis

The purpose of this study was to assess the effectiveness of such proprioceptive exercise following ankle ligament injury. A systematic review of the databases MEDLINE, EMBASE, CINHAL, AMED, the Cochrane library database and the PEDro database, in addition to unpublished literature databases was conducted to July 2011. When appropriate, meta-analysis was conducted to pool results from homogeneous studies. The methodological quality of the literature was reviewed using the Critical Appraisal Skills Programme tool. The results indicated that there is no statistically significant difference in recurrent injury between the addition of proprioceptive exercises during the rehabilitation of patients following ankle ligament injury (p = 0.68). The addition of proprioceptive training demonstrated a significant reduction in subjective instability and functional outcomes (p < 0.05). There was no consensus on the advantages of including proprioceptive training in the rehabilitation of this population for swelling, postural sway, joint position sense, ankle range of motion or return to sport outcomes. Further study is warranted to develop the rigour of the evidence-base and to determine the optimal proprioceptive training programme following ankle ligament injury with different populations.

Effects of cold water immersion on knee joint position sense in healthy volunteers

The purpose of this study was to determine the effects of cryotherapy, in the form of cold water immersion, on knee joint position sense. Fourteen healthy volunteers, with no previous knee injury or pre-existing clinical condition, participated in this randomized cross-over trial. The intervention consisted of a 30-min immersion, to the level of the umbilicus, in either cold (14 ± 1 °C) or tepid water (28 ± 1 °C). Approximately one week later, in a randomized fashion, the volunteers completed the remaining immersion. Active ipsilateral limb repositioning sense of the right knee was measured, using weight-bearing and non-weight-bearing assessments, employing video-recorded 3D motion analysis. These assessments were conducted immediately before and after a cold and tepid water immersion. No significant differences were found between treatments for the absolute (P = 0.29), relative (P = 0.21) or variable error (P = 0.86). The average effect size of the outcome measures was modest (range -0.49 to 0.9) and all the associated 95% confidence intervals for these effect sizes crossed zero. These results indicate that there is no evidence of an enhanced risk of injury, following a return to sporting activity, after cold water immersion.

Effects of whole-body cryotherapy (-110 °C) on proprioception and indices of muscle damage

The purpose of this study was to investigate the effects of whole-body cryotherapy (WBC) on proprioceptive function, muscle force recovery following eccentric muscle contractions and tympanic temperature (T(TY) ). Thirty-six subjects were randomly assigned to a group receiving two 3-min treatments of -110 ± 3 °C or 15 ± 3 °C. Knee joint position sense (JPS), maximal voluntary isometric contraction (MVIC) of the knee extensors, force proprioception and T(TY) were recorded before, immediately after the exposure and again 15 min later. A convenience sample of 18 subjects also underwent an eccentric exercise protocol on their contralateral left leg 24 h before exposure. MVIC (left knee), peak power output (PPO) during a repeated sprint on a cycle ergometer and muscles soreness were measured pre-, 24, 48 and 72h post-treatment. WBC reduced T(TY) , by 0.3 °C, when compared with the control group (P<0.001). However, JPS, MVIC or force proprioception was not affected. Similarly, WBC did not effect MVIC, PPO or muscle soreness following eccentric exercise. WBC, administered 24 h after eccentric exercise, is ineffective in alleviating muscle soreness or enhancing muscle force recovery. The results of this study also indicate no increased risk of proprioceptive-related injury following WBC.

Cryotherapy and joint position sense in healthy participants: a systematic review

OBJECTIVE

To (1) search the English-language literature for original research addressing the effect of cryotherapy on joint position sense (JPS) and (2) make recommendations regarding how soon healthy athletes can safely return to participation after cryotherapy.

DATA SOURCES

We performed an exhaustive search for original research using the AMED, CINAHL, MEDLINE, and SportDiscus databases from 1973 to 2009 to gather information on cryotherapy and JPS. Key words used were cryotherapy and proprioception, cryotherapy and joint position sense, cryotherapy, and proprioception.

STUDY SELECTION

The inclusion criteria were (1) the literature was written in English, (2) participants were human, (3) an outcome measure included JPS, (4) participants were healthy, and (5) participants were tested immediately after a cryotherapy application to a joint.

DATA EXTRACTION

The means and SDs of the JPS outcome measures were extracted and used to estimate the effect size (Cohen d) and associated 95% confidence intervals for comparisons of JPS before and after a cryotherapy treatment. The numbers, ages, and sexes of participants in all 7 selected studies were also extracted.

DATA SYNTHESIS

The JPS was assessed in 3 joints: ankle (n = 2), knee (n = 3), and shoulder (n = 2). The average effect size for the 7 included studies was modest, with effect sizes ranging from -0.08 to 1.17, with a positive number representing an increase in JPS error. The average methodologic score of the included studies was 5.4/10 (range, 5-6) on the Physiotherapy Evidence Database scale.

CONCLUSIONS

Limited and equivocal evidence is available to address the effect of cryotherapy on proprioception in the form of JPS. Until further evidence is provided, clinicians should be cautious when returning individuals to tasks requiring components of proprioceptive input immediately after a cryotherapy treatment.

Prehabilitation versus usual care before total knee arthroplasty: A case report comparing outcomes within the same individual

This case report compared pre- and postoperative functional ability, knee strength, and pain of a female who underwent two separate total knee arthroplasty (TKA) procedures. The female patient was part of a larger research study. The first surgery on the right knee was preceded with usual care and the second surgery on the left knee was preceded by prehabilitation. Functional ability was assessed by a 6-minute walk, chair raises, and the time required to ascend and descend stairs. Knee extension and flexion isokinetic strength was assessed using the KinCom Isokinetic Dynamometer. Pain was assessed using the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC). Functional abilities, knee strength, and pain were assessed at baseline measurements 4 weeks before surgery, 1 week before surgery, and at 1 and 3 months post surgery during each TKA procedure. Results indicate that the prehabilitation intervention had a favorable impact on improving functional ability up to 30%, increasing knee strength by 50% and decreasing pain prior to the left knee TKA. For this patient, prehabilitation increased functional ability and strength prior to surgery. Gains in strength were maintained in the nonsurgical knee after surgery. These findings indicate that prehabilitation may be effective at facilitating the rehabilitation following a TKA.