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Emergence of proprioceptive training in industrial training facilities seems to reflect current efforts of emphasizing neuromuscular function and postural control in general training programs. While it is encouraged to continue such efforts, correction of mythical beliefs is necessary for more suitable application. Clinicians for the recovery of the sensorimotor function originally suggested the idea of proprioceptive training. Adopting this clinically originated concept to general training created two main misconceptions. One is the premature assumption that proprioception can be improved with physical training. The other is the belief that proprioception is a key factor for the improvement of balance in every occasions. However, there is not sufficient neurophysiological evidence supporting the feasibility of the improvement of the proprioception through physical training. Moreover, proprioception can be effectively used only during the slow or moderately fast closed-loop control of movement. Therefore, overemphasis on proprioception may ignore the role of the central nervous system (CNS) in carrying out motor abilities and skills. A training program should be able to facilitate the CNS adaptation that is a key factor for the development of motor abilities and improvement of skill performance. In order to create an ideal learning environment for the CNS, an exercise program should distinctively train different motor skills with adequately changing task goals and sensory environment. Also, training should help the CNS to overcome its limited attentional capacity by adequately imposing multiple task demands.
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Clinical Kinesiology 65(1); Spring, 2011!
18!
Overcoming the Myth of Proprioceptive Training
Daehan Kim1, Guido Van Ryssegem2, and Junggi Hong3
1University of Saskatchewan, College of Kinesiology, Saskatoon, SK, S7N 5B2, Canada.
2Oregon State University, Department of Recreational Sports, Corvallis, OR 97331-3301.
3Willamette University, Department of Exercise Science, Salem, OR, 97301.
Abstract
Emergence of proprioceptive training in industrial training facilities seems to reflect current efforts of emphasizing
neuromuscular function and postural control in general training programs. While it is encouraged to continue such
efforts, correction of mythical beliefs is necessary for more suitable application. Clinicians for the recovery of the
sensorimotor function originally suggested the idea of proprioceptive training. Adopting this clinically originated
concept to general training created two main misconceptions. One is the premature assumption that proprioception
can be improved with physical training. The other is the belief that proprioception is a key factor for the
improvement of balance in every occasions. However, there is not sufficient neurophysiological evidence supporting
the feasibility of the improvement of the proprioception through physical training. Moreover, proprioception can be
effectively used only during the slow or moderately fast closed-loop control of movement. Therefore, overemphasis
on proprioception may ignore the role of the central nervous system (CNS) in carrying out motor abilities and skills.
A training program should be able to facilitate the CNS adaptation that is a key factor for the development of motor
abilities and improvement of skill performance. In order to create an ideal learning environment for the CNS, an
exercise program should distinctively train different motor skills with adequately changing task goals and sensory
environment. Also, training should help the CNS to overcome its limited attentional capacity by adequately
imposing multiple task demands.
Key words: Balance, motor control, proprioception, central nervous system, exercise program, application of
therapeutic exercise
INTRODUCTION
As strength and conditioning coaches started to
respect the importance of neuromuscular function
and postural control in physical training during the
past decade, ‘proprioceptive training’ became
popular. Many industrial training facilities advertise
‘proprioceptive training’ as if it is newer and more
effective balance training for preventing injuries.
Clinicians for the recovery of the sensorimotor
function originally suggested the idea of
proprioceptive training. Two main misconceptions
were caused while adopting this clinically-originated
concept to general training. One is the belief that
proprioception is a key factor for the improvement of
balance in every occasion. Balance control is an
intricate motor control process (18) affected not only
by the neuromuscular function but also by the
cognitive and environmental factors. Even though
balance and proprioception cannot be used
interchangeably, researchers have measured balance
to evaluate proprioceptive function (9,12,14,30). This
may confuse understanding of the role of the
proprioception in balance control (11). Another
misconception is the premature assumption that
proprioception can be improved with physical
training (2). Nevertheless, investigators have reported
that proprioceptive responses were improved as a
result of exercise (19,20,22,26,30). The
proprioceptive exercises in many of these studies
were either perturbed balance training or plyometrics,
agility, or strength training with emphasis on balance
component (19,20,26,30). These studies may also
lead to confusion, because little explanation about the
difference between regular balance training and the
proprioceptive exercises were provided in these
studies. Moreover, some of these studies reported
balance improvement as an outcome measure
(9,12,14,30), which makes it unclear if the effect was
the improvement of the proprioception per se. In this
context, the purpose of this review is to clarify the
concept of ‘proprioceptive training’, and to discuss
the feasibility as well as practicality of current
application of this concept to general training
programs. Without thoroughly comprehending the
concept of proprioception and balance, it is difficult
to understand the controversy regarding the
proprioceptive training. However, previous authors
have used slightly different definitions when
CLINICIANS CORNER:
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explaining these two concepts (19,37). Therefore, this
review will begin with meticulous overview of the
concepts of balance and proprioception. Then, based
on neurophysiological and motor control perspectives,
the low feasibility of improving proprioception
through physical training is discussed. Following this
discussion, more practical approach of training
balance will be introduced.
Definition of balance and proprioception
Balance is a mechanical term describing the state
of an object when the resultant loads acting upon it
are zero (37). In a static situation, an object is in
balance if the vertical line from the center of gravity
(COG) falls within the base of support (BOS).
Human balance, which is better defined as ‘postural
control’, is different from the mechanical
terminology because of our inherent ability of
controlling relative position of COG and the center of
pressure (COP) (37,49). Because the gravitational
force constantly challenges postural stability,
movement of COG and COP is ineluctable; even
during the quiet standing (49). A mechanical
definition of stability is the inherent ability of an
object to remain in or return to a state of balance (37).
Stability can be achieved either by moving the
line of gravity (LOG) back into the BOS or by
forming a new BOS. In the case of an in-animated
object, when the LOG deviates outside of the BOS,
the object falls, and the new BOS is formed (37).
However, dynamic nature of human body allows
marginal instability without falling. Humans can
recover the state of balance from the instable position
through reflexive and cognitive movement; such as
swaying and stepping (19). In other words, temporary
deviation of LOG outside of the BOS does not
always result in falling. Moreover, the deviation of
LOG outside of the BOS is often necessary for
dynamic human movement. In this sense, postural
stability can be defined as an inherent ability to
recover the position of LOG within BOS in order to
keep the upright position during both static and
dynamic situations.
Human balance can be further defined
considering three challenges to the postural stability:
maintenance of a specified posture, movement
between postures, and reaction to an external
disturbance (19). Maintenance of the postural
stability in all of these situations necessitates not only
a voluntary but also a reflexive control of movement.
In fact, Kavounoudias et al. (25) classified human
balance as both cognitive and reflexive motor control
activity. In summary, a reasonable universal
definition of human balance can be the inherent
ability of cognitively and reflexively controlling
relative position of COG and BOS in order to
maintain postural stability against both intrinsic and
extrinsic disturbances.
Proprioception is often roughly defined as
sensory information about limb, trunk, and head
position and movement (28). Goldscheider (2) was
one of the first to systematically quantify the
awareness of body segment positions and orientations,
later defined as ‘proprioceptions’ Over 100 years ago,
Goldscheider systematically measured and compared
the smallest joint rotations that could be detected at
different joints in the body. Sherrington (26) later
defined this awareness of the body position and
movement as ‘proprioception’, and further explained
the proprioception as a perception not necessarily
perceived consciously but contributes to conscious
sensations such as muscle sense, total posture, and
joint stability. According to Sherrington’s definition,
proprioception is the afferent information from the
proprio-ceptors. Proprio-ceptors are peripheral
sensory receptors located in the proprio-ceptive field
(the term ‘proprio’ from the Latin propius, meaning
‘one’s own). Proprioceptive fields are areas within
the joint and deep tissues which are capable of
delivering the perception of self-position and
movement.
Muscle spindle, Golgi-tendon organ (GTO), and
joint capsular and ligament receptors are the
proprioceptors (28). The perception of joint location
in space was specifically termed as ‘joint position
sense’, and sensation of joint movement direction and
velocity was termed as ‘kinesthesis’ (26). The
proprioceptive information is delivered to central
nervous system (CNS) through the afferent neural
pathways to produce awareness of limb, trunk, and
head position and movement, which contributes to
reflexive and cognitive motor response (2,6,44). Even
though proprioception does not directly affect
movement production, it is important in accurately
achieving a movement goal (28). Researchers have
evidenced that both surgical and non-surgical
removal of proprioception resulted in decrease of the
accuracy and the coordinative control of the
movement and alteration of the movement onset
timing (28,47,48). In understanding functional role of
proprioception, it is important to distinguish
proprioception from tactile senses. Tactile sense is
afferent information from skin mechanoreceptors
related to pain, temperature, and movement.
Functional characteristics of tactile sense and
proprioception are very similar because both
contribute to movement accuracy, consistency, and
force adjustment. Moreover, tactile feedback can be
used to augment proprioceptive feedback to estimate
movement distance (28). However, proprioceptors
and mechanoreceptors are two distinctive organs (26),
and it is important not to confuse these two terms. In
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sum, proprioception is the self-perception of body’s
segmental position and movement, which contributes
accuracy, consistency, and coordinative control of
reflexive and cognitive human movement.
Origin of proprioceptive training
Clinicians originally proposed ‘proprioceptive
training’ as one of the rehabilitative exercise concepts.
They modified typical weight bearing exercises by
making surfaces unstable on which the exercise was
performed (26). Unstable surface was assumed to
create a proprioceptively enriched environment that
progressively challenges the proprioceptors and
nervous system (42). For example, unipedal balance
tasks was performed; first on a firm floor, then on a
compliant surface such as a foam pad, and then on a
reduced base of support such as an ankle disc training
device (26). This reflects therapeutic approach of
rehabilitating motor performance through the
recovery of proprioception deficits (42). The need for
recovery of proprioception seems to be justified by
the clinical observations of pathologic functional
joint instability. For example, functionally instable
ankles (FIA) experience sensation of “giving way”
and are susceptible to recurrent ankle sprains (18).
This ankle instability exists following recovery from
ligament injury such as ankle sprain (39).
Researchers investigated what contributes to this
functional instability of the ankle even after the tissue
was already healed completely. They observed that
balance deficit was commonly shown among
population with FIA (18,39). Under the condition that
there was no strength deficit on FIA, it was
reasonable to speculate that balance impairment of
this population might have been caused by the
alteration of the sensorimotor function (26). The only
sensory function might have been affected by the
ankle sprain was somatosensory function because this
injury normally does not damage the CNS, vision, or
vestibular system. Most prevalent sensory receptors
in the ligaments are joint receptors that are
proprioceptors (26). In this reason, researchers
hypothesized that ligament injury results in alteration
of proprioception. In fact, the alteration of
proprioception was observed in FIA in the research
studies (18,34,39). In a logical sense, improvement of
balance should indicate recovery of proprioceptive
deficit under the assumption that diminished
proprioceptive function was the only cause of the
balance impairment. Studies actually showed that
proprioceptive balance training not only improved
balance but also reduced repetitive ankle injury rates
(13,29,40). This evidence gave clinicians and
researchers hope that there is a possibility to recover
deterioration of proprioception through physical
training (2). However, neurophysiological
mechanism underlying the improvement of the
balance through proprioceptive training is still not
well defined, and even clinicians are very careful
about acknowledging the trainability of the
proprioception (2). It seems like the misconception
about the proprioceptive training occurred as it was
adopted in commercialized training facilities. Many
of the personal trainers and strength conditioning
coaches name single leg balance training on the foam
pad as proprioceptive training (Fig. 1). They
advertise that such training can enhance balance and
even prevent athletic injuries. It is important to re-
emphasize that proprioceptive training is loosely
termed, and refers to concept of any training
methodology that respects various proprioceptive
feedback within the motor control process (26). That
being said, the single leg balance training is not the
representative form of the proprioceptive training.
Moreover, premature assumption that one can train
proprioception simply by stimulating proprioceptors,
and that proprioceptive improvement will enhance
balance ability as a whole can seriously mislead
training regimen. It is important to keep in mind that
the feasibility of proprioceptive training is greatly
challenged due to the lack of neurophysiological
evidence.
Figure 1. Faulty use of the term ‘proprioceptive training’: balance
training and proprioceptive training should not be used
interchangeably.
Proprioception; can it be improved?
Neurophysiological conduction of the
proprioceptive information is composed of three
different stages: acquisition of the mechanical
stimulus, conversion of the mechanical stimulus into
the neural signal, and the transmission of the neural
signal to the CNS (26). Therefore, in order to
evidence the trainability of the proprioception, we
need to prove that balance training can enhance either
the sensitivity of the proprioceptors responding to
mechanical stimulus or the neurophysiological
efficiency of signal conversion and transmission. In
this case, the sensitivity is better termed as ‘acuity’
(2). The velocity of the signal conversion and
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Figure 2. Possible volitional modulation of spindle acuity: Muscle spindle is the only proprioceptor that can be modulated efferently due to the
fusimotor drive.
transmission is known to be fixed (41). Therefore,
possible trainability of the proprioception can only be
explained by the modulation of the acuity of the
proprioceptors (2). It was speculated that muscle
spindles may be the only possible proprioceptors of
which acuity might be systematically modulated
through the gamma motoneuron (2).
The schematic process of the theoretical
modulation of spindle acuity is described in figure 2.
Theoretically, spindle acuity can be volitionally
modulated through task-dependent muscle
contraction (2). A slight increase in spindle fusimotor
drive, along with increased skeletomotor drive, has
been observed during visually-guided manual
tracking tasks which required increased precision
(46). Participants significantly increased spindle
output as they tensed the muscles within which the
muscle spindles were located (15). The increase of
the spindle output can be explained as a volitional
alpha-gamma coactivation during the voluntary
stiffening of the muscles (16). However, this is not
the evidence of an increase in proprioception per se,
because the related experiments were not designed to
test a hypothesis that increased fusimotor firing rate
results in increase of proprioception. With the
muscles being stiffened, the CNS increases the
fusimotor drive to the spindles, which possibly
increase the size of the ensemble response of the
primary spindle afferents (16).
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It is known that increased ensemble responses of
afferents assist in improved discrimination of muscle
length changes than the response of a single afferent
(5). Therefore, in order to ideally test if training of a
specific motor task results in improvement of
proprioceptive acuity, the study should measure size
of ensemble responses. In addition, plausible
investigation of proprioception should measure the
degree of correlation between intensity of fusimotor
activity and ensembles of afferents. However, no
such studies have been conducted, likely because the
feasibility of such studies on human participants is
low because of its invasive nature (2). Research
comparing the ability of detecting joint position
without involving voluntary motor task before and
after specific motor training can be an alternative
approach (2). However, randomized controlled
prospective trials used passive position sense did not
consistently show that exercise training improved
proprioception at the injured ankle (20,31). Therefore,
at this point, there is little evidence that supports the
hypothesis that proprioception can be improved
through training.
Figure 3. Closed-loop control system.
Figure 4. Open-loop control system.
The role of CNS in balance training
Commercialized training facilities often
emphasize the benefit of balance training in
preventing athletic joint injuries and falling. However,
it is important to note that injury prevention requires
more than proprioceptive improvement. Isolated
improvement of proprioception is not the practical
balance training strategy because the mechanism of
the balance improvement involves not only
neuromuscular and musculoskeletal factors, but also
task dependent motor learning. In this section, the
attention will be paid to the CNS adaptation-induced
motor learning, and to theoretical principles on how
the exercise should facilitate the CNS adaptation.
In order to discuss the importance of the CNS
adaptation in injury prevention oriented balance
training, it is necessary to understand situational
limitation of proprioceptive feedback. The degree of
proprioceptive contribution within motor control
process changes in accordance with the different
control systems employed differently task by task
(2,28). Afferent information is best utilized during
the closed-loop control system in which feedback is
compared against a standard or intended goal during
the course of action (28) (fig. 3). As demonstrated in
figure 4, an open-loop control system is a one-way
system in which the CNS plans and delivers all the
information needed to carry out an action to the
musculoskeletal system (28). In this context,
proprioception is thought to be most important in the
closed-loop control of slow to moderately fast
conscious and reactive movements (2). For example,
static single leg balance or a slow dynamic balance
tasks such as walking on a balance beam require
active contribution of proprioceptive feedback.
However, closed-loop postural reflex against
unexpected disturbance is not effective enough to
avoid injuries during time-critical tasks (2). For
example, during impact movement like running, the
ground reaction force reaches to the injurious level
within less than 50 milliseconds which is enough
time to force the ankle to invert more than 17° (33).
Closed-loop postural movement strategies triggers at
100 milisecond in response to an external
perturbation (28), unbalanced emphasis on slow and
controlled closed-loop movement training is not an
effective strategy in preventing athletic injuries.
Alternative and more effective protective movement
strategies should focus on prevention of the injurious
joint position rather than aftermath reaction.
Anticipatory preset of muscle stiffness is known to be
an effective protective mechanism by enhancing joint
stability and fusimotor drive (2).
Since there is not enough time available to
effectively utilize afferent feedback during the time-
critical situation, the movement is more likely to be
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Figure 5. Motor program-based motor control.
initiated via open-loop control system (2). The role of
the CNS is very important in open-loop system (28),
and successful avoidance of the injury depends on
appropriateness of the movement instruction prepared
by the CNS for the musculoskeletal system. In fact, it
has been suggested that protective motor behavior
can be developed through the CNS adaptation (24).
Experience of motor tasks helps the CNS updating
internal models used for open-loop controlled
movements, and thereby may help protect joints in
time-critical situations by increasing their resistance
to sudden disturbances (2). This hypothesis can be
related to central neuronal plasticity that is supported
by the evidence of the CNS adaptations that facilitate
recovery from an injury (1,7,22). These adaptations
include dynamic reorganization of brain areas, “re-
discovery” of previously recognized pathways, and
increased synaptic connections between neurons (3).
Exercise program facilitating CNS adaptation
Establishment of an adequate motor behavior
through the CNS adaptation is necessary in
successful avoidance of athletic joint injuries and
falling. There are two evidence-based theoretical
frames about how behavioral pattern of the
movement is generated. Motor program-based theory
explains that nervous system coordinates movement
components differently in accordance to the relative
importance given to movement instructions specified
by the CNS (28). According to this theory, the CNS
stores motor programs for each set of movement
pattern, and retrieve the programs when needed (41)
(fig. 5). The most acceptable motor program-based
theory is Schmidt’s generalized motor program
(GMP) theory (28). GMP is a set of memory-based
motor program of a class of actions that have
common unique set of features called invariant
features (41). Invariant features, such as relative
timing and speed of segmental movements, are the
“signature” of a specific class of the movements and
form the basis of what is stored in memory (41).
These features inherently remain consistent from one
occasion of movement to another.
The dynamic pattern theory is another motor
control theory of which concept opposes motor
program-based theory. According to this theory,
movement coordination is instantly controlled based
on information in the environment and the dynamic
properties of the body and limbs (28). This approach
emphasizes the ability of nervous system to self-
organize the motor pattern. Proponents of the
dynamic pattern view emphasize the interaction
between the performer and the task-oriented
environment in which the skill is performed (28). The
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nervous system reacts to the environment and task
demands by the movement of individual of muscles
and joints, which later forms a functional synergy
called coordinative structures (28). It was suggested
that the coordinative structures not only exist
naturally but also develop through practice or
experience (43). Reactive nature of the movements
generated through the dynamic pattern can be
mistakenly thought of an example of closed loop
control. However, dynamic pattern theory, in fact,
indicates that afferent information is used not only
for closed-loop control but also has an important role
in open-loop system during the action preparation (2).
The CNS can use sensory information to prepare
for upcoming movement demands, termed:
perception-action coupling (28). The term
‘perception-action coupling’ is mainly used to
describe the spatial and temporal coordination of
vision and the limbs that enables people to perform
hand-eye or foot-eye skills (8). However, CNS can
use more than just visual information (such as smell
or tactile sensation of the texture of the floor) for
action preparation. Considering that stiffening of the
muscles was observed during the movement
preparation, there is a high possibility that
perception-action coupling also contributes to the
preset of joint stability (2).
In summary, in discussing key factors for
generating motor behavior, GMP theory emphasizes
the role of memory, whereas dynamic pattern theory
emphasizes the interaction between performers and
physical environment. Research evidence supports
both of the theories; therefore, an ideal training
program should respect memory function, task
characteristics, and environmental effects. The
distinction of motor skills based on the invariant
features and separated repetition of those skills are
the key factors of improving memory-based motor
function. Change of the sensory environment and
task goals is necessary to stimulate dynamic pattern
of the movement behavior. For example, types of
balance tasks can be divided into static and dynamic
balance performance (single leg standing vs. balance
beam walking), and these can be subdivided based on
the goal of the tasks. The goal of static single leg
balance exercise can be either maintaining a good
joint alignment for one minute or hitting multiple
targets with the non-balancing leg without falling.
The goal of dynamic balance task can be either
crossing a 2-meter balance beam as quickly as
possible or a 2-meter tandem walk with correctly
stepping on target steps. Visual environment can be
altered by changing arrangement of obstacle settings
or changing movement patterns of other people
around a person. Sensory environment can be
changed by challenging proprioceptive feedback via
different sources (ground, upper body, or self-
induced perturbation by voluntary movement), or
changing visual or auditory information (causing
distraction through a moving-wall or noise). Strength
and conditioning coaches need to be not only creative
in implementing adequate changes of the exercise
programs, but also perceptive in finding out
appropriate amount of repetition necessary for
inducing motor learning.
Dual task training: overcoming the limited
capacity of the CNS
In order to provide an ideal training environment
for the CNS adaptation, one should also consider
inherent limitation of the CNS. There is a general
agreement that capability of the CNS to engage in
multiple cognitive and motor activities
simultaneously is limited (28). Ashton-Miller and
colleagues (2) suggested that the CNS must learn to
attend to what matters and to disregard irrelevant
stimuli in order to selectively focus on specific
environmental context features when we perform
motor skills (fig. 6).
As discussed earlier, injury prevention not only
requires basic static and dynamic balance abilities but
also goal-oriented motor skills. Disregarding athletic
events, daily movements continuously impose
simultaneous cognitive and motor demands on top of
the balance ability. For example, we talk on the
phone, carry something, or read a newspaper when
we walk on the street. Even when one does not
perform secondary motor tasks, the brain engages in
multiple cognitive tasks during walking. In this
reason, researchers currently focus on developing
balance training methods which help one to
overcome dual task interference (35,36,50).
According to Schmidt and Lee (2005), the term dual-
task interference refers to the decrement in
performance of one or both tasks when two activities
are carried out concurrently.
In a broad aspect, two schools of thoughts exist
from which distinctive training methodologies
originate. One theory explains that the CNS
overcomes dual task interference by mastering
single-component task (50). With practice, a skill
may become more automatic. With greater
automaticity, the attentional demand of the same task
is reduced. As a result, there are more CNS resources
available for the secondary task. Therefore, this
theory emphasizes separate practice of component
tasks. Another theory discusses that practice leads the
CNS to integrate different tasks together so that the
CNS can perceive the two different tasks as a single
higher order skill (34). This helps the CNS to
overcome dual task interference because tasks that
were previously recognized as dual-tasks become
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Figure 6. Theoretical motor cortex adaptation through training: As the CNS repeats selective modulation of input signals, the CNS learns to
attend to disregard irrelevant stimuli in order to attend to more meaningful afferent information. As a result, motor skill becomes autonomous.
recognized as single-tasks. Therefore, this theory
emphasizes simultaneous dual task training.
Silsupadol et al. (45) combined the two theories
mentioned above and created a dual task balance
training methodology of which effect can be
transferred to real life situation. They compared three
different balance training methods: a single task
balance training, a combined balance and cognitive
task training under a fixed-priority instructional set,
and a combined balance and cognitive task training
under a variable-priority instructional set. Single task
balance training included body stability, body
stability plus manipulation, body transport, and body
transport with manipulation. For the combined task
training they added cognitive tasks to the single task
training. Examples of cognitive tasks were auditory
discrimination tasks, simple calculation, spelling the
words backward, remembering things, etc. During the
fixed-priority instructional set, participants were
directed to maintain attention on both balance and
cognitive tasks at all times. Participants in the
variable instructional set group focused more on
balance task during the half of the session, and paid
more attention on cognitive tasks during the rest half.
Participants were randomly assigned to one of the
three training groups, and participated in 45-minute
training sessions 3 times a week for 4 weeks. Balance
performance with novel cognitive tasks was used to
measure the outcome. Novel cognitive tasks were the
ones that were not directly trained during the
intervention period. Only the participant who trained
under variable instructional set showed improvement
of balance during the balance performance with novel
cognitive tasks, and this benefit was maintained for 3
months (45). This result indicates that simultaneous
training of dual task with intentional shift of attention
between balance and cognitive tasks is most effective
in transferring the training effect to real life multiple
task situations.
Application of dual task training.
Dual task training is not always the best
methodology of training motor skill. Appreciation
about the best timing of the implementation of dual
task training is just as important as comprehension
about the method of training. Researchers suggest
that skill focused attention is important during the
initial stage of motor learning, but becomes
counterproductive for the experienced individuals
(4,17,32,38). Researchers showed that multiple task
training (motor + cognitive demands) were more
effective for performance developments of
experienced athletes (4,32). Intuitively, this indicates
that cognitive attention is productive for training
novice but certain amount of distraction from it is
necessary to help experienced individuals proceed to
more advanced level. Circumstantial evidence can be
found in performance of professional athletes. Their
practice and competition are full of continuous
secondary cognitive and motor task on top of the
balance performance. For example, professional
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figure skaters or gymnasts have to constantly focus
on the rhythmic beats of the background music and
the timing of the next movement at the same time
they maintain balance in an unstable position. These
multiple tasks continuously give dual task
interference challenge to the CNS. As athletes repeat
the practice, the CNS finally learns how to maintain
balance despite multiple environmental distractions.
CONCLUSION
Emergence of proprioceptive training in
industrial training facilities seems to reflect current
effort of applying therapeutic concept of
proprioceptive recovery to general training program.
While it is encouraged to continue such efforts,
correction of mythical beliefs is necessary for more
suitable application. Proprioception is sometimes
mistakenly considered as a key factor for the balance
improvement and injury prevention. However, there
is no neurophysiological evidence that proprioception
can be trained through physical training, and
proprioception is effectively used only during the
slow closed-loop control of movement. In addition,
overemphasis on proprioception may cause training
program to ignore the role of the CNS in carrying out
motor abilities and skills. Training program should be
able to facilitate the CNS adaptation that is a key
factor for development of motor abilities and
improvement of skill performance. In order to create
an ideal learning environment for the CNS, an
exercise program should distinctively train different
motor skills with adequately changing task goals and
visual environment. Also, training should help CNS
to overcome its limited attentional capacity by
adequately imposing multiple task demands.
Acknowledgement
We would like to sincerely thank Dr. Alison Oates
for her constructive advice and support.
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AUTHOR CORRESPONDENCE:
Daehan Kim
University of Saskatchewan
College of Kinesiology PAC 375
87 Campus Drive
Saskatoon, Saskatchewan S7N 5B2.
Tel: 1-306-716-6498
Danny82birdie@gmail.com
... Because of its involvement in joint stability and injury prevention, proprioception plays a very important role in sport. Proprioceptive or balance training (PT) [4], also called sensorimotor training [5,6], was originally proposed by clinicians as one of the rehabilitative exercise concepts [7]. To date, a large number of simple or more complex, static or dynamic exercises were proposed as proprioceptive, making it difficult to choose between them when intending to design an intervention program. ...
... When speaking about the benefits of PT for neuromuscular control, we refer to improvements in muscle reflex activity [6][7][8][9][10][11], reaction time [12]), rate of force development and electromiography activity [13]. On the other hand, the outcomes of interest for functional performance are expressed in terms of postural control [14,15], agility [15,16], muscle strength [15], jump performance [13,16,17], and sprint time [16][17][18]. ...
... Although some distinctions in the activated muscle groups and their actual level of involvement were documented [17,50], it is expected that the mechanisms through which PT influences the various jumps have many aspects in common. The better jumps of our EG group could most likely be explained by an improved intra-and intermuscular coordination of the lower leg extensor muscles [7]. ...
Article
Full-text available
The aim of the study was to determine the effects of proprioceptive training (PT) on balance, strength, agility and dribbling in adolescent soccer players. In this research, we included an experimental (n = 48) and a control (n = 48) group (CG) with 14 years old players. The experimental group (EG) participated in an 8 week PT program, with four 30 minute sessions per week. The experimental program included 12 bosu ball exercises to improve balance, stability and strength which were grouped into two subprograms: the first not using the soccer ball, the second subprogram using the soccer ball. The subprograms were implemented alternately during 16 proprioceptive training sessions, on two types of firm and foam surfaces. Pre- and post-tests included the static balance [Balance Error Scoring System (BESS)], vertical, horizontal, and lateral jumping, and the completion of agility (“arrowhead”) and dribbling (“short dribbling”) tests. Regarding the total BESS score, the CG has demonstrated progress between the pre- and the post-test, with 0.780 ± 0.895, fewer errors, while the EG had 5.828 ± 1.017 fewer errors. The difference between the two groups was of 5.148 fewer errors for the EG who had practiced the proposed program of proprioceptive training. The highest difference registered between the pre- and the post-test was at the test “single-leg forward jump with the right leg”, with a result of 1.083 ± 0.459 cm for the CG and of 3.916 ± 0. 761 cm for the EG. Through the analysis of average differences between the pre- and the post-tests, we observe that, regarding the “Agility right side test”, the EG has progressed with 0.382 s in comparison with the CG; regarding the “Agility left side test”, the EG has progressed with 0.233 s compared to the CG; regarding the “Agility right and left side test”, the EG has progressed with 0.196 s compared to the CG; in the “Short dribbling test”, the EG has progressed with 0.174 s compared to the CG. The highest progress was made at the “Agility right side test”, of 0.402 s for the EG, while the CG registered 0.120 s. Most of the results in all tests for both experimental groups show an effect size ranging from small to medium. The progress made by the experimental group in all tests was statistically significant, while in the control group the progress was mostly statistically insignificant for p < 0.05. The results suggest that a PT program performed at about 14 years of age could be successfully implemented in the training regime of soccer players to improve components of fitness along with dribbling skills. The results of the study revealed that sports training on the foam surfaces determined a superior progress of the development of proprioception compared to the increased training on the firm surfaces.
... Despite the important debate in the literature about the functional and anatomic changes and about the exercises and the volume of training most indicated for balance training in healthy individuals or with different conditions of functional impairment (Gebel et al., 2018;Kiss et al., 2018;Low et al., 2017;Behm et al., 2015;Lesinsky et al., 2015), there seems to be a lack of dialogical and interdisciplinary debate about the conceptual issues. Different terms, such as balance training, sensorimotor training, neuromuscular training and proprioceptive training (Taube et al., 2008;Kim et al., 2011;Rogers et al., 2013), and functional training (Abbasi et al., 2012) are commonly used to refer to those exercises usually recommended for improving postural balance. However, despite the widespread use of such terms in the literature, the debate about the scope and appropriateness of them is not so frequent (Taube et al., 2008). ...
... However, despite the widespread use of such terms in the literature, the debate about the scope and appropriateness of them is not so frequent (Taube et al., 2008). Kim et al. (2011), for instance, highlighted the lack of consensus regarding the use of these terms, because many authors use these different terms as synonyms or to address the same type of exercise, and there are also disagreements about the relevance of a certain term for a particular balance exercise. Kim et al. (2011) observed that the expression proprioceptive training is associated with balance, plyometric, agility and strength exercises that have some balance component. ...
... Kim et al. (2011), for instance, highlighted the lack of consensus regarding the use of these terms, because many authors use these different terms as synonyms or to address the same type of exercise, and there are also disagreements about the relevance of a certain term for a particular balance exercise. Kim et al. (2011) observed that the expression proprioceptive training is associated with balance, plyometric, agility and strength exercises that have some balance component. They argue that proprioceptive training is a clinical concept to be used for rehabilitation exercises. ...
... Auch Experimente mit genmanipulierten (Knockout-)Mäusen liefern hierfür Evidenz (Akay, Tourtellotte, Arber & Jessell, 2014;Santuz et al., 2019). Hierbei ist zu berücksichtigen, dass bewusste Propriozeption vor allem zur sogenannten "closed-loop"-Mechanismen beiträgt, da die supraspinale Verarbeitung zu langsam ist, als das sie direkten Einfluss auf (reflektorische) Reaktionen auf unvorhergesehene Pertubationen haben könnte (Daehan et al., 2011;Wollny, 2010 Bewegungen werden sowohl vom somatosensorischen als auch vom sensomotorischen System kontrolliert. Ein funktionelles Zusammenspiel dieser beiden Systeme ist somit essentiell für effiziente propriozeptive Sinnesleistungen (Kaya et al., 2018). ...
... So konnten Bartlett und Warren (2002) Zusammenfassen lässt sich, dass die zugrunde liegenden peripheren und zentralen Anpassungsmechanismen der propriozeptiven Wahrnehmungsleistungen noch nicht endgültig geklärt sind . So führen Bruhn und Wöhl (2009) aus, dass "bereits früh kontrovers diskutiert [wurde], ob die Anpassungsmechanismen an das SMT -PT der sensorischen Wahrnehmung selbst, oder eher der integrativen Verschaltung der Signale auf der Ebene der spinalen Interneuronen und der supraspinalen Zentren zuzuordnen sei." (S. 5) Daehan et al. (2011) betonen die Bedeutung von Adaptionen im Bereich des zentralen Nervensystems. Grundsätzlich kann jedoch, wie aufgezeigt, festgestellt werden, dass propriozeptive Fähigkeiten durch Training verbessert werden können. ...
... 24) (Haughey, 2013). Daehan et al. (2011) betonen die Bedeutung der Integration der propriozeptiven Informationen im Bereich des zentralen Nervensystems. Hospod, Aimonetti, Roll und Ribot-Ciscar (2007) konnten zeigen, das gezieltes Richten der Aufmerksamkeit dazu führen kann, dass Ia Afferenzen modifizierte Antworten auf Bewegung liefern, die zu einer verbesserten Bewegungswahrnehmung führen. ...
Thesis
Full-text available
Diese Arbeit befasst sich mit dem Zusammenhang des Fasziensystems – dem dreidimensionalen Netzwerk im menschlichen Körper – und der Propriozeption – der Wahrnehmung der Lage des Körpers im dreidimensionalen Raum – aus trainingswissenschaftlicher Sicht. Es wird ergründet, was Propriozeption ist, welchen Einfluss sie auf die sportliche Leistungsfähigkeit hat und inwiefern sie durch Training verbessert werden kann. Im Anschluss daran wird darauf eingegangen, worum es sich beim Fasziensystem handelt, welche Bedeutung es für die Propriozeption hat und welche Möglichkeiten es gibt, fasziale Strukturen zu trainieren. Abschließend soll geklärt werden, welche Schlussfolgerungen sich hieraus für das Training der propriozeptiven Fähigkeiten ergeben. Bei der Propriozeption handelt es sich um bewusste wie unbewusste Wahrnehmungsresultate, die die Körperposition- und -bewegung im Raum betreffen. Im engen Sinn bezieht sie sich auf die Informationen aus Rezeptoren in der Körperperipherie. Im weiten Sinn beruht sie auf der Integration des multimodalen Inputs aus verschiedenen Sinnessystemen und supraspinalen Instanzen. Begriffe, die sich auf die sinnesphysiologischen Grundlagen beziehen, sind vom Begriff „Propriozeption“ abzugrenzen. So umfasst der Begriff „propriozeptives System“ die Kette physikochemischer Ereignisse, die an der Aufnahme und Weiterleitung von sensorischen Informationen aus der Körperperipherie über Bewegung und Position beteiligt sind. Die Propriozeption ist gelenkspezifisch und dient der Bewegungskontrolle. Insbesondere die propriozeptive Wahrnehmung des Sprunggelenks ist von Bedeutung für die sportliche Leistungsfähigkeit. Die propriozeptiven Wahrnehmungsfähigkeiten können durch Training verbessert werden. Die genauen zentralen wie peripheren Anpassungsmechanismen sind indes nicht endgültig geklärt und auch hinsichtlich des optimalen Trainingsumfangs besteht noch weiterer Forschungsbedarf. Eine Vielzahl von Rezeptoren, die propriozeptive Informationen liefern, befinden sich im Fasziensystem. Dieses lässt sich in Schichten einteilen und vor allem die tiefe Faszie, die die aponeurotische wie die epimysiale Faszie umfasst, ist von Relevanz für die propriozeptive Wahrnehmung. Die mechanische Beschaffenheit des faszialen Gewebes trägt maßgeblich dazu bei, inwiefern Propriozeptoren aktiviert werden. Erste Studien konnten zeigen, dass eine myofasziale Selbstmassage der Oberschenkelrückseite zu akuten, aber auch überdauernden Verbesserungen der Wahrnehmung des Hüft- und Kniewinkels führt. Dabei zeigte die Anwendung mit vibrierenden Hartschaumrollen gegenüber der Anwendung mit nicht vibrierenden signifikant bessere Ergebnisse. Es deutet daraufhin, dass durch Training, das auf eine Verbesserung der mechanischen Eigenschaften des faszialen Bindegewebes abzielt, auch die propriozeptive Wahrnehmung verbessert werden kann. Da hinsichtlich der Anpassungsmechanismen und des optimalen Trainingsumfangs noch keine Klarheit besteht, sollte zukünftige Forschung prüfen, ob grundsätzlich ein Zusammenhang zwischen der faszialen Gewebeelastizität und propriozeptiven Wahrnehmungsleistungen festzustellen ist. Weiterhin besteht Forschungspotenzial hinsichtlich der Auswirkungen spezifischer Interventionen auf propriozeptive Sinnesmodalitäten an unterschiedlichen Gelenken.
... Patients of the control group received additional sub-effective lowintensity cardiovascular training (i.e. at an inadequate dose to produce effects). Physical activity at low intensity for only 15 minutes is not expected to induce a specific treatment effect to the sensorimotor system [58]. Patients were allowed to choose either the treadmill, elliptical cross-trainer, or a stationary bike and were instructed and positioned according to body constitution by an exercise therapist. ...
... Addressing specificity of SMT, in a narrative review on the topic, Kim et al. (2011) point out that there seems to be no formal definition of what SMT is or what it should entail [58]. When compared to other exercises, both approaches are likely to be equally effective in terms of improved function in CNLBP [41] or for injury prevention and it has been suggested that there might be no such thing as specific sensorimotor exercise [88]. ...
... In order to evaluate the specific effects of SMT, there must be some degree of standardization for implementation and recommendation [52]. Currently, recommendations regarding the implementation of SMT can only be derived from narrative reviews and expert opinions [42,50,58,89,90]. According to these, there are three training principles suggested to be of particular relevance if any effect from SMT could be expected: First, the level of instability must be adjustable and incremental over time. ...
... lack of neurophysiological evidence) about the validity of current proprioceptive exercises [17]. Although many therapists and clinicians report successful treatment cases, the exact effect and validity of sensorimotor interventions is still discussed controversially [17][18][19]. Despite extensive research activity on the topic of CNLBP, which has significantly contributed to the understanding of pain [20], the European guidelines on the management of CNLBP conclude that the effects of specific exercises, such as SMT, must be further evaluated [1]. ...
... PPT is indicated for postural specific back pain, functional instability of weightbearing joints (e.g. knee or ankle instability), hypermobility, and other postural deficiencies Physical activity at low intensity for only 15 minutes is not expected to induce a specific treatment effect to the sensorimotor system [19] but can improve the global perception of well-being and can, therefore, be recommended as part of CNLBP treatment [61] 3. What materials? PPT uses the Posturomed therapy device [29], which is a labile platform restricted to damped anterior-posterior and mediolateral sway. ...
Article
Full-text available
Background: Sensorimotor training (SMT) is popularly applied as a preventive or rehabilitative exercise method in various sports and rehabilitation settings. Yet, there is only low-quality evidence on its effect on pain and function. This randomised controlled trial will investigate the effects of a theory-based SMT in rehabilitation of chronic (>3 months) non-specific low back pain (CNLBP) patients. Methods/design: A pilot study with a parallel, single-blinded, randomised controlled design. Twenty adult patients referred to the clinic for CNLBP treatment will be included, randomised, and allocated to one of two groups. Each group will receive 9 x 30 minutes of standard physiotherapy (PT) treatment. The experimental group will receive an added 15 minutes of SMT. For SMT, proprioceptive postural exercises are performed on a labile platform with adjustable oscillation to provoke training effects on different entry levels. The active comparator group will perform 15 minutes of added sub-effective low-intensity endurance training. Outcomes are assessed on 4 time-points by a treatment blinded tester: eligibility assessment at baseline (BL) 2-4 days prior to intervention, pre-intervention assessment (T0), post-intervention assessment (T1), and at 4 weeks follow-up (FU). At BL, an additional healthy control group (n = 20) will be assessed to allow cross-sectional comparison with symptom-free participants. The main outcomes are self-reported pain (Visual Analogue Scale) and functional status (Oswestry Disability Index). For secondary analysis, postural control variables after an externally perturbed stance on a labile platform are analysed using a video-based marker tracking system and a pressure plate (sagittal joint-angle variability and centre of pressure confidence ellipse). Proprioception is measured as relative cervical joint repositioning error during a head-rotation task. Effect sizes and mixed-model MANOVA (2 groups × 4 measurements for 5 dependent variables) will be calculated. Discussion: This is the first attempt to systematically investigate effects of a theory-based sensorimotor training in patients with CNLBP. It will provide analysis of several postural segments during a dynamic task for quantitative analysis of quality and change of the task performance in relation to changes in pain and functional status. Trial registration: Trial registry number on cliniclatrials.gov is NCT02304120 , first registered on 17 November 2014.
... Durch die Verbesserung der Blickmotorik kann die Sakkadendauer und die Zeit an den Umkehrpunkten bei Blickbewegungen verkürzt werden (Ishigaki & Miyao, 1993;Kohmura & Yoshigi, 2004 (Hertel, 2000). Häufig wurde das Gleichgewicht gemessen, um den gesamten Umfang der propriozeptiven Funktion zu messen (Kim, van Ryssegem & Hong, 2011nach Mattacola & Lloyd, 1997Fu & Hui-Chan, 2005;Calmels, Escafit, Domenach & Minaire, 1991 (Browne & O'Hare, 2001). Instrumentelle Verfahren können zwar eine Prozessdiagnostik leisten, sind aber wesentlich kostenintensiver, aufwendiger und komplexer in der Durchführung. ...
Thesis
Full-text available
The research incentives of the dissertation are the further development of dynamic postugraphy by using a swinging plate (Posturomed) and the quantification of dynamic equilibrium. The dynamic. equilibrium and functional techniques for equalizing perturbations are analyzed in athletes (ice hockey, football, taekwondo) and inactive subjects. Furthermore, the publication thematises the classification of balance related to the skill-ability concept. The essay shows the quality of the method of posturography to describe the dynamic equilibrium. There were force plates, a 3-D camera system (Vicon) and accelerometry used to measure kinetic and kinematic quantities. The test conditions included bi- and uni-pedal stance positions with manipulations of visual, vestibular, somatosensory information. The evaluated parameters and test conditions delimit the subjects against each other but the test shows low values for reliability and reproducibility. The techniques for compensating perturbations differ among the groups and provide clues to the assumption of the skill approach.
... lack of neurophysiological evidence) about the validity of current proprioceptive exercises [18]. Although many therapists and clinicians report successful treatment cases, the exact effect and validity of sensorimotor interventions is still discussed controversially [18,19]. Thus, the European Guidelines on the management of CNLBP do not include recommendations for SMT [1]. ...
Data
Full-text available
SeMoPoP Study protocol approved by ethical committee. (PDF)
... However, the view that exercising on an unstable surface targets peripheral ankle proprioception has recently been challenged 1 and it has been suggested that an overemphasis on proprioception may ignore the role of the CNS. 2 In addition, the clinical relevance of proprioceptive deficits found after injury has not been established. 3,4 What is the most effective way of training proprioception and kinaesthesia for optimal sports performance? ...
Conference Paper
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Proprioception is a sense of body position whereas kinaesthetic awareness is a sense of body movement. Proprioception is a combination of balance, a sense of joint position and body awareness. Proprioception is an internal subconscious process with the central nervous system (CNS) playing a key role in the reestablishment of proprioception following injury. Kinaesthetic awareness requires a conscious effort to react to a situation that often relies on good proprioception but is a distinct process. Athletes are reliant on both proprioception and kinaesthesia in sports performance. For example, in making a football tackle the player needs to be able to sense the position of their limbs relative to the rest of their body, the position of their body relative to the pitch surface and to the ball and the player they are tackling. In addition, they need to assess the speed, acceleration and deceleration components of the tackle and to use these stimuli to make the appropriate muscular responses. To optimise neuromuscular rehabilitation the athlete needs to be engaged in a programme that retrains motor skills in a changing cognitive environment. It is the adaptation to this changing environment of cognitive stimuli that facilitates a training response and improvement in neuromuscular control. The motor skills are sports specific and therefore the rehabilitation programme needs to be as sports specific as possible. Deficits in proprioception are found following common lower limb football injuries including lateral ankle sprain and anterior cruciate ligament tear. Rehabilitation programmes frequently include exercises using wobble boards, foam rollers, trampolines and similar devices that create an unstable base. However, the view that exercising on an unstable surface targets peripheral ankle proprioception has recently been challenged1 and it has been suggested that an overemphasis on proprioception may ignore the role of the CNS.2 In addition, the clinical relevance of proprioceptive deficits found after injury has not been established.3, 4 What is the most effective way of training proprioception and kinaesthesia for optimal sports performance? Can proprioception and kinaesthesia be improved in the absence of injury and does this reduce future injury risk for the athlete? What is the best way to introduce a changing cognitive environment into a sport specific rehabilitation programme? These are all key questions that need to be considered when targeting proprioception and kinaesthesia rehabilitation goals. References 1. Kiers H, Brumagne S, van Dieen J, van der Wees P and Vanhees L. Ankle proprioception is not targeted by exercises on an unstable surface. Eur J Appl Physiol. 2012; 112: 1577-85. 2. Kim D, Van Ryssegem G and Hong J. Overcoming the myth of proprioceptive training. Clin Kinesiology. 2011; 65: 18-28. 3. Gokeler A, Benjaminse A, Hewett TE, et al. Proprioceptive deficits after ACL injury: are they clinically relevant? Br J Sports Med. 2012; 46: 180-92. 4. Relph N, Herrington L and Tyson S. The effects of ACL injury on knee proprioception: a meta-analysis. Physiotherapy. 2014; 100: 187-95.
... lack of neurophysiological evidence) about the validity of current proprioceptive exercises [43]. Although many therapists and clinicians report successful treatment cases, the exact effect and validity of sensorimotor interventions is still discussed controversially [43,44]. Accordingly, European Guidelines on the management of chronic nonspecific LBP do not include recommendations for PrT [45]. ...
... lack of neurophysiological evidence) about the validity of current proprioceptive exercises [43]. Although many therapists and clinicians report successful treatment cases, the exact effect and validity of sensorimotor interventions is still discussed controversially [43,44]. Accordingly, European Guidelines on the management of chronic nonspecific LBP do not include recommendations for PrT [45]. ...
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Background Proprioceptive training (PrT) is popularly applied as preventive or rehabilitative exercise method in various sports and rehabilitation settings. Its effect on pain and function is only poorly evaluated. The aim of this systematic review was to summarise and analyse the existing data on the effects of PrT on pain alleviation and functional restoration in patients with chronic (>=3 months) neck- or back pain. Methods Relevant electronic databases were searched from their respective inception to February 2014. Randomised controlled trials comparing PrT with conventional therapies or inactive controls in patients with neck- or low back pain were included. Two review authors independently screened articles and assessed risk of bias (RoB). Data extraction was performed by the first author and crosschecked by a second author. Quality of findings was assessed and rated according to GRADE guidelines. Pain and functional status outcomes were extracted and synthesised qualitatively and quantitatively. Results In total, 18 studies involving 1380 subjects described interventions related to PrT (years 1994-2013). 6 studies focussed on neck-, 12 on low back pain. Three main directions of PrT were identified: Discriminatory perceptive exercises with somatosensory stimuli to the back (pPrT, n = 2), multimodal exercises on labile surfaces (mPrT, n = 13), or joint repositioning exercise with head-eye coordination (rPrT, n = 3). Comparators entailed usual care, home based training, educational therapy, strengthening, stretching and endurance training, or inactive controls. Quality of studies was low and RoB was deemed moderate to high with a high prevalence of unclear sequence generation and group allocation (>60%). Low quality evidence suggests PrT may be more effective than not intervening at all. Low quality evidence suggests that PrT is no more effective than conventional physiotherapy. Low quality evidence suggests PrT is inferior to educational and behavioural approaches. Conclusions There are few relevant good quality studies on proprioceptive exercises. A descriptive summary of the evidence suggests that there is no consistent benefit in adding PrT to neck- and low back pain rehabilitation and functional restoration.
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Chapter
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