Proprioception – Science and
Guido Van Ryssegem.
Safe Recovery, LLC, Corvallis, Oregon,
Recently so called proprioceptive
exercises have become very popular and
have influenced the way exercise and
rehabilitation professionals prevent,
rehabilitate and augment performance.
Additionally, several have claimed that
balance and proprioceptive exercises
improve proprioception. Not only do we
find that the words ‘balance’ and
‘proprioception’ are used interchangeably in
the literature, its exercise strategies and
research measurements are applied
interchangeably as well. As exercises are
prescribed as an intervention to influence
balance and proprioception a clear
understanding of what proprioception,
balance and proprioceptive exercises are is
This paper reviews the literature
related to proprioception and balance, what
its relationship is to injury and
performance, how the concepts related to
proprioception theories and research can be
manipulated so performance or return to
performance can be improved. Exercise
recommendations are brought forward.
Key Words: proprioception,
balance, proprioceptive exercises, postural
As rehabilitation and exercise professionals
started to appreciate concepts related to
proprioception and balance, so called
proprioceptive exercises became a popular
intervention. It is the author’s opinion that
through this popularity people have ignored
to examine what proprioception really is,
what balance really is and what their
relationships are to performance and injury
(1). Simultaneously, by not respecting what
proprioception and balance is, exercise
intervention strategies should be questioned
and examined (1).
As balance control is a motor control
process (2) we must wonder that it is
inherent to proprioception and wonder if
proprioception can be improved by exercise
at all (3).
The purpose of this paper is to review what
proprioception is, what balance and
postural control is, what their relationships
are and how proprioception can be
improved if at all.
Defining Balance and Proprioception
Although human balance is often described
from a static perspective (19-20) even
during quite standing (20) body movement
is inevitable as inherent ability to control of
relative position of the center of gravity
(COG) and the center of pressure (COP)
occurs as postural control is challenged (19-
Human balance can be further defined as
the inherent ability of cognitive and
reflexive control of the relative position of
its COG and base of support (BOS) in order
to maintain postural stability against
intrinsic and extrinsic challenges (1).
Maintaining balance is thereby a process of
motor control, in order to maintain postural
control in various challenging tasks (19).
Proprioception is often defined as sensory
information about limb, trunk, and head
position and movement (11, 19). It is
thought to include self-perception of body’s
segmental position and movement, which
can be processed to elicit reflexive and
cognitive control of postural and joint
Improvement of Proprioception
Until recent, researchers have reported that
proprioception improved through exercises
(4-6). But the problem is that they
measured balance to evaluate
proprioceptive function (7-10).
Additionally, their interventions are
questionable as they targeted improvements
in balance, strength and postural control. It
appears that proprioception improves as a
result of exercise (11-15), while others
reported no improvement at all (16-18)
even if similar intervention strategies were
Based on the research above, the author
concludes that proprioception is a sense that
can not improve, while balance and thereby
postural control is a strategy (23) and can
thereby improve through appropriate
Unstable surface training has often been
claimed to improve proprioception (14),
often under the assumption that unstable
surface experiences challenge the
proprioceptors and the central nervous
system (CNS) and augment proprioceptive
deficits post-injury (24). Unstable surface
training seems beneficial for those that
suffered of ankle functional instability
creating speculation that balance
impairment was caused by alteration in
sensorymotor function (3, 14, 25-30).
Premature assumptions that one can train
proprioception simply by stimulating
proprioceptors, and that proprioceptive
improvement will enhance balance ability
as a whole can seriously mislead the
rehabilitation and exercise experts. It is
important to keep in mind that the
feasibility of proprioceptive training is
greatly challenged due to the lack of
neurophysiological evidence (3).
If proprioception can be improved as
claimed by some, then we must speculate
that its interventions improve either the
acquisition of the mechanical stimulus,
positively effects the conversion of that
signal into the neural signal and/or the
transmission of that signal to the central
nervous system (14). But, the velocity of
the signal conversion is known to be fixed
(31). Improved signal acuity of muscle
spindles has been speculated to be possible.
Theoretically, spindle acuity can be
volitionally modulated through a task-
dependent muscle contraction (3). An
increase in spindle fusimotor drive, along
with increased skeletomotor drive, has been
observed (32-33). However, this is not
evidence of an increase in proprioception
per se, because the related experiments
were not designed to test a hypothesis that
increased fusimotor firing rate resulted in
increase of proprioception.
The Role of the Central Nervous System
Adaptation Induced Motor Learning in
Establishing adequate motor behavior
through CNS adaptation is necessary to
successfully avoid joint injuries and falling.
According to the Schmidt’s generalized
motor program theory (41), the CNS stores
motor programs for each set of movement
pattern, and retrieves the programs when
needed (41). The dynamic pattern theory
opposes motor program-based theory.
According to the dynamic pattern theory,
movement coordination is controlled based
on information from the environment and
the dynamic properties of the body and
limbs (21). This approach emphasizes the
ability of nervous system to self- organize
motor patterns. As both theories are
supported by evidence, the author proposes
that ideal balance exercise programs should
respect memory function as also respects
the training effects of specific tasks and
variety of environmental exposure, so task
specific learning and movement emergence
In order to provide an ideal training
environment for CNS adaptation to occur,
one should also consider the inherent
limitation of the CNS to engage in multiple
tasks at once (21).
It is suggested that the CNS attends to what
matters and disregards irrelevant stimuli
when performing motor skills (3). But it is
clear that our brain can perform more than
one activity at once as seen in daily life
challenges such as walking and texting
According to Schmidt and Lee (31), the
term dual- task interference refers to the
decrement in performance of one or both
tasks when two activities are carried out
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 tasks (34).
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 a 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 (28).
This helps the CNS to overcome dual task
interference because tasks that were
previously recognized as dual-tasks become
recognized as single-tasks. Therefore, this
theory emphasizes simultaneous dual task
Silsupadol et al. (35) combined the two
theories mentioned above and created a
dual task balance training methodology.
Three different balance training methods
were compared: a single task balance
training task, a combined balance and
cognitive task under a fixed-priority
instructional set, and a combined balance
and cognitive task under a variable-priority
Only the participants who trained under
variable instructional set showed
improvement of balance during the balance
performance with novel cognitive tasks.
This benefit was maintained for 3 months.
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 situations.
Dual task training is not always the best
methodology of training motor skill though,
as researchers suggest that skill focused
attention is important during the initial
stage of motor learning, but becomes
counterproductive for the experienced
individuals (36-39). Researchers showed
that multiple task training were more
effective for performance developments of
experienced athletes (36,38). 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 cognitive
and motor task on top of the balance
performance. The author speculates that
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.
Emergence of so called proprioceptive
training methods in rehabilitation and
strength and performance settings are
common. While it is encouraged to
continue such methods, scientific evidence
does not necessarily proof its efficacy (1).
Proprioception is sometimes mistakenly
considered as a key factor to improve or
restore human balance and to prevent
injury. However, there is no
neurophysiological evidence that
proprioception can be improved (2).
If exercise interventions are applied to
augment the proprioceptors sensitivity, then
interventions should distinctively target a
variety of motor skills (3). Also, strategies
should target the CNS to overcome its
limited attentional capacity by adequately
imposing multiple task demands (28, 34).
More research is needed to identify what
proprioception is so its components can be
agreed upon. In the mean while
rehabilitation and exercise professionals
should be thoughtful in their claims and
their intervention strategies (1).
(1) Kim, D., Van Ryssegem, G., Hong,
J. (2011) Overcoming the myth of
proprioceptive training. Clinical
Kinesiology (65)1; Spring 2011.
(2) Horak, F.B. Postural orientation and
equilibrium: what do we need to
know about neural control of
balance to prevent falls? Age
Ageing. 35(Suppl 2): ii7–ii11, 2006.
(3) Ashton-Miller, J.A., E.M. Wojtys,
L.J. Huston, and D. Fry-Welch. Can
proprioception really be improved
by exercise? Knee Surg, Sports
Traumatol, Arthrosc. 9:128-136,
(4) Hupperets, M.D., E.A. Verhagen, W.
van Mechelen. Effect of
unsupervised home based
proprioceptive training on
recurrences of ankle sprain:
randomized controlled trial. BMJ
339: b2684, 2009.
(5) Jan, M.H., P.F. Tang, J.J. Lin, S.C.
Tseng, Y.F. Lin, and D.H. Lin.
Efficacy of a target-matching foot-
stepping exercise on proprioception
and function in patients with knee
osteoarthritis. J Orthop Sports Phys
Ther. 38(1):19-25, 2008.
(6) Loudon, J.K., M.J. Santos, L.
Franks, and et al. The effectiveness
of active exercise as an intervention
for functional ankle instability: A
systematic review. Sports Med
(7) De Carlo M.B., and R.W. Talbot.
Evaluation of ankle joint
proprioception following injection
of the anterior talofibular ligament.
J Orthop Sports Phys Therapy. 70-6,
(8) Calmels P., M. Escafit, M.
Domenach, and P. Minaire.
Posturographic evaluation of the
proprioceptive effect of ankle
orthoses in healthy volunteers. Int
Disabil Stud 13:42-5, 1991.
(9) Mattacola C.G., and J.W. Lloyd.
Effects of a 6-week strength and
proprioception training program on
measures of dynamic balance: a
single-case design. J Athl Train.
(10) Fu A.S., and C.W. Hui-Chan.
Ankle joint proprioception and
postural control in basketball
players with bilateral ankle sprains.
Am J Sports Med. 33: 1174-1182,
(11) Horak, F.B. Postural
orientation and equilibrium: what do
we need to know about neural
control of balance to prevent falls?
Age Ageing. 35(Suppl 2): ii7–ii11,
(12) Hughes, T., and R. Patsy.
The effects of proprioceptive
exercise and taping on
proprioception in subjects with
functional ankle instability: A
review of the literature. Phys Ther
Sport. 9(3): 136-147, 2008.
(13) Ilg, R., A.M. Wohlschlager,
C. Gaser, and et al. Gray matter
increase induced by practice
correlates with task-specific
activation: a combined functional
and morphometric magnetic
resonance imaging study. J
Neurosci. 28(16): 4210–4215, 2008.
(14) Lephart, S.M., and F.H. Fu.
Proprioception and neuromuscular
control in joint stability. Human
(15) Mattacola C.G., and J.W.
Lloyd. Effects of a 6-week strength
and proprioception training program
on measures of dynamic balance: a
single-case design. J Athl Train.
(16) Refshauge, K.M., Kilbreath,
S.L., and Raymond, J. The effect of
recurrent ankle sprains and taping
on proprioception at the ankle, Med
and Science in Sports and Exercise,
32, 10-15, 2000.
(17) Westlake, K.P. and E.G.
Culham. Sensory-specific balance
training in older adults: Effect on
proprioceptive reintegration and
cognitive demands. Physical
Therapy 87 (10): 1274-83, 2007.
(18) Kiers, H., Brumagne, S., van
Dieen, J., van der Wees, P., and
Vanhees, L. Ankle proprioception is
no targeted by exercise on an
unstable surface. Eur J Appl
Physiol. 112: 1577-85, 2012.
(19) Pollock, A.S., Durward,
B.R., Rowe, P.J., and Paul, J.P.
What is balance? Clin Rehabil.
14: 402– 406, 2000.
(20) Winter, D.A. Human
balance and posture control
during standing and walking.
Gait Posture. 3: 193-214, 1995.
(21) Magill, R.A. Motor
learning and control: concepts
and application. (9th ed.). New
York, NY: McGraw-Hill, 2010.
(22) Riemann, B.L. and
Lephart, S. M. The sensorymotor
system, Part 1: The physiologic
basis of functional joint stability.
J Athl Train. (37)1: 71-79, 2002.
(23) Shumway-Cook, A., and
Woollacott, M.H. Motor Control.
(24) Schmidhammer, R.,
Hausner, T., Hopf, R., Zandieh,
S. and Redl, H. In peripheral
nerve regeneration environment
enriched with activity stimulating
factors improves functional
recovery. Acta Neurochir Suppl.
(25) Freeman, M.A.R., Dean,
M.R.E, and Hanham, I.W.F. The
Etiology and Prevention of
Functional Instability of the Foot.
J Bone Joint Surg Am. 47 B(4):
(26) Hertel, J. Functional
instability following lateral ankle
sprain. Sports Med. 29(5): 361-
(27) Mandelbaum, B.R.,
Silvers, H.J., Watanabe, D.S., and
et al. Effectiveness of a
Proprioceptive Training Program
in Preventing Anterior Cruciate
Ligament Injuries in Female
Athletes: 2-Year Follow-up. Am.
J. Sports Med. 33: 1003-1010,
(28) Munn, J., Sullivan, S.J.,
and Schneiders, A.G. Evidence of
sensorimotor deficits in
functional ankle instability: A
systematic review with meta-
analysis. J Sci Med Sport.13(1):
(29) Ross, S.E., and
Guskiewicz, K.M. Examination
of Static and Dynamic Postural
Stability in Individuals With
Functionally Stable and Unstable
Ankles. Clin J Sport Med. 14(6):
332- 338, 2004.
(30) Rozzi, S.L., Lephart,
S.M., Sterner, R., and
Kuligowski, L. Balance training
for persons with functionally
unstable ankles. J Orthop Sports
Phys Ther . 29(8) :478-86, 1999.
(31) Schmidt, R.A., and Lee,
T.D. Motor control and learning.
A behavioral emphasis (4th ed.).
Champaign, IL: Human Kinetics,
(32) Sjölander, P., and
Johansson, H. Sensory endings in
ligaments: response properties
and effects on proprioception and
motor control. In: Y ahia L(ed)
Ligaments and ligamentoplastics.
Springer, Berlin Heidelberg New
York, 39–83, 1997.
(33) Gandevia, S.C., D.I.
McCloskey, and D. Burke.
Kinesthetic signals and muscle
contraction. Trends Neurosci. 15:
(34) Woollacott, M.H., and
Shumway-Cook, A. Attention
and the control of posture and
gait: A review of an emerging
area of research. Gait Posture.16:
(35) Silsupadol, P., Siu, K.,
Shumway-Cook, A., and
Woollacott, M.H. Training of
balance under single and dual-
task conditions in older adults
with balance impairment. Phys
Ther. 86: 269 – 281, 2006.
(36) Beilock, S.L., Carr, T.H.,
MacMahon, C., Starkes, J. L.
When Paying Attention Becomes
Counterproductive: Impact of
Divided Versus Skill-Focused
Attention on Novice and
Experienced Performance of
Sensorimotor Skills. J Exp
Psychol. 8(1): 6–16, 2002.
(37) Gray, R. Attending to the
execution of a complex
sensorimotor skill: Expertise
differences, choking, and slumps.
J Exp Psychol: Applied. 10: 42-
(38) McPherson, S.L. Expert-
novice differences in planning
strategies during collegiate
singles tennis competition.
Journal of Sport and Exercise
Psychology. 22: 39–62, 2000.
(39) Robertson, S.D.,
Zelaznik, H.N., Lantero, D.A.,
Bojczyk, K.G., Doffin, J.G., and
Schneidt, T. Correlations for
timing consistency among
tapping and drawing tasks:
Evidence against a single timing
process in motor control. J Exp
Psychol: Human perception and
performance. 25: 1316-1330,