Manual Therapy 20 (2015) 378e387

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Manual Therapy
journal homepage: www.elsevier.com/math

Masterclass

Proprioception in musculoskeletal rehabilitation. Part 2: Clinical

assessment and intervention
Nicholas C. Clark a, *, Ulrik Ro
€ ijezon b, Julia Treleaven c
a
School of Sport, Health, and Applied Science, St Mary's University, Twickenham, London, United Kingdom
b
Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
c
CCRE Spine, Division of Physiotherapy, SHRS, University of Queensland, Brisbane, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Proprioception can be impaired in gradual-onset musculoskeletal pain disorders and
Received 6 November 2014 following trauma. Understanding of the role of proprioception in sensorimotor dysfunction and methods
Received in revised form for assessment and interventions is of vital importance in musculoskeletal rehabilitation. In Part 1 of this
4 January 2015
two-part Masterclass we presented a theory-based overview of the role of proprioception in sensori-
Accepted 15 January 2015
motor control, causes and findings of altered proprioception in musculoskeletal conditions, and general
principles of assessment and interventions.
Keywords:
Purpose: The aim of this second part is to present specific methods for clinical assessment and in-
Proprioception
Musculoskeletal rehabilitation
terventions to improve proprioception in the spine and extremities.
Assessment Implications: Clinical assessment of proprioception can be performed using goniometers, inclinometers,
Intervention laser-pointers, and pressure sensors. Manual therapy, taping, and bracing can immediately enhance
proprioception and should be used to prepare for exercise interventions. Various types of exercise (active
joint repositioning, force sense, co-ordination, muscle performance, balance/unstable surface, plyo-
metric, and vibration training) should be employed for long-term enhancement of proprioception.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction 2. Clinical assessment of proprioception

Proprioception is essential for well-adapted sensorimotor con-
trol. Proprioception fulfills roles in feedback and feedforward
sensorimotor control and regulation of muscle stiffness, being
specifically important for movement acuity, joint stability, co-
ordination, and balance. Cervical proprioception is uniquely
important for head-eye co-ordination and movement control.
Proprioception can be disturbed in musculoskeletal disorders due
to pain, effusion, trauma, and fatigue. A variety of assessment pro-
cedures and interventions have been developed to specifically test
and enhance proprioception, respectively. We present an overview
of clinical assessment and intervention methods for proprioception
of the spine and extremities. Reference is made to research where
interventions have been reported to demonstrate positive effects
on proprioception. A special focus is made on exercise therapy.
Clinical assessment of proprioception should employ tests for
measuring joint position sense (JPS), kinesthesia, or force sense
(Roijezon et al., 2015). In the laboratory, custom-built devices or
expensive computer-interfaced equipment are frequently
employed (Lephart et al., 1994; Borsa et al., 1997; Docherty et al.,
1998; Waddington et al., 2000; Callaghan et al., 2002; Docherty
and Arnold, 2008; Benjaminse et al., 2009; Learman et al., 2009),
but are typically impracticable in the clinical setting. Researchers
and clinicians have attempted to develop clinical tests for the spine
and extremities, although some tests are more developed for some
body parts (e.g. cervical spine) than others. Further development
and refinement of clinical tests is needed.
2.1. Clinical apparatus

Goniometers, inclinometers, pressure sensors, and laser-

pointers are affordable and easy-to-use in a clinical context.
* Corresponding author. There is also scope for new affordable and accurate technology that
E-mail address: Nicholas.Clark@stmarys.ac.uk (N.C. Clark). includes smartphones with built-in accelerometers and gyros,

http://dx.doi.org/10.1016/j.math.2015.01.009
1356-689X/© 2015 Elsevier Ltd. All rights reserved.
 N.C. Clark et al. / Manual Therapy 20 (2015) 378e387
camera systems such as the Kinect, the Wii Balance Board, and
other video-based technology.
2.2. Specific tests
2.2.1. Joint position sense
For the cervical spine, active JPS testing can use a laser-pointer
attached to a headband to determine patients' ability to relocate
to the neutral starting position with the eyes closed after per-
forming an active head movement (e.g. right rotation) (Fig. 1). The
difference between the starting and end position can be measured
in millimetres, and the joint position error then calculated in de-
grees (Roren et al., 2009; Chen and Treleaven, 2013). This method is
reliable and valid when compared to sophisticated laboratory
equipment (Swait et al., 2007; Roren et al., 2009; Chen and
Treleaven, 2013). Errors greater than 4.5
are considered to indi-
cate abnormal cervical active JPS. Others have used the cervical
range of motion (CROM) device to measure cervical active JPS and
found this to also be a reliable and valid method (Wibault et al.,
2013; Treleaven et al., 2015).
For the extremity joints, goniometers (universal, bubble, digital)
can also be used to measure active JPS. The sequence of events is the
same as that described for laboratory measurement of active JPS
(see Masterclass Part 1) (Roijezon et al., 2015). Depending on the
device used and the extremity joint measured, reliability and
measurement error of active movement goniometry can range
widely (Gabbe et al., 2004; Lephart et al., 2007; Dickson et al., 2012;
Kolber and Hanney, 2012; Hamid et al., 2013), and this should be
carefully considered if goniometry is used to measure active JPS of
extremity joints. For the shoulder joint, laser-pointer active JPS
tests have also been developed and show promise in those with and
without shoulder injury (Balke et al., 2011). There is potential for
using the laser-pointer to measure JPS in other joints but, to date,
there is limited research.
2.2.2. Kinesthesia
For the cervical spine, kinesthesia can be assessed by following a
trace or intricate pattern as accurately as possible. This can be a
visual trace (e.g. figure-of-eight, zig-zag pattern) (Woodhouse et al.,
Fig. 1. Cervical Joint Position Sense Assessment. The patient is seated with the laser
pointer attached to a headband, 90 cm from the target. The target is adjusted so that
the laser projects to the centre of the target. They are asked to concentrate on this
resting head position and then close the eyes. They then perform an active movement
to comfortable limits and return to the resting head position as accurately as possible.
The difference between the initial and end position can be measured in millimetres
and then converted to degrees.
379
2010) or by following a computer generated marker that is moving
in a more unpredictable pattern (e.g. “the fly”) (Kristjansson et al.,
2004). Outcome variables usually used here are the mean
displacement or time on target. Advances in smart phone sensors
have made “the fly” technology more readily accessible to clinicians
(Kristjannson, 2014), although recent work has also been con-
ducted to investigate the feasibility of a low cost quantitative
method using video analysis of the patient tracing a pattern with a
head-mounted laser (Pereira et al., 2015).
2.2.3. Force sense
Force sense can be measured by the accuracy of reproducing a
specific target force. For example, the pressure biofeedback device
used for assessing the cranio-cervical flexion test could be
considered a method of assessing force sense in the cervical spine
(Jull, 2000). The ability to hold steadily or the accuracy in achieving
and maintaining a desired pressure can be used. Others have also
used custom-made dynamometry placed at the mandible to mea-
sure precision and accuracy of maintaining low load upper cervical
flexor force levels (O'Leary et al., 2005).
2.3. Non-specific tests
2.3.1. Balance tests
Balance tests, such as timed single-leg stance tests, have his-
torically been used to measure lower extremity (e.g. ankle) pro-
prioception. As discussed previously (see Masterclass Part 1)
(Roijezon et al., 2015), these tests are not specific tests of proprio-
ception since balance is a product of integrating sensory, central
nervous system (CNS), and motor functions (Macpherson and
Horak, 2013). Nevertheless, balance tests could potentially give an
indication of improvement following proprioceptive training. Bal-
ance tests can be modified to try to bias proprioception by, for
example, closing the eyes, adding neck torsion, or using unstable
surfaces (Roijezon et al., 2015).
2.3.2. Oculomotor and eye-head coordination tests
Oculomotor and eye-head co-ordination assessment in people
with neck pain is important as cervical spine afferents have a
unique and important role in maintaining eye and head movement
control (Corneil et al., 2002; Peterson, 2004). At present, clinical
tests incorporate qualitative assessment of the ability to: 1) main-
tain gaze while moving the head; 2) co-ordinate eye and head
movement; 3) eye follow while keeping the head still in neck tor-
sion compared to neck neutral positions (Fig. 2). Recent research
has found these clinical tests to be reliable and able to discriminate
between chronic neck pain and asymptomatic individuals (Della
Casa et al., 2014), and are described in detail elsewhere
(Treleaven, 2008; Grip et al., 2009; Treleaven et al., 2011).
3. Clinical interventions to improve proprioception
In Part 1 of this Masterclass (Roijezon et al., 2015), the impor-
tance of addressing causes of altered proprioception and rehabili-
tation techniques intended to enhance proprioception were
introduced. Pain, effusion, and fatigue can be common after
musculoskeletal injury, result in impaired proprioception
(Treleaven et al., 2003; Anderson and Wee, 2011; Cho et al., 2011),
and, consequently, are barriers against effective interventions for
enhancing proprioception and sensorimotor control. Therefore, it is
important to administer techniques to reduce pain, effusion, and
fatigue in order to facilitate the implementation of effective in-
terventions to enhance proprioception. Augmentation of somato-
sensory information via passive techniques such as manual
therapy, soft tissue techniques, and taping or bracing can be
380 N.C. Clark et al. / Manual Therapy 20 (2015) 378e387

Some researchers have reported that specific soft tissue techniques

can significantly and positively affect extremity joint propriocep-
tion defined by measures of active JPS (Henriksen et al., 2004).

3.2. Taping and bracing

Taping and bracing techniques are adjunct interventions used to

obtain specific clinical effects including, for example, pain relief,
swelling control, and protect injured anatomical structures
(Macdonald, 2004). Another clinical goal of applying athletic tape
(Fig. 3) and different types of brace is to enhance proprioception
(Macdonald, 2004) via stimulation of mechanoreceptors respond-
ing to skin stretch and compression during joint motion (Martin
and Jessell, 1991; Rothwell, 1994). Authors have reported that the
application of selected athletic taping techniques, elastic bandages,
and neoprene sleeves can immediately and significantly enhance
spinal and extremity proprioception in uninjured and injured in-
dividuals (Lephart et al., 1992; Jerosch et al., 1995; Jerosch and
Prymka, 1996; Simoneau et al., 1997; McNair and Heine, 1999;
Newcomer et al., 2001; Callaghan et al., 2002; Chu et al., 2002;
Chang et al., 2010).

Fig. 2. Eye Follow in Neck Torsion. The patient keeps the head still while following
with the eyes as accurately as possible a moving target (e.g. or a pen) with the eyes.
The target is moved slowly side to side (20
per second through a visual angle of 40
).
The test is repeated with the neck in torsion (head still but with the trunk rotated up to
45
) then repeated on the opposite side. Any difference noted in smooth eye follow
(quick catch up eye movements) in these positions compared to the neutral position is
noted.

important. Exercise therapy is a vital component in enhancing

proprioception and will be considered in detail. In order to deduce
that a clinical intervention yields a proprioceptive effect, one of the
specific modalities of proprioception (JPS, kinesthesia, force sense)
must be measured before and after the intervention. The following
sections will, therefore, refer only to research where this has
occurred.

3.1. Manual therapy

Joint mobilisation/manipulation can create a controlled stretch

to capsuloligamentous tissue (Kaltenborn, 1999; Greenman, 2003),
which is populated with multiple types of mechanoreceptors
(Kennedy et al., 1982; McLain and Raiszadeh, 1995; Michelson and
Hutchins, 1995; Steinbeck et al., 2003; Moraes et al., 2011), thereby
affecting proprioceptive feedback to the CNS. Authors have re-
ported that joint passive movement techniques can have an im-
mediate and significantly beneficial effect on spinal and extremity
proprioception (Heikkila et al., 2000; Vicenzino et al., 2005;
Palmgren et al., 2006; Learman et al., 2009; Ju et al., 2010; Haavik
and Murphy, 2011). Similarly, soft tissue techniques including a
wide variety of body segment massage and localized connective
tissue techniques mechanically affect the skin, connective tissue
(e.g. fascia), and muscles (Goats and Keir, 1991; Goats, 1994;
Greenman, 2003), which are also richly innervated with mecha- Fig. 3. Proprioception Knee Taping Technique (Modified from Callaghan et al., 2002).
noreceptors (Yahia et al., 1992; Rothwell, 1994; Stecco et al., 2007). Copyright Nicholas Clark. Reproduced with permission.
 N.C. Clark et al. / Manual Therapy 20 (2015) 378e387 381

3.3. Exercise therapy
Any active exercise can be considered ‘proprioceptive training’
because it will generate a barrage of afferent impulses to the CNS
from joint and muscle-tendon mechanoreceptors (Clark and
Herrington, 2010; Clark and Lephart, 2015). Thus, active exercises
would seem a vital component in augmenting proprioception
(Perez et al., 2004; Lagerquist et al., 2012; Clark and Lephart, 2015).
There is, however, much overlap across the potential purposes,
goals, and clinical uses for any single exercise. Terminology used in
exercise therapy (e.g. ‘proprioceptive training’, ‘strength training’)
can mean different things to different clinicians and researchers. A
single exercise can result in multiple different physiological and
physical adaptations in several body systems. In general, exercise
therapy refers to the performance of repeated movements as part of
a goal-directed training programme to improve a physiological or
physical characteristic (Clark and Lephart, 2015). For the purpose of
this paper we offer simplistic definitions according to the primary
characteristics of the exercise task, introduce basic concepts, offer
selected clinical examples, and present research reports on the
effect of an exercise type on proprioception.
3.3.1. Active joint repositioning training
Observation of injury mechanisms suggests that there are spe-
cific points in a joint's range-of-motion at which a joint is at risk of
injury. For example, non-contact injuries occur between 9 and 22

plantarflexion in the ankle (Mok et al., 2011), 10 and 60
flexion in
the knee (Koga et al., 2010), and at extremes of external rotation in
the shoulder (Wassinger and Myers, 2011). This suggests there may
be a ‘position of vulnerability’ in a joint's range-of-motion that may
be related to proprioceptive deficits (Myers and Lephart, 2000).
Active joint repositioning training involves a similar procedure to
that used in JPS testing: a starting positon/angle and target posi-
tion/angle are selected, and training involves moving from one
position to another as closely as possible, holding each for a short
duration (e.g. 5 s) (Myers and Lephart, 2000; Suprak et al., 2007). A
difference between JPS testing and training is that visual feedback
can be permitted for how accurately the task is performed. For the
cervical spine, training can be performed by actively moving the
head to a pre-determined target angle, or returning the head as
closely as possible to the initial position after movement, checking
accuracy by opening the eyes (Revel et al., 1994). For the extrem-
ities, both open (Fig. 4) and closed kinetic chain exercises can be
employed with emphasis on repositioning training occurring
within the specific range-of-motion associated with a specific
injury type (Borsa et al., 1994; Lephart and Henry, 1996). Head
repositioning training with eyes open and eyes closed has been
demonstrated to improve cervical JPS patients with chronic neck
pain (Revel et al., 1994; Jull et al., 2007). For peripheral joints,
including the shoulder and knee, the addition of a ‘low’ external
load to a limb segment (5e10% bodyweight) significantly improved
the accuracy of joint repositioning tasks in uninjured individuals
(Lamell-Sharp et al., 2002; Brindle et al., 2006; Suprak et al., 2007).
3.3.2. Force sense training
Perception of force and effort can be trained by activating a
muscle or muscle group to a predetermined amount of force, or
maintaining the same amount of force for a defined period-of-time
(e.g. 10 s) (Jull et al., 2007). Cranio-cervical flexor training using the
pressure biofeedback unit (Fig. 5) has demonstrated improved
precision for maintaining a low level upper cervical flexion force in
people with neck pain (O'Leary et al., 2007), and improved force
pressure levels achieved in people with cervicogenic headache (Jull
et al., 2002).
3.3.3. Co-ordination training
Co-ordination is the process of controlling the activation of
many different muscles so that they act together simultaneously as
a single functional unit (Gordon, 1991), and the process of inte-
grating different body parts in specific movement patterns (Kent,
2006). Co-ordination training has a different connotation
compared to movements in other types of exercise therapy. We
consider co-ordination training to have primary emphasis on
cueing an individual to specifically concentrate on very fine aspects
of sequencing and linking multiple muscles and/or body-parts. Co-
ordination training, thus, requires precise verbal cueing for the
clinician and a high cognitive demand for the patient. Examples of
co-ordination training are preferential activation of one muscle

Fig. 4. Shoulder Joint Active Repositioning Training. A target angle that lies at a specific point within the range-of-motion associated with shoulder injury is chosen (e.g. 80
external
rotation). A low external load is added to the limb (e.g. 1 kg dumb-bell) to enhance proprioception via increased mechanoreceptor stimulation. The individual is instructed to start at
0
external rotation, and then eccentrically externally rotate as closely as possible to the target angle, isometrically hold for up to five seconds, concentrate on feeling the position,
and then concentrically return to the start position. This can be performed with eyes open or eyes closed. Copyright Nicholas Clark. Reproduced with permission.
382 N.C. Clark et al. / Manual Therapy 20 (2015) 378e387
Fig. 5. Force sense training using the pressure biofeedback unit (PBU) in cranio-
cervical flexion training (CCFT). The patient is given feedback of the force applied
during the incremental stages of CCFT (22e30 mmHg) from the PBU. Patients close
their eyes during the task and then open them to check they have reached the
appropriate level.
versus another muscle within a synergistic muscle group (Jull et al.,
2007), specific eye-head-neck co-ordination during neck move-
ments (Revel et al., 1994; Humphreys and Irgens, 2002), and foot-
shank-thigh co-ordination on an elliptical training device (Lee
et al., 2014). Different types of co-ordination training have
enhanced proprioception of the spine and extremities. Cranio-
cervical flexor training focusing on use of the deep upper cervical
flexors versus the superficial cervical flexors can significantly
enhance cervical active JPS in people with neck pain (Jull et al.,
2007). Eye head neck co-ordination exercises demonstrates
improved JPS in people with neck pain (Humphreys and Irgens,
2002). Fine foot orientation training during external perturba-
tions on an elliptical training device has been shown to significantly
improve passive foot kinesthesia during full weight-bearing
movements in uninjured adults (Lee et al., 2014). Whole body co-
ordination exercises including yoga and tai chi have also demon-
strated improvements in proprioception (Tsang and Hui-Chan,
2003; Cramer et al., 2013).
3.3.4. Muscle performance training
The terms ‘muscle performance’ and ‘muscle strength’ both
broadly refer to the ability of a muscle to produce force, regardless
of the action (isometric vs. anisometric), load (body segment vs.
free-weight), or intensity (‘low load’ vs. ‘high load’) (Mayhew and
Rothstein, 1985; Sapega, 1990; Clark, 2001). Muscles must first
possess inherently sufficient muscle strength before they can
effectively control the mass, orientation, and alignment of body
segments (Borsa et al., 1994; Hodges and Moseley, 2003;
Macpherson and Horak, 2013). Muscle performance training usu-
ally involves the repeated activation of skeletal muscle around a
primary axis-of-rotation and in a single plane-of-motion, typically
against some ‘resistance’ (body segment or an added external load),
with the primary intent of modifying muscle force generating
characteristics. Examples are side-lying loaded shoulder external
rotation, double-leg bodyweight squats, and side-lying loaded
ankle eversion (Fig. 6). Muscle performance training has been re-
ported to beneficially modify proprioception. In the spine,
controlled head lift exercise in people with neck pain demonstrated
improved force sense (O'Leary et al., 2007). Scapular and gleno-
humeral anisometric bodyweight and dumb-bell strength training
has been reported to significantly improve glenohumeral active JPS
Fig. 6. Side-Lying Loaded Ankle Eversion. An external load is added to the foot (e.g. 2
kg ankle-weight). The individual is then instructed to perform dynamic eversion
against gravity. Traditional resistance training programme design methods are applied
(e.g. 3 sets  10 repetitions,  3 sessions per week). Copyright Nicholas Clark.
Reproduced with permission.
in uninjured military cadets (Rogol et al., 1998). General ankle
anisometric elastic resistance strength training was reported to
significantly enhance ankle inversion and plantarflexion active JPS
in athletes with functional ankle instability (Docherty et al., 1998),
and ankle invertor and evertor isokinetic strength training has also
been reported to significantly improve ankle inversion passive JPS
in recreational athletes with functional ankle instability (Sekir et al.,
2007).
3.3.5. Balance/unstable surface training
Balance is the process of maintaining the body's center of mass
within its base of support via appropriate internal moments
resisting destabilizing external moments acting on the body
(Macpherson and Horak, 2013). Balance is the result of feedback
and feed-forwards corrective movements at multiple joints to
maintain the position and orientation of one body segment relative
to another over the base-of-support (Macpherson and Horak,
2013). Balance training typically involves performing exercises on
an unstable surface (e.g. rocker-board, inflatable devices) (Clark and
Herrington, 2010). Examples of balance training exercises are
standing balance tasks on soft surfaces or wobble-boards (Beinert
and Taube, 2013), performing cervical movements whilst chal-
lenging balance (Gatti et al., 2011), press-ups on a Swiss-ball (Myers
and Lephart, 2000), and single-leg squats on a rocker-board (Fig. 7)
(Clark and Herrington, 2010). Single-leg stance, tandem stance, and
double-leg stance on a wobble-board has enhanced cervical spine
active JPS in a group of people with sub-clinical neck pain (Beinert
and Taube, 2013). Lower extremity wobble-board training has
enhanced ankle active kinesthesia (active movement
 N.C. Clark et al. / Manual Therapy 20 (2015) 378e387 383

to mid-stance of gait, lower extremity extensors use eccentric

muscle actions to decelerate the body, followed by very brief iso-
metric muscle actions, before transitioning to concentric muscle
actions to accelerate the body from mid-stance to push-off (Komi,
1992; Chu, 1998). Plyometric training uses the SSC as a key
feature during the execution of exercise drills. Plyometric training
must be executed rapidly with meticulous technique with
emphasis on the transition between eccentric and concentric
muscle actions being as fast and short duration as possible (Chu,
1998). Examples of plyometric training exercises are kneeling 90-
90 shoulder internal-external rotations against elastic resistance
(Swanik et al., 2002) (Fig. 8), double-leg barrier jumps (Chu, 1998)
(Fig. 9), and single-leg in-place (vertical) hops (Clark and
Herrington, 2010). Plyometric training can beneficially modify
proprioception of the extremities. Kneeling 90-90 shoulder inter-
nal-external rotations against elastic resistance and ball throwing
drills against a mini-trampoline have been reported to significantly
improve glenohumeral active JPS and passive kinesthesia in unin-
jured elite swimmers (Swanik et al., 2002). Jump-landing and
jump-landing with change-of-direction training has been reported
to significantly improve knee active kinesthesia in uninjured
Australian Rules Football players (Waddington et al., 2000).

Fig. 7. Single-Leg Rocker-Board Squat. Copyright Nicholas Clark. Reproduced with

permission.

discrimination) in uninjured, elite rugby league players

(Waddington et al., 1999), Australian Rules Football players
(Waddington et al., 2000), and independent older people
(Waddington and Adams, 2004). Swiss-ball training was shown to
significantly improve knee passive JPS in uninjured students (Cug 
et al., 2012). Upper extremity wobble-board training has been re-
ported to significantly enhance shoulder active kinesthesia
following shoulder dislocation (Naughton et al., 2005). A lower
extremity exercise programme including a rocker-board, wobble-
board, mini trampoline, tilted platform, and uneven walkway has
Fig. 8. Kneeling 90-90 Plyometric Shoulder Internal-External Rotation (From Swanik
also been reported to significantly improve ankle passive JPS in et al., 2002). The individual is instructed to perform concentric shoulder internal
adults with functional ankle instability (Eils and Rosenbaum, 2001). rotation to 90
, hold the position for two seconds, and then release the isometric hold
so that the tubing rapidly recoils and pulls the shoulder into external rotation. As soon
3.3.6. Plyometric training as the desired amount of external rotation is achieved, the individual is instructed to
stop the external rotation recoil and again perform concentric internal rotation to 90
.
Many functional tasks demonstrate an eccentric-isometric- Traditional plyometric training programme design methods are applied (e.g. 3 sets 
concentric sequence of muscle actions termed the stretch- 15 repetitions,  2 sessions per week). Copyright Nicholas Clark. Reproduced with
shortening cycle (SSC) (Chu, 1998). For example, from foot-strike permission.
384 N.C. Clark et al. / Manual Therapy 20 (2015) 378e387
Fig. 9. Double-Leg Barrier Jumps. Copyright Nicholas Clark. Reproduced with permission.
3.3.7. Vibration training
Vibration is a mechanical event that demonstrates rapid oscil-
latory movements and is a powerful stimulus for the muscle
spindle (Goodwin et al., 1972; Roll and Vedel, 1982). Vibration
training involves exercising with a device that produces a vibration
stimulus (e.g. vibration platform), where the combination of mus-
cle activation with the rapid small amplitude change in direction of
joint motion becomes a powerful stimulus for the muscle spindle
(Cardinale and Bosco, 2003). The intensity of the vibration is
determined by the amplitude and frequency of the oscillations
(Cardinale and Bosco, 2003), and devices vibrating from 5 to 50 Hz
are typically used in training (Fontana et al., 2005; Moezy et al.,
2008; Tripp et al., 2009). Examples of vibration training include
Fig. 10. Modified push-ups on a vibration platform.
modified push-ups (Hand et al., 2009) (Fig. 10), bodyweight double-
leg squats and bodyweight lunges onto a vibration platform (Moezy
et al., 2008). Vibration training can alter proprioception of the spine
and extremities. Isometric neck extension using a sling system with
superimposed vibration stimuli significantly enhanced force sense
(steadiness) of the cervical spine in chronic neck pain (Muceli et al.,
2011). Postural exercise involving lumbar hyperlordosis isometric
holds while standing on a vibration platform significantly improved
single-session lumbar spine active JPS (Fontana et al., 2005), and
isometric elbow flexion holding a vibrating dumb-bell has been
reported to significantly enhance elbow active JPS within in a single
training session (Tripp et al., 2009). Isometric and anisometric
double-leg and single-leg balance, squat, and lunge exercises on a
vibrating platform has also shown improvement in knee active JPS
after anterior cruciate ligament reconstruction (Moezy et al., 2008).
4. Summary
Clinical assessment of proprioception can be performed using
goniometers, inclinometers, laser-pointers, and pressure sensors.
These devices can be employed in a clinical context within tests of
active JPS and kinesthesia, and force sense. Balance tests can also be
employed in a clinical context for measuring integrated sensori-
motor control of balance, but it should be remembered that these
are not able to isolate proprioception alone. In the cervical spine,
head and eye movement control should also be assessed as one of
the important roles of proprioception. Following musculoskeletal
injury, pain, effusion, and fatigue can result in impaired proprio-
ception, and so these causes of impaired proprioception should be
treated alongside the implementation of other interventions.
Manual therapy interventions (joint mobilisations, manipula-
tions, soft tissue techniques) taping, and bracing show the ability to
immediately and beneficially affect proprioception. Several types of
exercise therapy have also demonstrated long-term improvements
in proprioception in the spine and the extremities. Although
manual therapy, taping, and bracing can immediately and benefi-
cially affect proprioception, concern has been stated with regards to
the size and duration of therapeutic effects of passive interventions
(Cook, 2011). Nevertheless, these passive interventions can be
employed immediately prior to same-session active rehabilitation

Table 1
Proposed specific example exercises to beneficially affect proprioception of different body parts.
Exercise type Cervical spine
Active joint Repositioning head to neutral
repositioning (JPS) and other points in ROM using
training ± visual laser-pointer (sitting, standing,
feedback SLS)
Path-of-motion Following a line or pattern (zig-
(kinesthesia) zag, figure-of-eight, computer
training generated) using a laser-
pointer on the head or motion
sensors
Force sense training CCFT with PBU
Force and effort perception
training using a dynamometer
at pre-determined percentage
of isometric MVMA (flexors,
extensors, lateral flexors,
rotators)
Co-ordination Head-eye co-ordination
training Trunk-head co-ordination
Eye, head, trunk, arm co-
ordination
CCFT
Neck extension with neutral
upper cervical spine
Gaze stability (eyes still, head
moves into flexion, extension
and rotation)
Eye follow side to side head still
in head neutral and in torsion
Muscle performance CCFT low-load endurance
training Cervical extensor training in
four-point kneeling ± external
load
Head-lifts into flexion,
extension, lateral
flexion ± external load
Balance/unstable Standing (eyes open or closed;
surface training narrow, tandem, SLS on firm
then soft surface (foam) then
unstable surface (rocker board))
Perform other exercises while
in unstable positions (JPS, eye
co-ordination)
Tandem walk, walking with
head movement
Neck resistance training in
slings
Control motion of a moving
object with the head and neck
(ball on head)
Plyometric training
Vibration training Neck extension resistance
training with vibration added
ROM ¼ range-of-motion.
SLS ¼ single-leg stance.
OKC ¼ open kinetic chain.
CKC ¼ closed kinetic chain.
CCFT ¼ cranio-cervical flexion training.
PBU ¼ pressure biofeedback unit.
JPS ¼ joint position sense.
MVMA ¼ maximum voluntary muscle action.
TrA ¼ transversus abdominis.
UL ¼ upper limb.
LL ¼ lower limb.
SLR ¼ straight leg raise.
N.C. Clark et al. / Manual Therapy 20 (2015) 378e387
Lumbar spine
Repositioning spine to neutral,
points in range (sitting, standing,
four-point kneeling)
Abdominal muscle training with
PBU
Force and effort perception training
using a dynamometer at pre-
determined percentage of isometric
MVMA (flexors, extensors, lateral
flexors)
TrA-multifidus co-activation
UL and LL movement while
maintaining trunk stability (neutral
lumbar spine)
Pilates
TrA, multifidus endurance
Curl-ups
Trunk extensor, front-plank, side-
plank isometric holds
Standing (eyes open or closed;
narrow, tandem, SLS on firm then
soft surface (foam) then unstable
surface (rocker board))
Sitting on a Swiss-ball ± UL
movements
Stabilising the trunk while
performing active UL movements
while controlling an oscillating pole
Performing active movements of
trunk while controlling oscillating
pole or Swiss-ball
Plyoball sit-ups
Plyoball back extension
Plyoball long-sitting side throws
Lumbopelvic postural exercises
while standing of vibration
platform
Upper limb
OKC and CKC shoulder, elbow,
wrist, finger repositioning to
different points in ROM
Tracing patterns with laser-pointer
Movement acuity exercises of wrist
and fingers (using smartphone or
surfpad)
Force and effort perception training
of hand and fingers with grip/pinch
dynamometer
Force and effort perception training
using a dynamometer at pre-
determined percentage of isometric
MVMA (shoulder external rotators,
elbow flexors, wrist extensors)
Scapular inter-muscular co-
ordination (scapular upward
rotation force couple)
Rotator cuff co-ordination with
gross UL movements
Wrist, hand, finger fine co-
ordination tasks
Bodyweight strength training
Resistance training machines
Free-weights
Elastic resistance training
Press-ups on a Swiss-ball or
wobble-board
Press-ups with legs elevated on a
Swiss-ball
Wrist gyroscopic exercise ball
training
Active UL movements while
controlling an oscillating pole
Control of ball on wall with
shoulder and UL
Kneeling 90-90 shoulder internal-
external rotations against elastic
resistance
Clapping press-ups
Ball throwing/catching against mini
-trampoline
Push-ups on vibration platform
Elbow, wrist movement with
vibrating dumb-bells
Arm movement with oscillating
pole
385
Lower limb
OKC and CKC hip, knee, ankle
repositioning to different points
in ROM
Tracing pattern with laser-
pointer (letters of alphabet with
foot and ankle)
Force and effort perception
training using a dynamometer
at pre-determined percentage
of isometric MVMA (hip
external rotators, knee flexors,
ankle evertors)
Gluteus maximus-hamstrings
co-ordination during prone SLR
Gluteus medius-TFL co-
ordination during hip
abduction variations
Pelvis-hip-knee-ankle-foot
alignment training during CKC
tasks
Knee valgus-varus movement
control during CKC tasks
Foot-shank-thigh co-ordination
on elliptical trainer
Tai Chi
Bodyweight strength training
Resistance training machines
Free-weights
Elastic resistance training
Standing (eyes open or closed;
narrow, tandem, SLS on firm
then soft surface (foam) then
unstable surface (rocker board))
Standing as above ± distraction/
perturbation from clinician
(ball throwing/catching, pelvic
girdle rhythmic stabilisations)
Single-leg squats on rocker-
board
Wobble-board, Swiss-ball,
mini-trampoline training
Double-leg and single-leg hops,
leaps, jumps,
bounding ± barriers, boxes,
platforms
Depth jumps
Skipping drills
Double-leg and single-leg
squats on vibration platform
Lunges on vibration platform
386 N.C. Clark et al. / Manual Therapy 20 (2015) 378e387
with a view to assisting patients to prepare for specific exercise
therapy interventions and functional movements (Clark and
Lephart, 2015). Thus, it is likely that a mixed mode intervention
approach is optimal for enhancing proprioception in clinical
practice.
As discussed in Part 1 of this Masterclass (Roijezon et al., 2015),
different exercise types will affect the CNS in different ways. Some
exercises will preferentially affect supraspinal levels of the CNS (e.g.
cerebrum), while others preferentially affect spinal cord levels and,
therefore, influence different aspects of proprioception in different
functional contexts. The types of exercise commonly used to
improve proprioception can vary according to different functional
demands of the body areas and joints. Exercises (active joint
repositioning, force sense, co-ordination, muscle performance,
balance/unstable surface, plyometric, and vibration training)
should be used to facilitate long-term beneficial adaptations in
proprioception and enhance overall sensorimotor control (Clark
and Lephart, 2015). There is also evidence that different exercise
types can enhance proprioception in asymptomatic individuals
and, therefore, may have specific clinical utility for the prevention
and rehabilitation of musculoskeletal disorders.
Based on research presented here, examples of exercises to
beneficially affect proprioception of different body parts are pro-
posed in Table 1. Future directions should consider advances in
clinical assessment of proprioception, which is lacking in a number
of areas. This might also direct future research towards identifying
other interventions, or the most appropriate combinations of in-
terventions, to improve proprioception in musculoskeletal
rehabilitation.
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