Utilization of Proprioception Training in Postoperative Rehabilitation
HHP 399
Concordia University - Seward, NE
Kendra Alberts
Introduction
At some moment, an athlete may experience a traumatic event that appears to be
detrimental to their sport career. However with the right rehabilitation, an athlete can eventually
return to the field of play. There are two methods of recovery that an athletic trainer or physical
therapist may use on the athlete. These methods are as follows: neuromuscular training and
traditional resistance training. Neuromuscular training involves the use of balance exercises,
dynamic joint stability exercises, plyometric exercises, and agility drills or sports specific
exercises. Neuromuscular training has been hypothesized to increase joint stability through a
variety of mechanisms including muscle strength, kinesthesia, and muscle tone (Baltaci & Kohl,
2003). The use of traditional resistance training consists of strengthening exercises that involve
primarily the muscles of lower extremities. During resistance training, the injured athlete will be
performing exercises that have an emphasis on the quadriceps femoris, hamstring, gluteus
medius and gastrocnemius muscles.
Sports medicine practitioners have begun to realize that factors proximal the site of the
injury, such as hip muscle weakness, may play a role in lower extremity injury potential.
Historically, examination findings and treatments by sports medicine practitioners have focused
directly on or distal to the site of pain, with no investigation of proximal findings. Significant
weaknesses have been discovered in all categories of injury. More specifically hip abductor and
adductor weakness in lower extremity injuries. Hip muscle weakness resulting in the lack of
proximal control of the leg is a risk factor of lower extremity athletic injuries (Niemuth, 2007).
Studies have found this to be particularly evident in female athletes. An assessment of strength
in these regions can be performed prior to season training and after season training to record the
development of strength throughout the program.
The young athletes and active individuals participating in various sports activities are at
risk for injuring themselves. Due to the lack of hip muscle strength one is more susceptible to
injury. The ACL and MCL of the knee are especially susceptible to injury. The frequency of
injury to these two ligaments account for 90% of all injuries to the knee (Woo et al., 2004). Woo
and associates estimated that 150,000-200,00 new ACL injuries and 140,000 new combined
ACL and MCL injuries occur annually. Of notable concern is the rise of injury to these injuries.
The inherent risk of injury in any athletic or exercise event is unavoidable, however injury due to
significant weaknesses in the lower extremities can be easily fixed with an appropriate workout
routine.
Statement of the Problem
This study will identify the benefits of neuromuscular training in postoperative
rehabilitation versus traditional resistance training with the athletes of Concordia University. It
will acknowledge the use of the two methods and which professionals prefer to use.
Purpose of the Study
The purpose of this study is to determine the rehabilitation methods of neuromuscular
training in postoperative rehabilitation versus the methods of traditional resistance training, and
using these findings to compare the utilization of either rehabilitation method.
Significance of the Study
A brief amount of medical research has been dedicated to the topic of neuromuscular
training versus traditional resistance training. However, there has been a considerable amount of
research dedicated to the individual topics. Injuries to the lower extremities are very common in
sports. Mechanisms for athletic injuries are often multifactorial and they are often as a result of
anatomical, biomechanical, and environmental causes. Past studies have been dedicated to the
contribution of biomechanics and orthopedics in postoperative rehabilitation. Today, athletic
trainers and physical therapists use a combination of both neuromuscular and traditional
resistance training for rehabilitation of their patients and athletes. More sophisticated equipment
and analyses have become available to perform better experiments that yield a much better
understanding of joint kinematics and tissue function during exercise and many daily activities.
Injuring the anterior cruciate ligament is a serious knee ligament injury. Following injury, there
are two main impairments: lack of neuromuscular control and muscular strength. The
reestablishment of the neuromuscular control of the lower extremity is one of the keys to
restoring dynamic joint stability and functional movements patterns. The goal to recreating this
neuromuscular control is to avoid subluxations and to the lower the risk of further injuries. The
chance of the injury reoccurring is existent in all cases, but with neuromuscular control this risk
can be decreased. Solutions to normalizing dynamic knee joint stability and muscular strength of
the lower extremity is significant in this study. These findings will aim to make rehabilitation
programs for people with ACL injury based upon the solutions.
Definition Terms
• Proximal: situated nearer to the center of the body or the point of attachment.
• Distal: situated away from the center of the body or from the point of attachment.
• Neuromuscular Training: training related to nerves and muscles.
• Resistance Training: training specializing in the use of resistance to induce muscular
contraction which builds the strength, anaerobic endurance, and size of skeletal
muscles.
• Kinematics: study of movement from a geometrical point of view.
• Adductor: a muscle whose contraction moves a limb or other part of the body toward
the midline of the body or toward another part.
• Abductor: muscle whose contraction moves a limb or part away from the midline of the
body.
• Proprioception: inborn kinesthetic awareness of body posture including movement,
tension, and changes in the equilibrium
Research Questions
This study will seek to resolve the following questions about neuromuscular training
versus traditional resistance training: What are the benefits of using both training options
together and by themselves? What are the most common forms of neuromuscular training being
used today? Do therapists and sports medicine personnel have a preference of training over the
other?
Literature Review
Some researchers have reported differences in neuromuscular performance in ACL
deficient and reconstructed knees. Other researchers have highlighted the importance of
regaining quadriceps femoris muscle strength following ACL reconstruction. Therefore, both
muscle strengthening programs and neuromuscular training programs have been implemented in
rehabilitation to restore knee function after ACL injury and reconstruction. Several
neuromuscular training programs have been evaluated through studies for injury prevention for
patients with ACL deficiencies but the studies have not evaluated the thoroughness of
neuromuscular training for patients with ACL reconstruction. Only a few studies have been
conducted to determine the differences between neuromuscular training and resistance training.
Therefore, more evidence is required to identify the obvious differences among the exercises
used in clinical settings for rehabilitation after ACL reconstruction. In all, the results of the
study showed minimal differences between the neuromuscular training program and the
resistance training program. In the ability to improve knee function after ACL reconstruction,
the neuromuscular program was superior to the resistance training program. However, there are
not any significant differences between the two programs for other outputs. Together, these
programs provided similar improvements when it came to overall strength, balance, and
proprioception (Risberg et. al, 2007).
Anterior cruciate ligament reconstruction is a standard practice for those who wish to
return to any sort of high level activities. However, the functional outcome after ACL
reconstruction is poor. Quadriceps strength weakness, abnormal movement patterns, and below
normal function from the injured extremity have been reported during the time after
reconstruction. Therefore, neuromuscular training is necessary for the improvement of outcomes
during postoperative rehabilitation. Not only should one focus on the treatment methods during
post-operation but they should also focus on preoperative strengthening. Preoperative
neuromuscular training programs have been successful at improving limb symmetry prior to
surgery. Although the benefits of preoperative strengthening are not long lasting, they have been
helpful in the success of improving postoperative deficits and lowering the risk of second injury.
Success after ACL reconstructive surgery is measured by using the return to sport rates. Despite
that second ACL injuries are not only common, they are even more devastating than the first and
typically have worse outcomes. The risk of second ACL injury is the highest during the first
year that the individual returns to the field of play after their ACL reconstruction. Also, research
shows that risk to the contralateral limb is higher than the operated limb due to limb
asymmetries. However, a neuromuscular training program that is focused on maximizing
performance after ACL reconstruction may be able to reduce the risk of a second ACL injury.
Research has shown neuromuscular training, consisting of destabilizing disturbances to both the
involved and uninvolved extremities, has been an effective means of enhancing functional
outcome after ACL reconstruction compared to the traditional resistance training methods.
Successful ACL prevention programs use a combination of balance, plyometric, and
strengthening exercises to decrease ACL injury risks. Specialists focus on incorporating
dynamic prevention exercises and quadriceps strengthening exercises that promote symmetrical
joint loading and decrease abnormal movement patterns to resolve remaining impairments after
surgery (White et al., 2013).
Among the most common injuries, in daily and sport activities, are knee and ankle
injuries. The terms related to these injuries are ‘proprioceptive deficit’, ‘proprioceptive training’,
and ‘proprioceptive rehabilitation’. These terms are being tossed around more frequently in the
sports medicine field. Medical professionals need a general understanding of the afferent
proprioceptive system and its importance in joint function. They must be aware of how to
incorporate this ‘proprioceptive training’ during rehabilitation. They observe a decreased range
of motion, decreased strength of knee extensors, and a decrease in joint proprioception as being
factors that contribute to functional knee and ankle instability. Proprioception refers to the
“inborn kinesthetic awareness” of body posture including movement, tension, and changes in the
equilibrium involving the affected joint. In the absence of mechanical stability symptoms of
functional instability are reported. An optimal rehabilitation program must acknowledge the
activity to which the patient will return. By taking into consideration the level of activity one
will be experiencing, the therapist is better able to make a rehab program for the individual.
Rehabilitation of the knee or ankle will concentrate on specific groups for each area. For
example, the therapist must consider the explosive power used for acceleration in sprinting for a
track athlete when creating a rehabilitation program. Therefore, rehabilitation of an injury must
consider restoring the proprioception sense. Typically, this can be done by the restoration of
neuromuscular function in ACL deficient patients by focusing on training the thigh muscle for
strength. Emphasis on the proprioceptive function of the ACL can enhance our understanding of
why reconstructions do not create the normal knee that once existed. Without proper training,
the proprioceptive sense that existed before the ACL injury can interrupt the ACL-muscle reflex
arc. This impedance triggers a slower pathway that may produce abnormal muscle activation
patterns of the hamstrings and quadriceps. Overall reducing the dynamic stability of the
extremity (Baltaci and Kohl, 2003).
Neuromuscular electrical stimulation can be a beneficial supplement to traditional forms
of postoperative therapy. There has been a significant increase in results when using
neuromuscular electrical stimulation. However, there has also been results with minimal or no
difference when neuromuscular electrical stimulation was used to strengthen the muscles
affected during postoperative rehabilitation. The primary objective during postoperative
rehabilitation is to reduce inflammation, regain neuromuscular strength and functional
performance, recover normal range of motion and reintegrate the patient to everyday activities.
Recent reviews conclude that rehabilitation training with neuromuscular electrical stimulation
superimposed on voluntary contraction was better than either neuromuscular electrical
stimulation or voluntary contraction practiced separately. When both ways of treatment are
used, either neuromuscular electrical stimulation or non-neuromuscular electrical stimulation,
there will be positive results in each. However, when neuromuscular electrical stimulation is
used the strength and functional performance results are consistently better. With the use of
neuromuscular electrical stimulation and other conventional rehabilitation methods, patients
could be able to return their everyday activities days sooner than those who may not use the
method of neuromuscular electrical stimulation. (Feil, et al., 2011).
Methodology
A survey was administered to a team of professionals that were either certified athletic
trainers or physical therapists. This survey provided an overview of the different aspects
addressed by this study. A survey was conducted with multiple choice questions and short
answer questions. This survey was sent to a small number of professionals with four out of the
five responding. Of these participants, three were in the age range of 25-30 and one between the
age range of 45-50. I thought these age factors may cause an interesting pattern in results due to
the continuous advancement that takes place in therapy. Typically the older population of
therapists and trainers will use different methods of therapy for rehabilitation because these
methods are what they learned in school. However, all four participants chose similar answers
proving this hypothesis invalid. Possibly the requirement of keeping up to date with the newest
techniques can be a factor for this result.
The survey itself was created to get a general consensus about what rehabilitation
methods therapists and trainers use and/ or prefer. This enabled for the analysis of
neuromuscular training versus traditional resistance training for postoperative rehabilitation. The
survey asked a series of questions pertaining to the use of each therapy method and the
preference of each therapist or trainer. These questions were created to be effective in compiling
an amount of data surrounding the topic being analyzed between neuromuscular training and
traditional resistance training. The study was administered through an email and an online survey
that was sent out to the participants, asking for their patience and participation. After the ten
days concluded, results were collected and ready to be analyzed. The survey that was
administered is on page 16.
Data Collection & Analysis
After the surveys had been taken, responses were recorded and then evaluated. Software
through Survey Monkey was used to evaluate data. Each aspect of the study was looked at
within the different questions to determine any information that may be valuable to the research
process.
Results
The results of this study were fairly straightforward and slightly expected. 100% of the
participants were familiar with both methods of therapy. 100% of the respondents preferred a
combination of both neuromuscular training and traditional resistance training for postoperative
rehabilitation. When focusing on the prevalence of ACL injuries per year, 66.7% involved 1-5
ACL injuries while 33.3% involved 6-9 ACL injuries. However, there was variation in answers
when focusing on the strength of lower extremity muscles during postoperative rehabilitation. A
100% was received for both the Quadriceps Femoris and Hamstring muscles, but 66.7% was
received for Gluteus Medius and 33.3% for the Gastrocnemius.
The purpose of this study was to determine the rehabilitation methods of neuromuscular
training in postoperative rehabilitation versus the methods of traditional resistance training. The
results show the familiarity of each form of rehabilitation.
The following graphs provide a visual of the results for the data collected. The first
graph illustrates the different sport teams each professional works with. The latter graphs
demonstrate the prevalence of injuries among the sports, preferred neuromuscular training
methods, and lower extremity muscles emphasized during postoperative rehabilitation.
Discussion & Recommendations
Prior to the survey, I was curious to see how the results would pan out. I thought there
might be a difference in the use of therapy methods. However, I was proved wrong. Results
show that physical therapists and physical therapists use similar methods of training for
rehabilitation. Typically, athletic trainers focus on acute care and prevention. They go through a
different schooling process to obtain their degree. While therapists are required to go to school
for three full years after their undergraduate studies to obtain their Doctorate’s Degree.
Therefore, the reasoning for my curiosity in the prescription and use of both therapy methods
between each group of survey participants.
Analysis of the data from this study showed that there was no difference in selection of
rehabilitation methods. Relatively both rehabilitation methods were popular among the two
groups. This does not mean that all athletic trainers and physical therapists prefer a combination
of both methods since a small group was surveyed. Although, each therapist and trainer will
have their own opinion in the use of particular methods, the trend from this survey shows there is
a preference for each.
Today, researchers are unable to prove that a particular rehabilitation method is better
than the other. The fact is that both rehabilitation methods have been used for years by physical
therapists and athletic trainers. Success from postoperative treatment provides proof for the use
of a combination of each method. Research has shown that there is a significant increase in
return to the daily activities when using a form of neuromuscular training paired with traditional
strength training during postoperative rehabilitation.
Dear Participant,
The purpose of this study is to determine the benefits of neuromuscular training in postoperative
rehabilitation versus the use of traditional resistance training, and using these findings to
compare to the incidence rates of injury. There are three main objectives for this study. They
are as follows: a) to determine the benefits of using both training options together and by
themselves, b) to determine the common forms of neuromuscular training being used today, and
c) to determine if specialists in the field have a preference of training techniques over the other.
You are invited to participate in this study because you are a specialist in the field of
rehabilitation for injuries.
Participation in this study will require approximately 5-10 minutes of your time. You will
complete a 12-question survey and then be asked for any additional thoughts about any of the
topics or the survey itself.
The information gained from this study may help us to better understand a) the benefits of
neuromuscular training and strength training techniques, b) common forms of neuromuscular
training and strength training, and c) the preference of training being used today.
Any information obtained from this survey will be kept confidential. The information taken
from this will be used to progress the results of this study.
Please follow the link below to participate in this survey:
https://www.surveymonkey.com/s/HG7N5J5
Thank you for your time and participation in our study.
Kendra Alberts
1. What sport teams do you typically work with? Please check all that apply.
Baseball
Men’s Basketball
Women’s Basketball
Men’s Cross Country
Women’s Cross Country
Dance
Football
Men’s Golf
Women’s Golf
Men’s Soccer
Women’s Soccer
Softball
Men’s Tennis
Women’s Tennis
Men’s Indoor Track and Field
Women’s Indoor Track and Field
Men’s Outdoor Track and Field
Women’s Outdoor Track and Field
Volleyball
Wrestling
2. What is the prevalence of ACL injuries within the sports teams you work with?
1-5
6-9
10-15
16-19
20-25
26-30
3. Are you familiar with the use of neuromuscular training as a postoperative rehabilitation
method?
Yes
No
4. Are you familiar with the use of strength training as a postoperative rehabilitation method?
Yes
No
5. Do you agree with the use of preoperative strengthening of the affected extremity?
Yes
No
6. Which forms of neuromuscular training are you most familiar with? Please check all that
apply.
Balance exercises
Dynamic Joint Stability exercises
Plyometric exercises
Agility Drills
Sport Specific exercises
If none of these apply please list..
7. When focusing on the strength of the lower extremity, which muscles do you place the most
emphasis on? Please check all that apply.
Quadriceps Femoris
Hamstring
Gluteus Medius
Gastrocnemius.
If none of these apply please list..
8. Do you have a preference of training type for postoperative rehabilitation over the other? Or
do you prefer a combination of both?
9. What is your gender?
Female
Male
10. How old are you?
11. Which academic institution did you earn your advanced degree from?
12. Please feel free to express any other information you feel would contribute to this survey.
References
Baltaci, G., & Kohl, H. W. (2003). Does proprioceptive training during knee and ankle
rehabilitation improve outcome?. Physical Therapy Reviews, 8(1), 5-16.
Feil, S., Newell, J., Minogue, C., & Paessler, H. H. (2011). The effectiveness of supplementing a
standard rehabilitation program with superimposed neuromuscular electrical stimulation
after anterior cruciate ligament reconstruction: a prospective, randomized, single-blind
study. The American Journal of Sports Medicine, 39(6), 1238-1247.
Niemuth, P. (2007). The role of hip muscle weakness in lower extremity athletic injuries..
International SportMed Journal, 8(4), 179-192.
White, K., Stasi, S. L., Smith, A. H., & Snyder-Mackler, L. (2013). Anterior cruciate ligamentspecialized post-operative return-to-sports (ACL-SPORTS) training: a randomized
control trial. BMC Musculoskeletal Disorders, 14(1), 108.