How does a motor or cognitive dual-task affect our sense of upper limb proprioception?

BACKGROUND: Daily upper limb activities require multitasking and our division of attention. How we allocate our attention can be studied using dual-task interference (DTi). Given the vital role proprioception plays in movement planning and motor control, it is important to investigate how conscious upper limb proprioception is impacted by DTi through cognitive and motor interference. PURPOSE: To examine how dual-task interference impacts conscious upper limb proprioception during active joint repositioning tasks (AJRT). METHODS: Forty-two healthy participants, aged between 18 and 35, took part in this cross-sectional study. Participants completed two AJRT during three conditions: baseline (single task), dual-cognitive task (serial subtractions), and dual-motor task (non-dominant hand movements). The proprioceptive error (PE; difference between their estimation and targeted position) was measured using an AJRT of 75% and 90% of maximum internal rotation using the Biodex System IIITM and the Upper Limb Proprioception Reaching Test (PRO-Reach). To determine if PEs differed during dual-task interference, interference change scores from baseline were used with one sample t-tests and analyses of variance. RESULTS: The overall mean PE with the Biodex was 4.1° ± 1.9 at baseline. Mean change scores from baseline reflect a mean improvement of 1.5° ± 1.0 (p < .001) during dual-cognitive task and of 1.5° ± 1.2 (p < .001) during dual-motor task. The overall mean PE with the PRO-Reach was 4.4cm ± 1.1 at baseline. Mean change scores from baseline reflect a mean worsening of 1.0cm ± 1.1 (p < .001) during dual-cognitive task and improvement of 0.8cm ± 0.6 (p < .001) during dual-motor task. Analysis of variance with the Biodex PEs revealed an interference effect (p < .001), with the cognitive condition causing greater PEs compared to the motor condition and a criterion position effect (p = .006), where 75% of maximum IR produced larger PEs during both interference conditions. An interference effect (p = .022) with the PRO-Reach PEs was found highlighting a difference between the cognitive and motor conditions, with decreased PEs during the contralateral motor task. CONCLUSION: Interference tasks did impact proprioception. Cognitive interference produced mixed results, whereas improved proprioception was seen during motor interference. Individual task prioritization strategies are possible, where each person may choose their own attention strategy when faced with dual-task interference.

Relationship between pain and proprioception among individuals with rotator cuff-related shoulder pain.

BACKGROUND: Individuals with rotator cuff-related shoulder pain (RCRSP) have altered proprioception. The relationship between shoulder pain and proprioception is not well understood. PURPOSE: This study aimed to investigate the relationship between shoulder pain and proprioception. STUDY DESIGN: This was a cross-sectional comparative study. METHODS: Twenty-two participants with RCRSP (mean age 27.6 ± 4.8 years) and 22 matched pain-free participants (23.4 ± 2.5 years) performed two upper limb active joint position sense tests: (1) the Upper Limb Proprioception Reaching Test (PRO-Reach; reaching toward seven targets) in centimeters and (2) Biodex System at 90% of maximum internal rotation in degrees. Participants performed three memorization and three reproduction trials blindfolded. The proprioception error (PE) is the difference between the memorized and estimation trials. Pain levels were captured pre- and post-evaluation (11-point Likert Numerical Pain Rating Scale). Relationships between PE and pain were investigated using independent t-tests and Spearman rank correlations. RESULTS: Overall, 22.7% RCRSP participants indicated an increase in pain following the PRO-Reach (X̅ increase of 1.4 ± 1.5 points), while 59% did so with the Biodex (X̅ increase of 2.3 ± 1.8 points), reflecting a clinically important increase in pain. Weak-to-moderate correlations between pain and PEs were found with the Biodex (r = 0.39-0.53) and weak correlations with the PRO-Reach (r = -0.26 to 0.38). Concerning PEs, no significant differences were found between groups with the Biodex (p = 0.32, effect size d = -0.31 [-0.90 to 0.29]). The RCRSP participants demonstrated lower PEs with the PRO-Reach in elevation compared to pain-free participants (global X̅ = 4.6 ± 1.2 cm vs 5.5 ± 1.5 cm; superior 3.8 ± 2.1 cm vs 5.7 ± 2.9 cm; superior-lateral nondominant targets 4.3 ± 2.2 cm vs 6.1 ± 2.8 cm; p = 0.02-0.05, effect size d = 0.72-0.74 [0.12-1.3]). CONCLUSIONS: Individuals with RCRSP demonstrated better upper limb proprioception in elevation, suggesting a change to interoception (sensory reweighting) in the presence of pain.

Measuring upper limb active joint position sense: Introducing a new clinical tool - The Upper Limb Proprioception Reaching Test.

BACKGROUND: Proprioception is our sense of body awareness, including the sub-category of active joint position sense (AJPS). AJPS is fundamental to joint stability and movement coordination. Despite its importance, there remain few confident ways to measure upper limb AJPS in a clinic. OBJECTIVE: To assess a new AJPS clinical tool, the Upper Limb Proprioception Reaching Test (PRO-Reach; seven targets), for discriminant validity, intra-rater and absolute reliability. DESIGN: Cross-sectional measurement study. METHODS: Seventy-five healthy participants took part in a single session with 2 consecutive evaluations (E1 and E2) (within-day reliability). Twenty participants were randomly selected to perform a dominant shoulder fatigue protocol (discriminant validity), whereafter a third evaluation was repeated (E3). The PRO-Reach was analyzed with paired t tests (discriminant validity), intra-class correlation coefficients (ICCs) and minimal detectable change [MDC]) (intra-rater: within-day and between-trial relative and absolute reliability). RESULTS: The PRO-Reach supports moderate (mostly superior targets) to excellent (mostly inferior targets) reliability. Between-trial ICCs (T1/T2/T3) varied between 0.72 and 0.90, and within-day (E1/E2) ICCs between 0.45 and 0.72, with associated MDC95 values (3.9-5.0 cm). The overall scores (seven targets) supported the strongest within-day reliability (ICC = 0.77). The inferior targets demonstrated the highest between-trial and within-day reliability (ICCs = 0.90 and 0.72). A fatigue effect was found with the superior and superior-lateral targets (P < .05). CONCLUSIONS: The inferior targets and overall scores demonstrate the strongest reliability. The use of the PRO-Reach tool may be suitable for clinical use upon further psychometric testing amongst pathological populations. LEVEL OF EVIDENCE: Level III cross-sectional study.

Effects of elastic kinesiology taping on shoulder proprioception: a systematic review.

BACKGROUND: Shoulder injuries are associated with proprioceptive deficits. Elastic kinesiology tape (KT) is used for treating musculoskeletal disorders, including shoulder injuries, as it arguably improves proprioception. OBJECTIVE: To synthesize the evidence on the effects of elastic KT on proprioception in healthy and pathological shoulders. METHODS: Four databases (PubMed, WoS, CINAHL, SPORTDiscus) were searched for studies that investigated the effects of elastic KT on shoulder proprioception. Outcome measures were active joint position sense (AJPS), passive joint position sense (PJPS), kinesthesia, sense of force (SoF), and sense of velocity (SoV). Risk of bias (RoB) was assessed using the Cochrane Collaboration RoB tool for randomized controlled trials (RCTs), and the ROBINS-1 for non-RCTs, while the certainty of evidence was determined using GRADE. RESULTS: Eight studies (5 RCTs, 3 non-RCTs) were included, yielding 187 shoulders (102 healthy and 85 pathological shoulders). RoB ranged from low (2 studies), moderate (5 studies), to high (1 study). Elastic KT has a mixed effect on AJPS of healthy shoulders (n=79) (low certainty). Elastic KT improves AJPS (subacromial pain syndrome and rotator cuff tendinopathy, n=52) and PJPS (chronic hemiparetic shoulders, n=13) among pathological shoulders (very low certainty). Elastic KT has no effect on kinesthesia among individuals with subacromial pain syndrome (n=30) (very low certainty). CONCLUSION: There is very low to low certainty of evidence that elastic KT enhances shoulder AJPS and PJPS. The aggregate of evidence is currently so low that any recommendation on the effectiveness of elastic KT on shoulder proprioception remains speculative.

Rehabilitation services must include support for sexual and gender-based violence survivors in Ukraine and other war- and conflict-affected countries.

Sexual and gender-based violence (SGBV)-both during times of war and peace-can have impactful negative social and health outcomes. Reports of rape being used as an act of war in Ukraine are drawing global attention to the need for specialized care for SGBV survivors during times of war and thereafter. While data remain limited, in 3 November 2022, 7 million people in Ukraine were reported to need SGBV prevention and response services. Services offered by the government and civil society include a coordination centre of free legal aid, online and mobile platforms, chat-bots, hotlines, assistance centres, shelters, crisis rooms and mobile brigades. Rehabilitation services to support women and girls who have experienced SGBV during times of conflict and war, however, remain limited. We must make sure that our understanding of rehabilitation extends beyond providing physical modalities or recovery after surgery and that SGBV survivors are not excluded from necessary care. This is particularly important if we want to ensure that rehabilitation services are meeting the needs of the most vulnerable populations. We call on the international rehabilitation community to ensure the availability of and access to these vital life-changing services.

Role of active joint position sense on the upper extremity functional performance tests in college volleyball players.

Background: It has been well established that proprioception plays a decisive role in shoulder stability and sport performance. Notwithstanding, there is a lack of clear association between active joint position sense (AJPS) and the performance of upper-extremity functional performance tests. The aim of this study was to determine whether the AJPS of the shoulder complex is associated with the performance of college volleyball players with the following functional tests: Y-Balance Test-Upper Quarter (YBT-UQ), Closed Kinetic Chain Upper-Extremity Stability Test (CKCUEST), and Seated Medicine Ball Throw (SMBT). The secondary aim was to investigate whether the magnitude of the proprioception error through the AJPS had the ability to act as a predictor for functional test scores. Methods: Cross-sectional study with a convenience sampling. Healthy college volleyball players (≥12 h of training/week), 30 males and 22 females, between 18 and 26 years of age were included. AJPS of the shoulder (90° of flexion (90°Flex), 90° of internal rotation at 90° of abduction (90°IR/ABD), 90° of external rotation at 90° of abduction (90°ER/ABD)) and three upper-extremity functional performance tests (YBT-UQ, CKCUEST and SMBT) were assessed. A Pearson's test and a stepwise multiple linear regression analysis were used to determine possible associations and relationships between outcome measures, respectively. Results: The analysis revealed that AJPS at 90°IR/ABD and 90°ER/ABD were the only proprioceptive variables with an association to the YBT-UQ and SMBT. Despite these relationships, only the AJPS at 90°IR/ABD was associated with the performance of the YBT-UQ in; superolateral direction (ß = -0.7; 95% CI [-1.3 to 0.1]; p = 0.025); inferolateral direction (ß = -1.5; 95% CI [-2.1 to -0.8]; p = 0.001); and composite score (ß = -0.8; 95% CI [-1.3 to -0.3]; p = 0.002). From these, AJPS at 90°IR/ABD mainly explained the variability of YBT-UQ (inferolateral direction) performance (R2 = 0.32; %R2 = 0.32). Our findings allow for a possible expanded role for proprioception as a contributing factor in upper limb motor control during functional movements. Further research is required to explore and distinguish the associations between proprioception, motor control and sport performance involving the upper limbs.

Is There a Decrease in the Acromiohumeral Distance Among Recreational Overhead Athletes With Rotator Cuff-Related Shoulder Pain?

CONTEXT: Recreational overhead athletes are exposed to high overload, which increases the risk of shoulder injuries. Reduction of the acromiohumeral distance (AHD) is often associated with rotator cuff-related shoulder pain (RCRSP) among the general population. However, the AHD of symptomatic shoulders of recreational athletes has not yet been compared with their asymptomatic shoulders. OBJECTIVE: To compare the AHD of a symptomatic to asymptomatic shoulder at rest (0°) and 60° abduction. To establish the relationship between AHD, pain, and functional limitations of recreational athletes with RCRSP. DESIGN: Cross-sectional study. SETTING: University laboratory. PARTICIPANTS: A total of 45 recreational overhead athletes with RCRSP were examined. MAIN OUTCOME MEASURES: The AHD was measured by ultrasonography at 0° and 60° abduction (angles). Shoulder pain was assessed using a numeric pain scale, whereas functional limitations were assessed using the The Disabilities of the Arm, Shoulder, and Hand questionnaire. Differences in the between-shoulders condition (symptomatic and asymptomatic) were determined using 2-way analysis of variance for repeated measures. A Pearson correlation established the relationship between AHD, pain, and functional limitations. RESULTS: No angles × shoulder condition interactions (P = .776) nor shoulder condition effects (P = .087) were detected, suggesting no significant differences (P > .05) between asymptomatic and symptomatic shoulders in the AHD at 0° or 60°. The AHD at 60° reduced significantly compared with 0° (3.05 [1.36] mm [2.77-3.33], angle effects: P < .001). The AHD at 0° and 60° was not correlated with pain or functional limitations (-.205 ≤ r ≤ .210, .167 ≤ P ≤ .585). CONCLUSIONS: The AHD of recreational athletes is not decreased in symptomatic shoulders compared with asymptomatic shoulders. Reduction of the AHD in symptomatic shoulders is not associated with an increase in pain or functional limitations of recreational athletes with RCRSP.

Can a Conservative Rehabilitation Strategy Improve Shoulder Proprioception? A Systematic Review.

CONTEXT: Proprioception deficits contribute to persistent and recurring physical disability, particularly with shoulder disorders. Proprioceptive training is thus prescribed in clinical practice. It is unclear whether nonsurgical rehabilitation can optimize shoulder proprioception. OBJECTIVES: To summarize the available evidence of conservative rehabilitation (ie, nonsurgical) on proprioception among individuals with shoulder disorders. EVIDENCE ACQUISITION: PubMed, Web of Science, and EBSCO were systematically searched, from inception until November 24, 2019. Selected articles were systematically assessed, and the methodological quality was established using the Dutch Cochrane Risk of Bias Tool and the Newcastle-Ottawa Quality Assessment Scale. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were utilized for this review. The conservative treatments were categorized as follows: (1) conventional therapy, (2) proprioceptive training, (3) elastic kinesiology tape, and (4) other passive therapies. EVIDENCE SYNTHESIS: Twelve articles were included, yielding 58 healthy control shoulders and 362 shoulders affected by impingement syndrome, glenohumeral dislocations, nonspecific shoulder pain, rotator cuff dysfunction, or subluxation poststroke. The level of agreement between the evaluators was excellent (84.9%), and the studies were evaluated to be of fair to excellent quality (risk of bias: 28.5%-100%). This review suggests, with moderate evidence, that proprioceptive training (upper-body wobble board or flexible foil training) can improve proprioception in the midterm. No decisive evidence exists to suggest that conventional therapy is of added value to enhance shoulder proprioception. Conflicting evidence was found for the improvement of proprioception with the application of elastic kinesiology tape, while moderate evidence suggests that passive modalities, such as microcurrent electrical stimulation and bracing, are not effective for proprioceptive rehabilitation of the shoulder. CONCLUSIONS: Proprioceptive training demonstrates the strongest evidence for the effective rehabilitation of individuals with a shoulder proprioceptive deficit. Elastic kinesiology tape does not appear to affect the sense of shoulder proprioception. This review suggests a possible specificity of training effect with shoulder proprioception.

Proprioception: How is it affected by shoulder pain? A systematic review.

INTRODUCTION: Proprioception encompasses the submodalities of joint position sense (JPS), kinesthesia, sense of force, and velocity. Owing to the vast mobility of the shoulder, it heavily relies on an intact sense of proprioception. Moreover, shoulder injuries are associated with a decreased sense of proprioception. What remains unclear is how shoulder proprioception is affected by pain and competing nociceptive senses. PURPOSE OF THE STUDY: To summarize the literature evaluating the relationship between pain and shoulder proprioception. METHODS: A literature review was conducted from inception until 22 October 2018, using electronic databases (PubMed, Web of Science, Scopus, EBSCO, CINAHL, and Embase). Retrieved citations were screened for eligibility, and methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS: Eleven studies were included (n = 447 participants with shoulder pain, n = 20 with experimentally induced pain [EIP]/n = 600 painful shoulders and n = 20 [EIP]). The mean methodological quality of the studies was good (76%). Five studies investigated active JPS, four investigated passive JPS, six investigated kinesthesia, sense of force was measured in one study, and no study investigated sense of velocity. There is moderate evidence for impaired kinesthesia and low evidence for reduced sense of force among painful shoulders. Conflicting evidence is seen for the other proprioceptive submodalities. CONCLUSION: The overall impact of pain on shoulder JPS remains unclear, while moderate evidence for an affected sense of kinesthesia is possible. There is low evidence for an impaired sense of force among painful shoulders. Standardization between studies is lacking, limiting the range of our conclusions. Further investigation is required into well-controlled and pain-induced studies to better understand the influence of pain on shoulder proprioception.

The Effectiveness of an Upper Extremity Neuromuscular Training Program on the Shoulder Function of Military Members With a Rotator Cuff Tendinopathy: A Pilot Randomized Controlled Trial.

INTRODUCTION: Shoulder pain, a leading reason to consult a physician or physiotherapist, continues to be a challenge to rehabilitate, particularly with a military population. A rotator cuff (RC) tendinopathy, the most important source of shoulder pain, is one of the leading reasons for sick leave or a discharge from active military service. Research encourages the use of exercise prescription for the management of a RC tendinopathy, however the ideal method of delivery (group setting versus one-on-one) remains uncertain. The purpose of this single-blind (evaluator) pilot randomized clinical trial was to compare two 6-week rehabilitation programs, a newly developed group-supervised neuromuscular training program and usual one-on-one physiotherapy care, on the pain and symptoms of Canadian soldiers affected by a RC tendinopathy. MATERIALS AND METHODS: Thirty-one soldiers with the Canadian Armed Forces were randomly assigned to (1) a group-supervised neuromuscular training program (UPEx-NTP) or; (2) one-on-one usual physiotherapy care (UPC). The primary outcome was the Disability of Arm, Hand and Shoulder (DASH) questionnaire. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) Index, pain levels at rest, and maximum isometric voluntary contractions (MIVC) of the abductors and external (lateral) rotators of the affected shoulder. Both were assessed at baseline (T0), 6 (T6) and 12 (T12) weeks. Analysis included two-way repeated measures of variance for intention-to-treat (ITT) and per-protocol analyses. RESULTS: Eighty military members with a RC tendinopathy were contacted, resulting in 31 participants who were randomized for their active intervention, in the UPEx-NTP or UPC, respectively. No significant group (p ≥ 0.16) or group × time interactions (p ≥ 0.11) were found for either ITT or per-protocol analyses. A statistically significant time effect (p < 0.001) was established for the DASH and WORC, showing that both groups improved over time. CONCLUSIONS: Our preliminary data demonstrates that both rehabilitation approaches, grounded in active exercises, were not statistically different from each other, and derived similar benefits over time for a military population. This suggests that a group intervention for a RC tendinopathy has potential to be just as effective as a one-on-one approach for a military population, an interesting avenue for an active working population. Larger sample sizes and further investigation are warranted regarding the cost and clinical resource benefits of a supervised group approach.

Shoulder proprioception: How is it measured and is it reliable? A systematic review.

STUDY DESIGN: Systematic review. INTRODUCTION: Constituents of proprioception include our awareness of the position (joint position sense [JPS]) and motion (kinesthesia) of our limbs in space. Proprioceptive deficits are associated with musculoskeletal disorders but remain a challenge to quantify, particularly at the shoulder. PURPOSE OF THE STUDY: To report the psychometric values of validity, reliability, and responsiveness for shoulder JPS and/or kinesthesia protocols. METHODS: A review of 5 databases was conducted from inception to July 2016 for studies reporting a psychometric property of a shoulder proprioception protocol. The included studies were evaluated using the QualSyst checklist and COSMIN 4-point scale. RESULTS: Twenty-one studies were included, yielding 407 participants and 553 evaluated shoulders (n). The included studies support excellent methodological scores using the QualSyst checklist (88.1 ± 9.9%) and good psychometric scores with the COSMIN for reliability (71.1%) and moderate-to-low quality score (50%) for criterion validity. Weighted average intraclass correlation coefficients (ICCs) for intrarater reliability were highest for passive JPS and kinesthesia, ICC = 0.92 ± 0.07 (n = 214) and ICC = 0.92 ± 0.04 (n = 74), respectively. The most reliable movement and tool are internal rotation at 90° of abduction, ICC = 0.88 ± 0.01 (n = 53), and the dynamometer, ICC = 0.92 ± 0.88 (n = 225). Only 2 studies quantify an aspect of validity and no responsiveness indices were reported among the included studies. CONCLUSION: Based on the results of the included studies, the evaluation of shoulder proprioception is most reliable when using a passive protocol with an isokinetic dynamometer for internal rotation at 90° of shoulder abduction. Standardized protocols addressing the psychometric properties of shoulder proprioception measures are needed. LEVEL OF EVIDENCE: Level 1a: systematic review.

Electromyographic analysis of rotator cuff muscles in patients with rotator cuff tendinopathy: A systematic review.

The shoulder is inherently an unstable joint which heavily relies on the neuromuscular activation of the rotator cuff (RC) complex for stability during movement. Currently, there is no consensus regarding how the activity of RC muscles is affected among individuals with a RC tendinopathy (RCTe). This study reviewed the evidence of studies comparing the electromyographic (EMG) activity of any RC muscle of shoulders with a symptomatic RCTe to asymptomatic shoulders. Eight databases were searched. Data from 343 participants (201 symptomatic and 209 asymptomatic shoulders) were analyzed from 10 out of 402 included studies. Strong evidence for the infraspinatus and supraspinatus during isometric contractions and limited evidence for the supraspinatus and infraspinatus during isokinetic contractions suggest that the muscular activity is not altered among individuals with a RCTe during these types of contraction. Very limited evidence indicates reduced muscle activity for the infraspinatus and subscapularis in the presence of a RCTe during isotonic contractions, and no alterations for the supraspinatus or teres minor were identified. Lastly, conflicting to moderate evidence suggests alterations in RC muscle activity during unrestrained movements and swimming. These findings indicate that EMG deficits associated with a RCTe can best be appreciated during unrestrained movements.