Journal of Hand Therapy xxx (2020) 1e4 Contents lists available at ScienceDirect Journal of Hand Therapy journal homepage: www.jhandtherapy.org Practical exercises for thumb proprioception Raquel Cantero-Téllez PhD, PT, OT *, Ivan Medina Porqueres PT, MSc Faculty of Health Sciences, Physiotherapy Department, University of Malaga, 29010, Málaga, Spain a r t i c l e i n f o Article history: Received 14 January 2020 Accepted 2 March 2020 Available online xxx Keywords: Thumb Thumb stability Proprioception Thumb proprioception Introduction We need a sense of where our thumb is and how it is moving to interact efficiently with our environment. Thumb movement is a fundamental and essential component of human life. All the afferent neural inputs originating from mechanoreceptors about the thumb joints constitute thumb proprioception. This proprioceptive input can be appreciated consciously as joint position sense and kinesthesia (joint movement sense) and force/application to the joints.1 Numerous studies have advocated that proprioception is crucial in hand function and plays a critical role for accurate movement and for preserving joint stability in shoulder, hip, knee, ankle, and wrist joints.2-5 Although the role of thumb proprioception has yet not been fully developed, the importance of neuromuscular control and mechanoreceptors present in ligaments and tendons for muscle action and thumb stability has been highlighted.6,7 Thumb mechanoreceptors detect abnormal mechanical stress and provide afferent information on joint position and velocity.8,9 Proprioceptive exercise regimes have been widely used for treating different conditions and are recognized as key components in the restoration of joint control and joint function.10,11 Previous research has stressed the relevance of proprioception in manual tasks when performing a variety of activities, such as buttoning a shirt, picking up small items, writing, and lifting objects with different weights.12 It has been established that the distribution of mechanoreceptors corresponds to specific proprioceptive functions and the innervation of ligaments could differ among patients with different pathologies.8 This fact could have repercussion on the type of exercises and may be the objective for future research. Purpose Based on previously described proprioception assessment techniques,13-15 a thumb proprioceptive exercise protocol will be determined to address impairments, dysfunction, and any imbalance to be corrected. Thumb exercises based on proprioception assessment techniques Proprioception can be assessed using different methodologies. There are three main testing techniques for assessing proprioception: Threshold to Detection of Passive Motion (TTDPM),15 Reproduction of Passive and Active Joint Position (RPJP and RAJP), also known as joint position matching,13 and Active Movement Extent Discrimination Assessment (AMEDA).14 Thumb exercises for Detection of Passive Motion (DPM) * Corresponding author. Faculty of Health Sciences, Physiotherapy Department, University of Malaga, 29010, Málaga, Spain. Tel./fax: þ34 952226453. E-mail address: cantero@uma.es (Raquel Cantero-Téllez). Movement type: Passive (Fig. 1A and B). Movement velocity: Very slow. Proprioceptive information: Largely movement information. Vision: Blocked. 0894-1130/$ e see front matter Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2020.03.005 2 R. Cantero-Téllez, I. Medina Porqueres / Journal of Hand Therapy xxx (2020) 1e4 Fig. 1. (A and B) Therapy passively reproduces flexion or extension movements in the desirable range of motion. The patient with eyes closed should tell whether the finger has been moved into flexion (in this case represented with the number 1) or extension (number 2). Fig. 2. The patient is asked to reproduce letters or numbers both in open and closed kinetic chain patterns. Fig. 4. (A and B) A tennis ball is used to ensure correct thumb position. An elastic band will guide the movement and mark two different positions. Patient is asked to slide his/her thumb along the line, stopping at position 1 and position 2. After 3 to 5 repetitions, the patient may repeat the exercise with eyes closed. Objective: Patients should report the perceived direction of movement of their thumb. Fig. 3. The patient is asked to perform pinch force until the dynamometer reaches a certain number. After 3 to 5 repetitions, the patient is asked to close their eyes and try to reproduce the movement by doing the same pressure. This exercise can also be performed with different types of clamp depending on the objective. Thumb exercises for Reproduction of Passive and Active Joint Position (RPJP and RAJP) Movement type: Passive/active (Figs. 2, 3, 4A, and 4B, 5A-5C). Movement velocity: Slow to normal. Proprioceptive information: Depends on whether a physical stop is used during target joint position establishment. Vision: Blocked. Objective: Patients should reproduce thumb movements. The thumb is returned to the initial start position, either passively by hand therapist or actively. Patients are then required to reproduce the target thumb position previously experienced, that is, he/she needs to remember the target position and reproduce it. R. Cantero-Téllez, I. Medina Porqueres / Journal of Hand Therapy xxx (2020) 1e4 3 Fig. 5. (A, B, and C) A stick marked with different numbered lines is used. The patient is asked to alternatively tip these marked points. Different wrist and elbow positions can be used. Reproducing these maneuvers with eyes closed will increase the difficulty. (D) With a finger dynamometer attached to the thumb, the patient is asked to perform a specific movement. Generated tension is then recorded. Subsequently, the patient is asked to reproduce the same tension in the same plane but with eyes closed. This action can be accomplished at any thumb movement. Objective: To allow proprioception assessment using “real-life” movements. Clinical implications Fig. 6. (A and B) Several daily-life activities are used using different thickness, strength, texture, or weight of objects. Patient should recognize the object: its shape, its weight, or its texture>. Thumb exercises for Active Movement Extent Discrimination Assessment (AMEDA) Movement type: Active (Fig. 6). Movement velocity: Normal. Proprioceptive information: Both movement and position information. Vision: Available. Clinically, reduced thumb proprioception can be found after stroke, thumb carpometacarpal joint osteoarthritis, ligament injuries, or any condition affecting thumb mobility. Proprioception is important for motor control and can be used in combination or in the absence of other sensory systems. An optimal rehabilitation must acknowledge the tasks the patient will assume in the future. Proprioceptor exercises could help therapists improve motor planning and patients' performance during task execution. With intent of providing a common foundation for thumb proprioception reeducation, a preliminary exercise regimen proposal is hereby provided to the reader. Clinical studies are needed to investigate the impact of proprioception loss on thumb and hand function, and the effect of proprioception reeducation in patients and subjects with a high demand on the thumb column in both preventing and rehabilitating thumb conditions. References 1. Myers JB, Lephart SM. The role of the sensorimotor system in the athletic shoulder. J Athl Train. 2000;35(3):351e363. 2. Hagert E. Proprioception of the wrist joint: a review of current concepts and possible implications on the rehabilitation of the wrist. J Hand Ther. 2010;23(1):2e17. 3. Ager AL, Roy J-S, Roos M, Belley AF, Cools A, Hébert LJ. Shoulder proprioception: how is it measured and is it reliable? A systematic review. J Hand Ther. 2017;30(2):221e231. 4 R. Cantero-Téllez, I. Medina Porqueres / Journal of Hand Therapy xxx (2020) 1e4 4. 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