Stroke rehabilitation often concentrates on whether the patient can move, which means muscle strength and movement. Another equally important problem is often overlooked: many patients cannot feel where their arms and legs are in space. This is impaired proprioception. It is not as easy to see as weakness, but it makes movement clumsy, so the patient has to confirm with vision before moving, and learning new movements is especially slow, which directly slows the whole of movement recovery.
This article looks only at the motor control side of physiotherapy. It explains what proprioception is, why stroke damages it, how a physiotherapist assesses it at the bedside, and the evidence-based principles of joint position sense re-education. This page concentrates on the relationship between proprioception (deep sensation) and movement. For the overall re-education of superficial sensation such as touch, pain and temperature, read the overview of sensory re-education after stroke first.
The difference between proprioception and touch
The sensory system falls roughly into two layers. Superficial sensation means touch, pain and temperature in the skin. Deep sensation (proprioception) comes from receptors in muscles, tendons and joints and tells the brain where the limb is, how far the joint is bent and in which direction it is moving. Proprioception can be divided further into two branches:
If stroke damages the sensory cortex, the thalamus or the ascending sensory pathways, the feedback of deep sensation is interrupted or weakened. Impaired proprioception can exist independently of a strength problem: some patients have fair strength but move inaccurately because they do not receive position feedback. This is also why it is often hidden behind weakness and missed.
In plain terms: the muscles produce the force, and proprioception reports back to the brain where the limb is and how it is moving. Even strong muscles are hard to control accurately and safely if those reports do not arrive. This is the situation of a patient with impaired proprioception.
How common impaired proprioception is
Impaired proprioception is not uncommon. Depending on the method of assessment, about 30 to 60% of affected upper limbs have some degree of impairment. In the chronic stroke cohort of Rand 2018, 31 of 102 people (about 30%) had impaired proprioception, and the severity of the impairment was significantly negatively correlated with motor ability, hand dexterity, the amount the affected hand is used in daily life and independence in daily activities. That is, the worse the proprioception, the worse the motor function and independence (Rand, 2018).
These figures show that impaired proprioception is not a minor problem. It is an important variable closely linked to movement recovery and independence in daily life. If only muscle strength is trained and sensation is ignored, recovery often stalls at the stage of being strong but not smooth to use.
How impaired proprioception affects motor control
Motor control is a closed loop: the brain sends a movement command, the limb moves, proprioception reports back to the brain where the limb has actually got to, and the brain corrects the next step at once. Impaired proprioception interrupts or weakens this feedback step, and several typical consequences follow:
Effects on carrying out movement
- Visual dependence: the eyes must keep watching during a movement, and the movement goes off course when the gaze moves away
- Movements are slow and inaccurate: because position errors cannot be felt at once, constant correction is needed and tasks take a long time
- Dark surroundings or doing several things at once are especially hard, because without the eyes to watch, the limb is harder to control
Effects on relearning movement
- The ability to relearn movement (motor relearning) falls, because learning new movements depends on sensory feedback
- It is hard to build a stable movement memory, which greatly reduces the benefit of practice
- The patient easily forms the habit of substituting with the good side or borrowing force, which gets in the way of recovery on the affected side
Sensory input is the foundation of movement output. The aim of proprioceptive re-education is to reconnect the sensation-to-movement link that stroke has weakened, so that the patient no longer compensates with the eyes alone and regains an internal sense of position.
Telling weakness from impaired sensation
Pure weakness and impaired sensation call for different approaches, so assessment comes before training. Physiotherapists commonly use the bedside tests below and quantify the severity as the basis for training:
Sensory assessment should be done by a professional. To test proprioception, the patient must close the eyes and must not use vision to help, and the test must follow a standard method for the result to be accurate. Trying it at home alone can easily give a wrong result, either because the patient peeks or because the method differs each time. Formal assessment and grading should be left to the physiotherapist.
Principles of proprioceptive training
Proprioception can be retrained. A systematic review (Aman 2015) confirmed that proprioceptive training improves both proprioception and motor function, and that the form with the best effect combines passive and active movement with visual feedback. The re-education principle of active work plus sensory feedback is based on this. The specific principles are as follows:
These principles apply to both upper and lower limbs. For the upper limb, the effect size of somatosensory re-education was about 0.3 to 2.2 (average about 0.85), most effect sizes in the proprioception and touch domains were greater than 0.5, and arm use tended to improve (Turville 2019). For the lower limb, a systematic review and meta-analysis of sensory re-education also supports that it improves lower limb sensation and the related balance and walking function (Chia 2019). The graded approach to touch discrimination training, which means telling apart texture, weight and shape, is covered separately in the article on tactile discrimination.
- Aim: sense of hand position, and precision of grasp and manipulation
- Increases day-to-day use of the arm (Turville 2019)
- The overall upper limb strategy is in the upper limb recovery overview
- Aim: sense of ankle and knee position, and stability in the stance phase
- Improves balance and walking-related function (Chia 2019)
- Overall gait training is in the gait retraining section
For upper limb recovery, see the overview of upper limb recovery after stroke. For the lower limb and gait, see gait retraining after stroke.
Lower limb proprioception and standing balance
Lower limb proprioception is one of the main sources of feedback for balance. Signals about the position and movement of the ankle and knee let the body keep fine-tuning its centre of gravity when standing and walking. When this feedback weakens, the patient is more likely to be unsteady on standing, inaccurate in gait and reliant on vision to keep balance, which is especially risky in dim light or on uneven ground.
This page only explains how impaired proprioception causes balance problems. A full balance assessment, grading of fall risk and strategies for preventing falls are a separate topic. For the general need to prevent falls in older people who have not had a stroke, see balance and fall prevention training.
How this page relates to other disciplines
Impaired proprioception involves several areas of rehabilitation. To avoid confusion, this page covers only the motor control side of physiotherapy. For the related but different areas below, refer to the corresponding pages as needed:
What this page covers in physiotherapy
- The causes and effects of impaired joint position sense and kinaesthesia
- Bedside sensory assessment and grading
- The training principles of proprioceptive re-education, which means how sensation and movement are reconnected
What is handled by other disciplines
- Spatial neglect, recognising objects and cognitive problems are handled by occupational therapy after stroke
- Applying sensation to daily self-care (ADL) and other life skills is handled by occupational therapy after stroke
- The overall balance assessment and fall prevention programme is covered by the page on balance and falls after stroke
Spatial neglect, application to daily living (ADL) and the cognitive side belong to occupational therapy and complement the sensation-and-movement training on this page, so they are best done together. See occupational therapy after stroke.
- If the patient clearly has strength but cannot use the limb smoothly, or has to watch to move it, ask for an assessment of deep sensation
- Training should rely mainly on the patient doing the movements, with the eyes observing and sensory discrimination added, from simple to harder
- Both hands and feet can have proprioceptive re-education, and the recovered sensation should be used in daily movements
- Training muscle strength alone while ignoring the sensory problem, so that recovery stalls
- Believing that the training on this one page alone can solve spatial neglect, daily self-care or falls
Self-testing at home and practising joint position matching
Assessment and grading are the physiotherapist’s job. After the formal assessment, the therapist usually teaches the patient a set of joint position matching self-tests and exercises that can be repeated at home every day, to watch whether proprioception improves and at the same time to retrain the sensation-to-movement link. The steps below are the general home version (practice consensus, not a replacement for professional assessment). The therapist should demonstrate once first, and the patient should practise on his or her own only after safety is confirmed.
The core of the design is two states, eyes covered and eyes open. Covering the eyes removes visual compensation, so the brain can sense position only through deep sensation. Opening the eyes lets the eyes check the answer and helps the brain recalibrate. Moving from eyes covered to eyes open first challenges proprioception and then corrects it.
- 1Sit securely and get ready (safety first)The patient sits on a firm chair with a back, feet flat on the floor. When testing the hand, the forearm rests lightly on a table or the thigh for support. When testing the foot, someone must be beside the patient, or the patient holds a firm handrail, so that balance is not lost. The process should not be painful.
- 2Eyes covered, caregiver places the limbThe patient closes the eyes or wears an eye mask. The caregiver gently places the affected elbow, wrist, knee or ankle at a certain angle, holds it for two or three seconds, and lets the patient feel the position.
- 3Eyes covered, copy with the other limbWith the eyes still closed, the patient uses the good arm or leg to make the angle he or she thinks is the same, or says how much the joint is bent and where it is. This step tests joint position sense.
- 4Eyes open, check the answer and correctThe patient opens the eyes and sees how far apart the actual angles of the two limbs are. Checking with the eyes open lets the brain use vision to calibrate the deep sensation. It does not matter if the two sides are far apart, because the aim is for the brain to update its information.
- 5Repeat and make it harder step by stepRepeat several times for each joint, using a different angle each time. When this is steady, the patient can first try holding the position longer with the eyes closed, then try moving to the target position with the eyes closed, and finally add daily movements, such as touching the nose with the eyes closed or placing the hand where a cup is with the eyes closed.
Practising along the three easy-to-hard lines below avoids too much tiredness or discouragement:
A self-test at home is only for recording progress and practising and is not a formal diagnosis. Do not peek with the eyes closed, and do the test the same way each time so that the numbers are worth comparing. Do not decide whether the patient is improving or declining from the self-test result alone, and do not change the treatment on your own. If the patient feels pain or dizziness, loses balance, or the movement clearly gets worse during practice, stop first and talk to the physiotherapist. Formal assessment and grading must be done by a physiotherapist.