|Year : 2015 | Volume
| Issue : 1 | Page : 41-45
A comparison of elastic tubing and step-up exercises on knee joint proprioception in normal subjects
Shashwat Prakash, Varun Singh
Department of Physiotherapy, Guru Jambheshwar University of Science and Technology, Hisar, Haryana, India
|Date of Web Publication||19-Jan-2015|
Department of Physiotherapy,Guru Jambheshwar University of Science and Technology, Hisar - 125 001, Haryana
Background: Proprioception encompasses the senses of joint position and joint motion. With the use of proprioceptive information the human body can better maintain joint stability during static posture and produce coordinated and precise motions during mobile tasks. It is learnt that proprioceptive acuity decreases not only due to injury and degenerative diseases but also as a result of aging. Most of the previous studies have focused on recipients of joint replacements or those with ligament injuries. This study was conducted to check the effectiveness of elastic tubing exercises (ETEX) and step-up exercises (STEX) on knee proprioception in normal healthy subjects. Materials and Methods: 30 college-going healthy females between 20-30 years of age were randomly assigned to be trained with either STEX or elastic-tubing exercises (ETEX). Outcomes of the interest were captured at baseline and at the end of 6 weeks training. Results: There was significant difference in both groups. However, ETEX are better than STEX at 20°; and STEX are better than ETEX at 30°. Conclusion: Both exercises are effective in improving knee joint proprioception in young and physically active females. These are simple exercises which can be carried out as a part of home protocol and require minimum supervision. It will be interesting to see if the same results can be replicated in all age-groups, especially the elderly. Regular training in elders can reduce likelihood fall and hence improve the overall quality of life.
مقارنة بين التمارين باستعمال أنابيب بلاستيكية وتمارين Set Up واثرها على استقبال الحس العميق لمفصل الركبة لدى الافراد العاديين
خلفية: استقبال الحس العميق يشمل الحواس الخاصة بمكان المفصل وحركته ومن المعروف ان هذا النوع من الاحساس يتاقص من جراء الاصابة والأمراض التنكسية وتقدم العمر ولقد ركزت الدراسات السابقة على المرضى المستفيدين من استبدال المفاصل أو الذين لديهم إصابات الاربطة. ولكن الدراسة الحالية اجريت للتحقق من فعالية التمارين باستعمال أنابيب بلاستيكية ومقارنتها بوسيلة التمارين (Step-up exercises -STEX) بقياس استقبال الحس العميق لمفصل الركبة لدى الافراد الاصحاء العاديين.
المواد والأساليب: اجريت الدراسة على 30 من طالبات الدارسات فى احدى الكليات اعماهم بين 30-20 سنة تم توزيعهم عشوائيا على احد وسيلتى التمارين المشار اليها وتم التقييم النهائى بعد ست اسابيع من التمارين.
النتائج: كان هناك اختلافا كبيرا في كلا المجموعتين الا EPAX كان أفضل من STEX في درجة 20°. وSTEX أفضل من EPAX في درجة 30°.
الاستنتاج: كلا وسيلتى التمارين يتساويان فى فعالية تحسين استقبال الحس العميق للركبة في الشابات والناشطات بدنيا. ان هذه هي التمارين البسيطة التي يمكن القيام بها كجزء فى المنزل وبالقليل من الاشراف ومن المثير للاهتمام أن نرى ما اذا كان يمكن تكرارها على نفس النتائج في كل جميع الفئات العمرية، وخاصة كبار السن. أن التدريب المنتظم لكبار السن يمكن أن يقلل من احتمال سقوط، وبالتالي تحسين نوعية الحياة عموما.
Keywords: Elastic-tubing exercises, joint position sense, proprioception, step-up exercises
|How to cite this article:|
Prakash S, Singh V. A comparison of elastic tubing and step-up exercises on knee joint proprioception in normal subjects. Saudi J Sports Med 2015;15:41-5
|How to cite this URL:|
Prakash S, Singh V. A comparison of elastic tubing and step-up exercises on knee joint proprioception in normal subjects. Saudi J Sports Med [serial online] 2015 [cited 2019 Jun 19];15:41-5. Available from: http://www.sjosm.org/text.asp?2015/15/1/41/149536
| Introduction|| |
Proprioception encompasses the senses of joint position and joint motion. These senses originate from the stimulation of specialized nerve-endings or mechanoreceptors in the joint capsule and ligaments. The receptors convert the mechanical energy of physical deformation into the electrical energy of a nerve action potential and this action potential propagates to the higher center for motor control.  Reflex contraction of muscles by stimulation of proprioceptors protects joints from mechanical insults.
Proprioception deteriorates with aging and more with degenerative disease in elderly.  A study by Barrett et al., showed that joint position sense (JPS) is less accurate in older normal subjects.  It is also supported by Stauffer et al., who suggested that proprioceptive diminution with age and might be the major factor for age related gait pattern. 
Most of the previous studies on proprioception have focused on recipients of total knee replacements or those with ligament injuries. ,,,, Very few have been done on healthy subjects. The purpose of this study was to check the effectiveness of step-up exercise (STEX) and elastic tubing exercises (ETEX) on the proprioception of knee in normal healthy subjects.
| Materials and methods|| |
In this study we recruited 30 college-going normal and physically active females over a period of 6 weeks. Inclusion criteria required the subjects to be between the age of 20-30 years and muscle strength of more than or equal to grade 4 on Manual muscle testing (MMT) of knee joint muscles. Subjects were excluded if they had any limitation of Range of motion (ROM) or musculoskeletal conditions associated with knee joint. Subjects taking any kind of medication along with those who were unable to comply with follow-up schedule were also omitted.
Following the baseline examination the subjects were randomly assigned to receive either STEX or ETEX.
Prior to participation, all subjects reviewed and signed a consent form approved by the Investigations and ethical committee of the department.
The ethical approval was taken from department's ethical committee. Informed written consent was taken in the patient's language.
In this study, Angle Reproduction Test was used as an outcome measure to evaluate the proprioceptive acuity or JPS. The subjects were positioned in supine lying and blindfolded. They wore shorts to negate any unnecessary skin sensation from clothing. In order to determine the angles a digital goniometer (iGaging) was used. This device was fastened on the lateral aspect of thigh and leg with the help of straps. In 90° flexion, the goniometer was set to 0 and thus, the initial position was set to be 0°. The target angles were determined as 20° and 30°. The angle of concern was instructed to the subjects twice before the measurement. The limb was passively moved from 90°-20°and 30 of knee extension which was maintained for 10 seconds. Subjects then returned to the starting position and after 5 seconds of rest, attempted to reproduce the previously attained target angle by actively stopping when they perceived that the angle had been replicated. All subjects completed two different target angle replication attempts, with 30 seconds rest between each trial. The deviations of the average of six measurements from the target angle were recorded for all angles.
A previous report using similar kind of test, has shown this technique to be reliable and reproducible. 
Initially both the groups were assessed for proprioceptive acuity at 20° and 30°prior to training.
Interventions were given three times per week, for over 6 weeks. After 6 weeks of training, proprioception was again assessed using angle reproduction test and compared.
Group A (STEX)
Subjects were asked to perform front and lateral STEX, using a wooden step of 8 inches height.
Group B (ETEX)
Subjects performed front pulls, back pulls, crossovers and reverse crossovers with a black colored elastic tube.
Data was analyzed by related and unrelated t-test. Level of significance was 5% (P < 0.05).
| Results|| |
[Table 1] and [Table 2] show that, there is extremely significant difference between pre and post readings at 30° in Group A and at 20° in Group B.
Between group study showed that statistically significant difference existed between the mean values of the two groups at both 20° and 30° [Table 3].
|Table 1: Comparison of mean values of pre and post readings of Group A (STEX) at 20° and 30°|
Click here to view
|Table 2: Comparison of mean values of pre and post readings of Group B (ETEX) at 200 and 300|
Click here to view
|Table 3: Shows difference in the mean values of Group A and Group B at 20° and 30°|
Click here to view
| Discussion|| |
This study was conducted with the aim to determine the effects of elastic tubing and step-up exercises on proprioception of normal and healthy female subjects. The purpose of choosing young and physically active women represent a step forward when trying to confirm the efficacy of the elastic tubing and STEX, as it may be easier to produce adaptations in women who are not physically active and/or aging population.
The proprioceptive capability of the subjects was tested by an angle reproduction test. 
Although this test can be done in both weight-bearing and non-weight bearing positions, but most studies have favored the later method. 
To date, there are limited studies investigating proprioceptive changes in normal subjects:
Jerosch et al., studied the proprioceptive status in 43 patients with unilateral PFPS and in 30 normal volunteers with the technique of angle reproduction test and found deterioration in pathologic and normal knees.  Although our study is different, but we used a similar test method.
There are various exercises which help in improving proprioception as well as muscle strength. In this study, we trained the subjects with elastic tubing and STEX.
Elastic tubing is a common material used for resistance training.  The band or tube is very versatile enabling the training of individual muscles or group of muscles depending on the starting position. Some elastic resistance exercises which help to improve balance and proprioception are: Front pull, back pull, cross over and reverse cross over. Colado et al., in their study found that elastic tubing is as effective as the free weights and weight machines. It is an inexpensive alternative for people who do not have access to sophisticated equipment for training.  Exercise protocol in the present study for ETEX group followed that of Docherthy et al., 1998. They started exercise with one set and progress to two sets of 20 repetitions using a black colored elastic tubing and found that strength and joint position sense increased in functionally unstable ankles.  Results of our study are consistent with their study.
In rehabilitation settings, functional tasks have become a standard treatment option and it is thought that the use of exercises, that mimic activities of daily living will accelerate an individual's return to normal function. STEX are commonly suggested in rehabilitation of knee. , Although there are no specifics pertaining to step heights in the literature, but because four inch and eight inch heights may be used clinically in knee rehabilitation, they were chosen for this study . The findings of the present study are parallel with the findings of a study by Hurley et al., 1998 which demonstrated that STEX improved the proprioceptive acuity in knee joint. 
It has been shown that muscle fatigue can impair postural control, which in turn can result in decreased joint acuity. , Thus it is likely that improvement in muscle strength and endurance through training will improve joint stability.  Therefore prior training of athletes or those who are susceptible to early fatigue, can prevent a possibility of injury.
Research in recent years has shown that proprioception and balance training in elderly is proving beneficial in decreasing the number of falls. ,, Research also show that patients of all age-group benefit from similar exercise programs, but for similar goals at hand. While the level of proprioception development may not reach similar levels due to age and physical limitations, the neurophysiological idea of cortical input via somatosensory afferents influencing balance and motor activity is the same in both elderly and young active population. This emphasizes that regardless of current patient activity, a proprioception training program would be beneficial in the treatment and prevention of multiple injuries.
Proprioceptive acuity requires the integrity of many sensory systems like- muscle spindles, golgi tendon organs, articular and cutaneous proprioceptors, the visual field and vestibular apparatus. , Out of these, the muscle spindles are considered of prime importance, as they give information about JPS and velocity of muscle stretch. , We believe the more likely mechanism for our results is muscle spindles. In addition to the sensory endings, the spindles also receive connections from static and dynamic γ-efferent nerves, which enhance the afferent responses. , It is possible that the strength training may have increased γ-efferent activity. The spindle may have been more sensitive to instantaneous stretch, resulting in greater acuity in sensing joint position.
Results of this study show that there was significant difference in both groups. However, ETEX are better than STEX at 20°; and STEX are better than ETEX at 30°.
From the present study, we conclude that elastic tubing and STEX are effective in improving knee joint proprioception in young, healthy and physically active females. These are simple exercises which can be carried out as a part of home protocol and require minimum supervision. We assume that these exercises can also prove effective for the elderly population, as regular training can prevent falls in elderly and the severe disability that often accompanies fall related injuries. Thus, by incorporating proprioceptive training in their daily routine, an overall increase in quality of life can be expected.
Most of the previous studies which have shown that STEX increase proprioception, have involved protracted research regimes. Looking at the size of patient population, poor patient compliance and prolonged exercise regimes, it may be difficult to implicate them in clinical practice. The current exercise program is as effective as the previous studies but much shorter and utilized unsophisticated, inexpensive equipment which is available in most physiotherapy department. Therefore, the adoption of this regime into clinical practice is quite feasible.
Only college going females were considered for this study and only two techniques that is ETEX and STEX were used.
| References|| |
Gardner EP, Martin JH. Coding of sensory information. In: Principles of Neural Science, Kandel ER, Schwartz JH, Jessell TM, editors. 4 th
ed. vol.1. New York: McGraw-Hill; 2000. p. 411-28.
Kumar A. Joint proprioception in normal and osteoarthritic knees. J Yoga Phys Ther 2012;2:119.
Barrett DS, Cobb AG, Bentley G. Joint proprioception in normal, osteoarthritic and replaced knees. J Bone Joint Surg Br 1991;73:53-6.
Stauffer RN, Chao EY, Gyory AN. Biomechanical gait analysis of the diseased knee joint. Clin Orthop Relat Res 1977:246-55.
Barrack RL, Skinner HB, Cook SD, Haddad RJ Jr. Effect of articular disease and total knee arthroplasty on knee joint position sense. J Neurophysiol 1983;50:684-7.
Cash RM, Gonzalez MH, Garst J, Barmada R, Stern SH. Proprioception after arthroplasty: Role of the posterior cruciate ligament. Clin Orthop Relat Res 1996:172-8.
Schultz RA, Miller DC, Kerr CS, Micheli L. Mechanoreceptors in human cruciate ligaments. A histological study. Am J Bone Joint Surg 1984;66:1072-6.
Postle K, Pak D, Smith TO. Effectiveness of proprioceptive exercises for ankle ligament injury in adults: A systematic literature and meta-analysis. Manual Ther 2012;17:285-91.
Borsa PA, Sauers EL, Lephart SM. Functional training for the restoration of dynamic stability in the PCL-injured knee. J Sport Rehabil 1999;8:362-78.
Hurley MV, Ng TS. The reliability, reproducibility and validity of two methods of assessing proprioceptive acuity in the lower limb. Br J Rheumatol 1996;35:140.
Jerosch J, Schmidt K, Prymka M. Proprioceptive capacities of patients with retropatellar knee pain with special reference to effectiveness of an elastic knee bandage. Unfallchirurg 1997;100:719-23.
Hopper DM, Creagh MJ, Formby PA, Goh SC, Boyle JJ, Strauss GR. Functional measurement of knee joint position sense after anterior cruciate ligament reconstruction. Arch Phys Med Rehabil 2003;84:868-72.
Schulthies SS, Ricard MD, Alexander KJ, Myrer JW. An electromyographic investigation of 4 elastic-tubing closed kinetic chain exercises after anterior cruciate ligament reconstruction. J Athl Train 1998;33:328-35.
Colado JC, Garcia-Masso X, Pellicer M, Alakhdar Y, Benavent J, Cabeza-Ruiz R. A comparison of elastic tubing and isotonic resistance exercises. Int J Sports Med 2010;31:810-7.
Docherty CL, Moore JH, Arnold BL. Effects of strength training on strength development and joint position sense in functionally unstable ankles. J Athl Train 1998;33:310-4.
Yocum LA, Bachman DC, Noble HB, Hoover RL. The deranged knee: Restoration and function. A protocol for rehabilitation of the injured knee. Am J Sports Med 1978;6:51-3.
Malone T, Blackburn TA, Wallace LA. Knee rehabilitation. Phys Ther 1980;60:1602-10.
Hurley MV, Scott DL. Improvements in quadriceps sensorimotor function and disability of patients with knee osteoarthritis following a clinically practicable exercise regime. Br J Rheumatol 1998;37:1181-7.
Vuillerme N, Danion F, Forestier N, Nougier V. Postural sway under muscle vibration and muscle fatigue in humans. Neurosci Lett 2002;333:131-5.
Yaggie JA, McGregor SJ. Effects of isokinetic ankle fatigue on the maintenance of balance and postural limits. Arch Phys Med Rehabil 2002;83:224-8.
Powers ME, Buckley BD, Kaminski TW, Hubbard TJ, Ortiz C. Six weeks of strength and proprioception training does not affect muscle fatigue and static balance in functional ankle instability. J Sport Rehabil 2004;13:201-27.
You SH. Joint position sense in elderly fallers: A preliminary investigation of the validity and reliability of the SENSERite measure. Arch Phys Med Rehabil 2005;86:346-52.
Marigold DS, Eng JJ, Dawson AS, Inglis JT, Harris JE, Gylfadóttir S. Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke. J Am Geriatr Soc 2005;53:416-23.
Duncan P, Richards L, Wallace D, Stoker-Yates J, Pohl P, Luchies C, et al
. A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. Stroke 1998;10:2055-60.
Fitzpatrick R, McCloskey DI. Proprioceptive, visual and vestibular thresholds for the perception of sway during standing in humans. J Physiol 1994;478:73-86.
Lord SR, Lloyd DG, Li SK. Sensori-motor function, gait patterns and falls in community-dwelling women. Age Ageing 1996;25:292-9.
Baldissera F, Hultborn H, Illert M. Integration in spinal neurone systems. In: Brooks V, editor. Handbook of Physiology. Vol. II. Sec. 1. Bethesda: American Physiological Society; 1981. p. 509-97.
McClosky DI. Kinaesthetic sensibility.
Physiol Rev 1978;58:763-820.
Crowe A, Matthews PB. The effects of stimulation of static and dynamic fusimotorfibres on the response to stretching of the primary endings of muscle spindles. J Physiol 1964;174:109-31.
Appleberg B, Bessou P, Laport Y. Effects of dynamic and static fusimotor -^.fibres on the responses of primary and secondary endings belonging to the same spindle.
J Physiol 1965;177:29-30.
[Table 1], [Table 2], [Table 3]