Written by Cosi Belloso as told to TMR Nerve
We talked with our friend, physical therapist and host of “Cosi Talks”, Cosi Belloso about proprioception. Cosi works exclusively with amputees of all ages and levels post-amputation. She broadcasts her live weekly show to a global audience providing education and information to her viewers and patients about recovery from limb loss. One of her most popular talks is on the importance of proprioception. Here, Cosi shares the basics as our first-ever guest blogger.
The basic definition of proprioception is the brain's ability to know where the body is in space. The popular example is to close your eyes and do a thumbs up. Even though your eyes are closed, your body relies on its systems to know where that thumb is in space. When a violinist is playing their instrument, the left hand is working on the fingerboard, and the right hand is doing everything with the bow to produce that beautiful sound. However, the musician is not looking at the fingers. The musician is not looking at the bow arm. The musician is looking straight ahead at their music or the audience.
I like to tell my patients and viewers that learning to walk with a prosthesis is much like playing a violin: In both cases, you are using two complementary instruments to produce a harmonized result. And in order to make this happen, proprioception must play a key role in the scenario.
Unfortunately, learning to walk with an efficient and smooth gait pattern is not just as easy as popping the prosthesis on and going about your way.
What happens exactly to your proprioception after amputation? What used to be the middle of the leg or the upper part of the leg, now becomes the bottom part of the residual limb, and this in turn sends mixed signals to the brain.
Proprioception is processed through three different systems: The visual system, the vestibular system, and proprioceptors.
The visual system is accessed through our eyes and it is the easiest system to understand. We take in what we see in the environment and it provides our brain with information as to where the body is in space.
The vestibular system, located in our inner ear, also provides input on our balance and proprioception. It detects all changes in movement, and it is also what goes screwy when we have had one or two too many margaritas!
Proprioceptors are located within our muscle fibers. I call them the “Pac-Men” because they just chomp away at the information that they're receiving from the muscle fibers in the environment.
Altogether, the visual, vestibular and proprioceptor systems work to interpret messages from the environment. They take this information to the back of the spinal cord and up to the brain. The brain processes messages in different areas, and then sends out information as to where to put that foot or where to put the arm in the next sequence of actions.
What happens after amputation? The three systems that normally work in harmony to allow for good proprioceptive information and feedback are now out of whack. Physical therapists have several tests to determine if a person is relying too much on their visual system, on their vestibular system, or on their proprioceptor system. These tests are meant to determine which system is taking over. These tests are utilized with traumatic brain injury and stroke patients, as well as with amputees.
In the case of amputees, the visual system is typically what takes over. A big tip off for this? My patients and viewers will tell me they cannot walk without looking down at the floor for fear of losing their balance. The visual system has taken over and is not playing nicely in the sandbox with the other two systems!
The good news is proprioception is a learned skill. We see this in our toddlers when they are learning to walk and clumsily place their little legs and feet in the right place as they negotiate their new skill. Even violin prodigies such as Mozart and Paganini had to learn proprioception to master their craft -- they just learned faster!
Since this is a learned skill, it means it can also be relearned!
How is this done? When I treat my patients, I begin by slowly incorporating all the systems and bringing them all back into the equation to work together. An analogy about how to ensure we are properly guiding the patient stems from something I did for my oldest daughter when she was 1 year old.
I had given her one of those balls with different cut out shapes to play with. She just kind of banged the pegs all over, not putting any shapes through any of the holes. I covered up all the shapes except the circle. Then I put the circle peg in her hand and guided it to the circle hole. I did not uncover any of the other holes until she mastered that one little shape. This is much like gait training: you must remove all the other variables out of the environment so the brain focuses on one task.
Once my patients understand the concept of how proprioception works and more importantly, how to initiate training, the foundation for smooth gait is set.
Many times patients will come in and report they are zipping up and down the parallel bars in their prothetist’s office, however the minute they try to take a walk without support or a cane, everything goes haywire. I tell them this is because somebody is handing them that ball of shapes and telling them to go for it and do all the shapes at the same time. The brain gets scrambled trying to negotiate too many variables at one time!
We need to retrain the brain by simplifying what it is trying to process.
I start with three exercises that are very basic and the same for everybody, regardless of their level of amputation, their age or level of fitness. My beginners and even my runners will do these three exercises. As a bonus, it is not only a treatment, it also provides me with diagnostic information about a patient’s socket fit, alignment, and posture.
These three exercises are prescribed to be performed several times a day in the first weeks of therapy. And I am always able to tell who is doing their ‘homework’ faithfully! Progress can be seen in the first week alone and continues to build with practice.
I have had so many patients come in years after their amputation using a cane, and in one month I have them walking independently. I attribute this success primarily to ‘rebooting’ their sense of proprioception and filling in the gaps of their foundation. Strength training and more advanced balance and coordination skills are also a part of treatment; once the proprioceptive system is re-established, everything else falls into place.
Proprioception is a learned skill and takes time and careful practice to master.
What can you do to spur your proprioception back in gear?
It all starts with going to your neighborhood friendly physical therapist.
Not all PTs are created equal and not all have had direct experience working with amputees. That being said, every licensed physical therapist will have the tools in their arsenal to treat proprioceptive impairments.
I tell viewers of Cosi Talks to use the right words. Tell your PT, “My proprioception is off.” It is a tongue twister, however it will cue your PT as to where to start looking and begin developing the right plan of care for you.
On the flip side, I encourage prosthetists, students, and fellow colleagues to talk to their amputee patients about proprioception. It has helped so many have a deeper understanding of how their bodies work and how to improve their outcomes.
It always gives me great joy to see the light bulbs go off when my patients begin to see improvement in their mobility and as a result, quality of life.
Cosi Talks! streams every Wednesday at 8:30 pm ET on Facebook. Be sure to tune in November 9th for a special Veterans Day edition. Cosi talks with Dr. Jason Souza, a Board certified Plastic and Reconstructive Surgeon and Director of the Orthoplastic Reconstruction and Advanced Amputation Program at The Ohio State University Wexner Medical Center in Columbus, Ohio. He has expertise in nerve and extremity reconstruction, limb salvage, limb restoration and advanced amputation, as well as extensive experience with management of combat casualty and blast injuries. Dr. Souza is a veteran of the United States Navy.
Written by Cosi Belloso as told to TMR Nerve
Targeted Muscle Reinnervation (TMR) is a surgical treatment that is gaining acceptance for nerve pain associated with amputation.
TMR is not a treatment option for patients with spinal cord injuries, brachial plexus injuries, or who are generally not healthy enough for surgery. The procedure does present typical risks of surgery. Patients may experience a temporary increase in pain as part of the nerve healing process. Your physician will help you determine whether TMR is right for you.
Gregory Dumanian, MD, is medical director of TMRnerve.com. He is a paid consultant of Checkpoint Surgical, Inc.