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The Role of the Sensorimotor System in the Athletic Shoulder Joseph B

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The Role of the Sensorimotor System in the Athletic Shoulder Joseph B Journal of Athletic Training 2000;35(3):351–363 © by the National Athletic Trainers’ Association, Inc www.journalofathletictraining.org The Role of the Sensorimotor System in the Athletic Shoulder Joseph B. Myers, MA, ATC; Scott M. Lephart, PhD, ATC Department of Orthopaedic Surgery, Neuromuscular Research Laboratory, Musculoskeletal Research Center, University of Pittsburgh, Pittsburgh, PA Objective: To discuss the role of the sensorimotor system as dressed. A functional rehabilitation program addressing aware- it relates to functional stability, joint injury, and muscle fatigue ness of proprioception, restoration of dynamic stability, facili- of the athletic shoulder and to provide clinicians with the tation of preparatory and reactive muscle activation, and necessary tools for restoring functional stability to the athletic implementation of functional activities is vital for returning an shoulder after injury. athlete to competition. Data Sources: We searched MEDLINE, SPORT Discus, and Conclusions/Recommendations: After capsuloligamen- CINAHL from 1965 through 1999 using the key words “propri- tous injury to the shoulder joint, decreased proprioceptive input oception,” “neuromuscular control,” “shoulder rehabilitation,” to the central nervous system results in decreased neuromus- and “shoulder stability.” cular control. The compounding effects of mechanical instabil- Data Synthesis: Shoulder functional stability results from an ity and neuromuscular deficits create an unstable shoulder interaction between static and dynamic stabilizers at the shoul- joint. Clinicians should not only address the mechanical insta- der. This interaction is mediated by the sensorimotor system. bility that results from joint injury but also implement both After joint injury or fatigue, proprioceptive deficits have been traditional and functional rehabilitation to return an athlete to demonstrated, and neuromuscular control has been altered. To competition. restore stability after injury, deficits in both mechanical stability Key Words: proprioception, neuromuscular control, func- and proprioception and neuromuscular control must be ad- tional stability he primary role of the shoulder is to place the upper clinicians with the necessary tools for restoring functional extremity in a position that allows for function of the stability in the athletic shoulder after injury. Thand.1 In order to accommodate this role, the osseous geometry of the glenohumeral joint allows for a high level of mobility.2 As a result of this increased mobility, stability at the ROLE OF THE SENSORIMOTOR SYSTEM IN shoulder joint is compromised.3 GLENOHUMERAL STABILITY The lack of osseous stability requires the shoulder to rely on As previously stated, the sensorimotor system encompasses an interaction between static and dynamic structures to provide 4 the sensory, motor, and central integration and processing joint stability. Statically, capsuloligamentous structures, in- components involved in maintaining functional joint stability.6 cluding the glenoid labrum, glenohumeral joint capsule, and Sensory information (proprioception) travels through afferent glenohumeral ligaments, and intra-articular pressure provide pathways to the CNS, where it is integrated with input from static joint stability. Dynamically, the rotator cuff, deltoid, other levels of the nervous system, eliciting efferent motor biceps brachii, teres major, latissimus dorsi, and pectoralis responses (neuromuscular control) vital to coordinated move- major muscles provide vital stabilizing support. Functional ment patterns and functional stability. stability is defined as possessing adequate stability to perform Originally, Sherrington7 defined proprioception as the affer- functional activity and results from the interaction between ent information arising from the “proprioceptive field” and 5 these static and dynamic components. This interaction be- specifically “proprioceptors.”5 A contemporary interpretation tween the static and dynamic components of functional stabil- suggests that proprioception is defined as the afferent informa- 5 ity is mediated by the sensorimotor system. The sensorimotor tion concerning the 3 submodalities of joint position sense, system encompasses all of the sensory, motor, and central kinesthesia, and sensation of resistance.5 We define joint integration and processing components of the central nervous position sense as the ability to consciously recognize where system (CNS) involved in maintaining functional joint stabil- one’s joint is oriented in space, while kinesthesia describes 6 ity. one’s ability to consciously appreciate joint motion. We define Our purpose is to discuss the role of the sensorimotor system sensation of resistance as one’s ability to appreciate force as it relates to functional stability, joint injury, and muscle generated within a joint. All 3 submodalities can be appreci- fatigue of the athletic shoulder. In addition, we will provide ated both consciously and unconsciously, mediating neuromus- cular control. Proprioceptive information originates at the level of the Address correspondence to Joseph B. Myers, MA, ATC, 104 Trees Hall, mechanoreceptor or “proprioceptor,” as termed by Sher- Pittsburgh, PA 15261. E-mail address: jbmst28ϩ@pitt.edu rington.7 Mechanoreceptors are sensory neurons or peripheral Journal of Athletic Training 351 afferents present within the muscle, tendon, fascia, joint The proprioceptive information provided by the mechano- capsule, ligament, and skin about a joint.8–10 Mechanorecep- receptors present within the musculotendinous, capsuloliga- tors are mechanically sensitive and transduce mechanical tissue mentous, and cutaneous structures is appreciated at 3 distinct deformation as frequency-modulated neural signals to the CNS levels of motor control in the CNS. Those levels of motor through afferent sensory pathways.8 Deformation to the tissues control include the spinal level, the brain stem, and higher in which the mechanoreceptors lie causes a mechanically gated levels of the central nervous system such as the cerebral cortex release of stored sodium, eliciting an action potential.11 An and cerebellum.5,21–23 Each level elicits unique motor re- increase in tissue deformation causes an increase in action sponses vital to coordinated movement and functional joint potentials, thereby increasing neural input to the CNS.8,11 stability. At the spinal level, direct motor responses in the form Specifically, at the shoulder joint, Vangsness et al10 reported of reflexes and elementary patterns of motor control result.5 that neural endings exist in ligamentous structures. Low- (The role of reflexes in glenohumeral joint stabilization is threshold, slow-adapting Ruffini afferents were most abundant addressed later within this section.) At the brain stem, infor- overall, except in the glenohumeral ligaments, where low- mation from the periphery is integrated with both visual and threshold, rapid-adapting, Pacinian-type afferents outnumber vestibular input to control automatic and stereotypical move- 5,21,24 Ruffini afferents.10 Ruffini afferents are believed to be stimu- ment patterns, as well as modulate balance and posture. lated only with extremes of motion through tensile force, In addition, the brain stem may play an influential role at the 5 acting as limit detectors.8 Like Ruffini receptors, Pacinian muscle spindle by maintaining and modulating muscle tone. corpuscles respond to extremes of motion but through both The third level of motor control is the higher regions of the central nervous system such as the cerebral cortex and cere- compressive and tensile mechanisms rather than stretching 25 alone.8 No mechanoreceptors were present in the subacromial bellum. Tibone et al demonstrated an afferent pathway from bursa or glenoid labrum.10 Because the capsuloligamentous the mechanoreceptors present in the joint capsule to the structures of the shoulder are reported lax in mid ranges of cerebral cortex using cortical evoked potentials. Evidence of motion,12,13 mechanoreceptors present within the joint capsule this pathway indicates that conscious awareness of propriocep- and ligaments are believed to contribute proprioception infor- tion may occur at the cortical level, where proprioceptive information is appreciated and plays a role in voluntary mation when maximal deformation occurs at end ranges of 26 8,14 movements that are stored as central commands. Tyldesley motion. The spiral tightening of the capsule that occurs with 21 abduction and external rotation sequentially tightens the cap- and Grieves reported that awareness of body position at this suloligamentous structures, stimulating the mechanorecep- level allows for various skills to be performed without con- scious reference. The cortical level initiates and modulates tors.15 both complex and discrete movements and organizes and In addition to the capsuloligamentous mechanoreceptors, the prepares motor commands.5 In addition, the cerebellum plays a musculotendinous mechanoreceptors play a significant role in significant role by acting as a “comparator.”27 Subconsciously, providing proprioceptive input. Both Golgi tendon organs and the cerebellum takes information from the periphery and muscle spindles are present in the musculature about the compares outcome movements with expected movements, shoulder joint.8,9 At the tendinous region of muscle, the playing a vital role in motor control.27 tension-sensitive Golgi tendon organs are recruited when The unconscious activation
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