PROPRIOCUSSION: PROPRIOCEPTIVE PERCUSSIVE THERAPY
By Dr. Ted Edwards, DC
Originator of “Cerebrospinal Kinesiology”
“Cerebrospinal Kinesiology” (CSK) includes a proprioceptive therapy system that creates a new functional state in the patient. It does this by acting upon three distinct levels of motor control in the central nervous system (CNS):
1. Spinal reflexes influencing unconscious movement patterns related to effort and heaviness.
2. Motor cortex activity for conscious cognitive awareness of body position and motion. 3. Brain stem activity between the basal ganglia and cerebellum to maintain posture and balance.
Because proprioception at the motor cortex level is necessary for proper muscle and joint function in activities of daily living and occupational tasks, loss of proprioception greatly impedes coordination and predisposes one to injury and re-injury (Lephart 1992, Gurney 2000). The proprioceptive input to the brain stem emanates from the joint and muscle proprioceptors, our ears, and our eyes. The cerebellum interprets proprioceptive information and formulates a plan on what the next muscle action should be to achieve the desired task (e.g. activities of daily living). The cerebellum then sends this plan to the motor cortex of the brain, which in turn sends the appropriate commands through the nervous system to the involved muscles. This all occurs in a fraction of a millisecond, and the whole time the cerebellum is receiving more proprioceptive feedback and continually adjusting its motor plan to fine tune the movements being taken..
“Proprioceptors tell us not only where our body parts are in relation to each other and the outside world but also how fast and where they may be moving” (Simpson). Proprioception is the ability of the nervous system to instantly determine the relative positions in space of each limb and other body components providing feedback the brain uses to make appropriate neuromuscular adjustments. Proprioceptive damage from trauma or injury alters movement patterns due to partial deafferentation and is accompanied by secondary changes in the central nervous system that negatively impact the neuromuscular system.
Neuromuscular Control and Proprioceptive Acuity
A patient who presents with virtually any injury has both proprioceptive deficits and mechanical instability, what Paul Chek refers to as sensory-motor amnesia, a concept he borrowed from Thomas Hanna (1988). These are assessed as alterations in neuromuscular control typically exhibited as deficits in range of motion, increases in muscle splinting, loss of muscle strength and joint position sense as well as increased nociceptive output. When articular structures loose their functional stability they tend to exhibit an increase in laxity. This makes them more prone to additional ligamentous instability from the micro-trauma of repetitive injury (Lephart 1992).
Schulte’s study (2001) suggests that proprioceptive acuity can be enhanced with oscillatory devices. Enhancing proprioceptive acuity assists the patient to regain joint position sense, initiates reflex muscular stabilization, and corrects faulty motor programming. Reiter & Cato (1970) indicated that the development of proprioception might be the most important factor for postural realignment. The reason for this is that proprioceptive information shapes spinal reflex responses and is at the root of postural maintenance. In Cerebrospinal Kinesiology (CSK) we have formed “an effective proprioceptive [rehabilitation] protocol emphasizing conditioning principles of strength and endurance” using the oscillating percussive device to deliver “proprioceptive enhancement by improving neuromuscular control and motor learning . . . and prevent injury by maintaining proper joint congruency (Gordon & Ghez, 1991).”
Applying CSK percussive therapy or what I’ve dumbed propriocussion at the spinal level facilitates dynamic joint stabilization and mediates movement patterns for improved neuromuscular control. The ultimate goal of CSK is to provide practitioners with a comprehensive rehabilitation program that is designed to return their patients to preinjury levels of activity by removing the mechanical instability and proprioceptive deficits that are commonly associated with injury to passive and dynamic structures. Clinically restoring proprioceptive mediated neuromuscular control after joint injury or trauma is assessed as normalization of muscle tone, improvements in muscle strength, increased range of passive and active movements, functional joint stability, ‘normal’ coordination and balance, greater flexibility in the joints, more endurance and improved posture. Regaining cognitive neuromuscular control after an injury is vital if one is to perform the movements required to execute safe, pain-free activities of daily living.
Functional Blockages & Segmental Control
The combination of propriocussion to muscles, ligaments and tendons along with specific Chiropractic Spinal Manipulation to functional blockages of spinal segments, restores joint mobility, normalizes muscle tone and opens the gate for the flow of correct proprioceptive information to the central nervous system. This results in restoration of normal recruitment patterns and improved mobility in the joints of the spine (Kozijavkin 2004).
Functional blockages of the spine in cases of trauma or injury disturb the flow of proprioceptive information. “Most proprioceptive information travels to higher CNS levels through either the dorsal lateral tracts or the spinocerebellar tracts” (Riemann 2002). Functional blockages are not limited to a single joint of the spine, but rather they occur in several adjacent vertebrae resulting in polysegmental spinal blockages. “These blockages influence all the organs of the human body which are innervated by the corresponding segments of the spinal cord” (Kozijavkin 2005). Functional blockages in articular structures cause the surrounding muscles, ligaments and tendons to spasm and become painful leading to reduced physical activity due to pain related ‘fear-avoidance’ behavior. Anticipation of pain evokes a protective modified motor control strategy that stiffens the spine by increasing the amount of coactivation leading to slow and jerky movements with decreased range of motion (Moseley 2004, Sjolander 2004). Paul Hodges (1996) has shown that an emotional state of fear causes “motor control deficits of the trunk muscles, in particular the transverse abdominus,” one of the inner core muscles (Chek, Lee).
Muscle dysfunction arising from increased joint trauma and ligamentous injury can result in mechanically inefficient intersegmental motion with reflexive neural activation producing muscle spasms or muscle guarding. Patients with varying degrees of spasms, pain and onset of tissue stasis have muscles that are over-dominant and have lost normal mobility. Subsequently muscle atrophy and a predisposition to muscle inflammation occurs, which is exhibited by loss of muscle strength and shortening of the proximal and distal musculature. For example, patients with Whiplash Associative Disorder (WAD) have reduced proprioceptive function of muscle spindles in the neck and shoulder, which is likely responsible for the negative effect on precision and the upper extremity muscle weakness typically found in these patients (Sandlund, 2004). These patients need a procedural rehabilitative technique that enhances proprioception restoring pain-free joints, decreasing range of motion deficits and preventing progressive muscle atrophy by restoring joint mobility and relieving associated spasms and pain.
Clinical findings indicate that Propriocussion following Cerebrospinal Kinesiology (CSK) protocol is an effective technique for reestablishing proprioception and thus neuromuscular control in the treatment of pain and neuromuscular disorders, including dysfunctional joints and subluxated spinal segments. It’s been shown that the application of propriocussion changes aberrant spinal loading patterns correcting the functional distortions associated with segmental dysfunction. By imparting percussive impulses lost mobility in spinal segments is restored. A rapid reduction in pain and improvement in function is often seen with its use as subjective function has been correlated with proprioceptive ability (Roberts 2004).
The CSK rehabilitation program follows the advice of Lephart (1997) that “simple tasks such as balance training and joint repositioning should begin early in the rehabilitation program and become increasingly more difficult as the patient progresses.” Kozijavkin (2004) reiterates, “Rehabilitation can be enhanced significantly when proprioception is addressed and instituted early in the treatment program. This theme was also echoed throughout the Fourth International Congress on Low Back and Pelvic Pain (2001).
Following the kinetic chain approach “correction of the spine is carried out consecutively in lumbar, thoracic and cervical regions.” The next focus of treatment is directed at the proximal structures. These consist of the large joints of the shoulder complex and pelvic girdle. “Creation of the higher and more distal fine motor functions of the hand, development of balance, and improvements in cognitive function is possible only after the development of the previous, more proximal functions.”…“Gradually activation of the medium sized joints are added, and finally the small distal structures are treated” (Kozijavkin 2004). It has been observed that the number of muscle spindles is higher in proximal joints and decreases in the more distal joints. Muscles and joints that have a higher density of muscle spindles are more susceptible to aberrant changes in proprioceptive acuity. For instance, the deep muscles of the cervical spine have a very high density of spindles presenting a rational for treating from the core outward to proximal and than distal joints as suggested by Kozijavkin and others
Mechanoreceptors – Muscle spindles
Lephart (1997) states: “The concept of proprioception is based on the fact that neural feedback to the central nervous system (CNS) is mediated by cutaneous, muscle (e.g. muscle spindles), and joint mechanoreceptors.” Riemann (2002) indicates that the CNS determines proprioceptive input from populations of receptors, what he refers to as ensemble coding. Information from proprioceptive mechanoreceptors is essential, not only for the performance of all movements, but also for motor training and learning new movements.
Evidence suggests that joint and muscle receptors are probably complimentary components of an intricate afferent system in which each receptor modifies the function of the other. However, muscle spindles are considered to be the most important mechanoreceptors for proprioception because of the major role they play in the control of muscular movement by adjusting activity levels in the lower motor neurons (Lephart 1997). Fatigue, inflammation and most especially trauma causing injuries to receptor bearing structures, such as ligaments, tendons and muscles, lead to pain that directly impacts muscle spindle activity. This impairs proprioceptive information, which alters motor control of the affected muscles and contralateral muscles as well (Sandlund 2004). By stimulating joint and muscle receptors percussive therapy encourages maximum afferent discharge to the respective CNS level.
Nathan and Keller (1994), state “There is increasing evidence that the frequency, and velocity of applied force may also play a key role in the therapeutic benefit…since the mechanical response of biologic structures is known to depend on the rate of load application.” In Cerebrospinal Kinesiology (CSK) treatments the Propriocussor is used as a delivery device that produces a set frequency and velocity with a variable applied force that enables the operator to alter the rate of applied load.
The Propriocussor utilizes a cam driven motor to produce a short lever, high velocity percussive force. The constant stimulation provided by the Propriocussor is very effective at reducing muscle spasms and at inducing motion into spinal segments and other articular complexes of the body influencing the muscle spindles to play their role in controlling muscular movements patterns. A continuous percussive stimulus produces mechanical deformation of joint and muscle proprioceptive afferents that amplifies the sensory signal. This is carried as proprioceptive information to the brain stem (basal ganglia and cerebellum) influencing posture and balance control and to the peripheral and central nervous system (CNS) for integration via spinal reflex pathways and cortical pathways. This in turn becomes efficient sensorimotor control that modulates muscle function as sensory information underlies the planning of all motor output (Lephart, Borsa).
Lephart (1997) notes that ligaments provide neurological feedback that directly mediates reflex muscular stabilization about the joint. Solomonow (1998) notes that while ligaments act as the major restraints for extremity joints it is now clear that spinal and abdominal muscles [especially the core muscles] are responsible for spinal stability. Research indicates that all spinal ligaments are equipped with proprioceptive mechanoreceptors of various types including fast adapting Pacinian and the slow adapting Golgi and Ruffini organs. Nociceptive nerve endings are also known to exist in the ligaments. These proprioceptive mechanoreceptors monitor strains, stresses and angles of different motion, reflexively initiating spinal and abdominal muscular activity that maintains the stability of the spine.
The continuous stimulus provided by Propriocussion inhibits Pacinian corpuscles within milliseconds. While the Ruffini endings, Ruffini corpuscles, and Golgi tendon-like organs continue to discharge sending afferent impulses to the CNS via the cortical pathway. Stimulation of Golgi tendon receptors results in a reflex lengthening of muscles (Lephart 1997). While percussive deformation (propriocussion) of the supraspinous ligament, and probable other spinal ligaments, recruits multifidus muscle force to stiffen one to three vertebral motion segments and improve functional joint stability (Solomonow 1998, Sjolander 2002). This occurs because propriocussion activates the reflexive response mechanism that the body uses to increase muscle stiffness and, therefore, enhance joint stiffness for augmented joint stability after an imposed joint trauma. As a result of propriocussive activation stiffer muscles transmit loads to muscle spindles more easily (Riemann 2002).
The head/neck relationship (“primary control”) is a psychophysical process that manifests itself as muscular activity but is controlled by thought processes of wish or intention (Carrington and Carey 1992). Assessment shows a patient with “slow movements, reduced range of motion (ROM), poor balance, poor movement precision and deranged coordination” (Sjolander 2004). Sensory input from the neck mechanoreceptors, which are more numerous than in other muscles, and from the balance organs (semi-circular canals) work in tandem to provide information essential for the maintenance of human upright posture. Control of posture and movement is primarily affected by the state of neck muscles with their strong input to the brain. Reduced acuity of the proprioceptive information from the cervical region increases the risk of developing musculoskeletal disorders, increases asymmetrical muscular co-activation and induces non-optimal postures. O’Sullivan (2001) adds, “individuals who habitually adopt passive postures for long periods, may de-activate and potentially de-condition the stabilizing muscles.” Propriocussion of the “stabilizing muscles with special emphasis on maintaining optimal postural alignment results in reduced pain and disability and enhanced motor control of these muscles” (O’Sullivan 2001).
CSK PROCEDURE: Have the patient repeat left and right cervical rotation several times. “Patients with neck pain show more irregular movement patterns during cervical rotation exhibiting reduced smoothness of motion.” When we see altered motor performance exhibited by a patient this reflects deranged sensorimotor function (Sjolander 2004). Applications of Propriocussion alters electrical nerve impulses nearly immediately and have been found to be helpful to patients suffering from severely altered motor performance exhibited as chronic neck pain, especially those with instability for whom manual adjusting is clinically contraindicated.
Postural sway can be significantly increased during “standing and walking in patients with neck pain” (Michaselson 2003). “Damage to joint proprioceptors after injury to a ligamentous complex diminishes afferent feedback from the injured joint, thereby resulting in increased postural sway (Lephart 1997). This is based on the notion that when proprioceptive information is altered or impaired aberrant perturbations in planning occur and there is incorrect execution of motor commands (Sjolander submitted). Input to and from our legs gives us our most sensitive means of feeling postural sway. This along with stimulation of vestibular centers and visual input from the eyes activates the second level of motor control, located within the brainstem, which affects postural sway and balance control of the body. For example, when the weight of the head is pushed towards the right shoulder balance is predominantly sifted to the right side of the body (Wierzbicka 1998).
When a cervical rotation is challenged by a decrease in proprioception, individuals often over recruit muscles in an attempt to stabilize (Anderson 2000). Consider how the reflexive pattern referred to by Frank Jones as the “Startle Pattern” applies to various traumas or injuries. In reaction to a sudden loud noise, [E.g. two car’s crashing into each other] the chin thrust forward as the neck muscles contract. The shoulders are lifted and the arms extended, the chest is flattened and the knees are flexed. The change, which is not instantaneous, begins in the head and neck, passing down the trunk and legs to be completed in about half a second (Jones 1976). In a car crash this startle pattern is infused with the alterations occurring from impact. The point here is that body parts do not operate in isolation. Here we can easily see how injuries that cause the chin to thrust forward, displaces the head backwards, contracts the necks muscles and reflexively shortens the back placing added weight and strain on the muscles and ligaments of the shoulders, arms, chest, knees and legs mainly because of interference in the righting reflexes by abnormal pressure on the joints of the neck (McCullough 1996). Pain originating in the neck is known to disturb proprioceptive function of the limbs and the jaw.
CSK PROCEDURE: Assess the anterior to posterior motion of each mastoid process of the temporal bone with its reciprocal contralateral greater sphenoid wing. When the mastoid/sphenoid complex is fixated it clearly indicates the presence of jaw clenching and possible grinding as well.
Temporal bone fixation is also associated with deficits in the semi-circular canals negatively impacting balance. An internal temporal lesion impacts the brain stem altering major circuits that control postural equilibrium and many of the automatic and stereotyped movements of the body. The brain stem directly regulates and modulates motor activities based on the integration of sensory information from visual, vestibular, and proprioceptive sources (Riemann 2002). CSK employs procedures that stimulate reflex joint stabilization, which emanate from the spinal cord along with activities the patient performs that alter joint positioning necessitating reflex neuromuscular control. We further enhance motor function at the brainstem level by asking the patient to perform postural activities, both with and without visual input.
CSK PROCEDURE: With the patient supine holding 2-5lb weights in each hand with their arms in a flexed position, ask them to lift and hold their head off the table in flexion and apply downward resistance. With prolonged loading of the musculotendinous junction, the firing pattern, corresponding to the sustained muscle contraction, may become suppressed. If they’re unable to hold their head in this position against resistance the test is positive and indicates delayed firing of the deep cervical flexors, sternocleidomastoid and anterior scalene muscles. Delay in the activity of these neck muscles “indicates a significant deficit in the feed forward control of the cervical spine” (Sjolander 2004). A feedforward loop involving the spinal cord, brain stem and cerebral cortex evolves and a re-patterning of motor output results from aberrant proprioception (Cremonese, 1998).
Lephart et al (1994) observed that individuals with chronic trauma or instability deal with significant deficits in proprioception. They suggested that proprioceptive deficits in, for example, a pathologic shoulder result in partial deafferentation and sensory deficits due to damage to capsuloligamentous structures. As a result of these deficits in proprioception, alterations in reflex activity and motor programs manifest as altered muscle-firing patterns (Myers 2002). This is demonstrated by alterations in joint motion, joint position sense and a loss of joint restraints. A damaged sensorimotor system will not automatically allow muscles to perform stabilization; they need to be rehabilitated (Simpson www.cdmsport.com). In the case of the shoulder Warner (1992) reports that the mechanism of muscle inhibition mainly affects the serratus anterior muscle. This was found in 100% of patients with subacromial impingement and in 64% of patients with glenohumeral instability. Methods that improve proprioception in patients with articular disorders can improve articular function and decrease the risk of reinjury. Thus it is efficacious to use percussive therapy (propriocussion) to remove proprioceptive deficits in unstable articular structures, as this appears to play an important role in restoring dynamic stability and in modulating muscle function.
CSK PROCEDURE: A decrease of internal or external shoulder rotation, assessed through range of motion testing, indicates alterations in the neuromuscular firing patterns transmitted through the cortical pathway as exemplified by reduction in neuromuscular activation of the serratus anterior, pectoralis major, subscapularis and latissimus dorsi muscles. This indicates shoulder instability and altered joint kinematics.
Proprioceptive Deficits in Joint Position Sense
Proprioceptive deficits may contribute to the etiology of degenerative joint disease through pathologic wearing of a joint. Barrett and coworkers (1991) demonstrated a decline in proprioceptive driven joint position sense in patients with osteoarthritis. Skinner et al. (1984) further demonstrated decreased kinesthesia with increasing age. Thus when an elderly patient with pre-existing osteoarthritis experiences a physical trauma, such as a motor vehicle crash, their chances of sustaining injury is significantly magnified. It should be obvious that their increased age and the presence of osteoarthritis predisposes these patients to poor position sense and decreased joint motion prior to the collision, which can only be exacerbated in the presence of the force from even a low-impact motor vehicle crash. Propriocussion enhances joint position sense and central peripheral control by creating a bioelectrical signal that triggers an intense increase in normal flow of proprioceptive information. By removing proprioceptive deficits, restoring appropriate joint position sense and improving joint motion, we can surmise that applications of Propriocussion may arrest osteoarthritis.
CSK PROCEDURE: With the patient supine, test the strength of the shoulder in flexion, extension, abduction and adduction. If they test strong have the patient place their short leg ankle over their long leg ankle – this induces gait – and retest. This often causes bilateral upper extremity muscle weakness indicating that the shoulder complex is not capable of bearing load and is recruiting back muscles to do the job.
CSK PROCEDURE: With the patient supine, have them perform a straight leg raise to about 45 degrees and apply load while giving the command hold. If this muscle group tests strong have the patient to rotate their head as far as they can to the ipsilateral side and retest – this often causes that previously strong muscle test to now test weak indicating proprioceptive deficits interfering with motor control. Whenever muscles test weak their orchestration is out of phase – they are firing too late or not strongly enough when needed.
Propriocussion and Nociception
Over months and years, asymmetrical posture and spastic distortions can result in muscle imbalances that lead to joint dysfunction. Kozijavkin (2005) states: “Increased muscle tone, pathological reflexes and movements patterns, and improper body position causes changes of the joints, shortening of the spastic muscles, tendons and ligaments, and abnormalities of blood circulation and metabolism.” Propriocussion intensifies reduction of spasticity and eliminates trigger points in the muscles with the added benefit of correcting autonomic disturbances.
As agonist/antagonist muscle relationship change, the muscles on the left side may become shorter and stronger than those on the right. An aberrant proprioceptive pattern, corresponding to abnormal tonicity of both agonist and antagonist muscles evolves. Such a change in proprioception seems to elicit postural changes that lower the nociceptive threshold and trigger a lingering pain response (Cremonese 1998, Norris 1993). Fuhr (1997) makes “a strong case that a decrease in mechanoreceptor input, as a result of the loss of mobility, can result in hyperirritable nociceptors response, resulting in certain pain syndromes.” Applying Melzack’s gate control theory, which simplified states: “An increase in sensory input will block nociceptive pathways” we can see that a steady state percussive wave supplies the increased sensory input necessary to restore balance to muscle groups improving neuromuscular function and blocking nociceptive (pain) transmitting pathways (Cremonese, 1998).
CSK PROCEDURE: Ever had a patient come into your office and say, “I don’t know what happened I just bent over to pick up a “pencil” and now I can’t straighten up and I’m having a lot of difficulty walking. Do you have any crutches? Have the patient “sit” down on your table (not lie down) and ask them to bend forward dangling their arms between their legs. This activates the core stabilizer muscles, the transverse abdominals, the pelvic floor muscles, and the diaphragm. It is these core stabilizer muscles that are not firing milliseconds before the global muscles as they should and thus the patient has difficulty standing from a seated position as well as walking. Apply propriocussion to the spiral muscle group that Paul Chek calls the lateral system, e.g. the gluteus maximus and the contralateral quadratus lumborum. Also percuss directly over the sacrum and lumbar spine.
Spiral Muscle Groups
A cornerstone of Cerebrospinal Kinesiology Rehabilitation is to influence the performance of the spiral muscle groups using the principles of proprioceptive correction. CSK focuses on functional coordination of spiral muscle groups during movements by emphasizing concordant position and movement of the trunk and extremities. The spiral muscle groups develop concurrently with motor development and are important for compound movements. “Spiral muscle groups cross the body from one side to another and join the left and right side as well as the upper and lower part of the body. They ensure bilateral symmetry and proper posture of the body in the field of gravity; crossed coordination of the upper and lower extremities during locomotion (walking, running, jumping), and shock-absorption during movements. Spiral muscle groups support the spine, secure the head position during movements, support physiological spinal curves, take part in the movement of the thorax during respiration and provide a stable position of the body and extremities” (Kozijavkin 2005).
Paul Chek refers to these spiral muscle groups as the deep longitudinal system, the posterior oblique system, the anterior oblique system and the lateral system stating that he adopted these concepts from Gracovetsky’s Spinal Engine (1998) and Diane Lee’s The Pelvic Girdle (1999). Myers (1997) believes it is more accurate to view the body as a series of interrelated myofascial chains. In the case of injury or trauma pathological motor development is accompanied by functional distortion of existing spiral muscle groups and formation of pathological muscle chains.
“The spirals of the human musculature are mirror images of each other. Designating the right side of the pelvis as a starting point, the muscle sheet of one of the spirals travels diagonally around the side of the torso, crossing over the front mid-section to wrap diagonally upward to the left side of the torso, where the road of muscle makes a “Y’, one avenue junctioning with the muscles of the left arm, the other avenue snaking its way diagonally across the back, continuing on its diagonal journey across the neck to hook onto the head behind the ear in its original hemisphere of the right side (Myers 1997).
CSK PROCEDURE: With the patient supine have them perform an active straight leg raise (ASLR) and ask them to hold as you apply resistance. In isolation this might test strong. However, as “upper extremity motion occurs with consistent synergistic muscle activation patterns in the legs and trunk” (McMullen 2000) ask the patient to reach upward with both arms to the shoulder level and have them move them in an alternating pattern from inferior to superior. Retest the ASLR and it will often become weak indicating delayed activation of leg and trunk muscles before activation of the anterior deltoid.
McMullen (2000) describes the normal sequential pattern associated with right arm movement to include: “Deactivation of the left soleus, activation of the right tensor fascia lata and rectus femoris, activation of the left semitendinosis and gluteus maximus, and finally activation of the right erector spinae before initial deltoid activity.” Because muscles are like large “sheets” that form spirals around the human torso, the simple act of raising the arm cannot be made without involving the muscles of low back and pelvis. The act of turning the head affects the musculature in the lower back; conversely, the muscular condition of the lower back affects cervical range of motion.
Proprioceptive information is then capable of influencing: muscle tone, motor execution programs, cognitive somatic perceptions and reflex joint stabilization. When an injury or trauma occurs to muscles and/or joint structures there is a disruption of the mechanoreceptors resulting in partial deafferentation of the joint and surrounding musculature.
Deafferentation of the mechanoreceptors alters the spinal reflex pathways to motor nerves and muscle spindles. Consequently, neuromuscular control is compromised as a result of the abnormal firing of the injured mechanoreceptors resulting in loss of neuromuscular joint stabilization due to proprioceptive deficits. The result of deafferentation of one limb is a tendency to use the non-involved side more because we are not getting good information into the CNS. Propriocussion supplies stable consistent sensory information that replaces inconsistent messages from damaged tissue. Propriocussion induces proprioceptive responses, which are “conveyed to all levels of the central nervous system, where it provides a unique sensory component to optimize motor control,” (Riemann 2002). The result of clinical experience indicates the inclusion of propriocussive treatments as part of a rehabilitative program help return patients to preinjury levels of activity following ligament and muscle injuries.