573055

research-article2015
NNRXXX10.1177/1545968315573055Neurorehabilitation and Neural RepairHillier et al

Review
Neurorehabilitation and

Assessing Proprioception: A Systematic

Neural Repair
117
The Author(s) 2015
Review of Possibilities Reprints and permissions:
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DOI: 10.1177/1545968315573055
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Susan Hillier, PhD1, Maarten Immink, PhD1,

and Dominic Thewlis, PhD1

Abstract
Proprioception is a vital aspect of motor control and when degraded or lost can have a profound impact on function in
diverse clinical populations. This systematic review aimed to identify clinically related tools to measure proprioceptive
acuity, to classify the construct(s) underpinning the tools, and to report on the clinimetric properties of the tools. We
searched key databases with the pertinent search terms, and from an initial list of 935 articles, we identified 57 of relevance.
These articles described 32 different tools or methods to quantify proprioception. There was wide variation in methods,
the joints able to be tested, and the populations sampled. The predominant construct was active or passive joint position
detection, followed by passive motion detection and motion direction discrimination. The clinimetric properties were
mostly poorly evaluated or reported. The Rivermead Assessment of Somatosensory Perception was generally considered
to be a valid and reliable tool but with low precision; other tools with higher precision are potentially not clinically feasible.
Clinicians and clinical researchers can use the summary tables to make more informed decisions about which tool to use to
match their predominant requirements. Further discussion and research is needed to produce measures of proprioception
that have improved validity and utility.

Keywords
proprioception, clinical tests, rehabilitation, clinimetrics, measurement, neurology

Introduction of velocity) is a part, along with cutaneous receptors, and

the vestibular and visual systems. Conversely, other authors
What Is Proprioception: Ambiguity Leading to cite proprioception as having 3 submodalities: kinesthesia,
Confusion joint position sense, and sensation of force (see, eg, Niessen
et al4). Others again add body segment static position, dis-
In the early 1830s, Sir Charles Bell described the sixth
placement, velocity, acceleration, and muscular sense of
sense, referring to the sense of position and action of the
force, effort, or heaviness (see Ogard5 or Proske and
limbs.1 Proprioception was further discussed by Sherrington
Gandevia6) to the list of proprioceptive constructs. In this
in his seminal text and lecture series some 70 years later.2
review, we will refer to proprioception as a collective term
Since then the term has been used to describe a variety of
for these subsenses, unless the evidence only pertains to
senses and therefore has become somewhat ambiguous. The
one in which case we will refer to that subsense
word proprioception comes from the Latin proprius, mean-
individually.
ing ones own, combined with the concept of perception:
Finally, proprioception can be considered one of the sub-
thus a literal translation is that of perceiving ones own
systems within the somatosensory system (along with pain,
self. This notion of self-perception reflects ones ability to
touch, and thermal sensation) and has also been considered
have both a sense of body orientation and position as well
interoceptive in that the sensory information is derived
as a sense of body and limb motion. Accordingly, words
from changes within internal structures. This classification
often used interchangeably with proprioception are (joint)
position sense, kinesthesia, movement sense, body position
in space, sense of effort, or sense of force. The confusing 1
University of South Australia, Adelaide, South Australia, Australia
and inconsistent application of these terms, particularly in
Corresponding Author:
the clinical domain, reflects the slowly emerging under-
Susan Hillier, International Centre for Allied Health Evidence, University
standing of the nature of how we sense ourselves. of South Australia, City East Campus, North Tce, Adelaide, South
Berthoz3 classically defines kinesthesia as the sense of Australia 5000, Australia.
movement, of which proprioception (sense of position and Email: Susan.hillier@unisa.edu.au

Downloaded from nnr.sagepub.com at University of South Australia on February 25, 2015

2 Neurorehabilitation and Neural Repair
is in distinction to exteroception where the stimulus origi-
nates from outside the body such as external heat for ther-
moreception or light stimuli for vision.
Proprioceptive Receptors
Proprioception, or proprioceptive acuity, is a complex sys-
tem that involves both peripheral and central systems. The
evidence for the prime proprioceptive receptor favors mus-
cle afferent input,6 in particular muscle spindles. These
receptors are specialized fibers within the muscle that detect
change in muscle length and also the velocity of contrac-
tion7 (or body part motion as the first derivative of length,
ie, the rate of the change in length). If a passive lengthening
is applied to a muscle, spindle exafferent signals are pro-
duced and interpreted as a sensation of movement, with
increasing velocities causing an increasing response.6 The
spindle system has the capacity to anticipate length change
because it can detect velocity as well as length (which
changes more quickly).3 Furthermore, motion direction can
be perceived relative to which particular muscle has short-
ening or lengthening activity, and presumably by compari-
son between agonist and antagonist activity ratios, joint
position can be perceived. The muscle spindle is also under
fusimotor control (the gamma system), during contractions,
which has the capacity to alter the calibration or sensitivity
of the receptor by altering its internal length.8 This modula-
tion allows adaptation of the receptors during action and
also allows simulation in the absence of real action.3 Related
to the sensitivity of the spindle is the role of thixotrophy
the phenomenon that demonstrates a relationship between a
muscles properties and its immediate history of contract-
ing/lengthening. It is a property of muscle (and muscle
spindles) and influences proprioceptionthat is to say pro-
prioception (spindle sensitivity) can be altered, dependent
on whether the muscle has recently contracted or not (see
Proske and Gandevia6)
Proske and Gandevia6 summarize the evidence that
receptors in the skin (cutaneous receptors) also contribute to
joint position and motion sense, for example, as skin strain,
particularly at the digits, elbow, and knee. Receptors analo-
gous to the cutaneous receptors also exist in joint structures.
For example, the more superficial Ruffini endings in the
joint capsule, ligaments, and menisci are slow adapting
mechanoreceptors. This allows detection of static joint posi-
tion, intra-articular pressure, and possibly joint motion in
terms of amplitude and velocity.8 Pacinian corpuscles are
deeper in these joint connective tissues with a lower mechan-
ical threshold and are faster adaptingallowing them to be
more responsive to changes in velocity, that is, acceleration
and deceleration. Lephart and Fu8 also describe free nerve
endings widely distributed in articular structures and which
may play a role in detecting severe mechanical deformation
or inflammatory changes. However, it is now accepted that
these mostly mechanical receptors predominate at extreme
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angles of joint position and motion and are relatively silent
midrange.6,9 Golgi tendon organ-like receptors are also
found in cruciate and collateral ligaments and menisci; like
the mechanoreceptors listed, it is reported that they are use-
ful at extremes of range as limit detectors.8 This then leaves
the muscle spindles to provide most information in the mid-
dle region of joint action.6
Effort-based signals, that is, the efferent commands to
muscles, have a role in proprioception (particularly sense of
force and/or position sense). These signals are distinct from
the traditional kinesthetic senses in that they are based on
motor commands and therefore not experienced in a passive
limb. However, Gandevia et al10 investigated paralyzed and
anesthetized upper limbs to demonstrate an alteration in
position sense at the wrist joint, relative to the effort of
attempting to produce a contraction in the paralyzed
muscle(s), concluding there is a definitive role for out-
flow (efferent) signals in proprioception.
In summary, proprioception is based on an ensemble of
sensory inputs that serve sensing, producing, predicting,
and simulating joint position, joint motion (velocity and
direction), and force specification.3 There is considerable
specificity and sensitivity in this ensemble arrangement as
well as redundancy, particularly when proprioception is
converged with the visual and vestibular systems in detect-
ing motion and spatial orientation (from visual- and grav-
ity-referenced coordinates).3,11 The most basic of postural
control tasks, such as standing in regular environments,12 is
contingent on the coordination of these processes.
Clinical Implications of Proprioception
In motor control, proprioception, along with the other
senses, is important in both feedback and feedforward oper-
ations and can be used in combination or in the absence of
other sensory systems. Proprioceptors have a role in motor
planning (feedforward for anticipation, preparation, and
response planning) as well as rapid wiring into adaptation
mechanisms to effect performance changes during task exe-
cution (feedback). Clinical scenarios where proprioception
is lost or degraded classically result in loss of movement
control where the person must then rely on visual input for
feedforward and feedback processes. This may result in dif-
ficulty in learning novel movement, and also difficulty in
improving the quality of movement or maintaining quality
over a series of repetitions because of the absence of feed-
back for adaptation and skill refinement.12 Not only are dex-
terous tasks affected but also balance and locomotion
despite the high degree of redundancy with vision and ves-
tibular input for these activities. Age has an impact on pro-
prioception13; proprioception lags somewhat behind vision
in an infants development and then declines with age, par-
ticularly beyond 50 years.
Clinically, reduced proprioception has been most obvi-
ously implicated in stroke,14 age-related falls,13 and peripheral
Hillier et al 3
neuropathy15 and also in movement disorders such as
Parkinsons disease, Huntingtons disease, and focal dysto-
nia.16 There has also been a lot of interest in the role of subop-
timal proprioception in the etiology and/or rehabilitation of
orthopaedic17 and sporting injuries.18 Poor proprioception has
been reported in pain states such as chronic low back19 and in
persistent whiplash and associated disorders,20 and in other
diverse conditions such as developmental coordination disor-
der,21 hypermobility syndrome22 and Asperger syndrome.23
Measuring Proprioception
There is clearly no single measure of proprioception due to
the complexity of the neurophysiological processes that
encompass proprioception described above.
In order to investigate the impact of a loss of propriocep-
tion on function, or the degree of loss from pathology, clini-
cians and researchers have developed many ways to capture
proprioceptive acuity. More recently this has been driven by
inquiry into the capacity of the proprioceptive senses to be
improved through sensory-specific training or upregulation
via afferent stimulation.24
Tests have differentiated between the 2 main propriocep-
tive functionsdetection of static position and detection of
motion. The latter is further broken down into the threshold
of motion detection, that is, the threshold amount/speed of
motion required for detection to occur, and second, the
direction of motion (eg, flexion or extension), which is con-
sidered a discrimination task. These 2 tests are usually per-
formed passively and clinically and are administered to the
great toe in a nonstandardized fashion. Detection of posi-
tion has been performed by position copying or position
matching tasks that can be done actively or passively. In
order to further refine testing, attempts are often also made
to reduce cutaneous stimulation during motion or position
detection. However, given the multiplicity of constructs
attributed to proprioception and the array of physiological
processes, such tests often raise more queries than answers.
We embarked on this review systematically as the first
stage in clarifying the ambiguities discussed above. We
chose a systematic approach to cover the greatest breadth
and depth of the literature. As such the aims of this system-
atic review were to
1. Identify the reported methods of assessing proprio-
ception in healthy and pathological populations
2. Classify the subsenses of proprioception they pur-
port to measure (external validity)
3. Report the clinimetric properties investigated for
each tool (internal validity)
The overall objective was to provide clinicians and clinical
researchers with a summary document of tools to enhance
selection relative to need, with an explanation of the limita-
tions or issues in the identified current approaches.
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Methods
To identify proprioception assessment tools, a systematic
search of the literature was conducted. The search strategy
involved 2 steps. First, a comprehensive electronic database
search was conducted. Then a secondary search was con-
ducted looking at the reference lists from articles that were
reviewed in full-text from the database search.
The databases searched included EBSCO, Journals@
OVID, AMED, EMBASE, Medline, Ovid Medline,
Science Direct, SportDiscus, E-journal, Ageline, CINAHL,
and Highwire Press. Dates were from database inception
and the searches were completed in December 2013.
Search terms used included combinations of propriocep-
tion, kinesthesia or joint position, joint motion, with terms
such as tests, clinical measures, clinical examinations,
diagnostic accuracy, predictive value, sensitivity or
specificity.
Articles identified in the database search were then eval-
uated by a team of researchers to ensure the research article
and tools of proprioception assessment met the following
inclusion criteria:
Explicitly described and employed a tool or tools to
measure proprioception (or allied terms)
In any human population
Written in English
Two researchers (SH and a research assistant) agreed on eli-
gibility for inclusion. There was no attempt to critically
appraise the quality of the individual articles as they were of
various study designs not necessarily related to the use of
the tool itself. For example, the primary article may have
been a randomized controlled trial using the tool as an out-
come measure or it may have been a single case study using
the same measure. We determined the level of study design
itself did not offer any indication of the robustness or utility
of the tool itself and therefore was not relevant.
The articles were then collated into similar tools with
similar targeted subsenses (relative to aim 2) and data
extracted to describe the joints measured, the construct, and
the broad method of testing. Further data regarding popula-
tion tested, equipment, and procedures were also extracted.
The subsense or construct clusters were identified as
1. Joint position detectionactive/instantaneous posi-
tion or passive (AJPD or PJPD) (acknowledging the
position is enacted AT the joint, not necessarily
detected BY the joint)
2. Passive motion detection threshold (PMDT)
3. Passive motion direction discrimination (PMDD)
To fulfil aim 3, further data were extracted from the arti-
cles retrieved (and from the reference lists) to record rele-
vant clinimetric properties, based on the process used by
4 Neurorehabilitation and Neural Repair

Initial search hits (n= 935)

Identiication Excluded based on title or

being duplicates (n =795)

Abstracts reviewed (n=140)

Screening

Excluded based on
abstract (n =10)

Articles reviewed based

Eligibility

on full-text (n = 130)

Excluded did not meet

inclusion criteria (n = 93)

Articles included (n = 40) Additional articles for

Secondary search

full-test review (n = 23)

Excluded did not meet the

inclusion criteria (n =6)
Included

Final sample (n =57) Articles included (n =17)

Figure 1. PRSIMA flow chart of article selection.

Slater et al.25 See Appendix 1 for an example of the data Results

extraction pro forma. The properties scrutinized were the
following: We will first report the results of the search and then results
relative to the 3 aims of the study.
Reliability: testretest, reproducibility, intra- and Step 1, which involved the database search, ultimately
interrater and internal consistency yielded 40 articles from the initial database search list of
Validity: face, criterion, content, construct, concur- 935, with the full process of inclusions and exclusions
rent, or factor analysis detailed in Figure 1. Step 2, which involved pearling the
Responsiveness: sensitivity, specificity, floor and reference lists of the articles retrieved for full-text review,
ceiling effects, discrimination revealed a further 17 articles to be retained for final inclu-
Precision: accuracy, standard error sion, giving a total of 57 articles.

To further inform potential readers of the clinical features of

the tool (also aim 3), we also considered subjectively
Client-centered attributes: appropriate, meaningful,
acceptable
Tester-centered attributes: feasibility and clinical
utilityease of use, clinically meaningful, ease of
interpretation, normative scores
Two researchers completed this data extraction phase and
crosschecks occurred on a random audit basis.
Identification of Tests
Table 1 summarizes the 57 research articles included in this
review. From these 32 tests of proprioception were identi-
fied (that appeared to be sufficiently distinct in relation to
purported constructs, administration, and/or joints) and data
extracted as detailed in the methods.
The body part most commonly measured was the knee (11)
followed by 4 tests identified for the lower trunk or back, 4 for
the ankle, and 2 distinct protocols for the cervical spine. Other
areas were often tested as a composite (eg, hip and knee and

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Hillier et al 5
Table 1. Summary of Identified Proprioception Tests.
Tool and Author/Date
Lumbar proprioception
equipment (LPE)
Zazulak et al26 (2007) and
previously described by Taimela
et al27 (1999)
Spinal Motion Apparatus
(SMA)
Pankhurst and Burnett17 (1994)
(also designer)
Active movement extent
discrimination apparatus
(AMEDA)
Hobbs et al28 (2010)
Neck proprioception testing
device (NPTD)
Lee et al29 (2005)
Proprioceptive apparatus
(no name)
Cuomo et al30 (2005)
Manipulandum
Bevan et al31 (1994) (previously
described by Cordo et al32 1994)
Kinarm
Bhanpuri et al33 (2012)
Manipulandum
Wong and Henriques34 (2009)
Manipulandum
Simo et al35 (2011)
Shuttle Miniclinic constant-
resistance device
Lin et al36 (2006)
Proprioceptive apparatus
(no name)
Friden et al37 (1996); Fischer-
Rasmussen and Jensen38 (2000);
Barrack et al39 (1983); Corrigan
et al40 (1992); Co et al41 (1993)
Also Barrack et al42 (1989) =
deviser
Body Part, Construct, and
Broad Method Population Equipment Procedure
Trunk Collegiate athletes26 Motorized apparatus fixes upper Active and passive repositioning
AJPD Population with lumbar body and rotates lower body apparatus rotates lower trunk and
PJPD fatigue27 around vertical pivot through then subject indicates regaining
Active repositioning and L4/5 of original neutral position either
passive recognition (joint actively OR when passive motion
angle error) reaches neutral position (lying)
Lower back Male firefighters with and Motorized apparatus that Apparatus moves lower body passively
PJPD without back injuries produces passive motion of Lx in in any 1 of the 3 planesperson
PMDT 3 planes (upper body fixed) detects motion; picks direction of
PMDD motion; has to identify test place from
Passive recognition (joint neutral (lying)
angle error)
Threshold for detection
Direction accuracy
Lumbar Healthy individuals; Unrestrained standing (WB) Person had to distinguish between 5
AJPD with spinal pain and with stopper at 5 preset preset active flexion positions as set
Discriminate position radiographic evidence of (demonstrated) distances by concealed stopper (standing)
differences in 11-19 Lx flex disc degeneration; post disc (stepper motor). Version for
replacement surgery ankle with variable plate
Cervical Healthy students (subclinical Cervical version of AMEDA Person had to distinguish between 5
AJPD neck pain) above. Unrestrained cervical preset active rotation and retraction
Discriminate position motion with stopper at 5 preset positions as set by concealed stopper
differences in Cx rotation positions (stepper motor) (sitting)
(25-41), Cx retraction (1
to 1.8 cm)
Shoulder Patients with unilateral Motorized apparatus to produce Subjects arm was passively moved
PJPD advanced glenohumeral motion at the GH in 3 planes by device through range and subject
PMDT arthritis before and after indicated when predetermined
Passive recognition (joint total shoulder arthroplasty; position attained; second test subject
angle error) healthy controls indicated when onset of passive
Threshold for motion motion was detected (seated and
detection standing)
Elbow Health subjects Elbow (forearm and upper arm) Person indicates when their elbow
PJPD strapped to motor device that reaches one of the pretrained joint
Passive recognition (joint produced passive change of joint angles (flex/ext); indicates when their
angle error) angle (verified by goniometry) forearm has moved the pretrained
Passive recognition specified distance (sitting)
(distance estimation error)
Elbow Cerebellar subjects Elbow (forearm and upper arm) Subjects report if they feel a
PJDT strapped to exoskeleton robot movement or not (by robot). Second
PMDT system that produced passive movement elicited and subject
Passive detection of motion change of joint angle indicates if greater or less than first
then discrimination of
magnitude
Upper limb Healthy subjects Robot manipulandum that Distinguish between 2 tilting
PMDD passively moves hand through pathways and 2 curved pathways
Direction accuracy different pathways (vision (sitting)
obscured)
Upper limb Healthy and stroke impaired Robot manipulandum that Distinguish movement in 1 of 2 time
PMDT produces arm displacements periods (other stationary)
Passive motion detection (vision obscured)
Hip and knee Normal maleselite, Constant resistance device Subject presses on device to extend
PJPD amateur, and novice tennis applied to sole of foot to allow limb from starting position of 60
Passive recognition (joint players increase/decrease hip and knee hip flex/90 knee flex to a pretrained
angle error) joint angles in closed chain target position and repeat (supine)
electro-inclinometer measured
thigh and shin motion
Knee Healthy subjects; subjects Motorized apparatus to passively Subject detects onset of passive
AJPD with ACL deficient knees move shin to change knee joint motion/change of position at
PMDT ACL reconstructions; angle; in some versions, motor knee; actively reproduces target
Active reproduction (joint bilateral OA knees; elderly can be disengaged to allow active demonstrated angle; indicates target
angle error) and also non-OA43 movement angle with goniometer (side-lying
reproduces visually with Health female gymnasts44 using underneath leg or supine);
object OA knees45 actively matches contralateral leg to
Threshold for motion match angle of test knee; indicates
detection onset of (slow) passive motion
(sitting)
(continued)
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6 Neurorehabilitation and Neural Repair
Table 1. (continued)
Tool and Author/Date
Proprioceptive device
(no name)
Brindle et al46 (2010)
Movement detection
apparatus
Matre and Knardahl47 (2003),
further described by Matre
et al48 (2002)
Passive ankle joint
repositioning test
Fu et al18 (2007)
Cervicocephalic kinesthesia
Kristjansson et al49 (2001) tests
from multiple authors
Also Cervical Joint position
error (JPE)
Treleaven et al50 (2003);
Treleaven et al20 (2006)
Also JPE-Torsion
Chen and Treleaven51 (2013)
Thoracolumbar
proprioception
Koumantakis et al52 (2002)
(original protocol by Gill and
Callaghan,19 1998)
Arm position-matching task
Dukelow et al53 (2010); Debert
et al54 (2012)
Active Knee joint reposition
sense
Bullock-Saxton et al13 (2001)
Active Knee joint reposition
sense
Kramer et al55 (1997)
Active knee joint reposition
test
Marks et al56 (1993)
Limb copying and
reproducing tests
Kaplan et al57 (1985)
Limb copying test
As reported in various including
Paqueron et al58 (2004); Goble
et al59 (2012)
Body Part, Construct, and
Broad Method Population Equipment Procedure
Knee/ankle Healthy subjects Motorized apparatus (Biodex) Subjects foot rotated to lengthen/
PMDT that passively moves both knee shorten gastrocnemius, while knee
PMDD and ankle flexed/extended. Indicate onset of
Passive detection of motion movement and direction
onset and direction
Ankle Healthy subjects Motorized rotating platform, axis Subjects foot rotated in dorsi- or
PMDT aligned with ankle joint plantarflexion directionindicate
PMDD when motion was detected AND
Threshold for motion which direction (seated)
detection
Direction accuracy
Ankle Health male basketball Cybex motorized apparatus Subjects foot rotated in
PJPD players to produce passive ankle plantarflexion directionindicated
Passive recognition (joint displacement at constant speed; when predetermined target was
angle error) electrogoniometry reached (prone)
Cervical Healthy volunteers49 Polhemus 3space Fast track Test 1: relocation of head to natural
AJPD Healthy controls and (sensors)calculated error, or head posture (NHP) (after active
Active reproduction (joint subjects with WADS laser marker51 rotation left and right)
angle error) (whiplash)50,51 Test 2: Active relocation to 30
rotation from NHP (after passive
criterion)
Test 3: Preset passive trunk rotation
30, subject repositions head to NHP
and then back to original 30 relative
Test 4: Figure of eight motion and
relocation to NHP (active)
Test 5: Figure of 8 movement
accuracy of passing through NHP at
each crossing of 8
JPE-Torsionmodification of
rotating trunk under fixed head
to differentiate from vestibular
stimulation
Spinal Individuals with and without Lumbar motion monitor Active target reproduction in 3
AJPD low back pain (exoskeleton) to measure planes after initial active criterion
Active reproduction (joint absolute error (between pelvis position (flex/rotation/lat flex)
angle error) and chest harnesses)
Upper extremity Healthy versus people with KINARM exoskeleton on both Passive positioning of arm, actively
AJPD stroke53 or traumatic brain armsto apply load/measure matched by contralateral arm
Active reproduction (spatial injury54 motion
coordinates)
Knee Young, middle age, and old Polhemus 3space Fast trak Sensors detect position of test limb
AJPD healthy subjects (sensors) in active criterion versus subsequent
Active reproduction (joint active reposition under FWB and
angle error) PWB conditions, and error is
calculated
Knee Healthy and with Electro-goniometer to measure Active knee repositioning to target
AJPD patellofemoral pain absolute error for reposition criterion angle in sitting (NWB) and
Active reproduction (joint syndrome standing (squattingWB)
angle error)
Knee Women with healthy versus Photographic capture of absolute WBstood on test limb and tried to
AJPD OA knees error in repositioning from actively reproduce criterion angles
Active reproduction (joint criterion (from limb markers) NWBstood on contralateral leg
angle error) and bent test leg (open chain) to
criterion angle
Knee Healthy older and younger Goniometer to measure error 1.  Knee passively positioned and
AJPD women between reproduction and contralateral actively reproduces
Active reproduction (joint criterion 2.  Reproduce criterion position in
angle error) ipsi- and ipsilateral knee at 15 seconds and
contralateral 60 seconds after demonstration
Elbow Anesthetized UL58 Observation Limb moved passively and while
AJPD Adults with cerebral palsy59 shielded from vision. Opposite limb
Active reproduction (joint copies actively OR ipsilateral limb
angle error) contralateral copies after period of time (requires
or ipsilateral spatial working memory). Improves
with longer encoding time for
example position.
(continued)
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Hillier et al 7
Table 1. (continued)
Tool and Author/Date
Joint position sense
Reported variously in Lord et al60-
62
(1991, 2000, 2002); Sturnieks
et al63 (2004); Whitney et al64
(2005); Tiedmann et al65 (2007);
Wood et al66 (2008)
Apparatus design by De
Domenico and McCloskey67
(1987)
Proprioceptive assessment:
Modified Thomas splint with
Pearson knee flexion piece
Reported variously in Warren
et al68 (1993); Barrett et al69
(1991)
Rivermead Assessment of
Somatosensory Perception
(RASP)
Winward et al70 (2002); Tyson et
al14 (2008)
Cumulative Somatosensory
Impairment Index (CSII)
Deshpande et al71 (2010)
Distal Proprioception Test
(DPT)
Richardson15 (2002)
Dual Joint Position Test
(DJPT)
Beckman et al72 (2013)
Standardized sensory
assessment for children
Cooper et al73 (1993)
Thumb finding test
Smith et al74 (1983)
Wrist Position Sense Test
Carey et al75 (1996)
Abbreviations: AJPD, active joint position detection; PJPD, passive joint position detection; PMDT, passive motion detection threshold; PMDD, passive motion direction
discrimination; L or Lx, lumbar; WB, weight bearing; Cx, cervical; GH, gleno-humeral; flex, flexion; ext, extension; ACL, anterior cruciate ligament; OA, osteoarthritis;
WADS, whiplash and associated disorders; NWB, nonweight bearing; MS, multiple sclerosis; MCP, metacarpophalangeal joint.
Body Part, Construct, and
Broad Method
Lower limb
AJPD
Active reproduction (joint
angle error) contralateral
Knee
PJPD
Reproduction (joint angle
error) on mock-up leg replaced knees;69 knee OA/
Elbow, wrist, thumb,
ankle and big toe
proprioceptive subtests
PMDT
PMDD
Threshold for motion
detection
Direction accuracy
Lower extremity
Proprioceptive subtest
AJPD
Reproduction (joint angle)
Toe, ankle
PMDT
PMDD
Threshold for motion
detection
Direction accuracy
Note these tests can also
be modified to simply detect
position up/down AFTER
passive motion, ie, PJPD
Digits
PJPD
Direction accuracy
(simultaneous in 2 digits)
Finger Typically developing children
PMDT
PMDD
Threshold for motion
detection
Direction accuracy
Thumb/upper limb
PJPD
Accuracy in locating
passively placed limb
(thumb)
Wrist
PJPD
Accuracy in indicating joint
angle
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Population
Healthy aged; Parkinsons;
older with arthritis
Adults anterior cruciate
reconstruction;18 normal
versus osteoarthritic and
arthroplasty68
Adults with stroke
Healthy controls, diabetic,
peripheral arterial disease,
stroke
Peripheral neuropathy,
control
Healthy controls and
those with lemniscal
system dysfunction (MS or
vasculitis)
(school-aged)
Adults with stroke
Adults with stroke
Equipment
Vertical Perspex sheeterror of
matching measured by inscribed
protractor in degrees
Thomas splint with a Pearson
knee-flexion piece was modified
to provide well-padded support
to whole leg. Protractor attached
to knee piece. Axes aligned.
Warner added electronic
goniometry and smoother
positioning (limits sensation to
capsular and ligamentous joint
receptors).
Nil
Nil
Nil
Nil
Nil
Nil
Splint device for forearm/hand
within obscuring box; overlaid
with protractor
Procedure
Limb on one side placed on sheet
(eg, big toe) and simultaneously
other leg positioned to touch
corresponding spot on sheet from
other side (eyes closed)
Supine and leg screened from view.
Leg moved passively to 1 of 10
predetermined positions of flexion.
Subject manually reproduces angle
on a mock-up leg with goniometry.
Error between real knee angle and
perceived angle is measurement
Participants eyes closed, joint moved
passively into flexion or extension:
for detection indicate when
movement occurs; for discrimination
indicate which direction. Score
system 0-1 absent; 2-5 impaired; 6
intact
Reference ankle positioned by
examiner and subject matches position
(10/20 degrees or neutral)
Grasp lateral borders of great toe
and perform up/down movements
first with eyes open then eyes
closedtest is 10 small amplitude
random, smooth movements over
a distance of app 1 cm and speed of
1 p/s. Score for correct perception
of movement and identify direction.
<8/10 trials positive.
As for DPT but move 2 digits
simultaneouslycombination both
up, both down, or one up/one down
As for DPT but with motion
occurring at the MCP of the finger,
scored x/5 to discern direction of
motion up/down
Not stated. Assumed to be passive
positioning of the affected thumb
in different spatial coordinates and
person has to make contact with test
thumb using other (unaffected) hand.
Score x/10
Tester positions subjects wrist in
predetermined positions of flexion/
extension; subject indicates best
matched joint angle using protractor
arms
8 Neurorehabilitation and Neural Repair
ankle in weight-bearing), or targeted distal joints of upper and
lower limbs (eg, toes and fingers/thumb).
The tests were used on widely varied populations. The
majority were with healthy adults or used healthy adults as
a control. Three looked at populations of athletes (gymnasts
and tennis and basketball players), a specific profession
(firefighters with and without lower back injuries), or the
influence of age (children, adults, and elderly). The major-
ity of pathological populations had musculoskeletal issues
such as anterior cruciate ligament deficiency (ACL; 4),
osteoarthritis (5), or pain (4). Postsurgical comparisons
were also featured, for example, pre- and post-ACL recon-
struction (3), shoulder arthroplasty, or knee replacement.
Neurological pathologies were less well featured with 4
tests described in stroke and 1 each for Parkinsons disease,
traumatic brain injury, cerebral palsy, peripheral neuropa-
thy, and anesthetized limbs.
Proprioceptive Subsenses Tested
Table 2 summarizes the tests in relation to what they test (the
subsenses or constructs). The majority of tests assessed joint
position detection either actively or passively (AJPD or
PJPD) through recognition or reproduction tasks with the
measurement being joint angle error (JAE; ie, the difference
between the true target angle and the reproduced angle or
angle at which recognition occurred). There was variation in
how the target angles were demonstrated (on the limb itself,
or the contralateral limb, using an angled lever) and whether
the JAE was measured via motion capture equipment, elec-
tro-inclinometry, photographic capture, Perspex protractor
grading, or goniometry (electric or manual). Various means
were used to produce the passive motion for PJPD from
motorized apparatus or robotics, to modified splints moved
by the tester to simply the tester moving the body part. Where
the task was active reproduction of the target angle, it was
mostly reproduced on the ipsilateral side, but in the more
manual-based tests it was reproduced on the contralateral
side or on a sheet of paper, a goniometer, or a simulated limb.
Ten tests15,17,30,33,35,37,45-48,70 measured the threshold for
detecting motion (PJMD) again using a variety of ways to
produce the passive motion as described above. The most
common measure was the error between the angle of actual
commencement of motion and the detection angle. However,
the more simple clinical tests simply required the person to
detect motion compared to static position and were scored
dichotomously for 5 to 10 trials.
Six tests15,34,46,48,70,73 also incorporated the direction of
motion discrimination task (PMDD) by requiring the per-
son to indicate whether the limb moved in a positive or
negative direction relative to the defined plane of motion.
Generally, the planes of motion were restricted to one but a
few tests did incorporate up to 3 planes and one used path-
ways, that is, tilting or curved.
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In all examples found, some attempt was made to reduce
the influence of confounding senses though the degree to
which this was attempted also varied, for example, all tests
excluded vision while the most elaborate tests produced pas-
sive motion with pneumatic splints so that there was no dis-
cernment of pressure to imply motion or motion direction
(via cutaneous receptors) or even used background white
noise to cancel out any clues to motion commencement from
the sound of the motor (see Table 2 for limitations).
Clinimetric Properties
Generally, the clinimetric properties for the identified tools
were poorly evaluated or reported. Table 3 summarizes
each test and the reported properties we were able to find, as
well as our judgments on the user- and client-centered
aspects. Six tests29,30,31,32,34,46,74,75 had no recorded proper-
ties tested. For the others, the main data available related to
the discriminant ability of the test, that is, to differentiate
between 2 groups (one normal and one pathological for
example). The Rivermead Assessment of Somatosensory
Perception (RASP)70 had the most reported properties and
achieved good or higher in the evaluations. Furthermore,
this test can be applied with no equipment to 5 different
joints for greater clinical utility; however, it was not consid-
ered precise in that the scoring for each test move is only
dichotomous and there is the confounder of the tester manu-
ally moving the body part with cutaneous input. The
Modified Thomas splint with Pearson knee flexion piece68,69
has been used and tested more widely with high values for
testretest and concurrent validity and ability to discrimi-
nate between different pathological groups and age ranges.
The equipment requirements are not onerous but this device
only assesses the knee.
Discussion
We have conducted a thorough search of the literature to
identify the most commonly used tools for the measurement
of proprioception in humans. Not surprisingly, we found a
plethora of different tools, and the variations came with
respect to
Measuring different proprioceptive subsenses (active
versus passive position, motion detection, or direc-
tion discrimination)
Measuring different joints
The use of different types of equipment and values
Differing populations.
Given the complexity of proprioception and the multifac-
etted aspects of kinesthesia and position sense as identified in
the introduction, it is not surprising that the tests are so seem-
ingly disparate. By highlighting this issue we hope that future
Hillier et al 9

Table 2. Proprioceptive Tools Clustered Within 4 Identified Subsenses.

Proprioception
Subsense Physiological Basis6 Tool(s) Strengths Limitations Populations Body Part Measured

Active joint position Muscle spindle (major Lumbar proprioception Reflects functional use More likely to be Collegiate athletes Lumbar spine
detection (subject source) both afferent equipment26,27 of proprioception limited by pain Lumbar fatigue Cervical spine
actively reproduces and efferent activity Active movement extent gauging position Requires kinesthetic Spinal pain/surgery Knee
established position) Skin stretch receptors discrimination apparatus28 in space through memory of Subclinical neck pain Upper limb
(Ruffini) Neck proprioception volitional movement preestablished ACL deficiency/ Elbow
Joint receptors (limit testing device29 No extraneous position reconstruction Lower limb
detectors) Proprioception sensory input from Requires sufficient OA Ankle
apparatus37-45 passive device motor control Elderly
Cervico-cephalic (pressure sense) Whiplash
kinesthesia/JPE20,49-51 Low back pain
Thoracolumbar Stroke/TBI
proprioception19,52 Patella-femoral pain
Arm positioning-matching Cerebral palsy
task53,54 Anesthetized
Active knee joint Parkinsons
reposition sense14,55 Diabetic
Limb copying and Peripheral arterial
reproducing tests57-59 disease
Joint position sense60-67
Cumulative
somatosensory
impairment index71
Passive joint position Muscle spindle Lumbar proprioception Does not require Possible additive Collegiate athletes Lumbar spine
detection (subject (major): mean rate equipment26,27 active control sensory input from Lumbar fatigue Shoulder
recognizes established of background Spinal motion apparatus17 passive device Male firefighters +/ Elbow
position when discharge generated Proprioceptive (pressure sense or back injuries Hip
reproduced passively) by both primary and apparatus30 auditory stimuli) Glenohumeral Ankle
secondary endings Manipulandum31,32 Requires kinesthetic arthritis Knee
Skin stretch receptors Kinarm33 memory of Cerebellar Digits
(Ruffini) Shuttle Miniclinic preestablished Elite/amateur/novice Wrist
Joint receptors (limit constant-resistance position tennis players
detectors) device36 Basketball players
Passive ankle Knee pathologies
repositioning test17 Lemniscal system
Proprioceptive dysfunction
assessment68,69 Stroke
Dual joint position test72
Thumb finding test74
Wrist position sense
test75
Passive motion Muscle spindle (major): Spinal motion apparatus17 Does not require Detection thresholds Male firefighters +/ Lumbar spine
detection threshold primary endings Proprioceptive working memory higher for slower back injuries Shoulder
(the threshold at which stimulated by change apparatus30 movements Glenohumeral Upper limb/hand
the subject can detect in length and rate of Kinarm33 arthritis and knee
a moving state from change in length Manipulandum35 Cerebellar Knee and ankle
the stationary) Skin mechano Proprioception Stroke Ankle
receptors (Meissner, apparatus37-45 ACL deficiency/ Thumb
Pacinian, Merkel and Proprioceptive device46 reconstruction Toe 1
Ruffini endings) Movement detection OA
Joint receptors (limit apparatus47,48 Elderly
detectors) Rivermead Assessment Stroke
of Somatosensory Peripheral
Perception70 neuropathy
Distal proprioception
test15
Passive motion direction As above Spinal motion apparatus Higher order test to Response can be Male firefighters +/ Lumbar spine
discrimination (subject Manipulandum34 not only detect motion dichotomous and back injuries Hand
discriminates between Proprioceptive device46 but to discriminate therefore easy to Stroke Knee and ankle
different movement Movement detection direction guess, eg, flexion Peripheral Ankle
directionsone or apparatus47,48 versus extension neuropathy Thumb
more axes of rotation) Rivermead Assessment Children Toe 1
of Somatosensory Elbow
Perception70 Wrist
Distal proprioception Finger
test14
Standardized sensory
assessment for children73

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10 Neurorehabilitation and Neural Repair
Table 3. Clinimetrics of Proprioception Tests From Published Literature.
Tool With Author/Date
Lumbar proprioception
equipment (LPE)
Zazulak et al26 (2007) and
previously described by Taimela
et al27 (1999)
Spinal Motion Apparatus
(SMA)
Pankhurst and Burnett17 (1994)
(also designer)
Active movement extent
discrimination apparatus
(AMEDA)
Hobbs et al28 (2010)
Neck Proprioception testing
device (NPTD)
Lee et al29 (2005)
Proprioceptive apparatus
(no name)
Cuomo et al30 (2005)
Manipulandum
Bevan et al31 (1994) (also described
by Cordo et al,32 1994)
Manipulandum
Wong and Henriques34 (2009)
Kinarm
Bhanpuri et al33 (2012)
Manipulandum
Simo et al35 (2011)
Shuttle Miniclinic constant-
resistance device
Lin et al36 (2006)
Proprioceptive apparatus
(no name)
Friden et al37 (1996)
Proprioceptive apparatus
(no name)
Fischer-Rasmussen and Jensen38
(2000); Barrack et al39 (1983);
Corrigan et al40 (1992); Co et al41
(1993)
Also Barrack et al42 (1989) is
deviser
Also Pai et al43 (1997)
Also Lephart et al44 (1996)
PTD. Also Hurkmans et al45
(2007)
Summary Reported Psychometrics Client-Centered Attributes Tester-Centered Attributes
Trunk Reproducibility of both active and Acceptable for research Not feasible clinically as complex
AJPD passive: ICCs 0.61 and 0.58 population equipment and requires technical
PJPD Rotation motion is expertise for data analysis
semifunctional Precise data for interpretation
Lower back Accuracy of motion within 2 mm range Acceptable for research Not feasible clinically as complex
PJPD (within 0.1) population equipment and requires technical
PMDT Reliability of PMDT ICC 0.46 to 0.92 Three planes to cover more expertise for data analysis
PMDD Reliability of PJPD ANOVA no sig. functional motion Precise data for interpretation
differences Does measure 3 planes of action
Lumbar Accuracy within 0.01 mm Active test therefore more Possible to reproduce clinically but
AJPD Reliability ICC 0.63 (95% CIs 0.44, 0.77) meaningful? questionable validity given the head
Weight bearing and tolerated is moving during the active test
by people with pain and so vestibular system could be
contributing
Cervical None stated Active test therefore more Possible to reproduce clinically but
AJPD meaningful? questionable validity given the head
is moving during the active test
and so vestibular system could be
contributing
Shoulder None stated Acceptable for research Not feasible clinically as complex
PJPD population and those in pain equipment and requires technical
PMDT Three planes to cover more expertise for data analysis
functional motion Precise data for interpretation
Does measure 3 planes of action
Elbow None stated Acceptable for healthy Not feasible clinically as complex
PJPD research population equipment and requires technical
Fore-arm motion is expertise for data analysis
semifunctional Precise data for interpretation
Upper limb None stated Acceptable for healthy Not feasible clinically as complex
PMDD research population equipment and requires technical
Forearm motion is expertise for data analysis
multiplanar and therefore Precise data for interpretation
more functional
Elbow Discriminating power between healthy Acceptable for research Not feasible clinically as complex
PJDT controls and people with cerebellar population with cerebellar equipment and requires technical
PMDT dysfunction dysfunction expertise for data analysis
Precise data for interpretation
Upper limb Discriminating power between healthy Acceptable for research Not feasible clinically as complex
PMDT controls and people with stroke (P < population with stroke equipment and requires technical
.0001) expertise for data analysis
Precise data for interpretation
Hip and knee Discriminating power between Acceptable for research Not feasible clinically as complex
PJPD elite players and amateur/novice population equipment and requires technical
Cite absolute error and variable error Combined hip and knee expertise for data analysis
as demonstrations of validity and motion is semifunctional Precise data for interpretation
reliability respectively (no data)
Knee Testretestwith 1 month delay, no Acceptable for research Not feasible clinically as complex
AJPD significant differences for any of the 3 population and with ACL equipment and requires technical
PMDT tests (no data) deficiency. Knee flexion expertise for data analysis
semifunctional but in side Precise data for interpretation
lying
Knee DiscriminatingCan detect difference Acceptable for research Not feasible clinically as complex
AJPD between injured ACL and non-injured population and with ACL equipment and requires technical
PMDT ACL knees deficiency expertise for data analysis
(P < .02) Precise data for interpretation
Distinguishes effect of ageincreased
threshold with increased age and with
degeneration39
Threshold detection distinguishes
injured from noninjured knee;41 ACL
tears from noninjured;42 trained
gymnasts from nontrained44
Increased threshold with increased age
and with OA43
Intra- and interrater reliability in OA
knees (ICC 0.91)45
(continued)
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Hillier et al 11
Table 3. (continued)
Tool With Author/Date
Proprioceptive device (no
name)
Brindle et al46 (2010)
Movement detection
apparatus
Matre and Knardahl47 (2003),
further described by Matre
et al48 (2002)
Passive ankle joint
repositioning test
Fu et al18 (2007)
Cervicocephalic kinesthesia
Kristjansson et al49 (2001) tests
from multiple authors
Also Cervical Joint position
error (JPE)
Treleaven et al50 (2003); Treleaven
et al20 (2006)
Also JPE-Torsion
Chen and Treleaven51 (2013)
Thoracolumbar proprioception
Koumantakis et al52 (2002) (original
protocol by Gill and Callaghan,19
1998)
Arm position-matching task
Dukelow et al53 (2010); Debert
et al54 (2012)
Active Knee joint reposition
sense
Bullock-Saxton et al13 (2001)
Active Knee joint reposition
sense
Kramer et al55 (1997)
Active knee joint reposition
test
Marks et al56 (1993)
Limb copying and reproducing
tests
Kaplan et al57 (1985)
Limb copying test
As reported in various including
Paqueron et al58 (2004); Goble et
al59 (2012)
Joint position sense
Reported variously in Lord et al60-62
(1991, 2000, 2002); Sturnieks
et al63 (2004); Whitney et al64
(2005); Tiedmann et al65 (2007);
Wood et al66 (2008). Apparatus
design by De Domenico and
McCloskey67 (1987)
Summary Reported Psychometrics Client-Centered Attributes Tester-Centered Attributes
Knee/ankle None stated Acceptable for healthy Not feasible clinically as complex
PMDT research population equipment and requires technical
PMDD expertise for data analysis
Precise data for interpretation
Ankle Established stable baseline which Acceptable for research Not feasible clinically as complex
PMDT suggests testretest reliability population. Ankle flexion equipment and requires technical
PMDD with foot plateclosed chain expertise for data analysis
semifunctional Precise data for interpretation
Ankle Absolute error in passive repositioning Acceptable for research Not feasible clinically as complex
PJPD of ankle to 5 PF gives ICC 0.84 for population. Ankle flexion equipment and requires technical
accuracy and repeatability with foot plateclosed chain expertise for data analysis
semifunctional but prone Precise data for interpretation
which is not
Cervical Testretest ICCs between 0.35 and Acceptable for research Not feasible clinically as complex
AJPD 0.90. Question usefulness of ICCs population and those with equipment for motion capture and
Concurrent validity correlates with WADS. Cervical motion requires technical expertise for data
reduced balance, smooth pursuit in functional with emphasis on analysis (feasible in specialist clinic
WADS20 natural head posture and and if used for retraining)
Discriminates between healthy and motion in all planes Precise data for interpretation and
WADS50,51 Neck torsion test arguably feedback
discriminates between neck
and vestibular signs
Spinal Reproducibility (non-LBP) ICCs 0.76- Acceptable for research Not feasible clinically as complex
AJPD 0.80 and SEM 0.91 to 1.34; less for population and those in pain equipment and requires technical
LBP group. Could not discriminate Three planes to cover more expertise for data analysis
between LBP and non-LBP. functional motion Precise data for interpretation
Upper extremity Could discriminate between healthy Acceptable for research Not feasible clinically as complex
AJPD and traumatic brain injury. Associated population equipment and requires technical
with dependence in ADL Three planes to cover more expertise for data analysis
functional motion Precise data for interpretation
Knee PrecisionPolhemus shown to have Acceptable for research Not feasible clinically as complex
AJPD 0.2-0.3 total error for representation population equipment and requires technical
of physiological joint motion76,77 Attempt at more functional expertise for data analysis
Did not discriminate between Dom application by having WB and Precise data for interpretation
and Ndom leg, nor age groups except PWB conditions
older had greater error for PWB
Knee Reliability modest 0.09 to 0.65 Acceptable for research Not feasible clinically as complex
AJPD coefficients. Could not discriminate population and those with equipment and requires technical
between symptomatic and knee pain. Attempt at expertise for data analysis
nonsymptomatic. No correlation more functional application Precise data for interpretation
between sitting and standing. by having WB and PWB
conditions.
Knee Could discriminate between healthy Acceptable for research Not feasible clinically as complex
AJPD and OA population and those with equipment and requires technical
Precision and testretestSEM knee pain. Attempt at expertise for data analysis
intersession 0.33-0.95 more functional application Precise data for interpretation
by having WB and NWB
conditions.
Knee Could discriminate between older and Acceptable clinically and for Clinically able to be performed
AJPD younger women research participants Measurement accuracy arguable not
PrecisionSEM for goniometer 5 Semifunctional as precise
Elbow (any limb) Could discriminate between Acceptable clinically and for Clinically able to be performed
AJPD anesthetized state and nonanesthetized research participants Measurement accuracy arguably not
state58 Semifunctional as precise
Lower limb Concurrent validitySome association Acceptable clinically and for Clinically able to be performed with
AJPD with tests of postural sway, reduced research participants some specialized equipment
stair performance (varied). Could Semifunctional Use of touch on the screen
discriminate between arthritic and not63 arguably a confounder for
proprioception
(continued)
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12 Neurorehabilitation and Neural Repair
Table 3. (continued)
Tool With Author/Date
Proprioceptive assessment:
Modified Thomas splint with
Pearson knee flexion piece
Reported variously in Warren et
al68 (1993); Barrett et al69 (1991)
Rivermead Assessment of
Somatosensory Perception
(RASP)
Winward et al70 (2002) in Tyson et
al14 (2008)
Cumulative Somatosensory
Impairment Index (CSII)
Deshpande et al71 (2010)
Distal Proprioception Test
(DPT)
Richardson15 (2002)
Dual Joint Position Test
(DJPT)
Beckman et al72 (2013)
Standardized sensory
assessment for children
Cooper et al73 (1993)
Thumb finding test
Smith et al74 (1983)
Wrist position sense test
Carey et al75 (1996)
Abbreviations: AJPD, active joint position detection; PJPD, passive joint position detection; PMDT, passive motion detection threshold; PMDD, passive motion direction
discrimination; ICC, intraclass correlation; CI, confidence intervals; ACL, anterior cruciate ligament; OA, osteoarthritis; PF, plantar flexion; WADS, whiplash and
associated disorders; LBP, low back pain; ADL, activities of daily living; Dom, dominant; Ndom, nondominant; SEM, standard error of measurement; ant, anterior; KR,
knee replacement; PCL, posterior cruciate ligament; JPA, joint position awareness; MS, multiple sclerosis; TD, typically developing; WB, weight bearing; NWB, nonweight
bearing.
Summary Reported Psychometrics Client-Centered Attributes Tester-Centered Attributes
Knee Normal kneesno difference between Acceptable clinically and for Clinically able to be performed with
PJPD males/females; right/left research participants some specialized equipment
Discriminate between age ranges (linear Not especially functional as
regression, P < .01); OA knees vs on mock leg
normal (P < .001); replaced vs normal
(P < .02). Wearing elastic bandage
increased accuracy by 40%69
Concurrent validityMeasure of
proprioception correlated with
function (r = .84) and with patient
satisfaction (r = .9)
Testretest: r = .82
Discriminated between ant
cruciate deficient vs ant cruciate
reconstruction18
Discriminated between arthroplasty
and OA (former is better); KR with
retained PCL has better JPA than if
PCL sacrificed68
Elbow, wrist, Interrater and testretest (intra-rater) Acceptable clinically and for Clinically able to be performed
thumb, ankle reliability for total score: Pearson research participants Use of touch on the limb or
and big toe correlation coefficient for both 0.92 Semifunctional digit arguably a confounder for
Proprioceptive and for individual proprioceptive proprioception
subtests tests retest scores were 0.83
PMDT (movement) and 0.50 (direction); face,
PMDD content validity given since all tests
drawn from traditional clinical tests;
discriminated significantly between
people with and without brain damage
(P < .001); and concurrent validity
between proprioceptive scores and
Motricity Index (Spearman correlation
coefficient, r = .31 and .32, both
significant) and with Barthel ADL Index
(r= .35 and r = .41)70
Lower extremity Discriminates between healthy and Acceptable clinically and for Clinically able to be performed
Proprioceptive subtest diabetic (P = .017), peripheral arterial research participants Measurement accuracy arguably not
AJPD disease (P = .006), stroke (P = .001) Semifunctional as precise
Toe, ankle With 1 of 2 other signs (Achilles Acceptable clinically and for Clinically able to be performed
PMDT tendon reflex or vibration detection) research participants Use of touch on the limb or
PMDD could discriminate peripheral Semifunctional digit arguably a confounder for
neuropathy; good to excellent proprioception
agreement for interrater reliability ( Probably large ceiling effect due to
range 0.677-1.00)14 dichotomous outcomes (guessing)
Digits Could discriminate between healthy Acceptable clinically and for Clinically able to be performed
PJPD controls and patients (MS or vasculitis) research participants Use of touch on the limb or
for upper and lower extremities Semifunctional digit arguably a confounder for
whereas single DPT did not proprioception
Finger Testretest and interrater reliability both Acceptable clinically and for Clinically able to be performed
PMDT 100% agreement research participants Use of touch on the limb or
PMDD Cutoff score for TD children Semifunctional digit arguably a confounder for
5/573 proprioception
Probably large ceiling effect due to
dichotomous outcomes (guessing)
Thumb/upper limb None stated Acceptable clinically and for Clinically able to be performed
PJPD research participants Use of touch on the limb or
Semifunctional digit arguably a confounder for
proprioception
Wrist None stated Acceptable for clinical and Clinically readily able to be
PJPD research participants performed, score out of 20
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Hillier et al 13
clinicians and researchers are aware of the variations in termi-
nology and practice and that some consensus can be reached
about the definition and assessment of proprioception.
It is interesting to contemplate the influence of current
understandings in the physiology of proprioception on the
testing of position and motion. We did not find strong indi-
cations that there was any clear incorporation or acknowl-
edgement of the primary role of muscle spindle activity, nor
was the influence of thixotrophy consistently acknowledged
(controlling for muscle activity prior to testing). There was
little acknowledgement of the differentiation of individual
proprioceptive senses, with most tests not controlling for
efferent influences (via electromyography for example).
Therefore, both the muscle afferents and efferents may con-
tribute to proprioception in the so-called passive tests. Well-
described examples of test procedures exist in the
experimental literature that do control for these factors (ie,
thixotrophy, muscle effort, force feedback; see Gandevia et
al10), and we encourage clinicians to familiarize themselves
with these procedures. Most tests were conducted in mid-
ranges and therefore not engaging the joint receptors as
limit detectors, highlighting the emphasis of tests for mus-
cle spindle afferent activity.
In considering the active tests there are also questions to
be considered. Bevan et al31 reported that the joint angle
may be less accurate than the angular distance travelled by
the limb, especially given the latter has more functional
meaning. Gandevia and Burke9 originally suggested that
repositioning or relocating after active positions or motions
may rely on central motor programs rather than a memory
of proprioceptive coordinates. Some tests (eg, Kristjansson
et al49) attempted to overcome this by increasing the com-
plexity of the active motion; however, this was for head
motion and they clearly could not control for vestibular
input into the relocation/repositioning response so the spec-
ificity of the test for neck proprioceptors is not clear.
Tests for the sense of force or effort are still not routinely
conducted in clinical settings; therefore, they were not avail-
able to be included in the review. We are aware of clinical
researchers using various means to evaluate the sense of
heaviness (see Konczak et al78) but there seems to be no con-
sistent uptake of these constructs in rehabilitation settings as
yet. Clear dialogue between researchers and clinicians is
required to further robust investigations into the clinical
import of these constructs in rehabilitation and recovery.
Some authors did attempt to reproduce more applied tests
such as weight-bearing or through more functional arcs of
motion rather than anatomical single planes of action. We
were unable to determine if these are any more accurate or
valid beyond an element of face validity in terms of rele-
vance to daily life. Further to this it has been questioned how
functional these point-in-time measures are. First, they do
not take into account the role of fatigue on proprioception.
Fatigue has been reported to influence proprioception
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whereby exercise-induced fatigue can produce inaccuracies
of proprioception,6 such as errors in matching torque,79
movement, or position.80,81 Furthermore, clinical fatigue
(from conditions such as chronic fatigue syndrome) may be
associated with kinesiophobia and other sensor-motor
impairment. Second, the tests only test conscious proprio-
ception, whereas it is clear that mostly we are reliant on sub-
conscious proprioception in daily activities. Further issues
include potential learning effects and the role of attention
levels. Some measures did attempt to control for confound-
ing alternate sensory inputs but others did not.
Some of the tests predate current proprioceptive under-
standingit may be considered a limitation of this review
that we did not exclude tests devised before the 1970s.
However, we could not be confident that tests produced in
more recent times in fact do take into account current theo-
ries; therefore, we have included all tests found and leave it
to the readers to evaluate for themselves the relative validity
of the tests.
We summarized the reported clinimetric properties for
each identified test and found that very few had a full suite
of properties evaluated and/or reported. Therefore, there is
a question mark over many in terms of robustness, believ-
ability, and utility in the clinical setting. There is a clear
trade-off between more research-oriented measures and
those used clinically. The former measures should be more
precise, accurate, and valid (particularly in terms of control-
ling for input other than proprioceptive); however, these
techniques may be beyond the scope of a general clinical
environment. In contrast, the clinically friendly tests are
arguably more for screening given their lack of precision.
We advise readers to carefully consider the constructs they
wish to test, the individual joints, and with what precision.
For example, if high precision is needed to evaluate the
impact of interventions for lowered proprioception, then the
expense of the more research-oriented tools may be war-
ranted. Certainly it has been our experience that an easy to
conduct, clinically based tool such as the distal propriocep-
tion test is not useful in clinical trials (see Lynch et al82).
However, if the use is for a clinical screen to simply identify
that there is a proprioceptive impairment that may be affect-
ing function in the clinical setting, then the RASP70 cer-
tainly seems to offer a useful means to standardize the
conduct and reporting of such an impairment. Subsequently,
it is then up to the clinician to establish an association
between the sensory impairment and the loss of function.
Some tests have established an overall concurrent validity
with aspects of functional performance, for example, the
cervico-cephalic kinasthesia tests correlate with reduced
balance and smooth pursuit in people with whiplash20; the
knee test using a modified Thomas splint correlated with
function and with patient satisfaction69; and proprioceptive
tests within the RASP correlated with scores for motricity
and activities of daily livings.70
14 Neurorehabilitation and Neural Repair

We recommend collaborations between neurophysiolo- Conclusion

gists, conducting precise proprioceptive testing, and clini-
cians, interested in understanding the influence of impaired
proprioception. This would further a more universal appre-
ciation of the interdependent nature of the various facets of
proprioception and motor function, clarify confusion around
terminology, and serve to identify and standardize tests that
have validity and utility for clinical populations in their
rehabilitation. Facets of proprioception missing from clini-
cal practice such as measures of sense of force, effort,
motion speed, and so forth, are areas we wish to particularly
highlight for further collaboration.
In summary, the information provided by this review should
be directly useful to clinicians and researchers alike to com-
pare and contrast their testing needs and therefore select the
most appropriate tool for the job at hand. We have identified
that whatever the need, proprioceptive tools are generally
poorly evaluated in clinical settings and further research is
required to establish reliability and validity as a starting
point in the existing tests. Current understandings of pro-
prioception from the research literature need to be applied
in clinical practice to further implement evidence-based
assessment and therefore rehabilitation.

Appendix 1

Measurement Critical appraisal tool (MCAT).

Full Name of measure

Abbreviated name
Designer of Outcome measure
1.Purpose: (what does it purport to measure) Continue? Y/N
2.Background; (what is the physiological/theoretical construct) Continue? Y/N
3.Population: (what population/s has it been used on? What joints?) Continue? Y/N
4.Pathology: (what pathologies has it been tested in?) Continue? Y/N
5. Number of items Continue? Y/N
6. Score system: Continue? Y/N
7. Equipment requirements
8.Time required to perform (not relevant for data extraction)
9.Description: Y/N/not stated
10. Normative data/scores: Are norms provided? Y/N/not stated
11.Validity: Have 3 types of validity been established? ie Criterion, Face, Content, construct, factor analysis? Y/N/not stated
Score /3
12.Reliability: Have 3 types of reliability been established? ie Internal consistency, test retest reliability, inter- Y/N/not stated
rater reliability Score /3
13.Responsiveness: Sensitivity, specificity and floor/ceiling effects Y/N/not stated
Score /1
14.Precision: Is the precision of the outcome measure sound Y/N/not stated
Score. /1
15. Client centeredness Y/N/not stated
Appropriateness: Is the test appropriate ie meaningful to the patient/parent
Acceptability: Is the test acceptable to the client ie time, activities carried out Score /2
16. Tester centeredness Y/N/not stated
Utility: Has the measure got adequate interpretability, acceptability and relevance
Feasibility: Ease of administration and process Score /2
TOTAL SCORE /12

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Hillier et al 15
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Financial assistance was provided by the Director, International
Centre for Allied Health Evidence. Research assistance was pro-
vided by Valentin Dones and Anthea Worley.
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