How do you assess proprioception during a neurophysical examination?

Assessment of Proprioception During Neurological Examination

The most effective method for assessing proprioception is through joint position sense testing, where the examiner moves a joint (typically starting with the great toe or finger) and asks the patient to identify the direction of movement with eyes closed. 1

Basic Proprioception Testing Techniques

• Begin proprioception assessment with distal joints and move proximally if abnormalities are detected, following the typical pattern of neurological disorders that affect sensation 2
• For lower extremity testing, hold the sides of the patient's great toe and move it up (dorsiflexion) or down (plantarflexion), asking the patient to identify the direction with eyes closed 1
• For upper extremity testing, hold the sides of the patient's finger (typically index finger) and move it up or down, asking the patient to identify the direction with eyes closed 1
• If distal joint position sense is intact, proximal joint testing is usually unnecessary; if impaired, proceed to test more proximal joints (ankle, knee, wrist, elbow) 2

Advanced Proprioception Assessment Methods

• The finger-to-nose test and heel-to-shin test assess coordination and proprioception of upper and lower limbs respectively 1
• The Romberg test evaluates proprioception by having the patient stand with feet together and eyes closed - increased swaying or falling indicates proprioceptive deficits 3
• The walking Romberg sign (having patient walk 5 meters with eyes open, then with eyes closed) is more sensitive than the traditional standing Romberg test for detecting proprioceptive deficits 3
• Assessment of postural stability can be performed in three positions (standing flat on both feet, standing on a single leg, and standing with eyes closed) to evaluate proprioceptive function 2

Clinical Pearls for Accurate Assessment

• Ensure the patient cannot see the movement being tested by having them close their eyes 1
• Move the joint slowly and hold it in position for 1-2 seconds before asking the patient to identify the position 1
• Avoid giving tactile cues that might help the patient guess the position (don't touch the nail bed or pad of finger/toe) 2
• Test both sides for comparison and to detect asymmetrical deficits 4
• For patients with cognitive impairment, simplify instructions and demonstrate what you want them to do before testing 1

Interpretation of Findings

• Proprioceptive deficits typically present in a "glove and stocking" distribution in peripheral neuropathies 2
• Asymmetrical findings may suggest focal pathology rather than systemic disease 4
• Proprioceptive loss with preserved pain and temperature sensation suggests large fiber neuropathy or posterior column disease 2
• Severe proprioceptive deficits may manifest as sensory ataxia, with worsening of coordination when visual input is removed 5

Common Pitfalls to Avoid

• Failure to have the patient completely relax during testing can lead to false positives due to voluntary muscle contraction 4
• Not using standardized testing methods may lead to inconsistent results 6
• Confusing proprioceptive deficits with other causes of incoordination (cerebellar dysfunction, vestibular disorders) 4
• Remember that proprioception assessment is just one component of the sensory examination and should be interpreted alongside other sensory and motor findings 2

By systematically assessing proprioception from distal to proximal joints and using standardized techniques, clinicians can accurately identify proprioceptive deficits that may contribute to functional impairments and guide appropriate treatment interventions.