Cont.

Definition

It is the phase of therapeutic exercises developed to:

The development, or
The recovery of voluntary control of skeletal ms.
Techniques of motor learning or re-learning are grouped
together under the single term m. re-education.
This leads to some confusion, because the approach to
learning & re-learning arent necessarily the same, even
though, each has certain principles in common.
Lack of effective muscle control may:
Result from many different causes & be manifested in
many different ways.

09/16/15

:Objectives of m. re-education
1.

To develop motor awareness & voluntary motor response

(Re-learn the injured muscle its ingram in the brain or
learning a new ingram for a new action for the
ms).

2.

To develop strength & endurance in patterns of movement that are

necessary, safe & acceptable.

1 & 2 are related to each other, that one could

hardly be achieved without the other.

We must initiate development of motor awareness & voluntary

motor responses before we can set up a program to develop
strength & endurance.

On the other hand, some degrees of strength & endurance are

necessary to the development of motor awareness & effective
voluntary response.

09/16/15

Necessary & Effective

Are used to emphasize a well-designed program of muscle
re-education, which must be based on very specific &
practical demands for: the patient & his environment.

Safe
Safe patterns: which minimize the hazards of trauma &
deformity that might abnormal stress & strain.

09/16/15

Acceptable
Acceptable patterns of movs are designed to:
fit the handicapped patient into
normal environment in contact & in competition with
physically normal people.
Acceptable patterns are acceptable to normal people in a
normal environment.
It is of some academic interest to teach a young patient
to grasp a fork with his toes to feed himself.
But
This becomes completely unacceptable when he becomes
a young adult.
09/16/15

Indications of M. Re-education
1)
2)

Diseases causing subnormal voluntary control.

LMNL mild and severe flaccid paralysis & weakness of
motor response

3)

Dyskinetic mov as
a. Spasticity
d. Rigidity
those.

4)
5)
6)
7)

b. Athetosis
c. Ataxia (sluggish)
e. Tremors.
f. Any combination of

UMNL: in flaccid stage m. weakness.

After prolonged immobilization or disuse.
After tendon transfer or m. transplantation.
After arthroplasty.

09/16/15

Pre-requisites for m. re-education

1. Patient Evaluation:

A detailed examination of patient is essential to adequate

prescription for muscle re-education.

Initial patient examination consists of > a simple muscle

test from which a prescription for muscle strengthening
can be written.

P.T. awareness of the factors directly related to effective m.

re-education including his knowledge of the disease & its
natural course.

09/16/15

General Physical & Mental Status. 2

Determine if the patient is medically able to safely exercise.
Extent of examination is dependent on background
information of nature & extend of disease.
Determine if the patient understand & follows directions.

if the patient is interested in his own recovery.
Many patients will refuse to cooperate due to conscious or
unconscious feeling that recovery would be disadvantageous
for them.
1st prerequisite to re-educate muscle is a co-operative
patient , who:
1 - is consistent with his age.
2 - understand reasons for the program.
3 - wishing to recover whatever functional capacity is
possible.
09/16/15

Available Motor Pathways. 3

Central & Peripheral nervous system (CNS & PNS).

The effective methods of determining state of neuromuscular
excitability is MMT for pts who show evidence of abnormality of m.
response.
Value of MMT: to know from where to start m. re-education.
MMT requires: a thorough knowledge of functional anatomy &
kinesiology of human body.
Use MMT or functional type of testing of carrying ADL.
In MMT & functional activity test: inco-ordination, substitution, dyskinesia, weakness
or inability are necessary to be observed.
These tests provide data for prescribing ex & repeated testing for prognosis.

09/16/15

EMG gives information for diag. & prognostic state

EMG gives data about:

1.
2.
3.

Actual motor denervation.

Map out areas of silence & areas of polyphasic reactions,
indicating progressive denervation or recovery of
innervation.
Galvanic current draw strength duration curve, & determining chronaxie
assess PNS injury.

M. re-education mustnt only be based on the:

1. Site
2. Extent of m. strength, but also on
3. Possibilities of recovery, which will be indicated by these tests (MMT,
EMG).

09/16/15

10

Available Sensory Pathways. 5

Intact sensory & motor pathways are:

important for necessary for m. re-education.

Extro & proprioceptive systems

provide information to motor awareness.

Its failure (sensory system)

severe loss of voluntary response, even though the motor pathways are intact.

Sensory system is tuned to m. tension , & its response is altered by:

1. motor unit denervation.
2. decay of m. strength through: disuse, prolonged stretching, development of substitute patterns of
mov.

Loss of superficial or deep sensation:

plays a profound role in m. re-education.
09/16/15

11

Muscle-Tendon Integrity & Mobility. 6

M. must be:
1. Intact throughout its length.
2. Stable at its origin & insertion before adequate
response can be expected.
3. Free to move within its normal components.
M. contracture

M-tendon
M-tendon contracture
contracture

Tendon stenosis

of ability to contract effectively, even though the motor pathways are in

09/16/15

12

Muscle-Tendon Integrity & Mobility. 6

Muscle must be:

1. Intact throughout its length.
2. Stable at its origin & insertion before adequate
response can be expected.
3. Free to move within its normal components.

M. contracture
M-tendon
M-tendon contracture
contracture

Tendon stenosis

13

Relation of Tendon Length to M.. 7

Mass

Ability of muscle to move the segment it controls

through desired ROM depends in great part on
the length of its tendon.
If the tendon is shortened
------- muscle normally can
accomplish a small portion of the R.

If the tendon is lengthened ----- ineffective

m. cont.
Repeated stretching or lengthening of tendon

w[ll caue m. mass to shorten &

limit m. ability to
contract through normal R
-- disuse- loss of m. strength.

14

Joint Mobility. 8

Loss of jtoint mobility has a profound effect on muscle reeducation.

Basic objectives of re-education can never be achieved
if the joint through which the muscle acts is
frozen in one position.
This doesnt mean that a jt. has to be completely &
normally mobile, but at least it should be mobile through a
functional range of motion before muscle re-education.

15

Skeletal Alignment. 9

Possibilities of m. re-education are directly related to

skeletal alignment.
This is particularly true in structural changes in the
spine, legs & feet following:
1. Paralytic disease
2. Malalignment of # post-traumas.

16

Pain

It is impossible to obtain coordinated movement

if such movement pain.
If this movement pain
patientll carry out the
movement by
substitute

17

Dyskinetic Movements
Abnormal motor activity due to UMNL
limit all attempts of muscle reeducation.
Classical muscle re-education used when there is LMNL will
be of:
little, if any value unless
the abnormal UMNL activity can be controlled.

18

Techniques of M Re-education
As muscle re-education is devoted to the:
1. Recovery of voluntary control of skeletal muscle, or
2. Development of motor control (active, strong,
coordinated, enduring), so

The primary OBJECTIVES must follow a certain

REASONABLE order:
I. Activation
II. Strength
III. Co-ordination
IV. Endurance
19

I. Activation

At that time muscle re-education program must begin by applying

certain techniques to activate these LMNU.
Techniques to activate LMNU:
A. Focusing procedures
B. Proprioceptive stimulations
No one technique alone is adequate in all problems,
PT must know & use all possible techs. in whatever
combination
give optimum response.

20

A. Focusing Procedure

All re-education techniques should be started

with: a discussion or demonstration of the
routines to be used.
Patient may not only know what is:
1. Being done? , but
2. Expected to do?:
1. if he is to relax, he must know
2. if he is to attempt to contract & when?,
All depends on the pts age & intelligence
21

Passive Motion (PROM). 1

1st step in starting activating LMNU.
Can be done for completely denervated muscle.
Make the patient aware of desired movement by:
feeling & seeing the
mov as they are carried out
Stimulates proprioceptive reflexes of flex, ext & stabilization.
Passive mov is difficult to be executed properly until desired
responses are obtained.
Begins within limits of pain & tightness, then progress.

22

Cutaneous Stimulation. 2

Assist patient to concentrate on areas under care, he

can better see & feel contraction in specific muscles.

Proprioceptive stimulation through tickling & scratching

various areas.

The PT may use:

1.
2.
3.
4.
5.

His fingers to: stroke or tap ms & tendons.

A brush or a rubber hammer.
Basic massage (effleurage, petressage, tapotement).
Cryotherapy (brief ice application).
Brief painful stim..

Electrical stimulation. 3

Cause muscle contraction

1-- patient see & feel m. cont.

2 -- sensations of value in sensory reflex
stimulation.
3 -- muscle tension
4 -- proprioceptive stimulation.

EMG & BFB. 4

Equipments with both visual & auditory output

assist patient more accurately contract his
muscles.
colors, sounds & height of changes of electrical.
potentials aid pts focusing on desired ms.
Indications:
1. Spotty m. weakness
2. Reactivation of ms after tendon transplantation.
3. As a focusing & motivating method.

B. Proprioceptive Stimulations
Is an activation method stimulation of muscle contraction by proprioceptive
stimulation (jt, muscle, tendon), these receptors can be stimulated
by
1.
2.
3.
4.
5.
6.
7.
8.
9.

Passive movement.
Positioning in various attitudes
Balance in sitting & crawling
kneeling & standing (righting reactions) vestibular stim.
Weight bearing
Traction
Approximation
Quick stretches
Resistance

We must use posture, passive mov, active mov to stretching, resistance &
reflexes necessary stim. proprioceptive system.

Stretching & Resistance

Muscle tissue responds best when:
extended & put under some tension
(stretching).
Obtaining strength & co-ordination must be based
on techniques requiring muscle to contract against
resistance when partially elongated.
Sudden stretching of muscle or sudden release of
tension facilitate active response.

27

Reflex Stimulation

Normal & Pathological reflexes initiate:

1. Muscle contraction
2. Righting reactions
3. Equilibrium
4. Protective reactions

Normal & Pathological reflexes are essential

steps in:
1. Muscle re-education
2. Functional training.
28

II. Strength

Definition:

1.

Ability of muscle to generate force or torque at a definite

velocity.
Ability of a muscle to develop force for providing:
1. stability (keep muscle stable).
2. mobility (strength to
move).
Ability of a muscle to continue successive exertions under
conditions where a load is placed on it.
Strength can be obtained only through muscle work
(force x distance).

2.

3.

29

1.
2.
3.
4.

circulation. & development of muscle sense through

proprioceptive system.
Hypertrophy of muscle fibers.
No. of motor units entering into the contractile effort.
Sprouting
(if motor units have been
denervated, some degrees of
re-innervation
will occur by adjacent intact neurofibrils).

30

Each of these factors demands R to the voluntary

effort max response.
Workload must be appropriate neither too little, nor too great.
If the demands are minimal
only few units activated & strength ll be
limited, load must be built up as m. tolerate.
Type of ex. for weak muscle depends on:
1. Site of weakness.
2.

Extent of weakness.

31

 Very limited (specific) exs. are built up, if only a m. is weak,

with strengthening, (larger) & more meaningful activities are built.
As m. work is essential to recovery of strength,
also overwork loss of strength.
Fatigue & overwork must not be confused.
Fatigue is a normal & physiological reaction that
protects the normal individual from overwork.
Overwork is neither normal, nor physiological reaction,
So its a pathological reaction.

32

Causes of Loss of M. Strength

Decrease of strength may occur in the muscle groups not in use.

M. re-education must encourage muscle strength for effective function
of body segments (reverse of disuse).
Orthotic devices as braces or corsets, are needed to:
1. Support weakened body seg.
2. Prevent deformity But may
a. Limit m. use
b. Cause m. weakness
Such disuse weakness can be determined by:
pain & limited response of these ms. to specific
activity.
33

 Usage of braces is a must in some situations where m.

cant maintain supporting body parts.
If brace used all the time without periods of exercises
every now & then, it might be better not to use brace
because it might cause more weakness.
We use braces to help as fifty/ fifty % with our ms, if we
became reluctant on it 100%, our m will be more weaker
than before brace use. At that case better not to use
brace without strengthening program. (this is the relation
between m re-education & braces.

34

Isolation of Islands of Contractile. 2

Units
AHC disease

a. Denervation of individual m. f.
b. Areas of degeneration & fatty infiltration surround area of intact m. f .
It is common to see gradual strength in weakened m. during:
1st 6 months of acute poliomyelitis.
At that time, motor denervation can take place,
so protection of any additional weakness is made by:
preventing persistent stretching of the ms. (Brace usage).

35

If the tendon is:

1. Contracted or
2. Abnormally lengthened

The normally moving m. can accomplish

a small part of effective mov.

36

Prolongation of Rest Period Required. 4

for Recovery

Rest periods for recovery is related to:

a. Fatigue
which is due to the accumulation
of waste products,
which
is in turn related to:
1. Blood supply.
2. Tissue drainage.
b. Individual motivation
Strength may be achieved by:
1. Graduated active exs
2. Elect. M. Stim. (EMS).
3. Etc.,
37

III. Coordination
Is the integration of different kinds of movements in a single pattern.
Is the ability to use the right muscle at the right time & right intensity to
achieve a desired movement.
Coordinated patterns are:
those with which the neuromuscular & musculoskeletal systems can
most efficiently & safely function.
Is achieved through conditioned reflex training (subconsciously).
Coordination mechanisms are highly complex,
with many of the components of the movement at a subconscious level
beyond voluntary control.
38

IV. Endurance
Definitions:
Ability to carry out repetitive movement essential to
prolonged activity.
Ability to repeat motor tasks or sustain motor activity over a
prolonged period of time.
Ability to maintain effort with demands placed upon the
muscle.
* Patterns of movement to endurance are similar to that
used to obtain strength, except that the demands on
neuromuscular system are less.

 Ex. to strength require effort & repetitions.

Ex. to endurance require repetitions & effort.
Endurance can also be developed by
repetitions & R.
Strength without endurance is inefficient.
Strength & coordination without endurance are
impractical.

40

Examples

According to the intensive evaluation, paralysis or severe

weakness with grade:
0:
- sensory input by splinting, passive mov,
- interrupted direct currents.
1&2
but with intact nerve:
- passive mov, EMS (faradic & HVG), brief icing,
brushing,
quick stretch, approximation,
TVR, hydrotherapy, isometric exs.
- Grade 1: static exs
- Grade 2: A A (suspension, sh wheel, finger ladder,
bicycle ergometer & PNF techs).
3,4 & 5:
- Active exs (AF, AR) via hydrotherapy, pulley, weights,
slings,
biofeedback, functional exs as up & down
stairs, PNF, etc.,

41