1. Cont.

2. 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 aren’t 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. 5/19/20152

3. 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. 5/19/20153

4. 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. 5/19/20154

5. 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. 5/19/20155

6. Indications of M. Re-education 1)Diseases causing subnormal voluntary control. 2)LMNL → mild and severe flaccid paralysis & weakness of motor response 3)Dyskinetic mov as a. Spasticity b. Athetosis c. Ataxia (sluggish) d. Rigidity e. Tremors. f. Any combination of those. 4)UMNL: in flaccid stage → m. weakness. 5)After prolonged immobilization or disuse. 6)After tendon transfer or m. transplantation. 7)After arthroplasty. 5/19/20156

7. 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. 5/19/20157

8. 2. General Physical & Mental Status  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.  1 st 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. 5/19/20158

9. 3. Available Motor Pathways 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. 5/19/20159

10.  EMG gives information for diag. & prognostic state  EMG gives data about: 1.Actual motor denervation. 2.Map out areas of silence & areas of polyphasic reactions, indicating progressive denervation or recovery of innervation. 3.Galvanic current draw strength duration curve, & determining chronaxie → assess PNS injury.  M. re-education mustn’t 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). 5/19/201510

11. 5. Available Sensory Pathways 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. 5/19/201511

12. 6. Muscle-Tendon Integrity & Mobility 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. 5/19/201512 M. contracture M-tendon contracture M. fibrosis Tendon stenosis Loss of ability to contract effectively, even though the motor pathways are intact.

13. 6. Muscle-Tendon Integrity & Mobility 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. 13 M. contracture M-tendon contracture M. fibrosis Tendon stenosis

14. 7. Relation of Tendon Length to M. 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.  Any tendon lengthening manually or surgically should be avoided, except when essential, to prevent severe deformity. As there’s danger of loss of power with un-needed m. lengthening. 14

15. 8. Joint Mobility Loss of jtoint mobility has a profound effect on muscle re- education. Basic objectives of re-education can never be achieved if the joint through which the muscle acts is frozen in one position. This doesn’t 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

16. 9. Skeletal Alignment 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

17. Pain It is impossible to obtain coordinated movement if such movement → pain. If this movement → pain → patient’ll carry out the movement by substitute 17

18. Dyskinetic Movements Abnormal motor activity due to UMNL → limit all attempts of muscle re-education. 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

19. 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

20. 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

21. 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 pt’s age & intelligence 21

22. 1. Passive Motion (PROM) 1 st 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

23. 2. Cutaneous Stimulation 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.His fingers to: stroke or tap ms & tendons. 2.A brush or a rubber hammer. 3.Basic massage (effleurage, petressage, tapotement). 4.Cryotherapy (“brief“ ice application). 5.Brief painful stim..

24. 3. Electrical stimulation Cause muscle contraction 1--» patient see & feel m. cont. 2 --» sensations of value in sensory reflex stimulation. 3 --» muscle tension 4 --» proprioceptive stimulation.

25. 4. EMG & BFB Equipments with both visual & auditory output → assist patient more accurately contract his muscles. ↑ colors, sounds & height of changes of electrical. potentials → aid pt’s focusing on desired ms. Indications: 1.Spotty m. weakness 2.Reactivation of ms after tendon transplantation. 3.As a focusing & motivating method.

26. B. Proprioceptive Stimulations Is an activation method → stimulation of muscle contraction by proprioceptive stimulation (jt, muscle, tendon), these receptors can be stimulated by 1.Passive movement. 2.Positioning in various attitudes 3.Balance in sitting & crawling 4.kneeling & standing (righting reactions) → vestibular stim. 5.Weight bearing 6.Traction 7.Approximation 8.Quick stretches 9.Resistance We must use posture, passive mov, active mov to → stretching, resistance & reflexes necessary → stim. proprioceptive system.

27. 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

28. 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

29. II. Strength Definition: 1.Ability of muscle to generate force or torque at a definite velocity. 2.Ability of a muscle to develop force for providing: 1. stability (keep muscle stable). 2. mobility (strength to move). 3.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). 29

30. 1.↑ circulation. & development of muscle sense through proprioceptive system. 2.Hypertrophy of muscle fibers. 3.↑ No. of motor units entering into the contractile effort. 4.Sprouting (if motor units have been denervated, some degrees of re-innervation will occur by adjacent intact neurofibrils). 30

31. 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

32. 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 it’s a pathological reaction. 32

33. 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

34. Usage of braces is a must in some situations where m. can’t 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

35. 2. Isolation of Islands of Contractile 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: 1 st 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

36. If the tendon is: 1.Contracted or 2.Abnormally lengthened The normally moving m. can accomplish a small part of effective mov. 36

37. 4. Prolongation of Rest Period Required 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

38. 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

39. 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.

40. 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

41. 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