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 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.

11/25/2019 2
 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.

11/25/2019 3
 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.

11/25/2019 4
 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.

11/25/2019 5
 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.

11/25/2019 6
 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.
11/25/2019 7
 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.
 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.
11/25/2019 8
 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.

11/25/2019 9
 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).

11/25/2019 10
 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.
11/25/2019 11
 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.
M. contracture M-tendon contracture M. fibrosis Tendon stenosis

Loss of ability to contract effectively, even though the motor pathways are intact.

11/25/2019 12
 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.

M. contracture
M-tendon contracture
M. fibrosis

Tendon stenosis

13
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
 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
 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
 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
 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
 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 pt’s age & intelligence

21
 1. Passive Motion (PROM)

• 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
 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..
 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.
 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.
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.
 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.
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
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
• 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 it’s 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.
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
 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:
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
 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
 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