MOTOR

RELEARNING
PROGRAMME
 BACKGROUND
– Negative expectations to stroke outcome

– Dissatisfaction with facilitation approach and functional

carryover to ADLs

– Inability to provide rationale for management

– Developments in the literature of the movement related

sciences
MRP
■ The Motor Relearning Programme (MRP) was developed by
the Australian physiotherapists Janet Carr and Roberta
Shepherd.
■ It is a task-oriented approach to improving motor control,
focusing on the relearning of daily activities.
■ It is strongly based on theories in kinesiology that emphasize a
distributed (rather than a hierarchal) motor control model.
Theoretical underpinnings of the MRP:
 
■Postural adjustments are anticipatory and ongoing.
■Changes occur in muscular organization of a person occur simultaneously with
the plan to move and prepare the person for performing the task.
■Motor behaviors emerge as a result of context or regulatory conditions in the
environment (performer-environment interaction).
■Postural adjustments can be learned only in the context of task performance.
■Skilled motor performance is defined as the ability to perform in different ways
according to variations in environmental demands.
■Deficits in generating appropriate models of action are the primary problem
following stroke, and not spasticity or pathologic movement synergies.
■Stereotypic movement patterns are compensatory strategies that result when
movement is attempted.
MRP

1-Strategy Development

• Cognitive stage
• Active participation of affected side
• Bilateral movements improve learning
• Visualization
MRP
2-Feed back

 Intrinsic (naturally)
 Extrinsic (therapist , visual , manual)
 Mirror

3-Practice

■ Practice session
■ Repetition
■ Rest periods
 MRP
■ Principles
– Neuroplasticity
– Elimination of unnecessary muscle activity
– Feedback and practice
– Importance of interrelationship between postural
adjustment and movement
– Real life activities
– Training motor control not muscle strength
Neural plasticity
 MRP

– Progression from cognitive control over muscle and

movement component to automatic activities
– Environment for recovery and learning and motivation
– Problem solving process
■ Recognition
■ Analysis
■ Decision making
■ Action taking
■ Re-evaluation
 The Four Steps of the Motor Relearning Programme

1. ANALYSIS OF TASK
Observation
Comparison
Analysis

2. PRACTICE OF MISSING COMPONENTS

Explanation – Identification of goal
Instruction
Practice plus verbal and visual feedback plus manual guidance

3. PRACTICE OF TASK
Explanation – Identification of goal
Instruction
Practice plus verbal and visual feedback plus manual guidance
Progression:
Increase complexity
Add variety
Decrease feedback and guidance
Reevaluation
Encourage flexibility

4. TRANSFERENCE OF LEARNING
Opportunity to practice in context
Consistency of practice and positive reinforcement
Organization of self-monitored practice
Structured and stimulating learning environment
Involvement of relatives and staff
ANALYSIS OF TASK
■Observation as the patient performs (or anticipates to perform) the
activity

Note: Any missing components

■ Incorrect timing of components within a movement pattern
■ Absence of specific muscle activity
■ Presence of any excessive or inappropriate muscle activity
■ Compensatory motor behavior
Selection of essential movements upon which the activity depends
Selection of the most essential components if many components are
missing (i.e., the patient is barely able to move)
PRACTICE OF MISSING COMPONENTS
■Practice at peak performance for at least 30-60 minutes or
more twice daily; progression when some form of control is
seen
■Switching from verbal instruction to visual demonstration
or vice versa if a person does not respond
PRACTICE OF TASK
■Transition from cognitive to automatic phase of learning
(overlaps with Step 2)
TRANSFERENCE OF LEARNING
■Carry-over of learning into task performance during daily
routines
Basic description and guidelines

 Theprogramme is composed of guidelines for

evaluating and improving 7 daily functions:

1. Upper limb function

2. Oro-facial function
3. Sitting up from supine
■ Sitting
■ Standing up and sitting down
■ Standing
■ Walking
■ Strategies for instructing the patient

■ Verbal instruction is kept to a minimum. The therapist identifies the most

important aspect of the movement on which the patient will concentrate.
■ Visual demonstration is provided by the therapist’s performance of the
task, focusing on one or two most important components.
■ Manual guidance helps to clarify the model of action by passively guiding
the patient through the path of movement or by physically constraining
inappropriate components
■ Accurate, timely feedback about the quality of performance helps the
patient to learn which strategies to repeat and which ones to avoid.
■ Consistency of practice facilitates development of skill in task
performance.
Important points to consider
■Motor tasks are either practiced in entirety or broken down into components. The
practice of each component is immediately followed by the practice of the entire
activity.
■Techniques principally comprise verbal and visual feedback and instruction, and
manual guidance.
■ Passive movement during demonstration should not persist >1-2 times
■ Body alignment should be monitored consistently
■Acceptable methods of progression
■Decrease in manual guidance and feedback
■Alteration in speed
■Increase in variety
■Inappropriate methods of progression
■Performance of motor activities in the neurodevelopmental sequence
■Passive ROM exercise to resistive exercise
■Parallel bars to quad cane
■Wide to narrow base of support
■Roll over before sitting balance
Effectiveness
■Depends on the therapist’s knowledge of biomechanics and
motor control, and problem-solving ability
■The therapist must recognize and analyze the motor
problem, select the most essential missing component,
effectively teach the patient the required movement, monitor
the patient’s response, give meaningful feedback, and create
an environment that promotes a drive toward recovery and
relearning.
Limitation
■Spasticity is not considered a significant residual problem of
stroke. However, no management is recommended to reduce
abnormal muscle tone.
■Focus on active learning indicates limited applicability in
patients with severe cognitive deficits.
 Equipment

– Low bed
– Several small steps (block)
– Stool
– Common objects for retraining hand function
– Calico splint
– Single walking stick if necessary
■ Unnecessary equipment
■ Parallel bars and canes
■ Splints / braces that hold the ankle in dorsiflexion
 Retraining Methods

– Normal function
– Essential component
– Common problems and compensatory strategies
– Practice of components (especially missing ones)
– Maintenance of length of muscles
– Transference to daily life
Method of Recording
Assessment
■ Motor Assessment Scale
– To keep abreast of developments in the movement sciences
– To analyze the patients motor performance
– To explain clearly to the patient by speech and
demonstration
– To monitor patients performance and give accurate and
usable feedback
 MAS

– To recognize and discourage compensatory behavior

– To re-evaluate throughout each session of her own and the
patients performance
– To progress the patients level of performance as soon as he
has grasped the idea of what he is practicing
– Opportunity to practice throughout day
– To provide environment for motivation towards recovery of
both mental and physical abilities
Bobath (NDT) MRP

Hierarchical or reflex theory System theory

Patient oriented research Normal oriented research

Therapeutic passive handling Active participation

Key points of control Task components

Exercise oriented Task oriented

Emphasize on spasticity reduction Emphasize on motor learning

UK AUS