107553_muscle re-education.ppt...........

Muscle reeducation

1. 09/01/2409/01/24 Ass. Prof. Salwa RoushdyAss. Prof. Salwa Roushdy 11
Muscle Re-educationMuscle Re-education
Ass. Prof. Salwa RoushdyAss. Prof. Salwa Roushdy

2. Lecture 1 Muscle Re-education
Objectives of the Lecture
 
At the end of the lecture the students will be able to:
Be familiar with a general introduction and definition on muscle re-education.
Know the ultimate goals of muscle re-education.
Be oriented to the administration of different muscle re-education techniques.
Define the concepts of strength, co-ordination and endurance.
Recognize the factors affecting muscle re-education.
Be aware how to practically re-educate muscles.
Know the concepts of muscle re-education.
 
Contents of the Lecture
 
Introduction and definition of muscle re-education.
Objectives of muscle re-education.
Indications for muscle re-education.
Pre-requisites for muscle re-education.
Techniques of muscle re-education.
Examples.
 
 
 
 
 
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3. • Definition
It is the phase of therapeutic exs developed to:
1.The development, or
2.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 m. control may:
1. Result from many different causes &
2. Be manifested in many different ways.
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4. Objectives of m. re-education:
1. To develop motor awareness & voluntary motor response
(Re-learn the injured m. 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 mov. 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 1. motor awareness
& 2. voluntary motor responses before we can
set up a program to develop 3. strength & 4.
endurance.
On the other hand, some degrees of strength & endurance
are necessary to the development of motor awareness
& effective voluntary response.
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5. Necessary & Effective
Are used to emphasize a well-designed program
of m. re-education,
which must be based on very specific
& practical demands for: the pt
& his environment.
Safe
Safe patterns: which minimize the hazards of trauma
& deformity that might
→ abnormal stress & strain.
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Safe Safe

6. Acceptable
Acceptable patterns of movs are designed to:
fit the handicapped pt 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 pt
to grasp a fork with his toes to feed himself.
But
This becomes completely unacceptable when he becomes
a young adult.
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7. Indications of M. Re-education
1.Diseases causing subnormal voluntary control.
2.LMNL → mild: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.
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8. Pre-requisites for m. re-education
1. Patient Evaluation:
A detailed exam. of pt. is essential to adequate
prescription for m. re-education.
Initial pt. exam consists of > a simple m. test from
which a prescription for m. 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.
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9. 2 .General Physical & Mental Status
Is a prerequisite for pt. eval. & m. re-education.
Determine if the pt. is medically able to safely exercise.
Extent of exam is dependent on background information of
nature & extend of disease.
Determine if the pt. understand & follows directions.
“ “ if the pt. is interested in his own recovery.
Many pts will refuse to cooperate due to conscious or unconscious
feeling that recovery would be disadvantageous for them.
•1
st
prerequisite to re-educate m., is a co-operative pt , who:
1 - is consistent with his age.
2 - understand reasons for the program.
3 - wishing to recover whatever functional capacity is possible.
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10. 4 .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.
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11. 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).
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12. 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.
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13. 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.
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M. contracture M-tendon contracture Tendon stenosis
Loss of ability to contract effectively, even though the motor pathways are intact.

14. 7 .Relation of Tendon Length to M. Mass
Ability of m. to move the segment it controls through
desired ROM depends in great part on the length of its
tendon.
If the tendon is contracted
-------» m. normally can accomplish a small portion of the
R.
If the tendon is lengthened -----» ineffective m. cont.
Repeated stretching or lengthening of tendon
--------» permit 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.
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15. 8 .Joint Mobility
Loss of jt. mobility has a profound effect on m. re-
education.
Basic objectives of re-education can never be achieved
if the jt. through which the m. 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 R before m. re-education.
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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.
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17. Pain
It is impossible to obtain co-ordinated mov.
if such mov → pain.
If this mov → pain
→ pt.’ll carry out the mov. by substitute patterns of
action
→ lessening the pain.
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18. Dyskinetic Movements
Abnormal motor activity due to UMNL
→ limit all attempts of m. re-education.
Classical m. re-education used when there is LMNL will be of:
little, if any value unless
the abnormal UMNL activity can be controlled.
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19. Techniques of M Re-education
As m re-education is devoted to the:
1.Recovery of voluntary control of skeletal m., 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
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20. I. Activation
If the pt can’t voluntarily contract a portion of m.,
or a m., or many ms. in either direct or associated
movs (with yawning) → there can be no degree of motor
control.
At that time m. 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.
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21. A. Focusing Procedure
All re-education techs. should be started with:
a discussion or demonstration of the routines
to be used.
Pt. 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
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22. 1 .Passive Motion (PROM)
1
st
step in starting activating LMNU.
Can be done for completely denervated m.
Pt shouldn’t assist or resist mov carried out.
May be: 1. One-jt ” one plane, or multiple planes mov”.
2. Multiple jt mov, “single” or “multiple“ planes.
Makes the pt. aware of desired mov 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.
Arc & speed of mov must be altered until desired responses are obtained.
Begins within limits of pain & tightness, then progress.
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23. 2 .Cutaneous Stimulation
Assist pt to concentrate on areas under care,
he can better see & feel cont. in specific ms.
Has some proprioceptive stim value:
in infants & young children tickling & scratching
various areas → promote movs.
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..
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24. 3 .Electrical stimulation
Cause m. cont 1--» pt. see & feel m. cont.
2 --» sensations of value in
sensory reflex stim.
3 --» m. tension

4 --» proprioceptive stim.
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25. 4 .EMG & BFB

Equipments with both visual & auditory output
→ assist pt more accurately contract his ms.
↑ colors, sounds & height of changes of elect. 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.
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26. B. Proprioceptive Stimulations
Is an activation method → stim. m. cont. by proprioceptive
stimulation (jt, m, tendon), these receptors can be stimulated
by:
1.Passive mov.
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.
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27. Stretching & Resistance
M. tissue responds best when:
extended & put under some tension
(stretching).
Obtaining strength & co-ordination must be based
on techniques requiring m. to contract against
resistance when partially elongated.
Sudden stretching of m. or
sudden release of tension
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28. Reflex Stimulation
Normal & Pathological reflexes → initiate:
1. M. cont
2. Righting reactions
3. Equilibrium
4. Protective reactions
Normal & Pathological reflexes are essential
steps in:
1.M. re-education
2.Functional training.
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29. II. Strength
Definition:
1.Ability of m. to generate force or torque at a definite velocity.
2.Ability of a m. to develop force for providing:
1. stability (keep me stable).
2. mobility (strength to move).
3.Ability of a m to continue successive exertions under
conditions where a load is placed on it.
Strength can be obtained only through m. work
(force x distance).
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30. 1.Training effect which is due to:
1. ↑ circ. &
2. development of m. sense through proprioceptive
system.
2.Hypertrophy of m. f.
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).
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31. Each of these factors demands ↑ R to the voluntary effort
→ max response.
Workload must be appropriate to the MMT grade,
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 m. depends on:
1.Site of weakness.
2.Extent of weakness.
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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.
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33. Causes of Loss of M. Strength
Decay of strength may occur in the m. groups not in use.
M. re-education must encourage m. strength for effective
fun. 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.
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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.
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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).

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36. If the tendon is:
1.Contracted or
2.Abnormally lengthened


The normally moving m. can accomplish
a small part of effective mov.
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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.,…
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38. III. Coordination
Is the integration of different kinds of movements in
a single pattern.
Is the ability to use the right m, at the right time & right
intensity to achieve a desired mov.
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 (out of) voluntary control.
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39. IV. Endurance
Definitions:
Ability to carry out repetitive mov 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
m.
* Patterns of mov to ↑ endurance are similar to that used to
obtain strength, except that the demands on neuromuscular
system are less.
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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.
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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.,09/01/2409/01/24 Ass. Prof. Salwa RoushdyAss. Prof. Salwa Roushdy 4141