Cont.

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• Cont.

Muscle reeducation
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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.

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Objectives of m. re-education

• 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).
• 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.

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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.

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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.

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Indications of M. Re-education

• Diseases causing subnormal voluntary control.
• LMNL ? mild and severe flaccid paralysis
  weakness of motor response
• Dyskinetic mov as
• a. Spasticity b. Athetosis
  c. Ataxia (sluggish) d.
  Rigidity e. Tremors. f.
  Any combination of those.
• UMNL in flaccid stage ? m. weakness.
• After prolonged immobilization or disuse.
• After tendon transfer or m. transplantation.
• After arthroplasty.

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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 gt 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.

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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.

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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.

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• EMG gives information for diag. prognostic
  state
• EMG gives data about
• 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).

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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
• motor unit denervation.
• 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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6. Muscle-Tendon Integrity Mobility

• M. must be
• Intact throughout its length.
• Stable at its origin insertion before adequate
  response can be expected.
• Free to move within its normal components.

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

• Muscle must be
• Intact throughout its length.
• Stable at its origin insertion before adequate
  response can be expected.
• Free to move within its normal components.

M. contracture
M-tendon contracture
M. fibrosis
Tendon stenosis
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• 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 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.

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• Possibilities of m. re-education are directly
  related to skeletal alignment.
• This is particularly true in structural changes
  in the spine, legs feet following
• Paralytic disease
• Malalignment of post-traumas.

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• It is impossible to obtain coordinated movement
  if such
  movement ? pain.
• If this movement ? pain
  
  ? patientll carry out the movement
  by
• substitute

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• 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.

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• As muscle re-education is devoted to the
• Recovery of voluntary control of skeletal muscle,
  or
• 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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• 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.

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• 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
• Being done? , but
• 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

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• 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.

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• 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
• 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..

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

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• 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
• Spotty m. weakness
• Reactivation of ms after tendon transplantation.
• As a focusing motivating method.

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• Is an activation method ? stimulation of muscle
  contraction by proprioceptive stimulation (jt,
  muscle, tendon), these receptors can be
  stimulated by
• 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.

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• 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.

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• Normal Pathological reflexes ? initiate
• 1. Muscle contraction
• 2. Righting reactions
• 3. Equilibrium
• 4. Protective reactions
• Normal Pathological reflexes are essential
  steps in
• Muscle re-education
• Functional training.

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• Definition
• 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).

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Recovery of Strength through work is due to

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).

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• 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
• Site of weakness.
• Extent of weakness.

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• 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.

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• Disuse

• 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
• Support weakened body seg.
• Prevent deformity But may ?
• Limit m. use
• Cause m. weakness
• Such disuse weakness can be determined by
  
  pain limited response of these ms. to
  specific activity.

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• 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.

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• 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).

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

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• Rest periods for recovery is related to
• a. Fatigue
  
  which is due to the
  accumulation of waste products,
  which is in turn related
  to
• Blood supply.
• Tissue drainage.
• b. Individual motivation
• Strength may be achieved by
• Graduated active exs
• Elect. M. Stim. (EMS).
• Etc.,

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• 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.

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• 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.

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• 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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• 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.,

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