Muscle Re-education Ass. Prof. Salwa Roushdy

1. Muscle Re-education Ass. Prof. Salwa Roushdy Ass. 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. Ass. Prof. Salwa Roushdy

3. Definition • It is the phase of therapeutic exs developed to: • The development, or • Therecovery 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: • Result from many different causes & • Be manifested in many different ways. Ass. Prof. Salwa Roushdy

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 motorawareness & effective voluntary response. Ass. Prof. Salwa Roushdy

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. Safe Ass. Prof. Salwa Roushdy

6. Acceptable • Acceptable patterns of movs are designed to: fit the handicappedpt into normal environment in contact& in competition with physically normal people. • Acceptable patterns areacceptable 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. Ass. Prof. Salwa Roushdy

7. Indications of M. Re-education • Diseases causing subnormal voluntary control. • LMNL→mild: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 immobilizationordisuse. • After tendon transfer or m. transplantation. • After arthroplasty. Ass. Prof. Salwa Roushdy

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 fromwhich 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. Ass. Prof. Salwa Roushdy

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. • 1st 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. Ass. Prof. Salwa Roushdy

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 orinability are necessary to be observed. These tests provide data for prescribing ex& repeated testing for prognosis. Ass. Prof. Salwa Roushdy

11. EMGgives information for diag. & prognostic state. • EMGgives data about: • Actual motor denervation. • Map out areas of silence&areas ofpolyphasic reactions, indicating progressive denervationorrecovery of innervation. • Galvanic current draw strength duration curve, & determining chronaxie→ assess PNS injury. • M. re-education mustn’t only be based on the: 1. Site2. Extent of m. strength, but also on 3. Possibilities of recovery, which will be indicated by these tests (MMT, EMG). Ass. Prof. Salwa Roushdy

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: • 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. Ass. Prof. Salwa Roushdy

13. 6. Muscle-Tendon Integrity & Mobility • M. must be: • Intact throughoutits length. • Stableat 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. Ass. Prof. Salwa Roushdy

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. Ass. Prof. SalwaRoushdy

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. Ass. Prof. Salwa Roushdy

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: • Paralytic disease • Malalignment of # post-traumas. Ass. Prof. Salwa Roushdy

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. Ass. Prof. Salwa Roushdy

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 valueunless the abnormal UMNL activity can be controlled. Ass. Prof. Salwa Roushdy

19. Techniques of M Re-education • As m re-education is devoted to the: • Recovery of voluntary control of skeletal m., or • Development of motor control (active, strong, coordinated, enduring), so • The primary OBJECTIVESmust follow a certain REASONABLEorder: I. Activation II. Strength III. Co-ordination IV. Endurance Ass. Prof. Salwa Roushdy

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. Ass. Prof. Salwa Roushdy

21. A. Focusing Procedure • All re-education techs. should be started with: a discussionordemonstration of the routines to be used. • Pt. 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 pt’s age & intelligence Ass. Prof. Salwa Roushdy

22. 1. Passive Motion (PROM) • 1ststep 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&speedof movmust be altereduntil desired responses are obtained. • Begins within limits of pain&tightness, then progress. Ass. Prof. Salwa Roushdy

23. 2. Cutaneous Stimulation • Assist pt to concentrate on areas under care, he can better see &feelcont. in specific ms. • Has some proprioceptive stim value: in infants & young children tickling & scratching various areas→ promote movs. • The PT may use: • His fingers to: stroke or tap ms & tendons. • A brushor a rubber hammer. • Basic massage (effleurage, petressage, tapotement). • Cryotherapy(“brief“ ice application). • Brief painful stim.. Ass. Prof. Salwa Roushdy

24. 3. Electrical stimulation • Cause m. cont 1--» pt. see&feelm. cont. 2 --» sensations of value in sensory reflex stim. 3 --» m. tension 4 --»proprioceptive stim. Ass. Prof. Salwa Roushdy

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: • Spotty m. weakness • Reactivation of ms after tendon transplantation. • As a focusing & motivating method. Ass. Prof. Salwa Roushdy

26. B. Proprioceptive Stimulations • Is an activation method→ stim. m. cont. by proprioceptive stimulation (jt, m, tendon),these receptors can be stimulated by: • Passive mov. • 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. Ass. Prof. Salwa Roushdy

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 → facilitate active response. Ass. Prof. Salwa Roushdy

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: • M. re-education • Functional training. Ass. Prof. Salwa Roushdy

29. II.Strength • Definition: • Ability of m. to generate force or torque at a definite velocity. • Ability of a m. to develop force for providing: 1. stability (keep me stable). 2. mobility (strength to move). • 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). Ass. Prof. Salwa Roushdy

30. Recovery ofStrength through work is due to: • Training effect which is due to: 1. ↑ circ. & 2. development of m. sense through proprioceptive system. • Hypertrophy of m. f. • ↑ No. of motor units entering into the contractile effort. • Sprouting (if motor units have been denervated, some degrees of re-innervation will occur by adjacent intact neurofibrils). Ass. Prof. Salwa Roushdy

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: • Site of weakness. • Extent of weakness. Ass. Prof. Salwa Roushdy

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. • Fatigueis a normal& physiological reaction that → protects the normal individual from overwork. • Overwork is neithernormal, norphysiological reaction, So it’s a pathological reaction. Ass. Prof. Salwa Roushdy

33. Causes of Loss of M. Strength Disuse • Decay of strengthmay 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: • 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. Ass. Prof. Salwa Roushdy

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. Ass. Prof. Salwa Roushdy

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: 1st6 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). Ass. Prof. Salwa Roushdy

36. 3. Relation of Tendon Length to M. Mass • If the tendon is: • Contracted or • Abnormally lengthened The normally moving m. can accomplish a small part of effective mov. Ass. Prof. Salwa Roushdy

37. 4. Prolongation of Rest Period Required for Recovery • Rest periods for recovery is related to: a. Fatiguewhich isdue 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.,… Ass. Prof. Salwa Roushdy

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 reflextraining (subconsciously). • Coordination mechanisms are highly complex, with many of the components of the movement at asubconscious level beyond (out of) voluntary control. Ass. Prof. SalwaRoushdy

39. IV. Endurance Definitions: • Ability to carry out repetitive mov essential to prolonged activity. • Ability to repeat motor tasks orsustain 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. Ass. Prof. Salwa Roushdy

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. Ass. Prof. Salwa Roushdy

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., Ass. Prof. Salwa Roushdy