2. •Definition
Muscle Re-education is the regaining of normal or near
normal functioning of an injured or denervated muscle or
muscle with lack of control by appropriate therapeutic
techniques.
Lack of effective muscle control may:
Result from many different causes & be manifested in
many different ways.
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3. 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.
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4. 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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5. 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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6. 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.
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7. 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.
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8. 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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9. 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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10. 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).08/15/1608/15/16 1010
11. 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.08/15/1608/15/16 1111
12. 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.
08/15/1608/15/16 1212
M. contracture M-tendon contractureM-tendon contracture M. fibrosis Tendon stenosis
Loss of ability to contract effectively, even though the motor pathways are intact.
13. 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.
1313
M. contracture
M-tendon contractureM-tendon contracture
M. fibrosis
Tendon stenosis
14. 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.
1414
15. 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.
1515
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.
1616
17. Pain
• It is impossible to obtain coordinated movement
if such movement → pain.
• If this movement → pain
→ patient’ll carry out the
movement by
substitute
1717
18. 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.
1818
19. 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
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20. 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.
2020
21. 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
2121
22. 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.
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23. 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..
24. 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.
25. 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.
26. 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.
27. 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.
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29. 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).
2929
30. 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).
3030
31. • 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.
3131
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.
3232
33. 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.
3333
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.
3434
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:
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).
3535
36. • If the tendon is:
1. Contracted or
2. Abnormally lengthened
The normally moving m. can accomplish
a small part of effective mov.
3636
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.,…
3737
38. 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.
3838
39. 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.
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.
4040
41. Techniques of Re-education
• Muscles with severe paralysis or weakness are evaluated by
MMT and re-educated from grade zero to grade five (normal) as
follows:
GRADE 0 (zero) - ↑ sensory input by splinting, passive
movements,facilitatory techniques such as joint approximation or
weight -bearing,warmth,manual contacts,quick stretching,fast
icing,hacking,Irradiation techniques,reeducation board, Electrical
muscle stimulations such as interrupted direct currents for
denervated muscles and faradic & HVG currents for innervated
muscles.
GRADE 1 & 2(Trace and Poor)- All Above techniques along with
suspension therapy,re-education board,mirror
therapy,hydrotherapy,assisted excercises, shoulder wheel
excercisis, finger ladder excercises, bicycle ergometer
& Proprioceptive neuromuscular facilitation techniques,
42. Techniques of Muscle Re-education
GRADE 2 to 3(Poor to fair)
- Active assisted and active excercises,active excercises
eliminating gravity by using suspension therapy,Re-education
table,hydrotherapy by placing limb towards flow of
water,pulleys.
Grade 3 to 4(fair-good)
Progressive resisted excercises,hydrotherapy,pulleys,sand
bags,weight cuffs,functional excercises, Manual resistance
excercises,PNF techniques,dumbells starting with low
weights,Therabands,rubber tubing,lower limb functional
excercises such as climbing a slope,walking down slope,stair
climbing up and down.
Grade 4 to 5(good)
All the above excercises increasing resistance gradually,quadriceps
table excercises,manual resisted excercises by increasing
leveragw,weight,number of repetitions to increase
endurance,mechanical weights used in gymnasium.
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