Neuromuscular Coordination

8/4/2019 Neuromuscular Coordination

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NEUROMUSCULARCO-ORDINATION


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INTRODUCTION

Motor control

Muscle tone

Postural response

Selective movement

CO-ORDINATION


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INTRODUCTION

Coordination is an ability to execute smooth,accurate, controlled and purposeful motorresponse.

It is dependent on somatosensory, visual, andvestibular input as well as a fully intactneuromuscular system.

Coordinated movts are characterized byappropriate speed, distance, direction, timing,muscular tension,synergistic influence (musclerecruitment), easy reversal between opposingmuscle groups & proximal fixation to allow distalmotion or maintenance of posture


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INTRODUCTION

DEXTERITY refers to the skillful use offingers during fine motor tasks

AGILITY refers to the ability to rapidly andsmoothly initiate, stop or modify movt whilemaintaining postural control


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INTRODUCTION

General types of coordination:- Intralimb coordination-movt occurring with

single limb.

Interlimb coordination-integratedperformance of two or more limb workingtogether.

Visual motor coordination-ability to integrateboth visual and motor abilities


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INTRODUCTION

Several condition that typically demonstratecoordination impairments include traumaticbrain injury, Parkinsons disease, multiple

sclerosis, cerebral palsy, cerebellarpathology and vestibular pathology


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1)INTRODUCTION

2) MOTOR SYSTEM

3) FEATURES OF CO-ORDINATIONIMPAIREMENT

4) CO-ORDINATION TESTING

5) TREATMENT


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MOTOR SYSTEM

Motor system

Peripheral element Central element

Muscles, joints,sensory & motor nerves

Association cortex, motor cortex,basal ganglia, cerebellum,brain stem & spinal cord


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MOTOR SYSTEM

CENTRAL ELEMENT


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MOTOR CORTEX


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MOTOR CORTEX

AREA-4 primary motor cortex

-largest concentration ofcorticospinal neurons

-precentral gyrus

-controls contralateral

movements.

AREA-6 - anterior to area 4- superiorly placed SMA

- inferiorly placed PMA


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MOTOR CORTEX

SMA -initiation of movement

-simultaneous bil grasping movt.

-sequencential task

-orientation of eye & head

PMA -controls trunk & proximal limb movt.

-contribute to anticipatory postural

changes


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MOTOR HOMONUCULUS

Schematicallyillustrates theamount of cortical

area devoted tomotor control of agiven body part orregion


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MOTOR CORTEX

The motor cortex receives informationfrom three primary sources:

1. The somatosensory cortex

2. The cerebellum

3. The basal ganglia


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CEREBELLUM

The primary function of cerebellum isregulation of movement, postural control andmuscle tone.

It functions as comparator and errordetecting mechanism.

It compares information received from thecortex with that obtained from peripheral

feedback mechanism


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CEREBELLUM

If the input from the feedback systems doesnot compare appropriately, the cerebellumsupplies a corrective influence

This effect is achieved by corrective signalssent to the cortex.

Cortex modifies or corrects the ongoingmovt via motor pathways


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BASAL GANGLIA

Caudate nucleus,putamen, globuspallidus,

subthalamic nucleiand substantia nigraconstitute basalganglia.


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BASAL GANGLIA

Basal ganglia play imp role in initiation andregulation of gross intentional movts,planning and execution of complex motor

responses, facilitation of desired motorresponses while selectively inhibiting others.


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DORSAL COLUMN TRACTS

They play imp rolein coordinated movtand posture.

They areresponsible formediatingproprioceptive input

from muscles andjoint receptors.


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Basal ganglia Cerebellum

Cerebral cortex

Central pattern

generator

Receptors

Muscles

Feedback loops

Descendingmotor tracts


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1)INTRODUCTION

2) MOTOR SYSTEM

3) FEATURES OF CO-ORDINATIONIMPAIREMENT


5) TREATMENT


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C/F OF CEREBELLARDYSFUNCTION

ATAXIA is a general term used to describethe combined influence of cerebellar andsensory dysfunction on gait, posture, and

patterns of movt. The c/f identified emphasis the crucial

influence of cerebellum on equilibrium,posture, muscle tone, and force of movt.


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1. HYPOTONIAis decrease in muscle tone.

- diminished resistance to passive movt

- muscle may feel abnormally soft andflaccid

-diminished deep tendon reflexes.

2. DYSMETRIAis disturbance in the abilityto judge the distance or range of movt

-manifested by hypermetria or hypometria


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3. DYSDIADOCHOKINESISis an impairedability to perform rapid alternating movt.

-deficit observed in movts such as rapid

alteration between pronation and supinationof forearm

-movts are irregular with rapid loss ofrange, and rhythm espescially as speed is

increased.


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4. TREMOR is an involuntary oscillatory movtresulting from alternate contractions ofopposing muscle groups.

-two types of tremors associated withcerebellar lesion are intention or kinetictremor and postural or static tremor.

-intention tremor occur during voluntary

motion of a limb and postural tremor maybe evident while the patient maintains aposture


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5. MOVT DECOMPOSITION (DYSSYNERGIA ) describes a movtperformed in a sequence of componentparts rather than as a single smoothactivity. ASYNERGIA is the loss of abilityto associate muscles together for complexmovements.


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6. DISORDERS OF GAITinvolve ambulatorypatterns that typically demonstrate abroad base of support.

-the arms may be held away from the bodyto improve balance

-gait is unsteady, irregular and staggeringwith deviation from an intended line of

progression


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7. DYSARTHRIA is referred to as scanningspeech

-speech is slow, slurred, hesitant with

inappropriate pauses.8. NYSTAGMUS is a rhythmic, oscillatory

movement of the eyes as the eyes moveaway from a midline resting point to fix on

a peripheral object.


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9. ASTHENIA is generalized muscle weaknessassociated with cerebellar lesions.

10. In addition to these c/f, difficulty may be

observed in stopping, or changing the force,speed, or direction of movt.


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IMPAIREMENT OF BASALGANGLIA

1. BRADYKINESIA is slowed or decreasedmovt.

- e.g., slow shuffling gait, difficulty

initiating or changing direction of movt,lack of facial expression, or difficultystopping a movt once begun.

2. RIGIDITY is an increase in muscle tone

causing greater resistance to passive movt.


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IMPAIREMENT OF BASALGANGLIA

3. Resting tremors typically disappear ordecrease with purposeful movt, but mayincrease with emotional stress. E.g., pill

rolling tremors.4. Akinesia is the inability to initiate movt and

is seen in late stages of parkisonism.

5. Chorea, athetosis, choreoathetosis,

hemibellismus and dystonia are involuntarymovts seen in basal ganglia impairement.


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IMPAIREMENT OFDORSAL COLUMNS

Equilibrium and motor control disturbancesrelated to patients lack of proprioception

Visioncompensates for the loss of

proprioception Problems will be exaggerated in poorly lit

areas or when patients eyes are closed.

Dysmetria is commonly seen in patient with

dorsal column impairement.


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IMPAIREMENT OFDORSAL COLUMNS

Noticeable slowing of voluntary movementsmay be observed

Gait pattern is wide-based, swaying with

uneven step length and excessive lateraldisplacement. Watching the feet duringambulation is indicative of proprioceptiveloss

The leg may be lifted too high and thendropped abruptly.


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1)INTRODUCTION

2) MOTOR SYSTEM

3) FEATURES OF CO-ORDINATION

IMPAIREMENT


5) TREATMENT


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COORDINATIONTESTING

rigidity

Passive movts

hypotonia

absent

Deep tendon reflexes sluggish

exaggerated

at rest Tremors posture holding

intentional


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COORDINATIONTESTING

Postural holding

fixation or positionholding (upper and

lower extremity) Balance

displace balanceunexpectedly in

sitting or standing.in standing, alterbase of support

Observe gait


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COORDINATIONTESTING Romberg's sign

Standing: eyes open toeyes closed; inability tomaintain uprightposture without visual

input is referred to aspositive rombergssign

Finger to nose test

The shoulder isabducted to 90 degrees

with the elbowextended. The patientis asked to bring the tipto the nose. Look fortremors, dysmetria or

dyssynergia.


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COORDINATIONTESTING

Tandem walkingWalking, placing heelof one foot directly infront of the toe ofthe opposite foot

Heel on shinFrom a supineposition, the heel ofone foot is slid up and

down the shin of theopposite lowerextremity.


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COORDINATIONTESTING

Pronation/supination test

With elbows flexed to 90 degrees and heldclose to body the patieht alternately turns

the palm up and down. Foot tapping

The patient is asked to tap the ball of thefoot on the floor without raising the knee;

heel maintains the contact with the floor.


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COORDINATIONTESTING

Rebound test

The patient is positioned with elbows flexed.

The therapist applies sufficient manualresistance to produce the isometriccontraction of the biceps. Resistance issuddenly released.


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1)INTRODUCTION

2) MOTOR SYSTEM

3) FEATURES OF CO-ORDINATION

IMPAIREMENT


5) TREATMENT


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THERAPY IS DIRECTED ATPROMOTING POSTURAL

STABILITY, ACCURACY OF LIMBMOVTS, AND FUNCTIONAL

BALANCE AND GAIT


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TREATMENT(Postural stability)

Can be improved by focusing on holding innumber of different weight bearing and anti-positions.

Progressed by gradually varying BOS, raisingthe COM, and increasing the number of bodysegments that must be controlled.

PNF techniques:- joint approximation

- rhythmic stabilization- slow reversal hold and relax


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TREATMENT(Functional balance)

Static balance can be improved using forceplatform and auditory/visual biofeedback.

Progression: standing eyes open to eyes

closed, standing on flat surface to foamsurface.

Dynamic balance can be challenged using selfinitiated movts.

A moveable surface like Swiss ball can alsobe used

TREATMENT


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TREATMENT(Limb movts)

Ataxic limb movts can be helped by lightweights to provide additional proprioceptiveloading and stabilize movts. E.g., velcro

weight cuffs, weight belt, weighted jackets,weighted canes, weighted walkers ortherabands.

The pool is an imp theraputic medium to

practice static and dynamic postural controlin sitting and standing


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FRENKELS EXCERSICE

Dr H. S Frenkel was the medicalsuperintendent of the sanatorium in theSwitzerland towards the end of last century.

He aimed at establishing voluntary control ofmovt by the use of any part of the sensorymechanism which remained intact, notablysight sound and touch to compensate for the

loss of kinesthetic sensation.


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FRENKELS EXCERSICE

The process of learning this techniquerequires:-

CONCENTRATION

PRECISIONREPETITION


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FRENKELS EXCERSICE(Technique)

1. The patient is suitably clothed andpositioned so that he can see the limbsthroughout the exercise.

2. A concise explanation and demonstration ofthe exercise is given before movt isattempted, to give the patient a clearmental picture of it.

3. The patient must give his full attention tothe performance of the movt to make themovt smooth and accurate.


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4. The speedof the movt is dictated by thephysiotherapist by means of rhythmiccounting, movt of her hand or the use of

suitable music.5. The range of movt is dictated by marking

the spot on which the foot or hand is to beplaced.


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6. The exercise is to be repeated many timesuntil it is perfect and easy. It is thendiscarded and the more difficult one is

substituted.7. As these exercise are very tiring at first,

frequent rest periods must be allowed. Thepatient retains little or no ability to

recognize fatigue, but it is usually indicatedby the deterioration in the quality of movt,or by a rise in the pulse rate.


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FRENKELS EXCERSICE(Progression)

Progression is made by altering speed, rangeand complexity of exercise.

Fairly quick movt require less control than

slow ones. Later, alteration in the speed of consecutive

movts, and interruptions which involvestarting and stopping to command are

introduced.

F E E E E E


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Wide range and primitive movts in whichlarge joints are used gradually give way tothose involving the use of small joints,

limited range and frequent alteration ofdirection.

Finally simple movts are built up intosequences to form specific actions which

require the use and control of a number ofjoints and more than one limb, e.g., walking

F EN EL E E E


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According the degree of disability,reeducation exs start in lying with headpropped up and with the limbs fully

supported and progress is made to exs insitting and then in standing.

FRENKEL EXCER CE


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FRENKELS EXCERSICE(Examples)

1. Half lying: hip and knee flexion andextension of each limb, foot flat on theplinth.

FRENKELS EXCERSICE


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2. Half lying: Hip abduction and adductionwith leg fully supported throughout on asmooth surface of a plinth or a reeducation

board.3. Half lying: Hip abduction and adduction of

each limb with foot flat, with knee flexed

FRENKELS EXCERSICE


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4. Half lying: one leg raising to place the heelon a specified mark.

Therapist

FRENKELS EXCERSICE


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5. Half lying: heel of one limb to opposite leg(toes ankle shin and patella)

6. Half lying: reciprocal movt of both the

limbs7. Sitting: knee flexion and extension of each

limb.

8. Sitting: one leg stretching, to slide the heel

to a position indicated by the mark on thefloor.

FRENKELS EXCERSICE


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9. Sitting; alternate leg stretching and liftingto place heel or toe on specified mark.

10. Stride sitting; change to standing and then

sit down again. The feet are drawn backand the trunk inclined forwards from thehips to get the centre of gravity over thebase. The patient then extends the legs

and draws himself up with the help of hishands grasping the wall bars or othersuitable apparatus.

FRENKELS EXCERSICE


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11. Stride standing; transference of weightfrom foot to foot

12. Stride standing; walking sideways placing

feet on the marks on the floor.

FRENKELS EXCERSICE


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13. Standing; walking placing feet on the marks.

left

right

leftright

FRENKELS EXCERSICE


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14. Standing; turn around

1

2

3 4

5

6

8 7

2

1

3 4

5

6

8 7

FRENKELS EXCERSICE


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15. Standing; walking and changing direction toavoid obstacles

Excercises for arm1. Sitting; one arm supported on a table or on

a sling; shoulder flexion or extension toplace hand on a specified mark

2. Sitting; one arm stretching to thread it

through a small loop or ring3. sitting; picking up objects and putting them

down on a specified mark

FRENKELS EXCERSICE


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Exercise to promote movement andrhythm

1. Sitting; one hip flexion and adduction tocross one thigh over the other, the movt isthen repeated and reversed.

2. Half lying; one leg abduction to bring kneeto side of plinth, followed by one knee

bending to put foot on floor, the movt isthen reversed and repeated

FRENKELS EXCERSICE


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3. Sitting; lean forward and take weight onfeet (as if to stand), then sit down again.

4. Standing; arm swing forwards and

backwards with partner, holding two sticks.5. Standing or walking; bounce and catch, or

throw and catch a ball.


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Neuromuscular Coordination