MUSCLE RE-EDUCATION

BY Dr.Eswar kolli,MPT

• 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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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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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

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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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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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

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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: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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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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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 M. fibrosis Tendon stenosis

Loss of ability to contract effectively, even though the motor pathways are intact.

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.

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M. contractureM-tendon contracture

M. fibrosis

Tendon stenosis

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. As there’s danger of loss of power with un-needed m. lengthening.

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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.

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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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Pain

• It is impossible to obtain coordinated movement if such movement → pain.

• If this movement → pain → patient’ll carry out the movement by

substitute

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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.

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Techniques of M Re-education

As muscle re-education is devoted to the: 1. Recovery of voluntary control of skeletal muscle, or2. 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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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.

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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

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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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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..

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.

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. weakness2. Reactivation of ms after tendon transplantation.3. As a focusing & motivating method.

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 attitudes3. Balance in sitting & crawling4. kneeling & standing (righting reactions) → vestibular stim.5. Weight bearing6. Traction7. Approximation8. Quick stretches9. Resistance

We must use posture, passive mov, active mov to → stretching, resistance & reflexes necessary → stim. proprioceptive system.

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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Reflex Stimulation

• Normal & Pathological reflexes → initiate: 1. Muscle contraction

2. Righting reactions 3. Equilibrium

4. Protective reactions• Normal & Pathological reflexes are essential

steps in:1. Muscle re-education 2. Functional training.

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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).

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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:1. Site of weakness.

2. 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 it’s a pathological reaction.

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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.

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• 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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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).

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• 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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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 exs2. Elect. M. Stim. (EMS).3. Etc.,…

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III. CoordinationIs 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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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.

• 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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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,

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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