Muscle Reeducation Ass Prof Salwa Roushdy 11262020 Ass

Muscle Re-education Ass. Prof. Salwa Roushdy 11/26/2020 Ass. Prof. Salwa Roushdy 1

Muscle Re-education Lecture 1 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. 11/26/2020 Ass. Prof. Salwa Roushdy 2

Definition • It is the phase of therapeutic exs developed to: 1. 2. 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 aren’t necessarily the same, even though, each has certain principles in common. Lack of effective m. control may: 1. 2. Result from many different causes & Be manifested in many different ways. 11/26/2020 Ass. Prof. Salwa Roushdy 3

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 motor awareness & effective voluntary response. 11/26/2020 Ass. Prof. Salwa Roushdy 4

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 patterns: which minimize the hazards of trauma & deformity that might → abnormal stress & strain. 11/26/2020 Ass. Prof. Salwa Roushdy 5

Acceptable patterns of movs are designed to: fit the handicapped pt 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 pt to grasp a fork with his toes to feed himself. But This becomes completely unacceptable when he becomes a young adult. 11/26/2020 Ass. Prof. Salwa Roushdy 6

Indications of M. Re-education 1. Diseases causing subnormal voluntary control. 2. LMNL → mild: severe flaccid paralysis & weakness of motor response 3. Dyskinetic mov as a. Spasticity d. Rigidity of those. b. Athetosis e. Tremors. c. Ataxia (sluggish) f. Any combination 4. UMNL: in flaccid stage → m. weakness. 5. After prolonged immobilization or disuse. 6. After tendon transfer or m. transplantation. 7. After arthroplasty. 11/26/2020 Ass. Prof. Salwa Roushdy 7

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 from which 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. 11/26/2020 Ass. Prof. Salwa Roushdy 8

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. • 1 st 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. 11/26/2020 Ass. Prof. Salwa Roushdy 9

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 or inability are necessary to be observed. These tests 11/26/2020 provide data for prescribing ex & repeated testing for Ass. Prof. Salwa Roushdy prognosis. 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 but also on indicated by these tests (MMT, EMG). 11/26/2020 2. Extent of m. strength, 3. Possibilities of recovery, which will be Ass. Prof. Salwa Roushdy 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. 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. 11/26/2020 Ass. Prof. Salwa Roushdy 12

6. Muscle-Tendon Integrity & Mobility M. must be: 1. 2. 3. 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 Loss of ability to contract effectively, even though the motor pathways are intact. 11/26/2020 Ass. Prof. Salwa Roushdy 13

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. Ø If the tendon is contracted -------» m. normally can accomplish a small portion of the R. Ø If the tendon is lengthened -----» ineffective m. cont. Ø Repeated stretching or lengthening of tendon Ø 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. 14 ----» permit m. mass to shorten & ----» limit m. ability to contract through normal R ----» disuse ------------» loss of m. strength. 11/26/2020 Ass. Prof. Salwa Roushdy

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. 11/26/2020 Ass. Prof. Salwa Roushdy 15

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. 2. Paralytic disease Malalignment of # post-traumas. 11/26/2020 Ass. Prof. Salwa Roushdy 16

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. 11/26/2020 Ass. Prof. Salwa Roushdy 17

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 value unless the abnormal UMNL activity can be controlled. 11/26/2020 Ass. Prof. Salwa Roushdy 18

Techniques of M Re-education As m re-education is devoted to the: 1. Recovery of voluntary control of skeletal m. , 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 11/26/2020 Ass. Prof. Salwa Roushdy 19

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. 11/26/2020 Ass. Prof. Salwa Roushdy 20

A. Focusing Procedure All re-education techs. should be started with: a discussion or demonstration of the routines to be used. Pt. may not only know what is: 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 1. 11/26/2020 Ass. Prof. Salwa Roushdy 21

1. Passive Motion (PROM) 1 st step 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 & speed of mov must be altered until desired responses are obtained. Begins within limits of pain & tightness, then progress. 11/26/2020 Ass. Prof. Salwa Roushdy 22

2. Cutaneous Stimulation Assist pt to concentrate on areas under care, he can better see & feel cont. in specific ms. Has some proprioceptive stim value: in infants & young children tickling & scratching various areas → promote movs. The PT may use: 1. 2. 3. 4. 5. 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. . 11/26/2020 Ass. Prof. Salwa Roushdy 23

3. Electrical stimulation Cause m. cont 1 --» pt. see & feel m. cont. 2 --» sensations of value in sensory reflex stim. 3 --» m. tension 4 --» proprioceptive stim. 11/26/2020 Ass. Prof. Salwa Roushdy 24

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: 1. 2. 3. Spotty m. weakness Reactivation of ms after tendon transplantation. As a focusing & motivating method. 11/26/2020 Ass. Prof. Salwa Roushdy 25

B. Proprioceptive Stimulations Is an activation method → stim. m. cont. by proprioceptive stimulation (jt, m, tendon), these receptors can be stimulated by: 1. 2. 3. 4. 5. 6. 7. 8. 9. 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. 11/26/2020 Ass. Prof. Salwa Roushdy 26

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. 11/26/2020 Ass. Prof. Salwa Roushdy 27

Reflex Stimulation Normal & Pathological reflexes → initiate: 1. M. cont 2. Righting reactions 3. Equilibrium 4. Protective reactions Normal & Pathological reflexes are essential steps in: 1. M. re-education 2. Functional training. 11/26/2020 Ass. Prof. Salwa Roushdy 28

II. Strength Definition: 1. Ability of m. to generate force or torque at a definite velocity. 2. Ability of a m. to develop force for providing: 1. stability (keep me stable). 2. mobility (strength to move). 3. 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). 11/26/2020 Ass. Prof. Salwa Roushdy 29

Recovery of Strength through work is due to: 1. Training effect which is due to: 1. ↑ circ. & 2. development of m. sense through proprioceptive system. 2. Hypertrophy of m. f. 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). 11/26/2020 Ass. Prof. Salwa Roushdy 30

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: 1. 2. Site of weakness. Extent of weakness. 11/26/2020 Ass. Prof. Salwa Roushdy 31

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, 11/26/2020 Ass. Prof. Salwa Roushdy 32 So it’s a pathological reaction.

Causes of Loss of M. Strength 1. Disuse Decay of strength may 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: 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. 11/26/2020 Ass. Prof. Salwa Roushdy 33

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. 11/26/2020 Ass. Prof. Salwa Roushdy 34

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: 1 st 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). 11/26/2020 Ass. Prof. Salwa Roushdy 35

3. Relation of Tendon Length to M. Mass If the tendon is: 1. 2. Contracted or Abnormally lengthened The normally moving m. can accomplish a small part of effective mov. 11/26/2020 Ass. Prof. Salwa Roushdy 36

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. 2. 3. Graduated active exs Elect. M. Stim. (EMS). Etc. , … 11/26/2020 Ass. Prof. Salwa Roushdy 37

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 reflex training (subconsciously). Coordination mechanisms are highly complex, with many of the components of the movement at a subconscious level beyond (out of) voluntary control. 11/26/2020 Ass. Prof. Salwa Roushdy 38

IV. Endurance Definitions: Ability to carry out repetitive mov 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 m. * Patterns of mov to ↑ endurance are similar to that used to obtain strength, except that the demands on neuromuscular system are less. 11/26/2020 Ass. Prof. Salwa Roushdy 39

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. 11/26/2020 Ass. Prof. Salwa Roushdy 40

Examples According to the intensive evaluation, paralysis or severe weakness with grade: 0: 1&2 - ↑ sensory input by splinting, passive mov, - interrupted direct currents. 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. , 11/26/2020 Ass. Prof. Salwa Roushdy 41