CO-ORDINATED MOVEMENT
Smooth, precise, and intentional movement is achieved through the coordinated action of numerous muscles superimposed on top of an effective foundation of postural activity. Based on the specific task they are required to execute, the involved muscles are classified as fixators, synergists, antagonists, and prime movers.
GROUP ACTION OF MUSCLES
Joints move when prime movers contract, and antagonists, the opposing group, reciprocally relax to control their action without obstructing it. When prime movers cross several joints, other muscles can act as synergists by stabilizing the joint where movement is not needed or by changing the direction of the pull. The additional guarantee of efficiency is provided by the muscles fixing the bone or bones that the prime movers originate from (or, if they operate with reversal origin and insertion, into). Even though these fixator muscles are located very next to the movement, the entire body usually twitches when substantial resistance is applied.
NERVOUS CONTROL
The routes of motor vehicles. Each muscle group's action is dictated by the afferent signals that go through its motor pathways. The Cortex of the Brain. Most of the time, though not always, voluntary movement is brought on by a sensory stimulation. It is currently believed that the brain stem contains an initiating center that signals the cerebral cortex, which plans the movement pattern. This strategy is predicated on recollections of patterns employed in the past.
The Brainstem:
The cerebellum serves as a receiving station for information that travels through afferent pathways from the peripheral to the cerebral cortex and vestibular nucleus. These pathways carry kinaesthetic sensation impulses. Based on this information, the extra-pyramidal tracts or other descending pathways make the little adjustments necessary to guarantee the harmonious interaction of the different muscle groups involved in the movement pattern and transmit those changes to the anterior horn cells pathways of the spinal cord.
Kinesthetic Sensation:
Proprioceptors found in muscles, tendons, and joints are the source of the afferent impulses responsible for kinesthetic sensation. These impulses record muscle contraction or stretching as well as information about limb position and movement. While many of these impulses terminate in the spinal cord and cerebellum, some of them reach the level of consciousness..
INCO-ORDINATION:
When any of the components that produce a coordinated movement are interfered with, the consequence is an uncoordinated movement that is jerky, arhythmic, or incorrect because the muscles' harmonious cooperation is disrupted. The location of the lesion causing the incoordination affects the type of incoordination and the activities intended to assist overcome it. Adequate exercise therapy is usually beneficial for four main types.
Incoordination, and Neurological Lesions:
lack of coordination linked to a specific muscle group's weakness or flaccidity. In this instance, either a lesion of the lower motor neurons prevents the right signals from reaching the muscles or the muscles' usual response to these impulses is altered. Correlation between muscle stiffness and incoordination. Muscle spasticity is caused by lesions affecting the upper motor neurons, or motor area of the cerebral cortex. As a result, even if certain suitable signals are able to reach the muscles, their reaction to them is abnormal.
Effects, Symptoms, and Implications:
Cerebellar lesions-induced incoordination. Generally speaking, this is referred to as cerebellar "ataxia," with the Greek term "taxis" meaning "order" and the prefix "a" meaning "without." Not only are the muscles immediately involved in the e group activity hypotonic, but the body as a whole exhibits inadequate fixator action. The muscles also tire easily. There is a noticeable purposeful tremor along with erratic and swinging movement.
Sensory Ataxia:
Incoordination brought on by kinaesthetic sense loss. This kind is known as sensory ataxia, or tabetic ataxia in the case of tabes dorsalis. The patient with this ailment has no idea where the joints are or how the body is positioned in space unless he uses his eyes to obtain this information. The muscles are hypotonic and readily fatigued, but they are not aware of this since they do not register a feeling of exhaustion. Movement may be impeded and less effective if there is an anomalous general stress placed on top of an otherwise regular pattern of group action, or if there are involuntary motions that are occasionally linked to these conditions.
RE-EDUCATION:
The body is designed for coordinated movement; if only incoordinated movement is possible, it would tend to remain motionless. Therefore, it is crucial to motivate and inspire individuals who are experiencing incoordination to keep trying to overcome it. The physiotherapist must be extremely patient and persistent in order to do this, particularly if the illness is linked to mental decline. Since no two patients have the same problems, each needs to get individualized care. Resistance frequently stabilizes and permits mobility, but as patients make progress, group therapy can be an invaluable addition to one-on-one care.
The Use of Alternative Nervous Pathways
Reeducation aims to promote the use of the neurological channels that are still open or create new ones because it is uncommon for all of them to be blocked, which is how impulses necessary for coordinated movement travel.
Consider a pathway that has been worn through an acre or so of bracken or other vegetation as an analogy. When the walkway is well-worn and often used, it is manageable to stroll across. If the pathway is obstructed, however, there is another route that may be used. It will be harder to traverse at first, but it will get easier with each use if the same other route is taken. Thus, a new route was eventually created.
The Condition of the Muscles
Since the muscles are the affected organs, it is necessary to address their condition before re-educating the action. In order to ensure that their response to the coordinating impulses is as normal as possible, they must prepare themselves by trying to strengthen their weaker muscles and relax their spastic or tense ones. Additionally, it is likely that all long-term cases where incoordination is a feature also have some degree of disuse atrophy because of the disinclination.
PRINCIPLES OF RE-EDUCATION
Lack of Strength or Flexibility in a Specific Muscle Group. In contrast to the other conditions, this one usually only results in a temporary incoordination. The body will accept uncontrollably coordinated movement if it can be avoided; in this instance, it can do so by changing the movement pattern so that the impacted muscles' functions are shifted to other groups. 'Trick' movement, which is usually energy-wasting but frequently functionally beneficial, is based on this replacement of an alternative pattern.
The goal of treatment is to restore the normal integrated action of muscles in the execution of patterns of functional movement and to rectify imbalances by focusing on the activity of weak or ineffective muscles. The best method for achieving the latter is to use gradual reversals with regular timing.
Spasticity of Muscles.
Because the muscles are unable to relax or can only do so very slowly, their spasticity alters how the muscles respond to external stimuli and permits movement. There is a noticeable hesitation to try movement, and when it is accomplished, the vital rhythm necessary for effective movement is gone. The goals of treatment are to increase confidence in one's ability to move, encourage effort, encourage relaxation, and teach rhythm. Techniques for relaxation have already been discussed. The patient gains confidence and becomes as autonomous as feasible through active workouts based on daily motions. First are those that use the larger, more fundamental joints and need the usage of the more proximal joints.
Rhythmic Exercise and Engagement:
To promote relaxation and lessen tiredness, all exercises are done rhythmically. Help is provided only when needed and only after making an effort to complete the exercises on your own. To control the pace of the movement, one can employ rhythmic counting, music, or the bounce of a ball. This keeps the patient engaged and requires all of his attention. Accuracy and more delicate, highly coordinated movements, including hand movements, should wait until basic rhythm and movement patterns are established. Ataxia Cerebellar. The coordinating impulses that are often released by the cerebellum, a coordinating center, are lost when its function is compromised.
Therapeutic Approaches and Goals:
The muscles becoming hypotonic and postural fixation being disrupted, balance becomes difficult and movements become erratic, swaying, and incorrect. Any improvement brought about by exercise-induced therapy is most likely the consequence of greater usage of the remaining pathways, or it's feasible that the brain can partially make up for the loss of cerebellar function. Restoring trunk and proximal joint stability is the goal of treatment in order to create a stable foundation for mobility. The major focus of treatment is on isometric contractions, or holds, performed in all ranges, however strengthening techniques must be utilized initially when there is considerable muscle weakness.
Enhancing Neuromuscular Coordination:
Holdings are kept for as long as feasible, and their resistance to increased pressure on the band helps to develop new neuromuscular connections that are necessary for medicine. Movement ought to be restricted to functional activities and a small number of resistance movements performed in patterns that closely resemble functional movements. The sense of kinaesthetics is lost. The position of the joints, the tension in the muscles, and the body's location in space are all crucial components of the data that underpin neuromuscular coordination. Hypotonicity and uncoordinated movement are the results of lesions that cause the loss of this information in the muscles.
Enhancing Neuromuscular Coordination:
Re-education is based on substituting the sense of sight for the lost kinaesthetic sense. By preserving comparatively normal body movements, it may be possible to reactivate some nerve pathways that were previously redundant but intact and capable of transmitting kinaesthetic sensation impulses. Training smooth movement and precision is accomplished by exercises based on Frenkel's principles, with the ultimate goal being to assist the patient in performing daily activities.
FRENKEL'S EXERCISES
Dr. H. S. Frenkel's Pioneering Approach:
At the close of the 20th century, Dr. H. S. Frenkel served as the medical superintendent of the Sanatorium 'Freihof' in Switzerland. He conducted a thorough investigation into tabes dorsalis and developed a way of treating ataxia, a common symptom of the condition, with progressive and methodical exercise. His techniques have since been used to the treatment of incoordination resulting from a variety of different illnesses, such as disseminated sclerosis. His goal was to compensate for the loss of kinesthetic. Experience by using whatever remaining portion of the sensory mechanism most notably, sight, hearing, and touch to regain deliberate control over movement. Learning this alternate control strategy requires a similar process to learning any new exercise, with the prerequisites being
a. Concentration of the attention.
b. Precision.
c. Repetition.
Methodology for Effective Exercise Instruction:
The ultimate goal is to give the patient control over their mobility so they can perform the tasks necessary for daily independence.
Method
- Throughout the activity, the patient is positioned and appropriately attired to allow him to see the limbs.
- To help the patient visualize the exercise, a brief explanation and demonstration are provided prior to any movement being attempted.
- For the exercise to be executed smoothly and accurately, the patient must focus entirely on it.
- The physiotherapist controls the movement's pace by using appropriate music, hand gestures, or rhythmic counting.
- By designating the location where the foot or hand should be positioned, the range of motion is given.
- Until the exercise is flawless and simple, it must be performed numerous times. After then, it is thrown away and replaced with a more challenging one.
- Regular rest intervals must be permitted because these activities are first quite taxing. The patient may not be able to identify fatigue at all, although it is typically indicated by a rise in heart rate or a decline in movement quality.
Progression
Exercise progression is achieved by varying the exercise's speed, range, and difficulty. Compared to slow movements, fairly swift movements require less control. Subsequently, there are introductions of changing the rate at which successive movements occur and of pausing and restarting commands. Large joints are utilized in wide range and basic movements, which gradually give place to small joints, limited range, and increasingly frequent direction changes. Eventually, basic motions are combined into sequences to create particular actions, like walking, that call for the use and control of multiple joints and limbs.
Reeducation activities begin with lying with the head propped up and the limbs fully supported, depending on the degree of handicap. Afterwards, sitting and standing exercises are added."
Examples of Frenkel's Exercises
Exercise for the legs in lying.
a. Head lifted when lying; hip adduction and abduction. On a re-education board or the sleek surface of a plinth, the leg is completely supported the entire time.
b. Lying with the head up; flexion and extension of one hip and knee. The physiotherapist will recommend the position for the heel to slip on the plinth while it is supported the entire time.
c. Lying with the head up, with one leg lifted to place the heel within a predetermined range. The patient may mark their shin, the plinth, or their hip and knee flexion and extension, abduction and adduction, or they may rest their heel in the palm of their physiotherapist lying position (head lifted).
Seated Leg Exercises
The legs could have opposing or complementary functions. You can start and stop the movement during the workout to help with the control required to finish any of these.
Sitting provides leg exercise.
a. While seated, extend one leg and glide your heel to the spot marked on the floor.
b. While seated, alternately extend and elevate your legs to position your heel or toe on the designated mark.
c. walk while seated, then rise up and return to a sitting position.
To shift the center of gravity over the base, the feet are brought back and the trunk is tilted forward from the hips. The patient then spreads his legs and raises himself up using his hands to hold onto the wall bars or any other appropriate equipment.
Standing Leg exercises.
Transfer of weight from foot to foot in a H stride.
Walk sideways while standing and placing your foot on the floor's markings.
The patient needs to be able to view his feet, but some assistance could be required.
placing feet on markers when standing or walking.
The physiotherapist can adjust the stride length based on the patient's ability.
Get up and turn around.
Patients find this challenging, although floor markings can be helpful.
standing; moving to avoid obstructions by walking and changing directions.
As control increases, group work is quite beneficial because it helps the patient to focus on his own task without getting sidetracked by other people's. Walking gives him confidence and helps him become used to navigating about with other people, changing course and pausing when necessary to avoid running into others. His ability to walk on and off curbs and climb stairs aids in his freedom.
EXERCISES TO PROMOTE MOVEMENT AND RHYTHM
Every exercise is performed repeatedly to appropriate music or to a rhythmic count.
When seated, one should stretch and adduct their hips to cross one thigh over the motion is thereafter repeated in reverse. b. While partially reclined, one leg is abducted to bring the knee to the side of the plinth, and then one knee bends to place the foot on the ground. The motion is then performed in reverse. c. when seated, bend forward, place weight on your feet (as though standing), and then resume your doted position. Subsequently, you might move along the scat in a manner akin to climbing up to create space for another person to sit.
While standing, swing your arms back and forth while holding two sticks with a partner.
Walking or standing; throwing and catching a ball, or bouncing and catching it. Swimming, ballroom dancing, and marching to music ought to be promoted.
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