NEUROMUSCULAR

CO-ODINATION
SALMAN KHAN
MSAPT (DUHS), BSPT (JPMC), DDPT
(JPMC)
LECTURER/PHYSIOTHERAPIST

DPT, SEMESTER 2
Sindh Institute of Physical Medicine and
Rehabilitation
DATED 09/10/2024

LECTURE 2.
INDICATIVE READING OF
LECTURE :
o The Principles of Exercise Therapy, 4th edition by M.
Dena Gardiner
o Chapter 17
o Page: 236
LEARNING OBJECTIVES
o Co-ordinated movement
o Group action of muscles
o Nervous control
o Inco-ordination
o Re-Education
o Frenkel’s exercises
CO-0RDINATED MOVEMENT
Which is smooth, accurate and purposeful, is brought about by the integrated action
of many muscles, superimposed upon a basis of efficient postural activity.
The muscles concerned are grouped together as prime movers, antagonists, synergists
and fixators, according to the particular function they are called upon to perform.
GROUP ACTION OF MUSCLES
The contraction of the prime movers results in the movement of a joint
While the reciprocal relaxation of the opposing group, the antagonists, controls action
Other muscles may work as synergists, either to alter the direction of the pull of the
prime movers, or, where the latter pass across more than one joint, to stabilize the
joint in which movement is not required.
Efficiency is still further ensured by muscular fixation of the bone from which the
prime movers take origin. These fixator muscles may be in the immediate vicinity of
the movement, but when strong resistance is offered, muscles all over the body are
frequently involved.
NERVOUS CONTROL

The Motor Pathways

The action of each muscle group is determined by the afferent impulses which reach it
by the motor pathways.
The Cerebral Cortex
Voluntary movement is usually, if not invariably, initiated in response to some sensory
stimulus. It is now thought that an initiation Centre exists in the brain stem which alerts
the cerebral cortex, which then is responsible for planning the pattern of movement.
This plan is based on memories of patterns used on previous occasions.
NERVOUS CONTROL
The Cerebellum
The cerebellum is a receiving station of information which reaches it by the afferent pathways
conveying impulses of kinaesthetic sensation from the periphery and from other parts of the
brain including the cerebral cortex and the vestibular nucleus. In the light of this information
the delicate adjustments, which ensure harmonious inter-action of the various groups of muscles
concerned in the pattern of movement, are made and conveyed to the anterior horn cells by
either the extra-pyramidal tracts or other descending pathways of the spinal cord.
Kinaesthetic Sensation
The afferent impulses of kinaesthetic sensation arise from proprioceptors situated in muscles,
tendons and joints and they record contraction or stretching of muscle and the knowledge of
movement and position of the limbs. Some of these impulses reach the level of consciousness
but many end in the spinal cord and cerebellum.
INCO-ORDINATION
Interference with the function of any one of the factors which contribute to the
production of a coordinated movement will result in jerky, arrhythmic or inaccurate
movement, which is said to be Inco-ordinated, as the harmonious working together of
the muscles is disturbed.
Four main types usually benefit from suitable exercise therapy.
Causation
1. Inco-ordination associated with weakness or flaccidity of a particular muscle group.
lesion of the lower motor neurons
2. Inco-ordination associated with spasticity of the muscles. Lesions affecting
the motor area of the cerebral cortex
INCO-ORDINATION
3. Inco-ordination resulting from cerebellar lesions
This is generally known as cerebellar ataxia', the prefix 'a' meaning 'without and the
Greek word 'taxis' meaning 'order'. There is marked hypotonicity of the muscles,
which tire easily, and inadequate fixator action, not only of the muscles directly
concerned with the group action, but of the body generally. Movement is irregular
and swaying, with a marked intention tremor.
4. Inco-ordination resulting from loss of kinaesthetic sensation
Sensory ataxia', or in the case of tabes dorsalis, 'tabetic ataxia', describes this type.
Without using his eyes to gain the information, the patient with this condition is
completely unaware of the position of the body in space, or of the position of the
joints. The muscles are hypotonic and tire easily, but they are unaware of this as the
sensation of fatigue is not recorded.
RE-EDUCATION
Co-ordinated movement is natural to the body, which tends to remain still if only Inco-
ordinated movement is possible. It is therefore of major importance to interest and
encourage patients suffering from Inco-ordination to persevere in making the effort to
overcome it. This requires infinite patience and persistence on the part of the
physiotherapist, especially if and when the condition is associated with mental
deterioration.
The Use of Alternative Nervous Pathways
It is rare that all the available nervous pathways, by which the impulses essential for
coordinated movement travel, are blocked, and the purpose of re-education is to
encourage the use of those which remain, or to develop alternative routes.
RE-EDUCATION
The Condition of the Muscles
As a preliminary to re-educating the movement, the condition of the muscles requires
attention as they are the effector organs concerned. They must be prepared to
receive the coordinating impulses so that their reaction to them is as normal as
possible, by an attempt to relax those which are spastic, and to strengthen those
which are weak.
It is probable also that in all long-standing cases in which Inco- ordination is a feature,
some degree of disuse atrophy is present owing to the disinclination to move.
PRINCIPLES OF RE-EDUCATION
Weakness or Flaccidity of a Particular Muscle Group
Treatment is designed to correct imbalances by emphasis on the activity of weak or
ineffective muscles and to restore the normal integrated action of muscles in the
performance of patterns of functional movement.
The latter is achieved most successfully by slow reversals techniques with normal
timing.
PRINCIPLES OF RE-EDUCATION
Spasticity of Muscles
The spasticity of the muscles modifies their reaction to the stimuli they receive as they
cannot, or can only with difficulty, relax and so allow movement to occur. There is
marked reluctance to attempt movement, while in those which are achieved, the
essential rhythm which is characteristic of efficient movement is lost. Treatment is
designed to promote relaxation.
Active exercises based on everyday movements help to make the patient as
independent as possible and give him confidence.
Training in accuracy and the finer and highly coordinated movements, such as those of
the hand, is deferred until basic movements and rhythm are established.
PRINCIPLES OF RE-EDUCATION
Cerebellar Ataxia
Loss of the function of the cerebellum, which is a coordinating Centre, results in loss of
the coordinating impulses which are normally discharged from it. The muscles become
hypotonic and postural fixation is disturbed, consequently balance is difficult and movements
are irregular, swaying and inaccurate.
Improvement probably due to an increased use of the pathways which remain, or
possible that the cerebrum may be able to compensate to some extent for the loss of
cerebellar function.
PT is to restore stability of the trunk and proximal joints to provide a stable
background for movement. When muscular weakness is severe, strengthening methods must
be used first but the main emphasis in treatment is isometric contraction.
Increased by resistance to increase the demand on the Neuromuscular Mechanism and help to
develop new nervous pathways for the impulses required.
PRINCIPLES OF RE-EDUCATION

Loss of the Kinaesthetic Sense

Information as to the whereabouts of the body in space, the position of the joints and
the tension in muscles, forms an essential part of the data upon which neuromuscular
coordination is based.
Lesions causing loss of this information result in hypo-tonicity of the muscles and
Inco-ordinated movement.
Substitution of the sense of sight to compensate for the loss of the kinaesthetic sense
forms the basis of re-education.
FRENKEL'S EXERCISES

Dr. H. S. Frenkel was Medical Superintendent of the Sanatorium 'Freihof' in Switzerland

towards the end of the last century. He made a special study of tabes dorsalis and devised a
method of treating the ataxia.
Then used to treat the Inco-ordination which results from many other diseases, e.g.
disseminated sclerosis.
The aim is to established voluntary control of movement by the use of any part of the sensory
mechanism which remained intact, notably sight, sound and touch, to compensate for the loss
of kinaesthetic sensation.
The process is similar to learn any new exercise.
Exercises based on Frenkel’s principles are used to train smooth movement and precision,
ultimate goal is to helping pts in normal ADL.
FRENKEL'S EXERCISES
The essentials are:-
1. Concentration of attention.
2. Precision.
3. Repetition.
The ultimate aim is to establish control of movement so that the patient is able and
confident in his ability to carry out those activities which are essential for
independence in everyday life.
TECHNIQUE

v1. The patient is positioned that he can see the limbs throughout the exercise.

v2. A good demonstration of exercise is given so, the pts have a clear mental picture of it.

v3. The pts must give his full attention to the performance of the exercise to make the
movement smooth and accurate.

v4. The speed of movement is dictated by the PT by means of rhythmic counting, movement of
her hand, or the use of suitable music.
 TECHNIQUE

v5. The ROM is indicated by marking the spot on which the foot or hand is to be placed.

v6. The exercise must be repeated many times until it is perfect and easy. It is then discarded
and a more difficult one is substituted.

v7. As these exercises are very tiring at first, frequent rest periods must be allowed. The pts
have little or no fatigue, but it is usually indicated by a deterioration in the quality of the
movement, or by a rise in the pulse rate.
PROGRESSION
Progression is made by altering the speed, range and complexity of the exercise.
Quick movements require less control than slow ones.
Later, alteration in the speed of movements, stopping and starting command are
introduced.
The use of large joints gradually give way to small joints.
Limited range and a more frequent alteration of direction.
Finally simple movements are built up into sequences to form specific actions which
require the use and control of a number of joints and more than one limb, e.g. walking.
EXAMPLES OF FRANKEL'S EXERCISES
Exercise for the legs in lying
EXERCISE FOR THE LEGS IN SITTING
EXERCISE FOR THE LEGS IN STANDING