FRENKEL'S EXERCISE

CO-ORDINATION:

• It is the ability to execute smooth, accurate, controlled motor responses (optimal interaction of muscle function).
• Coordination is the ability to select the right muscle at the right time with proper intensity to achieve proper action.
• Coordinated movement is characterized by appropriate speed, distance, direction, timing and muscular tension.
• It is the process that results in activation of motor units of multiple muscles with simultaneous inhibition of all other muscles in order to carry out a desired activity

Importance of the cerebellum in co-ordination :

 

 

The cerebellum is the primary center in the brain for co-ordination of movement.

Components of coordinated movement:

• Volition: is the ability to initiate,maintain or stop an activity or motion.
• Perception:in tact proprioception and subcortical centres to integrate motor impulses and the sensory feedback. When proprioception is affected it is compensated with visual feedback.
• Engramformation:is the neurologica lmuscular activity developed in the extrapyramidal system. Research proved that high repetitions of precise performance must be performed in order to develop an engram

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Types of co-ordination:

1) Fine motor skills:

Require coordinated movement of small muscles (hands, face).
Examples: include writing, drawing, buttoning a shirt, blowing bubbles

2) Gross motor skills:

Require coordinated movement of large muscles or groups of muscles (trunk, extremities).
Examples: include walking, running, lifting activities.

3)Hand-eye skills:

The ability of the visual system to coordinate visual information. Received and then control or direct the hands in the accomplishment of a task .
Examples : include catching a ball,sewing,computer mouse use.

Causes of coordination impairments , Causes of Ataxia

• Degeneration, damage or loss of nerve cells in the cerebellum, which is that part of the brain that controls muscle coordination, causes ataxia. 
• The cerebellum comprises of two small ball-shaped folded tissues present at the base of the brain near the brainstem.
•  Diseases which damage the spinal cord and peripheral nerves which connect the cerebellum to the muscles can also cause ataxia

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Other causes of ataxia include:

• Stroke is a condition where the blood supply to a part of the brain gets severely diminished or interrupted, which deprives the brain tissue of oxygen and other nutrients resulting in death of brain cells.
• Trauma or injury to the head, which causes damage to the brain or spinal cord, can cause sudden-onset ataxia (acute cerebellar ataxia).
• Chickenpox can result in a complication in the form of Ataxia; although this is not common. Ataxia can appear during the healing stages of the infection and persist for days to weeks and gradually resolve over the time.
• Transient ischemic attack (TIA) is caused by a temporary reduction in blood supply to a part of the brain. Majority of the TIAs last only for a few minutes. Some of the symptoms of TIA include ataxia, which is temporary.
• Multiple sclerosis is a chronic, potentially debilitating medical condition, which affects the central nervous system.
• Cerebral palsy consists of a group of disorders, which occurs as a result of damage to a child’s brain during its early development. It can be before, during or shortly after birth. It affects the ability to coordinate movements of the body.
• Paraneoplastic syndromes are rare, degenerative disorders, which are triggered by the response of the immune system to a tumor or neoplasm. This tumor is commonly in the lungs, ovaries, lymph nodes or breast. Patient can experience ataxia many months or years before cancer is actually diagnosed.
• Toxic reaction to some medications can also cause ataxia. Medicines, especially barbiturates and certain sedatives, like benzodiazepine, can cause ataxia as a side effect. Other things, which could cause toxic reactions, are heavy metal poisoning, alcohol and drug intoxication and solvent poisoning.
• Any type of growth on the brain, either cancerous or noncancerous, can damage cerebellum and cause ataxia.
• Deficiency of vitamin E or B-12 can also lead to ataxia.
• No specific cause can be found for some adults who develop sporadic ataxia, also known as sporadic degenerative ataxia, which can be of many types, such as multiple system atrophy which is a progressive and degenerative disorder.

Examples of co-ordination tests:

1) In the upper limb:

A) Finger-to-nose test

The shoulder is abducted to 90o with the elbow extended, the patient is asked to bring tip of the index finger to the tip of nose.Finger to therapist finger: the patient and the therapist site opposite to each other, the therapist index finger is held in front of the patient, the patient is asked to touch the tip of the index finger to the therapist index finger.

B) Finger-to-finger test

Both shoulders are abducted to bring both the elbow extended, the patient is asked to bring both the hand toward the midline and approximate the index finger from opposing hand

C) Finger-to-doctor’s finger test

the patient alternately touch the tip of the nose and the tip of the therapist’s finger with the index finger.

D) Adiadokokinesia or dysdiadokokinesia:

The patient asked to do rapidly alternating movement e.g. forearm supination and pronation, hand tapping.

E) Rebound phenomena:

The patient with his elbow fixed, flex it against resistance. When the resistance is suddenly released the patient’s forearm flies upward and may hit his face or shoulder.

F) Buttoning and unbuttoning test.

In any of the previous tests, we may find:

Intention tremors and Decomposition of movements
Dysmetria: in the form of hypermetria or hypometria

2) In the lower limb : 

Heel to chin test

A) Heel-to-knee test

B) Walking along a straight line. Foot close to foot:In case of cerebellar lesion, there is deviation of gait

C) Rom-berg test: Ask the patient to stand with heels together. Swaying or loss of balance occurs while his eyes are open or closed.

General principles of co-ordination exercises involve:

• Constant repetition of a few motor activities
• Use of sensory cues (tactile, visual,proprioceptive) to enhance motor performance
• Increase of speed of the activity over time
• Activities are broken down into components that are simple enough to be performed correctly.
• Assistance is provided when ever necessary.
• The patient there fore should have a short rest after two or three repetitions,to avoid fatigue.
• High repetition of precise performance must be performed for the engram to form.
• When ever a new movement is trained, various inputs are given, like instruction(auditory), sensory stimulation(touch) ,or positions in which the patient can view the movement (visual stimulation) to enhance motor performance.

PhysioTherapy exercises used to improve co-ordination:

• Frenkel’s exercises
• Proprioceptive Neuromuscular Facilitation
• Neurophysiological Basis of Developmental techniques
• Sensory Integrative Therapy

Frenkel's Exercises (A Regime for Sensory Ataxia):

Patients who suffer total or partial sensory ataxia will lose both cutaneous and proprioceptive sensation and therefore tend to exaggerate movements in an attempt to complete them. Their disability is easily tested. because patients with sensory loss perform a simple movement less smoothly and well with the eyes closed than with the eyes open. Their movements are also arrhythmical and lack smoothness and precision. The loss of proprioceptive impulses is compensated for by the use of vision and hearing. The movements must be performed accurately and with great precision and constant repetition of each movement is necessary until this is achieved. The patient must concentrate hard and watch the movement throughout while counting at a slow even tempo. No progression should be made until the first movement can be performed accurately. Adequate rest periods may be necessary during a treatment session as the patient may  tire and lose the concentration necessary to achieve precision.

 

The rules are:

(1) Every movement he performs must be watched by the patient and a high degree of concentration is required.

(2) He must count out loud at first, then to himself at a slow even tempo, and try to perform the same range of movement for each count with great precision.

(3) The counting tempo must be the patient's own and not one imposed by the therapist.

(4) Large single movements are retrained first, followed by alternate movements of contralateral limbs, then more complex movements.

(5) Every movement made in the treatment session is counted at the same tempo and watched closely.

(6) During performance the patient should be guarded against falls.

(7) The worst limb should be exercised most.

(8) Progression should not be made until smooth accurate performance of the first exercise is achieved and this rule is followed for all progressions.

(9) Give the patient adequate periods of rest.

The regime starts when the order in which movements are to be trained has been decided. The patient is suitably positioned for both maximum support to allow the part to be moved easily, and so that he can see the part moving through the selected range. The range of movement performed need not be the fullest possible range of the part, but should be that which can be easily managed and is functionally useful, e.g. in hip and knee flexion and extension, full extension is useful, flexion to 90°C is all that is functionally necessary for sitting down in a chair. A polished board or reasonably slippery surface is used. The two extremes of the selected range are decided

on and their positions on the supporting surface are marked with chalk. The distance between these two points is then marked out according to the agreed count. If the count is to include 'start, 1, 2, 3, 4' at which point the end of the range is reached then five marks are needed, but only four marks are required if the movement starts on the count of '1'.

The movement is first performed with the part supported. It is performed without pause during the movement, first in one direction, then in reverse and without wobbling. Next the patient can either lift the limb and touch each mark in turn or carry the limb through the air just off the support, passing each mark in turn.

Examples of Movements

 For the Lower Limb

• Side lying – knee flexion and extension.
• Side lying – hip flexion and extension.
• Half lying – hip abduction and adduction.
• Half lying – knee and hip flexion and extension.

The marks for counting; A, to a count of 4; B, to a 'start' command and count of 4.

 

For the Upper Limb

Sitting at a high table, arms held in abduction on the support:

• Shoulder flexion and extension.
• Elbow flexion and extension.
• Elbow flexion with supination.
• Elbow extension with pronation.
• Wrist flexion and extension.

 

All the above exercises can then be practised:

(1) With a voluntary halt

(2) With a halt on command

(3) With the part unsupported

(4) With the part unsupported and with a voluntary halt

(5) With the part unsupported and a halt on command

(6) Placing the heel or fingers on specific points

(7) As 6 with a voluntary halt, e.g. heel on opposite toes, ankle, shin and knee; fingers on opposite fingers, wrist, elbow and shoulder

(8) As 7 but halting on command

(9) As above but the therapist points to the part to be touched

(10) As above but the therapist moves her fingers as the patient reaches the part.

 

Next, a less supported position can be used and the above stages used for each position and exercise such as:

• Sitting – knee extension and flexion.

• Sitting – hip abduction and adduction.

• Sitting – moving the foot over a numbered board or pushing a beanbag on the board.

• Sitting – lifting objects about on a table.

• Sitting – personal toilet training.

 

Walking Training Follows

The patient stands using stride standing or oblique walk standing while holding on a firm hand support (wallbars or fixed parallel bars). Weight transference is practised first, remembering that counting must be maintained.

Sideways walking is practised first making the base narrower and wider in turn but never closing the base into close standing. A Frenkel mat can be used when the patient is first required to put the foot into a space and eventually on to the lines.

Forward progression is made to ordinary walking with a wide base using first a 'step to' gait, i.e. right foot forwards, left foot up to it. Then later the left foot can be carried through and forwards. The two outer sets of footprints on the Frenkel mat are used first followed by using one of the outer and the middle footprints.

Turning round may be performed by either step turning or pivot and step turning.

 

Step Turning

The direction of the turn is decided, e.g. to the right. The right foot is lifted and turned through 90° and placed in the right-hand footprint. The left foot is lifted, turned and placed in the left-hand footprint . The above manoeuvres are continued until the patient has turned through 180° or 360°.

 

The numbered board for co-ordinated lower limb movements in sitting.

 

A Frenkel mat.

 

A, Step turning; B, Pivot turning. A is easier than B. When using B the patient will not necessarily be in line with his stepping line on the Frenkel mat.

 

 

Pivot Turning.

A decision is again made about direction but this method may be used when the turn must be made in the direction of the worst leg. The patient pivots to the right on the heel of the right leg. The left foot is then lifted, turned and placed a short distance away alongside the first foot. The manoeuvre is repeated (Fig. 17.4B). Pivot turning may also be used as a progression on step turning as the base may be narrower.

 

Vertigo

Vertigo occasionally requires a regime of exercises when it follows concussion as a post-concussion syndrome or when it is associated with space-occupying lesions or vascular accidents of the brain. This regime may also be used for conditions such as Ménière's disease which does not respond to drug therapy.

The regime of exercises is based on the principle of gradually inducing an attack of vertigo and then, when the patient recovers, carrying on with the regime. In this way the threshold of onset of an attack is pushed back and the patient learns both to accommodate to and to cope with an attack.

The regime starts with the patient performing eye movements while fully supported and continues through lessening support until the body movements can be made fast enough to evade moving obstacles.

 

The positions used are:

• Lying with minimal pillows for comfort

• Half lying

• Sitting in a corner of a room (i.e. using two walls for moral support)

• Sitting free in a space

• Kneel sitting

• Standing – stride or walk and eventually walking.

The objective is achieved by the therapist using a small coloured ball which she moves about in front of the fully supported patient asking him to follow the movements with his eyes. Next the range of the movement is increased so that head movements must be performed to keep the ball in sight.

In half lying a return is made to eye movements only and then to head movements again.

In sitting the same procedure is followed. The ball can be bounced by the therapist, then by the patient, starting with a single bounce and catch, continuing with repetitive bouncing with either hand and in different areas round the patient. Throwing between patient and therapist follows, with the therapist aiming the ball to make the patient move both or either arm to catch. In other words obtaining spontaneous displacement from the sitting and supported position and recovery to that position. Kneel sitting is a position of security in which total body displacement can take place as the patient is required to retrieve objects placed further and further away.

Similar procedures can be practised in free sitting plus getting up from the stool and walking round it, first without, then with ball bouncing or throwing it in the air and catching.

An obstacle course is then set up and the patient is required to thread his way in and out of the course, to walk in tight circles round some of the obstacles at first carefully escorted by the therapist and then to cover the course with other people simultaneously using it from other directions. Such a course may be set up first indoors and then outdoors, or alternatively the patient should be taken on a walk in the grounds of the hospital and through the adjacent streets.

This regime can be taught to a group of patients once they are all able to sit on a chair or stool.

 

Posture

Posture is an alternative name for position but in an exercise context is usually taken to be a dynamic position in which the body components relate to one another so that the centre of gravity is over the base and the muscle work to maintain the position is reduced to a minimum.

Good posture is also pleasing to the eye and is dynamically adapted to the size of the base and the circumstances in which the body is resting or working. Good posture should not throw undue stress on muscle or joints and should be automatically resumed after displacement has occurred.

Poor posture is frequently produced by bad habits, e.g. the slouching posture adopted by the adolescent following the fashion of walking and standing with their hands in the front pockets of jeans. The use of unsuitable equipment may induce poor posture, e.g. a too low working surface will cause a kyphotic posture of the back at its weakest point; and associated round shoulders and poking chin will follow.

Holding the head to one side in a 'listening' posture due to slight deafness may become a bad habit and lead to the adoption of resultant deviations of the relationships of pelvis to shoulder girdle or of the vertebrae to one another.

Standing with most of the weight on one leg will lead to lateral deviations of the vertebrae and pelvis–shoulder girdle relationship. When the cause is shortness of the lower limb of more than 2.5 cm, correction will occur if raised footwear is worn, but if any of the above postural habits are allowed to persist they will become permanent disfigurements and adaptive shortening of the soft tissues will ensue.

 

Early detection of poor posture and retraining to good position can be most rewarding and may need the following procedures:

(1) The patient's interest must be gained and he must want to improve his posture.

(2) Local relaxation may need to be taught, preferably in lying.

(3) The patient is then 'straightened' by teaching the correct alignment of each body component to the other starting with the pelvis–shoulder girdle relationship. At this point the patient may complain that 'It, or he, feels odd'. The new proprioceptive pathways are being stimulated and he will now have to learn that 'feeling odd' may be correct. During this part of the proceedings he should be encouraged to maintain maximum body length by feeling as though he was stretching like a piece of elastic between his feet and his head.

(4) It is now important to displace body components while maintaining the corrected position, e.g. perform an arm or leg exercise and maintain the new posture.

(5) Next he must be totally displaced into a vigorous activity or maybe a game and then he must lie down and regain his new posture. This procedure can be repeated several times perhaps during the course of a class but at the first treatment the patient must also experience his corrected posture in sitting and standing and by constant reminder in all dynamic positions assumed during the course of that day's treatment session.

The treatment must include, for each patient, the adoption of their normal work or daily activity position so that the therapist can teach correction of what may be a poor posture adopted for the greater part of the day.