March, 1965 P H Y S I O T H E R A P Y Page 3 M U S C L E R E - E D U C A T I O N Some New Approaches and Facts By A. C. P E T R IC K (Dipl. Physiotherapy (Pta.), R .N .) (W ith kind perm ission o f D r. (med.) W. Z inn, Bad Ragaz, Switzerland) 2. 3. 4. 5. Muscle re-education is one o f the m ost im po rtant facets o f the physiotherapist’s work, irrespective o f whether it is a case o f weak, paralysed, injured or diseased muscle. D u ring her training the physiotherapist is taught all the essentials, but there are a few facts that are either ju st skipped o r never specifically m entioned. Some o f these will be considered in this paper. M ain Causes o f M uscle Atrophy are: 1. N eurological conditions: central an d /o r peripheral. O perations: e.g., the Facial Nerve may be injured in mastoidectom y. T ra u m a : to muscles, joints, bones and nerves. P ost-natal injuries and conditions. Ill-use o r disuse: (i) when a limb is im mobilized for a long period, w ithout sufficient sustaining exercise; (ii) the small intrinsics o f the feet atro p h y severely due to disuse causing dropped arches. The above conditions all necessitates muscle re-education by A CTIV E T R A IN IN G ! T he value o f passive movements, especially in the earlier stages, to keep the jo in ts and tissues m obile an d to m aintain the circulation, should certainly not be forgotten in the enthusiasm for active training. Muscle re-education by active training is mainly based on neurophysiological, physiological, anatom ical an d clinical considerations and facts. T he m ost im po rtant o f these are: 1. T he M o to r N erve Structure. 2. T he physiology o f a muscle contraction. 3. The M uscle G roups. 4. The Muscle arrangem ent in the body. 5. The M o to r Unit. 6. The Muscle U nit. 1. The M otor Nerve Structure: A true M otor N erve never consists o f only m otor nerve fibres, but rath e r: (i) 40 per cent sensory fibres (to the muscle spindle) (ii) 20 per cent m o to r fibres (of the alp ha type) (iii) 35 per cent m o to r fibres (of the gam m a type) (iv) few sym pathetic fibres. 2. The Physiology o f a M uscle Contraction: A muscle contraction is always the com bination o f a voluntary movement and a reflex reaction. Use this know ledge in muscle re-education, i.e., give a short sudden over stretch ju st before the exercise (reflex) an d give a clear com m and (voluntary). 3. The Muscle Groups: It is know n that hard w ork to one group o f muscles (e.g., the fingerflexors) causes the proxim al an d /o r distal muscles (e.g. the elbow and shoulder flexors) also to come into play to strengthen the action. 4. The Muscle Arrangement in the Body: The general arrangem ent o f most muscles an d even various other tissues in the body, lies in an oblique line. This type o f arrangem ent is noted in the tru n k an d the limbs. Therefore the most n atural and vigorous actions tak e place obliquely or with a small initial ro tation , e.g. when chopping wood. 5. The M otor U nit: This consists o f the m o to r nerve from the brain to the muscle fibres via the spinal cord. Each muscle fibre o f a particular muscle, e.g. gastrocnem ius, is synchronously innervated by the nerve. This ensures th a t either the con traction has a m axim um value o r else there is no co n tra c tion at all (depending on w hether the innervation is intact o r not). A n other interesting but logical fact, is th a t the innervation depends entirely on the num ber o f muscle fibres com prising a muscle, e.g. the eye-muscle has ab o u t 100 fibres and gastrocnem ius, ab o u t 2,000 fibres to be innervated, all by the same nerve, o r ra th e r a x o n ! __F ' . b f C A o f ’ (* 5 pct'res:*' o f loMCr . f.b'CS of Cir^aV .vA«-i~Si'C» o n 1o i And T ensor I o>.f> ^shsroe-clt i' TMC ftt. 3 ) \ Q , i r c t i c y o F P \ * l l o f Thg rrsftxog Tfcur** rAvvsct£'6. 6. The Muscle U nit: A muscle unit consits o f : (i) Muscle fibres. (ii) Golgi corpuscles in the muscle fibres. These are sensible to the ST R E T C H and I R R I T A T IO N R E F L E X in the fibres, provided th at the stretch is short an d quick. I f the stretch is slow, these corpuscles become inert (Similar bodies “ G o rhl Corpuscles” in the ten d o n ’s fibres react to the prolonged stretch.) (iii) T he muscle spindle with m o to r and sensory nerve endings which gives the sensation o f tension and pressure in an d to the muscle. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y March, 1965 Physiological Facts to Consider: 1. The Stretch Reflex: This is initiated by a tesnion/pressure sensation on the muscle spindle an d golgi corpuscles. Any stimulus o f pressure or overstretch on a muscle, provided it is o f short d u ratio n—causes a reflex tightening of that muscle, aimed al relieving the pressure. The stretch reflex is perhaps best illustrated in the case of flaccid paralysis (provided that other tests have proved that the innervation is intact). It oftens happens that quite a few stretches are necessary in the beginning to obtain any response, while in a spastic paralysis one obtains a far quicker response very similar to a norm al contraction. 2. Alpha and Gamma Fibre: T he M oto r N erve consists o f alpha and gam m a fibres. I f the gam m a fibres are injured—even if there is no direct central lesion— the result is spasticity! 3. C entral and Pyram idal Cell Lesions: These also cause spasticity. 4. The M otor Nerve I t has to be intact for any contraction to occur a t all! T he reflex contraction to the stretch stimulus will take place only if the nerve pathw ay from the anterior horn cell to the muscle exists. ( T o enable one to obtain a clear picture o f a specific case it is advisable to perform certain tests an d to perform these again a t regular intervals, their object is: (i) to obtain a better judgm ent o f what can an d w hat canno t be done, the stretch o f the muscles an d the extent o f atroph y; (ii) to have a continuous control throughout the treatm ent, to determ ine w hether there is any im provem ent o r not an d thus to establish if a given treatm ent is beneficial o r whether some other m ethod should be tried; (iii) to save time, because attention m ay be concentrated on muscles th a t are regener ating (or m ay possibly regenerate) so as to bring them to full strength; while completely denervated muscles can be neg lected, except, o f course fo r continuing with passive m ove m ents to keep the tissues and jo in ts m obile an d to m aintain the circulation. These well-known tests, include: (a) The functional muscle test (0-5); (b) Testing for any contractures; (e.g. testing for flexion co ntracture o f the hips.) T he p atient is p u t into a lying position with the hips extended. Flex one leg fully passively out. The test, should the other leg also tend to flex, it indicates a a co n tracture o f that hip’s flexors (and knee exten sors, should the knee also flex). (c) Pow er o f the muscles: F o r exam ple by using sandbags o r special weights the patient can hold for three seconds having the muscle in a contracted position, the lim b being in the position o f the longest lever possible (e.g. the straight arm abducted to 90 deg.) the weight held on the outstretch ed hand); (d) Jo in t M obility: th a t is the range o f m ovem ent the jo in t is capable o f attaining. (e) Circumference o f the Limb and/or Jo in t: M easure over the same level each time, e.g., for the knee-joint an d th ig h ; over the patella 2 } in. above an d 6 in. above the base o f the patella. T he com pared measurem ents o f right an d left will indicate atrophy, an d subsequently the am o u n t of hyp ertro phy o b tained. ( / ) Length o f the L im bs: T his is o f special im portance in the lower limb whether after fractures in a limb or after paralyses, especially in the case o f children. (N ote: It has recently been foun d in E urop e th at the adm inistration o f shortwave D iatherm y an d hot moist packs daily (the latter 3-4 times daily) is o f imm ense value to increase the growing pow er in the paralysed limbs o f children. Since this m ethod o f treatm ent was adopted (ab ou t 5 years ago) no severe shortening o f limbs has again been noted in treated cases. T he period is as yet too short to say whether the m ethod is entirely reliable an d whether the result is continuous, i.e., th a t shortening will n o t occur later as the children becom e older. However, the m ethod is harm less an d there is no reason why it should n o t be applied to obtain m ore evidence.) (g) G eneral Functional Ability o f the Limb: C an the patient walk, ascend an d descend stairs, wash his face, eat, dress, etc., by him self? W hat does he need? D oes he use trick-m ovem ents? (This, however, does not m a tter at all.) C onsider the gait carefully and m easure the length o f the steps. Find out the am ount o f activity the patient has during the day. E ncourage him to do as m uch as possible for himself. (h) Electro diagnosis: D eterm ine the rheobase, i.e., the smallest milliamper- age with the longest im pulse still allowing a co n traction. (/) Electrom yography: This test is usually done by a doctor. U nfortunately it is n o t as yet been used m uch in South A frica. It has the sam e principle as an electrocardiography. D u ring co ntraction each muscle gives rise to an electrical impulse (dem onstrated by a wave in a i graphic representation). A needle is inserted into the belly o f the m uscle to be tested and a graphic recording is m ade o f these electrical impulses. D iagram m atic Representation o f such a G raph: Time N o rm al: a t rest: G rap h represented by a straight line. active: Definite contractions with rest periods. Denervated: a t rest: Fibrillating. active: F ibrillating, no definite co ntraction an d relaxation indicated. R egeneration: a t rest: Fibrillatio n less, thou gh still noticeable. active: F ibrillatio n less harsh. Few definite contractions an d rest, periods a re distinguished. This test is influenced by: T em perature o f the surroundings; Obesity; Fatigue. N o te: One can never really fully isolate a muscle con tractio n as it is always com bined w ith th a t o f other muscles! R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) March, 1965 P H Y S I O T H E R A P Y Page 5 hgd- ~TKe. qro^oK *6 lo w e r ]r g r ^ p h in'H'c^U^ . / q h s r d P » C>r i t r ^ o ^ - S v-*p a r i 4V\ e o e ^ y CThfe). P a r h ^ \ , T W r ucx tW . "The f t r s b p c ir- t (£ 0re*̂ 5̂ \ iS low t^r ar-d Oo,o*'€_ -fb -fUe. T tU S<_cLo^d 15 ('■/tc ~t(^oA of- a *">or cjv~a p k . f'O c rx if 'r« cf~ ibios" a r t - s / o ^ ( fl "*8) 'H've 6 i * d d < r t / ^ s h \r /~ 'ho b z.c p fY ie s h o s - h a ^ d . shcxryo ( G - C ) jE > _ H C g r v - ^ - T i C { f & P R ^ S e r i 7 ~ 4 - r < O r t O F ~ T ~ f + £ C f t A P H ~TO f l E~ S E E r j ir< J ? J f F £ f r f / V r CASg-S UJ ITH T?*r S L £ < ^ T A p -» Olfl C,/iO&~TlC T ^ST ... ■̂ /V— 4 — 4*— A 1— 4*1— 4 ^ Noft.v JAnuR̂ KtqLrttWiijrt' 0t ê-sT: JC-Tii't : Ge.fi PU Re-pc.£T5erjT _SD «f • ^ h-« Fi&a,un nr*c T*V<; . r-clcv* O K'0,-v ST̂ flfOHr . Af̂ h/y<--:-sJs ĥ-taĈ YeO Q.S.Jn o c l e F - ' '* ^ , x j , - f.V.-IUh-*. I '" 0 M/F. b„1l»hs- I'm K»'^- f-' " Jefl'v"'feâ iJ resĤ ê '** a"£ dfsh^'&cJ M uscle Action depends on: 1. Stim ulus in the b rain : (i) the will o f the patient; (ii) vocal com m and; (iii) th e perfect u nd erstanding of a required exercise. 2. L earn t m ovem ent of the p a tte rn : T he aim should be to m ake this virtually autom atic. 3. Full proprioceptive an d sensory inform ation to the brain an d central nervous system. 4.’ T h e intactness o f the m oto r pathways to the an terior ho rn cells. 5. T h e continued existence o f prim ary reflexes (even in spastics) which prom otes special basic models o f movement. Active T raining: This can be defined as the ad aptatio n of a muscle to exercise an d rest. Effects: 1. H ypertrophy: N o t only do the individual fibres hypertrophy, b u t it has also been proved recently th a t there is actually form ation o f m ore fibres. Only exercises against stro ng resistance lead to hypertro phy. Often it is even better to give isometric (static) exercises alth ough the patient finds them m ore difficult than the m ore primitive type o f exercises (isotonic, i.e. concentric muscle work) with actual movement. 2. Adaptation o f the enzyme activity in the muscle fibres: 3. Formation o f a reflex a rc : I f the exercise is repeated often enough, a reflex arc may be form ed even if the muscle is com pletely denervated. 4. Improvement in the Blood Supply: Active training increases th e bloo d supply up to ten times m ore th a n any other m ethod (ice, heat, etc.). T his is especi ally seen in the case where isometric exercises are done. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y March, 1965 5. B etter O xygenation: D u e to the im proved circulation better oxygenation is possible, which again increases the endurance. Improvement Points to W atch During T reatm ent: 1. Always aim at m aking the exercises F U N for the patient! L et him realise their objective; praise him when he does well so as to stim ulate his perseverance. D o give him tim e to rest an d recuperate in between— for sh ort periods o f course. Y o u r treatm ent should n o t becom e a ch atting session! 2. A void giving him P A IN . I t will only break dow n w hat has been achieved already, will cause muscle spasm an d lessen th e co -op eration from th e patient. I f the treatm ent causes no pain, the p atient does not dread his treatm en t. U se ice o r heat, or any other m ethod you an d any m em ber o f the m edical team can think o f (e.g., pain-relieving tablets, procaine in filtrations, etc.). L ook for the actual cause o f the pain. T H E R E IS A LW A Y S A W AY! (Slogan o f M argaret K n o tt an d D e n a G ardiner.) 3. R egulate th e speed o f the exercise an d w atch the p a tien t’s co -ordination during his treatm ent. Physiotherapy: 1. D o all the tests available. 2. Electrotherapy. U se it as an aid only! T ry to get along with as little electrotherapy as possible. E lectrical stim uli do not (contrary to general belief) prevent atroph y, or m aintain jo in t an d tissue m obility, neither does it increase the circulation m uch. It often is unpleasant an d even painful. T he m ain use is to give the patient an idea o f w hat he is expected to do du ring active training. U se it with discretion, though. 3. Exercises: (i) Give passive exercises to keep the jo in ts and tissues m obile an d to increase the circulation. (ii) Always start an exercise with a slight to definite stretch o f the particular muscle to be trained never train a muscle in its shortened position, because th e muscle spindle is n o t stim ulated at all). (iii) P .N .F .: Use all the principles: stretch, vocal co m m and, m axim al resistance, m anual touch, tractio n an d com pression. R em em ber p a r ticularly the muscles with double function, e.g., the biceps. 4. Use all the Reflexes: (i) B alance reflex (especially in athetosis); (ii) S tretch reflex (especially in paralysis); (iii) F lexion reflex (especially in an kylosing spon dylitis.) N o te: T he quick stretch is N O T used on spastics. U se a slower stretch, avoid sudden touch an d pain. U se spastic relaxing positions (e.g., stride sitting) a n d oth e r spasm reducing m ethods (e.g., ice). 5. T rick M ovements: T rain the synergists— train trick— o r rath e r com- pensatory-m ovem ents w hen a muscle is com pletely denervated to allow a certain function to be done, e.g., to ab d u ct an d elevate the shoulder. 6. D o n o t forget to atte n d to the p a tien t’s posture gait, possibility to ascend an d descend stairs, an d his functional activities daily (e.g., dressing, getting into an d o u t o f a bath, etc.). This is n o t only the occupational therapists w ork! 7. Join the patients in invalid sports groups. I t is stim ulating an d encouraging to them ; arouse a com petitive atm osphere. Play various games (e.g. badm inton) even if modified position s, like sitting on th e floor o r in a w heelchair are used. A rchery is very m uch enjoyed by everybody. T he groups may be very mixed, e.g., paralytic cases of all types an d various limbs o r fracture, muscle an d oth e r injuries, an d various bone an d m uscle disease cases m ay be grouped together with no harm , as long as each p atient benefits from the group, each one aiding the other. 8. M echanical Aids: Sticks, splints, calipers, crutches. See th a t they fit correctly. P referably teach the use o f E LBOW C R U T C H E S with which they are much more independent. Even P .O .P . cases benefit m ore from elbow crutch use. See th a t these aids are correctly used. 9. O perations: I f operations are necessary, carry on with the usual pre- an d post-operative treatm ent. Resum e active training as soon as possible. 10. W ater T herapy: It is a fantastic aid to active training , when strongly resisted active w ork is given in the pool. R esults: The results to be obtained will depend o n : 1 (i) the muscle pow er a t the com m encem ent o f the treatm en t; (ii) Oedem a (w ehther it occurs o r not); (iii) at w hat stage exercises are started. (iv) d u ratio n o f the treatm ent an d exercises each day; (v) technique an d quality o f the treatm ent. T hese are the general principles o f active training in muscle re-education. T he physiotherapist, with her knowledge of physiology an d exercise m ust en deavour to get from the patient his fullest co-operation. H is recovery will be the greatest rew ard one can get. JUST OFF THE P R E S S ! K RUSEN— “ CO N CEPTS IN REHABILITATION OF TH E H A N D IC A P P E D ” 69 PAGES—R0.85 Order your Copy NOW from IH e d ia d V U T n b u te tL (Pty.) Ltd. “ C A PE Y O R K ,” 252 J E P P E ST R EE T , P .O . Box 3378 JO H A N N E S B U R G Tel. 23-8106 and 20 BARRACK S T R E E T , C A PE T O W N P .O . Box 195 Tel. 41-1172 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )