TECHNIQUES OF MOTOR

RELEARNING
PROGRAMME

Presented by –
Rutuja Suryawanshi
Roll no. :- 34
Batch :- Summer 2020-21
Date of presentation :- 1/5/2021
 CONTENT

 Introduction
 Four steps in MRP
 Techniques –
Techniques to train seven essential sections
in daily life by motor relearning programme.
INTRODUCTION
Motor - Movement
Relearning - Learn again
Programme - Plane of things to do

MRP :
Focus on practice of missing components &
whole tasks & transference of learning.
Tasked oriented focused on relearning of daily
activities.
4 Steps in MRP
Step 1 - Analysis of function/task
Observation
Comparison
Analysis

Step 2 Practice of missing component

Explanation + Instructions
Practice (with verbal feedback + manual guidance)
Step 3 - Practice of activity/task
Explanation + Instructions
Practice (with verbal feedback + manual guidance)
Progression :
1) Increase complexity
2) Add varity
3) Decrease feedback + Guidance
4) Reevaluation
5) Encourage flexiblity

Step 4 - Transference of learning

Opportunity to practice
Consistancy of practice
Involvement of relatives and staff
Positive reinforcement
Stimulating environment
 TASK INDIVIDUAL
• General tasks and demands – • Body functions -
Posture control/balance Mental functions
Mobility functions Sensory/perceptual functions
Stability functions Motor functions
UL functions/self care Cardiorespiratory functions
LL functions/walking • Overall health status
• Level of participation • Presonal factors

MOVEMENT

ENVIRONMENT
• Physical features –
Regulatory
Nonregulatory

Movement emerges from interaction between the task, the individual & the
environment
Techniques
 Instruction

 Manual Guidance

 Feedback
Visual
Verbal
Motor, cognative
MRP is made up of 7 sections representing the essential functions of
everday life :-
1. Oro-facial function
2. Upper limb function –
Arm
Hand
3. Lower limb function -
Sitting up from supine
Sitting
Standing up & sitting down
Standing
Walking
 Oro-facial function

Compromises of various activities such as

swallowing, facial expression, ventilation & motor
aspects of speech production.

Essential components of swallowing –

1) Jaw closure
2) Lip closure
3) Elevation of post. 3rd of tongue to close off post. Oral
cavity
4) Elevation of lateral borders of tongue
Step 1 – Analysis of orofacial function
• Observation of alignment & movements of lips, jaw &
tongue.
• Intraoral digital examination of tongue & cheeks.
• Observation of eating & drinking, difficulty with
swallowing, lack of control over orofacial musculature.
Step 2 – Practice of missing component
The missing component might jaw closure, lip
closure, tongue movements, gag reflex , facial
movements, breathing control & control over emotional
outbrust.
 TO TRAIN SWALLOWING

1. Train jaw closure

2. Train lip closure

3. Train tongue movement

4. Train Facial muscles
Step 3 – Practice of task
• Intraoral techniques should be interrupted frequentlu & jaw
held closed in order to allow pt. to swallow.
• Presence of saliva & closure of jaw & lips will combine with
improved muscular activity of tongue to trigger off
swallowing.
Step 4 – Transference of learning into daily life
• The therapist assist the pt. with his 1st few meals, using the
techniques described previous to train swallowing.
• This should be done just before atleast one meal a day while
such interventions are necessary.
• The pt. should sit up at a table to eat & mealtimes should be
organised so that they are pleasurable & social occasions .
 UPPER LIMB FUNCTIONS
Pre-requisites for effective use of UL :-
•The ability to see what one is doing.
•The ability to make postural adjustment & which
occure with arm movt. & which free hands for
manipulation
•Sensory information.
Essential components :-
• Despite the complexity of UL function, it is possible to
identify essential movt. components.
• First to be activated by the pt., & then combined with
other muscle joint components.
Step 1 - Analysis of UL function
• Immediately following stroke, many pts. Have no easily observable motor
activity in the UL.
• EMG usage – monitor activity and give feedback – both pt. & therapist –
essential in early stages
• Analysis of muscle activity ;
Shoulder - Supine, sitting
Hand - Sitting at table
Step 2 & 3 – Practice of missing component & Ul
function/task
• Arm movts., including movt. of the hand must be trained.
• All muscles activity unnecessary to the movt. being attempted must be
eliminated consciously by the pt.
• Gross therapist – controlled patterens of the movt. Of the UL should be
avoided.
• Activity should be elicited at 1st in the position of grestest advantages to the
muscle.
• If muscle does not contract in particular set of conditions, vary the conditions.
To elicit muscle activity & train motor control
for reaching & pointing
 To maintain length of muscle
 To elicit muscle activity and train motor control for
manipulation
a) To train wrist extension
b) To train supination

c) To train palmar abd. & rot. of thumb (opposition)

d) To train opposition of radial &
ulnar sides of hand (cupping)

e) To train manipulation of objects

Step 4 – Transference training into daily life
• He must not suffer secondary tissue injury
• During the day the pt. should practice particular
components or movts. On which the therapist
considered he should concentrate.
• Persistent posturing of the limb is a particular
problem in early stages of stroke.
 LOWER LIMB FUNCTION
1. Sitting up from supine :
Essential components –
• Turning onto the side
• Rot. & flexion of neck
• Hip & knee flexion
• Flexion of shoulder & protraction of shoulder girdle
• Rot. Within the trunk
• Sitting up over side of bed
• Lat. Flexion of neck & trunk
• Legs lifted & lowered over side of bed.

Step 1 – Analysis of sitting from supine

pt. may have difficulty in
• Flexion of hip & knee on affected side.
• Flexion of shoulder & protraction of shoulder.
• In sitting up over the side of bed.
Step 2 – Practice of missing component
To train lat. Flexion neck therapist assists pt. to lift his head off the
pillow & pt. attempts to lower his head to the pillow, contracting his lat.
Flexors eccentrically. He then practice lifting head sideways unaided.

Step 3 – Practice of function

Pt. lifts his head laterally, while therapist, with one hand
under shoulder & other pushing downwards on his pelvis, helps
him to move up into the sitting position.
Step 4 – Transference of training into daily life
• However, it is considered less effort for a patient to be assisted out of
bed on to a commode than to use a bed pan. In addition, the sitting
position appears to aid in emptying the bladder and bowel.
• If the patient must remain in bed, the task of getting on to a bedpan is
made easier if the nurse flexes his affected hip and
• knee, holds his foot firmly on the bed and asks
• him to bend his intact hip and knee, push
• down through his heels and lift his buttock.
• Normally the movement we called it as BRIDGING.
2. Balanced sitting :
Essential components :-
• Preparatory postural adjustment
• Ongoing postural adjustments which are specific to the movement or
motor task being performed
Step 1 – Analysis of balanced sitting
• Observation of the patient’s alignment in quiet sitting.
• Analysis of his ability to adjust to self-initiated movement
of limbs. Trunk and head as he performs a graded variety
of motor tasks.
• Patient is asked, for example, to look at the ceiling, to turn
and look behind him, to look forward, sideways and
backwards to touch or grasp an object, to lift his intact foot
off the floor, to pick up an object from the floor.

Step 2- Practice of balanced sitting

Train postural adjustments to shifts COG in Sitting, hand
in lap, patient turns head and trunk to look over his shoulder,
returns to the mid position, repeat to the other side.
Step 4- Transference of training into daily life
• Throughout the days, whenever the patient is sitting, he
should sit on a chair from which it is possible from him to
stand up (with assistance if necessary).
• The patient should remember to shift his weight from one
buttock to the other from time to time. If his arm is flaccid,
it should be supported on a table. In this position, he will
be able to read and do other activities.
3. Standing up & sitting down :

Step 1 – Analysis of task

• The therapist observes the patient’s body alignment
throughout the task, or his attempts at the task.
• Weight is borne principally through the intact side.
• Inability to shift COG sufficiently forward, example: failure to
move shoulders forward over feet and move knees forward.
• Patient tires to shift weight forward by flexing trunk and head
instead of hip or by wriggling forward to the edge of the chair.
• Failure to place the affected foot ensures that the patient, who
already has this tendency, will stand up and sit down with all
weight taken through the intact foot
Step 2 – Practice of missing component
To train trunk inclination forward at hips (with
knee movement forward)
 Instruction :
Move your shoulders in front of your feet and
push down and back through your feet
Push down more through this (affected) foot
Look straight ahead
Step 3 – Practice of function
Standing up –
• Do not let the patient move to the edge of the
chair to compensate for lack of forward inclination
of the trunk when the chair is of the correct height
and there is room for the feet to move back
• Do not extend the knee passively backwards when
it should be shifting forward
• Make sure the patient dies as much as task as he
can
• Make sure the shoulders move far enough
forward.
4. Balanced standing :

Essential components of standing -

Feet a few inches apart
Hips in front of ankles
Shoulders over hips
Head balanced on level shoulders
Erect trunk
Step 1- Analysis of standing
Observation of the patient’s alignment in
quiet standing.
Analysis of his ability to adjust to self-
initiated movements of limbs, trunk and
head as he performs a graded variety of
motor tasks.
Step 2 & 3 – Practice of Standing
Due to unilateral spatial neglect or diminished kinesthetic sensation
• first attempt to stand are off balance.
• shifting most of their weight on to the intact side.
If the therapist resists this impulse and gives him a strategy for
overcoming the problem,

Step 4 – Trancference of training into daily life

• The patient should be helped to stand up and should begin training
in standing from his first therapy session if his medical condition is
satisfactory.
• He should be given written instruction of the major points so that
he can monitor his own performance.
• Lack of practice of standing with hip forward result in shortening of
the calf muscles, which will prevent him from standing with weight
through his affected leg and will also interferes significantly with
walking training.
4. Walking :

Step 1 – Analysis of walking

Stance phase of affected leg -
•Lack of extension at hip and dorsiflexion of ankle
•Lack of controlled knee flexion and extension from 0 to 15
degree.
•Excessive lateral horizontal shift of pelvis
•Excessive downwards pelvic tilt on the intact side associated
with excessive lateral pelvic shift to the affected side.

Swing phase of affected leg -

•Lack of knee flexion at toe off
•Lack of hip flexion
•Lack of knee extension plus ankle dorsiflexion on heel strike
Step 2 – Practice of missing component
• Standing with hip in correct alignment, patient
practice stepping forward then backward with
intact leg, making sure he extends his affected hip
as he steps forward.
Step 3 – Practice of walking
• Practice of walking themself which enables the patient to
put these components together in their proper sequence.
• The patients steps with his intact leg first. The therapist
steadies him at the upper arms, standing behind so as
not to impede his vision and get in his way. The patient
should know how to stop and realign himself when feels
off balance and cannot correct this as he walks.
Step 4 – Transference of training into daily
life
• The therapist allows some time for the patient to walk at
least part of the way to his next appointment with her
accompanying him.
• He can set himself a goal of how far he walks on the first
day and can extent distance and/or time taken on the next
day.
• The patient needs the opportunity to practice by himself or
with the other members of staff and relatives.
 REFERENCE
1. A motor relearning programme for stroke – by Janet H.
Carr & Roberta B. Shepered
2. Manual therapy approaches in neurophysiotherapy – by
Suvarna Ganvir & Shyam Ganvir
Thank you