I. Overview
Coordination (Coordination) refers to the body’s ability to produce smooth, accurate, controlled movement. The quality of movement should include several aspects such as following a certain direction and rhythm, using the appropriate force and speed, and achieving an accurate goal. Coordination is closely related to balance. The main parts of the central nervous system involved in coordination and control are the cerebellum, basal ganglia, and posterior cord of the spinal cord. Coordination dysfunction, also known as ataxia, is divided into cerebellar ataxia, basal ganglia ataxia, and posterior spinal cord ataxia according to the different lesion sites in the central nervous system.
Second, the performance of coordination dysfunction
There are three areas of the central nervous system that control the production of coordinated movements: the cerebellum, the basal ganglia, and the posterior column of the spinal cord (posterior cord).
1. Coordination deficits caused by cerebellar insufficiency.
Lack of fine coordination and judgment of distances, which can affect gait, posture and movement patterns. Their gait is often characterized by wide separation of the feet, irregularity, instability and waddling.
(1) Poor distance discrimination: poor judgment of distance.
(2) Intentional tremor: tremor occurs during casual movements.
(3) Postural tremor: The body sways back and forth when standing.
(4) Rotational dyskinesia: also known as fast repetitive dyskinesia, difficulty in completing fast alternating movements.
(5) Motor fractional rhythm: the completed activity is not a smooth one movement, but a series of motor components.
2. Coordination deficits due to basal ganglia insufficiency.
Basal ganglia neuropathy, mainly abnormal movements and changes in muscle tone, whose one category mainly manifests as tremor, hypertonia, reduced random movements, slow movements, and dull facial expressions, such as Parkinson’s syndrome; the other category manifests as involuntary and purposeless movements of the upper limbs and head and face, which resemble a fragment of random movements, but with low muscle tone, such as chorea. Specific manifestations are.
(1) Resting tremor: the distinctive feature is that it decreases or disappears with purposeful movements.
(2) Motor inability: inability to initiate a movement.
(3) Tardive dyskinesia: slow, involuntary twisting movements of the extremities, trunk, and parts of the face other than the face.
(4) Eccentric chorea: sudden, spasmodic, forceful, purposeless whiplash-like movements on one side of the body.
(5) Dystonia: unpredictable change in muscle tone from high to low.
(3) Coordination disorders due to posterior spinal column (cord) insufficiency.
With posterior cord lesions, proprioceptive and discriminative tactile information cannot be transmitted to the cerebral cortex, and the patient cannot determine the position of the joints when the eyes are closed. This is manifested by.
(1) When the eyes are closed or the room is too dark, the weakened visual feedback increases the balance disturbance, which is seen when the patient stands with a swaying and tilting body, prone to fall.
(2) Gait: wide separation of the feet, swaying, unequal stride, high leg lift, landing with a sound, and walking looking at the feet.
(3) Poor distance discrimination: inability to accurately position the limbs or to reach a specific object; the patient cannot say the words written on his skin by the examiner without looking at them.
Ataxia is a disorder of the patient’s control of muscle contraction in space and time mainly manifested as poor disparity, that is, the amplitude of the action is either too large (excessive disparity) or too small (insufficient disparity), thus making the action decomposed, because the muscle groups in time do not work well together to form a smooth and fluent action, but become many isolated contraction stages, also related to muscle contraction and relaxation can not be timely, especially in doing It is also associated with the failure of muscle contraction and relaxation in a timely manner, especially when doing repetitive movements back and forth, and is clinically referred to as a rotational movement disorder. These disorders can also be reproduced in speech and writing. Patients with cerebellar ataxia have delayed and slurred speech, but suddenly burst out a few word sounds, called bursting sound nagging, and writing often has abnormal font and uneven strokes. The daily activities of patients with coordination disorder are often affected, such as dressing, fastening, fetching, eating, etc.
Assessment of coordination
The coordination (ataxia) test should be timed to determine the baseline level, and then the patient’s coordination function should be tested.
The grading of the function is.
① normal completion.
(ii) Mild residual impairment: able to complete the activity, but with a slight variation from normal speed and skill.
③ Moderate disability: able to complete the activity, but slow, clumsy and unstable movements are very obvious.
④severe disability: only able to initiate the activity and unable to complete it.
⑤ unable to move.
1. Assessment procedure.
Check the following in turn.
1. whether the movement is direct, precise and easy to do in return.
2. Whether the time to complete the movement is normal.
3. Whether the increase in speed affects the quality of movement.
4. the presence of body-independent movements when performing the activity.
5. Whether the quality of the activity is affected when not looking.
6. Whether there is more involvement of the proximal, distal or one side of the body in the activity.
7. Whether the patient feels fatigue quickly.
2. Assessment methods.
Coordination testing can be divided into gross motor activities involving large muscle groups (such as standing and walking) and fine motor activities using small muscle groups (such as manipulating objects with the hands).
Five areas of motor ability are evaluated with emphasis on.
① alternating and reciprocal movements: the ability to detect relative movements of two opposing muscle groups.
② Coordinated movement: including the control of movement obtained by the joint movement of muscle groups.
③ fine motor: assess the ability to detect and judge the distance and speed of random movements.
④ fixation and maintenance of a limb: the ability to detect the maintenance of a single limb or a part of a limb.
⑤ Maintenance of balance and posture: the ability to maintain balance and upright body posture was evaluated.
Before performing special tests, in order to determine the site of the defect in more detail, the patient’s functional activities, such as bed activities, activities of daily living, from doing standing to walking, should be observed first.
The following aspects should be observed.
(1) The level of each activity skill, including how much assistance is required or whether an assistive device is needed.
(2) Occurrence of instability, additional movements, etc.
(3) The number of involved limbs.
(4) Distribution of incoordination, e.g., distal or proximal muscles.
(5) Increase or decrease in the number of uncoordinated deficits and body positions.
(6) The time required to complete an activity.
(7) Level of safety.
The above information is obtained by helping to select the most appropriate experiment required. In addition, deficits in muscle strength, joint mobility, and sensation should be examined. Because these aspects may also affect motor coordination, however, incoordination may occur even when muscle strength, joint mobility, and sensation are normal.
When testing older patients, age differences should be allowed for, such as slower reflexes and poor balance and coordination in the elderly.
Specific tests are divided into two parts: non-balanced coordination test and balanced coordination test.
1, non-balanced coordination test.
It is the assessment of the components of rest and movement when the body is not in the upright position, and this type of test includes the examination of gross and fine movements. All tests should first be tested separately with the eyes open and with the eyes closed. Abnormal responses include gradual deviation from the position during the test and poor response to the test with eyes closed.
(1) Finger to nose: Have the patient abduct the shoulder at 90°, extend the elbow, and use the tip of the index finger to point to the tip of the nose. The starting position can be changed to assess the movement of different motor cuts.
(2) Finger of the subject and finger of the examiner: The patient and the examiner are opposite each other. The examiner’s index finger is held in front of the patient and the patient is asked to use his index finger to point at the examiner’s index finger. The examiner can also vary the position of his or her finger to assess the patient’s ability to respond to changes in direction, distance and speed.
(3) Finger retraction: Both shoulders are abducted at 90° and both elbows are extended. Have the patient touch the two index fingers together at the midline.
(4) Alternating nose and fingers: Have the patient alternate between the tip of the nose and the examiner’s fingertips with the index finger. The examiner may change the position to test the patient’s ability to respond to changes in distance and direction.
(5) Finger pairs: Have the patient use the tip of the thumb to touch the other fingertips of the hand in succession. The speed can be gradually increased.
(6) Group grasp: change between fully flexed to fully extended clenched and open fist, with gradual increase in speed.
(7) Rotation forward and backward: with the elbow flexed at 90° and tightly fixed to the body, the patient is allowed to turn the palm of the hand alternately downward and upward, which can be gradually increased in speed.
(8) Rebound test: The patient is in the flexed elbow position. The examiner gives enough freehand resistance to produce an isometric contraction of the biceps, and suddenly removes the resistance so that the opposite muscle group (triceps) will contract and block the movement of the limb when normal.
(9) Tapping with the hand: bend the elbow, rotate the forearm forward, and have the patient tap the knee with the hand.
(10) Tapping with the foot: Have the patient tap with the palm of one foot on the floor with the knee not raised and their heel maintained in contact with the floor.
(11) Finger and over-finger: The examiner and the patient sit opposite each other. They both flex their shoulders horizontally at 90°, accompanied by elbow extension and index fingers getting along. The patient is asked to fully flex the shoulder (fingers pointing to the ceiling) and then return to the horizontal position so that the index fingers are touching again. Abnormal reaction is “overfinger” or movement above the target.
(12) Alternating heel-to-knee and heel-to-toe: The patient is placed in the supine position, and the patient is asked to alternately touch the knee and thumb with the opposite side of the heel.
(13) Toe-to-toe finger: patient in supine position, let the patient touch the examiner’s finger with the thumb, the examiner can change the position of the finger to assess the patient’s ability to change direction and judge the distance.
(14) Supine position: The heel of one side slides up and down along the tibia of the opposite lower limb.
(15) Drawing a circle: The patient is asked to draw an imaginary circle in the air with the upper or lower limb. A more difficult test is to use an eight-shaped figure.
2. Balance coordination test.
Assesses body posture in the upright position, balance, and static and dynamic components.
(1) Standing in a normal, comfortable position.
(2) Standing with both feet together (narrow support surface).
(3) Standing with one foot in front of the other foot (i.e., the thumb of one foot touching the heel of the other foot).
(4) Standing on one foot.
(5) The position of the upper arm changes in various positions above (e.g., upper arm at the side of the body, raised above the head, placed at the waist, etc.).
(6) Suddenly breaking balance (in the case of protecting the patient).
(7) Standing position with the trunk shifting between forward flexion and reversion to a zero position.
(8) Standing position with lateral flexion of the trunk on both sides.
(9) Walking, placing the heel of one side directly in front of the toes of the opposite side.
(10) Walking along a straight line drawn on the floor or placing the foot on a mark on the floor while walking.
(11) Walking sideways and backward.
(12) Stepping in place.
(13) Varying the speed of walking activities (increasing speed will exaggerate coordination deficits).
(14) Abrupt stops and starts while walking.
(15) Walking in a circle and changing directions.
(16) Walking with the toes and heels.
(17) Normal standing position with observation of balance under open eyes and then closed eyes. Loss of balance under closed eyes indicates a lack of proprioception, which is often referred to as Romberg’s disease (positive).
Fourth, coordination training
1. Principles of coordination training.
In clinical rehabilitation, coordination training is applied to patients with ataxia or lack of motor control. It is generally used for patients with upper motor neuron disorders, such as cerebral palsy, traumatic brain injury and stroke, but its principles can also be applied to certain lower motor neuron and soft tissue lesions.
Most people know that training increases strength and endurance, but not much is known about the increased control and coordination, or the physiological effects. Control and coordination are inextricably linked, but not identical. The purpose of control and coordination exercises is to form sensory impressions and motor programs, both of which are stored in the brain, which in turn produce movement. When the central nervous system is damaged, sensory impressions and motor programs can be re-formed elsewhere outside the damaged area through the growth of lateral branches of undamaged neurons, or the replacement of other neurons or neural pathways. When the central nervous system is not damaged and lower motor neurons or soft tissue disorders cause motor deficits, exercises can be used to reactivate neural pathways that are inhibited with normal conditions.
The primary aspect of learning control and coordination is repetition. If a movement is repeated enough, this process will be learned and stored, and the effort required to complete this operation will become less and less as the practice is repeated over and over again.
One such experiment was done in which the dorsal root that innervates one side of a monkey’s forelimb was removed and the animal in general no longer used this loss of afferent access to the innervated limb. The normal lateral forelimb was then tied to prevent movement, and the animal learned to reach out of the cage for food with the afferently innervated forelimb when hungry. Shortly after the surgery, the limbs are extremely dependent on visual monitoring to perform any action, after 2 weeks to 3 months, the limb movement of the psychic talk restored, can carry out activities without the aid of vision.
2.Key points of coordination training.
(1) Specific exercise tasks must be completed.
In other words, if walking is the main goal, then the patient must practice walking no matter what method is used or what assistive device is used. There is no need to worry about whether the initial movements are correct or coordinated, and if the walking goal is difficult to accomplish, lower the standard to ensure that it can be accomplished (e.g., change from walking to standing, sitting, or balancing exercises) until the exercise is sufficiently mastered, then accomplish the higher level goal.
(2) Individual movement exercises.
Divide the task into multiple parts and practice individual movements before completing them in a coherent manner. For example, before walking, the patient practices the individual movements of walking, such as foot position, leg swing, foot touch, balance, and weight transfer. The walking exercises are performed until each movement is satisfactorily completed. The more complex the training task, the more detailed the division should be, and when each movement is satisfactorily practiced, the overall coherent movement is completed.
(3) Related movement exercises.
Before completing the specific tasks to improve control and coordination, perform some “less relevant” movement exercises. For example, before walking, the patient practices coordination of foot, ankle, and hip movements, antagonistic or facilitative patterns of multiple muscle groups, and then walks when satisfied; for example, improving hand control by inserting a nail into a small hole and then inserting a different type of nail from one place to another; and for example, practicing writing skills by sketching ovals and different shapes instead of directly practicing writing words.
However, the whole is not exactly the same as the sum of its parts, and the mastery of skills cannot depend entirely on the simple accumulation of parts.
3. Methods of coordination training.
Coordination training is to allow the patient to consciously train his or her ability to form pre-programmed programs in the nervous system so that automatic, coordinated movements of multiple muscles form a memory imprint, thus enabling the patient to reproduce at will the ability of coordinated, active forms of movement of multiple muscles, while operating more rapidly, more precisely, and more powerfully than those produced by the random control of a single muscle.
Coordination exercises have been widely used for deep sensory disorders, cerebellar, vestibular vagal and cerebral movement disorders, and a range of coordinated movement disorders due to involuntary movements. Coordination training is based on the use of the residual part of the sensory system and the use of vision, hearing and touch to manage random movements, the essence of which lies in the concentration and repetition of correct exercises. The main method is to train the coordination of limb, trunk, hand and foot activities in different positions and repeatedly reinforce the exercises.
Specific methods of coordination training.
1, single muscle training method.
When doing single muscle control training for patients in the clinic, certain principles and requirements should be followed.
(1) Because single muscle control training is a relearning process that requires a high degree of concentration and close cooperation, training should be conducted in a quiet environment, requiring patients to be emotionally stable, fully focused, and work closely together. When the patient feels fatigue or cannot concentrate on the training, it should be temporarily stopped.
(2) During training, the patient should maintain a relaxed, comfortable and safe position. If the patient has general weakness or balance disorder, he/she should be fully supported in reclined position.
(3) The patient should also have intact proprioceptors or distance receptors in order to monitor muscle activity throughout the training process, which focuses on proprioception. If there is impaired proprioception, each movement of the training should be felt by the patient so that it can be monitored using visual feedback.
(4) Patients should move within the joint range of motion without pain. If there is pain, training should not begin until the pain is reduced or at least the joint moves within 30° without pain.
(5) To help the patient achieve the goal as soon as possible, it may be possible to myoelectric line object feedback method to strengthen the action of the prime mover muscle or inhibit the action of other muscles that are not needed.
When the patient is conscious of the inability to start the prime mover or difficulty contracting a single muscle, simple or specialized facilitation methods should be applied, and this method should be stopped once the prime mover can actively contract before coordinating training.
(6) The load in training should be small and the patient should be asked not to overexert. Only with a small load can the activity be limited to a single muscle, and the use of minimal force to make the contraction of the prime movers should be accompanied by maximum assistance rather than resistance. Excessive force tends to cause excitation to spread to other neurons, which causes other muscles to contract, making the movement uncoordinated.
(7) Throughout the training process, alternative movements should be avoided. It is necessary to complete the single muscle control training before more complex coordinated movement training.
(8) Should be performed under the proper guidance and supervision of a trained therapist. Training instructions or commands should be precise and clear, and should also be easy for the patient to understand and implement. Adjust and correct incorrect training methods at any time.
(9) Specific clinical training methods: Different positions are adopted according to different treatment requirements. The more common basic position is the supine position with the head elevated so that the patient can see the entire training process. The patient is asked to focus on the trained area and muscles. The therapist gives the patient a passive movement and allows the patient to imagine the movement process and experience the sensation of muscle contraction. At the same time, the therapist combined with voice stimulation, shouting: “Harder, harder!” . When the trained muscles are able to make powerful movements and control the movement, the therapist should gradually decrease the assistance until the patient is able to perform the correct anti-gravity contraction. For those with hypertonia, slow passive extension of the whole joint should be performed first, and after reaching full extension there should be a short pause to reduce the hypertonia, or muscle relaxation training should be performed first.
2, the training of coordinated movements of multiple muscles.
Coordination training is a complex and integrated systematic training process, therefore, requires doing in accordance with certain training principles.
(1) should gradually transition from the initial prone training to sitting and standing training; after the previous training action is skilled, then the next action training.
(2) from simple, single action gradually and irregularly to the complex movement training with multiple muscle coordination; from a single side of the training to both sides of the complex movement training, and finally the most difficult simultaneous movement of both sides of the coordinated movement training.
(3) Start with a wide range of fast movements, and then move to a smaller range of slower movements as the training becomes more proficient and improves.
(4) Initially do the action with eyes open, to use visual feedback into the adjustment, and then alternate eyes open and closed after the action proficiency, and finally do the action with eyes closed.
(5) the complex movements should be broken down item by item, separate item by item training, and so can be accurate, skilled execution of a complex action of each decomposition of the action, before the decomposition of the action together training, until you can accurately complete the entire complex action. The training should be accurate for the movements done, and repeated training is required to obtain motor coordination ability.
(6) Specific clinical training methods: passive motor training, neurophysiological therapy, occupational therapy to improve coordination, balance training to improve balance function, EMG biofeedback therapy, Frenkel training method (training in supine, sitting, standing and walking positions, respectively), etc.
2. Exercises for coordination training
(1) Bilateral upper limb alternating exercise
1) alternate upper limb lifting activities: such as the right arm, the left arm alternate lifting, requiring high over the head, and as straight as possible, the speed can be gradually accelerated.
2) Bilateral alternate elbow flexion: both arms are held forward flat (shoulder flexion 90 degrees), forearms rotate back, left and right alternate elbow flexion and shoulder pat, elbow extension. The speed can be gradually accelerated.
3) Alternating touching shoulder lift: bend the elbow on the left side, with the tip of the hawk’s beak facing down, touch the shoulder on the same side with your hand, then lift it up, alternating between left and right.
4) Both arms are raised in front, and the left and right forearms are alternately rotated in front and behind. Perform quickly.
5) palm heart palm back clap: hands in front of the chest palm each other, and then the back of the two hands hit each other, alternately.
6)Two arms straight outward, forearm rotation back, alternately shoot the same side of the shoulder.
7)Taijiquan cloud hand.
8)With both hands in front of the chest, the five fingers of the left hand touch the corresponding fingers of the right hand one after another, alternating quickly.
9)Both hands simultaneously hit the table with five fingers alternately, making a rhythmic sound.
10) Tap the palm of the right hand with the left fist, then tap the palm of the left hand with the right fist.
11) Make a fist with both hands and alternately hit the table with the little finger, ring finger, middle finger, and fingernail, making a sound similar to that of a galloping horse.
(2) alternating movements of the lower limbs
1) alternately beat the ground with both feet, extend and flex the knees from left to right in the sitting position, and lift the legs and step in the sitting position.
2) high chair sitting position, both lower legs abducted, then inward, the left foot placed in front of the right foot in the inward position, then abducted inward, the right foot in front of the left foot in the inward position, alternately .
3) Sitting position with both legs straight, abducted, the left leg on the right leg in the internal position, alternately.
(3) Positioning and directional activities
1) Arm stability training using arm stability meter .
2) Upper limb coordination apparatus training.
3)Maze walking .
4) Wooden pegboard training .
5) Touching the therapist’s outstretched fingers (changing positions).
6) Catching a soft ball thrown to you.
7) Drawing circles on paper.
8)Whole body coordination exercise.
(4) Whole body coordination exercises
1) Swing arm stepping movement in place.
2) Lunge turn movement.
(3) Jumping and high-fiving: stand with both feet shoulder-width apart, hands flat, jump and land on the ground, hands up to the top of the head two palms, alternately.
4) Jump rope.
5) Power bicycle exercises, rowing, playing ball, obstacle walking, tai chi and other activities, can train patients to recover motor coordination.
(5) Water exercise
In the water should pay attention to do balance coordination training, let the patient stand in the pool of parallel wooden bar, the water depth to the patient can stand stable as appropriate, and then by the medical staff from different directions to the patient’s body to push the water for the wave, or the impact of the water, interference with the patient’s balance, require the patient through their own efforts, against the impact of the water and maintain balance. Then ask the patient to do coordination exercises, such as paddling action, double upper limbs to do breaststroke type water splitting or freestyle action, then the upper limbs to hold the edge of the pool for the lower limbs to strike the water action, and then do the upper and lower limbs coordination paddling exercises. Finally do walking exercises in the water, as long as the balance ability is strong, walking in the water is easier than on the ground. After entering the water, first in the parallel bar hands grab the bar to practice walking. Since the body weight is offset by buoyancy, this exercise is easy to complete even for paralyzed patients with weak muscles with the support of the hands. This is also applicable to patients recovering from muscle and joint lesions or fractures in the lower extremities.
(6) Frenkel training (Frenkel)
Frenkel (Frenkl H. S) designed a training treatment program for gait disorders caused by loss of proprioception. The main four postures are lying, sitting, standing and walking. The main point is to make the patient concentrate on the training and learn to replace the disappeared proprioception with vision in the following ways.
1）Supine position
(1) Flexion and extension of one lower limb: make it start from the flexed knee position and slide the heel on the treatment table until the lower extension is straight.
(2) abduction and adduction of the hip joint: bend the knee and place the heel on the treatment table without moving
③Adduction and adduction of the hip joint: extend the hip and knee joint and make the lower limb slide on the treatment table.
④Flexion and extension of the hip and knee joint: heel is lifted from the treatment table.
⑤ Place the heel on the contralateral knee and slide it along the tibia toward the foot.
(6) Simultaneous flexion and extension of both lower extremities: the heel is made to slide on the treatment table.
(7) Both lower extremities are alternately flexed and extended so that the heel slides on the treatment table.
(8) Flexion and extension of one lower limb, abduction and adduction of the other lower limb.
2）Sitting position
①Let the patient approach the PT’s hand with the foot: change the position of the hand each time.
②Lower limbs are lifted and then stepped on the pre-drawn footprints.
③Sit motionlessly for several minutes (stillness).
④Stand and sit alternately with both knees together.
3）Standing position
①Make the patient move his/her foot back and forth in a straight line.
②Walk along the curved line.
③Walk along a parallel line between 2 parallel lines.
④ Walk as accurately as possible on the pre-drawn footprints.
3. Precautions for coordination training
(1) Before training, ask the patient to learn to relax and reduce tension or fear. If there is muscle spasm, try to relieve it first.
(2) Close monitoring to prevent accidents, but not to fix the patient firmly, otherwise the patient can not respond.
(3) Make sure the patient feels safe to avoid inducing generalized spasms due to fear and tension.
(4) Patients with lower limb dysmotility should pay special attention to prevent falls.
(5) Do not exert excessive force during the operation to avoid causing the spread of excessive excitement, because excitement tends to aggravate the incoordination.
(6) Strictly control the amount of exercise, overexertion not only affects the continuation of training, but also makes the motor incoordination aggravated.
4 Coordination training clinical application range
Indications include: cerebral, cerebellar, vestibular vagus, deep sensory coordinated movement disorders and Parkinson’s disease and involuntary movements; upper motor neuron diseases and injuries (such as cerebrovascular accident, traumatic brain injury, myelitis, etc.) caused by hemiplegia, paraplegia or tetraplegia; lower motor neuron diseases and injuries (polyneuritis, poliomyelitis, etc.) caused by motor and coordinated movement disorders; motor system Patients with injuries or illnesses.
Contraindications include: acute or subacute phase of the disease; presence of acute inflammation, fever above 38°C, significantly increased white blood cell count, cardiac insufficiency or decompensation, such as severe arrhythmias, diastolic blood pressure above 16 Kpa or systolic blood pressure below 13.3 Kpa at more than 100 beats/min at rest, with conscious symptoms, approximately 2 weeks or less after the onset of myocardial damage Patients with poor general condition and loss of function, patients with obvious acute symptoms after trauma, patients with inadequate healing of fractures or those who have not removed stitches after surgery, patients with severe injuries, etc.
5. Factors affecting the effect of coordination training
The proper development of control and coordination requires the existence of specific organizational structures, i.e., complete neural pathways including motor, sensory control and storage centers, contact centers and end-effector organs.
The establishment of sensory impressions is the initial goal of control and coordination, so sensory feedback is particularly critical. Special emphasis should be placed on positional and tactile pressure sensation during training. If normal sensation is not available, then undamaged sensation must be utilized for compensation. When the patient is unable to perform active movement, passive movement can provide proprioceptive afferents. Verbal praise for correct motor practice will motivate the patient to do better; visual feedback is also beneficial. Visual and auditory cues can excite muscles, and electromyographic feedback can also be helpful. This aspect has been used in stroke patients with Achilles tendon grafting, foot drop, and shoulder subluxation, and has been reported in the treatment of patients with impaired hand function. If the patient lacks adequate strength, endurance and range of motion, these problems need to be corrected or additional assistance given along with exercise.
In addition, many factors such as mental age, concentration, attention, insight, and mobilization can affect the effectiveness of training. Therefore, it is necessary to mitigate the adverse effects of these factors by reducing distractions, increasing the fun of exercise, and reducing complexity; it is also important to avoid overwork and discomfort and to create a safe and relaxing environment. To form accurate sensory impressions, motor exercises must be clearly defined, substitution or overload exercises should be avoided, spontaneous exercises should be minimized, adequate support should be given and certain postures and equipment should be used, so that undesirable exercises can be reduced. Some scholars believe that endurance and effort are also important for the development of proprioceptive feedback. To mitigate the effects of these mental factors, the basic approach to practice is to specify the movement or task to be accomplished and to repeat the behavior continuously while correcting errors that occur until appropriate sensory impressions and motor patterns are developed.
In addition, other methods can be combined to promote movement. Reflexes, electrical stimulation, and sensory easing techniques (e.g., cold stimulation, vibration, and skin massage) are all beneficial. The use of reflexes and posture can also inhibit the appearance of unfavorable movements.
Frenkel first proposed a series of lower extremity coordination exercises for the treatment of motor ataxia, which consisted of repetition of slow, fine lower extremity movements using simple patterns in the opening phase, and increasing the difficulty as control was gained. Upper extremity coordination exercises usually include the use of various gripping styles, such as pinching or thumb-on-thumb pinching exercises. Using these different exercises, certain controlled activities can be accomplished such as; inserting pegs into board holes or being guided by an occupational therapist to complete functional or misuse recreational activities. Assistance is needed at the beginning and can be done gradually decreasing as progress is made.