Frankele's Co-ordination Exercise in Cerebeller Ataxia :

FRENKLE 'S  CO-ORDINATION    EXERCISE   FOR  CEREBELLER  ATAXIA :

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 coordination ;

The cerebellum is the primary center in the brain for coordination 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
.
Types of c-oordination:

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
.
 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 progressive and degenerative disorder.

Examples of coordination tests:

1) In the upper limb:

Finger To Nose Test in Upper Limb

A) Finger-to-nose test

The shoulder is abducted to 90o with the elbow extended, the patient is asked to bring the tip of the index finger to the tip of the nose. Finger to therapist's 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 the opposing hand

C) Finger-to-doctor's finger test

the patient alternately touches the tip of the nose and the tip of the therapist's finger with the index finger.

D) Adiadokokinesia or dysdiadokokinesia:

The patient was asked to do rapidly alternating movements 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 Sheen Test in Lower Limb

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 coordination 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.

Therapeutic exercises used to improve coordination:

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

FRENKEL’S EXERCISES:   

Frenkel aimed at establishing 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 of learning this alternative method of control is similar to that required to learn any new exercise,

the essentials being: Concentration of the attention, Precision and Repetition

The ultimate aim is to establish control of movement so that the patient is able and confident in his ability to carry out these activities which are essential for independence in everyday life.


They are a system of slow repetitious exercises. They increase in difficulty over the time of the program. The patient watches his hand or arm movements (for example) and corrects them as needed.

Although the technique is simple, needs virtually no exercise equipment, and can be done on one's own, concentration and some degree of perseverance is required. Research has shown that 20,000 to 30,000 repetitions may be required to produce results. A simple calculation will show that this can be achieved by doing 60 repetitions every hour for six weeks in a 16-hour daily waking period. The repetitions will take just a few minutes every hour.

The brain as a whole learns to compensate for motor deficits in the cerebellum (or the spinal cord where applicable). If the ataxia affects say, head movements, the patient can use a mirror or combination of mirrors to watch their own head movements.

History

Best Physiotherapy Exercises for In-Coordination--Frenkel’s Exercises :

Co-Ordination Exercise

Frenkel Exercises are a series of motions of increasing difficulty performed by ataxic patients to facilitate the restoration of coordination. Frenkel's exercises are used to bring back the rhythmic, smooth and coordinated movements.


Dr. H S Frenkel was a physician from Switzerland who aimed at establishing 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.

Frenkel Exercises were originally developed in 1889 to treat patients of tabes dorsalis and problems of sensory ataxia owing to loss of proprioception. These exercises have been applied in the treatment of individuals with ataxia, in particular cerebellar ataxia. The exercises are performed in supine, sitting, standing and walking. Each activity is performed slowly with the patient using vision to carefully guide correct movement. These exercises require a high degree of mental concentration and effort. For those patients with the prerequisite abilities, they may be helpful in regaining control of movement through cognitive compensation strategies. Patients with partial sensation can progress to practicing exercises with eyes closed. The main principles of Frenkel exercises are the following:

    Concentration or attention
    Precision
    Repetition

This program consists of a planned series of exercises designed to help patient compensate for the inability to tell where the arms and legs are- in space without looking.

    1. Exercises are designed primarily for coordination; they are not intended for strengthening.
    2. Commands should be given in an event, slow voice; the exercises should be done to count.
    3. It is important that the area is well lit and that patients are positioned so that they can watch the movement of their legs.
    4. Avoid fatigue. Perform each exercise not more than four times. Rest between each exercise.
    5. Exercises should be done within a normal range of motion to avoid over-stretching of muscles.
    6. These simple exercises should be adequately performed before progressing to more difficult patterns.

General Instructions for frenkel exercises

    Exercises can be performed with the part supported or unsupported, unilaterally or bilaterally.
    They should be practiced as smooth, timed movements, performed at a slow, even tempo by counting out loud.
    Consistency of performance is stressed and a specified target can be used to determine range.
    Four basic positions are used: lying, sitting, standing and walking.
    The exercises progress from postures of greatest stability (lying, sitting) to postures of greatest challenge (standing, walking).
    As voluntary control improves, the exercises progress to stopping and starting on command, increasing the range and performing the same exercises with eyes closed.
    Concentration and repetition are the keys to success.

Frenkel exercises for lower limb

Exercises for the legs in lying

    Flex and extend one leg by the heel sliding down a straight line on the table.
    Abduct and adduct hip smoothly with knee bent and heel on the table.
    Abduct and adduct leg with knee and hip extended by sliding the whole leg on the table.
    Flex and extend hip and knee with heel off the table.
    Flex and extend both the legs together with the heel sliding on the table.
    Flex one leg while extending the other.
    Flex and extend one leg while taking the other leg into abduction and adduction.
    Heel of one limb to opposite leg (toes, ankle, shin, patella).
    Heel of one limb to opposite knee, sliding down crest of tibia to ankle.

Whether the patient slides the heels or lifts it off the bed he has to touch it to the marks indicated by the patient on the plinth. The patient may also be told to place the heel of one leg on various points of the opposite leg under the guidance of the therapist.
Exercises for the legs in Sitting

    One leg is stretched to slide the heel to a position indicated by a mark on the floor.
    The alternate leg is lifted to place the heel on the marked point.
    From stride sitting posture patient is asked to stand and then sit.
    Rise and sit with knees together.
    Sitting hip abduction and adduction.

Exercises for the legs in Standing

    In stride standing weight is transferred from one foot to other.
    Place foot forward and backward on a straight line.
    Walk along a winding strip.
    Walk between two parallel lines
    Walk sideways by placing feet on the marked point.
    Walk and turn around
    Walk and change direction to avoid obstacles.


Frenkel exercises for upper limb :

Similar exercises can be devised for the upper limb wherein the patient may be directed to place the hand on the various points marked on the table or wall board to improve coordination of all the movements in the upper limb.
Some examples of Frankel exercises of upper limb in sitting position

    Have patient sit in front of a table and place a number of objects on the table. The patient then touches each object with the right hand and then the left hand.
    The patient flexes the right shoulder to 90 degree with elbow and wrist extended. The patient then takes his or her right index finger and touches the tip of his or her nose. This exercise is then repeated with the left hand. The exercise is performed alternating right and left index finger.
    The patient taps bilateral hands on bilateral thighs while alternating palmer and dorsal surfaces as fast as possible.

Certain diversional activities such as building with toy bricks or drawing on a black board, buttoning, combing, writing, typing are some of the activities that also improves the coordination.

Knee Joint : Detail And Basic Overview

Knee Joint: It’s Important : 

Knee Joint Detail

 The knee joint is one of the strongest and most important joints in the human body. It allows the lower leg to move relative to the thigh while supporting the body’s weight. Movements at the knee joint are essential to many everyday activities, including walking, running, sitting and standing.
The knee, also known as the tibiofemoral joint, is a synovial hinge joint formed between three bones: the femur, tibia, and patella. Two rounded, convex processes (known as condyles) on the distal end of the femur meet two rounded, concave condyles at the proximal end of the tibia.
The patella lies in front of the femur on the anterior surface of the knee with its smooth joint-forming processes on its posterior surface facing the femur.
The joint-forming surfaces of each bone are covered in a thin layer of hyaline cartilage that gives them an extremely smooth surface and protects the underlying bone from damage. Between the femur and tibia is a figure-eight-shaped layer of tough, rubbery fibrocartilage known as the meniscus. The meniscus acts as a shock absorber inside the knee to prevent the collision of the leg bones during strenuous activities such as running and jumping.

As with all synovial joints, a joint capsule surrounds the bones of the knee to provide strength and lubrication. The outer layer of the capsule is made of fibrous connective tissue continuous with the ligaments of the knee to hold the joint in place. Oily synovial fluid is produced by the synovial membrane that lines the joint capsule and fills the hollow space between the bones, lubricating the knee to reduce friction and wear.
Tendons connect the knee bones to the leg muscles that move the knee joint. Ligaments join the knee bones and provide stability to the knee:


The anterior cruciate ligament prevents the femur from sliding backward on the tibia (or the tibia sliding forward on the femur).
The posterior cruciate ligament prevents the femur from sliding forward on the tibia (or the tibia from sliding backward on the femur).
The medial and lateral collateral ligaments prevent the femur from sliding side to side.
Two C-shaped pieces of cartilage called the medial and lateral menisci act as shock absorbers between the femur and tibia.
Numerous bursae, or fluid-filled sacs, help the knee move smoothly

Anatomy of Knee Joint:-

Bones:-

The femur (thigh bone), tibia (shin bone), and patella (kneecap) make up the bones of the knee. The knee joint keeps these bones in place.

The patella is a small, triangle shaped bone that sits at the front of the knee, within the quadriceps muscle. It is lined with the thickest layer of cartilage in the body because it endures a great deal of force.

 

knee joint anatomy

Cartilage:-

There are two types of cartilage in the knee:

Meniscus: these are crescent-shaped discs that act as a cushion, or “shock absorber” so that the bones of the knee can move through their range of motion without rubbing directly against each other. The menisci also contain nerves that help improve balance and stability and ensure the correct weight distribution between the femur and tibia.

The knee has two menisci:

medial – on the inner side of the knee, this is largest of the two
lateral – on the outer side of the knee
Articular cartilage: found on the femur, the top of the tibia, and the back of the patella; it is a thin, shiny layer of cartilage. It acts as a shock absorber and helps bones move smoothly over one another.

Ligaments:-

Knee Joint SideView

Ligaments are tough and fibrous tissues; they act like strong ropes to connect bones to other bones, preventing too much motion and promoting stability. The knee has four:

ACL (anterior cruciate ligament) – prevents the femur from sliding backward on the tibia, and the tibia from sliding forward on the femur.
PCL (posterior cruciate ligament) – prevents the femur from sliding forward on the tibia, or the tibia from sliding backward on the femur.
MCL (medial collateral ligament) – prevents side to side movement of the femur.
LCL (lateral collateral ligament) – prevents side to side movement of the femur.

Tendons:-

These tough bands of soft tissue provide stability to the joint. They are similar to ligaments, but instead of linking bone to bone, they connect bone to muscle. The largest tendon in the knee is the patellar tendon, which covers the kneecap, runs up the thigh, and attaches to the quadriceps.

Muscles:-

Although they are not technically part of the knee joint, the hamstrings and quadriceps are the muscles that strengthen the leg and help flex the knee.

The quadriceps are four muscles that straighten the knee. The hamstrings are three muscles at the back of the thigh that bend the knee.

The gluteal muscles – gluteus medius and minimus – also known as the glutes are in the buttocks; these are also important in positioning the knee.

Joint capsule:-

The joint capsule is a membrane bag that surrounds the knee joint. It is filled with a liquid called synovial fluid, which lubricates and nourishes the joint.

Bursa:-

There are approximately 14 of these small fluid-filled sacs within the knee joint. They reduce friction between the tissues of the knee and prevent inflammation.

* Knee Conditions:-

(1)Chondromalacia patella (also called patellofemoral syndrome): Irritation of the cartilage on the underside of the kneecap (patella), causing knee pain. This is a common cause of knee pain in young people.
(2)Knee osteoarthritis: Osteoarthritis is the most common form of arthritis, and often affects the knees. Caused by aging and wear and tear of cartilage, osteoarthritis symptoms may include knee pain, stiffness, and swelling.
(3)Knee effusion: Fluid buildup inside the knee, usually from inflammation. Any form of arthritis or injury may cause a knee effusion.
(4)Meniscal tear: Damage to a meniscus, the cartilage that cushions the knee, often occurs with twisting the knee. Large tears may cause the knee to lock.
(5)ACL (anterior cruciate ligament) strain or tear: The ACL is responsible for a large part of the knee’s stability. An ACL tear often leads to the knee “giving out,” and may require surgical repair.
(6)PCL (posterior cruciate ligament) strain or tear: PCL tears can cause pain, swelling, and knee instability. These injuries are less common than ACL tears, and physical therapy (rather than surgery) is usually the best option.
(7)MCL (medial collateral ligament) strain or tear: This injury may cause pain and possible instability to the inner side of the knee.
(8)Patellar subluxation: The kneecap slides abnormally or dislocates along the thigh bone during activity. Knee pain around the kneecap results.
(9)Patellar tendonitis: Inflammation of the tendon connecting the kneecap (patella) to the shin bone. This occurs mostly in athletes from repeated jumping.
(10)Knee bursitis: Pain, swelling, and warmth in any of the bursae of the knee. Bursitis often occurs from overuse or injury.
(11)Baker’s cyst: Collection of fluid in the back of the knee. Baker’s cysts usually develop from a persistent effusion as in conditions such as arthritis.
(12)Rheumatoid arthritis: An autoimmune condition that can cause arthritis in any joint, including the knees. If untreated, rheumatoid arthritis can cause permanent joint damage.
(13)Gout: A form of arthritis caused by a buildup of uric acid crystals in a joint. The knees may be affected, causing episodes of severe pain and swelling.
(14)Pseudogout: A form of arthritis similar to gout, caused by calcium pyrophosphate crystals depositing in the knee or other joints.
(15)Septic arthritis: An infection caused by bacteria, a virus, or fungus inside the knee can cause inflammation, pain, swelling, and difficulty moving the knee. Although uncommon, septic arthritis is a serious condition that usually gets worse quickly without treatment.

Prevention of knee injuries:-

Quadriceps Active Exercise

Stepping Exercise For Quadriceps Strenthening Exercise

Prone Knee Bending For Hamstring Active Exercise

The following tips may help prevent common knee injuries:

Warm-up by walking and stretching gently before and after playing sports.
Keep the leg muscles strong by using stairs, riding a stationary bicycle, or working out with weights.
Avoid sudden changes in the intensity of exercise.
Replace worn-out shoes. Choose ones that fit properly and provide good traction.
Maintain a healthy weight to avoid added pressure on the knees.
Always wear a seatbelt.
Use knee guards in sports where knees could get injured.
Maintaining strong, flexible leg muscles and seeking prompt medical attention for all knee injuries is essential to assure accurate diagnosis and appropriate treatment of the injury. Additionally, keeping the supporting leg muscles strong and practicing injury prevention will help keep the knee healthy across the lifespan.

Strengthening exercise for the knee:-


(1)Mini or partial squats with a chair or at a counter (quadriceps):

Holding on to a chair or stable surface, with knees about shoulder-width apart and pointing forward, slightly bend hips and knees as if sitting down onto a chair, and then slowly stand back up. Repeat 10 to 12 times.

(2)Standing hamstring curls (hamstrings):

Holding on to the back of a chair or stationary surface, without moving hip, bend knee as far as possible, bringing your heel up towards your buttocks. Do 10 to 12 reps on each leg.

(3)Marching in place (hip flexors and a good balance exercise):

On your own or while holding on to the back of a chair or stationary object, take alternating steps in place, bringing your knee up to a comfortable height. Strive for 60 seconds of marching.

(4)Heel raises (calf muscle):

Holding on to the back of a chair or stable surface, rise up on toes, lift heels off ground, and then slowly lower back down. Do 10 to 12 reps.

(5)Quad sets:

This simple exercise may be done on the floor with or without a pillow under your knee. Sit with your legs out in front of you and your knees completely straight (lean against a wall or back on your hands). Focus on contracting your quadriceps muscle and holding it as tight as possible for several seconds; relax and repeat 10 times. Repeat several times a day if your knees actively ache.

(6)Straight leg raises:

In the same starting position as the quad sets, sit with your right leg (do one at a time) straight in front of you with your toes pulled towards the knee. (If this is too difficult you may also do these lying on your back to start.) Keep your left leg bent with your foot on the floor. Contract your quads on your right leg, lift your foot about 12 inches off the ground and hold it up for 5 seconds; slowly lower it back down and repeat 10 times. Switch legs.

(7)Wall slides with ball squeeze:

Stand with your back against the wall and your feet shoulder-width apart. Hold a small (soccer ball size) inflated ball between your knees. Slowly slide down the wall by bending your knees and lowering yourself (knees should form a right angle with quads parallel to the floor and shins perpendicular to the floor). Hold 5 to 10 seconds and slowly return to starting position. Repeat 10 or more times.

(8)Clams:

Lie on your side with your hip and knee bent to approximately a 90-degree angle, with feet together. While keeping your ankles together, raise your top knee up about 12 inches from the other in a clamshell-type motion. Repeat 10 to 25 times and switch sides.

(9)Glute bridges:

Lie on your back with both knees bent at about a 90-degree angle with your feet on the floor. Tighten your buttocks as you lift your bottom off the floor as high as you can without arching your back; shoulders, hips, and knees should align. Hold this position as you extend one leg up while keeping knees aligned; hold 3 to 5 seconds and lower. Repeat on the opposite side. Perform 10 to 25 reps per side.

Include one or more of these exercises along with or instead of your usual leg routine two to three times a week for stronger legs and healthier, pain-free knees.

Famous surgery for knee joint:-

 
(1)Arthroscopy:-

In knee arthroscopy, a surgeon will look inside the knee joint, repair torn ligaments and remove damaged parts. Two or three very small incisions are made on the front of the knee. A fiber-optic camera is inserted through one incision. A surgical instrument is inserted through the other incision.

The surgeon can then examine and repair the knee. Knee scopes are most often performed for meniscal tears (torn cartilage). A degenerative tear can be debrided (cleaned up) during the arthroscopy. A traumatic sports-related tear can be debrided or repaired via arthroplasty.

Because of the minimal soft tissue damage resulting from an arthroscopy, recovery is relatively quick. It is a relatively easy surgery and most patients go home immediately after the scope. Patients will typically be able to resume normal activity and return to work within two or three weeks. The knee will be swollen for less than a week.

(2)Osteotomy:-

Knee osteotomy is a surgical procedure in which the surgeon removes or adds a wedge of bone to the top of your tibia (shinbone) or the bottom of your femur (thighbone). This provides a less worn area of articular cartilage to the weight-bearing part of the joint.

Osteotomy is typically recommended for those with arthritis damage in just one area of the knee. Arthritis on just one side of the knee can cause the knee to bow inward (valgus deformity) or outward (varus deformity). This can be corrected by the removal or addition of a wedge of bone. (Traumatic injury or even birth defects can also cause misalignment for which osteotomy is an appropriate surgical intervention.)

Many patients who undergo knee osteotomy will eventually need a total knee replacement. The osteotomy will buy them a varying amount of time before the need for total joint replacement becomes necessary.

Importance of knee joint:- 

why knee joint is so important in India?


We need our knees to run, walk, squat. With research suggesting our bones are weaker than those of Westerners, here’s a quiz to test how well you are caring for your ‘hinges’
Walking, running, climbing, dancing — the knees bear the brunt of every move we make throughout our lives. The main hinge between the ground and the body, knees bring together the femur (thigh bone), tibia (shin bone), fibula (next to tibia), and kneecap, and work as wheels that keep you going.