Motor Relearning Program (MRP) - Neurological Physiotherapy II

Balanced Standing

• Importance of Standing Balance
  • The postural system faces three main challenges:
    • Maintaining a stable posture.
    • Generating anticipatory postural adjustments for goal-directed movements that adapt as the movement unfolds.
    • Reacting quickly and appropriately to threats to balance.
  • Balanced sitting, sit-to-stand, standing, and walking are essential daily tasks.
  • Sitting balance is needed for most self-care activities like dressing, transferring, and eating.
  • Standing balance is necessary for household and outdoor activities.
  • Postural adjustments often require moving body mass from a large base of support (BOS) like the thighs and feet to a smaller BOS like just the feet.
  • This involves extending the lower limbs to raise the body mass over the feet for support, propulsion, and balance.
  • These postural adjustments are ongoing and involve changes in muscular organization, occurring simultaneously with the plan to move, preparing the person for the task.
  • Stroke patients often have impaired postural adjustments.

Balance Standing

• Analysis of Task
  • Step 1: Task Analysis
    • Observation of the patient's alignment in quiet standing.
    • Observation of the patient's alignment while performing various motor tasks (reaching, grasping objects, etc.).
  • Steps 2 and 3: Practice of missing components and tasks
  • Step 4: Transference of learning
• Essential Components:
  • Feet a few inches apart.
  • Hips in front of ankles.
  • Shoulders over the hips.
  • Head balanced and level on the shoulders.
  • Erect trunk.

Common Problems and Compensatory Strategies

Based on Carr et al., 1985

Training Hip Alignment

Based on Carr et al., 1985

1. Initial Position: Patient lies supine, near the side of the bed.
2. Action: Patient practices small range of hip extension.
3. Instructions:
   • "Push your feet gently down to the floor and lift your hip up a little."
   • "Don’t lift your hip too high!"
4. Checkpoints:
   • Ensure correct thigh alignment; the hip should not be too abducted or internally rotated.
   • The knee should be at a right angle or less.
   • Discourage plantarflexing the foot.
   • Ensure patient does not move or tense up the intact side.
   • Push down through the knee to give the idea of the movement.

Followed by:

1. Action: Patient stands with weight on both feet and hips extended.
2. Instructions:
   • "Push down through your feet and stand up!"
   • "Bring your hips towards me/forward over your feet."
   • "Keep your weight over on this (affected) foot".

Training Postural Adjustments to Shift in COG

Based on Carr et al., 1985

1. Initial Position: Patient stands with feet a few inches apart.
2. Action: Patient looks up at the ceiling.
3. Instructions:
   • "Look up at the ceiling - don't just move your eyes. You won't fall over"
   • "Bring your hips forward."
   • "Move forward at your ankles as you look up!"
4. Checkpoints:
   • Correct tendency to fall backwards by reminding him to move his hips forward.
   • Discourage grabbing hold of support.
   • Discourage moving his feet.

Based on Carr et al., 1985

1. Initial Position: Standing with feet a few inches apart.
2. Action: Patient turns his head and trunk to look behind him, returns to the mid position, and repeats to the other side.
3. Progression: Progress to doing this with one foot in front.
4. Instructions:
   • "Turn around and look behind you-turn your body as well as your head."
   • "Don't move your feet!"
5. Checkpoints:
   • Make sure standing alignment is preserved.
   • Do not allow patient to shift his feet. If necessary, place your foot next to his.

Based on Carr et al., 1985

1. Action: Patient is in standing, reaching forward, sideways and backward to take an object from a table, and a variety of reaching and pointing tasks offering a degree of challenge.
2. Instructions:
   • "See if you can touch this. Come on, just a little further!"
   • "Don't shift your feet."
   • "Push down through your L. foot as you reach over to the R.’"
3. Checkpoints:
   • Make sure he is not expected to reach a distance at which it would be normal to take a step.
   • Encourage him to 'loosen up' and not hold himself stiffly.
   • Make sure he moves his body on his feet where this is required for the task.

Based on Carr et al., 1985

Followed by:

1. Action: Patient takes a step forward with the intact leg, then backwards.
2. Instructions:
   • "Keep your weight on this (affected) foot."
   • "Take a step forward with your other foot."
   • "Your hip should move in front of your foot."
   • "Now, step backwards!"
3. Checkpoints:
   • Do not allow hip on affected side to flex. It must extend as he steps forward with the intact leg.
   • Do not allow patient to shift pelvis too far laterally.
   • When patient steps forward, make sure he does not step too far to the side.

Walking

Phases of Gait:

• Stance Phase:
  • Heel strike
  • Loading response
  • Mid-stance
  • Terminal stance
  • Pre-swing
• Swing Phase:
  • Toe-off
  • Mid-swing
  • Terminal swing

Gait events and corresponding phases:

• Double support: Heel strike, Pre-swing
• Single support: Loading response, Mid-stance, Terminal stance, Mid-swing, Terminal swing
• Plantarflexion: Pre-swing
• Dorsiflexion: Loading response
• Neutral: Heel strike, Mid-stance, Terminal stance, Toe-off, Mid-swing, Terminal swing

Knee angle during phases of gait:

• Heel strike: Knee ext 5º
• Loading response: Knee flex 0-15º
• Mid-stance: Neutral
• Terminal stance: Knee flex 0-40º
• Pre-swing: Knee flex 40-60º
• Mid-swing: Knee ext 30º
• Terminal swing: Knee ext 30-0º

Hip angle during phases of gait:

• Loading Response: Hip flex 30º
• Mid-stance: Hip flex 30º to neutral
• Terminal Stance: Hip hypertext 10º
• Pre-swing: Hip flex 20-30º
• Mid-swing: Hip flex 30º
• Terminal Swing: Hip flex 30º to neutral

Essential Components: Stance Phase

• Extension of the hip throughout the stance phase (angular displacement taking place at ankle as well as hip).
• Lateral horizontal shift of the pelvis and trunk (normally approximately $4-5$ cm ($1.5-2$ in) in total).
• Flexion of the knee (approximately $15$°) initiated on heel strike, followed by extension, then flexion prior to toe-off.

Common Problems (Carr et al., 1985)

Training Hip Extension Throughout the Stance Phase

Based on Carr et al., 1985

1. Initial Position: Patient is standing with hip in correct alignment.
2. Action: Patient practices stepping forward, then backwards with the intact leg, making sure he extends his affected hip as he steps forward.
3. Instructions:
   • "Take your weight through your (affected) leg!"
   • "Step forward with this (intact) leg. You need to move forward at your affected) ankle."
4. Checkpoints:
   • Make sure patient does not step out to the side. Indicate where he is to step.
   • Make sure hip extends throughout.
   • Make sure hips do not move more than 2 cm laterally on stance leg.

Training Knee Control for Stance Phase

Based on Carr et al., 1985

1. Initial Position: Patient is in sitting (supine if hamstrings are tight), with knee held straight.
2. Action: The therapist gives firm pressure through heel towards knee while patient
   • practises controlling an eccentric and concentric contraction of the quadriceps through a $15$° range, and
   • attempts to keep knee straight (isometric con-traction).
3. Pressure: Pressure through the heel must be as firm as possible so the quadriceps must contract to prevent the knee from flexing.
4. Instructions:
   • "Bend your knee a little — not too much. Now straighten it."
   • (i) "Keep your knee straight!"
5. Checkpoints:
   • Make sure the patient's leg is positioned so that the bed does not block full knee extension and to allow hip as well as knee movement.
   • Do not allow knee movement to become jerky or uncontrolled.
   • (i) The patient should practise in the part of the range he can just control, progressing to moving in the $0-15$° range as soon as possible.
   • (i) As soon as he has some control, he practises holding his knee at varying positions between $0$° and $15$°.
   • In (ii) the knee must not be 'locked' into extension.
   • Do not allow him to plantarflex his foot.

Based on Carr et al., 1985

Followed by:

1. Action: Patient stands up and practises stepping forward and backwards with intact leg.
2. Action: Then, standing with intact leg in front of affected leg. Patient practises moving his weight forward over his intact foot and back while maintaining knee extension of the affected leg. The step size should be small or it will be inappropriate to keep the knee extended. The patient may get a better idea of how to control his knee if he flexes his knee a few degrees then extends it. Weight must be forward over the intact leg as he practises this, so he is practising controlling his knee with little weight through the leg.
3. Instructions
   • "Move your hips forward over your (intact) foot!" Keep your knees straight!'
   • 'Practise bending and straightening your (affected) knee a few degrees. Keep your hip forward while you do this!'
4. CHECK
   • Make sure affected knee remains straight-as the patient moves forward it may tend to flex

Based on Carr et al., 1985

Followed by:

1. Action: Patient steps on and off an $8$ cm ($3$ in) step with intact foot.
2. Instructions:
   • Put your (intact) foot on to the step!'
   • 'Keep your (affected) hip straight!
   • 'Put your foot back down again.'
3. CHECK
   • Ensure that centre of gravity is not shifted backwards as patient places intact foot on step, i.e. affected hip must be extended throughout.
   • Do not allow affected knee to flex or hyperextend.
   • Do not allow him to step out to the side.

Based on Carr et al., 1985

Followed by:

1. Action: Standing with affected foot on step. Patient shifts weight forward and steps up on to step and back down again with intact leg. Progress to stepping over
2. Instructions:
   • 'Put this (affected) foot on to the step!'
   • 'Move your (affected) knee forward.
   • 'Step up with the other (intact) leg!
   • 'Keep your knee bent until your weight is forward.'
   • 'Now, straighten your knee.'
3. CHECK
   • Do not allow knee to extend prematurely, i.e. knee must not be extended until it is well in front of the ankle.
   • Make sure he does not push himself up with intact leg instead of lifting his weight on his affected leg.
   • When stepping over the step with his intact leg, he must extend his affected knee fully in mid stance.
   • Make sure he does not put his intact foot to the ground prematurely but lowers his foot to the ground slowly.

Training Lateral Horizontal Pelvic Shift

Based on Carr et al., 1985

1. Action: Patient is in standing, hips in front of ankles, patient practises shifting his weight from one foot to the other.
2. Action: The therapist indicates with her finger how far his pelvis should shift, i.e. $2-5$ cm (approximately $1$ inch).
3. Instructions:
   • 'Move your weight over on to your right foot.'
   • 'Now move it back on to your left foot.'
   • 'To move to the right, push down gently through your left foot.’
4. Progression: Followed by, patient practises stepping forward with intact leg (right fig.).
5. CHECK
   • Make sure hips and knees remain extended
   • He must not shift his pelvis too far laterally

Essential Components: Swing Phase

• Flexion of the knee, with the hip initially in extension.
• Lateral pelvic tilt downwards (approximately 15°) in the horizontal plane to toe-off.
• Flexion the hip.
• Rotation of the pelvis forward on the swinging leg ($3-4$° on either side of the central axis depending on stride length).
• Extension of the knee plus dorsiflexion of the ankle immediately prior to heel strike.

Common Problems and Compensatory Strategies

Based on Carr et al., 1985

Training Flexion of Knee at the Start of the Swing Phase

Based on Carr et al., 1985

1. Initial Position: To elicit activity in the knee flexors, have the patient lie prone on bed. Therapist flexes knee to just below a right- angle. Patient practises
   • controlling his knee flexors both eccentrically and concentrically throughout a small range of movement,
   • holding his knee in different parts of the range, sustaining muscle activity to counting.
2. Instructions
   • (i) 'Hold your knee there— bend it up a little— now let it down slowly! 'Bend it up again. Don't be jerky —make a smooth slow movement.' 'Keep your hip down!'
   • (ii) 'Hold your foot here for the count of 'Hold it for longer this time!'
3. CHECK
   • Do not allow jerky uncontrolled movement. Therapist may assist by taking some of the weight of the leg
   • Do not allow the hip to flex

Based on Carr et al., 1985

Followed by:

1. Action: Standing, therapist holds patient's knee in some flexion.
2. Action: Patient practises controlled eccentric and concentric knee flexion.
3. Instructions:
   • 'Give me your leg. Don't let your hip bend.'
   • 'Take your toes down to touch the floor.'
   • 'Now, lift your toes up off the floor.'
4. Checkpoints:
   • Do not flex his knee too much. This will pull him off balance, and tension on his rectus femoris will cause his hip to flex as well as making it difficult for him to contract his knee flexors.
   • Do not allow hip to bend more than a few degrees.
   • Do not push the patient off balance— hold his opposite arm, and make sure his weight is balanced over his standing foot.

Based on Carr et al., 1985

Followed by:

1. Action: Patient steps forward with affected leg, therapist helping him control the initial knee flexion.
2. Instructions:
   • 'Bend your knee!'
   • 'Step forward. Heel down first!’
3. Action: Followed by, patient walks backwards. Therapist guides knee flexion and foot dorsiflexion.
4. Instructions:
   • 'Walk backwards!'
   • 'Bend your knee, step back and put your toes to the ground'.
5. CHECK
   • Make sure the patient extends the hip of his standing leg as he steps forward
   • Do not allow patient to incline trunk forward at hips instead of extending. He should step backwards one leg after the other in a rhythmical manner

Training Knee Extension and Foot Dorsiflexion at Heel Strike

Based on Carr et al., 1985

1. Action: Patient standing on intact leg, therapist holds the patient's affected foot in dorsiflexion, with the knee in extension. Patient moves his weight forward on to heel
2. Instructions:
   • 'Let me have your foot. Don't hold yourself stiffly. Now, shift your weight forward so you put this heel down!
3. CHECK
   • Do not allow him to bend the other knee. He will do this if he does not shift his weight forward by extending his hip
   • Step length should be average
   • Do not give too many instructions. At heel strike, the alignment of both lower limbs is incorrect. Weight is too far back and his R. knee is flexed. Training consists of instructing him to move forward by extending his R. hip

References

• Carr J. H. & Shepherd, R. B (1985). A Motor Relearning Programme for Stroke (2nd ed.). William Heinemann Medical Books.
• Chan, D. Y., Chan, C. C., & Au, D. K. (2006). Motor relearning programme for stroke patients: a randomized controlled trial. Clinical rehabilitation, 20(3), 191–200. https://doi.org/10.1191/0269215506cr930oa
• Immadi, Suneel & Achyutha, Kiran & Reddy, Amaranth & Tatakuntla, Krishna. (2015). Effectiveness of the Motor Relearning Approach in Promoting Physical Function of the Upper Limb after a Stroke. International Journal of Physiotherapy. 2. 386. 10.15621/ijphy/2015/v2i1/60047.