For physiotherapist

2. • Frenkel Exercises were originally developed in 1889 to
treat patients of tabes dorsalis and problems of sensory
ataxia owing to loss of proprioception.
• Dr.H.S. Frenkel made of special study of tabes dorsalis
and derived a method of treating the Ataxia, which is
prominent symptom of the disease, by means of
systematic and graduated exercises.

3. • Frenkel‘s Exercises are a series of motions of increasing
difficulty performed by ataxic patients to facilitate the
restoration of rhythmic, smooth and
coordinated movements.

4. • He 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
kinesthetic sensation.

5. • During exercises all movement required…..
1. concentration of the attention
2. precision
3. repetition
• The muscles sense is practically non-existent by the
time a patient comes for treatment, the objective of the
exercises is to teach him to replace his lost sense by the
sense of sight. If the patient is in the pre-ataxic stage,
he should perform the most complex movements as
much as possible.
Principles

6. • In the later stages, the exercise should begin with very
simple movements and gradually advance to more
complicated ones.

7. RULES OF GIVING FRENKEL’S EXERCISE
1. Commands should be given in an even, monotonous
and the exercise should be done by counting.
2. Patient should be able to do all exercise accurately and
smoothly.

8. 3. Exercise involving strong muscles work should not be
given. Progression is by complexity, not strength.
4. Movements in complete range are easier than those in
small range but no movement should be taken beyond
its normal built because the hypotonia of the muscle
and laxity of ligaments render the patient
vulnerable to dislocation or the onset of Charcot's
joints.

9. 5. The movements should be given rather quickly, then
more slowly, this being more difficult since it requires
greater control.
6. The patient should practice movements first with his
eyes open and then with close.
7. Rest must be given between the exercise; after so many
minutes work, an equal number of minutes rest should
be taken.

10. 8. It is necessary, when planning the treatment scheme to
take into consideration, the patient’s general health
and mental attitude, the state of his muscles and any
complications such as Charcot's joint

11. EXERCISES IN LYING
• The patient lies on a bed, plinth or couch with a
smooth surface along which the feet can move easily..
His head must be sufficiently raised for him to be
able to watch his feet. The exercises in this group
begin with simple movements and gradually more
difficult and complicated.

12. EXERCISES IN LYING

13. • The 1st set are as follows(one leg moved at a time, legs
move alternatively)
1. Flexion of one leg at hip & knee, foot kept on plinth,
extension.
2. Flexion as above, abduction , adduction ,extension.
3. Flexion as above, but only a half way; extension.
4. Flexion as above(half way),abduction, adduction,
extension.

14. The exercises are done slowly three or four times, by
using each leg in turn. The foot should be kept
dorsiflexed, so as no stretch on hypotonic anterior tibial
group. The Physiotherapist should count for during each
movement.
At a later stage both legs are moved together.

15. EXAMPLES OF MORE DIFFICULT EXERCISES IN THE LYING
SERIES:
i. Flexion of one leg at hip and knee, with the heel
raised some inches from the plinth, extension.
ii. Heel of one leg placed on patella of other leg,
Return.
iii. As above with voluntary halt.
iv. As above with halt to command.
v. Heel is placed on the middle of the other tibia,
lifted off and put by side of leg, extension.

16. vi. Heel placed on knee; heel slides along tibia to ankle
joint; extension.
vii. As above, but heel carried from ankle back to knee;
extension.
viii. Flexion and extension of both legs, with heel off bed.
ix. As above with halts
x. One leg flexed; left leg abducted & right leg flexed
simultaneously; left leg adducted and right leg
extended; left leg extended.

17. xi. Left leg flexed, right leg abducted and flexed; Right leg
adducted; both legs extended without heels touching
bed till end of movement.
xii. The physiotherapist places her finger on various places
on the leg; the patient places his other heel on her
finger
xiii. As above, but the patient reaches the finger, the
physiotherapist moves it, and the patient tries to
follow its course.
xiv. Right heel is placed on the knee of other limb, which is
in extension; with right heel in this position, the left
leg is flexed and extended.

18. xv. Right heel is placed on left knee, and slides down the
tibia to the ankle; as it slides down, the left leg is
flexed; as it is brought back to the knee, the left leg is
extended.

20. Hip range of motion

21. Knee range of motion

22. Combination of hip and knee

23. Anatomical landmark(Shin of
tibia)

24. Exercises in sitting
• Those given by Frenkel consist of rising from stool or
chair, and sitting down again the patient has literally
forgotten how to perform these ‘stock’ movements.
• The rising movement, therefore is divided into its
component parts, the operator counting three.
At one……..the patient draws his knees under the
stool.

25. At two……the bends his trunk forward.
At three….he rises extending hips and knees.
• These movements may be done at first in the reach-grasp
position, the patient sitting close to the wall-bars. Later,
he rises unsupported. Later still, he attempts to do so
with his eyes closed.

26.  Other exercises may be given in sitting :-
1. The patient may be directed to raise his knees and
place his foot on, say, the second rail from the bottom.
This is done in three movements……
A) flexion of hip
B) extension of knee
C) lowering of foot on to bar
He then replace the foot on the ground.
2. He may be made to tough marked points on the floor
with his foot.

29. EXERCISES IN STANDING
• These are designed to
give re-education in
walking.
• They should be
performed in a large
space.

30. Side walking

31. 1. Walking sideways
- In this prepare to give
support to the patient
if necessary, it begins
by walking sideways.
Balance is easier in
this way. Because in
long step he does not
have to rise on the
toes of one foot, thus
decreasing his base.

32. Turning towards left and right

33. - He should begin by taking half-step, with
physiotherapist counting three for each step, e.g. for half
step to right....
a. He places the right foot on the ground
a step away.
b. He transfers his weight from the left to
the right foot.
c. He brings the left foot up besides the
right.

34. - He then practices quarter steps, then long steps and then
finally combines all the three lengths in one exercise.
a. Three quarter step to right one-two-
three.
b. Quarter step to left one-two-three.
c. half step to right one-two-three.
d. whole step to left one-two-three.
- The long steps are more difficult because the toes have to
be put on the ground first. The heel is raised and the
patient’s base is therefore smaller.

35. 2. Walking forward
- whole half and quarter steps forward,
beginning with each foot alternately,
counting three before…..
Thus beginning with right foot…
a. Place right foot forward, heel on
ground.
b. Transfer weight to his foot, raising
heel of left foot.
c. Bring left foot up besides right foot.

36. 3. Walking backward, in a similar manner.
4. Walking heel to toe
5. Walking in footsteps painted on the floor
6.Turning round
7. Walking up and down stair or steps:
a. The patient first goes up one at a
time, later he practices walking up the
steps as a normal person would.
b. He walks up and down, with
support to begin with later without.

37. 8. Finally, he is taught to walk while using his arms at the
same time, carrying parcels, getting out of the way of
obstacles etc.
• When the arms are affected, which is much more rarely
the cause exercises of a similar nature are given, special
attention being paid to the fine movements of hands
and finger in holes in a board; inserting pegs or matches
into holes; picking up small objects like marbles and
arranging them in piles or patterns. He should also
practice going over diagrams with a
pencil,writing,drawing etc.

38. Exercises For The Arms
• a)Sitting (one Arm supported on a table or
in slings); Shoulder flexion or extension to
place Hand on a specified mark.
• b)Sitting; one Arm stretching, to thread
it through a small loop or ring.
• c)Sitting; picking up objects and putting
them down on specified marks

40. Exercise to promote movt and
rhythm
• Exercises are repeated to rhythmic count.
• a)Sitting; one Hip flexion & adduction.
• b)Half lying; one Leg abduction to bring knee
to side of plinth, followed by one Knee
bending to put Foot on floor, the movement is
then reversed & repeated.
• c)Sitting; lean forward and take weight on
Feet(as if to stand), then sit down again.
• d)Standing; Arms swing forwards
backwards(with partner holding two sticks).
• e)Standing or walking; bounce & catch, or
throw & catch a ball.

41. PROGRESSION of Frenkel’s
exercises
• alteration in speed, range & complexity
• Quick movements, less control
• Slowmovement, high control
• movements build up from simple to form
complex e.g walking
• Accordingto disability re-education starts
from lying to standing.

42. BENEFITS OF FRENKEL’S
EXCERCISE
• • Improve co-ordination.
• Improve balance.
• Improve body awareness.
• Improve postural awareness.
• Improve selective movements.
• Improve proprioception.

43. • In the paralytic stage, only very simple movements can
be given, but breathing exercise are important.

44. THANK YOU