This document outlines the motor relearning program (MRP) for patients recovering from stroke. The MRP has 7 components - upper limb function, oro-facial function, sitting up, balanced sitting, standing, balanced standing, and walking. It follows 4 steps - analysis of the task, practice of missing components, practice of the full task, and transference of training to daily life. Each step involves observation, identification of problems, and activities to improve specific skills like joint movement, posture, and coordination required for the component. The goal is to help patients relearn motions through structured practice and regaining independence in everyday activities.

1. Motor Relearning
Programme
Suvarna Ganvir
Professor
PDVVPF’s college of Physiotherapy
Ahmednaga
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2. Objectives
At the end f the lecture , the learner shall be able to
• Enlist all seven components of Motor Relearning Program (MRP)
• Enlist all four steps of MRP
• Describe the activities in each step of MRP.
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3. MOTOR RELEARNING PROGRAM
Activities to be achieved
1. Upper Limb Function
2. Oro- Facial Function
3. Sitting up over the side of bed
4. Balanced sitting
5. Standing and sitting down
6. Balanced standing
7. Walking
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4. Four steps in MOTOR RELEARING
PROGRAMME
STEP 1
Analysis Of Task
 Observation
 Comparison
 Analysis.
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5. Step 2
Practice of missing components
 explanation - identification of goal
 instruction
 practice and verbal and visual feedback +manual guidance.
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6. Step 3
Practice of task
 Explanation and identification of goal .
 Instruction
 Practice +verbal and visual feedback+ manual guidance.
 Re-evaluation.
 Encourage flexibility.
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7. Step 4
Transference of training
 Opportunity to practice in context.
 Consistency of practice .
 Organization Of Self Monitored Practice .
 Structured learning environment.
 Involvement of relatives and staff .
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8. Seven components
1. Upper Limb Function
2. Oro- Facial Function
3. Sitting up over the side of bed
4. Balanced sitting
5. Standing up and sitting down
6. Balanced standing
7. Walking
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9. UPPER LIMB FUNCTION
• Step1 - ANALYSIS OF ULF
• The therapist may enable the patient to elicit muscle activity by
altering the goal or by changing the length of ms contraction.
• Therapist must set up necessary condition for ms activation .
• Use of EMG to monitor the activity and give feedback to the patient
and therapist is imp.
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10. Common problems and compensatory
strategies
 Arm
-Poor scapular movement ( particularly lateral rotation and protraction )
and depression of the shoulder girdle .
- Lack of shoulder abduction and forward flexion compensated by
excessive shoulder girdle elevation and lateral flexion of trunk.
- Excessive elbow flexion ,internal rotation of shoulder and pronation of
forearm.
 HAND
- Difficulty in grasping in wrist with extension .
- Difficulty in extending and flexing the MCP with IP joints in some
flexion .
- Difficulty with abduction and rotation of thumb .
- Inability to release an object without flexing the wrist .
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11. • -Excessive extension of fingers and thumb on release .
- Excessive pronation of forearm while holding or picking objects .
- -Inability to hold different objects while moving arm .
- Difficulty in cupping hand .
- Compensation and use of intact arm to move the affected arm .
- Learned non use of affected arm.
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12. ANALYSIS OF THE PAINFUL SHOULDER
-As there is depressed motor activity around the shoulder the
surrounding ms becomes inactive .
- Pain ,stiffness and subluxation results from soft tissue injury which
may be due to any one of the reason :
- 1.Pinching or friction of soft tissue against bone.
2. traction .
3.soft tissue contractures .
-Passive ROM is the main cause of pain .
- So proper musculoskeletal assessment and apprropiate treatment
should be given .
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13. Step 2 and 3 Practice of upper limb function
• Motor activity can usually be elicited first in supine with his arm in
elevation .
• Ms can first be activated in eccentric then in concentric mode .
• A muscle may be activated as a part of one particular synergy
before it can be activated as part of another .
• The main objective is to discover what motor activity exist by giving
particular ms opportunity to contract and encourage the patient .
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14. Points to be considered during treatment
 Arm movement including both shoulder and hand must be trained
 Motor task involves complex combination of ms action. As soon as
individual ms action is elicited then carried out to meaningful task .
 Patient gaining control over movement first concentric then eccentric ms
activity .
 All muscle activity unnecessary to the movement be eliminated.
 Gross therapist controlled patterns of movement of upper limb should be
avoided.
 Activity should be elicited at first in the position of greatest advantage to
the muscle.
 Therapist should not hold the limb too firmly .
 The goal should be clearly identified should be of nature that patient
knows the improvement .
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15. 1.To elicit muscle activity and train motor control for reaching and
pointing .
2.To maintain length of muscle .
3.To elicit muscle activity and train motor control for manipulation:
-To train wrist extension .
-To train supination .
-To train palmar abduction and rotation of thumb .
-To train opposition of radial and ulnar sides of hands .
-To train manipulation of objects.
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16. Step 4 Transference of training into ADLS
1.Patient must not suffer secondary's of tissue injury .
2.Passive movements may damage the soft tissues around paretic
shoulder joint .
3.Pt should not be given pulley exercise .
4.Pt should not encouraged to develop learned non use of his
affected arm .
5.During the day patient should practice particular movements on
which therapist considers he should concentrates.
6.Persistence posturing of the limb is particular problem .
-Daily program of changing the limb posture and daily training session
should be included .
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17. Oro facial function
 It includes various activities such as swallowing ,facial expression
, ventilation motor aspect of speech production .
 Following stroke all these activities may be affected interfering
with eating ,communication and socialization .
 Essential components
1.Jaw closure
2.Lip closure
3.Elevation of posterior third of tongue
4.Elevation of lateral border of tongue .
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18. Step 1 analysis of oro -facial function
• Observation of alignment and movements of lips jaw and tongue .
• Intra oral digital examination of and cheeks
• Observation of eating and drinking .
A] Difficulty in swallowing -Lack of control over orofacial musculature
• Open jaw
• Poor lip seal
Immobile tongue .
Will result in -Drooling
-food collecting between cheek and gums
B] Imbalance of facial movements and expression .
C]lack of emotional control
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19. Step 2 and 3 PRACTICE OF OROFACIAL
FUNCTION
• To train sawallowing
-To train jaw closure
-To train lip closure
-To train tongue movement
-To elevate posterior third of tongue .
-To train facial movements
To improve breathing control.
To improve control over emotional outburst.
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20. Step 4 Transference of training into ADLS
• Therapist assist the patient first few meals as already described .
• During all training session therapist monitors the patients facial
posture .
• Improved oro facial control and appearance will motivate the
patient .
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21. Sitting up over side of bed
 Essential components
-Turning on to the side
1. Rotation and flexion of neck .
2. Hip and knee flexion .
3. Flexion and protraction of shoulder .
4. Rotation within trunk
-Sitting up over side of bed
1.Lateral flexion of neck .
2Lateral flexion of trunk .
3.Legs lifted and lowered over side of bed .
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22. Step 1. Analysis of sitting up over side of bed
• Turning may demonstrate following difficulties
-Flexion of hip and knee on affected side
-Flexion and protraction of shoulder girdle .
• Depressed muscle activity may be compensated by the following
-Rotation and forward flexion of neck
-Pulls with Intact hand
-Hooks intact leg under affected leg
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23. Step 2 Practice of missing component .
• The therapist assist the patient to his intact side .
• Encourages the patient to turn head assist in shoulder flexion and
flex his hip and knee .
• Instructions
• Lower yourself on to your arm
• Don’t let your head flop down .
Check –Do not pull on patient arm
-Remind him to control his head position
-Do not let his weight go backwards .
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24. Step 4 Transference of training into daily
activities
• Patient should only spend time in bed for medical reasons .
• Early assumption of erect position has stimulating effect on CNS .
• Sitting position helps to empty the bladder and bowel .
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25. BALANCED SITTING
• Essential components
-Feets and knee close together .
-weight evenly distributed .
-Flexion of hip with trunk extension
- Head balanced on level shoulders .
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26. • Step 1 – Analysis of balanced sitting
• Observation of patient alignment in quiet sitting
• Analysis of his ability to adjuct to self initiated movement of
limbs,trunk and head.
compensatory strategies observed by therapist
1 . Wide base of support
2 .voluntary restriction of movement
3 .patient shuffles feet
4 .lateral flexion of trunk is poorly controlled
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27. Steps 2 and 3 practices of balanced sitting
To train postural adjustment to shift in centre of gravity
- sitting,hands in lap,patient turns head and trunk to look over
shoulder return to mid position,repeats to other side
To increase complexity
- sitting,reaching sideways and downwards to pick up object from
floor
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28. Step 4 transference of training into ADLS
• Orgarnsing for resting posture of flaccid arm may vary through out
day and opportunity to practices standing up for which it is easier to
sit patient in chair
• Weight shifting can be down
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29. Standing up and sitting down
• Step 1 –analysis of Standing up and sitting down
Common problems are
• 1 –weight is borne mainly through intact side
• 2- inability to shift COG forward
• 3- failure of foot placement
• STEP 2- PRACTICE OF MISSING COMPONENTS
• 1- to train trunk inclination forward hips(with knee movement
forward)
• STEP 3-Practice of standing up and sitting down
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30. Standing up
• It may be facilitated by use of higher chair .
• With his shoulders and knees forward patient practices standing up .
• Step 4- Transferance of training into ADLS
-There is more improvement in lifestyle and morale of patient as he
stand up .
-Transferance using high chair .
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31. Balanced standing
• Analysis of balanced standing
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compensatory strategies observed by therapist
1 . Wide base of support
2 .voluntary restriction of movement
3 .patient shuffles feet.
Step 2 and 3 – Practice of balanced standing
1]To train hip alignment
2] To prevent knee from flexing .
3] To elicit quadriceps contraction .
4] To train postural adjustments to shift in COG

32. Step Transference of training into ADLS
• If patient is physically fit the training in standing should be started .
• Opportunity to practice during day with proper alignment .
• Practice of standing and walking .
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33. Walking
Step 1 –Analysis of walking
Stance phase of affected leg
• Lack of extension at hip and dorsiflexion at ankle .
• Lack of control in knee flexion extension from 0-15 degree .
• Excessive lateral shift of pelvis .
Swing phase of affected limb
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34.  Lack of 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 components
- Stance phase
1] To train hip extension throughout stance phase .
2]To train knee control .
3] To train lateral pelvic shift .
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35. • Swing phase
1] To train flexion of knee .
2] To train knee extension and foot dorsiflexion at heel strike
Step 3 Practice of walking
-Patient steps with his intact leg first then the therapist stands
behind .
-Patient should know to stop and re-align himself when he feels off
balance .
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36. Step 4 Transference of training
• By measuring the distance and time taken to cover the distance
graph can be plotted for improvement .
• Written instructions regarding specific goals number of repetitions
or distance to cover .
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37. Summary
1. Seven components are –Upper Limb Function, Oro- Facial
Function, Sitting up over the side of bed, Balanced sitting,
Standing up and sitting down, Balanced standing,Walking
2. Four steps are - Analysis Of Task, Practice of missing components,
Practice of task, Transference of training
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38. Commonly asked questions
• Describe steps of administering Motor relearning programme -7M
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39. THANK YOU
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