The document outlines a Motor Relearning Program (MRP) developed by physiotherapists Janet Carr and Roberta Shepherd, focusing on the task-oriented relearning of daily activities for stroke patients. Key principles include using a structured rehabilitation plan that emphasizes practice in varied environments, early intervention, and incorporating sensory feedback to improve motor control. Additionally, it discusses mechanisms of recovery, motivational factors in rehabilitation, and specific strategies for training upper limb function post-stroke.

1. Motor relearning program
Presenter : Ashik Dhakal
Moderator : Mr. Sydney Roshan Rebello

2. Main idea
Developed by Australian physiotherapist Janet Carr and Roberta Sheperd
‘Task oriented focused on relearning of daily activities.’

3. Background
Major assumption about motor control underlying this new model are :
Regaining the ability to perform motor tasks such as walking, reaching, standing up
involves a learning process and the disabled have the same learning needs as the non
disabled.
Motor control is exercised in both anticipatory and ongoing modes, and that postural
adjustments and focal limb movements are interrelated.
Control of specific motor task can best be regained by practice of that specific motor
task, and such task needs to be practiced in their various environmental contexts.
Sensory input related to the motor task helps modulate action.

4. Effectiveness of MRP
Recognition and analysing the problem
Select most essential missing components
Explain clearly to the pt by speech and demonstration
Monitor the patient’s performance and give verbal feedback
Re-evaluate
Positive feedback
Environment

5. Factors improve quality of rehabilitation
Early start : 24-36 hrs
Rehabilitation plan :
no long time doing nothing
Activities should be planned carefully, enjoyable and meaningful.
Organise environment which facilitates recovery
Consistency of goal :
should also continue outside therapy session, eg., standing up from sitting
Motivation:
Enriched environment plays significant part in recovery from brain damage.
Desire for need of training — recovery

6. Mental stimulation ;
If there are problems of intellect, improvement will not occur without specific
training.
Early experience of erect position — stimulate mental alertness.
Educational programme:
Edu program to relatives and patients on pathophysiology of stroke, meaning of
stroke, family and community participation in rehabilitation.
Planning for discharge :
Preparation of returning home = involves home visit by a therapist
Restricted mobility — access to shops without architectural barriers, deals on
wheels.

7. Mechanism of recovery
1. Von Monakow’s diaschisis theory:
This is theory of functional shock (temporary disruption of neural organisation and
integration).
Widespread effect of such processes as oedema and extracellular blood flow cause a
suppression of activity in areas far from the site of the lesion.
Reversible changes may occur in undamaged synapses resulting in a temporary
impairment of neural transmission.

8. 2. Denervation supersensitivity
The axons and terminals degenerate following a lesion.
The denervated part of the target cells may develop an increased post-synaptic
responsiveness to neurotransmitter substance, becoming increasingly sensitive to the
remaining afferent input.
3. Redundance theory :
A particular function is mediated by all the tissue in a given region.
If part of that region is damaged, the remaining intact tissue would continue to
mediate that function.
The effect of lesion would therefore depend more on the amount of tissue spared than
on the location of the lesion.

9. 4. Vicarious function :
The intact system may have had a latent capacity to control the function which are
lost.
After a lesion these latent functions would become overt.
5. Functional reorganisation :
It is possible that a neural system can change its function qualitatively.
neural pathway could take over control of some motor behaviour not ordinarily part
of its repertoire.

10. 6. Neural sprouting
a. Regeneration :
New growth in damaged neurons.
The newly generated axons may re-innervate the damaged areas.
b. Collateral sprouting :
there is new growth in undamaged neurons adjacent to destroyed neural tissue.
Sprouting would increase synaptic effectiveness and allow the new system to
substitute for the destroyed synapses.

11. Elimination of unnecessary muscle activity
Very early stage following stroke — flaccidity.
Gradually there is return of muscle activity.
There is tendency for the patient to make several types of error.
These errors are augmented by effort he uses as he tries hard to accomplish the desired
activity.
He may tend to activate the incorrect muscle for a particular motor task
May make too strong muscle contraction in compensation for poor control.
May move the intact side instead of the affected side.
May activate correct muscles but the dynamic(spatial and temporal) relationship
between muscles is disturbed.

12. Prevention of muscle imbalance
recognition and prevention of stereotyped and abnormal synergic activity even when
it is relatively minimal and not grossly evident.

13. Feedback :
Feedback gives information about the environment, knowledge of performance and
knowledge of results.
Three types of feedback:
1. Response feedback: in which information is received as a direct result of muscle
contraction.
2. External feedback : where information is received from the environment, usually in
relation to a goal and as an indirect result of muscle contraction
3. Internal feedback : information generated prior to the response from structures whithin
the nervous system.
In MRP only successful performance, is rewarded as good, so patient knows exactly
what he must repeat.

14. Practice :
Factors must be considered to make practice effective in rehabilitation
1. Goal identification :
The patient must be aware of goals for which he is practicing.
Goals should be ‘hard yet attainable.’
2. Relevance of practice :
Training of activity must be relevant to the task.
Rehabilitation should be more directly related to everyday life.

15. 3. Open and closed skills
Open task refers to those that require adaptation of movements to events in the
environment. Eg playing football
Closed task refer to those that can be carried out without reference to the
environment. eg., passing a ball
4. Whole or part practice :
It may be sufficient for the stroke patient to practice an entire activity,
Example : standing from the chair, it is often necessary for him to practice some
component of the activity with which he is having particular difficulty.

16. 5. Attentiveness
Patient will need to be reminded to concentrate and be attentive to what he is doing.
If too much of information is given to him, he may pay attention to what is irrelevent.
6. Cues :
Different cues are important at different stages of learning. visual, verbal, tactile etc
7. Fatigue:
Physical or mental
Can be given rest in normal fatigue
Change to interesting task which activates different muscles.

17. 8. Errors in practice :
The opportunity to make some errors in the execution of movements is beneficial for
learning.
Persistent incorrect practice of a task— unlearn the incorrect movements in order to
learn the activity correctly.
9. Patient participation :
Patient needs to know why he fails and why he succeeds and what solution are
available for overcoming error.
Mental practice or task rehearsal can be used even when there is no active muscle
contraction.

18. There are 7 aspects of daily life activities:
1. Upper limb function
Arm and hand
2. Lower limb function :
Sitting up from supine
Sitting
Standing up and sitting down
Standing
Walking
3. orofacial function

19. Steps of MRP
1. Analysis of function :
observation
Comparison
Analysis
2. Practice of missing component
Explanation — identification of goal
Instruction
Practice + verbal and visual feedback + manual guidance

20. 3. Practice of task
Explanation —- identification of goal
Instruction
Practice + verbal and visual feedback + manual guidance
Re-evaluation
Encourage flexibility
4. Transference of training : continue what learnt in therapy session
Opportunity to practice in context
Consistency of practice
Organisation of self monitored practice
Structured learning environment
Involvement of relatives and staff

21. 1. Upper limb
Daily activities involve complex movement of upper limbs
Motor task performed by the upper limb thus illustrate problems of degree of freedom.
Upper limb movements are complex because they involve the need to control many
joints and muscles.

22. There are certain pre-requisites for effective use of the upper limb. These are :
The ability to see what one is doing
The ability to make postural adjustments which occur with arm movement
Major importance to motor control comes from
Vision information
Tactile information
Proprioception information

23. Essential components
Despite the complexity of upperlimb function, it is possible to identify essential
components.
First to be activated by the patients, and then combined with other muscle-joint
components

24. Step I : analysis of upper limb function
Immediately following stroke, many patients have no easily observable motor
activity in the upper limb
EMG - monitor activity and give feedback - both patient and therapist - essential
in the early stages.
Analysis of muscle activity:
shoulder : supine - sitting
hand : sitting at a table

25. Common problems and compensatory strategies
ARM
Poor scapular movement and persistent depression of the shoulder girdle
Poor muscular control of glenohumeral joint, that is, lack of shoulder abduction and forward
flexion, or inability to sustain these positions.
The patient may compensate by using excessive shoulder girdle elevation and lateral flexion
of the trunk.
Excessive and unnecessary elbow flexion, internal rotation of shoulder and pronation of
forearm.

26. Hand
Difficulty grasping with wrist in extension
Difficulty with abduction and rotation of the thumb
Inability to release an object without flexing the wrist
Excessive extension of fingers and thumb on release
Tendency to pronate the forearm excessively while holding on to or picking up an
object.
Inability to hold different objects while moving arm
Difficulty cupping the hand

27. In addition, there are few common sequelae of stroke, all of which are probably
preventable:
Habitual posturing of the limb leading to length- associated changes in the soft
tissue of the shoulder, wrist , thumb, and fingers.
Compensation with the intact arm
Use of the intact arm to move the affected arm
Learned nonuse of the affected arm

28. Analysis of the painful shoulder
Soft tissue injury with resultant pain, stiffness and subluxation will usually result from four mechanical factors
Pinching of soft tissue across the acromian
Friction of soft tissue against bone
Traction of soft tissue
Soft tissue contracture
Pathological conditions which develop includes:
Degeneration of the acromioclavicular joint, bicipital tendinitis, bursitis, coracoiditis, supraspinatus tendinitis.
Major causes :
Use of passive exercises
Adoptive tissue contracture secondary to disuse
Adhesions between normally free-sliding structures

29. Step 2 and 3, practice of upper limb function
The points that should be kept in mind throughout this part of the program
Arm movement, including movement of the hand, must be trained early following
stroke.
All muscle activity unnecessary to the movement being attempted must be
eliminated consciously by the patient
Activity should be elicited at first in the position of greatest advantages to the
muscle

30. Muscle must not be encouraged to contract incorrectly
The goal should be clearly identified and should be of such a nature that the patient
will know whether or not he has achieved it.
Patient should not be encouraged to practice movements which have no functional
significance
Tasks involving both arms should be introduced as soon as possible
Passive movement may prevent the patient from eliciting any muscular activity by
interfering with his attempts

31. To elicit muscle activity and train motor control for reaching and pointing

32. Position : supine lying
Therapist lifts patient’s arm and supports it in forward flexion
Help the patient elicit muscle activity by asking her to attempt parts of various task : to take hand above
her head to the pillow.
Instructions :
Reach up towards the ceiling
Think about using your shoulder
Now let your shoulder go back on to bed

33. Progression :
Position : supine lying
Patient practices holding her arm in forward flexion and moving it within an ever
increasing range, in all directions, always maintaining control.

34. Position : sitting at a table
Instructions : reach out to touch this. Don’t let your arm drop.
Check :
do not allow elevation of the shoulder girdle as a substitute for abduction or flexion
Do not allow elbow to flex unless it is required
Make sure patient reaches forward with shoulder externally rotating.

35. To maintain length of muscle

36. Position : sitting
The patient sits with his affected hand flat on bed behind him. Therapist needs to
assist him
Position : standing or sitting
Therapist helps to keep hand on the wall with arm abducted/flexed forward at 90.
Initially support elbow and progress to without support.

37. To elicit muscle activity and train motor control for
manipulation

38. To train wrist extension
It is usually more effective to elicit wrist extensor activity by practicing radial deviation of the
wrist.
Position : sitting with arm supported on table, forearm in mid position, fingers and thumb
around a glass.
He attempts to lift the objects up

39. To train supination
Fingers around cylindrical object, patient attempts to supinate forearm so the end
of object touches table

40. To train palmar abduction and rotation of the thumb (opposition)
Therapist holds forearm in mid position and wrist in extension while patient attempts
to grasp and release a glass.
The therapist will need to guide the movement until there is some muscle control.

41. To train opposition of radial and ulnar sides of hand (cupping of the hand)
Forearm in supination, patient practices opposing thumb and other fingers,
particularly fourth and fifth fingers.
Therapist demonstrated how the palm of the hand should cup.

42. To train manipulation of objects
1. Patient practices picking up various small objects between thumb and each finger.
2. Patient practicing picking up polystyrene cup around the rim without deforming
it.

43. Patient practices picking a piece of paper from his opposite shoulder
In order to use hand effectively, it is necessary to have a fine degree of control over
shoulder, elbow, and wrist, since this is what enables the hand to reach its goal.

44. To improve the use of cutlery
The spoon
1. Difficulty moving spoon in hand once it is picked up with forearm in supination, patient practices touching
thumb and each fingertips separately a quickly as possible while monitoring accuracy.
With forearm in supination, patient practices turning over a small object in his hand.
2. Difficulty adjusting grasp in order to keep bowl of spoon level at it raised from plate to mouth
Patient practices moving his arm while holding spoon. Spoon should contain fluid, as this will be a
useful monitoring device for him.
Followed by : Patient practices taking spoon (with fluid) to mouth

45. Step 4 : transferring of training into dailly life
To achieve the potential recovery of upperlimb, there are 4 points need to consider
1. Patients must not suffer secondary tissue injury - explain, shoulder injury
2. Must not allowed or encouraged to develop learned non use. (CIMT should be
used )
3. Patient should practice particular components of movements on which the therapist
cosidered to be concentrate. (Complex movement can be practice mentally first)
4. Persistent posturing of the limb, early stage. (position. Splints etc) figure

46. Rehabilitation

47. Simple active exercises
Grasping a polystyerene cup gives feedback about excessive force generation
Therapist helps by holding forearm in mid position
allowing pt to adjust muscle force to avoid deformity of the cup

48. Initiated contraction of deltoid
Patient has to generate less friction on the table while sliding.

49. Reaching and balancing practice
Reaching to pick the glass
Activation of external rotators

50. Manipulation and dextirity practice
Tapping task :
Touch each finger tip to thumb in sequence as rapidly as possible
Tapping table with single finger
Hand-cupping task to train opposition of radial and ulnar sides of hand
Pick up different objects between thumb and finger and place them in different
target

52. Bimanual practice
As soon as the patient has the ability to control simple movements with the affected
limb, bimanual training should begin.
examples:
Folding a towel:

53. Removing the lid from a can
Pouring from one cup to other

54. Catching keys
Arm cycling
Rolling a ball between hands

55. Strength training :
patients who regain the ability to generate muscle force can benefit from strength
training,
Amount and intensity (i.e. amount of resistance and number of repetitions) are graded
to the individual's ability. As a guide, a maximum 10 repitition for 3 sets.
Strength training can increase muscle strength without an increase spasticity.
Elastic band exercises are progressed by changing to a different coloured band.

56. elastic band exercises for GHJ flexors, abductors, external rotators, elbow flexors
and extensors.
exercises with hand weights for wrist extensors and flexors.
use progressively heavier objects in reaching, lifting and manipulating tasks.

57. Shoulder pain prevention protocol:
Positioning for at least 30 min each day
in supine: hands behind head
at a table: GHJ in abduction, external rotation

58. Positioning in wheelchair:
in mid-GHJ rotation, arm resting. must not be positioned in
internal rotation for any more than brief periods during the day.
Pain-free active exercises for GHJ external rotators, abductors,
flexors as in guidelines,, with emphasis on GHJ between 90° and
full elevation

59. Electrical stimulation:
anterior and posterior deltoid muscle
Avoid activities likely to damage the shoulder, including passive range of
motion exercises, and pulling the patient by the arm

60. Sling and strapping for shoulder support

61. Reference
A motor relearning program for stroke, Carr and Sheperd
Stroke rehabilitation, Carr and Sheperd

62. Thank you