Motor Relearning Programme

1. Motor Relearning Programme
A Task oriented Approach
Dr M.Shahid Shabbir
DPT,MSNMPT*

2. BACKGROUND
• The Motor Relearning Programme (MRP) was developed
by the Australian physiotherapists Janet Carr and
Roberta Shepherd.
• It is a task-oriented approach to improving motor control,
focusing on the relearning of daily activities.

3. MRP/TOA
• Task-oriented approach improves motor control, focusing on
the relearning of daily activities.
• It is strongly based on theories in kinesiology that emphasize
a distributed (rather than a hierarchal) motor control model

4. MRP
• Principles
• Neuroplasticity
• Elimination of unnecessary muscle activity
• Feedback and practice
• Importance of interrelationship between postural adjustment and
movement
• Real life activities
• Training motor control not muscle strength

5. MRP
• Progression from cognitive control over muscle and
movement component to automatic activities
• Environment for recovery and learning and motivation
• Problem solving process
• Recognition
• Analysis
• Decision making
• Action taking
• Re-evaluation

6. Developmentofabnormalmovementpatterns
Attempt to move

Obstacles to efficient movement
Diminished soft tissue extensibility
Impaired balance
Postural insecurity and resultant fixation patterns
Specific muscle weakness

Compensatory movement strategy

Repeated practice of the compensatory strategy

Learned use of the compensatory strategy

7. Cont..
• Basic description and guidelines
•
• The programme is composed of guidelines for evaluating and
improving 7 daily functions:
• Upper limb function
• Oro-facial function
• Sitting up from supine
• Sitting
• Standing up and sitting down
• Standing
• Walking

8. TheFourStepsoftheMotorRelearningProgramme
1. ANALYSIS OF TASK
• Observation
• Comparison
• Analysis
2. PRACTICE OF MISSING COMPONENTS
• Explanation – Identification of goal
• Instruction
• Practice plus verbal and visual feedback plus manual guidance

9. Cont…
3. PRACTICE OF TASK
• Explanation – Identification of goal
• Instruction
• Practice plus verbal and visual feedback plus manual guidance
• Progression:
• Increase complexity
• Add variety
• Decrease feedback and guidance
• Reevaluation
• Encourage flexibility

10. Cont…
4. TRANSFERENCE OF LEARNING
• Opportunity to practice in context
• Consistency of practice and positive reinforcement
• Organization of self-monitored practice
• Structured and stimulating learning environment
• Involvement of relatives and staff

11. Strategies for instructing the patient
• Verbal instruction is kept to a minimum. The therapist identifies the
most important aspect of the movement on which the patient will
concentrate.
• Visual demonstration is provided by the therapist’s performance of the
task, focusing on one or two most important components.
• Manual guidance helps to clarify the model of action by passively
guiding the patient through the path of movement or by physically
constraining inappropriate components.
• Accurate, timely feedback about the quality of performance helps the
patient to learn which strategies to repeat and which ones to avoid.
• Consistency of practice facilitates development of skill in task
performance

12. Cont…
 Motor tasks are either practiced in entirety or broken down into
components.
 Passive movement during demonstration should not persist >1-2
times
• Body alignment should be monitored consistently

13. Acceptable methods of
progression
• Decrease in manual guidance and feedback
• Alteration in speed
• Increase in variety
• Performance of motor activities in the neurodevelopmental
sequence
• Passive ROM exercise to resistive exercise
• Parallel bars to quad cane
• Wide to narrow base of support
• Roll over before sitting balance
•

14. Equipment
• Low bed
• Several small steps (block)
• Stool
• Common objects for retraining hand function
• Calico splint
• Single walking stick if neccessary

15. Retraining Methods
• Normal function
• Essential component
• Common problems and compensatory strategies
• Practice of components (especially missing ones)
• Maintenance of length of muscles
• Transference to daily life

16. Method of Recording Assessment
• Motor Assessment Scale
• To keep abreast of developments in the movement sciences
• To analyze the patients motor performance
• To explain clearly to the patient by speech and demonstration
• To monitor patients performance and give accurate and usable
feedback

17. MAS
• To recognize and discourage compensatory behavior
• To re-evaluate throughout each session of her own and the
patients performance
• To progress the patients level of performance as soon as he has
grasped the idea of what he is practicing
• Opportunity to practice throughout day
• To provide environment for motivation towards recovery of both
mental and physical abilities

18. Limitation
• Spasticity is not considered a significant residual problem of stroke.
However, no management is recommended to reduce abnormal
muscle tone.
• Focus on active learning indicates limited applicability in patients
with severe cognitive deficits

19. MRP>>>
• Intervention:
• Steps of MRP???????

20. Essentialcomponentsofrollingontotheside
• Neck flexion and rotation
• Shoulder flexion and protraction
• Trunk rotation
• Hip and knee flexion
• Other components: posterior hip shifting; foot pushing on
the bed

21. Common compensatoryresponses
• Forward neck flexion and rotation
• Pulling self over using the intact hand; wriggling
• Hooking of the intact leg under the affected leg to dangle over the
side of the bed

22. Specific Techniques
• To stimulate shoulder girdle protraction for rolling over
• To stimulate hip extension for rolling onto the side
• To stimulate lateral neck flexion

23. Cont….
• BALANCED SITTING
• Appropriate body alignment
• Correct adjustments made to changes in body alignment (with
shifts in the center of gravity)
• ESSENTIAL COMPONENTS OF SITTING
ALIGNMENT
• Feet and knees close together
• Symmetrical weight-bearing / sitting
• Hip flexion with trunk extension
• Head balanced on level shoulders

24. Cont…
• Balance Reactions?????

25. Cont…
• BALANCE
Ability to maintain an upright posture against the dynamically
changing effects of gravity on our body segments.
COMPONENTS OF BALANCE REACTIONS:
Lateral shift in the center of gravity
Lateral neck flexion
Lateral trunk flexion (pelvic elevation, shoulder depression)
Backward shift in the center of gravity
Forward neck and trunk flexion

26. Cont..
• PROCEDURES / WHAT TO DO:
Observe sitting alignment
Sitting on a firm base with feet flat on the floor
Knees and feet a few inches apart
Hands on the lap
Test the ability to adjust to self-initiated movement of
head, trunk and limbs
Looking behind, up
Grasping an object from the floor
Lifting the intact leg and foot
Reaching in various directions
Test the displacement of weight sideways and backward
(equilibrium reactions)

27. STANDING UP AND SITTING
DOWN
• ESSENTIAL COMPONENTS OF STANDING UP
• Foot placement
• Forward trunk inclination by hip flexion with the neck and
spine extended
• Hip extension (for final standing adjustment)
•
• ESSENTIAL COMPONENTS OF SITTING DOWN
• Forward trunk inclination by hip flexion with the neck and
spine extended
• Knee flexion

28. BALANCED STANDING
• Appropriate body alignment
• Correct adjustments made to changes in body alignment (with shifts in the
center of gravity)
• Increases awareness of bilaterality, position in space and positioning of
body parts; may minimize the development of spasticity
• ESSENTIAL COMPONENTS OF STANDING ALIGNMENT
• Feet a few inches apart
• Symmetrical weight-bearing
• Extended knees and hips
• Hips over feet
• Erect trunk
• Shoulders over hips
• Head balanced on level shoulders

30. Cont…
• Dynamic Standing
• Test the ability to adjust to self-initiated movement of head,
trunk and limbs
• Looking behind, up
• Head movements, touch head, touch quadrant
• Grasping an object from the floor
• Standing on one leg
• Stand on balance board
• Reaching in various directions
• Test the displacement of weight sideways and backward
(equilibrium reactions) with feet a few inches apart

31. Cont…
• COMPONENTS OF BALANCE REACTIONS:
• Lateral shift in the center of gravity
Lateral neck flexion
Lateral trunk flexion (pelvic elevation, shoulder depression)
Backward shift in the center of gravity
Neck extension
Forward trunk inclination at the hips
Ankle dorsiflexion

32. CommonProblemsand Compensatory
Responsesin UL:
• Impaired scapular movement, especially rotation and
protraction
• Persistent depression of the shoulder girdle
• Impaired control over the deltoids causing the inability to
sustain shoulder abduction and flexion
• Compensation:
• Excessive shoulder girdle elevation
• Lateral trunk flexion
• Excessive shoulder internal rotation, elbow flexion and
forearm pronation

33. Objective Assessment

34. Assessment & Management

35. Cont…
•Assessment???
• Subjective??
• Objective??

36. Cont..
• REFERENCES
Carr, J. H., & Shepherd, R. B. (1987). A motor relearning
programme for stroke (2nd ed.). Oxford: Butterworth-
Heinemann.