Coordination

CO-ORDINATION
Prepared by
Ahmed Shawky Ali

Recommended texts
• S.B. O’sullivan, T.J. Schmitz, Physical
Rehabilitation: Assessment and
Treatment, F.A. Davis Company. 3rd
ed.
2012.
• R.L. Braddom, Physical Medicine &
Rehabilitation, W.B. Saunders Company.
1st
ed. 1996.

Introduction
• Coordination: “ability to execute smooth,
accurate, controlled movements.”

• Motor coordination is the combination
of body movements created with the kinematic (such as
spatial direction) and kinetic (force) parameters that
result in intended actions. Motor coordination is achieved
when subsequent parts of the same movement, or the
movements of several limbs or body parts are combined
in a manner that is well timed, smooth, and efficient with
respect to the intended goal. This involves the
integration of proprioceptive information detailing the
position and movement of the musculoskeletal system
with the neural process in the brain and spinal
cord which control, plan, and relay motor commands.
The cerebellum plays a critical role in this neural control
of movement and damage to this part of the brain or its
connecting structures and pathways results in
impairment of coordinaton, known as ataxia(Tresch,
MC.; Jarc, A. (Dec 2009)

• Coordinated movements are
characterized by:
1. “Appropriate speed, distance, direction,
rhythm, and muscle tension.”
2. “Appropriate synergist influences.”
3. “Easy reversal between opposing muscle
groups.”
4. “Proximal fixation to allow distal motion
or maintenance of a posture.”

• Incoordination (coordination deficit):
“abnormal motor function characterized by
awkward, extraneous, uneven, or
inaccurate movements.”
• Coordination deficits are often related to,
and indicative of, CNS involvement
including cerebellum, basal ganglia, and
dorsal columns.

• Examples of diagnoses that typically
demonstrate coordination deficits:
1. Multiple sclerosis.
2. Cerebral palsy.
3. Cerebellar tumors.
4. Parkinsonism: elderly; degeneration of
basal ganglia; bradykinesia, rigidity,
resting tremor, and impairments of
posture, balance, and gait.

5. Huntington’s disease: inherited; adults;
fatal; degeneration of basal ganglia and
cerebral cortex; dementia, chorea, and
disturbances of tone, posture, and gait.
6. Sydenham’s chorea: infectious; children;
self-limiting; rheumatic fever; chorea,
disturbances of balance and gait, and
impairments of speech and memory.

Cerebellum
 Primary functions:
1. Coordination of motor activity.
2. Equilibrium.
3. Muscle tone.
 Lesions produce:
1. Incoordination.
2. Impaired balance.
3. Decreased muscle tone.

“The cerebellum compares the commands
for movement transmitted from the motor
cortex with the actual motor performance
of the body segment.”
“This occurs by a comparison of
information received from the cortex with
that obtained from peripheral feedback
mechanisms.”

If movements deviate from the intended
command, the cerebellum sends
corrective signals to the cortex.

 Clinical features of cerebellar
dysfunction:
1. Hypotonia and hyporeflexia.
2. Dysmetria:
• “Disturbance in the ability to judge the
distance or range of a movement.”
• Hypometria = underestimation.
• Hypermetria = overestimation.

3. Dysdiadochokinesia:
• “Impaired ability to perform rapid
alternating movements.”
4. Tremor:
• “Involuntary oscillatory movement
resulting from alternate contractions of
opposing muscle groups.”
• Intention (kinetic) vs. resting (static)
tremors.

5. Movement decomposition:
• “Movement performed in a sequence of
component parts rather than as a single,
smooth activity.”

6. Disorders of gait:
• Broad base support.
• Unsteady, irregular, staggering, and
deviated gait pattern.
• Slow initiation of forward progression of
lower extremity.
• Difficulty in slowing down the forward
progression of the lower extremity once
initiated.

7. Ataxia:
• General term used to describe
uncoordinated movement that results
from the combined influence of
cerebellar dysfunction (especially
dysmetria and decomposition of
movement) on gait, posture, and
patterns of movement.

8. Dysarthria (scanning speech):
• “Disorder of the motor component of
speech articulation.”
• Speech pattern is slow, slurred, hesitant,
with prolonged syllables and
inappropriate pauses.
• Word selection and grammar remain
intact.

9. Nystagmus.
10.Rebound phenomenon:
• “Absence of a check reflex; when
resistance to an isometric contraction is
suddenly removed, the body segment
moves forcibly in the direction in which
effort was focused.”

11.Asthenia:
• “Generalized muscle weakness
associated with cerebellar lesions.”
12.Difficulty in initiating, stopping, or
changing the direction, speed, or force of
voluntary movements.

Basal ganglia
 Components:
1. Putamen.
2. Caudate nucleus.
3. Globus pallidus.
4. Substantia nigra.
5. Subthalamic nucleus.

 Primary functions:
1. “Initiation and regulation of gross
intentional movements.”
2. “Ability to accomplish automatic
movements and postural adjustments.”
3. Inhibitory effect on motor cortex and
posterior fossa brainstem to maintain
normal background muscle tone.”

4. Cognitive and perceptual functions.”
 Lesions produce:
1. Slowness of movement.
2. Involuntary movement.
3. Disturbance of muscle tone.
4. Diminished postural reactions.

 Clinical features of basal ganglia
dysfunction:
1. Bradykinesia:
• “Abnormally slow movements.”
• “Decreased arm swing; slow, shuffling
gait; difficulty initiating or changing
direction of movement; lack of facial
expression; or difficulty stopping a
movement once begun.”

2. Rigidity.
3. Dystonia.
4. Resting tremor.

5. Akinesia:
• “Inability to initiate movement; seen in
the late stages of parkinsonism.”
• Associated with fixed postures.
• “Tremendous amount of mental
concentration and effort is required to
perform even the simplest motor
activity.”

6. Chorea (choreiform movements):
• “Involuntary, rapid, irregular, jerky
movements; clinical feature of
Huntington’s disease.”
7. Athetosis (athetoid movements):
• “Slow, involuntary, writhing, twisting,
“wormlike” movements; clinical feature of
cerebral palsy.”

8. Choreoathetosis:
• Chorea + athetosis.
9. Hemiballismus:
• “Sudden, jerky, forceful, wild, flailing,
motions of one side of the body.”
• “Results from a lesion of the contralateral
subthalamic nucleus.”

Dorsal columns
Primary function:
• Mediate proprioceptive input from joint and
muscle receptors.

Lesions produce:
• Coordination and balance deficits that are
less characteristic than those produced by
other CNS lesions due to compensation
from visual feedback. Thus, these deficits
are exaggerated in dark or with closed
eyes.

 Clinical features of dorsal columns
dysfunction:
1. Dysmetria: visual feedback reduces the
manifestations of dysmetria.
2. Slowed movements: because visually
guided movements are more accurate
when the speed is reduced.

3. Disorders of gait:
• Wide base.
• Sway.
• Uneven step length.
• Excessive lateral displacement.

• Watching feet during ambulation.
• “Advancing leg may be lifted too high and
then dropped abruptly with an audible
impact.”

Changes in coordinated
movement with age
1. Decreased strength.
2. Slowed reaction time.
3. Loss of flexibility.
4. Faulty posture.
5. Impaired balance.

Assessment of coordination
• Assessment must be done bilaterally even
in unilateral lesion
• Assessment must be done in quiet place
to avoid distraction
• Age and psychological state must be
considered

Assessment of coordination
contain:
 Motor assessment including muscle tone and
muscle test
 Sensory assessment including superficial and
deep sensation
 ROM
 Orofacial function assessment including facial
expression ,lip &jaw closure
 Senstivity of face
 Coordination of respiration with swallowing and
speech

 Coordination assessment including non equilibrium and
equilibrium subtypes
 Non equilibrium coordination tests
 Finger to nose
 Finger to finger
 Finger to doctor’s finger
 Adiadokokinesia
 Rebound phenomenon
 Buttoning and unbuttoning
 Heal to knee
 Walking along a strieght line

Coordination tests
• Preliminary considerations:
1. Initial observation of functional activities
guides the therapist in test selection.
2. Initial assessment of motor and sensory
functions improves validity.
3. Apprehension, fear, and fatigue.
4. Lack of reliability.
5. Safety.

• Classifications of coordination tests:
1. Gross vs. fine motor activities.
2. Non-equilibrium vs. equilibrium tests.

• Coordination tests focus on assessment
of movement in four areas:
1. “Alternate or reciprocal motion, which
tests the ability to reverse movement
between opposing muscle groups.”
2. “Movement composition, or synergy,
which involves movement control
achieved by muscle groups acting
together.”

3. “Movement accuracy, which assesses
the ability to gauge or to judge distance
and speed of voluntary movement.”
4. “Fixation or limb holding, which tests the
ability to hold the position of an individual
limb or limb segment.

Recording test results
• Arbitrary scale.
• Timed tests.
• Videotape recording.

Coordination
Requires integration of:
◦Motor system
◦Cerebellar system
◦Vestibular system
◦Sensory system

Assessed by:
◦Rapid alternating movements
◦Finger-to-Nose / Heel-to-Knee Test
◦Romberg’s Test
◦Gait

Finger-to-Nose Test
Finger-to-nose with
moving target
Stationary finger-to-
nose with eyes closed

Rapid Alternating Movements
• First with hands
• Repeat with feet
• Diadochokinesia = ability to perform RAM
• Dysdiadochokinesis = slow, irregular, clumsy
movements

Romberg’s Test
• Station & Stance
– Pt stand with feet together
– First, eyes open
– Then, close eyes
– If okay with eyes open, but
sways w/ eyes closed = +
Romberg
– Mainly tests position sense
(Vision can compensate
for loss of position
sense)

Ahmad Alghadir M.S. Ph.D. P.T.

Standardized instruments for
coordination assessment
1. Jebsen-Taylor Hand Function Test:
• Measures hand function using seven
functional activities: writing; stacking;
card turning; simulated feeding; picking
up small objects; picking up large,
lightweight objects; and picking up large,
heavy objects.

2. Minnesota Rate of Manipulation Test:
• Assesses hand dexterity in five
operations: placing, turning, displacing,
one-hand turning and placing, and two-
hand turning and placing.

3. Purdue Peg board Test:
• Assesses hand dexterity using a test
board, pins, washers, and collars.
Subtests include prehension and
assembly using right, left, and both
hands.

4. Crawford Small Parts Dexterity Test:
• Assesses hand dexterity using a test
board, screwdriver, tweezers, pins,
screws, and collars.

treatment
 Methods of treatment:
 PNF technique
1- Rhythmic stabilization to improve
proximal stability
2-Reversal tech. to improve ability to
alternate movement from agonist and
antagonist
3-Approximation to improve proximal
fixation

 Tapping and weight bearing increasing
stability
 Using ankle and wrist weight to decrease
tremor
 Balance can improved in antigravity
position in normal base of support
 Postural stability is improved by using
antigravity position in the developmental
sequence
 Frenkel’s exercises improve co ordination

Frenkel’s exercises
• Definition :
a series of gradual progressive
exercises designed to increase
coordination
Aim :
Establishing control of movement by
use of any part of sensory mechanism
which remain intact as sight & hearing
to compensate for the loss of
kinethetic sensation

Frenkel’s exercises contain
• I-lying ---------
• flexion-extension
• Abduction – adduction
• Each movement will be performed
unilaterally fast then slow then
interrupted by hold
• bilateral performance simultaneusely
then alternatively

Frenkel’s exercises contain
• Sitting :
• 1-Slide heel to reach a mark on the
floor
• 2-change standing and sit again
• Standing :
• 1-transfer weight from foot to foot
• 2- walking side ways
• 3-placing foot on specific marks

Frenkel’s exercises cont
• For arms :
• Sitting with arm supported on a table
and placing hand at specific mark
• Try to reach an object
• Picking up objects
• Put the hand in a ring or hole

Coordination

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