Oliveira, Int J Phys Ther Rehab 2015, 1: 110

http://dx.doi.org/10.15344/ijptr/2015/110

International Journal of
Physical Therapy & Rehabilitation
Commentary Open Access
Reeducation Sensorimotor: Principles and A Model in Physiotherapy
Raul Oliveira
Laboratory of Motor Behavior. Human Kinetics Faculty, University of Lisbon, Alameda da Universidade, 1649-004 Lisboa, Portugal
Introduction Publication History:
Physiotherapy is the science and practice to prevent, assess and Received: December 09, 2015
treat movement disorders. Knowledge and understanding of the Accepted: December 30, 2015
mechanisms and processes of (re) motor learning, the control of Published: December 31, 2015
human movement and any changes in the case of neuro-musculo-
Keywords:
skeletal disorders are essential in implementing the appropriate
strategies to efficiently restore functionality. Physiotherapy, Sensorimotor, Neuromotor, Neuromuscular control,
Central nervous system
The sensorimotor or neuromotor reeducation should be based thus
on neurophysiological and biomechanical principles neuromuscular operationalized through motor programs that have a purpose and
control. The evolution of Physiotherapy as a scientific discipline not muscles in isolation. For example, in shoulder overhead activities
based on evidence still requires an applied or clinical research studies like tennis serve or javelin throw, particular neuromuscular activation
that integrate the most current concepts of neuroscience in clinical sequences and coordination occur between the rotator cuff muscles
practice. and scapula muscles (scapulo-humeral rhythm) to ensure that the
optimal glenohumeral alignment and compression required for
This paper aims to review and briefly describe the key concepts dynamic joint stability are provided. These muscle activations take
of neuromuscular control that must underlie and based the clinical place unconsciously and synonymously with the voluntary muscle
interventions in movement dysfunctions. activations directly associated with the particulars of the task
(ie, aiming, speed, distance, range of movement). Proprioceptive
Neuromotor Control & The Sensorimotor System-Key Concepts
information concerning the status of the joint and associated
Sensorimotor control refers to central nervous system (CNS) structures is essential for neuromuscular control [7].
control of movement, balance, posture, and joint stability [1,2]. Well-
Proprioception involves conscious or unconscious awareness
adapted motor actions require intact and well integrated information
of joint position (joint position sense), movement (kinesthesia),
from all of the sensory systems, specifically the visual, vestibular and
and force, heaviness, and effort (force sense) [8,9]. Proprioception
somatosensory systems, including proprioception [3,4].
is processed at all levels of the Central Nervous System (CNS) and
The sensorimotor system, a functional unit of the comprehensive is integrated with other somatosensory information (visual and
motor control system of the body, is extremely complex and has some vestibular) before culminating in a final motor command that
different dimensions. The term sensorimotor system was adopted by co-ordinates the activation patterns of skeletal muscles [3,10].
the participants of the 1997 Foundation of Sports Medicine Education Proprioception is the product of sensory information supplied by
and Research workshop to describe the sensory, motor, and central specialized nerve endings termed mechanoreceptors, i.e., transducers
integration and processing components involved in maintaining joint converting mechanical stimuli to action potentials for transmission
homeostasis during bodily movements (functional joint stability) [5]. to the CNS [9,11]. Mechanoreceptors specifically contributing to
proprioception are termed proprioceptors and are found in muscle,
The components giving rise to functional joint stability must tendon, joint and fascia, receptors in the skin can also contribute
be flexible and adaptable because the required levels vary among to proprioception [9,12]. Proprioceptive information is processed
both persons and tasks. The process of maintaining functional joint at the spinal level, brain stem and higher cortical centers, as well as
stability is accomplished through a complementary and constant subcortical cerebral nuclei and cerebellum [13-16].
interaction between static and dynamic components. Joint capsule,
ligaments, cartilage, friction, and the bony architecture within the From the spinal cord arise direct motor responses to peripheral
articulation comprise the static (passive) components [6,7]. Dynamic sensory information (reflexes) and elementary patterns of motor
contributions arise from feed forward and feedback neuromotor coordination (rhythmic and central pattern generators). Despite
mechanisms over the skeletal muscles crossing the joint. Underlying being the most primitive part of the brain from a phylogenetic
the effectiveness of the dynamic restraints are the biomechanical and perspective, [17] the brain stem contains major circuits that control
physical characteristics of the joint. postural equilibrium and many of the automatic and stereotyped
movements of the body [3,18,19]. In addition to being under direct
Neuromuscular control is a frequently used term in many disciplines cortical command and providing an indirect relay station from the
related to motor control. It can refer to any of the aspects surrounding *
Corresponding Author: Dr. Raul Oliveira, Laboratory of Motor Behavior.
nervous system control over muscle activation and the factors Human Kinetics Faculty, University of Lisbon, Alameda da Universidade, 1649-
contributing to task performance. Specifically, from a joint stability 004 Lisboa, Portugal; E-mail: [email protected]
perspective, we define neuromuscular control as the unconscious
activation of dynamic restraints occurring in preparation for and in Citation: Oliveira R (2015) Reeducation Sensorimotor: Principles and A Model
in Physiotherapy. Int J Phys Ther Rehab 1: 110. doi: http://dx.doi.org/10.15344/
response to joint motion and loading for the purpose of maintaining ijptr/2015/110
and restoring functional joint stability. Although neuromuscular
control underlies all motor activities in some form, it is not easily Copyright: © 2015 Oliveira. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
separated from the neural commands controlling the overall use, distribution, and reproduction in any medium, provided the original author
motor program [6]. Our brains are depicted actions or movements and source are credited.

Int J Phys Ther Rehab IJPTR, an open access journal

Volume 1. 2015. 110
Citation: Oliveira R (2015) Reeducation Sensorimotor: Principles and A Model in Physiotherapy. Int J Phys Ther Rehab 1: 110. doi: http://dx.doi.org/10.15344/
ijptr/2015/110

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cortex to the spinal cord, areas of the brain stem directly regulate experimental conditions following pain, joint effusion, abnormal
and modulate motor activities based on the integration of sensory movement and/or posture pattern and trauma as well as neural and
information from visual, vestibular, and somatosensory sources [3]. In muscular fatigue.
general, the motor cortex is responsible for initiating and controlling
There are a lot of research studies reported disturbed
more complex and discrete voluntary movements. It is divided into
proprioception in acute and chronic musculoskeletal pain disorders
three specialized and somatotopically organized areas, each of which
at the cervical [25,26] and lumbar [27,28] spine, as well as shoulder
project directly and indirectly (via the brain stem) onto interneurons
[29], elbow disorders [30] and knee disorders [31]. When there is
and motor neurons located in the gray substance of spinal cord. The
pain, proprioception can be disturbed due to altered reflex activity
major direct descending pathway from the motor cortex to the alpha
and sensitivity of the gamma-muscle spindle system via activation
motor neurons and gamma motor neurons is the corticospinal tract.
of chemosensitive type III and IV afferents (nociceptors) [32]. Pain
In addition to influencing motor functions directly, the corticospinal
can moreover influence body perception at the central level [33,34],
tract also affects motor activity indirectly through the descending
including reorganization of the somatosensory cortex [35]. Thus pain
brain stem pathways [3].
can negatively influence proprioception at both peripheral and central
Although the cerebellum and basal ganglia associate areas cannot levels of the CNS.
independently initiate motor activity, they are essential for the
Joint effusions can cause significant inhibition of muscle
execution of coordinated motor control. The cerebellum, operating
activation, and can also in the absence of pain, significantly impair
entirely at a subconscious level, plays a major role in both the
extremity proprioception [36]. Following trauma, and after pain
planning and modification of motor activities though comparison
and swelling have resolved, the loss of musculoskeletal tissue and
of the intended movement with the outcome movement [3,20].
its mechanoreceptors is associated with persistent impairment of
This is accomplished through the continuous inflow of information
proprioception [37,38].
from the motor control areas and the central and peripheral sensory
areas. The cerebellum has three functional divisions. The first A common phenomenon in fatigue conditions after performing
division receives vestibular input, both directly and indirectly from hard physical work or exercise (especially eccentric training) is the
the vestibular labyrinth (semicircular and otolith receptors) and, experience of clumsiness and difficulty performing fine motor tasks,
as might be surmised based on the input, is involved with postural verified in several studies demonstrating impaired proprioception
equilibrium. The second cerebellar division is mainly responsible for [39-41]. Thus the potential for increased injury risk exits in fatigue
the planning and initiation of movements, especially those requiring conditions. Associated to the causes reported, deleterious effects on
precise and rapid dexterous limb movements. It is the third division, proprioception have also been reported in association with conditions
the spinocerebellum, which receives the somatosensory information such as local [42] and general [43] joint hypermobility, stenosis [44] as
conveyed through the 4 ascending spinocerebellar tracts. In addition well as due to immobilization [45].
to the somatosensory input, this division of the cerebellum also
receives input from the vestibular labyrinth and visual and auditory In acute effects, disturbed proprioception is likely to have adverse
organs. The output from the spinocerebellum serves to adjust ongoing influence on feedback and feedforward motor control and the
movements through influential connections on the medial and lateral regulation of muscle stiffness. It may also explain various sensorimotor
descending tracts in the brain stem and cortex via projections on dysfunctions (besides increased errors in specific proprioception
the vestibular nucleus, reticular formation, red nucleus, and motor tests), which have been reported in the research literature. These
cortex. In addition to controlling movements, the spinocerebellum dysfunctions include reduced drive to alpha motor neurons [46],
also uses the somatosensory input for feedback regulation of muscle disturbed reflex joint stabilization [47], increased postural sway in
tone through regulation of static g-MN drive to the muscle spindles balance tasks [48-50] and increased error in visual movement acuity
[3]. Lastly, the cerebellum also receives an efferent copy of the motor tasks [28,51].
commands arriving at the ventral roots of the spinal cord [20]. The
cerebellum has also been implicated in motor learning and pre- In chronic effects, altered proprioception and subsequent impaired
programming of ballistic movements. actions outputs from the CNS and deficient muscular protection of
joint structures [52] may be pathophysiologically associated with
The role of proprioception in sensorimotor control is multifactorial. increased risk of injury and recurrence and persistence of pain
To plan appropriate motor commands, the CNS needs an updated disorders, including the onset and progression of secondary (post-
body schema of the biomechanical and spatial properties of the body injury) osteoarthrosis (OA) [53].
parts, supplied largely by proprioceptors [21]. Proprioception is
important also after movement for comparison of actual movement Reduced muscle performance [46,54], as a consequence of altered
with intended movement, as well as the predicted movement supplied mechanoreceptor input from injured structures to the CNS has
by the efference copy (corollary discharge). This is suggested to been associated with the onset and progression of peripheral joint
have importance for motor learning by updating of the internal OA in humans [55]. Trouble proprioception may also contribute to
forward model of the motor command [22]. During movements increased injury risk [56] and training directed towards improving
proprioception has importance for: feedback (reactive) and feed proprioception has been associated with reduced injury risk [57].
forward (preparatory) control, the regulation of muscle stiffness, Each strategy of intervention targeting normalized proprioception
to achieve specific roles for movement acuity, joint stability, co- and neuromuscular control, is relevant both in prevention and
ordination and balance [3,8,23]. Cervical proprioceptive information rehabilitation of movement disorders, and must follow some
also has a highly important specific role for head and eye movement guidelines [58] based on state of the art from neuroscience:
control [24].
1. Motor (re)learning and movement control should be associated
Changes and troubles in proprioceptive in-puts have been found with its goals: the whole body is organized and involved in the
to be associated with several neuromusculoskeletal disorders and/or
Int J Phys Ther Rehab IJPTR, an open access journal
Volume 1. 2015. 110
Citation: Oliveira R (2015) Reeducation Sensorimotor: Principles and A Model in Physiotherapy. Int J Phys Ther Rehab 1: 110. doi: http://dx.doi.org/10.15344/
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goal of the movement, including all anticipatory postural Indications and applications of sensorimotor programmes:
adjustments and motor pre-programming. The neuromotor
programmes are schemes representing movement sequences not a) Primary injuries prevention programs (integrated in training);
singular or specific muscle actions. All movement is goal or task b) Secondary injuries prevention programs after injury and/or
orientated. Motor control model. reintegration into the training (linked to the training - specific);
c) Improvement/optimization tasks in instability and/or fatigue
2. Muscles work always together in complex synergies – they contexts (improve specific performance);
never work alone or in an analytic away – through the CNS d) Integrated into therapeutic exercise program after an injury
coordination (intra-muscular & intermuscular). abnormal condition.
3. Neuromuscular activation is task-dependent; their role can
Any sensorimotor rehabilitation program must be personalized,
change in different tasks. Neuromuscular patterns activation
individualized and planned according to the specific needs of
change according to the ongoing task/function or change in the
each subject. This requires a careful clinical assessment before the
movement parameters. Functional approach.
imlementation any program. The sensorymotor programs should
4. All muscles are equally important in motor pattern, even the include:
muscles are silent (“off ”). Reciprocal innervation is a good
a) balance and coordination activities;
example.
b) dynamic joint stability exercices;
5. The proprioception and all somatosensory information are c) plyometric exercices (the stretch-shortening cycle);
essential for CNS: (a) planning patterns most appropriate d) Agility drills; Sport-specific demands/ exercises;
and efficient to the purpose; (b) give feedback to immediate
adjustments and refinement of movement; (c) motor learning It is essential to control a lot of parameters/factors, and the same time
and replenishing/reinforce existing programmes. Retrain or (re) they are criteria for increase the complexity and to have a rationale
learning a movement or a task is always reeducate information progression within the program:
inherent to this movement/task. Each and every movement is an
opportunity for sensorimotor training. a) Types of support: single leg/limb Vs both leg/limbs; multi-supports;
constant / intermittent supports.
6. Pain and fear´s pain, joint effusion, injury and fatigue central or
local could have important negative troubles in proprioception b) Types of surfaces:
and in neuromuscular patterns activation. We must always
1. Rigid and stable;
respect and understand these effects.
2. Rigid and unstable;
7. Promoting normal functional movement will “normalize” 3. Soft and unstable (Instability unidirectional / multidirectional);
proprioception and all information by facilitating positive regular / irregular
sensorymotor adaptations. All functional movements have c) Shoe types (for lower limbs): barefoot; daily shoes; sports specific
the adequate proprioceptive in-puts for motor learning and shoes.
refinement. d) Role of vision: eyes open / eyes closed
e) Kinetic chain open / Kinetic chain closed exercises: without/with
8. The main objective of neuromuscular rehabilitation is to bring weight bearing (partial / total).
motor control to an autonomous state where it becomes part of f) Parameters of exercises:
habitual movement repertoire. This requires practice.
1. Workload total: repetitions/rest time/range of motion/Types of
9. For effective motor learning, this practice must to apply some muscular contraction;
principles: a) to know the cognitive components of the practice; 2. Physiological loads/external loads;
b) being active and keep moving are key-words; c) recognize and 3. Uniaxial stimuli Vs multiaxial stimulus;
value feedback information for adjustments and corrections, d) g) All movement is goal or task orientated. Motor contol model
learning by repetition but avoid the repetitions of abnormal or exercises:
undesirable movements; e) promote the similarity: rehabilitation 1. Balance, coordination and control, speed and agility, time
should apply movement patterns that are similar to and within reaction and time stabilization, temporal coordinations and
rhythm;
the context of the movement or task being recovered; f) promote
the ability to transfer motor learning for new or unexpected 2. Horizontal/vertical/oblique displacements;
situations and contexts; g) encourage since early the functional 3. Jumps (plyometrics) and running progression;
autonomy. 4. Direction and/or speed changes: slow and planned Vs fast and
unforeseen;
10. Learning, retraining, motor organization to injury and/or 5. Programmed responses Vs responses to unforeseen / new
immobilization and return to functionality partly depend on situations;
the neurophysiological capacity of neuromuscular system 6. Tasks centered into the body Vs tasks centered on an external
to learn and adapt to new experiences and stimulus. Central objective – Automatization;
and peripheral adaptations are complementary and occur 7. Basic movements of the sport or daily activities Vs specific and
concurrently. complex movements of the sport or daily activities;
8. Manage and control the increased risk of movements;
11. Neuromuscular rehabilitation is more about facilitating 9. Manage and control in fatigue conditions (peripheral / central);
cognitive-sensory-motor processes and providing a stimulating
10. Particular considerations in programs for children/adolescents
and variations-rich environment. It is not just physical exercising. and in some conditions for women.

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Citation: Oliveira R (2015) Reeducation Sensorimotor: Principles and A Model in Physiotherapy. Int J Phys Ther Rehab 1: 110. doi: http://dx.doi.org/10.15344/
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