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
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
Physiotherapy is the science and practice to prevent, assess and
treat movement disorders. Knowledge and understanding of the
mechanisms and processes of (re) motor learning, the control of
human movement and any changes in the case of neuro-musculo-
skeletal disorders are essential in implementing the appropriate
strategies to efficiently restore functionality.
The sensorimotor or neuromotor reeducation should be based thus
on neurophysiological and biomechanical principles neuromuscular
control. The evolution of Physiotherapy as a scientific discipline
based on evidence still requires an applied or clinical research studies
that integrate the most current concepts of neuroscience in clinical
practice.
This paper aims to review and briefly describe the key concepts
of neuromuscular control that must underlie and based the clinical
interventions in movement dysfunctions.
Neuromotor Control & The Sensorimotor System-Key Concepts
Sensorimotor control refers to central nervous system (CNS)
control of movement, balance, posture, and joint stability [1,2]. Well-
adapted motor actions require intact and well integrated information
from all of the sensory systems, specifically the visual, vestibular and
somatosensory systems, including proprioception [3,4].
The sensorimotor system, a functional unit of the comprehensive
motor control system of the body, is extremely complex and has some
different dimensions. The term sensorimotor system was adopted by
the participants of the 1997 Foundation of Sports Medicine Education
and Research workshop to describe the sensory, motor, and central
integration and processing components involved in maintaining joint
homeostasis during bodily movements (functional joint stability) [5].
The components giving rise to functional joint stability must
be flexible and adaptable because the required levels vary among
both persons and tasks. The process of maintaining functional joint
stability is accomplished through a complementary and constant
interaction between static and dynamic components. Joint capsule,
ligaments, cartilage, friction, and the bony architecture within the
articulation comprise the static (passive) components [6,7]. Dynamic
contributions arise from feed forward and feedback neuromotor
mechanisms over the skeletal muscles crossing the joint. Underlying
the effectiveness of the dynamic restraints are the biomechanical and
physical characteristics of the joint.
Neuromuscular control is a frequently used term in many disciplines
related to motor control. It can refer to any of the aspects surrounding
nervous system control over muscle activation and the factors
contributing to task performance. Specifically, from a joint stability
perspective, we define neuromuscular control as the unconscious
activation of dynamic restraints occurring in preparation for and in
response to joint motion and loading for the purpose of maintaining
and restoring functional joint stability. Although neuromuscular
control underlies all motor activities in some form, it is not easily
separated from the neural commands controlling the overall
motor program [6]. Our brains are depicted actions or movements
Int J Phys Ther Rehab
Open Access
Publication History:
Received: December 09, 2015
Accepted: December 30, 2015
Published: December 31, 2015
Keywords:
Physiotherapy, Sensorimotor, Neuromotor, Neuromuscular control,
Central nervous system
operationalized through motor programs that have a purpose and
not muscles in isolation. For example, in shoulder overhead activities
like tennis serve or javelin throw, particular neuromuscular activation
sequences and coordination occur between the rotator cuff muscles
and scapula muscles (scapulo-humeral rhythm) to ensure that the
optimal glenohumeral alignment and compression required for
dynamic joint stability are provided. These muscle activations take
place unconsciously and synonymously with the voluntary muscle
activations directly associated with the particulars of the task
(ie, aiming, speed, distance, range of movement). Proprioceptive
information concerning the status of the joint and associated
structures is essential for neuromuscular control [7].
Proprioception involves conscious or unconscious awareness
of joint position (joint position sense), movement (kinesthesia),
and force, heaviness, and effort (force sense) [8,9]. Proprioception
is processed at all levels of the Central Nervous System (CNS) and
is integrated with other somatosensory information (visual and
vestibular) before culminating in a final motor command that
co-ordinates the activation patterns of skeletal muscles [3,10].
Proprioception is the product of sensory information supplied by
specialized nerve endings termed mechanoreceptors, i.e., transducers
converting mechanical stimuli to action potentials for transmission
to the CNS [9,11]. Mechanoreceptors specifically contributing to
proprioception are termed proprioceptors and are found in muscle,
tendon, joint and fascia, receptors in the skin can also contribute
to proprioception [9,12]. Proprioceptive information is processed
at the spinal level, brain stem and higher cortical centers, as well as
subcortical cerebral nuclei and cerebellum [13-16].
From the spinal cord arise direct motor responses to peripheral
sensory information (reflexes) and elementary patterns of motor
coordination (rhythmic and central pattern generators). Despite
being the most primitive part of the brain from a phylogenetic
perspective, [17] the brain stem contains major circuits that control
postural equilibrium and many of the automatic and stereotyped
movements of the body [3,18,19]. In addition to being under direct
cortical command and providing an indirect relay station from the
*
Corresponding Author: Dr. Raul Oliveira, Laboratory of Motor Behavior.
Human Kinetics Faculty, University of Lisbon, Alameda da Universidade, 1649-
004 Lisboa, Portugal; E-mail: roliveira@fmh.ulisboa.pt
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
Copyright: © 2015 Oliveira. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author
and source are credited.
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
cortex to the spinal cord, areas of the brain stem directly regulate
and modulate motor activities based on the integration of sensory
information from visual, vestibular, and somatosensory sources [3]. In
general, the motor cortex is responsible for initiating and controlling
more complex and discrete voluntary movements. It is divided into
three specialized and somatotopically organized areas, each of which
project directly and indirectly (via the brain stem) onto interneurons
and motor neurons located in the gray substance of spinal cord. The
major direct descending pathway from the motor cortex to the alpha
motor neurons and gamma motor neurons is the corticospinal tract.
In addition to influencing motor functions directly, the corticospinal
tract also affects motor activity indirectly through the descending
brain stem pathways [3].
Although the cerebellum and basal ganglia associate areas cannot
independently initiate motor activity, they are essential for the
execution of coordinated motor control. The cerebellum, operating
entirely at a subconscious level, plays a major role in both the
planning and modification of motor activities though comparison
of the intended movement with the outcome movement [3,20].
This is accomplished through the continuous inflow of information
from the motor control areas and the central and peripheral sensory
areas. The cerebellum has three functional divisions. The first
division receives vestibular input, both directly and indirectly from
the vestibular labyrinth (semicircular and otolith receptors) and,
as might be surmised based on the input, is involved with postural
equilibrium. The second cerebellar division is mainly responsible for
the planning and initiation of movements, especially those requiring
precise and rapid dexterous limb movements. It is the third division,
the spinocerebellum, which receives the somatosensory information
conveyed through the 4 ascending spinocerebellar tracts. In addition
to the somatosensory input, this division of the cerebellum also
receives input from the vestibular labyrinth and visual and auditory
organs. The output from the spinocerebellum serves to adjust ongoing
movements through influential connections on the medial and lateral
descending tracts in the brain stem and cortex via projections on
the vestibular nucleus, reticular formation, red nucleus, and motor
cortex. In addition to controlling movements, the spinocerebellum
also uses the somatosensory input for feedback regulation of muscle
tone through regulation of static g-MN drive to the muscle spindles
[3]. Lastly, the cerebellum also receives an efferent copy of the motor
commands arriving at the ventral roots of the spinal cord [20]. The
cerebellum has also been implicated in motor learning and pre-
programming of ballistic movements.
The role of proprioception in sensorimotor control is multifactorial.
To plan appropriate motor commands, the CNS needs an updated
body schema of the biomechanical and spatial properties of the body
parts, supplied largely by proprioceptors [21]. Proprioception is
important also after movement for comparison of actual movement
with intended movement, as well as the predicted movement supplied
by the efference copy (corollary discharge). This is suggested to
have importance for motor learning by updating of the internal
forward model of the motor command [22]. During movements
proprioception has importance for: feedback (reactive) and feed
forward (preparatory) control, the regulation of muscle stiffness,
to achieve specific roles for movement acuity, joint stability, co-
ordination and balance [3,8,23]. Cervical proprioceptive information
also has a highly important specific role for head and eye movement
control [24].
Changes and troubles in proprioceptive in-puts have been found
to be associated with several neuromusculoskeletal disorders and/or
Int J Phys Ther Rehab
Page 2 of 5
experimental conditions following pain, joint effusion, abnormal
movement and/or posture pattern and trauma as well as neural and
muscular fatigue.
There are a lot of research studies reported disturbed
proprioception in acute and chronic musculoskeletal pain disorders
at the cervical [25,26] and lumbar [27,28] spine, as well as shoulder
[29], elbow disorders [30] and knee disorders [31]. When there is
pain, proprioception can be disturbed due to altered reflex activity
and sensitivity of the gamma-muscle spindle system via activation
of chemosensitive type III and IV afferents (nociceptors) [32]. Pain
can moreover influence body perception at the central level [33,34],
including reorganization of the somatosensory cortex [35]. Thus pain
can negatively influence proprioception at both peripheral and central
levels of the CNS.
Joint effusions can cause significant inhibition of muscle
activation, and can also in the absence of pain, significantly impair
extremity proprioception [36]. Following trauma, and after pain
and swelling have resolved, the loss of musculoskeletal tissue and
its mechanoreceptors is associated with persistent impairment of
proprioception [37,38].
A common phenomenon in fatigue conditions after performing
hard physical work or exercise (especially eccentric training) is the
experience of clumsiness and difficulty performing fine motor tasks,
verified in several studies demonstrating impaired proprioception
[39-41]. Thus the potential for increased injury risk exits in fatigue
conditions. Associated to the causes reported, deleterious effects on
proprioception have also been reported in association with conditions
such as local [42] and general [43] joint hypermobility, stenosis [44] as
well as due to immobilization [45].
In acute effects, disturbed proprioception is likely to have adverse
influence on feedback and feedforward motor control and the
regulation of muscle stiffness. It may also explain various sensorimotor
dysfunctions (besides increased errors in specific proprioception
tests), which have been reported in the research literature. These
dysfunctions include reduced drive to alpha motor neurons [46],
disturbed reflex joint stabilization [47], increased postural sway in
balance tasks [48-50] and increased error in visual movement acuity
tasks [28,51].
In chronic effects, altered proprioception and subsequent impaired
actions outputs from the CNS and deficient muscular protection of
joint structures [52] may be pathophysiologically associated with
increased risk of injury and recurrence and persistence of pain
disorders, including the onset and progression of secondary (post-
injury) osteoarthrosis (OA) [53].
Reduced muscle performance [46,54], as a consequence of altered
mechanoreceptor input from injured structures to the CNS has
been associated with the onset and progression of peripheral joint
OA in humans [55]. Trouble proprioception may also contribute to
increased injury risk [56] and training directed towards improving
proprioception has been associated with reduced injury risk [57].
Each strategy of intervention targeting normalized proprioception
and neuromuscular control, is relevant both in prevention and
rehabilitation of movement disorders, and must follow some
guidelines [58] based on state of the art from neuroscience:
1. Motor (re)learning and movement control should be associated
with its goals: the whole body is organized and involved in the
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
goal of the movement, including all anticipatory postural
adjustments and motor pre-programming. The neuromotor
programmes are schemes representing movement sequences not
singular or specific muscle actions. All movement is goal or task
orientated. Motor control model.
2. Muscles work always together in complex synergies – they
never work alone or in an analytic away – through the CNS
coordination (intra-muscular & intermuscular).
3. Neuromuscular activation is task-dependent; their role can
change in different tasks. Neuromuscular patterns activation
change according to the ongoing task/function or change in the
movement parameters. Functional approach.
4. All muscles are equally important in motor pattern, even the
muscles are silent (“off ”). Reciprocal innervation is a good
example.
5. The proprioception and all somatosensory information are
essential for CNS: (a) planning patterns most appropriate
and efficient to the purpose; (b) give feedback to immediate
adjustments and refinement of movement; (c) motor learning
and replenishing/reinforce existing programmes. Retrain or (re)
learning a movement or a task is always reeducate information
inherent to this movement/task. Each and every movement is an
opportunity for sensorimotor training.
6. Pain and fear´s pain, joint effusion, injury and fatigue central or
local could have important negative troubles in proprioception
and in neuromuscular patterns activation. We must always
respect and understand these effects.
7. Promoting normal functional movement will “normalize”
proprioception and all information by facilitating positive
sensorymotor adaptations. All functional movements have
the adequate proprioceptive in-puts for motor learning and
refinement.
8. The main objective of neuromuscular rehabilitation is to bring
motor control to an autonomous state where it becomes part of
habitual movement repertoire. This requires practice.
9. For effective motor learning, this practice must to apply some
principles: a) to know the cognitive components of the practice;
b) being active and keep moving are key-words; c) recognize and
value feedback information for adjustments and corrections, d)
learning by repetition but avoid the repetitions of abnormal or
undesirable movements; e) promote the similarity: rehabilitation
should apply movement patterns that are similar to and within
the context of the movement or task being recovered; f) promote
the ability to transfer motor learning for new or unexpected
situations and contexts; g) encourage since early the functional
autonomy.
10. Learning, retraining, motor organization to injury and/or
immobilization and return to functionality partly depend on
the neurophysiological capacity of neuromuscular system
to learn and adapt to new experiences and stimulus. Central
and peripheral adaptations are complementary and occur
concurrently.
11. Neuromuscular rehabilitation is more about facilitating
cognitive-sensory-motor processes and providing a stimulating
and variations-rich environment. It is not just physical exercising.
Int J Phys Ther Rehab
Page 3 of 5
Indications and applications of sensorimotor programmes:
a) Primary injuries prevention programs (integrated in training);
b) Secondary injuries prevention programs after injury and/or
reintegration into the training (linked to the training - specific);
c) Improvement/optimization tasks in instability and/or fatigue
contexts (improve specific performance);
d) Integrated into therapeutic exercise program after an injury
abnormal condition.
Any sensorimotor rehabilitation program must be personalized,
individualized and planned according to the specific needs of
each subject. This requires a careful clinical assessment before the
imlementation any program. The sensorymotor programs should
include:
a) balance and coordination activities;
b) dynamic joint stability exercices;
c) plyometric exercices (the stretch-shortening cycle);
d) Agility drills; Sport-specific demands/ exercises;
It is essential to control a lot of parameters/factors, and the same time
they are criteria for increase the complexity and to have a rationale
progression within the program:
a) Types of support: single leg/limb Vs both leg/limbs; multi-supports;
constant / intermittent supports.
b) Types of surfaces:
1. Rigid and stable;
2. Rigid and unstable;
3. Soft and unstable (Instability unidirectional / multidirectional);
regular / irregular
c) Shoe types (for lower limbs): barefoot; daily shoes; sports specific
shoes.
d) Role of vision: eyes open / eyes closed
e) Kinetic chain open / Kinetic chain closed exercises: without/with
weight bearing (partial / total).
f) Parameters of exercises:
1. Workload total: repetitions/rest time/range of motion/Types of
muscular contraction;
2. Physiological loads/external loads;
3. Uniaxial stimuli Vs multiaxial stimulus;
g) All movement is goal or task orientated. Motor contol model
exercises:
1. Balance, coordination and control, speed and agility, time
reaction and time stabilization, temporal coordinations and
rhythm;
2. Horizontal/vertical/oblique displacements;
3. Jumps (plyometrics) and running progression;
4. Direction and/or speed changes: slow and planned Vs fast and
unforeseen;
5. Programmed responses Vs responses to unforeseen / new
situations;
6. Tasks centered into the body Vs tasks centered on an external
objective – Automatization;
7. Basic movements of the sport or daily activities Vs specific and
complex movements of the sport or daily activities;
8. Manage and control the increased risk of movements;
9. Manage and control in fatigue conditions (peripheral / central);
10. Particular considerations in programs for children/adolescents
and in some conditions for women.
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
Competing Interests
The authors have no competing interests with the work presented
in this manuscript.
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