FRENKEL’S EXERCISES

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Introduction

            Dr. H. S. Frenkel was Medical Superintendent of the Sanatorium Freihof in Switzerland towards the end of the last century. He made a special study of Tabes Dorsalis and devised a method of treating the ataxia, which is a prominent symptom of the disease, by means of systematic and graduated exercises.

 

He aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact.The capacity to execute smooth exact engine reaction relies upon:

1. Vision.

2. Profound sensations.

3. Motor framework.

4. Vestibular framework and cerebellum.

5. Adaptability and ROM.

 

This is to compensate for the loss of kinaesthetic sensation so that the patient is able and confident in his ability to carry out those activities which are essential for independence in everyday life.

 

Indications:

• Cerebellar ataxia

• Tabes Dorsalis

• Stroke

• Parkinson’s disease

• Multiple sclerosis

• Cerebral palsy

• Wilson’s disease

 

Mechanism:

The process of learning this alternative method of control is similar to that required to learn any new exercise, the essentials being –

1. Concentration of the attention.

2. Precision.

3. Repetition.

 

Factors affecting the exercises:

• Pain

• Deformity 

• Asymmetry

• Mental and psychological stress

• Obesity

 

Technique:

1. The patient is positioned and suitably clothed and the area is well lit so that he can see the limbs throughout the exercise.

2. A concise explanation and demonstration of the exercise is given before movement is attempted, to give the patient a clear mental picture of it.

3. The patient must give his full attention to the performance of the exercise to make the movement smooth and accurate.

4. The speed of movement is dictated by the physiotherapist by means of rhythmic counting,movement of her hand, or the use of suitable music.

5. The range of movement is indicated by marking the spot on which the foot or hand is to be placed.

6. Exercises are designed primarily for coordination; they are not intended for strengthening.

7. The exercise must be repeated many times until it is perfect and easy. It is then discarded anda more difficult one is substituted.

8. The first simple exercises should be adequately performed before progressing to more difficult patterns.

9. As these exercises are very tiring at first, frequent rest periods must be allowed. The patient retains little or no ability to recognize fatigue, but it is usually indicated by a deterioration in the quality of the movement, or by a rise in the pulse rate.

10. Group work is of great value as control improves, as it teaches the patient to concentrate on his own efforts without being distracted by those of other people. In walking, he gains confidence and becomes accustomed to moving about with others, to altering direction and stopping if he wishes, to avoid bumping into them. The ability to climb stairs and to step on and off a kerb helps him to independence.

11. These sessions should be done every day for at least six weeks.

 

Progression:

1. Progression is made by altering the speed, range and complexity of the exercise. Fairly quick movements require less control than slow ones.

2. Later, alteration in the speed of consecutive movements,and interruptions which involve stopping and starting to command, are introduced.

3. Wide range and primitive movements, in which large joints are used, gradually give way to those involving the use of small joints, limited range and a more frequent alteration of direction.

4. Finally simple movements are built up into sequences to form specific actions which require the use and control of a number of joints and more than one limb, e.g. walking.

5. According to the degree of disability, re-education exercises start in lying with the head propped up and with the limbs fully supported and progress is made to exercises in sitting, and then in standing.

 

Examples of Frenkel's Exercises:

 

Exercise for the legs in lying

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• Lying (Head raised); Hip abduction and adduction. The leg is fully supported throughout on the smooth surface of a plinth or on a re-education board.

• Lying (Head raised); one Hip and Knee flexion and extension. The heel is supported throughout and slides on the plinth to a position indicated by the physiotherapist.

• Lying (Head raised); one Leg raising to place Heel on specified mark. The mark may be made on the plinth, on the patient's other foot or shin, or the heel may be placed in the palm of the physiotherapist's hand.

• Lying (Head raised); Hip and Knee flexion and extension, abduction and adduction. The legs may work alternately or in opposition to each other.Stopping and starting during the course of the movement may be introduced to increase the control required to perform any of these exercises.

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Exercise for the legs in sitting

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• Sitting; one Leg stretching, to slide Heel to a position indicated by a mark on the floor.

• Sitting; alternate Leg stretching and lifting to place Heel or Toe on specified mark.

• Stride sitting; change to standing and then sit down again - The feet are drawn back and the trunk inclined forwards from the hips to get the centre of gravity over the base. The patient then extends the legs and draws himself up with the help of hishands grasping the wall-bars or other suitable apparatus.

 

Exercise for the legs in standing

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• Stride standing; transference of weight from Foot to Foot.

• Stride standing; walking sideways placing Feet on marks on the floor. Some support may be necessary, but the patient must be able to see his feet.

• Standing; walking placing Feet on marks. The length of the stride can be varied by the physiotherapist according to the patient's capacity.

• Standing; turn round. Patients find this difficult and are helped by marks on the floor.

• Standing; walking and changing direction to avoid obstacles.

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Exercises for the arms

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• Sitting (one Arm supported on a table or in slings); Shoulder flexion or extension to place. Hand on a specified mark.

• Sitting; one Arm stretching, to thread it through a small hoop or ring.

• Sitting; picking up objects and putting them down on specified marks. Diversional activities such as plaiting, building with toy bricks, or drawing on a blackboard, lead to more useful movements such as using a knife and fork, doing up buttons and doing the hair.

 

Reference

1. M. Dena Gardiner , The Principles of exercise therapy, 4th edition , Page no. – 240 – 243

2. Textbook of Rehabilitation by S Sunder

3. PHYSICAL REHABILITATION; SIXTH EDITION; BY SUSAN B.O’SULLIVAN.