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Anwesh Pradhan, MPT, PhD Scholar
Associate Professor, Nopany Institute of
Healthcare Studies, Kolkata
Consultant Physiotherapist, Mobility
Physiotherapy & Rehabilitation, Midnapore
Facilitatory and Inhibitory
Techniques
used in Neuro Physiotherapy
What are the sensory motor
approaches?
Rood’s approach
PNF
Neurodevelopmental approach
Sensory integration
Brunnstrom’s movement therapy
Theoretical Basis
Reflex and Hierarchical Theory
 The basic unit of motor control are reflexes
 reflexes => purposeful movement
 Damage to the CNS results to re-emergence of the
inability to control the reflexes
 Motor control is hierarchically arranged
 CNS structures involved with movement can be
grouped into higher, middle and lower levels
 Higher centers regulate and control the middle and
lower centers
 Damage to the CNS results to disruption of the
normal coordinated function of these levels
Manual Facilitatory and Inhibitory
Techniques
Quick stretch
 Receptor: muscle spindle endings, detecting length
and
velocity changes.
 Stimulus: quick stretch or tapping over muscle belly
or
tendon
 Response: activates agonist to contract: reciprocal
innervation effect will inhibit the
antagonist;
activates synergists.
 Response is temporary; can add resistance to
Prolonged stretch
 Receptor: muscle spindle endings and golgi
tendon organ
 Stimulus: maintained stretch in a lengthened
range
 Response: dampens muscle contraction
 Rationale for serial casting and splinting to
increase the effect, activates the antagonist.
Resistance
 Receptor: muscle spindles
 Stimulus: resistance given manually or with
body weight or gravity or mechanical weights
 Response: enhances muscle contraction
through recruitment; facilities synergists,
enhances kinesthetic awareness
 Resistance needs to be graded dependent on
the patient response and goal; additional
recruitment and overflow may be
counterproductive to movement goal.
Approximation
 Receptor: joint receptors
 Stimulus: Compression of joint surfaces;
manual or mechanical; bouncing; applied in
weight bearing
 Response: enhances muscular contraction,
proximal stability and postural extension,
increases kinesthetic awareness and postural
stability.
 Effective in combination with rhythmic
stabilization, contraindicated in inflamed
joints.
Traction
 Receptor: joint receptors.
 Stimulus: joint surfaces distracted, usually
manually and at the beginning of movement.
 Response: Facilitates muscle activation to
improve mobility and movement initiation.
 Useful to activate initial mobility; also used as
part of mobilization.
Inhibitory pressure
 Receptor: golgi tendon organ, muscle
spindles, tactile receptors.
 Stimulus: Firm pressure manually or with body
weight over muscle belly or tendon.
 Response: Inhibits muscle activity; damping
effect.
 Equipment can be used to achieve effect;
casts and splints, weight bearing activities can
provide inhibitory pressure.
Light touch
 Receptor: Rapidly adapting tactile receptors,
autonomic nervous system (sympathetic
division).
 Stimulus: Brief, light contact to skin.
 Response: Increased arousal, withdrawal
response.
 Effective in initiating a generalized movement
response, to elicit arousal, contraindicated
with agitated patients or where ANS is
unstable.
Maintained touch
 Receptor: Slowly adapting tactile receptors,
ANS (parasympathetic division).
 Stimulus: Maintained contact or pressure.
 Response: Calming effect, desensitizes skin,
provides general inhibition.
 Useful for patients with high level of arousal or
hypersensitivity.
Manual contacts
 Receptor: Tactile receptors, muscle
proprioceptors.
 Stimulus: Firm, deep pressure of hands over
body area.
 Response: Facilitates contraction of muscle
underneath hands.
 Activates muscle response; enhances
sensory and kinesthetic awareness; provides
security and support.
Slow stroking
 Receptor: Tactile receptors
ANS(parasympathetic division)
 Stimulus: Slow, firm stroking with flat hand
over neck or trunk extensors.
 Response: Produces calming effect, general
inhibition; induces feeling of security.
 Appropriate for overly aroused patients.
Neutral warmth
 Receptor: Thermo receptors
ANS(parasympathetic division)
 Stimulus: Towel or elastic wrap of body or
body parts(warm)
 Response: Provides general relaxation and
inhibition; decreased muscle tone; decreased
agitation or pain.
 Use for 10-15 mins; avoid overheating;
appropriate for highly agitated patients or
individuals with increased sympathetic
response.
Slow vestibular stimulation
 Receptor: Tonic vestibular receptors
 Stimulus: Slow rocking, slow movement on
ball, in hammock, in rocking chair.
 Response: Produces calming effect,
decreased arousal, generalized inhibition.
 Useful for patients who are defensive to
sensory stimulation, hyperreactive to
stimulation, hypertonic or agitated.
Fast vestibular stimulation
 Receptor: Semicircular canals
 Stimulus: Fast or irregular movement with
acceleration and deceleration component,
such as spinning, use of a scooter board, fast
rolling.
 Response: Facilitates general muscle tone
and promotes postural responses to
movement.
 Used with patients with hypotonia (CP, Down
syndrome); used to promote sensory
integration.
Roods approach
 Margarate Rood
Premise
 Motor patterns are developed from fundamental
patterns/ reflexes which are refined and
controlled as an individual mature
 Sensory stimulation is applied to muscles and
joints---> normalize tone--> produce desired
movement
 Sensorimotor control is developmental
 Movement should be purposeful
 Repetition of sensorimotor responses is
necessary
The Goals
The Goals and basic features of Rood’s theory are:
 Normalize muscle tone
 Treatment begins at the developmental level of
functioning
 Movements is directed toward functional goals
 Repetition is necessary for the re-education of
muscular response.
Principles of treatment
 Tonic neck reflex and labyrinthine reflexes can
assist or retard the effects of sensorimotor
stimulation
 Stimulation of specific receptors to produce
response
RULES OF SENSORY INPUT
 A fast, brief stimulus produces a large
synchronous movement
 A fast, repetitive produces a maintained response
 Slow. Rhythmical, repetitive sensory input
deactivates the body
Principles of treatment
 Muscles have different duties
 Heavy work muscles: Stabilizers (Maintenance of
posture)
 Light work muscles: Mobilizers (Skilled
movement, repetitive or rhythmical patterns of
distal musculature)
 Heavy work muscles should be integrated before
light work muscles
Components of Motor Control (Four)
1. Reciprocal inhibition
 Innervation, MOBILITY
 Phasic or quick type movements
 Contraction of agonist while antagonists relaxes
 Serves a protective function
2. Cocontraction
 Coinnervation, STABILITY
 Tonic or static type of movement
 Simultaneous contraction of the agonist and
antagonist
 Foundation of postural control
3. Heavy work
 Mobility superimposed on stability
 Proximal muscles contract and move while distal
segments are fixed
4. Skill
 Mobility and stability
 Proximal segments are stabilized while distal
segments move
Ontogenic developmental
patterns
 Supine withdrawal (supine flexion)
 Rollover to sidelying
 Pivote prone (prone extension)
 Neck cocontraction
 Prone on elbows
 Quadruped
 Standing
 Walking
Techniques and strategies
 FACILITATORY
TECHNIQUES
1. Cutaneous facilitation
 Light moving touch
 Fast brushing
2. Thermal facilitation
 A- icing
 C- icing
 Autonomic icing
3. Proprioceptive
facilitation
 Heavy joint
compression
 Quick stretch
 Intrinsic stretch
 Secondary ending
stretch
 Stretch pressure
 Resistance
 Tapping
 Vestibular stimulation
 Inversion
 Therapeutic vibration
 Osteo- pressure
Techniques and strategies
 INHIBITATORY TECHNIQUES
1. Neutral warmth
2. Gentle shaking or rocking
3. Slow rolling
4. Tendinous pressure
5. Light joint compression
6. Maintained stretch
7. Rocking in developmental positions
Cutaneous Stimulation by Quick Light
Brushing:
 This is used as a preparatory facilitation to
increase excitability of motor neurons which
supply inhibited muscles.
 The area to be brushed is specific in terms of the
nerve root supply to skin and muscles.
 A soft artist’s or decorator’s brush is used or if
available, an electrically powered brush is used.
 For skin supplied by anterior primary rami, the
excitatory effect is local and mainly to superficial
muscles.
 For skin supplied by posterior primary rami, the
effects is excitatory to deep back muscles.
Brief Application of Cold
 Quick wipe with ice ha san excitatory effect which
is immediate and most effective when applied to
skin overlying the extensors of limbs and when
the part is warm.
 Brushing or ice application to the palmer surface
of the finger tips alerts mental processes but
should be avoided if spasticity is present.
 Ice applied to the lips or tongue facilitates
sucking, swallowing and speech.
Slow Stroking
 If this is carried out from neck to sacrum over the
centre of the back it will reduce choreo-athetosis or
excessive muscle tone.
 It should be applied rhythmically for 3 minutes.
Precautions:
USE OF BRUSHING:
1. The area brushed is very specific in terms of
dermatome and myotome.
2. It should be used only for upto 3 seconds in one
place at a time; maximum effect can be delayed
for 20 to 30 minutes where nerve pathways
have not been active through disuse or
inhibition.
Precautions:
3. Do not use mechanical tools with revolutions of
360 or higher to operate a brush as this can
completely inhibit nerve pathways.
4. In case of flaccidity, brushing may cause a
seizure; should this occur slow rhythmical
stroking should be used over the posterior rami
dermatomes for 3 minutes.
5. Brushing the skin of the ear and the outer thirds
of forehead should be avoided as it has central
inhibiting effect.
Precautions:
WHILE USING ICE:
1. Ice used behind the ear can lead to a sudden
lowering of the blood pressure.
2. Ice applied to special receptors areas in the
sole of the feet or the palm of the hand should
be avided in young children as it is potentially
nocioceptive.
3. Ice applied over the skin supplied by the
posterior primary rami may set up a chain of
effects on viscera over which one has on
control.
4. Ice used on left shoulder may be dangerous if
there is known cardiac disease.
PNF
 Herman Kabat
 Maggie Knott
 1940-1956
 Voss and Meyers.
 Proprioceptive neuromuscular facilitation
(PNF) is a rehabilitation technique that was
initiated over 50 years ago. It is used to
stimulate the neuromuscular system in an
effort to excite proprioceptors (sensory organs
in muscles, tendons, bones, and joints) in
order to produce a desired movement.
by Ph.D Mark Damian Rossi, P.T.,
C.S.C.S.
 Knott and Voss defined facilitation as “the
promotion of any natural process; specifically,
the effect produced in nerve tissue by the
passage of an impulse”.
 The term proprioceptive means sensory
stimulation that is received from the receptors
within the body’s own muscles, tendons and
joints.
 Neuromuscular means this technique applies
to the nerves and the muscles.
 Therefore PNF is defined as an approach that
includes methods of promoting or hastening
the response of the neuromuscular
mechanism through stimulation of the
proprioceptors.
Stimulation techniques used during
PNF
Manual contacts
 Application: Pressure is given to the skin over
muscle being facilitated.
 Presumed benefit: Manually contacting the
patient utilizes sensory cues to direct the
patient’s attention to the desired movement.
Pressure activates mechanoreceptors.
Vision
 Application: Patient is asked to watch the
movement and to participate in giving the
movement direction.
 Presumed benefit: Visually directed
movement is used as reinforcement and to
offer extrinsic feedback to the patient as he or
she learns the movement.
Verbal commands
 Application: Tone of voice and specific
commands are used selectively to prepare the
patient for movement, direct the movement
and motivate the patient.
 Presumed benefit: voice is used to affect the
quality of the patient’s response. Tone and
timing of commands are used as teaching
aids.
Stretch
 Application: Quick stretch is given to the
muscle being facilitated. Stretch can be
applied at the beginning of the motion or
intermittently throughout the range of motion
to activate or reinforce muscle activation/
contraction.
 Presumed benefit: Quick stretch activates the
muscle spindles and excites the agonist
muscle through activation of the
monosynaptic reflex arc.
Traction
 Application: Separation of the joint surfaces to
activate joint receptors.
 Presumed benefit: Traction stimulus activates
proprioceptive joint receptors, theorized to
promote movement.
Approximation
 Application: Compression of joint surfaces
together, usually done with body part in a
weight bearing position.
 Presumed benefit: approximation is used to
activate proprioceptive joint receptors to
promote muscular co-contraction, joint
stability and weight bearing.
Timing
 Application: Timing is selectively used by the
therapist to either facilitate motor learning as the
patient recognizes the familiarity of a frequently
used movement pattern(normal timing) or to
emphasize a specific portion of the movement
pattern (timing for emphasis)
 Presumed benefit: The movement patterns used
in PNF are based on typically occurring patterns
of normal movement, used in work and sports.
Timing is an important component of learning a
movement pattern.
Rhythmic stabilization
 Application: Rhythmic, alternating isometric
contractions of agonist and antagonist without
intermittent relaxation; resistance is carefully
graded to achieve co-contraction.
 Presumed benefit: Used to promote weight
bearing and holding and improve postural
stability, strength and proximal control.
Brunnstrom’s approach
 Signe Brunnstrom (1970)
 Brunnstrom is credited with two main
contributions: a description of the stereotypical
synergy patterns and the recovery stages of
patients seen following a cerebrovascular
accidents.
 It highlights the importance of the current
emphasis on working towards the goal of
voluntary control and functional limitations
experienced by patients as they work towards
recovery.
 A basic concept of Brunnstrom’s approach is
that of synergies or motor patterns which are
patterned, recognizable flexion, or extension
movements of the entire limb, evoked by
attempts to move or by sensory stimulation,
characteristically seen during the period of
recovery following a neurological incident
such as CVA.
 Repeated use of the synergy which makes
isolated motor control more difficult, is viewed
as inappropriate and undesirable.
 Practical training activities to stimulate out of
synergy isolated movements are encouraged.
 Concepts of motor learning such as positive
reinforcement and repetition are
stressed(Sawner & La Vigne,1992; Smith &
Sharpe,1994).
 The stages of recovery are used as an overall
framework from which to view the patient’s
progression towards recovery of voluntary
motor control(Martin & Kessler,2000).
NEURODEVELOPMENTAL
TECHNIQUE (NDT)
 Dr. Karl and Berta Bobath during the 1950s.
 Originally, NDT concentrated on the effects of the
disturbed postural control mechanism on
movement.
 Its basic concept is that motor function can be
improved by modifying abnormal movement
patterns, and movement is a changeable,
dynamic phenomenon that can be affected by
external sensory inputs. (Bobath and Bobath,
1984; Valvano & Long, 1991)
NDT Techniques
Handling
 Clinical use: Hands are used to support and
assist movement (active and passive) from
one position to another; active assisted
movement is always encouraged.
 Application: Use of hands; light touch,
intermittent touch or firm manual contact to
guide and assist with movement.
Positioning
 Clinical use: Used to provide alignment,
comfort, support, prevent deformity and
provide readiness to support or enhance
independent movement.
 Application: Positioning for support is used to
provide stability and alignment and prevent
deformity.
 Positioning is also used to promote optimal
independent function or position from which
movement can most likely occur.
Use of adaptive equipment
 Clinical use: Used to provide postural support,
prevent deformity, promote alignment,
enhance function and offer mobility, a
common adjunct to intervention for children
with neurological impairment.
 Application: Equipment can be used
dynamically to assist in movement control.
Key points of control
 Clinical use: Parts of the body are chosen as
optimal from which to guide the person’s
movement.
 Application: Proximal key points of control
include trunk, shoulders and pelvis; distal
points are hands and feet.
Facilitating transitional movement
 Clinical use: Facilitates key movement
components during active transitional
movement.
 Application: Provides facilitation of antigravity
control, weight bearing, weight shifting,
responses to movement such as automatic
postural responses, rotation and dissociation.
Use of sensory input
 Clinical use: Voluntary movement control is
facilitated through use of proprioceptive
inputs, exteroceptive inputs, visual, vestibular
and verbal inputs.
 Application: proprioceptive inputs include
weight bearing, approximation, stretching and
traction or tapping.
 Exteroceptive inputs include manual guidance
and therapeutic use of hands.
Motor learning strategies
 Clinical use: Active movement is encouraged
through practice, repetition, feedback and use
of functional activities.
 Application: Use of variable practice and
problem solving in natural environment
promotes motor learning.
Sensory integration
 Founded and popularized by Jean Ayres (1973).
 It is based on three main assumptions:
1. Individuals receive information from their
bodies and the environment, process and
interpret the information within their CNS
and use the information in a functional
manner.
2. Individuals with sensory processing will
demonstrate problems in planning and
execution of adaptive responses.
3. Individuals who receive stimulation within a
meaningful context will have the opportunity
to integrate the sensory information,
demonstrating more efficient motor skills and
adaptive behaviors (Long and Toscano,
2002).
 Sensory integration is a theoretical
intervention frame of reference that is built
around the relationship between the brain and
behavior.
 Sensory stimulation activities emphasizing the
tactile, proprioceptive, and vestibular systems
are selected to engage the individual in the
meaningful, self directed context.(Ayres,1973;
Bundy et al.,2002)
 Intervention activities are often directed at
promoting antigravity flexion or extension,
increasing proprioception and a sense of
gravitational security, promoting equilibrium
responses and balance, and enhancing
tolerance of and integration of vestibular
stimulation.

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Ap facilitatory and inhibitatory technique

  • 1. Anwesh Pradhan, MPT, PhD Scholar Associate Professor, Nopany Institute of Healthcare Studies, Kolkata Consultant Physiotherapist, Mobility Physiotherapy & Rehabilitation, Midnapore Facilitatory and Inhibitory Techniques used in Neuro Physiotherapy
  • 2. What are the sensory motor approaches? Rood’s approach PNF Neurodevelopmental approach Sensory integration Brunnstrom’s movement therapy
  • 3. Theoretical Basis Reflex and Hierarchical Theory  The basic unit of motor control are reflexes  reflexes => purposeful movement  Damage to the CNS results to re-emergence of the inability to control the reflexes  Motor control is hierarchically arranged  CNS structures involved with movement can be grouped into higher, middle and lower levels  Higher centers regulate and control the middle and lower centers  Damage to the CNS results to disruption of the normal coordinated function of these levels
  • 4.
  • 5. Manual Facilitatory and Inhibitory Techniques Quick stretch  Receptor: muscle spindle endings, detecting length and velocity changes.  Stimulus: quick stretch or tapping over muscle belly or tendon  Response: activates agonist to contract: reciprocal innervation effect will inhibit the antagonist; activates synergists.  Response is temporary; can add resistance to
  • 6. Prolonged stretch  Receptor: muscle spindle endings and golgi tendon organ  Stimulus: maintained stretch in a lengthened range  Response: dampens muscle contraction  Rationale for serial casting and splinting to increase the effect, activates the antagonist.
  • 7. Resistance  Receptor: muscle spindles  Stimulus: resistance given manually or with body weight or gravity or mechanical weights  Response: enhances muscle contraction through recruitment; facilities synergists, enhances kinesthetic awareness  Resistance needs to be graded dependent on the patient response and goal; additional recruitment and overflow may be counterproductive to movement goal.
  • 8. Approximation  Receptor: joint receptors  Stimulus: Compression of joint surfaces; manual or mechanical; bouncing; applied in weight bearing  Response: enhances muscular contraction, proximal stability and postural extension, increases kinesthetic awareness and postural stability.  Effective in combination with rhythmic stabilization, contraindicated in inflamed joints.
  • 9. Traction  Receptor: joint receptors.  Stimulus: joint surfaces distracted, usually manually and at the beginning of movement.  Response: Facilitates muscle activation to improve mobility and movement initiation.  Useful to activate initial mobility; also used as part of mobilization.
  • 10. Inhibitory pressure  Receptor: golgi tendon organ, muscle spindles, tactile receptors.  Stimulus: Firm pressure manually or with body weight over muscle belly or tendon.  Response: Inhibits muscle activity; damping effect.  Equipment can be used to achieve effect; casts and splints, weight bearing activities can provide inhibitory pressure.
  • 11. Light touch  Receptor: Rapidly adapting tactile receptors, autonomic nervous system (sympathetic division).  Stimulus: Brief, light contact to skin.  Response: Increased arousal, withdrawal response.  Effective in initiating a generalized movement response, to elicit arousal, contraindicated with agitated patients or where ANS is unstable.
  • 12. Maintained touch  Receptor: Slowly adapting tactile receptors, ANS (parasympathetic division).  Stimulus: Maintained contact or pressure.  Response: Calming effect, desensitizes skin, provides general inhibition.  Useful for patients with high level of arousal or hypersensitivity.
  • 13. Manual contacts  Receptor: Tactile receptors, muscle proprioceptors.  Stimulus: Firm, deep pressure of hands over body area.  Response: Facilitates contraction of muscle underneath hands.  Activates muscle response; enhances sensory and kinesthetic awareness; provides security and support.
  • 14. Slow stroking  Receptor: Tactile receptors ANS(parasympathetic division)  Stimulus: Slow, firm stroking with flat hand over neck or trunk extensors.  Response: Produces calming effect, general inhibition; induces feeling of security.  Appropriate for overly aroused patients.
  • 15. Neutral warmth  Receptor: Thermo receptors ANS(parasympathetic division)  Stimulus: Towel or elastic wrap of body or body parts(warm)  Response: Provides general relaxation and inhibition; decreased muscle tone; decreased agitation or pain.  Use for 10-15 mins; avoid overheating; appropriate for highly agitated patients or individuals with increased sympathetic response.
  • 16. Slow vestibular stimulation  Receptor: Tonic vestibular receptors  Stimulus: Slow rocking, slow movement on ball, in hammock, in rocking chair.  Response: Produces calming effect, decreased arousal, generalized inhibition.  Useful for patients who are defensive to sensory stimulation, hyperreactive to stimulation, hypertonic or agitated.
  • 17. Fast vestibular stimulation  Receptor: Semicircular canals  Stimulus: Fast or irregular movement with acceleration and deceleration component, such as spinning, use of a scooter board, fast rolling.  Response: Facilitates general muscle tone and promotes postural responses to movement.  Used with patients with hypotonia (CP, Down syndrome); used to promote sensory integration.
  • 19. Premise  Motor patterns are developed from fundamental patterns/ reflexes which are refined and controlled as an individual mature  Sensory stimulation is applied to muscles and joints---> normalize tone--> produce desired movement  Sensorimotor control is developmental  Movement should be purposeful  Repetition of sensorimotor responses is necessary
  • 20. The Goals The Goals and basic features of Rood’s theory are:  Normalize muscle tone  Treatment begins at the developmental level of functioning  Movements is directed toward functional goals  Repetition is necessary for the re-education of muscular response.
  • 21. Principles of treatment  Tonic neck reflex and labyrinthine reflexes can assist or retard the effects of sensorimotor stimulation  Stimulation of specific receptors to produce response RULES OF SENSORY INPUT  A fast, brief stimulus produces a large synchronous movement  A fast, repetitive produces a maintained response  Slow. Rhythmical, repetitive sensory input deactivates the body
  • 22. Principles of treatment  Muscles have different duties  Heavy work muscles: Stabilizers (Maintenance of posture)  Light work muscles: Mobilizers (Skilled movement, repetitive or rhythmical patterns of distal musculature)  Heavy work muscles should be integrated before light work muscles
  • 23. Components of Motor Control (Four) 1. Reciprocal inhibition  Innervation, MOBILITY  Phasic or quick type movements  Contraction of agonist while antagonists relaxes  Serves a protective function 2. Cocontraction  Coinnervation, STABILITY  Tonic or static type of movement  Simultaneous contraction of the agonist and antagonist  Foundation of postural control
  • 24. 3. Heavy work  Mobility superimposed on stability  Proximal muscles contract and move while distal segments are fixed 4. Skill  Mobility and stability  Proximal segments are stabilized while distal segments move
  • 25. Ontogenic developmental patterns  Supine withdrawal (supine flexion)  Rollover to sidelying  Pivote prone (prone extension)  Neck cocontraction  Prone on elbows  Quadruped  Standing  Walking
  • 26. Techniques and strategies  FACILITATORY TECHNIQUES 1. Cutaneous facilitation  Light moving touch  Fast brushing 2. Thermal facilitation  A- icing  C- icing  Autonomic icing 3. Proprioceptive facilitation  Heavy joint compression  Quick stretch  Intrinsic stretch  Secondary ending stretch  Stretch pressure  Resistance  Tapping  Vestibular stimulation  Inversion  Therapeutic vibration  Osteo- pressure
  • 27. Techniques and strategies  INHIBITATORY TECHNIQUES 1. Neutral warmth 2. Gentle shaking or rocking 3. Slow rolling 4. Tendinous pressure 5. Light joint compression 6. Maintained stretch 7. Rocking in developmental positions
  • 28. Cutaneous Stimulation by Quick Light Brushing:  This is used as a preparatory facilitation to increase excitability of motor neurons which supply inhibited muscles.  The area to be brushed is specific in terms of the nerve root supply to skin and muscles.  A soft artist’s or decorator’s brush is used or if available, an electrically powered brush is used.  For skin supplied by anterior primary rami, the excitatory effect is local and mainly to superficial muscles.  For skin supplied by posterior primary rami, the effects is excitatory to deep back muscles.
  • 29. Brief Application of Cold  Quick wipe with ice ha san excitatory effect which is immediate and most effective when applied to skin overlying the extensors of limbs and when the part is warm.  Brushing or ice application to the palmer surface of the finger tips alerts mental processes but should be avoided if spasticity is present.  Ice applied to the lips or tongue facilitates sucking, swallowing and speech.
  • 30. Slow Stroking  If this is carried out from neck to sacrum over the centre of the back it will reduce choreo-athetosis or excessive muscle tone.  It should be applied rhythmically for 3 minutes.
  • 31. Precautions: USE OF BRUSHING: 1. The area brushed is very specific in terms of dermatome and myotome. 2. It should be used only for upto 3 seconds in one place at a time; maximum effect can be delayed for 20 to 30 minutes where nerve pathways have not been active through disuse or inhibition.
  • 32. Precautions: 3. Do not use mechanical tools with revolutions of 360 or higher to operate a brush as this can completely inhibit nerve pathways. 4. In case of flaccidity, brushing may cause a seizure; should this occur slow rhythmical stroking should be used over the posterior rami dermatomes for 3 minutes. 5. Brushing the skin of the ear and the outer thirds of forehead should be avoided as it has central inhibiting effect.
  • 33. Precautions: WHILE USING ICE: 1. Ice used behind the ear can lead to a sudden lowering of the blood pressure. 2. Ice applied to special receptors areas in the sole of the feet or the palm of the hand should be avided in young children as it is potentially nocioceptive. 3. Ice applied over the skin supplied by the posterior primary rami may set up a chain of effects on viscera over which one has on control. 4. Ice used on left shoulder may be dangerous if there is known cardiac disease.
  • 34. PNF  Herman Kabat  Maggie Knott  1940-1956  Voss and Meyers.
  • 35.  Proprioceptive neuromuscular facilitation (PNF) is a rehabilitation technique that was initiated over 50 years ago. It is used to stimulate the neuromuscular system in an effort to excite proprioceptors (sensory organs in muscles, tendons, bones, and joints) in order to produce a desired movement. by Ph.D Mark Damian Rossi, P.T., C.S.C.S.
  • 36.  Knott and Voss defined facilitation as “the promotion of any natural process; specifically, the effect produced in nerve tissue by the passage of an impulse”.  The term proprioceptive means sensory stimulation that is received from the receptors within the body’s own muscles, tendons and joints.
  • 37.  Neuromuscular means this technique applies to the nerves and the muscles.  Therefore PNF is defined as an approach that includes methods of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptors.
  • 38. Stimulation techniques used during PNF Manual contacts  Application: Pressure is given to the skin over muscle being facilitated.  Presumed benefit: Manually contacting the patient utilizes sensory cues to direct the patient’s attention to the desired movement. Pressure activates mechanoreceptors.
  • 39. Vision  Application: Patient is asked to watch the movement and to participate in giving the movement direction.  Presumed benefit: Visually directed movement is used as reinforcement and to offer extrinsic feedback to the patient as he or she learns the movement.
  • 40. Verbal commands  Application: Tone of voice and specific commands are used selectively to prepare the patient for movement, direct the movement and motivate the patient.  Presumed benefit: voice is used to affect the quality of the patient’s response. Tone and timing of commands are used as teaching aids.
  • 41. Stretch  Application: Quick stretch is given to the muscle being facilitated. Stretch can be applied at the beginning of the motion or intermittently throughout the range of motion to activate or reinforce muscle activation/ contraction.  Presumed benefit: Quick stretch activates the muscle spindles and excites the agonist muscle through activation of the monosynaptic reflex arc.
  • 42. Traction  Application: Separation of the joint surfaces to activate joint receptors.  Presumed benefit: Traction stimulus activates proprioceptive joint receptors, theorized to promote movement.
  • 43. Approximation  Application: Compression of joint surfaces together, usually done with body part in a weight bearing position.  Presumed benefit: approximation is used to activate proprioceptive joint receptors to promote muscular co-contraction, joint stability and weight bearing.
  • 44. Timing  Application: Timing is selectively used by the therapist to either facilitate motor learning as the patient recognizes the familiarity of a frequently used movement pattern(normal timing) or to emphasize a specific portion of the movement pattern (timing for emphasis)  Presumed benefit: The movement patterns used in PNF are based on typically occurring patterns of normal movement, used in work and sports. Timing is an important component of learning a movement pattern.
  • 45. Rhythmic stabilization  Application: Rhythmic, alternating isometric contractions of agonist and antagonist without intermittent relaxation; resistance is carefully graded to achieve co-contraction.  Presumed benefit: Used to promote weight bearing and holding and improve postural stability, strength and proximal control.
  • 47.  Brunnstrom is credited with two main contributions: a description of the stereotypical synergy patterns and the recovery stages of patients seen following a cerebrovascular accidents.  It highlights the importance of the current emphasis on working towards the goal of voluntary control and functional limitations experienced by patients as they work towards recovery.
  • 48.  A basic concept of Brunnstrom’s approach is that of synergies or motor patterns which are patterned, recognizable flexion, or extension movements of the entire limb, evoked by attempts to move or by sensory stimulation, characteristically seen during the period of recovery following a neurological incident such as CVA.  Repeated use of the synergy which makes isolated motor control more difficult, is viewed as inappropriate and undesirable.
  • 49.  Practical training activities to stimulate out of synergy isolated movements are encouraged.  Concepts of motor learning such as positive reinforcement and repetition are stressed(Sawner & La Vigne,1992; Smith & Sharpe,1994).  The stages of recovery are used as an overall framework from which to view the patient’s progression towards recovery of voluntary motor control(Martin & Kessler,2000).
  • 50. NEURODEVELOPMENTAL TECHNIQUE (NDT)  Dr. Karl and Berta Bobath during the 1950s.
  • 51.  Originally, NDT concentrated on the effects of the disturbed postural control mechanism on movement.  Its basic concept is that motor function can be improved by modifying abnormal movement patterns, and movement is a changeable, dynamic phenomenon that can be affected by external sensory inputs. (Bobath and Bobath, 1984; Valvano & Long, 1991)
  • 52. NDT Techniques Handling  Clinical use: Hands are used to support and assist movement (active and passive) from one position to another; active assisted movement is always encouraged.  Application: Use of hands; light touch, intermittent touch or firm manual contact to guide and assist with movement.
  • 53. Positioning  Clinical use: Used to provide alignment, comfort, support, prevent deformity and provide readiness to support or enhance independent movement.  Application: Positioning for support is used to provide stability and alignment and prevent deformity.  Positioning is also used to promote optimal independent function or position from which movement can most likely occur.
  • 54. Use of adaptive equipment  Clinical use: Used to provide postural support, prevent deformity, promote alignment, enhance function and offer mobility, a common adjunct to intervention for children with neurological impairment.  Application: Equipment can be used dynamically to assist in movement control.
  • 55. Key points of control  Clinical use: Parts of the body are chosen as optimal from which to guide the person’s movement.  Application: Proximal key points of control include trunk, shoulders and pelvis; distal points are hands and feet.
  • 56. Facilitating transitional movement  Clinical use: Facilitates key movement components during active transitional movement.  Application: Provides facilitation of antigravity control, weight bearing, weight shifting, responses to movement such as automatic postural responses, rotation and dissociation.
  • 57. Use of sensory input  Clinical use: Voluntary movement control is facilitated through use of proprioceptive inputs, exteroceptive inputs, visual, vestibular and verbal inputs.  Application: proprioceptive inputs include weight bearing, approximation, stretching and traction or tapping.  Exteroceptive inputs include manual guidance and therapeutic use of hands.
  • 58. Motor learning strategies  Clinical use: Active movement is encouraged through practice, repetition, feedback and use of functional activities.  Application: Use of variable practice and problem solving in natural environment promotes motor learning.
  • 59. Sensory integration  Founded and popularized by Jean Ayres (1973).
  • 60.  It is based on three main assumptions: 1. Individuals receive information from their bodies and the environment, process and interpret the information within their CNS and use the information in a functional manner. 2. Individuals with sensory processing will demonstrate problems in planning and execution of adaptive responses.
  • 61. 3. Individuals who receive stimulation within a meaningful context will have the opportunity to integrate the sensory information, demonstrating more efficient motor skills and adaptive behaviors (Long and Toscano, 2002).  Sensory integration is a theoretical intervention frame of reference that is built around the relationship between the brain and behavior.
  • 62.  Sensory stimulation activities emphasizing the tactile, proprioceptive, and vestibular systems are selected to engage the individual in the meaningful, self directed context.(Ayres,1973; Bundy et al.,2002)  Intervention activities are often directed at promoting antigravity flexion or extension, increasing proprioception and a sense of gravitational security, promoting equilibrium responses and balance, and enhancing tolerance of and integration of vestibular stimulation.