Facilitation is the process of intervention, which uses the improved postural tone in a goal-directed activity. Facilitation makes movement easier but in the treatment it also means “making it possible” and “making it have to happen”. (Tatjana Dolenc Velikovi1, Milivoj Velikovi Perat2) Medicina 2005 Through facilitation, the therapist communicates with the individual using somatosensory cues to foster any one of the following movement responses:
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 augment response; not appropriate to use in muscles where increased muscle tone limits function.
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.
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.
Herman Kabat and Maggie Knott developed the method of proprioceptive neuromuscular facilitation (PNF), which was later expanded by Voss and Meyers. 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.
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.
Neurodevelopmental technique was developed by Drs. 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)
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 is a theory founded and popularized by Jean Ayres, in 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.
Movement therapy in hemiplegia, developed by Signe Brunnstrom in 1970, was designed to promote recovery in individuals who had suffered a stroke. 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).
This technique was developed by Margaret Rood, an American physical therapist, in 1956. The Goals and basic features of Rood’s theory are: o Normalize muscle tone o Treatment begins at the developmental level of functioning o Movements is directed toward functional goals o Repetition is necessary for the re-education of muscular response.
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.
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.
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.
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.