The document describes various techniques used in physical therapy for neuromuscular re-education and facilitation including proprioceptive neuromuscular facilitation, neurodevelopmental technique, sensory integration, Brunnstrom movement therapy, and Rood's technique. It provides details on how each technique is applied and the receptors and responses targeted through different stimuli like stretching, traction, touch, and movement.

1. Presented By: Dr. Jyoti.K.Chauhan
1st M.P.T

2.  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:

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16.  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.

17.  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.

18.  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.

19. 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.

20. 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.

21. 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.

22. 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.

23. Traction
 Application: Separation of the joint surfaces to
activate joint receptors.
 Presumed benefit: Traction stimulus activates
proprioceptive joint receptors, theorized to
promote movement.

24. 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.

25. 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.

26. 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.

27.  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)

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35.  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.

36. 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.

37.  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.

39.  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.

40.  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.

41.  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).

42.  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.

43.  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.

44.  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.

45.  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.

46.  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.

47. 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.

48. THANK YOU……