motor relearning methods

1. Proprioceptive neuromuscular
facilitation
By
Prof Dr. MM Makkawy
Prof. of rheumatology & rehabilitation
Faculty of medicine- Zagazig university

2. The activity of weak muscles require
facilitation (their excitability level must be
raised) while the activity of spastic
muscles must be decreased (their
excitability must be diminished).
Principles of neuromuscular facilitation
technique:
1. Facilitation of voluntary motion by
maximal resistance (irradiation).

3. 2. Facilitation by various reflexes:
Stretch reflex.
Flexion reflex.
Postural reflex ( e.g., tonic neck reflex).
Rightening reflex (slow reversal of
antagonist).

4. 3. Facilitation by another voluntary
motion (irradiation).
4. Facilitation by another voluntary
motion (successive induction).
5. Inhibition of voluntary motion by
reflexes:
a. Cold reflex.
b. Pain reflex.
c. Sudden stretch reflex.

5. 6. Inhibition of a reflex by a voluntary
motion (reciprocal innervation).
7. Inhibition of one reflex by another
reflex (e.g., cold reflex).

6. I- Proprioceptive facilitation of voluntary
motion by maximal resistance:
An effective method of increasing
central excitation to stimuli in a great
proportion of motor units in a muscle ,
application of resistance to the
voluntary contraction.

7. Resistance will increase the central
excitation by discharging afferent
Proprioceptive impulses to CNS due to
increased tension in muscle, tendon
and joint.
With maximal resistance, the
contraction is not confined to a single
muscle but spread to other muscles
through a process of irradiation.

8. Indeed the process of irradiation is a
powerful means of Proprioceptive
facilitation to enhance and accelerate
recovery in patients with paralysis.
Resistance can be applied in the form of
antigravity exercise, with or without
addition of weight or maximal manual
resistance.

9. It should be pointed out that maximal manual
resistance is the basis to all PNF techniques,
and is used routinely in facilitation through
reflexes, irradiation and successive induction.
II - Facilitation of voluntary motion by the
various reflexes:
The proprioceptive reflexes can be shown to
facilitate the voluntary motion. This
mechanism can be used to enhance the
effectiveness of therapeutic exercise.

10. Stretch reflex:
-It is one of the simplest Proprioceptive reflexes of
all peripheral facilitatory mechanisms.
-Stretch reflex is initiated by mechanical
stimulation of receptors within the muscles
themselves.
-Afferent fibers arising from stretch receptors
within the muscle spindles make powerful
excitatory connections with alpha motor
neuron innervating the muscle from which the
afferent fibers arise.

11. -They also make inhibitory connections with
motor neurons innervating the antagonistic
muscles (providing the basis for
Sherrington's reciprocal innervation
principle).

12. - This reflex is of great importance in the
mechanism of muscle tone, posture and
also of great value in the facilitation
technique of voluntary motion. In this
instance the stretch reflex does not
produce the muscular contraction by itself
but it increase the excitability of neurons
and so it facilitates the voluntary of
paralyzed muscles.

13. -Thus, we may use muscle stretch for
facilitation of the muscle stretched or for
relaxation of its antagonists.
Flexion reflex:
-It is another simple reflex that can be
applied to voluntary motion.

14. -It is a manifestation of hypertonia in UMNL.
In doing the Babeniski sign the
hyperactive flexion reflex is stimulated
more effectively by Van Bechtrein
maneuver in which passive flexion of big
toe results in reflex mass flexion of LL
against resistance, the paralyzed
voluntary motion is facilitated by the
reflex.

15. Positive supporting reflex:
-It is extensor reflex produced by pressure
stimuli on the planter surface of the foot.
Postural reflex: e.g., tonic neck reflex
-Rotation of the head to one side results in
extension of the arm towards the side to
which the face is turned, and flexion of
the opposite arm.

16. -This reflex is inhibited in normal adults but
becomes active to a varying degree in
patients with spasticity.
It can be of value in facilitation of voluntary
elbow extension in spastic case:
voluntary contraction of triceps against
resistance is facilitated by tonic neck
(rotation of the head to the same side).

17. Rightening reflexes: (or slow reversal of
the antagonist):
-In resistive standing balance i.e. standing
patient is pushed slowly in various
directions in an attempt to throw in
balance, while he voluntarily resists the
effort.

18. -This results in voluntary resistive exercises
of many muscle groups in complex
balancing pattern, facilitated through
rightening reflexes through stimulation of
the labyrinth in human ear.

19. III- Inhibition of voluntary movement by
reflexes (pain reflex, cold reflex, sudden
stretch reflex):
_In performing a voluntary movement of the
antagonist it is essential to avoid sudden
stretch of a spastic muscle, because the
stretch reflex will interfere with the
movement mechanically as well as inhibiting
the voluntary movement.

20. _Another example, in performing
maximal resistive exercise, the
movements must not produce pain,
which will reflexly depress the
voluntary movement.

21. IV- inhibition of one reflex by another
_An effective procedure for inhibition of
spasticity in case of UMNL is the restoration
of voluntary movements of the antagonists
of the spastic muscles (reciprocal
innervation).
_Drugs may be useful in decreasing spasticity
_Cryotherapy (application of cold) is also a
valuable technique to reduce spasticity.

22. _Application of ice bags for short periods (10-40
minutes) often results in relaxation of spastic
muscles with releasing of the remaining
potentialsfor voluntary motion of their
antagonists.
_It is known that spasticity is based on hyperactive
stretch reflex and the effect of cold is also
through a reflex action, so there is one reflex
inhibiting another reflex.

23. V- Facilitation of voluntary motion by
another voluntary movement:
_The fundamental process of irradiation
state that: on performing the flexion
withdrawal reflex on LL, the stronger
the stimulus applied the more the
extent and spread of muscle response.
_Weak stimulus: flexion of ankle

24. *Stronger stimulus: flexion of the ankle +
knee.
*Stronger stimulus: mass flexion of
whole LL.
*Stronger stimulus: mass flexion of both
LLs.
*Still stronger stimulus: the response will
spread to produce reflex contraction of
more distal muscles.

25. _Irradiation spreads in a specific pattern of
muscular contraction.
_A similar process of irradiation occurs in
voluntary motion in man, with equally
specific pattern of spread of excitation
through the synergistic muscle groups.

26. _Unlike the flexion reflex, where the stimulus
is extrinsic, the stimulus of irradiation is
either extrinsic or Proprioceptive i.e.
generates by tension in the contacting
muscles and related structures.

27. _Irradiation in voluntary motion can be
produced by resistance to the movements.
So, voluntary resisted contraction of the
stronger muscle groups (with a specific
irradiation pattern) constitutes a powerful
propioceptive stimulus, which facilitates
the weaker motion (complex pattern).

28. _Irradiation pattern are best applied through
maximal muscular resistance, performed
by a trained physiotherapist.

29. _Examples are:
*Facilitation of trunk flexion by resisted neck
flexion.
*Facilitation of ankle dorsiflexion by resisted
muscular flexion of LL.

30. VI - Facilitation of voluntary motion by
another voluntary movement (Successive
induction)
_It was noticed that immediately after flexion
withdrawal reflex has been performed the excitability
of the extension reflex is increased.
-This principle is also applied to the voluntary motion,
so that after voluntary contraction of the agonist, the
antagonist is facilitated.

31. -Successive induction is particularly effective
for facilitation if one antagonist is much
stronger than the other, so that the stronger
antagonist becomes a source of
Proprioceptive facilitation for the weaker
agonist. Thus if the biceps is strong but the
triceps is weak, contraction of biceps against
resistance, if followed by immediate resistive
exercise to the triceps, results in a facilitated
triceps contraction.

32. VII – Inhibition of a reflex by voluntary
motion (Reciprocal innervation):
-In successive induction, it was pointed out
that immediately following the contraction of
an antagonist the agonist is facilitated.
-In the same procedure, at the time the agonist
is facilitated the antagonist is inhibited.
Reciprocal innervation is a useful
mechanism for inhibiting reflexes which
interfere with voluntary movements such as
spasticity, reflex spasm and flexion reflex.

33. -It should be pointed out that spasticity results from
getting free the reflex mechanism from the
inhibitory action of higher centers. Therefore, the
development of new effective controlling
inhibitory pathways is essential to treat the
defect, so that the decrease in spasticity can
become permanent.
-Inhibition of the antagonist is augmented when
the agonist is contracting against resistance,
since the stronger the contraction of agonist, the
greater reciprocal inhibition.

34. Basic techniques of PNF
-Basic techniques can be applied for both
spastic and flaccid muscles.
1. Stretch:
-Stimulate the activity of muscle spindle.
-It is the starting position of each pattern and
maintained through out the movement.
-Used to initiate the movement and to aid the
response of weak muscle.

35. 2. Maximal resistance: provided by weight
and pulley.
3. Traction and approximation:
The proprioceptors in joints are stimulated
by traction (separating joint surfaces) or
approximation (force compressing joint
surfaces) applied by the therapist during
the movement pattern.

36. 4. Irradiation reflex:
-The maximal resistance may be used to cause irradiation
from stronger pattern to weaker pattern or from
stronger group to weaker group in the same pattern.
5. The grip:
-The therapist grip must provide the following:
*Stretch
*Resistance: maximal throughout the movement.
*Traction and approximation.
*Exteroception gives sensory stimulation of skin in the
direction of movement.

37. 6. Voice: the therapist uses his voice to stimulate
the patient voluntary effort.
7. Eyes: the patient can increase his voluntary
effort when follow the movement with his eyes.
8. Pattern of movement:
*It is the movement in straight or diagonal direction
with a rotatory component acting as a holding
or stabilizing group.
*The diagonal is the line with the direction of
oblique trunk muscles.

38. 9. Timing:
*Timing of sequences of coordinated
movement of pattern can be varied.
*Movement of distal joint must be completed
before proximal joints.