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Approaches totherapeutic exercise:
* Rood Approach* Proprioceptive Neuromuscular Facilitation
concepts, principles, strategies
Aila Nica J. Bandong, PTRPInstructor, Department of Physical Therapy
UP- College of Allied Medical Professions
Learning Objectives
At the end of the lecture, the students should be able to:
Discuss the theoretical basis of the sensorimotor approaches
Identify the traditional sensorimotor approaches to therapeutic exercise
Discuss the reconstruction of the sensorimotor approaches
Differentiate and discuss the sensorimotor approaches to therapeutic exercise in terms of:› Proponents› Principles› Techniques/procedures› Components
What are the sensorimotor approaches?
Brunnstrom’s movement therapy
Neurodevelopmental approach
Rood approach Proprioceptive
neuromuscular facilitation
Theoretical BasisReflex and Hierarchical Theory The basic unit of motor control are reflexes
› Reflexes purposeful movement› Damage to the CNS results to re-emergence of
and 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
RoodTechniques
Margaret Rood
Premise Motor patterns are developed from fundamental
patterns/reflexes which are refined and controlled as an individual matures
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
Principles of treatment Tonic neck and labyrinthine reflexes can
assist or retard the effects of sensorimotor stimulation
Stimulation of specific receptors to produce response
Rules on sensory input› A fast, brief stimulus produces a large
synchronous movement› A fast, repetitive stimulus 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
Four components of motor control Reciprocal inhibition
› Aka innervation, mobility› Phasic or quick type of movement› Contraction of the agonist while antagonist
relaxes› Serves a protective function
Cocontraction› Aka coinnervation, stability› Tonic or static type of movement› Simultaneous contraction of the agonist and
antagonist› Foundation for postural control
Heavy work› Aka mobility superimposed on stability› Proximal muscles contract and move
while distal segments are fixed
Skill› Aka mobility and stability› Proximal segments are stabilized while
distal segments move
Four components of motor control
Ontogenetic development patterns
Supine withdrawal (supine flexion)
Rollover to sidelying Pivot prone (prone extension) Neck cocontraction Prone on elbows Quadruped Standing Walking
Techniques and strategies
Facilitatory Techniques
CutaneousFacilitation
1. Light moving touch2. Fast
brushing
ThermalFacilitation
1. A-icing2. C-icing
3. Autonomic
icing
Proprioceptive
Facilitation
1. Heav
y joint compressio
n2.
Quick stretc
h3.
Intrinsic
stretch4.
Secondar
y endin
g stretc
h5.
Stretch
pressure6.
Resistance
7. Tappi
ng8.
Vestibular stimulation
9. Inversion10.
Therapeuti
c vibrat
ion11.
Osteo-
pressure
Inhibitory Techniques
1. Neutral warmth2. Gentle shaking or rocking
3. Slow stroking4. Slow rolling
5. Tendinous pressure6. Light joint compression
7. Maintained stretch8. Rocking in developmental
poistions
Techniques and strategies
Proprioceptive Neuromuscular
FacilitationDr. Herman Kabat
Maggie KnottDorothy Voss
Premise
Brain knows nothing of individual muscle action, rather, total movement patterns
Extremity patterns of movement are rotational and diagonal in nature
Normal motor development proceeds in a cephalo-caudal and proximo-distal direction
Early motor behavior is dominated by reflex activity; Mature motor behavior is supported by postural reflexes
Principles of treatment All human beings have untapped movement
potential
Improvement in motor ability is dependent upon motor learning
Frequency of stimulation and repetition of activity promotes retention of motor learning and develops strength and endurance
Activities are goal-directed with techniques of facilitation, mainly proprioceptive, are utilized to hasten learning
Diagonal patterns Mass movement patterns observed in most
functional activities› Head, neck, trunk
Flexion with rotation to the right or left Extension with rotation to the right or left
› Extremities Three components
Flexion/extension Abduction/adduction External/internal rotation
Reference points UE: shoulder joint LE: hip joint
Unilateral patterns: Upper Extremity
UPPER EXTREMITY D1 pattern
JOINT FLEXION EXTENSION
Scapula Elevation, Abduction, Rotation
Depression, Adduction, Rotation
Shoulder Flexion, AdductionExternal rotation
Extension, AbductionInternal rotation
Elbow Flexion or Extension Flexion or Extension
Forearm Supination Pronation
Wrist and
Hand
Flexion to the radial side, Finger flexion and adduction, Thumb adduction
Extension to the ulnar side, Finger extension and abduction, Thumb in palmar abduction
UPPER EXTREMITY D2 pattern
JOINT FLEXION EXTENSION
Scapula Elevation, Adduction, Rotation
Depression, Abduction, Rotation
Shoulder Flexion, AbductionExternal rotation
Extension, AdductionInternal rotation
Elbow Flexion or Extension Flexion or Extension
Forearm Supination Pronation
Wrist and
Hand
Extension to the radial side, Finger extension and Abduction, Thumb extension
Flexion to the ulnar side, Finger flexion and adduction, Thumb in opposition
Unilateral patterns: Upper Extremity
Unilateral patterns: Lower Extremity
LOWER EXTREMITY D1 pattern
JOINT FLEXION EXTENSION
Hip FlexionAbductionExternal rotation
ExtensionAdductionInternal rotation
Knee Flexion/extension Flexion/extension
Ankle andFoot
DorsiflexionInversion
PlantarflexionEversion
Toe Extension Flexion
LOWER EXTREMITY D2 pattern
JOINT FLEXION EXTENSION
Hip FlexionAbductionInternal rotation
ExtensionAdductionExternal rotation
Knee Flexion/extension Flexion/extension
Ankle andFoot
DorsiflexionEversion
PlantarflexionInversion
Toe Extension Flexion
Unilateral patterns: Lower Extremity
Bilateral patterns
Combined upper extremity or lower extremity diagonal patterns
› Symmetrical› Asymmetrical› Reciprocal
Bilateral patterns Symmetrical
› Paired extremities (either UE of LE) perform the same diagonal pattern and direction
› Promotoes trunk flexion and extension
Bilateral patterns
Asymmetrical› Paired
extremities perform opposite diagonal pattern but same direction
› Facilitates trunk rotation
Bilateral patterns
Reciprocal› Paired extremities
move in opposite diagonal pattern and direction
› Promotes head, neck, and trunk stability
Combined movements of UE/LE
Combined upper extremity and lower extremity movements
› Ipsilateral› Contralateral› Diagonal reciprocal
Ipsilateral› Extremities of
the same side (UE and LE) move in the same diagonal pattern and direction
Combined Movements of UE/LE
Contralateral› Aka alternating
reciprocal pattern
› Extremities of the opposite sides move in the same diagonal pattern and direction
Combined Movements of UE/LE
Diagonal reciprocal› Contralateral
extremities moving in the same diagonal patterns and directions while opposite contralateral extremities move in the opposite diagonal pattern and direction
Combined Movements of UE/LE
Basic procedures
Manual contacts Communication/commands Stretch Traction Approximation Maximal resistance Timing
Manual contacts Placement of the therapist’s hand on the
patient
Used to provide pressure and tactile stimulation to muscles› Pressure should be applied opposite to the
direction of the desired motion
Guide direction of movement
Utilized by the patient as in “self-touching” during chopping and lifting movements
Communication/commands
effective use of volume and tone of voice can be facilitatory or inhibitory (use in moderation to not avoid adaptation)
preparatory commands need to be clear and concise
action commands should be accurate, short, and timed
provide visual cues, demonstration of movement
tailor your motivation strategies; know your patient (developmental and cognitive level)
Stretch part to be moved must be placed in the
extreme lengthened range of the pattern; all parts being considered; tension should be felt in all muscle components
apply stretch reflex manually by quickly taking the stretched part beyond point of tension then instructing the patient to perform the desired motion
Traction
separating joint surfaces stimulate the proprioceptive centers
promote movement
used during pulling motions
Approximation
compressing joint surfaces stimulate the proprioceptive centers
promote stability or maintenance of posture as well as postural reflexes
ensure proper alignment of the joint structures
Maximal resistance
maximum amount of resistance that can be applied without breaking the patient’s hold (Voss, et al., 1985)
principle of irradiation/overflow› weaker muscles are reinforced or
strengthened by resisted contraction of the stronger muscle components
increases strength
Timing
Refers to the sequence of muscle contraction that occurs during activity
Normal timing (PNF)› Distal segments move first followed by
proximal segemts› Rotation occurs throughout the pattern
Timing for emphasis› Superimposing maximal resistance upon
patterns of facilitation in order that overflow or irradiation occurs
Techniques and strategies
Reversal of antagonists› Dynamic reversals› Stabilizing
reversals› Rhythmic
stabilization Directed to the
agonists› Repeated
contractions› Rhythmic initiation
› Combination of isotonics
› Resisted progression
Relaxation Techniques› Contract relax› Hold-relax› Replication› Rhythmic rotation
Reversal of antagonists
Dynamic Reversals› Aka Slow reversals› Isotonic contractions of agonist
isotonic contraction of antagonist› Contraction of the stronger pattern
then progressed to weaker pattern› Indications
impaired strength and coordination limitation of motion fatigue
Reversal of antagonists
Stabilizing Reversals› Alternating isotonic contractions of
the agonists then antagonists› Very limited motion (ROM) allowed› Indications
Impaired strength Impaired stability and balance Impaired coordination
Reversal of antagonists
Rhythmic Stabilization› Alternating isometric contractions of
the agonist then antagonist› No motion is allowed› Indications
Impaired strength Impaired coordination Limitation of motion Impaired stabilization control and
balance
Techniques directed to the agonist
Repeated contractions› Repeated isotonic contractions from the
lengthened range (induced by quick stretch and enhanced by resistance)
› Performed throughout the range or part of the range at a point of weakness
› Indications Impaired strength Impaired initiation of movement Fatigue and LOM
Rhythmic Initiation› Aka Rhythm Technique› voluntary relaxation passive movement
active-assisted movement repeated isotonic contraction of major muscle components of the pattern (gradually increasing as patient responds) active motion
› Indications Inability to relax Hypertonicity Difficulty initiating movement Motor planning and motor learning deficits Deficits in communication
Techniques directed to the agonist
Combination of Isotonics› Aka Agonist Reversal› Resisted concentric contraction of agonist
muscles moving through the range stabilizing contraction (holding) eccentric lengthening contraction (moving slowly back to starting position)
› No relaxation between contractions› Indications
Weak postural muscles Inability to eccentrically control body weight
during transitions Poor dynamic postural control
Techniques directed to the agonist
Resisted Progression› Stretch, approximation, and tracking
resistance applied manually to facilitate pelvic motion and progression during movement
› Indications Impaired timing and control of lower
trunk/pelvic segments during movement Impaired endurance
Techniques directed to the agonist
Relaxation Techniques Contract-Relax
› Performed at a point of LOM› Strong, small range isotonic contraction
of the antagonist isometric contraction (hold: 5 to 8 seconds) voluntary relaxation passive movement into new range of the agonist pattern
› Contract-relax-active contraction: same as contract relax but active movement into the new range
› Indication Limitation of motion
Relaxation Techniques
Hold-relax› Performed in a position of comfort and
below level of pain› Isometric contraction of the antagonist
voluntary relaxation passive movement into the new range
› Hold-relax-active contraction: same as hold-relax but movement into new range is active
› Indication Limitation I PROM with pain
Relaxation Techniques Rhythmic Rotation
› Slow, repetitive rotation of a limb at a point where LOM is noted
› Limb is slowly moved into new range as muscles relax
› Repeated whenever tension is felt› Indication
Relaxation of excess tension in muscles (hypertonia) combined with PROM of the range-limiting muscles
References
Adler SA, Beckers D, & Buck M (1993). PNF in practice. Berlin, Springer-Verlag.
Levitt S (2004). Treatment of cerebral palsy and motor delay (4th ed). Singapore, McGraw-Hill Inc.
O’Sullivan S & Schmitz T (2007). Physical rehabilitation (5th ed). Philadelphia, F. A. Davis Company.
Pedretti LW & Early MB (Eds) (2006). Occupational therapy: Practice skills for physical dysfunction (6th ed). St. Louis, Mosby-Year Book, Inc.
Tecklin JS (1999). Pediatric physical therapy (3rd ed). Philadelphia, J.B. Lippincott Company.
Voss DE, Ionta MK, & Myers BJ (1985). Proprioceptive Neuromuscular Facilitation: Patterns and techniques (3rd ed). Philadelphia, Harper & Row Publishers.