concepts, principles, strategies Approaches to therapeutic exercise: * Rood Approach * Proprioceptive Neuromuscular Facilitation concepts, principles, strategies Aila Nica J. Bandong, PTRP Instructor, 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 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 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

Rood Techniques 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

Four components of motor 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

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 Cutaneous Facilitation 1. Light moving touch 2. Fast brushing Thermal 1. A-icing 2. C-icing 3. Autonomic icing Proprioceptive 1. Heavy joint compression 2. Quick stretch 3. Intrinsic stretch 4. Secondary ending stretch 5. Stretch pressure 6. Resistance 7. Tapping 8. Vestibular stimulation 9. Inversion 10. Therapeutic vibration 11. Osteo- pressure

Techniques and strategies Inhibitory Techniques 1. Neutral warmth 2. Gentle shaking or rocking 3. Slow stroking 4. Slow rolling 5. Tendinous pressure 6. Light joint compression 7. Maintained stretch 8. Rocking in developmental poistions

Proprioceptive Neuromuscular Facilitation Dr. Herman Kabat Maggie Knott Dorothy 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, Adduction External rotation Extension, Abduction Internal rotation Elbow 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

Unilateral patterns: Upper Extremity UPPER EXTREMITY D2 pattern JOINT FLEXION EXTENSION Scapula Elevation, Adduction, Rotation Depression, Abduction, Rotation Shoulder Flexion, Abduction External rotation Extension, Adduction Internal rotation Elbow 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: Lower Extremity LOWER EXTREMITY D1 pattern JOINT FLEXION EXTENSION Hip Flexion Abduction External rotation Extension Adduction Internal rotation Knee Flexion/extension Ankle and Foot Dorsiflexion Inversion Plantarflexion Eversion Toe

Unilateral patterns: Lower Extremity LOWER EXTREMITY D2 pattern JOINT FLEXION EXTENSION Hip Flexion Abduction Internal rotation Extension Adduction External rotation Knee Flexion/extension Ankle and Foot Dorsiflexion Eversion Plantarflexion Inversion Toe

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

Combined Movements of UE/LE 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

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 Combination of isotonics Resisted progression Dynamic reversals Stabilizing reversals Rhythmic stabilization Relaxation Techniques Directed to the agonists Contract relax Hold-relax Repeated contractions Replication Rhythmic rotation Rhythmic initiation

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

Techniques directed to the agonist 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

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.