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.