Approaches to therapeutic exercise: * Rood Approach * Proprioceptive Neuromuscular Facilitation

1. Approaches totherapeutic exercise:*Rood Approach* Proprioceptive Neuromuscular Facilitation concepts, principles, strategies AilaNica J. Bandong, PTRP Instructor, Department of Physical Therapy UP- College of Allied Medical Professions

2. 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

3. What are the sensorimotor approaches? • Brunnstrom’s movement therapy • Neurodevelopmental approach • Rood approach • Proprioceptive neuromuscular facilitation

4. 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

5. RoodTechniques Margaret Rood

6. 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

7. 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

8. 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

9. 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

10. 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

11. Ontogenetic development patterns • Supine withdrawal (supine flexion) • Rollover to sidelying • Pivot prone (prone extension) • Neck cocontraction • Prone on elbows • Quadruped • Standing • Walking

12. Techniques and strategies

13. Techniques and strategies

14. ProprioceptiveNeuromuscular Facilitation Dr. Herman Kabat Maggie Knott Dorothy Voss

15. 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

16. 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

17. 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

18. Unilateral patterns: Upper Extremity

19. Unilateral patterns: Upper Extremity

20. Unilateral patterns: Lower Extremity

21. Unilateral patterns: Lower Extremity

22. Bilateral patterns • Combined upper extremity or lower extremity diagonal patterns • Symmetrical • Asymmetrical • Reciprocal

23. Bilateral patterns • Symmetrical • Paired extremities (either UE of LE) perform the same diagonal pattern and direction • Promotoes trunk flexion and extension

24. Bilateral patterns • Asymmetrical • Paired extremities perform opposite diagonal pattern but same direction • Facilitates trunk rotation

25. Bilateral patterns • Reciprocal • Paired extremities move in opposite diagonal pattern and direction • Promotes head, neck, and trunk stability

26. Combined movements of UE/LE • Combined upper extremity and lower extremity movements • Ipsilateral • Contralateral • Diagonal reciprocal

27. Combined Movements of UE/LE • Ipsilateral • Extremities of the same side (UE and LE) move in the same diagonal pattern and direction

28. Combined Movements of UE/LE • Contralateral • Aka alternating reciprocal pattern • Extremities of the opposite sides move in the same diagonal pattern and direction

29. Combined Movements of UE/LE • Diagonal reciprocal • Contralateralextremities moving in the same diagonal patterns and directions while opposite contralateral extremities move in the opposite diagonal pattern and direction

30. Basic procedures • Manual contacts • Communication/commands • Stretch • Traction • Approximation • Maximal resistance • Timing

31. 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

32. 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)

33. 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

34. Traction • separating joint surfaces stimulate the proprioceptive centers • promote movement • used during pulling motions

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. References Adler SA, Beckers D, & Buck M (1993). PNF in practice. Berlin, Springer-Verlag. Levitt S (2004). Treatment of cerebral palsy and motor delay (4thed). Singapore, McGraw-Hill Inc. O’Sullivan S & Schmitz T (2007). Physical rehabilitation (5thed). Philadelphia, F. A. Davis Company. Pedretti LW & Early MB (Eds) (2006). Occupational therapy: Practice skills for physical dysfunction (6thed). St. Louis, Mosby-Year Book, Inc. TecklinJS (1999). Pediatric physical therapy (3rded). Philadelphia, J.B. Lippincott Company. Voss DE, Ionta MK, & Myers BJ (1985). Proprioceptive Neuromuscular Facilitation: Patterns and techniques (3rded). Philadelphia, Harper & Row Publishers.