Neurophysiotherapy techniques.pptx

Neurophysiotherapy Techniques:
Introduction
Facilitatory Techniques
Inhibitory Techniques

1. INHIBITION AND FACILITATION TECHNIQUES HETSHREE BHAVSAR MPT IN NEUROSCIENCES 1

2. INTRODUCTION It is of great challenge for physical therapist to select methods most efficient for each patient's needs. Following aspects needs considerations: The neuro -physiological basis of each method. The biomechanical influencing. The nature of pathology and symptoms affecting the patient's activity. The individual characters of each patient . 2

3. DEFINITION O’Sullivan S & Schmitz T (2007). Physical rehabilitation (5 th ed ). Philadelphia, F. A. Davis Company. The term neuromuscular facilitation refers to the facilitation, activation and inhibition of muscle contraction and motor responses. FACILITATION TECHNIQUES: It refers to the enhanced capacity to initiate a movement response through increased neuronal activity and altered synaptic potential. The stimulus applied may lower the synaptic threshold of the alpha motor neuron but may not be sufficient to produce an observable movement response. It helps to normalize the muscle tone from flaccid state. (On the other hand activation refers to the actual production of a movement response and implies reaching a critical threshold level for neuronal firing.) 3

4. DEFINITION INHIBITION TECHNIQUES: It refers to the decreased capacity to initiate a movement response through altered synaptic potential. The synaptic potential is raised, making it more difficult for the neuron to fire and produce movement. To normalize the muscle tone from hypertonic or spastic state. ( The combination of spinal and supraspinal inputs acting on the alpha motor neuron (final common pathway) will determine whether a muscle response is facilitated, activated or inhibited.) 4

5. THEORETICAL BASIS Roods approach- As a therapeutic technique presented originally by Margaret Rood to facilitate and inhibit movement responses . Reflex 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. 5

6. THEORETICAL BASIS Hierarchical Theory 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. 6

7. PRINCIPLE OF TECHNIQUES RECIPROCAL INHIBITION Aka innervation, mobility Phasic or quick type of movement Contraction of the agonist while antagonist relaxes Serves a protective function CO-CONTRACTION Aka co-innervation , stability Tonic or static type of movement Simultaneous contraction of the agonist and antagonist Foundation for postural control 7

8. PRINCIPLE OF TECHNIQUES 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 8

9. PRINCIPLE OF TECHNIQUES A fast, brief stimulus produces a large synchronous movement. F A fast, repetitive stimulus produces a maintained response. A Slow, rhythmical, repetitive sensory input deactivates the body. I 9

10. DIFFERENCE FACILITATION Provide sensation of normal movement Provide system for relearning normal movement Stimulates muscles to contract(flaccid or weak muscles) Allow for practice of movements Teach ways to incorporate involved side into functional tasks INHIBITION Decrease abnormal muscle tone(spasticity) Restore normal alignment Do not allow abnormal movements(associated reactions) Teach methods to decrease abnormal postures during functional tasks. 10

11. GENERAL GUIDELINES TO BE CONSIDERED Facilitative techniques (additive). Example, several inputs applied simultaneously, such as a quick stretch, resistance and verbal cues, are commonly combined during practice of a PNF. (SPATIAL SUMMATION) Repeated stimuli (e.g. tapping) may also produce the desired motor response owing to TEMPORAL SUMMATION . 11

12. GENERAL GUIDELINES TO BE CONSIDERED Sensory receptors based on adaptation: Slow- and Fast- adapting . Fast- adapting, phasic receptors such as touch receptors and phasic 1a muscle spindle endings are effective initiating and shaping dynamic movements. Slow- adapting, tonic receptors such as joint receptors, GTOs, and static 2 muscle spindle endings are effective in monitoring and regulating postural responses. 12

13. GENERAL GUIDELINES TO BE CONSIDERED The intensity, duration and frequency of stimulation need to be adjusted to meet individual patients needs. Unpredicted responses = Inappropriate application of techniques. For example, stretch applied to a spastic muscle may increase spasticity and negatively affect voluntary movement. Facilitation techniques are not appropriate for patients who demonstrate adequate voluntary control. 13

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16. RECEPTORS Muscle spindles : Detect changes in the length and speed of stretch. 16

17. RECEPTORS The Golgi Tendon Organ : Muscle tension or contraction 17

18. VARIOUS APPROACHES THAT WORKS ON F&I PRINCIPLES: ROODS APPROACH PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION THERAPY CHEST PNF NEURODEVELOPMENTAL THERAPY CONTRAINED INDUCED THERAPY SENSORY INTEGRATION THERAPY MASSAGE/ACUPUNTURE/ACUPRESSURE ROBOTICS VIRTUAL REALITY VESTIBULAR REHABILITATION THERAPY HYDROTHERAPY, CRYOPTHERAPY TAPING AEROBICS/PILATES/TREADMILL TRAINING/TAI CHI/YOGA ELECTROTHERAPY, FES BIOFEEDBACK ORTHOTICS/PROSTHETICS 18

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24. ALL THE APPROCHES WORKS IN COMBINATION OF INHIBITION AND FACILITATON. 24

25. CLINICAL IMPLICATIONS MAINLY INCLUDES THESE PATIENT POPULATION: STROKE TBI SCI PARKINSONISM MULTIPLE SCLEROSIS AMYOTOPHIC LATERAL SCLEROSIS CP DOWN SYNDROME SPINAL MUSCUALR ATROPHY 25

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28. FACILITATORY TECHNIQUES 28

29. CUTANEOUS FACILITATION LIGHT MOVING TOUCH Receptor: Rapidly adapting tactile receptors, autonomic nervous system (sympathetic division). Stimulus: Brief, light contact to skin. Response: Increased arousal, withdrawal response Effective in initiating a generalized movement response, to elicit arousal, contraindicated to agitated patients or when ANS is unstable. Low threshold response, accommodates rapidly. Can be used to initially mobilize patients with low response levels( eg ., the patients with TBI who is minimally responsive). R- TS , Jung JH, Jang SH, Kim KH, Jung KS, Cho HY. Effects of Light Touch on Balance in Patients with Stroke.  Open Med (Wars) . 2019;14:259-263. Published 2019 Apr 9. doi:10.1515/med-2019-0021 Findings indicate that light touch could be beneficial in postural control for individuals with hemi-paretic stroke. 29

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31. CUTANEOUS FACILITATION FAST BRUSHING (receptors: tactile receptors, ANS sympathetic division) Application can be manually or by using battery-operated brush. Skin overlying muscle can facilitate it and enhances static holding postural extensors and will have immediate and long latency responses . Used to facilitate inhibited muscles below the skin. Anterior primary rami: excitatory effect is local and mainly to superficial muscles. Posterior primary rami: effect is excitatory for deep back muscles. The area to be brushed is very specific to dermatomes and myotomes . Brush for at least 3 seconds , and wait for response until 20-30 minutes, where nerve pathways are not active due to disuse or inhibition. Positive effect on H-reflex. 31

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33. THERMAL FACILITATION- BRIEF ICING A ICING (FAST ICING) : stimulates A fibers causing reflex withdrawal response in superficial muscles. Patients with hypotonia , muscles are in state of relaxation causes alertness in them. C ICING : stimulates non-specific C fibers that maintain postural response. Applied according to dermatomes. Contraindications: avoid to patients with h/o cardiovascular problems. Do not apply over the neck, it will cause low BP. Ice applied over lips and tongue facilitates sucking, swallowing and speech. R- Abd El- Maksoud GM, Sharaf MA, Rezk -Allah SS. Efficacy of cold therapy on spasticity and hand function in children with cerebral palsy. Journal of Advanced Research. 2011 Oct 1;2(4):319-25 . It can be concluded that cold therapy in conjunction with conventional physical and occupational therapy significantly reduced spasticity, increased ROM and improved hand function in children with spastic CP. 33

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35. PROPRIOCEPTIVE FACILITATION HEAVY JOINT COMPRESSION Joint awareness will improve by joint compression which will enhance motor control. Receptors in joints and muscles are involved in awareness of joint position and movement which are stimulated by joint compression. Compression of the joint surfaces facilitates posture extensors which are needed to stabilize the body. Compression greater than that applied by body weight is thought to facilitate co-contraction at the joint. The application may be manually and/or by using weight bearing postures. R- Poole JL, Whitney SL. Inflatable pressure splints ( airsplints ) as adjunct treatment for individuals with strokes. Physical & Occupational Therapy In Geriatrics. 1993 Jan 1;11(1):17-27 . Paper concludes that splints have been effectively used to reduce tone, facilitate muscle activity around a joint, increase sensory input, control edema, and reduce pain. 35

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37. PROPRIOCEPTIVE FACILITATION QUICK STRETCH Receptor: muscle spindle endings, detecting length and velocity changes. Stimulus: quick stretch or tapping over muscle belly or tendon. Response: activates agonist( intrafusal & extrafusal ) to contract-stretch reflex, reciprocal innervation effect will inhibit the antagonist; activates synergists. Optimally applied in the lengthened range. A low-threshold response, relatively short-lived, can add resistance to maintain contraction. R- Bovend'Eerdt TJ, Newman M, Barker K, Dawes H, Minelli C, Wade DT. The effects of stretching in spasticity: a systematic review. Arch Phys Med Rehabil . 2008 Jul;89(7):1395-406. doi : 10.1016/j.apmr.2008.02.015. Epub 2008 Jun 13. PMID: 18534551. There is a wide diversity in studies investigating the effects of stretching on spasticity, and the available evidence on its clinical benefit is overall inconclusive.   37

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39. PROPRIOCEPTIVE FACILITATION INTRINSIC STRETCH Activates the proprioceptors in selected muscles and imply the principle of reciprocal innervation. It promotes stability of the scapulohumeral region, bearing more weight on the ulnar side of the hands and promoting resistive grasp. Joint compression to elbow with stretch to wrist extensors in quadruped position. 39

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41. PROPRIOCEPTIVE FACILITATION SECONDARY ENDING STRETCH Combination of resistance and stretch to facilitate developmental patterns. Once a muscle is put on a full stretch, secondary nerve endings which is facilitatory to the flexors and inhibitory to the extensors. 41

42. PROPRIOCEPTIVE FACILITATION STRETCH PRESSURE Mechanical stresses in contracting muscles in terms of stretch and pressure led to activation of glucose metabolism and protein synthesis. Hence causes muscular hypertrophy. Here comes the combine role of GTO(muscle tension and contraction) and muscle spindles.(change in length of muscle fibers) 42

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44. PROPRIOCEPTIVE FACILITATION RESISTANCE Receptors: muscle spindles Stimulus: resistance given manually or with body weight or gravity or mechanical weights Response: enhances muscle contraction through recruitment; facilitates synergists, enhances kinesthetic awareness Resistance needs to be graded dependent on the patient response and goal; additional recruitment and overflow may be counterproductive to movement goal. 44

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46. PROPRIOCEPTIVE FACILITATION TAPPING Stimulus: repeated quick stretch over tendon or muscle belly Response: activates agonist( intrafusal & extrafusal ) to contract-stretch reflex Tapping over muscle belly produces a weaker response than over the tendon. Tapping over a muscle is used to enhance holding in a weight bearing position. 46

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48. PROPRIOCEPTIVE FACILITATION VESTIBULAR STIMULATION(FAST) Receptor: semicircular canals in ears Stimulus: fast or irregular movement with acceleration and deceleration component, such as spinning, use of a scooter board, fast rolling Response: facilitates general muscle tone and promotes postural responses to movement Useful for patients with hypotonia (CP, downs syndrome); used to promote sensory integration. Also in patients with sensory integrative dysfunction(hyperactive child ADHD); patients with bradykinesia (PD). R- Lena Schmidt et al (2013). Galvanic Vestibular Stimulation Improves Arm Position Sense in Spatial Neglect : A Sham-Stimulation-Controlled Study. Neurorehabil Neural Repair published online 11 February 2013 DOI: 10.1177/1545968312474117   48

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50. PROPRIOCEPTIVE FACILITATION THERAPEUTIC VIBRATION High frequency: 100 to 300 cycles/second Low frequency: 50 to 60 cycles/second Uses: HF is used to elicit tonic vibration reflex which stimulates contraction of agonist muscle if applied directly over the muscle belly. Inhibits the contraction of antagonist muscle and suppress stretch reflex. LF is inhibitory and suppress pain perception, desensitize hypersensitive skin. R- Murillo N, Valls -Sole J, Vidal J, Opisso E, Medina J, Kumru H. Focal vibration in neurorehabilitation. Eur J Phys Rehabil Med. 2014 Apr;50(2):231-42. PMID: 24842220 . This review aimed to describe the effects of focal vibratory stimuli in neurorehabilitation including the neurological diseases or disorders like stroke, spinal cord injury, multiple sclerosis, Parkinson's' disease and dystonia.In conclusion, focal vibration stimulation is well tolerated, effective and easy to use, and it could be used to reduce spasticity, to promote motor activity and motor learning within a functional activity, even in gait training, independent from etiology of neurological pathology. 50

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52. PROPRIOCEPTIVE FACILITATION OSTEOPRESSURE Pressure on bony prominence to facilitate voluntary muscle contraction. 52

53. PROPRIOCEPTIVE FACILITATION JOINT APPROXIMATION Receptors: Joint receptors Stimulus: compression of joint surfaces, using manual pressure or position/gravity; weighted vest or belt. Response: facilitates postural extensors and stabilizing responses (co-contraction); enhances joint awareness (joint receptors) Approximation applied to top of shoulders or pelvis in upright weight-bearing positions facilitates postural extensors and stability ( eg ., sitting, kneeling, or standing). Used in PNF extensor extremity patterns, pushing actions. 53

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55. PROPRIOCEPTIVE FACILITATION JOINT TRACTION Receptors: Joint receptors Stimulus: manual distraction of joints; wrist and ankle cuffs. Response: facilitates joint motion; enhances joint awareness (joint receptors) Joint mobilization uses slow, sustained traction to improve mobility, relieve muscle spasm, and reduce pain. Used in PNF flexor extremity patterns, pulling actions. 55

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57. INHIBITORY TECHNIQUES 57

58. NEURAL WARMTH Receptors: thermo receptors, ANS(parasympathetic division) Stimulus: retention of body heat through body wraps (towel, snug-fitting clothing gloves, socks, tights); air splints(warm) Response: Provides general relaxation and inhibition; decreased muscle tone; decreased agitation or pain. Use for 10-15 mins ; avoid overheating; appropriate for highly agitated patients or individuals with increased sympathetic response. 58

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60. GENTLE SHAKING OR ROCKING Rhythmical circumduction of the head and slight approximation is given can also be used in the UE & LE. Provides inhibition/relaxation of muscles and painful muscle spasm. Decreases metabolic rate of the tissues. 60

61. SLOW STROKING Stimulus: applied to midline back Response: calming effect, generalized inhibition, decreased fight or flight responses Performed with patients in prone or in supported sitting (head and arms resting on table top). Can use massage, lubricant; stroke on either side of the spine; applied for 3-5 minutes. May be contraindicated with very hairy surface. 61

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63. SLOW ROLLING Patient is rolled slowly from a side lying position to prone and back in a rhythmical pattern; use on both sides of the body. Causes calming effect and generalized inhibition/relaxation. 63

64. MAINTAINED TENDINOUS PRESSURE Receptors: slowly adapting tactile receptors, ANS (parasympathetic division) Stimulus: manual pressure applied to the tendon insertion of a muscles; can be used in spastic or tight muscles. Response: calming effect, generalized inhibition, decreased fight or flight responses, desensitize skin. Useful with patients with agitation and high arousal ( eg ., patients with TBI). Can be combined with other relaxation techniques (deep breathing imagery, quiet environment). Also useful for patients with hypersensitivity ( eg ., patients with tactile defensiveness). R- Kukulka CG, Beckman SM, Holte JB, Hoppenworth PK. Effects of intermittent tendon pressure on alpha motoneuron excitability. Physical therapy. 1986 Jul 1;66(7):1091-4 . R esults suggest that a maintained reduction in muscle tone might be induced through intermittent tendon pressure. 64

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66. LIGHT JOINT COMPRESSION Light joint compression inhibits muscle control or relax muscle spasticity . 66

67. MAINTAINED STRETCH Receptor: muscle spindle endings and GTO Stimulus: maintained stretch in a lengthened range Response: dampens muscle contraction Rationale for serial casting and splinting to increase the effect, activates the antagonist. 67

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69. ROCKING IN DEVELOPMENTAL POSITION S timulus: Shifting the weight forward and backward, progressing to side to side then diagonal patterns. Response: calming effect and generalized relaxation. 69

70. PROLONGED ICING/COOLING Stimulus: immersion in cold water, ice wraps, ice massage, cooling suit Response: decrease neural and muscle spindle firing. Provides inhibition of muscles and painful muscle spasm. Decreases metabolic rate of tissues. Monitor effects carefully: can produce sympathetic arousal, withdrawal or fight-or-flight responses. Contraindicated in patients with sensory deficits, generalized arousal, autonomic instability and v ascular problems. 70

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72. POSITIONING Patients should be given individualized positioning and early mobilization management plans as soon as possible after a neurological impairment to prevent complications and to regain function. It is based on reducing the effects of gravity on alpha motor neuron and consequently inhibiting muscle tone. R- Keating M et al (2012) Positioning and early mobilisation in stroke. Nursing Times; 108: 47, 16-18. P ositioning and early mobilization strategies 24 hours a day, reducing the risk of complications and improving functional recovery.  72

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74. TECHNIQUES OF PNF Resistance Irradiation and reinforcement Manual contact Body position and body mechanics Verbal (commands) Vision Traction or approximation Stretch Timing Patterns 74

75. TECHNIQUES OF PNF Strengthening techniques Rhythmic initiation Repeated contraction Slow reversal Slow reversal-hold Rhythmic stabilization Stretching techniques Contract relax Hold relax 75

76. PATTERNS SHOULDER D1 Flexion Shoulder FLEX, ADD, ER Forearm - Sup Wrist - Rad. Flexion Fingers - flexion D2 Flexion Shoulder FLEX, ABD, ER Forearm - Sup Wrist - Rad. Flexion Fingers - Extension D1 Extension Shoulder EXT, ABD, IR Forearm - Pro Wrist - Ulnar. extension Fingers - Extension D2 Extension Shoulder EXT, ADD, IR Forearm - Pro Wrist - Ulnar ext. Fingers - flexion 76

77. LOWER EXTREMITY F-ABD-IR F-ADD-ER E-ABD-IR E-ADD-ER 77

78. REFERENCES O’Sullivan S & Schmitz T (2007). Physical rehabilitation (5 th ed ). Philadelphia, F. A. Davis Company. Levitt S (2004). Treatment of cerebral palsy and motor delay (4 th ed ). Singapore, McGraw-Hill Inc. Pedretti LW & Early MB ( Eds ) (2006). Occupational therapy: Practice skills for physical dysfunction (6 th ed ). St. Louis, Mosby-Year Book, Inc. Tecklin JS (1999). Pediatric physical therapy (3 rd ed ). Philadelphia, J.B. Lippincott Company . M, Stokes & E, Stack. Physical Management for Neurological Conditions. Edinburgh: Churchill Livingstone, 2011. Alison Baily Metcalfe, Nigel Lawes . A modern interpretation of the Rood Approach. Physical Therapy Reviews; Vol. 3, Iss . 4, 1998 Eisenberg MG. 1995. Dictionary of Rehabilitation. New York: Springer Publishing Company. p. 375 Tapping Available from : https://www.youtube.com/watch?time_continue=4&v=4b2UiVTlNLw  accessed on 31/05/19. Fast Brushing Heather Watson-Fournier Available from  https://www.youtube.com/watch?v=0B23ngwLcGc  accessed on 31/05/19.  A" Icing Available from  https://www.youtube.com/watch?v=nE7HcZqMEgs . Accessed on 31/02/19. Quick Stretch Available from  https://www.youtube.com/watch?v=tRlpD_cQtzQ  accessed on 31/05/19 Heavy Joint Compression Available from  https://www.youtube.com/watch?v=2acoY3HAskc . Accessed on 2/6/19 https ://www.physio-pedia.com/Neurology_Treatment_Techniques 78

79. THANK YOU 79