physiotherapy intensive care unit abcdes

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1. 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. DEFINITION
O'Sullivan S & Schmitz T (2007). Physical rehabilitation (5" 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. 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. 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. 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. 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. 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. 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. DIFFERENCE

FACILITATION INHIBITION
* Provide sensation of normal + Decrease abnormal muscle
movement

tone(spasticity)
* Provide system for relearning

normal movement * Restore normal alignment

* Stimulates muscles to * Do not allow abnormal
contract(flaccid or weak muscles) movements(associated reactions)
* Allow for practice of movements * Teach methods to decrease

* Teach ways to incorporate involved abnormal postures during
side into functional tasks functional tasks.

10. 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. GENERAL GUIDELINES TO BE
CONSIDERED

* Sensory receptors based on adaptation: Slow- and Fast- adapting.

* Fast- adapting, phasic receptors such as touch receptors and phasic la
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. 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. “Receptors of colt aed enr are Weiner cabert IMPALA PONS (hermoreceptars)

14. RECEPTORS

15. RECEPTORS

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

Muscle —-
Spindle

1) Stretch
2) Speed of Stretch

16. RECEPTORS

* The Golgi Tendon Organ: Muscle tension or contraction

Golgi Tendon ma
Organ
‘Myelin reat,
Connective tasut
pu

1) Tension

Meade Bra

17. VARIOUS APPROACHES THAT
WORKS ON F&I PRINCIPLES:

+ ROODS APPROACH
PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION THERAPY

NEURODEVELOPMENTAL THERAPY
CONTRAINED INDUCED THERAPY
SENSORY INTEGRATION THERAPY
MASSAGE/ACUPUNTURE/ACUPRESSURE
ROBOTICS

"vi JAL REALITY

TIBULAR RE

“VI
HYDROTHERAPY, CRYOPTHERAPY

TAPING

ABROBICS/PILATES/TREADMILL TRAINING/TAL CHIYOGA
ELECTROTHERAPY, FES

BIOFEEDBACK

ORTHOTICS/PROSTHETICS

ABILITATION THERAPY

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

24. CLINICAL IMPLICATIONS

MAINLY INCLUDES THESE PATIENT POPULATION:
* STROKE

* TBI

* SCI

* PARKINSONISM

* MULTIPLE SCLEROSIS

* AMYOTOPHIC LATERAL SCLEROSIS

«EP

+ DOWN SYNDROME

* SPINAL MUSCUALR ATROPHY

25. E Facilitatory Techniques

Thermal |

Cutaneous

Facilitation | Facilitation

)

1. Heavy joint
compression
2. Quick stretch
3. Intrinsic stretch

4. Secondary ending
stretch

5. Stretch pressure
6. Resistance
7.Tapping

1. A-icing
2. C-ieing

1. Light moving
touch

2. Fast brushing

Proprioceptive
Facilitation

8. Vestibular
stimulation

9. Therapeutic
vibration

10. Osteo-
pressure

IL. Joint
approximation
12. Joint traction

26. [i Inhibitory Techniques |

1. Neutral warmth
2, Gentle shaking or rocking.
3, Slow stroking
4. Slow rolling
5. Maintained Tendinous pressure
6, Light joint compression
7. Maintained stretch
8. Rocking in developmental positions
9, Prolonged icing/cooling
\ 10. Positioni

27. FACILITATORY TECHNIQUES

28. 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).

Findings indicate that light touch could be beneficial in postural control for individuals with hemi-
paretic stroke,

29. Sooth Your Nerves

30. 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.

32. 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.

+ CICING: stimulates non-specific € 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.

34. PROPRIOCEPTIVE FACILITATION

HEAVY JOINT COMPRESSION
+ Joint awareness will improve by joint compression which will enhance motor control.

: Receplors in joints and muscles are involved in awareness of joint position and movement
which are simulated 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
individ als with strokes. Physica ceupational Therapy In Geriatrics. 1993 Jan

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. «

ww NN

MC
y

36. 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, B r K, Dawes H, Minelli €, Wade DT. The
effects of stretching in spasticity: a tic n w. 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.

38. 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.

40. 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. 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)

43. 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,

45. 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.

47. 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
dyehunetron(hyperastive child ADHD); patients with bradykinesia (PD).

Position Sense i in Spatial Neglect : A Sham- O Aa Study;
blished onli el :

10.1177/15459683 12474117

48. PEA,
SFY,

49. PROPRIOCEPTIVE FACILITATION

THERAPEUTIC VIBRATION
+ High frequency: 100 to 300 cycles/second
+ Low frequency: 50 to 60 cycles/second

+ Uses:

used to elicit tonic vibration reflex which stimulates contraction of agonist muscle if applied
ly over the muscle belly. Inhibits the contraction of antagonist muscle and suppress stretch

= LF is inhibitory and suppress pain perception, desensitize hypersensitive skin.

R-Murillo N, Valls-Sole J, Vidal J, O; E, Medina J. Kumru H. Focal vibration in
neurorchabilitation. Eur I Phys Rel d. 2014 Apr.50(2):23 1-42. PMID: 24842220

This review aimed to describe the effects of focal vibratory stimuli in neurorehabilit o
the neurological diseases or disorders like stroke, spinal cord injury, multiple sclerosis, Parkinso
disease and dystonia.In conclusion, focal vibration stimulation is well tolerated, effective and easy to
dit could be used to reduce spasticity, to promote motor activity and motor {earning within a
ependent from etiology of neurological pathology.

use
functional activity, even in gait training, in

51. PROPRIOCEPTIVE FACILITATION

OSTEOPRESSURE

* Pressure on bony prominence to facilitate voluntary muscle
contraction.

52. 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.

54. 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.

56. INHIBITORY TECHNIQUES

57. 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.

59. 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. 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.

62. 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. MAINTAINED TENDINOUS PRESSURE

+ Receptors: slowly adapting tactile receptors, ANS (parasympathetic division)
+ Stimulu: angel pressure applied to the tendon insertion of a muscles; can be used in spastic or

ing effect, generalized inhibition, decreased fight or Might responses, desensitize

+ Useful with patients with agitation and high arousal (eg., patients with TBD.

+ 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,

Results suggest that a maintained reduction in muscle tone might be induced through intermittent
tendon pressure.

65. LIGHT JOINT COMPRESSION

* Light joint compression inhibits muscle control or relax muscle
spasticity.

ming Joint
COMPRESSIONS

66. 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.

68. ROCKING IN DEVELOPMENTAL
POSITION

+ Stimulus: Shifting the weight forward and backward, progressing to
side to side then diagonal patterns.

* Response: calming effect and generalized relaxation.

69. 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 vascular problems.

71. 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,
Positioning and early mobilization strategies 24 hours a day, reducing
the risk of complications and improving functional recovery.

72. Positioning the
Right Hemiplegic Arm

Lying on Hemiplegie Side Lying on Unaffected Side

Sitting in Wheelchair

Sitting in Bed

BD in vont mem tonte

73. TECHNIQUES OF PNF

* Resistance

+ Irradiation and reinforcement

* Manual contact

* Body position and body mechanics
+ Verbal (commands)

* Vision

* Traction or approximation

+ Stretch

* Timing

* Patterns

74. TECHNIQUES OF PNF

* Strengthening techniques
* Rhythmic initiation
+ Repeated contraction
+ Slow reversal
+ Slow reversal-hold
+ Rhythmic stabilization
* Stretching techniques
+ Contract relax
+ Hold relax

75. PATTERNS

D1 Flexion D2 Flexion
Shoulder FLEX, ADD, ER Pi FLEX, ABD,

Forcarm - Sup
Wrist - Rad. Flexion

Forearm - Sup
Wrist - Rad. Flexion

Fingers - flexion u Ñ
Fingers - Extension

D1 Extension

D2 Extension Shoulder EXT, ABD, IR
Shoulder EXT, ADD, IR Forearm + Pro

Forearm - Pro ‘Wrist - Ulnar, extension
Wrist - Ulnar ext. Fingers - Extension

Fingers - flexion

76. LOWER EXTREMITY

F-ABD-IR F-ADD-ER

E-ABD-IR E-ADD-ER

77. REFERENCES

O'Sullivan $ & Schmitz T (2007), Physical rehabilitation (5% cd), Philadelphia, E. A. Davis Company.

LevittS (2004), Treatment of cerebral palsy and motor delay (4% ed). Singapore, McGraw-Hill Inc.

Pedreni ¡VS Early MB (Eds) (2006), Occupational therapy: Practice skills for physical dysfunction (6% ed). St. Louis, Mosby-
fear Book, Inc.

Tecklin JS (1999), Pediatric physical therapy (3 ed), Philadelphia, J.B. Lippincott Company.
M, Stokes & E, Stack. Physical Management for Neurological Condi Edinburgh: Churchill Livingstone, 2011.
‘Alison Baily Metcalfe, Nigel Lawes. A modera interpretation of the Rood Approach, Physical Therapy Reviews: Vol. 3, Iss. 4.

Eisenberg MG. 1995. Dictionary of Rehabilitation. New York: Springer Publishing Company. p. 375
Tapping Available from ships: www.voutube com/watel time _continucsdevedh2UiVTINLW agcessed on 31/05/19,
Fast Brushing Heather Watson-Foumier Available from anus voue com watchs -OB2 Snel sie accessed om

A" Icing Available from jigps://www youtube, com/watehtv=nETHezaM Egs. Accessed on 31/02/19
Quick Stretch Available from hiips://www.younibs com/watshiiy1RIpD_sQizQ accessed on 31/05/19
Heavy Joint Compression Available from https//www. youtube com/ watch} v=2ac0V IH Aske. Accessed on 2/6/19

https://www.physio-pedia.com/Neurology Treatment Techniques

78. THANK YOU