Special TechniquesSpecial Techniques

MD Tshabalala

Effects of Special TechniquesEffects of Special Techniques 1)      To initiate movement2)      To re-educate movement patterns3)      To correct muscle imbalance4)      To increase strength5)      To improve stability and balance6)      To improve co-ordination7)      To relax8)      To decrease pain9)      To increase range of motion10)  To overcome fatigue

RHYTHMIC INITIATIONRHYTHMIC INITIATION

This technique is used for the following: To teach the pattern To improve the patients’ ability to initiate

movement For patients with rigidity or spasticity where

increasing tone is undesirable. To make the patient aware of the direction of

movement, especially those with decreased sensation.

TECHNIQUETECHNIQUE:RI:RI

  The patient is asked to relax and is moved passively and rhythmically through the pattern.

The therapist says, “Relax, let me move you”. Then the patient is asked to “help me a little” and

an active assisted movement is performed. The patient is told “help me a bit more”, and

performs an active movement. Then stretch and resistance is or may be applied. Calming verbal commands are used.

THE NEUROPHYSIOLOGY OF THE NEUROPHYSIOLOGY OF

RHYTHMIC INITIATIONRHYTHMIC INITIATION Verbal commands used during this technique i.e.

“relax” induce cortical inhibition which may be a contributing factor in decreasing tone.

The vestibular system may accommodate to repetitive rhythmic movements and the calming commands of rhythmic initiation.

Therefore arousal effects to the reticular activating system are minimised and tone is not increased as it would be using active movements and strong verbal stimulation.

COMBINATION OF ISOTONICSCOMBINATION OF ISOTONICS

A patient must be able to control his body weight as the muscles lengthen e.g. in descending the stairs or sitting from a standing position, eccentric control of the leg extensors is essential.

This technique incorporates both the concentric and eccentric muscle contractions.

TECHNIQUETECHNIQUE: CI: CI

The patient is instructed to move isotonically through a pattern.

He is asked to “hold” briefly. He is then told by the therapist. “Let me pull you back

slowly”. As she slowly move the part back towards the lengthened

range, and the patient controls the movement. The patient should then be asked to hold and then to move

back towards the shortened range concentrically. The patient should not relax at any stage during the cycle.

NEUROPHYSIOLOGYNEUROPHYSIOLOGY: CI: CI

When a muscle contracts against resistance eccentrically, both external and internal stretch occur simultaneously.

This enhances firing of the spindle afferents, having a facilitatory effect.

REPEATED CONTRACTIONS REPEATED CONTRACTIONS

(Isotonic)(Isotonic) This technique uses the “stretch reflex” to facilitate

maximum contraction throughout range. A re-stretch is applied at a point where facilitation

for further contractions is needed. Through re-stretch of all the agonists and synergists

we get a summation of impulses.

   This way we can increase:

- strength

- endurance

- mobility

TECHNIQUETECHNIQUE: RC: RC Start the pattern with stretch-reflex. At a point where strength is decreasing apply a re-stretch. The re-stretch must be applied before the patient quits

contracting maximally.  Re-stretch is a quick stretch back into the direction of the

antagonistic pattern. It has a short distance, rotation is most important. Re-stretch is immediately followed by resistance

allowing movement! The command is coinciding with the re-stretch to get the

patient’s voluntary input

NEUROPHYSIOLOGY OF NEUROPHYSIOLOGY OF REPEATED CONTRACTIONSREPEATED CONTRACTIONS

During a muscle contraction the skeleto-muscle fibres shorten.

During voluntary movement the intrafusal muscle fibres contract, maintaining some stretch on the muscle spindle.

Re-stretching the muscle which is contracting will re-fire the muscle spindle and re-initiate the myotatic stretch reflex.

Slow ReversalSlow Reversal

Seen in ADLs as reversal of antagonistic muscles groups e.g. walking, swimming, polishing etc

Slow reversal tech – used to re-educate reversal of antagonists

Based on Sherrington’s principle of reciprocal innervation & successive induction

Functions of Slow Reversal: Mm Strengthening Improve co-ordination and endurance Increase ROM by reducing pain

Technique: SR Technique: SR Upper Limb: Flex, Abd – Ext. Add Starting position – work through the pattern

maximally At EOR, change the proximal hand first! It becomes

the distal hand in new pattern When pt reacts to new pattern, place distal hand onto

the correct proximal surface of new pattern. Repeat several times Always start with the STRONG pattern! Ask pt to ‘hold’ the weaker agonistic pattern Slow Reversal uses both the Isotonic & Isometric

contractions

Neurophysiology of Slow Neurophysiology of Slow ReversalReversal

Sherrington’s law of Successive Induction maintains that a pattern is facilitated by immediately preceding it with contraction of the Antagonistic pattern

Inhibitory effects of the golgi tendon organ & renshaw cells on the agonists results in inhibition of the agonist & reciprocal facilitation of the antagonist

Antagonists are stretched as the pattern approaches the EOR, which facilitates these muscles

Also as the Stronger pattern approaches its shortened range, stretch on the muscles of the pattern diminishes, unloading the muscle spindle, which reduces the spindle afferent firing.

Rhythmic StabilizationRhythmic Stabilization

It is a reversal technique, but uses Isometric contractions

The object is to build up a co-contraction of antagonistic muscle groups around the jt.

All mm. Which have the potential to produce movt at the jt contract simultaneously

The technique is applicable on mat work.

Functions of Rhythmic Functions of Rhythmic StabilizationStabilization

To increase mm strength Improve postural stability of the jts For pts presenting with pain or where movt is not

allowed. NB: For the pattern to be effective, the pt must be

able to perform isometric contraction & “hold” Attention is paid to the rotation component of the

mvt, do not overpower the pt’s rotation & break their ability to hold.

Technique: RSTechnique: RS

Start with Isotonic contraction Stop at Strongest point Pt must “hold” against the therapist’s resistance

which changes slowly & fluently from one pattern into another.

Relaxation TechniquesRelaxation Techniques

Similarities b/t Contract-Relax & Hold-Relax To increase ROM To decrease Pain Both can be done with Ice Both have a period of relaxation

Differences Differences Contract-Relax Hold-Relax

1) Tightness without pain 1) Pain or tightness with pain

2) Done at point of tightness 2) Done in painfree range

3)Action comm: “push” or “pull”

3) command: “hold”

4) Minimal mvt into rotation & few degrees of ROM

4) No Movement!, true Isometric contraction

5) Maximal contraction 5) Contract as much as possible without causing pain

Contract-Relax Technique Contract-Relax Technique Part moved passively or actively to the point of limitation Pt get command for the antagonistic pattern Therapist resist all components of the pattern Only a small ROM may occur When pt working maximally, gets the command: “let go

slowly” Therapist gradually relaxes grip & move into the

antagonistic pattern Finish the whole pattern from stretch, no resistance Repeat the procedure, NB: strengthen the Newly gained

range

Neurophysiology of Contract - Neurophysiology of Contract - RelaxRelax

Fatigue play a greater role than in hold-relax Maximal effort results in the recruitment of more phasic

motor units Sustained maximal tension may serve to recruit more GTO

units As in Hold-relax, renshaw cell inhibition also occur Prolonged stretch/ resistance to muscles causes autogenic

inhibition via the Flower Spray fibres in the spindle Suprasegmental inhibition occurs as the patient is told to

relax Joint receptors may contribute inhibitory influences ot the

alpha motor neuron pools.

Hold-RelaxHold-Relax Can be done directly and indirectly Therapist moves part to the point of limitation i.e.

below pain threshold! Places hand on the correct surface, either agonists or

antagonists Command is: “hold” or “don’t let me move you” Build up resistance slowly No motion may occur, Watch rotatory component Ease off slowly with command: “Let go slowly” Therapist moves part further into limited direction Repeat the technique

Neurophysiology of Hold-Neurophysiology of Hold-Relax Relax

Fatigue occurs at the NMJs, dampening muscle tension. The GTO produces autogenic inhibitory impulses to the

anterior horn cells in response to increased mm tension, this inhibitory influence is brief & not the only mechanism

Alpha motor neurons discharge, its branch causes the renshaw cells to discharge, thus exert inhibition on that alpha neuron. This is known as recurrent inhibition.

All mm have both tonic & phasic fibres, Inhibition from renshaw cells influences tonic motor units

Tonic motor units are recruited first

Emphasis of Timing Emphasis of Timing Emphasizes on a particular weak mvt within a pattern Uses an overflow from strong groups If there is no strong part: work on whole pattern with

emphasis on proximal joints. Reinforcement is done by the so-called “PIVOT”, while

the strong groups contract isometrically Look at Pattern as having 3 Parts:

– Pivot joint: jt in which mvt is taking place through a pivot– Handle: part distal to the pivot joint– Stabilized part: Strong muscle groups contracting isometrically,

“locked in”

Technique: TETechnique: TE

Start from stretch, pt moves actively to stronger pattern Lock strong parts where they can work best Give maximal resistance, prevent motion Pivot the pivot joint with a re-stretch Give an adequate command Allow pt time for movement A pivot can be done several times, watch pt’s endurance,

avoid fatigue Continue the pattern with re-stretch for all componentsNB: Emphasis of timing can be done on bilateral pattern,

locking in one limb and pivoting the other.

Neurophysiology of TENeurophysiology of TE

Maintained isometric contraction of strong mm groups is capable of producing overflow to weaker mm.

The influence of the muscle-spindle & GTO is not restricted to the muscles to their own functional group

Collateral branches go via interneurons to mm of other parts of the body:– Ipsilateral = contralateral– Upward & downward– Across the spinal cord level– Far below consciousness

There is increase of alpha & gamma motor neuron recruitment.