Occupational therapy programs tables of content

OCCUPATIONAL THERAPY

PROGRAMS

Section 20

PROGRAM: TONE MANAGEMENT
DESCRIPTION/PURPOSE:
Facilitation and inhibition techniques are hands-on procedures used to normalize muscle tone.
Facilitation is the method utilized to promote or hasten the response of the neuromuscular mechanism.
Inhibition is the method utilized to decrease or slow the response of the neuromuscular mechanism.
OBJECTIVES/GOALS:

To normalize tone and evoke desired muscular response.
To educate resident/staff in proper handling and positioning.
INDICATIONS:

Central nervous system damage resulting in abnormal tone.
CONTRAINDICATIONS:

None
PRECAUTIONS:
Monitor for response to pain during facilitation techniques.
Use caution with the subluxed shoulder to prevent further injury.
EQUIPMENT:

Necessary weight bearing surfaces.
Weights and weighted utensils.
Mat table.
Vibrator.

Tone Facilitation and Inhibition Techniques (cont.)

PROCEDURE:
Three neurophysical based approaches most commonly used in the treatment of muscle control problems are included here. They are:
Bobath Neurodevelopmental Approach

Proprioceptive Neuromuscular Facilitation (PNF)

Brunnstrom Approach.
The approaches are most similar than diverse, since each has the goal of improved motor control for residents with brain damage and because each is based on information regarding the central nervous system. The therapist is encouraged to develop his/her own treatment approach based on sound rationale of motor development. The therapist may decide to select procedures from several of the approaches presented. However, there must be collaboration among members of the rehab team when approaches are used to ensure consistent stimulation to the resident throughout the day.

Prior to beginning treatment, review the medical record and obtain adequate knowledge of resident’s condition, disability, and referral for treatment.
Instruct the resident in procedure, length, goals of treatment and symptoms to notify therapist of, if they should occur.
Place resident in a comfortable position with proper body alignment.
Free area from restrictive clothing, linen, splints, dressing, etc. Drape resident as necessary. Be certain there is sufficient space in which to perform all exercise patterns. (Move furniture, plinths, etc.) Be sure the joint(s) to be treated have freedom of motion from external forces.
Select treatment techniques most appropriate for resident’s condition.
See attachments for various neurological approaches (Bobath, PNF, Brunnstrom).
DOCUMENTATION:
Documentation must reflect the need for skilled therapy, support the skilled nature of the tone facilitation and inhabition techniques utilized, present objective and measurable progress and the resident’s response and tolerance to the treatment procedure; to activity/training provided to family/staff, and post therapy recommendations.

PROGRAM: TONE MANAGEMENT
BOBATH

History
The neurodevelopmental treatment approach was first described by Berta and

Karel Bobath in the 1940's.

Philosophy
The concept is based on two fundamental principles about the nature of central

nervous system dysfunction:

The arrest or retardation of normal movement is caused by the interference with normal brain maturation resulting from a brain lesion and;

The resultant release of abnormal or immature postural reflex activity causes the observed abnormal patterns of posture and movement.

Principles
Overall the success of neurodevelopmental treatment is contingent on the

therapist’s ability to make changes in muscle tone. The Bobath approach

identifies three stages:

Stage 1 - Flaccidity - Treatment can include range of motion exercises and bed positioning outside abnormal patterns.

State 2 - Stage of Spasticity - Treatment can include placing of extremities outside synergy patterns, ROM outside synergy patterns, use of inhibition techniques to normalize tone and utilization of weightbearing.

Stage 3 - Stage of Relative Recover - Treatment can include continued use of weightbearing and facilitation techniques, encouragement of isolated motor control outside synergy patterns.
Examples of Inhibition Techniques:

Rotation

Positioning

Minimal Verbal Input

Decrease Extraneous Stimuli

Slow Rocking

Slow Stroking

Reflex Inhibiting Patterns (RIPS)

Bobath (cont.)

Often, we affect distal parts by handling proximally. The most obvious point of abnormality is not always the area to which handling techniques are applied; i.e., a fisted hand is often influenced by input at the shoulder.

Key Points of Control

	Movement	Facilitates/Inhibits
Head	extension	extension of head/trunk facilitated
	flexion	head control facilitated inhibits extensor spasm
Arms and Shoulder Girdle	rotate outwardly with supination extension of elbow	facilitates extension throughout body
	horizontal abduction of arms with outward rotation; elbow extension with supination	inhibits flexor spasticity facilitates leg extension, outward rotation facilitates hand opening
	elevation of arms with outward rotation	inhibits flexor spasticity, facilitates extension of spine, hips, legs
	diagonal extension backwards with outward rotation	opening of hand
Legs and Pelvis	flexion of legs	facilitates abduction and outward rotation of legs, facilitates dorsiflexion of ankles
	outward rotation in extension	facilitates abduction and dorsiflexion of ankles
	dorsiflexion of toes	inhibits extensor spasticity in leg, facilitates ankle dorsiflexion, facilitates outward rotation, abduction of leg

Once selected movements from the above list are established to influence muscle tone, the resident is then guided to perform balance maneuvers, (tilting, righting reactions), and more normal movement patterns in functional activities.

Examples of Facilitation techniques:

Tapping over Muscle Belly

Quick Stretch

Vibration

Resistance

Joint Approximation

Treatment
The primary focus of treatment is inhibition of abnormal movement with simultaneous facilitation of normal movement patterns, righting and equilibrium reactions. A typical treatment sequence would include:
The use of inhibition techniques to block abnormal tone and movement patterns.
Therapist takes the resident through a series of motor experiences to set the stage for learning new movement patterns.
Use of “preparation activities”, and progressively sequence the resident through normal developmental stages.
Utilization of key points of control such as shoulders and pelvis, to influence tone and movement in the rest of the body.

PROGRAM: TONE MANAGEMENT
PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)
HISTORY:
First identified in the 1940's by Dr. Herman Kabot and later expanded by Margaret Knott and Dorothy Voss.
PHILOSOPHY:

Proprioceptive Neuromuscular Facilitation (PNF), is a method of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptors.
Early motor behavior is dominated by reflex activity and mature motor behavior is reinforced or supported by postural reflex mechanisms. In treatment, the reflex mechanisms are utilized to reinforce voluntary effort.
Spontaneous movement of early motor behavior oscillates between extremes of flexion and extension; therefore, in treatment, reversing movements are used to establish or re-establish interaction of antagonistic muscle groups.
Stronger body parts, used to assist weaker parts, lead toward a good optimum function.
Repetition is important.
PRINCIPLES:

Manual contacts

Skin receptors are used to produce awareness.

Must be strong enough for resident to feel.
Maximal resistance (appropriate).

Resistance will make the resident aware of what you want so he is not using his cortical level to perform an activity.

When treating residents with a deficiency of innervation it is the maximal resistance that provides the means for causing overflow or irradiation from the stronger patterns to the weaker ones.

PNF (cont.)

Joint structures

Traction - aids in stabilizing/controlling motion.

Approximation - helps provide stability and maintenance of posture.

Contraindication - pain, non-union fracture.

Stretch response

Used to initiate motion, increase strength, relax muscle not under voluntary control.

Rotation is the key.

Don’t use with paint.

Verbal stimulus

Quality of command will influence response.

Visual stimulus

Let resident see part being exercised.

Patterns are:

Specific - every person is stronger in pattern.

Resemble normal activities.
Normal timing

In normal development, proximal control is evident before distal control. As purposeful coordinated movement is acquired, timing of muscles occurs from distal to proximal.

Irradiation

Apply more resistance to stronger component in pattern hoping for overflow to weaker.

Use of overflow on unaffected side to enhance weak components on more affected side.
IMPORTANT CONSIDERATIONS OF PNF:

Resident must be taught pattern.
Stay “in groove”.

Groove is the width of limb only; not an arc.

Rotation - key to all movements.
Body mechanics - stand in the diagonal.

PNF (cont.)

Teach resident on uninvolved side.
Repetition
PNF PATTERNS:

Upper Extremity

1^st Diagonal: Flex - Add - External rotation

Ext - Abd - Internal rotation

2^nd Diagonal: Flex - Abd - External rotation

Ext - Add - Internal rotation
Lower Extremity

1^st Diagonal: Flex - Add - External rotation - dorsiflex - inversion

Ext - Abd - Internal rotation - plantaflex - inversion

2^nd Diagonal: Flex - Abd - Internal rotation - dorsiflex - eversion

Ext - Add - External rotation - plantarflex - inversion
SPECIFIC TECHNIQUES:

Contract - Relax

Purpose - increase ROM in joints that aren’t painful.

Indication - decrease ROM

Contraindication - painful ROM

Procedure:

Resident assumes point of tightness actively or is moved to point of tightness passively. “Let me move you”.

About 5N isotonic contraction of the tight muscle group is allowed.

Allow resident to relax.

Move resident to next point of tightness.

Maximal contraction - relaxation - increase ROM.

Hold - Relax

Purpose - increase ROM and decrease pain on painful joints. Should not be painful.

Indication - where pain is preventing active motion.

Contraindication - resident can’t do isometric contraction.

Procedure:

Take resident passively to point just before painful area.

Ask resident to perform isometric contraction. “Hold”, “Don’t let me move it,” “Keep it there”.

PNF (cont.)

Gradually increase resistance to obtain maximal muscle contraction - do not move resident.

Slowly decrease resistance and allow resident to relax.

Move resident into ROM gradually, to next point of tightness.

Be sure to bring in every component of the pattern.

Contract - Relax	Hold - Relax
1. Isotonic muscle contraction.	Isometric muscle contraction.
2. Performed on non-painful joint.	Performed on painful joint.
3. Maximal resistance is immediate.	Maximal resistance is gradual.
4. Easier for resident to learn.	Resident must be able to hold.
5. Command - “push” or “pull”.	Command - “hold”.
6. Take part to point of tightness actively or passively.	Before painful area, slowly and passively.

Slow Reversals

Purpose - facilitate ROM and strength in weaker agonist muscles by utilizing the stronger antagonist.

Indication:

Decreased ROM.

Decreased strength with good strength of app. pattern.

Imbalance of agonist and antagonist.

Contraindications:

Weakness of both patterns.

No mobility allowed.

Procedure

Begin with isotonic muscle contraction into isotonic pattern.

Change hand hold without allowing resident to relax at end of pattern.

Go into weaker pattern.

Repeat several times.

Rhythm (Rhythmic initiation).

Purpose - improve ability to initiate movement. Increase active motion and reciprocal movement.

Indications:

Rigidity.

Inability to initiate movement.

Inability to control direction of movement.

Lack of awareness

Speed and control

(Not for power).
PNF (cont.)

Contraindications - if motion is contraindicated.

Procedure:

Resident relaxes initially and is moved passively through a pattern in one direction. “Let me move you”.

Go from passive to active assistive movement to active to resistive. “Now, help me.”

Resident’s efforts are gradually increased until the motion can be maximally resisted by therapist.

Keep the same rhythm.

Later do in both directions.
Rhythmic Stabilization.

Purpose - facilitate stability. Maybe co-contraction. Facilitates relaxation, increases strength.

Indication - weakness, decrease ROM, decreased ability to stabilize.

Contraindication - none.

Procedure:

Isotonic contraction against resistance to strongest part in range.

Resident holds as an equal amount of resistance is applied alternatively to the agonist and antagonist group of muscles (alternate isometric contractions).

Finish with agonist isotonic contraction through rest of range.

Command, “Keep it there. Don’t let me move you. Hold”.

PROGRAM: TONE MANAGEMENT
BRUNNSTROM
HISTORY:
First identified around 1951 by Signe Brunnstrom.
PHILOSOPHY:

Motor behavior of hemiplegic residents is reflective of a regression to forms of reflective behavior which are normal at certain stages of maturational development in infancy.
Stages of recovery following CVA are somewhat analogous to the maturational changes in normal development reflecting an increase in function (or a “re-functioning”) of higher centers of the CNS.
Progression in the treatment approach follows the stages of recovery and hence is commensurate with recovery in CNS.
Use of associated reactions, postural reflexes, cutaneous stimuli, etc., are a means of regulating tension in the muscle groups being activated.
Neurophysical phenomena of stretch, resistance, cutaneous stimuli, reciprocal innervation, irradiation are integral parts of the training process.
The “Capturing” of a reflex actively by superimposing volitional effort on that activity enhances the ultimate development of voluntary movement.
PRINCIPLES:

Synergies are a group of muscles which:

Work together as a bound unit.

Are primitive and automatic in nature.

Are present on a spinal cord level.

Brunnstrom (cont.)
Synergy patterns

UPPER EXTREMITY	FLEXION	EXTENSION
Shoulder girdle	elevation and/or retraction	depression and/or protraction
Shoulder	abduction to 90N, ER (hyperextension)	adduction, IR (strongest)
Elbow	flexion (biceps strongest)	extension
Forearm	supination	pronation (may be strong)
Wrist	flxion	extension (often)
Fingers	flexion (never extension)	flexion
LOWER EXTREMITY	FLEXION	EXTENSION
Hip	flexion (strongest)	extension (weak) adduction (strong) abduction (weak) IR
Knee	flexion to 90N (weak)	extension (strongest)
Ankle	dorsiflexion (weak)	plantar flexion (strong)
Foot	inversion (weak) never eversion	inversion (strong)

Six stages of Recovery

Stage 1 - Flaccidity

All reflexes are decreased and there is no voluntary movement.

Stage 2 - Spasticity Begins

Synergy patterns are evoked by outside stimulus.

Flexion synergy usually dominates the UE and extension synergy usually dominates the LE.

Stage 3 - Spasticity at Highest Level

Synergies can be elicited voluntarily.

Any attempt to use extremity voluntarily results in a synergy pattern.

Stage 4 - Spasticity Decreases

Resident can begin to move outside basic synergy patterns.

Brunnstrom (cont.)

Stage 5 - Independent Motion of Synergies

Spasticity almost gone.

Resident can move slowly and deliberately without eliciting synergies.

Stage 6 - Isolated Movements

Spasticity disappeared.

Individual joint motion is freer and has controlled movement and speed.

Rapid reciprocal movement may still be uncoordinated.

TREATMENT:
After evaluation of the resident’s sensory status and stage of recovery, the treatment progresses as follows:

Motion synergies are elicited on a reflex level which utilizes:

Tonic neck reflex.

Tonic labyrinthine reflex.

Tonic lumbar reflex.

Associated reactions.

Upper extremities - flexion of uninvolved facilitates flexion of involved. Extension of uninvolved facilitates extension of involved.

Lower extremities - flexion of uninvolved facilitates extension of involved.

Ramiste’s Phenomenon - in supine, resist abduction of uninvolved side; facilitates abduction on involved side.

Sensory stimulation - quick stretch, resistance, positioning, surface stroking, tapping, clapping.

“Capturing” of synergies - an effort is made to establish voluntary control of synergies which utilizes:

Repetition with and then without facilitation.

Use of reciprocal movements.

Working from proximal to distal concentrating on various isolated components of synergies.

Condition of Synergies - combining elements of antagonistic synergies starting with stronger components which utilizes:

Weaning away from any use of facilitation or reflexes.

Increasing speed from one reciprocal motion to the other.

Concentration on muscle groups which are not components of either synergy.

Brunnstrom (cont.)

Elicitation of Voluntary Isolated Movements.

Repetition of independent motor control.

Add resistance to isolated movement.