Download Approaches to therapeutic exercises

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
 Brunnstrom’s
movement
therapy
 Neurodevelopmental
approach
 Rood approach
 Proprioceptive neuromuscular
facilitation
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

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

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
 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

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
 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
Supine withdrawal (supine flexion)
 Rollover to sidelying
 Pivot prone (prone extension)
 Neck cocontraction
 Prone on elbows
 Quadruped
 Standing
 Walking

Facilitatory Techniques
Cutaneous
Thermal
Proprioceptive
Facilitation
Facilitation
Facilitation
1. Light
moving touch
2. Fast
brushing
1. A-icing
2. C-icing
3.
Autonomic
icing
1. Heavy joint
compression
7. Tapping
2. Quick stretch
8. Vestibular
stimulation
3. Intrinsic stretch
9. Inversion
4. Secondary
ending stretch
10.
Therapeutic
vibration
5. Stretch
pressure
6. Resistance
11. Osteopressure
Inhibitory Techniques
1. Neutral warmth
2. Gentle shaking or rocking
3. Slow stroking
4. Slow rolling
5. Tendinous pressure
6. Light joint compression
7. Maintained stretch
8. Rocking in developmental poistions

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

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

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
UPPER EXTREMITY D1 pattern
JOINT
FLEXION
EXTENSION
Scapula
Elevation,
Abduction, Rotation
Depression, Adduction,
Rotation
Shoulder
Flexion, Adduction
External rotation
Extension, Abduction
Internal rotation
Elbow
Flexion or Extension
Flexion or Extension
Supination
Pronation
Forearm
Wrist and Flexion to the radial
Hand
side, Finger flexion
and adduction,
Thumb adduction
Extension to the ulnar
side, Finger extension
and abduction, Thumb
in palmar abduction
UPPER EXTREMITY D2 pattern
JOINT
Scapula
Shoulder
Elbow
FLEXION
EXTENSION
Elevation, Adduction,
Rotation
Flexion, Abduction
External rotation
Depression, Abduction,
Rotation
Extension, Adduction
Internal rotation
Flexion or Extension
Flexion or Extension
Pronation
Forearm Supination
Flexion to the ulnar side,
Wrist and Extension to the radial
side, Finger extension and Finger flexion and
Hand
Abduction, Thumb
extension
adduction, Thumb in
opposition
LOWER EXTREMITY D1 pattern
JOINT
Hip
FLEXION
Flexion
Abduction
External rotation
EXTENSION
Extension
Adduction
Internal rotation
Knee
Flexion/extension
Flexion/extension
Ankle
and
Foot
Dorsiflexion
Inversion
Plantarflexion
Eversion
Extension
Flexion
Toe
JOINT
Hip
LOWER EXTREMITY D2 pattern
FLEXION
EXTENSION
Flexion
Abduction
Internal rotation
Extension
Adduction
External rotation
Knee
Flexion/extension
Flexion/extension
Ankle
and
Foot
Dorsiflexion
Eversion
Plantarflexion
Inversion
Extension
Flexion
Toe
 Combined
upper extremity or
lower extremity diagonal
patterns
› Symmetrical
› Asymmetrical
› Reciprocal

Symmetrical
› Paired
extremities
(either UE of LE)
perform the
same diagonal
pattern and
direction
› Promotoes trunk
flexion and
extension

Asymmetrical
› Paired
extremities
perform
opposite
diagonal
pattern but
same direction
› Facilitates trunk
rotation
 Reciprocal
› Paired
extremities move
in opposite
diagonal
pattern and
direction
› Promotes head,
neck, and trunk
stability
 Combined
upper extremity and
lower extremity movements
› Ipsilateral
› Contralateral
› Diagonal reciprocal
 Ipsilateral
› Extremities of
the same side
(UE and LE)
move in the
same diagonal
pattern and
direction

Contralateral
› Aka alternating
reciprocal
pattern
› Extremities of the
opposite sides
move in the
same diagonal
pattern and
direction

Diagonal reciprocal
› Contralateral
extremities moving in
the same diagonal
patterns and
directions while
opposite
contralateral
extremities move in
the opposite
diagonal pattern
and direction
 Manual
contacts
 Communication/commands
 Stretch
 Traction
 Approximation
 Maximal resistance
 Timing

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

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)

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
 separating
joint surfaces stimulate
the proprioceptive centers
 promote
 used
movement
during pulling motions
 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
 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

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

Reversal of
antagonists
› Combination of
isotonics
› Resisted
progression
› Dynamic reversals
› Stabilizing reversals
› Rhythmic
stabilization

Directed to the
agonists
› Repeated
contractions
› Rhythmic initiation

Relaxation
Techniques
› Contract relax
› Hold-relax
› Replication
› Rhythmic rotation
 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
 Stabilizing
Reversals
› Alternating isotonic contractions of the
agonists then antagonists
› Very limited motion (ROM) allowed
› Indications
 Impaired strength
 Impaired stability and balance
 Impaired coordination
 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
 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

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

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
 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

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
 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
 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
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