Augmented Interventions in Physical Therapy

Augmented Interventions

  • Defined as information provided by some external source.

    • Types of input include:

    • Verbal

    • Visual

    • Manual

  • Essential Use Cases:

    • When intrinsic information is not available or when the patient lacks an internal reference for the task.

    • Important for optimization of performance (not learning) or change in temporal characteristics (speed of movement).

    • When AI complements intrinsic information.

  • Detrimental Aspects:

    • AI can be harmful if it supersedes intrinsic feedback, leading to potential dependency.

Neurofacilitation Approaches

  • Techniques utilizing physical stimuli and movement patterns to enhance muscle activity and functional ability.

  • Key Approaches include:

    • NDT (Neuro Developmental Treatment)

    • Rood

    • Bobath

    • PNF (Proprioceptive Neuromuscular Facilitation)

  • Ultimate Goal:

    • To eventually withdraw these techniques, enabling patients to take ownership of their functional responses.

Importance of External Environment in Intervention

  • The difference between contrived and functional intervention emphasizes the therapist's role.

    • Patient success relies on the therapist's presence in the external environment; without it, the outcome may differ significantly.

    • As noted by Umphred, contrived (planned/purposeful) techniques must eventually be removed to facilitate total patient ownership of functional response.

Manual Techniques

  • Categorized as:

    • Neuromuscular Facilitation Techniques

    • PNF employs these principles.

    • NDT relies on key points of control and therapeutic handling.

    • Sensory Stimulation Techniques

    • Include biofeedback and electrical stimulation (E-stim).

Summary of Sensory System Components

  • Significant components of the sensory system allow for manual facilitation techniques to augment motor output.

  • Understanding the various components impacting motor control is vital before moving into treatment interventions.

  • Consideration of WHY each intervention is chosen is critical.

Resistance

  • Description:

    • Resistance can be applied in several ways:

    • Manually

    • Using body position/gravity

    • Mechanically

  • Functions of Resistance:

    • Facilitates muscle contraction and enhances kinesthetic awareness.

    • With very weak muscles, light resistance should be used.

    • Isometric and eccentric contractions can precede concentric contractions.

    • Maximal resistance may cause overflow from strong to weak muscles.

Techniques of Resistance

  1. Quick Stretch:

  • Applied to the agonist, facilitating intrafusal and extrafusal agonist muscle contraction (stretch reflex).

  • Optimal application occurs in the lengthened range, eliciting low-threshold responses that are relatively short-term.

  • Resistance can be added to maintain contraction.

  1. Tapping/Repeated Quick Stretch:

  • Applied over tendon or muscle belly, to facilitate both intrafusal and extrafusal muscle contraction.

  • Tapping over the muscle belly elicits a weaker response than tapping over the tendon.

  1. Joint Approximation:

  • Involves compression of joint surfaces using manual pressure or positional gravity (e.g., wearing a weighted vest or belt).

  • Facilitates postural extensors and stabilizing responses (co-contraction) and enhances joint awareness through joint receptors.

  • Applied at the shoulders or pelvis in weight-bearing positions (sitting, kneeling, standing) enhances stability.

  1. Joint Traction:

  • Refers to manual distraction of joints, utilizing wrist and ankle cuffs.

  • Facilitates joint motion and enhances joint awareness via joint receptors.

  • Joint mobilization with slow, sustained traction can improve mobility, relieve muscle spasm, and reduce pain.

  1. Prolonged Stretch:

  • Involves slow, maintained stretch at maximum available lengthened range.

  • Functions to inhibit or dampen muscle contraction and decreases tone via peripheral reflex effects.

  • Positioning techniques may include inhibitory splinting, casting, or mechanical low-load weights using traction.

  1. Deep Pressure:

  • Prolonged application of pressure to tendon that induces autogenic inhibition, leading to muscle relaxation.

Sensory Modalities in Therapeutic Activities

  • Therapeutic activities typically engage five sensory modalities:

    • Auditory

    • Visual

    • Vestibular

    • Tactile

    • Proprioceptive

  • The complexity of analyzing primary input systems during these activities is significant.

  • Master clinicians demonstrate a well-developed sensitivity to client responses, adjusting inputs to meet client needs effectively, as discussed by Umphred.

Proprioceptive Neuromuscular Facilitation (PNF)

  • Applicable to a wide range of patients, including

    • NMR (neuromuscular rehab):

    • Focus on motor control training, mobility, balance, and gait improvement.

    • MSK (musculoskeletal):

    • Goals include increasing range of motion, strength, coordination, and stability.

    • CardioPulm:

    • Enhances chest wall mobility and respiration.

  • Key Components of PNF:

    • Utilization of synergistic patterns of movement.

    • Application of techniques to facilitate coordinated muscle activity and strength.

    • Promotion of functional activities and postures for optimal recovery.

    • Implementation of motor learning and control principles to promote optimal movement.

PNF: Basic Principles and Procedures

  • Patient Positioning:

    • Should reflect neutral alignment and optimal range of motion.

  • Therapist Positioning:

    • Should be in line with the desired motion of the patient.

  • Manual Contacts:

    • Utilize a lumbrical grip with purposeful placement.

  • Verbal Commands and Cues:

    • Must be clear and concise for effective communication.

  • Patterns of Movement:

    • Focus on synergistic patterns that facilitate the desired responses.

  • Timing:

    • Follow a sequencing pattern from distal to proximal.

  • Appropriate Resistance:

    • Provide resistance manually through different types of contractions.

  • Approximation and Traction:

    • Approximation facilitates extensor patterns and stabilization, while traction is relevant throughout the arc of motion.

  • Visual Input:

    • Utilize vision as a source of feedback for the patient.

  • Irradiation and Reinforcement:

    • Refers to overflow from stronger motor units to weaker muscles, facilitating overall muscle engagement.

  • Stretch:

    • Employed to stimulate muscle activation, enhancing overall efficacy of the intervention.

PNF Upper Extremity (UE) Patterns

  • D1 Flexion:

    • Shoulder flexion, adduction, external rotation; scapular elevation; forearm supination; wrist and finger flexion.

  • D1 Extension:

    • Shoulder extension, abduction, internal rotation; scapular depression; forearm pronation; wrist and finger extension.

  • D2 Flexion:

    • Shoulder flexion, abduction, external rotation; scapular depression; forearm supination; wrist and finger extension.

  • D2 Extension:

    • Shoulder extension, adduction, internal rotation; scapular elevation; forearm pronation; wrist and finger flexion.

PNF Lower Extremity (LE) Patterns

  • D1 Flexion:

    • Hip flexion, adduction, external rotation; ankle dorsiflexion, inversion; toe extension.

  • D1 Extension:

    • Hip extension, abduction, internal rotation; ankle plantarflexion, eversion; toe flexion.

  • D2 Flexion:

    • Hip flexion, abduction, external rotation; ankle dorsiflexion, eversion; toe extension.

  • D2 Extension:

    • Hip extension, adduction, internal rotation; ankle plantarflexion, inversion; toe flexion.

Head and Neck Patterns

  • Cervical Spine:

    • Flexion with rotation to one side accompanied by chin tuck, followed by extension rotating to the opposite side with chin lift.

Trunk Patterns

  • Full Trunk Extension:

    • Consideration of spinal levels, rib movement, and pelvic/shoulder girdles movement.

  • Trunk Rotation:

    • Awareness of segmental involvement and rib movement is essential.

Techniques Organization

  • Techniques include:

    • Chop and Reverse Chop

    • Lift and Reverse Lift

    • Rhythmic Initiation

    • Dynamic Reversals (Isotonic Reversals)

    • Stabilizing Reversals (Isotonic Reversals)

    • Rhythmic Stabilization (Isometric Reversals)

    • Repeated Stretch (Repeated Contractions)

    • Combination of Isotonics

    • Contract-Relax

    • Hold-Relax

    • Hold-Relax-Active Motion