clinical application of facilitation & inhibition
Clinical Application of Facilitation and Inhibition Techniques
Review of Facilitation and Inhibition Techniques
Applying the same technique can result in either facilitation or inhibition.
The effect depends on:
Application speed (fast vs. slow).
Application location (specific area vs. regional/whole body).
Techniques affect multiple aspects of the nervous system, including:
Sensory system.
Motor system (primary target).
Autonomic nervous system (requires careful application).
Avoid overstimulation, especially in patients with head injuries or hypertonicity.
Techniques can affect multiple receptors, leading to a whole-body response.
Sensory stimulation can be integrated into exercises and functional training to augment effort.
Identifying Clinical Objectives and Appropriate Application
Determine if the technique helps achieve patient goals or if it could be counterproductive.
Identify which sensory receptors and nervous system parts are stimulated and how.
Consider the patient situation, including indications and contraindications (e.g., avoid facilitation techniques for patients with hypertonicity).
Understand if the technique is part of a broader exercise theory (e.g., Proprioceptive Neuromuscular Facilitation - PNF).
Use techniques during functional training to augment patient performance (e.g., transfers, gait).
Interoceptors: Auditory and Visual Receptors
Vision
Colors can be relaxing (greens, blues) or arousing (bright oranges, bright reds).
Different areas in hospitals or schools may use colors to create specific moods.
Some colors affect cognition; research suggests specific colors can optimize study environments.
Specific wavelengths of light can be therapeutic for patients post-TBI, aiding sensory integration and reducing agitation.
Avoid overstimulation with high facilitatory visual stimuli, especially in brain-injured patients, as this can increase agitation and distractibility.
Rehab centers typically use neutral colors to avoid unintended effects on patients.
Hearing
Auditory stimuli can be facilitatory or inhibitory.
Volume affects patient response: louder, more commanding voices can stimulate during exercise, while softer voices are more relaxing.
Different types of sounds can have different therapeutic effects.
Speech language therapists and OTs can use auditory stimuli to improve speech and cognition during ADL tasks.
Consider the patient's cognitive awareness and stability and state of arousal when applying auditory stimuli.
Interoceptors: Smell
Smell is used clinically during feeding to increase or decrease arousal.
Ammonia or smelling salts increase arousal for someone who has passed out.
Certain smells augment appetite and feeding efforts, while others decrease appetite.
Smells can evoke immediate emotional responses and memories (e.g., a favorite cookie).
Olfaction is the only sense that doesn't go through the thalamus, enabling immediate reactions to danger (survival mechanism).
Fibers of the olfactory tract disperse into the olfactory cortex (piriform cortex, amygdala, and entorhinal cortex).
The amygdala is part of the limbic system, regulating autonomic, endocrine, instinctive, and motivational behaviors (fight or flight).
The limbic system can be stimulated positively or negatively based on the smell, and caution is advised to avoid overstimulation.
Interoceptors: Taste
In feeding, flavors like vanilla and banana can stimulate a suckling reflex in infants, while harsher flavors may inhibit it.
Taste can be relaxing or arousing (e.g., hot pepper vs. vanilla ice cream).
Differentiating taste and smell is difficult, as the two are merged in the brain.
COVID-19 has demonstrated how the loss of smell affects taste, appetite, and tolerance of eating.
The autonomic and limbic systems are impacted by taste, similar to auditory, vision, and smell.
Interoceptors: Movement Receptors
Vestibular Input
Movement and positioning affect vestibular input, guiding motor effort (increase or decrease).
Bouncing or rocking at different speeds causes different reactions.
Vestibular input facilitates muscle activity for postural correction, adaptation, stability, and balance.
Movement generates an effect on the reticular activating system, either revving the brain up or lowering it down.
Stimulating alpha motor neurons can occur by stretching a muscle during postural correction.
The visual system may be stimulated; for example, hanging someone upside down provides a different reference of space.
Getting children upright helps them regard the environment in a normal upright position, influencing how they take in stimuli.
Fast Rocking/Bouncing
Benefits patients who are hypotonic with poor postural stability.
Arouses attention and the motor system, improving muscle response and postural reaction.
Contraindicated for children with high tone who react strongly to changes in position.
Slow rocking and soft bouncing are better for calming the reticular activating system in patients with high tone.
Exteroceptors: Vibration
Low frequency (20-50 Hz) is generally more relaxing/inhibitory.
Higher frequency (80-120 Hz) is generally more facilitatory, leading to tonic vibratory reflex or muscle contraction.
Frequencies above 200 Hz can be painful and cause skin damage.
Post-vibration facilitation means muscle contraction remains even after vibration is removed.
Contraindications:
Avoid higher frequencies for high-tone individuals.
Lower frequencies may be used for high-tone individuals.
Higher frequencies may be needed for hypotonic individuals.
Approximation and Pounding
Approximation
Approximating the joints, usually in weight-bearing positions.
Pounding
Rapidly applying a pounding sensation to the distal end of an extremity to get joint receptors to react.
Quick approximation builds a rapid response.
Sensory receptors: joint receptors, ligaments, muscle spindles.
Weight bearing can decrease tone in high-tone extremities and increase tone in low-tone extremities.
Pounding Considerations
May give quick stretches to tendons, getting muscles to operate more.
Can be shocking to the system and possibly noxious; be careful with patients who can't handle the stimuli.
Contraindications:
Conditions where pounding through the joint could be uncomfortable (e.g., arthritis).
Normal movement uses weight-bearing to facilitate the next step in the pattern (e.g., gait).
Used for:
Postural extension and stability.
Weight bearing during transfers.
Scapular involvement.
Tapping
Clinical imitation of a deep tendon response.
Objective: facilitate muscle contraction.
Application:
Tapping on the tendon is more facilitatory.
Fast tapping leads to temporal summation and maximal contraction.
Used to:
Build tone.
Maintain a contraction through exercise.
Prepare a segment for postural extension.
Affects muscle spindle and Golgi tendon organ.
Contraindications:
Hypertonic patients.
Joint or muscle pain.
Quick Stretch
Physiological response straight from the muscle spindle.
Facilitates other sensors in the tendons and joints.
Used to build tone if the tone is insufficient to do or accomplish a task.
Contraindications:
Hypertonicity from stroke.
Traumatic brain injury with hypertonicity, behavioral, and arousal problems.
Deep Tendon Pressure
Inhibitory technique that allows the tendon to reform/reset under pressure, reducing the muscle spindle's reactivity and relaxing the muscle.
Stimulates receptors in the tendon, affecting the muscle spindle.
May be used for hypertonic muscles (biceps, hamstrings, gastrocs) before working in a functional posture.
Contraindications:
Pain in the muscle or joint.
Slow Versus Fast Stroking
Slow stroking is inhibitory, causing consistent pressure that the nervous system accommodates, leading to relaxation.
Fast stroking is facilitatory, giving a stretch to stimulate the muscle spindle.
Hypertonic patients benefit from slow stroking, while hypotonic patients may be helped with fast stroking techniques.
Brunnstrom theory uses brushing as a technique to relax a hypertonic hand and open it up for weight bearing.
Ironing
Similar to slow stroking but with deeper pressure, affecting deeper tactile receptors and potentially the tendon.
Sustained Stretch
Commonly used in splinting or serial casting.
Objective: reset the gamma system, telling the muscle to reset at a new length.
Almost always inhibitory.
Beneficial for patients who are losing function due to hypertonicity (tight adductors or hamstrings).
Also used for athletes with tight muscles, stretching to the point of feeling the stretch and holding it.
Avoid pulling so hard that it becomes noxious, which could cause the patient to contract the muscle more.
In neurorehab, mobilizations are used to achieve range of motion and muscle relaxation; in orthopedics, mobilizations primarily target increasing joint range of motion.
Manual Contact
Usually facilitatory, used as part of an exercise to increase volitional effort.
Stimulates tactile receptors and proprioceptors.
Beneficial for patients who can feel and respond to pressure, resistance, and commands.
Contraindications:
Skin conditions, open wounds.
Total Contact
Spreads pressure over a surface area to avoid high pressure points (e.g., diabetic foot, wheelchair cushion).
Often combined with neutral warmth (e.g., air splint).
Air Splint
Provides total contact and warmth, which is inhibitory.
Used for:
Kids or patients with high tone, especially stroke patients, to relax limbs.
Can be used as temporary splint or brace for hypotonic legs or arms to give support/ facilitate postural extension.
Swaddling
Total contact device for the upper or lower extremity.
In pediatrics: children who have sensory integration problems, tone problems, or inability to relax.
Neutral Warmth (blankets, weighted blankets)
Good with:
Kids who have anxiety problems.
Children who have sensory integration problems.
Kids who tend to be in a more hyperaroused state or a more hypertonic state– it helps relax them.
Deep Pressure Therapy
*Rolling a swiss ball back and across the child to prepare the patient to be able to deal with the next activity
Ice and Warmth
Activate thermoreceptors and can be facilitatory or inhibitory.
Inhibitory if sustained (immersion in ice water, ice towel wraps, heating packs, heat pads).
Facilitatory if brief/quick (ice massage, quick brushing or stroking with ice), causing, for example, a scapular muscle contraction.
Can have autonomic nervous system effects, becoming noxious.
Respiration
Important to consider for patients when exercising to prevent holding breath.
Inspiration facilitates extension; expiration facilitates flexion.
Can be used to assist functional movements:
Breathe in at the beginning of the transfer to have a little bit more oomph to extend, and then they can breathe out and relax once you've gotten there.
If you have spinal cord patients who try to get them to be able to roll by flinging their arms to get momentum. So they fling them a little bit, then, you know, they do the one, two, three, on three, they really fling their arms, and they turn their head and look in the direction they're going, and that helps bring them over into a roll even if they don't have, you know, a lot of good trunk musculature. If we add respiration to that, if we have them inspire when they have the limbs over to the side that that away from the roll, and then they expire as they fling their arms and turn their head and try to roll in that position, it helps the trunk come over even more. It's it's it's actually pretty dramatic effect that, you know, we we we do use quite a bit to try to help someone get a little bit more oomph in a task they don't have very good power in.*
*Head hips relationship meaning spinal cord patients fling their head, and hips generally go the other away. Have them inspire as they extend, and then as they flex, have them expire quickly to give more force, more movement, and lift.
*
Proprioceptive Neuromuscular Facilitation (PNF)
Exercise theory used in regular exercise and neuro rehab.
Proprioceptive: depends on the sensory system to gain access to the peripheral and central nervous systems for an improved response.
Neuromuscular: tries to get efficient and effective motor output that follow the principles of motor control and motor learning.
Facilitation: Facilitation or inhibiton to generate the optimal motor response ( the best effort the patient can give you.).
Relies on the production of an essential movement task that's kind of habitual.
Key Concepts in PNF Theory
Apply input to the sensory system to improve motor output and to facilitate normal synergistic motion.
Give input to the extra receptors and some of the receptors that are more intro receptors are internal to the body to directly cue or to modify someone's motor output.
Facilitate improve motor control because we are using these motions that are common to ADL and IADL tasks so retraining or asking the brain to remember what normal motion felt like
Use muscle effort in distal segments to facilitate activation of more proximal groups; Radiation.
Exercises align with concepts of motor learning and motor control.
Emphasizes the facilitation of the best motor response.
Reinforces the response with repetition, by normal sensory input to get normal motor output, repeating the quality of output until the brain chooses it as the dominant pattern.
Maximal Response
Patient's best effort; improving patient's response throughout the treatment.
Stages of Motor Control in PNF
Mobility: having the available range of motion to move
Stability: having the strength or control to stabilize across a joint, a co contraction, or across an entire extremity, like weight bearing
Controlled mobility: to be able to fix a distal point like an arm, and then reach around and weight shift over it, or during gait when we weight shift over our pelvis, and then that allows us to to move the opposite foot into swing.
Skill: stabilizing proximally so well that the distal joints can move like you have to stabilize your scapula before you can reach, you have to have a stable pelvis before you can take a step on the other side.
Whole Part Whole Learning Theory
Single out specific muscles for exercise, single out specific patterns for exercise, single out a specific deficit in a specific muscle, and then put it back into the diagonal pattern or the functional task.
PNF Diagonals
Movements are named for the three components of motion at the proximal joints.
Patterns are either flexion or extension.
Scapular and pelvic patterns are extensions of extremity patterns.
Diagonal movement = groove (optimal direction of movement).
Diagonals Review
Follow the slides in the remainder to review extremity patterns (D1/D2 Flexion and Extension); skip the scapular and pelvic portions of the course until your brain injury course.
Facilitatory and Inhibitory Stimulus Use in PNF
Basic principles (hand placement, standing position, diagonal, verbal cueing), and
specific techniques (quick stretch, repeated contraction, slow reversal, approximation, traction).
Manual Contacts
Hand placement on the patient to facilitate a muscle contraction via stimuli to the tactile sensors.
PT Position and Movement:
Align within the diagonal.
Move in the groove with the patient to facilitate the movement through the extra receptors of the area that you want to move, developing optional motion with very little resistance
Appropriate Resistance
Facilitates the greatest muscle contraction without negatively affecting motor coordination or abnormal tone.
*Resistance can vary from none (passive range of motion) to the maximum amount you can give.
Verbal Commands
Verbal commands generate different types of contractions.
Concentric: "Pull/flex and push/extend"; can be fast or slow cues.
Eccentric: "Slowly let me pull you down; or slowly push you up."
Isometric: "Hold, hold hold. Don't let me move you."
Maintained isotonic (where the only difference from isometric is that you are not allowing movement, but the patient thinks they're going to be able to move, which generates a rapid full effort isometric. Ex: patients with low balance)
*
Adjustments
*If the patient's not giving us the response we want:
We can increase or decrease the resistance
Alternate the application of resistancelike, where do we put the resistance, are we resisting distally, are we resisting proximally
*emphasize a specific part of the diagonal pattern like the elbow
*Vary the techniques to try to directly affect one or more of the stages of motor control *, Might be stability might be control mobility.