NEUROMUSCULAR FACILITATION TECHNIQUES

Miss Rojaramani VasamshettyMPT II Yr

NMFT• A group of techniques used to facilitate or

inhibit muscle contraction or responses.– Proprioceptive Facilitation Techniques– Extereoceptive Stimulation Techniques– Vestibular Stimulation Techniques

Proprioceptive Facilitation Techniques:

• Quick Stretch• Prolonged Stretch• Resistance• Joint Approximation• Joint Traction• Inhibitory Pressure

QUICK STRETCH• Stimulus:

– quick stretch is applied to a muscle

• Activates: – muscle spindles, sensitive to velocity and length changes. Muscle spindle

provides input to higher centers.

• Response: – phasic, facilitates or enhances muscle contraction due to largely peripheral

reflex effects (facilitates agonist, inhibits antagonist, facilitates synergist, reciprocal innervation effects)

• Techniques: – quick stretch, tapping over muscle belly or tendon

• Comments: – a low threshold response, relatively short lived; can add resistance to maintain

contraction. Apply resistance in the lengthened range to initiate contraction

• Adverse Effects: – may increase spasticity

PROLONGED STRETCH • Stimulus:

– Slowly applied maintained stretch especially in lengthened ranges• Activates:

– Muscle spindles, golgi tendon organs; sensitive to length changes– Muscle spindle provides input to higher centers

• Response:– Inhibits or dampens muscle contraction and tone due to largely to peripheral

reflex effects.• Techniques:

– Manual contraction– Inhibitory splinting, casting,– Reflex inhibiting patterns– Mechanical low load weights

• Comments:– Higher threshold response– May be more effective in extensor muscles than flexors due to the added effects

of II inhibition.– To maintain inhibitory effects, activate antagonist muscles

RESISTANCE:• Stimulus:

– A force exerted to muscle

• Activates:– Muscle spindles and golgi tendon organs; sensitive to velocity and length

changes

• Response:– Facilitates or enhances muscle contraction due to peripheral reflex effects– Suprasegmental effects: recruits both alpha and gamma motor neurons,

additional motor unit– Hypertrophies extrafusal muscle fibers– Enhances kinesthetic awareness

• Techniques:– Manual resistance– Use of body weight and gravity– Mechanical weights

RESISTANCE

• Comments:– Light resistance is used to facilitate very weak muscles.

– With hypotonic muscles, eccentric and isometric contractions are used before concentric

– Maximal resistance may produce overflow to other muscles

• Adverse Effects:– Too much resistance can easily overpower weak, hypotonic muscle

and prevent voluntary movement, encourage substitution.

– May increase spasticity

JOINT APPROXIMATION• Stimulus:

– Compression of joint surfaces• Activates:

– Joint receptors• Response:

– Facilitates postural extensors and stabilizes– Enhances joint awareness

• Techniques:– Joint compression, either manual or mechanical using weight cuffs or belt– Bouncing while sitting on a Swiss ball

• Comments:– Applied in extensor patterns, weight-bearing positions, in middle to

shortened ranges of extensors• Adverse Effects:

– Contraindicated in inflamed joint

JOINT TRACTION:• Stimulus:

– Distraction of joint surfaces

• Activates:– Joint receptors

• Response:– Facilitates agonists, enhances contraction– Enhances joint awareness

• Techniques:– Manual distraction

• Comments:– Used as a facilitatory stimulus in flexor patterns, pulling action– Slow, sustained traction to joints can be used to improve mobility, relieve

muscle spasm, and reduce pain with techniques of joint mobilization

INHIBITORY PRESSURE• Stimulus:

– Prolonged pressure to long tendon• Activates:

– Muscle receptors and tactile receptors• Response:

– Inhibition, dampens muscle tone• Techniques:

– Firm pressure can be applied manually or with body weight; positioning at end ranges

– Mechanical: firm objects in hand inhibitory splints, cast• Comments:

– Weight bearing postures are used to provide inhibitory pressure, such as• Quadruped or kneeling posture• Sitting with hand open, elbow extended and upper limb supporting body

weight• Adverse Effects:

– Sustained positioning may dampen muscle contraction and affect functional performance

EXTEREOCEPTIVE STIMULATION TECHNIQUES

• Light touch• Maintained touch• Slow stroking• Manual contacts• Prolonged icing• Neutral warmth

LIGHT TOUCH• Stimulus:

– Brief, light contact to skin

• Activates:– Fast adapting tactile receptors, ANS, sympathetic divisions.

• Response:– Phasic withdrawal responses, flexion and adduction of the extremities

withdrawing away from the stimulus; increased arousal

• Techniques:– Brief, light stroke of the fingertips– Brief swipe with ice cubes– Light pinch or squeezing– Applied to areas of high tactile receptor density that are more sensitive to

stimulation

Light touch:

• Comments:– Low threshold response, accommodates rapidly– Effective in initially mobilizing patients with low response levels, for

example, the patient with TBI during early recovery

• Adverse effects:– Increased sympathetic arousal, may produce fight or flight responses– Contraindicated in patient with generalized arousal or autonomic

instability, for example, the patient with TBI who is agitated and combative

MAINTAINED TOUCH• Stimulus:

– Maintained contact or pressure• Activates:

– Tactile receptors, ANS, parasympathetics• Response:

– Calming effects, generalized inhibition, desensitized skin• Techniques:

– Firm manual contacts– Firm pressure to midline abdomen, back, lips, palms, and/or soles of feet.– Firm rubbing

• Comments:– Useful for patients with high arousal, patient with a hypersensitivity to sensory

stimulation– Can be applied to hypersensitive areas to normalize responses: patients with

peripheral nerve injury or paresthesias.– Brief touch stimuli should be avoided.– Can be used in combination with other maintained stimuli.

SLOW STROKING• Stimulus:

– Slow stroking, applied to paravertebral spinal region

• Activates:– Tactile receptors, ANS, parasympathetics

• Response:– Calming effects, generalized inhibition

• Techniques:– The patient is placed in a supported position such as prone, or sitting head

and arms supported and resting forward on a table top. A flat hand is used to apply firm, alternate strokes downward to paravertebral region for approximately 3-5 minutes

• Comments:– Useful with patients who demonstrate high arousal, increased sympathetic

responses.

MANUAL CONTACT:• Stimulus:

– Firm, deep pressure of the hand in contact with the body

• Activates:– Tactile receptors, muscle proprioceptors

• Response:– Facilitates contraction in muscle directly under the hands– Provide sensory awareness, directional cues to movement– Provide security and support unstable body segments

• Comments:– Can be used with or without resistance.

• Adverse effects:– contraindicated over spastic muscles and open wounds

PROLONGED ICING:• Stimulus:

– Cold application • Activates:

– thermoreceptors• Response:

– Decreases neural, muscle spindle firing– Provide inhibition of muscle tone and painful muscle spasm– Decreases metabolic rate of tissues

• Techniques:– Immersion in cold water, ice chips– Ice towel wrap, ice packs, ice massage

• Comments:– Monitor effects carefully

• Adverse effects:– Sympathetic nervous system arousal, protective withdrawal responses, fight or

flight responses.– Contraindicated in patients with sensory deficits, generalized arousal, autonomic

instability, vascular problems

NEUTRAL WARMTH• Stimulus:

– Retention of body heat• Activates:

– Thermoreceptors, ANS, parasympathetics• Response:

– Generalized inhibition of tone; produces a calming effect, relaxation, decreases pain

• Techniques:– Wrapping body or body parts: ace wraps, towel wraps– Application of snug fitting clothing or air splints– Tepid baths,– Applied for aproximately 10-20 minutes

• Comments:– Useful for patients with high arousal, or increased sympathetic activity;

spasticity• Adverse effects:

– Overheating should be avoided, may produce rebound effects

VESTIBULAR STIMULATION TECHNIQUES:

• Slow maintained vestibular stimulation• Fast vestibular stimulation

SLOW MAINTAINED VESTIBULAR STIMULATION

• Stimulus: – Low-intensity vestibular stimulation, for example slow rocking

• Activates:– Facilitates primarily otolith organs; less effects on semicircular canals

• Response:– Generalized inhibition of tone– Decreased arousal, calming effects

• Techniques:– Slow, repetitive rocking movements; assisted rocking in a weight bearing

position, for example, rocking with equipments: rocking chair, Swiss ball, equilibrium board, hammock

– Slow rolling movements.• Comments:

– Useful with patients who are hypertonic, hyperactive, or who demonstrate high arousal, or tactile defensiveness

– Combine with cognitive relaxation techniques

FAST VESTIBULAR STIMULATION:• Stimulus:

– High intensity vestibular stimulation, for example, fast spinning, irregular movements with acceleration and deceleration components

• Activates:– Facilitates semicircular canals, less effects on otoliths

• Response:– Generalized facilitation of tone– Improves motor co-ordination– Improves retinal image stability, decrease post-rotatory nystagmus

• Techniques:– Fast spinning, for example, spinning in a chair, mesh net or hammock– Fast acceleration /deceleration movements, for example, prone on a

scooter board– Fast rolling movements

• Comments:Useful with:– Hypotonic patients (down’s syndrome)– Patients with sensory integrative dysfunction– Patients with co-ordination problems (stroke, CP child)– Helpful in overcoming the effects of akinesia or bradykinesia in

patients with Parkinson’s disease

• Adverse effects:– Behavioral changes, seizures, sleep disturbances may occur– Contraindicated for patients with recurrent seizures or who are

intolerant to sensory stimulation