The light work muscles (Mobilizers) are primarily the flexors and

adductors used for skilled movement patterns.

The heavy work muscles (stabilizers) are principally the extensors
and abductors used for postural support.
Rood also believed that a voluntary motor act is based on
inherent reflexes and on modification of those reflexes at higher
centers.
Therefore she begun therapy by eliciting motor responses on a
reflex level and incorporating developmental patterns to enhance
the motor response.
The heavy work muscles are activated before the light work
muscles except for the feeding and speech muscles.

Treatment begins at the Developmental level of functioning-

Pts is evaluated developmentally and treated in a sequential
manner. The patients does not proceed to the next level of
sensory-motor development until some measure of voluntary
(supraspinal ) control is achieved.
This principal follows the cephalocaudal rule.
Treatment begins from the head and proceed downward
segment from the proximal to the distal to the sacral area.
The flexors are stimulated first ,the extensor second, the
adductors third and the abductors last.

Sequences in Gross Motor Development

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A1:
 Supine.
 Withdrawal pattern.
 Total flexion.
 Tonic heavy work.
 Reciprocal innervation.
 Bilateral.
 Centered at 10th thoracic vertebrae

A2:
 Roll over.
 Flexion top arm & leg.
 Phasic movement.

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A3:
 Pivot pattern.
 Total extension.
 Reciprocal innervation.
 Bilateral.
 Cen at 10th vertebrae

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 B. Fixed Distal Segments

B1:
 Neck Co contraction, Vertebral extension.
 For head & neck hyperkinesia.
 To stabilise eyes if nystagmus

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B2:
 Forearm support.
 Gleno humeral joint alignment.

B3:
 All fours.
B4:
 Sitting.
 Pressure on knees through to heels Auto
facilitation

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C:
 Movement over fixed distal segment.
 To ↑ Dynamic stability.
 Rock side to side, back and forward.
 Turning movements.

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 D:
 Skilled movement distal end of limbs free.
 To ↑ mobility.
 Reaching , Crawling, Walking.
Objective & Functional

Movement Control Sequence

 Flexion.
 Extension.
 Adduction.
 Abduction.
 Rotation

Movement is directed towards functional goals-

Rood realized that the patient’s motivation plays an

important role in rehabilitation.
The patients must first accept the activity as a meaningful
event.
Second ,the patient must develop a subcortical program in
his or her central nervous system (CNS) to perform a motor
act in a coordinated manner.
When the patient performs a willed movement with an
intended goal ,more neurons throughout the nervous system
must discharge to initiate the task.

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Repetition is necessary for the
re-education –

The importance of repetition to achieve coordination has

been emphasized by kottke.
Thousand of repetitions are required to formulate engrams.
Engrams are interneuronal circuits involving specific neurons
and muscles to perform a pattern of motor activity.

Principles of treatment

Tonic neck and labyrinthine reflexes can assist or retard the

effect of sensory stimulation:- the tonic neck receptors lie in
the muscles and skin of the neck region and respond to
changes in the relationship of the head to the neck.
The tonic neck reflexes are divided into symmetric and
asymmetric.

According to rood, the TNRs have a modifying influences on

extensor tone, especially the postural part.
The labyrinthine receptors lie in the ampullae of the
semicircular canals and in the vestibule..
These receptors are affected by the position of the head in
relation to gravity.

Stimulation of specific receptors can produce three major

reactions:-

The three major reaction that can be produced by stimulation

of specific receptors are
Homeostatic responses via the autonomic nervous system,
Reflexive –protective responses via spinal and brain stem
circuits and

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 Adaptive responses that require greater integration of all
regions of the nervous system.

In 1970 rood presented four rules of sensory input to clarify

the procedure.

1. The first rule is -

A fast brief stimulus produces a large synchronous motor
output.

This type of stimulus is used to confirm that the reflex arc is

intact.

2. The second rule is -

A fast repetitive sensory input produces a maintained
response.
3. The third rule is-
A maintained sensory input produces a maintained
response.
the force of gravity is an example of a maintained sensory input.
4. The Forth rule is ,
Slow rhythmical, repetitive sensory input deactivates body
and mind.

Any constant low frequency stimuli such as slow rocking in

an easy chair, soft music or even firm pressure to the upper
lip ,abdomen ,soles of feet activates the parasympathetic
system causing a generalized calming effect.

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 SEQUENCE OF MOTOR DEVELOPMENT

Rood proposed four sequential phases of motor control.

1) Reciprocal inhibition (innervation) – reciprocal

inhibition is an early mobility pattern that sub serve
a protective function.It is a Phasic types of
movement that requires contraction of the agonist
muscle as the antagonist muscle relax.
This basic movement pattern is primarily a reflex
governed by spinal and supraspinal centers.

2) Co-contraction(co- innervation)- co-

contraction provides stability and is consider to be a tonic ( static )
pattern.
This pattern provides the ability to hold a position or an
object for a longer duration.
Co-contraction is defined as simultaneous contraction of
agonist and antagonist muscle with the antagonist supreme.

3) Heavy work
Heavy work is described as “mobility
superimposed on stability”.
In this pattern the proximal muscle contract and
move, and distal segment is fixed.
4) Skill
Skill is the highest level of motor control and
combines the effort of mobility and stability.

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 To execute a skilled pattern, the proximal
segment is stabilized while the distal segment
moves freely.

Facilitation and inhibition technique

developed primarily by Roods
Facilitation technique:-
Techniques to facilitate muscle activation include application
of tactile, thermal, and proprioceptive stimuli to the special
senses.
These various techniques may be combined to produce a
greater response.
a) Cutaneous facilitation
1) Tactile stimuli :- Tactile stimulation is done using light
touch (A-brushing) or fast brushing (C-brushing).
Light touch or stroking of the skin activates the low
threshold A-size sensory fibers to activate a reflex action
of the superficial phasic or mobilizing muscles.
Light stroking of the dorsum of the webs of the fingers or
toes, or of the palms of the hands or soles of the feet elicits a
fast ,short-lived withdrawal motion of the stimulated limb.
The stroking is done at the rate of twice per second for
approximately 10 seconds.
After a rest period ,this procedure can be repeated 3-5 more
times.

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 2) Brushing:-
Fast brushing involves brushing the hairs or the skin
over a muscle with soft camel hair paint brush that has
been substituted for the hothead of a hand –held
battery powered cocktail mixer to produce a high
frequency high intensity stimulus.
Fast brushing thought to stimulate the C-size sensory fibers
,which discharge in to polysynaptic pathways that influence
the background activity of muscles involved in the
maintenance of posture.
Rood proposed that the effect of fast brushing was non
specific ,had a latency of 30 seconds, and reached its
maximum facilitative state 30-40 minutes after stimulation
because of the enhancement of the reticular activating
system in to which the c fibers feed.
Fast brushing produced a significant immediate facilitatory
effect, the effect lasted only 30- 45 seconds.

3) Thermal stimuli
Icing is thought to have similar effect as stroking through
the same neural mechanism .
Icing, however has been found to be significantly less
effective than fast brushing for recruitment of motor units
of hemiplegics patients.
Two types of icing , A and C are used.

1) A –Icing is the application of three quick swipes of an ice

cube to evoke a reflex withdrawal ,similar to the response
to light touch, when the stimulus is applied to the palms or
soles or the dorsal webs of the hands and feet. the water
is blotted up after every swipe. A –Icing of the upper right
quadrant of the abdomen in the dermatomal

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 representation for T7-9 stimulates the diaphragm and
inspiration.
Touching the lips with ice opens the mouth (a withdrawal
response).
but ice applied to the tongue and inside the lips closes the
mouth.
Swiping the ice upward over the skin of the sternal notch
promotes swallowing.

2) C icing is high threshold stimulus used to stimulate

postural tonic responses via the C-size sensory
fibers.
Icing to activate the C fibers is done by holding the ice cube
in place for 3-5 seconds, then wiping away the water.
The skin areas to be stimulated are the same as for fast
brushing ,with one exception.
The distribution of the posterior primary rami along the back
is avoided because it may cause a sympathetic nervous
system fight and flight protective responses.

4)Proprioceptivefacilitatory techniques
Quick stretch :-quick, light stretch of a muscle is a
low-threshold stimulus that activates an immediate
phasic reflex of the stretched muscle and inhibits
its antagonist .
Stretch is applied in the form of quick movement of
the limb or tapping over the muscle or tendon.
The therapist uses fingertips to vigorously tap the skin over a
muscle or tendon while the patient is attempting to contract
the muscle.

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This provides intermittent mechanical stretch to the muscle
to evoke a stronger response.

5)Vibration

Vibration can be defined as a series of rapid touch stimuli.

Used for tactile stimulation, to desensitize hypersensitive
skin and to produce tonal changes in muscles.
High frequency (100-300 Hz preferred) vibration ,delivered
by an electric vibrator that has an excursion of 1-2 mm , to
the belly or tendon of the slightly stretched muscles in an
additional form of stretch .
The action of the vibrator provides a rapidly repeated
mechanical stretch to the muscle, which increases the
number of motor unit recruited.
This is tonic vibratory reflex (TVR).
Tension within the muscles increases over 30-60 seconds
and is sustained for the duration of the application of the
vibrator.
The stronger response is obtained from application over the
tendon.
6)Stretch to finger intrinsics-
Stretch to intrinsic muscle of the hand is used for facilitate
co-contraction of the muscles around the shoulder joint.
This treatment is useful for patients who have distal
movement but proximal weakness.

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7)Heavy joint compression:-
Facilitates co-contraction of muscles around a joint ,thereby
facilitating the stability component movement in activity.

Heavy joint compression refers to resistance greater than

body weight that is applied so that the force is through the
longitudinal axes of the bones whose articular surface
approximate each other(Ayres,1974;Rood;1962)
8)Resistance:-
Resistance to an ongoing movement or maintained posture
is a form of stretch in which many or all of the spindles of a
muscle are stimulated ( Umphred ).
The muscle spindles, of course ,cannot know whether the
discrepancy between itself and the extrafusal muscle fiber is
due to stretching by a moving force or by resistance that is
preventing extrafusal muscle fibers from shorting as the
spindle continues to shorten as programmed.
The discrepancy cause the spindles to fire.
The electrical activity of the interneuronal pool is
consequently high ,and more and more motor units are more
easily recruited to fire, this phenomenon is called overflow.
9)Vestibular stimulation:-
Vestibular stimulation is a powerful proprioceptive input.
The static labyrinthine system can be used to promote
extensor patterns of neck ,trunk, and extremities.

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 The kinetic labrynth can be used to elicit phasic subcortical
responses, such as protective extension.
The vestibular system activates the antigravity muscles and
their antagonists before the stretch reflex of the muscle
spindles.
The vestibular system is a divergent system that affects
tone, balance, directionality, protective responses, cranial
nerve function, bilateral integration, auditory-language
development, and eye pursuits.
Vestibular stimulation can be either facilitative or inhibitory,
depending on the rate of stimulation.
Fast rocking tends to stimulate, whereas slow rhythmic tend
to relax.

Inhibition technique
Hypertonacity is treated with general inhibition techniques or
by applying tactile, thermal, or Proprioceptive stimulation
either to the muscle itself or to the antagonists of the spastic
muscle in the context of goal directed activity.
someof the following methods are aimed at the neural
component of hypertonacity, and other, such as prolonged
stretching address the viscoelastic component.
The therapist determines which component needs treatment
and choose appropriate technique.

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 1) Tactile stimuli
Slow stroking over the distribution of the posterior primary
rami produces general relaxation.
It involves rhythmical moving touch instead of maintained
touch.
The therapist uses the palm or extended fingers of one hand
to apply firm pressure along the vertebral musculature from
occiput to coccyx, at which time the therapist’s other hand
starts at the occiput and progress like wise to the coccyx.

This slow rhythmical stroking using alternating hand is done

until the patient relaxes for about 3-5minutes(Rood,1956;
Faber,1982).

2) Thermal stimuli
Both warming and cooling for prolong period can be
inhibitory.
Prolonged cooling:- sustained cooling of the skin to 50 °F (
10 ° C) decreases the monosynaptic stretch reflex
excitability.
A cold pack applied for 20 minutes achieves this effect.

3) Proprioceptive stimuli
Prolonged stretch- prolonged manual stretch is used to
inhibit a specific spastic muscle so that the patient may
move more easily .
The limb is held so that the muscle is steadily kept at itsgreatest
length for more than 20 seconds,until letting go is felt as the
muscle adjust to the longer length.

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Prolonged stretch by splinting or positioning the limb so that
the hypertonic muscles are maintained in stretch over
several hours to several weeks allows growth of additional
sarcomears and makes the muscles less sensitive to stretch
during movement.

4) Joint approximation
Light joint compression also called joint approximation,
can be used to inhibit specific spastic muscles.
This procedure is commonly used to relieve shoulder pain
in spastic muscles in hemiplegics patients.
The method is to grasp the patient’s elbow and while holding
the humerus abducted to about 30-45°,gently move the head
of the humerus into the glenoid fossa and hold it there until
the spastic muscles relax.

5) Neutral warmth
Neutral warmth refers to maintaining body heat by
wrapping the specific area to be inhibited or the area
served by the posterior primary rami for a general effect.
A cotton flannel or fleece blanket or a down comforter is
used for 10-20 minutes.
Elastic bandages or air splint s can be used also.
They not only maintain neutral warmth but also offer
sustained pressure, both of which are inhibitory.

6) Stimuli for special senses

Rood used stimulation to the special senses to facilitate or
inhibit the skeletal musculature generally.
Auditory and visual stimuli can be used deliberately.Music
with a definite beat is facilitatory.

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A noisy, harsh clinic is stimulating and may affect the
performance of the patient with CNS dysfunction.
A colorful, bright multistimulus environment has a general
facilitatory effect.
The therapist’s voice and manner of speech (fast and
staccato vs. slow and calming) may also affect the patient’s
performance.
A loud ,sharp command yields a quick response and recruits
more motor units.
Olfactory and gustatory stimuli are facilitating or inhibiting
through their influences on the autonomic nervous system.

Unpleasant or dangerous stimuli (like ammonia smell) elicit a

sympathetic fight or flight response, and pleasant stimuli (like
vanilla) evoke a parasympathetic response.
These stimuli, especially olfactory, produce an emotional
response as well as a motor response.

.
By – Dr. ChandanRai( MPT , Neurology )

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