Special Techniques

MD Tshabalala
Effects of Special Techniques
1) To initiate movement
2) To re-educate movement patterns
3) To correct muscle imbalance
4) To increase strength
5) To improve stability and balance
6) To improve co-ordination
7) To relax
8) To decrease pain
9) To increase range of motion
10) To overcome fatigue
 RHYTHMIC INITIATION

This technique is used for the following:

 To teach the pattern
 To improve the patients’ ability to initiate movement
 For patients with rigidity or spasticity where
increasing tone is undesirable.
 To make the patient aware of the direction of
movement, especially those with decreased
sensation.
 TECHNIQUE:RI
 The patient is asked to relax and is moved passively
and rhythmically through the pattern.
 The therapist says, “Relax, let me move you”.
 Then the patient is asked to “help me a little” and an
active assisted movement is performed.
 The patient is told “help me a bit more”, and performs
an active movement.
 Then stretch and resistance is or may be applied.
 Calming verbal commands are used.
 THE NEUROPHYSIOLOGY OF
RHYTHMIC INITIATION
 Verbal commands used during this technique i.e. “relax”
induce cortical inhibition which may be a contributing
factor in decreasing tone.
 The vestibular system may accommodate to repetitive
rhythmic movements and the calming commands of
rhythmic initiation.
 Therefore arousal effects to the reticular activating
system are minimised and tone is not increased as it
would be using active movements and strong verbal
stimulation.
 COMBINATION OF ISOTONICS

A patient must be able to control his body weight

as the muscles lengthen e.g. in descending the
stairs or sitting from a standing position, eccentric
control of the leg extensors is essential.
 This technique incorporates both the concentric
and eccentric muscle contractions.
 TECHNIQUE: CI

 The patient is instructed to move isotonically through a

pattern.
 He is asked to “hold” briefly.
 He is then told by the therapist. “Let me pull you back
slowly”.
 As she slowly move the part back towards the lengthened
range, and the patient controls the movement.
 The patient should then be asked to hold and then to move
back towards the shortened range concentrically.
 The patient should not relax at any stage during the cycle.
 NEUROPHYSIOLOGY: CI

 When a muscle contracts against resistance

eccentrically, both external and internal stretch
occur simultaneously.
 This enhances firing of the spindle afferents,
having a facilitatory effect.
 REPEATED CONTRACTIONS
(Isotonic)
 This technique uses the “stretch reflex” to facilitate
maximum contraction throughout range.
 A re-stretch is applied at a point where facilitation for
further contractions is needed.
 Through re-stretch of all the agonists and synergists we
get a summation of impulses.
This way we can increase:
- strength
- endurance
- mobility
 TECHNIQUE: RC
 Startthe pattern with stretch-reflex.
 At a point where strength is decreasing apply a re-stretch.
 The re-stretch must be applied before the patient quits
contracting maximally.
 Re-stretch is a quick stretch back into the direction of the
antagonistic pattern.
 It has a short distance, rotation is most important.
 Re-stretch is immediately followed by resistance allowing
movement!
 The command is coinciding with the re-stretch to get the
patient’s voluntary input
 NEUROPHYSIOLOGY OF
REPEATED CONTRACTIONS
 During a muscle contraction the skeleto-muscle
fibres shorten.
 During voluntary movement the intrafusal muscle
fibres contract, maintaining some stretch on the
muscle spindle.
 Re-stretching the muscle which is contracting will
re-fire the muscle spindle and re-initiate the
myotatic stretch reflex.
 Slow Reversal
 Seen in ADLs as reversal of antagonistic muscles
groups e.g. walking, swimming, polishing etc
 Slow reversal tech – used to re-educate reversal of
antagonists
 Based on Sherrington’s principle of reciprocal
innervation & successive induction
 Functions of Slow Reversal:
 Mm Strengthening
 Improve co-ordination and endurance

 Increase ROM by reducing pain

 Technique: SR
Upper Limb: Flex, Abd – Ext. Add
 Starting position – work through the pattern
maximally
 At EOR, change the proximal hand first! It becomes
the distal hand in new pattern
 When pt reacts to new pattern, place distal hand onto
the correct proximal surface of new pattern.
 Repeat several times
 Always start with the STRONG pattern!
 Ask pt to ‘hold’ the weaker agonistic pattern
 Slow Reversal uses both the Isotonic & Isometric
contractions
 Neurophysiology of Slow
Reversal
 Sherrington’s law of Successive Induction maintains that a
pattern is facilitated by immediately preceding it with
contraction of the Antagonistic pattern
 Inhibitory effects of the golgi tendon organ & renshaw
cells on the agonists results in inhibition of the agonist &
reciprocal facilitation of the antagonist
 Antagonists are stretched as the pattern approaches the
EOR, which facilitates these muscles
 Also as the Stronger pattern approaches its shortened
range, stretch on the muscles of the pattern diminishes,
unloading the muscle spindle, which reduces the spindle
afferent firing.
 Rhythmic Stabilization
 Itis a reversal technique, but uses Isometric
contractions
 The object is to build up a co-contraction of
antagonistic muscle groups around the jt.
 All mm. Which have the potential to produce
movt at the jt contract simultaneously
 The technique is applicable on mat work.
 Functions of Rhythmic
Stabilization
 To increase mm strength
 Improve postural stability of the jts
 For pts presenting with pain or where movt is not
allowed.
 NB: For the pattern to be effective, the pt must be
able to perform isometric contraction & “hold”
 Attention is paid to the rotation component of the
mvt, do not overpower the pt’s rotation & break
their ability to hold.
 Technique: RS
 Start with Isotonic contraction
 Stop at Strongest point
 Pt must “hold” against the therapist’s resistance
which changes slowly & fluently from one pattern
into another.
 Relaxation Techniques
Similarities b/t Contract-Relax & Hold-Relax
 To increase ROM
 To decrease Pain
 Both can be done with Ice
 Both have a period of relaxation
 Differences
Contract-Relax Hold-Relax
1) Tightness without pain 1) Pain or tightness with pain
2) Done at point of tightness 2) Done in painfree range

3)Action comm: “push” or 3) command: “hold”

“pull”
4) Minimal mvt into rotation 4) No Movement!, true
& few degrees of ROM Isometric contraction

5) Maximal contraction 5) Contract as much as

possible without causing pain
 Contract-Relax Technique
 Part moved passively or actively to the point of limitation
 Pt get command for the antagonistic pattern
 Therapist resist all components of the pattern
 Only a small ROM may occur
 When pt working maximally, gets the command: “let go
slowly”
 Therapist gradually relaxes grip & move into the antagonistic
pattern
 Finish the whole pattern from stretch, no resistance
 Repeat the procedure, NB: strengthen the Newly gained
range
 Neurophysiology of Contract -
Relax
 Fatigue play a greater role than in hold-relax
 Maximal effort results in the recruitment of more phasic
motor units
 Sustained maximal tension may serve to recruit more GTO
units
 As in Hold-relax, renshaw cell inhibition also occur
 Prolonged stretch/ resistance to muscles causes autogenic
inhibition via the Flower Spray fibres in the spindle
 Suprasegmental inhibition occurs as the patient is told to
relax
 Joint receptors may contribute inhibitory influences ot the
alpha motor neuron pools.
 Hold-Relax
 Can be done directly and indirectly
 Therapist moves part to the point of limitation i.e.
below pain threshold!
 Places hand on the correct surface, either agonists or
antagonists
 Command is: “hold” or “don’t let me move you”
 Build up resistance slowly
 No motion may occur, Watch rotatory component
 Ease off slowly with command: “Let go slowly”
 Therapist moves part further into limited direction
 Repeat the technique
 Neurophysiology of Hold-
Relax
 Fatigue occurs at the NMJs, dampening muscle tension.
 The GTO produces autogenic inhibitory impulses to the
anterior horn cells in response to increased mm tension,
this inhibitory influence is brief & not the only mechanism
 Alpha motor neurons discharge, its branch causes the
renshaw cells to discharge, thus exert inhibition on that
alpha neuron. This is known as recurrent inhibition.
 All mm have both tonic & phasic fibres, Inhibition from
renshaw cells influences tonic motor units
 Tonic motor units are recruited first
 Emphasis of Timing
 Emphasizes on a particular weak mvt within a pattern
 Uses an overflow from strong groups
 If there is no strong part: work on whole pattern with
emphasis on proximal joints.
 Reinforcement is done by the so-called “PIVOT”, while
the strong groups contract isometrically
 Look at Pattern as having 3 Parts:
– Pivot joint: jt in which mvt is taking place through a pivot
– Handle: part distal to the pivot joint
– Stabilized part: Strong muscle groups contracting isometrically,
“locked in”
 Technique: TE
 Startfrom stretch, pt moves actively to stronger pattern
 Lock strong parts where they can work best
 Give maximal resistance, prevent motion
 Pivot the pivot joint with a re-stretch
 Give an adequate command
 Allow pt time for movement
 A pivot can be done several times, watch pt’s endurance,
avoid fatigue
 Continue the pattern with re-stretch for all components
NB: Emphasis of timing can be done on bilateral pattern,
locking in one limb and pivoting the other.
 Neurophysiology of TE
 Maintained isometric contraction of strong mm groups is
capable of producing overflow to weaker mm.
 The influence of the muscle-spindle & GTO is not
restricted to the muscles to their own functional group
 Collateral branches go via interneurons to mm of other
parts of the body:
– Ipsilateral = contralateral
– Upward & downward
– Across the spinal cord level
– Far below consciousness
 There is increase of alpha & gamma motor neuron
recruitment.