Also known as Sensorimotor approach or the Rood’s system. Based on REFLEX-HIERCHIEAL Theory. Margaret Rood was both OT and PT She mainly developed this approach for patients with brain damage INTRODUCTION
She developed this technique by trial and
error method during her clinical practice. She had shared her findings through clinical and classroom teachings but has written very little on her techniques. The procedures and the rationale behind the techniques are elaborated by two therapists namely- Jean Ayres and Shirley Stockmeyer. PRINCIPLES Rood’s basic premise was: “Motor patterns are developed from fundamental reflex patterns present at birth which are utilized and gradually modified through sensory stimuli until the highest control is gained on the conscious cortical level. It seemed if it were possible to apply the proper sensory stimuli to the appropriate sensory receptor as it is utilized in normal sequential development, it might be possible to elicit motor responses reflexly and by following neurophysiological principles, establish proper motor engrams (Rood, 1954) PRINCIPLES
1. The normalization of tone and evocation of desired muscular
responses are accomplished through use of appropriately applied sensory stimuli. Correct sensory input is necessary for the development of correct motor responses. Controlled sensory input is used to evoke muscular responses reflexively, the earliest developmental step in gaining motor control (Rood 1954, 1962).
2. Sensorimotor control is developmentally based, and
therefore, therapy must start at the patient's current level of development and progress sequentially to higher levels of control (Rood, 1962; Minor, 1991).Roods identified several developmental sequences. PRINCIPLES
3. Movement is purposeful (Rood, 1962; Ayres 1963, 1974).
Rood used purposeful activity to demand a response from the patient to elicit sub-cortically (unconsciously) the desired movement pattern. The responses of agonists, antagonists, and synergists were believed to be reflexively (automatically) programmed according to a purpose or plan. The cortex does not direct each muscle individually. 4. Repetition (practice) of sensorimotor responses is necessary for motor learning (Ayres, 1974; Rood, 1956). Activities are used not only to elicit purposeful responses but also to motivate repetition. TECHNIQUES
Two Types- FACILITATION METHODS and
INHIBITION METHODS. However, the actual response each patient will exhibit will be an algebraic summation of all internal and external stimuli the patient experiences. Hence, response of the patient is carefully monitored and the stimuli changed as required to elicit the desired response FACILITATION METHODS FAST BRUSHING Stimulus: Fast brushing of the hair or skin, high-intensity Area stimulated: Over the muscle, Over the dermatome Equipment: Stirrer of a hand-held battery-operated cocktail mixer, soft camel hair paint brush Duration: 3-5 sec over the skin, 5 sec over each dermatome (if no response after 30 sec, repeat 3-5 times more) Response: Muscular Contraction that is nonspecific, has a latency of 30 sec, and does not reach its maximum potency until 30 to 40 min after stimulation, because of processing by the reticular activating system. (Rood) It produces a significant immediate facilitatory effect, the post- application effect lasted only 30 to 45 sec (Mason, 1985) FAST BRUSHING Rationale: High threshold stimulus to the C size sensory fibers are involved in the maintenance of posture and background gamma efferent activity. High threshold stimulation facilitates the gamma system to bias spindles to increase response to added external or internal stretch. AREA EFFECT Distribution of the posterior primary rami Facilitates the tonic, deep muscles of the adjacent to the vertebral column back Over the rest of the body, supplied by the Facilitates a tonic response of the anterior primary rami. (Dermatome pattern) superficial muscles Pinna of the ear Stimulates Vagus Nerve Dermatomes of L1-2 Voiding Dermatomes of S2-4 Bladder retention FAST BRUSHING LIGHT STROKING
Stimulus: Light touch or stroking of skin, low-
intensity Area stimulated: Over the dermatome Response: Fast, short-lived response through facilitation of extrafusal muscle fibers Rationale: Activates A fibers which activate reciprocal action of superficial phasic or mobilizing muscles. LIGHT STROKING
Light stroking of the dorsum of the webs of
the fingers or toes or of the palms or soles, elicit phasic withdrawal motion of the limb. Repetitive stimulation of this area results into crossed-extensor reflex pattern. ICING Stimulus: Icing to achieve skin temperature of 12 to 17 degree C. Type: “A”-icing and “C”-icing Equipment: Plastic ice popsicle C - Icing A - Icing
Stimulus High Threshold High frequency
Effect Stimulates postural tonic Evokes reflex withdrawal responses via C fibers via A fibers
Technique Hold the cube pressed in Quick icing
place for 3 to 5 sec then wipe the water ICING Area- same as for fast brushing except distribution posterior primary rami as this causes stimulation of sympathetic nervous system. A-icing of upper quadrant of abdomen i.e. dermatomes T7-9 causes stimulation of diaphragm. Touching lips with ice open mouth whereas touching tongue and inside of lips closes mouth. There is rebound effect of icing which occurs approximately 30 sec after stimulation which causes temporary inhibition. Precautions: same as Fast brushing. PROPRIOCEPTIVE STIMULI Stimuli has effects only as long as applied. 1. Quick stretch: light, low thresholds stimulus, activates phasic response of same muscle through afferent ending of the spindles and the alpha motor neuron, immediate effect, facilitates same muscle and inhibits antagonist. 2. Tapping: tendon or the belly of muscle, same as quick stretch, percussion over tendon using finger-tips. 3. Pressure: over muscle belly, elicits stretch response by placing a stretch on spindles, manually or by equipment. 4. Secondary stretch: maintained stretch at end on range to facilitate type-2 fibers of the spindle, facilitates antagonist at the time when they are at shortened range. PROPRIOCEPTIVE STIMULI
5. Co-contraction: stretch to intrinsic muscles of
the hand or foot, causes co-contraction of proximal stabilizing muscle, can be combined with weight bearing for further facilitation. E.g.: Prone on elbow => child shoots water pistols, grasping handle of pools, grasping Cone. 6. Resistance: many spindles stimulated, causes the spindle to fire impulses in order to get extrafusal muscle unit firings, overflow occurs. PROPRIOCEPTIVE STIMULI STIMULI EFFECT
Resistance to phasic Prevents immediate inhibition of the contracting
contraction muscles due to the effect of GTO
Resistance to contraction of Used to bias the spindles of deeper, tonic muscles
muscle in shortened range which cannot be stimulated by C fibers
Resistance to Eccentric Provides both internal and external stimuli which
contraction activates primary afferents PROPRIOCEPTIVE STIMULI Heavy Joint Compression: facilitates co-contraction of one joint-slow oxidative muscles around joint, resistance greater than that of body weight, activates high threshold receptors. E.g.: Prone on elbows, prone on hand, quadruped, standing and ask patient to lift one extremity, add weight (hat or crown with weight, weighted bags, lead X-ray aprons etc). Pressure on bony prominences: both facilitating and inhibiting effect. E.g.: Pressure on lateral aspect of calcaneous => facilitates medial dorsiflexors and inhibits calf muscle. Pressure over medial aspect => facilitates lateral dorsiflexors and inhibits calf muscle. SPECIAL SENSES Auditory : Facilitating-rhythmic music, noisy clinic, fast and high pitched voice of therapist; Inhibitory-lullaby, soft voice Visual: Facilitating- colorful environment, lighted or multi- stimulated clinic; Inhibitory – dull, colorless and uninteresting environment. Olfactory and Gustatory stimuli can be both facilitating and inhibiting through their influence on Autonomic nervous system. Labyrinthine system- static positions and movement of head used to influence postural tone and modify tonic labyrinthine reflexes. INHIBITORY METHODS LIGHT JOINT COMPRESSION
Inhibits spastic multi-joint fast glycolitic
muscles E.g. : Hemiplegic patients, shoulder spasticity, hold the elbow, abduct 35-45 degree and gently push the head into glenoid fossa. Compression in long axis of the body segments in correct weight-bearing alignment. SLOW STROKING
Slow stroking over area of posterior primary
rami with firm but light pressure inhibits muscle tone in general. E.g.: Stroking along the vertebral column using alternate hands for 3 minutes or until the patient relaxes. Reduces choreo-athetosis. SLOW ROCKING AND ROLLING
Chair rocking, hollow barrel, etc
Avoid self-rocking Slow rolling from supine to side-lying. NEUTRAL WARMTH
Maintenance of the body heat by wrapping
the area in cotton blanket or under pillow or comforter for 10-20 minutes. Rebound effect appears if heat greater than body temperature is used. PRESSURE ON THE TENDINOUS INSERTION Inhibits stimulated muscle Through Pacinian corpuscles. E.g.: Extrinsic flexors of hand- constant pressure over long tendons as Grasp of enlarged, firm or hard adapted handles. This has inhibitory effect on flexors and reciprocal facilitatory effect to extensors. MAINTAINED STRETCH
Stretch or lengthened position re-biases
spindle to longer position. The balance of tone between agonist and antagonist will be disturbed. However, sometimes prolonged positioning is desired E.g.: Spastic flexors held in cast or splints. Weak muscle can also be maintained in a shortened position. CONCLUSION
Positioning is a primary concern, especially
when little voluntary control exists. Extensive use of mats, bolsters, balls, and other specialized equipment is common in the Rood approach. Movement patterns can be incorporated into games, such as tug of war, to provide an occupational focus to regaining motor control. REFERENCES
Occupational Therapy for Physical
Dysfunction by Catherine Trombly and Anna Scott Cash’s Textbook of Neurology for Physiotherapist by Downie Neuro-rehabilitation: A Multisensory Approach by Shereen Farber Applied Theories in Occipational Therapy by Cole M. ANY QUESTIONS? THANKS…..