S74. Section V+ Trontment of Occupational Punction muscle fibers and the tendon ancl alon of the muscles. When stimulated by contaetion, they Inform the CNS about the amount of tension in the extrafusal fibers they monitor, Impulses fom the GTOS are transmitted to the spinal cont via Uh fibers, whict pse polyssnaptically (Gilman & Newman, 1992) to inhibit the cemotor neutoNs innervating the agonist muscle and facilitate motor neurons of the antagonist muscle. ascial coverings Low Tone Hypotonia is treated by stimulation that affects the “ymotor neurons to inerease the sensitivity of the intratt- sal muscle fibers and therefore the likelihood they will fire to activate oF facilitate agonists and homonymous cles (Braddom, 199%; Carpenter, 1996). Muscle is mu facilitated within the context of attempted goalstirectod Voss movement or maintained posture (Huss, 19 1967). Application of facilitation techniques alone is nadequate therapy. Even though the patient may not be able to do any activity, the effort to accomplish a simple goal is powerful and should be an integral part of every: therapy. session, Ayres (1962) noted that activity that directs attention away from the movement aspects ofthe task and toward a purposeful goal enhances neurologi cal integration. Therefore, facilitation is done within an ‘occupational context. Facilitation Techniques Techniques to facilitate mus cation of tactile, thermal, and ‘stimuli to the special senses. These may be combined to produce a greater response te activation include appli- ve stimuli and propriocept various techniques Tactile Stimult Je stimulation is done using light st brushing (C-brushing), touch (Abrushing) Light Touch Light touch or stroking of the skin activates ihe tow threshold Asize sensory fibers to activate a reflex action athe muperticial phasic or mobilizing muscles (Rood. Tose, 1942: Stockmeyer, 1967). Light stroking of the dow Toe f the webs of the Fingers oF foes, oF of he pals of aa olde or the soles ofthe feet elicits fast, shorted aerial motion of the stimulated limb (Rood. 196°) The stroking is done at a rate of bi approximately 10 seconds (Rood. 1956 Hod this procedure can be repeated 3 t When the reflex response occurs, resistance ment is usually given to reinforce it and to hel voluntary’ € ever, 1967). ve per second for ‘After a rest pe 10.5 more times, to the move: Ip develop “ontrol over it (Stockme: gure 26:2 fst singh ater operate ot Finger extension, Ld Brushing cast brushing involves brushing the baits OF the skin oy a muscle willy a soft camot hair paintbrush that haste substituted for the stitver ofa hant-held batten powers cocktail mixer to produce a highsrequency, big intensity stirmutus (Haris, 1969; Rood, 1962; Stocker 1967), The revolving brush, hekd sideways to awl ul pulling the hair (Fig, 262), is appli on slated! (Rood, 1956, 1962}. catching 3 each skin area to be sti Dishing is thonght to stimulate the Cize sensory Hs which discl ppolysyrnaptic pathovays that i rein ence the backgroud yefferent activity of musts posture (Harris, BRL involved in the maintenance of ntvas & Spicer, 1980; Rood, 1962). Spindles so heed respond more readily. to added extemal or inert stretch (Rood, 1962) Fast brushing over the primary rami of the periph the muscles and skin of the back (Carpentet TOSB), faciitates the deep tone muscles ef the Ime whereas fast brushing of the skin oxer the 108 0" trimk and extremities, supplied by the anterior NE fain (Carpenter & Sutin, 1988), facilitates 2 WE fl the superficial ventrotateral nnscles distribution of the pose eral nerves, which inert Sit sponse 1962). Brushing is done on the skin of the wed by the same spinal Se? whose spindles the therapist is ater Forinstance, to facilitate lermatome ment as tenis extensors (innervated by C68), brushing is annie the dorsal radial forearm ann nan, The Y na corresponds to the location of the muscle, By ga ddone lor 3 seconds for ench area (Huss. [DA ys bya rest period. I there is no response #0 IM hy aca 0 alter 30 seconds, the brushing of &% repeated 3 to 5 times (Rood, 1962).Chapter 21 good (1962) proposed that the effect of fast brushing Nonspecific, had a latency of 30 seconds, and 3 MG its maximum facilitative slate 30 to 40 minutes, ‘Gimulation because of the enhancement of the * yar activating system into which the C-fibers feed. Hn a2 na beng arp anormal lncMposstroke individuals, however, it was demon- ‘it immediate facilitatory effect, the effect lasted only Spo 45 seconds (Mason, 1985; Matyas & Spicer, 1980; Spicer & Matyas, 1980). Moreover, in normal subjects, ihe facilitatory effect was seen only in the lower ex- trenity, not in the upper extremity. Rider (1971) exam- vped fast brushing, among other stimuli. She found a daisicaly significant (p =.01) increase in the strength ff both triceps of eight children with bilateral upper txtremity flexor spasticity compared with eight chil ten who had normal upper extremities, following a week period of treatment consisting of brushing, stoking, rubbing, icing, and squeezing of the triceps of ne limb. Some precautions are to be observed in relation to fast brushing. Fast brushing of the pinna of the ear stimulates the vagal parasympathetic fibers, which influence cardiorespiratory func- tions (Rood, 1962). Activation of these fibers slows the heart, constricts the smooth muscles of the bronchial tree, and increases bronchial secretions (Gilman & Newman, 1992). Fast brush: ing or scratching of the skin over the hack at 1 of S24 may cause bladder emptying Gilman & Newman, 1992). after Thermal Stimuli ‘king is thought to have similar effects as stroking and Drishing through the same neural mechanisms (Hai, 9; Rood, 1962). Icing, however, has been found to be significantly Tess effective than fast brushing for recr ent of motor units in hemiplegic patients (Matyas & Spicer, 1980) Two types of icing, A-and C- (referring to the sine ofthe sensory fibers) are use Ming ‘cing isthe application of three quick swipes of an ice Cube to evoke a reflex withdrawal, similar to the 'SPonse to light touch, when the stimulus is applied to HRePalis or soles or the dorsal webs ofthe hands or feet od, 1962). The water is blotted up after every swipe. “cing of the upper right quadrant of the abdomen Cx dermatomal representation for T79 (along the sib, “S) Simulates the diaphragm and inspiration (Rood), {iiChing the lips with ice opens the mouth (a with Wal response). But ice applied to the tongue and the lips closes the mouth (Rood, 1962). Swiping side Managing Deficit of First-Level Motor Control Capacities 525 yal petch the ice upward over the skin of the 9 promotes swallowing Celeing Cieing is a highthreshold stimulus wed to tir postural tonic responses via the Cig sensyary fibers (Rood, 1962). Icing to activate the € fibers holding the ice cube in place for to 5 seconds, then wiping away the water, The: skin ierislated are the same as for fast brushing, with one exces The distribution of the posterior primary rari along the back is avoided because it may cause a sympathetic nervous system fight or Slight protec: tive response (Rood, 1962; Huss, 1971). Other precautions about icing are similar to those for brash Icing of the pinna causes cagal responses, including cardiovascular reactions such as low blood pressure (Umphred, 1995). Ice to the back at the level of 824 may cause voiding (Rood, 1962) tone: ra 10 bee Proprioceptive Stimuli ‘The difference between proprioceptive stimuli and the described tactile and thermal stimuli is that the effect of proprioceptive stimulation lasts only as long 2s the stimulus is applied, whereas the effects of tactile an thermal stimulation lasts several tens of seconds after the stimulus is removed. There are several types of propri- ceptive stimuli, described next. Quick Stretch Quick, light stretch of a muscle is 2 lowthr stimulus that activates an immediate pres: reflex of the stretched muscle and inhibits its antasonis. (Rood, 1962). Stretch is applied in the form of quick movement of the limb or tapping over the muscle oF tendon, The therapist uses stiffened fingertips t0 vigor ously tap the skin over a muscle or tendon while the patient is attempting to contract the muscle (See Fi 248). This provides intermittent mechanical ste the muscle to evoke a stronger response. Evoeation of the stretch reflex without a conjoint attenp to move hold a position is not therapeutic Vibration High frequency (100-300 He, with 100 te 125 Re preferred) vibration, delivered by an electtic personal vibrator that has an exeursion ob Ute) 2 ay}, to the belly for tendon of the slightly stretches! nmisele is ait adit tional form of stretch (Uimplinst, 1998) (Fig action of the vil MOT provieles a rapid rwpeatert mechanical stretch to the muscle, whieh ineretses the umber of motor units weritert This is. the: ibratory retlex CTVRD. Tension within he mnuisele im576 Section V« Treatment of Occupational Function Figure 26-3 A electrical ibrator applied to the triceps tendon to elicit ‘sustained elbow extensor response while the patient is weight bearing inquadruped. creases over 30 to 60 seconds and is sustained for the duration of the application of the vibrator (Umphred, 1995). The stronger response is obtained from applica- tion over the tendon; however, stimulation applied there can be conducted to adjacent muscles via the bone, and this possibility must be attended to and prevented (Dobkin, 1996; Preston & Hecht, 1999), Vibration evokes a tonic holding contraction and adds to the strength fof an already weakly contracting muscle. Vibration should not be maintained longer than I to 2 minutes in any one place because of the heat that develops from the friction and potential for tearing thin Vibration over areas pret ously immobilized can dislodge a blood clot and Cause an embolism (Umphred, 1995). Streteh to Finger Intrinsics Stretch to the intrinsic muscles of the hand is used to facilitate cocontraction, that is, the simultancous Con- traction of the muscles around the shoulder joint (Ay 1974; Stockmeyer, 1967). Forcefully grasping handles of tools obtains this response, especially if the handles have heen modified to be spherical or conical, with the widest part of the cone a the ulnar border of the hand, both of Which increase intermetacarpal siretch, This treatment is tised for patients who have distal movernent but proxi mal weakness. —— nated peo oe muscles around a joint. Heavy compeang tim laos greater ham bey Gage ne Naa that the foree is througt the long * apie’, (yres 197; Koval, 1962) testanec ge wedge is Ihat whlch is more than Beene? who is in a quadruped pos ‘ tudinal ance roxituateeaey each, 9 i ‘Mable, lit ane limb off the suppomingsuraes pomting surace tel eis can beaded he bat yp things as a lead radiography apron on the sous thing phy ap he shoud posture is a form of stretch in which many or a2 1585) To pine of cous canna vow was discrepancy between itself and the extrafusal m ' from shortening as the spindle continues to stores programmed. The discrepancy causes he spindle of ‘The electrical activity of the imterneuronal pas s consequently high, and more and more motor u more easily recruited to fire, a phenomenon <: overflow, Stimuli for the Special Senses Rood (1962) used stimulation to the special facilitate or inhibit the skeletal musculature s She reasoned that stimuli from all cranial senso* feed into the reticular activating formation, whe! affects the yetferents, Auditory and visual stim Used deliberately, However, auditory and vital also occur incidental to treatment, a fact of wi? therapist needs to be aware. Music with a define = facilitatory. A noisy, raucous clinic is stimuli may affect the performance of the patient dysfunction, A colorful, bright rultstimules © ment has a general facilitatory effect. The ther voice and manner of speect (last and siacca) slow and calming) may also altect the patitts Pe mance. A loud, sharp command yields a quick and recruits more motor units (Voss, 1967) command can avercome the akinesia of Pain’ ‘Olfactory and gustatory stimuli ave face inhibiting through their influence on the OP nt or dangerous si nervous system, Unple = ammonia smell) elicit a sympathetic fil & reaction, and pleasant stimuli (like vanilla)Chapter 26 « Managing Deh of Fi mmpathetic response that inhibits the sympathetic Te (Rood, 1962). These stimuli, especially olfac: reoduce an emotional response as well as a motor oh sesponse. problems Secondary to Low Tone tera period of therapy, voluntary movement may not develop and tone may remain low. If that is the case, itis important that the patient be taught preventive measures tp avoid the problems common to low tone. Those Increase tone atthe shoulder. > Increase active movement of the LUE, > Introduce a routine of inhibitory procedures prior to swimmning ¢ MANAGEMENT OF HYPERTONICITY: THREE MONTUS LATER Short-Term Goals > Decrease spasttlty ofthe elbow, ws, ager, thumb and Increase active movement ofthe Lj the ist day of therapy, the therapist wrapped theling warm cotton ant for 20 minutes ile Ms 8 wate, her occupational therapy appointment. When then, began, the blanket was removed and the wise hand appeared relaxed, Ms. B. as eagerto focus tara, on kitchen activites. The plan was to make muti a a mix. The left hand held containers: bag of mutfn and milk container, while they were opened and m tin while it was being filled. The elt hand aso fey the mixing bow! with a handle white the mitre xe stired, Alter this activity, hypertonicity was rapper ing, The therapist manually stretched and held the fr and thumb into full extension with the wrist in nes Position. The tension again reduced. This was repeat throughout the rest of the treatment session as eee, and Ms. B, was taught how to do this for herself thane The focus of treatment then turned to problem solving! practice of computer use. As therapy concluded tha the therapist again wrapped the LUE in the cotton ble! and sent Ms. B. to wait for her physical therapy apo ‘meat > Introduce a routine of inhibitory procedures prt to swimming. The therapist recommended that Is § ccome to the pool wearing her bathing suit covered t easily removable pants and top. He recommended ti? she take a warm shower and then wrap herself in i fluffy bath towel for 15 minutes before entering the poo!” provide a general inhibition of hypertonic muscles H# furtherrecommenced that Ms. B. swim ina pool whe ®* water is kept above 85°F. He recommended thats {ry to use both arms and legs atthe same time (jot iteases hypertonicity) but to hold on toa oat anti slowly awhile, then, without the float, keep the ke! while trying to do the side stroke with the let 2" extending overhead and the right am provi Power. He further recommended that she stop a ‘very 5t0 10 minutes to rest