THE ROOD APPROACH

                           THE ROOD APPROACH

1.       TERORY:

·         Margaret Rood drew heavily from both the reflex and the hierarchic models in designing her intervention approach. Key components of the Rood approach are the use of sensory stimulation to evoke a motor response and the use of developmental postures to promote changes in muscle tone.

·         Knowledge and observation of sensory stimulation to bring effective motor response

2.       BASIC ASSUMATION:

2.1   Normal muscle tone is prerequisite to movement

·         Rood believed that movement occurs in a developmental sequence.

·         Some muscles are used predominantly for heavy work and others for light work. Light work muscles are called mobilizers and are primarily the flexors and adductors.

·         The primary function of the light-work muscle is directed toward skilled movement patterns. Heavy-work muscles, however, act a stabilizers and consist of the extensors and abductors.       The primary function of         heavy-work muscles is to allow maintenance of posture and holding patterns of movement.

·         Heavy-work and light-work muscles act together to allow coordinated movements to occur

2.2   Treatment begins at the developmental level functioning

·         Rood believed that movement occurs in a developmental sequence.

·         Patients are evaluated developmentally, and treatment follows a developmental sequence.

·         This principle follows the cephalocaudal rule.

2.3   Motivation enhances purposeful movement.

·         Rood realized that motivation plays an important role in rehabilitation.

·         Activities that are meaningful for the patient encourage practice of desired movements. This results in greater patient participation in treatment.       

2.4   Repetition is necessary  for the reduction of muscular responses

3.       PRINCIPLES:

3.1   Reflexes can be used to assist or retard the effects of sensory stimulation   according to Rood, reflexes can be used to influence muscle tone.

·         Two commonly mentioned mechanisms               are the tonic neck reflexes (TNRs) and tonic labyrinthine reflexes (TLRs).The TNRs are triggered by changes in the relationship of the head to the neck; TLRs occur with changes in the relationship of the head to gravity.

·         Consequently,any changes in the position of the head to the neck,or in relationship of the head to gravity, can result in increases or decreases in muscle tone.

·         Clinicians must therefore be aware of the position of the head and neck and the potential effects of gravity on the body.

3.2   Sensory stimulation of receptor can produce predictable response.

·         Responses to sensory stimulation to specific       receptors are predictable. Clinicians using sensory stimulation can use this predictability to achieve a desired outcome

3.3   Muscles have different duties.

·         Responses to sensory stimulation to specific receptors are predictable. Clinicians using sensory stimulation can use this predictability to achieve a desired outcome

3.4   Heavy work muscle should be integrated  before light work muscle.

·         The principle of integrating heavy-work muscles before light-work muscles refers primarily         to the use of the upper extremities (UEs).

               

4.       SEQUENCE OF MOTOR DEVELOPMENT :

4.1  Reciprocal inhibition (innervation)

·         Reciprocal inhibition is an early mobility phase that serves a protective function. The muscle acting on one side of a joint     (agonist) quickly contracts while its opposite (amntagonist) relaxes.           

4.2   Co-contraction

·         Co-contraction occurs when opposing muscles (usually those surrounding a joint) contract simultaneously, resulting in stabilization of the joint. The co-contraction phase allows an individual to hold a position or an object for a longer time. Standing upright is a result of co-contraction      of the trunk muscles, as     well as  muscles                acting on the hips, knees, and ankles.

4.3   Heavy work

·         The heavy-work phase  has been defined as “mobility on stability.” In this phase the proximal muscles move, and the distal segments are Fixed.          

4.4   Skill

·         Skill is    the highest level of control and combines the efforts of                mobility and stability. In a skilled movement pattern the proximal segment is stabilized while the distal segment moves freely.

5.       ONTOGENIC MOVEMENT PATTERNS:

5.1   Supine Withdrawal (Supine Flexion)

·         Supine withdrawal is a total flexion response toward the navel.

·         This position is protective.

·         Supine withdrawal is a mobility posture that requires reciprocal innervation; it also requires heavy work of the proximal muscles and trunk. Rood recommended this pattern for patients who do not have the reciprocal flexion pattern and for          those dominated by extensor tone

                     5.2 Roll Over (Toward Side-Lying)

·         When the patient rolls over, the arm and leg flex                on the same side of the                body Rolling over is a mobility pattern                for the  Ues and lower extremities (Les)               and activates the lateral trunk musculature.             

·         This pattern is encouraged for patients who are dominated by reflexes or              who need segmental             movements of the extremities

                    5.3 Pivot Prone (Prone Extension)

·         The pivot-prone position demands a full   range of extension of the neck, shoulders, trunk, and LE    

·         This pattern has been called both a mobility pattern and a stability pattern.

·         The position is difficult to assume and hold.            

·         It plays      an important role in preparation for stability in the upright position

                   5.4 Neck Co-Contraction (Co-Innervation)

·         Neck co-contraction is the first real stability pattern.          

·         It is used to develop head control and stability of the neck              

·         This pattern is necessary to raise the head against gravity

                   5.5 On Elbows (Prone on Elbow)

·         Following co-contraction of the neck and prone extension, weight bearing on the elbows is the next    pattern to achieve.         

·         This pattern helps develop stability in the scapular and      glenohumeral (shoulder) regions.           

·         This position gives the       person  a better                view of the environment and an opportunity to    shift weight from side to side

                  5.6 All Fours (Quadruped Position)

·         The quadruped position develops stability of the lower     trunk and legs. 

·         Initially the patient holds the position.      

·         Eventually, weight shifting forward, backward, side to side,and diagonally is added.

·         The weight shifting may be preparatory for balance responses

                  5.7 Static Standing Static           

·         Standing is thought to be a skill of the upper trunk because it frees the Ues for prehension and manipulation.       

·         At first, weight is  equally distributed on both legs; then weight shifting begins.    

·         This position requires higher-level integration such as maintaining and achieving balance

                  5.8 Walking

·         Walking    unites skill, mobility, and stability.           

·         Walking    is a complicated process that requires coordinated movement patterns of the various parts of the body

6.       TECHNIQUES:

                  6.1 FACILITATION TECHNIQUES

·         Techniques to facilitate muscle activation include application of tactile, thermal, and proprioceptive stimuli, and stimuli to the special senses. These various techniques may be combined to produce a greater response.

    Tactile Stimul:

·         Tactile stimulation is done using light touch (A-brushing) or fast brushing (C-brushing).

Light Touch:

Ø  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

Ø  Light stroking of the dorsum of the webs of the fingers or toes, or of the palms of the hands or the soles of the feet elicits a fast, short-lived withdrawal motion of the stimulated limb

Ø  The stroking is done at a rate of twice per second for approximately 10 seconds

Ø   After a rest period, this procedure can be repeated 3–5 more times. 

Ø  The reflex response occurs, resistance to the movement in activity is usually given to reinforce it and to help develop voluntary control over it

      Brushing

Ø  Fast brushing involves brushing the hairs or the skin over a muscle with a soft camel hair paintbrush that has been substituted for the stirrer of a hand-held battery powered cocktail mixer to produce a high-frequency, high-intensity stimulus

Ø  Fast brushing is thought to stimulate the C-size sensory fibers, which discharge into polysynaptic pathways that influence the background activity of muscles involved in the maintenance of posture.

 Thermal Stimuli:

      A-Icing

Ø  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 or feet (Rood, 1962).

Ø  A-icing of the upper right quadrant of the abdomen in the dermatomal representation for T7-9 (along the rib cage) stimulates the diaphragm and inspiration.

Ø  Swiping the ice upward over the skin of the sternal notch promotes swallowing

    C-Icing

Ø  C-icing is a high-threshold stimulus used to stimulate postural tonic responses via the C-size sensory fibers

Ø  Icing to activate the C fibers is done by holding the ice cube in place for 3–5 seconds, then wiping away the water.

Proprioceptive Stimuli:

      Quick Stretch Quick

Ø  Quick Stretch Quick, light stretch of a muscle is a low-threshold stimulus that activates an immediate phasic stretch reflex of the stretched muscle and inhibits its antagonist (Rood, 1962). Stretch is applied in the form of quick movement of the limb or tapping over the muscle or tendon.

Ø  The therapist uses fingertips to vigorously tap the skin over a muscle or tendon while the patient is attempting to contract the muscle

      Vibration

Ø  Vibration High-frequency (100–300 Hz, with 100–125 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 muscle is an additional form of stretch 

Ø  This is the tonic vibratory reflex (TVR). Tension within the muscle increases over 30–60 seconds and is sustained for the duration of the application of the vibrator.

Ø   The stronger response is obtained from application over the tendon. Vibration evokes a tonic holding contraction and adds to the strength of an already weakly contracting muscle.

     Stretch to Finger Intrinsics

Ø  Stretch to the intrinsic muscles of the hand is used to facilitate co-contraction of the muscles around the shoulder joint

Ø  Forcefully grasping handles of tools obtains this response, especially if the handles have been modified to be spherical or conical, with the widest part of the cone at the ulnar border of the hand, both of which increase intermetacarpal stretch.

Ø  This treatment is used for patients who have distal movement but proximal weakness

   Heavy Joint Compression

Ø  Heavy joint compression facilitates co-contraction of muscles around a joint, thereby facilitating the stability component of movement in activity.

Ø  Heavy 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 surfaces approximate each other Resistance greater than body weight is resistance that is more than the weight of the body parts usually supported by the joint.

   Resistance

Ø  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 .

Ø  The muscle spindle, of course, cannot know whether the discrepancy between itself and the extrafusal muscle fibers is due to stretching by a moving force or by resistance that is preventing extrafusal muscle fibers from shortening as the spindle continues to shorten as programmed. The discrepancy causes the spindle to fire.

Ø  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.

6.2 INHIBITION TECHNIQUES

·         Hypertonicity 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.

       Tactile Stimuli:

    Slow stroking

Ø  Slow stroking over the distribution of the posterior primary rami produces general relaxation. It involves rhythmical moving touch instead of maintained touch.

Ø  The person lies prone or sits unsupported in a quiet environment with his or her back exposed. 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 progresses likewise to the coccyx.

Ø  One hand is always in contact with the patient. This slow, rhythmical stroking using alternating hands is done until the patient relaxes or for about 3–5 minutes

           

       Thermal Stimuli: Both warming and cooling can be inhibitory

    Neutral Warmth

Ø  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  

Ø  Neutral heat, rather than heat greater than body temperature, is used to avoid a rebound effect in 2–3 hours.

Ø   The rebound effect manifests as facilitated or even superfacilitated muscles

Ø  Elastic bandages and air splints (see Fig. 16-75) can be used also.

                  

                 Prolonged Cooling                   

Ø  Prolonged Cooling Sustained cooling of the skin to 50°F (10°C) decreases the monosynaptic stretch reflex excitability (Preston & Hecht, 1999). A cold pack applied for 20 minutes achieves this effect

  

         Proprioceptive Stimuli:Several proprioceptive techniques to inhibit one or both components of hypertonicity

                    Prolonged Stretch

Ø  Prolonged manual stretch is used to inhibit a specific spastic muscle so that the patient may move more easily (Carey, 1990).

Ø  The limb is held so that the muscle is steadily kept at its greatest length for more than 20 seconds, until letting go is felt as the muscle adjusts to the longer length.

Ø  The mechanical lengthening also changes the viscoelastic configuration of muscle by disrupting crossbridges between myosin and actin filaments and/or by reducing the stiffness of periarticular connective tissue

                     Light Joint Approximation

Ø  Light joint compression, also called joint approximation, can be used to inhibit specific spastic muscles.

Ø   The method is to grasp the patient’s elbow and, while holding the humerus abducted to about 35–45°, gently move the head of the humerus into the glenoid fossa and hold it there until the spastic muscles relax.

                     Tendon Pressure

Ø  Pressure on the tendinous insertion of a muscle inhibits that muscle  

Ø  The extrinsic flexors of the hand may be inhibited by applying constant pressure over the length of the long tendons through grasp of enlarged, hard handles of tools or utensils or via splints.

         Vestibular Stimuli:

                       Slow, rhythmical movement  

Ø  Slow, rhythmical movement is inhibiting  

Ø  Slow rolling is done by the therapist holding the patient at the hip and shoulder and slowly rolling from supine to side-lying.

Ø  The patient should be lying comfortably, with a pillow under the head and between the knees if necessary for comfort.

Ø   A decrease in hypertonicity should be seen within minutes

           6.3 STIMULI FOR THE 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.

·         Olfactory and gustatory stimuli are facilitating or inhibiting through their influence on the autonomic nervous system.

7.       PRECAUTIONS :

·         Fast brushing of the pinna of the ear stimulates the vagal parasympathetic fibers, which influence cardiorespiratory functions. Activation of these fibers slows the heart, constricts the smooth muscles of the bronchial tree, and increases bronchial secretions. Fast brushing or scratching of the skin over the back at the level of S2-4 may cause bladder emptying

·          In the application of C-icing, the distribution of the posterior primary rami along the back is avoided because it may cause a sympathetic nervous system fight or flight protective response.

·         Icing of the pinna causes vagal responses, including cardiovascular reactions such as low blood pressure. Ice to the back at the level of S2-4 may cause voiding .

·         Prolonged icing is contraindicated for patients with Raynaud’s phenomenon or circulatory disorders, including hypertension.

·         Vibration applied on tendons can be conducted to adjacent muscles via the bone, and this possibility must be attended to and prevented.

·         Vibration should not be maintained longer than 1–2 minutes in any one place because of the heat that develops from the friction and potential for tearing thin skin. Vibration over areas previously immobilized can dislodge a blood clot and cause an embolism.

·         Scapulohumeral rhythm must be adhered to during all upper extremity range of motion (UE ROM) movements to prevent damage to the shoulder muscles and development of pain syndromes.

·         Isometric contractions may produce the Valsalva maneuver, resulting in tachycardia and increased blood pressure, followed by reflexive bradycardia. Patients with cardiac conditions must be closely monitored.

·         Application of quick stretch (QS) in diagonal patterns must be carefully applied. If a muscle is very near its full anatomical range application of too great a stretch may damage the muscle. Neck muscles are also close to their full anatomical range at the beginning of patterns.