Rood’s Approach Dr. Hassan Sarsak, PhD, OT

Margaret Rood‘s Approach Principles Utilization of controlled sensory stimulation Provide sensory input to stimulate muscular response and normalize tone Utilization of developmental sequences Individuals are placed in various developmental postures to stimulate muscular response

Margaret Rood‘s approach Principles Utilization of activity to demand a purposeful response Purposeful activities are chosen to elicit desired movement patterns Sensorimotor control is developmentally based Treatment must begin at the person’s current level and progress sequentially Repetition/practice is necessary for motor relearning Broken record technique: repeat your position without losing control (assertiveness training)

Movement Control Sequence Flexion. Extension. Adduction. Abduction. Ulnar patterns develop before radial ones Rotation.

Muscle Work Light work muscles: Heavy work muscles: lie superficially, laterally, or distally primarily the flexors and adductors, finger and wrist extensors activated by light stretch or low-threshold stimulation Heavy work muscles: lie close to the joint. In the body they are located proximally and medially. They are primarily the trunk and proximal limb extensors and abductors activated by heavy resistance or maintained stretch and high threshold receptor stimulation In treatment: heavy work muscles should be integrated before light work muscles.

Margaret Rood‘s approach Phases of motor control Reciprocal inhibition/innervation Early mobility pattern that is primarily a reflex The movement of the neonate, waving his extremities back and forth typifies phasic movement. Co-contraction Simultaneous contraction of the agonist and antagonist around the joint that provides stability in a static pattern Utilized to hold a position or object for a long duration (improves posture) Heavy work Mobility superimposed on stability Proximal muscles contract and move and the distal segments are fixed Example on heavy work phase: An example of this kind of motion occurs when an infant learns to assume the quadruped position but has not learned to move in that position yet; he rocks back and forth with his knees and hands planted firmly on the floor.

Margaret Rood‘s approach Phases of motor control Skill Considered the highest level of control and combines stability and mobility Skill patterns consist of a stabilized proximal segment while the distal segment move in space Example of this level include walking, crawling, and use of hands

Sequences in Gross Motor Development A1:Supine withdrawal Supine. Withdrawal pattern. Total flexion. Bilateral. Centered at 10th thoracic vertebrae.

A2: Roll over. Flexion top arm & leg.

A3: prone extension Total extension. Bilateral. Cen. at 10th vertebrae.

B. Fixed Distal Segments Neck Co contraction, Vertebral extension. For head & neck hyperkinesia. To stabilise eyes if nystagmus. Nystagmus: rapid involuntary movements of the eyes

B2: prone on elbows Forearm support. Gleno humeral joint alignment.

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

Margaret Rood‘s approach Sequential patterns Supine withdrawal Position of total flexion while in the supine position The arms cross the chest, the legs flex and abduct Utilized to gain trunk stability and elicit flexion responses Rollover The arm and leg on the same side flex as the trunk rotates Utilized to elicit lateral trunk responses as well as for persons who are dominated by tonic reflexes Prone extension The person lies prone with upper trunk and head extension The shoulders abduct, extend and externally rotate, while the hips and keens extend off the support surface

Margaret Rood‘s approach Sequential patterns Neck cocontraction The individual is lying prone and encouraged to to lift the head into extension against gravity Utilized to develop head control Prone on elbows A pattern of trunk extension utilized to inhibit tonic neck reflexes as well as provide trunk and proximal limb stability Quadruped The person assumes an “on all fours” position to develop limb and trunk cocontraction patterns Standing (Standing is at first static followed by active weight shifting) Walking (Gait patterns are integrated into functional activities) -Asymmetric tonic neck reflex: fully rotate infant’s head and hold for 5 sec. extension of extremities on the face side, flexion of extremities on the skull side -Symmetric tonic neck reflex: place infant in the crawling position and extend the head. Flexion of hips and knees

Margaret Rood‘s approach Motor responses based on the sensory stimulation applied by the therapist: Fast brief stimuli produces a reflexive, large synchronized, output (e.g., tapping a tendon or muscle to facilitate muscular contraction) Fast repetitive sensory input produces a maintained response (e.g., application of high frequency vibration to a weakened muscle to evoke a tonic holding contraction) Maintained sensory input produces a maintained response (e.g., a prolonged manual stretch to a muscle group to inhibit overactive muscles) Slow, rhythmical, repetitive input produces a deactivating/calming effect (e.g., slow rocking, as in rocking chair to calm a child)

Margaret Rood‘s approach Evaluation Evaluate the distribution of muscle tone clinical observation and palpation techniques a lot to decide whether the muscle group needs inhibition or facilitation Determine the level of motor control based on Rood’s developmental sequence Individuals are guided through the sequence the point at which the subject can perform a task easily indicates his highest developmental level Determine the therapeutic activity of choice and how to progress the individual to the next level of control

Margaret Rood‘s approach Intervention Utilize controlled sensory input (cutaneous, thermal, olfactory, gustatory, auditory, and/or visual) to evoke desired motor responses Facilitation techniques Inhibition techniques Engage individual in purposeful activity to facilitate development, move to more difficulty ones

Margaret Rood‘s approach Intervention Facilitation techniques Tactile stimuli Light touch (stroking or A-brushing): A-size low threshold sensory fibers: stimulation of the webs of the fingers or toes or the palms of the hands or the soles of the feet elicits a fast, short lived withdrawal motion of the stimulated limb The stroking is done at a rate of twice per second for approximately 10 seconds After a rest period this procedure can be repeated 3 to 5 times When the reflex response occurs, resistance to the movement is usually given to reinforce it and to help develop voluntary control over it

Margaret Rood‘s approach Facilitation techniques Tactile stimuli Fast brushing (C-brushing) (battery operated brush) Brushing the hairs or the skin over a muscle with a soft camel hair paintbrush Brushing is done for 5 seconds for each area, followed by a rest period If there is no response after 30 seconds, the brushing of each area should be repeated 3 to 5 times

Margaret Rood‘s approach Facilitation techniques Tactile stimuli Fast brushing (C-brushing) (battery operated brush) Rood proposed that the effect of fast brushing is nonspecific, latent for 30 seconds, and reaches its maximum facilitative state 30 to 40 minutes after stimulation Short effect for 30 or 45 sec. Precautions: fast brushing of the pinna stimulates vagal cardiorespiratory response (slower heart, and constrict smooth muscles of the bronchial tree) fast brushing or scratching the back skin at level S2-4 may cause bladder emptying Don’t use mechanical tools Pinna: external part of the ear (the auricle) Fast brushing is thought to stimulate the C – size sensory fibers, that influence activity of muscles involved in the maintenance of posture. brushing applied to both non affected and the affected sides would probably be beneficial. As soon as the patient is able to voluntarily control movement, stroking (brushing) is no longer an effective or appropriate treatment.

Margaret Rood‘s approach Facilitation techniques Thermal: Quick icing over a muscle group to stimulate Proprioceptive: Stretch and tendon tapping (quick manual tapping with the therapist hand to apply a quick stretch to the desired muscle) High frequency vibration (100-300 cycles per second) Cutaneous brushing prior to vibrator  effective Heavy joint compression (applied manually and longitudinally through a joint in weight bearing position) Resistance utilizing gravity or via the therapist’s hands stimulates muscle recruitment Touching the lips with ice opens the mouth (a withdrawal response), but ice applied to the tongue and inside the lips closes the mouth. Heavy joint compression activates high-threshold joint receptors

Margaret Rood‘s approach Inhibition techniques Gentle rocking (in a chair or in therapist’s arms = generalized relaxation response) Slow stroking over the posterior rami of the spine (generalized relaxation) Slow rolling (from supine to sidelying and back in rhythmical pattern = generalized calming effect) Maintained stretched to an overactive muscle group (inhibition to spastic muscles) Neutral warmth (maintaining body heat by wrapping a person or body part in a blanket for 10-20 min. = relaxation response) Prolonged icing (over a muscle group) Icing precautions: Behind ear  sudden ↓ of blood pressure Left shoulder in cardiac diseased The difference between inhibition and facilitation is in the mode of application rather than the kind of stimuli: Light joint compression/joint approximation can be used to inhibit spastic muscles.

To normalize the muscle tone So …. Facilitatory technique: --To normalize the muscle tone from a flaccid state. --Quick icing, fast brushing, tapping, stroking, quick stretch. Inhibitory technique: --To normalize the muscle tone from hypertonic or spastic state. --Deep pressure, slow rolling, and slow rocking.

Isometric Isotonic

Full body Isometric contraction

Shoulder isotonic flexion with movement Resistance Movement Shoulder isotonic flexion with movement

Shoulder isometric flexion with no movement Resistance Shoulder isometric flexion with no movement

Special Cases Partial tear Complete tendon rupture Tendonitis Rotator cuff muscles: Partial tear: pain, muscle weakness Complete tendon rupture: painless, muscle weakness Tendonitis: pain, NO muscle weakness

In Cardiac Patients Know MET levels! (medical chart) NO isometrics Downgrade activity Stop activity when Dyspnea Chest pain Light-headedness Diaphoresis Dyspnea ضيق تنفس Diaphoresis تعرق شديد