Facilitation

Intervention for motor control

Authors

Affiliations

Nate Yomogida, B.S., SPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, B.S., SPT

Doctor of Physical Therapy

B.A. in Neuroscience

Understand where the task analysis issue is occurring

• Preparation: the interval between an external or internal stimulus to move
  • Did they establish correct alignment before beginning the movement?
• Initiation:
  • The transition from rest to movement; the time when movement begins
  • Where is the movement starting from: Is it too much? Not enough?
  • Reaction time?
• Execution: movement towards the specific task goal
• Termination: the transition from movement to rest
  • Do they have the adequate stability to terminate to effectively?

Guidance

Guidance refers to what the patient should be focusing on

• Teaches movement pattern, provides feeling of normal movement or intended movement;
• Helps facilitate motor learning and improve kinesthetic awareness;
• Use to guide whole functional movement tasks, or parts of movement, or just isolated movements

Variables of facilitation

Manual Contact points

• Proximal:
  • PT has more control, pt feels more secure
  • Examples of proximal contacts would be: trunk, shoulder blades, pelvis, patient needs to develop more control with task
• Distal:
  • PT has Less control, gives more control to patient;
  • Can still be used to influence trunk from elbows, knees, feet, hands, wrist via irradiation

Progression

• In general progress from proximal to distal, further away from center the more control you give to your pt
• As soon as pt takes over more of the task you move your hands more distally

Alignment

• Must always strive to achieve good positioning, to allow patient the opportunity to choose from many movement options and not get stuck in a pattern that is not as effective
• Also helps promote normal ROM and better use/ access of all of the limbs

Speed

Should you instruct the patient to move fast or slow during these movements? The answer is not very simple, it depends on your goal for the patient

Moving Slowly

• To teach movement pattern or functional activity begin slowly; use if trying not to increase tone or spasticity initially;
• Provides patient time to concentrate/ understand the sequence and process it better, decrease anxiety;
• Gives PT opportunity to change facilitation, hand placements, input, body position in response to pt

Moving quickly:

• Need to progress to faster movements to get to functional or normal speeds to help facilitate independence;
• Use faster movements when teaching pts to use momentum(as in some SCI compensatory techniques) or when ready to begin gaining power with mobility

ROM

How much ROM should the patient move through when using facilitation? You should choose the ROM based on what level of motor learning the patient is in. Start with small ROM and progress to larger ROM.

• Small ROM
  • Use small ranges initially to develop more control-
  • Can break down tasks into smaller parts of the movement to increase confidence, decrease anxiety
• Large ROM:
  • Progress to larger ranges of motion to facilitate normal movement, and do whole task training for improved motor learning,
  • If you don’t practice movement in normal ranges it cannot be functional in real world situations

When to progress ROM

N/A yet

Load

Type of resistance

Isometric –> Eccentric –> Concentric Movement Skills

Isometric:

• Sustained hold
• Use to get muscles on and hold contraction for longer periods of time;
• May be very difficult for persons with neurologic involvement

Eccentric:

• Use to gain control of movement, promotes co-activation, graded control (slowing down) and uses less metabolic output than concentric contractions;
• Promotes strength gains in less time

Concentric:

• a shortening contraction; use for gaining power/ speed for fast muscles/ movements;
• Increased metabolic output required

Weight-bearing percent

Light weight bearing: Less than body weight

• Helps to “normalize” tone or to dampen it;
• Example: weight bearing prone on elbows (POE) helps to turn on extensors and inhibit flexor tone
• Can promote controlled mobility

Example

Sitting weight bearing on one UE and reaching with other UE

Heavy weight bearing: Greater than body weight:

• used for holding, stabilizing, promotes co-activation

Example

Approximating at the trunk in upright standing, using vests or cuffs

Weight Shifts

• Helps to increase kinesthetic awareness and body in space, explore and increase limits of stability in all directions; works on controlled mobility;
• Facilitates symmetrical WB, can be used to decrease anxiety

Task-Specific Training

• You observe AND can FEEL to analyze the task and movement patterns that make up the task; break the task into component parts and note the parts that the pt cannot do or they are missing and that are NEEDED to complete that task normally
• You work on the missing components or parts, which may also include working directly with the impairments (like increasing ROM); may have to help create environment that allows successful mobility without that component if unable to recover it
• Then combine the tasks and work toward the whole functional skill and work toward transferring learning of the skill

Facilitation techniques:

Frontal plane Side Bend R Use more vertical force vectors Approximate the R side inferiorly Traction the L side superiorly (elongates the trunk) Side shift Translate both sides horizontally (i.e. approximate left shoulder and traction the other shoulder along the horizontal plane)

Sitting

• As much loading as possible!
• Feet on ground
• Load thru the elbow, hand and elbow, or AC joint or scapula itself
• Approximate tibia

Kneeling

Transitioning to Kneeling

Standing to kneeling

• Hand placement
  • Place your hands where the impairment is to provide the most support.
  • Otherwise, place your hands at the pelvis (ASIS) to facilitate PPT and APT.
• Have pt crawl on to table from standing to QP
• Facilitate from upper trunk for extension and/ or hip for extension
• Careful to allow weight shift posteriorly before extension
• From there go to heel sitting, to tall kneeling

Sidelying / Sidesitting

Sidelying / Heel

Stabilizing reversals

“Hold, don’t let me move/push/pull you”

• Ant/Post or Med/Lat direction
  • You can provide resistance at
    • Pelvis
    • Upper Trunk
• Posterior Scapular Depression/ Anterior Scapular Depression
  • BIL or UNIL with approx. to opposite pelvis

Facilitation Treatment

General Focus on treatment:

• Bigger amplitude (PD)
• Forced use (stroke)
• For BIL impairments: Focus more on stability (i.e. MS)