Proprioceptive Facilitation Therapy for Paralysis. Herman Kabat, M;D., Ph.D., and Margaret Knott, B.S. K a b a t-K a is e r In stitu te , Vellejo, C aliforn ia. (International Page Eight P H Y S I O T H E R A P Y October 1954 WE know th a t if a person has paralysis from actual destruction o f tissue in the central nervous system he cannot be cured. The main reason for this is th a t this tissue has become so highly specialized th at it has lost the ability to regenerate. Any nerve cells or nerve fibres in the brain o r spinal cord which have been destroyed are therefore lost perm anently. This accounts for the perm an- nent paralysis resulting from poliomyelitis, in which nerve cells in the spinal cord are attacked; for th e permanence of paraplegia from severance o f the spinal cord; and for the perm anent loss o f m otor function in hemiplegia, cerebral palsy and m ultiple sclerosis, in which nerve pathways o f vital im portance to voluntary m otion are destroyed. W hat­ ever spontaneous recovery does occur can be accounted for to a considerable extent by reversible tissue injury rather than destruction. I f loss o f nervous tissue is perm anent how can we expect to accom plish anything by treatm ent o f paralysis? A re we tilting a t windmills in our bright new field o f reha­ bilitation ? Y ou know very well, of course, th at patients with paralysis o f various types can be greatly benefited by neuro­ muscular rehabilitation. But there are many sceptics, and confusing controversies still rage. It is therefore o f the greatest im portance th at we in th e field o f rehabilitation clearly understand what we can and cannot accomplish through therapy, and why. It is also essential, if we are to convince the sceptics, th a t we clarify the basic principles o f treatm ent and utilize the m ost effective techniques for recovery from paralysis. We m ust shift our focus from pathology to physiology, for while a desturctive lesion o f the central nervous system is perm anent and irreversible the resulting loss of m otor function may nevertheless be significantly improved. We m ust adm it realistically th at even with intensive prolonged therapy using the best available therapeutic techniques we can never achieve complete restoration o f function in serious paralysis, and usually a great deal o f paralysis persists despite our best efforts. On the other hand, in spite of these limitations, the contribution o f rehabilitation to the patient with paralysis is so valuable th a t there can be no doubt o f th e increasing im portance o f this new branch o f medicine. One must recognise th a t therapy is necessary in a patient disabled by paralysis not only to get him better but also to prevent him from getting worse. The prolonged inactivity enforced by the paralysis results in serious decline in function. This is m ost evident in the well-known muscu­ lar atrophy o f disuse, but inactivity can also bring about contracture and disturbances of circulation. Failure to stand and walk for a long period can lead to osteoporosis and fragile bones as well as form ation o f stones in the urinary tract. The m otor mechanisms in the central nervous system also deteriorate with disuse, resulting in decreased volun­ tary control and co-ordination, disuse trem or, and greater fatigue. Even primitive reflexes show decline from in­ activity; examples include the deterioration o f reflex adjustm ent o f blood pressure in the sitting and standing positions from prolonged bed rest; decreased function o f postural reflexes for sitting and standing balance. In addition, inactivity seriously affects general health, such as appetite, bowel regulation, resistance to infection, &c. Prolonged inactivity has particularly devastating effects Congress Lecture) on m ental health, exaggerating regressive tendencies such as dependency, increasing depression, and affecting emo­ tional stability. Activity of the neurom uscular system is essential to prevent o r overcome the undesirable effects o f inactivity. Each specific part o f the neurom uscular mechanism must have sufficient activity to prevent disuse: use o f the arms will not prevent the effects o f inactivity in the legs, nor will activity o f the biceps necessarily avoid disuse o f the triceps. One o f the goals o f the rehabilitation program m e must be not only to prevent or eliminate the effects of disuse but also to ensure th at deterioration from inactivity will not occur in the future after th e patient discontinues treatm ent. F o r this reason, taking care o f oneself, walking, and other activities have m ore than their obvious practical significance but constitute daily therapy which the patient can perform him self to prevent disuse. In certain cases, continued specific home-therapy programmes, usually done by the patient himself but if necessary with some assistance from a member o f the family, may be essential to m aintain function. In addition, the rehabilitation pro­ gramme m ust include training in habit patterns th at will utilize'- all o f th e available and potential neurom uscular function th a t is left so th a t in various routine daily activities each specific part o f the neurom uscular system is as active as possible. As an example, where possible, walking should be encouraged, utilizing the hip flexors rath er than allow­ ing substitution by the quadratus lum borum , so th a t the h abit pattern of gait which is developed does not allow disuse o f the hip flexors. Just as inactivity is harm ful, activity is beneficial, and can be carried far beyond mere prevention o f the undesirable effects o f inactivity. In fact, activity o f the neurom uscular m echanism is undoubtedly the single most im portant therapeutic procedure available for restoration o f m otor function in paralysis. In addition to producing hypertrophy o f th e muscles, neurom uscular activity has a striking effect in improving endurance, voluntary control and co-ordina­ tion, and decreasing synaptic resistance for various essen­ tial m otor habit patterns. It improves th e functioning o f reflexes as well as voluntary m otion. Also, it brings about improvement in circulation, range o f jo in t m otion, and general health. A well-considered program m e o f neurom uscular activity with, a realistic rehabilitation goal has striking beneficial effects o n 'm e n ta l health. N eurom uscular activity can be beneficial in im prov­ ing function in patients with paralysis in several specific w ays: 1. In a patient with weakness o f elbow flexion, for example, therapeutic activity can increase the power and endurance o f this m otion considerably with practical benefit in reduction o f disability. While there is evident muscle hypertrophy and the associated im provement in chemistry o f th e muscle, this is but one m anifestation o f an overall neurom uscular process in which th e im provem ent in the nervous mechanism is inseparable from th at in th e muscle. In other words, elbow flexion becomes stronger in voluntary m otion not only because o f muscular hypertrophy but also because o f decreased synaptic resistance in the voluntary pathw ay to the anterior horn cells. This results in better voluntary control, co-ordination and endurance as well as R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) O ttob er 1954^ P H Y S I O T H E R A P Y Page Nine It also brings about greater ease o f development of Pk'Med patterns o f voluntary m otion incorporating elbow f1eXI° n' ^raining o f essential habit patterns o f m otion rented daily activity under supervision is essential r y n m D e r posture and gait and o ther activities. D aily Jvtition of transmission o f nerve impulses in a specific ttprn brings about gradual reduction o f synaptic resis- and the form ation of habits. H abits can become tanJe strongly fixed, as witness the signature by which verynle can be identified. In addition, therapeutic control Pf activity can eliminate substitution and overcome muscle • b a la n c e thereby preventing harm ful patterns leading to deformity.’ In many cases o f severe disability specialized devices are required fo r effective training in practical self- care, ambulation and other skilled activities. 3 Potential function in dorm ant neurons can be developed to an overt level for practical use. In upper m otor neuron lesions, for example, the anterior horn .cells and their axones to the muscles are all intact. The deficiency is in the corticospinal pathw ay to the spinal cord. Because a number o f other, extrapyram idal, pathways can also send impulses to the an terio r, horn cells, it is possible through therapeutic activity o f the neurom uscular mechanism to develop substitute pathways from the brain by means o f which many o f the dorm ant anterior horn cells can be excited to function. In this way, apparently zero muscles can be stimulated to sufficient activity so th at they can again serve a useful purpose. This fundam ental process by means of which another pathw ay in the central nervous system takes over the function o f one th a t is lost is called ‘C om ­ pensation.’ While this can and does occur to a limited extent spontaneously in m an, development o f com pensa­ tion mechanisms can be tremendously increased by effective therapy. Once the synaptic resistance is decreased suffi­ ciently and the dorm ant neurons can be excited in routine habit patterns, the restoration o f function becomes per­ manent. D etour pathw ays to dorm ant m otor neurons are also o f fundam ental im portance in poliomyelitis: While many anterior horn cells may be destroyed, others remain dorm ant, probably because o f dam age1 to the switchboard mechanism o f the internuncial neurons o f the spinal cord. It is now well established th at the corticospinal tract does not end directly on the anterior horn cells, but terminates on the internuncial neurons, which carry the excitation to the anterior horn cells.. Therapeutic activity o f the neuro­ muscular system can stim ulate these dorm ant m otor neurons and develop useful detour pathways through the inter­ nuncial switchboard to excite the anterior horn cells and restore them to useful function. Such dorm ant neurons for so-called ‘zero’ muscles have been restored to useful activity after as long as 40 years o f paralysis in cases o f both upper m otor neuron and lower m otor neuron lesions. This indicates th at while inactivity is a serious deleterious influence it is not in­ superable, and can be overcome by effective therapy after the lapse o f many years. 4. In patients who have been allowed to develop limitation o f jo in t m otion the contracture interferes with range o f active m otion and also with full utilization o f the remaining function o f the paralysed muscles at th a t joint. It also interferes with utilization o f natural patterns of m otion and development o f correct habit patterns. Full range of passive m otion may also be essential for certain activities even though the muscles at th at joint are com ­ pletely paralysed. W henever possible, it is preferable to develop range o f m otion th rough active m uscular exercise rather than passive stretching. However, passive stretching is frequently an essential element in therapy for rehabili­ tation and should be instituted early to prevent contracture. In late cases, if passive stretching fails, it may be necessary to resort to orthopaedic surgery to eliminate contracture. The basic process by which contracture occurs is o f considerable interest. It is now know n th at m any tissues o f the body are undergoing continual change with death o f some cells and replacement by new ones. Thus, the static structure o f skin and bone is based on a continuous dynamic process o f cell change and replacement. The same is true for connective tissue, which also apparently always assumes the extensibility which is applied to it in actual movement. In other words, contracture develops in m ost cases o f paralysis not by a pathological process of scarring but by the norm al process o f change in connective tissue, which is not m ade fully extensible by routine m otion. On the o ther hand, where injury and inflammation and edema are superimposed, as in fractures, scarring occurs in addition to develop contractures m ore rapidly. 5. A major factor in neurom uscular function in upper m otor neuron lesions is spasticity. Spasticity is based on hyperactive stretch and postural reflexes which are no longer held in check by the norm al inhibitory im­ pulses from the brain. This results in resistance to passive m otion and seriously interferes with voluntary contraction o f antagonists, both mechanically and through abnorm al influences on the nervous mechanism o f volitional move­ ment. I t also affects patterns o f movement and may en­ courage contracture and deformity. Spasticity may also ' cause insecurity in balance and gait and dim inish self-care. While drugs and sometimes surgery m ay be useful to relieve spasticity, one of the m ost im portant therapeutic procedures is neurom uscular activity. Relaxation o f spas­ ticity can be brought about through development o f power and active range o f m otion in the antagonists by a process o f reciprocal inhibition. Spasticity is decreased by devel­ opm ent o f com pensatory inhibitory pathways to replace the inhibitory action o f th e damaged corticospinal tract, in the sam e w a y 'th a t compensatory excitatory pathways can be developed to substitute for th e loss o f the voluntary m otor tract. Also, use o f natural patterns o f movement and training in correct habit patterns help to overcome spasticity. As im provem ent occurs, the greater relaxation o f the spastic muscles becomes perm anent and is m ain­ tained by th e habit patterns o f activity. Recently we have studied several other therapeutic measures which appear to be effective in diminishing spasticity. One is faradic stim ulation o f the antagonist. This is an application o f Sherrington’s experiment on the decerebrate anim al in which he showed th a t electrical stim ulation of the central end o f the cut nerve to the ham ­ strings brought about im mediate relaxation o f the spastic quadriceps. The faradic stim ulation is applied in com bina­ tion with passive m ovem ent through the entire range in diagonal spiral patterns. A nother reflex m ethod o f relaxa­ tion o f spasticity has been the use o f cold hydrotherapy. The application o f water at 50° F . for five minutes to the spastic foot and ankle has brought ab o u t relaxation o f the spasticity not only in the local area but also in the spastic muscles throughout th a t extremity. The mass flexion reflex o f th e lower extremity also helps to inhibit extensor spasticity. Because o f th e therapeutic value o f neurom uscular activity for restoration o f m otor function in praralysis, the quantity and types of m otor activity and their relative efficiency are o f th e greatest significance for rehabilitation. This is particularly im portant because recovery o f m otor function in cases o f paralysis is, at best, difficult and limited and takes a long period o f time. Since considerable activity is necessary merely to prevent or, m ore usually, to over­ come disuse, and a great deal m ore activity is necessary to bring ab o u t actual recovery o f function, it would seem desirable th a t the patient be active throughout the day to achieve the most effective recovery. This type o f intensive therapeutic program m e is carried out routinely at the K abat-K aiser Institute. Elsewhere, m any patients receive to o little activity in the course o f each day. Patients with poliomyelitis, for example, even m any m onths after the R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Ten P H Y S I O T H E R A P Y October, 1954. onset o f the disease, often spend practically all o f their time in bed and have therapeutic activity for at m ost an hour a day. This level o f activity w ould be insufficient to prevent disuse in m any o f the affected muscles. The lack of con­ fidence o f m any members o f the medical profession in this type o f therapeutic regime is understandable since the results are questionable, except for spontaneous im prove­ m ent and m aintenance o f range o f passive m otion. The main reasons given for this program m e o f limited activity are th at excessive activity and excessive fatigue are harm ful for paralysed muscles and th a t over-activity leads to inco-ordination and deformity. These argum ents stem from the concepts o f the past, before the recent rapid development o f neurophysiology. I t is obvious th at they do not take into account the trem endous im portance of disuse in deteriorating neurom uscular function. Also, this regime originated in a period when rest was held in much higher esteem as a therapeutic procedure than it is today. In recent years the dangers o f rest in bed have been em ­ phasized, and early activity and am bulation are accepted procedures following surgery, m ajor illness o r pregnancy. There is no rational basis for the argum ent th a t fatigue is harm ful in a properly regulated and supervised intensive neurom uscular rehabilitation programme. N eurom uscular fatigue is to a large extent central, occurring at synapses, and is rapidly and completely reversible. Intensive activity has been applied in thousands o f cases with no harm ful effects and with much m ore rapid recovery o f function th an with the program m e o f limited activity. In no instance has intensive! activity o f paralysed muscles caused anything but beneficial effects on the muscle and the neurom uscular mechanism. This is true not only for power, endurance and muscular hypertrophy but also for voluntary control and co-ordination as well as development o f correct patterns o f motion. Furtherm ore, the program m e o f neurom uscular activity must, to the greatest extent possible, be maximal activity. This has been the type o f program m e we have carried out a t the K abat-K aiser Institute, and contrasts with the usual therapeutic program m e. In m ost instances, the usual therapeutic program m e, in addition to being lim ited, in time, is also limited in intensity o f activity during that time. This older program m e is based on contraction o f isolated muscles in assistive m otion, progressing only very gradually to m otion against gravity and then against resistance. It is also based on avoidance o f stretch and of fatigue, with a large part o f the therapy time devoted to passive motion. In order to understand w hat is happening , in th era­ peutic exercise one must realize th a t the unit of function o f the neurom uscular system is the m otor unit, consisting of the anterior horn cell and a hundred or more muscle fibres which it innervates. This unit contracts ‘all or none’ or, in other words, it either responds in a maximal con­ traction o r does not respond at all. It is the excitation bom barding the anterior horn cells from higher centres and various reflex centres which determines w hether o r not an anterior horn cell will discharge and bring about an ‘all- or-none’ contraction o f its muscle fibres. In this mechanism the muscle fibres themselves function entirely autom atically and have no choice but to contract when the excitation reaches them through the m otor nerve fibre. The muscle fibres cannot even vary the strength o f contraction but merely can respond maximally. It is therefore ludicrous to talk about ‘muscle re-education,’ since the determining factors are all in the nervous mechanism and the therapeutic effects o f excitation o f m otor ne.urons result autom atically in m uscular hypertrophy. The focus o f the neurom uscular < re-education program m e m ust therefore be effective excitation o f the m otor centres rather th an concern for the muscle directly. In passive m otion no contraction o f m otor units occurs. In assistive m otion only a small percentage o f available m otor units discharge, since the stimulus to the anterior horn cells is very weak. Repeated assistive m otion excites only the sam e few anterior horn cells which have a low threshold o f excitation, causing contraction o f th e same small num ber o f m o to r units. W hat occurs, then, over a period o f time, is activity in a small p art o f the muscle, which is beneficial; but co m p lete' inactivity in the rest o f the available m otor units o f the muscle, which is harm ful because o f disuse. Because of the small proportion of total time spent in therapeutic activity and because a m ajority o f th e m otor units are kept inactive even during this activity, progressive disuse is frequently inevitable in spite o f this type o f therapy. In order to stim ulate every possible anterior horn cell o f a paralysed muscle in each effort maximal excitation is necessary. This, to us, is the desirable therapeutic approach. One obvious m ethod to increase excitation in the m otor centres is application o f resistance, and we use resistive exercises routinely. By applying maximal resistance it can be shown in electrom yographic studies th a t there is a trem endous increase in the action potential o f the con­ tracting rfiuscle, indicating a m arked increase in th e num ber o f discharging m otor units. We have w orked out technical procedures by which m anual resistance can be applied even to so-called ‘zero’ muscles with great benefit. U tilization o f resistance as a therapeutic tool is o f ‘ great significance, since this procedure harnesses one o f the most fundam ental mechanisms o f the neurom uscular system. Muscle tissue itself responds to increased length and tension by greater contraction. This is true for all muscle and is the basis for Starling’s ‘Law o f the H eart,’ by which the heart muscle performs m ore w ork when it is under greater tension. The same principle is applicable to skeletal muscle through a powerful neurom uscular mechanism. R esistance stimulates afferent proprioceptive discharges into the central nervous system, which greatly increase excitation at m otor centres and thereby excite m any additional m otor units. In fact, this mechanism is o f great im portance in all voluntary m otion, since it autom atically ensures the correct pow er o f m uscular con­ traction, adjusting quickly w ithout conscious effort to the weight to be lifted. G ellhorn has shown th a t resistance is effective in increasing the muscular contraction resulting from electrical stim ulation o f the m otor cortex in the monkey, through the increased excitation brought about by this pro­ prioceptive facilitation mechanism. Resistance is powerful enough to increase excitation in the monkey’s m otor cortex sufficiently so th a t a subthreshold cortical stimulus can cause muscular contraction. This experiment is com ­ parable o t our application o f resistance to facilitate con­ traction o f so-called ‘zero’ muscles in patients with paralysis. A nother tenet o f the widely accepted routine is careful isolation of contraction to a single muscle in therapeutic exercise. Any spread o f the contraction to other muscles is considered harm ful and the therapist attem pts to eliminate it. Such spread o f excitation is called “ substitution’ or ‘incoordination.’ We regard this approach as unsound physiologically and have discarded it entirely. I t should be pointed out that in every day activities we practically never use a single muscle in voluntary m otion, but rather use complex patterns o f m otion including the prim e mover, th e synergists and the fixating muscles as well as contraction in more distant muscles for com pensating changes in posture, &c. A pplication o f resistance autom atically prevents contraction o f a single muscle since it brings ab o u u t greater excitation in m otor centres with spread o f excitation o r ‘irradiation’ in specific patterns o f synergistic muscles. It is therefore obvious th at isolated muscle contraction is incom patible with maximal excitation o f the neurom uscular mechanism, and maximal activity is to be preferred. The attem pt to isolate activity to single muscles is based on the misconception th at spread o f excitation to other muscles is evidence o f ‘incoordination’ and is abnorm al and harm ful. T he truth o f the m atter is th a t irradiation in patterns is a basic characteristic o f the norm al neuro­ muscular mechanism, which is applicable no t only to R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) October, 1954. P H Y S I O T H E R A P Y Page Eleven voluntary m otion but also to reflexes, and was well des­ cribed by Sherrington. As excitation increases with greater resistance, irradiation occurs autom atically and brings in additional muscle groups to p e rfo rm , the greater am ount of work required. This is another example o f the im portant autom atic mechanisms which are essential in so-called ‘voluntary movem ent.’ There is considerable scientific evidence for the funda­ mental nature o f mass movem ent patterns in the functioning of the neurom uscular system. Coghill concluded, from investigations on the development o f am blystom a, that the earliest movements are perfectly integrated total patterns, within which partial patterns later arise as the basis for more discrete movements. In the hum an newborn and develop­ ing infant, co-ordinated mass-movement patterns are also prom inent in m otor behaviour. In m any activities in heavy work and sports, certain diagonal spiral patterns are applied routinely by people all over the world. These are evidently natural patterns o f m otion based on the patterns of anatom ical distribution o f synergistic muscles and on the associated patterns o f proprioceptive facilitation. Examples include the- patterns evident in chopping wood, playing golf, tennis, using a scythe, throwing a ball, using a shovel, &c. Also, G ellhorn has shown th at a threshold electrical stimulus applied to a single excitable point on the m otor cortex o f the monkey produces contraction in a synergistic pattern o f muscles throughout an extremity rath er than in a single muscle. Since a threshold stimulus is the minimal stimulus necessary to excite the cortical focus a t all, wide­ spread contraction cannot be attributed to spread o f the electrical stimulus over a wider area o f the cortex. We have shown in therapeutic exercise in patients with paralysis, and G ellhorn has shown independently in experiments on electrical stim ulation o f the m otor cortex in the monkey, th at stretch and resistance in mass movement patters have a powerful facilitating effect on the m otor centres. We have therefore discarded isolated motion, and routinely apply resistance in diagonal spiral mass-movement patterns or com binations o f mass-move- ment patterns for greater facilitation o f the m otor centres and greater excitation o f the m otor units. M anual resistance has also been used in m at w ork in primitive total body patterns. In other words, instead o f worrying ab o u t the natural process o f irradiation and considering it harm ful, we not only allow it to occur but harness it as a powerful facilitating mechanism to accelerate recovery o f neuro­ muscular function. In addition to the advantage afforded by the facilitation from resistive exercise in mass-movement patterns for the excitation o f a greater num ber o f m otor units in the paralysed muscles, these techniques also allow (the activity o f many muscle groups at one time. This greatly increases the economy o f utilization o f the physical therapist’s time, and thereby the practical effectiveness o f the rehabili­ tation programme. Besides m anual resistance, resistive exercise in mass- movement patterns is perform ed in the gymnasium with pulleys and dumb-bells, and anti-gravity exercise in total body patterns is carried ou t by the patient him self under supervision on mats. Resistive exercise in mass-movement patterns has also been applied successfully in occupational therapy. Stretch o f the muscles can also be used for proprio­ ceptive facilitation in accelerating restoration o f m otor function. I t was found that, particularly in flaccid paralysis, contraction o f paralysed muscles in the stretched range was more effective. N o t only stretch o f the prim e mover but also stretch o f other muscles in the mass-movement pattern helped to facilitate the response. This facilitation mechanism was also dem onstrated by G ellhorn in experi­ ments on electrical stim ulation o f the m otor cortex in monkeys. R ather than avoiding stretch o f paralysed muscles, as in the old treatm ent routine, we use stretch as a standard technique o f proprioceptive facilitation. V arious reflexes which we have used as facilitation tech­ niques in treatm ent o f paralysis include: the mass flexion reflex o f the lower extremity (von Bechterew); the tonic neck reflexes; the grasp reflex; th e positive supporting reaction; balancing reflexes; the gag reflex, and others. T raining in balancing illustrates the role of reflexes in facilitation. Applying maximal resistance in one direction at a time, the standing patient attem pts voluntarily to prevent being pushed off balance. But in the process powerful balancing reflexes are stim ulated which facilitate the voluntary m otor response so th at ‘zero’ muscles may be excited. In addition, there is undoubtedly facilitation, by the voluntary resistive exercise, o f the balancing reflexes themselves, just as the knee jerk is facilitated by clasping the hands and pulling ap art strongly (the Jendrassik m an­ oeuvre). In other words, both the reflex and the voluntary m otion, which are closely interrelated, are facilitated in the resistive exercise. ■ This procedure also accelerates training o f the balancing patterns fo r standing, which are o f immediate practical value for am bulation. This tech­ nique has been applied for standing balance, standing balance with crutches, braces, &c., sitting balance, and kneeling balance. A nother im portant mechanism for facilitation in therapeutic exercise is the alternate voluntary contraction o f antagonists against resistance. This is based on Sherring­ to n ’s principle o f ‘successive induction.’ H e found that, im mediately after stim ulation o f the flexor reflex, the ex­ tensor centre was hyperexcitable. This principle is used for greater power in a variety o f everyday activities, such as pitching in baseball, chopping wood, boxing, using a scythe, &c., in which the antagonist m otion is carried out immediately preceding the main m otion in a continuous sequence. We have applied this principle o f facilitation by isotonic alternation o f antagonists against resistance, as well as by isometric alternation o f antagonists against resistance (which has been designated ‘ryhthmic stabiliza­ tion’). These techniques are particularly helpful when the agonist is paralysed, but the antagonist is relatively un­ involved. The close relationship.of antagonist muscles to muscular relaxation was dem onstrated by Sherrington in experiments on ‘reciprocal innervation.’ D uring contraction o f the agonist, the antagonist is relaxed. Also, the stronger the agonist contraction the greater is the inhibition o f the antagonist. We have applied this principle to facilitate inhibition o f spasticity. F o r example, in relaxation o f a spastic hip adductor the technique is as follows: voluntary contraction o f the hip adductor pattern against maximal resistance in the stretched range, then voluntary relaxation o f the adductor, followed immediately by voluntary con­ traction o f the hip abduction pattern against resistance. In this technique direct relaxation and reciprocal inhibition are applied simultaneously to the spastic muscle. Also, proprioceptive facilitation is employed to enhance the inhibitory effect. This procedure is much m ore effective in reduction o f spasticity than the usual relaxation methods. F o r maximal excitation all o f the facilitation tech­ niques m ay be com bined and used simultaneously. Thus, rhythm ic stabilization m ay be applied, using maximal resistance in a mass-movement pattern emphasizing the stretched range o f the paralysed muscle groups. In this way we apply the principle o f ‘sum m ation’ of excitation, which is one o f the fundam ental principles o f activity of the m otor centres established by Sherrington. It must be emphasized that these techniques require great skill on the p art o f the physical-therapist, and that at least several m onths o f specialized training is necessary for successful application of proprioceptive facilitation therapy. Also, these methods require close medical super­ vision by specially trained physicians. Only expert indi­ vidual physical therapy with proprioceptive facilitation can develop the full potentialities o f ‘zero’ or severely paralysed muscles. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Twelve P H Y S I O T H E R A P Y October, 1954. Techniques o f propioceptive facilitation are particu­ larly advantageous for neurom uscular rehabilitation of infants and young children. In such cases co-operation in the usual therapy program m e is extremely difficult. On the other hand, m uch better co-operation acn be obtained in proprioceptive facilitation therapy, using primitive total body patterns on mats, balancing reflexes, stretch in mass-movement patterns, tonic neck reflexes, &c., for facilitation along with m aximal resistance. T raining o f such children, who have never stood or w alked before, in ambulation with braces and crutches is also accelerated by these techniques. Recently, we were able to give daily therapy successfully, beginning at the age o f six weeks, to a child with paralytic poliomyelitis affecting the right arm and leg. Obviously, voluntary co-operation was im­ possible at this age, but reflex patterns o f movement resulted in significant im provement. I t is therefore possible, with these new m ethods, to begin effective therapy at an earlier age in cases o f poliomyelitis, cerebral palsy and other types of paralysis in infants, with beneficial results. Techniques of proprioceptive facilitation can not only be helpful in restoring pow er and endurance o f paralysed muscles, but can also accelerate the training of m otor skills. Training depends on the form ation o f functional pathways in the central nervous system through gradual reduction in synaptic resistance. Synaptic resistance is undoubtedly reduced m ore rapidly as a result of the strong excitation in the m otor centres produced by proprioceptive facili­ tation. We have had extensive experience in training o f patterns o f balance against resistance. A pplication o f proprioceptive facilitation for a variety o f self-care activities, such as getting out o f the wheelchair to stand on long leg- braces, moving from bed to wheelchair, dressing, feeding, &c., has also accelerated training o f such skills in patients with paralysis. These m ethods are also applicable for ■ correction of posture, including suitable scases o f paralytic scoliosis. While proprioceptive facilitation therapy has been applied originally and most extensively to rehabilitation of paralysis these m ethods have dem onstrated their value in many non-paralytic conditions. We have had considerable experience in the use o f these techniques in the treatm ent o f traum atic arthritis, hypertrophic arthritis, chronic rheum atoid arthritis and chronic bursitis, chronic backache, and follow-up treatm ent of fractures and other injuries. Proprioceptive facilitation therapy has been applied follow­ ing such surgical procedures as arthroplasty, release of contracture, tendon transplantation and other operations, an d in the majority o f these cases the im provem ent in range of m otion, power and endurance o f the muscles, and relief of spasm and pain has been much better than w ith the usual therapy m ethods. F o r successful results a careful prescription of the correct procedures o f proprioceptive facilitation therapy is essential. Proprioceptive facilitation is not necessarily limited in its application only to neurom uscular therapy. It should _ also prove to be of value in accelerating th e training of many types of m o to r skills in norm al individuals. These methods are just as applicable to norm als, since they harness fundam ental functional mechanism s o f the neurom uscular system. Indeed, th e response should be m uch better in the norm al than in the patient with serious perm anent dam age to the m otor centres. We have found these tech­ niques useful in correcting habit patterns o f posture and gait in norm al children and adults. We may, perhaps, be able in the future, by applying proprioceptive facilitation, to accelerate m otor learning and create superior skill in such diverse activities as typing, writing, playing the violin, driving a car, playing tennis, or ballet dancing. GENERAL A letter has been received from the M inister of H ealth informing the Society th a t he intends introducing a Supple­ mentary H ealth Services Bill at the next session of P arlia­ ment. + + + The Society is having Christm as cards printed with the badge on the front, and a C hristm as and New Year greeting in English and A frikaans on the inside. These are available on application to th e Secretary, P.O. Box 11151, Johannesburg, Price 6 / - per dozen, including envelopes. + + + A private practitioners group is being planned, for members o f the Society only, to exchange ideas and p ro b ­ lems which may affect this group in particular. Will those interested please write to M r. M. D . Oliver, R oom 33, Adderley H ouse, 80, Adderley Street, Cape Town. The metal badges o f the Society are now ready. They are made o f sterling silver and are about 1-in. x ^-in. in size, w ith the pattern in royal blue and silver. Members o f the South African Society o f the Physiotherapists are the only people entitled to w ear this badge. I f members wish to buy one, price 1 0 /- each, they m ust subm it their names together w ith th e money, to their local Branch Secretary. T H E SO CIETY N O W HAS A BOX N U M B E R T O W H I C H A L L C O R R E S P O N D E N C E S H O U L D BE A D D R E S SE D . IT IS : P.O. BOX 11151, JOHANNESBURG. PLEASE TA K E C A R E F U L N O T E O F THIS. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )