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THE COMMON FACILITATORY AND INHIBITORY TREATMENT TECHNIQUES It is of great challenge for physical therapist to select methods most

efficient for each patient's needs. Appropriate selection of the treatment methods depends upon the :understanding of many aspects, such as 1) 2) The neuro-physiological bases of each method. The biomechanical influencing of the treated body part(s), segment(s), or body as a whole on the applied method, and the mechanical effect of the intervention on the treated part. 3) The nature of pathology and symptoms affecting the patient's activity. 4) The individual characters of each patient. To initiate a movement response we should try to increase the neuronal activity (it refers as facilitation) or to decrease the capacity to initiate a movement response we should try to decrease the neuronal activity (it refers as inhibition) The sensory stimulation technique can be used separately or grouped according to the receptors activated, the nature of stimulation (intensity, duration and frequency) need to be adjusted and readjusted to meet the individual needs of the patient. The techniques commonly used are classified according to the type of sensory receptors activated. The common facilitatory techniques are: 1) Proprioceptive stimulation techniques. 2) Extroceptive stimulation techniques. 3) Vestibular stimulation techniques. 4) Special senses ( vision, hearing, smell and taste ) stimulation techniques. 5) Multi-sensory stimulation techniques. 6) Autonomic nervous system stimulation techniques.

Proprioceptive stimulation techniques: a) Stretch: May be applied in three ways; quick, prolonged, and maintained stretch. Application of this technique may include tapping which is commonly used in three forms; on tendon, on muscle belly and with the use of gravity. It is used in preceding passive movement. The quick stretch produce a relatively short lived contraction of the agonist muscle and short lived inhibition of the antagonist muscle. Prolonged and firm stretch produces inhibition of muscle responses which may help in reducing hypertonus, e.g. Bobath's neurodevelopmental technique, inhibitory splinting and casting technique. The maintained stretch, resistance can be applied manually or mechanically or by using of gravity and body weight. Resistance facilitates muscle contraction which is directly proportional to the amount of resistance applied. Improving kinesthetic awareness and increasing strength are another two benefits gained from resistance. b) Vibration:May be applied in two ways; high and low frequency. The high frequency vibration is driven from vibratorthat optimally operates at a frequency of 100 200 Hz and at amplitude of 1 2 mA. This type of vibration produce facilitation of muscle contraction through what is known as tonic vibration reflex. This facilitatory effect sustained for a brief time after application. Therefore it can be used for stimulating muscles whose primary function is one of tonic holding. The low frequency stimulation 5 -50 Hz has an inhibitory effect on muscle through its activation of spindle secondary endings and golgi tendon organs. C) Approximation or compression of the joint surfaces: facilitates posture extensors which are needed to stabilize the body. Approximation can be applied slowly to inhibit muscle control or in jerky manner to facilitate muscle control. The application may be manually and/or by using weight bearing postures. Joint awareness may be improved by approximation which will lead to enhancing motor control. d) A firm and moderate inhibitory pressure on tendons: may result in inhibition of muscle control. It can be applied manually and/or through devices such as splints.

Positioning may be used to achieve an inhibitory pressure, e.g. quadruped position to inhibit the quadriceps muscle and the long finger flexors of the hand. Exteroceptive stimulation technique a) Touch: Is one of the simple ways of facilitation of muscle activity by eliciting the phasic, protective withdrawal reflexes. This reaction maintained for several seconds after discharge. The location of the stimulus and its intensity play the important role in the magnitude of reaction. Application of the touch m can be manually using brief, light stroke, brief swipe ice cube, noxious stimulus and/or light pinching. b) Brushing: As a therapeutic technique presented originally by Margeret Rood to facilitate movement responses. Application can be manually or by using battery-operated brush. Skin overlying muscle can facilitate it and enhances static holding postural extensors and will have immediate and long latency responses. c) Icing for a long period: (more than 20 min0 can inhibit muscle activity, postural tone (locally). Application of the prolonged ice can be used clinically by four types; ice chips, ice wraps, ice pack and immersion in cold water. d) Neutral warmth: It is one of the most common way to inhibit postural tone and muscle activity. It acts through stimulating the thermo receptors and activating of parasympathetic responses. Usually 10-20 minutes are sufficient period to produce effect. The application may be by wrapping body part with towels, hot packs, tepid baths and air splints. e) Maintained touch: It can be used to produce a general calming effect and generalized inhibition. Firm manual contacts (pressure0 to midline abdomen, back are the common used techniques. f) Slow stroking: It Is another technique used to produce a generalized calming effect by activation of ANS. It may be applied by using a flat hand over the paravertebral muscles from cervical to sacral regions.

The generally calming effect can decrease muscle tone. 3-5 minutes are a sufficient period to produce effect. g) Manual contact: Itis one of the most success technique to facilitate motor control. A manual direct firm contact over the desired muscles is the used technique. Vestibular Stimulation Technique The vestibular stimulation technique is a proprioceptive unique sensory system with multi-sensory function. According to the type of stimulus we can use the vestibular system to achieve many treatment alternatives. Total body inhibition can be achieved by slow rocking, slow anterior-posterior movement, slow horizontal movement, slow vertical movement and slow linear movement. Total body facilitation can be achieved by rolling patterns, a rocking pattern on elbows and extended elbows and crawling. Also spinning induces tonal responses and causes a strong facilitation of movement through the overflow of impulses to higher centers. A facilitation of postural extensors is another effect of vestibular stimulation if it is used by a rapid way anterior-posterior or angular acceleration of the head and body while the child in prone position. The inverted position is commonly used now to achieve a total body inhibition, while it may be used to increase to in certain extensors. Special Senses Stimulation technique Visual system: May be used to produce a decrease or an increase in firing of sensory afferent fibers and have an overall effect on CNS excitation. Cool colors, a darkened room and monotone color schemes all tend to have an inhibitory effect on muscle tone, a calming mood and generalized inhibitory response. On the other hand a facilitatory effect can be gained by intermittent visual stimuli, bright colors, bright light and a random color scheme. If the sensory component of the tactile, proprioceptive or vestibular system has been lost or severely damaged the visual stimulus may consider an effective alternative. b) Auditory system stimulation : As a treatment technique depends on the quality, quantity and effect of voice. The therapist's voice can be considered a very important therapeutic tool to produce a facilitatory or inhibitory response on muscle tone and activity. The same effect may be gained by music. Auditory biofeedback is a very important and famous therapeutic modality which depends on intact auditory system.

C) Olfactory system : May be used as a treatment modality especially during feeding procedures. Some odors such as vanilia and banana may be used to facilitate sucking movement. Withdrawal patterns can be facilitated with ammonia and vineger. Therapist should use olfactory system as a treatment technique under restricted precautions because its arousal and emotional effect. Multi-Sensory Treatment Techniques Multi-Sensory Treatment Techniques is the most common type of procedures used by therapists, who may concentrate on one target but more than one or two sensorysystems will work simultaneously. For example, tapping is akind of stimulation primarily can consider as a proprioceptive in origin but exteroceptive sense will work automatically. So facilitation of muscle activity will originate from two origins the proprioceptive stimulus through the afferent activity within the muscle spindle and the reflemechanism coming from the tactile receptors. Another example, any exercise including head and body movements in space The vestibular system and proprioceptive receptors will be fired simultaneously and influencing the muscle activity. Also, when therapist talk to the patient and demonstrate the exercise for him by any means or correct his performance, this means are auditory, visual, vestibular, tactile and proprioceptive stimulation working together. Autonomic nervous system stimulation technique Study of the interconnections between the ANS and CNS have lead the clinicians and therapist to know viable treatment approaches that depend on both systems. Both systems must react and work in integrated manner at appropriate intensities. should- according to that differentiate between hypertonicity and disturb movement created by emotional stresses which may lead to ANS reaction versus disorders resulting from CNS damage. There are four treatment procedures can be used to affect on movement and muscle one throughout ANS reaction which normally produce a parasympathetic response:

1) Slow stroking over the paravertebral areas will cause inhibition. 2) Inverted tonic labyrinthine therapy. 3) Slow, smooth, passive movement within pain free range. 4) Maintained deep pressure on the abdomen, palms, soles of the feet, peroneal area, and skin rostral to the top lip may cause a reduction of tone or hyperactivity.