Neurophysiotherapy

[omphysiotherapy]

Dear All
I would be grateful if anyone could please reply asap.
How would you describe tapping technique ? How effective it is? what position would you use of hands and how much force would you apply to facilitate muscles(gluteal/ quadriceps)? (For Stroke patient , while encouraging sit-stand).

thanks

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[gcoe]

Hi omphysiotherapy

tapping is one of a number of facilitation techniques proposed by Margaret Rood. this technique is aimed at exciting a muscle contraction. The way I learnt it was to tap directly over the muscle immediately preceding and during an attempt at voluntarily contracting the muscle.

The physiological basis for the technique is that tapping provides quick stretch to the muscle spindles thereby stimulating the monosynaptic stretch reflex and if you are lucky you get a contraction in the same muscle.

From a learning point of view the key is Pavlovian conditioning - that is the unconditioned stimulus is the stimulation of the stretch reflex and the unconditioned response is the muscle contraction. The conditioned stimulus is an instruction to the patient to contract the muscle who then attempts to contract the muscle and you pair the two stimuli together in hope of developing a conditioned response - the patient becoming able to contract the muscle voluntarily eventually without the unconditioned stimulus.

How much force to use? I don't know if this has ever been really agreed on. You can get the effect in the normal nervous system but you need to use quite a lot of vigour and you need to do it at fast rate to mimic a tetanic contraction. Try it yourself: with your forearm pronated on a table with the wrist and hand hanging relaxed in flexion over the edge of the table , tap vigorously and rapidly over the wrist/finger extensors. If you have adequately brisk reflexes you will get and involuntary concentric/static contraction. But you will have to apply quite a lot of force (can actually hurt a bit). Presumably in the patient with upper motor syndrome because the reflexes are more hyperactive you can get the effect often with much less force - so it is more comfortable to do.

Is it effective? To my knowledge there are not clinical trials of any quality that demonstrate the technique is effective. Neuro-facilitation techniques in general have not been shown to be particularly effective. James Gordon commented on this by saying (not a direct quote): It is easy to get facilitate a muscle contraction. But that isn't the problem. It is getting the patient to contract the muscle appropriately within the context of a functional movement that is the problem.

Do I use it personally? As a technique it keep it hidden in my bag of tricks. I think the more techniques you have in your bag of tricks you have something to offer when more evidence-based techniques fail to work. Occasionally when I am not getting a response I want it can be a useful thing to help the patient identify what to contract but it needs to be contextualised in relation to the motor task being worked on. One advantage is that it is quick to apply and requires no equipment so you just try it and if it works fine and if it doesn't try something else.

A more evidence-based option would be using FES. The disadvantage of FES is the need for intact pain sensation, the fiddling around to apply it, patient acceptance etc. But it often is worth the effort if you really aren't getting much contraction. And FES and FES+EMG really does have good evidence, for eliciting contractions strengthening and improving function.

So in your case of working on sitting to standing getting the patient to identify the quadriceps or glut max that they need to contract during the extension phase of standing up, you could use the tapping. However getting the patient to practice the task in a meaningful way and get in plenty of challenging trials, working on building capacity (strength of the muscles within the context of standing up) is far more important.

Sorry for the long winded answer but these things are worth exploring properly.