CHA PTER

22 Rood's Approach
Divya Midha

HISTORY
Using the words of Miss Rood (1966) "The
following hypothesis is an attempt at a
brief total concept of the reactions of the
body which might affect the evaluations
of patients and the clinical application
of therapy: Her approach deals with the
activation or de-activation of developing
somatic, autonomic and mental functions
(Fig. 22.1).
An approach for the treatment of
neurological dysfunction was proposed
by Margeret S Rood in the year 1950.
Margaret S Rood was formally educated Fig. 22.1: Margaret Rood.
in occupational and physical therapy. Her
theory originated in the 1940s and underwent many revisions before
she died. The work of Margaret Rood evolved from developmental
and neurophysiological literature of 1930s. Because of this literature,
it was believed that motor output is dependent upon sensory input,
motor response follow a normal developmental sequence and
psychic, somatic, and autonomic functions are also interrelated.
Rood's basic assumption rested upon the belief that motor
functions are inseparable from sensory mechanisms. Therefore,
sensory factors and their relationship to motor functions assumed
a major role in the analysis of dysfunction and in the application of
this treatment.
In the Roods approach, muscle groups are categorized according
to the type of work they perform and their responses to the
specific stimuli. Light work refers to the movement with reciprocal
inhibition of antagonist muscles. This may occur in voluntary
120 Advanced Techniques in Physiotherapy and Occupational Therapy

movement or autonomic nervous system action. The light work

muscles (mobilizers) are primarily the flexors and adductors used
for skilled movement patterns. Heavy work is defined as holding or
co-contraction of muscles that are antagonists in normal movement
and that are used to provide a stable support to the joint in a fixed
position. The heavy work muscles (stabilizers) are principally the
extensors and abductors used for postural support. Some muscles
perform both light and heavy work functions.
Using these concepts of light and heavy work, Rood outlined the
normal developmental sequence by using the following order of
activation of muscles groups.

STAGE: RECIPROCAL INNERVATION OR MOBILITY

It is reciprocal and alternate movement of the limbs through full
range while fully supported in the supine, roll over and prone
positions. For developing voluntary movement control, the reflex
activation of movement patterns is done via reciprocal innervations
of the joints till the control is developed without reflex, e.g. stroking
at palm of the hand or sole of the feet promotes crossed movement
of extremities over anterior surface of body. Rood called it as supine
withdrawal and she implemented it for the treatment of patients who
had extremities dominated by the extension.

STAGE-I: COINNERVATION OR co-cONTRACTION

Defined as simultaneous contractions of antagonists and agonists,
working together to stabilize and maintaining posture of the body,
e.g. maintaining posture of neck by co-contractions, prone on
elbows, all on fours and standing. Neck and head contraction can
be achieved by placing the patient in prone lying position on the bed
or supporting surface with head and neck hanging down without
support over the edge down towards the floor. Any visual or auditory
stimuli can be given or any activity can be provided for promoting
head righting. Co-contraction should be avoided in severe head
injury cases.

STAGE-Il: HEAVY WORK-MOVEMENT

SUPERIMPOSED ON MOBILITY
It is defined as movement of proximal limb segments with the distal
ends of limbs fixed on the base of support. It includes weight shifts
 Rood's Approach 121

on the floor, e.g. partial weight shifting in prone on elbows, all on

fours, to and fro rocking that later on can be promoted to crawling
in different directions. Weight shifts also make an individual to be
prepared for the equilibrium responses. Mobility superimposed on
stability is achieved by heavy work muscles or proximal muscles,
i.e. deep tonic extensors of neck and trunk, scapular muscles, pelvis
(abductors and external rotators), etc. Heavy work muscles are
mainly composed of red fibers (aerobic), run obliquely, have rich
blood supply with low metabolic cost. However, concept of mobility
superimposed over stability is yet controversial as some studies state
that proximal and distal controls develop separately, e.g. in case of
upper extremity fine motor skills can be developed separately even
without scapular stability.

STAGE-IV: SKILL
Skilled work with emphasis on the movement of distal portions
of the body that requires control from the highest cortical level. It
is produced by the light work muscles. Light work muscles are
responsible for carrying out phasic movements, i.e. repetitive or
rhythmic patterns of distal musculature. They are composed of white
fibers (anaerobic) and have high metabolic cost. They are primarily
adductors, flexors and internal rotators.
Along with the concept of light and heavy work in the
developmental sequence, the Rood approach identified two major
sequences in motor development that are distinctly different, but
inseparable due to their interaction. The two sequences are those of
skeletal functions and vital functions. The skeletal functions include
activities of the head, neck, trunk, and extremities while the vital
functions include vegetative, respiratory, and speech activities.
Rood also believed that a voluntary motor actis based on inherent
reflexes and on modification of those reflexes at higher centers.
Therefore, she begun therapy by eliciting motor responses ona
reflex level and incorporating developmental patterns to enhance
the motor response.
Stimulation of the sensory receptors is done in the sequence of
normal development from the most primitive reflexes to the skill
level. The purpose of treatment is to restore that component in the
sequence in the manner in which would be normally acquired.
Therefore, the Rood approach to treatment is proposed to be
applicable to any type of neurologic dysfunction at any age.
122 Advanced Techniques in Physiotherapy and Occupational Therapy
SEQUENCE OF GROss MOTOR DEVELOPMENT
1. Supine Withdrawal
Description: Flexed posture, heavy work of trunk, neck and all the
proximal joints, reciprocal innervation, movement occurs towards
t10 vertebra (Fig. 22.2).

Fig. 22.2: Supine withdrawal.

2. Roll Over
Description: Flexion of upper and lower extremities, phasic move-
ment pattern (Fig. 22.3).

Fig. 22.3: Roll over.

3. Pivot Pattern
Description: Total extension and bilateral holding of proximal
extensors, reciprocal innervation pattern (Fig. 22.4).

Fig. 22.4: Pivot pattern.

Ceygtedateril
 Rood's Approach 123

4. Co-contraction Neck
Description: Co-contraction of neck extensors, thoracic extension
(Fig. 22.5).

Fig. 22.5: Co-contraction neck.

5. Forearm Support
Description: Scapular co-contraction, glenohumeral joint co-
contraction (Fig. 22.6).

Flg. 22.6: Forearm support.

6. All on Fours
Description: Weight bearing on both upper limbs and lower limbs.
Weight shifts forward-backward, sideways (Fig. 22.7).

Fig. 22.7: All on four.

124 Advanced Techniques in Physiotherapy and Occupational Therapy

7. Standing
Description: Static weight bearing on bilateral limbs (Fig. 22.8).

Fig. 22.8: Standing.

8. Walking
Description: Dynamic weight bearing on both the lower limbs (Fig.
22.9).

Fig. 22.9: Walking.

Copyighted material
 Rood's Approach 125

MUSCLE TONE
Muscle tone involves active tension and passive (resting) intrinsic
viscoelastic tone. Human resting tone was defined as passive tone/
tension of the skeletal muscle that derives from intrinsic viscoelastic
properties, i.e. resting muscle tone is viscoelastic stiffness without
contractile activity.
Any neurological insult is associated with wide range of tone
abnormalities with which execution of any movement becomes
difficult. Two commonest tone abnormalities associated with
neurological disorders is hypertonicity and hypotonicity.
Hypertonia is a condition in which there is increased muscle
tone. Arms, legs or any affected part becomes stiff and offers
too much resistance against movement on passive elongation.
Abnormal high tone causes malalignment of the trunk and limbs.
Excessive shortening of muscles may cause a joint to become
frozen and subsequent deformity thus interfering with the ADLs,
e.g. if hypertonia affects lower limbs, walking becomes difficult as it
becomes difficult for the body to react quickly to regain balance.
Hypertonicity or high tone is increased resistance to the passive
elongation of the muscle. It causes greater impairment, worst
function; low health related quality of life. In addition to increased
rest activity, abnormal patterns of muscle activation such as spastic
co-contractions may contribute to disability.
Hypotonia is described as reduced resistance to passive range of
motion in joints. A hypotonic muscle lacks ability to sustain postural
control and movement against gravity. Such patients exhibit poor
control of movements and delayed motor skills.
Primary goal of treatment for patients with neurological
dysfunction having tone abnormalities is "normalization of tone'
Goal can be achieved completely through various sensory inputs for
eliciting muscle contraction or inhibiting muscle tone.

ROODS TREATMENT TECHNIQUEs

Every patient has different characteristics so it is a great challenge
for the physical therapist to select methods most efficient for each
patient's needs. Appropriate selection of the treatment methods and
techniques depends upon the understanding of many aspects, such
as:

Conygted mato l
 Rood's Approach 127

interfere with the cardiorespiratory functions such as slowing down

of heart rate, constriction of bronchial muscles with activation of
smooth muscles. It should also be avoided over lower lumbar area
at the level of $2-S4 as it may induce bladder dysfunction causing
urination.
Thermal Stimulation
Thermal stimulation by means of icing was developed by Rood for
eliciting motor patterns. Rood used repetitive stimulus with the help
of an ice cube. Ice cube is rubbed with pressure for 3-5 seconds
in the form of quick swipes. Once the stimulus is given initially it
may develop a phasic withdrawal reflex. It causes stimulation of
exteroreceptors and propioceptors and also a brief cortical arousal
due to activation of reticular activating system. Two different types
of icing are A-icing and C-icing based on the type of fibers needed to
be stimulated.
A-icing: A-icing is done by means three quick strokes done with an
ice cube over palm of the hands. Sole of foot or dorsal surface of the
hand to evoke flexor response of the limb generating withdrawal
reflex. Many researches have been done on the facilitatory responses
generated by means of A-icing. Stimulation of the diaphragm and
muscles of inspiration by application of the icing along the rib cage at
T7-T9 level, touching the lips stimulates mouth opening, application
of ice to the tongue facilitates mouth closure. Swallowing can also be
initiated by application of quick ice strokes over sternal notch.
C-icing: C-icing is also done with the help of an ice cube but stimulus
is relatively of high threshold than the A-icing. It is accomplished by
placing and keeping the ice cube onthe targeted area for 3-6 seconds.
It causes activation of the C-sensory fibers. Icing is contraindicated
in the distribution of posterior primary rami along the lower lumbar
area as it may cause sympathetic nervous system fight and flight
response. Icing is also contraindicated in patients with circulatory
disturbances, e.g. Reynauld's phenomena. Icing should be avoided
in the hypersensitive areas like pinna of the ear as it may induce
vagal responses along with the cardiorespiratory disturbances. It
should also be avoided over areas like forehead, upper portion of lips
and midline of trunk as there is higher concentration of pain fibers
over these areas.

Cepyg ted materal

128 Advanced Techniques in Physiotherapy and Occupational Therapy

Quick Stretch
Quick stretch is administered for initiating muscle contraction. Itis
administered by providing submaximal stretch to the targeted muscle
by keeping it in a maximally lengthened position. Excessive stretch
should not be given as it may cause pain and cause withdrawal of the
extremity. It can also be applied by the therapist by keeping fingertips
to vigorously tap the skin over muscle or tendon while patient attempts
to do the movement. Quick stretch is given via low threshold stimulus
that activates immediate phasic response by activating stretch reflex
facilitating agonists and inhibiting antagonists, producing a very short
contraction or movement via la fibers of muscle spindle.
Vibration
High frequency vibration can be applied by a mechanical or an
electrical vibrator over the muscle belly or over muscle tendon
over a slightly stretched muscle. Though some researchers say that
application of vibration stimulus over muscle tendon may cause
unnecessary activation of the undesired muscles of surrounding
areas. Excursion of such device is up to the depth of 1-2 mm.
Vibration causes stimulation of la fibers of the muscle spindle, also
providing repetitive mechanical stretch to the muscle fibers known
as tonic vibratory reflex. Effect of vibration lasts for 30-60 seconds as
long as stimulus is applied. Duration of the stimulus should be kept
for 1-2 minutes longer than this duration can cause heat and friction
causing potential tearing of the underlying skin.
Lot of researches has been done to find out the appropriate
frequency of vibration stimulus for getting desirable response yet the
matter is debatable. Trombly suggests 100 Hz to 300 Hz, Umphered
and Mc Cormack say frequency over 200 Hz may cause damage to
skin tissue and discomfort and pain to the muscle fibers.

Muscle Tapping
Muscle tapping facilitates muscle by initiating muscle contraction.
It is done with the fingertips striking quickly at the muscle belly.
Muscle tapping promotes contraction for very shorter duration by
stimulating primary la fibers of the muscle spindle. Many researches
have been conducted on the speed of muscle tapping and findings
suggest that muscle tapping can cause radiation of the force to the
unwanted muscles via bone if tap is given at higher intensity than
the lower intensity.
 Rood's Approach 129

Joint Distraction
This is administered by moving articular surfaces of the joint apart
from each other. Joint distraction causes stimulation of the joint
receptors located within the joint cavity as well as the surrounding
structures of the joint. Joint distraction is applied by manually
pulling both the articulating surfaces apart along the longitudinal
axis of the bone.

Resistance
Resistance is provided to the ongoing movement or to promote
co-contraction of the muscles. Co-contraction promotes postural
stability as there occurs firing of the Golgi tendon organs (GTO) with
significant increase in their firing as the amount of the resistance
increases. Amount of motor unit firing is higher when muscle is
loaded against resistance than without resistance this is known
as overflow phenomena. Resistance also enhances kinesthetic
awareness which further promotes motor learning.

Inhibition Techniques
Inhibition techniques are applied with the provision of the sensory
stimuli for the longer duration. Inhibition techniques are used for
the treatment of hypertonicity.

Slow Stroking
Slow and rhythmic stroking over distribution of posterior rami
induces general relaxation. Slow stroking is applied on the whole
back starting from occiput till coccyx along the vertebral musculature
by using palm or fingers extended. Stimulus should be applied from
occiput to coccyx and vice versa continuously for 3-5 minutes longer
than this may cause rebound of autonomic responses. Therapist
should not leave the contact with the skin by keeping one hand in
contact with the skin as long as the stimulation is in process. Once
the one hand is over the lowest lumbar area, the other hand should
be placed over cervical region. Before concluding the stimulation
therapist should not lift the hands. Any lubricant can also be used
over the area to be treated and index and middle fingers are used
over paravertebrally. Stroking should be avoided in the patients who
have hypersensitivity over hair follicles.

Cpyg teatrl
130 Advanced Techniques in Physiotherapy and Occupational Therapy

Neutral Warmth
Neutral warmth is given by wrapping the body part to be inhibited
for the duration of 3-5 minutes. Whole body relaxation can be
induced by application of stimuli over distribution of posterior
rami on the back. Neutral warmth can be given by a cotton flannel
or fleece blanket or a down comforter for 10-15 minutes. Neutral
warmth is applied with the temperature keeping more than the body
temperature to avoid rebound effect in 2-3 hours. Effect of neutral
warmth can be enhanced with the application of prolong pressure
that can be applied manually, perpendicular to the longitudinal axis
to the muscle tendon or mechanically with the help ofvarious objects
like cone in the hand for inhibiting finger flexion, platform shoes
for inhibiting plantar flexion. Elastic bandages and air splints can
also be used for inhibiting hypertonicity. Prolong pressure causes
activation of the Golgi tendon organs (GTO), that causes inhibition
of the agonist muscle, pacinian corpuscles.

Prolong lcing
With prolong icing neural transmission of impulses is reduced in
both afferents and efferents. Prolong icing can be given in the form
of ice massage. It reduces hypertonicity and induces relaxation in
the agonist muscles. Prolong icing can be applied for 10-15 minutes
for inducing inhibiting effect. Prolong icing can also be applied with
an ice pack to be placed over the area to be inhibited. Prolong icing
causes inhibition of the stretch reflex by inhibiting tone of agonist
muscles.

Vestibular Stimuli
Vestibular system is responsible for maintenance of balance as it
relays information about the orientation of head and neck and linear
acceleration in the space. Vestibular system has connections with
auditory, visual, propioceptive and motor system. Slow, rhythmic
rolling can be done by the therapist by moving the patient from
supine lying to side lying by taking the patient comfortable supine
lying with proper pillow support under head and neck and below
knees. Therapist supports the patient at the shoulder and hip.
Constant, slow and rhythmic rocking movement cause general
inhibition of the total body response. Stimulation should be stopped
ifundesired responses are generated.