Chapter 12 Specific treatment techniques
Introduction
Physiotherapists working in neurological rehabilitation employ a large variety of techniques. When examining treatment approaches from different philosophical backgrounds, it is apparent that similar techniques may be being utilized (see Ch. 11). A technique can be defined as a ‘method or skill used for a particular task’ (Collins English Dictionary). With this definition in mind it is important to consider to what purpose different techniques are employed. It is also important that the technique is appropriate in order to help meet the treatment goals.
This chapter illustrates the diversity of the techniques used by physiotherapists. It is clear that there is a wealth of research supporting the use of some techniques and a lack of a clear evidence base to justify the use of others. Many techniques continue to rely on anecdotal evidence to support their use. In this chapter a variety of techniques are reviewed and the evidence available to support their use is considered. Physiotherapists are challenged to provide best practice based on evidence. However, such evidence may be unavailable or incomplete (Jones et al., 2006) and this is reflected in the field of specific treatment techniques used in neurological physiotherapy.
Facilitation
Many of the techniques used in neurological rehabilitation are applied to facilitate and enhance muscle activity, and thus help achieve improved control of movement. It is also proposed that these interventions are chosen to facilitate neuroplasticity (Umphred et al., 2007a). Many of the specific techniques used for facilitation have their origins in the work of Margaret Rood. For a comprehensive examination of the Rood approach and the most recent interpretation of its relevance, the reader is directed to Baily Metcalfe and Lawes (1998) and Schultz-Krohn et al. (2006). Some of those most commonly used techniques are outlined below.
Brushing
In the 1950s Rood proposed that fast brushing, using a battery-operated brush, of the skin overlying a muscle could be used to facilitate a muscle contraction. Brushing has been used widely by physiotherapists, applied either using an electrically operated brush or manually using a bottle brush, but there is little indication given about the required rate or duration of the brushing, or pressure to be applied. It would make sense that the skin being brushed and the muscle being facilitated should be supplied by the same spinal segment. Although Garland and Hayes (1987) observed an effect of brusing in hemiplegic subjects with foot drop, there is little evidence to support its effectiveness. In subjects who received a combination of brushing preceded by voluntary contraction of the tibialis anterior, a significant change in electromyographic (EMG) activity was seen both immediately and 30 minutes after stimulation.
Brushing may be a powerful method of facilitation but it is clearly not well researched in terms of its continued effects, particularly as much of the work has been carried out on subjects with no neurological impairments. It is worth noting that caution in its use has been advised (Farber, 1982) and that Schultz-Krohn et al. (2006) consider it beyond the scope of entry-level practice.
Ice – brief
In order to facilitate a motor response, an ice cube is quickly swept over the chosen muscle belly (Umphred et al., 2007a). Following each swipe the iced area is blotted with a towel. After three swipes the patient is asked to produce an active muscle contraction. If ice is being used to facilitate lip closure and encourage feeding and sucking, an ice lolly can be placed in the mouth with pressure on the tongue (Farber, 1982).
When using ice as a stimulating technique it is important to remember that it can be a potent stimulus and results can be unpredictable. Putting ice on the face above the level of the lips and to the midline of the trunk should be avoided, as it has been reported that undesirable behavioural and autonomic responses may be provoked (Umphred et al., 2007a; Schultz-Krohn et al., 2006).
Retraining of sensory function has received little attention in the physiotherapy literature. However, the use of repeated ice water immersions of the affected hand in chronic stroke patients was investigated by Bohls and McIntyre (2005) in a small scale study. Although wrist position sense was not improved by the intervention it was suggested that a positive effect may be found in relation to the sensation of light touch and temperature discrimination.
Tapping
Tapping is the use of a light force applied manually over a tendon or muscle belly to facilitate a voluntary contraction. Tapping over a tendon would usually be used to assess reflex activity. A normal response would be a brisk muscle contraction. It is not therefore recommended that tendon tapping be used in a treatment situation, as the response is a crude muscle contraction and will be of little use to help a patient produce a graded, functional movement (Umphred et al., 2007a).
Rood recommended three to five taps over the belly of the muscle being facilitated. In addition, tapping can be applied to a muscle that has been stretched by the effect of gravity. Once the muscle responds to the stretch produced by gravity the therapist taps the muscle, using the hand, facilitating further activity (O’Sullivan, 2007). For example, with a patient who is standing, weight-bearing through both legs, if one knee gives way gravity will stretch the quadriceps muscle group. The therapist can then tap the muscle, facilitating a return to full knee extension.
Sweep tapping is a light touch sweeping movement applied by the back of the therapist’s fingers over the dermatomal area innervating the muscles the patient is required to contract (Umphred et al., 2007a). Davies (2000) described the use of sweep tapping to provide an excitatory stimulus to activate the finger extensors in hemiplegia. This is applied by providing support to the affected upper limb with one hand, while the other hand sweeps firmly and briskly over the extensors of the wrist and fingers; the sweep commences just below the elbow and continues over the dorsum of the hand and fingers. In common with other tapping techniques, an active response is requested from the patient following its application.
Joint compression
Receptors in joints and muscles are involved with the awareness of joint position and movement. Compression of a joint stimulates these receptors and can produce both inhibitory and facilitatory effects. Joint compression (approximation) is achieved either by normal body weight (or less) being applied through the longitudinal axis of the bone (light compression) or as heavy joint compression, where the approximation is greater than that produced by body weight (Schultz-Krohn et al., 2006). Heavy joint compression is thought to facilitate cocontraction at the joint undergoing compression, whereas light joint compression is reported to produce an inhibitory (relaxing) effect on spastic muscles around joints (Schultz-Krohn et al., 2006).
Bone pounding or jamming is used to inhibit plantarflexion and facilitate cocontraction around the ankle. It can be applied with the patient sitting, by pounding the heel on the floor whilst supporting the knee. Alternatively, with the patient lying prone over a pillow with some degree of flexion at the hips and knees, force can be applied to the heel by the therapist using the ulnar side of a clenched fist (Umphred et al., 2007a).
Other techniques that use joint compression include weight-bearing through a hemiplegic arm to facilitate cocontraction and activation of the muscles around the shoulder joint (Davies, 2000). Weight belts and weighted wrist or ankle cuffs have also been used to increase joint compression. Joint compression can be applied to many joints using a variety of positions or patterns of movement. For example, using four-point kneeling as a starting position, joint compression can be applied to the shoulders and/or hips. Ideally, joint compression should be applied in a functional position, but if this is not possible treatment should quickly progress to using the joint in a functional manner. Joint compression is also a procedure used in PNF and is considered in this context below.
Several authors described joint compression, either in terms of normal weight approximation or by other means, but only anecdotal evidence is given to support its use (Davies, 2000; Farber, 1982; Schultz-Krohn et al., 2006; Umphred et al. 2007a).
Vibration
Muscle vibration
Therapeutic vibration is a directly applied stimulus of high frequency (100–300 Hz) and low amplitude, which stretches the muscle spindle and activates type 1a afferent fibres. Vibration is generally applied directly to the chosen muscle or its tendon. Bishop (1974) identified three motor effects achievable by vibrating a muscle: (1) a sustained contraction of the vibrated muscle (via the tonic vibration reflex); (2) the depression of the motoneurones innervating the antagonistic muscles (reciprocal inhibition or antagonist inhibition); and (3) suppression of the monosynaptic stretch reflexes of the vibrated muscle (during the period of vibration). There appears to be disagreement, however, as to whether vibration has a sustained effect on muscle contractility (Umphred et al., 2007a) and thus any long-term benefit.
It would appear that vibration has potential clinical applications via agonist facilitation or antagonist inhibition. Bishop (1974) identified four factors that influenced the strength of the tonic vibration reflex (TVR):
Application of the vibrator to the belly of a stretched muscle or over the tendon allows easy facilitation of the TVR. It appears that the tonic neck reflexes and body-righting reflexes (Rothwell, 1994; Shepherd, 1994) interact with the TVR; so, treatment in the supine position results in an improved extensor TVR, and that in the prone position results in increased flexor TVR. Finally, increasing the amplitude of the vibration increases the stretch on the muscle but, more significantly, the TVR is greater as the frequency of the vibratory stimulus increases.
Another quite different investigation involving vibration was made by Lovgreen et al. (1993), who studied the effects of muscle vibration on the voluntary movements of patients with cerebellar dysmetria. Part of the study was to consider whether vibration could improve movement accuracy and reduce hypermetria. They found that antagonist vibration reduced the amplitude of patients’ movements and suggested that vibration had potential for use in both hyper- and hypometria, although the feasibility of its application would require careful thought.
Vibration has the potential to be a potent treatment technique but there are various precautions that must be considered when using it. Key points to remember include: vibration will generate heat at its point of application and there is potential to cause damage to the skin, particularly at high amplitudes (Farber, 1982). Vibration to augment a muscle contraction should not be applied with cutanteous pressure, which is known to cause inhibition as the two oposing effects could negate each other (Umphred et al., 2007a).
Umphred et al. (2007a) recommend that vibrators registering 100–125 Hz be used and noted that most battery-operated hand-held vibrators register only 50–90 Hz. There is a wide range of commercially available vibrators, so the available frequency range should always be checked prior to purchase.
The use of more generalized vibration has also been considered. Its current use as part of exercise training formed the basis of a study by Jackson et al. (2008) examining its effect on lower limb performance in patients with multiple sclerosis, although results were inconclusive.
Whole body vibration
Whole body vibration is a relatively new modality in neurological rehabilitation, which involves the patient standing on a vibrating platform (Wunderer et al., 2008). The effect of vibration compared to conventional physiotherapy to improve balance and gait in Parkinson’s disease was explored by Ebersbach et al. (2008). However, improvements were demonstrated in both groups, so its superior efficacy in comparison to a standard approach to rehabilitation was not established. Another study exploring its use in Parkinson’s disease (Arias et al., 2009) concluded that any effect from whole body vibration in Parkinson’s disease was solely due to a placebo effect. A systematic review by Wunderer et al. (2008) concluded that whole body vibration appeared to produce similar gains to traditional exercise and resistance training but also limited fatigue, so its use could therefore be considered beneficial in neurological patients.
Vestibular stimulation
Any static position or movement will have an effect on the vestibular system, so many interventions will result in vestibular stimulation in some way or other. However, specific vestibular stimulation has not been widely used in neurological physiotherapy and was, until recently, mainly described in relation to a multisensory approach to neurological rehabilitation in paediatrics. Advocates of its use are anxious to remind others that vestibular stimulation is a powerful form of stimulation that should be used with care. Umphred et al. (2007a, p. 231) stated that it is important to remember that ‘the rate of vestibular stimulation determines the effects. A constant, slow, repetitive rocking pattern, irrespective of plan or direction, generally causes inhibition of total-body responses, whereas a fast spin or fast linear movement tends to heighten both alertness and the motor responses.’
The management of vestibular dysfunction has evolved from increasing research to become recognized as a specialist area within physiotherapy. Chapter 13 explains that patients with a primary problem of vestibular dysfunction require vestibular rehabilitation, which involves specific assessment and treatment techniques.
Facilitation of movement
Facilitated movements do not require the patient to activate the nervous system to produce the required movement. This lack of self-initiation of movement has been criticized for not providing a basis for the learning of movement. However, it could be argued that once movement can be initiated in patients the possibility of the production of an active response then exists with the potential for learning of functional movements (Baily Metcalfe & Lawes, 1998). However, it must be remembered that eventually the patient must become independent of the physiotherapist in order to produce the movements required for functional indpendence.
Normalization of tone and the maintenance of soft-tissue length
The Bobath approach is widely used as a treatment approach in neurological physiotherapy (Lennon, 2003; Sackley & Lincoln, 1996) and the control and normalization of tone clearly contribute to the theoretical assumptions of the Bobath concept of stroke rehabilitation (Raine 2007; also see Ch. 11). An awareness of the potential for changes in the musculoskeletal system and the subsequent loss of range of movement associated with neurological dysfunction (Ch. 14) is essential for effective management of patients with neurological disorders.
Passive stretching – slow
Slow stretch is applied to a muscle or joint such that a stretch reflex is not elicited and the effect is, therefore, inhibitory in terms of the neural response. The effect of prolonged, slow stretching on muscle is not entirely clear, although it certainly varies depending upon the time for which the stretch is maintained. It appears to have an influence on both the neural components of muscle, via the Golgi tendon organs and muscle spindles (O’Sullivan, 2007), and the structural components in the long term, via the number and length of sarcomeres (Hale et al., 1995).
Changes in muscle length
The presence of increased tone, possibly combined with paresis and/or weakness, can ultimately lead to joint contracture and changes in muscle length (see Ch. 14). Slow, prolonged stretching is therefore applied to maintain or prevent loss of range of movement (ROM). It has been demonstrated in animal studies that if a muscle is immobilized in a shortened position, sarcomeres will be lost and, conversely, a muscle immobilized in a lengthened position will add on sarcomeres (Goldspink & Williams, 1990). A shortened immobilized muscle will also show an increase in stiffness related to an increase in connective tissue within the muscle (Williams et al., 1988). However, it has been demonstrated in mice that a stretch of 30 minutes daily will prevent the loss of sarcomeres and changes in the connective tissue of an immobilized muscle (Williams, 1990). The timescale relating to changes in the mouse may not be relevant to humans.
Manual stretching
A prolonged muscle stretch can be applied manually, using the effect of gravity and body weight, or mechanically (by machine or splint). When applied, the stretch should provide sufficient force to overcome the hypertonicity and passively lengthen the muscle. When contractures are already present, it is doubtful whether the use of manual stretching alone will be sufficient to provide a sustained improvement in the ROM, if any was achieved. A systematic review exploring the effects of stretching in spasticity by Bovend’Eerdt et al. (2008) found some positive evidence to support the immediate effects of one stretching session, but the long-term effects were unclear. Overall the heterogeneic nature of the studies made a meta-analysis unfeasible and they concluded that the available evidence related to the clinical benefits of stretching and spasticity was inconclusive.
Splinting
Low-force stretching of long duration can be provided by splinting. The clinical practice guidelines on splinting adults with neurological dysfunction (Association of Chartered Physiotherapists Interested in Neurology (ACPIN), 1998) identified a paucity of research in the area, making it almost impossible to adopt an evidence-based approach to the use of splints. Over a decade later, little has changed.
Dynamic Lycra splints have been used as part of the management of patients with hemiplegia (Gracies et al., 2000). Lycra splints are custom-made, individually designed garments – it is claimed that Lycra splinting is effective in managing posture, and motor and sensory changes following a stroke. The study by Gracies et al. (2000) investigated acceptability and effects on swelling, resting posture, spasticity, active ROM and passive ROM of an upper-limb Lycra garment when worn for 3 hours by patients with a hemiplegia. The findings from this small-scale study, using a convenience sample, indicate some support for the use of these garments in reducing spasticity and swelling. Overall the use of lycra splits or orthoses in adult patients with neurological dysfunction is not widespread. In contrast there is increasing use of lycra splinting in children with cerebral palsy, although a review by Attard and Rithalia (2004) identified a lack of scientific research to support their use.
Different types of splinting and the rationale for use are discussed in Chapter 14, with further details being provided by Edwards and Charlton (2002). Examples of splints used for peripheral nerve injuries are illustrated in photographs in Chapter 9.
Weight-bearing
Several studies report the use of weight-bearing to reduce contractures in joints of the lower limb (Bohannon, 1993; Richardson, 1991). These reports illustrate the effectiveness of using a tilt table to achieve a sustainable position in which a prolonged stretch is applied. The angle of table tilt needs to be considered when standing patients with knee joint contractures, as the supporting straps bear more of the body weight than when the knees are extended (Morgan et al., 2003). Force exerted at the supporting straps is greater the higher the degree of flexion, and is more pronounced with greater body weight, but can be modified by reducing table incline, thus reducing the pressure on underlying tissues. However, a study by Ben et al. (2005) challenged some of the assumptions about the benefits of standing where small changes to ankle mobility and little or none to mineral density were found during a single blinded randomized trial examining the effects of a 12-week standing programme in patients with recent spinal cord injuries. Illustrated examples of equipment to assist standing can be seen in Chapters 4 and 14.
Serial casting
Serial plaster casting is another technique used to prevent or reduce contractures (O’Sullivan 2007), which may be most effective when the contractures result from spasticity. Serial casting methods were described and illustrated by Edwards and Charlton (2002) and a comprehensive overview of the practicalities of casting the lower limb in neurology was provided by Young and Nicklin (2000).
The use of a soft splint has been shown to be effective in the acute management of elbow hypertonicity (Wallen & Mackay, 1995). This splint has certain advantages over casting in that it is more dynamic in nature, less likely to cause unwanted pressure and provides neutral warmth (Wallen & O’Flaherty, 1991). However, it is also easily removed and thus a level of compliance is necessary!
Moseley (1997) also demonstrated the effectiveness of serial casting and stretching on regaining ROM in the ankle due to established shortening of the calf muscles. Jones (1999) undertook a series of single-system studies to examine the efficacy of lower-extremity serial casts on gait in four adults with hemiparetic gait patterns. There was an improvement in walking speed and a reduction in the level of assistance required during walking following the intervention. Singer et al. (2004) reported a descriptive study of the non-surgical management of ankle contracture in patients with acquired brain injury. Serial casting was used when the contracture appeared to be worsening, despite standard physiotherapy. In some cases of serial casting this also included an injection of botulinum toxin type A.
When spasticity is present, physiotherapists are often reluctant to use splints or other externally applied devices for stretching as, despite the lack of supporting evidence, it is thought that splinting can lead to an increase in muscle tone. However, it has been demonstrated that inhibitory splinting can reduce contractures without causing detrimental effects to muscle tone (Mills, 1986). Indeed, the ACPIN guidelines (1998) recommend that patients suitable for splinting are those who may have, or be at risk of, contractures as a result of significant increases in muscle tone or immobility.
Duration of stretch to reduce spasticity
Although it has been shown that prolonged stretching can reduce spasticity, the time needed is not clear. Hale et al. (1995) found that the most beneficial duration of stretch applied to reduce spasticity was 10 minutes. This study used a variety of methods to assess the level of spasticity, including both subjective and objective measures. The results illustrated the difficulties that arise when measuring spasticity (see Ch. 14), and that perhaps the concurrent problems of length-associated changes in muscle required greater consideration.
Duration of stretch to prevent contracture
Tardieu et al. (1988) investigated how long it was necessary to stretch the soleus muscle each day to prevent contracture in children with cerebral palsy and concluded that it must be stretched for 6 hours a day.
Some work has been done to evaluate the effect of stretching, mainly on normal subjects (Harvey et al., 2002). However, it is clear that further work is still required to establish the appropriate stretching techniques and the duration required to produce the desired effect in different situations.
Positioning
Positioning is used widely by physiotherapists to prevent the development of contractures (Fraser, 2009) and to discourage unwanted reflex activity (Carr & Kenney, 1992; Pope, 2002). A survey of practice of positioning for stroke patients identified that one of the most common aims of physiotherapists advocating its use was to modulate muscle tone and prevent damage to affected limbs (Chatterton et al., 2001). A study by Ada et al. (2005a) of stretching in patients with a recent stroke, in which the affected shoulders were positioned in 90° of flexion with the maximum external rotation tolerable for two 30 minute sessions a day, 5 days a week, for 4 weeks, found significantly reduced incidence of contracture when compared with a control group. This contrasted with Dean et al. (2000) who failed to demonstrate a significant effect of prolonged positioning of the shoulder, applied daily for 6 weeks, in patients undergoing a multidisciplinary rehabilitation programme. Turton et al. (2005), although supporting the principle that early treatment to prevent the loss of range of movement in the affected limb post stroke is essential, also raised the issue of patient compliance, which must be considered in any intervention requiring patients to adopt a sustained position. However, a recent meta-analysis of positioning to prevent loss of range of movement in the shoulder post stroke did not support its use (Borisova & Bohannon, 2009).
Specific positions are often adopted to achieve a slow maintained stretch on a particular muscle and the thinking behind this has already been explored. Bromley (2006) gave detailed guidelines for the positioning of patients following spinal cord injury and described its importance for: correct alignment of fractures, prevention of contractures, prevention of pressure sores and inhibiting the onset of severe spasticity.
Indeed, historically many of the positions advocated by physiotherapists relate to the desire to avoid the development of spastic patterns of movement (Bobath, 1990). Positions are chosen to minimize the influence of the primitive reflexes. The three reflexes, which are normally under cortical control and whose release can be influenced by careful choice and use of positions, are: (1) the symmetrical tonic neck reflex; (2) the asymmetrical tonic neck reflex; and (3) the labyrinthine reflex (Carr & Kenney, 1992).
Davies (2000) gave fairly detailed descriptions of desirable positions that should be used following stroke, urging the avoidance of supine lying, as in this position the influences of the tonic neck and labyrinthine reflexes are great and this could result in an overall increase in extensor activity throughout the body. Fraser (2009) advocates the use of good seating and positioning to facilitate appropriate alignment and stability of the trunk and limbs, thus avoiding compensatory responses to prevent falling.
Careful positioning to limit musculoskeletal changes is essential, but it appears that there is a lack of consensus about the precise positions necessary to limit the onset of spasticity and unwanted patterns of movement, particularly after stroke (Carr & Kenney, 1992; Chatterton et al., 2001). Certainly, Bobath (1990) identified a need to be more dynamic and advocated the use of reflex-inhibiting patterns of movement, rather than static postures, to inhibit abnormal postural reactions and facilitate automatic and voluntary movements.
These concepts are discussed in Chapter 11. Positioning is also discussed in Chapters 4 and 14, where illustrations show various types of equipment used for posture and seating.
Pressure
Pressure is used by physiotherapists both to facilitate and inhibit a response in muscle, more especially in muscle tone (O’Sullivan, 2007). This pressure can be applied in a variety of ways, including the use of air-filled splints (Johnstone, 1995), tone-inhibiting casts (Zachazewski et al., 1982) or manually (Umphred et al., 2007a). Pressure can be applied directly over a tendon (Leone & Kukulka, 1988) or over the muscle itself (Robichaud et al., 1992). The pressure can be sustained or intermittent, and variable in terms of the degree applied.
Most of the research investigating the effects of a variety of pressure conditions has measured motoneurone excitability, via change in the Hoffman reflex (H reflex). Studies have suggested that the characteristic appearance of the H reflex reflects spinal motor function and, therefore, it can be used to evaluate the effects of therapeutic interventions that aim to reduce motoneurone excitability (Suzuki et al., 1995). It is important to remember, however, the problems of quantifying that part of muscle tone that occurs as a direct result of reflex activity.
Leone and Kukulka (1988) investigated the effects of Achilles tendon pressure on the H reflex in stroke patients. The assumption was made that any change in motoneurone excitability would be reflected in an associated alteration in tone as, again, no direct measurement of tone was made. Pressure was applied both continuously and intermittently, and under both conditions depression of the H reflex occurred. Intermittent pressure, however, was significantly more effective than continuous. Further investigation revealed that increasing the amount of pressure had no greater effect, and the effect of the pressure was sustained only during its actual application. No carryover effect was observed, but it is suggested that tendon pressure could be used therapeutically, e.g. when a short-term reduction in tone would allow achievement of an improved patient position in bed.
The strongest proponent of the use of pressure during treatment was Johnstone (1995), who advocated the use of constant pressure provided by orally inflated splints and intermittent pressure produced by a machine. The uses of the splint are to: reduce the therapist’s need for extra hands; provide stability to the limb; divert associated reactions; allow early weight-bearing through the affected limb; and increase sensory input (Johnstone, 1995). It was claimed that when the antigravity muscles of the upper limb are held in a position of sustained stretch using the air splints, tonic and phasic wrist flexor EMG activity is reduced (Johnstone, 1995).
Robichaud et al. (1992) supported the use of air-splint pressure to reduce motoneurone excitability of the soleus muscle when circumferential pressure was applied around the lower leg. As in the tendon pressure study, the reduction was not sustained once the pressure had been released. Conversely, an increase in motoneurone excitability following the application of muscle pressure has been reported (Kukulka et al., 1987). This may reflect the different methods employed to apply pressure, which can include tapping and massage (Umphred et al., 2007a).
It is clear that the application of pressure has many potential effects, some of which are still not understood. Externally applied pressure over muscle or tendon must also cause a disturbance in the cutaneous mechanoreceptors. Because of the wealth of afferent activity caused by pressure, its application poses many questions yet to be answered. Pressure is postulated to be one of the mechanisms supporting the therapeutic use of lycra body suits (Attard & Rithalia, 2004). The efficacy of using pressure as a technique has largely been supported by observations of therapists, but outcome studies are now required (Umphred et al., 2007a).
Neutral warmth
When considering exteroceptive input techniques, Umphred et al. (2007a) identified an additional use for air splints – that of the provision of neutral warmth. Johnstone (1995) also advocated their use to provide sensory stimulation of soft tissues, causing inhibition of the area under which the neutral warmth is applied. Alternative techniques used for achieving neutral warmth are tepid baths, whole-body wrapping and wrapping of isolated body parts (O’Sullivan, 2007). The required range of temperatures that should be utilized for this technique is 35–37°C (Farber, 1982).
There appears to be little research to support the use of this concept of neutral warmth. Baily Metcalf and Lawes (1998) suggested that the inhibition seen is due to inhibition of tonic muscles via the stimulation of low-threshold mechanoreceptors through light touch. One study looked specifically at the effect of a wrapping technique on a passive ROM in a spastic upper extremity (Twist, 1985
