PNF Patterns and Rood's Approach

• These are notes on PNF (Proprioceptive Neuromuscular Facilitation) Patterns and Rood's Approach.

PNF Basic Procedures and Strengthening Techniques

• PNF is based on functional anatomy and neurophysiology principles and used for rehabilitation of MSK conditions with altered neuromuscular control.
• It involves multi-joint, multiplanar, diagonal, and rotational movements.
• PNF develops muscular strength, endurance, & ROM and facilitates both stability & mobility, forming a foundation for restoring function.

Key Aspects of the PNF Approach:

• Utilizes diagonal patterns and sensory cues.
• Seeks to elicit the best possible neuromuscular response using sensory cues superimposed on diagonal patterns.
• Manual contacts should be placed on agonist muscle groups or tendinous insertions whenever possible, adjusted based on patient response and level of control.
• Apply the greatest possible resistance during dynamic concentric contraction, ensuring the patient can move smoothly without pain, adjusting as needed.
• Slight separation of joint surfaces can inhibit pain & facilitate movement during rehabilitation, most often during flexion.
• Compression or weight-bearing stimulates contraction of agonist & antagonist muscles, enhancing dynamic stability & postural control.
• Therapists should face the direction of the moving limb, applying resistance via body weight, not just upper extremities, considering biomechanics.
• Auditory cues enhance motor output, instructing the patient to "squeeze my fingers and pull across your chest."
• Explain and teach the client the pattern of movement from start to finish, visual stimuli allows enhanced control of the movement through the ROM.
• Patient should look at the limb during the pattern, coordinated motion is essential, and rotational & diagonal movement are important.
• Distal segment moves first.
• Concerns gross movement pattern opposed to specific muscle actions
• Traction or approximation facilitates stretch reflexes.

PNF Patterns Explained

• PNF patterns involve rotational and diagonal movements, mirroring functional actions like brushing hair or reaching.
• Movement occurs with flexion-extension and abduction-adduction.
• The order to proceed is flexion-extension, abduction-adduction, then internal-external rotation.
• During D1 flexion, the verbal cue is "squeeze my finger, turn your palm up, pull your arm up & across your face"
• While in D1 extension, the verbal cue is "Open your hand", then "push your arm down & out"

D1 & D2 Diagonal Patterns for Upper and Lower Extremities

• D1 Diagonal Pattern:

  • Starting Position: Shoulder Extension, Abduction and intemal rotation, Elbow extension, Forearm pronation, Wrist and finger flexion.
  • End Position: Shoulder flexion, Adduction and External rotation, Partial elbow flexion, Forearm supination, Wrist and finger flexion.

• D2 Diagonal Pattern:

  • Starting Position: Shoulder extension, Adduction and internal rotation, Elbow extension, Wrist & finger flexion.
  • End Position: Shoulder flexion, abduction, and external rotation, Elbow extension, Forearm supination, Wrist & finger extension.

• D1-FLX Lower Extremity:

  • Starting Position: Hip extension, abduction & internal rotation, Knee extension, Plantar flexion, Ankle eversion and Toe extension.
  • End position: Hip flexion, adduction & external rotation, Knee flexion, Dorsiflexion, Ankle inversion and Toe flexion.
  • Verbal Cues "foot & toes up & in, bend your knee, & pull your leg over & across".
  • For Extension, the cue is "curl (point) your toes, push down & out".

• D2-FLX Lower Extremity:

  • Starting Position: Hip extension, adduction, and external rotation, Knee extension, ankle plantarflexion and inversion.
  • End Position: Hip flexion, abduction, and internal rotation, Knee flexion, Ankle dorsiflexion and Foot eversion.
  • Verbal Cues "foot & toes up & out, lift your leg up & out"
  • Extension verbal cue "curl (point) toes down & in, push leg down & in".

• Flexion and extension range of motion requires considering Major muscle of flexion and extension.

• The abduction and adduction range of motion is considered next.

• Rotation is considered last.

• All components above are combined for a diagonal and rotational movement pattern.

PNF Strengthening Techniques:

• Rhythmic stabilization, slow reversal, and slow reversal hold.
• Designed to strengthen the body in functional patterns using spiral and diagonal movements and include proprioceptive, kinaesthetic, visual, and auditory feedback.
• Core stability is required to successfully complete the patterns.

Therapist Techniques for Applying Choreographed Resistance:

• Hand placement and choreographed resistance are carefully positioned and applied.
• Resistance adjustment might need to improve.
• Smooth, controlled, pain-free movement throughout the range is the number 1 goal, along w/ promoting neuromuscular control.
• It calibrates passive movement of the joint, re-educating the neuromuscular system.
• The therapist passively moves the extremity through desired movement pattern.
• Progress with AAROM, AROM, RROM through the pattern to help the patient improve on coordination and control.
• It helps to develop AROM & coordinate agonist & antagonist muscles.
• It helps to increase strength of a specific ROM and promotes rapid, reciprocal movement.
• This technique adds an isometric contraction (hold) at the end-range of each muscle group.
• Enhances dynamic stability of proximal muscle groups, encouraging stability of postural trunk muscles and stabilizers of the hip and shoulder girdle.
• The patient "holds" his position, while manual resistance is alternately applied in a single starting position of the involved limb.
• Can be applied to strengthen trunk, a single extremity or bilateral extremities, and can be applied the limbs in alternating positions
• Muscular co-contraction further enhances joint stability.
• Manual isometric resistance is applied in a multidirectional pattern to multiple muscle groups simultaneously to support and stabilize the extremity.
• It is particularly beneficial in isometrically contracting the proximal joint rotators( it's a level up from alternating isometrics)
• Together-maximal facilitation uses functions, patterns, contact, cues, and goals.
• PNF is primarily used for stretching although it has a strengthening aspect to it
• it can be used in conjunction with other treatment approaches.
• PNF stretching is superior to all other stretching techniques.

PNF Stretching:

• Neuromuscular inhibition procedures reflexively relax muscles for increased range of motion.
• Lengthen a tight muscle and ask the patient to isometrically contract it for several second.
• This relies on the firing of GTO to cause reflexive muscle relaxation to new newfound end-range of motion
• PNF stretching can decrease activity of selected hamstring muscles
• A sudden stretch can predispose patients to increased risk of musculotendinous injury, if applied directly before activity (if chosen for a sports event)

Techniques to Hold-Relax with Agonist Contract:

• Follow Hold-Relax (HR) Technique where, after tight muscle is contracted isometrically against therapists resistance.
• The patient concentrically contracts opposite the tight muscle to actively move the joint through the increased range while the therapist passively lengthens the tight muscle (antagonist) to the end-range.
• Agonist contract is applied while the patient concentrically contracts opposing muscle group (agonist) to move to a new range of motion.

Rood’s Approach

• Rood's approach is a neurophysiologic and developmental treatment approach developed by Margret Rood in 1950's to improve the tone of muscles (both flaccid and spastic).
• The Rood Approach used for the treatment of CNS disorders.
• Rood's main principles are normalization of tone, gradual developmental sequence, purposeful movement and repetition or practice.
• It reduces spasticity, stimulates flaccid muscles, increases soft tissue ROM and muscle strength, helps stabilize joints, and calms the CNS.
• It is divided into main Facilitatory and inhibitory Techniques

Facilitatory Techniques:

• Improve the tone of flaccid muscles through tactile stimulation, applied distal to proximal.
• Use Fast Brushing in a distal to proximal direction where muscle stimulated with a soft brush for 3-5 times/3-5 minutes
• Precautions for Fast Brushing:
  • stimulation of vagus nerve (may influence CV system)
  • Posterior primary rami of L1-L2Over 52-53 (may cause bladder retention)
  • 54 (used for patients w/ incontinence)
• Quick swipes of ice cubes before C icing

Facilitatory Icing Procedure

• A-Icing-application of quick swipes of ice cubes to stimulate withdrawl reflex similar to light touch
• C-Icing-continuous threshold stimulus, done by ice cube pressed for 3-5 minutes on muscles.
• Always perform A icing before C icing.
• Brushing and icing have effects, that stimulation of the unaffected side in hemiplegic patients has before stimulation of the affected side is also helpful.
• Light, quick stretches activate phasic response of the muscle being stretched, and is immediate.
• Tapping the muscle belly assists with moving by using light force applied manually over a tendon or mm belly to improve voluntary contractions, which leads to brisk reflexes.
• Applying with the patient in AROM assists in a specific pattern.
• Spindles overall activates a stretch response.
• Joint compression is applied to a longitudinal axis and can be given using manual or weight-bearing positions, such as the prone on hands.
• Do not use joint compression technique if there is skin integrity issues

Inhibitory Techniques

• Intended to reduce spasticity, applied proximal to distal.
• involves stroking of posterior column with a firm pressure graduaally (for 3-5 minutes until the patient feels relaxed) in proximal to distal pattern.
• Swinging or slow rocking movements may be useful to reduce muscle tone
• Wrapping the affected area to be inhibited with for 10-20 minutes causes warmth
• Prolonged positioning of Muscle insertion point to point A muscles in lengthened position for a period of time for several minutes helps the muscle spindle to longer positions
• balance of tone can be disturbed if prolonged positioning is allowed
• Light joint compression is used to reduce tone in hypertonic spastic muscles.
• Fluidity and timing is very important when applying ROODs:
• Assess skin integrity, sensory/sensitivity-especially w/ elderly patients.
• Apply flex/ext and abd/add from distal to proximal