Class 2 – Notes PDF

Class 2 – Notes 2025-01-12 2:54 PM PNF Patterns: Proprioceptive Neuromuscular Facilitation An approach to therapeutic exercise Based on the princi...

Class 2 – Notes 2025-01-12 2:54 PM PNF Patterns: Proprioceptive Neuromuscular Facilitation An approach to therapeutic exercise Based on the principles of functional anatomy and neurophysiology Replicates normal movement patterns Movements we want to gain in order: Used for rehabilitation for pt with MSK conditions that result in altered neuromuscular control 1. Flex/ext 2. Abd/add Basic movements composed of multi joint, multiplanar, diagonal & rotational 3. Int/ext rot PNF Strengthening Techniques Start distal to proximal Used to develop muscular strength, endurance & ROM Always start with ROODs, then move on to PNF strengthening Facilitate stability & mobility Lays a foundation for restoring function Hallmarks to this approach: use of diagonal patterns & sensory cues **** Proprioceptive Cutaneous Visual Auditory What are we trying to do? Elicit or augment motor responses PNF Basic Procedures Using sensory cues superimposed on the diagonal patterns = best possible NM response Manual Contract How and where you place your hands on the patient Whenever possible manual contracts placed over agonist mm groups or tendinous insertions Adjusted based on the patient's response & level of control Maximal Resistance Greatest possible amount of resistance applied during dynamic concentric mm contraction Patient must still be able to move smoothly without pain Adjust to accommodate strong & weak components Traction Slight separation of the jt surfaces Inhibit pain Facilitate movement during patterns Most often applied during flexion Approximation Gentle compression of the joint surfaces Either by manual compression or weightbearing Stimulates contraction of agonist & antagonist Enhances dynamic stability & postural control Position & Movement of the Therapist Facing the direction of the moving limb Resistance applied via body weight not your upper extremities Think about your biomechanics as best as possible Verbal Commands Auditory cues given to enhance motor output Instruct the patient what to do "squeeze my fingers and pull across your chest" curl your toes down & in, push your leg down & in Visual Cues Patients are asked to watch and follow the movement Allows enhanced control of the movement through the ROM Basic Principles/How to Teach your client the pattern of movement from start to finish Patient should look at the limb while moving through the pattern Visual stimuli Explain the movement to the patient Verbal cues Manual contact with appropriate stimulation on the muscles that must do the work Maximal resistance that allows for smooth, coordinated motion is essential Mechanics and body positioning is essential Rotational and diagonal movement is a critical component Distal segment moves first Timing of movement Traction or approximation Stretch reflexes of the extensors or flexors PNF Patterns: Concerned with gross movements as opposed to specific muscle actions Rotational and diagonal patterns Functional patterns of movement ie. Brushing hair, reaching above, dressing Three component movements: The order you want to do this in *** 1. Flexion-extension 2. Abduction-adduction 3. Internal-external rotation D1 Diagonal Pattern: Starting Position Shoulder Extension, Abduction and internal rotation Elbow extension Forearm pronation Wrist and finger extension End Position Shoulder flexion, Adduction and external rotation Partial elbow flexion Forearm supination Wrist and finger flexion Flexion hand placement Palmar side Verbal cue "squeeze my finger, turn your palm up, pull your arm up & across your face" Extension hand placement Dorsal side Verbal cue "open your hand" or "wrist & fingers up" then "push your arm down & out" Upper Extremity D1 – FLX/EXT D2 Diagonal Pattern: Starting Position Shoulder extension, Adduction and internal rotation Elbow extension Forearm pronation Wrist & finger flexion End Position Shoulder flexion, abduction, and external rotation Elbow extension Forearm supination Wrist & finger extension Flexion hand placement Dorsal surface of hand Verbal cue "open your hand & turn it to your face" "lift your arm up & out" "point your thumb out" Extension hand placement Palmar side Verbal cue "squeeze my finger & pull down across your chest" Upper Extremity D2 – FLX/EXT D1 – FLX Lower Extremity Starting Position Hip extension, abduction and internal rotation Knee extension Plantar flexion Ankle eversion Toe flexion End Position Hip flexion, adduction, and external rotation Knee flexion Dorsiflexion Ankle inversion Toe extension Hip should be adducted across midline creating lower trunk rotation Flexion hand placement Dorsal, medial foot & toes / anteromedial thigh proximal to knee Verbal cue "foot & toes up & in, bend your knee, pull your leg over & across" Extension hand placement Plantar, lateral foot, base of toes/posterior knee/popliteal fossa Verbal cue "curl (point) your toes, push down & out" Lower Extremity D1 - FLX D2 – FLX Lower Extremity Starting Position Hip extension, adduction and external rotation Knee extension Ankle plantarflexion Foot inversion Toe flexion End Position Hip flexion, abduction, and internal rotation Knee flexion Ankle dorsiflexion Foot eversion Toe extension Flexion hand placement Dorsal lateral foot/anterior lateral thigh Verbal cue "foot & toes up & out, lift your leg up & out" Extension hand placement Plantar medial foot/posterior medial thigh, just proximal to knee Verbal cue "curl (point) toes down & in, push leg down & in" Lower Extremity D2 – FLX Positioning of a Pattern Positioning of a pattern is lengthened ROM requires consideration of all the components from PROXIMAL to DISTAL Major muscle of flexion and extension are considered first Abduction and adduction are considered next Rotation is considered last All components are combined for a diagonal and rotational movement pattern PNF Strengthening Techniques: 1. Rhythmic stabilization 2. Slow Reversal 3. Slow reversal hold 4. Alternating isometrics 5. Alternation rhythmic stabilization PNF Strengthening Strengthen the body in a more functional pattern Body movement in a spiral and diagonal direction Using sensory cues, specifically proprioceptive, cutaneous, visual and auditory feedback, to improve muscular response The patterns incorporate rotational movements of the extremities and also require core stability to successfully complete the motion Although may forms of resistance can be applied to the patient The interaction b/w the therapist and client is key in early success Carefully positioned hand placement and appropriate choreographed resistance Resistance over the agonist, while guiding the patient through the proper range of movement Minor adjustment might need to be made as coordination and strength improve Smooth, controlled, pain-free movement throughout the range is the number 1 goal, along w/ promoting neuromuscular control and coordination, with proper sequencing of muscular contraction from distal to proximal 1. Rhythmic Initiation Incorporates passive movement of the joint through the desired range of motion Is a teaching tool to re-educate the neuromuscular system to initiate desired movement This technique begins with therapist passively moving the extremity through the desired movement pattern at the desired speed several times Progression should be to AAROM, AROM, RROM through the pattern to help the patient improve on coordination and control 2. Slow Reversal Isotonic contraction of agonist & immediate contraction of the antagonist It helps to develop AROM & coordinate b/w agonist & antagonist This helps to increase strength of a specific ROM This technique promotes the rapid, reciprocal activities the agonist and antagonist muscle groups need for many functional activities There is NO REST between agonist & antagonist contractions 3. Slow Reversal Hold This technique adds an isometric contraction (hold) at the end-range of each muscle group It's especially beneficial in enhancing dynamic stability of the larger proximal muscle groups 4. Alternating Isometrics This technique encourages stability of postural trunk muscles and stabilizers of the hip and shoulder girdle With alternating isometrics, the patient "holds" his position, while manual resistance is alternately applied in a single plane from one side of the body to the other No motion should occur The patient should maintain the starting position of the involved limb This technique can strengthen the trunk, a single extremity or bilateral extremities, and can be applied with the limbs in the open or closed-kinetic chain 5. Alternating Rhythmic Stabilization Extension of alternating isometrics in which the involved muscle groups co-contract Rhythmic stabilization is most commonly performed in a closed-chain position to further enhance muscular co-contraction and joint stability With this technique, the therapist applies manual isometric resistance in a multidirectional pattern The clinician may apply simultaneous manual resistance in multiple directions, forcing the multiple muscle groups to contract simultaneously to support and stabilize the extremity This technique is particularly beneficial in isometrically contracting the proximal joint rotators It’s a level up from alternating isometrics Summary PNF is a manual therapy approach that applies to posture, movement patterns, contact, cues, and goals ALL TOGETHER = MAXIMAL FACILITATION Treatment is based on improving function, and using functions that are possible to reach the goals chosen PNF lends itself to be used in conjunction with other treatment approaches PNF Stretching Techniques: 1. Hold-relax 2. Hold-relax with Agonist Contraction 3. Agonist Contraction PNF Stretching PNF is primarily used for stretching although it has a strengthening aspect to it PNF stretching is superior to all other stretching techniques The NM inhibition procedures reflexively relax the contractile components of shortened muscles, so patients can gain range of motion 1. Hold Relax This technique involves lengthening a tight muscle and asking the patient to isometrically contract it for several seconds As the patient relaxes, the clinician lengthens the involved muscle further and holds the stretch at the newfound end-range of motion This technique relies on the firing of GTO to cause reflexive muscle relaxation Precautions: 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 used in a sports event) 2. Hold-Relax w/ Agonist Contract This technique follows the same procedure as the Hold-Relax technique After the tight muscle is contracted isometrically against the therapists resistance, the patient concentrically contracts the muscle opposite the tight muscle to actively move the joint through the increased range The therapist then applies a static stretch at the end of this new ROM Repeats the process several times 3. Agonist Contraction The therapist passively lengthens the tight muscle (antagonist) to the end-range Patient concentrically contracts the opposing muscle group (agonist) to move to a new ROM Therapist can add mild resistance to the agonist contraction, but must be careful to not impede new gains in length This technique is using reciprocal inhibition to encourage the tight muscle to relax and lengthen ROOD'S ROOD's Approach: Rood's approach is a neurophysiologic and developmental treatment approach that was developed by Margret Rood to improve the tone of muscles (both flaccid and spastic) in 1950's Purpose The Rood Approach used for the treatment of CNS disorders It helps improve ROM as well as manipulate the CNS into facilitating or inhibiting muscle function The main principles of the Rood Approach are normalisation of tone, gradual developmental sequence, purposeful movement restoration, and repetition or practice What can the techniques achieve? Reduce spasticity Stimulate flaccid mm Increase soft tissue ROM Increase muscle strength and abilities help stabilize joints General calming of the CNS Techniques: Two main Techniques Facilitatory Technique Used to improve the tone of flaccid muscles through tactile stimulation All facilitatory techniques are applied in a distal to proximal direction We want to stimulate the nervous system to we "piss off the cat" by petting it backwards General rule: 3-5 times/3-5 minutes Inhibitory Technique It is used to reduce the tone of muscles mainly the spasticity of muscles All inhibitory techniques will be applied in a proximal to distal direction As to calm down the nervous system or to "pet the cat" General rule: 3-5 times/3-5 minutes Facilitatory Techniques: DISTAL TO PROXIMAL – PISS OFF THE CAT Fast Brushing Brisk cutaneous brushing distal to proximal On the skin over the muscle to be stimulated with a soft brush The stimulation effect is non-specific Precautions Over outer ear (stimulation of vagus nerve may influence CV system) Posterior primary rami of L1 – L2 Over S2 – S3 (may cause bladder retention) S4 (used for patients w/ incontinence) Short segmental strokes – fast Light Touch Brief light contact using fingers or cotton swabs It helps to stimulate low threshold receptors by facilitating tactile receptors Slower than fast brushing – segmental strokes Thermal Facilitation A icing and C icing: A – Icing – application of quick swipes of ice cubes to stimulate withdrawl reflex similar to light touch A – Icing is always used first before going into C – Icing In segments for 3 – 5 minutes C – Icing – continuous threshold stimulus, done by ice cube pressed for 15 – 20 minutes on the muscle belly or dermatome area Precautions are the same as brushing Brushing and icing have effects on both sides – stimulation of the unaffected side in hemiplegic patients prior to stimulation of the affected side is also helpful Quick Stretch Low initial stimulus which activated phasic response of the same muscle which are stretched Response to quick stretch is immediate Tapping the muscle belly is creating that quick stretch (the same thing as tapping but a harder tap) Light tapping distal to proximal – segmental Tapping Tapping technique over the tendon or mm belly is useful in facilitating the muscle action movement Use of a light force applied manually over a tendon or mm belly to improve voluntary contraction Examining reflex activity with a normal response being a brisk muscle contraction Rood suggested 3 – 5 taps over the muscle belly to facilitate movement Resistance Applying resistance to the patient in AROM Apply pressure on the muscle belly and get the patient to do a specific movement of the main muscle you are focusing on Pressure Pressure applied on the muscle belly creates stretch on muscle spindles and overall activates a stretch response Do not use this technique if there is skin integrity issues Heavy joint compression-traction It facilitates co-contraction of all muscles that pass through the joint Joint compression is applied to a longitudinal axis of the bone – it's going to create some space within the joint It can be given using manual or weight-bearing positions such as the prone on hand Do not use this technique if there is skin integrity issues Inhibitory Techniques: PROXIMAL TO DISTAL – PET THE CAT Slow Stroking Slow stroking of posterior rami with a firm but gradual pressure helps to reduce muscle tone It is done for 3 – 5 minutes until the patient feels relaxed On extremities, applied proximal to distal Slow Vestibular Motion Swinging or slow rocking movements may be useful to reduce muscle spasticity Wave like feeling Neutral Warmth It is recommended to maintain the body heat by wrapping the affected area to be inhibited it It is done for 10 – 20 minutes Inhibitory Pressure On the insertion point of a muscle inhibits that muscle through the receptors located there Maintained Stretch Maintenance of a lengthened position for a period of time for several minutes relapse the muscle spindle to longer positions The balance of tone b/w agonist and antagonists will be disturbed if prolonged positioning is allowed Light joint Compression or approx. Using body weight/light pressure to compress the joints or to approximate the tissue Is used to reduce tone in hypertonic spastic muscles Things to Think about When applying ROODs timing and fluidity is very important, incorporate these techniques as if we are dancing with the body These techniques are meant to be used in conjunction with other treatment styles Assess skin integrity, sensory/sensitivity - especially w/ elderly patients