PNF Patterns (Proprioceptive Neuromuscular Facilitation) PDF

PNF Patterns (Proprioceptive Neuromuscular Facilitation) Proprioceptive Neuromuscular Facilitation (PNF) An approach to therapeutic exercise Based on the principles of functional anatomy and neurophysiology Replicates normal movement patterns Used for rehabilitation for patients with MSK con...

PNF Patterns (Proprioceptive Neuromuscular Facilitation) Proprioceptive Neuromuscular Facilitation (PNF) An approach to therapeutic exercise Based on the principles of functional anatomy and neurophysiology Replicates normal movement patterns Used for rehabilitation for patients with MSK conditions that result in altered neuromuscular control Basic movements composed of multi joint, multiplanar, diagonal & rotational PNF Strengthening Techniques used to develop muscular strength, endurance & ROM 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 neuromuscular response Manual contact how & where you place your hands on the patient whenever possible manual contacts placed over agonist mm groups or tendinous insertions (ie: dorsum of hand, cubital fossa) 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 PNF Basic Procedures Traction slight separation of the joint 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 Basic Principles Continued 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 Principles of PNF continued 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: bruising hair, reaching above, dressing Three component movements ○ Flexion-extension ○ Abduction-adduction ○ 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, external rotation, partial elbow flexion, forearm supination, wrist and finger flexion https://www.youtube.com/watch?v=jFCpI6cu2bQ 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– Flexion/ Extension Kisner & Colby 4th edition p. 198 Upper Extremity D1 D2 – Diagonal Pattern Starting position ○ Shoulder extension, adduction and internal rotation, elbow extension, forearm pronation, wrist & finger flexion End position ○ Shoulder flexion, abduction, external rotation, elbow extension, forearm supination, wrist & finger extension https://www.youtube.com/watch?v=tmVLUwCny5k flexion hand placement: dorsal surface of hand verbal cue “open our hand & turn it to your face” “lift your arm up & out” “point your thumb out” extension hand position: palmer side verbal cue “squeeze my finger & pull down across your chest” Upper Extremity D2 – Flexion Magee 4th edition. P. 199 Upper Extremity D2 – Flexion/ Extension D1 – Flexion Lower Extremity Starting Position ○ Hip extension, abduction and internal rotation, knee extension, plantar flexion, ankle eversion, toe flexion End Position ○ hip flex, ADd, external rotation, knee flex, dorsiflexion, inversion, toe extension, hip should be ADD across midline creating lower trunk rotation https://www.youtube.com/watch?v=pBIvfoxv8kY flex 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” ext hand placement: planter, lateral foot, base of toes/ post knee/popliteal fossa verbal cue “curl (point) your toes, push down & out” Lower Extremity D1 – Flexion Magee 4th edition. p. 200 D2 – Flexion Lower Extremity Starting Position ○ Hip ext, adduction and external rotation, knee ext, ankle plantar flex; foot inversion; toe flex Movements ○ hip flex, ABd, internal rotation, knee flex, ankle dorsiflexion & eversion, toe extension https://www.youtube.com/watch?v=g_ECDLvf7dk flex hand placement: dorsal lat foot/ ant lat thigh verbal cue “foot & toes up & out, lift your leg up & out” ext hand placement: plantar medial foot/ post med thigh, just proximal to knee verbal cue “curl (point) toes down & in, push leg down & in” Lower Extremity D2 – Flexion Kisner & Colby 4th edition. p.201 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 Rhythmic stabilization, Slow Reversal, Slow reversal hold, Alternating isometrics, 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 many forms of resistance can be applied to the patient. The interaction between 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 through out the range is the number one goal, along with promoting neuromuscular control and coordination, with proper sequencing of muscular contraction from distal to proximal. 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 Slow Reversal Isotonic contraction of agonist & immediate contraction of the antagonist It helps to develop AROM & coordinate between 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  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. 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. Instead, 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. 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 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 Hold-relax, Hold-relax with Agonist Contraction, 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 neuromuscular inhibition procedures reflexively relax the contractile components of shortened muscles, so patients can gain range of motion 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. ○ Precaution: 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 environment) Hold-relax with Agonist Contraction 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 range of motion. Repeats the process several times. 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 range of motion 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.