Proprioceptive Neuromuscular Facilitation – PNF PDF

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Proprioceptive Neuromuscular Facilitation – PNF PNF is used to develop muscle strength and endurance; to facilitate stability, mobility, neuromuscular control and coordinated movements; to lay a foundation for the restoration of function Why PNF?  Spiral/diagonal patterns of facilitation provide for an optimal contraction (maximal contraction)  The patterns facilitate muscles to move from lengthened to shorten position  A single muscle is not solely responsible for a single motion component  Able to resist movement in multiple planes simultaneously  Sensory, Motor and Psychological components o This reinforces what the patient can do and promotes it  Mimics sport/functional tasks  PNF diagonal patterns enhance proper sequencing of muscular contraction, from distal to proximal, which promotes neuromuscular control and coordination o The shoulder and hip joints have a diagonal alignment Treatment Goals:  Mobility  Stability  Controlled mobility  Skill development  Neuromuscular control o Coordinated muscle performance  PNF is useful throughout the continuum of rehabilitation: from early stages to final phases  Hallmarks: use of diagonal patterns and application of sensory cues to augment motor responses o Theory: stronger muscle groups of a diagonal pattern facilitate the responsiveness of the weaker muscle groups o Multijoint, multiplanar, diagonal, and rotational movements of the extremities, trunk and neck. Components of PNF:  Principles and Procedures o Positioning and body mechanics  The PT should be at a diagonal, in line with the direction of the motion  Not squared off to the patient—either slightly facing their head or slightly facing their feet o Shoulders facing the direction of the moving limb o Wide base of support o Weight shifting/pivoting  Helps to facilitate rotational component o Communication  Verbal/Tactile cues

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Verbal instructions give instructions prior to starting treatment Preparation: during motion and then verbal cuing for corrections Tone of voice: may influence considerably the quality of the motion/effort of the motion Strong, sharp commands will promote maximal stimulation of active motion if desired. Overuse will result in adaptation of the patient Moderate tone should be used when patient is responding with his/her best effort Soft tone of voice when reinforcement is needed, pain is present or perhaps working on gentle stretching Commands should be short, accurate and timed to physical demands you are asking of the patient. “Push” or “Pull” is good to use for isotonic (eccentric or concentric) contractions “Hold” is good to use for an isometric contraction “Relax” or “let go” is good to use for voluntary relaxation Timing will come with practice Commands play a lesser role as patients become more familiar with the patterns, expectations and timing. o Do away with commands and just use hands once patient understands and see how they respond.

Timing  Normal timing: the sequence of muscle contraction that occurs in any motor activity  Timing for emphasis: change normal time to emphasize a place in the range. Greater resistance can be placed either distally or proximal depending on goals and objectives o Maximum resistance is applied to facilitate overflow or irradiation o The stronger muscles assist the weaker ones o Timing for emphasis provides the means for increasing the response and stimulating action at a specific motion within a pattern o After you ask a patient to “hold” a position, the patient is then asked to “pull” or “push” strongly with no joint motion being allowed except in the joint needing the emphasis. Block the joints you don’t want to move, emphasizing the one you want to move o Resistance must be provided slowly to allow maximal “build up” for irradiation/overflow.  Vision  Instruct the patient to look at his/her hand o Reinforces motor pattern o Hand placement/Manual contacts  PT should hold the patient’s hand with a lumbrical grip  Manual contact provides appropriate sensory input through pressure over the appropriate muscle groups  Ex: to facilitate elbow flexion, palpate biceps

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Manual contact is usually over the agonist muscle groups or their tendinous insertions  Your manual contact should act as a guide for direction of movement  Always be in direct contact with the skin (pelvis is exception)  Be sure your hand position allows the full ROM to occur  You will move your hands/arms along with the patient o Resistance  Used to recruit motor units and to strengthen the response  Optimal resistance- apply just enough to have smooth, controlled, pain-free movement throughout the ROM  Do not let patient hold breath  Appropriate resistance during dynamic concentric muscle contraction is the greatest amount possible that still allows the patient to move smoothly and without pain through the available ROM. Resistance should be adjusted throughout the pattern to accommodate strong and weak components of the pattern.  Resistance should be applied using PT’s body weight, not just UE strength  Forms of resistance: theraband, weights, pulley systems, etc.  Interaction between therapist and patient provides greatest amount and variety of sensory input, particularly in the early phases of reestablishing neuromuscular control. o Traction and Approximation – additional sensory feedback  Traction is the separation of joint surfaces  Assists to promote movement  Used as stretch stimulus  “Pulling”  Approximation is the compression of joint surfaces  Assists to promote stability and postural reflexes  “Pushing”  Both are directed at the joint receptors, which assist with joint positioning  May be contraindicated if your patient is having acute symptoms: pain, edema, etc. Patterns o Patterns are named according to their finished position of shoulder or hip when the diagonal pattern has been completed. o Scapula: initially performed in side lying in good alignment, close to the edge of the plinth, knees and hips flexed as needed and be sure the patient has full ROM prior to initiating strength techniques  D1: stand at patient’s hips, face patient’s head  Anterior Elevation o Muscles: upper traps, levator scap, serratus  Posterior Depression o Muscles: rhomboids, lats, lower trap  Functional Translation: Reaching for something in a cabinet

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o o D2: stand at patient’s head, facing patient’s feet  Anterior Depression (a little protraction with elevation) o Muscles: serratus, pecs, eccentric rhomboids  Posterior Elevation: o Muscles: upper traps, levator scap  Harder to do than D1 o Functional Translation: occurs with throwing mechanisms

o Trunk/Pelvis: greater exposure in neuro-management class o UE: rotation should be the first motion to start to be truly a diagonal pattern  D1- D1 Flexion and D1 Extension

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D2- D2 Flexion and D2 Extension

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o LE: rotation should be the first motion to start to be truly a diagonal pattern  D1: D1 Flexion and D1 Extension  D1: flexion  hip flexion, adduction, ER, DF/INV  D1: extension  hip extension, ABD, IR, PF/EVE

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D2: D2 Flexion and D2 Extension  D2: flexion  hip flexion, ABD, IR, DF/EVE  D2: extension  hip extension, ADD, ER, PF/INV

o Pelvic Patterns:  Anterior elevation/Posterior depression  Key for weight acceptance- efficient goal  Terminal stance/jumping/steps/rolling  Posterior elevation/Anterior depression  Eccentric control (ex: step down)  Terminal swing and loading/kick ball  Initially performed in side-lying with involved extremity toward ceiling (free to move)  These patterns can be done in sitting, supine, quadruped and standing

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This motion comes from the trunk not the legs.

o Can be performed unilaterally or bilaterally  Bilateral symmetrically  Ex: D1 Flexion of both extremities  Bilateral asymmetrically  Ex: D1 Flexion of one extremity coupled with D2 flexion of other extremity  Bilateral reciprocally  Ex: D1 flexion of one extremity coupled with D1 extension of opposite extremity. Techniques o Rhythmic initiation: used to teach the pattern for the first time  Rhythmic motion of the limb or body through the desired range (move through the pattern)  Begin with passive, move to active assisted and then resisted  Therapist passively moves relaxed patient through available range several times until patient becomes familiar with pattern  Then practice actively or active assisted without resistance to allow the patient to learn the movement pattern  Next resistance can be applied o Stretching/Increase Mobility Techniques:  Hold relax/contract relax  Resisted sub-maximal isometric contraction for 3-5 seconds followed by relaxation and movement into the increased range (autogenic)  Ex: stretching biceps: contract biceps and resist elbow flexion 3-5 seconds, then relax and then passively stretch it  Ex: stretching hamstrings: contract hamstrings, resist and then relax and then passively push into stretch  Classically (not required for this class), instead of hold relax, the contract relax technique consisted of allowing the rotators to contract concentrically while all other muscle groups of the diagonal pattern contract isometrically

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Hold relax active contraction (HRAC)  Hold relax technique for a tight muscle followed by a concentric contraction of the muscle opposite the tight muscle  The patient actively stretches the muscle after contraction vs. passively bringing them into stretch  Agonist contraction  Uses the principles of reciprocal inhibition  Slow controlled contraction of the opposite muscle being stretched with or without manual resistance. Hold for 3-5 seconds and repeat 2-4x or as long as you are making a change  Good for muscle guarding, a follow up to gaining new ROM and to reestablish dynamic flexibility  Ex: hamstrings: resist quad contraction, then relax into a hamstring stretch passively or actively  Ex: biceps: resist triceps contraction, then relax into elbow extension o Techniques to Improve Stability  Alternating Isometrics  Alternating isometric of the agonist followed by an isometric contraction of the antagonists o Isometrically strengthens the agonists and antagonists  Resistance can be applied in one or more straight planes (no rotation)  No motion is intended  Start with one plane and add another to progress then progress to rhythmic stabilization  Rhythmic Stabilization  A progression of alternating isometrics  Isometric contractions of agonists and antagonists in all 3 planes to produce a co-contraction  All hand contacts are placed on opposite joint surfaces simultaneously  Used to promote stability  Often performed in weight bearing positions to incorporate joint approximation in the procedure  PT applies multidirectional resistance and position is held  To make harder: close eyes, add weight, randomize direction of resistance, etc.  Stabilizing Reversals  Alternating isotonic contractions opposed by enough resistance to prevent motion with only a small movement allowed  Can isolate end-range, midrange depending on what you are trying to accomplish o Techniques to Increase Strength of Motor Control:  Reversal of Antagonists- stimulation of a weak agonist pattern by first resisting static or dynamic contractions of the antagonist pattern  Dynamic Reversals (slow reversal) o Active motion changing from one direction to the opposite

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o Dynamic concentric contraction of stronger agonist pattern followed by dynamic concentric contraction of weak antagonist pattern o No pause or relaxation between patterns  Stabilizing Reversals o Add an isometric contraction at the end range of each pattern o No period of relaxation o Used to enhance dynamic stability, particularly in proximal muscle groups Timing for Emphasis  Repeated Contractions o Repeated use of the stretch reflex to initiate a muscular response or to reinforce and strengthen a pre-existing contraction o “Quick stretch” o Initiated with repeated quick stretches followed by resistance at any point in ROM to strengthen a weak agonist component of the diagonal pattern Combination of Isotonics  Concentric, isometric and eccentric  Perform contractions of one group of muscles without relaxation  Ex: biceps: bend elbow (concentric), hold and don’t let me push you down (isometric), now slowly lower down (eccentric) o Can use weights for resistance

Progression:  Scapula: o Progression depends on your goal o Always think stability before strengthening within mobility (dynamic mobility) o Muscles:  Glenohumeral: rotator cuff, biceps-long head, deltoid  Scapular pivotors: serratus anterior, trapezius  Scapular stabilizers: rhomboids o Position progressions: prone on elbows with resistance  Progression from B UE to single UE while in prone on elbows  Add dynamic surface to progress further  B UE to single UE on dynamic surface o Add Weight Bearing:  Start on a wall with shoulders at 90 or modified plantigrade position  Progress to dynamic surfaces (ex: medicine ball) o Quadruped position  UE Progression: o Half kneeling is more stable than standing (wider BOS, lower COG); progress from table to half kneeling to standing o Add resistance band to patterns...