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PNF: Diagonal patterns and facilitation techniques

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- the stronger muscles in the diagonal pattern facilitate the weaker ones - the brain knows nothing of the individual muscle actions - only movements ---------------------------------------------------------------- - when facilitating, incorporate all 3 planes of movement - start in lengthening range and end in shortened range

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PNF

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- uses controlled sensory input - stronger muscles in diagonal patterns influence weaker ones - brain registers movement (not individual muscles) - PNF works with whole movement patterns to engage and improve motor output - a balance of antagonists are required - if an individual does not have this balance start with techniques that enhance the agonist movement

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PNF theory

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- brain registers total movement - movements are spiral and diagonal - facilitation techniques are superimposed on these movement patterns - based on combination of cardinal planes of movement: flexion/extension, abduction/adduction, internal/external rotation

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What is PNF? (quote)

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"A method of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptors." - sensory stimulation is provided through manual contacts

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PNF techniques are employed through patterns of movement using:

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-sensory stimulation - visual cues - verbal commands

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History of PNF: Kabat

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- founder of PNF approach - neurophysiologist and physician - began work with poliomyelitis and MS - expanded to many disorders including orthopedic conditions - arthritis, peripheral nerve injuries, painful shoulders he found that when groups of muscles were stretched, they produce movement in diagonal patterns. This is the same for functional skills and in atheletes

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History of PNF: theoretical background (Sherrington)

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1) Irradiation - facilitation of voluntary motion by another (when one m. fires, the other mm. fire) 2) successive induction - stronger antagonists facilitates a weaker agonist (ex: trying to move triceps, the biceps can be used) 3) reciprocal innervation

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History of PNF: Theoretical background (Gesell)

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- motor behavior and patterned movements Gesell studied children and their writing habits: first random, then vertical, then horizontal, then circular, and finally diagonal: applied to gross movements. He also suggested that movements develop in the same way. First an infant moves with random movements of the arms and legs, then flexion and extension (vertical movements) followed by abduction and adduction(horizontal) and circumduction (circular) and lastly diagonal movements. It is of interest that diagonal movements which are the most complex are the first to be lost with neurophysiological disorders.

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History of PNF: Hellebrandt

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- efficiency of movement (He found that certain combo of movements cn circumvent fatigue or speed recovery depending on the combination) - head movements affect arm and leg - studied TLR and ATNR

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History of PNF: Pavlov

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- studied learning and habit development - Pavlov dogs - salivation

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History of PNF: Margaret Knott

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- 1st physical therapist at the institution - worked alongside Kabat utilizing PNF approach - helped Kabat apply the techniques clinically

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History of PNF: Dorothy Voss

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- worked with Knott (1952-54) - expanded theory by adding developmental total patterns -Voss helped develop theory and introduced the concept of total patterns and whole body movements

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History of PNF: Voss and Knott

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Published first book in 1954 "Proprioceptive neuromuscular facilitation: patterns and techniques". Several editions have been published since 1954 Current edition is proprioceptive neuromuscular facilitation: patterns and techniques, 3rd ed., 1985. First course taught to OT's was in 1974 and continuing education courses are offered in PNF 1-2 week

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Diagonal Patterns

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- When topographical aligned groups of muscles were stretched they produced movement in a diagonal pattern -Functional movements and sport skills revealed spiral and diagonal characteristics, highly skilled movements - The most successful combinations were those that permitted maximum elongation of related muscle groups so that the stretch reflex could be elicited through a "pattern". -a diagonal position of a limb put the group of muscles in their maximum elongation and this facilitated, through the stretch reflex, a diagonal movement in the opposite direction.

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Evaluation with PNF

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1. Vital functions 2. Response to sensory cues 3. Head and neck patterns 4. Bilateral symmetrical to bilateral asymmetrical to bilateral reciprocal 5. Developmental postures 6. Functional taskS

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Vital Functions

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Vital functions: respiration and breathing, swallowing, voice production, facial and tongue movements,

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Sensory cues

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sensory (visual, auditory, and touch): what does the patient respond to

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Proximal to distal

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head and neck, upper trunk, upper extremities, lower trunk, lower extremities especially look at head and neck patterns which are the key to upper trunk patterns and observe during developmental and functional activities.

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Bilateral symmetrical to bilateral asymmetrical to bilateral reciprocal

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Movements develop in the following sequence and diagonal patterns return in the following sequence in patients with CNS disorders: evaluate where a patient is at during initial assessment and move the patient through the sequence in treatment Bilateral symmetrical, bilateral asymmetrical, bilateral reciprocal: influence of head, neck, and trunk postures, ROM, quality of movement: smoothness and rhythm, normal timing: coordinated

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Developmental postures

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Developmental postures: supine, prone, sidelying, sitting, quadreped, kneeling, standing (example: a person may not exhibit shoulder flexion during isolated arm movements but when rolling may be able to perform this movement)

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Treatment principles: 1

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All human beings have potentials not fully developed - Emphasis is on abilities to reduce inabilities, stronger movements strengthen weaker movements

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Treatment principles: 2

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2.Normal movement follows a cervicocaudal and proximodistal direction -Attention is first given to the head, neck and then trunk and then extremities (particularly true for a patient with severe disability or a comatose patient), head and neck are involved in postural reflexes, influences reflexes and postural response, weight tends to shift to the side you are looking at

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Treatment principles: 3

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3.Early motor behavior is dominated by reflex activity. Mature motor behavior is supported or reinforced by postural reflexes -Remember that reflex activity can be used to reinforce a movement, look to a certain side and create extension in the upper extremity using ATNR (integration of reflexes means they still are present in movement just not dominated by them)

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Treatment principles: 4

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4.Early motor behavior is characterized by spontaneous movement, which oscillates between extremes of flexion and extension. Rhythmic and reversing in character. -Goal directed activity is made up of reversing movements 1 Standing up or sitting down 2 Dressing and undressing 3 Taking something out of the refrigerator 4 Zip and unzip 5 Writing (adduction and abduction 6 Turning something on and off

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If patient is dominated by flexors facilitate extensors

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be careful in facilitating flexors too much (primitive response and may dominate) reciprocal patterns are goal

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Treatment principles: 5

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5.Developing motor behavior is expressed in an orderly sequence of total patterns of movements and posture

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Treatment principles: 6

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Normal movement and posture depend on "synergism" and a balanced interaction of antagonists

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treatment principles: 7

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7.Normal motor development occurs in an orderly sequence but overlap does occur.

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Sensory cues include

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-visual - auditory - tactile

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Visual sensory cues

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- look in the direction of the movement - engage the person in the task with vision

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Auditory sensory cue

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- verbal commands and tone of voice - Auditory: facilitate movement - tone of voice: soft voice if the goal is to reduce spasticity and slow down movement, loud to facilitate for weak muscles

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Tactile sensory cue

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- patient feels the movement "I do - I understand" - touch helps guide and reinforce movement - May just need to touch lightly to assist a fatigued patient to complete a task. Remember guiding and key points of control from NDT

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Facilitation techniques

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- practice, repetition - may break down the task into steps - goal directed techniques - to engage person in their environment - stress is needed for learning to take place - needs to be the right balance though

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Movements are in harmony with topographica alignment of the....

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muscles from origin to insertion and spiral and rotary characteristics of skeletal systems of bones and joints

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Diagonal Patterns - how are they made up, what is the major component, what are they combined with

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1. Each diagonal is made up of 2 patterns that are antagonistic to each other 2 flexion 2 extension * these refer to shoulder or hip (not the knee or elbow) 2. Each pattern has a major component of flexion or one of extension 3. the major components (flexion or extension) are always combined with two other components making a total of 3 components external or internal rotation abduction or adduction

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proximal pivots

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shoulder and hip

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Upper extremity: D1 flexion components

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flexion, adduction, external rotation But scapula is abducted, wrist is flexed, elbow can be flexed or extended, forearm is supinated, wrist flexed to radial side, fingers flexed

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UE: DI extension components

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extension, abduction, internal rotation Scapula: adducted, depressed, rotated, elbow extended, forearm pronated, wrist extended to the ulnar side, fingers extended and abducted, thumb abducted

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UE: D2 flexion components

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flexion, abduction, external rotation scapula is elevated, adducted and rotated Elbow flexed or extended, forearm supinated, wrist ext to radial side, finger ext and abducted, thumb extended

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UE D2 extension components

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extension, adduction, internal rotation Scapula is depressed, abducted, and rotated, elbow flexed or extended, forearm is pronated, wrist is flexed to ulnar side and fingers flexed and adducted and thumb is in opposition

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Supination of forearm and wrist to radial side consistent with....

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flexion and external rotation

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Pronation of wrist to ulnar side consistent with...

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extension and internal rotation

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Wrist flexion consistent with...

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shoulder adduction

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wrist extension consistent with..

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shoulder abduction

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Procedures

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1. Manual Contact 2. Stretch 3. Traction and approximation 4. Maximal resistance 5. Timing

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Manual Contact

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open hand placed on patient - direction of pressure guides movement - location of hand can guide direction of movement

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Stretch

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a quick stretch at end range - used to initiate voluntary movement - concentrate where needed - based on sherrington's principle of reciprocal inhibition Repeated stretch followed by assisted or voluntary motions can be effective technique in a patient with little or no voluntary control

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Shortened range of a pattern/lengthened range

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Example: D2 extension is the shortened range of D2 flexion, you would give the quick stretch into D2 extension to facilitate D2 flexion

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Traction and Approximation

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Traction: separating joint surfaces Approximation: compression of joint surfaces *both stimulate joint receptors

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Maximal resistance

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optimal resistance that still allows your pt. to move *does not mean the most resistance you can provide but the optimal resistance that still allows your patient to move through the complete range of the movement Resistance combined with stretch as in repeated contractions may elicit irradiation for the purpose of using the motions of the stronger muscle groups to facilitate the weaker ones (or components)

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irraditation

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contraction of stronger components facilitates contraction of weaker components

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Timing

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Increase response and stimulating action at a specific pivot within a pattern (what is missing?)

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Therapeutic application

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-All movements are reversing -Must have a balance of antagonists -If patient does not have this, first focus on techniques for the agonist -Need rotational component for PNF - it is not PNF if not rotational

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Positions and Treatment

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Side-lying, prone on elbows, quadruped, plantigrade, kneeling, half-kneeling, long sit, short sit, tailor sitting, heel sitting, side sitting and chair sitting Modified plantigrade: standing or sitting with both arms in contact with a surface such as a table Start treatment in a position where the client is most stable Progression: basic mobility (ROM), stability, controlled mobility, skill

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Progression

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Stability -Tonic holding -Co-contraction Controlled mobility: used once a patient demonstrates stability in a bilateral weight bearing position and isometric contractions in mid-range progress to one arm leaving contact with a stable surface, Simultaneous static dynamic (SSD) Consider the activity and the postural demands Can start in one posture, show progression, as patient fatigues return to less demanding posture

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Tonic Holding v. Co-contraction

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Tonic holding is where the muscles can maintain an isometric contraction in their shortened range where muscles can maintain an isometric contraction in mid-range

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Reflexes

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Reflexes support movement and underlie normal movement Use ATNR, optical righting reflex

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Controlled Sensory Input

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Quick Stretch and Resistance Tactile Visual Stimuli

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Quick Stretch

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Perform in lengthened range (use whole body)

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Resistance: Goal

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Goal is irradiation to weaker synergistic muscles (overflow)

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Tactile

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Where do you place manual contacts (MC)

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Visual Stimuli

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Optical righting reflexes Head neck and trunk patterns

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Basic Techniques

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First observe and decide which is the agonist movement and which is the antagonist Irradiation: weaker components of the movement are facilitated by the stronger muscle groups reciprocal inhibition: voluntary contraction of the muscle results in the antagonist relaxing Successive induction: the stronger antagonist becomes a source of proprioceptive facilitation for the weaker agonist- one action lowers the threshold for the other action

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