Lecture 2: Foundation for General Neuro-Based Interventions Flashcards
Our goal in Neuro is to optimize functional competence.
* The ability to perform daily activities in a variety of environments, under different conditions, with a minimal expenditure of physical and cognitive resources. We want them to get to the point where they don’t feel like they have to put so much effort into every single action. This includes the cognitive realm (thinking about not falling for instance)
This is kind of like a new normal. Some people have all their normal functions come back after a stroke and they feel like they’re “normal” again. While others dont
4 principles of neuro rehab - don’t memorize these
1) Effective neuro rehab involves a continuous cycle of deductive and inductive reasoning
2) The goal of neuro rehab is functional competence
3) Functional competence is promoted by basing rehab strategies on embedded models of motor behavior and neuro rehab
4) Functional competence requires motor learning and self efficacy
* Self efficacy = the condifence in yourself to do something. The more confident you are in doing something the better its going to turn out
*
Use of theories or models to guide interventions is inductive or deductive reasoning?
Deductive
Use of patient releated data to support or reformulate theories is inducted or deductive reasoning?
Inductive
these are more our obsevrations
How models can affect what we do
* movement science
* Medical Science
* Rehabilitation science
Coordinate that deductive reasoning w/ our observations (inductive reasoning)
how you view something is everything. Your lense / interpretation makes everything different
You can see the other 3 pictures show different treatment styles. Using different techniques to get the same outcome to decrease tone. Different ways we will approach one pt. Theres no one set way, but there are things you shouldnt do. Not every therapist sees things from the same POV
Different approaches for neuro rehab: - probs mix and match
1) muscle reeducation - theoredical basis is on the physiology of the muscle. Importance of pt knowledge and and motivation. Conscious activation and relaxiation of the muscles. Assumes that increased strength and endurance improves function - however this isnt true, and we know we might not be able to strengthen a m after an injury - however, they can learn techniques to work around that
2) Neurofacilitation - looking at reflex and heirachical models of motor contorl - here they want normal posture and tone - then work w/ them so fix these details first
3) Motor learning - mostly base don healthy individuals is the problems w/ these studies. Emphasis on patient driven approach to motor planning, error detection, and problem solving. Emphasis on importance of task and environment; Use of task and environment set-up information delivery, and structured practice for motor learning. Motor learning is the process of acquiring and refining skilled movements through practice and experience
Which of our 3 theraories (muscle reeducation, neurofacilitation, motor learning) is focused on the use of strengthening exercises and conditioning activities to promote the performance of functional activities with the least energy cost to the pt.
In this theory we increase the strength and contorl of areas of the body beliebed to be spared by a pathology, rather thant rying to restore lost functions
Muscle reeducation
Assumption: increase in strength will directly translate into improved function
Principles: anatomy, kinesiology, exercise science
Which neuro therory focuses on specific exercises, not actual tasks and environment
Muscle reeducation
In which of our neuro theries should pts relearn functional activities through practice and repetition of the normal movement patterns used by healthy individuals?
Manual guideance and sensorimotor stimulation were used to eleicit and strengthen motor responses, and specific movement progressions where utilized to promote the restoration of skilled motor behavior
* these will help you form that skill
Allowing erroneous or compensatory movements was beleieved to interfere w/ the restoration of skilled motor control - so we want to normalize/correct the abnormal movement
Principles: reflex, feedback, hierarchial models of motor contorl.
Neurofacilitation
Get them in that normal pattern and only focus on that normal pattern.
Which neuro theroy says: Motor behavior of patients with neurological pathology reflected their best attempts to carry out functional tasks with a limited motor capacity
Patients needed to learn to regain their motor function as independently as possible through structured exploration of motor tasks, self assessment, information processing, self-correction, and practice
Principles: biomechanics, neuroscience, cognitive and behavioral psychology, cybernetics and human ecology.
Motor learning
remember motor learning is in everything we do, not just neuro
In the neuro setting we need to
* Promote neuroplasticity
* Function based therapy
* integrate multiple components of the therories
10 principles of neuro plasticity
Which principle of neurplasticity is failure to drive specific brain function can lead to functional degradation
Use it or lose it
Which principle of neuroplasticity is training that drives a specific brain function can lead to an enhancement of that function
Use it and improve it
Train that function to better that function
Which principle of neuroplasticity is the nature of the training experience dictates the nature of the plasticity
* has to be specific to what the goal is
Specificity
Which principle of neuroplasticity is induction of plasticity requires sufficient repetition
Repetition matters
Which principle of neuroplasticity is induction of plasticity requires sufficient training intensity
Intensity matters
Which principle of neuroplasticity is different forms of plasticity occur at different times during training
* think someone had a stroke and didnt get therapy for a while. That time that wasnt spent healing will be a major factor in not getting back to prior level of function
Time matters
Which principle of neuroplasticity is the training experience must be sufficiely salient (releates to pt) to induce plasticity
Salience matters
needs to be meaningful and important
Which principle of neuroplasticity is plasticity in response to one training experience can enhance the acquisition of similar behaviors
Transference
Which principle of neuroplasticity is plasticity in response to one experience can interfere with the acqusition of other behaviors
* think if someone was going through rehab and stopped, that could interfere w/ their progression or if something else happened at that time (think another event)
Interference
Knowledge check: What kind of reasoning would be more pt releated information?
Inductive
Remember, deductive is the models
Principle 2: The goal of neuro rehab is functional competence
Activities that are meaningful and important to the pts life motivates and engages the pt
* think salience
Goals of body structure and function are part of this, but should not supersede the goal of functional competence
Setting ROM/MMT goals wouldnt supercede standing and getting out of a chair for a neuro pt
* Function first - link everything to function
Through movement strategies/patterns were trying to create coordination (also known as schema)
We are coordinated individuals, the halves of our body work together. However, in neuro injuries the halves of the body don’t work togther properly
* so our schema after a neuro energy is damaged
Another word for coordination mode?
Schema
What we use to carry out a motor task. Its a plan
Movement strategies
The actual kinematics employed to perform the task?
Movement patterns
General form of actions that can be adapted to specific tasks and environments
* EX: how to perform sit to stand
Coordination mode (schema)
pts need to generate a variety of movements with flexible coordination modes when carrying out activities, not just performing a specific set of movement patterns
* so you need to know how to do a sit to stand in multiple different environments
* Not just a specific set of movement patterns
Principle 3: Functional competence is promoted by basing rehab strategies on embedded models of motor behavior and neuro rehab
* rehab works when we can give our pt a well designed functional task that quires the use of desired movements in a meaningful context
* so were designing a program where a pt is able to use tools / what they learned and be sucessful in their lives
Promote spontaneous use of the pattern within functional tasks (carryover)
Increase availability of movement patterns to increase strategies
* have more tools in the toolbox
Embedding - meaningul tasks that require performance of the targeted movement pattern
* EX: supination impaired after CVA - incoporate into opening a book, carrying dinner plate
Meaningful task that require performance of the targeted movement pattern
Embedding
EX: supination impaired after CVA - incorporate into opening a book, carrying dinner plate
* things that are meaningful to the pt
A = traditional ICF model
B = we want to also make sure were opening our eyes to see the ICF as an imbedded model.
* think about the impairment being at the core and were building around it
* especially if that health condition isnt going away
Principle 4: Functional competence requires motor learning and self efficacy
Choose interventions and use rehab strategies that promote retention and transfer of skills, not just initial performance
An important key to learning is to optimize patient engagement by manipulating the conditions for pt experiences and practice and building the confidence of pts in their abilities
* give them the environment to build confidence to make errors then advance it
Should always incooperate aerobic EX in w/ pts
Promotes:
* Greater capacity for motor learning and neuroplasticity
* Improved executive function
* Improved cardiovascular health and physical performance
Recent advances in the study of neuroplasticity show aerobic EX as low as 30 minutes of exercise at 60% of maximum heart rate increases production of brain derived neutrophic factor, an important facilitator of motor learning and neuroplasticity
Pt w/ gratest potential
* Motivated, confident in their abilities, and wiling to meet the challenges they encounter when performing functional tasks
One of the most commonly reported barriers to EX and mobility for pts at home in the community is low self-efficacy
* Self-efficacy = belief in self that task can be accomplished or goal can be achieved
Motor learning: Learning the mechanics of their new self-organized system, how to utilize mechanisms of control at various levels of their system, and how to use a variety of strategies and mvoements to carry out their desired activities with the least cost to their system
* so its all about efficiency and how to self organize efficiently
* initially after some big event (think a stroke) their energy usage will be through the roof because they are inefficent (think not being able to use half their body) - however, w motor learning they adapt to the new normal and will decrease their total energy expenditure
motor learning abilities among individuals vary across three main foundational categories of abilities:
1) cognitive abilities
2) Perceptial speed ability
3) Psychomotor ability
factors to be aware of: alertness, anxiety, memory speed of processing information, speed and accuracy of movements, and uniquness of the setting
Recovering patients may vary in their learning potential according to the pathology present, the number and type of impairments, recovery potential and general health status, and comorbidities
NOTE: we set the goals to their prior level of function before the event
* if the were non ambulatory we dont want to set gait goals
main principle of motor learning: optimize pt engagement
* what two things make this up
Acqusition of new behavior + retention and transfer of that behavior
So motor learning = acquire skill –> keep the skill –> transfer the skill
What are the 3 stages of motor learning?
Cognitive - What to do
Associative - How to do (physically doing it)
Autonomous - How to succeed
* environment is very variable, and they should be very independent and ready to take on new tasks
* errors should be minimal and they should have good carry over to lots of environments
When breaking down motor learning
Think about:
* Task (general task and demands)
* Individual (body functions)
* Environment (physical features)
“TIE”
Knowledge check: in what stage of motor learning would require the least amount of cueing and be good in the most variable environment
Autonomous
True motor learning = retention of the motor skill
* they can replicate it in any environment
* Factors liek fatigue, anxiety, poor motivation, boredom, or drugs can cause performance to deterorate during practice while learning may still be occured
Defined as a leveling off of performance after a period of steady performance
* Is learning still happening?
Plateau
Characterize normal practice and can be expectued
During pleastus, learning may still be going on, whereas performance is not changing much
* spin the narrative and maybe tell the pt that they need to go home and work on things and come back later
The patient who is able to engage in active introspection and self evaluation of performance and reach decisions independently about how to improve performance demonstrates an important element of learning
* if you can reach your own decisions on what you need to do, thats awesome
Much of the necessary learning of functional skills occurs after discharge and during outpatient episodes of care
The therapist cannot possibly structure practice sessions to meet all of the functional challenges the patient may face
* set your goals wisely
* pt may take a break or come back later
The acquisition of independent problem soliving/decision making skills ensures that the ginal goal of rehabilitation can be achieved
* having the pt be more independent and thinking about their own body is best
out patient works more on skills
in patient is more about getting them moving / discharged
Is our goal restoration or compensation?
Its both
Of course we want to restore as much function as possible, but some times thats not possible so thats why we add compensation techniques when they plateu or have total paralysis
A sequence of practice and rest times in which the rest time is much less than the practice time
Massed practice
Spaced practice intervals in which the practice time is equal to or less than the rest time
Distributed practice
A practice sequence organized around one task performed repeatedly, uninterrupted by practice or any other task
Blocked practice
So again, this is the pt repeating the same skill loads of time in a row before moving on to another skill
* think shooting 50 free throws in a row before moving to some other skill
* Good for beginners because they have less time to forget
A practice sequence in which a variety of tasks are ordered randomly across trials
Random practice
The gain (or loss) in the capability of task performance as a result of practice or experience on some other task
Transfer training
components parts of a task are practiced before practice of the whole task
part/whole practice
A practice strategy in which performance of the motor task is imagined or visualized without overt physical practice
Mental practice
Feedback can be
* Extrinsic
* Intrinsic
* Knowledge of results - task success - external focus
* Knowledge of performance - how to task was perfomed - internal focus
Environment can be:
* Closed - think working on eye movements in a dark room where theres not much going on
* Open - think being in a gym with lots of things going on. This can just be some changing things.
* Variable - this can also be the gym and you can’t contorl for a lot of things happening
how the task was performed is knowledge of results or knowledge of performance?
* internal or external focus?
Knowledge of performance
internal focus
Task sucess is knowledge of performance or knowledge of results?
* internal or external focus?
Knowledge of results
External focus
While you were walking you dragged your feet. Knowledge of results or knowledge of performance
Knowledge of performance
Wow, you just walked 200 feet is knowlege of performance or results?
Results
Different constrains (on motor learning I think)
All of this overalps on individual to impact their ability to learn - based on their diagnosis this will obviously shift
Therapists design the intital plan of rehabilitation by:
* Understanding the pathology, impairments and functional limitations of patients and the ways tasks and environments, information delivery and practice can be used to optimize pt engagement
* Optimize pt engagement, if they’re just coming in 1 time a week they’re not getting better. espically in a neuro setting.
Considerations include:
* Interactions that occur between the intrinsic biomechanical, psychological and neuromuscular constrains of pts
* Extrinsic spatial and temporal constrains of tasks and environments - what is their environment like?
* How the interal information processing of pts can be enhanced
* Optimal strategies for practice - how do we make them excited and give them the tools they need.
Theraputic progression model three categories
1) Those releated to motor learning
* What do they need to learn
2) Those releated to characteristics of the movement or task
* impairment level stuff you need to do
3) Other considerations such as equipment used and the level of physical assistance provided
* Equipment that lets them reah goals
Progression
Start w/ less advanced tasks –> more advanced
Think starting in hallway w/o people –> hallway w/ people
I like how high you picked up your feet when stepping over the cones is knowledge of performance or results?
Performance
Talking about an aspect of the task
3 neurorehabilitation models
1) Neurofacilitation
2) Task-Oriented
3) Complementary Movement
Which neurorehabilitation model:
* is Based on reflex and hierarchial models of motor contorl
* Developed for individuals w/ abnormal sensorimotor function or muscle tone and were used to either inhibit abnormal movement or facilitate more normal motions
* Still in use today
Neurofacilitation
What are the 4 levels of motor contorl?
Mobility
Stability
Controlled mobility
Skill
What part of motor contorl is free, flexible motion that translates the body or body part in space and includes qualitites of range and speed?
Level 1: mobility
What part of motor control is cocontraction of agonists and antagonists that fixes parts of the body to allow for weight bearing and latear allow for dynamic holding in levels 3 and 4
Stability (level 2)
So agonist and antagonist are contracting
What part of motor contorl is the distal body parts are fixed on the support surface and the proximal segment moves over a fixed distal segment (weight shifting)
Controlled mobility (level 3)
think shifting in quadruped
* contorlled mobility
What part of motor contorl does is the distal part of the extremity is free from the support surface and coordinated movement of this segment is superimposed on proximal stability?
Skill (level 4)
Think alternating arm in leg in quadruped. think bird dog
Motor contorl levels:
Mobility –> Stability –> Contorlled Mobility –> Skill
This is showing mobility –> stability –> combined mobility and stability in weight-bearing –> skill
So its showing how they transfer
What does facilitation mean?
arousing / exciting / getting a contraction
think light touch, tapping, quick stretch etc… were trying to excite the muscle
Inhibitory means?
If someone has a tight muscle, we want to relax it. So think the opposite of muscle contraction
were inhibiting the tightness of that muscle
This is an example of how to manage high tone
Application of quick light strokes to the skin over a muscle using either fingers, cotton, or a brush facilitates contraction of the underlying muscle
* This is facilitation or inhibition
Light touch
facilitation
involves brisk taps with fingertips over the tendon or muscle belly of the involved muscle to facilitate phasic contraction of this muscle
* This is facilitation or inhibition
Tapping
* facilitaion
A quicj over elongation of a muscle (often applied at its lengthened range) facilitates contraction of the muscle
* This is facilitation or inhibition
Quick stretch
* facilitation
Quick Stroking with ice on the skin over the muscle belly facilitates contraction of the underlying muscle
* This is facilitation or inhibition
Quick ice
* facilitation
Manually applied distraction force to a joint or limg segment causes muscle relaxation and promotes movement
* This is facilitation or inhibition
Traction
* facilitation
Compression of a joint or body segment stimulates contraction of muscles around the body segment and promotes stability
* This is facilitation or inhibition
Approximation
* facilitation
Think putting hand on table and leaning down into it. The muscles are having to contract to keep the shoulder/elbow/wrist from dislocating causing muscle contraction
however, she said this was appropriate for pts w/ increased and decreased tone (so I think its faciliattion and inhibition technique)
Manual application of force away from the axis of motion at the joints as the pt is asked to move or to stabilize
* This is facilitation or inhibition
Resistance
* Facilitation
Application of slow passive lengthening of a muscle inhibits its contraction
* This is facilitation or inhibition
Prolonged stretch
* inhibition
Think turning off muscle spindles by staying in that squat position
Manual pressure across the longitudinal axis of the muscle tendon causes relaxation of the muscle
* This is facilitation or inhibition
Deep Pressure
* inhibition
Wrapping of body or limb in blanket, towel, or air splint for purpose of general relaxtion
* This is facilitation or inhibition
Neutral warmth
* inhibition
Slow stroking with the hand along midline of the back, near the posterior rami, for 3 to 5 minutes leads to calming of pt
* This is facilitation or inhibition
Slow stroking
* inhibition
Application of an ice pack or ice massage over a muscle leads to its relaxation and reduction of pain
* This is facilitation or inhibition
Prolonged cold
* inhibition
These just suck. Memorize the individual positions.
What is a synergy?
When several muscles come together to do a movement
* think agonist and antagonist working together for a movement
A stroke can cause abnormal synergies. What happens is either a flexion or extension synergy
They can also be upper or lower extremeity
Explain an UE flexion abnormal synergy
Explain a UE extension abnormal synergy
Explain a LE flexion abnormal synergy
Explain an LE abnormal extension synergy
NOTE: you cannot have a flexion and extension synergy in the same extremeity at the same time
Explain stage 1 of motor recovery following a stroke (Brunnstrom)
Extremities are flaccid. This typically occurs immediately after the lesion and typically persists for a few hours to a few days - flaccid, this is like the shock phase
* however you can get stuck in this category
Explain stage 2 of motor recovery following a stroke (Brunnstrom)
Minimal volitional motions are possible and associated reactions are seen in synergistic patterns. Spasticity begins to develop - no longer flacid
* so this is right after that shock phase
* spasticity = velocity dependent (velocity matters)
Explain stage 3 of motor recovery following a stroke (Brunnstrom)
Voluntary control of the synergies is possible through partial range. Spasticity will peak during this stage.
Explain stage 4 of motor recovery following a stroke (Brunnstrom)
Limited motions combining the synergistic movements are possible. Spasticity begins to decline
Explain stage 5 of motor recovery following a stroke (Brunnstrom)
More advanced movement combinations are possible as spasticity continues to diminish
* pt is begining to get more isolated w/ movements (due to the decreased spasticity)
Explain stage 6 of motor recovery following a stroke (Brunnstrom)
Isolated movements are possible with near normal coordination. Spasticity has declined and may only be evident with increased speed of movement
* spasticity is near gone
Happens when patients move into the synergistic patterns involuntarily when another part of the body is performing a strong or forceful movement
* voluntary or involuntary
* what pathology leads to this
Associated reaction
* this is completely involuntary
* Stroke leads to this
Knowledge check: Which of these options are a facilitation technique = tapping over a muscle belly to get a contraction
Health Promotion:
* Includes all factors, information, and activities that improve the health status of an individual or population
* Comprises a large body of knowledge representing many academic and clinical disciplines including education, public health, and psychology
* Integrated into health professions!
*
Doesnt know the risks associated w/ smoking. doesnt understand that it can releate to healing
* says she will do anything but still smokes
lots of things go into wellness
A dynamic physical state- comprising cardiovascular/pulmonary endurance; muscle strength, power, endurance, and flexibility; relaxation; and body composition - that allows optimal and efficient performance of daily leisure activities
Physical fitness
A multidimensional state of being, describing the existence of positive health in an individual as exemplified by quality of life and a sense of well being
Wellness
A state of being associated with freedom from disease, injury, and illness that also includes a positive component (wellness) that is associated w/ a quality of life and positive well being
Health
Prevention of disease in a susceptible or potentially susceptible population through specific measures such as general health promotion efforts
* decreasing modifiable risk factors
Primary prevention
So decreasing modifiable risk factors is an example of this.
* Smoking
* trying to do something to decrease the risk of actually developing the pathology
Efforts to decrease duration of illness, severity of disease, and sequelae through early diagnosis and prompt intervention
* Early detection and prompt treatment
Secondary Prevention
* think prompt treatment following an event (starting PT)
* so the difference is that they have it already and now were trying to make it less bad
Efforts to decrease the degree of disability and promote rehabilitation and restoration of function in patients w/ chronic and irreverible diseases
* Limiting complications in estabilished disease
Tertiary prevention
Think limiting complications in an established disease
* Pt has bed sores due to lack of ambulation following a stroke, preventing this would be considered tertiary prevention
give them resources
how smoking gets easier w/ time
target these areas
Knowledge check: Which level of prevenetion limits complication in established diseases
Tertiary
Lecture break
What are Task oriented approaches?
Essentially breaking down a task into its subparts
* range from repetition of component parts of functional tasks to completion of obstacle courses requring problem solving skills
Motor Relearning Programme - MRP
* Step 1: Observation and analysis of the task
* Step 2: Practice of the missing components with feedback
* Step 3: Practice of the task with feedback and ongoing reevaluation
* Step 4: Transference of training in varied environments to enhance consistency
Explain the 4 steps of motor relearning programme in the task oriented approaches
- Step 1: Observation and analysis of the task
- Step 2: Practice of the missing components with feedback
- Step 3: Practice of the task with feedback and ongoing reevaluation
- Step 4: Transference of training in varied environments to enhance consistency
So if pt has trouble walking you don’t go right into walking. You break things down. Maybe work on leg strength, or sit to stand then walking. Break task down then start putting it together in variable environments
What is constrain-induced movement therapy?
Constraining the uninvoled side and making the impacted side have to work harder
* lazy eye example
What are complementary movement approaches?
Unconventional approaches
* think thai chi / yoga / aquatics
Proprioceptive Neuromuscular Facilitation (PNF) - Therapist identifies the neuromuscular and musculoskeletal problems of the whole pt and guides them to attain the highest activity and participation level as possible
* its a group of movements we take the pt through to help them be more functional in their everyday tasks - NEEDS TO TRANSLATE TO FUNCTION
* We can do a PNF while someone is doing a sit to stand, or a roll - you can use them functionally
PNF
Guides pts to reach better kinesthetic awareness and neuromuscular control
Facilitates improved efficiency of movement, timing and coordination
Increases ROM, strength, endurance
Procedures of PNF
Manual Contacts w/ PNF training
Contact on the side of the limb in the direction of movement
Start w/ 1 hand distal and the other proximal (so don’t grab around them I guess)
Keep your body in line w/ the motion
Cue pts head/eyes to follow
Lumbrical grip
Touch is healing!
Purists used to say you have to do it a specific way - however, research is spotty on this and this is probs untrue
Verbal Commands - For PNF
* clear
* Simple
* Appropriate timing
* Engaging - not boring
All encompasing patterns below
* movements are specific and the patterns are named for diagnals in flexion or extension
* Scapula and pelvis named for depression/elevation
* we do not have to use these exact cues that are below, those are for the purists - which we are not
What promotes movement traction or approximation?
Traction
* makes sense, we traction a joint to get more movement
* This could be for stroke pts who have higher tone and were trying to losen it up
What promotes stability traction or approximation?
Approximation
* think pushing hand into table
* This would be done for people w/ people who are hypotonic
What technique is used by bring on a stretch reflex by elongating a muscle or synergistic group of muscles to their lengthened range, then quickly overelongating the muscle to facilitate muscle contraction
* explain why it brings on that muscles contraction?
Quick stretch
* essentially lengthening the muscle so it can snap back and quickly concentrically contract
It causes the muscle spindles to concentrically contract the muscle (because remember, they respond to muscle stretch/elongation) which causes contraction of the agonist muscle
This is synchronized w/ a verbal command and is followed immediately by appropraite resistance
* you give a verbal command then go through the PNF pattern
so your prestretch them before going into the pattern
What 3 patterns of movement do we follow for PNF stretching?
* is it just one joint?
Patterns are diagonal/ rotation (think supination/pronation) - think the PNF pattern for flexion/extension
* we don’t do a straight plane single joint movement - we want multiple muscles involved
Multi joint
How are PNF patterns named?
Named for the end result of the movement combination that is occuring
* so if you end in flexion than its named flexion
Describe D1 flexion
Describe D1 Extension
exact opposite of D1 flexion
D1 flexion pattern
* notice its named flexion because you’re ending in flexion
D1 extension pattern
Describe D2 flexion
Describe D2 Extension
D2 flexion pattern
D2 extension pattern
Describe LE D1 flexion
Describe LE D1 extension
PNF LE D1 flexion
LE D1 extension pattern
Describe D2 LE flexion
Describe LE D2 extension
LE D2 flexion
LE D2 extension
all of the patterns compared to eachother
* repeating info from before
The above are all unilatearl patterns
We can have:
Bilatearl symmetrical
* same pattern w/ both extremeities moving in the same direction
Bilatearl asymmetrical
* Same pattern but extremeities are moving opposite directions
Reciprocal symmetrical
* different pattern moving in the same direction
Reciprocal alternating
* different pattern moving in opposite direction
Same pattern but extremitites moving in same direction
Bilateral symmetrical
Same pattern moving in opposite direction
Bilatearl asymmetrical
Different pattern moving in same direction
Reciprocal symmetrical
Different pattern moving in opposite direction
Reciprocal alternating
Knowledge check: how should starting hand palcement be fore PNF?
One hand distal and one proximal for contacts w/ PT
Describe the two movements here
Up arrow = Anterior elevation (moving up and forward)
Down arrow = posterior depression
this of it this way: if you kept going along the line would you elevate or depress? would you translate anterior or posterior?
Describe the directions the shoulder blade is moving
Up arrow = posterior elevation (sliding around the back of the rib cage being more posterior)
Down arrow = anterior depression (sliding forward around the rib cage)
This is the PNF patterm for scapula anterir elevation (note - you can sneak you hand under arm so it moves better)
PNF pattern for scapular posterior depression
PNF pattern for scapular anterior depression
PNF pattern for scapular posterior elevation
Describe the patterns at the hip (remember, the reference point is the top of the iliac crest)
Up arrow = anterior elevation
Down arrow = posterior depression
Describe what motion is happening at each arrow
Up arrow = Posterior elevation
Down arrow = Anterior depression
this one is confusing
PNF pattern for pelvic anterior elevation pattern
notice how knees are bent for all these
PNF pattern for posterior depression
PNF pattern for posterior elevation
PNF pattern pelvic anterior depression
Remember post stroke lots of these areas were wokring on my be very stiff
PNF techniques:
Rhythmic initiation (PNF technique)
* Facilitating or inhibitory?
* What kind of pts is it used for?
* How is it done?
Facilitatory
Used to treat patients who have difficulty initiating or controlling the speed, direction, and/or quality of movement
Can be used to teach new movement
Therapist moves the extremity passively, then asks the patient to slowly take over the motion
* so therapist starts, pt takes over
* were taking the pt through the movement pattern. We do this before we work into higher level tasks w/ them
* Because they have difficulty initiating or contorlling the quality of the movement (said above)
MAKE SURE YOU KNOW THIS IS DONE WHEN THE pt HAS DIFFICULTY INITIATING MOVEMENT
Agonist reversal/combination of isotonics (PNF tehcnique)
* faciliating or inhibitory?
* What is there a focus on w/ this technique?
* What is it used for to do? (3)
* How is it done?
Faciliating
Used to assess and treat the patient’s ability to perform and alternate between different types of muscle contractions with a focus on eccentrics
For the rest of these tecniques you’re picking out their challeng and deciding what they need to work on.
Used to increase joint ROM, improve strength, and improve coordination of movement
Concentric contraction of the agonist group, momentary isometric, eccentric back to starting position
GPT:
Concentric Contraction – The patient actively moves through a motion against resistance (e.g., lifting a leg or pushing against a therapist’s resistance).
Isometric Hold – At the end of the movement, the patient holds the position briefly without moving.
Eccentric Contraction – The patient slowly controls the return to the starting position while still resisting the movement (rather than just letting gravity take over)
https://www.youtube.com/watch?v=P8aLuuhZauo&ab_channel=DaniTann727
Repeated contraction/repeated quick stretch (PNF tecnique)
* faciliating or inhibitory?
* How is it done?
Faciliating
Repetive use of the stretch reflex to initiate a muscular contraction or to reinforce and strengthen an existing muscle contraction
* so, stretch the opposite way (lengthen the muscle) then contract it
Used to increase active ROM of the agonist to achieve relaxation of the antagonist, and to improve strength and endurance of the agonist
Repeat the pattern with quick stretch at the beginning each time, or quick stretch any time during the pattern to icnrease muscle recruitment
Reversal of antagonist techniques
Promote coordinated contorl between antagonistic muscle groups and to promote smooth reversal of direction of movement
Maximum contraction of the antagonist muscle reciprocally inhibits the agonist
This is focusong on the m on the back side of the movement.
GPT:
Resisted Contraction of the Antagonist – The patient moves in one direction against resistance, activating the antagonist muscle group.
Reciprocal Inhibition – The strong contraction of the antagonist temporarily inhibits the agonist, allowing for better control and relaxation.
Smooth Transition to the Agonist – The patient then smoothly reverses the movement in the opposite direction, activating the agonist muscle group.
Repeating the Cycle – This pattern is repeated back and forth, improving coordination, strength, and fluidity of movement between opposing muscles.
Slow reversal/isotonic reversal (PNF techniques)
* describe how its done?
* Whats it specifically used for
Facilitate alternating, concentric contractions of anatgonistic muscle groups within the same diagonal pattern
Continuous motion, resistance in both directions (slow-reversal hold = isometric contraction at each end before reversal of motion)
* so your hands are kind of going back and forth to where you’re resiting, however, there is always resistance
Used specifically to increase stability because the person is always working and moving
* not great for someone who is very weak because they will fatigue easily
Alternating isometrics (PNF technique)
Used to improve isometric strength of postural muscles of the trunk or proximal stabilizing muscles of the limbs
Manual resistance on one side with smooth shift to manually resist opposite side
great for someone thats weaker because were working on isometric control.
GPT:
The patient holds a position while the therapist applies manual resistance to one side.
The therapist smoothly shifts resistance to the opposite side, requiring the patient to maintain stability without losing posture or position.
The patient does not move but must activate muscles isometrically to resist the force.
This pattern continues, strengthening the stabilizing muscles and improving control.
Rhythmic stabilization/Stabilizing reversals (PNF technique)
Used to improve pts postural control, balance, and stability in various functional, weight bearing positions such as sitting or standing
Similar to alternating isometrics, with a focus on rotation
This is similar to alternating isometrics, except its adding rotation
* think someones in seated and you’re trying to rotate them - telling them not to move while you push on either side of them - thats rhythmic stabilization
Which PNF technique is used w/ the weakest pts?
Rhythmic initation
once you progress from this you can sprinkle in the other techniques
Contract relax PNF technique
* facilitating or inhbiting move?
* How is it done?
Inhibiting
* You would want to inhibit a movement when theres high tone (when the muscle is over excited)
Achieve relaxation of muscle antagonistic to the active muscle group to increase ROM into the agonist movement pattern
Antagonist muscle isotonic contraction maximally reissted, passively moved into increased range (reciprocal inhibition)
did this when I played soccer
GPT:
Passive Stretch – The therapist passively moves the limb into a stretch until resistance is felt.
Resisted Contraction of the Antagonist – The patient actively contracts the antagonist muscle (the muscle being stretched) against maximal resistance for a few seconds.
Relaxation and Passive Movement – The patient relaxes, and the therapist passively moves the limb into a deeper stretch, increasing ROM.
Repeat as Needed – This cycle is repeated multiple times to continue improving flexibility.
Hold reflex PNF technique
* facilitating or inhibiting?
* Describe it?
Inhibitory technique
Used to achieve relaxatino and icnrease ROM, but of the muscles active in the agonist pattern itself, particularly when tehre is pain or when the patient may be able to overpower the therapist w/ contract relax
Agonist isometric contraction, passively moved into increase range (autogenic inhibition), agonist isometric contraction
GPT:
Passive Stretch – The therapist moves the limb into a comfortable stretch and holds it.
Isometric Contraction of the Agonist – The patient performs an isometric contraction (pushing against resistance without movement) using the agonist muscle (the muscle being stretched). This contraction is held for several seconds.
Relaxation and Passive Stretch – The patient relaxes, and the therapist gently moves the limb into a deeper stretch, increasing ROM.
Repeat as Needed – This process is repeated multiple times to gradually improve flexibility.
For PNF
Is setting dependent, but even when getting someone into bed you can be working on this shit
In out pt its easy to do these w/ a medicine ball or a theraband.
however, in inpatient / neuro your focus is function so maybe work on them when getting into bed
* or use them to help them stand up
Contraindication for PNF:
* Recent surgery
* Orthostatic hypotension
* dislocation
* several more, we just came up w/ these in class
When to apply these PNF techniques: (making them functional)
Bed mobility: rolling, side-lying <> sit
Transfers: sit <> stand
Pre-gait/gait: weight shifting in standing, hip flexion needed for walking, ankle DF needed for walking
Balance: sitting, standing
UE activities: reaching OH, reaching into pockets, donning/doffing shirt
when doing PNF:
* want to be on sides of pt
* she basically went through all the PNF shit that was on the slides (pelvis, scap, UE)
NOTE: there is a lab sheet that was unfilled out
NDT:
* hands on approach
* Key points of control
* Control the pelvis to control the motion
* Facilitate vs inhibit movement patterns
* Key component - analysis of posture first and its impact on function - think of core tability and alignment
NDT key points of contorl
* do we start proximal or distal?
Start proximal move distal
Pressure you provide is based on what the pt needs
Goal for patient to gain control of the movement pattern
How to progresss: increase speed, increase weight shift, alternate task/environment, equipment - therapy ball (integrate all sensory systems)
w/ NDT
Facilitate the muscles/groups that are not working
Inhibit abnormal movement or abnormal tone
Always start with the pelvis!
Passive motion –> active assisted –> active –> resisted/isometric
Normal to use both aspects in a treatment session
* Both inhibition and facilitation
Is NDT symmetrical?
Yes
