PNF Lower Trunk and LE

Question 1

Why PNF

Answer 1

• Can improve performance of functional tasks by increasing strength, flexibility, ROM, & overall motor control
• Uses the developmental sequence as a guide to promote achievement of progressively higher levels of proficiency and functional independence in bed mobility, transitional movements, sitting, standing and walking

Question 2

Essential elements of PNF

Answer 2

• Manual contacts
• Body position and body mechanics
• Stretch
• Manual resistance
• Joint facilitation
• Timing of movement
• Patterns of movement
• Cues: visual cues and verbal input
• Irradiation/reinforcement

Question 3

Describe pelvic patterns

Answer 3

• More limited ROM vs scapular patterns
• Utilize same clock as with scapular patterns
• Diagonals: 11-5 o’clock = posterior elevation to anterior depression; 1-7 o’clock = anterior elevation to posterior depression

Question 4

Functionally relevant pelvic patterns during gait

Answer 4

• Anterior elevation: pull your pelvis up & forward; promotes pelvis protraction during preswing
• Posterior depression: sit back into my hands; promotes trailing limb posture

Question 5

Describe D1 hip flexion

Answer 5

• Hip flexion, adduction, & ER
• “Pull your foot up & in and pull your leg across”
• Works against spastic patterns, promotes swing phase
• Functionally: cross leg while sitting, take off shoes
• No knee/ankle movements
• Think dog & fire hydrant
• Not frequently used functionally but a good exercise to break abnormal synergy by combining ankle eversion with DF (difficult for stroke pts)

Question 6

Describe D1 hip extension

Answer 6

• Hip extension, abduction, & IR
• “Push your foot down & out”
• Promotes stance phase and sit to stand
• In standing think soccer kick

Question 7

PNF Facilitation Techniques for LE

Answer 7

• Each technique promotes a few stages of motor control: mobility, stability, controlled mobility
• Rhythmic Initiation
• Rhythmic Rotation
• Hold Relax Active Movement
• Hold Relax
• Contract Relax
• Alternating Isometrics
• Rhythmic Stabilization
• Slow Reversal
• Slow Reversal Hold
• Agonistic Reversals

Question 8

Describe rhythmic initiation

Answer 8

• Improves mobility: movement initiation or relaxation; helps with lower level functional tasks where there is a lack of initiation due to weakness or hypertonicity

Question 9

Sequence of rhythmic initiation

Answer 9

• Initially PROM to encourage relaxation & teach movement of task
• Ask patient to assist while slowly removing assistance & maintaining manual contacts
• Resistance as tolerated
• Think initiate mobility; momentum strategy, or teach movement pattern

Question 10

Describe rhythmic rotation

Answer 10

• Improve mobility
• PROM in a rotational pattern
• Slow rhythmical movement about longitudinal axis: relaxation & tone reduction to reduce spasticity/rigidity

Question 11

Describe hold relax active movement/contraction (Replication)

Answer 11

• Improves mobility/ROM towards end range of agonist pattern by improving muscle recruitment

Question 12

Sequence of hold relax active movement/contraction (Replication)

Answer 12

• Position near end range of restricted movement
• Perform resisted isometric contraction of agonist muscle group
• Have pt relax & move passively into lengthened position
• Have pt perform active movement into the agonist pattern.
• Do this with increasing increments into lengthened position as the pt gains greater agonist range
• Can also apply quick stretch at lengthened position to recruit muscle spindles
• Apply slight resistance

Question 13

Describe hold relax

Answer 13

• Increases passive joint ROM & decreases movement related pain

Question 14

Sequence of hold relax

Answer 14

• Patient or PT moves the joint to the limit of pain free ROM
• Verbal cue of ‘hold’ as the patient maintains this position while the PT resists an isometric contraction of the antagonist (the muscles restricting the motion) - 5-8 secs
• Verbal cue of ‘relax’ as the PT gradually eliminates resistance to isometric contraction and
• The joint ROM is increased passively by PT or preferably actively by patient to tolerance
• Alternative method: can also be done with isometric contraction of ‘agonist’

Question 15

Describe contract relax

Answer 15

• Increases passive joint ROM & soft tissue length
• Most effective with 2 joint muscles contractures involving rotary component & when pain is not a significant factor

Question 16

Sequence of contract relax

Answer 16

• PT or patient moves joint to end ROM, a VC to “turn and push or pull” is given to generate contraction of short muscles
• Resistance overcomes all motions except for rotation resulting in isometric contraction of all muscles components except for the concentric rotary component
• Held for 5 seconds, then pt relaxes and the joint is lengthened actively or passively to the new limit ROM

Question 17

Describe alternating isometrics (isotonic stabilizing reversals/alternating holds)

Answer 17

• Promotes stability, strength, & endurance for postural control in specific postures
• Isometric contractions of agonist/antagonist promote alternating pattern
• Verbal cues: don’t let me push you or push against my hand (external perturbations
• Trunks ability is often the focus
• One hand on patient at all times, manual contacts can shift
• Often applied in various postures to improve postural control
• Can also be applied to extremities

Question 18

Describe rhythmic stabilization (isometric stabilizing reversals)

Answer 18

• Promotes stability through co-contraction of muscles surrounding target joints
• Rotary force is emphasized to encourage simultaneous contraction of primary stabilizers around joint
• Pt is asked to hold the position
• Force increased slowly matching pt’s effort
• Mostly used for trunk stabilizers to improve postural control/balance
• Often used in various postures

Question 19

Describe slow reversal (dynamic reversals)

Answer 19

• Promotes controlled mobility
• Used to address weakness, joint stiffness, or impaired coordination
• Concentric agonist contraction promoted with manual contacts & verbal cues (push or pull against me)
• At end range manual contacts switch smoothly to facilitate antagonist concentric contraction
• Resistance from slight to maximal
• Can be performed to improve control of diagonal limb patterns or trunk movements in different postures

Question 20

Describe slow reversal hold

Answer 20

• Variation of slow reversal technique in which resisted isometric is held at completion of ROM in each direction of pattern
• Helps in building stability at end ROM
• Verbal cues of “push against my resistance and hold”, “pull against my resistance and hold”

Question 21

Describe agonistic reversals (combination of isotonics)

Answer 21

• Improves functional movement throughout a pattern or task by promoting controlled mobility, also promotes strength & endurance
• Both concentric & eccentric contractions of the agonist musculature are promoted

Question 22

Sequence of agonistic reversals

Answer 22

• Concentric contraction of the agonist group is resisted through a specific direction and range of the chosen pattern or task
• At desired endpoint, the pt holds with isometric contraction against resistance (briefly),
• Then the clinician resists slow controlled return toward beginning of movement emphasizing eccentric control
• At the other end, another isometric hold

Question 23

PNF techniques to improve bridging, postural control in bridging

Answer 23

• Once in hook lying
• Rhythmic rotation in hook-lying to improve trunk rotation for rolling: reduce tone in trunk ms and improve mobility
• Alternating isometrics for stability
• Rhythmic initiation through the knees by stabilizing feet – to improve mobility for assuming bridging position
• Hold-relax active movement to improve mobility for assuming bridge posture
• Alternating isometrics: stability with bridge posture by resisting sideways pushes
• Rhythmic stabilization: stability
• Agonistic reversals: controlled mobility/skill

Question 24

PNF techniques to improve rolling

Answer 24

• Rhythmic initiation w/ or w/o prepositioning of LE into flexion/adduction - mobility
• Hold relax active movement: mobility to enhance ability to roll through greater range
• Slow reversal, slow reversal hold: controlled mobility
• Agonistic reversals: controlled mobility
• Combine with D1F of UE or LE to encourage rolling from supine<>sidelying
• And, D1E of UE or LE sidelying<>supine
• Chops and Lifts during rolling

Question 25

PNF techniques to improve prone positions

Answer 25

• In prone on elbows or prone on hands position (specifically useful in SCI patients)
• Alternating isometrics: stability
  Rhythmic stabilization: stability
• Slow reversal: controlled mobility through lateral or diagonal wt shits
• Slow reversal hold: controlled mobility

Question 26

PNF techniques for prone on elbows to quadruped

Answer 26

• Manual contact at the ischial tuberosity to assume quadruped: mobility
• Once in quadruped (or for working in reverse)
• Alternating isometrics and rhythmic stabilization for stability
• Slow reversals for lateral weight shifts/rocking for controlled mobility
• D1/D2 flexion patterns in quadruped for controlled mobility
• Agonistic reversals forward<>backward to promote rocking: controlled mobility in preparation for kneeling

Question 27

PNF techniques for quadruped to kneeling

Answer 27

• Manual contact on ischial tuberosity, verbal cue of ‘push back into my hands’
• As patient unloads UEs shift manual contact to iliac crest & posterior pelvis, verbal cue ‘straighten your hips & trunk’
• Hold relax active movement/agonistic reversals for kneel-sitting to kneeling
• Once in kneeling: alternating isometrics & rhythmic stabilization on upper trunk & pelvis for stability in kneeling posture
• May need to work in reverse from kneeling to kneel-sitting

Question 28

PNF techniques to improve sitting

Answer 28

• Improve ant./post. pelvic tilts: rhythmic initiation, hold relax active movement for training to assume upright sitting posture (mobility); slow reversals for controlled mobility while sitting
• Improve trunk stability: alternating isometric, rhythmic stabilization

Question 29

PNF techniques for sit to stand

Answer 29

• Improve flexion momentum of trunk (mobility): hold relax active movement
• Improve controlled trunk movement forward during momentum transfer or during triple extension: Slow reversals, agonistic reversals (may need to adjust manual contacts on upper trunk/pelvis during sit<>stand task depending on pt’s abilities and weakness), approximation on pelvis may help
• Also need to train stand to sit (work in reverse)

Question 30

PNF techniques to improve stability in symmetrical or mid-stance standing

Answer 30

• Approximation on pelvis: downward & posteriorly or downward & anteriorly
• Approximation on trunk: downward
• Techniques on trunk/pelvis: alternating isometrics, rhythmic stabilization (can do in various stance phases)
• Can also apply techniques on stance knee: alternating isometrics

Question 31

PNF techniques to improve swing phase of gait

Answer 31

• Manual contacts on weaker pelvis
• Apply quick stretch to facilitate muscle recruitment for pelvic anterior elevation/protraction to initiate swing
• May need assistance on posterior pelvis to promote swing
• Can also train gait swing/stance phases in sidelying: remember quick stretch & irradiation to pelvis to promote anterior elevation or posterior depression to promote swing or push off