PNF: Techniques and Patterns Flashcards
Stages of motor control
(1) Mobility = Presence of functional ROM to assume a posture and presence of sufficient motor unit activity to initiate and sustain active movement throughout a ROM
- - Deficits due to impaired strength or tissue tightness
- - Initiation
- - Assuming postures
- - Activating within postures
- - ROM
(2) Stability = Development of static proximal stability
- - NWB tonic muscle holding = Ability to maintain contraction in shortened range against gravity or resistance (sensitivity in postural muscles) (e.g., pivot prone)
- - WB postural muscle co-contraction = Simultaneous contraction of muscles around a joint (agonists, antagonists, and synergists) while maintaining a posture (e.g., prone on elbows)
(3) Controlled mobility = Development of dynamic proximal stability
- - Weight-bearing and weight shifting
(4) Static dynamic = Transitional stage between controlled mobility and skill
- - Previously WB limb lifted from supporting surface (smaller BOS) (e.g., bird dog)
(5) Skill = Consistency in performing functional tasks with economy of effort and normal timing
- - Dynamic proximal control required for distal control of movement/task (free distal segment)
- - UE = manipulation of environment (e.g., brushing hair)
- - LE = locomotion (e.g., walking, creeping, tip toeing)
Components of PNF treatment
A = Activities
- Postures AND/OR
- Movement patterns
- Based on bio mechanical, tonal and neurophysiological factors
T = Technique
- Promote functional movement
- Use facilitation, inhibition, strengthening, and relaxation of muscle groups
- Use graded isometric, concentric, and eccentric contractions
- Developed to achieve stages of motor control
P/E = Elements or parameters Parameters -- Duration -- Intensity -- Frequency Elements -- Manual contact -- Sensory cues (verbal, visual)
Stages = Stages of motor control
- Mobility
- Stability
- Controlled mobility
- Static dynamic
- Skill
- Strength and endurance are not stages but are critical elements within each stage
Mobility techniques
– ROM
– Rhythmic rotation (RR)
– Hold relax (HR)
– Contract relax (CR)
– Agonist contraction (AC)
– Hold relax - Agonist contraction (HRAC)
– Rhythmic stabilization (RS)
NOTE: RS most often in stability, aids mobility by reducing muscle splinting
– Initiation
– Rhythmic initiation (RI)
– Repeated contractions (RC)
– Replication (REPL)
– Hold relax active movement (HRAM)
Stability techniques
Controlled mobility techniques
Static dynamic techniques
Stability = NWB tonic muscle holding and WB postural muscle co-contraction
– NWB (tonic muscle)
– Shortened held resisted contractions (SHRC)
– WB (postural stability co-contraction)
– Alternating isometrics (AI)
– Rhythmic stabilization (RS)
NOTE: Usually AI transitions to RS
Controlled mobility = weight-bearing and weight shifting
- Slow reversal (SR)
- Slow reversal hold (SRH)
- Agonistic reversal (AR)
Static dynamic = lifting previously WB limb from supporting surface
- NONE specific to stage
- May use any from stability and controlled mobility
Skill techniques
Strength/endurance techniques
Skill = dynamic proximal control for distal control of movement/task Free distal segment: -- Slow reversal -- Slow reversal hold -- Agonistic reversal -- Resisted progression -- Repeated contractions -- Timing for emphasis
Strength/Endurance
– SAME AS SKILL
Postural progressions
Supine progression:
= Supine – Sidelying – Rolling
Prone progression:
= Pivot prone – Prone on elbows – Prone on hands – Quadruped
– Pivot prone = prone, arms ABD, elbow bent, upper back EXT (LEs also EXT)
Lower trunk progression:
= Hooklying – Bridging – Kneeling – Half kneeling
– Hooklying = supine, knees bent, feet flat
– Kneeling = trunk upright, on both knees
– Half kneeling = one leg on knee, one leg on foot in front
– Stabilization of posterior limb (proximal stability)
– Distal control of front leg
Upright progression:
= Sitting – Modified plantigrade – Standing
– Modified plantigrade = standing, feet flat, UEs resting on table
Factors affecting activities
Activities = Postures and movement patterns
Factors:
(1) Biomechanical
– Base of support ~ amount of body in contact with surface and size of BOS
– Center of gravity ~ COM raised above BOS
– Number of segments (joints) involved ~ usually WB segments
– Length of lever arm ~ muscle force required to resist external force
– Weight bearing ~ through joint (approximation) or on joint (requires ROM)
(2) Tonal
– Reflexes
– Phasic ~ facilitate movement
– Tonic ~ may need to be reduced
– Reactions ~ postural control and righting reactions
(3) Neurophysiological
– Resistance ~ always within patient’s capability allow for smooth, controlled movement
– Manual, mechanical, or gravitational
– Overflow ~ spread of facilitation
– ROM ~ available for movement
– Approximation/Traction ~ Increase postural stability or facilitate movement
– Cutaneous and pressure input ~ manual contacts or other proprioceptive stimuli alter muscle responses
Patterns of movement/facilitation
Patterns = diagonal planes across body
- Created by synergistic muscle groups
- Based on multidimensional functional patterns
- At each end one group is fully shortened and one is fully lengthened
- Diagonals identified by placing all muscles in group equally on stretch (lengthened)
- Agonists shorten completely while antagonists lengthen
- Extremity (trunk or LE/UE) patterns combine three components of action
Trunk:
-- FLEX/EXT
-- Lateral bending
-- Rotation
LE/UE:
-- FLEX/EXT
-- ABD/ADD
-- Rotation
Mobility: ROM Hold relax (HR)
Goals:
– Increase PROM/AROM
– Decrease pain
Indications:
– Limited ROM due to tightness on one side of joint
– Especially if pain companies or is cause
– Isotonic contractions too strong for PT to control
Contraindicated:
– Patient cannot initiate isometric contraction
Application (ROM)
– Bring limb to pain free range
– Slowly build and release isometric contraction of antagonists for 5-8 seconds
– Resist all components of pattern with min-mod force
– Completely relax antagonist group
– Actively move limb or segment into new range
– Repeat until no additional range is gained
NOTE: Use same application for pain w/ emphasis on (1) resisting isometric contraction of muscles affecting painful limb and (2) be careful to not cause pain when building/releasing resistance
Rationale
– Autogenic inhibition
– Successive induction
Tips:
– Gently increase resistance
– Support limb during relaxation
– Have patient move actively into new range immediately after relaxing
– Encourage contraction without defeating it
Example: Increase SLR with tight hamstrings (pattern LE DI)
Mobility: ROM Contract relax (CR)
= Isometric contraction of antagonist muscles, except concentric contraction of rotational component against resistance, to increase ROM of agonists
Goals:
– Increase PROM
– Facilitate relaxation
Indications:
– Limited ROM
– No pain
Contraindicated:
– Pain
Application (ROM)
– Bring limb to point of limitation in pattern
– Resist all components of antagonist pattern isometrically EXCEPT
– Allow concentric motion of rotational component (“pull and turn” or “push and turn”) in antagonist direction
– Faster build up and release AND greater resistance than HR (mod-max)
– Completely relax
– Actively move limb or segment into new range (agonist direction), while tracking resistance applied
– Repeat until no additional range is gained
Tips:
– Immediately increase and abruptly release resistance
– Have patient move actively into new range
– Encourage maximal isometric contraction without defeating it
Rationale
– Autogenic inhibition
– Successive induction
Example: Increase SLR with tight hamstrings (pattern LE DI)
Mobility: ROM Rhythmic rotation (RR)
= Completely passive technique used to increase ROM
Goals:
– Relaxation of all muscles around a joint
– Inhibit hypertonia
Indications:
– Limited ROM due to pain, noncontractile or contractile tissue tightness, or hypertonia
– Hypertonia and no active motion or guarding (difficulty relaxing)
Contraindicated:
– Pain w/ rotation
Application
– Slow rhythmic rotation of limb or body segment about longitudinal axis
– Firm but gentle manual contacts
– Quiet and soothing verbal commands (“relax and let me move you”)
Rationale
– Slow vestibular stimulation has calming effect and causes generalized inhibition of tone
– Inhibition from joint mechanoreceptors
– Decreased sympathetic input
– Supraspinal inhibition (patient instructed to relax)
Example: Adhesive capsulitis of shoulder with muscle guarding
Mobility: Initiation Rhythmic initiation (RI)
Goals:
– Aid initiation of movement
– Improve coordination and movement sense
– Normalize rate of movement
– Teach movement
– Help patient relax
Indications:
– Difficulty initiating movement
– Movement too slow or too fast
– Uncoordinated movement
– Normalize muscle tone
– General tension or guarding
Contraindications: None
Application: Progression from PROM – AAROM – AROM – Active resisted
– Passive = PT passively performs desired movement while patient relaxes
– Establishes consistent rhythm in unidirectional pattern
– Active assistive = Patient asked to work in one direction (must be coordinated and smooth)
– PT performs return movement
– Active = Patient moves actively both directions (must be coordinated and smooth)
– PT changes hand placement to direction of movement
– Resistive = PT applies resistance through motion and quick stretch at beginning of motion
– Patient increases active participation
Tips:
– Use speed of verbal commands to set rhythm
– At end patient can perform independently
– May combine with other techniques
Mobility: Initiation Repeated contractions (RC)
= Repeated use of quick stretch (stretch reflex) through unidirectional movement
Goals:
– Facilitate initiation of movement
– Increase strength and ROM
– Prevent or reduce fatigue
– Guide movement in desired direction
Indications:
– Inability to move through full ROM or initiate movement due to weakness
– Fatigue (decreased muscular endurance)
– Decreased awareness of movement
Contraindications:
– Joint instability
– Pain
– Fracture or osteoporosis
– Damaged muscle or tendon
Application:
– Fully elongate muscles in pattern (especially rotation)
– Combine verbal command for movement with quick stretch (“Now..Pull!”)
– Apply:
(1) Throughout range = superimpose stretches on existing contraction
– Repeat as many times as needed to achieve visible response
(2) During certain portion of ROM where weakness is observed
– Immediately impose series of stretches on existing contraction
– Immediately resist and conclude with isometric at end of gained ROM
Rationale
– Stretch reflex
– Repeated excitation of CNS pathway promotes transmission of impulses through pathway
– Subsequent resistance makes muscle spindles more responsive to stretch
Tips:
– Combine stretch with patient’s voluntary effort
– MUST resist resultant muscle contraction but allow patient to move
– Stronger muscle contraction should follow each re-stretch
– Rule of thumb: 3-4 repeated stretches per movement pattern
Mobility: Initiation
Replication (REPL)
= Unidirectional movement of body segment through progressively increasing increments of range, until patient gains active movement through intended range
Goals:
– Teach new movement pattern (end position of movement)
– Facilitate motor learning of functional movement
– Assess ability to maintain contraction when agonists are shortened
Indications
– Aid initiation of movement
– Improve coordination and movement sense
– Teach outcome (end position) of movement
Application:
– Place patient in end position w/ all agonists shortened
– Develop isometric hold (~5 seconds) in position
– Have patient slowly “let go” as PT moves short distance opposite (lengthened)
– Direct patient to move back into shortened end range
– Repeat going further into lengthened each time
Tips:
– Redirect movement if out of pattern or not smooth
Mobility: Initiation
Hold relax active movement (HRAM)
Goals: Initiation of movement from lengthened range
Indications:
– Marked weakness in lengthened range of movement
– Marked lack of endurance
– Marked imbalance in favor of antagonistic pattern
Contraindications: Pain with full passive or resisted movement
Application:
– Patient holds isometric contraction of agonist in shortened position (“Hold”) (SHRC)
– PT tells patient to relax while quickly moving patient to lengthened range (“Relax”)
– Followed by series of quick stretches back into shortened range
– PT may assist, track, or resist isotonic contraction into shortened position (“Now..Pull!”)
Rationale:
– SHRC (isometric in shortened) makes muscle spindles more responsive (gamma bias)
– Stretch reflex from lengthened range
Example: Rolling supine to prone
Stability: NWB Tonic holding
Shortened held resisted contraction (SHRC)
Goals:
– Improve muscle spindle stretch sensitivity of postural muscles
– Improve slow twitch motor unit recruitment
– Improve control and endurance of postural muscles in range they most commonly function
Indications: Decreased control and endurance of postural extensors in WB postures
Contraindications: Pain
Precaution: Watch that isometric contention does not increase BP in CVD/PD patients
Application:
– Move postural extensors into shortened range (passively or actively)
– Gradually build low-intensity isometric contraction for 10 seconds
– Grade and limit resistance to 40% maximal voluntary effort (Type I fibers only)
– Gradually and smoothly release isometric contraction and patient relaxes
– Repeat
Rationale:
– Promotes muscle spindle sensitivity
– Low intensity sustained contractions recruit slow twitch muscle fibers
Example: Pivot prone held vs, gravity or manual resistance
Stability: WB Postural stability co-contraction Alternating isometrics (AI)
= Holding on one side of joint immediately followed by holding of other side of joint
Goals:
– Increase stability, balance, and muscle strength
– Increase coordination between antagonist and agonist muscle groups
Indications:
– Decreased stability
– Weakness
– Poor static postural control
Application:
– Slowly build isometric contraction (5-7 seconds) on one side of joint (strong side)
– Slowly release AT SAME TIME as building contraction on other side (“Hold”)
– Rhythmically transition resistance from one side to the other (NO RELAXATION)
– Apply approximation along with resistance
Tips:
– Resist as many components as possible
– Try to stay in diagonal
Rationale
– Builds endurance for holding contraction in WB posture
– Builds contraction of agonists synergistic to movement
Example: Sitting BUE support (MC’s: superior/lateral scapula, anterolateral shoulder)
Stability: WB Postural stability co-contraction Rhythmic stabilization (RS)
= Progression from AI w/ simultaneous isometric contractions of agonist and antagonist muscle groups in all three planes
Goals:
– Improve ability to maintain isometric contraction as resistance switches sides
– Improve control of balance and posture
– Develop strength/stretch sensitivity of extensor muscles in shortened range
– Promote relaxation and pain reduction
– Maintain proximal stability in WB postures
Indications:
– Joint or postural instability
– Weakness
– Poor balance
Application:
– Usually start with AI and transition to RS
– One hand maintains resistance on one side
– Other hand slowly releases, shifts sides, and builds contraction
– Resist rotary and diagonal components (“Don’t let me twist you”)
– Use approximation to maintain proximal stability in WB postures
Tips:
– Maintain contraction while switching, NO relaxation, and smooth transition
– Stabilization with muscles distant from painful area
Example: Sitting, UE WB
NOTE: UE or LE WB emphasizes co-contraction at proximal joint, NWB emphasizes trunk stability/strengthening
Controlled mobility
Slow reversal (SR)
Slow reversal hold (SRH)
= Alternate, slow, rhythmic concentric contractions of all components of a movement pattern of the agonist and then antagonist (SRH adds isometric hold at each end of pattern)
Goals:
– Improve ability to smoothly change direction of movement (coordination, timing)
– Increase AROM, strength, and endurance
– Prevent or relieve fatigue
– Decrease muscle tone
– Facilitate holding in shortened range (SRH)
Indications:
– Decreased AROM, endurance, strength, and ability to change movement directions
– Relaxation in hypertonic muscle groups
Application:
– Perform on stronger direction or pattern first
– Elicit concentric motion through desired pattern in WB position
– Begin in small increments then progress to large increments
– Move in one direction then the other
– MCs encourage desired movement and transition smoothly to antagonist surface
– Resistance appropriately graded to guide or resist concentric contraction through pattern
– Quick stretch at lengthened range
– SRH: Isometric contraction applied at shortened range before changing direction
– Precursor to SR b/c hold helps develop joint stability and immediate reciprocation is hard
Rationale:
– Successive induction
– Isometric contraction induces motor unit activation in shortened range (SRH)
– Quick stretch in lengthened range elicits stretch reflex for opposite movement
– Continuous activity (NO relaxation)
Controlled mobility: Agonistic reversals (AR)
Goals:
– Evaluate ability to switch between concentric, isometric, and eccentric contractions
– Increase strength, AROM, coordination, and ability to control weight shift over stable BOS
Indications:
– Poor eccentric control
– Decreased strength, AROM, coordination, and dynamic stability
Application:
– One side of joint at a time (agonist)
– Patient concentrically contracts agonist against gravity and/or manual resistance
– Patient holds isometric contraction in shortened range
– Patient slowly “lets go” w/ eccentric contraction against gravity and/or manual resistance
– May require assistance lowering if unable to control
– Repeat, starting with quick stretch
Rationale:
– Stretch of muscle spindles during eccentric contraction enhances firing of spindle afferents
Tips:
– NO relaxation between contraction types but may after cycle complete
Skill: Resisted progression (RP)
Goals:
– Facilitate sequencing of pelvis, hip, and knee during locomotion
– Improve gait kinematics and coordination
Application:
– May begin in parallel bars
– For gait:
– MCs at anterior iliac crests (fingers pointed 45 degrees towards heels)
– Stand facing patient and walk backwards (or sit on rolling stool behind)
– For creeping:
– MCs at anterior iliac crests or ankles/heels from behind
– Begin training with R to L or front to back shift (in stance or stride positions)
– After developing proximal control transition to gait or creep
– Slight quick stretch w/ approximation and tracking resistance on “swing” leg
– Approximation on “stance” leg through midstance
– Repeat cycle
Tips:
– Approximation and resistance must not impede motion or throw off balance
Example:
- Standing, stance or stride weight-shifting L to R or forward to back, or gait
- Quadruped, creeping forward or backward
Skill:
Timing for emphasis (TE)
Goals:
– Strengthen component of movement
– Improve coordination and sequencing of movement (movement kinematics)
Indications:
– Weakness in one component of movement
– Decreased coordination (e.g., poor timing) and muscle endurance
– Often proximal component imitates movement and distal component lags behind
Application:
– Start with quick stretch, then isotonic contraction of all components until strongest point
– Usually mid range for flexors and shortened for extensors
– Isometric hold of all components except weakest
– Isotonic contraction of weakest only with series of quick stretches
– Once weak component activated, remaining components allowed to move through range
– Begin with quick stretch of all components
Rationale:
– Isometric contraction of strong muscles causes overflow into weaker muscles
Example: Supine, unilateral UE D2 flexion; SRH w/ TE for finger/hand EXT
Neurophysiological effects:
– Overflow
– Autogenic inhibition
– Successive induction
– Gamma bias
– Stretch reflex
- Overflow (i.e., irradiation) = spreading of response from one muscle or group to another
- Stronger synergistic segments may enhance activation of weaker segments
- Promotes strengthening
- May occur: ipsilateral, contralateral, trunk to extremities, extremities to trunk
– Autogenic inhibition
= reflex inhibition of motor unit in response to excessive tension on muscle
– Strong contraction of antagonist followed by relaxation allows greater movement by agonist
– Reciprocal inhibition
= Relaxation of antagonist muscle due to concentric contraction of agonist
– Successive induction
= Increased agonist strength following contraction of antagonist
- Gamma bias = constant firing of gamma neurons without muscle stretch or force
- Muscle spindle sensitivity depends on level of gamma bias (higher = more sensitive)
- Stretch reflex = muscle contraction in response to stretch of muscle spindle
- Stretch of muscle spindle (muscle lengthening) increases its nerve activity
Use of different manual contacts
Lumbrical grip
(1) Strength/Power
- - Hand placement over actual muscle
(2) Movement direction
- - Hand placement over surface in direction of intended movement
(3) Movement
- - Light or intermittent contact (often with traction)
- - Traction = separation of joint surfaces or limb elongation to enhance movement
(4) Hold
- - Firm, maintained contacts
- - Broad and firm for co-contraction (often with approximation)
- - Approximation = compression through a joint to enhance stability
- - May superimpose on WB or holding response in functional position
- - Beware underlying joint pathology (contraindicated)
Lumbrical grip = intrinsic muscles of hand
- Thenar and hypothenar eminences and finger pads (NOT tips or thumb)
- Minimizes risk of grabbing too many surfaces (allows for specificity)
Variables that change difficulty:
Person
LISTED EASY TO HARD FOR EACH VARIABLE
Person:
- Transport (moving) NO – YES
- Number of segments FEW – MANY
- BOS: WIDE – NARROW
- COM: LOW – HIGH
- UE: BWB (wide-narrow) – UWB – NWB
- - simple manipulation – complex manipulation – increase speed
- UE: BWB (wide-narrow) – UWB – NWB
- LE: BWB (wide-narrow) – staggered – 1WB – alternate WB – NWB quiet –
- - simple NWB movement – complex NWB movement – increase speed
- LE: BWB (wide-narrow) – staggered – 1WB – alternate WB – NWB quiet –
- Trunk: Passive placement – Active placement – Active resisted
- Head: Stable – Moving – Complex visual field
- Eyes: Open – Closed – Complex visual field
- Cognitive challenge: Low – High
Variables that change difficulty:
Environment
Motor learning
Exercise variables
LISTED EASY TO HARD FOR EACH VARIABLE
Environment
- Seated surface: Stable (firm) – Unstable (soft) – Moving (consistent) – Moving (variable)
- Seat height: Low (hips < 90) – Even (hips = 90) – High (hips < 90)
- Seat angle: Posterior tilt – Anterior tilt
- Armrests: YES – NO
- Back support: High – Low – None
Motor learning
- Feedback:
- Frequency: High (guided) – Low (discovery)
- Timing: Instantaneous KR – Delayed KR
- Scheduling: Reverse faded – Constant – Faded
- Practice
- Specificity: Low – High
- Variability: Blocked & Nonvariable – Random & Unpredictable
- Part-Whole: Part – Whole
Exercise variables
- Frequency: Low – High
- Duration: Short – Long
- Intensity: Low – High
Strength
Endurance
Strength = Sufficient motor unit activation to perform task-related goal
- Enhance force production and control via:
- Motor unit recruitment
- Contraction intensity and grading
- Transitioning between contraction types (e.g., concentric to isometric)
Endurance = Sufficient aerobic capacity to maintain controlled movement
- Resistance to fatigue
- Enhanced by manipulating exercise parameters (e.g., duration, intensity)
Techniques:
- Slow reversal
- Slow reversal hold
- Agonist reversal
- Repeated contractions
- Timing for emphasis
- Resisted progression
Bilateral extremity patterns
= Combo of unilateral patterns that uses overflow to increase strength of response
- Used to emphasize activity at proximal joints and/or associated trunk movements
- Both extremities move simultaneously
- Only one broad MC on each extremity (less fine control)
Direction = Bilateral/Reciprocal (e.g., FLEX/EXT) Pattern = Symmetrical/Asymmetrical (e.g., D1/D2)
Extremities:
– Bilateral symmetrical (BS) = SAME direction – SAME pattern
Example: UE D1 FLEX
– Bilateral asymmetrical (BA) = SAME direction – DIFFERENT pattern
Example: LE D1 and D2 FLEX
– Reciprocal symmetrical (RS) = DIFFERENT direction – SAME pattern
– Reciprocal asymmetrical (RA) = DIFFERENT direction – DIFFERENT pattern
Upper trunk: BA UE patterns with LIMBS in CONTACT (head and trunk follow)
- Chop = D1 extension w/ neck flexion = upper TRUNK FLEX
- Reverse chop = D1 flexion
- Lift = D2 flexion w/ neck extension = upper TRUNK EXT
- Reverse lift = D2 extension
Lower trunk: BA LE patterns
- BA LE flexor patterns = lower trunk flexion
- BA LE extensor patterns = lower trunk extension in hooklying
- BA LE flexor 0-90 deg = lower trunk rotation
- BA LE extensor 90-180 deg = lower trunk rotation
Reciprocal patterns in gait TS IS IC MS
Terminal stance
- Pushing off toe on one side with leg behind
- Pelvis is reaching backward = posterior depression of pelvis (PDP)
- Arm on same side swings forward = anterior elevation of scapula (SAE)
Initial swing
- Arm swings back = posterior depression of scapula (SPD)
- Leg swings forward = anterior elevation of pelvis (PAE)
Initial contact
- Leg forward but hip drops (reaching down) = anterior depression of pelvis (PAD)
- Arm swings behind = posterior elevation of scapula (SPE)
Midstance
- Shifting weight onto stance leg (swing leg comes forward w/ hip drop)
- Posterior elevation of pelvis on stance (higher, behind) (PEP)
- Arm swings forward (reaching) = anterior depression of scapula (SAD)
Trunk patterns
- Girdle
- Mass
- Reciprocal
For each:
Position
MCs
Position: Sidelying, spine neutral, FLEX knees and hips 70-90 deg
PT: Behind patient in line w/ diagonal (esp. forearms)
Diagonal: 11 to 5 or 1 to 7 o’clock
Girdle patterns: Scapula and pelvis
- Anterior elevation - Posterior depression
- Scapula: Anterior acromion – Lateral inferior angle of scapula
- Pelvis: Anterior iliac crest (above ASIS) – Ischial tuberosity
- Anterior depression - Posterior elevation
- Scapula: Elbow of arm draped over side – Spine of scapula
- Pelvis: Above PSIS – Greater trochanter
Mass patterns: Same position and MCs as girdle patterns (forearms in diagonal)
- Mass flexion = Scapula anterior depression + Pelvis anterior elevation
- Mass extension = Scapula posterior elevation + Pelvis posterior depression
Reciprocal patterns: Scapular and pelvic girdle patterns in opposite directions
- SAE + PPD
- SPD + PAE
- SAD + PPE
- SPE + PAD
UE D1
= “cross body to grab seatbelt from behind head”
FLEX:
Scapula: ANT ELEV
Shoulder: FLEX, ADD, ER ("lift across")
Forearm: Supination
Wrist: FLEX and UD
Fingers: FLEX to ulnar side with thumb ADD
NOTE: Final position has hand behind ear
EXT:
Scapula: POST DEP
Shoulder: EXT, ABD, IR
Forearm: Pronation
Wrist: EXT and RD ("hand to hip")
Fingers: EXT to radial side with thumb ABD
UE D2
= “grabbing and unsheathing sword”
FLEX
Scapula: POST ELEV
Shoulder: FLEX, ABD, ER
Forearm: Supination
Wrist: EXT and RD
Fingers: EXT to radial w/ thumb ABD ("fingers to the sky")
EXT:
Scapula: ANT DEP
Shoulder: EXT, ADD, IR
Forearm: Pronation
Wrist: FLEX and UD ("thumb to hip")
Fingers: FLEX to ulnar side w/ thumb OPP
LE D1
= “hacky sac” and “kick door closed behind”
FLEX:
Pelvis: ANT ELEV
Hip: FLEX, ADD, ER (“knee to opposite shoulder”)
Knee: FLEX
Ankle: DF and INV (“heel to opposite thigh”)
Toes: EXT (“toes up”)
NOTE: Make sure knee crosses midline to get ADD
EXT:
Pelvis: POST DEP
Hip: EXT, ABD, IR ("kick down and out")
Knee: EXT
Ankle: PF and EVER
Toes: FLEX ("point your toes")
LE D2
= “fire hydrant” and “ballerina”
FLEX:
Pelvis: POST ELEV
Hip: FLEX, ABD, IR ("bring your leg to me")
Knee: FLEX
Ankle: DF and EVER
Toes: EXT ("toes up")
EXT:
Pelvis: ANT DEP
Hip: EXT, ADD, IR
Knee: EXT
Ankle: PF and INV
Toes: FLEX ("point your toes")
Therapist body position and mechanics
- Position at either end of desired movement
- Hips and shoulders facing direction of movement (in diagonal)
- For complex movements align forearms in diagonal
- Position allow resistance to come from patient trunk and pelvis, not just extremities
- Movement must reflect patient movement (do not impede)
- Movement from hips and legs (weight shift) with neutral spine
- Movement in direction desired of patient
- Movement in direct proportion to patient movement
- Movement directly related to arc of motion by patient
Resistance
= Optimal or appropriate (“maximal”) resistance
- NOT maximum therapist can apply
- Allow smooth controlled movements
- Always within physiological capability of patient
Uses:
- Facilitate muscle contraction
- Inhibit or relax muscle group
- Increase motor control
- Increase strength
- Help patient gain awareness of motion
Goals:
- Initiate movement
- PROM and AROM (improve and maintain)
- Muscle strength
- Muscle and postural stability
- Total body and muscular endurance
- Relaxation
- Coordination
- Timing, sequencing and recruitment of responses
Forms:
- Manual
- Gravity (body weight)
- External device
NOTE: Tracking resistance used to guide movement rather than strengthen
Quick stretch
= Subtle, quick elongation of muscle or group into direction of pattern from lengthened range
Must:
- Synchronize with verbal command to stimulate effort by patient
- Immediately follow with appropriate resistance (may be partial)
Uses: Lengthened range: -- Facilitate initiation of movement -- Facilitate ease of contraction -- Increase contraction power Throughout ROM: -- Increase strength of muscle contraction General: -- Increase endurance by decreasing effort needs to initiate movement -- Influence direction of movement
Contraindication: PAIN!!!
Precaution: Hyperactive stretch reflex
