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
