Unit 1A - PNF

Proprioceptive Neuromuscular Facilitation (PNF)

Based on Spiral-Diagonal Patterns

  • Functional activities

  • Used for both ortho and neuro patients

  • Combined with Muscle Energy Techniques (MET)

Primary Purpose

  • To promote motor learning

  • Refer to Unit 1-B Motor Control Theory and Motor Learning in the course study guide

Appropriate Assessments for Motor Learning

  • Refer to Unit 2-A Neurological Assessments

  • Manske Box 7-1 p. 127

  • O&S Table 6.2 pp. 218-219

Coordination Tests (Manske, p 127, Box 7-1)

  • Rapid alternating movement: Patient places hands on thighs (palms down), turns hands over (palms up), and lifts them off thighs as quickly as possible. Rapidly returns to starting position for 10 repetitions.

  • Finger to nose: Patient touches the tip of the index finger to the tip of the nose.

  • Finger opposition: Patient alternately touches the tip of each finger with the tip of the thumb.

  • Fixation-position hold: Arms are held horizontally or knees are extended in a static position.

  • Heel on shin: Patient is supine and slides the heel of one leg from the ankle to the knee of the opposite leg, testing reciprocal motion and accuracy.

  • Pronation-supination: Palms are rotated up and down.

  • Tapping foot or hand: Patient taps the ball of one foot repeatedly while keeping the heel in contact with the floor, or taps the hand on the knee.

  • Throwing and catching a ball: Patient receives and delivers a ball.

Uses of PNF

  • Increase joint ROM (active or passive)

  • Increase muscle flexibility

  • Increase muscle strength

  • Increase muscle endurance (not overall CV endurance)

  • Increase coordination

  • Increase circulation

  • Decrease spasms and/or spasticity

Spasm vs. Spasticity

PNF Components

  • Proprioceptors: Position and motion sense.

  • Neuromuscular: Nerve & muscle.

  • Facilitation: Reinforcement. Facilitate (+) = makes result more likely to occur

PNF Involves

  • A demand to produce a response.

  • Repetition (critical for motor learning).

  • Using less involved (stronger) parts to (+) use of the more involved (weaker) parts; or stronger muscle to strengthen weaker; or start a muscle in the strongest range and progress to weaker part.

Sensory Stimulation

  • Stimulus → Response

Categories of Sensory Stimulation

  • Proprioceptive Stimulation

  • Exteroceptive Stimulation

  • Auditory and Visual Stimulation

  • Vestibular Stimulation

  • See O & S

Sensory Stimulation Techniques (Table 10.9)

Stimulus

Response

Comments

Maintained pressure: firm manual pressure; mechanical pressure

Calming effect, generalized inhibition, decreased fight or flight responses; desensitizes skin

Useful with patients with agitation and high arousal (e.g., TBI). Can combine with other relaxation techniques. Also useful for patients with hypersensitivity (e.g., tactile defensiveness).

Slow, repetitive stroking: applied to midline back

Calming effect, generalized inhibition, decreased fight or flight responses

Performed while patient is prone or in supported sitting (head and arms resting on table top).

Light touch: brisk, quick stroking

Facilitates muscle; can elicit protection/flexor withdrawal response

Low threshold response, accommodates rapidly.

Neutral warmth: retention of body heat through wraps, clothing, air splints

Calming effect, generalized inhibition, decreased fight or flight responses

Can be used to initially mobilize patients with low response levels (e.g., minimally responsive TBI). Useful for patients with high arousal or increased sympathetic activity. Overheating should be avoided, may produce rebound effects.

Prolonged cooling: immersion in cold water; ice wraps, ice massage

Decreases neural and muscle spindle firing

Provides inhibition of muscles and painful muscle spasm. Decreases metabolic rate of tissues. Monitor effects carefully: can produce sympathetic arousal, withdrawal or fight-or-flight responses. Contraindicated in patients with sensory deficits, generalized arousal, autonomic instability, and vascular problems.

Slow vestibular stimulation: constant, repetitive rocking

Calming effect, generalized inhibition, decreased fight or flight responses

Useful with patients who are hypertonic, hyperactive, or who demonstrate high arousal or tactile defensiveness (e.g., agitated patient with TBI).

Rapid vestibular stimulation: rapid movements, fast spinning movements

Heightens postural responses

Useful for patients with hypotonia (e.g., Down syndrome); patients with sensory integrative dysfunction (e.g., child with hyperactivity); patients with bradykinesia (e.g., patient with PD) Can activate sympathetic arousal responses.

A. Proprioceptive Stimulation

  • Acts on receptors in the muscles and joints.

  • Stimulates receptors that carry information about joint position and movement (Interoceptors).

  • See Gibbons book METs Chapters 3 & 4

Includes

  1. Stretch

  2. Resistance

  3. Firm Pressure

  4. Vibration

  5. Approximation

  6. Traction

1. Stretch
a. Slow, Prolonged Stretch

  • Raises the threshold of the muscle spindle, therefore inhibits (-) the spindle.

  • The GTO is activated muscles accommodates to the new position.

Sensory Receptor Involved

  • GTO: located in tendon

  • Sensitive to prolonged stretch/pressure.

GTO Prolonged Stretch Causes Muscle to Relax

  • Autogenic Inhibition

Mechanism:

  • Afferent Sensory Neurons from GTO synapse with Interneuron.

  • Inhibits the Efferent Motor Neuron.

b. Quick Stretch/Primary Stretch

  • Direct stimulation of the muscle spindle causes a reflex muscle contraction.

Sensory Receptor Involved

  • Spindle: located in muscle

  • Sensitive to rapid changes in muscle length.

Quick Stretch Causes Muscle to Contract

  • Stretch Reflex

Mechanism:

  • Afferent (Sensory) Neurons from Spindle activate Efferent Motor Neuron.

Quick Stretch Details

  • Muscle responds with greater force after being quickly stretched in the almost fully lengthened position.

  • Facilitates (+) the muscle being stretched and inhibits (-) the antagonist muscle.

Tapping

  • Facilitates muscle

2. Resistance

  • Maximal resistance elicits a maximal response.

  • Maximal resistance leads to contraction of other muscles through the process of irradiation.

Resistance Examples in PNF

  • Modify resistance in PNF patterns to obtain a smooth contraction.

  • Place some demand / not TOO easy assuming patient has sufficient strength or motor control.

  • Hand placement is critical with PNF techniques.

3. Firm Pressure

  • Inhibitory (-) effect through stimulation of the GTO.

  • Inhibitory pressure at tendon.

  • Maintained touch.

4. Vibration

  • Facilitates (+) tonic contraction.

  • Using a vibrator to increase tone in a muscle.

5. Approximation

  • Compressing joint surfaces to produce stability, co-contraction, or to maintain posture.

6. Traction

  • Separating the joint surfaces to produce movement.

B. Exteroceptive Stimulation

  • Acts on sensory receptors in the skin overlying the muscles we want to (+) or (-).

  • See O & S

Includes

  1. Manual contacts: light touch = (+) or (-); firm deep pressure = (+)

  2. Brushing = (+)

  3. Prolonged icing = (-)

  4. Warmth = (-)

  5. Slow stroking = (-)

C. Auditory and Visual Stimulation

  • Acts on sensory receptors in the ears and eyes.

Includes

  1. CNS: feedback

  2. PNS: reflex arc

  3. Examples: study guide pg 4

D. Vestibular Stimulation

  • Acts on sensory receptors in the inner ears concerned with equilibrium and head position.

Includes

  1. Rocking

  2. Rolling

  3. Balancing on a ball

  • Affects tone and movement as well as postural tone.

Neurophysiological Principles

  • Stimulus → Response

  • Sensory Input → Movement

A. Facilitation vs. Inhibition

  1. Excitatory/Facilitatory synapses (+)

  2. Inhibitory synapses (-)

  3. Techniques:

    • (a) Facilitation techniques = increase the neuron’s chances of firing. Examples

    • (b) Inhibitory techniques = decrease the neuron’s chances of firing. Examples: see course guide page 5 (next slide)

Facilitation Techniques:

  • Techniques to increase the neuron's chances of firing

  • Examples:

    • quick stretch to the muscle

    • quick icing (as with an ice cube following muscle fibers)

    • short, quick, loud commands

    • tapping over the muscle belly

    • brushing over the muscle belly

    • light touch (such as light tactile cues to guide the direction of movement)

    • vibration (such as with a vibrator)

    • approximation to the joint to stimulate a co-contraction of muscles

    • weight-shifting and weight-bearing to normalizes tone: (+) flaccid muscles

Inhibition Techniques:

  • Techniques to decrease the neuron's chances of firing.

  • Examples:

    • slow, sustained stretch (like what we did in Ther Proce)

    • prolonged application of cold (as with a CP)

    • slow, quiet, soft commands

    • firm, prolonged hand placement (≈ a light prolonged stretch)

    • air splints (firm, prolonged pressure)

    • slow, rhythmic rotation

    • weight-bearing activities to normalize tone: (-) spastics muscles

Facilitation and Inhibition

  • Inseparable

B. Reciprocal Inhibition (RI)

  • Gibbons pp. 30 -36

  • When a muscle contracts, its antagonist is inhibited

  • The stronger the agonists contraction, the more relaxation is produced in the antagonist muscle

  • Example:

Which Active Inhibition Technique is based on RI?
C. Successive Induction (SI)

  • When the agonist muscle contracts, the antagonist is being prepared to contract

  • Example. It is being “primed”

Aren’t Reciprocal Inhibition and Successive Induction exact opposites?!?
Reciprocal Inhibition vs. Successive Induction

  • Timing:

    • RI occurs early in the contraction

    • SI occurs later in the contraction

  • Range:

    • RI occurs throughout the range

    • SI occurs at the end of the range

  • Application:

    • Patient needs to go full range

D. Autogenic Inhibition (AI)

  • Gibbons pp. 30 -36: “post-isometric relaxation” (PIR)

  • When a muscle contracts forcibly for a prolonged period of time, or if you have a sustained stretch there is inhibition of the muscle

  • A protective mechanism???

  • Can consciously override it to some extent

Which Active Inhibition Techniques are based on AI?
E. Irradiation

  • When a muscle contracts forcibly, impulses spread and overflow to (+) contraction of other muscles

  • (+) muscles that work synergistically with the agonist

  • PNF patterns use synergistic muscles

  • MMT prevents substitutions via proximal stabilization

F. Repetition

  • Repeating the activity (+) the development of a “motor program”

  • Table 3-4 Principles of Experience-Dependent Plasticity M&K on p. 59

  • Motor Program: A series of sequenced, automatic actions

Must repeat activity frequently and correctly for motor learning to occur

  • (3 million times!!!)

  • Examples: PTA Lab practicals

G. Recuperative Motion

  • Performing another activity that allows rest

  • May be a similar activity or an activity with the opposite extremity

  • Examples: alternate UE and LE exercises or same exs w/ no wgt

H. Specificity of Exercise

  • To increase motor control for a specific functional activity, must work on that specific activity

  • Similar to part vs. whole training (more later)

  • Similar to open vs. closed chain activities

  • M&K Table 3-4 Principles of Experience-Dependent Plasticity p. 59

Conclusions

  • Strength and Motor Control are similar, but different

  • Must incorporate functional activities into your therapeutic interventions (exercise programs)

Coordination Examination

  • Manske Box 7-1 p. 127 nonequilibrium coordination tests

  • O&S Table 6.2 p. 218 – 219 nonequilibrium coordination tests

  • O&S Administering the Coordination Examination pp. 217 – 223

  • Refer to Unit III-A Neurological Assessments in course manual for more information