Functional Mobility, PNF, and NDT

Supine Progression

  • Key Movements in Supine Positioning:   - Rolling: Transitioning from supine to sidelying and sitting.   - Supine to Elbow Prop: Movement from supine to elbow prop then to long-sitting.   - Transition from Long-sitting to:     - Scooting to short-sitting.     - Short-sitting to standing.

Prone Progression

  • Key Movements in Prone Positioning:   - Prone to Pivot Prone: 90 degrees shoulder abduction and 90 degrees elbow flexion.   - Prone on Elbows: Engaging the core and upper body from a prone position.   - Prone Prop: Using elbow extension to raise the chest.   - Transition to:     - Quadruped Position.     - Heel Sitting.     - Tall Kneel.     - Half Kneel.     - Modified Plantigrade: Standing position where arms are used for support.     - Full Standing.

PNF Techniques

PNF Exercises

  • PNF Diagonal Patterns:   - Upper Extremity (UE) Diagonal Patterns.   - Lower Extremity (LE) Diagonal Patterns.

  • Types of PNF Techniques:   - Agonist Reversal (AR).   - Alternating Isometrics (AI).   - Contract-Relax (CR).   - Hold-Relax (HR).   - Hold-Relax Active Movement (HRAM).   - Joint Distraction.   - Normal Timing (NT).   - Repeated Contractions (RC).   - Resisted Progression (RP).   - Rhythmic Initiation (RI).   - Rhythmic Stabilization (RS).   - Rhythmic Rotation (RR).   - Slow Reversal (SR).   - Slow Reversal Hold (SRH).   - Timing for Emphasis (TE).

Upper Extremity PNF Patterns

D1 Flexion – Upper Extremity

  • Movements Involved:   - Fingers: Flexion.   - Wrist: Flexion with radial deviation.   - Supination of forearm.   - Elbow: Variably flexed.   - Shoulder: Flexion, adduction, external rotation.   - Scapula: Elevation, abduction, upward rotation.

  • Note: Hand begins in pronation with finger extension.

D1 Extension – Upper Extremity

  • Movements Involved:   - Fingers: Extension.   - Wrist: Extension with ulnar deviation.   - Pronation of forearm.   - Elbow: Variably extended.   - Shoulder: Extension, abduction, internal rotation.   - Scapula: Depression, adduction, downward rotation.

  • Note: Hand begins in supination with finger flexion.

D2 Flexion – Upper Extremity

  • Movements Involved:   - Fingers: Extension.   - Wrist: Extension with radial deviation.   - Supination of forearm.   - Elbow: Variably flexed.   - Shoulder: Flexion, abduction, external rotation.   - Scapula: Elevation, adduction, upward rotation.

  • Note: Hand begins in pronation with finger flexion.

D2 Extension – Upper Extremity

  • Movements Involved:   - Fingers: Flexion.   - Wrist: Flexion with ulnar deviation.   - Pronation of forearm.   - Elbow: Variably extended.   - Shoulder: Extension, adduction, internal rotation.   - Scapula: Depression, abduction, downward rotation.

  • Note: Hand begins in supination with finger extension.

Lower Extremity PNF Patterns

D1 Flexion – Lower Extremity

  • Movements Involved:   - Toes: Extension.   - Foot and Ankle: Inversion, dorsiflexion.   - Knee: Variably flexed.   - Hip: Flexion, adduction, external rotation.

  • Note: Toes begin in flexion and ankle is in plantarflexion and eversion.

D1 Extension – Lower Extremity

  • Movements Involved:   - Toes: Flexion.   - Foot and Ankle: Eversion, plantarflexion.   - Knee: Variably extended.   - Hip: Extension, abduction, internal rotation.

  • Note: Toes begin in extension and ankle is in dorsiflexion and inversion.

D2 Flexion – Lower Extremity

  • Movements Involved:   - Toes: Extension.   - Foot and Ankle: Eversion, dorsiflexion.   - Knee: Variably flexed.   - Hip: Flexion, abduction, internal rotation.

  • Note: Toes begin in flexion and ankle is in plantarflexion and inversion.

D2 Extension – Lower Extremity

  • Movements Involved:   - Toes: Flexion.   - Foot and Ankle: Inversion, plantarflexion.   - Knee: Variably extended.   - Hip: Extension, adduction, external rotation.

  • Note: Toes begin in extension and ankle is in dorsiflexion and eversion.

Rhythmic Initiation (RI)

  • Purpose and Technique:   - Used to assist in the initiation of movement.   - Effective for educating patients on new movement patterns.   - Involves:     - Passive range of motion (PROM).     - Active assisted range of motion (AAROM).     - Active range of motion (AROM).     - Resistance.

Chop & Lift Techniques

  • Movements:   - Chop: Movement from D1 flexion to D1 extension.   - Lift: Movement from D2 extension to D2 flexion.

Agonist Reversal (AR) vs. Slow Reversal (SR) vs. Slow Reversal Hold (SRH)

  • Agonist Reversal (AR):   - Involves concentric contraction followed by eccentric contraction of the same muscle.   - Hands remain on the same side of the body.

  • Slow Reversal (SR):   - Involves concentric contraction of both muscle groups (opposite muscle group).   - Hands alternate sides of the body.

  • Slow Reversal Hold (SRH):   - Involves concentric contraction of both muscle groups; patient holds at weak points with isometric contraction.   - Hands alternate sides with periods of holding with resistance.

Hold-Relax vs. Contract-Relax vs. Hold-Relax Active Movement (HRAM)

  • Hold-Relax:   - Stretch antagonist muscle for 30 seconds.   - Patient performs isometric contraction against resistance for 6-10 seconds.   - Relax and re-initiate stretch.

  • Contract-Relax:   - Stretch antagonist muscle for 30 seconds.   - Patient performs isotonic contraction against resistance for 6-10 seconds.   - Relax and re-initiate stretch.

  • Hold-Relax Active Movement:   - Stretch antagonist muscle for 30 seconds.   - Patient performs isometric contraction against resistance for 6-10 seconds.   - Patient is instructed to activate agonist muscle.   - Relax and re-initiate stretch.   - Usually involves 3 sets on each side with the stated timing.

Alternating Isometrics (AI) vs. Rhythmic Stabilization (RS)

  • Alternating Isometrics (AI):   - Isometric contraction by antagonist muscle followed by agonist muscle.   - Aimed at enhancing balance and postural stability.

  • Rhythmic Stabilization (RS):   - Similar definition as AI but involves perturbations in all directions without a specific movement pattern.   - Should be initiated proximally and progress distally.   - Duration: 15-30 seconds, effective for posture and trunk stability.

Rhythmic Rotation (RR)

  • Technique:   - Slow, passive rhythmic rotation around the longitudinal axis of a body part.   - Benefits include increased range of motion (ROM), enhanced control and stability, and reduction in spasticity.

Resisted Progression

  • Purpose:   - Enhances coordination of proximal components during gait.   - Targets high-functioning patients who can ambulate well, with exercises challenging this.   - Resisted areas include:     - Forward: ASIS (anterior superior iliac spine).     - Side: Iliac crest and greater trochanter.     - Backward: PSIS (posterior superior iliac spine).   - Pressure is always applied at the hips.

Repeated Contractions

  • Technique:   - Provide a quick stretch followed by isometric and isotonic contractions.   - Designated for patients who have strength and range of motion (MMT score of at least 3/5).   - Functions as a strength-building activity resembling quick stretch PNF while ensuring sufficient range of motion.

Joint Distraction

  • Involves consistent manual traction provided slowly, often in conjunction with mobilization techniques.

  • Caution: Not advisable for weak or debilitated patients, as it could risk causing subluxations.

Normal Timing (NT)

  • Technique:   - Movement is sequenced from distal to proximal.   - Proximal components are restricted until distal components are activated to initiate movement.   - Recognized as a high-functioning exercise.

Levels of Motor Control

  • Classification of Techniques:   - Mobility Techniques:     - Contract-Relax.     - Hold-Relax.     - Hold-Relax Agonist Contraction.     - Joint Distraction.     - Repeated Contractions.     - Rhythmic Initiation.     - Rhythmic Stabilization.     - Rhythmic Rotation.   - Stability Techniques:     - Alternating Isometrics.     - Rhythmic Stabilization.     - Slow Reversal.     - Slow Reversal Hold.   - Controlled Mobility Techniques:     - Agonist Reversal.     - Slow Reversal.     - Slow Reversal Hold.   - Skill Techniques:     - Agonist Reversal.     - Normal Timing.     - Resisted Progression.     - Slow Reversal.     - Slow Reversal Hold.

NDT Techniques

NDT Exercises

  • Key Methods:   - Resistance.   - Quick Stretch.   - Tapping.   - Prolonged Stretch.   - Joint Approximation.   - Overpressure.

Quick Stretch

  • Description:   - Quick movement opposite to desired contraction leading to a brief contraction of the agonist muscle.   - Ideal for patients who require muscle contractions (with flaccidity), not for spasticity (scores of 0 or 1 on MMT).   - Best applied to muscles including biceps, tibialis anterior, and hamstrings in a prone position.

Tapping

  • Method:   - Light tapping over a tendon or muscle belly to facilitate muscle contraction (not during relaxation).   - Aimed at increasing AROM for patients with MMT score of 3/5 or lower and flaccidity.

Joint Approximation

  • Application:   - Pressure applied to bring two bones together, usable in various contexts (sitting, standing, moving).   - A key strengthening technique, especially in conjunction with rhythmic rotation to decrease spasticity.

Overpressure

  • Description:   - Sustained pressure on specific muscles to elicit movement, applicable to high-functioning patients for posture.   - It provides tactile cues necessary to maintain upright positioning.

Expectations for Comps

  • General Guidelines:   - Introduce yourself to the patient and perform hand hygiene.   - Conduct a comprehensive chart review within 10 minutes, addressing pertinent information, and ask relevant questions related to the patient’s history.

  • Subjective Assessment:   - Gather thorough subjective data on:     - Pain assessment (location, 0-10 scale).     - Patient goals and priorities for exercise.     - Two goniometric measurements and two manual muscle tests (MMTs).

  • Treatment Session:   - Customize session to meet patient's needs, using understandable language for exercises chosen.   - Ensure safe positioning using gait belts and proper patient guarding during the session.

Complications Following Treatment

  • Post-Session Assessment:   - Obtain post-treatment pain ratings focusing on location.   - Complete treatment within a maximum of 15 minutes.   - Document in a full SOAP note format within 15 minutes; ensure equipment adjustments such as orthotics are noted where necessary.

References

  • Giles, S. M. (2020). PTAEXAM: The complete study guide. Scarborough, ME: Scorebuilders.

  • O’Sullivan, S.B. & Schmitz, T. (2014). Physical rehabilitation (6th ed.). Philadelphia, PA: F. A. Davis.