Advanced Proprioceptive Neuromuscular Facilitation For Neurological Patients Physical Education Essay

Proprioceptive Neuromuscular Facilitation (PNF) consists of patterns and techniques used for stimulating the human’s proprioceptors to promote neuromuscular system response (1)

PNF techniques:

PNF techniques, aims, and principle:

The first PNF technique is timing for emphasis, whose aim to strength and improve endurance in weak muscle groups, correct muscle imbalance, and increase ROM. This technique is based on the principle of using strong component to facilitate movement on the weaker component normal timing from distal to proximal, but the pattern can be altered by doing what the patient needs. Second PNF technique is hold-relax, aims to achieve relaxation, and increase ROM if pain is present. Based on the principle of moving the joint actively or passively to the limited range, then provides isometric contraction to the opposite pattern muscles with maximum resistance. Followed by relaxation and move toward the limited direction actively or passively depending on the condition, then repeat it in the new ROM. The thired technique is contract-relax, which targets to increase ROM, and it’s based on the principle of starting with isotonic contraction of the rotation component, followed by the isometric contraction for weak muscle. Slow reversals is the fourth technique, aims for weaker muscles contraction facilitation, improving coordination, and increasing endurance. Based on the principle of beginning movement at the strong component by isotonic contraction with maximal resistance immediately followed by isotonic contraction of the weak component with maximal resistance, without any relaxation. The fifth technique is repeated Contractions, it’s target are increasing ROM, improving strength and endurance in weak muscle group, and correct muscle imbalance. The principle used in this technique is reinforcing weak component by repeating maximal isometric contraction of the strong components of the pattern. The last technique is rhythmic stabilization. The aims of this technique are: used when movement at the joint is restricted, to strengthen muscles by co-contraction, improve circulation, improve postural stability in joints, and decrease pain. This technique is based on the principle of beginning with stability at the strong component by isometric contraction with maximum resistance followed by immediate without relaxation isometric contraction of the weak component with maximum resistance, until a co-contraction of the muscles of both component are build.

The aim of using PNF techniques is to enhance functional level of movements, by facilitation, inhibition, strengthening, and relaxation of muscles. In PNF concentric, eccentric, and static contractions are used alongside with resistance. (2) These techniques are classified according to their functions: reversal antagonist, which is a general class of techniques in which the patient contracts his agonist muscles, then the antagonist, without pause or relaxation. This technique includes: dynamic reversals, stabilizing reversals, and rhythmic stabilization. Another PNF technique is rhythmic initiation which is a passive rhythmic movement of limb or body through the desired range, and progress into active rhythmic resisted movement. Combination of isotonics, which is another technique in which a combination of concentric, eccentric, and stabilizing contractions are used for specific muscle groups (e.g. agonist) without relaxation, and it starts at the patient’s maximum strength or best coordination.

Another technique is repeated stretch, also known as repeated contractions; it’s applied in two ways: either repeated stretch from the beginning of the range or repeated stretch through the range.

Contract-relax and hold-relax, these two techniques either used as direct or indirect treatment. The last PNF technique is replication, which facilitates motor learning of functional activities. (2)

Normal motor activities:

In normal individuals, the developmental sequence of motor activities are varied, unified , and interrelated. The normal individual learns in his childhood to roll from supine to prone and vies versa, then sitting,etc. There is a variation of motor activities in the performance and sequence of these activities. The use of developmental sequence of motor activities is like when a person lays on a beach and senses danger, and then automatically rolls away into prone then sitting, then scrambles to his feet and runs, these actions serve his need the best, and these reactions are from birth and the people used them according to their needs. (1)

PNF principles:

The principles of PNF are: reflex mechanism, restoration of motor abilities, repetition of coordinated movements, and developmental sequence processes. In reflex mechanism, which helps to enhance movement and posture by using the coordination of the visual-motor mechanism and the auditory-motor mechanism. While during restoration of motor abilities, PNF patterns and techniques are used to provide suitable sensory cues, to enhance motor learning and abilities. Repetition of coordinated movements is used to increase strength and endurance, and adjusts the coordinated movements by the use of graded resistance. The last principle is developmental sequence process, which uses a sequence of training from proximal-to-distal and general-to-specific pattern. In these principles, PNF patterns and techniques are precisely applied to developmental activities by using techniques based on isotonic contractions for improving movement and isometric contractions for improving stability. (1)

Developmental sequence:

In the developmental sequence the physical therapist uses the progression of primitive movements and postures for more advanced movements and postures. The therapist also uses progression from general-to-specific pattern, specific movement to change positions and postures, eye-head coordination to enhance movements. In addition, this developmental sequence provides total pattern of movements, which includes head, neck, trunk, and four extremities, in various relations like ipsilateral, bilateral symmetrical, bilateral asymmetrical, and reciprocal, in which certain segments move while others adjust to the movement. And this sequence promote the patient’s ability to contract muscle isotonically during movements and isometrically during balance activities, and also enhance the transition from isometric to isotonic contraction. From this we find that PNF restore motor function in a person with a disability, by using variety of principles, patterns, and techniques used in Mat activities to enhance movement, self-care, and independence. (1)

Body of knowledge:
Mat activities:

Mat activities involves all principles of PNF, these activities include both stability and movement, which could be single or combined complex movements. To vary the effect of reflexes or gravity on the body, mat activities done in various positions which are chosen by the physical therapist to control abnormal movements. It’s better to begin with strong and pain free movements, because it focuses on irradiation from strong parts of movements to facilitate achieving the desired movements. (2) Also the use of diagonal movements involve greater number of muscle groups or movements (1). Any chosen mat activity is broken down into parts. In such treatment, the progression is by using weight bearing activities involving more extremities. (2)

Activities practiced on the mat teach the patient: mobility which is moving in the position, stability which is maintaining balance in the position, skill which combines mobility with stability or in transition. And the condition of the patient determines whether to start with any of these. (2) Basic procedures used in these activities to promote patient’s working capacity with minimum fatigue are: approximation to enhance stabilization and balance, traction and stretch to increase patient’s ability movements, grips and proper body position in which the physical therapist guides patient’s movement, resistance to enhance and reinforce movements, and it includes graded resistance which strengthen the weaker movements, and resisting strong movement for irradiation to the weaker movements. Another basic procedures are: timing for emphasis which use strong movements to exercise the weaker ones, and patterns to enhance functional activities performance. (2) All of the previous techniques, patterns, and basic procedures are used in mat activities, as follow: for stability, stabilizing reversals and rhythmic stabilization are used. While for mobility, combination of isotonics, rhythmic initiation, dynamic reversals, and repeated stretch are used. And for Skill, a combination of moving and stabilizing techniques are used.(2) The advantages of mat activities are: safe for people who fear to fall, performing activities without limitations, well-distributed balance, and postural reactions and reflexes are induced more effectively. (1)

The activities:
Mat characteristics:

The characteristics that should be in a mat used for activities are firm, smooth, comfortable, protect patient from abrasions and stress, large enough to accommodate both the therapist and the patient, and the size is 6 feet for adult, and 4 feet for child(1)

Rolling:

The first mat activity practiced with a neurological patient is rolling, which is divided into two parts: the first part is rolling to mid-position, which is a concentric action of flexor chain, and the other part is from mid-position to the end and it is an eccentric action of the extensor chain. For facilitating rolling, the therapist can use different combination of scapula, pelvis, neck, or extremities pattern.

Figure XX Rolling facilitation by Head
Rolling facilitation by Scapula:

First facilitating rolling by scapula, if the therapist resists anterior pattern of scapula, this will facilitate forward rolling, while resisting posterior pattern of scapula, facilitate backward rolling.

The patient can also facilitates rolling by moving his head in the same direction of rolling. The given commands for rolling with scapular anterior depression eg. For left :”pull your shoulder toward your opposite(right) hip, lift your head, pull your left arm down and across, pull your foot up and across, then roll”. While commands given for rolling backward with posterior elevation:”push back”.

In order to start, the therapist should stretches the scapula in the elongated range, and continue this diagonal movement until trunk muscles stretch. After that, the therapist applies resistance to initial scapular contraction until the contraction of trunk muscles is felt, then allows it to move. Locking scapula at the end of the range by applying more resistance with either approximation or traction. Types of scapular patterns in rolling are: Anterior elevation, in which the patient rolls forward with trunk extension and rotation, and it facilitated by neck extension and rotation in the rolling direction. Posterior elevation, in which the patient rolls backward with

Figure XXX Rolling facilitation by Scapula

trunk extension, and facilitated by neck extension in the rolling direction. Posterior depression, the patient perform a backward roll, with trunk extension, lateral flexion, and rotation, and facilitated by neck lateral flexion and full rotation in the rolling direction. And anterior depression, in which the patient rolls forward with trunk flexion, and facilitated by neck flexion in the rolling direction.(2)

Rolling facilitation by Pelvis:

Second, Pelvic facilitation in rolling, the resistance applied to anterior pattern of pelvis facilitate forward rolling, while resistance to posterior pattern of pelvis facilitate backward rolling. The patient can flex the neck to facilitate forward roll, and extend the neck for backward roll. Commands for the patient when rolling forward with anterior elevation: “pull your pelvis up and roll forward”, while when rolling backward roll with posterior depression: sit down into my hand and roll back”.

The therapist places the pelvis in the elongated range and continue this diagonal movement until trunk muscles stretch. Therapist resists initial pelvic contraction until he/she feels contraction of the desired trunk muscles, then allows it to move. In order to lock the pelvis at the end of the range, the therapist must apply more resistance with either approximation or traction. Types of pelvic patterns used in rolling are: Anterior elevation, in which the patient rolls forward with trunk flexion, flexes the neck for facilitation. Posterior elevation, in which backward rolling is performed with trunk lateral shortening, and facilitated by ipsilateral neck rotation. Posterior depression, in which the patient rolls backward with trunk extension, and extends the neck for facilitation. And anterior depression, in which the patient rolls forward with trunk extension and rotation, the facilitation in this pattern is neck extension and rotation in the rolling direction.(2)

Rolling facilitation by scapula and pelvic patterns combination:

Combining scapular and pelvic patterns can facilitate rolling, by performing pelvic anterior elevation and scapular anterior depression for forward rolling, while performing pelvic posterior depression and scapular posterior elevation backward roll .(2)

Figure XXX Rolling facilitation by pelvis
Rolling facilitation by upper extremities

In upper extremities facilitation in rolling, trunk muscles should be strengthen in order to facilitate, by combining strong arm muscles with scapular patterns. Adduction patterns used to facilitate forward rolling, while abduction patterns used to facilitate backward rolling. Also, head movements with the arm used for facilitation. Irradiation into trunk muscles, by resisting strong muscles of elbow. In order to facilitate upper extremities, the distal grip of the therapist is placed on patient’s hand or distal forearm to control the whole extremity. However, the therapist proximal grip is on or near patient’s scapula, which is more effective for guidance and resistance of the patient’s head movements. Forward rolling commands with extension-adduction pattern:”squeeze my hand and pull your arm down to your opposite hip, lift your head, then roll”. For backward roll with flexion-abduction pattern:”wrist back, lift your arm up & follow your hand with your eyes, then roll back”.

Figure XXX Rolling facilitation by pelvis

To start rolling, the therapist needs to stretch the arm and scapular muscles of the patient, and puts the arm in the elongated range and then tract. Sustaining this diagonal movement and traction, until synergistic trunk muscles stretch and maintain initial arm movements, until the therapist feels contraction of the trunk muscles, then allows it to move. Locking of upper extremities can be at any strong point in ROM. To lock the arm at end of the range, is by applying approximation with resistance to rotation.

Types of rolling using one arm are: Forward roll with trunk-extension, lateral flexion and rotation, facilitated by neck extension and rotation in rolling direction, and the patterns used are flexion-adduction-external rotation and ulnar thrust pattern. Backward roll with trunk-extension, lateral flexion and rotation, which is facilitated by neck lateral flexion and full rotation in the rolling direction, and the patterns used are extension-abduction-internal rotation and ulnar withdrawal pattern. Forward roll with trunk-flexion, facilitated by neck flexion in the rolling direction, and the patterns used are extension-adduction-internal rotation and radial thrust pattern. And backward roll with trunk-extension, facilitated by neck extension in the rolling direction, and the patterns used are flexion-abduction.(2)

Rolling facilitation by U.L bilateral combination:

Bilateral combination used in upper extremities rolling facilitation are: Forward roll with trunk flexion, which is Chopping and Reverse of Chopping. And backward roll with trunk extension, which is Lifting. (2)

Figure XXXX Rolling facilitation by U.L bilateral combination
Rolling facilitation by lower extremities:

In the facilitation of lower extremities in rolling, combining strong leg muscles with pelvic patterns are used for facilitation and strengthen trunk muscles. Flexion patterns of lower limbs facilitate forward rolling and extension patterns facilitate backward rolling. Irradiation into trunk muscles by resisting strong muscles of the knee. Head moves in flexion to facilitate forward roll and in extension for backward roll. Physical therapist distal grip is placed on the patient’s foot to control the whole extremity. It will be more effective activity, if the knee movements are resisted. And the proximal grip of the therapist is on patient’s thigh or pelvis, in flexion-abduction the proximal hand on contralateral iliac crest to facilitate trunk flexion. Commands given for forward roll with flexion-abduction pattern:”foot up, pull your leg up and out, then roll away”. And for backward roll with extension-adduction pattern:”push your foot down, kick your leg back, then roll back toward me”.

Figure XXXX Rolling facilitation by U.L bilateral combination

Starting position for this rolling is to stretch the leg and lower trunk muscles, and putting the leg in the elongated range of pattern and apply traction. And this movement is maintained until the therapist feels contraction of trunk muscles, then allows it to move. The locking can be at any strong point in ROM.

Types of rolling with one leg are: Flexion-adduction, for rolling forward with trunk flexion. Extension-abduction, for rolling back with trunk extension and elongation. Flexion-abduction, for rolling forward with trunk lateral flexion, flexion ,and rotation. And extension-adduction, for rolling back with trunk extension, elongation, and rotation.(2)

Rolling facilitation by L.L bilateral combination:

Bilateral combination of lower extremities for facilitating rolling are: Lower extremity flexion, by rolling forward with trunk flexion. And lower extremity extension, by rolling back with trunk extension. (2)

Rolling facilitation by neck:

The last pattern for facilitating rolling is neck patterns. These patterns are used to facilitate rolling when patient has no pain free motion or no strong movement in scapula or arm. The main force in neck flexion is traction, while in neck extension we apply gentle compression. In rolling, neck flexion is used to facilitate rolling forward from supine to side-laying, and neck extension is used to facilitate rolling back from side-laying to supine. (2)

Prone-on-elbows:

After achieving rolling, the next mat activity is prone-on-elbows exercise. There are three methods that enable the patient to assume this position, are: side-laying, rolling from supine-to-prone, and prone position. If any of the previous methods are against gravity, the therapist resists concentric contraction. And if it is gravity assisted, the therapist resists eccentric contraction.

Figure XXXX Prone-on-elbows

In order for the patient to achieve this position, the therapist should apply stabilization with approximation for scapula, and resistance in diagonal and rotatory direction is necessary. The patient must avoid trunk sag. The therapist should keep the patient’s head, neck, and trunk aligned, and apply gentle resistance on the head for stabilization along with rhythmic stabilization. And if the patient can’t do isometric contraction, the therapist can use stabilizing reversal. When the patient is able to maintain this position, the therapist can work on improving head, neck, and shoulder, neck resisted motions which is effective, resisted arm motions to strengthen the weight-bearing arm, upper trunk rotation, and weight shifting. (2)

Side-sitting:

The paitent then progresses from prone-on-elbow position into side-sitting. This position involves weight-bearing on arm, leg, and trunk of one side, while the other arm is free to function, then the patient should learn mobility like scooting. Four methods to assume this position, which are: side-laying, prone-on-elbows, sitting, and quadruped. The physical therapist in this position, can work on activities of balance, like upper extremity weight-bearing exercises , and scapular and pelvic reciprocal motions, in which the movements of this combination promotes trunk mobility, and stabilizing contraction of this combination promotes trunk stability. Activities of mobility in this position are: scooting, moving to sitting, to prone on elbows, and to quadruped position. (2)

Quadruped:

The other mat activity that follows side-sitting is quadruped. In this position the patient will be able to exercise trunk, hips, knees, and shoulder, using isotonics and dynamic reversals. Also the patient will be able to move from one place to another. The physical therapist makes sure that the patient has strong scapular muscles to support the weight of upper trunk. Patient with spinal pain or has stabilization problems, can practice activities in this position, but the therapist must be assertive of absence of pain in knee joint. The patient can assume this position by two methods, are: prone-on-elbows, and side-sitting. In quadruped position, the therapist can works on activities of balance, by using stabilizing reversal and rhythmic stabilization techniques, for balance and stabilization of the trunk and extremity joints. Also the therapist can work on rocking forward and backward, by using combination of resistance, isotonics, and dynamic reversals. Crawling can be practiced in this position, by applying resistance on scapula, pelvis, neck, arms, and legs movements, in order to enhance patient’s skill. (2)

Figure XXX Facilitation to Quadruped

Kneeling:

In this position the patient will be able to exercise trunk, hips, and knees, while arms are free and used for support, able to move from one place to another, and moves from kneeling to standing. For patients who have knee pain and can’t assume this position, they can work in kneeling down. Kneeling will help to promote the strength, coordination, and ROM of hips and knees, by exercise moving between kneeling and side-sitting, and by combining isotonics contractions for concentric and eccentric muscles. To assume this position, is by three methods, are: side-sitting, kneeling-down, quadruped position. Activities that can be practiced in this position are: balance activities such as, scapula and head motions resistance, using stability reversals and rhythmic stabilization techniques to promote trunk strengthen and stability. Other balance activities are resistance to: pelvic motion, pelvis and scapula motions, trunk and head motion, and resisting arm movement when sitting of the heels. Another activity, which can be practiced in this position is walking on the knees forward, backward, and sideways. (2)

Half-Kneeling:

This mat activity is where the patient can go to standing position. There are two methods to assume this position: kneeling and standing. The physical therapist can work on activities of balance, such as: strengthening trunk and lower extremity muscles, by using stabilizing and moving techniques. Activities of weight shifting over back leg with trunk elongation, this activity challenge patient’s balance, coordination, ROM, and strength. Activities of shifting weight to front leg, which increase DF ROM. And standing up as the last activity. (2)

Sit-to-stand:

In order for the patient to stand up from a chair, he or she should moves forward in the chair, stand up, get his or her balance in standing. The patient should be able to rise from sitting on surfaces of different heights.

Sit-to-stand is divided into two parts. The first part which involves flexion of head, neck, and trunk, pelvic anterior tilt, and knee extension with forward movement over the base of support. The second part of this activity is backward movement toward a vertical position characterized by extension of head, neck, and trunk, posterior pelvic tilt, and the knees go into extension and backward movement as the trunk comes over the base of support. Commands given for a patient standing up from the floor:” pull yourself forward, and push with your right foot. Now push with both feet, lift your head to the left, stand up. Hold, now pull your left foot forward and step on it.”

In this activity the therapist holds the patient’s iliac crests in order to increase the patient’s ability in standing up. Then the therapist rocks the pelvis by rhythmic initiation and stretches it into posterior tilt, and resists or assists as it moves into anterior tilt. Rhythmic initiation is used enable the patient to place his or her hands on bars or chairs arm, and stabilizing contractions and combination of isotonics are used to enable the patient to assist with their arms. When the patient is moving toward standing, the therapist should assist his or her pelvis by guiding it through anterior tilt. Resistance is applied to the movement that the patient is capable of doing it without help. In the time the patient stands with upright posture, the therapist moves the pelvic into the appropriate degree of posterior tilt. For promoting weight bearing, approximation is done through the pelvic. (2 & 1)

2.2.9 Standing:

This position is considered to be the first stage in walking and a form of functional activity. In standing the therapist should stand in a diagonal plane in front of the leg that initially will receive the patient’s weight. Commands given in this activity:”Hold, don’t let me pull your head forward, don’t let me push your hip back. Hold, don’t let me turn you to the other side. Hold don’t let me pull you forward.”

Accepting the patient’s body weight on his or her lower limb, is fulfilled by combining approximation through the pelvis on the strong side with stabilizing resistance at the pelvis. For the weaker side, the therapist uses the same techniques in addition to blocking the knee. Then the therapist stabilizes lower trunk and legs by combining approximation and stabilizing reversals at the pelvis. The same techniques directed at the shoulders used to stabilize upper and lower trunk. When using combination of isotonics with small motions or stabilizing reversals, it will resist balance in all directions, and it’ll work on stabilizing the head, shoulders, pelvis, and their combinations. . (2&1)

Conclusion:

In conclusion, deficient neuromuscular mechanism leads to limited response due to faulty development, trauma, or disease of the nervous or musculoskeletal systems. As we know, PNF is related to normal response of the neuromuscular mechanism, which enables it to widen the range of motor activities within the limitations of anatomical structure, developmental level, and inherent and previously learned neuromuscular response. By using various combinations, patterns, and techniques of PNF, the patient will be able to regain and restore his or her previous functional level.

Refrences:

1. Voss, Dorothy E., Ionta, Marjorie K., & Myers, Beverly J. (1968). Proprioceptive neuromuscular facilitation: patterns and techniques. Philadelphia : Harper and Row.

2. Adler, Susan S., Beckers, Dominiek, & Buck, Math. (2003). PNF in Practice: an illustrated guide. Germany: Springer.

Content Page

Content page

Introduction 2

Background about PNF 2

PNF techniques 2

Normal motor activities 4

PNF principles 4

Developmental sequence 5

Body of knowledge 6

Mat activities 6

The activities 7

Mat characteristics 7

Rolling 7

Rolling facilitation by Scapula 9

Rolling facilitation by Pelvis 11

Rolling facilitation by scapula and pelvic patterns combination 11

Rolling facilitation by upper extremities 12

Rolling facilitation by U.L bilateral combination 15

Rolling facilitation by lower extremities 16

Rolling facilitation by L.L bilateral combination 17

Rolling facilitation by neck 17

Prone-on-elbows 18

Side-sitting 19

Quadruped 20

Kneeling 21

Half-Kneeling 23

Sit-to-stand

24

Standing

25

Conclusion

26