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Edit Comment Close Premium member Presentation Transcript PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION : PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION Total Rehabilitation Using Your Hands as the Primary Tools Slide 2: BY :- Dr. Vishal B. Boricha (MPT, Sports) DEFINITION : DEFINITION Proprioceptive: having to do with any of the sensory receptors that give information concerning movement and position of the body Neuromuscular: involving the nerves and muscles Facilitation: making easier PNF : PNF Proprioceptive and sensory mechanisms Feed information to the nervous system Facilitate the desired response Response: contraction for strengthening Response: relaxation for stretching Response: improved balance and equilibrium CONTEXT : CONTEXT It was started by Dr. Herman Kabat and Margaret knot in 1940s. Dorothy Voss joined the team in 1953 and continued to expand and develop the treatment procedures and technique Margaret and Dorothy wrote the first PNF book published in 1956 BASIC NEUROPHYSIOLOGY : BASIC NEUROPHYSIOLOGY Afterdischarge Temporal summation Spatial summation Irradiation Successive induction Reciprocal innervation The work of Sir Charles Sherrington was imp in developing the techniques of PNF The effect of stimulus continues after the stimulus stops. If the strength and duration of the stimulus increase, the afterdischarge increases also. BASIC NEUROPHYSIOLOGY : BASIC NEUROPHYSIOLOGY Afterdischarge Temporal summation Spatial summation Irradiation Successive induction Reciprocal innervation The work of Sir Charles Sherrington was imp in developing the techniques of PNF A succession of weak stimulli (submaximal) occuring within short period of time combine to cause excitation. BASIC NEUROPHYSIOLOGY : BASIC NEUROPHYSIOLOGY Afterdischarge Temporal summation Spatial summation Irradiation Successive induction Reciprocal innervation The work of Sir Charles Sherrington was imp in developing the techniques of PNF Weak stimuli applied simultaneously to different areas of body reinforce (summate) each other to cause excitation BASIC NEUROPHYSIOLOGY : BASIC NEUROPHYSIOLOGY Afterdischarge Temporal summation Spatial summation Irradiation Successive induction Reciprocal innervation The work of Sir Charles Sherrington was imp in developing the techniques of PNF There is spreading and increased strength of response when either the number of stimuli or the strength of stimuli is increased. The response may be either excitation or inhibition BASIC NEUROPHYSIOLOGY : BASIC NEUROPHYSIOLOGY Afterdischarge Temporal summation Spatial summation Irradiation Successive induction Reciprocal innervation The work of Sir Charles Sherrington was imp in developing the techniques of PNF An increased excitation of agonist muscles follows stimulation (contraction) of antagonist. Techniques involving reversal of antagonists make use of this property BASIC NEUROPHYSIOLOGY : BASIC NEUROPHYSIOLOGY Afterdischarge Temporal summation Spatial summation Irradiation Successive induction Reciprocal innervation The work of Sir Charles Sherrington was imp in developing the techniques of PNF Contraction of muscles is accompanied by simultaneous inhibition of their antagonists Relaxation techniques make use of this property. BASIC PROCEDURES : BASIC PROCEDURES Resistance Irradiation and reinforcement Manual contact Body positioning and body mechanics Verbal commands Vision Traction and approximation Stretch Timing Patterns 1. RESISTANCE : 1. RESISTANCE The amount of resistance provided during an activity must be correct for the patient’s condition and the goal of the activity. This is called optimal resistance. 1. RESISTANCE : 1. RESISTANCE Resistance is used in the treatment to: Facilitate the ability of the muscle to contract Increase motor control Help the patient gain an awareness of motion and its direction Increase strength 1. RESISTANCE : 1. RESISTANCE Effects: Most effective proprioceptive facilitation Increase the response of synergistic muscles at the same joint and associated synergists at the neighboring joints. 1. RESISTANCE : 1. RESISTANCE Facilitation can spread proximally or distally Antagonist is inhibited Intense activity of the agonist stimulates activity in the antagonist group as well (co-contraction) BASIC PROCEDURES : BASIC PROCEDURES Resistance Irradiation and reinforcement Manual contact Body positioning and body mechanics Verbal commands Vision Traction and approximation Stretch Timing Patterns IRRADIATION & REINFORCEMENT : IRRADIATION & REINFORCEMENT DEFINITIONS Irradiation : the spread of response to stimulation is called irradiation. Reinforcement : means “to strengthen by fresh addition, make stronger” IRRADIATION & REINFORCEMENT : IRRADIATION & REINFORCEMENT Effects : Maximal resistance may be used to cause irradiation or overflow from stronger patterns to weaker patterns or from stronger groups of muscles within a pattern to weaker groups within the same pattern. IRRADIATION & REINFORCEMENT : IRRADIATION & REINFORCEMENT Spread of muscular activity will occur in specific patterns Increasing the amount of resistance will increase the amount and extent of the muscular response. Working against maximal resistance can produce associated reactions in spastic patient IRRADIATION & REINFORCEMENT : IRRADIATION & REINFORCEMENT For spastic pt, maximal resistance is defined as “the amount of resistance the pt can take without producing associated reaction.” If associated reactions occur, it means the therapist is applying too much resistance. IRRADIATION & REINFORCEMENT : IRRADIATION & REINFORCEMENT Examples: Resist muscle activity of the sound limb to produce contraction of the muscles in the immobilized contralateral limb. Resist supination of the forearm to facilitate contraction of the external rotators of that shoulder IRRADIATION & REINFORCEMENT : IRRADIATION & REINFORCEMENT Resist hip flexion to cause contraction of the trunk flexor muscles. Resist hip flexion with adduction and external rotation to facilitate the ipsilateral dorsiflexor muscles to contract with inversion. Resist neck flexion to stimulate trunk and hip flexion. IRRADIATION & REINFORCEMENT : IRRADIATION & REINFORCEMENT Resist neck extension to stimulate trunk and hip extension. Resist dorsiflexion to facilitate contraction of ipsilateral quadriceps BASIC PROCEDURES : BASIC PROCEDURES Resistance Irradiation and reinforcement Manual contact Body positioning and body mechanics Verbal commands Vision Traction and approximation Stretch Timing Patterns MANUAL CONTACT : MANUAL CONTACT Effects: Stimulates the muscle Stimulates the synergistic muscle to reinforce the movement Promotes trunk stabilization and indirectly helps the limb motion Prevents confusion (04) MANUAL CONTACT : Alpha Motor Neuron MANUAL CONTACT skin + + + MANUAL CONTACT : MANUAL CONTACT Four vital features of the grip: Stretch: the correct grip enables the therapist to stretch all the components of a pattern simultaneously. Exteroception: the grip must be such that it gives sensory stimulation to the skin in the direction of movement. MANUAL CONTACT : MANUAL CONTACT Resistance: the grip must be such that the therapist is able to exert max resistance throughout the full range of movement. Traction/approximation: the grip must be such that the therapist is able to exert either traction or approximation to the part MANUAL CONTACT : MANUAL CONTACT Lumbrical Grip is used by the therapist to control movement and resist rotation Pressure comes from the flexion at MCP joints Therapist’s finger conform to the body part Does not cause pain due to squeezing or putting too much pressure on the bony body parts. BASIC PROCEDURES : BASIC PROCEDURES Resistance Irradiation and reinforcement Manual contact Body positioning and body mechanics Verbal commands Vision Traction and approximation Stretch Timing Patterns BODY POSTION & BODY MECHANICS : BODY POSTION & BODY MECHANICS The therapist body should be in line of motion Shoulder and pelvis face the direction of motion. Therapist stands in walk standing position. The resistance comes from the therapist’s body, while the hands and arms stay comparatively relaxed. VERBAL STIMULATION (COMMANDS) : VERBAL STIMULATION (COMMANDS) Tells the pt what to do and when to do Instructions need to be clear and concise without the use of unnecessary words. May be combined with passive movement to teach the pt the desired motion The timing of the command is very imp VERBAL STIMULATION (COMMANDS) : VERBAL STIMULATION (COMMANDS) The volume with which the command is given affects the strength of resulting muscle contraction. Louder command when strong muscle contraction is required. Softer and calmer tone when the goal is relaxation and relief of pain. VERBAL STIMULATION (COMMANDS) : VERBAL STIMULATION (COMMANDS) The command is divided into three parts: Preparation: readies the pt for action. “ready” Action: tells the pt to start the action. “now pull your leg up and in” Correction: tells the pt how to correct and modify the action. “keep pulling your toes up” VISION : VISION The feedback from visual sensory system can promote a more powerful muscle contraction Helps the pt to control and correct his position and motion Moving the eyes will influence both the head and body motion Eye contact between pt and therapist provides a mode of communication TRACTION & APPROXIMATION : TRACTION & APPROXIMATION The therapeutic effects of traction and approximation is due to stimulation of joint receptors. Traction is applied when the movement is occurring against the gravity and approximation when the movement occurs in the direction of gravitational pull Slide 38: Alpha Motor Neuron + + JOINT + Sensory neuron muscle TRACTION : TRACTION Definition: Traction is elongation of trunk or an extremity Traction force is applied gradually, maintained throughout the movement, and combined with appropriate resistance. TRACTION : TRACTION Joint separation stimulates joint receptors Muscle stretch stimulates muscle spindle stretch receptor Facilitates Alpha Motor Neuron Facilitates Strength TRACTION : TRACTION Uses: Facilitate motion, especially pulling and antigravity motions Aid in elongation of muscle tissue, when using the stretch reflex. Resist some part of motion. E.g., use traction at the beginning of shoulder flexion to resist scapula elevation. APPROXIMATION : APPROXIMATION Definition: Approximation is the compression of the trunk or an extremity. Compression through a joint stimulate joint receptors Facilitate alpha motor neuron Facilitate stability APPROXIMATION : APPROXIMATION Uses: Promote stabilization Facilitate weight bearing and contraction of postural muscles Facilitate upright reactions Resist some component of motion. E.g., use approximation at the end of shoulder flexion to resist scapula elevation (11) APPROXIMATION : APPROXIMATION There are two ways of apply the approximation: Quick approximation: the force is applied quickly to elicit a reflex-type response. Slow approximation: the force is applied gradually up to the pt ‘s tolerance APPROXIMATION : APPROXIMATION The approximation is always maintained, whether done quickly or slowly When the therapist feels that the active muscle contraction decreases the approximation is repeated and resistance is given STRETCH : STRETCH The stretch stimulus occurs when the muscle is elongated The lengthened position of the muscle is the starting position of each pattern and the stretch is maintained throughout the movement. All the components of a pattern must be stretched simultaneously STRETCH : STRETCH Effects: Stimulates the activity of muscle spindle Any contraction of muscle on stretch will result in movement and the brain knows not of muscles but of movement. Quick Stretch : Alpha Motor Neuron Quick Stretch + Muscle Spindle + + (06B, 06A) STRETCH : STRETCH Uses: Can be used to initiate voluntary movement The pt is instructed to coincide with the reflex movement brought about by the therapist Can also be used to aid the response of weak muscles. STRETCH : STRETCH Used to obtain lengthening reaction of hypertonic muscle: By stimulating a contraction of opposing muscle group. the hypertonic muscle will reciprocally lengthen By reflexly stimulating a contraction of hypertonic group.this contraction will be followed by relaxation phase. TIMINGS : TIMINGS Timing is the sequencing of motions Normal timing of most coordinated and efficient motions is from distal to proximal Timing for emphasis involves changing the normal sequencing of motion to emphasis a particular muscle or desired activity TIMINGS : TIMINGS There are two ways the therapist can alter the normal timing for therapeutic purpose By preventing all motions in a pattern except the one that is to be emphasised. By resisting an isometric or maintained contraction of strong motions in a pattern while exercising the weaker muscles. PATTERNS : PATTERNS Each pattern has three dimension – Flexion or extension Abduction or adduction Rotation Movement occurs in a straight line, in diagonal direction with a rotatory component UPPER EXTREMITY : UPPER EXTREMITY F-ABD-ER F-ADD-ER E-ABD-IR E-ADD-IR (04, 07) Slide 55: Diagonal One Diagonal Two F-ABD-ER E-ADD-IR F-ADD-ER E-ABD-IR Slide 56: F-ADD-ER E-ABD-IR Slide 57: F-ABD-ER E-ADD-IR LOWER EXTREMITY : LOWER EXTREMITY F-ABD-IR F-ADD-ER E-ABD-IR E-ADD-ER Slide 59: F-ABD-IR F-ADD-ER Slide 60: F-ADD-ER F-ABD-IR PATTERNS : PATTERNS Patterns are named according to the direction of movement and therefore finishing, not the starting position. In completing the pattern the muscle contracts through full range from its lengthened to its shortened position PATTERNS : PATTERNS Two types of pattern: Unilateral: one arm or one leg Bilateral: both arms, both legs or combination of arms and legs. - symmetrical: limbs move in same pattern. - asymmetrical: limbs move in opp patterns Slide 63: Bilateral Asymmetrical Bilateral Asymmetrical ‘Chopping’ ‘Lifting’ Slide 64: Bilateral symmetrical patterns QUICK STRETCH : QUICK STRETCH Stimulates stretch receptors of at the muscle spindle Facilitates Alpha Motor Neuron Facilitates Strength TIMING : TIMING Rhythmical reversal of direction Distal to proximal coordination MAXIMAL RESISTANCE : MAXIMAL RESISTANCE By muscle group By joint By limb VISION : VISION PATIENT LOOKS IN THE DIRECTION YOU WISH THE BODY/HEAD TO MOVE WATCH THE LIMB TO IMPROVE COORDINATION Lk Up R AGONIST : AGONIST Muscle(s) that move the joint in the desired direction Question: What are the agonists to shoulder flexion/abduction/external rotation? DIAGONAL PATTERNS : DIAGONAL PATTERNS Whole Limb Rotational Component Diagonal (not pure planar movements) Functional (07) RHYTHMIC STABILIZATION : RHYTHMIC STABILIZATION Isometric hold Against manual resistance given in diagonal patterns Purpose: Increase strength and stability around a joint Can be done with limb fixed (closed chain) or limb free (open chain) (14, 15) SLOW REVERSAL : SLOW REVERSAL Isotonic contraction followed immediately by isotonic contraction of the antagonistic muscles Overflow from strong pattern to weaker pattern Purpose: Increase strength and facilitate normal timing and coordination (07) SLOW REVERSAL-HOLD : SLOW REVERSAL-HOLD Isometric hold performed in the range of a pattern of isotonic diagonal pattern Purpose: Increase strength in a particularly weak or uncoordinated portion of the range. HOLD RELAX : HOLD RELAX CONTRACT RELAX : CONTRACT RELAX AGONIST CONTRACT : AGONIST CONTRACT DEVELOPMENTAL SEQUENCE : DEVELOPMENTAL SEQUENCE Prone Rolling Prone on elbows Prone push up Quadruped Crawl Kneel Half-kneel Stand Walk THERAPEUTIC DEVELOPMENTAL SEQUENCE : THERAPEUTIC DEVELOPMENTAL SEQUENCE Facilitate normal reflexes and responses (pediatrics and neurological impairments) Isometric contraction within the stage: Static For stability (FIRST) Easiest Movement within the stage: Dynamic For strength and coordination (SECOND) Hardest (13-15-12,12B-17) Rood Approach : Rood Approach Rood Inhibition Technique: Neutral Warmth: Non Invasive, Non threatening approach of Wrapping targeted body part or entire body in blanket, towel, or sheet for 5-10 min Client feels light pressure & warmth of wrap & often feels relaxed, resulting in decreased tone. Gentle Rocking or Shaking : Gentle Rocking or Shaking Rhythmical, controlled rocking or shaking movement that incorporates joint approximation & distraction Commonly used at head, shoulder, forearm, pelvis & lower extremities Precise hand placement & manipulation skills are necessary Slow Stroking : Slow Stroking Application of firm, direct pressure to both sides of spinous process( primary post rami ) from occiput to coccyx for up to 3 min, with client in prone May be accomplished with index & long digits in V position, stroking down the spine As one hand reaches coccyx area, alternate hand begins to repeat stroking from occipital area to ensure continuous pressure Slow Rolling : Slow Rolling Slow, passive rolling of client by therapist from side lying toward prone May include slow manual rotation of pelvis & trunk Technique should be completed on each side Deep Tendon Pressure : Deep Tendon Pressure Deep, direct pressure at tendon insertion site of targeted muscle Joint Compression : Joint Compression Application of pressure less than or equal to body weight to move bones on either side of a joint closer together Commonly performed at shoulder followed by moving humerus in small circles, resulting in decreased pain & stiffness May also be a accomplished by client in weight bearing position in which pressure is less than body weight Maintained Stretch : Maintained Stretch Maintenance of affected muscle in elongated position Light Moving touch : Light Moving touch Stimulation applied by fingertips, cotton ball, or camel hair brush Limited to three to five strokes with 30 sec intervals between applications Fast brushing : Fast brushing Use of battery – operated brush over dermatomal area supplying muscle to be stimulated Application limited to 3 – 5 sec with 30 sec intervals between application Icing : Icing Three different applications techniques to stimulate client’s level of alertness, postural responses, & or parasympathetic responses Heavy joint compression : Heavy joint compression Pressure greater than body weight applied through longitudinal axis of bone Most commonly used through long bones May be accomplished in combination with developmental positions ( prone on elbows, quadruped, standing ) Quick Stretch : Quick Stretch Accomplished by providing a quick stretch movement to limb in opposite direction of desired movement just distal to joint while stabilizing proximally Pressure : Pressure Rubbing belly of muscle being facilitated with finger tips of index, long & ring fingers Stretch pressure : Stretch pressure Manual stretching of belly of muscle being facilitated with finger tips while applying pressure Tapping : Tapping Tapping 3 – 5 times over belly of muscle being facilitated with finger tips before or during muscle contraction Vibrations : Vibrations Use of small hand – held vibrator parallel to muscle fibers on belly of muscle being facilitated Contra indicated in young children Slide 96: THANK YOU You do not have the permission to view this presentation. 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