proPRIO! ipTRODUCTION guRoPH 4 NEURO! MOVEMENT , 2 ysialogical technique of movement erect on Which the movement YSIOLOGICAL VIEW OF is baste or mechanical and physiological, When pends erry injury or damage to the CNS, this ah iological view is lost. So some at damage which \d many more. ire_the normal movements Pe zy good effect on sensory and motor. se The Wo basic things on which the Seen of technique depends are:~ 1. Sensory-motor aspect of movement” 2. Tone of muscle.“ te sensory partis impaired, then patient will, be aware of the stating positions, accuracy. and nealleffeciveness afmovement. Injury to CNS gr musculoskeletal system will also lead to zbnormal movement patterns. Tone of muscle may be influenced due to jon of UMN(leading to spasticity or rigidity) HiN(eading to flaccidity).Hypertonia occurs itz to the imbalance of the inhibitory influence ‘on the motor system, while hypotonia develops éueto lack of excitatory impulse on motor system. 4 Spasticity : ILis the abnormal. increase in the tone of muscle due to lesion in corticospinal tract leading to uncontrolled voluntary ovement. Thisis limited to a particular mass movement for e.g. in hemiplegia it develops in the flexors of upper limb and extensors of lower limb. Rigidity : \tis an increase in the muscle tone wl hich is equal in all muscle group and is aintained through-the fal rough the full range of Movement. A pathological co-contraction is Seen for eg. Parkinsonism, eons CHAPTER 10 \CEPTIVE NEUROMUSCULAR, FACILITATION(PNF) © Spasm : It isan increase in the tone of muscle occurring as the protective, phenomenon in.all the individuals, It may occur as a response to jammatory.reaction. Itis ery Co-ordination : tis again very important for a normal movement to occur. All the groups of muscles-i.e. agonist. _ _aptagonist, synergists and fixators have to contract in a.particular.manner to result into a fine and a smooth movement. If this is not there then als the movement will become abnormal. Normally in daily activities like walking ,eating, combing. kicking ete the diagonal movement with a rotatory component is used. Normal pattern_of the body are thus disturbed due to- _ © Sensory impairment c © Tone abnormality. : © Lack of co-ordination. © Motor disturbances. © Locomotor system Balancing system. PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION INTRODUCTION This technique of PNF was developed by Dr.Herman, Kabat and Dorothy Voss in America between 1946 and 1951 at Kabat Kaiser Institute. They worked on the principal that the strength of. the muscle contraction is directly proportional to the excitation of the motor units which depends upon the str stimulus. So they worked on the paralysi by stressing more over the each voluntary effort and maximum repetition of each movement. By there work they found out various patterns of the upper limb , lower limb, trunk and head and148 Goel's Physiotherapy(Vol. 1) neck. These were according to the patterns used in the daily living. For e.g. the flexion / adductior - /medial rotation pattem of the upper limb is used for the ez 7 ‘Not only that they also found certain special techniques which can be used to reduce the rip: spasticity , to gain the muscle power.,to induce ” The grip of the thera ist acts asa key to facilitation Felzxation and so for these all and many more, ands the most salisiatlory War oT So = techniques are described in this project. maximal resistance. The characteristic of effective grip is- BASIC TECHNIQUES USED IN PN1 The proprioceptors lying in the muscle are tlie Primary source which when get excited results into the contraction of muscle. The strength and tone of the muscle can be increased by progressive resisted exercises. The basic technique used in the PNF are position of the therapist, eyes, voice or command, erip. tra if tern of movement, timing, maximal resistance and_re-inforcement. Position Of The Therapist : It should be such that the therapist should be able to perform the movement smoothly, is able to transfer the weight and can apply the maximal resistance. Usually the lunge position with forward foot pointing in the line of movement and the backward foot placed at right angle to the front foot (for stability) is used. Therapist should stand close to the pari to be exercised and should move or change the position accérding to the movement. The back of the therapist should remain straight so that the weight taken through the therapist's arm while giving resistance to the gravity assisted movement,is transmitted to the floor without any strain, ee. Eyes also serve as the source of sensory input. Patient is asked to follow the movement with the eye"So that the voluntary muscle can be re- inforced, ° Voice or Command : The words of the therapist act as a sensory ‘stimulator and also stimulates the patient's voluntary effort. The command should be such that the patient is able to per ive it and can perform fa ateich : accordingly. Usually the command is given wig, the word "NOW" followed by the word indicati, the appropriate desired action like "HOLD" for isometric muscle work .."PUSH or PULL Tas sotonic muscle work , "RELAX" for relaxation a 5 * It should provide uniform resistance” throughout the idvement ; © It should make the therapist to stré components ofthe paem conta ee If grip is causing any discomfort to the atient then it should be changed to elsewhere: itis also changed in cases of impairment, . nsory stimulation on to ient in the direction of movement. © The grip must be such that the therapist is able to exert traction.or approximation to the pant as and when required. The grip used is called as "tumbricals grip” in which the fingers are flexed from the metacarpo- Phalangeal joint and are extended (but not very rigidly) at the interphalangeal joint. Traction or Approximation : Traction is the force which separates the joint surface and approximation is the force which compresses the joint surface. These are appliéd by the physiotherapist during the movement for the stimulation of the proprioceptors. Traction is given when movement is occurring towards the gravity. Proprioceptors lying in the muscle belly get stimulated when muscle is stretched. This results into reflex contraction of muscle, But the stimulus should have enough strength to reach to the dormant anterior horn cell to increase the central excitation.th stimulus to the desi i se thened position Which increases Ir eula tension. The sharp, uniform and eit etch is given through the movement, conte is instructed 10 make his effort tq ae palit coincide withthe reflex movement ont out bythe physiotherapist. Xt should be youd he mind that the excessive force should rept in th Iis the command, the skill of the lied 13 apis which elicits thé stretch reflex. phy hythmical repetition of the technique is done PNE 149 she maximum response which is desired is, J Timing: ‘i Command used _is on “NOW PULL". achieve (eretch seats and ses ¢ forthe stretch reflex to act, the reflex are should te intact and the stretch should be applied ‘eaecly and efficiently. So the stretch helps in: Initiating the contraction. Increases the response of weaker muscle + Strengthening. 7 + By stimulating the contraction of opposing muscle group, the hypertonic muscle will lengthen reciprocally. @ Induce felaxation after the phase of contraction, in the hypertonic muscle grow; fatern of Movement The usual pattern of movement (in mass activity)are rotatory and diagonal These movements occur in straight line with the direction thenby the diagonal component and stabilization and holding provided by the spiral or rotatory Component, Thus the movement occur in three dimensional space. For the arms or legs the pattern are flexion or quittion abduction or adduction and rotation. ar diagonal movement also apply to head and nin Suze isin the line with the oblique tothe faa ls. The patterns are named according Pstgg Poston ofthe pater, So the stating Just opposite to that of the final Position, Wy " When the pattern is completed, the Normal timing: is the sequen contraction occur erence muses i oeC in a co-ordii during the mir activi: Normally. hemmorerert 's initiated by the rotatory component which Proce stability and dicection to.the movement ‘ollowing this the movement is initiated first in the distal joints for eg. fingers then wrist aad toes then foot, then in the proximal joints for eg. elbow, shoulder and knee, hip. It should be kept in mind that before starting the movement at proximal joint the distal joint movement should get completed. Maximal Resistance Itisthe maximum amount of resistance which can be applied to a particular movement by the physiotherapist. The amount of resistance depends upon the power of the muscle and the type of muscle work Ifthe power of muscles less than 3 ie, patient ‘s not able to do the movement actively against the gravity in full range then itis necessary for the therapist to assist the patient, Then gradually as the power improves—by—the_resisted. ises,the therapist then progresses. If muscle is contracting isometrically then the maximal resistance is such that the patient is able to hold the muscle in a contracted state without any relaxation. In case of isotonic muscle work the maximal resistance is that against which the patient can do the smooth, co-ordinated movement without any fatigue, through the full range. ‘The amount of resistance remains same through the movement. All the three components ofthe movement should be maximally resisted.150 Goet's Physiotherapy(Vol 1) - he variation in the strength ofeach component Thon be checked in different ranges trapped either manually ot by holding. feces and uses Renan resistance ead oe Stimulation of motor units lying inthe mascle spindle and also increases the amount oh intramuscular tension. Both of these aaeael ead to the activation of the other adjacent ane units by the irradiation method. More is : demand of resistance, more will be the extent of excitation Sothe application of maximal resistance helps ins * Increasing excitation, © Strengthening of muscle * Todevelop endurance * Forrelaxation * Co-ordination. (feinforcement + When the pattern of movement is performed against the maxin Stimulated .By the process of irradiation or overflow the other. weaker muscle also~get © Simulated Thus by this method the weaker group “ofmuscles involved in a particul muscle to the weaker muscles, ak quadriceps the orsiflexors are worked against resistance , This causes y quadriceps PATTERN OF THE Upprn LIMBS Extension, abduc Tens med relation Estey tien, edducions, med. rotaion pay SHY Strong contraction of the SS Estenioy 7 Abducti Adduction 7 Flexion « . Fleion; abduction; let oaign Fletion PATTERNS OF Uppy UC Flexion fabduction / Position of patient : STARTING PostTION © Extension, shoulder. adduction and medial ‘otaton * Extension of elbow, © Pronation of forearm. © Flexion and ulnar deviation Of wrist, * Flexion of fingers and opposition Of thung, Position of therapist: * Lunge with face towards the patient's feet. © Right leg forward with weight on it, © During the movement the therapist shifts Weight from the right foot to the left foot ang rotates her body so that she Can See the Patient's hand throughout the Movement, Grip : Therapist holds the right hand of the patient with her left hand by using the lumbrical rip from the dorsum of the patient, Grip Command ; "NOW" to prepare the patent and then apply stretch to Produce the stretch Feflex, When the Movement get started, then the therapist grip with her right hand over the extenst!as waist from the radial side, fs and wrist are not upto given by the therapist's movement of hand. aq, abduction 3 FINISHING POSITION ipsa ining moverent is started by roratony teaponent which is followed firstly By distal joint fe pinsofhand and then by the proximal joints fie shoulder).Rotation occurs through the ovement, ther method : Flxiovabduction/lateral rotation with elbow fexion «In this except for the grip, all the puiton are same. While gripping, the right hand ofthe therapist is placed over the lateral ‘condyle of humerus to encourage the flexion. V/ Extension/adduction and medial rotation Postion of patient : © Flexi Flexion, abduction and lateral rotation of shoulder joint. * Extension of elbow. ‘ Sopination of forearm. * Soin : : — of wrist with radial deviation. sion of fingers and thumb. PNF 151 Position of therapist : Same as that of a a intagonistic ‘ gonistic patter bi therapies thepatnts useced and h forward with knee fi is i lexed. Weig transfered from forward le oct the igh fom ile doing the movement, ae Grip : Therapist holds the right hand of the patient with herright hand by using the umbrical grip ensuring hat fingers should remain extended, The left hand of the therapist is on the radial side of flexor surface of wrist. If movement at wrist is not upto the mark, then resistance is given over the wrist to stimulate the activity. FINISHING POSITION Command? "NOW", apply stretch and then instruct "HOLD MY HAND AND PULL Start the patient to DOWN". Movement © Extension of fingers (mainly index and middle) with opposition of thumb, Flexion with ulnar deviation of wrist of forearm. @ Proni e Extension of elbow. «Extension, adduction of shoulder joint. Timing is same as of antagonistic movement. CAC Flexion/adduction/Lateral rotation Position of patient + extension, abduct shoulder. Extension of elbow. tion and medial rotation ofvol 1) Movement * ‘ Pipsetner arnt : rexion of fingers(mainly ring ang ; M8 and j, fou * Fingers) with adduction and flexion ori © Prom jation of wrist. : we : with ulnar devi b. jon with radial deviation of wr © Extension i ‘ers with abduction of thum! © Flexion with ra ist, 9°: Breeton of es ¢ Supination of forearm. ua | STARTING POSITION FINISHING POSITION : © Flexion of elbow. Position of therapist : . " ; Longe with face towards patient's feet. * Flexion, adduetion and lateral rotatig . Ide" joint. © Right leg forward with weight on it. shoulder joint © During themovement, the therapist shifisher © Elevation and adduction of scapula weight from right foot to the left foot and Normal timing is same as previous Movement, rotates her body so that she can see the 4p tang n/Abduction/Medial rot Patient's hand throughout the movement. Position of the patient Grip: ion Therapist holds the patient's right hand with her reson, janes 8 44 Tatra rotation o lefthand approsching from the left side, using the aan lumbrical erp. Grip should be such that it should ® Extension of elbow, ot reach o the extensor surface of patient's hand Right hand fingers are placed onthe flexor surface Ofpatnts wis pproaching fiom the sing cess, ® Flexion with radon deviation of wrist © Supination of forearm, cnr Commands : Flexion of fingers an dthumnp Therapist starts with yoy» Position of the “On “HOLD MY Ha NOW" and then rapist : ’ YOUR No} D AND PULL, UPTOCROSss —* Lunge wi isao the movement stherapist shifts her During 1 ‘Forward left foot to the right foot . ght fo weight for er body so that she can see the ate sueats isd throughout the movernent, Gip* -perapist olds the patient's dorsum of right hand e per pu hand by umbrical grip. It should be wither #8 at stretch is maintained throughout kept it After the initiation of movernent, the ON places her right hand fingers onthe ie he eae ofthe patient’ wrist approaching e from the radial side. GRIP Command = “NOW PUSH" Movement + Extension of fingers with extension and abduction of thumb. # Flexion of elbow. ¢ Extension with ulnar deviation of wrist. « Pronation of forearm. © Extension, abduction and medial rotation of shoulder joint. * Depression and adduction of scapula. Normal timing is same as for the previous patterns. v FINISHING POSITION THRUST PATTERN These are those powerful movements which can ‘occur in any position for eg. in prone, they are used to support the body on hands as in press UPS- Other form of these movements are, reaching for an object with an opening hand in preparation for grasping. 1, Flexion/Adduction Position of the patient : Extension, abduction and lateral rotation of shoulder. STARTING POSITION @ Flexion of elbow. © Supination of forearm. e Flexion with ulnar deviation of wrist. Flexion of fingers and thumb. Position of the therapist : Lunge position with right foot forward at the head end of the patient. Grip: Therapist places her left hand over the extensor surface of right hand of the patient. Pressure is given with the fingers over the ulnar side, Right hand of therapist is placed over the elbow joint on flexor aspect with thumb abducted. Command : "NOW - THRUST (push)". Movement : ¢ Protraction of scapula, © Flexion, adduction and medial rotation of shoulder joint. Extension of elbow.Vanity. I's Physiotherapy ‘i 134 Goel’ ‘ a Extension with ulnar deviation of Extension of fingers and thumb. FINISHING POSITION 2. Extension/Adduction Position of patient : ¢ Flexion,abduction and medial rotation of shoulder. © Flexion of elbow. * Pronation of fore-arm. © Flexion with ulnar deviation of wrist, Flexion of fingers and thumb, STARTING Position Postion of therapist: Same as for flexion and abduction Arp: The left hand of therapist ig on the extensor surface of patient's hand obtaining stretch through he fingers. The therapists righ i mene Tm ight hand is placed FINISHING Posirroy Command : "NOW - THRUST". Movement : Protraction of scapula . , Extension, adduction and lateral rotation, ° Extension of elbow. © Supination. / Extension and radial deviation of wrist, Extension of fingers and thumb. LOWER LIMB PATTERNS Extemion abiuctons, med roBxlonsion, adduction, meg va K SS. Extension | Abduction \GYP AA “Flexion \ / Flesion : ' Mlesion; abduction; lat rotation Flexion; adduction; at Totation Adduction 1. Flexion/Adduction/Lateral rotation, Position of patient : © Extension, abduction and medial-rotation of hip. © Extension of knee, © Planter-flexion and eversion of foot, © Flexion of toes, Position of therapist + ® Lunge position with left foot forward and weight on the back Tight foot.It is to exert the STA, RTING Position Both knees flexed,