PNF in Practice-An Illustrated Guide - 3rd Edition

Susan Adler 5 Certified as Physical Therapist at Northwestern University, Chica- go, Illinois 5 Master of Science in Physical Therapy at the University of Southern California, Los Angeles 5 PNF education in 1962 at the Kaiser Foundation Rehabilitati- on Center in Vallejo, California Worked and taught with Maggie Knott 5 International PNF senior instructor of the IPNFA. Developed and led PNF courses in the USA and Europe Dominiek Beckers 5 Master of Physical Therapy, Movement Science and Rehabilitati- on at the University of Leuven, Belgium in 1975 5 Physical Therapist at the Rehabilitation Center of Hoensbroek, The Netherlands since 1975 5 International PNF instructor since 1984 5 Instructor SCI Rehabilitation 5 Author of numerous books and articles Math Buck 5 Certified as Physical Therapist at the Hoge School in Heerlen, The Netherlands in 1972 5 Physical Therapist at the Rehabilitation Center of Hoensbroek, The Netherlands, since 1973 5 International PNF instructor of the IPNFA since 1984. Currently a senior instructor and honorary member of the IPNFA 5 Co-author of numerous books and articles

Susan S. Adler Dominiek Beckers Math Buck PNF in Practice An Illustrated Guide Third edition With 215 Figures in 564 Separate Illustrations 13

1 Susan S. Adler Math Buck 2 161 E Chicago Ave, Apt 35E Rehabilitations Centre Hoensbroek 3 Chicago, IL 60611 Zandbergsweg 111 4 USA NL-6432 CC Hoensbroek 5 6 Dominiek Beckers 7 Rehabilitations Centre Hoensbroek 8 Zandbergsweg 111 9 NL-6432 CC Hoensbroek 10 11 3rd edtion 2008 12 13 ISBN-13 978-3-540-73901-2 Springer Medizin Verlag Heidelberg 14 15 Library of Congress Control Number: 2007938182 16 17 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, 18 specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction 19 on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is 20 permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer Medizin Verlag. Violations are liable for prosecution under the German Copyright Law. Springer Medizin Verlag springer.de © Springer Medizin Verlag Heidelberg 1993, 2000, 2008 Printed in Germany The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about the application of operative techniques and medications contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editor: Marga Botsch, Heidelberg Projectmanagement: Claudia Bauer, Heidelberg Typesetting: medionet Prepress Services Ltd., Berlin Layout Design: deblik Berlin Cover Design: Frido Steinen, Girona, Spanien Printing and Binding: Stürtz GmbH, Würzburg SPIN 11863106 Printed on acid-free paper 22/2122/cb – 5 4 3 2 1 0

To Maggie Knott, teacher and friend. Devoted to her patients, dedicated to her students, a pioneer in profession

VII Preface Proprioceptive neuromuscular facilitation (PNF) is a philosophy and a concept of treatment. The PNF philosophy is timeless, and the concept is a continuous process of growth. This third edition of our book, with a complete review, better user-friendly layout and integration of the latest developments, aims to support this growth. PNF has been one of the most recognized treatment concepts in physical therapy since the 1940s. Dr. Kabat and Margaret (Maggie) Knott started and continued to expand and develop the treatment techniques and procedures after their move to Vallejo, California in 1947. Af- ter Dorothy Voss joined the team in 1953, Maggie and Dorothy wrote the first PNF book, pub- lished in 1956. At first mostly patients with multiple sclerosis and poliomyelitis were treated with this method. With experience it became clear that this treatment approach was effective for pa- tients with a wide range of diagnoses. Today, patients with neurological, traumatic as well as orthopedic symptoms are treated with this concept. The three- and six-month PNF courses in Vallejo began in the 1950s. Physical therapists from all over the world came to Vallejo to learn the theoretical and practical aspects of the PNF concept. In addition, Knott and Voss traveled in the United States and abroad to give introduc- tory courses in the concept. When Maggie Knott died in 1978 her work at Vallejo was carried on by Carolyn Oei Hvis- tendahl. She was succeeded by Hink Mangold as director of the PNF program. Tim Josten is the present program director. Sue Adler, Gregg Johnson, and Vicky Saliba have also continued Maggie’s work as teachers of the PNF concept. Sue Adler designed the International PNF As- sociation (IPNFA) Advanced and Instructor course programs. The authors acknowledge their debt to these outstanding people, and also to all members of the International PNF Association (IPNFA), and hope that this book will encourage others to carry on the work. Developments in the PNF concept are closely followed throughout the world. It is now pos- sible to take recognized training courses in many countries given by qualified PNF instruc- tors. There are other excellent books dealing with the PNF method, but we felt there was a need for a comprehensive coverage of the practical tools in text and illustrations. This book should thus be seen as a practical guide and used in combination with existing textbooks. This book covers the procedures, techniques, and patterns within PNF. Their application to patient treatment is discussed throughout, with special attention on mat activities, gait and self-care. The emphasis within this book is twofold: developing an understanding of the prin- ciples that underlie PNF, and showing through pictures rather than with words how to per- form the patterns and activities. Skill in applying the principles and practices of PNF to pa- tient treatment cannot be learned only from a book. We recommend that the learner combine reading with classroom practice and patient treatment under the supervision of a skilled PNF practitioner. Movement is our way to interact with our environment. Such interactions are directed by the mechanism of motor learning. Integration of motor learning principles includes a progres- sion from hands-on to hands-off treatments; it includes goal-orientated functional activities and independence. Based on the untapped existing potential of all patients, the therapist will always focus on mobilizing these reserves to reach the highest level of function. Especially in the first and cognitive stage of motor control, the therapist’s manual facilitation will be a help-

VIII Preface ful tool in reaching this goal. This includes goals on the level of body structures as well as on 1 the activity level and the participation level (ICF). This fully revised third edition includes a description of how the principles of the Interna- 2 tional Classification of Functioning, Disability and Health (ICF), and aspects of motor learn- ing and motor control (from “hands-on” to “hands-off ” management), are applied in modern 3 PNF evaluation and treatment. The section on “Activities of Daily Living” has been expand- ed with new photos and more in-depth text instructions. The new design and layout highlight the clearly structured way in which the philosophy, basic procedures and treatment patterns 4 of PNF are presented. Thus, this textbook provides a systematic and easily accessible guide to learning and understanding PNF as a practical tool and using it to full effect in patient treat- 5 ment. A special note of thanks goes to the following: Jan Albers and The Rehabilitation Centre in 6 Hoensbroek (The Netherlands), F. Somers for the photography, colleague José van Oppen for acting as a model and Ben Eisermann for the drawings. But most of all we are grateful to all our colleagues, the PNF instructors and all our patients. 7 Without them this work would not be possible. 8 June 2007 S.S. Adler, 9 D. Beckers, M. Buck 10 11 12 13 14 15 16 17 18 19 20

IX Contents 1 Introduction to Proprioceptive 6 The Scapula and Pelvis. . . . . . . . . . . . . . . . . . . . . . 53 Neuromuscular Facilitation . . . . . . . . . . . . . . . . . 1 6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 6.2 Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 2 Basic Procedures for Facilitation . . . . . . . . . . . . . 5 6.3 Basic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 2.1 Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 6.4 Scapular Diagonals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 2.2 Irradiation and Reinforcement . . . . . . . . . . . . . . . . . . . 7 6.4.1 Specific Scapula Patterns . . . . . . . . . . . . . . . . . . . . . . . . 56 2.3 Manual Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6.4.2 Specific Uses for Scapular Patterns . . . . . . . . . . . . . . . 63 2.4 Body Position and Body Mechanics . . . . . . . . . . . . . . 11 6.5 Pelvic Diagonals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 2.5 Verbal Stimulation (Commands) . . . . . . . . . . . . . . . . . 11 6.5.1 Specific Pelvic Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . 64 2.6 Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 6.5.2 Specific Uses for Pelvic Patterns . . . . . . . . . . . . . . . . . . 72 2.7 Traction and Approximation . . . . . . . . . . . . . . . . . . . . . 12 6.6 Symmetrical, Reciprocal and Asymmetrical 2.8 Stretch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.9 Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 2.10 Patterns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 6.6.1 Symmetrical-Reciprocal Exercise . . . . . . . . . . . . . . . . . 73 6.6.2 Asymmetrical Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . 74 3 Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 7 The Upper Extremity. . . . . . . . . . . . . . . . . . . . . . . . 77 3.1 Rhythmic Initiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 7.1 Introduction and Basic Procedures . . . . . . . . . . . . . . . 78 3.2 Combination of Isotonics 7.2 Flexion – Abduction – External Rotation. . . . . . . . . . 80 7.2.1 Flexion – Abduction – External Rotation with (described by Gregg Johnson and Vicky Saliba). . . 21 3.3 Reversal of Antagonists. . . . . . . . . . . . . . . . . . . . . . . . . . 23 Elbow Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 3.3.1 Dynamic Reversals (Incorporates Slow Reversal) . . 23 7.2.2 Flexion – Abduction – External Rotation with 3.3.2 Stabilizing Reversals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3.3.3 Rhythmic Stabilization. . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Elbow Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 3.4 Repeated Stretch (Repeated Contractions) . . . . . . . 29 7.3 Extension – Adduction – Internal Rotation . . . . . . . 88 3.4.1 Repeated Stretch from Beginning of Range . . . . . . 29 7.3.1 Extension – Adduction – Internal Rotation with 3.4.2 Repeated Stretch Through Range . . . . . . . . . . . . . . . . 30 3.5 Contract-Relax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Elbow Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 3.5.1 Contract-Relax: Direct Treatment. . . . . . . . . . . . . . . . . 31 7.3.2 Extension – Adduction – Internal Rotation with 3.5.2 Contract-Relax: Indirect Treatment . . . . . . . . . . . . . . . 33 3.6 Hold-Relax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Elbow Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 3.6.1 Hold-Relax: Direct Treatment . . . . . . . . . . . . . . . . . . . . 33 7.4 Flexion – Adduction – External Rotation. . . . . . . . . . 94 3.6.2 Hold-Relax: Indirect Treatment. . . . . . . . . . . . . . . . . . . 34 7.4.1 Flexion – Adduction – External Rotation with 3.7 Replication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3.8 PNF Techniques and Their Goals . . . . . . . . . . . . . . . . . 35 Elbow Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 7.4.2 Flexion – Adduction – External Rotation with 4 Patient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.1 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Elbow Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 4.1.1 Evaluation of Areas of Activities. . . . . . . . . . . . . . . . . . 40 7.5 Extension – Abduction – Internal Rotation . . . . . . . 101 4.1.2 Evaluation of Areas of Impairments and 7.5.1 Extension – Abduction – Internal Rotation with Activity Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Elbow Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 4.2 Hypothesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 7.5.2 Extension – Abduction – Internal Rotation with 4.3 Tests for Causal Impairments and Elbow Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Activity Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 7.6 Thrust and Withdrawal Combinations . . . . . . . . . . . . 108 4.4 Treatment Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 7.6.1 Ulnar Thrust and Withdrawal. . . . . . . . . . . . . . . . . . . . . 109 4.5 Treatment Planning and Treatment Design . . . . . . . 42 7.6.2 Radial Thrust and Withdrawal . . . . . . . . . . . . . . . . . . . . 109 4.5.1 Specific Patient Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 7.7 Bilateral Arm Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 4.5.2 Designing the Treatment . . . . . . . . . . . . . . . . . . . . . . . . 42 7.8 Changing the Patient’s Position . . . . . . . . . . . . . . . . . . 112 4.5.3 Direct and indirect Treatment. . . . . . . . . . . . . . . . . . . . 42 7.8.1 Arm Patterns in a Side Lying Position. . . . . . . . . . . . . 113 4.6 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 7.8.2 Arm Patterns Lying Prone on Elbows . . . . . . . . . . . . . 113 4.7 Re-Test for Causal Impairments and 7.8.3 Arm Patterns in a Sitting Position . . . . . . . . . . . . . . . . 114 7.8.4 Arm Patterns in the Quadruped Position . . . . . . . . . 114 Activity Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 7.8.5 Arm Patterns in a Kneeling Position . . . . . . . . . . . . . . 115 4.8 Treatment Examples. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 8 The Lower Extremity. . . . . . . . . . . . . . . . . . . . . . . . 117 5 Patterns of Facilitation . . . . . . . . . . . . . . . . . . . . . . 47 8.1 Introduction and Basic Procedures . . . . . . . . . . . . . . . 118 8.2 Flexion – Abduction – Internal Rotation . . . . . . . . . . 120 8.2.1 Flexion – Abduction – Internal Rotation with Knee Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

X Contents 1 8.2.2 Flexion – Abduction – Internal Rotation with 11.5.4 Quadruped . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 2 Knee Extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 11.5.5 Kneeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 3 11.5.6 Half-Kneeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 4 8.3 Extension – Adduction – External Rotation . . . . . . . 126 11.5.7 From Hands-and-Feet Position (Arched Position 5 8.3.1 Extension – Adduction – External Rotation with 6 on All Fours) to Standing Position and back 7 Knee Extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 to Hands-and-Feet Position . . . . . . . . . . . . . . . . . . . . . . 214 8 8.3.2 Extension – Adduction – External Rotation with 11.5.8 Exercise in a Sitting Position . . . . . . . . . . . . . . . . . . . . . 215 9 11.5.9 Bridging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 10 Knee Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 11.6 Patient Cases in Mat Activities . . . . . . . . . . . . . . . . . . . 223 11 8.4 Flexion – Adduction – External Rotation. . . . . . . . . . 133 12 8.4.1 Flexion – Adduction – External Rotation with 12 Gait Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 13 12.1 The Importance of Walking . . . . . . . . . . . . . . . . . . . . . . 234 14 Knee Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 12.2 Introduction: Basics of Normal Gait . . . . . . . . . . . . . . 234 15 8.4.2 Flexion – Adduction – External Rotation with 12.2.1 The Gait Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 16 12.2.2 Trunk and Lower Extremity Joint Motion 17 Knee Extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 18 8.5 Extension – Abduction – Internal Rotation . . . . . . . 139 in Normal Gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 19 8.5.1 Extension – Abduction – Internal Rotation with 12.2.3 Muscle Activity During Normal Gait (Perry 1992) . 236 20 12.3 Gait Analysis: Observation and Manual Evaluation. 238 Knee Extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 12.4 The Theory of Gait Training . . . . . . . . . . . . . . . . . . . . . . 239 8.5.2 Extension – Abduction – Internal Rotation with 12.5 The Procedures of Gait Training . . . . . . . . . . . . . . . . . . 240 12.5.1 Approximation and Stretch . . . . . . . . . . . . . . . . . . . . . . 241 Knee Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 12.5.2 Using Approximation and Stretch Reflex . . . . . . . . . 242 8.6 Bilateral Leg Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 12.6 Practical Gait Training . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 8.7 Changing the Patient’s Position . . . . . . . . . . . . . . . . . . 147 12.6.1 Preparatory Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 8.7.1 Leg Patterns in a Sitting Position . . . . . . . . . . . . . . . . . 147 12.6.2 Standing Up and Sitting Down. . . . . . . . . . . . . . . . . . . 249 8.7.2 Leg Patterns in a Prone Position. . . . . . . . . . . . . . . . . . 149 12.6.3 Standing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252 8.7.3 Leg Patterns in a Side Lying Position . . . . . . . . . . . . . 151 12.6.4 Walking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 8.7.4 Leg Patterns in a Quadruped Position . . . . . . . . . . . . 151 12.6.5 Other Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 8.7.5 Leg Patterns in the Standing Position . . . . . . . . . . . . 154 12.7 Patient Cases in Gait Training . . . . . . . . . . . . . . . . . . . . 265 9 The Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 13 Vital Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 9.1 Introduction and Basic Procedures . . . . . . . . . . . . . . . 156 13.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 9.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 13.1.1 Stimulation and Facilitation. . . . . . . . . . . . . . . . . . . . . . 272 9.3 Flexion to the Left, extension to the Right . . . . . . . . 158 13.2 Facial Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 9.3.1 Flexion/Left Lateral Flexion/Left Rotation . . . . . . . . 158 13.3 Tongue Movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 9.3.2 Extension/Right Lateral Flexion/Right Rotation . . . 162 13.4 Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 9.4 Neck for Trunk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 13.5 Speech Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 9.4.1 Neck for Trunk Flexion and Extension . . . . . . . . . . . . 164 13.6 Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 9.4.2 Neck for Trunk Lateral Flexion. . . . . . . . . . . . . . . . . . . . 165 14 Activities of Daily Living . . . . . . . . . . . . . . . . . . . . 289 10 The Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 10.1 Introduction and Basic Procedures . . . . . . . . . . . . . . . 170 Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 10.2 Chopping and Lifting. . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 10.2.1 Chopping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 10.2.2 Lifting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 10.3 Bilateral Leg Patterns for the Trunk . . . . . . . . . . . . . . . 177 10.3.1 Bilateral Lower Extremity Flexion, with Knee Flexion, for Lower Trunk Flexion (Right) . . . . . 177 10.3.2 Bilateral Lower Extremity Extension, with Knee Extension, for Lower Trunk Extension (Left) . 179 10.3.3 Trunk Lateral Flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 10.4 Combining Patterns for the Trunk . . . . . . . . . . . . . . . . 182 11 Mat Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 11.1 Introduction: Why Do Mat Activities?. . . . . . . . . . . . . 186 11.2 Treatment Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 11.3 Basic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 11.4 Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 11.5 Mat Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 11.5.1 Rolling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 11.5.2 Prone on Elbows (Forearm Support) . . . . . . . . . . . . . 197 11.5.3 Side-Sitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Introduction to Proprioceptive Neuromuscular Facilitation 1 1 Introduction to Proprioceptive Neuromuscular Facilitation

2 Chapter 1 · Introduction to Proprioceptive Neuromuscular Facilitation [ Definition and PNF Philosophy 4. Consider the total human being: whole 1 Proprioceptive: Having to do with any of the sen- sory receptors that give information concerning person with his/her environmental, per- 2 movement and position of the body sonal, physical, and emotional factors. Neuromuscular: Involving the nerves and muscles 5. Use of motor control and motor learn- 3 Facilitation: Making easier ing principles: repetition in a different context; respect stages of motor control, Proprioceptive Neuromuscular Facilitation (PNF) variability of practice. 4 is a concept of treatment. Its underlying philosophy is that all human beings, including those with dis- 5 abilities, have untapped existing potential (Kabat Movement is our way to interact with our envi- 1950). ronment. All sensory and cognitive processes may 6 In keeping with this philosophy, there are cer- be viewed as inputs that determine future motor tain principles that are basic to PNF: outputs. There are some aspects of motor control 5 PNF is an integrated approach: each treatment and learning that are important for rehabilitation 7 is directed at a total human being, not just at a (Mulder 2004). One of the key elements of any in- specific problem or body segment. teractive situation is the exchange of information. 8 5 Based on the untapped existing potential of all This is also true for any form of therapy. Without patients, the therapist will always focus on mo- information, patients are severely limited in mas- 9 bilizing the patient’s reserves. tering new tasks. This is particularly important in 5 The treatment approach is always positive, re- inforcing and using that which the patient can 10 do, on a physical and psychological level. 5 The primary goal of all treatment is to help pa- 11 tients achieve their highest level of function. Attention 5 To reach this highest level of function, the therapist integrates principles of motor con- 12 trol and motor learning. This includes treat- ment on the level of body structures, on the ac- 13 tivity level as well as on the participation level (ICF, International Classification of Function- 14 ing, WHO). Cognitive Associative Autonomous stages of learning a 15 PNF philosophy 1. Positive approach: no pain, achievable 16 tasks, set up for success, direct and indi- FACILITATION rect treatment, strong start. Attention 2. Highest functional level: functional ap- Hands on 17 proach, ICF, include treatment on body PNF Visual, verbal and structure level and activity level. tactile facilitation 18 3. Mobilize potential by intensive training: active participation, motor learning, self- 19 training. Cognitive Associative Autonomous stages of learning b 20 6 . Fig. 1.1. a Different stages of motor learning (Fitts and Pos- ner). b Facilitation and PNF in stages of motor learning (draw- ing by Ben Eisermann)

Introduction to Proprioceptive Neuromuscular Facilitation 31 the first stages of motor learning (. Fig. 1.1) and of inforce each other (summate) to cause exci- the rehabilitation process when, due to the damage, tation. Temporal and spatial summation can the patient often can no longer trust his or her in- combine for greater activity. ternal information. In these cases the therapist, and 5 Irradiation: This is a spreading and increased facilitation like PNF, becomes the most important strength of a response. It occurs when either source of external information. the number of stimuli or the strength of the stimuli is increased. The response may be ei- This positive functional approach is, we feel, the ther excitation or inhibition. best way to stimulate patients and to attain superi- 5 Successive induction: An increased excita- or results from treatment. tion of the agonist muscles follows stimula- tion (contraction) of their antagonists. Tech- This book covers the procedures, techniques, niques involving reversal of antagonists make and patterns within PNF. Their application to pa- use of this property (Induction: stimulation, tient treatment is discussed throughout with spe- increased excitability.). cial attention to mat activities, gait, and self-care. 5 Reciprocal innervation (reciprocal inhibition): The emphasis within this book is twofold: develop- Contraction of muscles is accompanied by si- ing an understanding of the principles that under- multaneous inhibition of their antagonists. Re- lie PNF, and showing through pictures rather than ciprocal innervation is a necessary part of co- with words how to perform the patterns and activ- ordinated motion. Relaxation techniques make ities. Skill in applying the principles and practices use of this property. of PNF to patient treatment cannot be learned only from a book. We recommend that the learner com- “The nervous system is continuous throughout its ex- bines reading with classroom practice and patient tent – there are no isolated parts.” treatment under the supervision of a skilled PNF practitioner. References The aims of this book are: IPNFA (2007) International PNF Association. http://www.ipn- 5 To show the PNF method and, in so doing, fa.org. help students and practitioners of physical IPNFA (2007) http://www.ipnfa.jp (Japan) therapy in their PNF training. IPNFA (2007) http://www.pnf.or.kr (Korea) 5 To attain a uniformity in practical treatment. IPNFA (2007) http://www.ipnfa.de (Germany) 5 To record the most recent developments in Kabat H (1950) Studies on neuromuscular dysfunction. XIII. PNF and put them into word and picture. New concepts and techniques of neuromuscular reeduca- Basic neurophysiologic principles: tion for paralysis. Perm Found Med Bull 8 (3):121–143 The work of Sir Charles Sherrington was im- Mulder T, Hochstenbach J (2004) Motor control and learning: Implications for neurological rehabilitation. In: Green- portant in the development of the procedures and wood (ed) Handbook of neurological rehabilitation. Erl- techniques of PNF. The following useful definitions baum, Hillsdale were abstracted from his work (Sherrington 1947): Sherrington C (1947) The integrative action of the nervous sys- 5 Afterdischarge: The effect of a stimulus contin- tem. Yale University Press, New Haven Voss DE, Jonta M, Meyers B (1985) Proprioceptive Neuromus- ues after the stimulus stops. If the strength and cular Facilitation: Patterns and Techniques, 3rd ed. Harper duration of the stimulus increase, the afterdis- and Row, New York charge increases also. The feeling of increased WHO (1997) ICDH-2-The international classification of impair- power that comes after a maintained static ments, activities, and participation: A manual of dimen- contraction is a result of afterdischarge. sions of disablement and functioning (Beta-1 draft for 5 Temporal summation: A succession of weak field trials). World Health Organization, Geneva stimuli (subliminal) occurring within a certain WHO (2007) International classification of functioning, disabil- (short) period of time combine (summate) to ity and health (ICF). http://www.who.int/classifications/ cause excitation. icf/. Cited 5 Spatial summation: Weak stimuli applied si- multaneously to different areas of the body re-

5 2 2.1 · Basic Procedures for Facilitation 2.1 Resistance – 6 2.2 Irradiation and Reinforcement – 7 2.3 Manual Contact – 10 2.4 Body Position and Body Mechanics – 11 2.5 Verbal Stimulation (Commands) – 11 2.6 Vision – 12 2.7 Traction and Approximation – 12 2.8 Stretch – 13 2.9 Timing – 14 2.10 Patterns – 16

6 Chapter 2 · Basic Procedures for Facilitation Therapeutic Goals 5 Manual contact: To increase power and guide 1 The basic facilitation procedures provide motion with grip and pressure. tools for the therapist to help the patient gain 5 Body position and body mechanics: Guidance 2 efficient motor function and increased motor and control of motion or stability. 5 Verbal (commands): Use of words and the ap- control. Their effectiveness does not depend propriate vocal volume to direct the patient. on having the conscious cooperation of the 5 Vision: Use of vision to guide motion and in- 3 patient. These basic procedures are used to: crease force. 5 Traction or approximation: The elongation or 5 Increase the patient’s ability to move or compression of the limbs and trunk to facili- 4 remain stable. tate motion and stability. 5 Stretch: The use of muscle elongation and the 5 Guide the motion by proper grips and stretch reflex to facilitate contraction and de- crease muscle fatigue. 5 appropriate resistance. 5 Timing: Promote normal timing and increase muscle contraction through “timing for em- 5 Help the patient achieve coordinated mo- phasis”. tion through timing. 6 5 Increase the patient’s stamina and avoid 7 fatigue. 8 5 Patterns: Synergistic mass movements, compo- The basic facilitation procedures overlap in their ef- nents of functional normal motion. 9 fects. For example, resistance is necessary to make the response to a stretch effective (Gellhorn 1949). Combine these basic procedures to get a maximal The effect of resistance changes with the alignment response from the patient. 10 of the therapist’s body and the direction of the man- ual contact. The timing of these procedures is im- 11 portant to get an optimal response from the patient. 2.1 Resistance For example, a preparatory verbal command comes before the stretch reflex. Changing of the manual Therapeutic Goals 12 contacts should be timed to cue the patient for a Resistance is used in treatment to: 5 Facilitate the ability of the muscle to change in the direction of motion. contract. 13 We can use these basic procedures to treat pa- 5 Increase motor control and motor learn- tients with any diagnosis or condition, although a ing. 14 patient’s condition may rule out the use of some of 5 Help the patient gain an awareness of them. The therapist should avoid causing or increas- motion and its direction. ing pain. Pain is an inhibitor of effective and coor- 5 Increase strength. 5 Help the patient relax (reciprocal inhibi- 15 dinated muscular performance and it can be a sign of potential harm (Hislop 1960; Fisher 1967). Oth- tion). 16 er contraindications are mainly common sense: for example, not using approximation on an extremity 17 with an unhealed fracture. In the presence of unsta- ble joints, the therapist should take great care when using traction or the stretch reflex. Most of the PNF techniques evolved from knowing 18 The basic procedures for facilitation are: the effects of resistance. 5 Resistance: To aid muscle contraction and mo- 19 tor control, to increase strength, aid motor [ Definition learning. The amount of resistance provided during an 20 5 Irradiation and reinforcement: Use of the spread activity must be correct for the patient’s condition of the response to stimulation. and the goal of the activity. This we call optimal resistance.

2.2 · Irradiation and Reinforcement 72 Example – Stabilizing isotonic: The intent of the 5 The resistance for learning a functional patient is motion; the motion is prevented by an outside force (usually resistance). activity like standing up from a sitting po- sition or going down the stairs is mostly a 5 Isometric (static): The intent of both the guidance resistance to teach the patients patient and the therapist is that no motion to control these activities. occurs. 5 Resistance for irradiation or strengthening of muscles is intensive. The resistance to concentric or eccentric muscle contractions should be adjusted so that motion can Gellhorn showed that when a muscle contraction occur in a smooth and coordinated manner. The is resisted, that muscle’s response to cortical stim- antagonists of the facilitated muscles allow a coor- ulation increases. The active muscle tension pro- dinated activity and therefore they are sufficiently duced by resistance is the most effective proprio- inhibited to allow that activity. Resistance to a sta- ceptive facilitation. The magnitude of that facilita- bilizing contraction must be controlled to maintain tion is related directly to the amount of resistance the stabilized position. When resisting an isometric (Gellhorn 1949; Loofbourrow and Gellhorn 1949). contraction, the resistance should be increased and Proprioceptive reflexes from contracting muscles decreased gradually so that no motion occurs. increase the response of synergistic muscles1 at the same joint and associated synergists at neighbor- It is important that the resistance does not ing joints. This facilitation can spread from prox- cause pain, unwanted fatigue, or unwanted irra- imal to distal and from distal to proximal. Antag- diation. Both the therapist and the patient should onists of the facilitated muscles are usually inhib- avoid breath-holding. Timed and controlled inha- ited. If the muscle activity in the agonists becomes lations and exhalations can increase the patient’s intense, there may be activity in the antagonistic strength and active range of motion. muscle groups as well (co-contraction). (Gellhorn 1947; Loofbourrow and Gellhorn 1948). 2.2 Irradiation and Reinforcement How we give resistance depends on the kind of Properly applied resistance results in irradiation muscle contraction being resisted (. Fig. 2.1). and reinforcement. [ Definition [ Definition We define the types of muscle contraction as fol- Irradiation. We define irradiation as the spread of lows (International PNF Association, unpublished the response to stimulation. handout): 5 Isotonic (dynamic): The intent of the patient is This response can be seen as increased facilitation to produce motion. (contraction) or inhibition (relaxation) in the syn- – Concentric: Shortening of the agonist ergistic muscles and patterns of movement. The re- produces motion. sponse increases as the stimuli increase in intensity – Eccentric: An outside force, gravity or or duration (Sherrington 1947). Kabat (1961) wrote resistance, produces the motion. The that it is resistance to motion that produces irradi- motion is restrained by the controlled ation, and the spread of the muscular activity will lengthening of the agonist. occur in specific patterns. 1 Synergists are muscles which act with other muscles to [ Definition produce coordinated motion. Reinforcement. Reinforce, as defined in Webster’s Ninth New Collegiate Dictionary, is “to strengthen by fresh addition, make stronger.”

8 Chapter 2 · Basic Procedures for Facilitation 1 let me pull pull your you slowly leg up back 2 3 4 5 6 7 8a b don’t let me pull stay here, no motion 9 you down, try to keep your leg here 10 11 12 I have to pull to keep 13 my leg here 14 15 16 d c 17 . Fig. 2.1. Types of muscle contraction of the patient. a Isotonic concentric: movement into a shortened range; the force or re- 18 sistance provided by the patient is stronger. b Isotonic eccentric: the force or resistance provided by the therapist is stronger; movement into the lengthened range. c Stabilizing isotonic: the patient tries to move but is prevented by the therapist or anoth- er outside force; the forces exerted by both are the same. d Isometric (static): the intent of both the patient and the therapist is that no motion occurs; the forces exerted by both are the same 19 20

2.2 · Irradiation and Reinforcement 92 The therapist directs the reinforcement of the weaker muscles by the amount of resistance given to the strong muscles. Increasing the amount of resistance will increase . Fig. 2.2. Irradiation into the trunk flexor muscles when do- the amount and extent of the muscular response. ing bilateral leg patterns Changing the movement that is resisted or the po- sition of the patient will also change the results. The therapist adjusts the amount of resistance and type of muscle contraction to suit 1) the condition of the patient, for example, muscle strength, coordina- tion, muscle tone, pain, different body sizes, and 2) the goal of the treatment. Because each patient re- acts differently, it is not possible to give general in- structions on how much resistance to give or which movements to resist. By assessing the results of the treatment, the therapist can determine the best uses of resistance, irradiation, and reinforcement. Example a Examples of the use of resistance in patient treatment: 5 Resist muscle contractions in a sound limb to produce contraction of the mus- cles in the immobilized contralateral limb. 5 Resist hip flexion to cause contraction of the trunk flexor muscles (. Fig. 2.2). 5 Resist supination of the forearm to facili- tate contraction of the external rotators of that shoulder. 5 Resist hip flexion with adduction and ex- ternal rotation to facilitate the ipsilateral dorsiflexor muscles to contract with inver- sion (. Fig. 2.3). 5 Resist neck flexion to stimulate trunk and hip flexion. Resist neck extension to stimulate trunk and hip extension. b . Fig. 2.3. a Irradiation to dorsiflexion and inversion with the leg pattern flexion-adduction-external rotation; b Irradiation for mid-stance support to the ipsilateral leg

10 Chapter 2 · Basic Procedures for Facilitation 2.3 Manual Contact . Fig. 2.4. The lumbrical grip 1 Therapeutic Goals 2 5 Pressure on a muscle to aid that muscle’s ability to contract 3 5 To give the patient security and confidence. 5 To promote tactile-kinesthetic perception. 4 5 Pressure that is opposite to the direction of motion on any point of a moving limb stimulates the synergistic limb muscles to 5 reinforce the movement. 5 Contact on the patient’s trunk to help the 6 limb motion indirectly by promoting trunk stability. 7 If the patient has no or decreased control over an eccentric muscle activity, for example, go- 8 The therapist’s grip stimulates the patient’s skin re- ing from standing to a sitting position, the ther- ceptors and other pressure receptors. This contact apist can give the patient the kinesthetic informa- 9 gives the patient information about the proper di- tion for this goal-oriented movement by putting rection of motion. The therapist’s hand should be his hands on the top of the iliac crest and apply- placed to apply the pressure opposite the direction ing pressure down and backward. If some muscles 10 of motion. The sides of the arm or leg are consid- show too little synergistic activity, we can facilitate ered neutral surfaces and may be held. the desired muscle activity by giving a tactile stim- 11 To control movement and resist rotation the ulus. The therapist should give tactile stimuli when therapist uses a lumbrical grip (. Fig. 2.4). In this and where the patient needs it but only as long as grip the pressure comes from flexion at the meta- the patient needs it to increase the patient’s inde- 12 carpophalangeal joints, allowing the therapist’s fin- pendence and promote motor learning. The goal gers to conform to the body part. The lumbrical is for the patient to be able to control the activi- 13 grip gives the therapist good control of the three- ty by himself. Normally the therapist has one hand dimensional motion without causing the patient distally and the other hand also distally or proxi- 14 pain due to squeezing or putting too much pressure mally when treating patients with extremity activi- on bony body parts (. Fig. 2.5). ties. If it is necessary to solve the patient’s problem 15 16 17 18 19 ab 20 . Fig. 2.5. Lumbrical grips. a For the leg pattern flexion-adduction-external rotation. b For the arm pattern flexion-abduction- external rotation

2.5 · Verbal Stimulation (Commands) 211 in another way, the therapist can change the nor- so line up with the motion. If the therapist can- mal grips. not keep the proper body position, the hands and arms maintain alignment with the motion 2.4 Body Position and Body (. Fig. 2.6). Mechanics 5 The resistance comes from the therapist’s body while the hands and arms stay comparative- Therapeutic Goals ly relaxed. By using body weight the therapist can give prolonged resistance without fatigu- 5 Give the therapist effective control of the ing. The relaxed hands allow the therapist to patient’s motion. feel the patient’s responses. 5 Facilitate control of the direction of the Not only are the body position and body mechanics resistance. of the therapist important, but also the position in which the patient is treated. The treatment goal as 5 Enable the therapist to give resistance well other factors influence this position. The func- without fatiguing. tional activity that the patient needs, muscle tone, muscle strength, pain, and stability of the patient Johnson and Saliba first developed the material on and therapist are some of the factors that need to be body position presented here. They observed that considered when choosing the appropriate position more effective control of the patient’s motion came in which to treat patients. when the therapist was in the line of the desired motion. As the therapist shifted position, the di- 2.5 Verbal Stimulation rection of the resistance changed and the patient’s (Commands) movement changed with it. From this knowledge they developed the following guidelines for the Therapeutic Goals therapist’s body position (G. Johnson and V. Saliba, unpublished handout 1985): 5 Guide the start of movement or the mus- 5 The therapist’s body should be in line with the cle contractions. desired motion or force. To line up properly, 5 Affect the strength of the resulting muscle the therapist’s shoulders and pelvis face the di- contractions. rection of the motion. The arms and hands al- 5 Give the patient corrections. . Fig. 2.6. Positioning of the therapist’s body for the leg pat- The verbal command tells the patient what to do tern flexion-abduction-internal rotation and when to do it. The therapist must always bear in mind that the command is given to the patient, not to the body part being treated. Preparatory in- structions need to be clear and concise, without un- necessary words. They may be combined with pas- sive motion to teach the desired movement. The timing of the command is important to co- ordinate the patient’s reactions with the therapist’s hands and resistance. It guides the start of move- ment and muscle contractions. It helps give the pa- tient corrections for motion or stability. Timing of the command is also very impor- tant when using the stretch reflex.The initial com-

12 Chapter 2 · Basic Procedures for Facilitation mand should come immediately before the stretch 1 the muscle chain to coordinate the patient’s con- scious effort with the reflex response (Evarts and 2 Tannji 1974). The action command is repeated to urge greater effort or redirect the motion. 3 In reversal techniques, proper timing between verbal commands and muscle activity is important when we change the direction of the resistance. A 4 preparatory command should be given with the therapist changing hand and an action command 5 should be given with the therapist applying resist- ance in the new direction. 6 The volume with which the command is giv- en can affect the strength of the resulting muscle contractions (Johansson et al. 1983). The therapist 7 should give a louder command when a strong mus- cle contraction is desired and use a softer and calm- 8 er tone when the goal is relaxation or relief of pain. The command is divided into three parts: 9 1. Preparation: readies the patient for action 2. Action: tells the patient to start the action 10 3. Correction: tells the patient how to correct and . Fig. 2.7. Visual control modify the action. 11 For example, the command for the lower extremity 1999). For example, when a patient looks at his or pattern of flexion-adduction-external rotation with her arm or leg while exercising it, a stronger con- knee flexion might be [preparation] “ready, and”; traction is achieved. Using vision helps the patient 12 [action] “now pull your leg up and in”; [correction] control and correct his or her position and motion. “keep pulling your toes up” (to correct lack of dor- Moving the eyes will influence both the head 13 siflexion). and body motion. For example, when patients looks in the direction they want to move, the head follows 14 2.6 Vision the eye motion. The head motion in turn will facili- tate larger and stronger trunk motion (. Fig. 2.7). 15 Therapeutic Goals Eye contact between patient and therapist pro- vides another avenue of communication and helps 16 5 Promote a more powerful muscle contrac- to ensure cooperative interaction. tion. For elderly patients the visual input can be of 17 5 Help the patient control and correct posi- more importance than the verbal input (Gentile, tion and motion. Lee). 5 Influence both the head and body mo- 18 tion. 2.7 Traction and Approximation 5 Provide an avenue of communication and 19 help to ensure cooperative interaction. [ Definition Traction is the elongation of the trunk or an 20 The feedback (and –forward) system can promote extremity. a much stronger muscle activity (Schmidt and Lee

2.8 · Stretch 213 Knott, Voss, and their colleagues theorized that the Therapeutic Goals therapeutic effects of traction are due to stimula- tion of receptors in the joints (Knott and Voss 1968; Approximation is used to: Voss et al. 1985). Traction also acts as a stretch stim- 5 Promote stabilization ulus by elongating the muscles. 5 Facilitate weight-bearing and the contrac- Apply the traction force gradually until the de- tion of antigravity muscles sired result is achieved. The traction is maintained 5 Facilitate upright reactions throughout the movement and combined with ap- 5 Resist some component of motion. For propriate resistance. example, use approximation at the end of Therapeutic Goals shoulder flexion to resist scapula eleva- tion. Traction is used to: There are two ways to apply the approximation: 5 Facilitate motion, especially pulling and 5 Quick approximation: the force is applied antigravity motions. quickly to elicit a reflex-type response. 5 Aid in elongation of muscle tissue when 5 Slow approximation: the force is applied grad- using the stretch reflex. ually up to the patient’s tolerance. 5 Resist some part of the motion. For The approximation force is always maintained, example, use traction at the beginning of whether the approximation is done quickly or shoulder flexion to resist scapula eleva- slowly. The therapist maintains the force and gives tion. resistance to the resulting muscular response. An appropriate command should be coordinated with Traction of the affected part is helpful when treat- the application of the approximation, for example ing patients with joint pain. “hold it” or “stand tall.” The patient’s joints should be properly aligned and in a weight-bearing posi- [ Definition tion before the approximation is given. Approximation is the compression of the trunk or an extremity. When the therapist feels that the active muscle contraction decreases the approximation is repeat- The muscle contractions following the approxima- ed and resistance given. tion are thought to be due to stimulation of joint receptors (Knott and Voss 1968; Voss et al. 1985). While traction usually facilitates motion and Another possible reason for the increased muscu- approximation facilitates isometric or stabilizing lar response is to counteract the disturbance of po- activity, the therapist should use the one which is sition or posture caused by the approximation. Giv- most effective. For example, using PNF activities in en gradually and gently, approximation may aid in an upright position and combining them with ap- the treatment of painful and unstable joints. proximation together with concentric and eccen- tric muscle activity may be the most effective treat- ment. Using arm activities against gravity can be combined with approximation instead of traction when this promotes a better function. 2.8 Stretch The response to a stretch of the muscle chain given by the therapist can lead to a stretch reflex or only to stimulation of these muscles. Giving a stretch to

14 Chapter 2 · Basic Procedures for Facilitation muscles should only be done when the therapist ex- treatment, the muscular contraction following the 1 pects to facilitate the dynamic muscle activity. Some- stretch must be resisted. times a stretch activity is contraindicated when the The strength of the muscular contraction pro- 2 muscles, tendons, bones, or joint are injured. duced by the stretch is affected by the intent of the subject, and therefore, by prior instruction. 3 Stretch stimulus. Monkeys show changes in their motor cortex and Therapeutic Goals stronger responses when they are instructed to re- 4 5 Facilitate muscle contractions. sist the stretch. The same increase in response has 5 Facilitate contraction of associated syner- been shown to happen in humans when they are gistic muscles. told to resist a muscle stretch (Hammond 1956; 5 Evarts and Tannji 1974; Chan 1984). 6 The stretch stimulus occurs when a muscle is elon- 2.9 Timing gated. Stretch stimulus is used during normal activ- Therapeutic Goals 7 ities as a preparatory motion to facilitate the muscle 5 Normal timing provides continuous, contractions. The stimulus facilitates the elongated coordinated motion until a task is ac- complished. 8 muscle, synergistic muscles at the same joint, and other associated synergistic muscles (Loofbourrow 5 Timing for emphasis redirects the energy of a strong contraction into weaker 9 and Gellhorn 1948). Greater facilitation comes from muscles. lengthening all the synergistic muscles of a limb or the trunk. For example, elongation of the anterior 10 tibial muscle facilitates that muscle and also facili- tates the hip flexor-adductor-external rotator mus- 11 cle group. If just the hip flexor-adductor-external rotator muscle group is elongated, the hip muscles [ Definition and the anterior tibial muscle share the increased Timing is the sequencing of motions. 12 facilitation. If all the muscles of the hip and ankle are lengthened simultaneously, the excitability in Normal movement requires a smooth sequence of 13 those limb muscles increases further and spreads to activity, and coordinated movement requires pre- the synergistic trunk flexor muscles. cise timing of that sequence. Functional movement 14 Stretch reflex. requires continuous, coordinated motion until the task is accomplished. Therapeutic Goals 15 How, why, and when to use the stretch reflex [ Definition 16 is described in Chapter III, Sect. 3.4. Normal timing of most coordinated and efficient motions is from distal to proximal. 17 The evolution of control and coordination during The stretch reflex is elicited from muscles that are development proceeds from cranial to caudal and under tension, either from elongation or from con- from proximal to distal (Jacobs 1967). In infancy 18 traction. The reflex has two parts. The first is a short the arm determines where the hand goes, but after latency spinal reflex that produces little force and the grasp matures the hand directs the course of the 19 may not be of functional significance. The sec- arm movements (Halvorson 1931). The small mo- ond part, called the functional stretch response, tions that adults use to maintain standing balance 20 has a longer latency but produces a more power- proceed from distal (ankle) to proximal (hip and ful and functional contraction (Conrad and Mey- trunk) (Nashner 1977). To restore normal timing of er-Lohmann 1980; Chan 1984). To be effective as a motion may become a goal of the treatment.

2.9 · Timing 215 Normally the timing of an activity is from dis- contraction into a weaker muscle. This alteration of tal to proximal. Moving an extremity presupposes timing stimulates the proprioceptive reflexes in the that the central part of the body is stabilized. Mov- muscles by resistance and stretch. The best results ing the leg forward in gait requires that the trunk come when the strong muscles score at least “good” and opposite hip and leg have enough stability to in strength (Manual Muscle Test grade 4; Partridge move the leg. Central stability is needed to move an 1954). extremity. However, studies showed that timing can be changed according to the functional task. There are two ways the therapist can alter the normal timing for therapeutic purposes (. Fig. 2.8, [ Definition 2.9): Timing for emphasis involves changing the 5 By preventing all the motions of a pattern ex- normal sequencing of motions to emphasize a particular muscle or a desired activity. cept the one that is to be emphasized. 5 By resisting an isometric or maintained con- Kabat (1947) wrote that prevention of motion in a stronger synergist will redirect the energy of that traction of the strong motions in a pattern while exercising the weaker muscles. This re- sistance to the static contraction locks in that ab cd . Fig. 2.8. Timing for emphasis by preventing motion. a, b Leg pattern flexion-abduction-internal rotation with knee flexion. The strong motions of the hip and knee are blocked and the dorsiflexion-eversion of the ankle exercised using repeated stretch reflex. c, d Arm pattern flexion-abduction-external rotation. The stronger shoulder motions are blocked while exercising radi- al extension of the wrist

16 Chapter 2 · Basic Procedures for Facilitation 1 2 3 4 5 a b 6 7 8 9 10 11 d c 12 . Fig. 2.9. Timing for emphasis using stabilizing contractions of strong muscles. a, b Exercising elbow flexion using the pattern 13 of flexion-adduction-external rotation with stabilizing contractions of the strong shoulder and wrist muscles, c, d Exercising fin- ger flexion using the pattern extension-adduction-internal rotation with stabilizing contraction of the strong shoulder muscles 14 segment, so resisting the contraction is called Conrad B, Meyer-Lohmann J (1980) The long-loop transcortical 15 “locking it in.” load compensating reflex. Trends Neurosci 3:269-272 16 17 2.10 Patterns Dudel JR, Menzel R, Schmidt RF (1996) Neurowissenschaft. 18 Springer, Heidelberg Berlin New York 19 The patterns of facilitation may be considered one 20 of the basic procedures of PNF. For greater clarity Evarts EV, Tannji J (1974) Gating of motor cortex reflexes by pri- we discuss and illustrate them in Chapter 5. or instruction. Brain Res 71:479-494 References Fischer E (1967) Factors affecting motor learning. Am J Phys Med Rehabil 46 (1):511-519 Brooks VB (1986) The neural basis of motor control. Oxford Uni- versity Press, New York Frank JS, Earl M (1990) Coordination of posture and move- ment. Phys Ther (12):109-117 Chan CWY (1984) Neurophysiological basis underlying the use of resistance to facilitate movement. Physiother Can 36 Gellhorn E (1947) Patterns of muscular activity in man. Arch (6):335-341 Phys Med Rehabil 28:568-574 Gellhorn E (1949) Proprioception and the motor cortex. Brain 72:35-62 Gentile AM (1987) Skill acquisition: action, movement and neu- romotor processes. In Carr JH, Shepherd R B (eds) Move- ment science. Foundations for Physical Therapy in Reha- bilitation. Rockville MD: Aspen Publications

2.10 · Patterns 217 Grzebellus M, Schäfer C (1998) Irradiation aus biomecha- Umphred D (2001) Neurological rehabilitation. Mosby, St. nischer Sicht. Krankengymnastik Zeitschrift für Physio- Louis therapeuten (9):1489-1494 Voss DE, Ionta M, Meyers B (1985) Proprioceptive neuromus- Halvorson HM (1931) An experimental study of prehension in cular facilitation: patterns and techniques, 3rd edn. Harper infants by means of systematic cinema records. Genet Psy- and Row, New York chol Monogr 10:279-289. Reprinted in: Jacobs MJ (1967) Development of normal motor behavior. Am J Phys Med Webster’s Ninth New Collegiate Dictionary (1984) Merriam- Rehabil 46 (1):41-51 Webster, Springfield Hammond PH (1956) The influences of prior instruction to Wilmore JH, Costill DL (1994) Physiology of sport and exercise., the subject on an apparently involuntary neuromuscular Human Kinetics, Champaign response. J Physiol (Lond) 132:17P-18P Further Reading Hislop HH (1960) Pain and exercise. Phys Ther Rev 40 (2):98- General Resistance, Irradiation and 106 Reinforcement Jacobs MJ (1967) Development of normal motor behavior. Am Hellebrandt FA (1958) Application of the overload principle to J Phys Med Rehabil 46 (1):41-51 muscle training in man. Arch Phys Med Rehabil 37:278- 283 Johansson CA, Kent BE, Shepard KF (1983) Relationship between verbal command volume and magnitude of Hellebrandt FA, Houtz SJ (1956) Mechanisms of muscle train- muscle contraction. Phys Ther 63 (8):1260-1265 ing in man: experimental demonstration of the overload principle. Phys Ther 36 (6):371-383 Kabat H (1947) Studies on neuromuscular dysfunction, XI: New principles of neuromuscular reeducation. Perm Found Hellebrandt FA, Houtz SJ (1958) Methods of muscle training: Med Bull 5 (3):111-123 the influence of pacing. Phys Ther 38:319-322 Kabat H (1961) Proprioceptive facilitation in therapeutic exer- Hellebrandt FA, Waterland JC (1962) Expansion of motor pat- cise. In: Licht S Johnson EW (eds) Therapeutic exercise, terning under exercise stress. Am J Phys Med Rehabil 2nd edn. Waverly, Baltimore 41:56-66 Kandel ER, Schwartz JH, Jessell TM (2000) Principles of neu- Moore JC (1975) Excitation overflow: an electromyographic ral science 4th edn. Mc-Graw Hill, New York, St. Louis, San investigation. Arch Phys Med Rehabil 56:115-120 Fransisco Stretch Knott M, Voss DE (1968) Proprioceptive neuromuscular facilita- tion: patterns and techniques, 2nd edn. Harper and Row, Burg D, Szumski AJ, Struppler A, Velho F (1974) Assessment of New York fusimotor contribution to reflex reinforcement in humans. J Neurol Neurosurg Psychiatry 37:1012-1021 Kofotolis N, Vrabas IS, Vamvakoudis E, Papanikolaou A, Man- droukas K (2005) Proprioceptive neuromuscular facilita- Cavagna GA, Dusman B, Margaria R (1968) Positive work done tion training induced alterations in muscle fiber type and by a previously stretched muscle. J Appl Physiol 24 (1):21- cross sectional area. Br J Sports Med (3):11 32 Lance JW (1980) The control of muscle tone, reflexes and move- Chan CWY, Kearney RE (1982) Is the functional stretch response ment: M. Robert Wartenburg lecture. Neurology 30:1303 servo controlled or preprogrammed? Electroencephalogr Clin Neurophysiol 53:310-324 Lee DM, Lishman R (1975) Visual proprioceptive control of stance. Human Movement Studies (1): 87-95 Ghez C, Shinoda Y (1978) Spinal mechanisms of the functional stretch reflex. Exp Brain Res 32:55-68 Loofbourrow GN, Gellhorn E (1948) Proprioceptively induced reflex patterns. Am J Physiol 154:433-438 Loofbourrow GN, Gellhorn E (1949) Proprioceptive modifica- tion of reflex patterns. J Neurophysiol 12:435-446 Nashner LM (1977) Fixed patterns of rapid postural responses among leg muscles during stance. Exp Brain Res 30:13-24 Partridge MJ (1954) Electromyographic demonstration of facilitation. Phys Ther Rev 34 (5):227-233 Rosenbaum DA (1991) Human motor control. Academic Press, San Diego Schmidt R (1988) Motor and action perspectives on motor behaviour: the motor action controversy. Elsevier, Amster- dam Schmidt R (1999) Motor control and learning: A Behavioural Emphasis. Human Kinetics, Champaign Sherrington C (1947) The integrative action of the nervous sys- tem, 2nd edn. Yale University Press, New Haven Umphred D (1996) Neurological rehabilitation. Mosby, St. Louis

3.1 · 319 Techniques 3.1 Rhythmic Initiation – 20 3.2 Combination of Isotonics (described by Gregg Johnson and Vicky Saliba) – 21 3.3 Reversal of Antagonists – 23 3.3.1 Dynamic Reversals (Incorporates Slow Reversal) – 23 3.3.2 Stabilizing Reversals – 26 3.3.3 Rhythmic Stabilization – 27 3.4 Repeated Stretch (Repeated Contractions) – 29 3.4.1 Repeated Stretch from Beginning of Range – 29 3.4.2 Repeated Stretch Through Range – 30 3.5 Contract-Relax – 31 3.5.1 Contract-Relax: Direct Treatment – 31 3.5.2 Contract-Relax: Indirect Treatment – 33 3.6 Hold-Relax – 33 3.6.1 Hold-Relax: Direct Treatment – 33 3.6.2 Hold-Relax: Indirect Treatment – 34 3.7 Replication – 35 3.8 PNF Techniques and Their Goals – 35

20 Chapter 3 · Techniques Introduction Rhythmic Stabilization works to increase the pa- 1 The goal of the PNF techniques is to promote func- tient’s ability to stabilize or hold a position as well.1 tional movement through facilitation, inhibition, 2 strengthening, and relaxation of muscle groups. The techniques described are: The techniques use concentric, eccentric, and stat- 5 Rhythmic Initiation 5 Combination of Isotonics (G. Johnson 3 ic muscle contractions. These muscle contractions with properly graded resistance and suitable facili- and V. Saliba, unpublished handout 1988) tatory procedures are combined and adjusted to fit (also called Reversal of Agonists; Sullivan et al. 1982) 4 the needs of each patient. 5 Reversal of Antagonists 5 To increase the range of motion and strength- – Dynamic Reversal of Antagonists 5 en the muscles in the newly gained range of (incorporates Slow Reversal) motion. Use a relaxation technique such as – Stabilizing Reversal – Rhythmic Stabilization 6 Contract-Relax to increase range of motion. 5 Repeated Stretch (Repeated Contraction) Follow with a facilitatory technique such as – Repeated Stretch from beginning of Dynamic Reversals (Slow Reversals) or Com- range 7 bination of Isotonics to increase the strength – Repeated Stretch through range and control in the newly gained range of mo- 5 Contract-Relax 5 Hold-Relax 8 tion. 5 Replication 5 To relieve muscle fatigue during strength- 9 ening exercises. After using a strengthening technique such as Repeated Stretch (repeat- ed stretch reflex), go immediately into Dynam- 10 ic Reversals (Slow Reversals) to relieve fatigue in the exercised muscles. The repeated stretch 11 reflex permits muscles to work longer without In presenting each technique we give a short char- fatiguing. Alternating contractions of the an- acterization, the goals, uses, and any contraindica- tagonistic muscles relieves the fatigue that fol- tions. Following are full descriptions of each tech- 12 lows repeated exercise of one group of muscles. nique, examples, and ways in which they may be modified. 13 We have grouped the PNF techniques so that those with similar functions or actions are togeth- 14 er. Where new terminology is used, the name de- 3.1 Rhythmic Initiation scribes the activity or type of muscle contraction involved. When the terminology differs from that Characterization 15 used by Knott and Voss (1968), both names are giv- Rhythmic motion of the limb or body through the en. desired range, starting with passive motion and 16 For example, Reversal of Antagonists is a gener- progressing to active resisted movement. al class of techniques in which the patient first con- 17 tracts the agonistic muscles then contracts their an- Goals tagonists without pause or relaxation. Within that 5 Aid in initiation of motion class, Dynamic Reversal of Antagonist is an isoton- 5 Improve coordination and sense of motion 18 ic technique where the patient first moves in one direction and then in the opposite without stop- 19 ping. Rhythmic Stabilization involves isometric 20 contractions of the antagonistic muscle groups. In 1 G. Johnson and V. Saliba were the first to use the terms “stabilizing reversal of antagonists”, “dynamic reversal of this technique, motion is not intended by either the antagonist”, “combination of isotonics”, and “repeated patient or the therapist. We use both reversal tech- stretch” in an unpublished course handout at the Institute niques to increase strength and range of motion. of Physical Art (1979).

3.2 · Combination of Isotonics 321 5 Normalize the rate of motion, either increasing Modifications or decreasing it 5 The technique can be finished by using eccen- 5 Teach the motion tric as well as concentric muscle contractions 5 Help the patient to relax (Combination of Isotonics). 5 The technique may be finished with active mo- Indications tion in both directions (Reversal of Antago- 5 Difficulties in initiating motion nists). 5 Movement too slow or too fast 5 Uncoordinated or dysrhythmic motion, i.e., Points to Remember ataxia and rigidity 5 Use the speed of the verbal command to 5 Regulate or normalize muscle tone set the rhythm. 5 General tension 5 At the end the patient should make the Description motion independently. 5 The therapist starts by moving the patient pas- 5 The technique may be combined with sively through the range of motion, using other techniques. the speed of the verbal command to set the rhythm. 3.2 Combination of Isotonics 5 The patient is asked to begin working actively (described by Gregg Johnson in the desired direction. The return motion is and Vicky Saliba) done by the therapist. 5 The therapist resists the active movement, Characterization maintaining the rhythm with the verbal com- Combined concentric, eccentric, and stabilizing mands. contractions of one group of muscles (agonists) 5 To finish the patient should make the motion without relaxation. For treatment, start where the independently. patient has the most strength or best coordination. Example Goals Trunk extension in a sitting position: 5 Active control of motion 5 Move the patient passively from trunk 5 Coordination 5 Increase the active range of motion flexion into extension and then back to 5 Strengthen the flexed position. “Let me move you up 5 Functional training in eccentric control of straight. Good, now let me move you back down and then up again.” movement 5 When the patient is relaxed and moving easily, ask for active assisted motion. “Help Indications me a little coming up straight. Now relax 5 Decreased eccentric control and let me bring you forward.” 5 Lack of coordination or ability to move in a 5 Then begin resisting the motion. “Push up straight. Let me bring you forward. Now desired direction push up straight again.” 5 Decreased active range of motion 5 Independent: “Now straighten up on your 5 Lack of active motion within the range of mo- own.” tion

22 Chapter 3 · Techniques Description Example Trunk extension in a sitting position 1 5 The therapist resists the patient’s moving ac- (. Fig. 3.1 a, b): 5 Resist the patient’s concentric contraction tively through a desired range of motion (con- into trunk extension. “Push back away 2 centric contraction). from me.” 5 At the end of motion the therapist tells the pa- 5 At the end of the patient’s active range of motion, tell the patient to stabilize in that 3 tient to stay in that position (stabilizing con- position. “Stop, stay there, don’t let me traction). pull you forward.” 5 When stability is attained the therapist tells 5 After the patient is stable, move the pa- tient back to the original position while he 4 the patient to allow the part to be moved slow- or she maintains control with an eccentric ly back to the starting position (eccentric con- contraction of the trunk extensor muscles. “Now let me pull you forward, but slowly.” 5 traction). 5 There is no relaxation between the different 6 types of muscle activities and the therapist’s hands remain on the same surface. 7 – Note The eccentric or stabilizing muscle contraction 8 may come before the concentric contraction. Modifications 9 5 The technique may be combined with Reversal of Antagonists. 10 11 12 13 14 15 16 17 18 19 a b 20 . Fig. 3.1a, b. Combination of Isotonics: coming forward with eccentric contraction of trunk extensor muscles

3.3 · Reversal of Antagonists 323 Example Example Trunk flexion combined with trunk extension: Trunk flexion in a sitting position: 5 After repeating the above exercise a 5 Resist the patient’s concentric contraction number of times, tell the patient to move into trunk flexion. “Push forward toward actively with concentric contractions into me.” trunk flexion. 5 After the patient reaches the desired 5 Then you may repeat the exercise with degree of trunk flexion, move the patient trunk flexion, using Combination of back to the original position while he or Isotonics, or continue with Reversal of An- she maintains control with an eccentric tagonists for trunk flexion and extension. contraction of the trunk flexor muscles. “Now let me push you back, but slowly.” Modification Points to Remember 5 The technique can start at the end of the range 5 Start where the patient has the most of motion and begin with eccentric contrac- strength or best coordination tions. 5 The stabilizing or eccentric muscle con- Example traction may come first Eccentric trunk extension in a sitting position 5 To emphasize the end of the range, start (. Fig. 3.1 a, b): 5 Start the exercise with the patient in trunk there with eccentric contractions extension. 3.3 Reversal of Antagonists 5 Move the patient from extension back to These techniques are based on Sherrington’s princi- trunk flexion while he or she maintains ple of successive induction (Sherrington 1961). control with an eccentric contraction of the trunk extension muscles. “Now let me pull you forward, but slowly.” Modifications 3.3.1 Dynamic Reversals (Incorporates Slow Reversal) 5 One type of muscle contraction can be changed to another before completing the full Characterization range of motion. Active motion changing from one direction (agonist) to the opposite (antagonist) without pause or relax- 5 A change can be made from the concentric to ation. In normal life we often see this kind of muscle the eccentric muscle contraction without stop- activity: throwing a ball, bicycling, walking etc. ping or stabilizing. Goals 5 Increase active range of motion 5 Increase strength 5 Develop coordination (smooth reversal of mo- tion) 5 Prevent or reduce fatigue 5 Increase endurance 5 Decrease muscle tone

24 Chapter 3 · Techniques Indications er pattern. However, don’t leave the patient with a limb “in the air”. 1 5 Decreased active range of motion 5 Weakness of the agonistic muscles 2 5 Decreased ability to change direction of mo- Example tion 3 5 Exercised muscles begin to fatigue Reversing lower extremity motion from flex- 5 Relaxation of hypertonic muscle groups ion to extension: 5 Resist the desired (stronger) pattern of 4 Description lower extremity flexion. “Foot up and lift 5 The therapist resists the patient’s moving in your leg up.” (. Fig. 3.3 a) 5 As the patient’s leg approaches the end of 5 one direction, usually the stronger or better di- the range, give a verbal cue (preparatory rection (. Fig. 3.2 a). command) to get the patient’s atten- tion while you slide the hand that was 6 5 As the end of the desired range of motion ap- proaches the therapist reverses the grip on the distal portion of the moving segment and gives resisting on the dorsum of the foot to the plantar surface (the dorsiflexor muscles 7 a command to prepare for the change of direc- are still active by irradiation from the tion. proximal grip) to resist the patient’s foot during the reverse motion. 8 5 At the end of the desired movement the ther- 5 When you are ready for the patient to apist gives the action command to reverse di- move in the new direction give the action command “Now push your foot down and 9 rection, without relaxation, and gives resist- kick your leg down.” (. Fig. 3.3 b) ance to the new motion starting with the distal 5 As the patient starts to move in the new direction, move your proximal hand so part (. Fig. 3.2 b). that it also resists the new direction of motion (. Fig. 3.3 c). 10 5 When the patient begins moving in the oppo- site direction the therapist reverses the proxi- 11 mal grip so all resistance opposes the new di- rection. 5 The reversals may be done as often as neces- 12 sary. 13 Normally we start with contraction of the strong- er pattern and finish with contraction of the weak- 14 15 16 17 18 19 ab 20 . Fig. 3.2. Dynamic Reversal of the arm diagonal flexion-abduction into extensionadduction. a Reaching the end of flexion-ab- duction. b After changing the hands, resisting the movement into extension-adduction

3.3 · Reversal of Antagonists 325 Modifications 5 The speed used in one or both directions can be varied. 5 Instead of moving through the full range, the change of direction can be used to emphasize a 5 The technique can begin with small motions in particular range of the motion. each direction, increasing the range of motion – Start the reversal from flexion to extension as the patient’s skill increases. before reaching the end of the flexion mo- tion. You may reverse again before reach- 5 The range of motion can be decreased in each ing the end of the extension motion: direction until the patient is stabilized in both directions. 5 The patient can be instructed to hold his or her position or stabilize at any point in the range of motion or at the end of the range. This can be done before and after reversing direction. Example Reversing lower extremity motion with stabili- zation before the reversal. 5 When the patient reaches the end of the flexion motion give a stabilizing com- mand (“keep your leg up there”). a 5 After the leg is stabilized change the distal hand and ask for the next motion (“kick down”). Example Reversing lower extremity motion with stabili- zation after the reversal. 5 After changing the distal hand to the plantar surface of the foot give a stabi- b lizing command (“keep your leg there, don’t let me push it up any further”). 5 When the leg is stabilized, give a motion command to continue to exercise (“now kick down”). c 5 The technique can begin with the stronger di- rection to gain irradiation into the weaker . Fig. 3.3. Dynamic Reversal of the leg diagonal: flexion-ad- muscles after reversing. duction with knee flexion into extension-abduction with knee extension. a Resisting flexion adduction. b Distal grip changed 5 A reversal should be done whenever the ago- and motion into extension-abduction started. c Resisting ex- nistic muscles begin to fatigue. tension abduction 5 If increasing strength is the goal the resistance increases with each change and the command asks for more power.

26 Chapter 3 · Techniques 1 Points to Remember Example 5 Only use an initial stretch reflex. Do not Trunk stability (. Fig. 3.4 a): 5 Combine traction with resistance to the 2 re-stretch when changing the direction because the antagonist muscles are not patient’s trunk flexor muscles. “Don’t let me push you backward.” 3 yet under tension 5 When the patient is contracting his or her 5 Resist, don’t assist the patient when trunk flexor muscles, maintain the traction changing the direction of motion and resistance with one hand while mov- ing your other hand to approximate and 4 5 Change the direction to emphasize a particular range of the motion 5 resist the patient’s trunk extension. “Now don’t let me pull you forward.” 6 3.3.2 Stabilizing Reversals 5 As the patient responds to the new resist- ance, move the hand that was still resist- 7 Characterization ing trunk flexion to resist trunk extension. Alternating isotonic contractions opposed by 5 Reverse directions as often as needed to 8 enough resistance to prevent motion. The com- be sure the patient is stable. “Now don’t mand is a dynamic command (“push against my let me push you. Don’t let me pull you.” 9 hands”, or “don’t let me push you”) and the thera- pist allows only a very small movement. Modifications 10 Goals 5 The technique can begin with slow reversals 5 Increase stability and balance and progress to smaller ranges until the patient 11 5 Increase muscle strength is stabilizing. 5 Increase coordination between agonist and an- 5 The stabilization can start with the stronger tagonist muscle groups to facilitate the weaker muscles. 5 The resistance may be moved around the 12 Indications patient so that all muscle groups work 13 5 Decreased stability (. Fig. 3.4 b). 5 Weakness 14 5 Patient is unable to contract muscle isometri- Example cally and still needs resistance in a one-way di- Trunk and neck stability: rection 5 After the upper trunk is stable, you may 15 give resistance at the pelvis to stabilize Description 16 5 The therapist gives resistance to the patient, the lower trunk. starting in the strongest direction, while ask- 5 Next you may move one hand to resist 17 ing the patient to oppose the force. Very little neck extension. motion is allowed. Approximation or traction should be used to increase stability. 18 5 When the patient is fully resisting the force the – Note therapist moves one hand and begins to give The speed of the reversal may be increased or 19 resistance in another direction. decreased. 5 After the patient responds to the new resist- 20 ance the therapist moves the other hand to re- sist the new direction.

3.3 · Reversal of Antagonists 327 ab . Fig. 3.4. Stabilizing Reversal for the trunk. a Stabilizing the upper trunk. b One hand continues resisting the upper trunk, the therapist’s other hand changes to resist at the pelvis Points to Remember Goals 5 Starting working in the strongest direction 5 Increase active and passive range of motion 5 You can begin with slow reversals and 5 Increase strength 5 Increase stability and balance decrease the range until the patient is 5 Decrease pain stabilizing Indications and contraindications 3.3.3 Rhythmic Stabilization Indications 5 Limited range of motion Characterization 5 Pain, particularly when motion is attempted Alternating isometric contractions against resist- 5 Joint instability ance, no motion intended.2 5 Weakness in the antagonistic muscle group 5 Decreased balance 2 In the first and second editions of Proprioceptive neu- romuscular facilitation, Knott and Voss describe this tech- Contraindications nique as resisting alternately the agonistic and antagonis- 5 Rhythmic stabilization may be too difficult for tic patterns without relaxation. In the third edition (1985), Voss et al. describe resisting the agonistic pattern distally patients with cerebellar involvement (Kabat and the antagonistic pattern proximally. 1950) 5 The patient is unable to follow instructions due to age, language difficulty, cerebral dysfunction

28 Chapter 3 · Techniques Description 1 5 The therapist resists an isometric contrac- tion of the agonistic muscle group. The patient 2 maintains the position of the part without try- ing to move. 3 5 The resistance is increased slowly as the patient builds a matching force. 5 When the patient is responding fully, the ther- 4 apist moves one hand to begin resisting the an- tagonistic motion at the distal part. Neither the 5 therapist nor the patient relaxes as the resist- ance changes (. Fig. 3.5). 6 5 The new resistance is built up slowly. As the patient responds the therapist moves the other hand to resist the antagonistic motion also. 7 5 Use traction or approximation as indicated by the patient’s condition. 8 5 The reversals are repeated as often as needed. 5 Use a static command. “Stay there.” “Don’t try 9 to move.” 10 Example . Fig.3.5. Rhythmic Stabilization of the shoulder in the diag- 11 Trunk stability: onal of flexion-abduction/extension-adduction 12 5 Resist an isometric contraction of the 13 5 To increase the range of motion the stabiliza- 14 patient’s trunk flexor muscles. “Stay still, tion may be followed by asking the patient to 15 match my resistance in front.” move farther into the restricted range. 16 5 Next, take all the anterior resistance 17 with your left hand and move your right 5 For relaxation the patient may be asked to re- 18 hand to resist trunk extension. “Now start lax all muscles at the end of the technique. 19 matching me in back, hold it.” 20 5 As the patient responds to the new resist- 5 To gain relaxation without pain the technique ance, move your left hand to resist trunk may be done with muscles distant from the extension. “Stay still, match me in back.” painful area. 5 The direction of contraction may be reversed as often as necessary to reach Example the chosen goal. “Now hold in front again. Trunk stability and strengthening: Stay still. Now start matching me in the 5 Resist alternate trunk flexion and exten- back.” sion until the patient is stabile. Modifications 5 When the trunk is stabile, give increased 5 The technique can begin with the stronger stabilizing resistance to the stronger group of muscles for facilitation of the weaker direction (“Match me in back” for exten- muscle group (successive induction). sion). 5 The stabilizing activity can be followed by a 5 Then ask for motion into the direction to strengthening technique for the weak muscles. be strengthened (“Now push me forward as hard as you can” to strengthen flexion).

3.4 · Repeated Stretch (Repeated Contractions) 329 . Table 3.1. Differences Between Stabilizing Reversals and Rhythmic Stabilization Stabilizing Reversals Rhythmic Stabilization Isotonic muscle action Isometric muscle co-contraction, no movement allowed Rhythmic stabilization requires concentration and may be easier in a closed muscle chain Intention to move No intention to move Command: »Stay here, against me« Static command: “Stay still, don’t try to move” Hand grip: changes with each change in direction. Hand grip: May grip on both sides and change direction of Change from one part of the body to another part is al- resistance slowly lowed Muscle activity: From agonist to antagonist to agonist Muscle activity: Agonistic and antagonistic activity togeth- to antagonist er (possible co-contraction) Patient needs one direction; to control both directions Patient is still able to control both directions together is too difficult Points to Remember 5 Prevent or reduce fatigue 5 Guide motion in the desired direction 5 Use static commands because no motion intended Indications and Contraindications Indications 5 The stabilization may be done with mus- 5 Weakness cles distant from a painful area 5 Inability to initiate motion due to weakness or 5 Stabilization can be followed by a rigidity strengthening technique 5 Fatigue 5 Decreased awareness of motion 3.4 Repeated Stretch (Repeated Contraindications Contractions) 5 Joint instability 3.4.1 Repeated Stretch from Beginning 5 Pain of Range 5 Unstable bones due to fracture or osteoporosis 5 Damaged muscle or tendon Characterization Description The stretch reflex elicited from muscles under the tension of elongation. 5 Lengthened muscle tension = stretch stimulus 5 Lengthened muscle tension + tap = stretch re- – Note Only muscles should be under tension; take care flex not to stretch the joint structures. – The therapist gives a preparatory command Goals while fully elongating the muscles in the 5 Facilitate initiation of motion pattern. Pay particular attention to the ro- 5 Increase active range of motion tation. 5 Increase strength – Give a quick “tap” to lengthen (stretch) the muscles further and evoke the stretch re- flex.

30 Chapter 3 · Techniques – At the same time as the stretch reflex, give 3.4.2 Repeated Stretch Through Range 1 a command to link the patient’s voluntary Characterization effort to contract the stretched muscles 2 with the reflex response. The stretch reflex elicited from muscles under the – Resist the resulting reflex and voluntary tension of contraction (. Fig. 3.6). 3 muscle contraction. Goals 4 Example 5 Increase active range of motion 5 Increase strength Stretch of the pattern of flexion-abduction- 5 Prevent or reduce fatigue 5 internal rotation: 5 Guide motion in the desired direction 5 Place the foot in plantar flexion-inversion then rotate the patient’s lower extremity Indications and Contraindications 6 into external rotation and the hip into Indications full extension, adduction, and external 5 Weakness 7 rotation. 5 Fatigue 5 When all the muscles of the flexion-ab- 5 Decreased awareness of desired motion 8 duction-internal rotation pattern are taut, Contraindications give the preparatory command “Now!” 9 while quickly elongating (stretching) all 5 Joint instability the muscles farther. 5 Pain 5 Immediately after the stretch, give the 5 Unstable bones due to fracture or osteoporosis 10 command “Pull up and out.” 5 Damaged muscle or tendon 5 When you feel the patient’s muscles con- 11 tract, give resistance to the entire pattern. Description 5 The therapist resists a pattern of motion so all 12 Modifications the muscles are contracting and tense. You can start with an initial stretch reflex. 5 The technique may be repeated, without stop- 13 ping, from the beginning of the range as soon as the contraction weakens or stops. 14 5 The resistance may be modified so that on- Range New effort ly some motions are allowed to occur (timing New effort with stronger contraction for emphasis). For example, the therapist may with stronger contraction 15 prevent any hip motion from occurring while New effort resisting the ankle dorsiflexion and eversion with stronger contraction 16 through its range. Repeated stretch through range Points to Remember Initial Repeated contraction stretch through range 17 5 Combine the stretch reflex with the Repeated 18 patient’s voluntary effort 5 Wait for the resulting muscle contraction, stretch through range Time then resist Initial stretch from beginning of range 19 20 . Fig. 3.6. Repeated Stretch through range: stretch reflex at the beginning of the range and repeated stretch reflex through range (Drawing by Eisermann)

3.5 · Contract-Relax 331 5 Next give a preparatory command to coor- Modifications dinate the stretch reflex with a new and in- 5 The therapist may ask for a stabilizing con- creased effort by the patient. traction of the pattern before re-stretching the 5 At the same time you slightly elongate (stretch) muscles. “Hold your leg here, don’t let me pull the muscles by momentarily giving too much it down. Now, pull it up harder.” resistance. 5 The therapist may resist a stabilizing contrac- tion of the stronger muscles in the pattern 5 A new and stronger muscle contraction is while re-stretching and resisting the weaker asked for and resisted. muscles (timing for emphasis). 5 The stretch reflex is repeated to strengthen the Example contraction or redirect the motion as the pa- Repeated contractions of ankle dorsiflexion tient moves through the range. and eversion with the hip motion stabilized. 5 “Lock in” the hip motion by resisting a 5 The patient must be allowed to move before the next stretch reflex is given. stabilizing contraction of those muscles. “Hold your hip there.” 5 The patient must not relax or reverse direction 5 The ankle motion of dorsiflexion and during the stretch. eversion is re-stretched and the new con- traction resisted through range. “Pull your Example ankle up and out harder.” Repeated Stretch of the lower extremity pat- tern of flexion-abduction-internal rotation Points to Remember 5 Resist the patient’s moving his or her 5 A new and stronger muscle contraction lower extremity into flexion-abduction- should follow each re-stretch internal rotation. “Foot up, pull your leg up and out.” 5 The patient must be allowed to move 5 Give a preparatory command (“Now!”) before the next stretch reflex is given while slightly over-resisting the motion so that you pull the patient’s leg a short 5 A rule of thumb is three to four re-stretch- distance back in the direction of exten- es during one pattern sion-adduction-external rotation. The patient must maintain the contraction of 3.5 Contract-Relax the stretched muscles. 5 Give the command “Pull again, harder” We refer to the resisting patterns or muscles as “an- immediately after the stretch. tagonists”, and the opposite patterns or muscles as 5 Give appropriate resistance to the “agonists”. increased contraction that follows the re- stretch of the muscles. 3.5.1 Contract-Relax: Direct Treatment 5 Repeat the stretch and resistance if you feel the patient’s strength decreasing. Characterization 5 Repeat the stretch reflex if you feel the pa- Resisted isotonic contraction of the restricting mus- tient start to move in the wrong direction. cles (antagonists) followed by relaxation and move- 5 Always allow a response to occur before ment into the increased range. giving another re-stretch. A rule of thumb is three to four re-stretches during one pattern.

32 Chapter 3 · Techniques Goal 5 Active resisted exercise of the agonistic and an- tagonistic muscles in the new range of motion 1 5 Increased passive range of motion 2 Indication finishes the activity. 5 Decreased passive range of motion Example 3 Description Increasing the range of shoulder flexion, 5 The therapist or the patient moves the joint or abduction, and external rotation. 5 The patient moves the arm to the end of 4 body segment to the end of the passive range of motion. Active motion or motion against a the range of flexion-abduction-external rotation. “Open your hand and lift your 5 little resistance is preferred. arm up as high as you can.” 5 The therapist asks the patient for a strong con- 5 Resist an isotonic contraction of the pattern of extension-adduction-internal 6 traction of the restricting muscle or pattern rotation. “Squeeze my hand and pull your (antagonists). (The authors feel that the con- arm down and across. Keep turning your hand down.” traction should be held for at least 5–8 sec- 7 onds) (. Fig. 3.7 a) 5 A maximal contraction in the most lengthened 8 position of the muscle chain will provoke a structural change in the actin-myosin complex 9 (Rothwell 1994). 5 Allow enough motion to occur for both you 5 Enough motion is allowed for the therapist to and the patient to know that all the muscles in be certain that all the desired muscles, particu- the pattern, particularly the rotators, are con- 10 larly the rotators, are contracting. tracting. “Keep pulling your arm down.” 5 After sufficient time, the therapist tells the pa- 5 After resisting the contraction (for a sufficient 11 tient to relax. amount of time), both you and the patient re- 5 Both the patient and the therapist relax. lax. “Relax, let everything go loose.” 5 The joint or body part is repositioned, either 5 Now, resist the patient’s motion into the new- 12 actively by the patient or passively by the ther- ly gained range. “Open your hand and lift your apist, to the new limit of the passive range. Ac- arm up farther.” 13 tive motion is preferred and may be resisted. 5 When no more range is gained, exercise the 5 The technique is repeated until no more range agonistic and antagonistic patterns, either in 14 is gained. the new range or throughout the entire range 15 16 17 18 19 ab 20 . Fig. 3.7. Hold-Relax or Contract-Relax. a Direct treatment for shortened shoulder extensor and adductor muscles. b Indirect treatment for shortened shoulder extensor and adductor muscles

3.6 · Hold-Relax 333 of motion. “Squeeze and pull your arm down; 3.6.1 Hold-Relax: Direct Treatment now open your hand and lift your arm up again.” Characterization Resisted isometric contraction of the antagonistic Modifications muscles (shortened muscles) followed by relaxation 5 The patient is asked to move immediately into (. Fig. 3.7 a). the desired range without any relaxation. Goals 5 Alternating contractions (reversals) of ago- 5 Increase passive range of motion 5 Decrease pain nistic and antagonistic muscles may be done. “Keep your arm still, don’t let me pull it up. Indications and Contraindication Now don’t let me push your arm down.” Indications 5 Decreased passive range of motion 3.5.2 Contract-Relax: Indirect 5 Pain Treatment 5 The patient’s isotonic contractions are too Description strong for the therapist to control 5 The technique uses contraction of the agonis- Contraindication tic muscles instead of the shortened muscles. 5 The patient is unable to do an isometric con- “Don’t let me push your arm down, keep push- ing up.” (. Fig. 3.7 b). traction Indication Description 5 Use the indirect method when the contraction For increasing range of motion 5 The therapist or patient moves the joint or of the restricting muscles is too painful or too weak to produce an effective contraction. body segment to the end of the passive or pain-free range of motion. Active motion is Points to Remember preferred. The therapist may resist if that does not cause pain. 5 The technique is only to increase passive range of motion – Note If this position is very painful the patient should 5 The patient’s active motion is always move slightly out of position until it is no longer preferred painful. 5 When the contraction of the restricting 5 The therapist asks for an isometric contraction (antagonist) muscles is painful or weak, of the restricting muscle or pattern (antago- use the agonist nists) with emphasis on rotation. (The authors feel that the contraction should be maintained 3.6 Hold-Relax for at least 5–8 seconds) We refer to the resisting patterns or muscles as “an- 5 The resistance is increased slowly. tagonists”, and the opposite patterns or muscles as 5 No motion is intended by either the patient or “agonists”. the therapist. 5 After holding the contraction for enough time the therapist asks the patient to relax. 5 Both the therapist and the patient relax grad- ually.

34 Chapter 3 · Techniques 5 The joint or body part is repositioned either Example Indirect treatment for decreasing pain in the 1 actively or passively to the new limit of range. right shoulder and relaxation of the shoulder internal rotator muscles. Active motion is preferred if it is pain-free. The 5 The patient lies with his or her right arm 2 motion may be resisted if that does not cause supported in a comfortable position and pain. the right elbow flexed. 5 Hold the patient’s right hand and ask 3 5 Repeat all steps in the new limit of range. for an isometric contraction of the ulnar flexor muscles of the wrist. “Keep your For decreasing pain hand and wrist right there. Match my resistance.” 4 5 The patient is in a position of comfort 5 Resist an isometric contraction of the 5 The therapist resists an isometric contraction ulnar wrist flexor muscles and forearm pronator muscles. Build the resistance 5 of muscles affecting the painful segment up slowly and keep it at a pain-free level. “Keep holding, match my resistance.” Points to Remember 5 While maintaining the resistance, moni- 6 5 The patient’s active motion is always 7 preferred 5 Both the therapist and the patient must relax 8 9 tor muscle activity in the patient’s right shoulder, particularly the internal rotation. 3.6.2 Hold-Relax: Indirect Treatment 5 Both you and the patient relax slowly and completely. “Now let go slowly all over.” 10 5 Both you and the patient breathe In the indirect treatment with Hold-Relax you re- 5 Repeat the technique in the same posi- tion to gain more relaxation, or move the 11 sist the synergists of the shortened or painful mus- forearm into more supination or prona- cles and not the painful muscles or painful motion. tion to change the effect on the shoulder If that still causes pain, resist the synergistic mus- 12 cles of the opposite pattern instead (. Fig. 3.7 b). 13 Indication muscles. 5 When the contraction of the restricted muscles 14 is too painful. Modifications Description 5 The technique may be done with contraction of the synergistic muscles of the opposite pat- 15 5 The patient is in a position of comfort. 5 The therapist resists isometric contractions of tern, in this case resisting an isometric contrac- 16 synergistic muscles distant from the painful tion of the radial extensor muscles of the wrist segment. and the forearm supinator muscles. 17 5 The resistance is built up slowly and remains at 5 Alternating isometric contractions or Rhyth- a level below that which causes pain. mic Stabilization may be done. 5 During relaxation the resistance decreases 5 If the patient is unable to do an isometric con- traction, carefully controlled stabilizing con- 18 slowly. tractions may be used. The therapist’s resist- 19 ance and the patient’s effort must stay at a level that does not cause pain. 20

3.8 · PNF Techniques and Their Goals 335 Points to Remember 5 For each replication of the movement start far- ther toward the beginning of the movement to 5 Resist the synergists of the shortened or challenge the patient through a greater range painful muscle of the motion. 5 Both therapist and patient keep breathing 5 At the end the patient should perform the ac- 5 The effort stays at a level that does not tivity or motion alone, without facilitation or manual contact by the therapist. cause pain Points to Remember 3.7 Replication 5 Exercise or teach functional activities 5 Use all the Basic Procedures for facilitation Characterization A technique to facilitate motor learning of function- 3.8 PNF Techniques and Their al activities. Teaching the patient the outcome of a Goals movement or activity is important for functional work (for example sports) and self-care activities. Goals Suggestions for PNF techniques that can be used to 5 Teach the patient the end position (outcome) achieve a particular goal are outlined below. of the movement. 1. Initiate motion 5 Assess the patient’s ability to sustain a contrac- – Rhythmic Initiation – Repeated Stretch from beginning of tion when the agonist muscles are shortened. range Description 2. Learn a motion 5 Place the patient in the “end” position of the – Rhythmic Initiation – Combination of Isotonics activity where all the agonist muscles are – Repeated Stretch from beginning of shortened. range 5 The patient holds that position while the thera- – Repeated Stretch through range pist resists all the components. Use all the basic – Replication procedures to facilitate the patient’s muscles. 5 Ask the patient to relax. Move the patient, pas- 3. Change rate of motion sively a short distance back in the opposite di- – Rhythmic Initiation rection, then ask the patient to return to the – Dynamic Reversals ’end’ position. – Repeated Stretch from beginning of range End range of – Repeated Stretch through range Functional act 4. Increase strength – Combination of Isotonics – Dynamic Reversals – Rhythmic Stabilization Start range time now alone! . Fig. 3.8. Replication: patients learn step by step to execute 6 the whole activity. (Drawing by Ben Eisermann)

36 Chapter 3 · Techniques 1 – Stabilizing Reversals References 2 – Repeated Stretch from beginning of 3 Arai M (2001) Effects of the use of cross-education to the affect- 4 range ed side through various resistive exercises of the sound 5 – Repeated Stretch through range side and settings of the length of the affected muscles. 6 5. Increase stability Hiroshima J Med Sci (3): 65-73 7 – Combination of Isotonics 8 – Stabilizing Reversals Bonnar BP, Deivert RG, Gould TE (2004) The relationship 9 – Rhythmic Stabilization between isometric contraction durations during hold- 10 6. Increase coordination and control relax stretching and improvement of hamstring flexibili- 11 – Combination of Isotonics ty. J Sports Med Phys Fitness (3): 258-261 12 – Rhythmic Initiation 13 – Dynamic Reversals Carter AM, Kinzey SJ, Chitwood LF, Cole JL (2000) PNF decreas- 14 – Stabilizing Reversals es muscle activity during the stretch reflex in selected 15 – Rhythmic Stabilization posterior thigh muscles. J Sport Rehab (9): 269-278 16 – Repeated Stretch from beginning of 17 Chalmers G (2004) Re-examination of the possible role of Golgi 18 range tendon organ and muscle spindle reflexes in propriocep- 19 – Replication tive neuromuscular facilitation muscle stretching. Sports 20 7. Increase endurance Biomechanics: (1) 159-183 – Dynamic Reversals – Stabilizing Reversals Cornelius WL, Jensen RL, Odell ME (1995) Effects of PNF stretch- – Rhythmic Stabilization ing phases on acute arterial blood pressure. Can J Appl – Repeated Stretch from beginning of Physiol (2): 222-229 range Davis DS, Ashby PE, Mc Cale KL, Mc Quain JA, Wine JM (2005) – Repeated Stretch through range The effectiveness of 3 stretching techniques on ham- 8. Increase range of motion string flexibility using consistent stretching parameters. J – Dynamic Reversals Strength Conditioning Res (1):27-32 – Stabilizing Reversals – Rhythmic Stabilization Deccicco PV, Fisher FM (2005) The effects of proprioceptive – Repeated Stretch from beginning of neuromuscular facilitation stretching on shoulder range of motion in overhand athletes. J Sports Med Phys Fitness range (2): 183-187 – Contract-Relax – Hold-Relax Feland JB, Marin HN (2004) Effect of sub maximal contraction 9. Relaxation intensity in contract-relax proprioceptive neuromuscular – Rhythmic Initiation facilitation stretching. Br J Sports Med. Vol 38 (4) – Rhythmic Stabilization – Hold-Relax Ferber R, Gravelle DC, Osternig LR (2002) Effect of PNF stretch 10. Decrease pain techniques on trained and untrained older adults. J Aging – Rhythmic Stabilization (or Stabilizing Phys Activity (10): 132-142 Reversals) Ferber R, Osternig LR, Gravelle DC (2002) Effect of PNF stretch – Hold-Relax techniques on knee flexor muscle EMG activity in older adults. J Electromyography Kinesiol (12): 391-397 Funk DC, Swank AM, Mikla BM, Fagan TA, Farr BK (2003) Impact of prior exercise on hamstring flexibility: a comparison of proprioceptive neuromuscular facilitation and static stretching. J Strength Conditioning Res (3): 489-492 Kabat H (1950) Studies on neuromuscular dysfunction, XII: Rhythmic stabilization; a new and more effective tech- nique for treatment of paralysis through a cerebellar mechanism. Perm Found Med Bull 8: 9–19 Knott M, Voss DE (1956) Proprioceptive neuromuscular facilita- tion: patterns and techniques. Harper and Row, New York Knott M, Voss DE (1968) Proprioceptive neuromuscular facilita- tion: patterns and techniques. 2nd edn. Harper and Row, New York Kofotolis N, Eleftherios K (2006) Effects of two 4-week PNF programs on muscle endurance, flexibility, and function- al performance in women with CLBP. Phys Ther (7): 1001- 1012 Marek SM (2005) Acute effects of static and PNF stretching on muscle strength and power output. J Athletic Training (2): 94-103

3.8 · PNF Techniques and Their Goals 337 Moore MA, Kulkulka CG (1991) Depression of Hoffmann reflex- Tanigawa MC (1972) Comparison of the hold-relax procedure es following voluntary contraction and implications for and passive mobilization on increasing muscle length. proprioceptive neuromuscular facilitation therapy. Phys Phys Ther 52:725–735 Ther (4):321-329; discussion 329-33 Olivo SA, Magee DJ (2006) Electromyographic assessment of the activity of the masticatory using the agonist contract – antagonist relax technique (AC) and contract – relax technique (CR). Manual Ther (2): 136-145 Rowlands AV, Marginson VF, Lee J (2003) Chronic flexibility gains: effect of isometric contraction duration during pro- prioceptive neuromuscular facilitation stretching tech- niques. Res Quart Exercise Sports (1): 47-51 Sarburg PR, Schrader JW (1997) Proprioceptive neuromuscular facilitation techniques in sports medicine: a reassessment. J Athletic Training (1): 34-39 Schuback B, Hooper J, Salisburg L (2004) A comparison of a self stretch incorporating PNF components and a thera- pist applied PNF technique on hamstring flexibility. Phys- iother (3): 151-157 Sullivan PE, Markos PD, Minor MAD (1982) An integrated approach to therapeutic exercise. Reston, Virginia Voss DE, Ionta M, Myer BT (1985) Proprioceptive neuromuscu- lar facilitation, patterns and techniques. 3rd edn. Harper and Row, New York Weerapong P, Hume PA, Kolt GS (2004) Stretching: mecha- nisms and benefits for sport performance and injury pre- vention. Phys Ther Rev (9): 189-206 Wenos DL, Konin JG (2004) Controlled warm-up intensity enhances hip range of motion. J Strength Conditioning Res (3): 529-533 Further Reading Beradelli AH, Hallet JC, Rothwell R, Marsden CD (1996) Sin- gle joint rapid arm movements in normal subjects and in patients with motor disorders. Brain 119: 661-664 Kandell ER, Schwarte JH, Gesell TM (2000) Principles of neural science. McGraw-Hill, New York, St. Louis, San Fransisco Markos PD (1979) Ipsilateral and contralateral effects of pro- prioceptive neuromuscular facilitation techniques on hip motion and electro-myographic activity. Phys Ther 59 (11): 1366–1373 Moore M, Kukulkan C (1988) Depression of H reflexes following voluntary contraction. Phys Ther 68:862 Rothwell J (1994) Control of human voluntary movement. Chapman and Hall, Cambridge Rose-Jacobs R, Gilberti N (1984) Effect of PNF and Rood relaxa- tion techniques on muscle length. Phys Ther 64:725 Sady SP, Wortman M, Blanke D (1982) Flexibility training: bal- listic, static or proprioceptive neuromuscular facilitation? Arch Phys Med Rehabil 63:261–263 Sato A, Schmidt RF (1973) Somatosympathetic reflexes: affer- ent fibers, central pathways, discharge characteristics. Physiol Rev 53 (4): 916-947 Sherrington C (1961) The integrative action of the nervous sys- tem. Yale University Press, New Haven

4.1 · 439 Patient Treatment 4.1 Evaluation – 40 4.1.1 Evaluation of Areas of Activities – 40 4.1.2 Evaluation of Areas of Impairments and Activity Limitations – 40 4.2 Hypothesis – 41 4.3 Tests for Causal Impairments and Activity Limitations – 41 4.4 Treatment Goals – 41 4.5 Treatment Planning and Treatment Design – 42 4.5.1 Specific Patient Needs – 42 4.5.2 Designing the Treatment – 42 4.5.3 Direct and indirect Treatment – 42 4.6 Assessment – 43 4.7 Re-Test for Causal Impairments and Activity Limitations – 44 4.8 Treatment Examples – 44

40 Chapter 4 · Patient Treatment 1 To make an exact evaluation we should use assessment guides us in adjusting the treatment as the patient progresses. the ICF Model (International Classification of 2 Function and Activity and Participation, WHO Patient Treatment Scheme 2001). Evaluation of areas of function (activities) 3 5 Body functions are the physiological (7 Sect. 4.1.1) functions of body systems (including Evaluation of impairments and activity limitations psychological functions). (7 Sect. 4.1.2) 4 5 Body structures are anatomical parts of Hypothesis of the causal impairments (7 Sect. 4.2) the body such as organs, limbs, and their Test for causal impairment and activity limitation 5 components. (7 Sect. 4.3) 5 Impairments are problems in body Treatment goals (7 Sect. 4.4) 6 function or structure such as a significant Treatment planning (7 Sect. 4.5.1) deviation or loss. Treatment design (7 Sect. 4.5.2) 5 Activity is the execution of a task or ac- (Re)-assessment (7 Sect. 4.6) Re-test for causal impairment and activity limita- 7 tion by an individual. tion (7 Sect. 4.7) 5 Participation is involvement in a life situ- 8 ation. 4.1 Evaluation 5 Activity limitations are difficulties an indi- 9 vidual may have in executing activities. 5 Participation restrictions are problems an individual may experience in their 4.1.1 Evaluation of Areas of Activities 10 involvement in life situations. Working within the PNF philosophy, we look first 5 Environmental factors make up the physi- 11 cal, social, and attitudinal environment in for the patient’s areas of activity. We will use this which people live and conduct their lives knowledge of the patient’s abilities, strong areas and the patient’s own goals to construct effective treat- 12 ments. Planning treatment is a systematic process to devel- Next we note the patient’s general (functional) 13 op the most appropriate treatment for each patient problems. (Sullivan et al. 1982). Our treatment seeks to help 14 each patient gain the highest level of function pos- sible. 4.1.2 Evaluation of Areas of 15 [ Definition Impairments and Activity Limitations The PNF philosophy means we mobilize the 16 patient’s reserves through a positive approach Last, we identify the specific dysfunctions that are toward the total human being during intensive causing the general problems. 17 functional training. 5 Areas of function a. Pain free An effective treatment depends on our doing a b. Strong c. Able to move and stabilize 18 complete and accurate evaluation to identify the d. Motion is controlled and coordinated patient’s areas of function and dysfunction. Based 19 on this evaluation we set general and specific goals, 5 Dysfunctions both immediate and for the long term. We also as- a. General (functional) loss 20 certain the patient’s personal goals. Then we design – Static: loss of the ability to maintain a a treatment plan to achieve those goals. Continuous position

4.4 · Treatment Goals 441 – Dynamic: loss of the ability to move or 4.4 Treatment Goals control motion 5 What are the treatment goals of the patient? b. Specific deficits (the reasons for the func- 5 What are the treatment goals of the therapist? tional losses) – Pain After doing the evaluation, we set both the general – Decreased range of motion due to: and the specific treatment goals. 1. joint restrictions 5 General goals are expressed as functional ac- 2. muscle tightness or contracture – Weakness tivities. These goals are not limits, we change – Loss of sensation or proprioception them as the patient improves. – Deficits in sight, hearing 5 Specific goals are set for each treatment activity – Deficient motor control and for each treatment session. – Lack of endurance 4.2 Hypothesis Example General goals and one specific treatment goal Hypotheses and conclusion of impairments and ac- for three patient examples: tivity limitations: 1. Static dysfunction: A patient who has dif- 5 What is the hypothesis of the possible causes ficulty maintaining standing balance after of the limitations of the activity: which impair- suffering a head injury. ments can be responsible for these limitations? – General goal: The patient can stand 5 Different therapists can have different hypoth- eses about the causes of the problem and about without support while doing func- the way of treatment. The therapist should be tional upper extremity activities. open to other ideas. – Specific treatment goal: The patient 5 Which clinical measurement tools do we use to can maintain a steady bridging posi- assess the changes in the level of impairments tion without using the arms for 30 and in the level of limitation of activities? seconds. (Begin treatment in a more 5 What is the clinical reasoning for choosing the stable and less threatening position.) procedures to treat the patient’s dysfunctions? 2. Dynamic dysfunction due to pain: A pa- tient who has pain in his right knee after 4.3 Tests for Causal Impairments miniscus injury. and Activity Limitations – General goal: The patient will be able to run one mile (1.6 km) in less than 6 Measurements should be on the level of impair- minutes without pain in the knee. ments and on the level of activities. These meas- – Specific treatment goal: The patient urements should be done quickly and should be can hold a one-leg bridging posi- as simple as possible and should be reproducible. tion on the right leg with the left leg Examples of measurements on the level of impair- extended for 30 seconds. (Begin treat- ments: Muscle function test, testing the mobility, ment with limited weight-bearing on Ashworth-Scale, 2 point discrimination test. Exam- the right leg.) ples of measurements on the level of activity: Bar- thel Index, FIM, Motor Assessment Scale (MAS), 6 Jebsen Test, Time up and go test

42 Chapter 4 · Patient Treatment 1 3. Dynamic dysfunction due to the loss of 3. Increase strength, coordination, and control of motion ability to move: A patient who has had a 4. Develop a proper balance between motion and 2 stroke with resultant hemiplegia. stability – General goal: The patient will be able 5. Increase endurance to walk 25 feet (8 m) in 2 minutes 3 using a cane and an ankle-foot orthosis. 4.5.2 Designing the Treatment 4 – Specific treatment goal: The patient can shift weight from the right to the The therapist designs a treatment to meet the pa- 5 left ischial tuberosity while sitting tient’s needs. Factors to be considered include: without any support. (Begin treat- 1. Direct or indirect treatment 6 ment with weight shifting in a stable 2. Appropriate activities position.) – Movement or stability – What types of muscle contractions 7 3. The best position for the patient. Consider: Each treatment goal should be (SMART analysis): – The patient’s comfort and security 8 Specific – The effect of gravity Measurable – The effect on two-joint muscles 9 Acceptable – Progression of treatment Realistic – Reflex facilitation Time related – Use of vision – Closed chain or open chain muscle work 10 – Position to decrease spasticity 4. Techniques and procedures 11 4.5 Treatment Planning and Treatment Design 5. Patterns and combinations of patterns 6. Functional and goal oriented tasks. 12 PNF uses muscle contractions to affect the body. If muscle contractions are not appropriate for the pa- The treatment of the therapist should always be: 13 tient’s condition or if their use does not achieve the Goal oriented: all the activities are focussed desired goals, the therapist should use other meth- on the treatment goal. Systematic: the treatment 14 ods. Modalities such as heat and cold, passive joint should be set up in a logical way. motion, and soft tissue mobilization may be com- Process oriented: all aspect of the treatment bined with PNF for effective treatment. should be related to and influence each other. 15 Selection of the most effective treatment de- Conscious: every application should be made pends on the condition of the patient’s muscles and with a specific treatment goal in mind and if neces- 16 joints and any existing medical problems. The ther- sary be adapted to it. apist combines and modifies the procedures and the 17 techniques to suit the needs of each patient. Treat- – Note ment should be intensive, mobilizing the patient’s The treatment goals should be clear, measurable, reserves without resulting in pain or fatigue. and reachable within a realistic timeframe. 18 19 4.5.1 Specific Patient Needs 4.5.3 Direct and indirect Treatment 20 The therapist lists the patient’s needs. For example: Direct Treatment 1. Decrease pain Direct treatment may involve: 2. Increase range of motion

4.6 · Assessment 443 1. Use of treatment techniques on the affected the body. Using carefully guided and controlled ir- limb, muscle, or motion. radiation the therapist can treat the affected limb or joint without risk of increasing the pain or injury. Example To gain increased range in the shoulder Indirect treatment may involve: motions of flexion, abduction, and external 5 Use of the techniques on an unaffected or less rotation, the therapist treats the involved shoulder using the technique Contract-Relax affected part of the body. The therapist directs on the tight pectoralis major muscle. the irradiation into the affected area to achieve the desired results. 2. Directing the patient’s attention to stabilizing or moving the affected segment. Example To gain range in shoulder flexion, abduction Example and external rotation. While the patient stands on the involved leg, 5 The therapist resists an isometric contrac- the therapist gives approximation through the pelvis to facilitate weight-bearing. tion of the ulnar wrist flexor and the pronator muscles of the affected arm. Indirect Treatment 5 After resisting the contraction, the thera- Many studies have shown the effectiveness of indi- pist and the patient relax. rect treatment that begins on strong and pain-free 5 This use of Hold Relax will produce a con- parts of the body. Hellebrandt et al. (1947) report- traction and relaxation of the ipsilateral ed the development of muscle tension in unexer- pectoralis major muscle. The treated arm cised parts of the body during and after maximal need not be moved but may remain in a exercise of one limb. Other experiments have de- position of comfort. scribed electromyographic (EMG) activity in the agonistic and antagonistic muscles of the contralat- 5 Directing the patient’s attention and effort to- eral upper or lower extremity during resisted isot- ward working with the less affected parts of the onic and isometric exercise (Moore 1975; Devine et body. al. 1981; Pink 1981). The trunk musculature can al- so be exercised indirectly. For example, the abdom- Example inal muscles contract synergistically when a person To improve lower extremity weight bearing. raises his arm. This activity occurs in normal sub- 5 While the patient sits with both feet on jects and in patients suffering from central nervous system disorders as well (Angel and Eppler 1967). the floor, the therapist resists the “lifting” An increased passive range of motion can be gained pattern (trunk extension) on the side of indirectly by using Contract-Relax on uninvolved the involved lower extremity. areas of the body (Markos 1979). 5 This produces contraction of the extensor muscles in the lower extremities and To give the patient maximum benefit from in- increased weight-bearing through the direct treatment the therapist resists strong move- ipsilateral ischial tuberosity and the foot. ments or patterns. Maximum strengthening occurs when the patient’s strong limbs work in combina- 4.6 Assessment tion with the weak ones. When pain is a presenting symptom, treatment focuses on pain-free areas of The process of patient evaluation and the assess- ment of treatment is continuous. By assessing the results after each treatment, the therapist can deter-

44 Chapter 4 · Patient Treatment mine the effectiveness of both that treatment activ- c) Combinations – Hold-Relax followed by Combination 1 ity and treatment session and can then modify the treatment as necessary to achieve the stated goals. of Isotonics 2 Treatment modifications may include: – Rhythmic Stabilization followed by 1. Changing the treatment procedures or the Slow Reversal (Dynamic Reversals) 3 techniques moving first toward the painful range 2. Increasing or decreasing facilitation by chang- 2. Decreased strength and active range of motion ing the use of: a) Procedures – Appropriate resistance 4 – Reflexes – Manual contact – Timing for emphasis 5 – Visual cues – Stretch – Verbal cues – Traction or approximation 6 – Traction and approximation – Patient position 3. Increasing or decreasing the resistance given b) Techniques 4. Working with the patient in positions of func- – Repeated Stretch from beginning of range 7 tion 5. Progressing to more complex activities – Repeated Stretch through range (Re- 8 peated Contractions) – Combination of Isotonics 9 4.7 Re-Test for Causal Impairments – Dynamic (slow) Reversal of Antago- and Activity Limitations nists 10 The same test you were using at the beginning of 1. Facilitation from stronger antago- the assessment is repeated at the end of treatment. nists 2. Prevention and relief of fatigue 11 c) Combinations – Dynamic Reversal of Antagonists com- 4.8 Treatment Examples bined with Repeated Stretch through range (Repeated Contractions) of the 12 The following examples of procedures, techniques, weak pattern 13 and combinations to treat specific patient problems – Rhythmic Stabilization at a strong should not be interpreted as definitive but only as point in the range of motion followed 14 guidelines. Let your imagination and the patient’s by Repeated Contractions of the weak condition be your guides. pattern 1. Pain 3. Decreased passive range of motion a) Procedures 15 a) Procedures – Indirect treatment – Timing for emphasis 16 – Resistance below that which produces – Traction pain or stress – Appropriate resistance 17 – Isometric muscle contraction b) Techniques – Bilateral work – Contract-Relax or Hold-Relax – Traction – Stabilizing Reversal of Antagonists – Rhythmic Stabilization 18 – Position for comfort c) Combinations b) Techniques 19 – Rhythmic Stabilization – Contract-Relax followed by Combina- – Hold-Relax tion of Isotonics in the new range 20 – Stabilizing Reversals – Contract-Relax followed by Slow Re- versals, beginning with motion into the new range