Stimuli for Facilitation in PNF
Sensory Input:
• Verbal/Hearing (specific words / tone of voice to prepare &
motivate a patient’s response)
• Visual (to guide motion, visual feedback)
• Vestibular (Vestibular-Ocular-Reflex / VOR – this reflex is responsible for maintaining eye fixation during head rotation. You will learn more about this in later subjects).
• Touch/Pressure/Manual contact (touch and pressure sensory cures to guide patient to desired movement). Examples that can facilitate a motor response include: Fast brushing, quick ice, vibration, sweep tapping
Stimuli for Facilitation in PNF
Proprioceptive Sensory Input:
– Resistance (Increased recruitment of motor units, helps to aid muscle
contraction / motor control, increases strength)
– Stretch (repeated stretch of muscle to facilitate contraction of muscle)
– Traction/Distraction (Lengthens muscles / tendons / joint structures, separation of joint surfaces facilitates motion, joint proprioceptive receptors involved à FLEXION response)
– Approximation/Compression (compression of surfaces of joint to increase co-contraction and joint stability > EXTENSION response)
Remember: proprioceptive - sensory stimulation that is received from the receptors of the body’s own muscles, tendons and joints
Stretch Reflex
- Muscle spindle = the sensory receptor which will initiate a stretch reflex.
- Stretching a muscle spindle à increased activity / excitability of motor neurons innervating that same muscle and any synergistic muscles.
- The motor neurons innervating the antagonists are inhibited.
Stimuli for Facilitation in PNF
Other factors:
- Timing (sequence of motions; used selectively to facilitate motor learning)
- Patterns of movement (normal synergies; components of normal functional motion)
- Body position/mechanics (guidance and control of motion via the alignment of the therapist)
- Capitalise on automatic righting and equilibrium reactions
When is inhibition appropriate?
- If the goal is to decrease excitability in the muscles.
* If you are trying to decrease muscle spasticity or reduce muscle overactivity.
Inhibitory Specific Techniques (range gaining)
• Contract relax = To increase ROM.
• Hold relax = To increase ROM and decrease pain (Choose if PAIN is a problem).
Aim of inhibitory techniques is to try and decrease excitability in the muscles / decrease spasticity / decrease overall muscle activity.
Prescription guidelines: 5 second contraction, relaxation, 5 second contraction, relaxation.
Contract Relax
Application:
• Passively take the limb to the point in range in the agonist PNF pattern that is restricted.
• Ask the patient to actively contract the antagonists (tight muscle group).
• Only allow rotation to occur à All other groups must contract isometrically.
• Relax (fully support the weight of the patient’s limb).
• When limb is relaxed, passively move the limb into new range (remember to include rotation back into the pattern).
• This is using AUTOGENIC INHIBITION – contraction of same muscle results in subsequent relaxation of muscle due to golgi tendon organ
Hold Relax
Application:
• Ask patient to actively move their limb to a point of limitation in agonist pattern.
• Ask patient to contract into antagonist pattern (tight muscle groups).
• Don’t allow any movement à isometric only.
• Relax.
• Once you feel relaxation, ask the patient to actively move into the gained range using the PNF pattern movement combination.
• This is also utilising principle of AUTOGENIC INHIBITION
Contract Relax / Hold Relax
• The main method of contract relax / hold relax (activating tight muscle / antagonist in pattern then letting this relax to move further into range) is based on autogenic inhibition principles.
• There is more evidence surrounding this application and it is generally used much more in a clinical setting.
• It is possible to use the principle of ‘reciprocal inhibition’ in a contract relax / hold relax technique also.
• RECAP: Reciprocal Inhibition > Contraction of muscles leads to simultaneous relaxation / inhibition of
their antagonists.
• Therefore you could contract the AGONIST muscle/s (i.e. hip flexors in the LL hamstring example) and then Reciprocal inhibition would allow the hamstrings to relax and you could move further into hip flexion ROM.
• Not used as much clinically and not as much evidence.
Stimuli for Inhibition in PNF
• Similar neurological principles, however inhibitory neurophysiological principles are utilised (autogenic inhibition / reciprocal inhibition)
• Sensory stimulation methods that can inhibit a motor response include prolonged ice and prolonged stretch.
• Possible techniques:
– Distal to proximal muscle contractions.
– Reversed origin / insertion muscle contractions.
– Passive lengthening
How do I select a pattern/technique?
- Through analysis of movement, identify the muscle / groups of muscles that have a problem.
- Pick the PNF pattern that will maximally work that muscle / group of muscles through full range of movement.
- Decide what the problem is (e.g. Weakness OR tightness OR increased tone, or perhaps a combination of these).
- Choose the appropriate specific PNF technique to address the problem.
Clinical Reasoning
When applying your clinical reasoning, consider:
• You need head control to communicate, eat, breathe & read.
• You need trunk control to breathe and to digest food, sit unsupported, stand and walk.
• Therefore, head and trunk control should be the FIRST goals in treating your patients (PNF principles depends on developing axial / core stability on which to then develop all movement).
• Remember that not all patients will have exclusively MS problems.
PRACTICAL TIPS
Considerations for PNF Application
• Accurate manual contact is paramount
• Ensure you have positioned the patient appropriately
• Ensure you think about your position as the therapist in order to:
– Allow facilitation
– Control the response
– Ensure safety of both patient / physiotherapist
PRACTICAL TIPS
Manual Contact / Resistance
- Allows sensory and proprioceptive input.
- Provides direction for the movement response, and stimulation of neural end organs (touch and pressure).
- Ensures increased muscle fiber recruitment OR inhibition of undesired muscle activity.
- Hand placement must be exact so as to facilitate the desired movement and apply resistance accurately.
- Ensure you are applying optimal resistance based on the patient’s presentation and the goal you are trying to achieve (e.g. strength vs endurance).
PRACTICAL TIPS
Patient / Therapist Positioning
- Position the patient so they are close to you and as stable as possible to maximise ROM.
- Position yourself close to the patient with your body pointing in the direction of the movement diagonal. You will need to pivot when you change directions.
- Traditionally, PNF techniques are described with patient supine on a plinth.
- They can be undertaken in a range of positions though (i.e. kneeling on mats, sitting, standing, gait re-ed).
- Consider the FUNCTIONAL GOALS of the patient, as well as safety and the available environment. Be prepared to be inventive – and remember to be specific!
PRACTICAL TIPS
Other Key Points
- Commands and facilitatory input must be timed to the response demand.
- The volume of the command may affect muscle contraction, so ensure a LOUDER command when a stronger contraction is required and a calm and soft voice if the aim is to relax the patient and / or decrease pain.
- Success relies on the therapist’s skill in application and this comes with PRACTICE!!! (Remember skill acquisition – this applies to you too!)
SUMMARY TECHNIQUES
Facilitatory: • Rhythmic initiation • Slow reversals Slow reversals hold R epeated contractions Rhythmic stabilisations Inhibitory: • Contract relax • Hold relax
NEUROPHYSIOLOGICAL PRINCIPLES SUMMARY
- After Discharge
- Temporal Summation
- Spatial Summation
- Irradiation
- Successive Induction
- Autogenic Inhibition
- Reciprocal Innervation (Inhi
