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(PRINCIPLES OF TECHNICAL APPLICATION) - Coggle Diagram
PRINCIPLES OF TECHNICAL APPLICATION
Appropriate positioning
The patient should be positioned appropriately so that movements are free to occur without any hindrance.
The therapist position should be comfortable and such that he is able to maintain the manual contact without any discontinuity.
Manual contact
Manual contact of the therapist is necessary to facilitate and guide movement.
The specific manual contact recommended is lumbrical grip.
The grip should offer exteroception, stretch, resistance and traction / approximation.
Multiple grips may cause a conflict in the sensory
information sent to the brain and hence should be prevented.
Stretch
Stretch is used to facilitate movement or to increase the power of the weak muscle.
According to Sherrington’s principle, when a muscle is stretched, the Ia and Il fibres in the muscle
spindle send excitatory messages to the alpha motor neurons which innervate the stretched muscle.
Inhibitory messages are sent to the antagonistic muscle simultaneously.
In PNF, while giving stretch, the muscle is kept in the lengthened position which is the starting position of the
pattern.
Stretch produces reflex activation of the muscle which is then synchronized with the volitional effort using the visual, verbal and auditory cueing.
The applied stretch should be
appropriate as stretching too enthusiastically can only be harmful.
4.Patterns
The therapeutic movement given in PNF are usually mass movement pattern that is
used for our activity of daily living.
The patterns given are spiral or diagonal movement pattern
forming an angle of approximately 45 degrees to the trunk.
These should be movements which are
essentially crossing the midline of the body.
5.Timings
There is a normal sequence in which various components of a movement pattern occur.
The timing for which each component should work is determined by the control exhibited by the cerebellum.
Under normal circumstances, the movement is initiated by the rotary components, because the rotary component initiates the movement, the movement starts in the distal most components, then the intermediate and lastly the proximal components.
This is called as appropriate timing and sequencing of all movements.
It is important that the movement at the
distal components gets completed before the movement at the proximal components gets completed.
Overflow or irradiation
This means there is a spread of impulses or energy from a strong muscle to weak muscle especially when the stronger muscles work against a very high resistance.
Irradiation is possible from proximal to distal or from distal to proximal.
Weaker muscle group is usually benefitted with this
irradiation.
In order to stimulate irradiation of impulses from stronger muscles to weaker muscle, the therapist must give a very high resistance to the strong muscle such that there is spread of impulse to the
weaker muscle and that in turn facilitates
the weak muscle.
Therapist can stimulate the contraction of quadriceps by giving resistance to the dorsiflexor, or can give very high resistance to the hip flexors to stimulate dorsiflexors.
Irradiation is also possible from the stronger arm to the weaker arm.
In spasticity, irradiation of impulses give rise to associated reaction which is pathological and should
be discouraged otherwise, the patient will habituate.
In normal circumstances, associated movements are noted like swinging of arm while walking,
clenching of teeth while lifting heavy weight. These reactions are also due to irradiation but they
are physiological.
Maximal resistance
The therapist should be skillful enough to give maximal resistance and not maximum resistance.
Maximal resistance is the one against which the patient is able to perform full range of movement in a smooth manner for an isotonic muscle work.
For an isometric muscle work,
maximal resistance is the one which stimulates the muscle to work to its maximum capacity without the therapist breaking the hold of the patient.
However, it should be noted that the
therapist needs to also assist the patient when he or she finds it difficult to perform the movement smoothly against resistance.
Stimulation of joint structures
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Slow reversal
Based on Sherrington’s principle of successive induction
immediately following the excitation of the flexor reflex neuronal pool, there is also excitation in the reflex neuronal pool of its antagonist which is the extensor reflex
In this if a specific muscle group is week, then its antagonist is made to contract maximally so that all the motor units fire, following which even before the patient relax completely, the therapist reverses the grip and asks the patient to perform the movement in the week agonist pattern.
Thus in this technique, the strong antagonist pattern or ms are used to facilitate the weak pattern or muscles.
they are also called as relaxation techniques and are very effective when the movement is restricted at a joint due to high tightness or hypertonicity of the muscle.
In spatial summation
normal timing
Timing for emphasis
Combination of
isometric & isotonic ms work
Useful when the ms needs to be strengthened at a specific range and is very effective in strengthening those ms which become weak due to relative lengthening.
Eg: patient with extensor lag due to relative lengthening of quadriceps due to immobilization of the knee in flexed attitude.
Patient is asked to perform isotonic work of the agonist ms till further movement cannot be brought about due to weakness.
At this point the therapist gives resistance & makes the ms contract isometrically to bring about requirement of all the motor units in the ms.
Immediately following which the patient is asked to take the limb further into the agonist pattern by making the weak ms contract isotonically
Thus, this technique is effective to facilitate contraction of ms which have not been active for some time in this shortened range, also it helps to bring about the lengthening effect in the antagonist ms through the principle of reciprocal inhibition (contraction of a ms caused relaxation of its antagonist)
Used whenever there is patchy weakness. Although a pattern may appear quite good, detailed evaluation of the pattern may suggest that it is inefficient especially due to the weaker component.
Can also be used in LMN conditions where a single ms or group of ms working across a joint is weak.
In this technique, the principle of normal timing is modified to facilitate movement at the weaker point
This part to be treated is divided into 3 components,
1.Pivot
joints across which the weak ms or weak component of the pattern is present.
Movement is allowed to take place in full range.
Muscles are allowed to contract for a longer time than usual.
Handle
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It involves repeating & chosen pattern several times through full range against maximum resistance ensuring movement at all times.
Once the pattern has been completed, the therapist passively returns the limb to the lengthened position ready for the next repetition.
Repetition helps in the bombardment of the motor neurons by many impulses – summation.
Best suited for conditions with generalized weakness of the ms or stroke where the patient is not able to perform a specific pattern or if the movement is performed in a faulty way
LENGTHENING TECHNIQUES
MISCELLANEOUS PNF TECHNIQUES
1- Rhythmic stabilization
2- Rhythmic initiation
This technique is applied when there is already co-contraction of both the groups of ms which prevents the patient from initiating a movement like in the case of parkinsonism
Here, the movement is progressed from passive - then active assisted - active against resistance
The main aim of treatment is to train the patient perform isotonic work against resistance by keeping the tone in the muscles under control.
Usually, when the patients with PD get excited (as it normally happens when they are asked to perform a movement), it causes a generalized increase in tone that prevents the movement from taking place or makes the movement arhythmic
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Helps in relaxation & strengthening.
It aims to bring about stability around a joint by correcting the muscular imbalance. It is very effective in patients with cerebella lesions who exhibits problems in proximal fixation.
Co-contraction occurs if the patient is not allowed to relax
The skills lies in rhythmically alternating the resistance between both the group of muscles (agonist & antagonist).
There is coordinated transitions between antagonists
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PNF lengthening techniques are also used when there is pain at the treatment area.
PNF stretch is effective than a conventional stretch in improving lengthening reaction in tight muscles.
In PNF, the therapist can bring about lengthening of ms by 2 ways
By working on the hypertonic ms
a.Contract relax
b.Hold relax
Difference between the two:
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Eg: if the elbow flexion range is restricted to 90 degrees, then the therapist takes the limb passively up to this restricted range, & then he grips the patient in a way that gives cue to the patient to move his limb in the extension direction.
Patient is asked to perform isotonic contraction of the elbow extensors for up to 10-15 degrees of extension, but the resistance offered by the therapist should be gradually and smoothly build up to such an extent that the patient is stimulated to contract the elbow extensors maximally
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By working on the ms antagonist to the hypertonic ms
a. Slow reverse-hold relax
It is based on the principle that maximum contraction is followed by maximum relaxation in a muscle
Thus the technique directly works on the hypertonic muscles that contributes in the decreased ROM at the joint
Eg: if elbow flexion is restricted due to hypertonic elbow extensors, then according to this method, the elbow extensors should be made to contract maximally so that it follows up with complete relaxation