Proprioceptive Neuromuscular Facilitation

With Rhythmic Initiation the patient relaxes, the limb is moved _______ through the pattern with _______ assistance, then actively and finally if possible with ______. May be unidirectional or bidirectional

passively; active; resistance

What is the purpose of treating movement of the lips?

talking, eating, prevent drooling etc.

Approximation can be applied to long bones or the _______

trunk

What muscles are being used for knee extension during D1 extension pattern?

vastus intermedius and vastus lateralis

What are the indications for using quick stretch and repeated contractions?

weak muscles to improve ROM (facilitate movement)

If an alpha motor neuron is destroyed what is the most likely impairment?

weakness

contract-relax technique is synonymous with ________

hold-relax (named this way becuase its on a straight plane)

Fill in the blank regarding what is happening at each joint throughout the D2 flexion pattern - pelvis: - hip: - knee: - ankle: - toes:

- pelvis: anterior elevation - hip: flexion, abd, IR - knee: flex or ext - ankle: DF, EV - toes: ext

Fill in the blank regarding what is happening at each joint throughout the D1 flexion pattern - pelvis: - hip: - knee: - ankle: - toes:

- pelvis: anterior elevation - hip: flexion, add, ER - knee: flex or ext - ankle: DF/ IV - toes: ext

Fill in the blank regarding what is happening at each joint throughout the D1 extension pattern - pelvis: - hip: - knee: - ankle: - toes:

- pelvis: posterior depression - hip: ext, abd, IR - knee: flex or ext - ankle: PF, EV - toes: flex

Fill in the blank regarding what is happening at each joint throughout the D2 extension pattern - pelvis: - hip: - knee: - ankle: - toes:

- pelvis: posterior depression - hip: ext, add, ER - knee: flex or ext - ankle: PF, IV - toes: flex

When you treat the jaw for vital functions what does this include?

open/close mouth/ TMJ

What are the 6 PNF vital functions

1. Eye motions 2. respirations 3. open/close mouth 4. facial motions 5. tongue motions 6. swallowing

What are the 4 philosophies of PNF

1. Underdeveloped potential (every pt. has area to improve) 2. Demand Response (wolffs law) 3. Normal neuromuscular development/motor learning (mobility, stability, controlled mobility, skill) 4. Holistic approach (individualistic, goal directed)

What are the 3 areas PNF can work on?

1. extremities 2. vitals 3. development

What are the 3 joints/muscles responsive to inhibitory pressure?

1. hamstrings 2. elbow flexors/ biceps 3. hand

What are the indications for slow reversal and slow reversal holds

1. inability to reverse direction 2. muscle imbalances 3. weakness 4. incoordination 5. lack of endurance

What are the 3 theories of PNF?

1. neurophysiological 2. neurodevelopmental 3. biomechanical

What are 4 inhibitory techniques besides hold relax and contract relax

1. neutral warmth 2. inhibitory pressure 3. vestibular stimulation 4. prolonged stretch

What are the 2 main muscles that someone would be using in the UE if there is too much resistance is applied

1. upper trap 2. biceps

What are the 3 sensory cues of PNF

1. visual (watch hand) 2. manual (contact) 3. commands (short, sharp commands)

In the extremities there are ___ patterns

2 (D1 and D2) note: there are 3 components to each motion

Bilateral symmetrical UE pattern promotes: a. stability b. mobility c. intensity d. traction e. warmth

A

Use isometrics to build ________ a. stability b. mobility c. intensity d. traction e. warmth

A

Why should the patient watch their hands during PNF patterns? a. For sensory stimulation b. To increase ROM c. To prevent the pt. from getting distracted d. Helps with coordination of movement e. None of the above

A

Which of the following scenarios most likely requires an inhibitory technique followed by movement a. someone with spasticity b. someone with decreased ROM c. someone with visual deficits d. someone with muscle grade <2/5

A (becuase inhibitory techniques decrease tone and promote movement)

Your patient is 3 weeks s/p CVA with good return in both the UE and LE. Which of the following patterns may benefit the patient the most to come out of synergy? a. LE D-2 Flexion with the knee straight b. LE D-1 Flexion with the knee flexing c. LE D-1 Flexion with the knee straight d. LE D-2 Extension with the knee straight e. All the above

A (remember that LE synergy is PF and IV so you want to cross out any patterns that involved PF/IV)

In the PNF pattern in the UE, ER is always combined with: a. flexion b. extension c. radial deviation d. unlar deviation

A (shoulder flexion)

In the PNF pattern in the UE, radial deviation is always combined with: a. flexion b. extension c. adduction d. abduction

A (shoulder flexion)

Your treating a young adult male in your outpatient clinic who suffered a shoulder injury playing baseball. You want to strengthen his shoulder using PNF techniques. Which is the BEST answer? a. Use a physio ball to stretch shoulders b. Use chops and lifts c. Use rhythmic initiation d. Use quick stretch e. Use D1/D2 LE flexion/extension patterns

B --> chops and lifts are used commonly to strengthen shoulders after injury

What are the dominant component of the synergy extremity pattern?

Adduction, elbow flexion, pronation, wrist and finger flexion (important to know so you would choose an extremity pattern which brings patient into opposite motion)

What muscles are being used at the ankle, foot and toes during D1 flexion pattern?

Anterior tib (DF/IV) Extensor hall longus

A general _______ is applied to either long bones or the trunk to promote stability.

Approximation

You ask your pt. to complete a D2 PNF pattern and you, the PT, resist abduction to stretch ______ muscle a. deltoid b. pecs c. biceps d. tricep

B

Your patient is 3 weeks s/p CVA with good return in both the UE and LE. Which of the following patterns may benefit the patient the most to come out of synergy? a. UE D-1 Flexion with elbow flexing b. UE D-2 Flexion with the elbow straight c. UE D-2 Extension with the elbow straight d. UE D-2 Extension with the elbow bending e. All the above

B

_______ is one of the main reason we are able to have coordinated movements a. reciprocal rehibitition b. reciprocal inhibition c. inhibitory neuron d. autogenic inhibition

B

You want prolonged stretch for the elbows with weight bearing. The best way to do this is: a. plantegrade b. quadruped c. tilt table d. childs pose

B (A may be correct but is not the BEST answer) also note that prolonged stretch is an additional method to inhibition

After putting an air splint on your pt. who just suffered a stroke how could you work on stability at the shoulder a. passive ROM b. active assist ROM c. sit to stands d. supine rolling to the strong side

B (anytime you use the brace though you want to have a functional activity associated with it so the next thing you can do is go to plantegrade and have them crawl in that position)

Which of the following is an example of a symmetrical UE pattern which promotes stability? a. UE D2 flexion b. Bilateral UE D2 flexion c. Rhythmic stabilizations d. Alternating isometrics e. B + D

B (note that rhythmic stabilizations and alternating isometrics also promote stability but that is not the answer bc the question is asking for an UE PATTERN)

In the PNF pattern in the UE, IR is always combined with: a. flexion b. extension c. radial deviation d. unlar deviation

B (shoulder extension)

In the PNF pattern in the UE, ulnar deviation is always combined with: a. flexion b. extension c. adduction d. abduction

B (shoulder extension) i.e D1 extension pattern - shoulder extension, wrist extension plus ulnar dev i.e D2 extension pattern - shoulder extension, wrist flexion plus ulnar dev

Your patient has low tone so you put them on a physioball and... a. complete weight shifting b. move them around really fast c. use slow controlled movements d. all the above

B (with low tone you want to shake them really fast... C would be best for someone with high tone)

Which of the following follow the principle of autogenic inhibition AND reciprocal inhibition? (choose any that apply) a. hold-relax b. hold-relax active c. contract relax d. contract relax active

B + D

Which of the following is false about contract relax active motion (CRAC)? a. Rotation components are allowed to occur b. This is indicated for those who have decrease ROM and pain c. The indicated muscle should be lengthened within the appropriate pattern d. After the person relaxes the limb is moved actively into new range e. None of the above

B - its actually not indicated for decreased ROM due to pain

Development of a baby starts _____ and moves _____ a. distal; cepahlo-cauda; b. cepahlo-caudal; distal c. distal; proximal d. proximal; proximal

B Motor development progresses: cepahlo-caudal and proximal distal

Brain knows only movement, not individual muscles is defined as:

Beevor's Axiom

All of the following are general rules for treating vital functions except: a. work bilaterally b. work with very little resistance c. complete this Tx 3-5x a day d. make sure to be bilaterally especially at the face

C

Resistance is always: a. Given at 80% b. Needs to be in a vertical plane c. Is surface specific d. Should not be given if the patient was not a 3/5 during gross eval testing e. All the above

C

Which of the following is not a sensory cue a. Manual contact b. Visual c. Quick stretch d. Commands; prepatory explanation

C

Which of the following promotes mobility? a. Approximation b. Symmetrical bilateral UE patterns c. Asymmetrical bilateral UE patterns d. B + C e. All the above

C

Your patient is a person with quadraparesis at the C-7 level. He is having difficulty with sliding board transfers into his new car (the seat is about 1" higher than his old car, according to the patient). After observing the task, you decide to perform UE _______________ to strengthen the UE muscles most involved in the transfer (you will perform these on both sides, 2-3 sets of 10 as tolerated). a. D-1 Flexion with the elbow flexing b. D-2 Extension with the elbow extending c. D-1 Extension with the elbow extending d. D-2 Extension with elbow straight e. All the above

C you get lats which is why

Normal movement occurs in a _______ and ______ pattern a. linear; spiral b. spiral; linear c. diagonal; linear d. spiral; diagonal e. diagonal; horizontal

D (because youre taking the muscles from a shortened to a lengthened position) note: this occurs with ligaments, muscles, and fibers within a muscles

Which of the following follow the principle of autogenic inhibition? (choose any that apply) a. hold-relax b. hold-relax active c. contract relax d. contract relax active

Choose ALL!

During a slow reversal the patient performs an isotonic contraction of the agonist pattern followed by an isotonic contraction into the antagonistic pattern progressing to an isometric hold into the shortened range of first the agonist pattern then the antagonist pattern. What are the indications for using this technique? (choose any that apply) a. inability to reverse directions b. muscle imbalance c. weakness d. incoordination e. lack of endurance

Choose ALL! and note that by using slow reversals it builds stability at end range (many benefits)

Why is contract relax PNF pattern NOT appropriate for those who have limited motion due to pain?

Contract relax techniques may not be appropriate for the patient who has limited range due to pain becuase you bring the pt. into most lengthened position and it includes the rotation component of the pattern

If you want a prolonged stretch on the gastroc for your non ambulatory pt. you can use: a. A GS wedge b. Manual graston techniques c. Ice pack and wedge d. Tilt table

D

Which of the following is false about the hold relax PNF relaxation technique? a. It can be used with a painful joint b. A shortened muscle is brought to max lengthened position c. Ask the patient to push isometrically d. Ask the patient to move through a painless ROM actively e. None of the above

D

Which of the following special techniques builds stability at end ranges? a. Quick stretch b. Approximation c. Hold relax d. Slow reversal hold e. All the above

D

chopping and lifting is a bilateral UE _________ pattern which promotes ________ a. symmetrical; stability b. symmetrical; mobility c. asymmetrical; stability d. asymmetrical; mobility e. none of the above

D

Your pt. is a C8 SCI patient who you have been treating for 5 weeks. He is progressing well but you want to progress his rolling using PNF skills for improved bed mobility. Choose the BEST option. a. Commando crawl b. Use biceps on bed rail to pull into a roll c. Use chopping pattern d. Use lift D2 flexion pattern e. He most likely wont be strong enough to roll yet so complete rhythmic initiation

D --> this will promote rolling (you might think C for chopping but this would not be functional bc the patients arm might get stuck and would have to use a bed rail)

Which of the following does NOT provide neutral warmth? a. air splint b. body wraps c. swaddling d. immersion in warm water e. prolonged touch

E (note: neutral warmth is another inhibitory technique)

Generally, what is appropriate resistance for a PNF pattern:

Enough resistance for the patient to complete the pattern with full ROM without substitution (from biceps or upper trap)

What is the order for treatment for the PNF vital functions?

Eyes --> nose --> mouth --> jaw --> tongue --> swallowing --> larynx --> breathing

True or False: Once a patient suffers a neuro problem they have a limited amount of recovery and cannot recover after a certain point

False - note the theory of Underdeveloped Potential (Wolffs law) aka every patient has areas they can improve upon.. you can generate change by stressing the body a little

True or False: Normal timing in PNF is always proximal to distal

False: distal to proximal

Fill in the blanks regarding what actions are occurring during UE D2 extension pattern: Scapula: Shoulder: Elbow: Forearm: Wrist: Fingers: Thumb:

Scapula: anterior depression; inf angle abd Shoulder: ext, add, IR Elbow: flex or extend Forearm: pronation Wrist: flex, ulnar dev Fingers: flex, add Thumb: opposition

Prolonged stretch inhibits ______ and ________ becuase youre stretching the muscle

GTO and Ia fibers

What is the difference between hold relax and hold relation active motion?

Hold relax is passive after the relax whereas hold relax active the patient is the one to bring himself into more motion after the relax (but both are in a straight plane)

How does the neurophysiological principle promote coordinated movements?

It uses the concept of reciprocal inhibition where agonist turns on and antagonist turns off (so you dont have a spasms)

What are the adjuncts to treating vital functions?

Q (quick stretch) I(ice) V (vibration)

________ is used and occurs at the beginning of the range only, to the rotary component. Its used for weak muscles to facilitate movement. This can be performed to all straight patterns (UE/LE)

Quick stretch

________ is used to teach a pattern to a patient to decrease tone when a patient is familiar with the pattern. Used for patients who cannot initiate movement independently

Rhythmic Initiation

What is the first movement of the proximal joint?

Rotation

Fill in the blanks regarding what actions are occurring during UE D1 flexion pattern: Scapula: Shoulder: Elbow: Forearm: Wrist: Fingers: Thumb:

Scapula: anterior elevation; inf. angle abd Shoulder: flex, add, ER Elbow: flex or ext Forearm: supination Wrist: flexed; radial deviation Fingers: flexed, add Thumb: ext, add

Fill in the blanks regarding what actions are occurring during UE D1 extension pattern: Scapula: Shoulder: Elbow: Forearm: Wrist: Fingers: Thumb:

Scapula: posterior depression; inf angle add Shoulder: ext, abd, IR Elbow: flex or extend Forearm: pronation Wrist: ext, ulnar dev Fingers: ext, abd Thumb: abd

Fill in the blanks regarding what actions are occurring during UE D2 flexion pattern: Scapula: Shoulder: Elbow: Forearm: Wrist: Fingers: Thumb:

Scapula: posterior elevation; inf. angle add Shoulder: flex, abd, ER Elbow: flex or ext Forearm: supination Wrist: ext; radial deviation Fingers: ext, abd Thumb: ext

True or False: the rotary component of the PNF pattern is most important

TRUE!

True or False: The PT must stay on a diagonal when completing PNF patterns

TRUE!!

________ can be performed to the long bones (humerus or femur) to promote movement and is used for weak muscles

Traction

True or False: Postural stability is a prerequisite for purposeful movement

True

True or False: we rely on sensory input to get motor output

True (this principle is how PNF can be applied to the dynamic systems model)

In a chop the lead arm is moving through what UE pattern?

UE D1 extension

What is a slow reversal?

When the pt. moves through an alternating sequence of isotonic contractions of the agonist and antagonistic patterns. No relaxation is allowed between contractions. AKA ITS THE NORMAL PATTERN W/ NO SPECIAL TECHNIQUE

When you put your baby in they high chair with a bowl of cheerios you notice full fine motor control of the hand but their elbow and shoulder are stiff and not part of the movement. Is this normal and why?

Yes normal --> fine motor control develops distal before proximal

The principle of _____ _____ states that you want to resist a tight muscle to relax the muscle

autogenic inhibition

When you contract the muscle itself, afterwards it will be easier to stretch because it will relax is defined as

autogenic inhibition (think of the contract relax or hold relax techniques)

What muscles are being used for knee flexion during D1 extension pattern?

biceps femoris, popliteus, gastroc

What is the D1 UE extension pattern?

extension, abduction, IR

What muscles are being used to flex the knee vs. extend the knee during D2 flexion pattern?

flex - biceps fem extend - vastus lat, intermedius, rectus fem

What muscles are being used to flex the knee vs. extend the knee during D2 extension pattern?

flex - semimem, semitendin extend - vastus medialis

What is the D1 UE flexion pattern?

flexion, adduction, ER

What muscles are being used at the ankle, foot and toes during D1 extension pattern?

gastroc, soleus, peroneus longus

What muscles are being used at the hip for D2 extension?

glut max (ext), piriformis (ER), adductor magnus

What muscles are being used at the hip for D1 extension pattern?

glut med (Abd), min (IR), max (ext) biceps femoris

With contract relax PNF relaxation technique, a shortened muscle is brought into its ________ position and an __________ contraction of the pattern is performed with accompanying ______ contraction of the rotary component

lengthened; isometric; isotonic

Isotonic is:

movement: concentric and eccentric

Isometric is:

no movement

What muscles are being used at the ankle, foot and toes during D2 extension pattern?

plantaris, gastroc, soleus, posterior tib

Your pt. had a stroke and her arm is very dysfunctional and her leg is also non functional. You plan on treating the trunk first becuase....

postural stability the basis of all movement and you need to open up the trunk to be able to breathe

What muscles are being used at the hip for D1 flexion?

psoas major, illiacus, rectus femoris, pectineus (Add/ER), adductor longus/brevis, gracilis/sartorius

What muscles are being used for knee extension during D1 flexion pattern?

rectus femoris, vastus medialis

What muscles are being used at the hip for D2 flexion?

rectus, glut med, TFL, glut min

When you contract the biceps, the triceps automatically __________. This is a basic concept of spinal cord principles.

relax

A stretch is given in other than the elongated range. _______ ________, through repeat stimuli, will ease transmission of the stimuli, subsequently promoting facilitation of the pattern.

repeated contractions (repeated excitation)

When a person moves through a series of isotonic contractions of the agonistic pattern. A hold is placed at a weak part in the range so the patient can increase muscle tension. A quick stretch is then applied and the patient moves into shortened range. The hold and quick stretch can be applied at several points at ROM is a description of what special technique:

repeated contractions (repeated excitation)

You want to roll your patient to the left teaching him the chop technique. What arm is the lead arm and what UE pattern is being utilized?

rolling to left = left arm is lead (right arm is holding on to that arm) and you move from D1 flexion into D1 extension (reverse chop --> chop) to roll

Contract-relax is similar to hold-relax but the ________ components of the pattern are allowed to occur

rotation

What muscles are being used at the scapula and shoulder during UE D1 extension?

scap - lower trap/rhomboids shoulder - lats, teres major, triceps, posterior delt, subscapularis

What muscles are being used at the scapula and shoulder during UE D2 extension?

scap - pec minor, subclavius shouldr - pec major, sub scap

What muscles are being used at the scapula and shoulder during UE D1 flexion?

scap - serratus anterior shoulder - pec major, anterior delt, bicep, infra, teres minor

What muscles are being used at the scapula and shoulder during UE D2 flexion?

scap - upper trap (to elevate scap) and levator scap (adduct inferior angle) shoulder - teres minor and infra, anterior delt, mid delt, supraspinatus

What muscles are being used for knee flexion during D1 flexion pattern?

semi membranosus, semi tend, sartorius, gracillis

In addition to movement through the diagonal patterns, PNF employs a number of special techniques to increase ROM, increase control or increase ________

strength