PNF Interventions to Improve Motor Control and Motor Learning part 2 Flashcards
1
Q
Objectives
- Compare and contrast theories of motor control, motor learning and common principles of therapeutic interventions.
- Identify the purposes and components of a motor control assessment
- Define: spasticity, clonus, decerebrate rigidity, decorticate rigidity and flaccidity (delivered via BB)
- Identify common causes of motor control impairments (discussed last lecture & throughout course)
A
fyi
2
Q
What About Practice?
A
- Make sure that patient practices desired activity
- Helps to increase the learning
- Watch for faulty postures and habits- educate families so they can help fix if needed
3
Q
Massed vs Distributed Practice
A
- Rest time is much shorter than practice time
- May see fatigue, decreased performance and risk of injury can occur
- Distributed Practice: spaced practice intervals Practice and rest are close to 1:1 ration
- Use massed practice when motivation and skill level are high
4
Q
Blocked vs random practice
A
- Blocked: practice sequence, perform one task repeatedly
- Random practice: test/practice a variety of tasks that are ordered randomly across trials
- Random practice has been shown to have better carry over
5
Q
Mental Practice
A
- Imagine or visualize the task
- Creates cognitive rehearsal
- Mental practice helps facilitate the acquisition of motor skills
- Mental practice helps relieve anxiety
6
Q
Part vs Whole practice
A
- Break movement down into component parts
- Practice all of the components and then group them together
7
Q
Closed vs Open environments
A
- Initial trials of an exercise should be in a controlled environment
- As learning progresses, take it to a more open, variable environment
- As performance becomes more consistent then modify the environment
- Some people with TBI or other serious injury will never be able to perform well in challenging environments
8
Q
Sequence in which tasks are practiced- name the types
A
Practice order
- Blocked order
- Serial order
- serial random order
9
Q
What type of practice order
- repeated practice of a task or tasks in order
- better prediction of improved early acquisition of skills
A
Blocked order
10
Q
What type of practice order?
non repeating and non-predictable
A
Random order
11
Q
what type of practice order?
predictable and repeating order
A
Serial order
12
Q
What type of practice order?
better retention and generalizability of skills
should go to too soon
A
Serial and Random
13
Q
- How much did you gain/lose in skill as a result of practicing?
- Can a patient gain from exercising contralateral extremities? called bilateral transfer
- With stroke: try activity with stronger side first
- Does not work if affected arm is flaccid
- Works best if the task is very similar side to side
A
Transfer of Learning
14
Q
simple versions of what you want to see as a final complex task
usually Practice in easier positions, with less degrees of freedom
A
Lead up activities
15
Q
- Forced use of the involved extremity
- See improvement in UE function
- See cortical reorganization
- Needs repetitive practice (up to 6 hrs a day)
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Constraint-Induced Movement Therapy or Forced-Use Therapy
16
Q
- functional/task oriented training,
- neuromotor development training,
- compensatory training
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Framework for Intervention
17
Q
- Specific task oriented training with lots of practice- essential to reacquiring a skill
- There are specific important functional tasks that are emphasized
- Grasp and release, stand and walk
A
Functional task-oriented training
18
Q
Reinforce, reward and promote skill development
Guide initial movements
A
Behavioral shaping techniques can be used
19
Q
why can you not use task-oriented training with everyone
A
Lack voluntary control or cognitive function
Example: early stages of traumatic brain injury
20
Q
- Includes developmental activities training, motor training, movement pattern training, and neuromuscular re-education/education.
- Target affected body segments
- No compensatory movements
- Hands on approach for guidance
A
Neuromotor Development Training
21
Q
WHat is the Treatment philosophy for Neuromotor Development Training?
A
- Use sensory input to modify CNS, stimulate motor output
- Emphasis on developmental activities
- More functional training as time has progressed
22
Q
Neuromotor Development Training
3 Treatment Approaches
A
- NDT (Neurodevelopmental Treatment)
- PNF (Proprioceptive Neuromuscular Facilitation)
- Neuromuscular/Sensory Stimulation Techniques
- Facilitation
- Inhibition
23
Q
- Developed in 40’s and 50’s by Dr Karel and Berta Bobath
- Worked with patients who had a stroke and had abnormal tone and postural reflexes
- Considers weakness, decreased ROM, impaired tone, impaired communication
- Use sensory stimulation during treatment
- Facilitate postural alignment and decrease excessive tone
- “Postural control is the foundation for all skill learning”
- Uses key points of control
A
NDT
Neuromotor Development Training
24
Q
- Synergistic patterns are part of normal movement
- Diagonal planes
- Work to improve functional performance and coordinated patterns
A
Proprioceptive Neuromuscular Facilitation
(PNF)
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“Techniques that enhance capability to initiate a movement response through increased neuronal activity and altered synaptic potential” (facilitation)
Focus is also on activation- production of a movement response
Neuromuscular/Sensory Stim Techniques
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_Neuromuscular/Sensory Stim Techniques_
decreased capacity to initiate movement response
Inhibition
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_Neuromuscular/Sensory Stim Techniques_
what are the treatment guidelines?
* Repeat application of same stimulus
* Some stimulus is contraindicated (i.e. facilitation for spasticity)
* Response to treatment varies from pt. to pt.
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Resume functional skills early with use of uninvolved or less involved segments
Compensatory Training
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Patient is aware of deficits and formulates a new way to complete tasks
Substitution
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Modify the task and the environment
Adaptation
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what is the best way to Integrate approaches
* Don’t just use one approach
* Must use what will work with the specific patient
* Be in tune with changes in patients status
* Promote adaptability of skills in the real world (the front yard)
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Muscle Strength
Independent Review of Information
1. Strength training: increases production of max force
2. Causes change in neural drive (inc motor unit recruitment, increase rate and synchronization of firing)
3. Change in muscle: hypertrophy, inc size/number myofibrils, CT tensile strength, inc bone mineral densit
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what does an Exercise Prescription involve
1. Mode/type of exercise
2. Intensity
3. Frequency
4. Rest interval
5. Duration
6. Correct alignment
7. stabilization
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_Effective strength Training_
loads placed on mm must be greater that those normally incurred
Overload principle
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_Effective strength Training_
training effects are specific to the mode of exercise stress imposed
Specificity principle
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_Effective strength Training_
variety of training elements
Cross training
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_Effective strength Training_
failure to sustain benefits of strength training if mm aren't regularly used
Reversibility Principle
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_Effective Strength Training FYI_
1. Base program on patients needs
1. _isometric_: less stress on joint motion, may use early in rehab
2. _Dynamic_: use to develop power and strength and endurance
## Footnote
fyi
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Deficits in motor function
* May see deficit in motor activation
* Focus on isometric and eccentric contractions initially, followed by isotonic contraction (start in lengthened
* range)
* Weak muscles: lightly resist
* Control velocity
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* Distal segment moves in space
* Resistance is applied to distal moving segment, usually in NWB position
Open chain exercises
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* Distal part is fixed, with proximal segment moving (squats)
* Performed in WB posture
* Involve simultaneous action of synergists at multiple joints
Closed chain exercise
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Closed vs open chain
* _Closed_: can see substitution of agonists for weak muscles
* _Open_: can isolate contraction of a muscle
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Quick powerful movements, start with muscles in prestretched position for improved neuromuscular response
Plyometric
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free weights or fixed
Progressive resistive exercise
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can only lift as much as muscle can do at weakest point of range
mechanical resistance
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accomodating resistance through entire range
Isokinetic
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functionally based, synergistic pattern (PNF), can accommodate weakness in patient
Use strength training +task specific skills
Mechanical resistance
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dynamic contraction of large muscle groups: have cardiovascular and muscular effects
With deficits in motor function- will see fatigue and poor muscle endurance
Endurance training
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_Debilitating Fatigue_
Will see this in MS, Guillain-Barre syndrome, CFS, post polio syndrome
why should you be careful?
Be careful of overwork weakness
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_Flexibility Exercises_
* Joint ROM/muscle flexibility: need to have adequate motion for normal functional excursion of mm and biomechanical alignment
* Disuse and immobility: atrophy fibrosis, etc
* Age related changes
Avoid what limitations?
ROM exercise, muscle strenghtening, joint mob
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ROM exercises REVIEW
* AROM voluntary
* AAROM: ext assist voluntary
* PROM no assist from patient
* Can do ex in anatomic planes or diagonal patterns
fyi
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* Lengthen structures
* Static: slow elongation to tolerance: hold 20-30 sec, this decreases activation of muscle spindle and reflex contractions
* Maintain max end range; firing of GTO, which inhibits muscle being stretched
* Low load for up to 30 min
* Decreases chance of damage to muscle
Stretching
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_Stretching techniques_
use high load short duration
Usually contraindicated for elderly or neuromuscular impairments
Ballistic stretching
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_Stretching techniques_
* Use with PNF: uses inhibition techniques to elongate muscles
* Will discuss more during PNF lecture
Facilitated stretch
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* Replicates normal movement patterns
* Teach the pattern from starting position to terminal position
* Verbal cues used to enhance pt. performance
* Manual cues with appropriate pressure
* PT/PTA- appropriate position and body mechanics. With contact, your movement should mimic what you want pt to do
* Need appropriate amount of resistance which will allow appropriate coordination and timing
PNF
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Patterns are named for proximal joint motions
* _UE D1, flex:_ Flex, add, ext rot of shoulder/supination of forearm/flex, rad dev of wrist/flex, add of fingers
* _UE D1 Ext:_ ext, abd, int rot of shoulder/ pronation of forearm/ ext, ulnar dev of wrist/ext, abd of fingers
* _UE D2 flex:_ flex, abd, ex rot of shoulder/supination of forearm/ ext, rad dev of wrist/ ext, abd of fingers
* _UE D2 ext:_ ext, add, int rot of shoulder/ pron of forearm/ flex, ulnar dev of wrist/ flex, add of fingers
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PNF LE Patterns
* _LE D1 Flex_: flex, add, ext rot of hip/ dorsiflex, inv of ankle/ ext of toes
* _LE D1 Ext:_ ext, abd, int rot of hip/ plantar flex, eversion of ankle/ flex of toes
* _LE D2 Flex_: Flex, abd, int rot of hip/ dorsiflex, eversion of ankle/ ext of toes
* _LE D2 Ext:_ Ext, add, ext rot of hips/ Plantar flex, inv of ankle/ flex of toes
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_Basic Procedures for PNF_
Timing
* normal timing is smooth and coordinated
* Distal to proximal
* Rotation occurs from beginning to end
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_Basic Procedures for PNF_
Timing for emphasis
* Max resistance to strong muscles is used to elicit a strong contraction and overflow to weak components
* “lock in” strong muscles; allow weak muscle to move
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_Basic Procedures for PNF_
Resistance
* Facilitates muscle contraction
* Tracking- in combo w/ light stretch to weak muscles
* Max Resistance- see above
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_Basic Procedures for PNF_
Overflow or irradiation
* Spreads mm response from stronger mm to weaker mm
* Happens typically with max resistance
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_Basic Procedures for PNF_
* Manual Contacts
* Precise manual contacts: provides pressure to tactile and pressure receptors: facilitate contraction and guide movements
* i.e. Provide manual contact to flexors if you want the flexors to contract
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_Basic Procedures for PNF_
Positioning
Position mm at optimum range (length-tension relationship)
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_Basic Procedures for PNF_
Verbal Commands
* Preparatory commands
* Action commands
* Corrective commands
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_Basic Procedures for PNF_
Visual Commands
(demonstration)
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_Basic Procedures for PNF_
## Footnote
Stretch
Elongated position and stretch reflex: facilitate mm contraction
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Approximation:
facilitates extensor mm contraction/stability
Can use gravity, manually or using weights
Example: approximation through pelvis to promote sitting posture
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Traction (distraction)
facilitates mm contraction and motion esp in flex pattern
force is applied manually
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_PNF Techniques_
Isotonic contraction; first agonist then antagonist. Start with strong pattern
Dynamic reversal (slow reversals)
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PNF Techniques
Alternate isotonic contractions agonist and antagonist: very limited ROM
Stabilizing reversals
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_PNF Techniques_
alternate isometric contractions; agon/antag, no
motion is allowed
Rhythmic Stabilization (RS)
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_PNF Techniques_
Repeated contractions from lengthened range, induce by quick stretches, perform through range or at weak point
Repeated Stretch (Repeat Contractions) (RC)
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_PNF Techniques_
Resisted isotonic contraction of agonist through range, stabilizing contraction and then eccentric contraction back to start position.
Combination of Isotonics(Agonist Reversals) (AR)
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_PNF Techniques_
Start with passive movement and progress to A-A motion then active motion, then resistive
Rhythmic Initiation (RI)
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_PNF Techniques_
* Usually use at point of limited range in agonist pattern
* Do small range isotonic contraction of antagonists, follow with isometric hold for 5-8 sec then relax and move into new range of agonist pattern
* CR-active- contraction- active contraction of the agonist into the newly gained range
Contract Relax (CR)
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_PNF Techniques_
* Start in position of comfort; below level of pain
* Strong isometric contraction of antagonists is resisted and then have voluntary relaxation, passive motion into new range
* HR-active-contraction- active contraction of agonist into the newly gained range
Hold Relax (HR)
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Position patient in shortened range, hold position (isometric), follow with voluntary relaxation and passive movement into lengthened range, then followed by active movement back to end point (resistance offered)
Replication (HRA)
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Stretch, approximation and tracking resistance applied to facilitate pelvic motion and progression during locomotion; light resistance
Resisted Progression (RP)
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Slow repeated rotation of a limb where limitation is noticed. As muscles relax, limb is moved slowly
Rhythmic Rotation (Rro)
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What we did in lab so fyi stuff
* In prep for the lab, and to enhance learning, read and continuously review the following:
* Boxes 2.10, 2.11 & 2.14
* Phys Rehab text, Appendix C, I & II of Chapter 13: Neuromuscular/Sensory Stimulation Techniques
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