PNF Interventions to Improve Motor Control and Motor Learning part 2 Flashcards Preview

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Flashcards in PNF Interventions to Improve Motor Control and Motor Learning part 2 Deck (81):


  • 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)



What About Practice?

  • 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


Massed vs Distributed Practice

  • 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


Blocked vs random practice

  • 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


Mental Practice

  • Imagine or visualize the task
  • Creates cognitive rehearsal
  • Mental practice helps facilitate the acquisition of motor skills
  • Mental practice helps relieve anxiety


Part vs Whole practice

  • Break movement down into component parts
  • Practice all of the components and then group them together


Closed vs Open environments

  • 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


Sequence in which tasks are practiced- name the types

Practice order

  1. Blocked order
  2. Serial order
  3. serial random order


What type of practice order


  1. repeated practice of a task or tasks in order
  2. better prediction of improved early acquisition of skills

Blocked order


What type of practice order?

non repeating and non-predictable

Random order


what type of practice order?

predictable and repeating order

Serial order


What type of practice order?

better retention  and generalizability of skills

should go to too soon 

Serial and Random


  • 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

Transfer of Learning


simple versions of what you want to see as a final complex task


usually Practice in easier positions, with less degrees of freedom

Lead up activities



  • Forced use of the involved extremity
  • See improvement in UE function
  • See cortical reorganization
  • Needs repetitive practice (up to 6 hrs a day)

Constraint-Induced Movement Therapy or Forced-Use Therapy


functional/task oriented training,
  2. neuromotor development training,
  3. compensatory training

Framework for Intervention


  • 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

Functional task-oriented training


Reinforce,  reward and promote skill development

Guide initial movements

Behavioral shaping techniques can be used


why can you  not use task-oriented training with everyone

Lack voluntary control or cognitive function
Example: early stages of traumatic brain injury


  • 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

Neuromotor Development Training


WHat is the Treatment philosophy for Neuromotor Development Training?

  • Use sensory input to modify CNS, stimulate motor output
    • Emphasis on developmental activities
    • More functional training as time has progressed


Neuromotor Development Training

3 Treatment Approaches

  • NDT (Neurodevelopmental Treatment)
  • PNF (Proprioceptive Neuromuscular Facilitation)
  • Neuromuscular/Sensory Stimulation Techniques
    • Facilitation
    • Inhibition


  • 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 


Neuromotor Development Training


  • Synergistic patterns are part of normal movement
  • Diagonal planes
  • Work to improve functional performance and coordinated patterns

Proprioceptive Neuromuscular Facilitation



“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


Neuromuscular/Sensory Stim Techniques

decreased capacity to initiate movement response



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. 


Resume functional skills early with use of uninvolved or less involved segments

Compensatory Training


Patient is aware of deficits and formulates a new way to complete tasks 



Modify the task and the environment



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)


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


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


Effective strength Training

 loads placed on mm must be greater that those normally incurred

Overload principle


Effective strength Training

training effects are specific to the mode of exercise stress imposed

Specificity principle


Effective strength Training

variety of training elements

Cross training


Effective strength Training

failure to sustain benefits of strength training if mm aren't regularly used

Reversibility Principle


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




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


  • Distal segment moves in space
  • Resistance is applied to distal moving segment, usually in NWB position

Open chain exercises


  • Distal part is fixed, with proximal segment moving (squats)
  • Performed in WB posture
  • Involve simultaneous action of synergists at multiple joints

Closed chain exercise


Closed vs open chain

  • Closed: can see substitution of agonists for weak muscles
  • Open: can isolate contraction of a muscle


Quick powerful movements, start with muscles in prestretched position for improved neuromuscular response



free weights or fixed 

Progressive resistive exercise


can only lift as much as muscle can do at weakest point of range

mechanical resistance


accomodating resistance through entire range



functionally based, synergistic pattern (PNF), can accommodate weakness in patient
Use strength training +task specific skills

Mechanical resistance


 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


Debilitating Fatigue

Will see this in MS, Guillain-Barre syndrome, CFS, post polio syndrome

why should you be careful?

Be careful of overwork weakness


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


ROM exercises REVIEW

  • AROM voluntary
  • AAROM: ext assist voluntary
  • PROM no assist from patient
  • Can do ex in anatomic planes or diagonal patterns



  • 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 techniques

use high load short duration
Usually contraindicated for elderly or neuromuscular  impairments

Ballistic stretching


Stretching techniques

  • Use with PNF: uses inhibition techniques to elongate muscles
  • Will discuss more during PNF lecture

Facilitated stretch


  • 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



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


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


Basic Procedures for PNF


  • normal timing is smooth and coordinated
    • Distal to proximal
    • Rotation occurs from beginning to end


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


Basic Procedures for PNF


  • Facilitates muscle contraction
  • Tracking- in combo w/ light stretch to weak muscles
  • Max Resistance- see above


Basic Procedures for PNF

Overflow or irradiation

  • Spreads mm response from stronger mm to weaker mm
  • Happens typically with max resistance


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


Basic Procedures for PNF


Position mm at optimum range (length-tension relationship)


Basic Procedures for PNF

Verbal Commands

  • Preparatory commands
  • Action commands
  • Corrective commands


Basic Procedures for PNF

Visual Commands



Basic Procedures for PNF


Elongated position and stretch reflex: facilitate mm contraction



 facilitates  extensor mm contraction/stability

Can use gravity, manually or using weights

Example: approximation through pelvis to promote sitting posture


Traction (distraction)

facilitates mm contraction and motion esp in flex pattern
force is applied manually


PNF Techniques

Isotonic contraction; first agonist then antagonist.  Start with strong pattern

Dynamic reversal (slow reversals)


PNF Techniques

Alternate isotonic contractions agonist and antagonist: very limited ROM

Stabilizing reversals


PNF Techniques

alternate isometric contractions; agon/antag, no
  motion is allowed

Rhythmic Stabilization (RS)


PNF Techniques

Repeated contractions from lengthened range, induce by quick stretches, perform through range or at weak point

Repeated Stretch (Repeat Contractions) (RC)


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)


PNF Techniques

Start with passive movement and progress to A-A motion then active motion, then resistive

Rhythmic Initiation (RI)


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)


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) 


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)


Stretch, approximation and tracking resistance applied to facilitate pelvic motion and progression during locomotion; light resistance

Resisted Progression (RP)


Slow repeated rotation of a limb where limitation is noticed.  As muscles relax, limb is moved slowly

Rhythmic Rotation (Rro)


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