Chapter 15: PNF and Other Soft Tissue Mobilization Techniques in Rehabilitation

1. Chapter 15: PNF and Other Soft Tissue Mobilization Techniques in Rehabilitation

2. Ability of soft tissue to withstand loads diminishes following injury • Must manage tissue in order to restore ability to cope with functional loading • Soft tissue techniques • Specific, graded and progressive application of force • Physiological and/or accessory techniques • Promote appropriate collagen synthesis and production and/or changes in viscoelastic tissue responses • Should be used in conjunction with rehabilitation regimens • Multiple soft tissue techniques can be utilized in rehabilitation

3. Proprioceptive Neuromuscular Facilitation • Based on principles of functional anatomy and neurophysiology • Involves integration of proprioceptive, cutaneous and auditory input to produce coordinated movements • Critical component of rehabilitation • Utilized to increase strength, range of motion, and neuromuscular control

4. Neurophysiological Basis of PNF • Initially used to treat patients with paralysis and neuromuscular disorders • Facilitation and inhibition • Impulse travels down corticospinal tract or up afferent pathway from peripheral receptors • Results in muscle impulse volley, causing discharge of motor neurons, including those in fringe region • Discharge activating fringe motor neurons = facilitatory • Stimulus causing motor neurons to drop out of discharge zone = inhibitory

5. Facilitation • Results in increased excitability • Utilized to aid functioning of weak muscles • Inhibition • Results in decreased excitability • Can be critical in treatment of muscle spasticity • Sherrington • Impulses from peripheral stretch receptors has major influence on alpha motor neurons • Modify input to influence motor neuron excitability • Utilize peripheral stimulation to excite or inhibit motor neurons

6. Stretch Reflex • Muscle spindles • Sensitive to length changes and rate of length change • Golgi tendon organs (GTO) • Detect changes in tension • Performing a stretch • Increases impulse frequency transmitted to spinal cord from muscle spindles • Results in increased impulses sent via motor neurons back to muscle causing reflexive resistance to stretch • Increased tension activates GTO that relays message to spinal cord which ultimately produces an inhibitory effect on motor nerves (relax muscle)

7. Autogenic Inhibition • Inhibition mediated by afferent fibers of stretched muscle on alpha motor neurons resulting in muscle relaxation • GTO’s ability to override excitatory impulses • Dominates weaker muscle spindle signaling • Inhibitory impulses that last through the duration of the increased tension • Protective mechanism – muscle injury due to reflexive contractions (excessive stretch)

8. Reciprocal Inhibition • Agonist and antagonist muscles • Agonists receive excitatory impulses through afferent nerves • Afferent impulses inhibit antagonist muscle activity • Relaxation of antagonist due to contraction or stretch

9. Excitation or inhibition of motor neurons will be dependent on ratio of incoming impulses • Multiple approaches to therapeutic exercise rely on principles of facilitation and inhibition • Bobath method • Brunnstrom method • Rood method • Knott and Voss method • Most explicit use of proprioceptive stimulation

10. Rationale for Use • Aimed at what patient can do physically within limitation of injury • Used to increase deficits in strength, range of motion and neuromuscular control • Emphasis on selective re-education of individual motor elements • Develop neuromuscular control, joint stability and coordinated mobility • PNF attempts to provide maximal response • Program intensity vs. goals and stages of healing

11. PNF approach is holistic • Integrates sensory motor and psychological aspects of rehabilitation • Incorporates reflexive spinal cord activities (inhibitory or facilitatory) • Role of brain • Recognize gross movements, not individual muscle actions • Strength of muscle contraction is proportional to motor unit recruitment • Irradiation or overflow effect • Stronger muscles help weaker ones in task completion • Results in return of completion of movement patterns (restoration of function)

12. Basic Principles of PNF • Based on sound neurophysiological and kinesiologic principles as well as clinical experience • Patient must be taught sequential movement patterns • Instruction should be brief, demonstrated, potentially aided • Use in conjunction with techniques to increase effects of treatment • Have patient utilize visual stimulus (feedback) to acquire directional and positional control • Verbal cue are critical • Manual contact with appropriate pressure is essential • Reflex responses are altered by pressure • Contact should be firm

13. Proper mechanics and body positioning for athletic trainer and patient are critical for effective treatment • Amount of resistance should induce a maximal response • Smooth, coordinated motions – dependent on patient capabilities • Rotational movement is a critical component – maximal contraction is impossible without it • Timing of muscle sequential firing • Distal movements must occur first • Timing for emphasis is used primarily with isotonic contractions • Superimposes maximal resistance facilitating overflow or irradiation (facilitation of movement)

14. Use of traction or approximation can facilitate process • Stimulation of joint receptors • Means of promoting movement and stability • Utilization of quick stretch facilitates muscle response • Stretch all components of movement (simultaneously) • Beware of contraindications

15. Techniques of PNF • Strengthening technique • Rhythmic initiation • Progression of initial passive followed by active-assistive and active movement against resistance • Slow movement through available range of motion • Used in instances of limited range and increased tone • Can be utilized to teach movement patterns • Initiate early use in rehabilitation process • Repeated contraction • Useful for treating weakness at differing points throughout the range of motion • Correct imbalances • Movement against isotonic resistance until fatigue, followed by period of stretching • Resistance and stretch must be modified for each athlete

16. Slow reversal • Isotonic contraction of agonist followed by contraction of antagonist • Initial contraction facilitates antagonist activity • Used to develop contraction of agonist and reciprocal timing of antagonist – critical for coordination • Help improve muscle endurance • Slow reversal hold • Agonist isotonic contraction followed by isometric contraction with a hold at the end of each active movement • Alternate with antagonist activity • Used to develop strength at specific points in range of motion • Correct weakness at certain points in range • Rhythmic stabilization • Isometric contraction of agonist and antagonist to resist motion • Maintain “hold” position” while movement in applied in multiple directions • Neuromuscular control and stability

17. Stretching Techniques • Contract Relax • Moves body part passively into agonist pattern • Contract antagonist against resistance (muscle to be stretched) • Athlete relaxes and athletic trainer takes muscle through as much range as is possible • Useful when range of motion is limited by muscle tightness

18. Hold Relax • Isometric contraction of antagonist followed by concentric contraction of agonist to produce maximal stretch of antagonist • Slow Reversal Hold • Isotonic contraction of agonist, followed by isometric contraction of antagonist (during the push phase) • Agonist contracts while antagonist is relaxed to stretch antagonist • Can be used to increase ROM when antagonist is limiting range

19. Treating Specific Problems with PNF Techniques • Useful in a variety of conditions • Technique is often dictated by condition and capabilities of athlete • PNF is not cumbersome (not machine intensive) • Can emphasize using tri-planar motion • Resistance and range of motion can be readily altered • Can be used concurrently with a variety of strengthening techniques

20. PNF Patterns • Gross movements not specific muscle actions • Incorporate rotational and diagonal patterns similar to motions required in sports and daily activities • Three components • Flexion-extension • Abduction-adduction • Internal-external rotation • Distinct diagonal and rotational patterns of upper and lower extremity along with upper/lower trunk and neck

21. Pattern is initiated with muscle groups in a lengthened position and then contracted to move limb through ROM, shortening muscles • Upper and lower extremity diagonal patterns • D1 – flexion and extension • D2 – flexion and extension • Named for proximal pivots at either the shoulder or hip

22. D1 Patterns for Upper Extremity

23. D2 Pattern for Upper Extremity

24. D1 Lower Extremity Pattern

25. D2 Lower Extremity Pattern

26. Upper Trunk Chopping and Lifting

27. Lower Extremity Rotation

28. Neck Patterns

29. Muscle Energy Techniques • Manual therapy technique that is a variation on contract-relax and hold-relax • Same neurophysiological basis • Voluntary muscle contractions in specific directions and intensities against counterforce • Patient creates corrective intrinsic forces with muscle contraction • Athletic trainer control precision and localization

30. Five Components • Active muscle contraction by patient • Muscle contraction oriented in a specific direction • Patient control of contraction intensity • Athletic trainer control of joint position • Athletic trainer application of appropriate counterforce

31. Clinical Application • Utilized in situations where muscle is restricting joint motion • Muscle energy technique uses muscle contraction to restore physiological movement to a joint • Potential treatment goals • Lengthening of a shortened, contracted or spastic muscle • Strengthening of a weak muscle or group • Reduction of localized edema through muscle pumping • Mobilization of an articulation with restrictions • Stretching of fascia

32. Treatment Techniques • Utilize 4 types of muscle contraction • Isometric • Used to treat hypertonic muscles in vertebral column • Concentric • Used in extremities • Mobilization techniques against motion barrier • Eccentric • Used in extremities • Isolytic – overpowering of concentric contraction by clinician in opposite direction

33. Athlete is prone Athletic trainer stabilizes knee with one hand and ankle with the other Athletic trainer fully extends knee until extension barrier is felt Athlete flexes knee with minimal force while athletic trainer provides counterforce (3-7 seconds) Athlete relaxes and athletic trainer extends knee to next barrier Repeat 3-5 times Isometric Technique (hamstrings)

34. Quadriceps/Hamstrings Imbalance • Athlete is supine • Athletic trainer stabilizes knee with one hand and ankle with the other • Athlete instructed to extend the knee forcefully • Athletic trainer provides counterforce to slow extension • Athlete relaxes and athletic trainer flexes knee and repeats with additional resistance to full extension • Repeat 3-5 times

35. Strain/Counterstrain • Technique used to decrease muscle tension and normalize muscle function • Passive technique that places body in a position of comfort - thereby relieving pain • Locate tender points (tense, tender, edematous spots, <1cm in diameter, may run few centimeters long in muscle, may fall w/in a line, or have multiple points for one specific joint)

36. Tender points monitored as athlete placed in position of comfort (shorten muscle) • When position is found, tender point is no longer tense • After being held for 90 seconds, point should be clear • Patient should then be returned to neutral position • Physiological rationale based on stretch reflex • Muscle relaxed instead of stretched • Muscle spindle input is reduced allowing for decreasing in tension and pain

37. Positional Release Therapy • PRT is based on the strain/counterstrain technique • Difference is the use of a facilitating force (compression) to enhance the effect of positioning • Osteopathic mobilization technique • Technique follows same procedure as strain/counterstrain however, contact is maintained and pressure is exerted • Maintaining contact has therapeutic effect

38. Positional Release

39. Active Release Therapy • ART is relatively new type of therapy used to correct soft tissue problems caused by formation of fibrotic adhesions • Result of acute injury and repetitive overuse injuries or constant pressure/tension • Disrupt normal muscle function affecting biomechanics of joint complex leading to pain and dysfunction • Way to diagnose and treat underlying causes of cumulative trauma disorders

40. Deep tissue technique used for breaking down scarring and adhesions • Locate point and trap affected muscle by applying pressure over lesion • Athlete actively moves body part to elongate muscle • Repeat 3-5 times/treatment • Uncomfortable treatment but will gradually soften and stretch scar tissue, increase ROM, strength, and improve circulation, optimizing healing • Must follow up w/ activity modification, stretching and exercise

41. Active Release Therapy

42. Sports Massage • Mechanical stimulation of tissue through rhythmically applied pressure and stretching • Therapeutic benefits • Increase flexibility • Increase pain threshold • Decrease neuromuscular excitability • Stimulate circulation • Facilitate healing and restore joint mobility

43. Effects of massage • Reflexive or mechanical • Neurophysiological effects will differ according to method used, pressure applied and duration • Reflexive massage • Relies heavily on slow rhythmic effleurage • Relieve tension – soothing • Primarily local sensory-motor impact • Mechanical • Induce mechanical or histological changes in myofascial structures through direct force

44. Massage Techniques • Hoffa massage • Classic form • Effleurage, petrissage, percussion, tapotement vibration • Friction massage • Increase inflammatory response • Acupressure • Massage of acupuncture and trigger points • Pain reduction through use of anatomical points • Connective tissue massage • Stroking technique used on layers of connective tissue

45. Myofascial release • Used to release soft tissue from grips of tight fascia • Rolfing • System devised to correct inefficient structure by balancing body with gravitational fields • Soft tissue manipulation • Trager • Establishes neuromuscular control so that more normal movement patterns can be routinely performed