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Normal functional motion is composed of mass movement patterns of the limbs and the synergistic trunk muscles (Kabat 1960) (O Fig. 5.1). The motor cortex generates and organizes these movement patterns, and the individual cannot voluntarily leave a muscle out of the movement pattern to which it belongs. This does not mean that we cannot contract muscles individually, but our discrete motions spring from the mass patterns (Beevor 1978; Kabat 1950). These synergistic muscle combinations form the PNF patterns of facilitation.
Some people believe that you must know and use the PNF patterns to work within the concept of PNF. We think that you need only the PNF philosophy and the appropriate procedures. The patterns, while not essential, are however valuable tools to have. Working with the synergistic relationships in the patterns allows problems to be treated indirectly. Also, the stretch reflex is more effective when an entire pattern rather than just the individual muscle is stretched.
The PNF patterns combine motion in all three planes:
1. The sagittal plane: flexion and extension
2. The coronal or frontal plane: abduction and adduction of limbs or lateral flexion of the spine
3. The transverse plane: rotation
We thus have motion that is "spiral and diagonal" (Knott and Voss 1968). Stretch and resistance reinforce the effectiveness of the patterns, as shown by an increased activity in the muscles. The increased muscular activity spreads both distally and proxi-mally within a pattern and from one pattern to related patterns of motion (irradiation). Treatment uses irradiation from those synergistic combinations of muscles (patterns) to strengthen the desired muscle groups or reinforce the desired functional motions.
When we exercise in the patterns against resistance, all the muscles that are a part of the synergy will contract if they can. The rotational component of the pattern is the key to effective resistance. Correct resistance to rotation will strengthen the entire a
Fig. 5.1. Diagonal motions in sport: a tennis; b golf
Fig. 5.1. Diagonal motions in sport: a tennis; b golf b a pattern. Too much resistance to rotation will prevent motion from occurring or "break" a stabilizing contraction.
The motion occurring at the proximal joint names the patterns, as in flexion-adduction-external rotation of the shoulder. Two antagonistic patterns make up a diagonal. For example, an upper extremity diagonal contains shoulder flexion-adduction-external rotation and the antagonist pattern extension-abduction-internal rotation. The proximal and distal joints of the limb are linked in the pattern. The middle joint is free to flex, extend or maintain its position. For example, finger flexion, radial flexion of the wrist, and forearm supination are integral parts of the pattern of shoulder flexion-adduction-external rotation. The elbow, however, may flex, extend or remain in one position.
The trunk and limbs work together to form complete synergies. For example, the pattern of shoulder flexion-adduction-external rotation with anterior elevation of the scapula combines with trunk extension and rotation to the opposite side to complete a total motion. If you know the synergistic muscle combinations, you can work out the patterns. If you know the pattern, you will know the synergistic muscles. When an extremity is in its fully lengthened position the synergistic trunk muscles are also under tension. The therapist should feel tension in both the limb and trunk muscles.
The groove of the pattern is that line drawn by the hand or foot (distal component) as the limb moves through its range. For the head and neck, the groove is drawn by a plane through the nose, chin, and crown of the head. The groove for the upper trunk is drawn by the tip of the shoulder and for the lower trunk by the hip bone. Because the trunk and limbs work together, their grooves join or are parallel (O Fig. 5.2). As discussed earlier, the therapist's body should be in line with or parallel to the relevant groove. Pictures of the complete patterns with the therapist in the proper position come in the following chapters.
To move concentrically through the entire range of a pattern:
— The limb is positioned in the "lengthened range".
- All the associated muscles (agonists) are lengthened.
- There is no pain, and no joint stress.
- The trunk does not rotate or roll.
— The limb moves into the "shortened range."
- The end of the range of contraction of the muscles (agonists) is reached.
- The antagonistic muscle groups are lengthened.
- There is no pain and no joint stress.
- The trunk did not rotate or roll.
We can vary the pattern in several ways.
The normal timing of an extremity pattern is:
— The distal part (hand and wrist or foot and ankle) moves through its full range first and holds its position.
— The other components move smoothly together so that they complete their movement almost simultaneously.
— Rotation is an integral part of the motion and is resisted from the beginning to the end of the motion.
We can vary the pattern in several ways:
— By changing the activity of the middle joint in the extremity pattern for function Example: First, the pattern of shoulder flexion-abduction-external rotation is done with the elbow moving from extension to flexion. The patient's hand rubs his or her head. The next time, the same pattern is done with the elbow moving from a flexed to an extended position, so the patient's hand can reach for a high object.
— By changing the activity of the middle joint in the extremity pattern for the effect on two-joint muscles.
Example: First, the pattern of hip flexion-adduction-external rotation is done with the knee moving from the extended to the flexed position. In this combination, the hamstring muscles shorten actively. Next time, the same pattern is used with the knee staying straight. This combination stretches the hamstring muscles.
— By changing the patient's position to change the effects of gravity.
Example: The pattern of hip extension-abduction-internal rotation is done in a side lying position so the abductor muscles work against gravity.
— By changing the patient's position to a more functional one.
Example: The upper extremity patterns are exercised in a sitting position and incorporate functional activities such as eating or combing the hair.
— By changing the patient's position to use visual cues.
Example: Have the patient in a half-sitting position so that he or she can see the foot and ankle when exercising it.
We name the pattern combinations according to how the limb movements (arms, legs or both) relate to each other:
— Unilateral: one arm or one leg
— Bilateral: both arms, both legs, or combinations of arms and legs (O Fig. 5.3):
- Symmetrical: the limbs move in the same pattern (e. g., both move in flexion-abduction) (O Fig. 5.3 a)
- Asymmetrical: the limbs move in opposite patterns (e. g., the right limb moves in flexion-abduction, the left moves in flexion-adduction) (O Fig. 5.3 b)
- Symmetrical reciprocal: the limbs move in the same diagonal but opposite directions (e. g., the right limb moves in flexion-abduction, the left in extension-adduction) (O Fig. 5.3 c)
- Asymmetrical reciprocal: the limbs move in opposite diagonals and opposite directions (e. g., the right limb moves in flexion-abduction, the left in extension-abduction) (O Fig. 5.3 d)
We can combine the patterns in many ways. The emphasis of treatment is on the arms or legs when the limbs move independently. The emphasis is on the trunk when the arms are joined by one hand gripping the other arm or when the legs are touching and move together. Choosing how to combine the patterns for the greatest functional effect is a part of the assessment1 and treatment planning.
1 To evaluate: to identify the patient's areas of function and dysfunction. To assess: to measure or judge the result of a treatment procedure.
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