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Facilitation of the Diaphragm (O Fig. 13.24)

You can facilitate the diaphragm directly by pushing upward and laterally with the thumbs or fingers from below the rib cage (O Fig. 13.24 a, b). Apply stretch and resist the downward motion of the contracting diaphragm. The patient's abdominal muscles must be relaxed for you to reach the diaphragm. If this is difficult, flex both hips to get more relaxation in the abdominal muscles and the hip flexor muscles. To give indirect facilitation for diaphragmatic motion, place your hands over the abdomen and ask the patient to inhale while pushing up into the gentle pressure (O Fig. 13.24 c). Teach your patients to do this facilitation on their own.

O Fig. 13.24. Facilitation of the diaphragm: a stretch of diaphragm at end of exhalation; b inspiration; c alternative indirect facilitation c

O Fig. 13.24. Facilitation of the diaphragm: a stretch of diaphragm at end of exhalation; b inspiration; c alternative indirect facilitation b a c

Further Reading

Beurskens CHG, van Gelder RS, Heymans PG et al (2005) The facial palsies. Lemma Publishers, Utrecht: Beurskens CHG (2003) Mime therapy: rehabilitation of facial expression. Proefschrift, University of Nijmegen, Medische Wetenschappen Kendall FP, McCreary EK (1993) Muscles, testing and function.

Williams and Wilkins, Baltimore Lee DN, Young DS (1985) In: Ingle DJ et al (eds) Visual timing in interceptive actions. Brain mechanisms and spatial vision. Martinus Nijhoff, Dordrecht Manni JJ, Beurskens CH, van de Velde C, Stokroos RJ (2001) Reanimation of the paralyzed reconstruction face by indirect hypoglossal-facial nerve anastomosis. Am J Surg 182:268-73

Schmidt R, Lee T (1999) Motor control and learning, 3rd edn.

Human Kinetics, Champaign Shumway-Cook AW, Woollacott M (2001) Motor control: theory and practical applications. Williams and Wilkins, Baltimore

Activities of Daily Living

Our final treatment goal is to reach the highest functional level and maximal independence in activities of daily living (ADL), to increase the quality of life for each patient. On the level of participation, the patient should take part in normal activities again. The therapist will always integrate principles of motor learning and motor control in his PNF treatment to reach this highest functional level.

The stages of motor control - mobility, stability, mobility on top of stability - and skills are described in 7 Chap. 11 (mat activities). Therapists will always respect these stages in all ADL, such as eating, dressing, wheelchair driving, gait or walking up stairs.

Give patients feedforward as well as feedback concerning the desired activity and allow them to make mistakes so they can learn from their trials. The PNF concept provides us with many tools -such as verbal and visual input, tactile information and techniques like rhythmic initiation, combining of isotonics and replication - to give the patient information about these activities.

The way patients choose their strategy to fulfill a task depends on the goal of the activity, the environment and the patients themselves. At the structural level, we can treat a patient, in a supine position on a table. But at the activity level, we have to bring the patient to an environment that is optimal for this activity. Only by practicing the activity in a meaningful context, with and without feedback, with and without repetition, and by variability in practice, will the patient be able to reach an optimal functional performance of this activity.

During the cognitive phase of learning the therapist can give extensive proprioceptive and exteroceptive input. In the associative phase, the therapist gives less input to the patient, changes the environments and allows some mistakes to be made. Mostly in the automatic phase, the patient no longer needs input and is able to fulfill double tasks at the same time.

The question is not "'hands on' or 'hands off'?," but rather "when does my patient need 'hands on' or 'hands off' treatment?". Both are necessary and possible, but the therapist has to decide when and how much external information the patient needs. With the PNF philosophy in mind, the therapist will always offer the best facilitation. However, in the end the patient has to fulfill all activities independently and without our help.

Mastering the activities of daily living (ADL) is an important step in the patient's progress toward independence. The previous chapters have described a range of activities for achieving this goal: mat activities (rolling, bridging, crawling, kneeling, sitting), standing, walking, head and neck exercises, facial exercises, breathing, and swallowing. In chapter 4 we have already emphasized the ICF model.

When the patient has mastered the fundamentals needed for success in ADL, time may be spent working on more advanced or difficult activities. All the skills that a patient needs for independence can be taught using the PNF treatment approach. Guidance given by grip and resistance helps the patient develop effective ways to perform these activities (Klein 2002).

Some of the practical activities are:

— Transferring from the wheelchair to bed (O Fig. 14.1) and from bed to wheelchair

(O Fig. 14.2 a), onto the toilet (O Fig. 14.2 b), into a shower, a bathtub (O Fig. 14.2 c, d) a chair, a car, etc.

— Dressing and undressing (O Fig. 14.3), washing

Further Reading

Klein DA, Stone WJ (2002) PNF training and physical function in assisted living older adults. J Aging Phys Activity (10): 476-488

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