To Maggie Knott teacher and friend

Devoted to her patients, dedicated to her students, a pioneer in profession

Maggie Knott Pnf

Preface

Proprioceptive neuromuscular facilitation (PNF) is a philosophy and a concept of treatment. The PNF philosophy is timeless, and the concept is a continuous process of growth. This third edition of our book, with a complete review, better user-friendly layout and integration of the latest developments, aims to support this growth.

PNF has been one of the most recognized treatment concepts in physical therapy since the 1940s. Dr. Kabat and Margaret (Maggie) Knott started and continued to expand and develop the treatment techniques and procedures after their move to Vallejo, California in 1947. After Dorothy Voss joined the team in 1953, Maggie and Dorothy wrote the first PNF book, published in 1956.

At first mostly patients with multiple sclerosis and poliomyelitis were treated with this method. With experience it became clear that this treatment approach was effective for patients with a wide range of diagnoses. Today, patients with neurological, traumatic as well as orthopedic symptoms are treated with this concept.

The three- and six-month PNF courses in Vallejo began in the 1950s. Physical therapists from all over the world came to Vallejo to learn the theoretical and practical aspects of the PNF concept. In addition, Knott and Voss traveled in the United States and abroad to give introductory courses in the concept.

When Maggie Knott died in 1978 her work at Vallejo was carried on by Carolyn Oei Hvis-tendahl. She was succeeded by Hink Mangold as director of the PNF program. Tim Josten is the present program director. Sue Adler, Gregg Johnson, and Vicky Saliba have also continued Maggie's work as teachers of the PNF concept. Sue Adler designed the International PNF Association (IPNFA) Advanced and Instructor course programs.

The authors acknowledge their debt to these outstanding people, and also to all members of the International PNF Association (IPNFA), and hope that this book will encourage others to carry on the work.

Developments in the PNF concept are closely followed throughout the world. It is now possible to take recognized training courses in many countries given by qualified PNF instructors.

There are other excellent books dealing with the PNF method, but we felt there was a need for a comprehensive coverage of the practical tools in text and illustrations. This book should thus be seen as a practical guide and used in combination with existing textbooks.

This book covers the procedures, techniques, and patterns within PNF. Their application to patient treatment is discussed throughout, with special attention on mat activities, gait and self-care. The emphasis within this book is twofold: developing an understanding of the principles that underlie PNF, and showing through pictures rather than with words how to perform the patterns and activities. Skill in applying the principles and practices of PNF to patient treatment cannot be learned only from a book. We recommend that the learner combine reading with classroom practice and patient treatment under the supervision of a skilled PNF practitioner.

Movement is our way to interact with our environment. Such interactions are directed by the mechanism of motor learning. Integration of motor learning principles includes a progression from hands-on to hands-off treatments; it includes goal-orientated functional activities and independence. Based on the untapped existing potential of all patients, the therapist will always focus on mobilizing these reserves to reach the highest level of function. Especially in the first and cognitive stage of motor control, the therapist's manual facilitation will be a help ful tool in reaching this goal. This includes goals on the level of body structures as well as on the activity level and the participation level (ICF).

This fully revised third edition includes a description of how the principles of the International Classification of Functioning, Disability and Health (ICF), and aspects of motor learning and motor control (from "hands-on" to "hands-off" management), are applied in modern PNF evaluation and treatment. The section on "Activities of Daily Living" has been expanded with new photos and more in-depth text instructions. The new design and layout highlight the clearly structured way in which the philosophy, basic procedures and treatment patterns of PNF are presented. Thus, this textbook provides a systematic and easily accessible guide to learning and understanding PNF as a practical tool and using it to full effect in patient treatment.

A special note of thanks goes to the following: Jan Albers and The Rehabilitation Centre in Hoensbroek (The Netherlands), F. Somers for the photography, colleague José van Oppen for acting as a model and Ben Eisermann for the drawings.

But most of all we are grateful to all our colleagues, the PNF instructors and all our patients. Without them this work would not be possible.

June 2007

Contents

1 Introduction to Proprioceptive Neuromuscular Facilitation 1

2 Basic Procedures for Facilitation 5

2.1 Resistance 6

2.2 Irradiation and Reinforcement 7

2.3 Manual Contact 10

2.4 Body Position and Body Mechanics 11

2.5 Verbal Stimulation (Commands) 11

2.6 Vision 12

2.7 Traction and Approximation 12

2.8 Stretch 13

2.9 Timing 14

2.10 Patterns 16

3 Techniques 19

3.1 Rhythmic Initiation 20

3.2 Combination of Isotonics

(described by Gregg Johnson and Vicky Saliba). . . 21

3.3 Reversal of Antagonists 23

3.3.1 Dynamic Reversals (Incorporates Slow Reversal). . 23

3.3.2 Stabilizing Reversals 26

3.3.3 Rhythmic Stabilization 27

3.4 Repeated Stretch (Repeated Contractions) 29

3.4.1 Repeated Stretch from Beginning of Range 29

3.4.2 Repeated Stretch Through Range 30

3.5 Contract-Relax 31

3.5.1 Contract-Relax: Direct Treatment 31

3.5.2 Contract-Relax: Indirect Treatment 33

3.6 Hold-Relax 33

3.6.1 Hold-Relax: Direct Treatment 33

3.6.2 Hold-Relax: Indirect Treatment 34

3.7 Replication 35

3.8 PNF Techniques and Their Goals 35

4 Patient Treatment 39

4.1 Evaluation 40

4.1.1 Evaluation of Areas of Activities 40

4.1.2 Evaluation of Areas of Impairments and

Activity Limitations 40

4.2 Hypothesis 41

4.3 Tests for Causal Impairments and

Activity Limitations 41

4.4 Treatment Goals 41

4.5 Treatment Planning and Treatment Design 42

4.5.1 Specific Patient Needs 42

4.5.2 Designing the Treatment 42

4.5.3 Direct and indirect Treatment 42

4.6 Assessment 43

4.7 Re-Test for Causal Impairments and

Activity Limitations 44

4.8 Treatment Examples 44

5 Patterns of Facilitation 47

6 The Scapula and Pelvis 53

6.1 Introduction 54

6.2 Applications 54

6.3 Basic Procedures 54

6.4 Scapular Diagonals 56

6.4.1 Specific Scapula Patterns 56

6.4.2 Specific Uses for Scapular Patterns 63

6.5 Pelvic Diagonals 64

6.5.1 Specific Pelvic Patterns 64

6.5.2 Specific Uses for Pelvic Patterns 72

6.6 Symmetrical, Reciprocal and Asymmetrical Exercises 73

6.6.1 Symmetrical-Reciprocal Exercise 73

6.6.2 Asymmetrical Exercise 74

7 The Upper Extremity 77

7.1 Introduction and Basic Procedures 78

7.2 Flexion - Abduction - External Rotation 80

7.2.1 Flexion - Abduction - External Rotation with

Elbow Flexion 83

7.2.2 Flexion - Abduction - External Rotation with

Elbow Extension 86

7.3 Extension - Adduction - Internal Rotation 88

7.3.1 Extension - Adduction - Internal Rotation with Elbow Extension 90

7.3.2 Extension - Adduction - Internal Rotation with Elbow Flexion 92

7.4 Flexion - Adduction - External Rotation 94

7.4.1 Flexion - Adduction - External Rotation with

Elbow Flexion 96

7.4.2 Flexion - Adduction - External Rotation with

Elbow Extension 98

7.5 Extension - Abduction - Internal Rotation 101

7.5.1 Extension - Abduction - Internal Rotation with Elbow Extension 103

7.5.2 Extension - Abduction - Internal Rotation with Elbow Flexion 106

7.6 Thrust and Withdrawal Combinations 108

7.6.1 Ulnar Thrust and Withdrawal 109

7.6.2 Radial Thrust and Withdrawal 109

7.7 Bilateral Arm Patterns 111

7.8 Changing the Patient's Position 112

7.8.1 Arm Patterns in a Side Lying Position 113

7.8.2 Arm Patterns Lying Prone on Elbows 113

7.8.3 Arm Patterns in a Sitting Position 114

7.8.4 Arm Patterns in the Quadruped Position 114

7.8.5 Arm Patterns in a Kneeling Position 115

8 The Lower Extremity 117

8.1 Introduction and Basic Procedures 118

8.2 Flexion - Abduction - Internal Rotation 120

8.2.1 Flexion - Abduction - Internal Rotation with

Knee Flexion 122

8.2.2 Flexion - Abduction - Internal Rotation with

Knee Extension 124

8.3 Extension - Adduction - External Rotation 126

8.3.1 Extension - Adduction - External Rotation with

Knee Extension 129

8.3.2 Extension - Adduction - External Rotation with

Knee Flexion 132

8.4 Flexion - Adduction - External Rotation 133

8.4.1 Flexion - Adduction - External Rotation with

Knee Flexion 135

8.4.2 Flexion - Adduction - External Rotation with

Knee Extension 137

8.5 Extension - Abduction - Internal Rotation 139

8.5.1 Extension - Abduction - Internal Rotation with

Knee Extension 141

8.5.2 Extension - Abduction - Internal Rotation with

Knee Flexion 143

8.6 Bilateral Leg Patterns 144

8.7 Changing the Patient's Position 147

8.7.1 Leg Patterns in a Sitting Position 147

8.7.2 Leg Patterns in a Prone Position 149

8.7.3 Leg Patterns in a Side Lying Position 151

8.7.4 Leg Patterns in a Quadruped Position 151

8.7.5 Leg Patterns in the Standing Position 154

9 The Neck 155

9.1 Introduction and Basic Procedures 156

9.2 Indications 158

9.3 Flexion to the Left, extension to the Right 158

9.3.1 Flexion/Left Lateral Flexion/Left Rotation 158

9.3.2 Extension/Right Lateral Flexion/Right Rotation. . . 162

9.4 Neck for Trunk 164

9.4.1 Neck for Trunk Flexion and Extension 164

9.4.2 Neck for Trunk Lateral Flexion 165

10 The Trunk 169

10.1 Introduction and Basic Procedures 170

10.2 Chopping and Lifting 171

10.2.1 Chopping 171

10.2.2 Lifting 174

10.3 Bilateral Leg Patterns for the Trunk 177

10.3.1 Bilateral Lower Extremity Flexion, with

Knee Flexion, for Lower Trunk Flexion (Right) 177

10.3.2 Bilateral Lower Extremity Extension, with

Knee Extension, for Lower Trunk Extension (Left) . 179

10.3.3 Trunk Lateral Flexion 180

10.4 Combining Patterns for the Trunk 182

11 Mat Activities 185

11.1 Introduction: Why Do Mat Activities? 186

11.2 Treatment Goals 186

11.3 Basic Procedures 187

11.4 Techniques 187

11.5 Mat Activities 187

11.5.1 Rolling 188

11.5.2 Prone on Elbows (Forearm Support) 197

11.5.3 Side-Sitting 200

11.5.4 Quadruped 203

11.5.5 Kneeling 208

11.5.6 Half-Kneeling 212

11.5.7 From Hands-and-Feet Position (Arched Position on All Fours) to Standing Position and back to Hands-and-Feet Position 214

11.5.8 Exercise in a Sitting Position 215

11.5.9 Bridging 220

11.6 Patient Cases in Mat Activities 223

12 Gait Training 233

12.1 The Importance of Walking 234

12.2 Introduction: Basics of Normal Gait 234

12.2.1 The Gait Cycle 234

12.2.2 Trunk and Lower Extremity Joint Motion in Normal Gait 235

12.2.3 Muscle Activity During Normal Gait (Perry 1992) . 236

12.3 Gait Analysis: Observation and Manual Evaluation. 238

12.4 The Theory of Gait Training 239

12.5 The Procedures of Gait Training 240

12.5.1 Approximation and Stretch 241

12.5.2 Using Approximation and Stretch Reflex 242

12.6 Practical Gait Training 242

12.6.1 Preparatory Phase 242

12.6.2 Standing Up and Sitting Down 249

12.6.3 Standing 252

12.6.4 Walking 257

12.6.5 Other Activities 262

12.7 Patient Cases in Gait Training 265

13 Vital Functions 271

13.1 Introduction 272

13.1.1 Stimulation and Facilitation 272

13.2 Facial Muscles 272

13.3 Tongue Movements 283

13.4 Swallowing 284

13.5 Speech Disorders 284

13.6 Breathing 285

14 Activities of Daily Living 289

Glossary 297

Introduction to Proprioceptive Neuromuscular Facilitation

Chapter 1 • Introduction to Proprioceptive Neuromuscular Facilitation

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