Evidence-based content uses over 5, references to support the basic science information principles for rehabilitation interventions and provide the best evidence and physiological reasoning for treatment. Over tables and text boxes highlight key points within the text for better understanding.
Here is a practical, step-by-step guide to understanding the treatment process and selecting the most appropriate intervention for your patient. Superbly illustrated, in-depth coverage shows you how to identify functional deficits, determine what treatments are appropriate, and then to implement them to achieve the best functional outcome for your patients. Master the role of the physical therapist or physical therapist assistant in neurologic rehabilitation! Neurologic Interventions for Physical Therapy, 3rd Edition helps you develop skills in the treatment interventions needed to improve the function of patients with neurologic deficits.
It provides a solid foundation in neuroanatomy, motor control, and motor development, and offers clear, how-to guidelines to rehabilitation procedures. This edition demonstrates how the principles of the International Classification of Functioning, Disability and Health ICF and aspects of motor learning and motor control are applied in modern. The approach here is based on the concepts set out by Dr. Herman Kabat and taught by Margaret Knott, and this second edition adds many new illustrations including demonstrations of the techniques and pictures of actual patient treatment.
The gait section has been expanded with an introduction to normal components and photos of patient treatment. The mat section has also been enlarged and includes illustrations of patient treatment. The PNF approach, presented in a fully illustrated hands-on guide, including photos Focus on practical aspects of patient evaluation and treatment ICF and Motor Learning and how these concepts are applied in PNF 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 New for this edition: new fully-color textbook design for more user-friendly learning experience; fully revised introductory chapter on the PNF basics, now.
The text provides a useful overview of PNF stretching - safe and easy-to-use method that involves stretching the muscle, contracting it isometrically against resistance, then stretching it again to a new range of motion. Whether you're a fitness professional, therapist, coach, athlete, or student, Facilitated Stretching, Third Edition, will help you assess current muscle function, improve range of motion, increase strength, reduce overuse injuries, and enhance performance.
This book is the first to view the effects of development, aging, and practice on the control of human voluntary movement from a contemporary context. Emphasis is on the links between progress in basic motor control research and applied areas such as motor disorders and motor rehabilitation. PNF uses muscle contractions to affect 2. Dynamic dysfunction due to pain: A patient the body.
Modalities such as heat and one mile 1. The therapist combines and modifies the proce- 3. Dynamic dysfunction due to the loss of ability dures and the techniques to suit the needs of each to move: A patient who has had a stroke with patient. Treatment should be intensive, mobilizing resultant hemiplegia. Begin treatment with weight shifting in a stable position.
For example: Specific: the goal is specific for each individual. Decrease pain Measurable: the goal is measurable, for example, 2. Increase range of motion distance of walking.
Increase strength, coordination, and control of Acceptable: the therapist and the patient agree motion on the goal. Develop a proper balance between motion and Realistic: the goal is attainable by the patient stability with his specific problem.
Increase endurance Time: the goal should be met within a reason- able amount of time. The results achieved after each The therapist designs a treatment to meet the pa- treatment are documented.
Factors to be considered include: and results of the treatment are clear. This form of 1. Direct or indirect treatment assessment requires objective testing. These tests 2. Appropriate activities should be done on all levels: body function and 5 Movement or stability body structure, activity and participation. The best position for the patient. Techniques and procedures 5. Patterns and combinations of patterns Example 6.
Functional and goal oriented tasks. While the patient stands on the involved leg, the therapist gives approximation through the pelvis to The treatment of the therapist should always be: facilitate weight-bearing. Goal oriented: all the activities are focused on the treatment goal. Definition Process oriented: all aspect of the treatment In indirect treatment, the chosen facilitation is should be related to and influence each other.
The indirect way of treatment uses with a specific treatment goal in mind and if neces- the principle of synergistic muscles. Hellebrandt et al. Other experiments have described electromyo- The authors distinguish between direct and indirect graphic EMG activity in the agonistic and antago- treatment. The decision of the therapist to use the nistic muscles of the contralateral upper or lower direct or the indirect method depends mostly on the extremity during resisted isotonic and isometric specific problems of the patient.
The trunk musculature can also be exercised jDirect Treatment indirectly. For example, the abdominal muscles con- tract synergistically when a person raises his arm. Definition This activity occurs in normal subjects and in pa- In direct treatment, the therapist treats the af- tients suffering from central nervous system fected body part or area that is involved.
For disorders as well Angel and Eppler An example, the muscles near the joint or within a increased passive range of motion can be gained in- certain problematic part of the movement. To give the patient maximum benefit from in- Direct treatment may involve: direct treatment the therapist resists strong move- 1.
Use of treatment techniques on the affected ments or patterns. Maximum strengthening occurs limb, muscle, or motion. When pain is a presenting Indirect treatment can also be applied when symptom, treatment focuses on pain-free areas the treatment goals are for strengthening. The of the body. Using carefully guided and controlled maximal strength can be reached when the the- irradiation the therapist can treat the affected limb rapist combines patterns that are weak with pat- or joint without risk of increasing the pain or injury.
The patient is able to do more Indirect treatment may involve: in the treatment and can reach the highest possible 4 Use of the techniques on an unaffected or less effects sooner when the stronger patterns are re- affected part of the body. The therapist directs sisted. By assessing the results after each treatment, the therapist can Example determine the effectiveness of both the treatment To gain range in shoulder flexion, abduction, and activity and treatment session and can then modify external rotation.
Changing the treatment procedures or the 4 After resisting the contraction, the therapist and techniques the patient relax. Increasing or decreasing facilitation by chang- 4 This use of Hold—Relax will produce a contraction ing the use of: and relaxation of the ipsilateral pectoralis major 5 Reflexes muscle.
The treated arm need not be moved but 5 Manual contact may remain in a position of comfort. Increasing or decreasing the resistance given body. Working with the patient in positions of func- tion Example 5. Progressing to more complex activities To improve lower extremity weight-bearing. These tests will be evaluated and compared. A further advantage of the indirect treatment is that it gives the patient the opportunity to be treated 4.
If the pain is initially in the foreground, then the treatment is The following examples of procedures, techniques, generally performed in a pain-free area. Pain b. Techniques a. Combinations — Isometric muscle contraction — Contract—Relax followed by Combination — Bilateral work of Isotonics in the new range — Traction — Contract—Relax followed by Slow Rever- — Position for comfort sals, beginning with motion into the new b. Combinations 4. Coordination and control — Hold—Relax followed by Combination of a.
Procedures Isotonics — Patterns of facilitation — Rhythmic Stabilization followed by Slow — Manual contact grip Reversal Dynamic Reversals moving — Vision first toward the painful range — Proper verbal cues, decreased cueing as 2. Decreased strength and active range patient progresses of motion — Decreasing facilitation as the patient a.
Procedures progresses — Appropriate resistance b. Techniques — Replication — Repeated Stretch from beginning of range c. Facilitation from stronger antagonists nists 2.
Prevention and relief of fatigue — Combination of Isotonics combined c. Stability and balance range Repeated Contractions of the a.
Procedures weak pattern — Approximation — Rhythmic Stabilization at a strong point — Vision in the range of motion followed by Re- — Manual contact grip peated Contractions of the weak pattern — Appropriate verbal commands 3.
Decreased passive range of motion b. Endurance letic performance. Varying the activity or exercise be- myotonic dystrophy. Med Sci Sports Exerc patient to work longer and harder. Attention to — breathing while exercising as well as specific breath- Partridge MJ Repetitive resistance exercise: a method ing exercises work to increase endurance.
Phys Ther — a. Procedure Pink M Contralateral effects of upper extremity pro- prioceptive neuromuscular facilitation patterns. Phys — Stretch reflex Ther — b. Technique Richardson C, Toppenberg R, Jull G An initial evalua- — Reversal of antagonists tion of eight abdominal exercises for their ability to pro- — Repeated Stretch and Repeated Contrac- vide stabilization for the lumbar spine.
Aust Physiother tions —11 kHemiplegia 4. Neurol Rep 7 1 :3—4 On which three levels should the therapist car- Harro CC Implications of motor unit characteristics to ry out, plan, evaluate, and adapt his treatment speed of movement in hemiplegia. J Neurol hip replacement. Which tests and re-tests are Neurosurg Psychiatry — possible for this patient on the three ICF levels?
Phys Ther — lateral effects of unimanual training. J Appl Physiol — py Association monograph. Proceedings of the II Step conference. Foun- the influence of pacing. Arch to muscle training in man. Pain, manage- mental hypothesis. Phys Ther 68 2 — ment and control in physiotherapy. Arch Neurol prioceptive neuromuscular facilitation techniques on — hip motion and electromyographic activity.
Phys control. Ann Neurol — for rehabilitation outcomes research. Clin Orthop — Potney et al. Phys Ther — Prentice WE Jr An electromyographic analysis of the effectiveness of heat or cold and stretching for inducing relaxation in injured muscle.
The sagittal plane: flexion and extension 2. The coronal or frontal plane: abduction and Normal functional motion is composed of mass adduction of limbs or lateral flexion of the movement patterns of the limbs and the synergistic spine trunk muscles Kabat The motor 3. The transverse plane: rotation cortex generates and organizes these movement patterns, and the individual cannot voluntarily leave We thus have motion that is »spiral and diagonal« a muscle out of the movement pattern to which it Knott and Voss Stretch and resistance rein- belongs.
This does not mean that we cannot con- force the effectiveness of the patterns, as shown by tract muscles individually, but our discrete motions an increased activity in the muscles. The increased 5 spring from the mass patterns Beevor ; Kabat muscular activity spreads both distally and pro- These synergistic muscle combinations ximally within a pattern and from one pattern to form the PNF patterns of facilitation.
Treatment uses irradiation from those synergistic combina- tions of muscles patterns to strengthen the desired 5. Some people believe that you must know and use When we exercise in the patterns against resis- the PNF patterns to work within the concept of PNF.
The rotational component and the appropriate procedures. The patterns, while of the pattern is the key to effective resistance. Cor- not essential, are, however, valuable tools to have. Too much resistance to rotation will pre- patterns allows problems to be treated indirectly.
Two antagonistic pat- planes: terns make up a diagonal. For example, an upper. 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 pat- terns. If you know the pattern, you will know the. When an extremity is in its from Klein-Vogelbach 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 5 The trunk did not rotate or roll. For the head and neck, the groove is drawn by a plane through the nose, chin, The normal timing of an extremity pattern is: and crown of the head.
The groove for the upper 4 The distal part hand and wrist or foot and an- trunk is drawn by the tip of the shoulder and for the kle moves through its full range first and lower trunk by the hip bone. Because the trunk and holds its position. Pictures of the complete patterns with 4 Rotation is an integral part of the motion and the therapist in the proper position come in the fol- is resisted from the beginning to the end of the lowing chapters.
To move concentrically through the entire range We can vary the pattern in several ways: of a pattern: 4 By changing the activity of the middle joint in 4 The limb is positioned in the »lengthened the extremity pattern for function range.
The 5 There is no pain, and no joint stress. The next 5 The trunk does not rotate or roll. In this combination, the hamstring adduction.
Next time, the same 5 Symmetrical reciprocal: the limbs move in pattern is used with the knee staying straight. The choice of the starting position depends on Example: The upper extremity patterns are ex- many factors, which are selected by the therapist, ercised in a sitting position and incorporate such as spasticity, pain, finding a comfortable pain functional activities such as eating or combing free position of the patient or the therapist, pro- the hair.
Example: Have the patient in a half-sitting posi- tion so that he or she can see the foot and ankle when exercising it. The 4 What is the greatest advantage of the PNF pat- emphasis of treatment is on the arms or legs when terns?
The emphasis is 4 What is more important in gait or mat train- on the trunk when the arms are joined by one ing: the pattern of movement or the functional hand gripping the other arm or when the legs are activity?
Choosing how to 4 What are the advantages of using the patterns combine the patterns for the greatest functional ef- of movement on the mats and in gait training? We name the pattern combinations according to a. The PNF concept only allows using PNF how the limb movements arms, legs or both relate patterns in treatment to each other: b. Normal movements are always identical 4 Unilateral: one arm or one leg with PNF patterns 4 Bilateral: both arms, both legs, or combina- c. Normal ADL activities are always three- tions of arms and legs.
Each phase of gait is related to a PNF pattern pattern e. Using PNF patterns, you always use the full tion. To assess: to measure or judge the result of a treatment procedure. J Neurophysiol — Gellhorn E The influence of alterations in posture of the limbs on cortically induced movements. Functional Kinetics: Die Grundlagen, 6. The scapular muscles control or influence the In the shoulder girdle, the scapula and clavicle function of the cervical and thoracic spine.
Proper work together as a unit. Pelvic motion axial skeleton, at the manubrium. The shoulder and stability are required for proper function of the girdle is dependent on muscular function and its trunk and the lower extremities. In its Exercise of the scapula and pelvis can have var- normal function it is not a weight-bearing structure. It is a weight-bearing structure. The pelvic patterns do not always function in accord — Facilitate cervical motion and stability by with the lower extremity patterns because the pelvis resisting scapular motion and stabilization, is truly divided in its function.
It — Facilitate arm motion and stability by resis- is only involved in lower extremity function as an ting scapular motion and stabilization, since extension of the innominate. The innominate bone the scapula and arm muscles reinforce each is clearly an extension of the lower extremity and in other. The sacro-iliac SI articulation is the ation or continuing movements.
Therefore, the pelvic patterns are direct- — Exercise the pelvis for motion and stability. The lower extremity — Facilitate leg motion and stability. The sacrum has the functional propagating movements. The innominate has only a minor passive function unless the extremity is added. That is why, for example, it is so important to 6. Johnson, personal communication, jDiagonal Motion The scapular and pelvic patterns occur in two diago- nals: anterior elevation—posterior depression and posterior elevation—anterior depression.
Picture a patient lying on the left side. Now imagine that the patient is lying on the right side. All references are to mo-. The line of the scapular or pelvic diagonal and with arms use of these patterns in other positions is illustrated and hand aligned with the motion. All the grips in later chapters.
The therapist stands The patient should be positioned so that his or her in front of the patient in the line of the chosen di- back is close to the edge of the treatment table. The agonal. In this posi- lateral bend. Weight shifting is place the scapula or pelvis in a mid-position where done by moving from the position of sitting on the the line of the two diagonals cross.
The scapula heels kneeling down to partial or fully upright should not be rotated, and the glenohumeral com- kneeling kneeling up. The pelvis should be in the middle, between anterior and jGrips posterior tilt. You can use a pillow between the The grips follow the basic procedure for manual knees when the pelvis is rotated. From this midline contact, which is opposite the direction of move- position, the scapula or pelvis can then be moved ment. This section describes the two-handed grips into the elongated range of the pattern.
These are minimal changes that lead to a fluent diagonal movement. The humerus must be free to move as the scapula moves. Side-lying illustrated allows free motion of 6 the scapula and easy reinforcement of trunk activi- ties. The main muscle components are as follows ex- trapolated from Kendall and McCreary We know of no confirming electromyographic studies.
The other hand covers and supports the resistance by shifting your weight from the back to first. Contact is with the fingers and not the palm of the front leg. To resist the rotation compo- lower thoracic spine posterior depression with nent, the therapist resists the angulus inferior in the the angulus inferior rotated toward the spine.
Be direction of the spine. At posterior to the central anteroposterior line of the the end of the pattern, your elbows are extending body midfrontal plane. You should see and feel and you are lifting upward.
Contin- jEnd Position. The angulus inferior is segment. In the end position, the muscular activity moves the scapula in this direc- jCommand tion. The scapular retractor and depressor muscles »Shrug your shoulder up toward your nose. The inferior an- reaching in front of the body, and gait-related phas- gle moves away from the spine. The scapula moves down caudal and back adduc- tion , toward the lower thoracic spine, with the in- Posterior Depression ferior angle rotated toward the spine.
Upright and in stride position, cranial to the other. Your fingers lie on the flex the elbows to keep your forearms parallel to scapula pointing toward the acromion. Try to keep the line of resistance.
During the movement, shift all pressure below caudal to the spine of the the weight to the back foot and allow the elbows to scapula. To resist the rotation com- muscles below the spine of the scapula are tight. As the ment. By the end of the motion the »Push your shoulder blade down to me. Be roposterior line of the trunk. The vertebral border sure that the glenohumeral complex is positioned should lie flat and not wing out. You should see and feel jFunctional Activities that the abdominal area is taut from the ipsilateral This scapula pattern activates trunk extension, ribs to the contralateral pelvis.
Continued pressure rolling backward, using crutches while walking, on the scapula should not cause the patient to roll and pushing up with a straight trunk. When a back or rotate the spine around one segment. The scap- ula moves forward with the inferior angle in the Anterior Depression direction of the spine.
The other underlying hip. Your arms and legs are slightly bent. The fingers of both hands point toward the less in an upright position. Let the resistance come opposite ilium, and your arms are lined up in the from your body weight as you shift from the back to same direction.
Continued body. The glenohumeral complex is anterior to the central anteroposterior line of the body. The glenohumeral complex off socks and shoes.
Posterior Elevation jBody Mechanics. Stand nearly upright in a stride Place your hands posterior on the upper trapezius position. At the beginning, your elbows are more muscle, staying above superior to the spine of the or less extended and at the same level as the wrists.
Overlap your hands as necessary to stay During the movement, shift your weight from distal to the junction of the spine and first rib. By the end of the movement, your elbows jElongated Position. Moving backward, reaching out before throwing something, and putting on a shirt are activities that show these movements of the scapula. The humerus must be ing forward or backward 7 Sect. Give a movement command such as »roll forward« and resist the functional activity using the stabilized scapula as the handle.
The the scapula so that both the scapula and the resistance can vary depending on whether trunk motion are resisted. Depending on the goal of the treat- train coordination and prevent or reduce ment, use either contract—relax or hold— fatigue of the scapular and trunk muscles. Posterior Ipsilateral quadratus lumborum, ipsilateral 5 Scapular elevation patterns work with arm elevation latissimus dorsi, iliocostalis lumborum, flexion patterns. Give sustained maximal resistance to stabilizing or isometric scapula patterns until Anterior Elevation and Posterior you see and feel contraction of the desired Depression.
Points to Remember Anterior Elevation 4 The scapular patterns work directly on the. Your oth- er hand overlaps the first. The pelvis 6. See and feel that the tissues stretching The pelvis is part of the trunk, so the range of mo- from the crest of the ilium to the opposite rib cage tion in the pelvic patterns depends on the amount are taut.
Continued pressure should not cause the of motion in the lower spine. Pelvic patterns can be patient to roll backward or rotate the spine around treated isolated from the trunk if no great increased one segment. Biomechani- cally, it is impossible to move the pelvis without mo- jCommand tion in the spine because it is connected with the »Shrug your pelvis up.
Pelvic patterns can be done with the patient lying, sitting, quadruped, or standing. The side that jMovement is moving must not be weight-bearing. Side-lying The pelvis moves up and forward with a small pos- illustrated allows free motion of the pelvis and terior tilt to follow the arc movement. At the same time, an elon- The movements and muscle components main- gation on the contralateral side occurs.
Start with your knees and the mid-position the line of the resistance is almost elbows flexed to pull the iliac crest down as well as straight back. At the end of the motion the resis- back. As the movement progresses, your elbows and tance is up toward the ceiling. The upper side left of the trunk is body. Start by pulling the pelvis back toward you shortened and laterally flexed with no change in and down toward the table.
As the pelvis moves to lumbar lordosis. Posterior Depression. The upper side left of Overlap and reinforce the hold with your other the trunk is elongated with no change in the lumbar hand. The fingers of both hands point diagonally lordosis. Continued pressure should not Anterior Depression and Posterior cause the patient to roll forward or rotate the spine Elevation. The pelvis moves in a ventral The therapist stands behind the patient, facing to- convex arc, ventral and up see arc,.
There are four possible grips: T ere is an elongation of the trunk on that side with- 1. Place the fingers of one hand on the greater out a change in the lumbar lordosis. The other hand may reinforce the first hand. Stand upright in stride 2. For a grip using the leg, place your right hand position with your elbows extended. Stand upright with your knees slightly bent in stride 3.
Place the slightly flexed fingers of one hand on position behind the patient. Adler Dominiek Beckers Math Buck. Fully illustrated guide: approx.
Pages Basic Procedures for Facilitation. Patient Treatment. Patterns of Facilitation. The Scapula and Pelvis. The Upper Extremity.
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