PNF本体感觉神经肌肉易化技术

神经肌肉本体感觉促进技术 (proprioceptive neuromuscular facilitation) PNF,背景,1940-1954年，Dr. Herman Kabat 在Washington，D.C.首先开始使用PNF的治疗技术，用于治疗骨性疾患的疾病；1956年，第一本PNF的书出版；随后，PNF被进一步发展；英文第二版1999年出版,Introduction,Initially developed (Knott & Voss, 1940s-1950s) for patients with permanent neurological disorders techniques can be applied to athletic injuries/rehabilitationGoal is to have an increased neuromuscular response (usually an increase in strength) but can also be used to increase relaxation (inhibition),概念,利用运动觉、姿势感觉等刺激，增强有关神经肌肉反应，促进相应肌肉收缩；利用牵张、关节压缩、牵引和施加阻力等本体感觉刺激，促进功能恢复；,PNF治疗作用,在不同的姿势发展稳定和动态平衡同等地增强所有肌群的肌力增强耐力改善协调改善运动控制技能在增加运动的同时产生放松,PNF技术的神经生理学原理,交互抑制：肌肉收缩时肌梭将兴奋传递到运动神经元，同时将抑制传递到拮抗肌；放射论：对较强运动肌肉给予最大的阻力可引起较弱运动肌肉的收缩；相继诱导：通过拮抗肌的收缩促进主动肌运动模式的发展；肢体运动模式：每个运动模式有三种成份（屈或伸、外展或内收、内旋或外旋的组合）；,螺旋对角交叉式的基本原理,符合正常的生理运动形式：大多数肌肉的附着点和纤维的排列；自主运动由大量的运动模式，而不是由单一的肌肉运动组成；对角线形式运动是屈伸、内外旋、内收外展三对肌肉的相互作用所形成的运动，是正常发育的最后部分和最高形式；,所有对角线形式运动都跨越中线，能促进身体两侧的相互作用；对角线形式的运动总是合并旋转的成分，而旋转是发育的最后、最高形式之一；,充分挖掘潜能：所有个体都有尚未开发的潜能； 利用各种反射：早期运动由反射活动控制，成熟运动通过姿势反射得到强化或加强； 按照正常发育顺序：从头到脚，由近及远；拮抗中平衡：早期的动作是在屈肌和伸肌优势交替转换中向前发展的；,PNF的治疗原理（1）,注意双向运动(屈伸,伸屈)：早期动作是有节律性的、可逆转的、自发性的屈伸运动；正常运动与姿势取决于“协同作用”与拮抗肌的相互平衡影响；,动作发展是按照运动和姿势的总体模式的一定顺序进行的； 动作的发育具有一定的规则和顺序，但并非按部就班，其间可有跳跃和重叠；动作能力的提高依赖于动作的学习；,PNF的治疗原理（2）,重复所学动作：反复刺激和重复动作可促进和巩固动作的学习，发展肌力和耐力； 强调感觉反馈：借助于视觉、听觉、前庭感觉、本体感觉、平衡反应； 治疗要有目的：借助促进技术加强有目的性的活动。,特点,螺旋对角交叉式的运动模式；借助于视觉、听觉、前庭感觉、本体感觉、平衡反应；屈、伸肌相互交替收缩，以维持一动作或姿势的稳定；反复刺激、反复自我学习的过程；极具开发潜能、较难掌握的一种技术；,肩,D2F屈曲,D1F屈曲,D1E伸展,D2E伸展,屈曲（肩）外旋（肩）旋后（前臂）桡侧偏（腕）,外展（肩）腕伸展指伸展,伸展（肩）内旋（肩）旋前（前臂）尺侧偏（腕）,内收（肩）腕屈曲指屈曲,体育运动中所见的PNF范型,上肢伸展内收内旋范型：网球中的击球 排球中的扣球屈曲外展外旋范型：柔道伸展外展内旋范型：自由泳屈曲内收外旋范型：仰泳下肢伸展内收内旋范型：柔道屈曲外展内旋范型：空手道伸展外展内旋范型：柔道屈曲内收外旋范型：足球,D1F进食、仰卧至俯卧 D1E反手打网球,D2F举双手赞同 D2E棒球手掷球后,髋,D2F屈曲,D1F屈曲,D1E伸展,D2E伸展,屈曲（髋） 踝关节背屈足趾伸展,外展（髋）内旋（髋）足外翻,伸展（髋）踝关节趾屈足趾屈曲,内收（髋）外旋（髋）足内翻,D1F踢球 D1E骑自行车上车,D2F中国功夫踢腿 D2E行走时摆动相,基本操作方法及技术,手法接触（manual contacts）牵张 （stretch）牵引 （traction）挤压 （approximation）最大阻力（maximal resistance）时序 （timing)口令交流（commands and communication）强化 （reinforcement）视觉刺激（optical stimulation）,Manual Contacts手法接触,“Pressure” used to give sensory clues to performing movement and generating stronger muscular contraction压力提供感觉暗示产生更强的肌肉收缩Apply over desired muscle/s and along line of desired motion沿着运动方向施加在目标肌肉Should not cause pain or discomfort不能产生疼痛或不舒适感,在肢体运动方向上任何一点施加相反的压力将刺激协同肌强化运动蚓状肌抓握能使治疗师很好控制运动而不会因挤压或给予身体骨骼的压力太大而引起患者疼痛,Commands and Communication口令与交流,Clinician can actively demonstrate or passively move patient through desired pattern of movement治疗师示范或被动活动患者Tell patient what to do voice inflection声音Sharp/strong commands increase muscle contractionSoft/calm commands promote relaxationModerate tones for directions/instructionsTerminology (guidelines, not absolutes)Flexion pattern “pull”Extension pattern “push”Isometrics “hold/relax”,言语指令告诉患者做什么及何时做指令必须是清楚明确指令的顺序对患者的反应与治疗师的手及阻力之间的协调是重要的指令指导运动和肌肉收缩的开始指令帮助患者校正运动或稳定,Stretch Reflex,Start pattern with agonist in lengthened state stretch facilitates stronger contraction of musclesTo initiate stretch reflex, briefly take beyond lengthened position牵引在于肌肉被拉长形成牵张反射Contraindicated if painful,Traction and Approximation牵引和挤压,Traction facilitates movement associated with flexion (“pull”) movementsApproximation facilitates stability associated with extension (“push”) movements挤压促进稳定、负重和抗重力肌的收缩Contraindicated if painful,Maximal Resistance最大阻力,Clinician applies maximal resistance which allows movement through full desired ROMAccommodating resistance is the ruleCan enhance muscular endurance by increasing repetitions/sets对较强的肌群施加阻力，以使兴奋向较弱的肌群扩散；所谓最大是相对的，不能大到患者收缩时发生振颤或不能作最大范围的ROM运动。,Timing for Emphasis时间顺序的强调,Normal timing in sequence of joint actions in order for movements to occurTypically move in distal to proximal relationshipCan be used to correct abnormal timing/muscle firing patterns可以用以纠正异常时间顺序的肌肉收缩模式Irradiation (overflow) occurs from stronger muscle/s to weaker ones stronger muscle/s augment and reinforce contraction of weaker ones时间顺序是在任何运动中肌肉收缩的顺序，其目的是保证运动的协调。,视觉,来自视觉系统的反馈能促进更有力的肌肉收缩用视觉帮助患者控制和纠正体位和运动眼睛的移动将影响头和身体的运动,特殊操作方法及技术,Classification of Techniques,Techniques directed to agonists直接作用主动肌Techniques using antagonists to facilitate contraction of agonists利用拮抗肌促进主动肌收缩Techniques using antagonists for relaxation of agonists利用拮抗肌放松主动肌,Techniques Directed to Agonists直接作用于主动肌,Objective: increase agonistic strength增强主动肌肌力Repeated contractions重复收缩Repetitive concentric contractions in agonistic pattern with no resistance to antagonists主动肌重复向心收缩(拮抗肌无阻力)Can add isometric holds at weak points in ROM在关节活动范围的弱点保持等长收缩,Rhythmic Initiation,The one exception to active motion in PNFProgression used for those who are very weak or unable to initiate a motion (passive to active-assisted to active)Rhythmic motion through a desired ROM beginning with passive motion,Rhythmic Initiation节律性起动,Description of techniqueTherapist moves the patient passively through a desired ROM, using speed and verbal commands to cue movementPatient is asked to move actively with therapist through ROMTherapist then begins to apply resistance,节律性起动（rhythmic initiation）,先给患者进行数次被动运动，然后让患者利用病变轻的肢体或借助滑车、重锤等工具给患肢进行数次自主的辅助运动，再试让患者自己作主动运动，成功后可作轻的抗阻运动。要注意与运动方向相反的运动是由治疗师完成的（回返动作）RI有改善起动运动的能力。RI对于帕金森综合征、较严重痉挛等难以起动运动的情况有用。,Techniques Using Antagonists to Facilitate Contraction of Agonists利用拮抗肌促进主动肌收缩,Slow reversal缓慢逆转Repeated alternating concentric contractions of agonists and antagonistsSlow reversal hold缓慢逆转维持Adds isometric hold/s at weak point/s in ROMRhythmic stabilization节律性稳定Co-contraction, muscle “setting”Quick reversalRepeated alternating concentric contractions of agonists and antagonists at increased pace,Slow Reversals缓慢逆转,使拮抗的两个肌群缓慢地交替地作等张收缩，在逆转中没有间歇，若关节周围的肌肉不平衡，阻力应先加在强的肌群上，阻力的强度应使患者能完成最大范围的ROM运动；SR的作用是促进主动肌，松弛拮抗肌，增加主动肌的肌力、耐力及协调主动肌和拮抗肌之间的运动。其原理是利用Sherrington的相继诱导定律（low of successive induction），即拮抗肌收缩停止的瞬间，对主动肌有促进作用。,Rhythmic Stabilization节律性稳定,Description of techniqueAlternating isometric contraction against resistance, no motion intendedTherapist slowly increases resistance of agonist which patient resists until maximum, then slowly decrease and add resistance in opposite direction交替地使主动肌和拮抗肌作等长收缩，是发展稳定性，刺激协同肌的活动和松弛对抗肌的手法。 有提高肌力、提高稳定性和协调性的作用。,Techniques Using Antagonists for Relaxation of agonists利用拮抗肌放松主动肌,Relaxation techniques (stretching)Contract-relaxPassive agonistic motion followed by contraction of antagonists through ROMHold-relaxPassive agonistic motion followed by isometric contraction of antagonists,Hold Relax维持放松,Description of techniquePatient actively contracts agonist in available ROMTherapist provides resistance to an isometric contraction of the antagonistPatient again actively contracts agonist to new available ROM患者主动活动关节到末端，治疗师给予拮抗肌（限制肌）等长抗阻收缩（最少维持5秒），最后主动活动关节到增加的活动范围。,Example腘绳肌紧张限制了伸膝先伸膝到现有活动范围，然后让腘绳肌作等长抗阻收缩5-8秒，再放松，主动伸膝。适应证：被动关节活动度降低、疼痛、患者等张收缩太强治疗师无法控制,Contract Relax收缩放松,Description of techniqueActive contraction of agonists to end of available ROM followed by concentric contraction of antagonists, then another active contraction of agonists to new available ROM收缩放松与维持放松不同点仅在于收缩放松时不作等长抗阻收缩而作等张抗阻收缩,When to Use PNF Techniques,Increase ROM增加关节活动度Contract-Relax, Hold-relax, rhythmic initiation, rhythmic stabilizationIncrease Initiation of ROM增加关节活动起动Repeated Contraction, Rhythmic InitiationIncrease Strength增加肌力Slow reversal, repeated contractions, rhythmic stabilization,When to U