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Selecting the most appropriate treatment for a given patient involves both patient factors (e.g.

, age,
co-morbidities and compliance) and tear characteristics (e.g., location of tear/age/reducibility of
tear).

PHILOSPHY:

The philosophy of PNF approach is based on the hypothesis that all human
beings have untapped existing potential. Hence the role of the physiotherapist is
to evaluate the dysfunctions and facilitate the optimal physical functional ability
of the patient. Therapist should develop an effective rapport with the patient to
facilitate the optimal functional level and to assure his/her full participation in
the rehabilitation program. For this, the therapist should identify the strength of
patient that would become foundation for his/her re-education and learning.
Because to achieve success, one should work from the someone’s strength
rather than his/her deficits. Short term and long term goals should be developed
on the basis of the evaluation and need of the patient. Based upon the
established goal, the treatment program should be designed to treat the
diagnosed functional limitations. When treating neuromuscular dysfunctions
complex motor patterns are reduced to their basic movement and developmental
components. The emphasis should be placed on the selective re-education of
individual motor elements through the development of fundamental skills of
trunk control, stability and co-ordinated movement. A repetition of the learned
movement and postures is necessary for the reinforcement. The intensity of the
program should be graded to meet the specific strength and endurance needed
for the performance of efficient postures and movements.

They studied researchers such as Sherrington, Gellhorn, Coghill, Gesell,


Helebrandt and others who documented the influence of stretch reflex,
resistance, traction, irradiation and other proprioceptive input on muscle
response. Kabat and Knott combined spiral and diagonal movement patterns
with the procedures and techniques that induces the muscular contraction,
relaxation and strengthening. They integrated the pattern of movement because
all normal coordinated movements occur in spiral or diagonal motions and
muscular contractions are strongest and most co-ordinated during diagonal
patterns of movement.

. Originally, PNF techniques were used as the rehabilitation therapy of


paralysed and stroke patient for
Factors that are responsible neurologically are Proprioceptors, Golgi Tendon
Organ
The nerve endings that relay all the information about muscle skeletal system to
the CNS are called proprioceptors. It detects any changes in physical
displacement and changes in tension or force within the body. It related to
stretching are located in the tendons and in the muscle fibres. Muscle spindle or
stretch receptors: Primary (type 1) or Secondary (type 2). Afferent fibres arise
from the muscle spindles, synapses on the other alpha or gamma motor neurons
and facilitate contraction of the extrafusal and intrafusal fibres.
Golgi tendon organ is located near the musculotendinous junction and wraps
around the ends of extrafusal fibres of a muscle. It is sensitive to the tension in a
muscle caused by either passive stretch or active muscle contraction and has a
high threshold for fib ring with passive stretch. When excessive tension
develops in a muscle Golgi tendon organ fibres inhibit motor neuron activity
and decreases tension in the muscle.
Pacinian Corpuscles Located closes to the Golgi tendon organ and is
responsible for detecting changes in the movement and pressure within the
body. When the muscle is stretched, muscle spindle records the change in the
length and sends signals to the spine. Which convey this information triggering
the stretch reflex which attempts to resist the change in muscle length by
causing the stretched muscle contract. Gradually train stretch receptors to allow
greater lengthening of the muscles. Component of the stretch reflex are; It has
both a dynamic component and a static component. The reason that the stretch
reflex has two components is because these are actually two kinds of intrafusal
muscle fibres: nuclear chain fibres, which are responsible for the static
component, and nuclear bag fibres, which are responsible for dynamic
component.
When the muscle contracts, they produce tension at the point. Where the muscle
is connected to the tendon, where the Golgi tendon organ is located, that records
the change in tension and rate of change of tension. When this tension is
exceeds a certain thresholds ,it triggers the lengthening reaction ,which inhibits
the muscles from contracting and causes them to relax that is inverse mitotic
reflex ,autogenic inhibition and clasped knife reflex. When an agonist contracts,
in order to cause the desired motion, it usually forces the antagonist to relax.
This phenomenon is called reciprocal inhibition because the antagonist is
inhibited from contracting. Sometime called reciprocal innervations.
Mechanism for Autogenic Inhibition: Autogenic inhibition reflex is
triggered when an excessive tension is applied to a muscle, then this
tension is monitored by GTO that sends the impulses to spinal cord by Ib
afferent fibres. These afferents have their cell bodies in Dorsal root
ganglia of spinal cord that synapse onto an interneuron called Ib
inhibitory interneuron. This interneuron makes an inhibitory synapse onto
the alpha motor neuron that innervates the homonymous muscle that
inhibits the contraction of same muscle and facilitates relaxation.

Mechanism of Reciprocal Inhibition:


When a muscle is contracted, the reflex is triggered and impulse is transmitted
by Ia afferent fibres. The Ia afferent fibres bifurcates in the spinal cord. One of
the branch synapses with alpha motor neuron that in turn facilitates the
homonymous muscle to contract, producing behavioural reflex. The other
branch synapse with Ia inhibitory interneuron, which further synapse with alpha
motor neuron of the antagonist muscle. As this interneuron is inhibitory, it
inhibits the contraction of antagonist muscle.
According to Sherrington, an afferent impulse travelling up from peripheral
receptors in the muscles causes an impulse cascade that result in the discharge
of a limited number of specific neurons along with the discharge of surrounding
motor neurons in the subliminal fringe area. So the impulse that causes the
recruitment and discharge of additional motor neurons within the subliminal
fringe is known to be FACILITATORY. But the stimulus that causes motor
neurons to drop out of discharge zone and away from the subliminal fringe is
known to be INHIBITORY. Facilitation results in increased excitability
whereas inhibition results in decreased excitability of motor neurons. Thus the
function of weak muscles could be aided by facilitation and muscle spasticity
could be decreased by inhibition.

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