NEURORESTORASI PASIEN PASCA

STROKE FASE POST AKUT

: Pendekatan Konsep PNF
(Proprioceptive Neuromuscular Facilitation)
Dr. Umi Budi Rahayu, SSt. FT., Ftr. MKes

Disampaikan dalam Seminar dan Miniworkshop Stikes ‘Aisyiyah Surakarta

07 April 2019
Outline:
• Neurorestorasi _5 menit
• Fase stroke_10 menit
• Problem of post stroke: ICF_15 menit
• Pendekatan Konsep PNF_75 menit
• Contoh-contoh intervensi yang bisa dilakukan untuk pasca stroke
dengan pendekatan Konsep PNF_50 menit
• Kesimpulan_5 menit
NEURORESTORASI
• Restorative neurology is defines as the branch of neurological
sciences which applies active procedures to improve functions of the
impaired nervous system through selective structural or functional
modification of abnormal neuron control according to underlying
mechanisms and clinically unrecognized residual functions.
(Hamburg, 1985).
• Neurorestorasi pasca stroke dicapai dengan meningkatnya
neurogenesis, angiogenesis, dan oligodendrogenesis, yang
merupakan peningkatan perbaikan saraf (Chen et al., 2014).
• Lingkup neurorestorasi meliputi neurofisiologi terapan, neurobiologi
klinis dan fungsional neurologi.
FASE STROKE
Phases of stroke
 Problem of post stroke
(khususnya problem sensomotorik)

Area lateral premotor dan area supplementary motor Intracortical network 1 (Stein, 2009)
(Lundy-Ekman, 2013)
Medial dan Lateral upper motor neurons (UMNs)
(Lundy-Ekman, 2013).
The 7 basic measurement instruments
1. Muscle strength on the hemiplegic side ᷉ Motricity Index (MI)
2. Trunk activity ᷉ Trunk Control Test (TCT)
3. Balance ᷉ Berg Balance Scale (BBS)
4. Walking speed ᷉ 10 Meter Walk Test (10MWT)
5. Walking ability ᷉ Functional Ambulatory Categories (FAC)
6. Dexterity ᷉ Frenchay Arm Test (FAT)
7. Basic ADL activities ᷉ Barthel Index (BI)
Problem of post stroke
Pendekatan Konsep PNF
• Regenerasi saraf *video
PHYSLOSOPLY OF
PNF CONCEPT
Motor control
(4 stages)

SKILL
 Basic principles and
procedures of PNFC

Basic
Procedure
principles

1. Body position &

Exteroceptor stimuli: Proprioceptor stimuli: mechanics
Tactile stimulation Resistance 2. Timing
Visual stimulation Traction & Approximation 3. Pattern
Auditory stimulation Stretch 4. Irradiation &
Reinforcement
Exteroceptors stimuli

Tactil Visual Auditory

• Manual contact • Visual references to • Verbal
(lumbrical contact) patient’s body stimulation/command
• Contact environment • Visual references to • Others
environment
• Eye contact patient-
therapist
Proprioceptor stimuli

Traction &
Resistance Approximation
Stretch
• Optimal resistance • To stimulate joint • On muscles under
• Considering type of receptor tension of elongation -
muscle contraction: • Traction: elongation of short term elongation
• Dynamic (concentric, joint receptor & - quick stretch
eccentric) & Static longitudinal axis • On muscles under
(isometric) • Approximation: tension of contraction -
• Three dimensional quick/slow re-stretch
direction approximation & • Maintained elongation
maintain approximation - eg for inhibition
 Procedure

Irradiation & Body position and

Timing Reinforcement mechanics Patterns
• The sequence of • The spread of • Main key for PNF • Three
motions response to patterns dimensional
• Facilitate weak stimulation • Therapist & muscle chain
components and within the patients position • In relation to the
motion nervous system - movement body-diagonal
• Used for • Groove
facilitation or for • Line in diagonal
inhibition motion
• Overflow
• Indirect approach
Clinical application of irradiation &
reinforcement
Irradiation: the spreading and increased strength of the response to stimulation
(it occurs when either the number of stimulus or the strength of the stimuli are
increased).
Reinforcement: to strengthen by new addition, make stronger.
Summation: spatial and temporal summation.
The clinical application:
1. start with strong part
2. use some part of pattern
3. Use straight pattern
4. In groove
5. Use basic principles: approximation, resistance, tactile stimulation
Pentingnya stimulus:
Clinical application of body position & body
mechanics
1. Stay in diagonal motion
2. Move together with patient and therapist in a groove
3. This can be guide coordination movements
4. Therapist position is one step advance position than patient
5. Considering patient safety of physically and emotion
Clinical application of pattern
1. Prepare activities of daily life: functional activities, efficacy
2. use of irradiation: the other part action, easy facilitaion
3. Treat on level of body function and body structure: stretching,
mobilizing
----
4. Symmetrical or asymmetrical
5. Bilateral or single
Techniques of PNF Concept

RELAXATION AND/OR
AGONISTIC ANTAGONISTIC
STRETCHING
TECHNIQUES TECHNIQUES
TECHNIQUES
Rhythmic Initiation Stabilizing
Combination of Isotonic Contract Relax Reversal
(Agonistic Reversal)
Replication Dynamic Reversal
Repeated Stretch from
beginning of Range
Hold Relax Rhythmic
Repeated Stretch
through Range Stabilization
 Purpose of agonistic techniques
(involve one muscle group/muscle chain, with focus in one direction)
Rhythmic Initiation
Teach a desired movement
or pattern
Assist in initiation of motion
Patient relaxation when abnormally
increased muscle tone is present
Normalize the velocity of
motion
Improve coordination and
kinesthetic awareness
Combination of
Replication
Isotonic
Increase power and muscular Teach the route to the end position (outcome)
of the desired pattern / functional movement
endurance over time
Assess the patient’s ability to sustain a
contraction at the end of the desired pattern or
Improve coordination and active
control of motion
functional movement
Assess the patient’s ability to return to a pre-determined
end position from various points further away from the
Improve movement control within a end position
functional activity (especially effective for
eccentric control)
Improve coordination
Functional training for Activities of
daily Living (ADL) Improve body awareness
Teach a pattern (find the Improve DLA (daily life
goove) activities)
Purpose of RELAXATION and/or stretching
techniques

Contrac Relax Hold Relax

Relaxation and/or stretching
Relaxation and/or stretching of muscles
of muscles
Increase ROM

Increase ROM
Decrease pain
 Purpose of antagonistic techniques
(involve agonists and antagonists with focus in both di directions)

Dynamic Reversals Stabilizing Reversals Rhythmic Stabilization

Increase muscle power Increase stability Increase stability looking for co-
and endurance contraction
Improve postural control Improve postural control and
Increase active range of
motion balance
Improve coordination Improve coordination
Improve ability to coordinate Maintain a position
change of direction Maintain a position
Teach (re-education) a new
Teach (re-educate) a new position or ROM
Reduce fatigue position or ROM
Increase static muscle power
Increase muscle power and endurance
Normalize tone and endurance Promote relaxation
Intervensi Konsep PNF pasca stroke
(post acute)
Outcome:
1. Muscle strength on the hemiplegic side
2. Trunk activity
3. …to the next phases
Physiotherapy processes:
1. Assessment (on Form)
2. Treatment planning (on Form)
3. The best technique for the problem (PNF intervention):
- Goals/reasons
- Position
- Patterns/movement
- Techniques
- Remaks
Demonstration
• Contoh-contoh latihan dengan pendekatan PNF
Muscle strength on the hemiplegic side
(Upper and lower extremity)
Latihan 1.
• Body position and mechanics:

• Manual contact:

• Resistance:

• Timing:

• Pattern:

• Irradiation/reinforcement:

• Functional activity:
Muscle strength on the hemiplegic side
(Upper and lower extremity)
Latihan 2.
• Body position and mechanics:

• Manual contact:

• Resistance:

• Timing:

• Pattern:

• Irradiation/reinforcement:

• Functional activity:
Muscle strength on the hemiplegic side
(Upper and lower extremity)
Latihan 3.
• Body position and mechanics:

• Manual contact:

• Resistance:

• Timing:

• Pattern:

• Irradiation/reinforcement:

• Functional activity:
Trunk activity
Latihan 1.

• Body position and mechanics:

• Manual contact:

• Resistance:

• Timing:

• Pattern:

• Irradiation/reinforcement:

• Functional activity:
Trunk activity
Latihan 2.

• Body position and mechanics:

• Manual contact:

• Resistance:

• Timing:

• Pattern:

• Irradiation/reinforcement:

• Functional activity:
Trunk activity
Latihan 3.

• Body position and mechanics:

• Manual contact:

• Resistance:

• Timing:

• Pattern:

• Irradiation/reinforcement:

• Functional activity:
KESIMPULAN
TERIMA KASIH