UPPER EXTREMITY DIAGONAL PATTERNS
NOTE: All descriptions for hand placements are for the patient’s right (R) upper extremity. During each pattern tell the patient to watch the moving hand. Be sure that rotation shifts gradually from internal to external rotation (or vice versa) throughout the range. By mid-range, the arm should be in neutral rotation. Manual contacts (hand placements) may be altered from the suggested placements as long as contact remains on the appropriate surfaces. Resist all patterns through the full, available ROM.
Starting Position. Position the upper extremity in shoulder extension, abduction, and internal rotation; elbow extension; forearm pronation; and wrist and finger extension with the hand about 8 to 12 inches from the hip.
Hand Placement. Place the index and middle fingers of your (R) hand in the palm of the patient’s hand and your left (L) hand on the volar surface of the distal forearm or at the cubital fossa of the elbow.
Verbal Commands. As you apply a quick stretch to the wrist and finger flexors, tell the patient “Squeeze my fingers, turn your palm up; pull your arm up and across your face,” as you resist the pattern.
Ending Position. Complete the pattern with the arm across the face in shoulder flexion, adduction, external rotation; partial elbow flexion; forearm supination; and wrist and finger flexion.
D1Extension
Starting Position. Begin as described for completion of D1Flexion.
Hand Placements. Grasp the dorsal surface of the patient’s hand and fingers with your (R) hand using a lumbrical grip. Place your (L) hand on the extensor surface of the arm just proximal to the elbow.
Verbal Commands. As you apply a quick stretch to the wrist and finger extensors, tell the patient, “Open your hand” (or “Wrist and fingers up”); then “Push your arm down and out.”
Ending Position. Finish the pattern in shoulder extension, abduction, internal rotation; elbow extension; forearm pronation; and wrist and finger extension.
Starting Position. Position the upper extremity in shoulder extension, adduction, and internal rotation; elbow extension; forearm pronation; and wrist and finger flexion. The forearm should lie across the umbilicus.
Hand Placement. Grasp the dorsum of the patient’s hand with your (L) hand using a lumbrical grip. Grasp the dorsal surface of the patient’s forearm close to the elbow with your (R) hand.
Verbal Commands. As you apply a quick stretch to the wrist and finger extensors, tell the patient, “Open your hand and turn it to your face”; “Lift your arm up and out”; “Point your thumb out.”
Ending Position. Finish the pattern in shoulder flexion, abduction, and external rotation; elbow extension; forearm supination; and wrist and finger extension. The arm should be 8 to 10 inches from the ear; the thumb should be pointing to the floor.
D2Extension
Starting Position. Begin as described for completion of D2Flexion.
Hand Placement. Place the index and middle fingers of your (R) hand in the palm of the patient’s hand and your (L) hand on the volar surface of the forearm or distal humerus.
Verbal Commands. As you apply a quick stretch to the wrist and finger flexors, tell the patient, “Squeeze my fingers and pull down and across your chest.”
Ending Position. Complete the pattern in shoulder extension, adduction, and internal rotation; elbow extension; forearm pronation; and wrist and finger flexion. The forearm should cross the umbilicus.
LOWER EXTREMITY DIAGONAL PATTERNS
NOTE: Follow the same guidelines with regard to rotation and resistance as previously described for the upper extremity. All descriptions of hand placements are for the patient’s (R) lower extremity.
Starting Position. Position the lower extremity in hip extension, abduction, and internal rotation; knee extension; plantar flexion and eversion of the ankle; and toe flexion.
(NOTE: This pattern may also be initiated with the knee flexed and the lower leg over the edge of the table.)
Hand Placement. Place your (R) hand on the dorsal and medial surface of the foot and toes and your (L) hand on the anteromedial aspect of the thigh just proximal to the knee.
Verbal Commands. As you apply a quick stretch to the ankle dorsiflexors and invertors and toe extensors, tell the patient, “Foot and toes up and in; bend your knee; pull your leg over and across.”
Ending Position. Complete the pattern in hip flexion, adduction, and external rotation; knee flexion (or extension); ankle dorsiflexion and inversion; toe extension. The hip should be adducted across the midline, creating lower trunk rotation to the patient’s (L) side.
D1Extension
Starting Position. Begin as described for completion of D1Flexion.
Hand Placement. Place your (R) hand on the plantar and lateral surface of the foot at the base of the toes. Place your (L) hand (palm up) at the posterior aspect of the knee at the popliteal fossa.
Verbal Commands. As you apply a quick stretch to the plantarflexors of the ankle and toes, tell the patient, “Curl (point) your toes; push down and out.”
Ending Position. Finish the pattern in hip extension, abduction, and internal rotation; knee extension or flexion; ankle plantarflexion and eversion; and toe flexion.
D2Flexion
Starting Position. Place the lower extremity in hip extension, adduction, and external rotation; knee extension; ankle plantarflexion and inversion; and toe flexion.
Hand Placement. Place your (R) hand along the dorsal and lateral surfaces of the foot and your (L) hand on the anterolateral aspect of the thigh just proximal to the knee. The fingers of your (L) hand should point distally.
Verbal Commands. As you apply a quick stretch to the ankle dorsiflexors and evertors and toe extensors, tell the patient, “Foot and toes up and out; lift your leg up and out.”
Ending Position. Complete the pattern in hip flexion, abduction, and internal rotation; knee flexion (or extension); ankle dorsiflexion and eversion; and toe extension.
D2Extension
Starting Position. Begin as described for the completion of D2Flexion.
Hand Placement. Place your (R) hand on the plantar and medial surface of the foot at the base of the toes and your (L) hand at the posteromedial aspect of the thigh, just proximal to the knee.
Verbal Commands. As you apply a quick stretch to the plantarflexors and invertors of the ankle and toe flexors, tell the patient, “Curl (point) your toes down and in; push your leg down and in.”
Ending Position. Complete the pattern in hip extension, adduction, and external rotation; knee extension; ankle plantarflexion and inversion; and toe flexion.
There are a number of specific techniques that may be used during the execution of a PNF pattern to stimulate weak muscles further and enhance movement or stability. These techniques are implemented selectively by the therapist to evoke the best possible response from the patient and to focus on specific treatment goals.
Rhythmic Initiation
Rhythmic initiation is used to promote the ability to initiate a movement pattern. After the patient voluntarily relaxes, the therapist moves the patient’s limb passively through the available range of the desired movement pattern several times so the patient becomes familiar with the sequence of movements within the pattern. It also helps the patient understand the rate at which movement is to occur. Practicing assisted or active movements (without resistance) also helps the patient learn a movement pattern.
Repeated, dynamic contractions, initiated with repeated quick stretches followed by resistance, are applied at any point in the ROM to strengthen a weak agonist component of a diagonal pattern.
Many functional activities involve quick reversals of the direction of movement. This is evident in diverse activities such as sawing or chopping wood, dancing, playing tennis, or grasping and releasing objects. The reversal of antagonists technique involves stimulation of a weak agonist pattern by first resisting static or dynamic contractions of the antagonist pattern. The reversals of a movement pattern are instituted just before the previous pattern has been fully completed. The reversal of antagonists technique is based on Sherrington’s law of successive induction. There are two categories of reversal techniques available to strengthen weak muscle groups.
Slow reversal. Slow reversal involves dynamic concentric contraction of a stronger agonist pattern immediately followed by dynamic concentric contraction of the weaker antagonist pattern. There is no voluntary relaxation between patterns. This promotes rapid, reciprocal action of agonists and antagonists.
Slow reversal hold. Slow reversal hold adds an isometric contraction at the end of the range of a pattern to enhance end-range holding of a weakened muscle. With no period of relaxation, the direction of movement is then rapidly reversed by means of dynamic contraction of the agonist muscle groups quickly followed by isometric contraction of those same muscles. This is one of several techniques used to enhance dynamic stability, particularly in proximal muscle groups.
Another technique to improve isometric strength and stability of the postural muscles of the trunk or proximal stabilizing muscles of the shoulder girdle and hip is alternating isometrics. Manual resistance is applied in a single plane on one side of a body segment and then on the other. The patient is instructed to “hold” his or her position as resistance is alternated from one direction to the opposite direction. No joint movement should occur. This procedure isometrically strengthens agonists and antagonists; and it can be applied to one extremity, to both extremities simultaneously, or to the trunk. Alternating isometrics can be applied with the extremities in open-chain or closed-chain positions.
For example, if a patient assumes a side-lying position, manual contacts are alternately placed on the anterior aspect of the trunk and then on the posterior aspect of the trunk. The patient is told to maintain (hold) the side-lying position as the therapist first attempts to push the trunk posteriorly and then anteriorly. Manual contacts are maintained on the patient as the therapist’s hands are moved alternately from the anterior to posterior surfaces. Resistance is gradually applied and released. The same can be done unilaterally or bilaterally in the extremities.
Rhythmic stabilization is used as a progression of alternating isometrics and is designed to promote stability through co-contraction of the proximal stabilizing musculature of the trunk as well as the shoulder and pelvic girdle regions of the body. Rhythmic stabilization is typically performed in weight-bearing positions to incorporate joint approximation into the procedure, hence further facilitating co-contraction. The therapist applies multidirectional, rather than unidirectional, resistance by placing manual contacts on opposite sides of the body and applying resistance simultaneously in opposite directions as the patient holds the selected position. Multiple muscle groups around joints must contract, most importantly the rotators, to hold the position.
For example, in the selected position, the patient is told to hold that position as one hand pushes against the posterior aspect of the body and the other hand simultaneously pushes against the anterior aspect of the body. Manual contacts are then shifted to the opposite surfaces and isometric holding against resistance is repeated. There is no voluntary relaxation between contractions.
Use of these special techniques, as well as others associated with PNF gives the therapist a significant variety of manual resistance exercise techniques to increase muscle strength and to promote dynamic stability and controlled mobility as the foundation of and in preparation for initiating task-specific skilled movements in a rehabilitation program.
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