Proprioceptive
Neuromuscular Facilitation
Proprioceptive Neuromuscular Facilitation
(PNF): Principles and Techniques
Developed in the 1940s and 1950s by
Kabat, Knott, and Voss. Their work
integrated the analysis of movement
during functional activities with theories of
motor development, motor control, and
motor learning. They used principles of
neurophysiology as the foundation of their
approach to exercise and rehabilitation.
(PNF): Principles and Techniques (cont.)
PNF: an approach to therapeutic exercises
that combines functionally based diagonal
patterns of movement with techniques of
neuromuscular facilitation to evoke motor
responses and improve neuromuscular
control and function.
PNF techniques have widespread
application for rehabilitation of patients with
musculoskeletal conditions that result in
altered neuromuscular control of
extremities, neck, and trunk.
Diagonal PNF Patterns
Diagonal patterns of PNF movement
are composed of multi-joint, multi-
planar, diagonal and rotational
movements of the extremities, trunk,
and neck.
Multiple muscle groups contract
simultaneously.
Diagonal PNF Patterns (cont.)
2 pairs of Diagonal 1 Diagonal 2
diagonal patterns (D1) (D2)
for both UEs and
LEs and both D1 Flexion D2 Flexion
pairs can be
performed in
flexion and D1 D2
extension. Extension Extension
Diagonal PNF Patterns (cont.)
The patterns are identified by the motions
occurring at the proximal joint: either shoulder
or the hip depending on which extremity is
moving.
Flexion or extension is coupled with abduction
or adduction as well as External Rotation or
Internal Rotation
The distal units also move simultaneously.
There are specific patterns for scapula and
pelvis and techniques that integrate diagonal
movements into functional activities such as
rolling, crawling, and walking.
Patient-Therapist Contact During PNF
Major contributors to the best performance
of neuromuscular response
1. PT’s manual contacts
2. Maximal resistance provided by PT
3. Position and movement of the PT
4. Stretch
5. Normal timing
6. Traction
7. Approximation
8. verbal commands
9. Visual cues
Stretch Stimulus and Stretch Reflex
Stretch is a valuable way of initiating
contraction; and when applied to
weak muscles, increases their
response and accelerates their
strengthening process.
Stimulation of muscle spindle elicits a
reflex contraction of the muscle
If the stimulus is of optimal threshold
And the reflex arch is intact
Application of stretch stimulus
Repeated stimulation of spindles
The muscles that need to work
are put in a full stretch --- stimulus
All components of the pattern
Tension felt in all working muscle
groups
Application of stretch reflex
A controlled and sustained stretch at the
muscles’ maximum extended range is
combined with a dynamic command; so the
patient’s maximum voluntary effort can be
induced to perform the movement.
Command provided by PT: Now (Stretch) …
Pull!
Voluntary effort is obtained by rhythmical
repetition of this technique until the
maximum response obtainable is achieved
Application of stretch reflex
Stretching of the muscle spindles
leads to the summation of the stimuli
--- causing movement
Summation is achieved by rhythmical
repetition of the stretch stimulus
technique
Maximal Resistance
Greatest amount of resistance which
can be given to contracting muscles.
For isometric contraction:
hold.
For Isotonic Contraction:
coordinated movement through full
ROM
Application of Maximal Resistance
Applied manually to movements and
holdings in patterns of facilitation
All 3 components of the movement are
resisted maximally at every stage of the
movement
Variation in the strength of each
component and in different areas of the
range must be taken into account by
PT.
Uses of Reinforcement
Reinforcement always takes place from
strength
In a movement pattern, the maximal
contraction of strong muscles is used to
reinforce the action of weaker allied
muscles.
It is used with optimal timing to
emphasize the contraction of ineffective
or weak muscles to correct imbalances.
Specific Techniques Associated with
PNF
1. Rhythmic Initiation
2. Repeated Contractions
3. Reversal of Antagonists
1. Slow Reversal
2. Slow Reversal Hold
4. Alternating Isometrics
5. Rhythmic Stabilizations
Rhythmic Initiation
Used to:
Promote the ability to initiate a movement
pattern
Technique:
First pt voluntarily relaxes
PT passively moves the pt’s limb through the
available range of desired movement pattern
several times so that the patient becomes
familiar with the sequence and the rate of
movement within the pattern.
Also practicing assisted or active movements
will help the patient learn the pattern as well.
Repeated Contractions
Used to:
Strengthen a weak agonist component
of a diagonal pattern
Technique:
Repeated, dynamic contractions,
initiated with repeated quick stretches
followed by resistance
Applied at any point in the ROM
Reversal of Antagonists
Used to:
Stimulate 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
Based on Sherrington’s law of successive
induction
Two categories of this technique to strengthen
weak muscle groups.
Slow Reversal
Technique:
Involves a dynamic concentric
contraction of a stronger agonist pattern
immediately followed by a dynamic
concentric contraction of the weaker
antagonist pattern
No voluntary relaxation between patterns
Promotes rapid, reciprocal action of
agonists and antagonists.
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 a dynamic contraction of the agonist muscle
groups quickly followed by an isometric
contraction of those same muscle
One of several techniques to enhance dynamic
stability, particularly in proximal muscle groups.
Alternating Isometrics
Used to:
Improve isometric strength and stability of the postural muscle of the
truck or proximal stabilizing muscles of the shoulder girdle and hip
Technique:
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
Isometrically strengthens agonists and antagonists
Can be applied to one extremity, both simultaneously, or to the trunk;
in open or closed chain positions.
Rhythmic Stabilization
Used as:
A progression of alternating isometrics and is designed to
promote stability through co-contraction of the proximal
stabilizing muscles of the truck as well as shoulder and
pelvic girdle regions of the body.
Techniques:
Typically performed in WB positions to incorporate joint
approximation into the procedure, hence further
stimulating co-contraction
PT applies multidirectional, rather than unidirectional,
resistance by placing manual contacts n opposite sides of
the body and applying resistance simultaneously in
opposite directions as the patient holds the selected
position.
Multiple ms groups around joints must contract, most
importantly the rotators, to hold the position.
No voluntary relaxation between contractions
Hold-Relax Technique
Relaxation technique designed to
obtain a lengthening reaction of the
antagonistic muscles to the limited
range of movement of agonists.
Hold-Relax Technique
Usually performed at the point of
limited ROM in the agonist pattern.
An isometric contraction of the range
limiting antagonist pattern is performed
against slowly increasing resistance,
followed by voluntary relaxation and
passive movement into the newly
gained range of agonist pattern.
Hold-Relax Technique
Isometric contraction of the reciprocal
muscles:
Same technique as that for hypertonic
muscles
However, the isometric contraction done is
of agonists (that are limited in ROM due to
the hyper-tonicity of antagonists)
Done to obtain reciprocal relaxation of the
hypertonic group
