PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION

PNF

DEFINITION

• Proprioceptive: having to do with any of the sensory receptors that give information concerning movement and position of the body

• Neuromuscular: involving the nerves and muscles

• Facilitation: making easier

Mechanisms of PNF

• Autogenic inhibition: It a sudden relaxation of muscle upon development of high tension. It is a self-induced, inhibitory, negative feedback lengthening reaction that protects against muscle tear. Golgi tendon organs are receptors for the reflex.

• Reciprocal inhibition: contraction of agonist muscle elicits relaxation of antagonist.

• Stretch Reflex: sudden stretch of muscle spindle causes agonist to contract and antagonist to relax (ie., patellar tap reflex)

Basic Principles

• Patterns of movement - should be taught to patient

• Visual stimulus - look at moving limb• Verbal cues - to coordinate reflex and voluntary

movements• Manual contact - to resist and direct• Proper mechanics - body positioning of therapist• Resistance - should be maximal• Rotational movement - for maximal ROM

• Normal timing - proper sequence of muscle contraction

• Timing for emphasis - to affect specific points on a range

• Traction or approximation - for extra proprioceptive response

• Quick stretch - facilitates greater muscular contraction

• Proprioceptive neuromuscular facilitation is exercise based on the principles of functional human anatomy and neurophysiology.

• It uses– Proprioceptive– Cutaneous– Auditory inputTo produce functional improvement in motor output

and can be a vital element in the rehabilitation process of sports related injuries.

NEUROPHYSIOLOGICAL BASIS OF PNF

• Sherrington..– Concepts of facilitation and inhibition– Stretch reflex– Neurophysiological phenomena

FACILITATION

• Facilitory - an impulse causing the recruitment and discharge of additional motor neurons in the spinal cord– Results in increased

excitability in the muscles.– Weak muscles would be

aided through facilitation

INHIBITION

• Inhibitory - any stimulus that causes motor neurons to drop away from the discharge zone and away from the spinal cord.– Inhibition results in

decreased excitability of motor neurons.

– Muscle spasticity can be decreased

STRETCH REFLEX

• The stretch reflex involves two types of receptors

Muscle spindlesGolgi tendon organs

NEUROPHYSIOLOGICAL PHENOMENA

• RECIPROCAL INHIBITION• AUTOGENIC INHIBITION is defined as inhibition

mediated by afferent fibers from stretched muscle acting on the alpha motor neurons supplying that muscle, causing it to reflex

Reciprocal inhibition

• Is the second mechanism which deals with the relationships of the agonist and antagonist muscles

USES OF PNF• 1. PNF treatment has been used to increase

strength, flexibility, coordination and functional mobility.

• 2. The main goal of treatment is to facilitate the patient in achieving a movement or posture.

• 3. Stretches as well as diagonals and rational exercise patterns are used to improve ADL’s functional mobility and athletic performance

• 4. It is mainly used in orthopedic rehabilitation for musculoskeletal injuries and in neurological rehab.

• 5. PNF can be used for any condition, however the patient condition level may require modifications.

BASIC PRINCIPLES OF PNF

1. Resistance2. Irradiation and reinforcement3. Manual contact4. Stretch5. Verbal commands6. Traction and approximation7. Timing8. Body positioning and body mechanics

1. RESISTANCE

Opposing force to the patient’s movement is called resistance.

The amount of resistance provided during an activity must

be correct for the patient’s condition and the goal of the activity. This is called optimal

resistance.

1. RESISTANCE

Resistance is used in the treatment to:1. Facilitate the ability of the muscle to contract2. Increase motor control3. Help the patient gain an awareness of motion

and its direction4. Increase strength

IRRADIATION & REINFORCEMENT

DEFINITIONS

• Irradiation : the spread of response to stimulation is called irradiation.

• Reinforcement : means “to strengthen by fresh addition, make stronger”

IRRADIATION & REINFORCEMENT

Effects :• Maximal resistance may be used to cause

irradiation or overflow from stronger patterns to weaker patterns or from stronger groups of muscles within a pattern to weaker groups within the same pattern.

MANUAL CONTACT

Effects: 1. Stimulates the muscle2. Stimulates the synergistic muscle to reinforce

the movement3. Promotes trunk stabilization and indirectly

helps the limb motion4. Prevents confusion

Touch or manual contact

Contributes to facilitation by stimulating the exteroceptors and it should be

1. Purposeful2. Directional3. comfortable

STRETCH

• The stretch stimulus occurs when the muscle is elongated

• The lengthened position of the muscle is the starting position of each pattern and the stretch is maintained throughout the movement.

• All the components of a pattern must be stretched simultaneously

STRETCH

Effects:1. Stimulates the activity of muscle spindle2. Any contraction of muscle on stretch will

result in movement and the brain knows not of muscles but of movement.

Alpha Motor Neuron

Quick Stretch

+

Muscle Spindle

++

TRACTION

• Traction is elongation of trunk or an extremity

• Traction force is applied gradually, maintained throughout the movement, and combined with appropriate resistance.

TRACTION

• Joint separation stimulates joint receptors• Muscle stretch stimulates muscle spindle

stretch receptor• Facilitates Alpha Motor Neuron• Facilitates Strength

APPROXIMATION

• Definition: Approximation is the

compression of the trunk or an extremity.

• Compression through a joint stimulate joint receptors

• Facilitate alpha motor neuron• Facilitate stability

APPROXIMATION

Uses:1. Promote stabilization2. Facilitate weight bearing and contraction of

postural muscles3. Facilitate upright reactions4. Resist some component of motion. E.g., use

approximation at the end of shoulder flexion to resist scapula elevation

(11)

VERBAL STIMULATION (COMMANDS)

• The volume with which the command is given affects the strength of resulting muscle contraction.

• Louder command when strong muscle contraction is required.

Softer and calmer tone when the goal is relaxation and relief of pain.

VERBAL STIMULATION (COMMANDS)

• The command is divided into three parts:1. Preparation: readies the pt for action.

“ready”2. Action: tells the pt to start the action. “now

pull your leg up and in”3. Correction: tells the pt how to correct and

modify the action. “keep pulling your toes up”

Commmads used

• HOLD• PULL/PUSH• RELAX

TIMINGS

• Timing is the sequencing of motions

• Normal timing of most coordinated and efficient motions is from distal to proximal

• Timing for emphasis involves changing the normal sequencing of motion to emphasis a particular muscle or desired activity

BODY POSTION & BODY MECHANICS

• The therapist body should be in line of motion

• Shoulder and pelvis face the direction of motion.

• Therapist stands in walk standing position.

• The resistance comes from the therapist’s body, while the hands and arms stay comparatively relaxed.

TECHNIQUES OF PNF

• Rhythmic initiation• Repeated contraction• Slow reversal• Slow reversal-hold• Rhythmic stabilization

Strengthening techniques

• Contract relax• Hold relax

Stretching techniques

RHYTHMIC INITIATION• Progression from( agonist pattern)

USED IN• Limited ROM due to increase tone• Who are unable to initiate movement

PASSIVE

ACTIVE ASSISTED

ACTIVE

REPEATED CONTRATION

• Patient move isotonically against maximum resistance repeatedly until fatigue is evidenced

• When fatigue is evident then a stretch at that point in the range should facilitate the weaker muscles and results in coordinated movement.

• USED • To develop strength and endurance.

SLOW REVERSAL

• Involves isotonic contraction of the agonist followed immediately by an isotonic contraction of the antagonist.

• USED 1. For development of active ROM and2. Normal reciprocal timing b/w agonist and

antagonist

SLOW REVERSAL HOLD

• Involves isotonic contraction of the agonist followed immediately by an isometric contraction, with a hold command given at the end of each active movement.

• USED • In developing strength at a specific point in the

range of motion.

RHYTHMIC STABILIZATION

• Uses an isometric contraction of the agonist, followed by an isometric contraction of the antagonist.

• USED • To increase strength and endurance

STRETCHING TECHNIQUES/PNF STRETCHING

• It is often a combination of passive stretching and isometrics contractions.

• encourage flexibility and coordination throughout the limb's

entire range of motion.

• PNF is used to supplement daily stretching and is employed to make quick gains in range of motion to help athletes improve performance.

• Good range of motion makes better biomechanics, reduces fatigue and helps prevent overuse injuries.

CONTRACT-RELAX

• Moves the body part passively into the agonist pattern.

• Patient is instructed to push by contracting the antagonist isotonically against the resistance.

• USED• When ROM is limited by muscle tightness.

HOLD RELAX

• Begins with isometric contraction of the antagonist against resistance, followed by concentric contraction of the agonist muscle.

PNF STRETCHING

The initial movement is in the direction of the stretch

Next the athlete pushes in a direction against the stretch

The last movement is a repeat of the initial

PNF PATTERNS

• Each pattern has three dimension – 1. Flexion or extension 2. Abduction or adduction3. Rotation • Movement occurs in a straight line, in

diagonal direction with a rotatory component

UPPER EXTREMITY

F-ABD-ERF-ADD-ER

E-ABD-IR E-ADD-IR

PATTERNS

SHOULDERSHOULDER

D1 FlexionShoulder FLEX, ADD, ER

Forearm - Sup

Wrist - Rad. Flexion

Fingers - flexion

D1 FlexionShoulder FLEX, ADD, ER

Forearm - Sup

Wrist - Rad. Flexion

Fingers - flexion

D2 FlexionShoulder FLEX, ABD, ER

Forearm - Sup

Wrist - Rad. Flexion

Fingers - Extension

D2 FlexionShoulder FLEX, ABD, ER

Forearm - Sup

Wrist - Rad. Flexion

Fingers - Extension

D1 ExtensionShoulder EXT, ABD, IR

Forearm - Pro

Wrist - Ulnar. extension

Fingers - Extension

D1 ExtensionShoulder EXT, ABD, IR

Forearm - Pro

Wrist - Ulnar. extension

Fingers - Extension

D2 ExtensionShoulder EXT, ADD, IR

Forearm - Pro

Wrist - Ulnar ext.

Fingers - flexion

D2 ExtensionShoulder EXT, ADD, IR

Forearm - Pro

Wrist - Ulnar ext.

Fingers - flexion

Diagonal One Diagonal Two

F-ABD-ER E-ADD-IRF-ADD-ER E-ABD-IR

LOWER EXTREMITY

F-ABD-IRF-ADD-ER

E-ABD-IR E-ADD-ER

LOWER EXTREMITY