PNF

1. Faizan Zaffar Kashoo Lecturer PT department CAMS, MAJMAAH UNIVERSITY KSA Proprioceptive Neuromuscular Facilitation

2. Objectives • Learn the basics terms related to PNF. • Determinants of PNF • Techniques of PNF • Diagonal patterns of PNF

3. Definition: • Techniques of proprioceptive neuromuscular facilitation may be defined as “methods of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptors”.

4. Principles: • Manual contacts • Traction • Approximation • Stretch • Timing for emphasis • Maximal Resistance • Reinforcement

5. Manual Contacts • Procedure: • Deep pressure which is not painful is applied to the parts and muscle groups where response is desired. • Manual contacts of the antagonistic pattern may be used when the agonistic pattern is performed passively for determining limitation in range of motion. • Purpose: • To stimulate proprioceptors in muscles, tendons and joints. • May be used with or without resistance.

6. Traction • Procedure: • Separation of joint surfaces by manual contact by the physiotherapist • Purpose: • To stimulate proprioceptors related to stretch • To separate joint surfaces in order to make joint motion less painful

7. Approximation • Procedure: • Joint compression by manual contact of physiotherapist • Purpose: • To stimulate proprioceptors related to compression

8. Stretch • Procedure: • Maximal stretch of major muscle components in lengthened range of pattern • Purpose: • To initiate active motion in lengthened range of pattern • To achieve increased response throughout the major muscle components

9. Timing for emphasis • Procedure: • Sequence of contraction of major muscle components from distal to proximal • Type of contraction: • Superimposed upon Isotonic or Isometric contraction. • Purpose: • To develop co-ordinate movements • To make possible overflow and reinforcement when resistance is superimposed

10. Indications: • Conditions that permit active motion or motion against resistance • Contra- indications: • Only when any form of exercise is contra-indicated

11. Maximal Resistance • Procedure: • Graded according to the patient’s abilities and needs • May be a slight amount for weak components and a great amount for stronger components • Patient must be allowed to move if command is for active motion • Must not be so excessive that it prevents the patient from holding when the command is to hold

12. Purpose: • To stimulate active motion • To obtain overflow from stronger components to weaker components • To reinforce weaker patterns with stronger related patterns • To develop power, endurance and coordination • To correct imbalances • To demand relaxation • To reverse adaptive shortening

13. Reinforcement • Procedure: • Accomplished by resisted motion in strongest part of range of reinforcing components of pattern • Patterns selected as reinforcement must be related and stronger than the pattern to be reinforced • Purpose: • To stimulate weaker components or weaker patterns • To establish coordination between combinations of patterns

14. Techniques • Repeated Contractions • Hold relax active motion • Rhythmic Initiation – Rhythm technique • Slow reversal • Slow reversal hold • Rhythmic stabilisation • Quick reversal • Contract relax • Hold relax • Slow reversal hold relax • Rhythmic rotation

15. Repeated contractions • Procedure: • Sustained and repeated effort in one direction • May be performed at any desired point of range of motion • Type of contraction: • Isotonic following initial isometric contraction • Isometric → Isotonic • Purpose: • To stimulate gains in range of active motion of agonistic pattern • To demand relaxation or lengthening reaction of antagonistic pattern • To improve endurance, coordination and strength

16. Indications: • Weakness • Lack of endurance • Imbalance • Contra-indications: • Conditions that do not permit sustained effort against resistance • Acute orthopaedic conditions • Recent post-operative conditions • Cerebrovascular accidents

17. Hold relax active motion • Procedure: • Repeated effort without sustained effort • Performed from shortened range to lengthened range • Type of contraction: Isometric followed by voluntary relaxation, followed by isotonic contraction Isometric contraction ↓ Voluntary Relaxation ↓ Isotonic contraction

18. Purpose: To stimulate response in lengthened range of pattern To demand relaxation or lengthened reaction of antagonistic pattern To improve endurance, strength and coordination of the antagonistic pattern Indications: Lack of endurance Extreme weakness Conditions where sustained effort by the patient is not possible Imbalance Contra-indications: Conditions that do not permit full range of passive or resisted motion

19. Rhythmic initiation – Rhythm technique • Procedure: • Repeated movement without sustained effort • Performed from lengthened to shortened range • Type of contraction: Voluntary Relaxation ↓ Assisted isotonic contraction ↓ Resisted isotonic contraction

20. Purpose: To promote ability to initiate movement To increase rate of movement Indications: Rigidity Spasticity Contra-indications: Conditions where passive movement is contraindicated

21. Slow reversal • Procedure: • May be performed through available range or partial range according to patient’s response • Type of contraction: Isometric contraction of antagonists ↓ Isometric contraction of agonists • Purpose: • To stimulate active motion of agonistic pattern • To redevelop normal reversal of antagonists • To develop coordination of two antagonistic patterns • To develop strength in two antagonistic patterns • To achieve relaxation as a result of stimulation of agonistic pattern

22. Indications: • Weakness • Conditions where normal reversal of antagonists is desired • Contra-indications: • Conditions where reversal does not stimulate the agonistic pattern • Acute orthopaedic conditions

23. Slow Reversal Hold • Procedure: • May be performed through available range of motion or partial range according to patient’s response • Type of contraction: Isotonic, then isometric of antagonistic pattern ↓ Isotonic, then isometric of agonistic pattern

24. Purpose: • To stimulate active motion of agonistic pattern • To redevelop normal reversal of antagonists • To develop coordination of two antagonistic patterns • To develop strength in two antagonistic patterns • To achieve relaxation as a result of stimulation of agonistic pattern • To develop stability and ability to perform isometric contractions in specific patterns

25. Indications: • Weakness • Conditions where normal reversal of antagonists is desired • Conditions where isometric contraction ability is deficient • Contra-indications: • Conditions where reversal does not stimulate the agonistic pattern • Acute orthopaedic conditions

26. Rhythmic Stabilization • Procedure: • May be performed at any point of available range of motion • Type of contraction: Isometric of agonist pattern ↓ Isometric of antagonistic pattern • Purpose: • To stimulate active motion of agonistic pattern • To develop stability of the part • To achieve relaxation • To stimulate circulation through isometric contraction

27. Indications: • Weakness • Conditions where stabilisation provides stimulation of the agonistic pattern • Active movements not possible due to pain • Where isometric contraction is deficient • Contra-indications: • Conditions where stabilisation does not stimulate agonistic pattern

28. Quick reversal • Procedure: • Used to facilitate agonist by resistance to antagonist through full range followed by sudden reversal with isotonic contraction of agonist and with assistance to shortened range • Type of contraction: Isotonic contraction of antagonists ↓ Isotonic contraction of agonists • Purpose: • To correct the imbalance • Indications: • Marked imbalance • Contra-indications: • Conditions where sudden movement is harmful

29. Contract Relax • Procedure: • Mainly performed at succeeding points of range of motion beginning with the point where limitation by antagonist pattern presents itself • Type of contraction: Isotonic contraction of antagonist pattern – No range of motion allowed ↓ Passive motion of agonist pattern • Procedure followed by attempted performance of agonistic pattern from stretch stimulus or from isometric contraction in shortened range

30. Purpose: • To achieve relaxation of antagonistic pattern • Indication: • Spasticity • Contra-indication: • Acute orthopaedic conditions

31. Hold relax • Procedure: • May be performed at any point of range where limitation presents itself as a result of pain and muscle spasm • Type of contraction: Isometric of antagonists ↓ Free active motion of agonists • Isometric contraction of agonists may follow initial contraction of antagonists

32. Purpose: • Relaxation of antagonists • Encourage active motion of agonists • Indications: • Conditions where pain prevents active motion • Acute orthopaedic conditions • Contra-indications: • Conditions where ability to perform isometric contraction is deficient

33. Slow Reversal Hold Relax • Procedure: • Performed at exact point of range of motion where limitation by antagonistic pattern presents itself. • Type of contraction: Isotonic of antagonists ↓ Isometric of antagonists ↓ No range of motion allowed ↓ Voluntary relaxation ↓ Isotonic of agonist pattern

34. Purpose: • Relaxation of antagonistic pattern • To stimulate agonists following relaxation of antagonists • Indications: • Limitation of range of motion • Contraindications: • Conditions where active motion against resistance is not permitted

35. Rhythmic rotation • Procedure: • Repeated rotations of a segment at the point in the range where limitation is noted • Type of contraction: • Voluntary relaxation when possible • When technique is self directed, isotonic contraction of range limiting muscles occur • Purpose: • Relaxation of range limiting muscles • Stimulation of rotation components

36. Indications: • Conditions where imbalance of reflexes exist due to trauma to spinal cord • Orthopaedic conditions with lack of flexibility of soft tissue structures • Contraindications: • Acute orthopaedic conditions • Recent post-operative conditions • Circulatory conditions

37. Techniques directed to agonist • Repeated contractions • Rhythmic Initiation • Hold Relax Active motion

38. Techniques reversal of antagonist • Slow Reversal • Slow Reversal Hold • Rhythmic Stabilisation • Quick Reversal

39. Relaxation techniques • Contract Relax • Hold Relax • Rhythmic rotation • Slow Reversal Hold Relax

40. Diagonal Patterns of Extremities

41. Upper extremity • Flexion - Adduction – External Rotation ( D1 Flexion) • Extension – Abduction – Internal rotation (D1 Extension) • Flexion – Abduction – External Rotation (D2 Flexion) • Extension – Adduction – Internal Rotation (D2 Ext)

42. Lower Extremity • Flexion – Adduction – External Rotation (D1 Flexion) • Extension – Abduction – Internal Rotation (D1 Extension) • Flexion – Abduction – Internal Rotation (D2 Flexion) • Extension – Adduction – External Rotation (D2 Extension)

43. Head, Neck & Upper Trunk Patterns Flexion with rotation to right ( D Flexion R) Combination with upper extremity: D1 Ex R, D2 Ex L Extension with rotation to left ( D Extension L) Combination with Upper extremity: D2 Flex L, D1 Flex R Flexion with rotation to Left ( D Flexion L) Combination with Upper extremity: D1 Ex L, D2 Ex R

44. Extension with rotation to right (D Extension R) Combination with Upper extremity: D2 Flex R, D1 Flex L Rotation to Left (RoL) Combination with Upper extremity: D1 Ex L, D1 Flex R Rotation to Right (RoR) Combination with Upper extremity: D1 Ex R, D1 Flex L

45. Lower Trunk Patterns Flexion with rotation to Left (D Flexion L) Combination with lower extremity: D2 Flex L, D1 Flex R Extension with rotation to Right (D Extension R) Combination with lower extremity: D1 Ex R, D2 Ex L Flexion with rotation to Right (D Flexion R) Combination with lower extremity: D2 Flex R, D1 Flex L

46. Extension with rotation to Left (D Extension L) Combination with lower extremity: D1 Ex L, D2 Ex R Rotation to Left (RoL) Combination with lower extremity: D1 Ex L, D1 Flex R Rotation to Right (RoR) Combination with lower extremity: D1 Ex R, D1 Flex L

47. Proximal Pivots • Upper Extremity: • Shoulder flexion and extension is combined with Adduction and Abduction. • External Rotation is consistent with Flexion • Internal Rotation is consistent with Extension • Lower Extremity: • Flexion and Extension is combined with Abduction and Adduction and with External Rotation and Internal Rotation • Adduction is consistent with External Rotation • Abduction is consistent with Internal Rotation

48. Intermediate Pivots • Elbow and Knee can be flexed or extended

49. Distal Pivots: • Upper Extremity: • Supination of forearm and Radial deviation of the wrist is consistent with Flexion and External Rotation of shoulder • Pronation of forearm and Ulnar deviation of the wrist is consistent with Extension and Internal Rotation of shoulder • Wrist Flexion is consistent with Shoulder Adduction • Wrist Extension is consistent with Shoulder Abduction

50. Lower Extremity: • Ankle Plantar is consistent with Hip Extension • Ankle Dorsiflexion is consistent with Hip Flexion • Inversion of the foot is consistent with Adduction and External Rotation of hip • Eversion of the foot is consistent with Abduction and Internal Rotation of hip