Proprioceptive neuromuscular facilitation

History

Developed by Dr. Herman Kabat in the 1940s

Maggie Knott, PT worked with Dr. Kabat to create handling techniques and principles of PNF

Dorothy Voss, PT also collaborated with Kabat and Knott to further develop PNF

Originally developed for use with patients with permanent neuromuscular dysfunction

Before PNF, patients were rehabilitated using one motion, one joint, one muscle at a time

Kabat observed normal human motion and began working with patients to discover patterns of movement that were consistent with neuro-physiological theory

Kabat’s research and experimentation led him to discover that movement occurs in spiral-diagonal patterns

Kabat and Knott believed that using natural patterns of movement would stimulate the nervous system more normally than would therapy that isolated each muscle

PNF has continued to develop and change

Proprioceptive Neuromuscular Facilitation

Proprioceptive: refers to stimuli aroused in an organism through the movement of its tissues

Neuromuscular: pertaining to nerves and muscles

Facilitation: hastening of any natural process

Definition

Methods of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptor (Voss)

Methods used to place specific demands on specific muscles in order to elicit a desired reaction.

PNF – “A method of treatment to promote or hasten the response of one neuromuscular mechanism through the stimulation of various neurological pathways. This is done by placing specific demands on the patient’s nervous system to assure a desired response which is related to normal function” (Knott and Voss)

When to use PNF

Used when a deficient neuromuscular mechanism results in altered patterns of motion or posture

Most commonly used in Phase II & III, but some techniques can even be used in Phase I.

Proprioceptive Neuromuscular Facilitation Can be used for increasing strength,

flexibility(ROM), and coordination. Uses autogenic and reciprocal inhibition to

increase stretch Good technique to improve flexibility Great technique for strengthening too

Principles of Therapeutic Exercise

Exercise patient by using voluntary and active motion. Return the patient to original strength and ROM

Pain-free ROM. Patient should be worked through existing pain-free ROM.

Use of “maximal” resistance Relaxation of body part before strengthening. Use diagonal spiral patterns of motion

Nerve Afferent

Type Ia, Ib, II Efferent

Alpha Motor neuron - Extrafusal fibers Gamma Motor neuron - Intrafusal fibers

Myotatic Reflexes Muscle Spindle

Reciprocal Inhibition Golgi Tendon

Autogenic Inhibition

Muscle spindle -- GTO

Ib

alpha

Ia and II

Neurophysiologic Principles

Use of reflex activity Proprioceptors (muscle spindles, golgi tendon

organs, joint mechanoreceptors)Exteroreceptors (touch, pressure)Other (righting reflex, extensor reflex)

Neurophysiologic Basis for PNF

Irradiation: Energy is channeled from stronger to weaker muscle groups or patterns

Sherrington’s Law of Successive Induction When a movement is completed in one direction,

the response of the antagonist will be augmented Successive induction: An increased response of

the agonist results after contraction of its antagonist Increased agonist strength following contraction of antagonist

Autogenic inhibition –A reflex muscular relaxation that occurs in

the same muscle where the GTO is stimulated.

1. Stimulus -

Large force exerted on muscle tendon

2. Sense organ

excited -Golgi tendon organs

3. Primary response -

Muscle attached to

tendon relaxes

AUTOGENIC INHIBITION

Reciprocal inhibition -A reflex muscular relaxation that occurs in the muscle that is opposite the muscle where the GTO is stimulated.

Successive Induction Voluntary motion of one muscle can be facilitated by

the voluntary motion of another

Basic Concepts

Movements are goal oriented From isolation (single plane) to functional large

patterns (multi plane) – Phase II/III of rehab Movements occur in diagonal patterns with

rotational components, not in single plane Resemble ADL’s and sport specific activities

Stimulate muscle spindles and Golgi tendon organs which in turn contribute to motion and stimulation of joint receptors

Goals

To restore or enhance postural responses or normal patterns of motion in a patient with a deficient neuromuscular mechanism

to enhance stability or mobility to strengthen or stretch any muscle group

Restore ROM Decrease pain to improve posture, balance, and

coordination for functional activities

Component of PNF

Basic of Procedure

Classification of Techniques

Diagonal Patterns

Basic Procedures

Patterns of movement Visual stimulus Proper mechanics Normal timing

Basic Procedures (cont’d)

Manual contacts Commands and communication Stretch reflex Traction and approximation Maximal resistance Timing for emphasis

Manual Contacts

“Pressure” used to give sensory clues to performing movement and generating stronger muscular contraction

Manual contacts .Contact over a muscle group facilitates that muscle group to contract

Manual Contacts Lumbrical grip aides in keeping contacts

facilitates unidirectional movement

Placed proximal and distal of joint

Best point of manual contact varies slightly with individuals

Should not cause pain or discomfort

Commands and Communication

Clinician can actively demonstrate or passively move patient through desired pattern of movement

Cues should be clear, concise, and appropriate to the patient’s needs and comprehension

Tell patient what to do – voice inflection

Sharp/strong commands increase muscle contraction Soft/calm commands promote relaxation Moderate tones for directions/instructions

Terminology (guidelines, not absolutes)

Flexion pattern – “pull” Extension pattern – “push” Isometrics – “hold/relax

Stretch Reflex Stretch is used as a stimulus

Start pattern with agonist in lengthened state – stretch facilitates stronger contraction of muscle/s

stretch facilitates muscle spindles

To initiate stretch reflex, briefly take beyond lengthened position

Causes muscle contraction

May be repeated throughout the pattern

Does not work on completely flaccid muscle

Contraindicated if painful

Traction and Approximation

Traction facilitates movement – associated with flexion (“pull”) movements

Approximation facilitates stability – associated with extension (“push”) movements

Contraindicated if painful

Approximation Compression of joint surfaces Facilitates co-contraction around joints Used to increase stability

Traction (distraction) movementsSeparation of joint surfacesCan decrease pain Facilitates movement

Maximal Resistance

maximal resistance which allows movement through full desired ROM

Accommodating resistance is the rule

Can enhance muscular endurance by increasing repetitions/sets

Direction, quality, and quantity of resistance is adjusted to prompt a smooth and coordinated response, whether for stability or mobility

When applying resistance, consider the treatment goal:

Power or endurance Quality of movement Presence of spasticity

Timing for Emphasis

Normal timing in sequence of joint actions in order for movements to occurTypically move is distal to proximal

relationship Timing for Emphasis

Can be used to correct abnormal timing/muscle firing patterns

Irradiation (overflow) occurs from stronger muscle/s to weaker ones –

stronger muscle/s augment and reinforce contraction of weaker ones

Body Position and Mechanics

Position yourself “in the diagonal”

Maintain good body mechanics

Visual stimulus

Promotes more powerful contraction Helps to control & correct the motion Influences both head and body motion Helps in patient / therapist communication

The PNF patterns combine motion in all three planes:

1. The saggittal plane: flexion and extension.

2.The coronal or frontal plane: abduction and adduction of limbs or lateral flexion of the spine.

3. The transverse plane: rotation.