Proprioceptive Neuromuscular Facilitation (PNF) Techniques in Rehabilitation

1
Proprioceptive Neuromuscular Facilitation (PNF)
Techniques in Rehabilitation

• Chapter 14

2
Introduction

• The method
• Patient contract isometrically resulted in
  increased response of the agonist, this was named
  rhythmic stabilization. Following using this
  stabilization, it was found slow reversal
  technique, alternate resistance to isotonic
  contractions of antagonist and agonist also had a
  facilitating effect.

3
Introduction

• Definitions of PNF
• Proprioceptive, means receiving stimulation
• within the tissues of the body.
• Neuromuscular, means pertaining to the nerves and
  muscles.
• Facilitation, means the effect produced in nerve
  tissue by the passage of an impulse.

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Introduction

• Definitions of PNF
• Therefore, PNF can be defined as, methods of
  promoting or hastening the response of the
  neuromuscular mechanism through stimulation of
  the proprioceptors.

5
Introduction

• To perform PNF exercises, it is important to
  remember the following
• principles
• Patient must be taught the pattern.
• Have the patient watch the moving limb moved
  passively.
• The patient must give proper verbal command.
• Manual contact with appropriate pressure is very
  important.

6
Introduction

• Principles

• Contraction of the muscle group is facilitated by
  hand placement.
• Apply maximal resistance throughout ROM.
• Resistance will change.
• Rotation of movement will change throughout ROM.
• Distal movement should occur first .

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Introduction

• Plan of volume
• Patterns of motion
• Various techniques used to promote the desired
  response
• Application of the method for improvement of
  vital and related functions.
• Suggestions for evaluation of the patient
  performance and for planning treatment program.

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PNF Strengthening Diagonal Patterns

• D1 Flexion Upper Extremity

Taken from Prentice, Rehabilitation Techniques in
Sports Medicine, 3rd ed
9
D1 Flexion Upper ExtremityJoint Specific
Movements
Shoulder Flexion
External Rotation
Adduction
Forearm Supination
Wrist Radial Deviation
Fingers Flexion
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PNF Strengthening Diagonal Patterns

• D1 Extension Upper Extremity

Taken from Prentice, Rehabilitation Techniques in
Sports Medicine, 3rd ed
11
D1 Extension Upper ExtremityJoint Specific
Movements
Shoulder Extension
Internal Rotation
Abduction
Forearm Pronation
Wrist Ulnar Deviation
Fingers Extension
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PNF Strengthening Diagonal Patterns

• D2 Flexion Upper Extremity

Taken from Prentice, Rehabilitation Techniques in
Sports Medicine, 3rd ed
13
D2 Flexion Upper ExtremityJoint Specific
Movements
Shoulder Flexion
External Rotation
Abduction
Forearm Supination
Wrist Radial Deviation
Fingers Extension
14
PNF Strengthening Diagonal Patterns

• D2 Extension Upper Extremity

Taken from Prentice, Rehabilitation Techniques in
Sports Medicine, 3rd ed
15
D2 Extension Upper ExtremityJoint Specific
Movements
Shoulder Extension
Internal Rotation
Adduction
Forearm Pronation
Wrist Ulnar Deviation
Fingers Flexion
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PNF Strengthening Diagonal Patterns

• D1 Flexion Lower Extremity

Taken from Prentice, Rehabilitation Techniques in
Sports Medicine, 3rd ed
17
D1 Flexion Lower ExtremityJoint Specific
Movements
Hip Flexion
Adduction
External Rotation
Ankle Dorsiflexion
Inversion
Toes Extension
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PNF Strengthening Diagonal Patterns

• D1 Extension Lower Extremity

Taken from Prentice, Rehabilitation Techniques in
Sports Medicine, 3rd ed
19
D1 Extension Lower ExtremityJoint Specific
Movements
Hip Extension
Abduction
Internal Rotation
Ankle Planar Flexion
Eversion
Toes Flexion
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PNF Strengthening Diagonal Patterns

• D2 Flexion Lower Extremity

Taken from Prentice, Rehabilitation Techniques in
Sports Medicine, 3rd ed
21
D2 Flexion Lower ExtremityJoint Specific
Movements
Hip Flexion
Abduction
Internal Rotation
Ankle Dorsiflexion
Eversion
Toes Extension
22
PNF Strengthening Diagonal Patterns

• D2 Extension Lower Extremity

Taken from Prentice, Rehabilitation Techniques in
Sports Medicine, 3rd ed
23
D2 Extension Lower ExtremityJoint Specific
Movements
Hip Extension
Adduction
External Rotation
Ankle Plantar Flexion
Inversion
Toes Flexion
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Proprioceptive Training for upper Extremities

• Types of exercises used for upper extremity
  proprioceptive training
• 1. Balance training. One major category of
  proprioceptive exercise is balance training.
  These exercises help to train the proprioceptive
  system in a mostly static activity. Activities or
  exercises in weight bearing using unstable
  supporting surface, profitter, swiss ball,
  balance board are example of balance training in
  the upper extremity.

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• 2. Kinetic chain exercises . Open-chain manual
  resistance exercises with rhythmic stabilization
  are also considered proprioceptively enriched.
  In either case, resistance can be modified,
  depending on pain, as the patient progresses

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• Quadruped stabilization on a balance
  
• Four closed-chain exercises have been described
• to stimulate co-activation in the shoulder
  pushups, horizontal abduction on a slide board,
  and tracing circular motions on a slide board
  with the dominant and non-dominant arms. These
  exercises accommodate for the individual's
  tolerance to joint loads by progressing from a
  quadruped to a push-up position
  

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• Wall push-ups are also useful and can be
  proprioceptively enhanced by having a physical
  therapist or resistance band provide resistance
  to the patient's back.

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• 3. Sport-specific maneuvers. Rehabilitation is
  incomplete until maneuvers specific to the sport
  and the athlete's position in the sport can be
  performed maximally and without pain or loss of
  function.
• Starting sport-specific maneuvers with weighted
  resistance (eg, swinging a weighted tennis racket
  or baseball bat), Functional positions, such as
  overhead throwing, should be incorporated and
  are more sport-specific.

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• 4. PNF (Proprioceptive neuromuscular
  facilitation) These techniques may be defined as
  methods of promoting or hastening the response of
  the neuromuscular mechanism through stimulation
  of the proprioceptors. Emphasis is placed on the
  application of maximal resistance through out the
  range of motion, using many combinations of
  motions in a pattern format. Motion is first
  performed in the strongest part of the range,
  with progression toward the weaker parts of the
  range of motion. The patterns used are spiral and
  diagonal in character and closely resemble the
  movements used in sports and in occupational
  activities.

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• 5. Plyometrics. It is a quick powerful movement
  involving pre-stretching of a muscle, followed by
  a shortening cycle. The stretch shortening cycle
  occurs when elastic loading, through a quick
  eccentric muscular contraction, is followed by a
  burst of concentric muscular contraction.

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• 6. Ballistic stretching uses the momentum of a
  moving body or a limb in an attempt to force it
  beyond its normal range of motion. This is
  stretching, or "warming up", by bouncing into (or
  out of) a stretched position, using the stretched
  muscles as a spring which pulls you out of the
  stretched position.

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Proprioceptive Training for Lower Extremities

• Proprioceptive training improves a patient's
  static and dynamic equilibrium. The static
  proprioceptive re-education is begun when
  patients proceed to weight bearing without
  crutches and consists of six stages
• 1-Recovery of sense of body position muscle
  contraction and joint movement.
• 2-Transition from bilateral to unilateral
  activities
• 3-Transition from eyes-open to eyes-closed
  activities.
• 4-Transition from activities on a stable support,
  such as the ground, to unstable surfaces, such as
  a soft mattress, a trampoline and Freeman's
  boards, or more modern equipment, such as the
  kinesthetic ability trainer
• 5-Throwing and catching a football to take the
  patient's mind off active control of his balance.
• 6-Balance recovery exercises are carried out
  different joint positions to evoke different
  responses from the tendon and muscle receptors.

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• The dynamic proprioceptive re-education consists
  of seven stages
• 1. Slow exercises followed by quicker movement
• 2. Exercise with limited effort followed by
  exerciserequiring greater strength
• 3. Exercises requiring volition, followed by
  exercisesdone freely
• 4. Progress from walking to jogging
• 5. Running and sprinting
• 6. Jumping and changes of direction
• 7. Twirling and twisting around the injured or
  operated knee

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• Balance and control proprioceptive exercise
• 1.    Stand on one leg.    2.    Stand on one
  leg with eyes closed.    3.    Stand on one leg
  throw and catch a ball.    4.    Stand on one
  leg bend and straighten knee    

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• 5.    Stand on one leg- pick up item from
  floor.   
• 6.    Hold knee dip throw and catch a ball.
• 7.    Stand on one leg move other leg to side,
  front and back.  
• 8.    Push up onto toes (2 legs) and hold.  
• 9.   Push up onto toes with eyes closed.   
• 10.   Push back onto heels, balance and hold.
• 11.   Push up on toes on one leg.     

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• Walking proprioceptive exercises
• 13.    Walk forward along a straight
  line. 14.    Walk on tip toes along straight
  line.  15.    Walk backwards along straight
  line.16.    Side step along straight
  line.  17.    Walk sideways crossing one foot
  over other (Cariocas).  18.    Walk fast in one
  direction, quickly changing direction at
  intervals.

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• Running proprioceptive exercises
• 19.    Run fast in one direction.    20.    Run
  backwards and do sidesteps.    21.    Fast
  crossovers (Cariocas).    22.    Run in figure
  of eight make it smaller and smaller.    

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• 23.    Hopping on spot.    24.    Hop forwards
  and backwards stop between hops.    25.    Hop
  in zigzags.    26.    Hop on and off
  step.    27.    Do triple jump - run, hop, jump
  and land.