Posted at 11.20.2018
Proprioceptive Neuromuscular Facilitation (PNF) contains habits and techniques used for stimulating the human's proprioceptors to promote neuromuscular system response (1)
PNF techniques, goals, and process:
The first PNF strategy is timing for emphasis, whose aim to durability and improve strength in weak muscle groups, correct muscle imbalance, and increase ROM. This system is based on the basic principle of using strong component to facilitate motion on the weaker component normal timing from distal to proximal, however the style can be transformed by doing what the patient needs. Second PNF technique is hold-relax, seeks to achieve relaxation, and increase ROM if pain is present. Predicated on the process of moving the joint actively or passively to the limited range, then provides isometric contraction to the contrary style muscles with maximum level of resistance. Followed by leisure and move toward the limited course positively or passively depending on condition, then duplicate it in the new ROM. The thired strategy is contract-relax, which focuses on to increase ROM, and it's really predicated on the concept of you start with isotonic contraction of the rotation element, accompanied by the isometric contraction for weakened muscle. Slow-moving reversals is the fourth approach, seeks for weaker muscles contraction facilitation, enhancing coordination, and increasing stamina. Based on the theory of beginning movement at the strong element by isotonic contraction with maximal level of resistance immediately followed by isotonic contraction of the weak part with maximal amount of resistance, without any relaxation. The fifth approach is repeated Contractions, it's aim for are increasing ROM, enhancing strength and strength in weak muscle group, and correct muscle imbalance. The process used in this technique is reinforcing fragile component by repeating maximal isometric contraction of the strong the different parts of the pattern. The final strategy is rhythmic stabilization. The goals of this technique are: used when movement at the joint is restricted, to reinforce muscles by co-contraction, improve circulation, improve postural steadiness in joint parts, and reduce pain. This technique is based on the rule of beginning with stability at the strong element by isometric contraction with maximum resistance followed by immediate without relaxation isometric contraction of the fragile part with maximum amount of resistance, until a co-contraction of the muscles of both aspect are build.
The aim of using PNF techniques is to improve functional degree of movements, by facilitation, inhibition, strengthening, and rest of muscles. In PNF concentric, eccentric, and static contractions are used alongside with amount of resistance. (2) These techniques are classified according with their functions: reversal antagonist, which really is a general class of techniques in which the patient contracts his agonist muscles, then your antagonist, without pause or relaxation. This system includes: dynamic reversals, stabilizing reversals, and rhythmic stabilization. Another PNF strategy is rhythmic initiation which is a passive rhythmic activity of limb or body through the required range, and progress into active rhythmic resisted motion. Combination of isotonics, which is another approach in which a combination of concentric, eccentric, and stabilizing contractions are used for specific muscles (e. g. agonist) without rest, and it begins at the patient's maximum strength or best coordination.
Another approach is repeated stretch, also called repeated contractions; it's applied in two ways: either repeated stretch out from the beginning of the range or repeated stretch through the number.
Contract-relax and hold-relax, these two techniques either used as immediate or indirect treatment. The past PNF approach is replication, which facilitates motor learning of functional activities. (2)
In normal individuals, the developmental collection of motor activities are assorted, unified, and interrelated. The standard specific learns in his youth to spin from supine to prone and vies versa, then sitting down, etc. There's a variation of motor activities in the performance and sequence of these activities. The usage of developmental sequence of motor unit activities is similar to whenever a person lays over a beach and senses hazard, and then automatically rolls away into prone then sitting down, then scrambles to his feet and works, these actions provide his need the best, and these reactions are from birth and the people used them matching to their needs. (1)
The key points of PNF are: reflex device, restoration of motor unit ability, repetition of coordinated moves, and developmental sequence functions. In reflex mechanism, which helps to enhance motion and posture by using the coordination of the visual-motor device and the auditory-motor device. While during restoration of electric motor abilities, PNF patterns and techniques are being used to provide suitable sensory cues, to improve motor learning and capabilities. Repetition of coordinated moves can be used to increase durability and strength, and adjusts the coordinated moves through graded resistance. The final basic principle is developmental collection process, which uses a series of training from proximal-to-distal and general-to-specific structure. In these guidelines, PNF habits and techniques are specifically put on developmental activities by using techniques based on isotonic contractions for improving activity and isometric contractions for improving stability. (1)
In the developmental sequence the physical therapist uses the development of primitive moves and postures for more complex moves and postures. The therapist also uses progression from general-to-specific structure, specific movement to improve positions and postures, eye-head coordination to enhance movements. Furthermore, this developmental series provides total pattern of movements, which include head, neck of the guitar, trunk, and four extremities, in a variety of relationships like ipsilateral, bilateral symmetrical, bilateral asymmetrical, and reciprocal, where certain sections move while some change to the motion. And this sequence promote the patient's ability to long term contract muscle isotonically during moves and isometrically during balance activities, and also improve the transition from isometric to isotonic contraction. From this we find that PNF restore motor function in a person with a impairment, by using variety of rules, habits, and techniques used in Mat activities to improve motion, self-care, and independence. (1)
Mat activities requires all principles of PNF, these activities include both stableness and movement, which could be sole or combined intricate movements. To vary the effect of reflexes or gravity on your body, mat activities done in a variety of positions which are chosen by the physical therapist to regulate abnormal movements. It's better to get started with strong and pain free movements, because it focuses on irradiation from strong parts of motions to facilitate attaining the desired movements. (2) Also the use of diagonal actions involve greater quantity of muscle groups or actions (1). Any chosen mat activity is broken down into parts. In such treatment, the development is to apply weight bearing activities including more extremities. (2)
Activities employed on the mat teach the individual: range of motion which is moving in the position, steadiness which is retaining balance in the position, skill which combines ability to move with stability or in transition. And the condition of the patient can determine whether to start with these. (2) Basic types of procedures used in these activities to promote patient's working capacity with minimum amount tiredness are: approximation to improve stabilization and balance, traction and expand to increase patient's capability moves, grips and proper body position in which the physical therapist leads patient's movement, amount of resistance to enhance and reinforce moves, and it includes graded amount of resistance which strengthen the weaker motions, and resisting strong movement for irradiation to the weaker movements. Another basic steps are: timing for emphasis which use strong actions to exercise the weaker ones, and patterns to enhance useful activities performance. (2) All the previous techniques, habits, and basic procedures are being used in mat activities, as follow: for balance, stabilizing reversals and rhythmic stabilization are used. While for freedom, blend of isotonics, rhythmic initiation, dynamic reversals, and repeated stretch are used. And for Skill, a mixture of moving and stabilizing techniques are utilized. (2) The features of mat activities are: safe for individuals who fear to fall, doing activities without limitations, well-distributed balance, and postural reactions and reflexes are induced better. (1)
The characteristics that should be in a mat used for activities are firm, even, comfortable, protect patient from abrasions and stress, large enough to accommodate both therapist and the individual, and the scale is 6 feet for adult, and 4 feet for child(1)
The first mat activity employed with a neurological patient is moving, which is divided into two parts: the first part is moving to mid-position, which is a concentric action of flexor string, and the other part is from mid-position to the end which is an eccentric action of the extensor chain. For facilitating rolling, the therapist can use different combination of scapula, pelvis, throat, or extremities routine.
First facilitating rolling by scapula, if the therapist resists anterior design of scapula, this will accomplish onward rolling, while resisting posterior pattern of scapula, facilitate backward rolling.
The patient can also facilitates rolling by moving his head in the same course of rolling. The given commands for rolling with scapular anterior depression eg. For left :"pull your make toward your opposite(right) hip, lift up your head, yank your still left arm down and across, move your foot up and across, then roll". While commands given for rolling backward with posterior elevation:"rebel".
In order to start, the therapist should stretches the scapula in the elongated range, and keep on with this diagonal motion until trunk muscles stretch. From then on, the therapist applies resistance to original scapular contraction before contraction of trunk muscles is experienced, then allows it to move. Locking scapula by the end of the number through the use of more resistance with either approximation or grip. Types of scapular habits in rolling are: Anterior elevation, in which the patient rolls onward with trunk expansion and rotation, and it facilitated by neck of the guitar extension and rotation in the rolling route. Posterior elevation, where the patient rolls backward with
trunk extension, and facilitated by neck of the guitar expansion in the rolling direction. Posterior depression, the patient perform a backward spin, with trunk expansion, lateral flexion, and rotation, and facilitated by throat lateral flexion and full rotation in the rolling way. And anterior depression, in which the patient rolls frontward with trunk flexion, and facilitated by throat flexion in the rolling direction. (2)
Second, Pelvic facilitation in rolling, the level of resistance applied to anterior style of pelvis aid onward rolling, while resistance to posterior structure of pelvis facilitate backward rolling. The patient can flex the throat to facilitate forward roll, and extend the neck for backward roll. Commands for the individual when rolling forward with anterior elevation: "yank your pelvis up and spin in advance", while when rolling backward roll with posterior depression: sit back into my palm and roll back".
The therapist places the pelvis in the elongated range and keep on with this diagonal activity until trunk muscles stretch. Therapist resists original pelvic contraction until he/she seems contraction of the required trunk muscles, then allows it to move. In order to lock the pelvis at the end of the number, the therapist must apply more level of resistance with either approximation or grip. Types of pelvic patterns used in rolling are: Anterior elevation, where the patient rolls ahead with trunk flexion, flexes the neck of the guitar for facilitation. Posterior elevation, in which backward rolling is performed with trunk lateral shortening, and facilitated by ipsilateral throat rotation. Posterior depression, in which the patient rolls backward with trunk extension, and expands the throat for facilitation. And anterior depression, where the patient rolls frontward with trunk expansion and rotation, the facilitation in this style is neck extension and rotation in the rolling path. (2)
Combining scapular and pelvic habits can accomplish rolling, by undertaking pelvic anterior elevation and scapular anterior depression for forwards rolling, while performing pelvic posterior depression and scapular posterior elevation backward move. (2)
In higher extremities facilitation in rolling, trunk muscles should be bolster to be able to accomplish, by merging strong arm muscles with scapular habits. Adduction habits used to help forwards rolling, while abduction habits used to help in backward rolling. Also, head actions with the arm used for facilitation. Irradiation into trunk muscles, by resisting strong muscles of elbow. In order to facilitate top extremities, the distal grip of the therapist is located on patient's side or distal forearm to regulate the complete extremity. However, the therapist proximal grasp is on or near patient's scapula, which works more effectively for advice and amount of resistance of the patient's brain movements. Forwards rolling commands with extension-adduction design:"press my side and draw your arm down to your reverse hip, lift your head, then move". For backward move with flexion-abduction design:"wrist back, lift your arm up & follow your hands with your eyes, then rotate back".
To start rolling, the therapist must stretch out the arm and scapular muscles of the individual, and puts the arm in the elongated range and then tract. Sustaining this diagonal activity and grip, until synergistic trunk muscles stretch and maintain initial arm movements, before therapist feels contraction of the trunk muscles, then allows it to move. Locking of higher extremities can be at any strong point in ROM. To lock the arm at end of the number, is through the use of approximation with level of resistance to rotation.
Types of rolling using one arm are: In front rotate with trunk-extension, lateral flexion and rotation, facilitated by neck of the guitar expansion and rotation in rolling direction, and the habits used are flexion-adduction-external rotation and ulnar thrust design. Backward spin with trunk-extension, lateral flexion and rotation, which is facilitated by neck lateral flexion and full rotation in the rolling route, and the patterns used are extension-abduction-internal rotation and ulnar withdrawal style. Forward move with trunk-flexion, facilitated by neck flexion in the rolling course, and the habits used are extension-adduction-internal rotation and radial thrust design. And backward roll with trunk-extension, facilitated by neck of the guitar extension in the rolling direction, and the patterns used are flexion-abduction. (2)
Bilateral combination used in upper extremities rolling facilitation are: Front move with trunk flexion, which is Chopping and Opposite of Chopping. And backward move with trunk extension, which is Lifting. (2)
In the facilitation of lower extremities in rolling, merging strong quads with pelvic patterns are being used for facilitation and improve trunk muscles. Flexion habits of lower limbs help forward rolling and extension patterns assist in backward rolling. Irradiation into trunk muscles by resisting strong muscles of the knee. Head movements in flexion to aid forward spin and in expansion for backward spin. Physical therapist distal hold is positioned on the patient's foot to regulate the whole extremity. It will be more effective activity, if the leg movements are resisted. And the proximal grip of the therapist is on patient's thigh or pelvis, in flexion-abduction the proximal side on contralateral iliac crest to help trunk flexion. Commands given for forward roll with flexion-abduction design:"foot up, take your leg up and out, then rotate away". As well as for backward spin with extension-adduction structure:"push your foot down, kick your calf back, then roll back again toward me".
Starting position because of this rolling is to stretch out the knee and lower trunk muscles, and adding the knee in the elongated range of style and apply traction. And this movement is maintained before therapist seems contraction of trunk muscles, then allows it to go. The locking can be at any strong point in ROM.
Types of rolling with one knee are: Flexion-adduction, for rolling onward with trunk flexion. Extension-abduction, for rolling back with trunk extension and elongation. Flexion-abduction, for rolling forward with trunk lateral flexion, flexion, and rotation. And extension-adduction, for rolling back with trunk expansion, elongation, and rotation. (2)
Bilateral mixture of lower extremities for facilitating rolling are: Lower extremity flexion, by rolling frontward with trunk flexion. And lower extremity expansion, by rolling back again with trunk expansion. (2)
The last style for facilitating rolling is neck patterns. These patterns are used to assist in rolling when patient does not have any pain free movement or no strong movements in scapula or arm. The primary force in throat flexion is traction force, while in neck expansion we apply soothing compression. In rolling, throat flexion can be used to accomplish rolling forwards from supine to side-laying, and throat extension is used to assist in rolling again from side-laying to supine. (2)
After reaching rolling, the next mat activity is prone-on-elbows exercise. There are three methods that allow the patient to presume this position, are: side-laying, rolling from supine-to-prone, and prone position. If any of the previous methods are against gravity, the therapist resists concentric contraction. And if it is gravity aided, the therapist resists eccentric contraction.
Figure XXXX Prone-on-elbows
In order for the patient to do this position, the therapist should apply stabilization with approximation for scapula, and level of resistance in diagonal and rotatory way is necessary. The individual must avoid trunk sag. The therapist should keep the patient's head, neck of the guitar, and trunk aligned, and apply light resistance on the top for stabilization along with rhythmic stabilization. And when the patient can't do isometric contraction, the therapist can use stabilizing reversal. When the patient is able to maintain this position, the therapist can work on improving mind, neck, and make, neck resisted movements which works well, resisted arm movements to fortify the weight-bearing arm, top trunk rotation, and weight shifting. (2)
The paitent then advances from prone-on-elbow position into side-sitting. This position consists of weight-bearing on arm, leg, and trunk of one side, while the other arm is free to function, then the patient should learn mobility like scooting. Four solutions to presume this position, that are: side-laying, prone-on-elbows, resting, and quadruped. The physical therapist in this position, can work on activities of balance, like upper extremity weight-bearing exercises, and scapular and pelvic reciprocal movements, where the movements of this combination stimulates trunk mobility, and stabilizing contraction of this combination encourages trunk steadiness. Activities of flexibility in this position are: scooting, moving to sitting, to prone on elbows, also to quadruped position. (2)
The other mat activity that comes after side-sitting is quadruped. In this position the patient can exercise trunk, hips, knees, and shoulder, using isotonics and active reversals. Also the individual can move from one spot to another. The physical therapist makes sure that the patient has strong scapular muscles to aid the weight of upper trunk. Patient with spinal pain or has stabilization problems, can practice activities in this position, but the therapist must be assertive of lack of pain in leg joint. The patient can suppose this position by two methods, are: prone-on-elbows, and side-sitting. In quadruped position, the therapist can works on activities of balance, by using stabilizing reversal and rhythmic stabilization techniques, for balance and stabilization of the trunk and extremity joint parts. Also the therapist could work on rocking onward and backward, by using combo of amount of resistance, isotonics, and powerful reversals. Crawling can be utilized in this position, by applying amount of resistance on scapula, pelvis, throat, arms, and lower limbs movements, to be able to enhance patient's skill. (2)
Figure XXX Facilitation to Quadruped
In this position the patient can exercise trunk, hips, and legs, while forearms are free and used for support, in a position to move in one location to another, and moves from kneeling to standing up. For patients who have leg pain and can't believe this position, they could work in kneeling down. Kneeling will promote the power, coordination, and ROM of hips and knees, by exercise moving between kneeling and side-sitting, and by combining isotonics contractions for concentric and eccentric muscles. To expect this position, is by three methods, are: side-sitting, kneeling-down, quadruped position. Activities that may be used in this position are: balance activities such as, scapula and mind motions resistance, using stability reversals and rhythmic stabilization ways to promote trunk strengthen and balance. Other balance activities are level of resistance to: pelvic motion, pelvis and scapula movements, trunk and head action, and resisting arm activity when resting of the heels. Another activity, which is often applied in this position is walking on the legs ahead, backward, and sideways. (2)
This mat activity is where the patient can go to ranking position. A couple of two solutions to expect this position: kneeling and ranking. The physical therapist could work on activities of balance, such as: strengthening trunk and lower extremity muscles, by using stabilizing and moving techniques. Activities of weight moving over back leg with trunk elongation, this activity task patient's balance, coordination, ROM, and durability. Activities of moving weight to forward lower leg, which increase DF ROM. And standing up as the last activity. (2)
In order for the individual to stand up from a seat, she or he should moves forward in the couch, stand up, get his / her balance in standing up. The patient can rise from seated on surfaces of different levels.
Sit-to-stand is divided into two parts. The first part that involves flexion of brain, neck of the guitar, and trunk, pelvic anterior tilt, and leg extension with forward movement over the base of support. The next part of the activity is backward movements toward a vertical position seen as a extension of brain, neck, and trunk, posterior pelvic tilt, and the legs go into extension and backward movement as the trunk comes over the bottom of support. Commands given for an individual taking a stand from the floor:" pull yourself onward, and press with your right foot. Now thrust with both feet, lift your head left, stand up. Maintain, now take your left ft. forward and step onto it. "
In this activity the therapist keeps the patient's iliac crests to be able to increase the patient's potential in standing up. Then your therapist stones the pelvis by rhythmic initiation and exercises it into posterior tilt, and resists or aids as it moves into anterior tilt. Rhythmic initiation is utilized enable the patient to place his / her hands on bars or chair arm, and stabilizing contractions and blend of isotonics are being used to enable the patient to assist using their arms. When the patient is moving toward position, the therapist should assist his or her pelvis by guiding it through anterior tilt. Amount of resistance is applied to the movements that the patient is with the capacity of doing it without help. In the time the individual stands with upright good posture, the therapist moves the pelvic into the appropriate degree of posterior tilt. For promoting weight bearing, approximation is performed through the pelvic. (2 & 1)
2. 2. 9 Ranking:
This position is considered to be the first level in walking and a kind of useful activity. In located the therapist should stand in a diagonal airplane before the lower leg that in the beginning will have the patient's weight. Instructions given in this activity:"Carry, don't let me pull your mind forward, don't allow me press your hip back. Hold, don't let me turn someone to the other area. Hold don't allow me pull you forwards. "
Accepting the patient's body weight on his / her lower limb, is fulfilled by combining approximation through the pelvis on the strong part with stabilizing amount of resistance at the pelvis. For the weaker aspect, the therapist uses the same techniques in addition to blocking the leg. Then the therapist stabilizes lower trunk and feet by merging approximation and stabilizing reversals at the pelvis. The same techniques directed at the shoulders used to stabilize higher and lower trunk. When using mixture of isotonics with small movements or stabilizing reversals, it'll resist balance in all directions, and it'll work on stabilizing the head, shoulder blades, pelvis, and their combinations. . (2&1)
In conclusion, lacking neuromuscular mechanism causes limited response anticipated to faulty development, injury, or disease of the anxious or musculoskeletal systems. As we realize, PNF relates to normal response of the neuromuscular mechanism, which permits it to broaden the number of motor activities within the limitations of anatomical framework, developmental level, and inherent and recently learned neuromuscular response. Through the use of various combinations, patterns, and techniques of PNF, the individual will be able to regain and reestablish his / her previous useful level.
1. Voss, Dorothy E. , Ionta, Marjorie K. , & Myers, Beverly J. (1968). Proprioceptive neuromuscular facilitation: patterns and techniques. Philadelphia : Harper and Row.
2. Adler, Susan S. , Beckers, Dominiek, & Buck, Math. (2003). PNF used: an illustrated guide. Germany: Springer.
Background about PNF 2
PNF techniques 2
Normal motor unit activities 4
PNF key points 4
Developmental sequence 5
Body of knowledge 6
Mat activities 6
The activities 7
Mat characteristics 7
Rolling facilitation by Scapula 9
Rolling facilitation by Pelvis 11
Rolling facilitation by scapula and pelvic habits combination 11
Rolling facilitation by higher extremities 12
Rolling facilitation by U. L bilateral combination 15
Rolling facilitation by lower extremities 16
Rolling facilitation by L. L bilateral mixture 17
Rolling facilitation by neck of the guitar 17