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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

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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

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Neuromuscular: pertaining to nerves and muscles

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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.

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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 

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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

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Nerve  Afferent 

Type Ia, Ib, II

 Efferent  

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

Myotatic Reflexes  Muscle 

Reciprocal Inhibition

 Golgi 

Spindle

Tendon

Autogenic Inhibition

Muscle spindle -- GTO Ia and II

alpha

Ib

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

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Autogenic inhibition – A reflex muscular relaxation that occurs in the same muscle where the GTO is stimulated.

AUTOGENIC INHIBITION

1.

Stimulus -

Large force exerted on muscle tendon

Primary response

2. Sense organ

3.

excited -Golgi tendon organs

Muscle attached to

-

tendon relaxes

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

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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

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Movements occur in diagonal patterns with rotational components, not in single plane  Resemble

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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

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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

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

Manual Contacts 

Lumbrical grip aides in keeping contacts facilitates unidirectional movement

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Placed proximal and distal of joint

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Best point of manual contact varies slightly with individuals

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Should not cause pain or discomfort

Commands and Communication 

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

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

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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

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

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stretch facilitates muscle spindles

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To initiate stretch reflex, briefly take beyond lengthened position

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Causes muscle contraction

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May be repeated throughout the pattern

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Does not work on completely flaccid muscle

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Contraindicated if painful

Traction and Approximation 

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

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

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Contraindicated if painful

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Approximation  Compression

of joint surfaces  Facilitates co-contraction around joints  Used to increase stability 

Traction (distraction) movements  Separation

of joint surfaces  Can decrease pain  Facilitates movement

Maximal Resistance 

maximal resistance which allows movement through full desired ROM

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Accommodating resistance is the rule

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Can enhance muscular endurance by increasing repetitions/sets

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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 occur  Typically

move is distal to proximal relationship

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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”

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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.  