This is one of the important approach used in neuro rehabilitation.

1. PNF
Presenter : Ashik Dhakal
Moderator : Mr. Sydney Roshan Rebello

2. Content
PNF definition
History
Neurophysiological basis of PNF
Uses of PNF
Basic principles of PNF
Techniques of PNF
Patterns of PNF

3. Learning objectives
What is PNF
How did this therapy came into existence
What are the principles of PNF therapy
What are the techniques of PNF
Where can we use these concept

4. Definition
Proprioceptive : having to do with any of the sensory receptors that give
information concerning movement and position of the body
Neuromuscular: involving the nerves and muscles
Facilitation: making easier
Adler SS, Beckers D, Buck M. PNF in practice: an illustrated guide. Springer Science & Business Media; 2007 Dec 22.

5. 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.
Margaret KN, VOSS DE. Proprioceptive neuromuscular facilitation.

6. PNF is the rehabilitating technique that aims at engaging the proprioceptive
system thereby activating or facilitating the neuromuscular system and helping in
the production of desired movement or motor function.
Imp : if we can actually fire afferent system efferent system will automatically
respond and help in the production of the response
In PNF we are stimulating afferent system by engaging proprioceptive system.

7. Development of PNF
Developed by: Dr. Herman Kabat and Maggie Knott in the late 1940s and early
1950s as a means of rehabilitation for neurological disorders such as
poliomyelitis(first), multiple sclerosis, and cerebral palsy.
Margaret KN, VOSS DE. Proprioceptive neuromuscular facilitation.
Neurophysiologist and
physician
Physical therapist

8. Dorothy Voss joined the team of Dr. Herman Kabat and Margeret knott to develop
the foundation concept of PNF.
Dorothy Voss and Margeret Knott together wrote first book on PNF therapy and
was published in 1956.
Till today developed many folds
1956 2018

9. Basic underline philosophy of PNF
All human beings including those with disabilities have untapped existing
potential.

10. Important principles of PNF
1. PNF is an integrated approach:
i.e, the therapy is always targeted to the total human being as a whole and not to a
specific problem or a body segment.
2. Positive approach
i.e, therapist always reinforce and utilise what the patient can do in physical as
well as mental level.
3. Achieving highest level of function

11. PNF approach emphasises that plasticity mechanism is not only applicable to the
central nervous system but also to the other system of the human body.
All system have the capability to re organise and adapt them-self following an
insult or injury.
Plasticity
Neurology
Musculoskeletal
conditions
Cardiovascular

12. Indication
PNF
Co-ordination
Initiation difficulty
Muscular weakness
Relaxation
Pain
Fatigue
Joint stiffness

13. Neurophysiological Principles
1. Principle of After Discharge
If inc intensity
Response still
present for some time
Stimulus
stops
Response (effect)
Stimulus
After discharge inc

14. 2. Temporal summation
Temporal = time , summation = addition
When there is weak stimuli — no response, addition of many weak stimulation —
response.
Temporal summation occur by adding up of high frequency pre synaptic potentials
from a single neuron which excites post synaptic neuron.
Eg. quick stretch rapid for some period of time will have better effect than single
stretch and performing action.

15. 3. Spatial stimulation
Adding up multiple stimuli from different pre synaptic neurons.
This principle states that when weak stimuli are applied simultaneously over
different neurons can also add up to produce a response.

16. 4. Irradiation
Refers to the overflow of the energy occurs from the stronger to weaker muscle
groups.
Can occur due to increase strength or the number of stimulus.
eg. exercising the weaker muscle group along with stronger muscle group in the
same synergy.
Opening the jammed lock (note — use of elbow and shoulder muscle, trunk, also
contralateral role action)

17. 5. Successive induction
When agonist have contracted to their maximum — antagonist gets stimulated
After complete flexion of elbow, triceps are activated which leads to extension.

18. 6. Reciprocal inhibition
Contraction of particular muscles is simultaneously accompanied by inhibition of
antagonist.
To produce coordination movement.

19. Basic procedure of PNF
1. Resistance
2. Irradiation and reinforcement
3. Manual contact
4. Stretch
5. Verbal commands
6. Vision
7. Traction and approximation
8. Timing
9. Body positioning and body mechanics
10. Patterns

20. 1. Resistance
Opposing force to the patient’s movement
Optimal resistance : the amount of resistance provided during an activity must be
correct for the patient’s condition and the goal of the activity.

21. Therapeutic goals of resistance:
Facilitates muscle contractions.
Improve motor control and motor learning.
Help the patient gain an awareness of motion and its direction.
Increase muscle strength.
Help the patient relax (reciprocal inhibition).

22. 2. Irradiation and Reinforcement
The spread of response to stimulation is called irradiation.
Reinforcement means to strengthen by fresh addition, make stronger.

23. Effects:
Maximal resistance may be used to cause irradiation or overflow from stronger
patterns to weaker patterns or from stronger groups of muscles within a pattern to
weaker groups within the same pattern.

24. 3. Manual contact:
Therapeutic goals
Stimulate the muscle, touch and pressure receptors.
Stimulate the synergistic muscle to reinforce the movement
Promotes trunk stabilisation and indirectly helps the limb motion
Prevents confusion

25. Touch or manual contact contributes to facilitation by stimulation the
exteroceptors and it should be
Purposeful
Directional
Comfortable

26. 4. Stretch
The stretch stimulus occurs when the muscle is elongated
Stretch can be given to individual muscle or the whole functional pattern.
Stretch which is given simultaneously results in increased motor response.

27. Effects :
Stimulates the activity of muscle spindle, thereby improves the reflex muscle
activity.
Any contraction of muscle on stretch will result in movement (brain knows not of
muscles but of movement).

28. 5. Traction
Traction is elongation of trunk or an extremity
Traction force is applied gradually, maintained throughout the movement and
combined with appropriate resistance.
Joint separation stimulates joint receptors
Muscle stretch stimulates muscle spindle stretch receptor, Facilitates strength
Provides increase in ROM and relieve pain

29. 6. Approximation
Is the compression of the trunk or an extremity
Compression through a joint stimulate joint receptors
Facilitate stability
Uses
Promote stabilization
Facilitate weight-bearing and the contraction of antigravity muscles

30. 7. Verbal stimulation (commands)
The command is divided into three parts
1. Preparation : readies the pt for action. “ready”
2. Action : tells the pt to start the action.
3. Correction : tells the pt how to correct and modify the action.

31. Commands used
Hold
pull/push
Relax
Command should be louder for stronger contraction and slower for relaxation

32. 8. Vision
When a patient looks at his or her arm or leg while exercising it, a stronger
contraction is achieved.
Using vision helps the patient control and correct his or her position and motion.
A feedback and feed forward system can promote a much stronger muscle activity.

33. 9. Timing
Timing is the sequence of motion
Normal timing of most coordinated and efficient motions is from distal to
proximal. Eg scratching of head, starts from action of hand to elbow and then
shoulder.
Proximal should be stable for distal to move.
Timing for emphasis :
We can alter this timing to produce necessary effects.
Changing the normal sequencing of motion to emphasis a particular muscle or
desired activity.

34. 10. Body position and body mechanics
The therapist body should be in line of motion
Shoulder and pelvis face the direction of motion
Therapist stands in walk standing position
The resistance comes from the therapist’s body, while the hands and arms stay
comparatively relaxed.

35. Techniques of PNF
The goal of any PNF technique is to promote functional movements, and this can be
achieved by facilitation, inhibition, relaxation, strengthening.
• Rhythmic initiation
• Combination of isotonic
• Reversal of antagonists
• Dynamic reversal
• Stabilizing reversals
• Rhythmic stabilization

36. • Repeated stretch (repeated contraction)
• Repeated stretch from beginning of range
• Repeated stretch through range
• Contract relax
• Direct treatment
• Indirect treatment
• Hold- relax
• Direct treatment
• Indirect treatment

37. 1. Rhythmic initiation
Helps in co-ordination of motion, control over motion, and relaxation.
Reverse motion to be done by the therapist
Things to be taken care first = what motion needs to be trained?, what activity
should be chosen.
Functional task for better learning, and motivation.
Rhythmic motion
of limb/whole
body parts
Active resisted
motion
Active
motions
Active assisted
motions
Passive motion

38. Used in :
Limited ROM due to increase tone
Unable to initiate movement

39. 2. Combination of isotonic
• This technique is characterised by concentric, eccentric and isometric contraction of a
single muscle group without any pause or relaxation.
• Any contraction can come first, range can be varied.
• Exercise should be started from positions/range where the patient has maximum strength/
coordination.
Contraction of
same muscle group
Isometric
stabilizing
Eccentric
Concentric

40. Indications :
Active control over motions
To strengthen muscle groups
To develop eccentric control
To improve co-ordination

41. 3. Reversal of antagonist
• Based on the Sherington principle of successive induction, which is,’ increase
excitation of agonist muscle is followed up by increased contraction of their
antagonist.’
• Emphasis is both on agonist and antagonist.
I. Dynamic reversal/slow reversal :
• Characterised by active motions by patient from one direction to other without any
pause or relaxation. Eg- cycling, walking etc.
Dynamic
reversal
Antagonist
Agonist

42. Indication :
To improve AROM
To improve strength and co-ordination
To improve endurance
Reduce fatigue
Example: limited elbow extension (poor m control, joint stfns or dec strength)
Therapeutic goal : to increase range of elbow extension
Choose functional task : wipe the table (activation of both flexor and extensor grp of motion)
Grip : distal, over dorsum resisting ulnar and radial deviation. proximal, mid arm resisting
internal and external rotation.

43. II. Stabilizing reversal
Characterised by altering contractions of agonist and antagonist which are resisted by the
therapist, so no or very little motion is produced.
Example :
For trunk flexion and extension
1st : resist pt to go for extension
2nd : bring one hand forward and resists
3rd : bring both hand forward and resists flexion
4th : again continue 1st.

44. Indication :
Stability of the patient
Strength
Co-ordination between agonist and antagonist group of muscle.

45. III. Rhythmic stablization :
Ask the patient to hold the position against resistance so that no motion is
intended.
Isometric muscle contraction (no intention of movement).

46. 4. Repeated stretch (repeated contraction)
Quick stretched in
beginning of range and
through range
Repeated stretch — activation os stretch reflex— inc muscle ability to contract

47. Indication :
Improve active ROM
Improve control over motion
To initiate motion
To improve strength
Contraindication :
Osteoporosis
Joint instability
Damaged m and tendons
Severe joint pain

48. 5. Contract relax :
It works by gaining relaxation in the tight muscle.
Once the range is achieved exercise agonist and antagonist in that range for better
stability.
Indications:
Improving passive ROM
Imp flexibility
Post fracture stiffness
Frozen shoulder

49. Types :
1. Direct :
relaxes antagonist through autogenic inhibition
Resisted isotonic contraction of antagonist muscles
2. Indirect :
relaxes antagonist through reciprocal inhibition
Resisted isotonic contraction of agonist muscles.

50. 7. Hold relax
It is preferred over contract relax in situations when resisted isotonic contractions
are painful.
Direct : isometric contraction of tight antagonist muscle
Indirect: when isometric contractions are painful.
Option 1 : exercise isometric contraction of synergistic muscle of antagonist
group. — new range
Option 2: resist the agonist movement pattern to indirectly relax the antagonist
(reciprocal inhibition)— new range

51. 8. Replication :
Motor learning for functional activities
Gives opportunity to patient to feel the functional outcome of an activity

52. Step 1 : choose an activity, (wearing and removing of shirts)
Step 2 : motion analysis (all joints and motion )to determine agonist and antagonist
patterns
Step 3: passively place the patient in end position of functional activity which he is
not able to perform, and experience and feel that position.
Step 4: resist the shortened agonist muscles for 5-8 secs. In same position.
Step 5 : ask patient to relax and passively move the patient a little in opposite
direction
Step 6 : ask patient to actively come back to the end position

53. PNF techniques and their goal
1. Initiate motion
Rhythmic Initiation
Repeated Stretch from beginning of
range
2. Learn a motion
Rhythmic Initiation
Combination of Isotonics
Repeated Stretch from beginning of
range
Repeated Stretch through range
Replication

54. 3. Change rate of motion
Rhythmic Initiation
Dynamic Reversals
Repeated Stretch from beginning of
range
Repeated Stretch through range
4. Increase strength
Combination of Isotonics
Dynamic Reversals
Rhythmic Stabilization

55. PNF patterns
Each pattern has three dimension -
1. Flexion or extension
2 Abduction or Adduction
3. Rotation - movement occurs in a straight line, in diagonal direction with a rotatory
component

56. Upper extremity

59. Lower extremity patterns

61. Symmetrical reciprocal
Symmetrical

62. Asymmetrical Asymmetrical reciprocal

63. Evidence
1. Influence of Proprioceptive Neuromuscular Facilitation on Lung Function in
Patients After Coronary Artery Bypass Graft Surgery.
42 patients in two groups (PNF, n=22),and standard rehab, n=20
Treated for 45 mins, 2-3 times a day, 5 days a week.
Outcome measure taken : spirometry, body plethysmography using body box 5500
In conclusion, the PNF method has an edge over the standard rehabilitation in
improving lung function.

64. 2. Effect of aquatic PNF lower extremity patterns on Balance and ADL of stroke
patients.
20 patients, experimental group = 10 (lower limb patterns in aquatic environment ,
control group 10 (patterns on ground).
30 mins /day, 5 days/week for 6 weeks
Outcomes : BBS, TUGT, FRT, one leg stand test, ADL — FIM
Exercise group had significantly better outcomes compared to the controlled.

65. 3. Immediate effect of PNF patterns on muscle tone and muscle stiffness in chronic
stroke patients.
15 chronic stroke patients and 15 in control grp. Grade 2 on MAS.
PNF pattern for lower limb for 30 mins.
Outcome myoton r pro — muscle tone measuring device.
Before intervention measurement was taken which showed abnormal increased
muscle tone in stroke group,
And was checked after intervention, was found to be reduced, but was not
significantly different.

66. Summary
What is PNF
How did this therapy came into existence
What are the principles and concepts of PNF therapy
Where can we use these concept/Clinical implications

67. Thank you

68. References
Margaret KN, VOSS DE. Proprioceptive neuromuscular facilitation.
Adler SS, Beckers D, Buck M. PNF in practice: an illustrated guide.
Springer Science & Business Media; 2007 Dec 22.