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.
PNF is a concept of treatment. Its underlying philosophy is that all human beings, including those with disabilities, have untapped existing potential (Kabat 1950)
In keeping with this philosophy, there are certain principle that are basic to PNF:
- PNF is an integrated approach; each treatment is directed at a total human beings, not at a specific problem or body segment.
- The treatment approach is always positive, reinforcing & using that which patient can do, on physical and psychological level.
- The primary goal of all treatment is to help patients achieve their highest level of function.
The basic procedures overlap in their effects. For example, resistance is necessary to make the stretch reflex effective (Gellhorn 1949). The effect of resistance changes with the alignment of the therapist's body and the direction of the manual contact. The timing of these procedures is important to get an optimal response from the patient. For example, a preparatory verbal command comes before stretch reflex. Changing of manual contacts should be timed to cue patient for change in the direction of motion.
Use these basic procedures to treat patients with any diagnosis or condition, although a patient's condition may rule out the use of some of them. The therapist should avoid causing or increasing pain. Pain is an inhibitor of effective and coordinated muscular performance and it can be a sign of potential harm (Hislop 1960; Fisher 1967). (Refuse "No Pain, No Gain"!!)
The basic procedures for facilitation are;
- Resistance; To aid muscle contraction and motor control, to increase strength, aid motor learning.
- Irradiation and reinforcement; Use of the spread of the response to stimulation.
- Manual contact; To increase power and guide motion with grip and pressure.
- Body position and body mechanics; Guidance and control of motion or stability.
- Verbal (commands); Use of words and the appropriate vocal volume to direct the patient.
- Vision; Use of vision to guide motion and increase force.
- Traction or approximation; The elongation or compression of the limbs and trunk to facilitate motion and stability.
- Stretch; The use of muscle elongation and the stretch reflex to facilitate contraction and decrease muscle fatigue.
- Timing; Promote normal timing and increase muscle contraction through "timing for emphasis".
- Patterns; Synergistic mass movements, components of functional normal motion.
*Combine these basic procedures to get a maximal response from the patient.
PNF Techniques and Goals
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 rage
- Repeated Stretch through rage
3. Change rate of motion
- Rhythmic Initiation
- Dynamic Initiation
- Repeated Stretch from beginning of range
- Repeated Stretch through range
4. Increase strength
- Combination of Isotonics
- Dynamic Reversals
- Rhythmic Stabilization
- Stabilizing Reversals
- Repeated Stretch from beginning of range
- Repeated Stretch through range
5. Increase stability
- Combination of Isotonics
- Stabilizing Reversals
- Rhythmic Stabilization
6. Increase coordination and control
- Combination of Isotonics
- Rhythmic Initiation
- Dynamic Reversals
- Stabilizing Reversals
- Rhythmic Stabilization
- Repeated Stretch from beginning of range
- Replication
7. Increase Endurance
- Dynamic Reversals
- Stabilizing Reversals
- Rhythmic Stabilization
- Repeated Stretch from beginning of range
- Repeated Stretch through range
8. Increase range of motion
- Dynamic Reversals
- Stabilizing Reversals
- Rhythmic Stabilization
- Repeated Stretch from beginning of range
- Contract-Relax
- Hold-Relax
9. Relaxation
- Rhythmic Initiation
- Rhythmic Stabilization
- Hold-Relax
10. Decrease pain
- Rhythmic Stabilization (or Stabilization Reversals)
- Hold-Relax
Resistance
Resistance is used to treatment to;
- Facilitate the ability of the muscle contract.
- Increase motor control.
- Help the patient gain and awareness of motion and its direction.
- Increase strength.
Definition
- The amount of resistance provided during an activity must be correct for the patient's condition and the goal of the activity. This is called "optimal resistance"
Gellhorn showed that when a muscle contraction is resisted, that muscle's response to cortical stimulation increases. The active muscle tension produced by resistance is the most effective proprioceptive facilitation. the magnitude of that facilitation is related directly to the amount of resistance (Gellhorn 1949; Loofbourrow and Gellhorn 1949). Proprioceptive reflexes from contracting muscles increase the response of synergistic muscles at the same joint and associated synergists at neighboring joints. This facilitation can spread from proximal to distal and from distal to proximal. Antagonists of the facilitated muscles are usually inhibited (relaxed). If the muscle activity in the agonists becomes intense, there may be activity in the antagonistic muscle groups as well (co-contraction). (Gellhorn 1947; Loofbourrow and Gellhorn 1948).
Definition
- The types of muscle contraction is defined as follows (International PNF Association, unpublished handout);
- Isotonic (dynamic); The intent of the patient is to produce motion.
- Concentric; Shortening of the agonist produces motion.
- Eccentric; An outside force, gravity or resistance, produces the motion. The motion is restrained by the controlled by the
controlled lengthening of the agonist.
- Stabilizing isotonic; The intent of the patient is motion; the motion is prevented by an outside force (usually resistance).
- Isometric (static); The intent of both the patient and the therapist is that no motion occurs.
The resistance to concentric or eccentric muscle contraction should be adjusted so that motion can occur in a smooth and coordinated manner. Resistance to a stabilizing contraction must be controlled to maintain the stabilized position. When resisting an isometric contraction, the resistance should be increased and decreased gradually so that no motion occurs. It is important that the resistance does not cause pain or unwanted fatigue. Both the therapist and the patient should avoid breath holding. Timed and controlled inhalations and exhalations can increase the patient's strength and active range of motion.
Irradiation and Reinforcement
Properly applied resistance results in irradiation and reinforcement.
Irradiation
Definition
- The spread of the response to stimulation.
This response can be seen as increased facilitation (contraction) or inhabitation (relaxation) in the synergistic muscles and patterns of movement. (Sherrington 1947). Kabat (1961) wrote that it is resistance to motion that produces irradiation, and the spread of the muscular activity will occur in specific patterns.
Reinforcement
Definition
- "To strengthen by fresh addition, make stronger" (in Webster's Ninth New Collegiate Dictionary). Increasing the amount of resistance will increase the amount and extent of the muscular response. Changing the movement that is resisted or the position of the patient will also change the results. The therapist adjusts the amount of resistance and type of muscle contraction to suit the condition of the patient and the goal of the treatment. Because each patient reacts differently, it is not possible to give general instructions on how much resistance to give or which movements to resist. By assessing the results of the treatment, the therapist can determine the best uses of resistance, irradiation, and reinforcement.
Example of the use of resistance in patient treatment;
- Resist muscle contractions in a sound limb to produce contraction of the muscles in the immobilized contra lateral limb.
- Resist supination of the forearm to facilitate contraction of the external rotators of that shoulder.
- Resist hip flexion with adduction and external rotation to facilitate the ipsilatetal dorsiflexor muscles to contract with inversion.
- Resist neck flexion to stimulate trunk and hip flexion. Resist neck extension to stimulate trunk and hip extension.
Manual Contact
- Pressure on a muscle aids that muscle's ability to contract.
- Putting pressure that is opposite to the direction of motion on any point of the moving limb will stimulate the synergistic
muscles to reinforce the movement.
- Manual contact on the patient's trunk helps the limb motion indirectly by promoting trunk stabilization. The therapist's grip stimulate the patient's skin receptors and other pressure receptors. This contact gives the patient information about the proper direction of motion. The therapist's hand should be placed to apply the pressure opposite the direction of motion. The sides of the arm or leg are considered neutral surfaces and may be held. To control movement and resist rotation the therapist uses a lumbrical grip (eagle's bill). in this grip the pressure comes from flexion at the metacarpophalangeal joints, allowing the therapist's fingers to conform to the body part. The lumbrical grip gives the therapist good control of the three dimensional motion without causing the patient pain due to squeezing or putting too much pressure on bony body parts..
Johnson and Saliba first developed the material on body position presented here. They observed that more effective control of the patient's motion came when the therapist was in the line of the desired motion. As the therapist shifted position, the direction of the resistance changed and the patient's movement changed with it. From this knowledge they developed the following guidelines for the therapist's body position (G. Johnson and V. Saliba, unpublished handout 1985);
- The therapist's body should be in line with the desired motion or force. To line up properly , The therapist's shoulders and pelvis face the direction therapist cannot keep the proper body position, the hands and arms maintain alignment with the motion.
- The resistance comes from the therapist's body while the hands and arms stay comparatively relaxed. By using body weight the therapist can give prolonged resistance without fatiguing. The relaxed hands allow the therapist to feel the patient's responses.
Verbal Stimulation (Commands)
The verbal command tells the patient what to do and when to do it. The therapist must always bear in mind that the command is given to the patient, not to the body part being treated. Preparatory instructions need to be clear and concise, without necessary words. They may be combined with passive motion to teach the desired movement.
The timing of the command is important to coordinate the patient's reactions with the therapist's hands and resistance. It guides the start of movement and muscle contractions. It helps give the patient corrections for motion or stability.
Timing of the command is also very important when using the stretch reflex. the initial command should come immediately before the stretch reflex to coordinate the patient's conscious effort with the reflex response (Everts and Tannji 1974). The action command is repeated to urge greater effort or redirect the motion.
The volume with which the command is given can affect the strength of the resulting muscle contractions (Johnson et al. 1983). The therapist should give a louder command when a strong muscle contraction is desired and use a softer and calmer tone when the goal is relaxation or relief of pain.
The command is divided into three parts;
1. Preparation; readies the patient for action
2. Action; tells the patient to start the action
3. Correction; tells patient how to correct and modify the action.
For example, the command for the lower extremity pattern of flexion-adduction-external rotation with knee flexion might be ready, and now pull your leg up and keep pulling your toes up to correct lack of dorsiflexion.
Vision
The feedback from the visual sensory system can promote a more powerful muscle contraction. For example, 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. Moving the eyes will influence both the head and body motion. For example, when patient?s looks in the direction they want to move, the head follows the eye motion. The head motion in turn facilitates larger and stronger trunk motion. Eye contact between patient and therapist provided another avenue of communication and helps to ensure cooperative interaction.
Traction and Approximation
Definition
- The elongation of the trunk or an extremity.
Knott, Voss, and their colleagues theorized that the therapeutic effects of traction are due to stimulation of receptors in the joints (Knott and Voss 1968; Voss et al. 1985). Traction also acts as a stretch stimulus by elongating the muscles.
Apply the traction force gradually until the desired result is achieved. The traction is maintained throughout the movement and combined with appropriate resistance.
Traction is used to;
- Facilitating motion, especially pulling and antigravity motions.
- Aid in elongation of muscle tissue when using the stretch reflex.
- Resist some part of the motion. For example, use traction at the beginning of shoulder flexion to resist scapula elevation.
Traction of the affected part is helpful when treating patients with joint pain.
Definition
- Approximation is the compression of the trunk or an extremity.
The muscle contractions following the approximation are thought to be due to stimulation of joint receptors (Knott and Voss 1968; Voss et al. 1985). Another possible reason for the increased muscular response is to counteract the disturbance of position or posture caused by the approximation. Given gradually and gently, approximation may aid in the treatment of painful and unstable joints.
Approximation is used to;
- Promote stabilization
- Facilitate weight-bearing and the contraction of antigravity muscles
- Facilitate upright reactions
- Resist some component of motion. For example, use approximation at the end of shoulder flexion to resist
scapula elevation.
There are two ways to apply the approximation;
1. Quick approximation; the force is applied quickly to elicit a reflex-type response.
2. Slow approximation; the force is applied gradually up to the patient's tolerance.
The approximation force is always maintained, whether the approximation is done quickly or slowly. The therapist maintains the force and gives resistance to the resulting muscular response. An appropriate command should be coordinated with the application of the approximation, for example "hold it" or "stand tall". The patient's joints should be properly aligned and in a weight-bearing position before the approximation is given. When the therapist feels the active muscle contraction decreases the approximation is repeated and resistance given.
Definition
- The stretch stimulus occurs when a muscle is elongated.
Stretch stimulus is used during normal activities as a preparatory motion to facilitate the muscle contractions. The stimulus facilitates the elongated muscle, synergistic muscles at the same joint, and other associated synergistic muscles (Loofbourrow and Gellhorn 1948). Greater facilitation comes from lengthening all the synergistic muscles of a limb or the trunk. For example, elongation of the anterior tibial muscle facilitates that muscle and also facilitates the hip flexor-adductor-external rotator muscle group. If just the hip flexor-adductor-external rotator muscle group is elongated, the hip muscles and the anterior tibial muscle share the increased facilitation. If all the muscles of the hip and ankle are lengthened simultaneously, the excitability in those limb muscles increases further and spreads of the synergistic trunk flexor muscles.
Definition
- The stretch reflex is elicited from muscles that are under tension, either from elongation or from contraction.
The reflex has two parts. The first is a short-latency spinal reflex that produces little force and may not be of functional significance. The second part, called thefunctional stretch response, has a longer latency but produces a more powerful and functional contraction (Conrad and Meyer-Lohmann 1980; Chan 1984). To be effective as a treatment, the muscular contraction following the stretch must be resisted. The stretch of the muscular contraction produced by the stretch is affected by the intent of the subject, and therefore, by prior instruction. Monkeys show changes in their motor cortex and stronger responses when they are instructed to resist the stretch. The same increase in response has been shown to happen in humans when they are told to resist a muscle stretch (Hammond 1956; Evarts and Tannji 1974; Chan 1984).
Timing
Definition
- The sequencing of motions.
Normal movement requires a smooth sequence of activity, and coordinated movement requires precise timing of that sequence. Functional movement requires continuous, coordinated motion until the task is accomplished.
Definition
- Normal timing of most coordinated and efficient motions is from distal to proximal.
The evolution of control and coordination during development proceeds from cranial to caudal and from proximal to distal (Jacobs 1967). In infancy the arm determines where the hand goes, but after the grasp matures the hand directs the course of the arm movements (Halvorson 1931). The small motions that adults use to maintain standing balance proceed from distal (ankle) to proximal (hip and trunk) (Nashner 1977). To restore normal timing of motion may become a goal of the treatment.
Definition
- Timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or a desired activity. Kabat (1947) wrote that prevention of motion in a stronger synergist will redirect the energy of that contraction into a weaker muscle. This alteration of timing stimulates the proprioceptive reflexes in the muscles by resistance and stretch. The best results come when the strong muscles score at least "good" in strength (Manual Muscle Test grade 4; Partridge 1954).
There are two ways the therapist can alter the normal timing for therapeutic purposes.
- By resisting an isometric or maintained contraction of the strong motions in a pattern while exercising the weaker muscles. This resistance to the static contraction locks in that segment, so resisting the contraction is called "locking it in".
Patterns
The patens of facilitation may be considered one of the basic procedures of PNF.