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PNF( Proprioceptive Neuromuscular Facilitation ):
PNF Stretching is an occupational therapy and physical
therapy procedure designed in the 1940s and 1950s to
rehabilitate patients with paralysis. It is often a combination
of passive stretching and isometrics contractions. In the
1980s, components of PNF began to be used by sport
therapists on healthy athletes. The most common PNF leg or
arm positions encourage flexibility and coordination
throughout the limb's entire range of motion.
PNF is used to supplement daily stretching and is
employed to make quick gains in range of motion to help
athletes improve performance. Good range of motion makes
better biomechanics, reduces fatigue and helps prevent
overuse injuries. PNF is practiced by chiropractors, physical
therapists, occupational therapists, massage therapists,
athletic trainers and others.
PNF stretching is one of the most effective forms of
flexibility training for increasing range of motion.PNF
techniques can be both passive (no associated muscular
contraction) or active (voluntary muscle contraction). While
there are several variations of PNF stretching, they all have
one thing in common - they facilitate muscular inhibition. It is
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believed that this is why PNF is superior to other forms of
flexibility training.
Both isometric and concentric muscle actions completed
immediately before the passive stretch help to achieve
autogenic inhibition - a reflex relaxation that occurs in the
same muscle where the golgi tendon organ is stimulated.
Often the isometric contraction is referred to as 'hold' and the
concentric muscle contraction is referred to as 'contract'.
A similar technique involves concentrically contracting
the opposing muscle group to that being stretched in order to
achieve reciprocal inhibition - a reflex muscular relaxation
that occurs in the muscle that is opposite the muscle where
the golgi tendon organ is stimulated.
History:
In the early to mid 1900s physiologist Charles
Sherrington popularized a model for how the neuromuscular
system operates. Radiation is when maximal contraction of a
muscle recruits the help of additional muscle flexibility. Based
on that, Herman Kabat, a neurophysiologist, began in 1946 to
look for natural patterns of movement for rehabilitating the
muscles of polio patients. He knew of the myostatic stretch
reflex which causes a muscle to contract when lengthened
too quickly, and of the inverse stretch reflex, which causes a
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muscle to relax when its tendon is pulled with too much force.
He believed combinations of movement would be better than
the traditional moving of one joint at a time. To find specific
techniques, he started an institute in Washington, DC and by
1951 had two offices in California as well. His assistants
Margaret Knott and Dorothy Voss in California applied PNF to
all types of therapeutic exercise and began presenting the
techniques in workshops in 1952.
During the 1960s, the physical therapy departments of
several universities began offering courses in PNF and by the
late 1970s PNF stretching began to be used by athletes and
other healthy people for more flexibility and range of motion.
Terms about muscle contraction are commonly used when
discussing PNF.
Concentric isotonic contraction is when the muscle
shortens, eccentric isotonic is when it lengthens even though
resisting a force, and isometricis when it remains the same
length.
Indications of PNF : -
1. Loss of range of motion.
2. Acute and chronic pain.
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3. Muscle tightness.
4. Muscle cramp.
5. Loss of flexibility.
Contra-indications : -
1. Post-operative : PNF Stretching is not done after recent post
operation because the repairs that were made during surgery can be
counteracted like muscle or tendons pulling away from reattachment
due to tension stretching implements. Tissue healing must be
determined from intense stretching can be performed.
2. Instability of joints : If a person has an unstable joint in the area
where stretching is applied, he/she may not be able to control the
movement of the stretch and hyper mobility may cause injury.
3. Under age 18 years : PNF stretching is not recommended for
anyone below the age of 18 years as intense stretching may disrupt
the growth plates and may cause disease like Osgood Schlatter’s
disease.
4. Already stretched muscles : PNF is not performed more than once
a day due to stress it produces on muscles and tendons.
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The Fundamentals of PNF : -
PNF may be categorised in terms of five P-factors: Principles,
Procedures, Patterns, Positions and Postures, with joint Pivots and
Pacing (Timing) as important sub-categories. The methods comprising
these factors were formulated from findings on neuromuscular
development, such as the functional evolution of all movement from
motor immaturity to motor maturity in the growing child or novice
athlete in definite sequences progressing logically from:
* total to individuated
* proximal to distal, distal to proximal
* mobile to stabile
* gross to selective
* reflexive to deliberate
* overlapping to integrative
* incoordinate to coordinate
The Principles of PNF : -
The basic principles of PNF may be summarised as follows:
1. Use of spiral and diagonal movement patterns
2. Motion crossing the sagittal midline of the body
3. Recruitment of all movement components (e.g. flexion-extension)
4. Exercising of related muscle groups
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5. Judicious eliciting of reflexes
6. Movement free of pain, but not free of effort
7. Comfortable full-range movement
8. Application of maximal resistance throughout the range of non-ballistic movement
9. Use of maximal resistance to promote overflow (irradiation) of muscle activity
10. Use of multiple joint and muscle action
11. Commencement of motion in the strongest range
12. Use of static and dynamic conditions
13. Appropriate positioning of joints to optimise conditioning
14. Exercising of agonists and antagonists
15. Repeated contractions to facilitate motor learning, conditioning and adaptation
16. Selection of appropriate sensory cues to facilitate action
17. Emphasis on visuo-motor and audio-motor coordination
18. Use of distal to proximal sequences in neuromuscularly mature subjects
19. Use of stronger muscles to augment the weaker
20. Progression from primitive to complex actions
21. Planning of each phase to lay foundations for the next phase
22. All activities are integrated and goal directed
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23. Use of adjunct techniques (e.g. massage, vibration).
Procedure for PNF : -
Pattern of Motion : Normal motor activity occurs in
synergistic and functional patterns of movement. PNF
patterns are “spiral and diagonal” in character and combine
motion in all three planes flexion/extension,
abduction/adduction and transverse rotation.
Neck Patterns : -
1. Neck flexion with rotation to the right.
2. Neck extension with rotation to the left
Upper Extremity : -
Diagonal 1 : – Shoulder Flexion, Adduction, External Rotation
(D1 Flexion) and Extension, Abduction, Internal Rotation (D1
Extension); Elbow flexed/extended; Wrist & Fingers
Extension to flexion.
Diagonal 2 : – Shoulder Flexion, Abduction, Lateral Rotation
(D2 Flexion) and Extension, Adduction and Medial Rotation
(D2 Extension); Elbow Extended; Wrist & Fingers Flexion to
Extension.
Trunk : -
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Upper trunk in sitting position : Flexion with rotation to the left
(Chopping), Extension with rotation to the right (Lifting).
Lower Trunk in supine position : Flexion with rotation to the
left, Extension with rotation with the right.
Lower Extremity : -
Diagonal 1 : Hip Flexion, Adduction, External Rotation; Knee
extended; Foot Dorsi Flexion (D1 Flexion) and Hip Extension,
Abduction, Internal Rotation; Knee Extension; Foot Planter
Flexion (D2 Extension).
Diagonal 2 : Hip Flexion, Abduction, External Rotation; Knee
Extension; Foot Planter Flexion (D2 Flexion) and Hip
Extension, Adduction, Interna Rotation; Knee Extension; Foot
Dorsi Flexion (D2 Extension).
Timing: In PNF patterns normal timing is from distal to
proximal. Distal segments (hand/wrist or foot/ankle) move
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first followed closely by more proximal components. Rotation
occurs throughout the pattern, from beginning to end.
Timing for Emphasis : Maximum resistance is used to elicit a
strong contraction and allow overflow to occur from strong to
weak components within a synergistic pattern; the strong
muscles are resisted isometrically while motion is allowed in
the weaker muscles.
Resistance : Resistance facilitates muscle contraction and
motor control. Resistance is applied manually and
functionally through the use of gravity to all types of
contractions.
Overflow or Irradiation : Refers to spread of muscle response
from stronger muscles in a synergistic pattern to weaker
muscles; maximal resistance is the main mechanism for
securing overflow or irradiation. Enhance synergistic actions
of muscles, increase strength.
Manual Contacts : Precise manual contacts (grip) are used to
provide pressure to tactile and pressure receptors overlying
the muscles to facilitate contraction and guide direction of
movements; pressure is applied opposite to the direction of
the desired motion.
Positioning : Muscle positioning at optimal range of function
allows for optimal responses of muscles. The greatest muscle
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tension is generated in mid-ranges with weak contractile
force occuring in the shortened ranges.
Therapist Position and Body Mechanics : Therapist is
positioned directly in line with the desired motion in order to
optimize the direction of resistance that is applied.
Verbal Commands : Verbal commands allow for the use of
well-timed words and appropriate vocal volume to direct the
patient’s movement.
Vision : Vision is used to guide the patient’s movements,
enhance muscle contraction, and synergistic patterns of
movement.
Stretch : The elongated position/lengthened range and the
stretch reflex are used to facilitate muscle contraction. All
muscles in the pattern are elongated to optimize the effects of
stretch. Commands for voluntary movement are always
synchronized with the stretch to enhance the response.
Approximation : Approximation is used to facilitate
extensor/stabilizing muscle contraction and stability; can be
applied manually, functionally through the use of gravity
acting on body during upright positions, or mechanically using
weights or belts.
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Traction : A distraction force is used to facilitate muscle
contraction and motion, especially is applied in flexion
patterns or pulling motions; force is applied manually during
PNF. Gentle distraction force is also useful in reducing joint
pain.
PNF Techniques : –
Reversal of Antagonists : A group of techniques that allow
for agonist contraction followed by antagonist contraction
without pause or relaxation.
* Dynamic Reversals (Slow Reversals) : Utilizes isotonic
contractions of first agonists, then antagonists performed
against resistance. Contraction of stronger pattern is selected
first with progression to the weaker pattern. The limb is
moved through full ROM.
* Stabilizing Reversals : Utilizes alternating isotonic
contractions of first agonists, then antagonists against
resistance, allowing very limited ROM.
* Rhythmic Stabilization : Utilizes alternating isotonic
contractions of first agonists, then antagonists against
resistance, no motion is allowed.
Repeated Contractions : Repeated isotonic contractions
from the lengthened range, induced by quick stretches and
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enhanced by resistance; performed through the range or part
of range at a point of weakness. Technique is repeated
during one pattern or until contraction weakens.
Combination of Isotonics : Resisted concentric contraction
of agonist muscles moving through the range is followed by a
stabilizing contraction and then eccentric contraction, moving
slowig back to the start position; there is no relaxation
between the types of contractions. Typically used in anti
gravity activities/assumption of postures.
Rhythmic Initiation : Voluntary relaxation followed by
passive progressing to active-assisted and active-resisted
movements to finally active movements. Verbal commands
are used to set the speed and rhythm of the movements.
Light tracking resistance is used during the resistive phase to
facilitate movement.
Contract-Relax : a relaxation technique usually performed at
a point of limited ROM in the agonist pattern. Strong, small
range isotonic contraction of the restricting muscles
(antagonist) with emphasis on the rotators is followed by an
isometric hold. The contraction is held for few seconds and is
then followed by voluntary relaxation and movement into the
new range of the agonist pattern. Movement can be passive
but active contraction is preferred.
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Hold-relax : A relaxation technique usually performed in a
position of comfort and below a level that causes pain. Strong
isometric contraction of the restricting muscles (antagonists)
is resisted, followed by voluntary relaxation, and passive
movement into the newly gained range of the agonist pattern.
Replication (Hold-Relax Active motion) : The patient is
positioned in the shortened/end position of a movement and
is asked to hold. The isometric contraction is resisted
followed by voluntary relaxation and passive movement into
the lengthened range. The patient is then instructed to move
back into the end position; stretch and resistance are applied
to facilitate the isotonic contraction. For each repetition,
increasing ROM is desired.
Resisted Progression : Stretch, approximation and tracking
resistance is applied manually to facilitate pelvic motion and
progression during locomotion; the patient’s momentum,
coordination and velocity. It can be applied using elastic band
resistance
Rhythmic Rotation : Relaxation is achieved with slow,
repeated rotation of a limb at a point where limitation is
noticed. as muscles relax the limb is slowly and gently moved
into the range, As a new tension is felt, it is repeated. The
patient can use active movements for rhythmic rotation or the
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therapist can perform it passively. Voluntary relaxation when
possible is important.
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General guidelines when completing PNF stretching:
1. Leave 48 hours between PNF stretching routines.
2. Perform only one exercise per muscle group in a session.
3. For each muscle group complete 2-5 sets of the chosen
exercise.
4. Each set should consist of one stretch held for up to 30
seconds after the contracting phase.
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5. PNF stretching is not recommended for anyone under the
age of 18.
6. If PNF stretching is to be performed as a separate
exercise session, a thorough warm up consisting of 5-10
minutes of light aerobic exercise and some dynamic
stretches must precede it.
7. Avoid PNF immediately before, or on the morning of
competition.
Gallery:
Arm-front diagonal flexion.
Leg-front diagonal flexion.
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PNF patterns (diagonal), lower extremities
Front cross
Out back
Back cross
Out front
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PNF patterns (diagonal), upper extremities
Cross low
Back high
Cross high
Back low