USING PNF PATTERNS IN THE CLINIC

BY: MEGAN SIEBERT, SPT

UNIVERSITY OF NORTH DAKOTA
WHAT ARE PNF PATTERNS?

 Proprioceptive Neuromuscular Facilitation Patterns

 Normal motor movements in synergistic and functional patterns emphasizing rotational and diagonal movements
 Used to improve motor function
KEY CONCEPTS

 Use manual contact, verbal commands, body position and body mechanics to improve motor control, strength and
endurance
 Do not use with significant pain, unstable joints or fractures, and unstable medical conditions
 Focus more on the rotational/diagonal aspect of the movements
UPPER EXTREMITY D1

 Flexion:
 Scapula: elevation, abduction, upward rotation
 Shoulder: Flexion, adduction, external rotation
 Elbow: supination, flexion
 Wrist: flexion, radial deviation
 Hand: finger and thumb flexion
 Extension:
 Scapula: depression, adduction, downward rotation
 Shoulder: extension, abduction, internal rotation
 Elbow: pronation
 Wrist: Extension, ulnar deviation (Image 1)
 Hand: fingers extended, thumb abducted
UPPER EXTREMITY D2

 Flexion:
 Scapula: elevation, adduction, upward rotation
 Shoulder: flexion, abduction, external rotation
 Forearm: supination, extension
 Wrist: extension, radial deviation
 Hand: fingers and thumb extension

 Extension:
 Scapula: depression, abduction, downward rotation
 Shoulder: extension, adduction, internal rotation
 Forearm: pronation, extension
 Wrist: flexion, ulnar deviation
 Hand: finger extension, thumb abduction (Image 2)
LOWER EXTREMITY D1

 Flexion:
 Hip: flexion, adduction, external rotation
 Knee: flexion
 Ankle: Dorsiflexion, eversion
 Extension:
 Hip: extension, abduction, internal rotation
 Knee: extension
 Ankle: Plantarflexion, inversion (Image 3)
LOWER EXTREMITY D2

 Flexion:
 Hip: flexion, abduction, internal rotation
 Knee: flexion
 Ankle: dorsiflexion, eversion

 Extension:
 Hip: extension, adduction, external rotation
 Knee: extension
 Ankle: plantarflexion, inversion

(Image 4)
PRINCIPLES

 Pt position: have pt in as neutral position as possible and support body segments as needed
 PT position: be directly in line with the desired movement to provide optimal resistance and better control
 Manual contacts: used to guide the movement and apply resistance. The sensory input helps pts anticipate the movement and
facilitate feedforward adjustments
 Verbal cues/Demands: must be clear and well timed for the movements. If commands are too wordy it will make the activity
counterproductive and motor learning will not occur
 Timing: the movements should be fluid, smooth and coordinated. PT’s need to ensure that the movement starts distal and moves
proximal in the extremities and that rotation occurs smoothly throughout the motion
 Traction: can be used throughout the motion to facilitate muscle responses via the GTO
 Irradiation: using stronger muscles to spread a response to weaker/inhibited muscles that can be used in any direction. (ipsilaterally,
contralaterally, extremities to trunk, trunk to extremities) Must use the appropriate resistance
 Quick Stretch: used to initiate dynamic movement and increase motor unit recruitment
MOBILITY TECHNIQUES

 Hold Relax
 Contract Relax
 Rhythmic Rotation
 Rhythmic Initiation
 Hold Relax/Hold Relax Active Contraction
 Goals: stretch/relaxation to improve limited PROM
 Steps:
 Strong isometric contraction of the restricting muscle
 Followed by relaxation and passive movement into the restricted ROM

*Uses autogenic inhibition*

 Contract Relax/ Contract Relax Active Contraction
 Goals: to improve ROM
 Steps:
 Strong contraction of antagonists with emphasis on the rotation
 Hold contraction for 5-8 seconds
 Voluntary relaxation and passive/active movement into the new ROM
 Rhythmic Rotation
 Relaxation technique that uses slow, repeated rotation of limb or body segments
 Can be active or passive
 Until muscle tension relaxes
 Goals: promote relaxation and increase range in muscles restricted by excess tone
 Indications: relaxation of hypertonia
 Rhythmic Initiation
 Goal: learning of new movement or relaxation
 Steps:
 PROM demonstrating appropriate speed/rhythm with verbal commands

 AAROM

 AROM

 Resisted AROM

 Indications:
 Inability to relax

 Hypertonicity

 Difficulty initiating movements

 Motor learning/planning/communication deficits

CONTROLLED MOBILITY TECHNIQUES

 Dynamic Reversals
 Combination of Isotonics
 Dynamic Reversals (Isotonic)
 Goal: improve coordination, strength, AROM, and endurance
 Use isotonic concentric contractions of agonists first, then antagonists; both against resistance
 Initial stretch can be used to initiate movement
 Indications
 impaired strength
 rage and coordination

 inability to easily reverse directions

 Fatigue

*Hand placement changes*

 Combination of Isotonics
 Goal: to improve motor learning and coordination, increase strength, promote stability and eccentric control
 Steps:
 Resisted concentric contraction of agonists through range
 Isometric hold contraction
 Eccentric contraction

*Hand Placement NEVER changes*

STABILITY TECHNIQUES

 Static Holding
 Stabilizing Reversals
 Rhythmic Stabilization
 Static Hold
 The patient’s body segments are assisted into correct alignment from PT
 Patient asked to hold this position
 Stabilizing Reversals (Isometric)
 Goals: improve stability, strength, coordination, endurance, and ROM
 Use alternating isometric contraction of both agonists and antagonists
 “Don’t let me move you”
 Indications: impaired strength, stability, balance and coordination
 Rhythmic Stabilization
 Goals: improve stability, strength, endurance, ROM, relaxation and decrease pain
 Resist agonists and antagonists in a twisting motion
 “Don’t let me twist you”
 Indications:
 Impaired strength and coordination
 Limitations in ROM
 Impaired stabilization control and balance
EFFECT OF A PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION
(PNF) PROTOCOL ON THE POSTURAL BALANCE OF OLDER WOMEN

 Small sample size of 20 women 65-85 yrs

 Used TUG and functional reach test, forefoot, back foot and total plantar area assessed with and without disturbance
 UE and LE both D1 and D2 were performed bilaterally as well as shoulder and pelvic exercises in sidelying with diagonal
anterior/elevation, posterior/depression.
 Muscles were elongated first using hold-relax in diagonals, then followed by rhythmic initiation and reversal of antagonists for change
of movement direction.
• Principles used:
• Rhythmic Initiation, hold-relax, reversal of antagonists
 4 week treatment:
(combination of isotonics)
 Week 1: series of ten reps
• Conclusion:
 Week 2: 2 sets of 10 reps
• There was also a reduction in plantar area but was not
 Week 3: 3 sets of 10 significant
 Week 4: 3 sets of 10 • Static and dynamic balance improved reducing TUG time
and increase in trunk flexion in functional reach test
EFFECTIVENESS OF THE PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION
METHOD ON GAIT PARAMETER IN PATIENTS WITH STROKE: A SYSTEMATIC REVIEW

 5 Studies
 Sample sized ranging from 18-40 subjects post stroke
 All studies used PNF as primary intervention focusing on gait training using pelvic/LE patterns,
manual resistance, rhythmic initiation, slow reversal, agonistic reversal
 Compared to the control groups: PNF showed significantly more gain improvement compared to
conventional exercises
 Outcome measures were different in all studies
 Statistical significance of improvement in gait outcome measures in all the studies and most found
that PNF improved gait more than the control groups (however all studies had small sample sizes)
A COMPARATIVE STUDY OF STATIC STRETCH AND PROPRIOCEPTIVE
NEUROMUSCULAR FACILITATION (PNF) STRETCH ON PECTORAL MUSCLE FLEXIBILITY

 Two randomized groups into a static stretch group (15 subjects) and a PNF stretch group (15 subjects) ages
from18-35 all male. Subjects were included if they had tight pectoral muscles and round or forward shoulder
posture. Patient’s were excluded if they were being treated for shoulder dysfunction, trauma/injury, acute pain, and
delayed onset of muscle soreness.
 Static Stretching: pt seated with hands laced behind head, PT pulls back and up in diagonal holding for 30 seconds
 PNF Stretching: pt seated with hands laced behind head, PT pulls back and up in diagonal performing hold-relax
6 sec contraction, 10 sec relax/stretch, x2
 5 days/ week for 6 weeks
 Shoulder ER measured with goniometer and forward posture by a Baylor square measuring distance from C7
spinous process to anterior tip of acromion process (measurements taken at initial, week 3 and week 6)
 Both groups showed significant improvement, however PNF stretching showed greater improvement than static
stretching.
BAYLOR MEASURING TOOL

(Image 5)
REFERENCES
 https://www.findclip.net/search/pnf%2Bpatterns%2Bu pper%2Bextremity (Image 1)
 http://coinme.pw/d1-d2-patterns.html (Image 2)
 https://www.youtube.com/watch?v=pBIvfoxv8kY (Image 3)
 https://www.youtube.com/watch?v=wbCZ1oDBwes (Image 4)
 https://www.jospt.org/doi/pdfplus/10.2519/jospt.1997.25.1.34 (Image 5)
 Almeida Silva I, Rodrigues Amorim J, Teixeira de Carvalho F, de Andrade Mesquita LS. Effect of a Proprioceptive Neuromuscular
Facilitation (PNF) protocol on the postural balance of older women. Fisioterapia e Pesquisa. 2017;24(1):62-67. doi:10.1590/1809-
2950/16636724012017.
 Gunning E, Uszynski MK. Effectiveness of the proprioceptive neuromuscular facilitation method on gait parameters in patients with
stroke: A systematic review. Arch Phys Med Rehabil. 2019;100(5):980-986. doi: S0003-9993(18)31558-2 [pii].
 Ramneesh V, Sheetal K, Joginder Y. A Comparative Study of Static Stretch and Proprioceptive Neuromuscular Facilitation (PNF)
Stretch on Pectoral Muscle Flexibility. Indian Journal of Physiotherapy & Occupational Therapy. 2014;8(4):37-42. doi:10.5958/0973-
5674.2014.00008.2.
 Prentice WE. Proprioceptive Neuromuscular Facilitation Techniques in Rehabilitation. In: Hoogenboom BJ, Voight ML, Prentice
WE. eds. Musculoskeletal Interventions: Techniques for Therapeutic Exercise, Third Edition New York, NY: McGraw-Hill;
2013. http://accessphysiotherapy.mhmedical.com.ezproxylr.med.und.edu/content.aspx?bookid=960&sectionid=53549680. Accessed
October 08, 2019.