In Adult Neurorehabilitation

Elham Attari, SPT

Joseph Jemera, SPT
Bryce Stavness, SPT

Angela Corchado, SPT

Michael Sterken, SPT
Jennifer Ferguson, SPT
 Learning Objectives
At the completion of this presentation the student will be
able to:

1. Define proprioceptive neuromuscular facilitation (PNF).

2. Discuss the treatment philosophy that serves as the

framework for using PNF intervention techniques.

3. List the theoretical explanations for the effectiveness of

PNF techniques on increasing muscle length.

4. Discuss the current use of PNF in adult

neurorehabilitation.
 Learning Objectives (cont.)
5. Discuss the efficacy of PNF as a neurorehabilitation
intervention technique based upon the most current
literature.

6. Discuss the implications of PNF research on PT

Practice.
•.

History 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 multiple sclerosis, cerebral
palsy and poliomyelitis.
 PNF Definition
Definition: A motor learning approach used in
neuromotor development training to improve motor
function and facilitate maximal muscular contraction.

Kabat (1951): “The basis of the PNF philosophy is the

idea that all human beings, including those with
disabilities have untapped existing potential.”

PNF in practice 2007

 PNF Philosophy
1. Positive approach: no pain, achievable tasks, set up
for success, direct and indirect treatment, strong
start.
2. Highest functional level: functional approach, ICF,
include treatment on body structure level and
activity level.
3. Mobilize potential by intensive training: active
participation, motor learning, self training.
PNF in practice 2007
 Philosophy cont…
4. Consider the total human being: whole person with
his/her environmental, personal, physical, and
emotional factors.

5. Use of motor control and motor learning principles:

repetition in a different context; respect stages of
motor control, variability of practice.

PNF in practice 2007

 How is PNF used today?
PNF treatment has been used to increase strength,
flexibility, coordination, and functional mobility.

The main goal of treatment is to facilitate the patient

in achieving a movement or posture.

Stretches as well as diagonals and rotational exercise

patterns are used to improve ADLs, functional
mobility, and athletic performance.
PNF in practice 2007
 PNF Today cont…
It is mainly used in Orthopedic Rehab for
Musculoskeletal Injuries & in Neurological
Rehab for Stroke & TBI.

PNF can be used for any condition, however

the pt. condition level may require
modifications.

PNF in practice 2007

 PNF Stretching
Sherrington (1900): Developed
concepts of neuromuscular
facilitation and inhibition.
Kabat: Clinical PNF stretching
techniques.
Types: Contract relax, hold relax,
agonist contract, and hold relax
with agonist contract.
Proposed Mechanisms: autogenic
inhibition, reciprocal inhibition,
passive properties of the
musculoskeletal unit, and stretch
perception.
 PNF for Strength
PNF utilizes two types of contractions: Isotonic and
Isometric.

Uses manual contacts to produce motor responses that

influence the stimulation of skin and other receptors.

When applying these exercises, it is important to apply

the appropriate resistance.

This resistance is meant to facilitate the muscles to

contract, improve motor control, and improve strength.

PNF in practice 2007

Research Reviews
 Dickstein et al. (1986)
Compared efficacy of adult stroke rehab techniques…
(n = 131)

 Conventional Treatment Exercises (57)

 PNF Techniques (36)

 Bobath NDT Techniques (38)

Conclusion: “No substantial advantage could be

attributed to any one of the three therapeutic
approaches.”
 Trueblood et al. (1989)
Testing efficacy of resisted pelvic motions using PNF
for improving hemiplegic gait ≈ 2 months s/p stroke.
(n = 20)

 Pretest: gait parameters assessed

 15 minute PNF pelvic pattern work
 Posttest 1: gait assessed immediately
 Posttest 2: gait assessed 30 minutes later

Results/Conclusion: 50% improved on 8 gait variables

(not clinically sig.) at first posttest. NO subjects
demonstrated carryover 30 mins after treatment!
 Wang RY (1994)
Testing efficacy of resisted pelvic motions using PNF
for improving hemiplegic gait. (n = 20)

 Group 1: CVA s/p ≈ 4.4 months

 Group 2: CVA s/p ≈ 15.4 months

 Treatment: 30 mins, 3 times / week for 4 weeks

Results/Conclusion: After first treatment, Group 1 saw

immediate improvements in gait speed and cadence.
After 12 sessions, both groups had similar treatment
effects, resulting in increased gait speed and cadence.
Trueblood et al. (1989) & Wang (1994) both used the
same PNF techniques for pelvic motion to improve gait…
 Why the mixed results?
Trueblood et al. (1989) Wang RY (1994)

Treatment Time: 15 minutes  Treatment Time: 30 minutes

Dosage:  Dosage:
4 sets of 5 reps with one 10 mins rythmic initiation,
10 mins slow reversal,
minute rest intervals. 10 mins agonistic reversals.

 Patients were treated and

Patients were treated and tested for TWELVE sessions.
tested for ONE session.
 Kraft et al. (1992)
Compared treatments to improve function of the arm and
hand in chronic hemiplegia. (n = 22)

 EMG-initiated E-stim of wrist extensors (6)

 Low intensity E-stim with voluntary contraction (8)

 Proprioceptive Neuromuscular Facilitation Exercises (3)

 No Treatment (5)

Results/Conclusion: Fugl-Meyer scores improved 42 % for

EMG-stim, 25% for B/B, 18% for PNF, and negligible for no
treatment.
 Problems with Kraft et al. (1992)
Small sample size for each group.
Unspecified methods and dosage.
EMG-stim group had higher Fugl-Meyer scores at
admission to study.
Many patients won’t tolerate a max contraction
induced by E-stim.

In 2001, the Heart and Stroke Foundation of Ontario

found that when the data was recalculated after
combining the PNF group with the control group, the
EMG-stim group did not have significantly different
improvements in Fugl-Meyer scores!
Management of the Post Stroke
Arm and Hand 2001 HSFO
recommendations…
http://profed.heartandstroke.ca/
ClientImages/1/
PostStrokeArmAndHandFinal2002%5B1%5D
.pdf
Yildirim SA, Erden Z, & Kilinc M (2007)
Compared treatments for improving UE muscular
strength in patients with neuromuscular diseases.
(n = 48)
 PNF Techniques
 Weight Training

Conclusion: After 8 weeks, total UE strength improved in

both groups with no sig. difference between groups.

UPPER EXTREMITY FUNCTIONAL LEVEL DID NOT

CHANGE FOR PATIENTS IN EITHER GROUP !!
 Other Research…
Several studies were omitted due to weak evidence:

- poor research designs (lack of reproducibility)

- small sample sizes (case reports)

- poor generalizability (e.g. healthy, athletic subjects)

-unsubstantiated conclusions (lack of causality)

 Conceptual Framework
For PT Practice?
Natarajan et al. (2008) surveyed 100+ stroke rehab
clinicians with 12 yrs experience (SD of 8.2yrs) in
Kansas & Missouri.

92% reported that they believed that

reeducating “normal” movement
patterns AND facilitating adaptation
to function are both important
treatment aims!
 PNF and Adult
Neurorehabilitation

“Nearly all respondents

• According to Natarajan et al. (2008)…
that use Brunnstrom/PNF
or Bobath/NDT reported
practicing these
techniques, despite the
lack of evidence to
support the approaches.”
“Current literature does NOT favor
either Bobath/NDT or
Brunnstrom/PNF methods over
other treatment options
[in stroke rehabilitation].”

 According to Natarajan et al. (2008)

So why are clinicians choosing PNF
for neurorehabilitation treatment?

Though clinicians recognize there is limited evidence, PNF provides:

• Time efficient treatment
• Treatment of multiple joints/muscles
• Movement through functional patterns
• Safe motion
 Implications of PNF on PT
Practice
Not enough evidence to use PNF as sole treatment in

neurorehabilitation patients.

PNF stretching is supported

by evidence when used to

treat “healthy populations.”
 PNF Stretching
The most effective PNF technique combines
concentric contraction of agonist, and static
contraction of the antagonist muscle (target muscle)

Recommendations for Augmented ROM:

- 3 second contraction holds (20% max)
- 30-60 second total duration
- 1 repetition (minimum)
- 2x/wk
Note: These recommendations are based on
research using healthy populations.
Sharman et al. (2006)
 Should you Employ PNF?
In reference to your patients impairments and
functional limitations….

•1. Does PNF fit in your conceptual framework for

clinical practice?
•2. Could PNF address your patient’s problems?
•3. Is PNF considered EBP for your pt. population?**

-Yes to all 3 = Yes to PNF

**PNF use in neurorehab lacks evidence but can be

used in conjunction with other EB interventions!!
 References
 Adler, S.S., Beckers, D., & Buck, M. (2008) PNF in Practice: An Illustrated Guide (3rd ed.).
Germany: Spinger.

 Colby, L.A., Kisner, C. (2007) Therapeutic Exercise: Foundations and Techniques (5th ed.).
Philidelphia: F.A. Davis Company.

 Dickstein R, Hocherman S, Pillar T, & Shaham R. Stroke Rehabilitation: Three Exercise

Approaches. Physical Therapy. August 1986; 66 (8): 1233-1238.

 Kraft GH, Fitts SS, & Hammond MC. Techniques to Improve Function of the Arm and
Hand in Chronic Hemiplegia. Archives of Physical Medicine and
Rehabilitation. 1992; 73 (3): 220-227.

 Natarajan P, Oelschlager A, Agah A, et al. Current clinical practices in stroke

rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
Development. 2008; 45(6):841-850.
 References (cont.)
 Sharman MJ, Cresswell AG, & Riek S. Proprioceptive Neuromuscular Facilitation
Stretching: Mechanisms and Clinical Implications. Sports Medicine. 2006;
36 (11): 929-939.

 Trueblood PR, Walker JM, Perry J, & Gronley JK. Pelvic Exercise and Gait in
Hemiplegia. Physical Therapy. January 1989; 69 (1): 18-26.

 Wang RY. Effect of Proprioceptive Neuromuscular Facilitation on the Gait of Patients

with Hemiplegia of Long and Short Duration. Physical Therapy. December
1994; 74 (12): 1108-1115.

 Yamashiro, K.M. Proprioception Neuromuscular Facilitation Level 1.

 Yildirim SA, Erden Z, & Kilinc M. Comparison of the Effects of Proprioceptive

Neuromuscular Facilitation Techniques and Weight Training in Patients with
Neuromuscular Diseases. [Abstract.] Fizyoterapi Rehabilitasyon. August 2007; 18 (2):
65-71.
 Review Learning Objectives
1. Define proprioceptive neuromuscular facilitation (PNF).

2. Discuss the treatment philosophy that serves as the framework for

using PNF intervention techniques.

3. List the theoretical explanations for the effectiveness of PNF

techniques on increasing muscle length.

4. Discuss the current use of PNF in adult neurorehabilitation.

5. Discuss the efficacy of PNF as a neurorehabilitation intervention

technique based upon the most current literature.

6. Discuss the implications of PNF research on PT Practice.