Proprioceptive Neuromuscular

Facilitation (PNF)
Methods of promoting or hastening the response of the
neuromuscular mechanism through stimulation of the
.proprioceptor

Definition: is an approach to therapeutic

exercise that combine functionally based
diagonal patterns of movement with techniques
of neuro- muscular facilitation to evoke motor
responses and improve neuro- muscular control
• Purpose:
Strengthening the weak muscles by through a
pattern of movement in the diagonal plane.
Physiological principles of PNF
technique
• When a muscle is put on stretch for a
prolonged amount of time or contracts
isometerically, the GTO is activated and
inhibits the tension, allowing the muscle to
relax and elongate.
• This elongation during a stretch or extreme
tension helps prevent the possible tearing
of a tendon or muscle.
• This process is known as autogenic
inhibition.
 Physiological principles of PNF
technique
• Reciprocal inhibition is the physiological
process that occurs when the agonist
muscle concentrically contracts, causing
the antagonist muscle to in turn relax.
• This relaxation of the antagonist muscle
allows the agonist muscle to move the
limb through the total allowed ROM
without interfering tension.
 Stretch reflex
MS, stimulated by a Lengthening the whole muscle.
b. Stimulating the contractile portion of the
intrafusal muscle.

GTOs, records the change in tension, Speed, and

signals to the SC to convey this information.

When muscle is stretched → muscle spindle records

the change in length and speed and sends signals to
the SC.

With INJURY there is a delay in the stimulation of

the MS and GT resulting in weakness of the muscle.

PNF exercises help to “re-educate” the

motor units which are lost due to the injury.
 Stretch reflex
To initiate it, the muscle is taken briefly beyond
lengthened position.

A resistance for length change in muscle by

causing the stretched muscle to contract.

The more sudden the change length, the

stronger the contractions will be.
Holding a stretch cause MS to habituates and
reduces signaling. And eventually greater
lengthening of the muscles.
 Stretch reflex

Isolation → short-lived contraction.

Facilitate the initiation, force, direction,

or endurance of motor response through
quick stretch .

Stretch can be repeated at start of

range or superimposed during a pattern.

Contraindicated if painful.
Patterns of Facilitation

Manually resistive exercises that create the

diagonals of movement by coupling pairs of
antagonistic patterns, providing a path for
reversing motions, and using the agonist–
antagonist relationship of the nervous system as
.techniques are applied
Procedures
1. Body positioning and mechanics
2. Manual contacts
3. Manual and maximal resistance
4. Irradiation
5. Verbal and visual cuing
6. Traction and approximation
7. Stretch
8. Timing
 Manual Contacts

The term manual contact refers to how and where the

therapist’s hands are placed on the patient. Whenever
possible, manual contacts are placed over the agonist
muscle groups or their tendinous insertions.
These contacts allow the therapist to apply resistance to the
appropriate muscle groups and cue the patient as to the
desired direction of movement.
For example, if wrist and finger extension is to be resisted,
manual contact is on the dorsal surface of the hand and
wrist.
Manual Contacts

Use contacts overlying agonist muscle

group to strengthen contractions and/or
direction of movement.
Use lumbrical grip to provide contact.
Contact the target group (direct effect)
or synergist or antagonist (indirect).
In the extremity patterns one manual contact is
placed distally (where movement begins).
The other manual contact can be placed more
proximally, for example, at the shoulder or
scapula. Placement of manual contacts is
adjusted based on the patient’s response and
level of control.
 Maximal Resistance
The amount of resistance applied during dynamic
concentric muscle contractions is the greatest amount
possible that still allows the patient to move smoothly
and without pain through the available range.
Resistance should be adjusted throughout the pattern to
accommodate to strong and weak components of the
pattern. Resistance to motion enhances muscle
activation.
Direction, quality, and quantity of resistance are
adjusted according to treatment goals.
Position and Movement of the Therapist

The therapist remains positioned and aligned along the

diagonal planes of movement with shoulders and trunk
facing in the direction of the moving limb. Use of
effective body mechanics is essential. Resistance should
be applied through body weight, not only through the
upper extremities.
The therapist must use a wide base of support, move with
the patient, and pivot over the base of support to allow
rotation to occur in the diagonal pattern.
 Normal Timing
A sequence of distal to proximal, coordinated muscle
contractions occurs during the diagonal movement
patterns.
The distal component motions of the pattern should
be completed halfway through the pattern.
Correct sequencing of movements promotes
neuromuscular control and coordinated movement.
 Traction

Traction is the slight separation of joint surfaces

theoretically to inhibit pain and facilitate
movement during execution of the movement
patterns.
Traction is most often applied during flexion
(antigravity) patterns.
 Approximation

The gentle compression of joint surfaces by means

of manual compression or weight bearing
stimulates cocontraction of agonists and
antagonists to enhance dynamic stability and
postural control via joint and muscle
mechanoreceptors.
 Verbal Commands
• Auditory cues are given to enhance motor output.
• The tone and volume of the verbal commands are
varied to help maintain the patient’s attention.
• A sharp verbal command is given simultaneously
with the application of the stretch reflex to
synchronize the phasic, reflexive motor response
with a sustained volitional effort by the patient.
• Verbal cues then direct the patient throughout the
movement patterns.
• As the patient learns the sequence of movements,
verbal cues can be more succinct.
 Visual Cues

The patient is asked to follow the movement

of a limb to further enhance control of
movement throughout the ROM.
Irradiation (Overflow)

Spread of energy from agonist to complimentary

.agonists and antagonists within a pattern

Irradiation is stimulated through clinician’s use

of resistance.

Weaker muscle groups benefit while working in

synergy with more normal partners.
Stretch

Often performed at the starting position of

a pattern or movement.
Result – Reflex activation.
Resistance through entire range provides
continued stretch through tension.
Stretch can be repeated at start of range
or superimposed during a pattern.
:Four types of PNF Strengthening
Rhythmic initiation: includes progression from
passive to active-resistive, then followed by
active movement. This is used when a patient
cannot start a range of motion, and to teach the
patient the movement.
Uses of Rhythmic Initiation

Initiate movement.
Define the direction or pattern of
movement.
Set the appropriate rate of movement.
Improve coordination and sense of
motion.
Promote general relaxation.
Repeated contraction: Patient moves
limb isotonically through resistance until
fatigue is present. Help to initiate
movement.
Strengthen agonist movement pattern from
lengthened range.
Strengthen agonist movement pattern
within available ROM.
Redirect motion within pattern or task.
Slow reversal: isotonic contraction of
agonist and immediate contraction of
antagonist.

It helps to develop AROM and

coordination between agonist and
antagonist.

This helps to increase strength of a

specific ROM.
http://www.youtube.com/watch?
v=gWAAN-wFfro
Slow reversal hold:

Slow reversal hold adds an isometric

contraction at the end of the range of a pattern to enhance
end-range holding of a weakened muscle. With no period
of relaxation, the direction of movement is then rapidly
reversed by means of dynamic contraction of the agonist
muscle groups quickly followed by isometric contraction
of those same muscles. This is one of several techniques
used to enhance dynamic stability, particularly in proximal
muscle groups.
 Rhythmic stabilization
• isometric contraction of agonist followed by isometric
contraction of antagonist, No motion intended and It
increases the holding power of a specific ROM.
• Improve strength of antagonists.
• Improve balance of antagonists.
• Improve stability
• It increases the holding power of a specific ROM.
• Increase active and passive ROM following
technique.
• Decrease pain.
http://www.youtube.com/watch?
v=LXDbHgkCNKo&feature=related
Use of Dynamic Reversals of
Antagonists: Active motion changing from one
direction ( agonist) to opposite without pause or
.relaxation

Increase active ROM.

Improve strength in the available ROM.
Improve balance and coordination of
antagonist.
Improve endurance of antagonistic
patterns.
Use of Stabilizing Reversals: alternative
isotonic con. Opposed by enough Resistance to
.prevent motion

Improve balance and stability.

Improve strength.
Integrate a new posture or ROM into function.
Increase coordination btw Agonist -antagonist
Alternating Isometrics
Another technique to improve isometric strength and stability
of the postural muscles of the trunk or proximal stabilizing
muscles of the shoulder girdle and hip is alternating
isometrics.
Manual resistance is applied in a single plane on one side of a
body segment and then on the other.
The patient is instructed to “hold” his or her position as
resistance is alternated from one direction to the opposite
direction. No joint movement should occur.
This procedure isometrically strengthens agonists and
antagonists; and it can be applied to one extremity, to
both extremities simultaneously, or to the trunk.
Alternating isometrics can be applied with the extremities in
open-chain or closed-chain positions.
For example, if a patient assumes a side-lying position,
manual contacts are alternately placed on the anterior
aspect of the trunk and then on the posterior aspect of the
trunk.
The patient is told to maintain (hold) the side-lying position
as the therapist first attempts to push the trunk posteriorly
and then anteriorly.
Manual contacts are maintained on the
patient as the therapist’s hands are moved
alternately from the anterior to posterior
surfaces.
Resistance is gradually applied and released.
The same can be done unilaterally or
bilaterally in the extremities.
Use of Hold and Relax: Perform end- range isometric
con. of tight muscle before it passively lengthened. Using
.autogenic inhibition

Improve PROM.
Provide relaxation.
Reduce pain.

http://www.youtube.com/watch?
v=SIyGpF_XDgs&feature=related
Use of Contract and Relax

Improve passive ROM.

Provide relaxation.

http://www.youtube.com/watch?
v=L6YDDWdarSk&feature=related
Use of Combination of Isotonics

Increase strength of agonist.

Increase active ROM.

Teach functional control.

Summary
PNF is a manual therapy approach that applies
postures, movement patterns, contacts, cues,
and goals. All = Maximally facilitating.

Treatment is based on improving function, and

using functions that are possible to reach those
are attainable goals.

PNF lends itself to use as an adjunct to other

treatment approaches.
 Evidence Based Practice of PNF

Article(1): Effects of Hot or Cold Water Immersion

and Modified Proprioceptive Neuromuscular
Facilitation Flexibility Exercise on Hamstring Length

Objective: To compare the changes in hamstring

length resulting from modified PNF flexibility training
in combination with cold-water immersion, hot water
immersion, and stretching alone.

Subjects: 45 uninjured subjects (21 women, 24 men;

age range, 18–25 years) were recruited from an
undergraduate college population.

Journal of Athletic Training,2001,VOL(36)

Result.

Modified PNF flexibility training alone or in

conjunction with heat or cold thermal agents resulted
in significant increases in hamstring length.

Of the 3 basic kinds of stretching (ballistic, slow

stretch, and PNF), it was shown that PNF and its
derivatives are the most effective techniques for
increasing flexibility.

Journal of Athletic Training,2001,VOL(36)

Article(2): Effects of Two 4-Week PNF Programs on
Muscle Endurance, Flexibility, and Functional
Performance in Women With Chronic LBP

Object:
To examine the effects of 2 proprioceptive neuromuscular
facilitation (PNF) programs on trunk muscle endurance,flexibility,
and functional performance in subjects with chronic, low back
pain (CLBP).

Subjects:
86 women (40.2±11.9 years of age) who had complaints of CLBP
were randomly assigned to 3 groups:
1.Rhythmic stabilization training,
2.Combination of Isotonic exercise.
3.Control.

Nick Kofotolis, Eleftherios Kellis (2006)

Result

It was found that both training groups

demonstrated significant improvements
in lumbar mobility (8.6%-24.1%).

Static and dynamic muscle endurance

(23.ri%-81%)

Oswestry Index {29.3%-31.8%)

measurements.
Nick Kofotolis, Eleftherios Kellis (2006)
Nick Kofotolis, Eleftherios Kellis (2006)
 Conclusion
PNF is a manual therapy approach that applies postures,
movement patterns, contacts, cues, and goals. All =
Maximally facilitating.

Treatment is based on improving function, and using

functions that are possible to reach those are attainable
goals.

The using of PNF alone or in conjunction with thermal agent

will result in an increase in muscle strength

PNF is consider an effective technique for subject with CLBP.

:PNF Techniques
• Always you should remember the following:
• D: Diagonal Plane
• D1: end the (flexion) pattern by crossing the
midline.
• D2: start the (flexion) pattern from the
midline.
• Flexion or Extension: is related to the end
position of the shoulder or hip joint (pivot joint)
in each pattern
 PNF upper extremities pattern
D1 FLEXION D2 FLEXION
Shoulder-flex Shoulder-Flex.
Shoulder flexion
Add. Abd.
Ext. Rot. External Ext.Rot
Forearm-Sup. rotation Forearm - Sup.
Wrist- Radial Flex. Wrist - Radial Ext.
Finger- Flex. Wrist supination
D Fingers - Ext.
D
1 2
Shoulder adduction Shoulder abduction
Shoulder
wrist flexion Wrist extension
D pivot
Finger flexion D Finger extension

2 1 D1 EXTENSION
D2 EXTENSION Shoulder
Shoulder- Ext. Shoulder- Ext.
extension
Add. Add.
Int.Rot Internal Int.Rot
Forearm-Pron. rotation Forearm- Pron.
Wrist- Ulnar Ext. Wrist- Ulnar Ext.
Wrist Fingers- Ext.
Fingers- Flex. pronation
 PNF lower extremities pattern
D1 FLEXION
Hip - Flex. D2 FLEXION
Hipflexion
Hip flexion
Add. Hip - Flex.
Foot
Foot Abd.
Ext.Rot
dorsiflexion
dorsiflexion Int.Rot.
Foot - Dorsi.
Inver. Toe Foot - Dorsi.
Toe
Toes - Ext. extension
extension Ever.
Toes - Ext.
Hip
Hipadduction
adduction Hipabduction
abduction
Hip
External HIP
Externalrotation
rotation Internalrotation
Internal rotation
PIVOT
Foot
Footinversion
inversion Footeversion
eversion
Foot

D2 EXTENTION D1 EXTENSION
Hip
Hipextension
extension
Hip - Ext. Hip - Ext.
Add. Foot
Footplantar
plantar Abd.
Ext.Rot. flexion
flexion Int.Rot.
Foot - Plant. Flex. Toe
Toeflexion
flexion
Foot - Plant. Flex
Inver. Ever.
Toes - Flex. Toes - Flex.
D1 upper extremity movement pattern
moving into flexion.
.Starting position
D1 upper extremity movement pattern moving into
flexion.
.Ending position
D2 upper extremity movement
pattern moving into flexion.
Starting position.
D2 upper extremity movement moving
into extension.
.Ending position
 Diagonal Patterns
The patterns of movement associated with PNF are composed
of multijoint, multiplanar, diagonal, and rotational
movements of the extremities, trunk, and neck.
Multiple muscle groups contract simultaneously.
There are two pairs of diagonal patterns for the upper and
lower extremities:
diagonal 1 (D1)
diagonal 2 (D2).
Each of these patterns can be performed in either flexion or
extension. Hence, the terminology used is D1Flexion or
D1Extension and D2Flexion or D2Extension of the upper or
lower extremities.
 Diagonal Patterns
The patterns are identified by the motions that occur at
proximal pivot points—the shoulder or the hip joints.
In other words, a pattern is named by the position of the
shoulder or hip when the diagonal pattern has been
completed.
Flexion or extension of the shoulder or hip is coupled with
abduction or adduction as well as external or internal
rotation. Motions of body segments distal to the shoulder
or hip also occur simultaneously during each diagonal
pattern.
 Diagonal Patterns
Table 6.9 summarizes the component motions of each of the
diagonal patterns.
As mentioned, the diagonal patterns can be carried out
unilaterally or bilaterally.
Bilateral patterns can be done symmetrically (e.g., D1Flexion
of both extremities); asymmetrically (D1Flexion of one
extremity coupled with D2Flexion of the other extremity);
or reciprocally (D1Flexion of one extremity and D1
Extension of the opposite extremity).
 Component Motions of PNF Patterns:
Upper Extremities
(D2Ext) (D2Flx) (D1Ext) (D1Flx) Joints or
Segment
s
Ext-add, IR Fl-abd ER Ext- abd, IR Flex-add, ER Shoulder

Depression, Elevation, abd, Depression, add, Elevation, abd, Scapula

add, upward downward upward rotation
downward rotation rotation
rotation
Flex or ext Flex or ext Flex or ext Flex or ext Elbow
Pronation Supination Pronation Supination Forearm
Flexion, ulnar Extension, Extension, ulnar Flexion, radial Wrist
deviation radial deviation deviation
deviation
Flexion, Extension, Extension, Flexion, Finger and
adduction abduction abduction adduction thumb
 Component Motions of PNF
Patterns: Lower Extremities
(D2Ext) (D2Flx) (D1Ext) (D1Flx) Joints or
Segment
s

Ext-add, ER Fl-abd IR Ext- abd, IR Flex-add, ER Hip

Flexion or Flexion or Flexion or Flexion or Knee

extension extension extension extension

Plantarflexion, Dorsiflexion, Plantarflexion, Dorsiflexion, Ankle

inversion eversion eversion inversion

Flexion Extension Flexion Extension Toes

 Upper Extremity Diagonal Patterns

• N O T E : All descriptions for hand placements are for the

patient’s right (R) upper extremity.
• During each pattern tell the patient to watch the moving
hand.
• Be sure that rotation shifts gradually from internal to
external rotation (or vice versa) throughout the range.
• By mid-range, the arm should be in neutral rotation.
• Manual contacts (hand placements) may be altered from
the suggested placements as long as contact remains on
the appropriate surfaces.
• Resist all patterns through the full, available ROM.
 D1Flexion
Starting Position
Position the upper extremity in shoulder extension, abduction, and internal
rotation; elbow extension; forearm pronation; and wrist and finger
extension with the hand about 8 to 12 inches from the hip.
Hand Placement
Place the index and middle fingers of your (R) hand in the palm of the
patient’s hand and your left (L) hand on the volar surface of the distal
forearm or at the cubital fossa of the elbow.
Verbal Commands
As you apply a quick stretch to the wrist and finger flexors, tell the patient
“Squeeze my fingers, turn your palm up; pull your arm up and across
your face,” as you resist the pattern.
 D1Flexion
Ending Position
Complete the pattern with the arm across the
face in shoulder flexion, adduction, external
rotation; partial elbow flexion; forearm
supination; and wrist and finger flexion.
 D1Extension
Starting Position
Begin as described for completion of D1Flexion.
Hand Placements
Grasp the dorsal surface of the patient’s hand and
fingers with your (R) hand using a lumbrical grip.
Place your (L) hand on the extensor surface of the
arm just proximal to the elbow.
Verbal Commands
As you apply a quick stretch to the wrist and finger
extensors, tell the patient, “Open your hand” (or
“Wrist and fingers up”); then “Push your arm
down and out.”
 D1Extension

Ending Position
Finish the pattern in shoulder extension,
abduction, internal rotation; elbow
extension; forearm pronation; and wrist
and finger extension.
 D2Flexion
Starting Position
Position the upper extremity in shoulder extension,
adduction, and internal rotation; elbow extension;
forearm pronation; and wrist and finger flexion.
The forearm should lie across the umbilicus.
Hand Placement
Grasp the dorsum of the patient’s hand with your (L)
hand using a lumbrical grip. Grasp the dorsal
surface of the patient’s forearm close to the elbow
with your (R) hand.
Verbal Commands
As you apply a quick stretch to the wrist and finger
extensors, tell the patient, “Open your hand and
turn it to your face”; “Lift your arm up and out”;
“Point your thumb out.”
 D2Flexion
Ending Position
Finish the pattern in shoulder flexion, abduction,
and external rotation; elbow extension; forearm
supination; and wrist and finger extension.
The arm should be 8 to 10 inches from the ear; the
thumb should be pointing to the floor.
 D2Extension
Starting Position
Begin as described for completion of
D2Flexion.
Hand Placement
Place the index and middle fingers of your (R)
hand in the palm of the patient’s hand and
your (L) hand on the volar surface of the
forearm or distal humerus.
Verbal Commands
As you apply a quick stretch to the wrist and
finger flexors, tell the patient, “Squeeze
my fingers and pull down and across your
chest.”
 D2Extension
Ending Position
Complete the pattern in shoulder extension,
adduction, and internal rotation; elbow extension;
forearm pronation; and wrist and finger flexion.
The forearm should cross the umbilicus.
 Lower Extremity Diagonal
Patterns
NOTE:
• Follow the same guidelines with regard to
rotation and resistance as previously
described for the upper extremity.
• All descriptions of hand placements are for
the patient’s (R) lower extremity.
 D1Flexion
Starting Position
Position the lower extremity in hip extension,
abduction, and internal rotation; knee extension;
plantar flexion and eversion of the ankle; and toe
flexion.
Hand Placement
Place your (R) hand on the dorsal and medial surface
of the foot and toes and your (L) hand on the
anteromedial aspect of the thigh just proximal to
the knee.
Verbal Commands
As you apply a quick stretch to the ankle dorsiflexors
and invertors and toe extensors, tell the patient,
“Foot and toes up and in; bend your knee; pull
your leg over and across.”
 D1Flexion

Ending Position
• Complete the pattern in hip flexion, adduction, and
external rotation; knee flexion (or extension); ankle
dorsiflexion and inversion; toe extension.
• The hip should be adducted across the midline,
creating lower trunk rotation to the patient’s (L)
side.
 D1Extension

Starting Position
Begin as described for completion of D1Flexion.
Hand Placement
Place your (R) hand on the plantar and lateral
surface of the foot at the base of the toes. Place
your (L) hand (palm up) at the posterior aspect
of the knee at the popliteal fossa.
Verbal Commands
As you apply a quick stretch to the plantarflexors of
the ankle and toes, tell the patient, “Curl (point)
your toes; push down and out.”
 D1Extension
Ending Position
Finish the pattern in hip extension,
abduction, and internal rotation; knee
extension or flexion; ankle plantarflexion
and eversion; and toe flexion.
 D2Flexion
Starting Position (Fig. 6.39A)
Place the lower extremity in hip extension, adduction,
and external rotation; knee extension; ankle
plantarflexion and inversion; and toe flexion.
Hand Placement
Place your (R) hand along the dorsal and lateral
surfaces of the foot and your (L) hand on the
anterolateral aspect of the thigh just proximal to
the knee. The fingers of your (L) hand should
point distally.
Verbal Commands
As you apply a quick stretch to the ankle dorsiflexors
and evertors and toe extensors, tell the patient,
“Foot and toes up and out; lift your leg up and
out.”
 D2Flexion
Ending Position
Complete the pattern in hip flexion, abduction,
and internal rotation; knee flexion (or
extension); ankle dorsiflexion and eversion;
and toe extension.
 D2Extension

Starting Position
Begin as described for the completion of D2Flexion.
Hand Placement
Place your (R) hand on the plantar and medial
surface of the foot at the base of the toes and
your (L) hand at the posteromedial aspect of the
thigh, just proximal to the knee.
Verbal Commands
As you apply a quick stretch to the plantarflexors
and invertors of the ankle and toe flexors, tell the
patient, “Curl (point) your toes down and in;
push your leg down and in.”
 D2Extension
Ending Position
Complete the pattern in hip extension,
adduction, and external rotation; knee
extension; ankle plantarflexion and
inversion; and toe flexion.
 Head and Neck
Flexion with rotation to the right
 Head and Neck
Extension with Rotation to the left
 Head and Neck
Rotation to the right
 References:

Practical exercise therapy Margaret Hollis and

phyla Fletcher -cook,1999

Therapeutic exercise ,function and techniques

2003

Proprioceptive neuromuscular facilitation ,pattern

and techniques,margert knott, OBS .and dorottlye
.vosc,B.EP,1968.