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

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

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.

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 Schlatters disease. 4. Already stretched muscles : PNF is not performed more than once a day due to stress it produces on muscles and tendons.

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

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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. flexionextension) 4. Exercising of related muscle groups

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 conditioning and adaptation to facilitate motor learning,

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

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 : -

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 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 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 patients movement. Vision : Vision is used to guide the patients 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.

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

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.

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 patients 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

therapist can perform it passively. Voluntary relaxation when possible is important.

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.

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.

PNF patterns (diagonal), lower extremities

Front cross

Out back

Back cross

Out front

PNF patterns (diagonal), upper extremities

Cross low

Back high

Cross high

Back low