Techniques of PNF

Rhythmic initiation
Combination of isotonics
Reversal of antagonist:
- Dynamic reversal
- Stabilizing reversals
- Rhythmic stabilization
Repeated stretch:
- Stretch from beginning range
- Stretch through the range
Contract relax:
- Direct method
- Indirect method
Hold relax
- Direct method
- Indirect method
Replication

Rhythmic Initiation

Rhythmic motion of the limb or body through the desired range, starting with passive motion and progressing to active resisted movement.

Method

Start by passively moving the part in desired ROM(set a rhythm)
Patient is asked to actively move the part in desired direction, return is passive
The therapist resists the active movement,
Maintaining the rhythm with the verbal commands.
To finish the patient should make the motion
independently

Indications

Difficulties in initiating motion
Movement too slow or too fast
Uncoordinated or dysrhythmic motion
Regulate or normalize muscle tone
General tension

Goals

Aid in initiation of motion
Improve coordination and sense of motion

Example

Trunk extension in a sitting position: Move the patient passively from trunk flexion into extension and then back to the flexed position. “Let me move you up straight. Good, now let me move you back down and then up again.” When the patient is relaxed and moving easily, ask for active assisted motion. “Help me a little coming up straight. Now relax and let me bring you forward.” Then begin resisting the motion. “Push up straight. Let me bring you forward. Now push up straight again.” Independent: “Now straighten up on your own.”

Combination of Isotonics

Combined concentric, eccentric, and stabilizing contractions of one group of muscles (agonists) without relaxation in between

Method

concentric contraction: resisting the AROM through the desired direction
stabilizing contraction: holding the terminal position against resistance
eccentric contraction: actively bring the part back to the starting position
there is no relaxation between different types of muscle activity

Indications

Decreased eccentric control
Lack of coordination or ability to move in a desired direction
Decreased AROM

Goals

Active control of motion
Coordination
Increase the active range of motion
Strengthen
Functional training in eccentric control of movement

Example

Trunk extension in a sitting position Resist the patient’s concentric contraction into trunk extension. “Push back away from me.” At the end of the patient’s active range of motion, tell the patient to stabilize in that position. “Stop, stay there, don’t let me pull you forward.” After the patient is stable, move the patient back to the original position while he or she maintains control with an eccentric contraction of the trunk extensor muscles. “Now let me pull you forward, but slowly.”

Reversal of Antagonists

Dynamic Reversal of Antagonists

Active motion changing from one direction (agonist) to the opposite (antagonist) without pause or relaxation

Method

Resisting movement in stronger or better direction in the terminal range the direction of resistance is changed and the patient is prepared for the change in direction of movement the above procedure is repeated with no relaxation in between the reversals may be done as often as necessary

Indications

Decreased active range of motion
Weakness of the agonistic muscles
Decreased ability to change direction of motion
Exercised muscles begin to fatigue
Relaxation of hypertonic muscle groups

Goals

Increase active range of motion
Increase strength
Develop coordination (smooth reversal of motion)
Prevent or reduce fatigue
Increase endurance
Decrease muscle tone

Example

Reversing lower extremity motion with stabilization before the reversal. When the patient reaches the end of the flexion motion give a stabilizing command (“keep your leg up there”). After the leg is stabilized change the distal hand and ask for the next motion (“kick down”).

Stabilizing Reversals

Alternating isotonic contractions opposed by enough resistance to prevent motion

Method

The therapist gives resistance to the patient, starting in the strongest direction, while asking the patient to oppose the force. Very little motion is allowed. Approximation or traction Should be used to increase stability.
When the patient is fully resisting the force the therapist moves one hand and begins to give resistance in another direction.
After the patient responds to the new resistance the therapist moves the other hand to resist the new direction

Indications

Decreased stability
Weakness
inability to perform isometric contractions

Goals

Increase stability and balance
Increase muscle strength
Increase coordination between agonist and antagonist

Example

Trunk stability

Combine traction with resistance to the patient’s trunk flexor muscles. “Don’t let me push you backward.” When the patient is contracting his or her trunk flexor muscles, maintain the traction and resistance with one hand while moving your other hand to approximate and resist the patient’s trunk extension. “Now don’t let me pull you forward.” As the patient responds to the new resistance, move the hand that was still resisting trunk flexion to resist trunk extension. Reverse directions as often as needed to be sure the patient is stable. “Now don’t let me push you. Don’t let me pull you.”

Rhythmic Stabilization

Alternating isometric contractions against resistance, no motion intended

Method

isometric contraction of agonist muscle in mid rangewhen the patients force matches the resistance the grip is reversed now resisting the opposite muscle group
use static command ”stay there, don’t move ”

Indications

reduced muscle strength
pain
joint instability

Goals

increase stability and balance
reduce pain
increase muscle strength

Example

Trunk stability:

Resist an isometric contraction of the patient’s trunk flexor muscles. “Stay still, match my resistance in front.” Next, take all the anterior resistance with your left hand and move your right hand to resist trunk extension. “Now start matching me in back, hold it.” As the patient responds to the new resistance, move your left hand to resist trunk extension. “Stay still, match me in back.” The direction of contraction may be reversed as often as necessary to reach the chosen goal. “Now hold in front again. Stay still. Now start matching me in the back.”

Repeated Stretch

Repeated Stretch from beginning of range

Method

Stretch stimulus: Lengthen the muscle in initial range
Stretch reflex: lengthen muscle + tap
Followed by rapid voluntary contraction

Indications

Weakness
Rigidity
Inability to initiate movement
Fatigue
Reduced awareness of motion

Goals

Facilitate initiation of movement
Increase strength of muscle

Example

Repeated contractions of ankle dorsiflexion and eversion with the hip motion stabilized. “Lock in” the hip motion by resisting a stabilizing contraction of those muscles. “Hold your hip there.” The ankle motion of dorsiflexion and eversion is re-stretched and the new contraction resisted through range. “Pull your ankle up and out harder.”

Repeated Stretch through range

Method

Give initial stretch
Give resistance to the movement let the resistance increase more than the force of contraction producing an isolytic contraction
Repeat the procedure

Indications

Reduced range of motion

Goals

Increase range of motion
Increase muscle strength
Facilitate stronger muscle contraction

We refer to the resisting patterns or muscles as “antagonists”, and the opposite patterns or muscles as “Agonists”.

Contract-Relax

Direct method:

Isotonic contraction of restricting muscle followed by relaxation and movement into increased range.

Indications

increases range of motion
passive elongation of restricting muscle

Goals

increase active ROM
increase muscle strength

Example

Increasing the range of shoulder flexion, abduction, and external rotation. The patient moves the arm to the end of the range of flexion-abduction-external rotation. “Open your hand and lift your arm up as high as you can.”

Resist an isotonic contraction of the pattern of extension - adduction - internal rotation. “Squeeze my hand and pull your arm down and across. Keep turning your hand down.”

Allow enough motion to occur for both you and the patient to know that all the muscles in the pattern,

If the rotators, are contracting. “Keep pulling your arm down.” After resisting the contraction (for a sufficient amount of time), both you and the patient relax.“Relax, let everything go loose.” Now, resist the patient’s motion into the newly gained range. “Open your hand and lift your arm up farther.” When no more range is gained, exercise the agonistic and antagonistic patterns, either in the new range or throughout the entire range

Indirect method:

isotonic contraction of antagonist muscle followed by relaxation and stretch to the agonist, range limiting muscle

Indications

Pain
Contraction of agonist is painful

Goals

Reduce pain
Increase range of motion

Example

Contract biceps brachii to increase isotonically to improve elbow extension

We refer to the resisting patterns or muscles as “antagonists”, and the opposite patterns or muscles as “agonists”.

Hold-Relax

Direct method:

Resisted isometric contraction of restricting muscle (antagonist/shortened) followed by relaxation and movement into increased range

Indications

Increases range of motion
Passive elongation of restricting muscle
Isotonic contraction of large muscle group is difficult to handle by therapist

Goals

Increase active ROM
Increase muscle strength

Example:

Considered if biceps brachii is range limiting muscle (antagonist) to elbow extension to increase elbow extension we ask the patient to flex the elbow against resistance which does not cause any movement at elbow then after relaxation we passively push the elbow into increased amount of extension.

Indirect method:

Isometric contraction of agonist muscle followed by relaxation and stretch to the antagonist (range limiting muscle) resist the synergists of the shortened or painful muscles and not the painful muscles or painful motion.

Indications

Pain
Large muscle group
Contraction of agonist is painful

Goals

Reduce pain
Increase range of motion

Example

If biceps brachii is range limiting muscle (antagonist) to elbow extension then triceps and anconeus will be agonist. To increase elbow extension we ask the patient to extend the elbow against resistance which does not cause any movement at elbow then after relaxation we passively push the elbow into increased amount of extension. This will prevent the biceps from contracting but provides stretch.

Replication

A technique to facilitate motor learning of functional activities. Teaching the patient the outcome of a movement or activity is important for functional work (for example sports) and self-care activities.

Goals

Teach the patient the end position (outcome) of the movement.
Assess the patient’s ability to sustain a contraction when the agonist muscles are shortened.

REFERENCES

Therapeutic Exercises by Carolyn Kisner and Lynn Allen Colby 7th Edition

PNF in Practice: An Illustrated Guide by Dominiek Beckers, Math Buck, and Susan S. Adler 3rd Edition