1. Proprioceptive Neuromuscular Facilitation (PNF) Techniques in Rehabilitation
Chapter 14

2. Introduction The method:
Patient contract isometrically resulted in increased response of the agonist, this was named rhythmic stabilization. Following using this stabilization, it was found slow reversal technique, alternate resistance to isotonic contractions of antagonist and agonist also had a facilitating effect.

3. Introduction Definitions of PNF:
Proprioceptive, means receiving stimulation
within the tissues of the body.
Neuromuscular, means pertaining to the nerves and muscles.
Facilitation, means the effect produced in nerve tissue by the passage of an impulse.

4. Introduction Definitions of PNF:
Therefore, PNF can be defined as, methods of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptors.

5. Introduction
To perform PNF exercises, it is important to remember the following
principles:
Patient must be taught the pattern.
Have the patient watch the moving limb moved passively.
The patient must give proper verbal command.
Manual contact with appropriate pressure is very important.

6. Introduction Principles:
Contraction of the muscle group is facilitated by hand placement.
Apply maximal resistance throughout ROM.
Resistance will change.
Rotation of movement will change throughout ROM.
Distal movement should occur first .

7. Introduction Plan of volume: Patterns of motion
Various techniques used to promote the desired response
Application of the method for improvement of vital and related functions.
Suggestions for evaluation of the patient performance and for planning treatment program.

8. PNF Strengthening Diagonal Patterns
D1 Flexion Upper Extremity
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed

9. D1 Flexion Upper Extremity Joint Specific Movements
Shoulder
Flexion
External Rotation
Adduction
Forearm
Supination
Wrist
Radial Deviation
Fingers

10. PNF Strengthening Diagonal Patterns
D1 Extension Upper Extremity
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed

11. D1 Extension Upper Extremity Joint Specific Movements
Shoulder
Extension
Internal Rotation
Abduction
Forearm
Pronation
Wrist
Ulnar Deviation
Fingers

12. PNF Strengthening Diagonal Patterns
D2 Flexion Upper Extremity
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed

13. D2 Flexion Upper Extremity Joint Specific Movements
Shoulder
Flexion
External Rotation
Abduction
Forearm
Supination
Wrist
Radial Deviation
Fingers
Extension

14. PNF Strengthening Diagonal Patterns
D2 Extension Upper Extremity
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed

15. D2 Extension Upper Extremity Joint Specific Movements
Shoulder
Extension
Internal Rotation
Adduction
Forearm
Pronation
Wrist
Ulnar Deviation
Fingers
Flexion

16. PNF Strengthening Diagonal Patterns
D1 Flexion Lower Extremity
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed

17. D1 Flexion Lower Extremity Joint Specific Movements
Hip
Flexion
Adduction
External Rotation
Ankle
Dorsiflexion
Inversion
Toes
Extension

18. PNF Strengthening Diagonal Patterns
D1 Extension Lower Extremity
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed

19. D1 Extension Lower Extremity Joint Specific Movements
Hip
Extension
Abduction
Internal Rotation
Ankle
Planar Flexion
Eversion
Toes
Flexion

20. PNF Strengthening Diagonal Patterns
D2 Flexion Lower Extremity
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed

21. D2 Flexion Lower Extremity Joint Specific Movements
Hip
Flexion
Abduction
Internal Rotation
Ankle
Dorsiflexion
Eversion
Toes
Extension

22. PNF Strengthening Diagonal Patterns
D2 Extension Lower Extremity
Taken from Prentice, Rehabilitation Techniques in Sports Medicine, 3rd ed

23. D2 Extension Lower Extremity Joint Specific Movements
Hip
Extension
Adduction
External Rotation
Ankle
Plantar Flexion
Inversion
Toes
Flexion

24. Proprioceptive Training for upper Extremities
Types of exercises used for upper extremity proprioceptive training: 1. Balance training. One major category of proprioceptive exercise is balance training. These exercises help to train the proprioceptive system in a mostly static activity. Activities or exercises in weight bearing using unstable supporting surface, profitter, swiss ball, balance board are example of balance training in the upper extremity.

25. 2. Kinetic chain exercises
2. Kinetic chain exercises . Open-chain manual resistance exercises with rhythmic stabilization are also considered proprioceptively enriched. In either case, resistance can be modified, depending on pain, as the patient progresses

26. Quadruped stabilization on a balance Four closed-chain exercises have been described to stimulate co-activation in the shoulder: push­ups, horizontal abduction on a slide board, and tracing circular motions on a slide board with the dominant and non-dominant arms. These exercises ac­commodate for the individual's tolerance to joint loads by progressing from a quadruped to a push-up position

27. Wall push-ups are also useful and can be proprioceptively enhanced by having a physical therapist or resistance band provide resistance to the patient's back.

28. 3. Sport-specific maneuvers
3. Sport-specific maneuvers. Rehabilitation is incomplete until maneuvers specific to the sport and the athlete's position in the sport can be performed maximally and without pain or loss of function.
Starting sport-specific maneuvers with weighted resistance (eg, swinging a weighted tennis racket or baseball bat), Functional positions, such as over­head throwing, should be incorporated and are more sport-specific.

29. 4. PNF (Proprioceptive neuromuscular facilitation): These techniques may be defined as methods of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptors. Emphasis is placed on the application of maximal resistance through out the range of motion, using many combinations of motions in a pattern format. Motion is first performed in the strongest part of the range, with progression toward the weaker parts of the range of motion. The patterns used are spiral and diagonal in character and closely resemble the movements used in sports and in occupational activities.

30. 5. Plyometrics. It is a quick powerful movement involving pre-stretching of a muscle, followed by a shortening cycle. The stretch shortening cycle occurs when elastic loading, through a quick eccentric muscular contraction, is followed by a burst of concentric muscular contraction.

31. 6. Ballistic stretching uses the momentum of a moving body or a limb in an attempt to force it beyond its normal range of motion. This is stretching, or "warming up", by bouncing into (or out of) a stretched position, using the stretched muscles as a spring which pulls you out of the stretched position.

32. Proprioceptive Training for Lower Extremities
Proprioceptive training improves a patient's static and dynamic equilibrium. The static proprioceptive re-education is begun when patients proceed to weight bearing without crutches and consists of six stages:
1-Recovery of sense of body position muscle contraction and joint movement.
2-Transition from bilateral to unilateral activities
3-Transition from eyes-open to eyes-closed activities.
4-Transition from activities on a stable support, such as the ground, to unstable surfaces, such as a soft mattress, a trampoline and Freeman's boards, or more modern equipment, such as the kinesthetic ability trainer
5-Throwing and catching a football to take the patient's mind off active control of his balance.
6-Balance recovery exercises are carried out different joint positions to evoke different responses from the tendon and muscle receptors.

33. The dynamic proprioceptive re-education consists of seven stages:
1. Slow exercises followed by quicker movement
2. Exercise with limited effort followed by exercise requiring greater strength
3. Exercises requiring volition, followed by exercises done freely
4. Progress from walking to jogging
5. Running and sprinting
6. Jumping and changes of direction
7. Twirling and twisting around the injured or operated knee

34. Balance and control proprioceptive exercise
1.    Stand on one leg.      2.    Stand on one leg with eyes closed.      3.    Stand on one leg – throw and catch a ball.      4.    Stand on one leg – bend and straighten knee     

35. 5. Stand on one leg- pick up item from floor. 6
5. Stand on one leg- pick up item from floor. 6. Hold knee dip – throw and catch a ball. 7. Stand on one leg – move other leg to side, front and back. 8. Push up onto toes (2 legs) and hold. 9. Push up onto toes with eyes closed. 10. Push back onto heels, balance and hold. 11. Push up on toes on one leg.

36. Walking proprioceptive exercises
13.    Walk forward along a straight line.  14.    Walk on tip toes along straight line.   15.    Walk backwards along straight line. 16.    Side step along straight line.   17.    Walk sideways crossing one foot over other (Cariocas).   18.    Walk fast in one direction, quickly changing direction at intervals.

37. Running proprioceptive exercises
19.    Run fast in one direction.      20.    Run backwards and do sidesteps.      21.    Fast crossovers (Cariocas).      22.    Run in figure of eight – make it smaller and smaller.     

38. 23.    Hopping on spot.      24.    Hop forwards and backwards – stop between hops.      25.    Hop in zigzags.      26.    Hop on and off step.      27.    Do triple jump - run, hop, jump and land.