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)
Treatment Time:

15

Wang RY (1994)
Treatment Time:

30 minutes

minutes
Dosage:

Dosage:

4 sets of 5 reps with one

minute rest intervals.

Patients were treated and

tested for ONE session.

10 mins rythmic
initiation,
10 mins slow reversal,
10 mins agonistic
reversals.
Patients were treated and

tested for TWELVE sessions.

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 wont 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/Client

Images/1/PostStrokeArmAndHandFinal
2002%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

that use Brunnstrom/PNF
or Bobath/NDT reported
practicing these
techniques, despite the
lack of evidence to
According to Natarajan et al. (2008)

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 patients 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): 12331238.

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

Research &

rehabilitation: Regional pilot survey. Journal of Rehabilitation

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
December

with Hemiplegia of Long and Short Duration. Physical Therapy.

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.