Slide 1

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 2

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 3

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 4

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 5

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 6

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 7

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 8

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 9

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 10

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 11

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 12

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 13

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 14

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 15

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 16

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 17

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 18

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 19

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 20

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 21

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 22

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 23

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 24

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 25

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 26

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 27

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 28

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 29

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 30

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 31

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.


Slide 32

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
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.
1.

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)

Wang RY (1994)

 Treatment Time: 15 minutes

 Treatment Time: 30 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 won’t 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/ClientImage

s/1/PostStrokeArmAndHandFinal2002%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 patient’s 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): 1233-1238.
 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
rehabilitation: Regional pilot survey. Journal of Rehabilitation Research &
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
with Hemiplegia of Long and Short Duration. Physical Therapy. December
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.