Physical Therapy Haven

Proprioceptive Neuromuscular Facilitation (PNF) was developed in the 1940's and 1950's by Dr. Herman Kabat and physical therapist Margaret (Maggie) Knott.  They developed the approach on their neurologic patient population, with a passion to do more for their patients than traditional physical therapy offered at that time. When they began the development of PNF, traditional physical therapy for neurological patients consisted primarily of training with assistive devices and methods to help patients accommodate their lives to the newly acquired physical limitations.  Dr. Kabat and Maggie Knott believed they could find ways to truly improve their patients’ physical function.

Most physical therapists are familiar with the better-known aspects of PNF, the extremity patterns and contract/relax stretching techniques. However, these are only minute components of the PNF treatment approach.  What most therapists do not know is that the patterns were actually the last of the original PNF principles developed. Everything else about the approach, including how to facilitate more efficient movement in the human body, was developed prior to the patterns.  The handling skills developed by Dr. Kabat and Maggie Knott provided the skill set, which allowed for the discovery of the patterns as they were treating patients. These same handling techniques allow the physical therapist to sense the strengths and weaknesses of the human system, determining which components may be missing or deficient, keeping the human body from achieving optimal movement.

The ability to perform PNF is a skill set, which takes time and practice to develop. Once a therapist becomes proficient with PNF, that individual can use PNF to enhance the function of the neuromuscular system in all patient populations. The identical skill set is utilized to determine the neuromuscular function or motor control deficit in both the neurological and high level sports patients.

A basic foundation of PNF is the concept that the human body is supposed to work as an entire system, reinforcing movements at one part of the body with coordinated stabilizing contractions occurring throughout the rest of the system.  A simple example is that when a person performs active hip flexion, even distant muscles such as the deep flexors of the neck should activate to support and reinforce the movement of the femur.  PNF can be utilized to quickly evaluate the body for neuromuscular deficiencies and seamlessly progress into treatment to facilitate a more efficient neuromuscular response throughout the body.

The primary goal of using PNF to enhance the performance of a high level athlete is to instate efficient neuromuscular function, which includes muscular initiation, strength and endurance with the appropriate timing muscular recruitment.  Additionally, the goal is to facilitate the most efficient habitual motor control strategies for movement. CoreFirst^TM Strategies for Posture and Movement and Automatic Core Engagement are terms developed by Vicky Saliba Johnson to describe the proper timing of muscular contractions and the automatic (non-volitional) nature which we want to facilitate as physical therapists.  We don’t want patients to have to think about what muscles to use when performing a movement, we want to facilitate those muscles to recruit automatically. The key word in that sentence, which is also the last word in the name PNF, is “facilitation.” The objective is not strengthening, but to improve neuromuscular recruitment of appropriate muscles and muscle fibers, thereby increasing the motor output through spatial and temporal summation. Our objective is not to add strength to a muscle, but rather to increase the strength of a movement by facilitating the appropriate response of all of the correct muscles which should synergistically work together to accomplish the desired movement, thereby increasing the overall force and speed capabilities of performing a desired movement.

I am going to utilize a patient example for how to utilize PNF to enhance an athlete’s performance. The patient is a nationally ranked high school senior indoor track runner. Going into the competition she was ranked 35^th in the country. I had a 2-hour treatment session with her the day before her national track meet. The second day she set a new personal record, cutting 0.08 seconds off of her 60-meter dash time, and finished 13^th overall in the country. This placement in a national track meet should allow her to get full ride scholarships to some of the top schools in the country.

Prior to the treatment session, I spent time studying videos of her running.  She clearly had a strong start out of the block, but she struggled maintaining speed during the second half of her race.  It appeared that every time she began to lose momentum it was subsequent to her extending her upper cervical spine and lifting her chest into thoracic extension. It also looked as if she had limited extension in both of her pelvic girdle hip complexes (L>R) which significantly limited her push off strength in her left lower extremity.

During the subjective interview she confirmed that the observations made above were what she was experiencing as her challenges to improving her performances in the 60-meter dash. Evaluation of her rolling patterns showed that she had no ability to roll using a trunk flexion pattern, but was instead compensating; completely dominated by trunk, cervical and lower extremity extension while rolling. Even when verbally instructed on how to roll using a mass flexion pattern, she had an inability to coordinate her body to roll in any method other than a trunk extension pattern. This correlated with her movement patterns that she used during running.

My PNF treatment approach began in side lying, where I took her to the end range of the flexion pattern and began manually resisting her ability to maintain this position. The first goal was to instate a CoreFirst^TM strategy for maintaining this position with a low-grade, prolonged isometric contraction. When patients have not used a movement pattern for a long period of time (or possibly ever), it is extremely difficult for them to perform a low grade contraction where they match the resistance applied to them and do not pull into the resistance. Most of them will try to perform an isotonic contraction instead of an isometric, resulting in the patient pushing into you instead of maintaining the position.

Once the patient was able to maintain the target position using an isometric contraction, I progressed towards developing her ability to perform smooth, coordinated isotonic movements into and out of this end range position. This is called Combination of Isotonics (COI), which is a term developed by Gregory S. Johnson and Vicky Saliba Johnson in 1979.  To begin this, the patient has to slowly let the therapist move them out of the end range position (controlled eccentric isotonic contraction) followed by a controlled movement back into the end range target position (concentric isotonic contraction). This range is slowly increased until the individual is able to move through the whole range of motion using the newly developed movement pattern. This is then followed by having the patient perform the movement (which in this case was a flexion rolling pattern) on their own without any manual contact.

I performed this multiple times making sure all parts of her body, from her neck to her toes, were engaged and capable of performing the mass flexion rolling pattern.  I also took her through a similar progression in side lying for trunk reciprocal patterns of movement, which are the foundation of the gait cycle, and also further reinforce the mass flexion pattern. These trunk patterns involve movement of the upper part of the trunk in an opposite direction of the lower part of the trunk.  Serge Gracovetsky describes in his book The Spinal Engine how the curves of the human spine create reciprocal and rotational movement, therefore generating the gait pattern. The reciprocal patterns strengthen and facilitate these central aspects of human locomotion.

Although changes in her gait were immediately apparent after the side lying treatments on the mat, I needed to progress to treatment in weight bearing to reinforce the changes that were seen from the non-weight bearing treatments.  To fully integrate some of these new movement strategies into her system I performed exaggerated resisted gait to get her pulling forward with her trunk and pelvis during each step.  By the end she was able to create more force with forward gait and expressed a subjective report that she felt like she could finally push off better with her left lower extremity.

I ended by giving her two quick home exercise programs, practicing flexion rolling (generating the motion from her trunk) and an isometric hold of a high step against a wall (where she placed herself in an exaggerated gait position and held the position). These helped to engage her core and reinforce the new movement patterns integrated into her system.

I am hoping that this article describes the thought process and the approach in enough brief detail that some of you will be able to integrate this treatment concept into enhancing the function of all your patients.

Get out there and have fun, because we work in the best profession where we get to have fun working with our patients while improving their quality of life through enhancing the function of their entire neuro-musculoskeletal system!