Proprioceptive Neuromuscular Facilitation 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. 2

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. 3

. 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. 4

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. PNF in practice 2007 6

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 7

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 8

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 9

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. 10

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 11

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 Dosage: 4 sets of 5 reps with one minute rest intervals. Patients were treated and tested for ONE session. Treatment Time: 30 minutes Dosage: 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/ClientImages/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 support the approaches.” According to Natarajan et al. (2008)…

[in stroke rehabilitation].” “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.