Dominiek Beckers · Math Buck

PNF in Practice
An Illustrated Guide
Fifth Edition
PNF in Practice
Dominiek Beckers · Math Buck

PNF in Practice
An Illustrated Guide

5th Edition
Dominiek Beckers Math Buck
Maasmechelen, Belgium Beek, Limburg, The Netherlands

ISBN 978-3-662-61817-2 ISBN 978-3-662-61818-9 (eBook)

https://doi.org/10.1007/978-3-662-61818-9

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V

Preface

Proprioceptive neuromuscular facilitation (PNF) is a philosophy and a

concept of treatment. The PNF philosophy is timeless, and the concept
is a continuous process of growth.
PNF has been one of the most recognized treatment concepts in
physical therapy since the 1940s. Dr. Kabat and Margaret (Maggie)
Knott started and continued to expand and develop the treatment
techniques and procedures after their move to Vallejo, California in
1947. After Dorothy Voss joined the team in 1953, Maggie and Doro-
thy wrote the first PNF book, published in 1956.
At first mostly patients with multiple sclerosis and poliomyelitis
were treated with this method. With experience it became clear that
this treatment approach was effective for patients with a wide range of
diagnoses. Today, patients with neurological, traumatic as well as or-
thopedic symptoms, adults as children are treated with this concept.
This PNF-concept was growing till a universal concept in the Physio-
therapy.
The three- and six-month PNF courses in Vallejo began in the
1950s. Physical therapists from all over the world came to Vallejo to
learn the theoretical and practical aspects of the PNF concept. In ad-
dition, Knott and Voss travelled in the United States and abroad to
give introductory courses in the concept.
When Maggie Knott died in 1978 her work at Vallejo was carried
on by Carolyn Oei Hvistendahl. She was succeeded by Hink Mangold
as director of the PNF program. Tim Josten is the present program
director. Sue Adler, Gregg Johnson, and Vicky Saliba have also con-
tinued Maggie’s work as teachers of the PNF concept. Sue Adler de-
signed the International PNF Association (IPNFA) Instructor course
programs. Developments in the PNF concept are closely followed
throughout the world. It is now possible to take recognized training
courses in many countries given by qualified PNF instructors.
We acknowledge our debt especially to Sue Adler for her big contri-
bution on this book, especially on the first English editions. There are
other excellent books dealing with the PNF method, but we felt there
was a need for a comprehensive coverage of the practical tools in text
and illustrations. This book should thus be seen as a practical guide
and used in combination with existing textbooks.
This book covers the procedures, techniques, and patterns within
PNF. Their application to patient treatment is discussed throughout,
with special attention on mat activities, gait and self-care. The em-
phasis within this book is twofold: developing an understanding of
the principles that underlie PNF, and showing through pictures rather
than with words how to perform the patterns and activities.
VI Preface

In summary, the aim of the authors is:

5 to give a clear presentation of the PNF concept and the in-
structions for the practice of PNF techniques and to support
­physiotherapy students as well as practicing therapists in their PNF
training,
5 to achieve uniformity in practical treatment and
5 to present the latest developments of the PNF concept in words
and pictures

Skill in applying the principles and practices of PNF to patient treat-

ment cannot be learned only from a book. We recommend that the
learner combine reading with classroom practice and patient treatment
under the supervision of a skilled PNF-practitioner.
Movement is our way to interact with our environment. Such inter-
actions are directed by the mechanism of motor learning. Integration
of motor learning principles includes a progression from hands-on to
hands-off treatments; it includes goal-orientated functional activities
and independence. Based on the untapped existing potential of all pa-
tients, the therapist will always focus on mobilizing these reserves to
reach the highest level of function. Especially in the first and cogni-
tive stage of motor control, the therapist’s manual facilitation will be
a helpful tool in reaching this goal. This includes goals on the level of
body structures as well as on the activity level and the participation
level (ICF).
This revised fifth edition includes a description of how the princi-
ples of the International Classification of Functioning, Disability and
Health (ICF), and aspects of motor learning and motor control (from
“hands-on” to “hands-off ” management), are applied in modern PNF
evaluation and treatment.
Several chapters were expanded with new indications and casu-
istry and supported and supplemented with new, more recent scien-
tific ­literature. The design and layout as well as the color ­illustrations
highlight the clearly structured way in which the philosophy, basic
­principles, treatment patterns and activities of the PNF concept are
presented. Thus, this book provides a systematic and easy-to-under-
stand guide to learning and understanding PNF as a practical tool and
application to full effect in treatment.
The authors are indebted to many people. We thank all our
­colleagues, the PNF instructors and members of the IPNFA, for their
cooperation, their exchange of knowledge and experience and further
development of the PNF concept. A special thanks goes to Agnieszka
Stepien from Poland for her contribution abouth pediatrics and scoli-
osis. We are very grateful to Fred Smedes for his contribution to this
edition. He is very active as a “chairman” of the IPNFA research com-
mittee and has helped us intensively with all relevant scientific PNF lit-
erature. We also thank Carsten Schäfer and Frits Westerholt for their
additions.
Preface
VII 
Our thanks also go to our physiotherapy colleagues of Adelante,
Rehabilitation Center Hoensbroek, The Netherlands. In particular we
thank Lisan Scheepers for acting as a model and Ben Eisermann for
editing the drawings.
We would like to thank our colleague Laurie Boston, PNF instruc-
tor in Switzerland, for all her support in correcting the English transla-
tions and contents of the manuscript.
But most of all we are devoted and grateful to our patients; without
them this work would not be possible.

Maggie Knott
To Maggie Knott, teacher and friend.
Devoted to her patients,
dedicated to her students,
a pioneer in profession

Dominiek Beckers
Math Buck
Autumn 2020
Acknowledgement To Susan Adler

With this new 5th edition of our PNF-book, we particularly wish to

acknowledge the help of Sue Adler, not only as co-author of former
editions of this book, but also because she had so an important influ-
ence on the spread of our PNF-concept worldwide.
Sue Adler has a long-term involvement in our PNF-concept. Sue was
certified as physical therapist at the Northwestern University, Chicago,
Illinois. She became a master in science in physical therapy at the Uni-
versity of Southern California, Los Angeles. She started her PNF edu-
cation in 1962 at the Kaiser Foundation Rehabilitation Center in Vallejo,
California, where she worked and taught together with Maggie Knott.
Beside her big contribution on our first (1993) and second edition
(1999) of this book, Sue Adler designed in the eighties and nineties the
International PNF Advanced and Instructor course programs. She had
diligently monitored the grow and quality during the “young years” of
the IPNFA®.
We also acknowledge our dept to this outstanding person because of per-
sonal reasons. First of all, Sue had an important influence on our PNF-edu-
cation. She led our instructor course in 1984 in Bad Ragaz, Switzerland and
certify both of us as international PNF instructor.
Our first edition of our German PNF-book came out in 1988 and
when we asked Sue in 1992 to join us as co-author for an English trans-
lation and new edition, she directly accepted. As co-author she had a
great contribution to and improvement of the contents of our first Eng-
lish editions in the nighties. Her support certainly lead to the great in-
ternational interest for our work and also for translations. In the mean-
while this work is edited in more than 15 countries and languages.
As pioneer of the IPNFA® and as co-author of the first editions of
this book, Sue Adler had an enormous direct and indirect influence on the
worldwide spread of the PNF-concept.

Dominiek Beckers
Math Buck
IX

The International PNF-Association®

The objectives of the IPNFA® are as follows

5 To promote further worldwide development of the clinical use of

PNF
5 To maintain continuity and standards of the instructors of PNF
techniques
5 To maintain continuity and standards of PNF course material for
beginning and advanced instructors
5 To educate and train new PNF instructors
5 To promote research into PNF theory and practice
5 To identify further developments in the PNF concept
5 To ensure that developments in neurophysiology and other related
fields (ICF, Neuroplasticity, etc.) are incorporated into PNF clinical
practice
5 To develop peer review in order to maintain the necessary clinical
and educational standards required to teach PNF

The IPNFA® has following possibilities for education

(7 www.IPNFA.org)
X The International PNF-Association®

References
On the website of the IPNFA® (International PNF Association) you
can find actual scientific PNF-literature: 7 www.IPNFA.org.
The authors recommend especially to read the following article and
books which are helpful:
Article:
5 Smedes F, Heidmann M, Schäfer C, Fischer N, Stepien A. (2016)
The proprioceptive neuromuscular facilitation-concept; the state
of the evidence, a narrative review. Physical Therapy Reviews
21(1):17–31

Books:
5 Hedin-Andén S (2002) PNF – Grundverfahren und funktionelles
Training. Urban & Fischer, München
5 Horst R (2005) Motorisches Strategietraining und PNF. Thieme,
Stuttgart
5 Knott M, Voss DE (1968) Proprioceptive Neuromuscular Facilita-
tion, patterns and techniques, 2nd ed. Harper & Row, New York
5 Voss DE, Ionta M, Meyers B (1985) Proprioceptive Neuromuscular
Facilitation, patterns and techniques. 3rd ed. Harper & Row, New
York
5 Sullivan PE, Markos PD, Minor MAD (1982) An Integrated Ap-
proach to therapeutic Exercise, Theory and Clinical Application.
Reston Publishing Company, Reston, VA
5 Sullivan PE, Markos PD (1995) Clinical decision making in thera-
peutic exercise. Appleton and Lange, Norwalk, CT
XI

Contents

1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Positioning of the PNF Concept in the Modern Holistic Treatment. . . 2
1.2 PNF: Definition, Philosophy, Neurophysiological Basics. . . . . . . . . . . . . 11
1.3 Test Your Knowledge: Question. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2 PNF Basic Principles and Procedures for Facilitation . . . . . . . . . 17

2.1 Optimal Resistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.2 Irradiation and Reinforcement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.3 Tactile Stimulus (Manual Contact) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.4 Body Position and Body Mechanics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.5 Verbal Stimulation (Commands). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.6 Visual Stimulus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.7 Traction and Approximation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.8 Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.9 Timing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.10 Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.11 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

3 PNF Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.2 Rhythmic Initiation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.3 Combination of Isotonics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.4 Reversal of Antagonists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.5 Repeated Stretch (Repeated Contractions) . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.6 Contract–Relax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.7 Hold–Relax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.8 Replication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.9 PNF Techniques and Their Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.10 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

4 Patient Assessment and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

4.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.2 Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.3 Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
4.4 Tests for Causal Impairments and Activity Limitations
Adjust to the Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
4.5 Treatment Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
4.6 Treatment Planning and Treatment Design. . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.7 Re-Test for Causal Impairments and Activity Limitations. . . . . . . . . . . . . 65
4.8 Treatment Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
4.9 Indications and Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.10 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
XII Contents

5 Patterns of Facilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
5.2 PNF Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
5.3 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

6 The Scapula and Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

6.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.2 Applications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.3 Basic Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.4 Scapular Diagonals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.5 Pelvic Diagonals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
6.6 Symmetrical, Reciprocal, and Asymmetrical Exercises. . . . . . . . . . . . . . . . 96
6.7 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

7 The Upper Extremity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

7.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
7.2 Basic procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
7.3 Flexion–abduction–external rotation (Fig. 7.2). . . . . . . . . . . . . . . . . . . . . . . 105
7.4 Extension–Adduction–Internal Rotation (Fig. 7.5). . . . . . . . . . . . . . . . . . . . 112
7.5 Flexion–Adduction–External Rotation (Fig. 7.8) . . . . . . . . . . . . . . . . . . . . . . 118
7.6 Extension–Abduction–Internal Rotation (Fig. 7.11). . . . . . . . . . . . . . . . . . . 124
7.7 Thrust and Withdrawal Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
7.8 Bilateral Arm Patterns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
7.9 Changing the Patient’s Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
7.10 Therapeutic Applications of Arm Patterns. . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
7.11 Test your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

8 The Lower Extremity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

8.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
8.2 Basic Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
8.3 Flexion–Abduction–Internal Rotation (Fig. 8.2). . . . . . . . . . . . . . . . . . . . . . . 145
8.4 Extension–Adduction–External Rotation (Fig. 8.5). . . . . . . . . . . . . . . . . . . . 151
8.5 Flexion–Adduction–External Rotation (Fig. 8.8) . . . . . . . . . . . . . . . . . . . . . . 157
8.6 Extension–Abduction–Internal Rotation (Fig. 8.11). . . . . . . . . . . . . . . . . . . 162
8.7 Bilateral Leg Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8.8 Changing the Patient’s Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8.9 Therapeutic Indications for Leg Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
8.10 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

9 The Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

9.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
9.2 Basic Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
9.3 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Contents
XIII 
9.4 Flexion to the Left, Extension to the Right (Fig. 9.1) . . . . . . . . . . . . . . . . . . 187
9.5 Neck for Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
9.6 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

10 The Trunk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

10.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
10.2 Treatment Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
10.3 Chopping and Lifting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
10.4 Bilateral Leg Patterns for the Trunk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
10.5 Combining Patterns for the Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
10.6 Test Your Knowledge: Question. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

11 Mat Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

11.1 Introduction: Why Do Mat Activities?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
11.2 Basic Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
11.3 Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
11.4 Mat Activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
11.5 Patient Cases in Mat Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
11.6 Therapeutic Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
11.7 Test Your Knowledge: Question. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

12 Gait Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

12.1 Introduction: The Importance of Walking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
12.2 Basics of Normal Gait. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
12.3 Gait Analysis: Observation and Manual Evaluation. . . . . . . . . . . . . . . . . . . 266
12.4 The Theory of Gait Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
12.5 The Procedures of Gait Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
12.6 Practical Gait Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
12.7 Patient Cases in Gait Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
12.8 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298

13 Vital Functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

13.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
13.2 Stimulation and Facilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
13.3 Facial Muscles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
13.4 Tongue Movements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
13.5 Swallowing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
13.6 Speech Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
13.7 Breathing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
13.8 Test Your Knowledge: Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
XIV Contents

14 Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

14.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
14.2 Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
323
14.3 Dressing and Undressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
14.4 Test Your Knowledge: Question. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328

15 Test Your Knowledge: Questions and Answers. . . . . . . . . . . . . . . . 331

Supplementary Information
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
XV

About the Authors

Dominiek Beckers
5 M
aster of Physical Therapy, Movement Science and
Rehabilitation at the University of Leuven, Belgium,
in 1975
40 years Physical Therapist in Adelante, the Rehabili-
5 
tation Center of Hoensbroek, The Netherlands
5 International PNF senior instructor of the IPNFA
5 Instructor SCI Rehabilitation
5 Co-author of numerous books and article

Math Buck
Certified as Physical Therapist at the Hoge School in
5 
Heerlen, The Netherlands, in 1972
Since 1984 IPNFA instructor and “Fachlehrer” for
5 
PNF in Germany
5 S
ince 2002 senior instructor and in 2004 honorary
member of the IPNFA
More than 37 years practical working with patients
5 
with mainly spinal neurological diseases in a rehabili-
tation center. Many post graduate education which he
uses in his courses
Co-author of some books of treatment of spinal cord
5 
patients and articles with different topics
1 1

Introduction
Contents

1.1 Positioning of the PNF Concept in the Modern

Holistic Treatment – 2
1.1.1 The ICF Model – 2
1.1.2 Treatment and the PNF Concept: Basic Principles
and Techniques – 5
1.1.3 Learning Phases – 6
1.1.4 Motor Control and Motor Learning – 7

1.2 PNF: Definition, Philosophy, Neurophysiological

Basics – 11
1.2.1 Definition – 11
1.2.2 PNF Philosophy – 11
1.2.3 Basic Neurophysiological Principles – 12

1.3 Test Your Knowledge: Question – 13

References – 13

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer-Verlag
GmbH, DE, part of Springer Nature 2021
D. Beckers and M. Buck, PNF in Practice,
https://doi.org/10.1007/978-3-662-61818-9_1
2 Chapter 1 · Introduction

1.1  Positioning of the PNF

1 Concept in the Modern Holistic
Treatment

In this chapter, we illustrate the position of the

PNF concept within the current holistic treat-
ment spectrum. Furthermore, we show how
the PNF concept works in conjunction with
the assessment and treatment of our patients.
On the one hand, a detailed assessment
of the clinimetry findings (measurements)
and the experience and expertise of the ther-
apist are necessary for making clinical deci-
sions. On the other hand, scientific knowl-
edge about motor learning and motor con-
trol plays an important role in determining
the treatment goals. A patient treatment plan
is established from the results of the assess- . Fig. 1.1 Factors determining the choice of therapy
and their integration into the PNF concept
ment and from following the criteria of “ev-
idence-based practice.” (Sacket et al. 1996,
1998, 2000). ­lassification of Functioning, Disability
C
In addition, social norms and cultural and Health 2007) formulated by the World
models also influence the treatment. We will Health Organization (WHO 2007, Chap. 4)
briefly describe the factors determining the is recommended as a framework for organ-
choice of therapy and their integration into izing and directing patient treatment. The
the PNF concept (. Fig. 1.1). goal is to develop a common international
and standard language to simplify the com-
munication between different professions
1.1.1  The ICF Model within the health sector.
The ICF is a model of understanding
Assessment and Evaluation (Suppé 2007) (. Fig. 1.2) comprising the fol-
Before a treatment can be started, the ther- lowing five dimensions:
apist must perform a detailed patient eval- 5 Body structures and body functions
uation. The ICF model (International 5 Activities

. Fig. 1.2 The five

dimensions of the ICF
model
1.1 · Positioning of the PNF Concept in the Modern Holistic Treatment
3 1
5 Participation Finally, the existing capabilities of the pa-
5 Personal factors tient’s level of participation (work, hobbies)
5 Environmental factors as well as the problems that may be encoun-
tered in his/her social life are documented.
The patient evaluation documents which an- Personal factors (age, culture) and environ-
atomical structures (joint, muscle, tone, sen- mental factors (stairs, accessibility) must also
sation etc.) and functions are involved and be considered.
which motor skills are possible for the pa-
tient (positive approach) (Smedes et al. 2016; Treatment Goals
Horst 2008); it also lists any existing defi- After documenting the existing capabilities
cits. This examination gives guidelines on the and problems, a discussion begins with the pa-
specific activities that the patient more than tient (Cott 2004) to determine the treatment
likely can or cannot perform. The PNF phi- goals. It is not just the medical team/therapist
losophy of a “positive approach” entails (supply-driven) or only the patient (demand-dri-
questioning first those activities that the pa- ven) who formulates the treatment goals. To-
tient can still perform, and later the activities gether, through consultation, the team/thera-
linked to difficulties. pist and the patient determine and agree on set
After this, we examine which limitations goals (dialog-driven). Ultimately, the goal is to
of the body structures and body functions achieve the highest level of participation that
(Causal Impairments) can be responsible for the patient desires and is realistically able to
the limitations of activities (Activity Limita- achieve. Besides these factors, environmental
tion) and participation (Restriction of Partic- (social environment) and personal factors (in-
ipation). dividual background) also play a role.

Patient Example: Mr. B.

Mr. B, a 60-year-old man, has worked as a ing his legs and he can transfer himself inde-
supervising engineer in a multinational com- pendently from the wheelchair to the bed.
pany and has suffered from a severe form of Limitations on the level of activity are, in-
Guillain–Barré syndrome (his second epi- itially, a loss of gait functions; within the ac-
sode). After a long stay in the intensive care tivities of daily living (ADLs), he is almost to-
unit (ICU) with intubation, we note at the tally dependent on assistance. His speaking is
level of body function and structure good difficult to understand because of bilateral fa-
joint mobility, muscle strength (MFT 4), and cial paralysis. Eating and drinking are difficult.
stability in the trunk. He is very motivated. Driving and gardening are not possible.
There is proximal 4 and distal 3 muscle At the level of participation, Mr. B can go
strength in the lower extremities. There are to his own home on weekends where his chil-
no vegetative disturbances (we refer to these dren and grandchildren can visit him. Restric-
as autonomic disorders). There have been no tions on the level of participation are that he is
autonomic disorders. Psychologically, he is not able to work, he cannot visit his children
clear and oriented. He is apprehensive about or grandchildren because of the long drive,
his future. As impairments, we note serious and under his current circumstances he avoids
problems: general loss of strength through- dining in restaurants. The following personal
out the body including his face, severe limi- factors hinder him from attaining his goals: his
tations in joint movements of the upper ex- social status, his character, his age, and the fact
tremities, sensory disturbances (primarily that this is the second episode of the disease.
in the hands), pain, extensive edema in the The external factors such as his social status,
hands, and breathing problems. At the level his work, and his hobbies determine what is re-
of activities, he can propel a wheelchair us- quired to restore his physical functional ability.
4 Chapter 1 · Introduction

The treatment goals that were formulated The achievable treatment goals that have
1 together with the patient are adjusted and re- been determined should comprise a logical
defined on an ongoing basis. Thus, the pa- and structured process based on clinical rea-
tient is an active member and a fully fledged soning.
discussion partner within the team, which
consists of the rehabilitation doctor, the phy- Clinical Reasoning
sician, speech and occupational therapists, This is a clinical process for achieving opti-
the nurse, the psychologist, social workers, mal treatment results combining therapeutic
and others. knowledge, skills, and empathy.
The therapist proposes a hypothesis re-
After the jointly defined treatment goals garding which limitations at the level of body
have been clarified, an objective should be structure and body function can hypothet-
formulated for each goal using the SMART ically be responsible for the cause of the re-
analysis. strictions on the level of activity. To create
SMART (Oosterhuis-Geers 2004; Scager the hypothesis, the therapist needs sufficient
2004) stands for: professional knowledge and clinical prac-
5 S = specific: the objective is directed to- tice. At the same time, the therapist should be
ward the patient’s individual target goal. open to other ideas that refute these hypoth-
5 M = measurable: progress is documented eses and he should not ignore others in ad-
by the improvement of the activity as well vance (unbiased). The hypothesis will be re-
as by clinimetry. viewed regularly during the treatment and
5 A = acceptable: the objective should be amended when necessary.
accepted by the patient as well as by the The therapist should be able to complete
treatment team. the next steps at the right time so as to make
5 R = realistic: the objective should always optimal use of the total treatment time.
be an attainable goal. Combining the different steps, determin-
5 T = time related: the objective should be ing a physical therapy diagnosis, establishing
achievable within a realistic time frame. a treatment plan, executing it, and adjusting
it if necessary is a cyclical process.

SMART Analysis of Mr. B. Clinimetry

Clinimetry is used to measure and objec-
The treatment goal is for Mr. B. to be to- tify the results of the treatment. When using
tally independent. tests the therapist should be clear that these
S: goal setting of Mr. B. is to become to- tests really test what he/she wants to test (Va-
tally independent in his ADLs. lidity, Reliability, Sensitivity, and Specificity)
By testing the results of the therapy offered,
M: Mr. B. should wash, dress, and undress changes in the results become clear. This is
himself independently. necessary in order to demonstrate the effec-
tiveness of the treatment.
A: Mr. B. and the treatment team expect
The following overview lists examples of
that Mr. B. will ultimately be doing all his
measurements and tests.
ADLs on his own.

R: it is realistic that despite the loss of mo-

tor function and sensation, Mr. B. will be-
Objective Results of Treatment
Measurements at the level of body struc-
come totally independent in all of his ADLs.
ture and function:
T: the time for achieving the intermediate 5 Muscle strength (Manual Muscle Test-
and the final goals will be discussed. Mr. B. ing and Dynamometer)
should be totally independent after 4 months. 5 Mobility (i.e., goniometer)
1.1 · Positioning of the PNF Concept in the Modern Holistic Treatment
5 1
– Rhythmic initiation
5 Sensitivity (i.e., two-point discrimina- – Combination of isotonics
tion, dermatomes) – Replication
5 Spasticity (Modified Ashworth Scale) 2. Muscle Weakness
5 Pain (Visual Analog Scale) a) To improve muscle weakness, the following
5 Vital capacity basic principles can be used:
– Optimal resistance
Tests at the Level of Activity: – Approximation
5 FIM (Functional Independence Meas- – Stretch
ure) – Verbal stimulus
5 Barthel Index (index for testing ADL – PNF pattern
skills) b) Useful techniques are:
5 Timed Up and Go test – Dynamic reversals
5 10-m walk test – Combination of isotonics◄
5 COPM (Canadian Occupational Perfor-
mance Measure, client-oriented test in z Activities
occupational therapy) Working on the limitations of activity in-
5 Berg Balance Scale (test to objectify volves improving the ADLs), such as stand-
balance) ing up, sitting down, walking, climbing stairs,
5 Jebsen test or the Van Lieshout test, toileting, brushing teeth, shaving, dress-
both for hand function ing, and undressing. Improved speaking and
training activities to be carried out and prac-
tical training of hobbies are also examples of
working at the level of activities.
1.1.2  Treatment and the PNF The task of the therapist is to analyze the
Concept: Basic Principles functional limitations and to logically choose
and Techniques which PNF principles and techniques can be
used to efficiently treat these problems. The
z Structures and Body Function PNF concept offers many possibilities. One
At the level of impairments, the PNF con- can deviate from the standard PNF patterns.
cept gives us an excellent opportunity to treat If the functional activities do not fit within
the resulting limitations. PNF can also be a conventional PNF pattern as described in
easily combined with other treatment con- this book, the activity should be practiced ac-
cepts. There are manifold applications of the cording to the patient’s needs. One can use
basic principles and techniques of the PNF the basic principles such as resistance, ver-
approach, as we can see in the following ex- bal and visual input, timing, approximation,
amples. stretch, etc., in order to achieve the desired
goal (Horst 2008).

► Example > Important

1. Insufficient Coordination In training a patient to bring a glass to his
a) If the deficit is at the level of impairments, mouth, the PNF patterns of
the following basic principles can be imple- 5 Flexion–adduction–external rotation
mented: with elbow flexion
– Guidance resistance 5 Flexion–abduction–external rotation
– Visual and auditory (feedforward) input with elbow flexion are not adequately
– Approximation problem-oriented
– Body position of the patient The reversal of radial thrust (see . Fig. 7.18a,
b) Techniques to improve or to guide the co- b) is probably the pattern that best matches
ordination: this activity. One would not facilitate
6 Chapter 1 · Introduction

. Fig. 1.3 a Phases of motor learning (Fitts and Posner 1967). b Facilitation and PNF in the phases of motor
learning

c­ omplete flexion–abduction–external rotation the patient at the level of activities. Walk-

in the shoulder. The pronation of the fore- ing in the clinic is very different than walking
arm in this pattern and palmar flexion (con- outside the clinic or at home, where the pa-
centric–eccentric alternately) are identical to tient performs other activities simultaneously
those of functional activity. (dual task). The therapist should bring the
The choice of the position of the patient patient into a situation that resembles the fu-
during treatment depends on the treatment ture situation or into his own social situation.
goals and on the capabilities of the patient.
One does not always follow normal mo-
tor development when choosing starting po- 1.1.3  Learning Phases
sitions. If the patient is already able to walk
but is not able to come to a side-lying posi- Fitts and Posner (1967) described three learn-
tion, to sit up, or to transition from a sitting ing phases (. Fig. 1.3):
to a standing position (which we see with 1. Cognitive phase: the patient has to think
many neurological patients), we should treat about every action and cannot do another
this patient in the positions where improve- task at the same time.
ments are needed, for example, treating also 2. Associative phase: the patient tries to find
in a side-lying position (for turning), stand- a solution to the problem. The therapist
ing (for walking), sitting, standing up, etc. should allow the patient to make mistakes
so that he can learn from them. He may,
z Participation however, help the patient to find the right
The aim of the therapy is for the patient to solution.
achieve optimal functional ability at the level 3. Autonomic phase or automatic phase: the
of participation. Problems at the level of patient no longer needs to think about
body function and structure are solved as far solving the problem and can even simulta-
as possible and the activities that are impor- neously fulfill other tasks (dual tasks).
tant for the patient are practiced. In the end,
the patient should be able to perform all the Patients who have suffered an illness or have
activities needed in his/her everyday environ- had a severe accident must often go through
ment, and without the presence of the thera- these learning phases multiple times. It is
pist. To prepare for this, everyday situations role of the therapist to identify which phase
are created that simulate closely the activities the patient is in and to set up the therapy ac-
that are needed. This is practiced both within cordingly, so as to treat the patient optimally.
the hospital setting as well as outside the fa- Therefore, the basic principles and tech-
cility. The possibilities for facilitation with niques are suitable options.
the PNF concept at this level (participation) There are several possibilities for relearn-
can be the same as those used for ­treating ing an activity.
1.1 · Positioning of the PNF Concept in the Modern Holistic Treatment
7 1
Declarative Learning Patient Example: Mr. B.
Every action is analyzed exactly and then
practiced. This form of learning is applied, After receiving many treatments, the active
for example, in sports, where one needs to and passive motion in Mr. B.’s shoulder in-
learn a specific movement pattern perfectly. creased. Actively raising his right shoul-
This requires almost 3000 repetitions. New der is possible, but he can hold this posi-
activities that we want to teach our patients tion only briefly. Therefore, the activities of
require a high intensity and great number putting his glasses on and off, eating, and
of repetitions (repetition without repetition, drinking are not yet possible. The central
Bernstein 1967). trunk stability is sufficient. Sequence of
treatment: phase 2 should be treated first:
Procedural Learning stability of the shoulder in the desired po-
It is not necessary to think consciously. Ac- sition. Principles that are applicable are ap-
tivities are learnt by practicing them under proximation, resistance, verbal command,
constantly changing circumstances (jumping, and manual contact. Techniques that can
cycling, etc.). be applied are Stabilizing Reversals, Com-
bination of Isotonics, and Rhythmic Sta-
bilization. Phase 3: controlled mobility can
1.1.4  Motor Control and Motor be achieved by controlling the stability in
Learning the proximal joints, and then moving the
distal joints. Phase 4: finally, a skill can be
Applying the principles of motor control and practiced. At the end of the rehabilitation,
motor learning challenges the treating team the patient is able to trim a tree standing
to solution-oriented thinking for the indi- on a ladder.
vidual limitations of the patient. These prin-
ciples are helpful in the subsequent steps of
treatment, integrating the process of clinical
reasoning and improving the multidiscipli- The therapist can use the following possi-
nary teamwork. ble phases to recognize the patient’s problems
and to structure the treatment:
Motor Control 1. Mobility: the ability to assume a posture
Motor control is the study of postures and and to start a movement
movements that are controlled by central 2. Stability: stabilizing a new position and
commands and spinal reflexes, including the controlling gravity
functions of mind and body that govern pos- 3. Controlled mobility/mobility on stability:
ture and movement (Brooks 1986). Motor the movement can be controlled at each
control organizes activities that are already point in a stable position
present in the patient or have already been 4. Skill: all movements are possible, all parts
learned. Furthermore, in motor develop- of the body can move and be controlled
ment, motor control proceeds in progressive in all directions
processes or planned steps. There are four During the treatment, the therapist
progressive phases of motor control, each adapts to the capabilities and needs of the
having specific characteristics (see overview patient.
below). The therapist should adjust his/her
goals and exercises within these phases. Thus, On the basis of the analysis of the scope of
if the patient lacks the necessary mobility or possibilities and problems of the patient, the
stability for a particular activity, then these therapist chooses a problem-oriented exer-
are trained first before the actual activity can cise and a patient position. The phase of mo-
be performed (patient example: Mr. B.). tor control is taken into consideration and a
8 Chapter 1 · Introduction

. Fig. 1.4 a, b Activity: bringing a cup to the mouth

s­pecific exercise in a specific body position is Determining which facilitation is to be ap-

chosen that the patient is not yet able to achieve plied depends not only on the actual patient
or do alone. Feedforward can be used (Mulder assessment findings (before treatment began),
1991, Mulder and Hochstenbach 2004). The but also on the reactions during the treatment
therapist gives the patient the goal of the activ- of the patient, which play an important role.
ity, so that the patient can think about a move- After practicing, one can give the patient
ment plan to qualitatively carry out the activity. feedback about the end result of the activity
The execution of this activity is determined by: (knowledge of results). Additionally, tactile
5 The goal or target and verbal feedback during the execution of
5 The task of the activity the activity focused on the quality of the per-
5 The patient himself formance (knowledge of performance) can
5 The situation in which the activity happens be stimulating.

The movement is facilitated by using PNF Motor Learning

principles and techniques: Motor learning is not a treatment ap-
5 To improve the stability, we can use re- proach, such as the PNF concept, but
sistance, approximation, and verbal com- rather a model of how the therapist plans
mand and the techniques Rhythmic Stabi- his method of treatment. Motor learning is
lization and Stabilizing Reversals. a set of processes associated with practice
5 To improve the execution of the mo- or experience leading to relatively perma-
vement, we can use resistance, verbal com- nent changes in the capability for respond-
mand, visual input, manual contact, trac- ing (Schmidt and Wrisberg 2004). This pro-
tion, and timing. As techniques we can cess consists of: perception–cognition–ac-
use Rhythmic Initiation, Combining of tion (Shumway-Cook and Woollacott 1995)
Isotonics and Replication. (. Fig. 1.4 and 1.5).
1.1 · Positioning of the PNF Concept in the Modern Holistic Treatment
9 1

. Fig. 1.5 The process of motor learning: interaction

between the individuum, the goal or the task, and the
situation

Patient Example: Mr. B.

Mr. B is still not able to drink or to eat

without help. The required mobility in the . Fig. 1.6 Activity: garden work
upper extremity is present, as is the stabil-
ity of the trunk. He is unable to stabilize
his shoulder in the position long enough to be repeated many times under ever-chang-
bring a fork to his mouth. ing circumstances (Bernstein 1967, repetition
Sequence of treatment: to train the shoul- without repetition) and should ultimately be
der to stay in a desired position (stability), implemented in everyday activities (participa-
the basic principles of approximation, re- tion) (. Fig. 1.6).
sistance, and verbal command can be ef- The learning process is more effective
fectively implemented. After Mr. B. has if the therapist allows the patient to make
trained by himself to maintain this po- ­mistakes, so that the patient can learn from
sition for long enough, he can work on these errors. This method of learning gives
bringing the fork to his mouth (skill). Re- the ­patient the minimal amount of input and
sistance, verbal instructions, visual input, guidance so that he can perform the activity
and the technique of the combination of optimally.
isotonics and replication can be used to fa- Therapists who work with the PNF con-
cilitate this skill (. Fig. 1.4). cept often apply tactile and verbal input,
but this should not always be the case. Ulti-
mately, patients should learn to perform this
Each task that the patient is given should task by themselves. In the treatment at the
have a specific goal and a specific function. level of body structure and function, “hands
Performing the task is determined by the ca- on” work can be very useful. If the patient
pabilities and limitations of the patient and still has difficulty in performing the activities,
by the given situation in which the task is to hands on work in the cognitive and associa-
be fulfilled. The way of completing a task, tive phase can still be useful. It helps the pa-
and the capability to do so, depend on bio- tient to perform this activity more easily. The
mechanical, psychological, and neuropsy- basic principles such as (guiding) resistance,
chological factors. For a positive outcome of verbal instruction, approximation, movement
therapy, the activities must be practiced by patterns (traditional as well as adapted to the
the patient (Weinstein 1991) and the activi- functional activity), and techniques are avail-
ties have to be meaningful for the patient (law able. Ultimately, the goal is for the patient to
of effects). Only then will the patient main- be able to carry out the activity without facil-
tain his motivation. These activities should itation (hands off).
10 Chapter 1 · Introduction

Proprioceptive information and sen- Sequence of Treatment

1 sory input by using hands on or other tactile When the biomechanical prerequisites are
means of information are more appropriate fulfilled, then the training on tucking the
when they are integrated in a motoric activity shirt into the pants can begin (. Fig. 1.7a,
(Horst 2005). b). Guided resistance, manual contact, ver-
Manual Guidance: bal instruction, rhythmic initiation, combina-
5 Makes the learning process easier for ade- tion of isotonics and replication can be used
quately conducting a motoric strategy as possibilities to learn this skill. Ultimately,
5 Gives the patient security Mr. B. will learn to do this activity by himself
5 Increases the patient’s self-confidence and not only with his jogging pants but with
5 Provides sensory feedback a pair of pants that he wears for work (situa-
tion). The training situation is adapted to the
Children also learn new motoric activities daily life situation.
such as walking, cycling, or swimming, at
least in the beginning, with manual facilita- Evidence-Based Medicine
tion given by their parents. In a study in 2007 Today we live in a society where the ther-
about “hands on” versus “hands off,” Hache apy that we offer our patients should meet
and Kahlert showed that therapists find it use- the requirements of evidence-based med-
ful to apply manual facilitation in treatment at icine (EBM) and should be explained by
the level of body structure and function as well evidence-based practice (EBP). This means
­
as in the cognitive phase of a­ ctivities (Hache that evidence for the effectiveness of treat-
and Kahlert 2007). However, at the level of ment should be given. For EBP, Sackett and
participation or in the autonomic phase, a colleagues (1996, 1998, 2000) describe a five-
sensory input is usually not needed. rank order with decreasing conclusiveness
In addition to the learning phase, there (and evidential value).
are other areas where manual facilitation can Studies are differentiated as being either
be useful in patients: fundamental research or experimental re-
5 Problems in performing a task search.
5 Cognitive, communication, or sensory 5 In fundamental research, general princi-
problems ples such as anatomy, physiology, etc., are
5 Treatment of spasticity assessed.
5 Balance problems 5 In clinical experimental research, the ef-
5 Insecurity fects of the interventions are evaluated.

In physical therapy, many studies have been

conducted to document the effectiveness of
Patient Example: Mr. B.
strength, mobility, coordination, etc., as well
Mr. B. has great difficulties in tucking his as at the level of activity, such as getting up,
shirt into the back of his pants after visit- walking, etc. Unfortunately, only a few studies
ing the bathroom, an activity that is very have described the exact treatment form that
important for him (target). This problem is was effective for a typical p ­ roblem (­Smedes
very much at the level of impairments: not 2009). Furthermore, even fewer studies have
only because mobility is decreased in the been conducted in which the patient has been
shoulder, but more so because of inade- treated with the PNF concept only.
quate fine motor skills as well as a distur- Smedes et al. published an extended lit-
bance of sensation in the hands. In this ac- erature study (Smedes et al. 2006 (IPNFA);
tivity he is also missing visual control (in- Smedes 2016) as well as a literature list Sme-
dividuum), which plays an important role des et al. 2007; 2008–2018). This list will be
too. With this in mind, the treatment is ini- constantly updated.
tially at the level of impairments. As mentioned earlier, there have been
only a few concrete treatment studies us-
1.2 · PNF: Definition, Philosophy, Neurophysiological Basics
11 1

. Fig. 1.7 Activity: tucking the shirt into the pants

ing purely the PNF concept. Mostly, a PNF Neuromuscular – involving the nerves and
method (part of the concept) has been used the muscles.
but not the overall concept of PNF. This Facilitation – making things easier.
makes it difficult to compare the results of
treatments (Smedes et al. 2016).
To promote scientific research is one of 1.2.2  PNF Philosophy
the targets of the IPNFA (International
PNF Association, 7 www.IPNFA.org; IP- In keeping with this definition, there are certain
NFA 2005, 2006, 2007a, b, c, d, 2008), with basics that are part of the PNF philosophy:
more and more studies now being pub- PNF is an integrated approach: each treat-
lished. ment is directed at the total human being,
not just at a specific problem or body seg-
ment.
1.2  PNF: Definition, Philosophy, Mobilizing reserves: based on the un-
Neurophysiological Basics tapped existing potential of all patients, the
therapist will always focus on mobilizing the
patient’s reserves.
1.2.1  Definition Positive approach: the treatment approach
is always positive, reinforcing and using what
Proprioceptive neuromuscular facilitation the patient can do, at a physical and psycho-
(PNF) is a concept of treatment. Its under- logical level.
lying philosophy is that all human beings, in- Highest level of function: the primary goal
cluding those with disabilities, have untapped of all treatments is to help patients to achieve
existing potential (Kabat 1950). their highest level of function.
Proprioceptive – having to do with any of Motor learning and motor control: to
the sensory receptors that give information reach this highest level of function, the ther-
concerning movement and position of the apist integrates principles of motor control
body. and motor learning. This includes treatment
12 Chapter 1 · Introduction

at the level of body structures, at the activity According to the authors, this positive
1 level, as well at the participation level (ICF, functional approach is the best way to stim-
International Classification of Functioning, ulate the patient to attain excellent treatment
WHO 1997). results.
The PNF philosophy incorporates certain
basic thoughts, which are anchored in the
treatment concept shown below. 1.2.3  Basic Neurophysiological
Principles
Overview The work of Sir Charles Sherrington was im-
The philosophy of the PNF treatment con- portant in the development of the procedures
cept: and techniques of PNF. The following use-
5 Positive approach: no pain, achievable ful definitions were abstracted from his work
tasks, set up for success, direct and indi- (Sherrington 1947):
rect treatment, start with the strong 5 Afterdischarge: the effect of a stimulus
5 Highest functional level: functional ap- continues after the stimulus stops. If the
proach and use ICF, include treatment strength and duration of the stimulus in-
of impairments and activity levels crease, the afterdischarge increases as
5 Mobilize potential by intensive active well. The feeling of increased power that
training: active participation, motor comes after a maintained static contrac-
learning, and self training tion is the result of afterdischarge.
5 Consider the total human being: the en- 5 Temporal summation: a succession of
tire person with his/her environmental, weak stimuli (subliminal) occurring (sum-
personal, physical, and emotional fac- mate) to cause excitation.
tors 5 Spatial summation: weak stimuli applied si-
5 Use motor control and motor learning multaneously to different areas of the body
principles: repetition in different con- reinforce each other (summate) to cause ex-
texts, respect of the stages of motor citation. Temporal and spatial summation
control, variability of practice can combine for greater activity.
5 Irradiation: this is a spreading and increased
strength of a response. It occurs when either
Movement is our way to interact with our the number of stimuli or the strength of the
environment. All sensory and cognitive stimuli is increased. The response may be ei-
processes may be viewed as input that de- ther excitation or inhibition.
termines motor output. There are some 5 Successive induction: an increased excita-
aspects of motor control and learning tion of the agonist muscle follows stimu-
that are very important for rehabilitation lation (contraction) of their antagonists.
(Mulder and Hochstenbach 2004). A key Techniques involving reversal of ago-
element of any interactive situation is the nists make use of this property (Induc-
exchange of information. This also applies tion: stimulation, increased excitability).
to every type of therapy. Without an ex- 5 Reciprocal innervation (reciprocal inhibi-
change of information, patients are severely tion): contraction of muscles is accompa-
limited in mastering new tasks. This is par- nied by simultaneous inhibition of their
ticularly important in the first stages of antagonists. Reciprocal innervation is a
motor learning (. Fig. 1.3) as well as in the necessary part of coordinated motion.
rehabilitation process when, because of the Relaxation techniques make use of this
damage, the patient can no longer trust his property.
or her internal information. In these cases,
the therapist using PNF as facilitation pro- > The nervous system is continuous through-
vides an important source of external in- out its extent – there are no isolated parts
formation. (Sherrington 1947).
References
13 1
1.3  Test Your Knowledge: Question Sacket DL, Rosenberg WMC, Gray JAM, Haynes RB,
Richardson WS (1996) Evidenced based medicine:
what is it and what isn’t? BMJ 312:71–72
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fluence on your treatment. What are five im- idence-based medicine: how to practice and teach
portant principles of the PNF philosophy? EBM, 2. Aufl. Churchill Livingstone, Edinburgh
Sackett DL (1998) Getting research findings into prac-
tice. BMJ 317:339–342
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Brooks/Cole, Belmont cept? A literature search on electronically databases.
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logical rehabilitation. Erlbaum, Hillsdale het functioneel oefenen binnen het PNF concept.
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tät Twente meaning for PNF)
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Smedes F, Heidmann M, Schäfer C, Fischer N, Stepien Latash ML, Levin MF, Scholz JP, Schöner G (2010)
1 A (2016) The proprioceptive neuromuscular facil-
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Motor control theories and their applications. Me-
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of proprioceptive neuromuscular facilitation in Luft CDB (2014) Learning from FB. The neural mech-
physiotherapy practice. Phys Ther Rev 15(1):23–28 anisms of fb processing facilitating beter perfor-
mance. Behav Brain Res 261:356–368
Further Reading – Use of motor learning and Malouin F, Jackson PL, Richards CL (2013) Towards
motor control principles the integration of mental practice in rehab pro-
grams. a critical review. Front Hum Neurosci 9:1–20
Bach-y-Rita P, Balliet R (1987) Recovery from stroke. Marks R (1997) Peripheral mechanisms underlying the
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ical publishers, S 79–107 motor behaviour: toward a theoty-based rehabilita-
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17 2

PNF Basic Principles

and Procedures
for Facilitation
Contents

2.1  Optimal Resistance – 20

2.2  Irradiation and Reinforcement – 22

2.3  Tactile Stimulus (Manual Contact) – 23

2.4  Body Position and Body Mechanics – 25

2.5  Verbal Stimulation (Commands) – 26

2.6  Visual Stimulus – 27

2.7  Traction and Approximation – 28

2.7.1  Traction – 28
2.7.2  Approximation – 28

2.8  Stretch – 29

2.9  Timing – 30

2.10  Patterns – 30

2.11  Test Your Knowledge: Questions – 32

References – 33

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer-Verlag
GmbH, DE, part of Springer Nature 2021
D. Beckers and M. Buck, PNF in Practice,
https://doi.org/10.1007/978-3-662-61818-9_2
18 Chapter 2 · PNF Basic Principles and Procedures for Facilitation

apist should be extremely cautious and de-

The basic facilitation principles and pro- liberate when using traction or the stretch
cedures, when used correctly, provide tools reflex.
2 for the therapist to use in helping the pa-
tient to gain efficient motor function and
The IPNFA made a distinction between
“basic principles” and “procedures” (IPNFA
increased motor control. Instructor Day, Tokyo 2005 and Ljubljana
2006).
Basic principles:
Exteroceptive stimuli:
Therapeutic Goals 5 Tactile stimulation (7 Sect. 2.3)
The basic facilitation procedures can be 5 Verbal stimulation (7 Sect. 2.4)
used to: 5 Visual stimulation (7 Sect. 2.6)
5 Increase the patient’s ability to move Proprioceptive stimuli:
5 Increase the patient’s ability to remain 5 Resistance (7 Sect. 2.1)
stable 5 Traction (7 Sect. 2.7)
5 Guide the motion by proper grips and 5 Approximation (7 Sect. 2.7)
appropriate resistance 5 Stretch (7 Sect. 2.8)
5 Help the patient achieve coordinated Procedures are:
motion through timing 5 Reinforcement/Summation
5 Increase the patient’s stamina and avoid 5 Patterns (7 Chap. 5)
fatigue 5 Timing (7 Sect. 2.9)
5 Body mechanics and body position
(7 Sect. 2.4)
The individual facilitation procedures are 5 Irradiation (7 Sect. 2.2)
not used as isolated applications; rather,
they overlap and complement each other in The basic principles and procedures for facili-
their effectiveness. For example, resistance is tation are:
necessary to make the response to a stretch 5 Resistance:
­effective (Gellhorn 1949). The effect of re- Used to aid muscle contraction.
sistance changes with the alignment of the Used to increase motor control and mo-
therapist’s body and the direction of the
­ tor learning.
manual contact. The timing of these proce- Used to increase strength.
dures is important to get an optimal response 5 Irradiation and reinforcement: used to
from the patient. For example, a preparatory spread the response to stimulation.
verbal command comes before the stretch re- 5 Manual contact: used to increase power
flex. Changing of the manual contacts should and guide motion or movement with
be timed to cue the patient for a change in proper grip and pressure.
the direction of motion. 5 Body position and body mechanics: proper
We can use these basic procedures to treat body mechanics and proper positioning
patients with any diagnosis or condition, al- of the therapist enable him/her to provide
though a patient’s condition may rule out the a specific and well-aimed guidance to bet-
use of some of them. The therapist should ter control motion, movement, or stabil-
avoid causing or increasing pain. Pain is an ity.
inhibitor of effective and coordinated mus- 5 Auditory stimulation (commands): use of
cular performance and it can be a sign of words and the appropriate vocal volume
potential harm (Hislop 1960; Fisher 1967). to direct the patient.
Other contraindications are mainly common 5 Visual stimulation: use of vision to guide
sense: for example, not using approximation motion and increase force. The visual
on an extremity with an unhealed fracture. feedback simplifies motion. This is be-
In the presence of unstable joints, the ther- cause the patient tracks and controls
PNF Basic Principles and Procedures for Facilitation
19 2
. Table 2.1 Basic principles of facilitation

Treatment Definition Main goals, applications

Optimal resistance The intensity of resistance depends Promotes muscle contractility. Improves mo-
on the patient’s capabilities and on tor learning. Improves perception and control
the treatment goal of movement. Muscle strengthening
Irradiation The spread of the response of Facilitates muscle contractions (including the
Reinforcement nerve impulses of a given stimula- effect on the contralateral side)
tion. Increase stimulation by the
addition of a new stimulus
Tactile stimulus Stimulation of sensitive skin recep- Improves muscle activity. When used on the
(manual contact) tors and other pressure receptors trunk, promotes trunk stability. Provides con-
fidence and security. Promotes tactile and kin-
esthetic perception
Body position and Therapist: position in the direction Enables the patient to work in an econom-
body mechanics of movement. Patient: correct start- ical and goal-oriented way without hinder-
ing position ing movement. Allows the therapist to use his
body weight optimally to avoid fatigue
Verbal stimulation Tells the patient what to do and Guides the start of movement. Affects the
when to do it strength of the muscle contractions or of re-
laxation. Promotes the attentiveness of the
patient. Helps the patient to learn a func-
tional activity
Visual stimulation The patient follows and controls his Stimulates muscle activity in terms of coor-
movements by having eye contact dination, strength, and stability. Informs the
therapist on the appropriateness of the ap-
plied stimulus; whether it was too intensive or
caused pain. Informs the therapist about the
pain intensity and compatibility of the ap-
plied stimuli. Provides an avenue of commu-
nication and helps to achieve a cooperative
interaction
Traction An extension of the trunk or a limb Facilitates motion, especially pulling and an-
performed by the therapist tigravity motions. Aids in elongation of mus-
cle tissue when using the stretch reflex. Helps
to prepare for the stretch reflex and stretch
stimulus. Provides relief of joint pain
Approximation Compression of the trunk or an ex- Promotes stabilization. Facilitates weight
tremity bearing and the contraction of antigravity
muscle. Facilitates upright reactions. Used to
resist some component of motion
Stretch stimulus Occurs when a muscle is elongated Facilitates muscle contractions. Facilitates
under optimal tension contraction of associated synergistic muscles
Timing Sequencing of motions
Normal timing Normal timing provides continu- Improves coordination of normal movement
ous, coordinated motion, from dis-
tal to proximal
Timing for emphasis Changing the normal sequencing Redirects energy from the stronger to the
of motions to emphasize a particu- weaker muscles
lar muscle or a desired activity
PNF patterns Synergistic combinations of Facilitates and increases muscular response
three-dimensional muscle contrac-
tions
20 Chapter 2 · PNF Basic Principles and Procedures for Facilitation

movement and position with his eyes. By ► Example

having eye contact, the therapist and the 5 The resistance for learning a functional ac-
patient receive feedback about the per- tivity like standing up from a sitting posi-
2 formed movement. tion or going down the stairs is mostly a
5 Traction or approximation: the elongation guidance resistance to teach the patients to
or compression of the limbs and trunk to control these activities.
facilitate motion and stability. 5 Resistance for irradiation or strengthening
5 Stretch: the use of muscle elongation and of muscles is intensive.◄
the stretch reflex to facilitate contraction
and decrease muscle fatigue. Gellhorn showed that when a muscle con-
5 Timing: promote normal timing and in- traction is resisted, that muscle’s response
crease muscle contraction with proper in- to cortical stimulation increases. The ac-
puts and through “timing for emphasis.” tive muscle tension produced by resistance
5 Patterns: synergistic mass movements, is the most effective proprioceptive facilita-
components of functional normal mo- tion. The magnitude of that facilitation is
tion. related directly to the amount of resistance
(Gellhorn 1949; Loofbourrow and Gellhorn
The therapist can combine these basic pro- 1948a). Proprioceptive reflexes from con-
cedures to get a maximal response from the tracting muscles increase the response of syn-
patient. Each of the basic procedures will be ergistic muscles1 at the same joint and associ-
explained in detail. Their definition, appli- ated synergists at neighboring joints. This fa-
cation, and treatment goals will be summa- cilitation can spread from proximal to distal
rized. and from distal to proximal. Antagonists of
the facilitated muscles are usually inhibited.
If the muscle activity in the agonists becomes
2.1  Optimal Resistance intense, there may be activity in the antago-
nistic muscle groups as well (co-contraction).
(Gellhorn 1947; Loofbourrow and Gellhorn
Therapeutic Goals 1948a).
Resistance is used in treatment to: How we give resistance depends on the
5 Facilitate the ability of the muscle to kind of muscle contraction being resisted
contract. (. Fig. 2.1).
5 Increase motor control and improve
motor learning. Definition
5 Help the patient to gain an awareness
We define the types of muscle contraction
of motion and its direction.
as follows (International PNF Association,
5 Increase strength.
unpublished handout; Hedin-Andèn 2002):
5 Help the patient to relax the muscle (re-
5 Isotonic (dynamic): the intent of the
ciprocal inhibition).
patient is to produce motion.
– Concentric: shortening of the ago-
nist produces motion.
Most of the PNF techniques evolved from
– Eccentric: an outside force, gravity
knowledge of the effects of resistance.
or resistance, produces the motion.
The motion is restrained by the con-
The intensity of resistance provided during trolled lengthening of the agonist.
an activity is dependent on the capabilities
of the patient as well as on the goal of the
activity. This we call optimal resistance. 1 Synergists are muscles that act with other muscles to
produce coordinated motion.
2.1 · Optimal Resistance
21 2

. Fig. 2.1 Types of muscle contraction of the patient. a Isotonic concentric: movement into a shortened range; the
force or resistance provided by the patient is stronger. b Isotonic eccentric: the force or resistance provided by the
therapist is stronger; movement into the lengthened range. c Stabilizing isometric. The patient tries to move but is
prevented by the therapist or another outside force; the forces exerted by both are the same. d Isometric (static): the
intent of both the patient and the therapist is that no motion occurs; the forces exerted by both are the same
22 Chapter 2 · PNF Basic Principles and Procedures for Facilitation

. Fig. 2.1 e PNF receptors. (Modified from Klein-Vogelbach 2000)

– Stabilizing isometric: the intent of isometric contraction, the resistance should

the patient is motion; the motion is be increased and decreased gradually so that
prevented by an outside force (usu- no motion occurs.
ally resistance). It is important that the resistance does
5 Isometric (static): the intent of both the not cause pain, unwanted fatigue, or un-
patient and the therapist is that no mo- wanted irradiation in the wrong direc-
tion occurs. tion or into an undesired part of the body.
Both the therapist and the patient should
avoid breath holding. Timed and con-
The resistance to concentric or eccentric trolled inhalations and exhalations can in-
muscle contractions should be adjusted so crease the patient’s strength and active
that motion can occur in a smooth and co- range of motion.
ordinated manner. The antagonists of the fa-
cilitated muscles allow a coordinated activity
and therefore they are sufficiently inhibited 2.2  Irradiation and Reinforcement
to allow that activity. Resistance to a stabiliz-
ing contraction must be controlled to main- Properly applied resistance results in irradia-
tain the stabilized position. When resisting an tion and reinforcement.
2.3 · Tactile Stimulus (Manual Contact)
23 2

Irradiation is defined as the spread of the

response of nerve impulses of a given stim-
ulation.

This response can be seen as increased fa-

cilitation (contraction) or inhibition (relax-
ation) in the synergistic muscles and pat-
terns of movement. The response increases
as the stimuli increase in intensity or dura-
tion (Sherrington 1947). Kabat (1961) wrote
that it is resistance to motion that produces . Fig. 2.2 Irradiation into the trunk flexor muscles
irradiation, and the spread of the muscular when doing bilateral leg patterns
activity will occur in specific patterns. These
patterns can vary from patient to patient.
► Example
Definition Examples of the use of resistance in patient
Reinforcement. Reinforce as defined in treatment:
Webster’s Ninth New Collegiate Diction- 5 Resist muscle contractions in a sound limb
ary, is “to strengthen by fresh addition, to produce contraction of the muscles in
make stronger.” the immobilized contralateral limb.
The therapist directs the reinforcement of 5 Resist hip flexion to cause contraction of
the weaker muscles by the amount of re- the trunk flexor muscles (. Fig. 2.2).
sistance given to the strong muscles. 5 Resist supination of the forearm to facili-
tate contraction of the external rotators of
that shoulder.
Increasing the amount of resistance will in- 5 Resist hip flexion with adduction and ex-
crease the amount and extent of the muscu- ternal rotation to facilitate the ipsilateral
lar response. Changing the movement that dorsiflexor muscles to contract with inver-
is resisted or the position of the patient will sion (. Fig. 2.3).
also change the results. The therapist adjusts 5 Resist neck flexion to stimulate trunk and
the amount of resistance and type of mus- hip flexion. Resist neck extension to stimu-
cle contraction to suit (1) the condition of late trunk and hip extension.◄
the patient, for example, muscle strength, co-
ordination, muscle tone, pain, different body
sizes, and (2) the goal of the treatment. To in- 2.3  Tactile Stimulus (Manual
crease the irradiation and reinforcement it is Contact)
not limited to use only resistance. The ther-
apist can also use other stimuli such as ap-
proximation, verbal stimulation, stretch, and Therapeutic Goals
manual contact. By using these stimuli the 5 Pressure on a muscle to aid that mus-
temporal as well the spatial summation can cle’s ability to contract.
increase. 5 To give the patient security and confidence.
Because each patient reacts differently, it 5 To promote tactile and kinesthetic per-
is not possible to give general instructions on ception.
how much resistance to give or which move- 5 Pressure that is opposite to the direc-
ments to resist. By assessing the results of the tion of motion on any point of a mov-
treatment, the therapist can determine the ing limb stimulates the synergistic limb
best uses of resistance, irradiation, and rein- muscles to reinforce the movement.
forcement.
24 Chapter 2 · PNF Basic Principles and Procedures for Facilitation

. Fig. 2.3 a Irradiation to dorsiflexion and inversion with the leg pattern flexion–adduction–external rotation. b
­Irradiation for mid-stance support to the ipsilateral leg with the arm pattern into flexion–adduction–external rotation

5 Contact on the patient’s trunk to help

the limb motion indirectly by promot-
ing trunk stability.

The therapist’s grip stimulates the patient’s

skin receptors and other pressure receptors.
This contact gives the patient information
about the proper direction of motion. The
therapist’s hand should be placed to apply
the pressure opposite to the direction of mo-
tion. The sides of the arm or leg are consid-
ered neutral surfaces and may be held.
The tactile stimulation from the precise . Fig. 2.4 The lumbrical grip
application of the therapist’s hands has the
following effects on the stimulated structures:
5 The ability of a muscle contraction is in- squeezing or putting too much pressure on
creased when a pressure is exerted on it. bony body parts (. Fig. 2.5). Using the lum-
5 The synergists are facilitated when a mus- brical grip allows the therapist to apply trac-
cle is given resistance against its move- tion, which makes a movement easier. Trac-
ment. This leads to reinforcement in re- tion is also a condition for the application of
gard to the motor control. stretch.
5 Tactile stimuli promote the tactile and If the patient has no or decreased con-
kinesthetic perception during the perfor- trol over an eccentric muscle activity, for ex-
mance of movement. ample, going from a standing to a sitting po-
sition, the therapist can give the patient the
To control movement and resist rotation the kinesthetic information for this goal-oriented
therapist uses a lumbrical grip (. Fig. 2.4). movement by putting his hands on the top of
In this grip the pressure comes from flexion the iliac crest and applying pressure down-
at the metacarpophalangeal joints, allowing ward and backward. If some muscles show
the therapist’s fingers to conform to the body too little synergistic activity, we can facilitate
part. The lumbrical grip gives the therapist the desired muscle activity by giving a tac-
good control of the three-dimensional mo- tile stimulus. The therapist should give tac-
tion without causing the patient pain due to tile stimuli when and where the patient needs
2.4 · Body Position and Body Mechanics
25 2

. Fig. 2.5 Lumbrical grips. a For the leg pattern flexion–adduction–external rotation. b For the arm pattern flex-
ion–abduction–external rotation

it, but only for as long as the patient needs f­ollowing guidelines for the therapist’s body
it to increase the patient’s independence and position (G. Johnson and V. Saliba, unpub-
promote motor learning. The goal is for the lished handout 1985):
­patient to be able to control the activity by 5 The therapist’s body should be in line
himself/herself. Normally, the therapist has with the desired motion or force. To line
one hand distally and the other hand also up properly, the therapist’s shoulders and
distally or proximally when treating patients pelvis face the direction of the motion.
with extremity activities. If it is necessary to The arms and hands also line up with
solve the patient’s problem in another way, the motion. If the therapist cannot keep
the therapist can change the normal grips. the proper body position, the hands and
arms maintain alignment with the motion
(. Fig. 2.6).
2.4  Body Position and Body 5 The resistance comes from the therapist’s
Mechanics body whereas the hands and arms stay

> Proper Body Mechanics of the Therapist:

5 Give the therapist effective control of
the patient’s motion.
5 Facilitate control of the direction of
the resistance.
5 Enable the therapist to give resistance
without provoking pain.
5 Ensure that the therapist’s movement
will be ergonomic and aimed correctly.

Johnson and Saliba first developed the ma-

terial on body position as presented here.
They observed that more effective control
of the patient’s motion came when the ther-
apist was in the line of the desired motion, as
presented here. As the therapist shifted posi-
tion, the direction of the resistance changed
and the patient’s movement changed with . Fig. 2.6 Positioning of the therapist’s body for the
it. From this knowledge they developed the leg pattern flexion–abduction–internal rotation
26 Chapter 2 · PNF Basic Principles and Procedures for Facilitation

comparatively relaxed. By using body

weight the therapist can give prolonged 5 Affect the strength of the resulting mus-
resistance without fatiguing. The relaxed cle contractions or affect relaxation.
2 hands allow the therapist to feel the pa- 5 Give the patient corrections. Correct
tient’s responses. commands promote the attentiveness of
the patient. A clear and precise verbal
Not only are the body position and body me- command, without unnecessary words,
chanics of the therapist important but also is helpful for the patient to learn a func-
the position in which the patient is treated. tional activity.
The treatment goal as well other factors in-
fluence this position. The functional activ-
ity the patient needs, muscle tone, muscle
strength, pain, and stability of the patient The verbal command tells the patient what
and therapist are some of the factors that to do and when to do it.
need to be considered when choosing the ap-
propriate position in which to treat patients.
The patient sits or lies comfortably and near The therapist must always bear in mind that
the edge of the treatment table. The therapist the command is given to the patient, not to
stands by the patient’s side, where he can of- the body part being treated. Preparatory in-
fer the patient adequate security and stability structions need to be clear and concise,
(. Fig. 2.6). without unnecessary words. They may be
­
combined with passive movement and visual
Points to Remember
control from the patient to teach the desired
movement.
5 An optimal body position and body The timing of the command is important
mechanics from the therapist promote a to coordinate the patient’s reactions with the
smooth and ergonomic movement from therapist’s hands and resistance. It guides the
the patient without having to give much start of movement and muscle contractions.
resistance. By moving as much as possi- It helps to give the patient corrections for
ble in the diagonal direction, the ther- motion or stability.
apist gives the patient nonverbal infor- Timing of the command is also very im-
mation regarding the desired move- portant when using the stretch reflex. The in-
ment. itial command should come immediately be-
5 A good body position and movement fore the stretch of the muscle chain to coor-
of the therapist gives the patient a se- dinate the patient’s conscious effort with the
cure feeling. reflex response (Evarts and Tannji 1974). The
5 A good body position enables the thera- action command is repeated to urge greater
pist to use his body weight optimally to effort or redirect the motion.
provide the resistance and to avoid fa- In reversal techniques, proper timing be-
tiguing. tween verbal commands and muscle activity
is important when we change the direction
of the resistance. A preparatory command
should be given with the therapist chang-
2.5  Verbal Stimulation ing hand and an action command should be
given with the therapist applying resistance in
(Commands)
the new direction.
The volume with which the command is
given can affect the strength of the resulting
Therapeutic Goals muscle contractions (Johansson et al. 1983).
5 Guide the start of movement or the The therapist should give a louder command
muscle contractions. when a strong muscle contraction is desired
2.6 · Visual Stimulus
27 2
and use a softer and calmer tone when the
goal is relaxation or relief of pain. 5 Visual stimuli provide an avenue of
The command is divided into three parts: communication and help to ensure co-
1. Preparation: readies the patient for action operative interaction.
2. Action: tells the patient to start the action
3. Correction: tells the patient how to correct
and modify the action The feedback (and -forward) system can pro-
mote much stronger muscle activity (Schmidt
The repetition, the type of command, as well and Lee 1999). For example, when a patient
as the correction of the movement contribute looks at his or her arm or leg while exercising
to the attentiveness of the patient. Further- it, a stronger contraction is achieved. Using
more, the patient is inspired to exert more ef- vision helps the patient to control and cor-
fort or correct his movement. For example, rects his or her position and motion.
the command for the lower extremity pattern Moving the eyes will influence both the
of flexion–adduction–external rotation with head and body motion. For example, when
knee flexion might be [preparation] “ready, patients look in the direction in which they
and”; [action] “now pull your leg up and in”; want to move, the head follows the eye mo-
[correction] “keep pulling your toes up” (to tion. The head motion in turn will facil-
correct lack of dorsiflexion). itate larger and stronger trunk motion
(. Fig. 2.7).
Points to Remember
Eye contact between patient and therapist
provides another avenue of communication
For elderly patients, the visual input can and helps to ensure cooperative interaction.
be more important than the verbal input
(Gentile 1987; Lee and Lishman 1975)! > The visual contact between the patient and
the therapist provides an important non-
verbal avenue of communication, which
can improve the patient’s motivation and
2.6  Visual Stimulus coordination.

Visual feedback promotes muscular activ-

ity, by helping with coordination, strength,
and stability.

Therapeutic Goals
5 The therapist receives visual informa-
tion as to whether the applied stimulus
was appropriate for the task, or whether
it was too intensive or even caused pain.
5 Visual input promotes a more powerful
muscle contraction.
5 Visual feedback helps the patient to
control and correct position and mo-
tion.
5 Visual stimuli influence both the head
and body motion.
. Fig. 2.7 Visual control promotes motor learning
28 Chapter 2 · PNF Basic Principles and Procedures for Facilitation

2.7  Traction and Approximation posture caused by the approximation. Given

gradually and gently, approximation may
aid in the treatment of painful and unstable
2 2.7.1  Traction joints.

Traction is the elongation of the trunk or Therapeutic Goals

an extremity by the therapist. Approximation is used to:
5 Promote stabilization.
5 Facilitate weight bearing and the con-
Knott, Voss, and their colleagues theorized traction of antigravity muscles.
that the therapeutic effects of traction are 5 Facilitate upright reactions.
due to stimulation of receptors in the joints 5 Resist some component of motion. For
(Knott and Voss 1968; Voss et al. 1985). example, use approximation at the end
Traction also acts as a stretch stimulus by of shoulder flexion to resist scapula ele-
elongating the muscles. vation and to increase the irradiation or
The traction force is applied gradually un- reinforcement of other parts of the body.
til the desired result is achieved. The traction
is maintained throughout the movement and
combined with appropriate resistance. There are three ways to apply the approxima-
tion:
5 Quick approximation: the force is applied
Therapeutic Goals quickly to elicit a reflex-type response.
Traction is used to: 5 Slow approximation: the force is applied
5 Facilitate motion, especially pulling and gradually up to the patient’s tolerance.
antigravity motions. 5 Maintained approximation: after either a
5 Aid in elongation of muscle tissue when quick or slow approximation, the pressure
using the stretch reflex. will be maintained as long as necessary
5 Resist some part of the motion. For ex- for the muscles to build up the proper
ample, traction is used at the beginning muscle tension.
of shoulder flexion in order to counter-
act or to facilitate scapula elevation. The approximation force is always main-
tained, whether the approximation is done
quickly or slowly. The therapist maintains
Traction of the affected part is helpful when the force and gives resistance to the resulting
treating patients with joint pain. muscular response. An appropriate command
should be coordinated with the application
of the approximation, for example “hold it”
2.7.2  Approximation or “stand tall.” The patient’s joints should be
properly aligned and in a weight-bearing po-
sition before the approximation is given.
Approximation is the compression of the When the therapist feels that the active
trunk or an extremity. muscle contraction decreases, the approxima-
tion is repeated and resistance is given.
The muscle contractions following the ap- > Since traction usually facilitates motion
proximation are thought to be due to stim- and approximation facilitates isometric or
ulation of joint receptors (Knott and Voss stabilizing activity, the therapist should use
1968; Voss et al. 1985). Another possible rea- the one that is most effective. It is also pos-
son for the increased muscular response is sible to use a maintained approximation
to counteract the disturbance of position or during a motion.
2.8 · Stretch
29 2
For example, using PNF activities in an up- the hip and ankle are lengthened simultane-
right position and combining them with ously, the excitability in those limb muscles
­approximation together with concentric and increases further and spreads to the synergis-
eccentric muscle activity may be the most tic trunk flexor muscles.
effective treatment. Using arm activities
against gravity can be combined with approx- z z Stretch Reflex (Technique)
imation instead of traction when this pro- The stretch stimulus is a basic principle; us-
motes better function. ing the stretch reflex is a technique. The au-
thors describe it here to explain the difference
between them.
2.8  Stretch

The response to a stretch of the muscle chain Therapeutic Goals

given by the therapist can lead to a stretch re- How, why, and when to use the stretch re-
flex or only to stimulation of these muscles. flex is described in 7 Chap. 3 (7 Sect. 3.5).
Giving muscles a stretch should only be done
when the therapist expects to facilitate the
dynamic muscle activity. Sometimes a stretch The stretch reflex is elicited from muscles
activity is contraindicated when the muscles, that are under tension, either from elonga-
tendons, bones, or joints are injured. tion or from contraction.

z z Stretch Stimulus
The reflex has two parts. The first is a short
latency spinal reflex that produces little force
and may not be of functional significance.
Therapeutic Goals
The second part, called the functional stretch
5 Facilitate muscle contractions.
response, has a longer latency but produces
5 Facilitate contraction of associated syn-
a more powerful and functional contraction
ergistic muscles.
(Conrad and Meyer-Lohmann 1980; Chan
1984). To be effective as a treatment, the
muscular contraction following the stretch
must be resisted.
The stretch stimulus occurs when a muscle
The strength of the muscular contraction
is elongated under optimal tension.
produced by the stretch is affected by the in-
tent of the subject, and therefore, by prior in-
Stretch stimulus is used during normal ac- struction. Monkeys show changes in their
tivities as a preparatory motion to facilitate motor cortex and stronger responses when
the muscle contractions. The stimulus facili- they are instructed to resist the stretch. The
tates the elongated muscle, synergistic mus- same increase in response has been shown to
cles at the same joint, and other associated happen in humans when they are told to re-
synergistic muscles (Loofbourrow and Gell- sist a muscle stretch (Hammond 1956; Evarts
horn 1948b). Greater facilitation comes from and Tannji 1974; Chan 1984).
lengthening all the synergistic muscles of a
limb or the trunk. For example, elongation Points to Remember
of the anterior tibial muscle facilitates that
muscle and also facilitates the hip flexor–ad- In patients with increased tonus such as
ductor–external rotator muscle group. If someone with spinal spasticity, a reflex is
just the hip flexor–adductor–external rota- easily provoked and can be used to initiate a
tor muscle group is elongated, the hip mus- movement. Furthermore, it can be used to in-
cles and the anterior tibial muscle share the hibit the spasticity, by eliciting m
­ ovement in
increased facilitation. If all the muscles of the direction opposite to the spastic pattern.
30 Chapter 2 · PNF Basic Principles and Procedures for Facilitation

2.9  Timing t­ iming can be changed depending on the task

­(Dudel et al. 1996).

2 Therapeutic Goals Timing for emphasis involves changing the

5 Normal timing provides continuous, co- normal sequencing of motions to empha-
ordinated motion until a task is accom- size a particular muscle or a desired activ-
plished. ity.
5 Timing for emphasis redirects the en-
ergy of a strong contraction into
weaker muscles. Kabat (1947) wrote that prevention of mo-
tion in a stronger synergist will redirect the
energy of that contraction into a weaker
muscle. This alteration of timing stimulates
the proprioceptive reflexes in the muscles by
Timing is the sequencing of motions.
resistance and stretch. The best results come
when the strong muscles score at least “good”
Normal movement requires a smooth se- in strength (Manual Muscle Test grade 4;
quence of activity, and coordinated Partridge 1954).
movement requires precise timing of that
­ There are two ways in which the therapist
sequence. Functional movement requires
­ can alter the normal timing for therapeutic
continuous, coordinated motion until the purposes (. Fig. 2.8 and 2.9):
task is accomplished. However, first, proxi- 5 By preventing all the motions of a pattern
mal stability must be present before the distal except the one that is to be emphasized.
movement can begin. 5 By resisting an isometric or maintained
contraction of the strong motions in a
pattern while exercising the weaker mus-
In adults, normal timing of most coordi- cles. This resistance to the static contrac-
nated and efficient motions is from distal tion locks in that segment; thus, resisting
to proximal. the contraction is called “locking it in”
(. Table 2.1).

The evolution of control and coordination

► Example
during development proceeds from cranial to
caudal and from proximal to distal (Jacobs Timing for emphasis for the dorsiflexion–su-
1967). In infancy the arm determines where pination–adduction of the foot: the therapist
the hand goes, but after the grasp matures prevents the movements in the hip and knee
the hand directs the course of the arm move- joint by giving appropriate resistance to the
ments (Halvorson 1931). The small motions flexion–adduction–external rotation of the hip
that adults use to maintain standing balance joint and the flexion in the knee joint. Mean-
proceed from distal (foot) to proximal (hip while, for stimulating the components of dor-
and trunk) (Nashner 1977). To restore nor- siflexion–supination–adduction he/she uses the
mal timing of motion may become a goal of technique of repeated contractions or combin-
the treatment. ing of isotonics.
Normally, the timing of an activity is
from distal to proximal. Moving an extrem-
ity presupposes that the central part of the 2.10  Patterns
body is stabilized. Moving the leg forward
in gait requires the trunk and opposite hip The patterns of facilitation may be consid-
and leg to have enough stability to move ered one of the basic procedures of PNF. For
the leg. Central stability is needed to move greater clarity, we discuss and illustrate them
an extremity. However, studies showed that in 7 Chap. 5.
2.10 · Patterns
31 2

. Fig. 2.8 Timing for emphasis by preventing motion. a, b Leg pattern flexion–abduction–internal rotation with
knee flexion. The strong motions of the hip and knee are blocked and the dorsiflexion–eversion of the ankle exer-
cised using a repeated stretch reflex. c, d Arm pattern flexion–abduction–external rotation. The stronger shoulder
motions are blocked while exercising the radial extension of the wrist
32 Chapter 2 · PNF Basic Principles and Procedures for Facilitation

. Fig. 2.9 Timing for emphasis using stabilizing contractions of strong muscles. a, b Exercising elbow flexion us-
ing the pattern of flexion–adduction–external rotation with stabilizing contractions of the strong shoulder and wrist
muscles, c, d Exercising finger flexion using the pattern extension–adduction–internal rotation with stabilizing con-
traction of the strong shoulder muscles

2.11  Test Your Knowledge: 5 Name at least ten different basic princi-

Questions ples or basic procedures and their main
goals or objectives.
Using the PNF procedures or principles en- 5 Why it is so important to combine basic
ables the therapist to activate the motor re- principles?
serves of the patient and to help with motor
learning.
References
33 2
References Knott M, Voss DE (1968) Proprioceptive neuromuscu-
lar facilitation: patterns and techniques, 2nd edn.
Brooks VB (1986) The neural basis of motor control. Harper and Row, New York
Oxford University Press, New York Kofotolis N, Vrabas IS, Vamvakoudis E, Papaniko-
Chan CWY (1984) Neurophysiological basis underlying laou A, Mandroukas K (2005) Proprioceptive neu-
the use of resistance to facilitate movement. Physio- romuscular facilitation training induced alterations
ther Can 36(6):335–341 in muscle fiber type and cross sectional area. Br J
Conrad B, Meyer-Lohmann J (1980) The long-loop Sports Med 39(3):e11
transcortical load compensating reflex. Trends Neu- Lee DN, Lishman JR (1975) Visual proprioceptive con-
rosci 3:269–272 trol of stance. J Hum Mov Stud 1:87–95
Dudel JR, Menzel R, Schmidt RF (1996) Neurowissen- Lee DN, Young DS (1985) Visual timing in interceptive
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37 3

PNF Techniques
Contents

3.1 Introduction – 38

3.2 Rhythmic Initiation – 39

3.3 Combination of Isotonics – 40

3.4 Reversal of Antagonists – 41

3.4.1 Dynamic Reversals (Incorporates Slow Reversal) – 41
3.4.2 Stabilizing Reversals – 44
3.4.3 Rhythmic Stabilization – 45

3.5 Repeated Stretch (Repeated Contractions) – 47

3.5.1 Repeated Stretch from Beginning of Range (Repeated
Initial Stretch) – 47
3.5.2 Repeated Stretch Through Range (Old Name: Repeated
Contractions) – 48

3.6 Contract–Relax – 50
3.6.1 Contract–Relax: Direct Treatment – 50
3.6.2 Contract–Relax: Indirect Treatment – 51

3.7 Hold–Relax – 52
3.7.1 Hold–Relax: Direct Treatment – 52
3.7.2 Hold–Relax: Indirect Treatment – 52

3.8 Replication – 54

3.9 PNF Techniques and Their Goals – 55

3.10 Test Your Knowledge: Questions – 55

References – 55

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer-Verlag
GmbH, DE, part of Springer Nature 2021
D. Beckers and M. Buck, PNF in Practice,
https://doi.org/10.1007/978-3-662-61818-9_3