Proprioceptive

neuromuscular facilitation
By
Dr. Hari Narayan Saini (PT)
Associate Professor
NIMS College of Physiotherapy & Occupational Therapy
 Procedure:-

• After the patient voluntarily relaxes, the therapist moves the

patient’s limb passively through the available range of the
desired movement pattern several times so the patient
becomes familiar with the sequence of movements within
the pattern.

• The patient is asked to begin working actively in the desired

direction. The return motion is done by the therapist.

• The therapist resists the active movement, maintaining the

rhythm with the verbal commands.
 .

• To finish the patient should make the motion independently.

• It also helps the patient understand the rate at resistances

movement is to occur.

• Practicing assisted or active movements(without resistance)

also helps the patient learn a movement pattern.
 Cont.

•Repeated, dynamic contractions, initiated with

repeated quick stretches followed by resistance, are
applied at any point in the ROM to strengthen a
weak agonist component of a diagonal pattern.
Alternating Isometrics

• Improve isometric strength and stability of the

postural muscles of the trunk or proximal stabilizing
muscles of the shoulder girdle and hip.

• Manual resistance is applied in a single plane on

one side of a body segment and then on the other.
 .

• The patient is instructed to “hold” his or her position as

resistance is alternated from one direction to the opposite
direction.

• This procedure isometrically strengthens agonists &

antagonists; and it can be applied to one extremity, to both
extremities simultaneously, or to the trunk.

• Alternating isometrics can be applied with the extremities in

open-chain or closed-chain positions.
Reversal of Antagonists

• Many functional activities involve quick reversals of the

direction of movement.

• This is evident in diverse activities such as sawing or

chopping wood, dancing, playing tennis, or grasping and
releasing objects.

• The reversal of antagonists technique involves

stimulation of a weak agonist pattern by first resisting
static or dynamic contractions of the antagonist pattern.
 .

• The reversals of a movement pattern are instituted just

before the previous pattern has been fully completed.

These are:
• Dynamic Reversal – Slow Reversal
• Stabilizing reversal
• Rhythmic Stabilization
Dynamic Reversal – Slow Reversal

• Active motion changing from one direction(agonist)

to the opposite (antagonist) without pause or
relaxation
 .

•The therapist resists the patient’s moving in one

direction, usually the stronger or better
direction.

•As the end of the desired range of motion

approaches the therapist reverses the grip on the
distal portion of the moving segment and gives a
command to prepare for the change of direction.
 .

• At the end of the desired movement the therapist gives the

action command to reverse direction, without relaxation,
and gives resistance to the new motion starting with the
distal part.

• When the patient begins moving in the opposite direction

the therapist reverses the proximal grip so all resistance
opposes the new direction. The reversals may be done as
often as necessary.
 .

• Normally we start with contraction of the stronger.

• Pattern and finish with contraction of the weaker pattern.

However, don’t leave the patient with a limb “in the air”.
 .

• Resisted isotonic contraction of the restricting muscles

(antagonists) followed by relaxation and movement into the
increased range.

• The therapist or the patient moves the joint or body

segment to the end of the passive range of motion. Active
motion or motion against a little resistance is preferred.
 .

• The therapist asks the patient for a strong contraction of the

restricting muscle or pattern (antagonists). The contraction
should be held for at least 5–8 seconds.

• A maximal contraction in the most lengthened position of

the muscle chain will provoke a structural change in the actin-
myosin complex.

• After sufficient time, the therapist tells the patient to relax.

• Both the patient and the therapist relax.

 .

• The joint or body part is repositioned, either actively by the

patient or passively by the therapist, to the new limit of the
passive range. Active motion is preferred and may be
resisted.
 .

• Resisted isometric contraction of the antagonistic muscles

(shortened muscles) followed by relaxation.

• The therapist or patient moves the joint or body segment to

the end of the passive or pain-free range of motion. Active
motion is preferred. The therapist may resist if that does not
cause pain.
 .

• The therapist asks for an isometric contraction of the

restricting muscle or pattern (antagonists) with emphasis on
rotation.

• The contraction should be maintained for at least 5–8

seconds.

• The resistance is increased slowly.

• No motion is intended by either the patient or the therapist.
• After holding the contraction for enough time the therapist
asks the patient to relax.
• Both the therapist and the patient relax gradually.
 .

• The joint or body part is repositioned either actively or

passively to the new limit of range.

• Active motion is preferred if it is pain-free.

• The motion may be resisted if that does not cause pain.

• Repeat all steps in the new limit of range.

 Exercise-
• According WHO- It is a subcategory of physical activity that is
planned, structured, repetitive and purposeful in the sense
that the improvement or maintenance of one or more
components of physical fitness is the objective.

• Individual exercise- defined by individual subject doing

exercise either by himself or under supervision of a
physiotherapist.
Group exercise-

• Defined by group of people performing a

determined set of exercise under the supervision of
a physiotherapist.
• Group exercise is very much different from mass
exercise.
• Group exercise-
Homogenous group members
Consists of 6-8 subjects
Individual concentration
Stimulation is utilized from working with each other.
Mass exercise

• Homogenous group members

• Large number of population
• Formal word or command or a rhythm dictated by
the instructor to the entire mass.
• Stimulation is utilized by the rhythm/formal
word/command given by the instructor.
 Values of group exercises

• The patient learns to take responsibility for his own exercise

during the group exercise therapy which helps towards
adequate home practise. Patients treated individually. The
amount of attention given to the individual patient
decreases in proportion to the number in the group and yet
a measure of help, supervision and encouragement is
available when required.
• The patient learns to work with others and no longer
considers himself set apart from his fellow members
because of his disability.
 Cont.

• The patient is given confidence in the treatment and

stimulated to further effort, as progress on the part of other
members of the group does not pass unnoticed.
• The patient is given confidence In his ability to hold his own
with others when the group performs some exercise in
Union.
• Effort is stimulated by some activities which call for mild
form of competitions.
• Sometimes group exercises are fun. Patients are helped to
forget their disabilities temporarily by objective and game
like activities, which are only possible in group treatment.
 Merits of group exercise

• Build up confidence.
• Stimulates his effort while performing exercise thus
improving endurance as well as strength.
• Group exercise is can be modified to attain the balance and
co-ordination in subjects with the respective deficits or even
in geriatric group.
• If performed by geriatric, it build good communication.
• Builds a mild form of competitive levels while performing.
Demerits

• Individualised focus for attention cannot be

delivered.
• Individualised help can not be delivered.
• Every subject cannot participate.
• only certain form of exercise can be practised small
proof gives better outcome.