Sometimes referred to as active stretching or facilitative stretching

The methods comprising these factors were formulated frm findings on neuromuscular development of all movements fem a stage of motor immaturity to a stage of motor maturity in the growing child in a definite sequence of progressing logically from:

• Total to individual
• Proximal to distal & distal to proximal
• Mobile to stable
• Gross to selective
• Reflexive to voluntary
• Overlapping to integrative
• Uncoordinated to coordinated
  

This adapts certain PNF techniques & principles for application by hand or apparatus in physical conditioning.
Eg: springs, weights, therabands etc

• The capacity of motor activity performed by an individual depends upon his learned neuromuscular response.
• This capacity even under normal circumstances is much less than the actual potential of the individual.
• Such untapped potential can be developed under environmental situations, stressful situations, or by increased voluntary efforts.
  PNF is based on this principle where the remaining potential in the patient is used to reach the maximum performance level in him or her
  

• During normal growth & development, motor activity first develops in the head & lastly in the extremities (cephalocaudal) & proximal to distal.
• Thus, the treatment using PNF also should progress in the same developmental sequence.
  

• With maturity, the primitive reflexes get integrated & become useful for various activities like crawling, rolling, etc.
• Even in normal individuals, some of these reflexes have been shown to influence tonic changes in the ms ( Helebrant & associates).
• Thus, reflexes may be used to facilitate movement at some body parts by using various developmental posture or by using the head & trunk with extremity patterns.
  

• These movements are rhythemic & oscillatory.
• This principle means that any goal directed movement that we perform has 2 directions, one to accomplish the task & the other for unwinding the task.
• Hence, when we treat a patient we should give the movement patterns in both the direction.
  

• During growth, it is noted that milestones are reached in a specific sequence, initially simple movements are achieved, & finally complex skillful activities are learned.
• The movem patterns of the extremities usually require proper contribution from specific movem pattern & position of the head, neck & trunk (eg while bowling; hand moves along with specific movement of trunk for speed, power, accuracy, & timings).
• Thus, while treating patients, fundamental movements are first taught & then more complex movements are given.
• Emphasize on proximal stability before going for coordinated skillful movements of the distal part.
  

• During normal growth development, there exists shifts between the agonist and antagonists in
  terms of its dominance which is essential to establish a balance between the agonist and
  antagonists.
• Otherwise, one group would have been weak and other strong. Eg: A child practicing rocking move ments before crawling.
• PNF also aims at developing balance between the opposite
  group of muscles, working on the weak muscle.
  
  

• During normal growth and development, the child does not necessarily perfect one activity before going to next task.
• In training a patient for a specific task against a certain postural background, it is necessary to follow the developmental sequence.
• For eg: If you are not able to teach positioning
  the UE to a stroke patient in sitting posture, then we need to teach him the same activity in supine lying then progress.
• On the contrary, some activities are benefitted by making the patient to perform on a higher level activity.
• For instance, while gait training, even before the patient walks perfectly on a level surface, the patient can be taught to walk on uneven surface or climb stairs.
• This development will enable the patient to walk better on even surfaces.
  

Functional movements depend upon the balance between reflex activity, flexor extensor
dominance and reversing movement – Main objective of PNF. Eg: If a patient is not able to sit due
to dominance of back extensors or if a hemiplegic patient has poor release due to dominant flexor
synergy, then the opposite movements have to be given to restore balance between the two
groups.

• PNF approach uses multisensory input to enhance motor learning. Visual, auditory, verbal and
  tactile inputs are given to the patient.
• Eg: When working on the shoulder flexion and adduction by asking the patient to take his hand towards the mouth, at the same time, the patient may be asked to see the movement and the therapist appropriate hold provides the multisensory input that helps in learning the task.
• Motor learning is said to be accomplished only when the patient does not need such external cues to perform a task.
  

The patient needs the opportunity to practice the learned motor skills. Only after repeated practice
will the activity become automatic and efficient.

• Realistic functional goals are continually set for the patient through-out the treatment.
• Activities that have meaning for the patient are more effectively integrated into motor learning.
• Improvement in function cannot be achieved with instruction and practice alone, it is essential that
  the therapist provides manual contacts and techniques to facilitate a desired response.
• Eg: To train
  a stroke patient for release of hand, sudden stretch to finger extensors may be given or joint
  approximation to the shoulder can be given to develop proximal fixation in cerebellar lesion.
  

• The patient should be positioned appropriately so that movements are free to occur without any hindrance.
• The therapist position should be comfortable and such that he is able to maintain the manual contact without any discontinuity.
  

• Manual contact of the therapist is necessary to facilitate and guide movement.
• The specific manual contact recommended is lumbrical grip.
• The grip should offer exteroception, stretch, resistance and traction / approximation.
• Multiple grips may cause a conflict in the sensory
  information sent to the brain and hence should be prevented.
  

• Stretch is used to facilitate movement or to increase the power of the weak muscle.
• According to Sherrington’s principle, when a muscle is stretched, the Ia and Il fibres in the muscle
  spindle send excitatory messages to the alpha motor neurons which innervate the stretched muscle.
• Inhibitory messages are sent to the antagonistic muscle simultaneously.
• In PNF, while giving stretch, the muscle is kept in the lengthened position which is the starting position of the
  pattern.
• Stretch produces reflex activation of the muscle which is then synchronized with the volitional effort using the visual, verbal and auditory cueing.
• The applied stretch should be
  appropriate as stretching too enthusiastically can only be harmful.
  

• The therapeutic movement given in PNF are usually mass movement pattern that is
  used for our activity of daily living.
• The patterns given are spiral or diagonal movement pattern
  forming an angle of approximately 45 degrees to the trunk.
• These should be movements which are
  essentially crossing the midline of the body.
  

• There is a normal sequence in which various components of a movement pattern occur.
• The timing for which each component should work is determined by the control exhibited by the cerebellum.
• Under normal circumstances, the movement is initiated by the rotary components, because the rotary component initiates the movement, the movement starts in the distal most components, then the intermediate and lastly the proximal components.
• This is called as appropriate timing and sequencing of all movements.
• It is important that the movement at the
  distal components gets completed before the movement at the proximal components gets completed.
  
  

• This means there is a spread of impulses or energy from a strong muscle to weak muscle especially when the stronger muscles work against a very high resistance.
• Irradiation is possible from proximal to distal or from distal to proximal.
• Weaker muscle group is usually benefitted with this
  irradiation.
• In order to stimulate irradiation of impulses from stronger muscles to weaker muscle, the therapist must give a very high resistance to the strong muscle such that there is spread of impulse to the
  weaker muscle and that in turn facilitates
  the weak muscle.
• Therapist can stimulate the contraction of quadriceps by giving resistance to the dorsiflexor, or can give very high resistance to the hip flexors to stimulate dorsiflexors.
• Irradiation is also possible from the stronger arm to the weaker arm.
• In spasticity, irradiation of impulses give rise to associated reaction which is pathological and should
  be discouraged otherwise, the patient will habituate.
• In normal circumstances, associated movements are noted like swinging of arm while walking,
  clenching of teeth while lifting heavy weight. These reactions are also due to irradiation but they
  are physiological.
  

• The therapist should be skillful enough to give maximal resistance and not maximum resistance.
• Maximal resistance is the one against which the patient is able to perform full range of movement in a smooth manner for an isotonic muscle work.
• For an isometric muscle work,
  maximal resistance is the one which stimulates the muscle to work to its maximum capacity without the therapist breaking the hold of the patient.
• However, it should be noted that the
  therapist needs to also assist the patient when he or she finds it difficult to perform the movement smoothly against resistance.
  

The joint structures are the articular cartilage, capsule, synovium, ligaments, etc.

• Approximation is necessary to stimulate co-contraction of muscles around a joint that will
help in stability. Approximation is given in PNF when the movement is performed towards
gravity. It is also given through the use of weight bearing postures in addition to the manual
forces.

• Traction, on the contrary is given when the movement is done against gravity and it
produces a stretch stimulus and enhances movement by elongating the adjacent muscles.

• The auditory input given by the patient can be used very effectively both to facilitate as
  well as inhibit. Input should be very simple, easy for the patient to understand.
• The therapist should avoid
  long sentences as this will confuse the patient. Buchwald states the tones of moderate intensity evoke gamma motor neuron activity while louder ones alter the alpha motor neuron
  activity.
• Strong commands are used when the maximal motor stimulation is desired.
• A soft voice is used to offer
  reassurance and to relax the muscle.
  

• Visual stimuli help in initiation and coordination of movement.
• It also guides the movement in proper direction.
  
  • Using these various sensory feedbacks will cause summation of the stimulus provided that will help in
    maximizing the motor output which is the ultimate aim of any therapy.
    

4.Extension Abduction
(D2 Extension)

• Shoulder flexion with shoulder girdle elevation & lateral rotation
• Shoulder extension with shoulder girdle depression & internal rotation
• Abduction with wrist extension
• Adduction with wrist flexion
  

• they are also called as relaxation techniques and are very effective when the movement is restricted at a joint due to high tightness or hypertonicity of the muscle.

Facilitatory impulse are given simultaneously to promote excitation of a maximal response.

Facilitatory impulse are given one after the other but very close to each other in time so that there is overlapping of input given to produce maximal output from the patient

• Thus, this technique is effective to facilitate contraction of ms which have not been active for some time in this shortened range, also it helps to bring about the lengthening effect in the antagonist ms through the principle of reciprocal inhibition (contraction of a ms caused relaxation of its antagonist)

• joints across which the weak ms or weak component of the pattern is present.
• Movement is allowed to take place in full range.
• Muscles are allowed to contract for a longer time than usual.

part proximal to pivot and in this part is contracting at the middle range.

it is the part distal to the pivot & ms at this part is contracting at their inner range

Best suited for conditions with generalized weakness of the ms or stroke where the patient is not able to perform a specific pattern or if the movement is performed in a faulty way

• After the patient is able to master several repetitions of active movement without increase in generalized tone, resistance is incorporated into the exercise

• Then the co-contraction can be trained in a new range

• In contract relax- the contraction of the antagonist ms is brought about in an isotonic way
  .
• In hold relax- the contraction of the antagonist ms is brought about in an isometric way
  

Then the entire procedure is repeated in this new range.

Eg: if elbow flexion is restricted due to hypertonic elbow extensors, then according to this method, the elbow extensors should be made to contract maximally so that it follows up with complete relaxation