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Proprioceptive Neuromuscular Facilitation
Techniques in Sports Medicine: A
Reassessment
Paul R. Surburg, PhD, RPT; John W. Schrader, HSD, ATC
Objective: The purpose of this survey was for comparison with a similar 1981 survey to determine if proprioceptive neuromuscular facilitation (PNF) techniques are being imple- mented in the same manner today. Design and^ Setting: The^ survey was^ made^ available^ at^ the 1993 NATA^ Clinical Symposium. Subjects: The subjects were 131 athletic trainers represent- ing all^ major national athletic^ conferences^ who^ attended the 1993 NATA^ Clinical Symposium^ and^ who stated that^ they used PNF exercise in their practice. Measurements: The (^) survey consisted of 15 questions deal- ing with^ academic^ preparation,^ years^ of^ practice,^ scope^ and method of preparation in PNF, application of nine PNF tech- niques to various joints and regions of the body, and the most successful use of PNF techniques. Resufts: PNF techniques are most frequently applied during rehabilitation of the knee, shoulder, and hip, similar to 1981
H ow do athletic trainers use proprioceptive neuromuscu- lar facilitation (PNF)? More specifically, what^ PNF techniques have athletic trainers found^ to^ be^ effective in treating injuries in specific areas of the^ body? The^ response to this question will vary in^ context and^ scope. Several reasons for response variability will be^ briefly examined in this introductory section. In accredited^ athletic training programs, undergraduate athletic^ training students^ are exposed to^ PNF.^ Students^ are^ expected to^ understand the underlying principles of this^ system and^ glean concepts related to (^) application. The scope of coverage is predicated upon the preparation and practical experience of the instructor in PNF. Thus, the reply to the question regarding application of PNF techniques may be brief and vague for some athletic trainers. The information in this study should expand knowledge of PNF applications and possibly provide new insights for effec- tive use and variations. A brief review of the literature on PNF techniques and their applications is^ provided in the^ following paragraph. While these studies (^) provide some (^) guidance for PNF application, one must be aware that the majority of these studies involve subjects with no type of athletic injury. By contrast, the responses of athletic trainers in this study relate to treating injured athletes. Numerous investigations establish PNF techniques as more efficacious treatments than traditional static stretching exer-
except that the use of these techniques during ankle rehabili- tation has increased. In both studies, the most frequently used techniques were contract-relax and hold-relax. Two techniques not surveyed in 1981, contract-relax-contract and hold-relax- contract, are becoming techniques of choice for elbow, wrist, hip, and knee rehabilitation. The use of PNF techniques in the muscle re-education phase of rehabilitation is an application identified in this survey not cited by athletic trainers in the 1981 survey. Conclusions: Proprioceptive and kinesthetic deficits are known to occur after certain types of injuries, and the use of PNF techniques to correct these problems is a natural applica- tion. A contemporary trend in exercise rehabilitation is multi- planar exercises, which are typified by PNF techniques. Key words: proprioception, neuromuscular, facilitation, inju- ries
cises for range of motion or flexibility enhancement.'-3 Treat- ment modalities used with PNF^ techniques have^ been^ exam- ined to ascertain the relative merits of combination treatments. Results of studies applying cryotherapy with^ PNF^ are^ mixed^ in nature.45 Using the Hoffman reflex to assess motor unit recruitment, results show that^ PNF^ techniques produce a^ strong but brief neuromuscular inhibition.6 While investigating the role of PNF techniques for flexibility development, a physical therapist reported a significant increase in hamstring flexibility of the contralateral, nonexercised leg with the contract-relax technique. This transfer effect provides additional evidence of neurological mechanisms operating with PNF applications.2 A
study by Hardy' provides insights into certain^ applications and
modifications of PNF techniques. He examined duration of isometric contractions and found 6 seconds to be the ideal length of contraction time for the hold-relax technique. An- other finding is that this hold-relax procedure may be more effective when an isotonic contraction of the hip flexors follows the isometric contraction of the hip extensors. This modification, called hold-relax-contract, was incorporated into our study. There is a (^) paucity of (^) data about the application of PNF for injured athletes at the high school and college levels. While athletic trainers should be cognizant of data-based, quasi-
experimental studies,7-9^ it^ is^ important^ for^ them^ to^ gain
insights into PNF practices implemented by their peers, thereby adding to a valuable body of knowledge in the area of rehabilitation. In essence, this survey represents the "best practice" in^ over^131 case^ studies.
34 Volume 32 *^ Number 1 * March 1997
Paul R. (^) Surburg is a professor and John W. Schrader is coordinator of the athletic training program in the Department of Kinesiology, Indiana University, Bloomington, IN 47405.
Over a 13-year period, aspects of therapeutic exercise or protocols have changed in emphasis, role, and (^) importance. Isokinetic exercises were the exercise of choice 13 years ago for various aspects of the rehabilitation process and considered "cutting edge" protocols. While isokinetic exercises are still important in rehabilitation, closed kinetic chain exercises are considered vital in many contemporary therapeutic protocols. Along with changes in priority and usage among types of exercises, there may also be application changes within a therapeutic regimen. Are certain PNF techniques being used more frequently or differently in contemporary rehabilitation programs than in 1981? The purpose of this study was to
compare this survey with a 1981 studyl to determine if PNF
techniques are being implemented in the same manner as 13 years ago.
METHODS One hundred and thirty-one athletic trainers participated in this study and represented all major athletic conferences in the United States. The survey instrument was made available at the 1993 National Athletic Trainers' Clinical Symposium. Survey instruments were (^) available on (^) a table in the registration area. Potentially all registered athletic trainers, approximately 8,000, could have (^) participated. Participants were (^) asked to complete this survey only if they used some type of PNF exercise. As with the 1981 study, athletic trainers were selected because they either inaugurate and supervise the use of PNF techniques or administer these exercises based upon a physician's recom- mendation. The foundation of this therapeutic system is predicated upon the involvement of four neurophysiological mechanisms: re- flexes, resistance, irradiation, and successive induction. Irradi- ation is the "spread of excitation in the central nervous system which causes contraction of synergistic muscles in a specific pattern."1' Successive induction refers to contraction of an agonist muscle group followed by activation of the antagonist muscle group. A key component in PNF is the execution of movement in diagonal, spiral patterns. 12-14^ Some of the PNF techniques discussed in succeeding paragraphs are executed in the cardinal planes rather than diagonal, spiral patterns. These modifica- tions of PNF techniques will be designated as Facilitation Patterns. Diagonal patterns accompanied by resistance are intended to elicit irradiation and muscle recruitment. Detailed explanations of PNF may be found in various publica- tions. 13- Nine different PNF techniques were surveyed in this study. Seven were included in the 1981 study and were based upon the work of Kabat' 1 and Knott and Voss12: (^) repeated- contraction, (^) rhythmic-initiation, slow-reversal, slow-reversal- hold, rhythmic-stabilization, contract-relax, and hold-relax. Two additional techniques included in this study, contract- relax-contract and hold-relax-contract, were based upon the work of Hardy' and represent modifications of hold-relax and contract-relax (^) techniques. Respondents identified use of these techniques for^ the^ following joints: neck, shoulder, elbow/ wrist, fingers, back, hip, knee, and ankle.
As with the 1981 study, an open-ended question was included in the survey. Athletic trainers were asked to describe their most successful use of PNF techniques. Ninety-two (70%) individuals provided additional insights into PNF or Facilitation Patterns use through this question. The frequency and nature of the responses in this portion of the survey were similar to and seem to validate the responses of the multiple choice portion of this instrument. While frequency of use for the nine techniques is not synonymous with technique efficacy, it would seem evident that the pragmatic athletic trainer would discontinue application unless satisfactory results are obtained. The instrument consisted of 15 questions. Questions 1 through 4 dealt with academic preparation, years of practice, and scope and method of preparation in PNF. The next 7 questions dealt with the application of the nine PNF techniques to various joints and regions of the body. Following the open-ended question, all nine PNF techniques were succinctly described. The first few sentences in each succeeding para- graph are a paraphrase of the technique description.
Repeated-Contraction
This technique involves executing diagonal, spiral-patterned movements against resistance several times through a full range of motion. The athletic trainer selects the diagonal pattern that will enhance the strength or movement of a targeted muscle or muscle group. A vital element in PNF is the diagonal spiral pattern, which serves as a basis of movement for the various techniques. These diagonal patterns with a rotary component involve movements in three dimensions with sequential, and at times, simultaneous movement at several joints. Motions are initiated distally and proceed proximally. Patterns are named according to their finished position. For each direction there are two basic patterns (Fig 1). For the shoulder the motions are flexion-adduction-external rotation, also referred to as Dl, and flexion-abduction-external rotation, also referred to as D2. Reciprocal or antagonist patterns are implemented with certain PNF techniques. Extension- abduction-internal rotation and extension-adduction-internal rotation are the reciprocal shoulder patterns. One could substi- tute hip for shoulder and repeat the pattern sequences for DI and for (^) D2; the rotation motion would change from external to internal (^) rotation or vice versa for the D2 sequences.
EXTENSION r d' EXTENSION Fig 1.^ The^ PNF^ techniqu of^ repeated contraction involves execut- ing diagonal, spiral-pattemed movements against resistance sev- eral times through a full range of motion. Shown here are the two basic patterns for the shoulder and hip.
Joumal of Athletic Training 35
40
P E R C E N T 0 T 0 T A L S A M L E
30
120 .g
NECKSHOULDER ELBOW/FINGERS WRIST BACK HIP KNEE ANKLE
Fig 2. PNF^ techniques were used most frequently for injuries to the knee, shoulder, hip, ankle, elbow/wrist, and neck.
Neck and Upper Extremity Usage
Figure 3 shows the usage of the nine techniques for neck and upper extremity treatments. (^) Contract-relax, the (^) technique used most frequently with the neck, involves passive motion in one direction followed by resisted motion in the (^) antagonistic pattern. Slow-reversal^ was^ opted as^ the^ second most frequently used (^) technique. An area of (^) commonality among these proce- dures is neck motion in one (^) direction followed by movement in the opposite direction. Slow-reversal, however, initially in- volves movement (^) by the antagonistic muscle groups, and contract-relax is begun with passive motion of the agonist muscles. A finding of this study was the decline in use of rhythmic stabilization for neck conditions. The three most frequently applied techniques for shoulder rehabilitation are contract-relax, repeated-contraction, and hold-relax. Use of the latter two techniques has reversed since
- Repeated contractions are cited as rehabilitation protocol for "throwing shoulder and shoulder strains." One respondent elaborates upon the implementation of repeated contractions, and emphasizes the use of spiral pattems along with rotation, flexion/extension, and abduction/adduction.
60: NECK (^) :SHOULDER LIIELBOW/WRIST
PE (^) 40~ 3 0 _
1'
REPEAT. RHYTH. SLOW SLOW RHYTH. (^) CONT. CONT. HOLD HOLD CONT. INIT. REV. REV.H. STAB. RELAX REL.C. RELAX REL.C.
Fig 3. Contract-relax and slow reversal were the PNF techniques used most frequently for injuries to the neck, while contract-relax, repeated contraction, and hold-relax were used most often for injuries to the shoulder.
For the elbow/wrist areas, contract-relax, hold-relax, and contract-relax-contract were the three most (^) frequently used techniques. In the 1981 study repeated-contraction was the second most frequently applied technique.
Back and Lower Extremity Injuries
As with the 1981 study, contract-relax and hold-relax were the techniques of choice for the hip region. In the open-ended question these techniques are often cited as successful rehabil- itation procedures for hamstring problems. The sequencing of hold-relax followed by contract-relax was noted by several persons. As one peruses Figure 4, one sees that the hip designation could cover injuries to abductors, adductors, and the quadriceps. Technique use at the knee parallels usage at the hip. The biarticular nature of certain muscle groups would again ac- count for some of this duplication of the two most frequently selected techniques. Rhythmic-stabilization is not selected very frequently by respondents but is mentioned by several athletic trainers in the open-ended question. While the specificity of the injury was not delineated, motionless exercises have been suggested in managing chondromalacia patella. Hold-relax- contract was selected by one person to treat patella tendinitis. This technique and contract-relax-contract were being exten- sively used for hip and knee problems. Inspection of Figure 4 reveals that, as one descends the joints of the lower extremity, repeated-contraction becomes more frequently applied in rehabilitation situations. This same observation may be applied to (^) rhythmic-initiation. Several participants cited the latter^ technique as^ the^ one^ found^ to provide the most success in treating ankle (^) injuries. One athletic
trainer stated,"[For] lateral ankle sprain I like to use slow
reversal to maintain and (^) gain strength." While not for exclusive use at the (^) ankle, another trainer (^) commented, "I have had success (^) using PNF (^) patterns in (^) the swimming pool for both upper extremity and lower^ extremity muscular problems." Again, a^ more^ generic application was provided by another respondent: "The^ type I^ use^ most depends: for a very acute or
60
p E R C E N T (^0) F S A MP L E
_ BACK HIP KNEE EMU ANKLE 50
40
30 -
20
REPEAT. RHYTH.SLOW SLOW RHYTH. CONT. CONT. HOLD HOLD CONT. INIT. REV. REV.H. STAB. RELAX REL.C. RELAX REL.C. TECHNIQUE Fig 4. For injuries to the back and lower extremities, the use of repeated contraction and rhythmic initiation increased.
Journal of Athletic Training 37
painful athletic injury I will use hold-relax. For stretching I use contract-relax or slow-reversal and for re-education I^ use repeated-contraction."
DISCUSSION A comparison of PNF use for various joints of the body revealed similar trends between this study and the 1981 publication. In both studies knee, hip, and shoulder joints were the most frequently treated with PNF techniques. The most radical departure in usage between the two studies is the ankle, which in our study replaces the neck among the top four joints. In the 1981 study, rhythmic stabilization was implemented more extensively than slow-reversal and con- tract-relax. Rhythmic stabilization has been recommended as a mobilizing technique,'7'18 and as a means to gain relaxation, increase strength,'5 and enhance circulation.'2 An athletic trainer notes, for throwing injuries, the use of repeated con- tractions with flexion/extension, abduction/adduction, and ro- tation incorporated into spiral patterns. A study by Blakely and Palmer'9 found with flexion, adduction, and external rotation pattern of the shoulder, lateral or external rotation occurred during the first phase of this pattern and medial rotation was evident during the last phase of this spiral pattern. This finding should be considered when selecting patterns for^ shoulder rehabilitation. Contract-relax, hold-relax, and contract-relax-contract were the three most frequently used techniques for the elbow/wrist areas. The second most frequently applied technique in the 1981 study was repeated-contraction. Contract-relax-contract technique was^ not^ included^ in that^ survey. While^ repeated- contraction and this (^) technique are both isotonic in nature, contract-relax-contract involves motion of both (^) antagonistic and (^) agonistic muscle (^) groups. This (^) reciprocity of motion (^) may enhance the rehabilitation process for these joints, because successive induction is a basic tenet of PNF. For lower extremity rehabilitation, two techniques (contract- relax-contract and hold-relax-contract) are being applied more frequently than four of the original techniques." While these two techniques were not included in the 1981 instrument, the open-ended part of the 1981 survey did not elicit responses about utilizing these techniques. In a relatively short period of time these techniques are becoming standard protocols for certain treatment situations. In (^) 1981, PNF exercises were (^) being used as (^) warm-up procedures. While this may continue to be the case, no one mentioned this usage in the present survey. A role for PNF in the re-education phase of rehabilitation was identified by certain athletic trainers. There is documen- tation that with (^) certain types of athletic injuries proprioception and kinesthesis are adversely affected. A loss of kinesthetic sense after glenohumeral dislocations is identified in a study, and the use of PNF exercises to remediate this deficit is recommended.20 Two researchers emphasize the need to de- velop proprioception, kinesthesia, and neuromuscular control for shoulder complex rehabilitation.2' They suggest a type of plyometric training utilizing D2 movements. Additional clini- cal and (^) laboratory investigations are needed to ascertain how
the standard PNF techniques and elements of the therapeutic approach devised by these investigators may be used to enhance kinesthesia and neuromuscular control. In like manner, additional investigations are needed to determine the optimal duration of isometrics contraction (hold) incorporated into PNF techniques. At the present time there is not a clear trend regarding this issue. Hardy's' work indicates 6 seconds as an effective duration, but Nelson and Cornelius found no significant differences among 3-, 6-, or 10-second isometric contractions. Two issues must be addressed when comparing these studies. First, different PNF techniques were used in these studies. Duration of the isometric contraction may be related to the type of PNF technique. Second, while Hardy found 6 seconds to be statistically significant, Nelson and Cornelius did not find any significant differences. One must be cautious about trying to prove a point by retaining the null hypothesis. In the present survey, no input was received about optimal duration of isometric contraction associated with the hold aspect of a technique. Four of the surveyed techniques did involve an isometric contraction in^ some^ aspect of^ the technique. Respondents in certain^ cases^ did^ designate a^ type of athlete for whom^ a^ PNF^ technique was^ most^ effective.^ Repeated- contraction was cited as (^) being effective for the (^) throwing type of shoulder. Work done (^) by a (^) group of researchers8 indicates that different (^) types of athletes (^) (in their (^) study endurance athletes and (^) high-intensity athletes like (^) volleyball players and (^) sprinters) respond differently to contract-relax and a technique called agonist contract-relax. The possible interaction between a specific PNF technique and a certain type of athlete is a situation that the athletic trainer in the field should be cogni- zant of and is a possible line of inquiry for the researcher.
CONCLUSION
Proprioceptive neuromuscular facilitation^ techniques incor- porate movement in the three^ planes of the^ body. With the current emphasis on^ multi-planar exercises in^ treating athletic injuries, PNF procedures provide an effective means for delivering this^ type of^ approach. Specific techniques for treating various injuries and areas of the body are provided in this (^) study by athletic trainers who have (^) successfully applied them to injured persons. Rehabilitation of injuries has transcended strictly strength and range-of-motion development. While increments in these areas are important, neurological and neuromuscular enhancement are vital in contemporary rehabilitation protocols. Proprioceptive and kinesthetic deficits do accompany many types of injury. Data from this (^) study indicate that (^) athletic trainers are using PNF techniques in the re-education phase of injury treatnent.
REFERENCES
- Hardy L. Improving active range of hip flexion. Res Q Exerc Sport. 1985;56:1 11-
- Markos PD. Ipsilateral and contralateral effects of propnrioceptive neuro- muscular facilitation (^) techniques on (^) hip motion (^) and electromyographic activity. Phys Ther. 1979;59:1366-1373.
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