PNF Masterclass: Principles, Techniques & Practice MCQs

Proprioceptive Neuromuscular Facilitation (PNF)

💡 Definition: PNF is a method of promoting or hastening the response of the neuromuscular mechanism through stimulation of the Proprioceptors. Developed by Kabat, Knott, and Voss.

1. Neurophysiological Principles (Sherrington's Laws)

PNF is based on the physiology of the nervous system.

• After Discharge: The effect of a stimulus continues after the stimulus stops. (Feeling of increased strength after a contraction).
• Temporal Summation: Weak stimuli occurring repeatedly within a short time combine to cause excitation.
• Spatial Summation: Weak stimuli occurring simultaneously from different areas combine to cause excitation.
• Irradiation (Overflow): The spread of response from strong muscles to weaker neighboring muscles.
• Successive Induction: Maximum contraction of the agonist is followed immediately by maximum excitation of the antagonist.
• Reciprocal Inhibition: Contraction of the agonist causes reflexive relaxation of the antagonist.

2. Basic Procedures for Facilitation (The 10 Elements)

These elements must be present for a technique to be "PNF".

1. Manual Contact: Using the Lumbrical Grip to stimulate skin receptors and guide motion.
2. Body Position/Mechanics: Therapist moves in the diagonal line of movement.
3. Appropriate Resistance: Optimal resistance (not maximal) to recruit motor units without stopping movement.
4. Traction & Approximation:
   • Traction: Elongation of trunk/limb (Facilitates Flexion/Mobility).
   • Approximation: Compression of joint (Facilitates Extension/Stability).
5. Quick Stretch: Activates the muscle spindle (Stretch Reflex) to initiate contraction.
6. Verbal Command: "Push," "Pull," "Hold." Sharp for activity, soft for relaxation.
7. Visual Stimulus: Patient watches the movement for feedback.
8. Patterns: Spiral and Diagonal movements (Mass movement patterns).
9. Timing: Normal timing is Distal to Proximal.
10. Reinforcement: Using stronger muscles to help weaker ones (Irradiation).

3. PNF Patterns (Spiral & Diagonal)

Functional movements are spiral and diagonal, not linear.

• D1 Flexion (UE): "Eating an apple" (Flexion-Adduction-External Rotation).
• D1 Extension (UE): "Throwing apple away" (Extension-Abduction-Internal Rotation).
• D2 Flexion (UE): "Drawing a sword" (Flexion-Abduction-External Rotation).
• D2 Extension (UE): "Sheathing a sword" (Extension-Adduction-Internal Rotation).

4. PNF Techniques (Detailed Introduction)

Techniques are specific methods used to treat dysfunction (e.g., weakness, stiffness, spasticity).

A. Rhythmic Initiation (RI)

• Goal: To initiate motion, teach the movement, promote relaxation.
• Indication: Parkinson's (Rigidity), Hypertonicity, inability to relax.
• Description: Progression from Passive → Active Assisted → Active Resisted movement. It is rhythmic and soothing.
• Point to Remember: Best starting technique for hypertonic patients.

B. Repeated Contractions (RC)

• Goal: To increase strength and endurance in weak muscles.
• Indication: Muscle weakness (Grade 2/3), fatigue.
• Description: Patient moves isotonically. At the point of weakness, the therapist applies a Quick Stretch followed by resistance. Can be repeated multiple times in one range.

C. Reversal of Antagonists

Slow Reversal (SR) vs. Slow Reversal Hold (SRH)
SR: Isotonic contraction of Agonist followed immediately by Isotonic contraction of Antagonist.
SRH: Same as SR, but with an Isometric Hold at the end of each range. (Increases stability).

D. Rhythmic Stabilization (RS)

• Goal: To increase stability and static muscle control.
• Indication: Joint instability, pain, weakness.
• Description: Patient holds a position (Isometric). Therapist applies manual resistance in opposing directions (rotary force) without allowing movement. "Don't let me twist you."
• Contraindication: Cerebellar Ataxia (sometimes too difficult), Fractures.

E. Relaxation Techniques (Stretching)

1. Hold Relax (HR)

• Goal: Increase Passive ROM (especially if pain is present).
• Mechanism: Autogenic Inhibition (GTO activation).
• Description: 1. Move to point of limitation. 2. Isometric contraction of the tight muscle (Antagonist) against resistance (No movement). 3. Relax. 4. Passively move into new range.

2. Contract Relax (CR)

• Goal: Increase Passive ROM (when no pain).
• Mechanism: Autogenic Inhibition.
• Description: Similar to Hold Relax, but allows Rotational movement (Isotonic) while holding the other components isometric.

3. Agonist Contraction (Slow Reversal Hold Relax)

• Mechanism: Reciprocal Inhibition.
• Description: Patient actively contracts the muscle opposite to the tight muscle to pull themselves into the new range.

5. Summary: Techniques & Goals

Technique	Primary Goal
Rhythmic Initiation	Initiation, Relaxation (Parkinson's)
Repeated Contractions	Strength, Endurance
Rhythmic Stabilization	Stability, Balance
Hold Relax	Increase ROM (Autogenic Inhibition)
Agonist Contraction	Increase ROM (Reciprocal Inhibition)
Slow Reversal	Coordination, Active Motion

⚠️ General Contraindications for PNF

• Unstable fractures.
• Acute inflammation/pain (Resistance may worsen it).
• Osteoporosis (Avoid vigorous stretching/resistance).
• Recent surgery where resisted motion is prohibited.

📝 20 High-Yield MCQs

Test your knowledge for AIIMS/JIPMER.

Q1. Which neurophysiological principle states that "Contraction of the agonist causes reflex relaxation of the antagonist"?

A. Successive Induction B. Reciprocal Inhibition C. Temporal Summation D. Irradiation

Rationale: Reciprocal Inhibition (Sherrington's Law) ensures that when a prime mover contracts, the opposing muscle relaxes to allow smooth movement.

Q2. The "Lumbrical Grip" is used in PNF Manual Contact to:

A. Avoid squeezing/painful pressure on muscles B. Apply maximum force C. Stimulate bone growth D. Block blood flow

Rationale: The lumbrical grip uses the pads of the fingers and palm, avoiding the fingertips which can dig in and confuse the patient's sensory input.

Q3. Rhythmic Initiation is the technique of choice for:

A. Flaccidity B. Parkinson's Disease (Rigidity) C. Ataxia D. Fracture

Rationale: RI progresses from passive to active motion, helping patients with rigidity or hypertonia "learn" the movement and relax.

Q4. Traction (elongation) is primarily used to facilitate:

A. Flexion / Mobility B. Extension / Stability C. Weight bearing D. Co-contraction

Rationale: Traction stimulates joint receptors to facilitate movement (usually flexion). Approximation (compression) facilitates stability (usually extension).

Q5. "Hold Relax" technique utilizes which physiological mechanism?

A. Reciprocal Inhibition B. Autogenic Inhibition C. Temporal Summation D. Irradiation

Rationale: Isometric contraction of a tight muscle activates the Golgi Tendon Organs (GTOs), causing reflex relaxation of that same muscle (Autogenic Inhibition).

Q6. Which PNF pattern mimics "Combing hair" on the right side with the right hand?

A. D1 Flexion B. D2 Flexion C. D1 Extension D. D2 Extension

Rationale: D2 Flexion involves Shoulder Flexion, Abduction, and External Rotation (The "Sword Draw" or combing hair motion).

Q7. "Normal Timing" in PNF refers to movement occurring from:

A. Proximal to Distal B. Distal to Proximal C. Randomly D. Mid-range outwards

Rationale: In coordinated movement (and PNF), functional patterns naturally initiate distally (hands/feet) and progress proximally. (Except for postural stabilization).

Q8. Rhythmic Stabilization involves:

A. Isometric contractions of agonists and antagonists (Co-contraction) B. Isotonic contractions C. Passive stretching D. Rapid ballistic movement

Rationale: RS uses alternating isometric resistance to opposing muscle groups to build stability without joint movement.

Q9. "Irradiation" in PNF is also known as:

A. Radiation therapy B. Overflow / Reinforcement C. Fatigue D. Relaxation

Rationale: Irradiation is the spread of energy from stronger muscles to recruit and strengthen weaker muscles within a pattern (Overflow).

Q10. What triggers the "Stretch Reflex" used in PNF (Quick Stretch)?

A. Muscle Spindle B. Golgi Tendon Organ C. Pacinian Corpuscle D. Ruffini Endings

Rationale: A quick elongation of the muscle stimulates the Muscle Spindle (Ia fibers), causing a reflex contraction of that muscle.

Q11. Which technique is best for increasing ROM when pain is NOT a limiting factor?

A. Rhythmic Initiation B. Contract Relax C. Rhythmic Stabilization D. Slow Reversal

Rationale: Contract Relax uses active isotonic rotation (concentric) against resistance, which is more vigorous than Hold Relax and better for chronic stiffness without pain.

Q12. Approximation is contraindicated in:

A. Ataxia B. Inflamed/Painful Joints C. Chronic weakness D. Spasticity

Rationale: Approximation involves compressing joint surfaces. This will aggravate pain and damage tissue in an inflamed joint.

Q13. Successive Induction explains why:

A. Contracting the antagonist facilitates the agonist B. Contracting the agonist relaxes the antagonist C. Weak stimuli summate D. Reflexes fatigue

Rationale: Maximum contraction of the antagonist leaves a "facilitatory trace" (after-discharge) that makes the subsequent contraction of the agonist stronger. This is the basis of "Reversal" techniques.

Q14. Visual cues in PNF help primarily with:

A. Muscle hypertrophy B. Motor control and coordination C. Increasing resistance D. Reducing pain

Rationale: Eye-hand coordination is crucial. Asking the patient to "Look at your hand" provides feedback on position and movement direction.

Q15. Which UE pattern involves "Extension, Abduction, Internal Rotation"?

A. D1 Extension B. D2 Extension C. D1 Flexion D. D2 Flexion

Rationale: This is the "Throwing the apple away" pattern (D1 Extension). Note: D2 Extension involves Adduction.

Q16. "Repeated Contractions" is used to treat:

A. Rigidity B. Weakness at a specific point in the range C. Spasticity D. Pain

Rationale: If a patient is weak at a specific angle, the therapist applies a quick stretch and resistance repeatedly at that angle to build strength.

Q17. Which component is emphasized in PNF patterns because it is the first to happen?

A. Flexion/Extension B. Rotation C. Abduction/Adduction D. Elbow movement

Rationale: Rotation is the key to PNF. Movements spiral. The rotary component starts first (distally) to unlock the motion.

Q18. "Agonistic Reversals" involves:

A. Concentric contraction followed by Eccentric contraction of the same muscle group B. Isometric holding only C. Passive movement D. Switching between D1 and D2

Rationale: Also called "Combination of Isotonics." The patient pushes against resistance (Concentric) and then slowly resists the return movement (Eccentric) using the same muscle. Used for motor control.

Q19. Which command is appropriate for a "Hold" (Isometric) contraction?

A. "Push!" B. "Pull!" C. "Stay there, don't let me move you" D. "Relax"

Rationale: "Stay there" implies keeping the position static against resistance. "Push/Pull" implies movement (Isotonic).

Q20. The optimal position for the therapist during PNF is:

A. In the "Diagonal Line" of the movement B. Perpendicular to the patient C. Sitting down D. Behind the patient's head always

Rationale: The therapist must align their shoulders and hips with the diagonal pattern to apply resistance effectively using body weight, not just arm strength.