Tuesday, October 24, 2006 PNF in the Pool   by Terri Mitchell  PNF in the Pool By Terri Mitchell Proprioceptive Neuromuscular Facilitation.  Wow.  What a mouthful!  Try to again.  Pro-prio-ceptive. Neuro. Muscular. Facilitation. Now you know why it is simply called PNF!  But what is PNF?  And, how is it done in the pool?  Let’s start with some basic definitions, learn about some of the benefits, understand the PNF diagonal patterns and discover how to implement PNF in our aquatic fitness classes or with individual clients. Definitions: Proprioceptive: receiving stimulation within the tissues of the body.  Proprioceptors are nerve terminals, which give information concerning movements and position of the body.  They occur chiefly in the muscles, tendons and the labyrinth (inner ear).  Neuromuscular: nerves and muscles.  Facilitation:  1) promotion of any natural process; 2) effect produced in nerve tissue by the passage of an impulse.  In other words, PNF is a method of promoting or hastening the response of the nerves and muscles through stimulation of the nerve terminals. Think about your everyday life and the spiral and diagonal components of your movements. When you get out of bed, do you take the covers from your chin and fling them open as you get up?  What about brushing your hair, or putting your wallet in your back pocket?  How about putting on your seat belt or playing tennis or golf? Or even waving to your friend in a crowd? All of these suggestions include moving the arms or legs in a spiral and diagonal pattern. Benefits of PNF: PNF techniques are primarily used in the therapeutic setting with patients who need neuromuscular retraining and increased flexibility, strength and endurance.  The patient may exhibit deficiencies in coordination, strength and joint mobility. Some patients may have muscle spasms or spasticity. These challenges may have occurred due to a stroke, surgery or other trauma.  PNF patterns can improve these decreased functions, as well as improve balance, posture and kinesthetic awareness.  These same benefits apply to participants of all ages and abilities in aquatic fitness classes. The philosophy of using PNF patterns involves: •    Improving coordination •    Using repetition in the re-learning process and development of endurance, •    Moving very specifically and directed toward a goal •    Using the weaker body parts to promote a balance of muscles motion and reflex activity PNF is characterized by mass movement patterns that are spiral and diagonal. These movement patterns, which were developed through research performed by Herman Kabat, M.D., Ph.D., allow the strongest contraction of the contributing muscle component. PNF Patterns The PNF patterns are named according to the component of movement in the joint nearest the trunk and the end position of the pattern. They are named D1 and D2.  There is a D1 pattern for the arms (upper extremities) and legs (lower extremities).  There is a D2 pattern for the arms and legs, as well.  Each pattern has a major component of internal or external rotation, flexion or extension, abduction or adduction. Let’s begin with the D1 upper extremity pattern. Internally rotate the right shoulder, abduct and extend the right shoulder slightly behind the body, hand opened wide.  Now, externally rotate the right shoulder while adducting and flexing it across midline, making a fist to come to the left ear.  This is D1 flexion. Reverse the pattern.  This is D1 extension.  Repeat several times, always initiating the movement with the rotational component.  Practice with the left arm.  Do you notice the diagonal pattern?  Practice again, this time allowing the eyes to follow the hand in each direction, which cause cervical rotation with flexion or extension, depending on the pattern. Now, let’s try the D2 upper extremity pattern. Internally rotate the right shoulder.  Adduct and extend the right shoulder with the hand in a hitchhike fist. Touch the right thumb just above the left hip.  Now, externally rotate the right shoulder to the upper right side of the body, opening the hand while abducting the right shoulder. This is the D2 flexion pattern.  (Think of both arms up in the air in a V and say, “tah dah”). Reverse the pattern. This is D2 extension. Repeat several times, always initiating the movement with the rotational component.  Practice with the left arm.  Practice again, this time allowing the eyes to follow the hand in each direction. These patterns can be done bilateral symmetrical, which means that each arm is doing the extension pattern and then the flexion pattern at the same time.  Doing the patterns bilateral reciprocal means that one arm is doing the flexion pattern while the other arm is doing the extension pattern. Ready for the lower extremity patterns?  Let’s stand and begin with D1.  Internally rotate the right hip, abduct and extend it slightly behind the body.  The foot is in plantarflexion with the sole of the foot everted (turned outward). Now, externally rotate the hip, while adducting and flexing it up and across your body, (like you were kicking a hacky sack). The ankle dorsiflexes and the sole of the foot inverts.  This is the D1 flexion pattern.  Reverse the pattern.  This is D1extension.  Repeat several times, always initiating the movement with the rotational component and keeping the diagonal pattern.  Practice with the left leg.  Practice again, this time allowing the eyes to follow the foot in each direction. Now, let’s try the D2 lower extremity pattern.  Externally rotate the right hip, adduct across midline and extend it behind the body.  The foot is in plantarflexion and the sole is inverted; just as if you were to curtsy. Now, internally rotate the right hip, abduct and flex it to the upper right side of the body.  The foot is dorsiflexed and is everted.  This is D2 flexion. Reverse.  This is D2 extension. Repeat several times, always initiating the movement with the rotational component and keeping the diagonal pattern.  Practice with the left leg.  Next, let the eyes follow the foot in each direction, allowing for cervical rotation with flexion or extension, depending on the pattern. The goal is to perform each pattern with coordination though a full range of motion and with a balance of power between the antagonistic patterns of both diagonals of movement. The patterns can be done with a focus on trunk stabilization OR utilizing big movement to incorporate great trunk mobility.  Try it both ways. PNF patterns were developed and performed in a dry-land environment.  The patterns described above are for performance in the standing position on land or in the pool.  In the water, however, PNF patterns can be applied and performed in ways that are not always possible on dry land.  In the pool, for example, PNF patterns can be done in various body positions such as standing, supine, sitting, prone with a mask and snorkel, or kneeling on a bench or ramp.  Other advantages of PNF in the pool include: •    Buoyancy of water – to assist, resist or support the motion or the limb •    Viscosity of water – to increase resistance through the motion •    Surface tension – from the resistance of the water to the lesser resistance of air – this is generally OK for participants without shoulder impairments •    Body positions – the 3 dimensional affect of water allows more variety. •    The use of the principles of inertia, action/reaction, acceleration, surface area, lever length to increase or decrease intensity. The basic PNF D1 and D2 patterns can be done while standing along the side of the pool, holding onto the edge for balance and then progressing to a freestanding position to work on dynamic balance and coordination.  Try the same exercises while seated sideways on a noodle or in the deep water with a flotation belt. Once these patterns are mastered, progression for increased intensity includes: •    Using more force and power through the full range of motion •    Adding a prop such as a glove, paddle or fin for increased surface area resistance through the full range of motion. •    Adding a prop such as a handbar or ball for increased buoyancy resistance or buoyancy assistance though the full range of motion. Samples of water aerobics that incorporate some PNF patterns include, but are not limited to: •    Jumping jacks with D1 upper extremities.  Add the internal and external hip rotation component to the jumping jack, as well •    Cross country ski with D2 upper extremities (tah dah!).  Keep the arms under the surface of the water to prevent a ballistic affect on the shoulders. •    Touch opposite hand to foot (hacky sack legs) •    Speed skate with bilateral reciprocal D1 upper extremities. Let’s not get complicated with the terminology.  Just understand the different patterns and be creative in incorporating more rotational and diagonal components in each move.  With the eyes following the hands, water exercise participants may soon notice increased range of motion from their neck down to their pelvis. Some absolutes! •    No pain, no gain is no sense! •    Persons with total hip replacements (THR) should NOT perform the D1 nor D2 lower extremity patterns. THR precautions include not crossing midline, not flexing the hip more than 90 degrees and not internally rotating the hip. •    Use the Principle of Progressive Overload regarding # of repetitions and props used. •    Stop the pattern with fatigue to prevent poor performance •    Emphasize proper posture •    Provide reminders to breathe! •    Have fun! References: Rice, J., 1986. Medical Terminology with Human Anatomy. Appleton-Centruy-Crofts. Norwalk. Jamison, L. and Odgen., D., 1994. Aquatic Therapy Using PNF Patterns. Therapy Skill Builders. Tuscon. Voss, D.E., Ionta, M., and Myers, B. 1985. Proprioceptive Neuromuscular Facilitation (PNF) Patterns and Techniques. Harper and Rowe. Philadelphia. Mitchell, T, Ogden, D. 2002. Applications of PNF Patterns in the Aquatic Setting. Aquatic Ms. Fit. Austin. Terri Mitchell is a Training Specialist for AEA and a Physical Therapist Assistant in Austin, Texas where she works and plays in fitness and therapy pools year round. She presents continuing education workshops globally.  She is the co-author with David Ogden, PT on a PNF manual and co-producer with Julia Meno Fettig, CTRS on a PNF DVD. Terri uses PNF daily with clients and in classes. She can be contacted at texterri@austin.rr.com Close