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the Hold-Relax with Agonist Contraction has gained popularity. Research indicates that sub-
maximal contractions that are progressive in intensity over the course of a rehab program increase
flexibility.9 For the best results, clinicians should use PNF stretching early in the rehabilitation
program and gradually increase the intensity of the contractions throughout the rehab process.
While clinicians know the difference between the three techniques, they often intermix
terminology. For example, many clinicians and authors refer to Hold-Relax stretching as Contract-
Relax stretching. Some even incorporate a concentric contraction of the tight muscle against
minimal resistance before applying a second stretch.
This procedure, however, is incorrect and doesn't allow for maximum gains in flexibility; any firing
of the GTO is negated by the time the person moves the extremity back to the starting point of the
concentric contraction.
Strengthening Techniques
Along with stretching, PNF strengthens the body through diagonal patterns, often referred to as D1
and D2 patterns. It also applies sensory cues, specifically proprioceptive, cutaneous, visual and
auditory feedback, to improve muscular response. 1 The diagonal movements associated with PNF
involve multiple joints through various planes of motion. These patterns incorporate rotational
movements of the extremities, but also require core stability if patients are to successfully
complete the motions.
Two pairs of diagonal patterns exist. 10 These patterns can be performed in flexion or extension
and are often referred to as D1 flexion, D1 extension, D2 flexion or D2 extension techniques for
the upper or lower extremity. 1 Although patients can perform these patterns with many forms of
resistance, the interaction between patient and clinician is key to the early success of PNF
strengthening. 1
This interaction requires manual resistance throughout the range of motion through carefully
positioned hand placement and appropriately choreographed resistance. By placing the hands
over the agonist muscles, the clinician applies resistance to the appropriate muscle group, while
guiding the patient through the proper range of movement. 1
In using manual resistance, the clinician can make minor adjustments as the patient's coordination
improves or fatigue occurs during the rehab session. In general, the amount of resistance applied
is the maximum amount that allows for smooth, controlled, pain-free movement throughout the
range of motion. 10 In addition to manual resistance strengthening, PNF diagonal patterns enhance
proper sequencing of muscular contraction, from distal to proximal. This promotes neuromuscular
control and coordination.1
To enhance coordination, movement and stability, clinicians use numerous techniques during PNF
exercises, among them:
Rhythmic stabilization. This technique, which incorporates passive movement of the joint
through the desired range of motion, is a teaching tool to re-educate the neuromuscular system to
initiate the desired movement. The technique begins with the clinician passively moving the
extremity through the desired movement pattern at the desired speed several times. It then
progresses to promote active assistive or active movement, with resistance, through the same
pattern to help the patient improve coordination and control.
Slow reversal. This technique involves a dynamic concentric contraction of the stronger agonist
muscle group. A second dynamic concentric contraction immediately follows, this time involving
the weaker antagonist muscle group. 1 Rest periods don't occur between contractions. Therefore,
this technique promotes the rapid, reciprocal activities the agonist and antagonist muscle groups
need for many functional activities.
Slow reversal hold. This technique adds an isometric contraction (hold) at the end-range of each
muscle group. It's especially beneficial in enhancing dynamic stability of the larger proximal muscle
groups.
Alternating isometrics. This technique encourages stability of postural trunk muscles and
stabilizers of the hip and shoulder girdle. With alternating isometrics, the patient "holds" his
position, while manual resistance is alternately applied in a single plane from one side of the body
to the other. No motion should occur.
Instead, the patient should maintain the starting position of the involved limb. This technique can
strengthen the trunk, a single extremity or bilateral extremities, and can be applied with the limbs
in the open- or closed-kinetic chain.
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