|Year : 2022 | Volume
| Issue : 1 | Page : 23-28
Proprioceptive neuromuscular facilitation exercises versus lumbar stabilization exercises for chronic low back pain patients: A randomized interventional study
Sunita Koutarapu1, Dipti Ghumare2
1 OT School and Centre, T.N.M.C. and BYL Nair Ch. Hospital, Worli, Mumbai, Maharashtra, India
2 National Sports Club of India (NSCI) RFH Jumbo Covid Facility, Worli, Mumbai, Maharashtra, India
|Date of Submission||30-Jan-2021|
|Date of Decision||18-May-2021|
|Date of Acceptance||02-Mar-2022|
|Date of Web Publication||25-Mar-2022|
17, Premsagar, 69, Sion (East), Mumbai - 400 022, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Chronic low back pain causes discomfort and disturbance in the mechanoreceptor and proprioception centers. Exercises improve muscle strength, flexibility, endurance, and ability to perform life activities. Proprioceptive neuromuscular facilitation (PNF) involves stretching, resisted movements which improves muscle disharmony, atrophy, and joint movement limitation. Lumbar stabilization exercises (LSE) develop the awareness of muscle contraction and control from simple to complex patterns. Both exercises are effective individually in chronic low back pain patients. This study was conducted to find out which technique is better. Objectives: The objective of the study is to determine the efficacy of PNF versus LSE program in chronic low back pain patients. Study Design: A Randomized study was conducted. Methods: A prospective, interventional study was conducted on patients with mechanical low back pain of more than 3 months, in both males and females, of age 20–45 years. Patients having systemic illness, central or peripheral neurologic signs, and specific causes of low back pain were excluded. Individuals having systemic illness and psychiatric illness were also excluded from the study. Twenty-two patients were selected and divided into two groups. Patients were assessed on the Visual Analog Scale (VAS), modified Schober's test, Modified Oswestry Low Back Pain Disability Questionnaire (ODI), Roland and Morris Low Back Pain and Disability Questionnaire (RMDQ). Patients in the PNF Group received concentric and eccentric contractions of agonist and antagonist muscles, patterns such as chopping, lifting, bilateral leg, and trunk lateral flexion. LSE Group received core strengthening exercises. Both group received 3 treatment sessions per week for 4 weeks, each session lasting for 45 min. Results: PNF group showed significant improvement in pain on VAS (P = 0.003; 95% confidence interval [CI[, 2.15–3.01), in disability on ODI (P = 0.001, 95% CI, 12.09–20.1), and in lumbar flexibility Modified Schober's test (P = 0.000, 95% CI, 5.15–5.93) On RMDQ, there was no statistically significant difference between PNF and LSE groups (P = 0.061, 95% CI, 6.87–8.97). Conclusion: There was a significant improvement seen in the pain and disability which was assessed on VAS and ODI in the PNF group over LSE. Hence, PNF exercises can be incorporated with LSE in the treatment of LBP.
Keywords: Chronic Back Pain, Disability, Lumbar Stabilization Exercises, Proprioceptive Neuromuscular Facilitation Exercises, Roland and Morris Disability Questionnaire
|How to cite this article:|
Koutarapu S, Ghumare D. Proprioceptive neuromuscular facilitation exercises versus lumbar stabilization exercises for chronic low back pain patients: A randomized interventional study. Indian J Occup Ther 2022;54:23-8
|How to cite this URL:|
Koutarapu S, Ghumare D. Proprioceptive neuromuscular facilitation exercises versus lumbar stabilization exercises for chronic low back pain patients: A randomized interventional study. Indian J Occup Ther [serial online] 2022 [cited 2022 Jul 4];54:23-8. Available from: http://www.ijotonweb.org/text.asp?2022/54/1/23/340893
| Introduction|| |
Low back pain is extremely common condition affecting up to 85% of population. It is defined as pain and discomfort located below the costal margin and above the inferior gluteal fold with or without referred leg pain. Chronic low back pain is defined as pain that persists beyond the normal time of healing. It is a complex and multifactorial condition with pain and disability linked to physical, neurophysiological, psychological, and social factors. The muscles which are related to the stability of the trunk are weakened and this causes pain and functional limitations.
Physical exercise improves muscle strength, flexibility, and endurance, to restore the injured tissues and help the patient to perform normal life activities. There are various treatment patterns available. Neurophysiologic studies have linked pain development in the lumbar spine region with disturbances in mechanoreceptors and probably with impairment of superior proprioception centers.,, Therefore, exercise program that enhances proprioception may be beneficial.
Proprioceptive neuromuscular facilitation (PNF) involves stretching, resisted movements, traction and approximation to ameliorate muscle decline, disharmony, atrophy, and joint movement limitation. When PNF exercises are performed correctly, sloppy postures and habits that put chronic strain on the muscle causing muscle soreness, stress and eventually leading to injury, are corrected and pain and spasm decrease greatly.
“Proximal stability for distal mobility” is an underlying principle of therapeutic exercise. The primary function of the trunk muscles is to provide stabilizing force so upright posture can be maintained. Studies by Franklin. and Lee et al., have demonstrated altered or delayed neuromuscular recruitment patterns in deep stabilizing muscles of the lumbar spine during the active movement in the individual with low back pain. Stabilization training follows the basic principle of learning motor control first by developing awareness of muscle contraction and spinal position and then by developing control in simple patterns and progress to complex.
PNF and lumbar stabilization exercises (LSE) were found to be individually effective. Both exercises are effective individually in chronic low back pain patients. This study was conducted to find out which technique is better. The objective of the study was to determine the effect of PNF and LSE exercise program and compare their efficacy on pain, disability, flexibility in chronic low back pain patients.
| Methods|| |
A prospective, comparative, randomized interventional study was conducted on patients with mechanical low back pain of more than 3 months, in both males and females of age 20–45 years. Patients were randomized (by lottery method) into two groups, i.e., PNF Group and LSE Group. Patients having the systemic illness, central or peripheral neurologic signs and specific causes of low back pain such as disc herniation, lumbar stenosis, spinal deformity, fractures, and spondylolisthesis were excluded. Patients having systemic illness (tumor and rheumatologic disease) and psychiatric illness were also excluded from the study. The study protocol was approved on March 2018 by the ethics committee for the academic research project, T. N. Medical College and B. Y. L Nair Ch. Hospital, Mumbai. Patients were invited for participation and their consent was taken after explaining to them the purpose of the study, the risk factor involved, and assurance that confidentiality will be maintained. Case record form and demographic data of those subjects who fit the inclusion criteria were collected and allotted in PNF and LSE groups.
Proprioceptive Neuromuscular Facilitation Group
Forward and backward rocking without relaxation. Resisted active concentric and eccentric contraction of the trunk for 5 sec, chopping, lifting, bilateral leg patterns, and trunk lateral flexion patterns were prescribed.,
Lumbar Stabilization Exercises Group
Ankle pump, static quadriceps exercises, straight leg raise, static abdominal exercises, static glutei, trunk rotation, abdominal curl up, static back exercise, bridging, Thomas stretches, bridging with alternate knee extension, cat and camel exercise, etc. were prescribed.
Patients were assessed on the visual analog scale (VAS) for pain, modified Schober's test for spine range of motion, Modified Oswestry LBP disability questionnaire Oswestry Low Back Pain Disability Questionnaire (ODI), and Roland and Morris Low Back Pain and Disability Questionnaire (RMDQ) for disability. Both the groups received 3 exercise sessions per week, for 4 weeks, each session lasting for 45 min. When patients were able to perform exercises of the current level without discomfort, then patients progressed to the next level.
The data were entered using MS-Excel 2016 and data was analyzed using SPSS version 23 developed by International Business Machines (IBM) headquartered in Armonk, New York, USA. Following statistical tests were used for statistical analysis: Wilcoxon signed-rank test was used to compare the pre-and post-score within the groups. Friedman test was used to find differences in repeated measures within the groups. Mann–Whitney U-test was used to compare scores between the two groups. The level of significance was set at P < 0.05 and a 95% confidence interval (95% confidence interval [CI]) was computed.
| Results|| |
This is prospective, comparative, randomized interventional study involved 22 patients with chronic low back pain fulfilling the selection criteria. One group was given PNF exercises and the other group was given the LSE program. The decreased pain scores of after 4 week intervention period were statistically significant when compared with the baseline scores in both groups [Table 1]. In both the groups, there was a significant difference in scores from day 1 to the end of week 2 and the end of week 4. Comparison of pain scores between the groups was not significant at the baseline and at week 2, but the decreased pain score was statistically significant between the groups at week 4 [Table 2].
|Table 1: Representation Visual Analog Scale Score of Proprioceptive Neuromuscular Facilitation and Lumbar Stabilization Exercises Groups Over 4 Weeks|
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Within-group differences of mean range of lumbar flexion and extension were statistically significant over the time [Table 3] and [Table 4].
|Table 3: Comparison of Mean and Standard Deviation Scores of Lumbar Flexion From Day 1 to End of Week 2 and 4|
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|Table 4: Comparison of Mean and Standard Deviation of Extension from Day 1 to End of Week 2 and 4|
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[Table 5] is a comparison of differences of ODI, RMDQ scores from Day 1 to the end of weeks 2 and 4 in both the groups. There was a significant improvement seen in ODI and in RMDQ in both groups. [Table 6] shows the comparison of ODI scores and RMDQ scores between PNF and LSE groups. Comparison of ODI Scores between both groups shows statistical significance at the end of week 4. Comparison of RMDQ scores shows statistical Insignificance at the end of week 4.
|Table 5: Comparison of Differences of Oswestry Disability Index, Rolland and Morris Disability Questionnaire Scores from Day 1 to End of Week 2 and 4 in Both the Groups|
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|Table 6: Comparison of Oswestry Disability Index Scores and Rolland and Morris Disability Questionnaire Scores Between Proprioceptive Neuromuscular Facilitation and Lumbar Stabilization Exercises Groups|
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There was a significant improvement seen in the pain and disability which was assessed on VAS and ODI in the PNF group over LSE.
| Discussion|| |
In this study, we have investigated the efficacy of PNF exercise and LSE program in chronic low back pain patients. Various assessment parameters such as VAS, modified Schober's test, ODI and RMDQ were used.
Pain was assessed by using VAS. There was a significant reduction in the mean value of pain over 4 weeks in both groups was seen.
On comparison from Day 1 to end of week 2 and week 4 and end of week 2 to end of week 4 showed a significant difference in the scores in PNF group.
Lee et al. stated that PNF exercises control the proprioception and sensory-motor functions. It avoids direct stimulation of pain area. It also strengthens the extensor muscles to effectively reduce the pain. Franklin et al., showed that PNF exercises facilitate the agonist's muscle which increases the motor neuron's recruitment and reduces the pain.
In the LSE group also significant improvement was seen from Day 1 to the end of week 2 and week 4. Puntumetakul R et al., stated that stabilization exercises improve not only activation of trunk muscles but also improve the coordination of trunk muscles. They reduce the spinal overload thereby reducing the intensity of the pain.
On comparison between both the groups showed statistical significance at the end of 4 weeks. Both the methods showed significant improvement, but PNF exercises were more effective in reducing pain compared to the LSE group.
Spine flexibility in flexion and extension was assessed by using the modified Schober test. There was a significant difference in flexion from Day 1 to the end of week 2 and week 4 in PNF and LSE groups. Extension is significantly improved over 4 weeks from Day 1 to the end of week 2 and week 4 in PNF and LSE group.
However, Between-group comparisons of PNF and LSE groups at the end of week 4 were statistically insignificant. Kofotolis et al. showed that the PNF exercises improved both flexion and extension which could be attributed to the design of PNF exercises. It causes muscle relaxation and allows greater stretch which helps to improve flexibility.
PNF exercises involve stretching, resisted movements, and approximation. In PNF exercises, limb is positioned in lengthened range, i.e., agonist is lengthened and then, it moves to the shortened range. At the end range, contraction of agonist causes lengthening in antagonist.
It gives stretch to muscles which initiate voluntary movements and enhances the speed of response and strength in the weak muscle. When the muscle is stretched, the 1a and 2 fibers in the muscle send excitatory messages to the alpha motor neuron which innervates the stretched muscle and inhibits the antagonists. Ultimately, these exercises elongate the muscle fibers thereby improving flexibility.
According to this study by Hwangbo et al., core strengthening exercises (LSE) activate the abdominal muscles and multifidus muscles. When these muscles are activated, they improve the stability of the trunk, decrease the pain, and improve flexibility.
ODI was used to measure functional disability and to test the patient-specific physical functions likely to be affected by low back pain RMDQ was administered.
There was a significant improvement was seen in ODI and RMDQ over 4 weeks in both groups. Kofotolis et al. showed PNF exercises improve muscle endurance and thereby reduce pain. Improvement in functional ability is seen as a result of improvement in endurance and flexibility.
On RMDQ comparison between PNF and LSE showed statistical significance from Day 1 to the end of 2 and 4 weeks in PNF and LSE groups. At the end of 4 weeks, comparison of ODI scores between the groups showed statistical significance, whereas RMDQ scores showed statistical insignificance. Rungthip et al., explained that LSE activate the deep abdominal muscles. It plays an important role in the stability of the spine. Improved trunk muscle recruitment patterns reduce pain and disability.
ANarrative review by Igor Grabovac showed that there is a clear association between low back pain and various aspect of functional ability. Low back pain leads to fear movement avoidance due to pain which leads to inactivity. PNF exercises cause muscle relaxation which allows the greater magnitude of stretch which results in improvement in flexibility. It also stated that interventions reducing fear-avoidance belief and kinesophobia ultimately improved the functional ability of patients.
When PNF exercises are performed correctly, the client will eventually adapt them into their everyday movements, thereby sloppy postures and habits that put chronic strain on the muscle causing muscle soreness, stress, and eventually leading to injury, will be corrected and their pain and spasm will decrease greatly.
It is based on the basic principle of learning motor control first by developing awareness of muscle contraction and spinal position and then by developing control in simple patterns and progress to complex. Hence, improvement is seen in functional ability as a direct result of flexibility, pain, and endurance.
This study has a small sample size which limits the generalization of research findings.
PNF exercises helped to improve spinal range of motion leading to reduction in pain and functional disability. LSE program improves muscle strength and endurance which improves the stability of the spine. Hence, the further study which combines PNF exercises with the LSE program can be conducted to see the complementary effect of both interventions in comprehensive care of chronic low back pain.
| Conclusion|| |
There was a significant improvement seen in the pain, flexibility, and disability which was assessed on VAS and ODI in the PNF group over LSE in the management of low back pain. PNF exercises showed faster improvement. Hence, PNF exercises can be incorporated with LSE in the treatment of chronic low back pain.
We would like to express our sincere gratitude to Dr Ramesh Bharmal, Dean, TNMC and to Dr Pratibha Vaidya, Head of the department O T School & Centre, TNMC. for their unstinted support during the study and to all our patients who participated in the study for their unwavering cooperation
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Franklin C, Kalirathinam D, Palekar T, Nathani N. Effectiveness of PNF training for chronic low back pain. IOSR J Nurs Health Sci 2013;2:41-52.
Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al.
Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;15 Suppl 2:S192-S300.
Merskey H, Bogduk N. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl 1986;3:S1-S226.
Farragher JB, Pranata A, Williams G, El-Ansary D, Parry SM, Kasza J, et al.
Effects of lumbar extensor muscle strengthening and neuromuscular control retraining on disability in patients with chronic low back pain: A protocol for a randomised controlled trial. BMJ Open 2019;9:e028259.
Hwangbo G, Lee CW, Kim SG, Kim HS. The effects of trunk stability exercise and a combined exercise program on pain, flexibility, and static balance in chronic low back pain patients. J Phys Ther Sci 2015;27:1153-1155.
Van Tudler M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain. Cochrane Database Syst Rev 2000;25:2784-2796.
Yamashita T, Cavanaugh JM, el-Bohy AA, Getchell TV, King AI. Mechanosensitive afferent units in the lumbar facet joint. J Bone Joint Surg Am 1990;72:865-870.
Loeser JD, Melzack R. Pain: An overview. Lancet 1999;353:1607-1609.
Adler SS, Backers D, Buck M. PNF in Practice. Heidelberg: Springer Medizine; 2008.
Kofotolis N, Kellis E. Effects of two 4-week proprioceptive neuromuscular facilitation programs on muscle endurance, flexibility, and functional performance in women with chronic low back pain. Phys Ther 2006;86:1001-1012.
Kisner C, Colby LA. Therapeutic Exerises. Philadelphia: F.A. Davis; 2012.
Puntumetakul R, Chalermsan R, Hlaing SS, Tapanya W, Saiklang P, Boucaut R. The effect of core stabilization exercise on lumbar joint position sense in patients with subacute non-specific low back pain: A randomized controlled trial. J Phys Ther Sci 2018;30:1390-1395.
Kajiki S, Izumi H, Hayashida K, Kusumoto A, Nagata T, Mori K. A randomized controlled trial of the effect of participatory ergonomic low back pain training on workplace improvement. J Occup Health 2017;59:256-266.
Grabovac I, Dorner TE. Association between low back pain and various everyday performances: Activities of daily living, ability to work and sexual function. Wien Klin Wochenschr 2019;131:541-549.
Lee CW, Hwangbo K, Lee IS. The effects of combination patterns of proprioceptive neuromuscular facilitation and ball exercise on pain and muscle activity of chronic low back pain patients. J Phys Ther Sci 2014;26:93-96.
Puntumetakul R, Areeudomwong P, Emasithi A, Yamauchi J. Effect of 10-week core stabilization exercise training and detraining on pain-related outcomes in patients with clinical lumbar instability. Patient Prefer Adherence 2013;7:1189-1199.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]