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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 2, Issue 4 (Sep. – Oct. 2013), PP 41-52
www.iosrjournals.org
www.iosrjournals.org 41 | Page
Effectiveness of PNF Training for Chronic Low Back Pain
1C. V. John Franklin,2Deivendran Kalirathinam,3TusharPalekar, 4NikkyNathani.
1. Associate professor, Padmashree Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y.
PatilVidyapeetUniversity, Pimpri, Pune, India
2. Lecturer in physiotherapy, Faculty of medicine& Health Sciences, Universiti TUNKU ABDUL RAHMAN,
sungai long campus, Bandar sungai long,Cheras,43000KajangSelangorDarulehsan,Malyasia
3. Professor, Padmashree Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. PatilVidyapeethuniversity,pimpri
Pune, India
Background: The primary goals of physical exercise in the management of chronic low back pain are to gain
the muscle strength, flexibility and endurance, to restore injured tissues and to contribute to the ability to
sustain normal life activities.5Core serves as a muscular corset that works as a unit to stabilize the body and
spine hence its strengthening helps to prevent and rehabilitate various lumbar spine and musculoskeletal
disorders6.PNF is very effective in improving flexibility, strength and range of motion in a damaged or stiff
muscle1. This study compared the effect of proprioceptive neuromuscular facilitation program versus core
stabilization exercises for decreasing pain, improving flexibility and functional ability of the patients with
chronic low back pain.
Design and setting: 60 subjects having low back pain for more than 3 months, between 20-50 year of age were
randomized into two groups (group 1- PNF, group 2-core strengthening). For group 1 treatment were
combination of Isotonic Exercisesconsisting of alternating concentric and eccentric contractions of the agonists
without relaxation, three sets of 15 repetitions at maximal resistance were performed16and Short Wave
Diathermy given initially for 20–3020 minutes on continuous mode21 to the low back. For group 2 treatment
included SWD to low back pain region for 20-3020 minutes on continuousmode44and Core Stability Exercises
given for 2 weeks with 10 repetitions and the next 2 weeks as home program with 20 repetitions for each
exercise.
Results: In the present study, the PNF group shows highly significant improvement in all the outcomes
measures as compared to core strengthening when pre and post treatment parameters were compared after 4
weeks in Visual Analog Scale(t = 2.006, p= 0.0502), Modified modifiedSchober method (Flexion) (t = 2.39, p=
0.0202), Modified modifiedSchober method (Extension)(t = 2.74, p= 0.0083), Modified Oswestry Low Back
Pain Disability Score( t = 4.406, p<0.0001 )
Conclusion: When we compare both the groups, the results signify that PNF program is better suited for
chronic low back pain as compared to core stabilization exercises.Core Stability Exercises are as effective but
not superior to, other modes of physiotherapy management in the treatment of chronic low back pain. We
recommend that Investigation of long term effect of PNF programmeand Core Stability Exercises in Indian
population with large number of sample and longer session is needed.
I. Introduction
Low backache is an extremely common symptom in the general population affecting up to 85% and is
the most common disability in those under the age of 45 and the most expensive health problem in those
between the ages of 20 to 501.
It is tiredness, discomfort, or pain in the low back region, with or without radiating symptoms to the leg
or legs and categorized as acute, sub-acute and chronic low back pain2.
Patients with chronic low back pain present with impaired psychomotor functioning such as decreased
speed of information processing and poor postural control. They also experience more frequent and severe pain
and have poorer scores for physical and social functioning than other low back pain patients and have adaptive
changes related to long-term dysfunction. Therefore, when reviewing treatments for low back pain, chronic low
back pain should be considered separately from acute and sub acute low back pain3.
The primary goals of physical exercise in the management of chronic low back pain are to gain the muscle
strength, flexibility and endurance, to restore injured tissues and to contribute to the ability to sustain normal life
activities5.
Core strengthening is a description of the muscular control required around the lumbar spine to
maintain functional stability and particular attention has been paid to the core strengthening because the core
serves as a muscular corset that works as a unit to stabilize the body and spine, with and without limb movement
and hence its strengthening helps to prevent and rehabilitate various lumbar spine and musculoskeletal
disorders6.
Effectiveness of Pnf Training for Chronic Low Back Pain
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Neurophysiologic studies have linked pain development in the lumbar spine region with disturbances in
the mechanoreceptors and probably with impairment of the superior proprioception centers7,8.Therefore,
exercise programs that enhance proprioception may be beneficial for managing chronic low back pain.
Proprioceptive neuromuscular facilitation is a concept of treatment whose underlying philosophy is that
all human beings, including those with disabilities, have untapped existing potential (Kabat 1950). The primary
goal of treatment is to help patients achieve their highest level of function9. PNF involves stretching, resisted
movement, traction and approximation to ameliorate muscle decline, disharmony, atrophy and joint movement
limitations10. Originally used as a rehabilitative therapy, it is very effective in improving flexibility, strength and
range of motion in a damaged or stiff muscle11. Recently, it has been used in orthopedic diseases of bones and
joints (like lower back, neck and shoulder pain), sports related trauma and CNS diseases such as stroke and its
usefulness has been reported in other medical fields12,13,14
When PNF exercises are performed correctly, the client will eventually adapt them into their everyday
movements, thereby sloppy postures and habits putting chronic strain on the muscles, causing soreness, stress
and eventually leading to injury will be corrected and their muscle spasms and pain will decrease greatly15.
There are different forms of PNF exercises. Two commonly used forms are rhythmic stabilization training
(RST) and combination of isotonic exercises (COI). The RST technique uses isometric contraction of
antagonistic patterns and results in co-contraction of the antagonists if the isometric contraction is not broken by
the physical therapist. It is used mainly to manage conditions in which weakness is a primary factor and in
which stabilization provides stimulation of the agonistic pattern16.The COI technique is used to evaluate and
develop the ability to perform controlled purposeful movements. It involves the performance of alternating
concentric, eccentric, and isometric contractions and is used to treat deficiencies in strength and range of
motion11.
Based on the above said concepts core stability and PNF have been practiced worldwide in the
treatment of chronic low pain and were found effective individually, but these two were not compared to find
out which is better in reducing pain and improving the functional ability of the patients.
Purpose of the study:
The purpose of this study is to compare the effect of proprioceptive neuromuscular facilitation program
versus core stabilization exercises for decreasing pain, improving flexibility and functional ability of the patients
with chronic low back pain.
AIM AND OBJECTIVES
AIM: To find out an effective method of treating chronic low back pain.
OBJECTIVES:
1) To study the effect of proprioceptive neuromuscular facilitation programme on decreasing pain, improving
flexibility and functional performance in chronic low back pain patients.
2) To study the effect of core stabilization exercises on decreasing pain, improving flexibility and functional
performance in chronic low back pain patients.
3) To compare the effectiveness of PNF program and Core stabilization exercises among chronic low back
pain patients.
II. Materials and Methodology
STUDY TYPE: Comparative Study
STUDY SETTING:Out-patient department of Physiotherapy, Dr. D. Y. Patil Medical College Hospital &
Research center, Pune.
SAMPLING DESIGN:
1) Block Randomization method was used.
2) Total 60 patients were selected out of which only 53 patients were able to complete the study.
SAMPLE SIZE: The total number of subjects in the study is n = 60, aged between 20 to 50 yrs.
SAMPLE POPULATION: Patients having Low back pain for more than 3 months of duration were included
as per the inclusion criteria.
TARGET POPULATION: Patients with Low Back Pain.
SAMPLING CRITERIA:
Inclusion Criteria:
Ages between 20 to 50 years were selected.
Both male and female patients were selected.
Patients having chronic low back pain with more than 3 months of duration.
Effectiveness of Pnf Training for Chronic Low Back Pain
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Low back pain with non-specific nature (mechanical) i.e. without identifiable specific anatomical or
neurophysiological causative factors.
Exclusion Criteria:
Patients with nerve root pain signs.
Patients with spine pathology.
Patients with previous spinal surgery.
Spondylosis.
Spondylolisthesis
Past history of vertebral fractures
Systemic disorders like tuberculosis of spine or rheumatoid arthritis.
MATERIALS USED:
Plinth.
Inch tape.
Marker.
Paper.
Scale.
Patient record form.
Modified Oswestry Low back pain disability Questionnaire.
PROCEDURE:
Data Collection:
Subjects were evaluated at the beginning of the therapy and reevaluated after 4 weeks. This was done
to note the changes after the treatment.
Table showing distribution of age and gender.
S.No
Category
Criteria
Group
1
Group
2
t = 0.28
p < 0.77
(NS)
1
Age
Mean
33.11
33.73
SD
8.10
8.01
2
Gender
Male
15
14
Female
12
12
It was found that there was no significant difference in basic parameters like Age & Gender.
OUTCOME MEASURES:
VISUAL ANALOGUE SCALE - Visual Analogue Scale is a pain rating scale on which the patient is
asked to rate his or her pain from 0 (no pain) to 10 (most severe pain imaginable). The line is 10 cms in
length on which patients mark is measured from the left (no Pain) end of the scale and is recorded in
centimeters. VAS has advantages over other methods in terms of feasibility and reliability17.
MODIFIED MODIFIED SCHOBER METHOD -Modified modifiedSchober method is easier and
quicker, less time taking, and a reliable method to obtain lumbar flexion and extension measurements in
patients with Low Back Pain18.
MODIFIED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE-This questionnaire
has been designed to give information as to how your back pain has affected your ability to manage in
everyday life and consists of 10 items addressing different aspects of function, each scored from 0 to 5, with
higher values representing greater disability. The total score is multiplied by 2 and expressed as a
percentage. This test is highly reliable19.
III. Method:
From the target population, the sample populations were selected based on the inclusion and exclusion
criteria and were randomly allocated into two groups and the subjects were examined in detail including
subjective and objective assessment.
Their evaluation was taken at the start of treatment and after 4 weeks of treatment in both the groups.
The consent was obtained from the subject and the procedure was explained to them. 45 – 60 min per day for 4
weeks and 2 weeks of duration respectively and for the next 2 weeks the patients with core stability exercises
group were taught home programs to be carried out at their home.
GROUP 1: (Proprioceptive neuromuscular facilitation group)
Effectiveness of Pnf Training for Chronic Low Back Pain
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The treatment to this group of patients includes Combination of Isotonic Exercises and Short Wave
Diathermygiven initially for 20–3020 minutes on continuous mode21 to the low back. The Combination of
Isotonic Exercises program consists of alternating concentric and eccentric contractions of the agonists without
relaxation. Resisted active concentric contraction for 5 seconds (trunk flexion), resisted eccentric contraction for
5 seconds (trunk flexion) and the resistance is maintained during contraction for 5 seconds (trunk flexion and
extension). Three sets of 15 repetitions at maximal resistance were performed16.
From the seated position, the subject flexes the trunk against manual resistance provided by the therapist.
When maximal trunk flexion is achieved, the subject is instructed to maintain the position
Upon maintenance of static position, the subject returns to the starting position (trunk extension) against
resistance provided by the therapist
GROUP 2:(core stabilization exercise group)
The treatment of this group of patients includes Short Wave Diathermy given initially to low back pain
region for 20-3020 minutes on continuousmode44and Core Stability Exercises given for 2 weeks with 10
repetitions under the supervision of the therapist and the next 2 weeks as home program with 20 repetitions for
each exercise.
1 week
o Curl up exercises6, 22, 23 – with one leg bent to about 900 and other leg relaxed.
o Side bridges – lift the hips off the floor. Repeat to both sides.
o Leg and Arm Extension (Brid Dog Exercise) – from 4-point kneeling position raise the arm then return to
beginning position and raise leg and again return to beginning position.
2 week
o Curl up exercise – with both knees bent about 900 with raise the elbow off the floor.
o Side Bridges – lift both legs off the floor.
o Leg and Arm Extension – with alternate arm and leg extension from 4 – point kneeling position.
3– 4 weeks
Continue the same exercise with advance progression
o Curl up – with fingers on the fore head.
o Side bridge – Support yourself on right hand extended.
o Leg and arm extension – Alternate leg and Arm extension.
IV. Results
Statistical Analysis was done by using paired‘t’ and unpaired‘t’ test. Intergroup significance was
calculated by using unpaired‘t’ test & intragroup significance was calculated by using paired‘t’ test.
In PNF group,
Paired ‘t’test was applied at 26 degrees of freedom
i.e. (n-1) = degree of freedom
(27-1) = 26
In Core Stabilization Exercise group,
Paired ‘t’test was applied at 25 degrees of freedom
i.e. (26-1) = 25
To compare both the groupsunpaired ‘t’ test was applied.
TABLE -1
COMPARISION OF PRE AND POST TREATMENT OF PNF GROUP VAS SCORE
When pre and post treatment parameters were compared after 4 weeks, the PNF group showed highly significant
difference in improvement of Visual Analog Scale.
Visual Analog Scale Score (t = 23.67, p < 0.000)
Pre treatment
Post treatment
MEAN
7.37
1.98
SD
1.20
1.16
Effectiveness of Pnf Training for Chronic Low Back Pain
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GRAPH-1
TABLE-2
COMPARISION OF PRE AND POST TREATMENT OF PNF
GROUP MMS SCORE
When pre and post treatment parameters were compared after 4 weeks, the PNF group showed highly significant
difference in improvement of flexion and extension range by modified modifiedSchober method.
Modified modifiedSchober method (Flexion)- (t = 13.79, p< 0.0001)
Modified modifiedSchober method (Extension)-
(t = 8.21, p< 0.0001)
GRAPH-2
TABLE-3
COMPARISION OF PRE AND POST TREATMENT OF PNF GROUP MOSW SCORE
When pre and post treatment parameters were compared after 4 weeks, the PNF group showed highly significant
difference in improvement of Modified Oswestry Low Back Pain Disability Questionnaire.
Modified Oswestry Low Back Pain Disability Score-
(t = 28.45, p<0.0001)
0
2
4
6
Flexion
Extension
2.67
1.65
5.49
2.98
MEAN
COMPARISION OF PRE AND POST TREATMENT OF PNF
GROUP OF MODIFIED MODIFIED SCHOBER METHOD
Pre
treatment
FLEXION
EXTENSION
Pre treatment
Post treatment
Pre treatment
Post treatment
MEAN
2.66
5.49
1.64
2.98
SD
0.99
1.17
0.71
0.67
Pre treatment
Post treatment
MEAN
68.51
26.59
SD
10.44
5.7
Effectiveness of Pnf Training for Chronic Low Back Pain
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GRAPH-3
TABLE-4
COMPARISION OF PRE AND POST TREATMENT OF CORE STABILIZATION EXERCISE
GROUP VAS SCORE
When pre and post treatment parameters were compared after 4 weeks, the PNF group showed highly significant
difference in improvement of Visual Analog Scale.
Visual Analog Scale (t = 24.41, p< 0.0001)
GRAPH-4
TABLE-5
COMPARISION OF PRE AND POST TREATMENT OF CORE STABILIZATION EXERCISE
GROUP MMS SCORE
0
20
40
60
80
68.5
26.59
MEAN
COMPARISION OF PRE AND POST TREATMENT OF PNF
GROUP OF MODIFIED OSWESTRY LOW BACK DISABILITY
SCALE
Pre
treatment
0
2
4
6
8
7.41
2.62
MEAN
COMPARISION OF PRE AND POST
TREATMENT OF CORE STABILISATION
EXERCISE GROUP VAS SCORE
Pre
treatment
Pre treatment
Post treatment
MEAN
7.40
2.62
SD
1.01
1.30
FLEXION
EXTENSION
Pre treatment
Post treatment
Pre treatment
Post treatment
MEAN
2.66
4.76
1.77
2.56
SD
0.96
1.17
0.71
0.68
Effectiveness of Pnf Training for Chronic Low Back Pain
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When pre and post treatment parameters were compared after 4 weeks, the PNF group showed highly significant
difference in improvement of flexion and extension range by modified modifiedSchober method.
Modified modifiedSchober method (Flexion)- (t = 9.63, p< 0.0001)
Modified modifiedSchober method (Extension)-
(t = 7.06, p< 0.0001)
GRAPH-5
TABLE-6
COMPARISION OF PRE AND POST TREATMENT OF CORE STABILIZATION EXERCISE
GROUP MOSW SCORE
When pre and post treatment parameters were compared after 4 weeks, the PNF group showed highly significant
difference in improvement of Modified Oswestry Low Back Pain Disability Questionnaire.
Modified Oswestry Low Back Pain Disability Score- (t = 34.89, p<0.0001)
GRAPH-6
TABLE-7
COMPARISION OF DIFFERENCE BETWEEN PRE AND POST TREATMENT VAS SCORE OF
BOTH GROUPS
PNF Group
Core Stabilization Exercise Group
MEAN
5.38
4.78
SD
1.18
0.99
0
2
4
6
Flexion
Extension
2.66
1.77
4.77
2.56
MEAN
COMPARISION OF PRE AND POST
TREATMENT OF CORE STABILIZATION
EXERCISE GROUP OF MODIFIED
MODIFIED SCHOBER METHOD (MMS)
Pre
treatment
0
50
100
67.38
33.31
MEAN
COMPARISION OF PRE AND POST TREATMENT OF CORE
STABILIZATION EXERCISE GROUP MODIFIED
OSWESTRY LOW BACK DISABILITY SCALE SCORE
Pre
treatment
Pre treatment
Post treatment
MEAN
67.38
33.30
SD
9.04
7.10
Effectiveness of Pnf Training for Chronic Low Back Pain
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When the difference between pre and post treatment parameters of both PNF and Core Stabilization Exercise
Groups were compared after 4 week showed no significant difference in improvement of Visual Analog Scale.
Visual Analog Scale (t = 2.006, p= 0.0502)
GRAPH-7
TABLE-8
COMPARISION OF DIFFERENCE BETWEEN PRE AND POST TREATMENT MMS SCORE OF
BOTH GROUPS
When the difference between pre and post treatment parameters of both PNF and Core Stabilization Exercise
Groups were compared after 4 week showed significant difference in improvement of Flexion and Extension
done by Modified modifiedSchober method.
Modified modifiedSchober method (Flexion)- (t = 2.39, p= 0.0202)
Modified modifiedSchober method (Extension)-
(t = 2.74, p= 0.0083)
GRAPH-8
4
4.5
5
5.5
5.38
4.78
MEAN
COMPARISION OF DIFFERENCE BETWEEN
PRE AND POST TREATMENT VAS SCORE
OF BOTH GROUPS
PNF Group
Core Stabilization
Exercise Group
0
1
2
3
Flexion
Extension
2.82
1.33
2.1
0.78
MEAN
COMPARSION OF DIFFERENCE BETWEEN PRE
AND POST TREATMENT MMS SCORE OF BOTH
GROUPS
PNF Group
Core Stabilization
Exercise Group
FLEXION
EXTENSION
PNF Group
Core stabilization
exercise group
PNF Group
Core stabilization exercise
group
MEAN
2.82
2.10
1.33
0.78
SD
1.06
1.11
0.84
0.56
Effectiveness of Pnf Training for Chronic Low Back Pain
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TABLE-9
COMPARISION OF DIFFERENCE BETWEEN PRE AND POST TREATMENT MOSW SCORE OF
BOTH GROUPS
PNF Group
Core Stabilization Exercise Group
MEAN
41.92
34.07
SD
7.65
4.97
When the difference between pre and post treatment parameters of both PNF and Core Stabilization Exercise
Groups were compared after 4 week showed highly significant difference in improvement of Modified Oswestry
Low Back Pain Disability Questionnaire.
Modified Oswestry Low Back Pain Disability Score( t = 4.406, p<0.0001 )
GRAPH-9
V. Results
Results Obtained:
On between both group comparison –
The subjects included in this study showed similar characteristics before starting the treatment for all
parameters.
Visual Analog Scale (t = 0.12, p = 0.90)
Modified ModifiedSchober Method
Flexion (t = 0.01, p = 0.98)
Extension (t = 0.61, p = 0.54)
Modified Oswestry Low Back Pain Disability Questionnaire
(t = 0.42, p = 0.67)
The Pre and Post treatment parameters were compared in PNF group
When pre and Post treatment parameters were compared after 4 weeks, the PNF group showed highly
significant difference in the improvement of all three parameters.
Visual Analog Scale ( t = 23.67, p < 0.0001)
Modified ModifiedSchober Method
Flexion (t = 13,79, p < 0.0001)
Extension (t = 8.21, p < 0.0001)
Modified Oswestry Low Back Pain Disability Questionnaire
(t = 28.45, p <0.0001)
The Pre and Post treatment parameters were compared in Core Stabilization Exercise group
When pre and Post treatment parameters were compared after 4 weeks,the Core Stabilization Exercise
group showed highly significant difference in the improvement of all three parameters.
Visual Analog Scale (t = 24.41, p < 0.0001)
Modified ModifiedSchober Method
Flexion (t = 9.63, p < 0.0001)
Extension (t = 7.06, p < 0.0001)
Modified Oswestry Low Back Pain Disability Questionnaire
(t = 34.89, p <0.0001)
0
10
20
30
40
50
41.92
34.07
MEAN
COMPARISION OF DIFFERENCE BETWEEN
PRE AND POST TREATMENT MOSW SCORE OF
BOTH GROUPS
PNF Group
Core Stabilization
Exercise Group
Effectiveness of Pnf Training for Chronic Low Back Pain
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The difference between Pre and Post treatment parameters were compared in PNF and Core
Stabilization Exercise group
When the difference between pre and post treatment parameters of both group were compared after 4
weeks, there is significant improvement in Modified modifiedschober method and Modified Oswestry Low
Back Disability Scale, but the Visual Analog Scale showed not significant.
Visual Analog Scale (t = 2.00, p = 0.05)
Modified ModifiedSchober Method
Flexion (t = 2.39, p = 0.02)
Extension (t = 2.7, p = 0.008)
Modified Oswestry Low Back Pain Disability Questionnaire
(t = 4.4, p < 0.0001)
Comparison between mean of the difference of Pre and Post treatment parameters value of PNF and
Core Stabilization Exercise group
Here, we can see that there is no significant difference between mean score of Visual Analog Scale of both
group, but significant difference seen in Modified modifiedSchober method and Modified Oswestry low back
pain disability scale showing the mean score of these parameters is larger in PNF group than Core Stabilization
Exercise group.
VI. Discussion
In the present study, the PNF group shows highly significant improvement in all the outcomes
measures
In PNF group the lumbar mobility, both in flexion and extension were improved in the mean value
showing greater amount of significance (Tab. 2).The positive effects could be attributed to the nature of PNF
exercises, which are designed primarily to maximize improvements in flexibility. Such exercises take advantage
of the body’s inhibitory reflexes to improve muscle relaxation which allows a greater stretch magnitude during
stretch training, resulting in superior gains in flexibility.
Nick Kofotolis, Eleftherios Kellies, (2006) found that the COI group demonstrated greater lumbar mobility
which could be attributed to the dynamic nature of the COI exercises, which used all muscle action types
(eccentric, concentric, and isometric) through a progressively increased range of motion24,25.
According to (Alter 1996), PNF is a technique involving combinations of alternating contractions and stretches.
Whose goal is facilitation of the agonist muscle thereby increase the recruitment of additional motorneurons or
increase the excitability of the motorneurons already in use. Agonist facilitation leads to inhibition (a decrease in
the excitability) of the antagonist (the stretched muscle) resulting in the relaxation of the inhibited muscle and
muscular resistance in the facilitated muscle26.
As this COI exercises includes the resistance, it becomes the most effective proprioceptive facilitation, as
muscle response to cortical stimulation increases (S.S Adler, D. Beckers). The magnitude of that facilitation is
related directly to amount of resistance.
Myers JB, Lephart SM (2000) – had stated that PNF is a normalized, facilitated training method for
muscles that involves stretching, resisted movement, traction (separating the joint surface), and approximation
(compressing the joint surface) to ameliorate muscle decline, disharmony, atrophy and joint movement
limitations10.
PNF group also showed an improvement in functional ability (Tab.3) (as registered by Oswestry Index)
could be seen as a direct result of flexibility and endurance improvements, thereby providingfurther support for
the effectiveness of PNF exercises for chronic low back pain treatment.
Despite the improvements in muscle mobility and functional ability, the visual analog scale (Tab.1) showed
similar improvements in this group. As the supporting studies mentioned that back pain intensity decreased
significantly.
Sr.no
Test
PNF group
Core Stabilization
Exercise group
‘t’value
‘p’value
1.
VAS
5.38
4.78
t= 2.006
p=0.05
2.
Flexion (MMS)
2.82
2.10
t=2.39
p=0.02
Extension (MMS)
1.33
0.78
t=2.74
p= 0.008
3.
MOSW
41.92
34.07
t=4.406
p<0.0001
Effectiveness of Pnf Training for Chronic Low Back Pain
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Neurophysiologic studies have linked pain development in the lumbar spinewith disturbances in the
mechanoreceptors and probably with impairment of the superior proprioception centers7,8therefore, exercise
programs that enhance proprioception may be beneficial for managing CLBP.
Also the reduction in pain may be due to application of short wave diathermy. (Wagstaff 1986) In
continuous mode of short wave diathermy, there is sensation of warmth because of accumulation of heat in the
tissues27. Therapeutic effects arise through specific tissue temperature increase of 1°C from a baseline
temperature of 37°C leading to increase in metabolic rate. Tissue temperature increases produce an increase in
blood flow and a decrease in pain, muscle spasm, and inflammation (Draper and Ricard, 1995; Lehmann et al.,
1970) 28, 29
In the present study, the second group i.e Core Stabilization Exercise group shows highly significant
improvement in all the outcomes measures.
These exercises have very significant effect on the pain and lumbar mobility. As the pain is decreased (Tab.4)
and lumbar mobility is increased (Tab.5), it could be attributed to the several other reported benefits through the
use of diathermy as explained earlier. Also (Low, Ann Reed) said that viscosity of tissues will be reduced,
which partly accounts for the reduction of joint stiffness that occurs with heating.
Hodges and Richardson (1996) showed that the deep trunk muscles, TransversusAbdominis (TA),
multifidus (MF), Internal Oblique (IO), Para spinal, pelvic floor are key to the active support of the lumbar
spine. The co-contraction of these muscles produce forces via the "thoracolumbar fascia" (TLF) and the "intra-
abdominal pressure" (IAP) mechanism which stabilize the lumbar spine, and the Para spinal and MF muscles act
directly to resist the forces acting on the lumbar spine. The co-contraction of the TA and MF muscles occurred
prior to any movement of the limbs suggestingthat these muscles anticipate dynamic forces which may act on
the lumbar spine and stabilize the area prior to any movement23.
In the present study, in both the groups, when we compare the lumbar flexion and extension
measurement statistically it is indicated that lumbar flexion measurement is more than the extension. (Tab.2 &
Tab.5)whichwould seem to be related to the fact that there is generally less available lumbar range of motion in
extension than in flexion. These findings could be attributed to the fact that trunk extensor musculature works
more statically and has a higher proportion of connective tissue than does trunk flexor musculature30.For this
reason, untrained people demonstrate stiffer trunk extensor musculature than trunk flexor musculature31.
Finally when we compare both the groups, the results signify that PNF program is better suited for
chronic low back pain as compared to core stabilization exercises.
Nick Kofotolis (2006) further support our study that short term PNF program are particularly effective in
improving trunk muscle endurance and mobility as well as in reducing back pain symptom and improving
functional performance in people with chronic low backpain14.
Rackwitz et al (2006) – found that for chronic low back pain, spinal stability exercises are more effective than
GP treatment and as effective as other physiotherapy treatments in reducing pain and disability, thus supporting
the Core stability exercises group32.
From the methodological point of view, the frequency and duration of the studied intervention (5 times per
week for 4 weeks) were deemed appropriate to produce demonstrable benefits. Attempt was made to avoid
confounding the results by balancing the exercise dosages between the groups. Exercises were administered for
both groups and classes were supplemented with exercise leaflets to maintain the motivation. The relatively high
level of adherence both during classes and at home confirms patient motivation to complete the exercise
programme.
VII. Conclusion
The Proprioceptive Neuromuscular Facilitation Programme and Core Stabilization Exercises, both the
groups showed highly significant difference of pre and post treatment. But when both these group were
compared, the results of PNF group is statistically larger than Core Stabilization Exercise group. So, the
Combination of isotonics PNF programme may be better suited for patients with chronic low back pain.
Core Stability Exercises are as effective but not superior to, other modes of physiotherapy management in the
treatment of chronic low back pain. They can be incorporated into general exercise programmes or provided
through one-to-one treatment sessions.
LIMITATIONS
The exercise programs applied in the present study were short term intensive programs and such
programs focusing on improvement may not be permanent. Although often patients are mainly interested in a
fast recovery, effects over the long term may be less distinctive due to, for example, recurrence of symptoms.
Recommendations: Investigation of long term effect of PNF programme and Core Stability Exercises in Indian
population with large number of sample and longer session is needed.
Effectiveness of Pnf Training for Chronic Low Back Pain
www.iosrjournals.org 52 | Page
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