An Integrated Approach to Chronic Low Back Pain: Evaluating the Impact of Consecutive Loop TheraBand Training Combined With Proprioceptive Neuromuscular Facilitation and Conventional Physiotherapy

Chronic low back pain (CLBP) is a prevalent musculoskeletal condition characterized by persistent discomfort in the lumbosacral region lasting beyond 12 weeks. Individuals with CLBP often experience limitations in range of motion and compromised performance of affected body parts. Core muscle weakness/delayed activation and impaired lumbar proprioception are established contributors to CLBP. And influence balance dysfunction in CLBP patients. Exercise therapy is a cornerstone in the management of CLBP, aimed at enhancing muscular endurance, strength, and flexibility of the back muscles and soft tissues. However, the efficacy of exercise interventions depends on various factors including the type, intensity, frequency, and duration of exercises. This case report presents the rehabilitation of a corporate employee with a non-specific CLBP. The rehabilitation goals focused on improving balance, reducing disability, and alleviating pain. An integrated approach combining proprioceptive neuromuscular facilitation (PNF) with Consecutive Loop TheraBand (CLX) (The Hygenic Corporation, Akron, USA) along with traditional physical therapy techniques was implemented. PNF, a well-established technique, was chosen for its effectiveness in reducing disability and LBP while enhancing balance. The integration of PNF alongside conventional physiotherapy resulted in notable improvements, including increased lumbar flexion range following the rehabilitation period. This case underscores the importance of early initiation of comprehensive rehabilitation in CLBP patients to preserve strength, alleviate pain, reduce functional disability, and enhance balance. By addressing both the muscular and proprioceptive aspects of CLBP, this integrated approach aims to optimize outcomes in CLBP management.

Management of Low Back Pain With Concurrent Hamstring Tightness: A Case Report Highlighting the Efficacy of Proprioceptive Neuromuscular Facilitation, Mulligan's Two-Leg Rotation Technique, and Exercise Regimen

Low back pain (LBP) is a prevalent musculoskeletal issue characterized by discomfort in the lumbosacral region. LBP localized between the 12th thoracic vertebra and inferior gluteal folds is common and often lacks a clear etiology. Various factors contribute to LBP, including increased lumbar lordosis, diminished abdominal muscle strength, reduced back extensor muscle endurance, and flexibility limitations in the back extensors, iliopsoas, and hamstrings. Treatment modalities for LBP encompass surgical intervention, pharmacotherapy, lumbar injections, psychotherapy, chiropractic care, and physiotherapy, with manual therapy being a prominent approach. Physiotherapists employ a spectrum of manual techniques, including mobilization, manipulation, and massage, to address LBP. Hamstring flexibility plays a pivotal role in spinal mechanics, and tight or shortened hamstrings can exacerbate LBP. Mulligan's techniques, notably the two-leg rotation (TLR) technique, are valuable interventions for addressing hamstring tightness in cases of LBP. Proprioceptive neuromuscular facilitation (PNF) was also used to manage pain and improve strength. This case report outlines the management of a 32-year-old male presenting with LBP and hamstring tightness coupled with core muscle weakness. Through comprehensive assessment and physiotherapeutic interventions, significant improvements were observed in pain intensity, lumbar range of motion, disability, straight leg raise (SLR), and core muscle strength following a three-week physiotherapy intervention.

The Effects of Proprioceptive Neuromuscular Facilitation Pattern Kinesio Taping on Arm Swing, Balance, and Gait Parameters among Chronic Stroke Patients: A Randomized Controlled Trial

(1) Background: This study aimed to investigate the effects of proprioceptive neuromuscular facilitation pattern kinesio taping on arm swing, balance, and gait parameters among chronic stroke patients. (2) Methods: Twenty-eight participants were randomized into proprioceptive neuromuscular facilitation pattern kinesio taping during gait training (n = 14) and gait training (n = 14) groups. The proprioceptive neuromuscular facilitation pattern kinesio taping during gait training group employed proprioceptive neuromuscular facilitation pattern kinesio taping during 15 min treadmill-based gait training five times a week for four weeks, while the gait training group underwent the same gait training without proprioceptive neuromuscular facilitation pattern kinesio taping. Arm swing angle was measured using the Image J program, static balance was assessed with an AMTI force plate, dynamic balance was evaluated through the Timed Up and Go test, and gait parameters were recorded using the GAITRite system and the Dynamic Gait Index. (3) Results: After 4 weeks of training, the proprioceptive neuromuscular facilitation pattern kinesio taping during gait training group exhibited significant improvements in all variables compared to the baseline (p < 0.05), whereas the gait training group did not show statistically significant differences in any variables (p > 0.05). (4) Conclusions: This study demonstrates the effectiveness of proprioceptive neuromuscular facilitation pattern kinesio taping during gait training in enhancing arm swing angle, balance, and gait parameters.

Effect of proprioceptive neuromuscular facilitation and cranio-cervical flexor training on pain and function in chronic mechanical neck pain: A randomized clinical trial

BACKGROUND

Chronic neck pain is known to be caused by the weakness of the deep neck flexors and disturbances in the mechanoreceptors and the proprioceptors of the cervical spine. Proprioceptive neuromuscular facilitation (PNF) is hypothesized to balance the relative stiffness and weakness of the muscles and activate the mechanoreceptors and proprioceptors.

OBJECTIVE

To investigate PNF techniques and the craniocervical flexor training (CCFT) techniques for pain and function in chronic neck pain.

METHODS

A randomized clinical trial was conducted on 66 chronic mechanical neck pain patients randomly assigned to either the PNF or CCFT groups using block randomization for a duration of 4 weeks. Numerical Pain Rating Scale (NPRS), Neck disability Index (NDI) and Active cervical range of motion (ACROM) were measured at baseline and after 4 weeks of intervention. Data were analysed using independent t test and MANOVA.

RESULTS

The mean difference scores for NPRS and NDI were 2.18 and 15.72 in PNF group and 2.26 and 15.76 in the CCFT groups, respectively. Both the groups showed a change that was statistically significant. Also, the mean differences for the ACROM in all the planes in both the groups were statistically significant. However, the between group changes did not reveal any statistical significance in this study except for the right rotation in the CCFT group (p = 0.01).

CONCLUSIONS

This study concluded that the PNF treatment is also beneficial to pain and function in treating chronic mechanical neck pain patients as its results stand similar to the CCFT treatment, which is already established to be a reliable tool to treat this condition.

Targeting Weakness With a Combination of Isotonic Exercises in Dermatomyositis With Polyneuropathy: A Case Report

Dermatomyositis, an autoimmune inflammatory myositis commonly linked to polymyositis, is marked by inflammatory and degenerative transformations impacting muscles, skin, limb girdles, the neck, and the pharynx. These changes result in symmetrical weakness and diverse levels of muscle atrophy. Uncommonly, the condition may impact the esophagus, lungs, and heart. While dermatomyositis is believed to involve genetic, immunological, and environmental factors, its precise etiology remains elusive. Typically, the classical presentation involves a symmetrical proximal myopathy alongside dermatological manifestations such as a purplish-red rash affecting the face, arms, hands, legs, and other areas. Additional symptoms may include dysphagia, myalgia, fever, and weight loss. The primary objectives of managing dermatomyositis are to address muscular weakness, skin manifestations, and any underlying health concerns. Integral to this management is the utilization of physical therapy and rehabilitation interventions. This study introduces a 23-year-old female patient with a noteworthy medical history covering a duration of two months. The patient reported a chief complaint of persistent thigh pain and a concurrent complaint concerning bilateral weakness in upper and lower extremities. Furthermore, the patient faced the additional challenge of difficulty swallowing. Intriguingly, the patient's clinical presentation was marked not only by the aforementioned symptoms but also by the development of a distinctive facial rash. This facial rash was accompanied by symptoms of stiffness in both small and large joints and a reduction in the range of affected joints. The physiotherapeutic assessment revealed quadriparesis of bilateral upper and lower limbs. The rehabilitation programme for the patient was planned by targeting proprioceptors to increase dynamic trunk balance in patients with DM. The Proprioceptive Neuromuscular Facilitation (PNF) technique employs diagonal movement patterns, thereby proving instrumental in enhancing the patient's daily activities. This methodology serves to optimize the individual's capacity to execute routine daily tasks, promoting independence in their daily life. An investigation like the Nerve Conduction Velocity (NCV) report shows the absence of motor excitation, suggesting motor axonal neuropathy. This approach, comprising isometric, concentric, and eccentric contraction exercises, demonstrated efficacy in mitigating muscular weakness, enhancing motor function, and alleviating the diverse symptoms associated with this condition.

Effect of PNF stretching performed in the AKE position on hip, knee, and ankle flexibility

BACKGROUND

To measure hamstring flexibility, the active knee extension (AKE) test is preferred over the straight leg raise (SLR) test as it can be used to measure hamstring flexibility more selectively. However, hamstring stretching is primarily conducted in the SLR position (maximal hip flexion in the supine position) as it allows for maximal hip flexion in the supine position.

OBJECTIVE

This study evaluates the effects of proprioceptive neuromuscular facilitation (PNF) stretching in the AKE position (maximal knee extension with 90∘ flexion of the hip in the supine position) on hip, knee, and ankle flexibility.

METHODS

SLR, AKE, and active dorsiflexion (ADF) tests were used to determine the range of motion (ROM) before (pre-ROM) and after (post-ROM) stretching. PNF stretching consisted of maximal isometric knee flexion at the end range with external resistance to prevent knee flexion. One set of PNF stretches (five trials of six seconds each) was conducted.

RESULTS

The post-ROMs of hip, knee, and ankle measured via the SLR, AKE, and ADF tests, respectively, were significantly higher than the pre-ROMs.

CONCLUSIONS

The improvement in knee flexibility was greater than the improvement in hip and ankle flexibility. The AKE position is recommended in clinical settings during PNF stretching for individuals with hamstring tightness. Furthermore, PNF stretching in the AKE position increases the ADF ROM.

Efficacy of proprioceptive neuromuscular facilitation on functioning in patients with bilateral hip osteoarthritis: A pilot randomized controlled trial

BACKGROUND

Hip osteoarthritis (OA) is a chronic progressive disease that impresses a noticeable burden to society and healthcare systems. Physical exercise constitutes the first-line hip OA treatment approach, nevertheless, there is currently no gold standard method to treat this disease.

OBJECTIVE

To evaluate the efficacy of proprioceptive neuromuscular facilitation (PNF) on functioning in patients with hip OA.

METHOD

A pilot randomized controlled trial (RCT) was carried out on patients with painful bilateral hip OA with a body mass index (BMI) < 30 kg/m2. After the randomization, the experimental group was treated with PNF protocol and the control group with conventional physical therapy (10 sessions of manual therapy, 5 sessions/week for 2 weeks). The Harris Hip Score (HHS) was the primary outcome, whereas we assessed as secondary outcomes: pain, range of motion, and muscle strength of hip, physical performance, and quality of life.

RESULTS

Twenty patients (40 hips) were enrolled and randomized into two groups: PNF group (mean age: 70.7 ± 8.07; BMI: 25.1 ± 3.07; 7 females and 3 males) and control group (mean age: 74.9 ± 10.72; BMI: 26.8 ± 3.78; 6 females and 4 males). The results showed a statistically significant improvement of HHS in the study group (T1: 90.6 ± 5.63) than in the control group (T1: 77.3 ± 10.9) (between-group p value < 0.001). Three months after the treatment we have statistically significant maintenance in the PNF group (T2:89.6±6.32, within-group ΔT0-T2 p< 0.01) while the control group did not maintain the improvements recorded at T1 (T2: 71.4 ± 15.8).

CONCLUSION

The results of this pilot RCT showed that incorporating PNF exercises into the rehabilitation program yielded notable enhancements in improving lower limb function, strength and ROM in hip OA patients. Nonetheless, further prospective studies including wider sample size are needed to implement scientific knowledge on this physical therapy approach, in patients with hip osteoarthritis.

Combined Effect of Pelvic Proprioceptive Neuromuscular Facilitation with Core Strengthening on Trunk Control, Balance, and Gait in Paraplegia

Spinal cord injury (SCI) has deleterious effects on quality of life and vocation. A partial or complete loss of sensory and motor functions below the site of injury is a potential clinical sign of SCI. Trunk and pelvic control are crucial for balance and gait to perform vocational tasks of daily living. In this case report, a 40-year-old male with traumatic incomplete paraplegia (AIS Grade C, neurological level T6) received 45 min of intervention per session, which included pelvic proprioceptive neuromuscular facilitation combined with core strengthening exercises 5 times a week for 4 weeks. Baseline and postassessments were done for trunk control with the trunk control test for SCI, balance with the Berg Balance Scale (BBS) and the SCI-functional ambulation inventory (SCI-FAI), and gait with the walking index for SCI II (WISCI). After 4 weeks of intervention, there were significant differences between baseline and postintervention scores on the trunk control test for SCI (16-18), WISCI (Level 1-2), SCI-FAI (03-06), and BBS (04-08). This is the first case report that enabled and promoted potentiate intervention to improve trunk control, balance, and gait in paraplegics. This outcome motivates additional research on its therapeutic potential and mechanism.

Functional Electrical Stimulation in Conjunction With Proprioceptive Neuromuscular Facilitation (PNF) Technique to Improve Upper Limb Function in Traumatic Brachial Plexus Injury: A Case Report

Traumatic brachial plexus injuries (TBPIs) in the adult population are primarily a result of road traffic accidents or falls on a shoulder, which mainly affects the young population. Adult TBPI is a serious incapacitating injury that affects young adults. It decreases the function of upper extremity muscles, which affects social participation and quality of life. Physiotherapy intervention demonstrates its effectiveness in enhancing and maintaining the function of the upper extremity, eventually decreasing the participation restriction and improving quality of life. The proprioceptive neuromuscular facilitation (PNF) technique has been selected as a useful therapeutic option to enhance upper limb function after TBPI. The preceding case report proved the effectiveness of six weeks of functional electrical stimulation in addition to the PNF technique in improving upper limb function after TBPI.

Effects of patterned electrical sensory nerve stimulation and static stretching on joint range of motion and passive torque

Static stretching and proprioceptive neuromuscular facilitation stretching techniques can modulate specific neural mechanisms to improve the range of motion. However, the effects of modulation of these neural pathways on changes in the range of motion with static stretching remain unclear. Patterned electrical stimulation of the sensory nerve induces plastic changes in reciprocal Ia inhibition. The present study examined the effects of patterned electrical stimulation and static stretching on a range of motion and passive torque in plantarflexion muscles. The subjects were 14 young men (age 20.8 ± 1.3 years). The effects of patterned electrical stimulation (10 pulses at 100 Hz every 1.5 s) or uniform electrical stimulation (one pulse every 150 ms) to the common peroneal nerve for 20 min on reciprocal Ia inhibition of the Hoffman reflex (H-reflex) were examined. Reciprocal Ia inhibition was evaluated as short-latency suppression of the soleus H-reflex by conditioning stimulation of the common peroneal nerve. Then, the effects of transcutaneous electrical nerve stimulation (patterned electrical stimulation or uniform electrical stimulation) or prolonged resting (without electrical stimulation) and static 3-min stretching on the maximal dorsiflexion angle and passive torque were investigated. The passive ankle dorsiflexion test was performed on an isokinetic dynamometer. Stretch tolerance and stiffness of the muscle-tendon unit were evaluated by the peak and slope of passive torques, respectively. Patterned electrical stimulation significantly increased reciprocal Ia inhibition of soleus H-reflex amplitude (9.7 ± 6.1%), but uniform electrical stimulation decreased it significantly (19.5 ± 8.8%). The maximal dorsiflexion angle was significantly changed by patterned electrical stimulation (4.0 ± 1.4°), uniform electrical stimulation (3.8 ± 2.3°), and stretching without electrical stimulation (2.1 ± 3.3°). The increase in stretch tolerance was significantly greater after patterned electrical stimulation and uniform electrical stimulation than after stretching without electrical stimulation. Stiffness of the muscle-tendon unit was significantly decreased by patterned electrical stimulation, uniform electrical stimulation, and stretching without electrical stimulation. Transcutaneous electrical nerve stimulation and static stretching improve stretch tolerance regardless of the degree of reciprocal Ia inhibition.

Exercise-Induced Hypoalgesia Following Proprioceptive Neuromuscular Facilitation and Resistance Training Among Individuals With Shoulder Myofascial Pain: Randomized Controlled Trial

BACKGROUND

Various exercises can attenuate pain perception in healthy individuals and may interact with the descending pain modulation in the central nervous system. However, the analgesic effects of exercise in patients with myofascial pain can be disrupted by the pathological changes during chronic pain conditions. Thus, the exercises targeted on the facilitation of the sensory-motor interaction may have a positive impact on the restoration of the descending pain modulation and the analgesia effects.

OBJECTIVE

This paper estimates the effect of proprioceptive neuromuscular facilitation (PNF) and resistance training on exercise-induced hypoalgesia (EIH) and conditioned pain modulation (CPM) among patients with myofascial pain syndrome.

METHODS

A total of 76 female patients with myofascial pain syndrome (aged 18-30 years), with the pain in the upper trapezius and a visual analog scale score of greater than 30/100 mm, were enrolled in the study. Participants were randomly assigned into 3 intervention groups, including isometric (n=18, 24%), isotonic (n=19, 25%), and PNF (n=20, 26%) exercises, as well as 1 control group (n=19, 25%) with no intervention. Pressure pain threshold and the CPM responses at the myofascial trigger point, arm, and leg sites were assessed before and after the exercise session. The effective EIH response was reflected in the improvement of pressure pain thresholds.

RESULTS

There was an increase in pressure pain thresholds and CPM responses at trigger point (P<.001 and P<.001), arm (P<.001 and P<.001), and leg sites (P<.001 and P=.03) in participants who performed PNF and isotonic exercise, while the isometric exercise only increased pressure pain thresholds at leg sites (P=.03). Compared with the control group, both the isotonic (P=.02) and PNF (P<.001) groups showed greater EIH responses at the trigger points. In comparison to the control group, only the PNF exercise (P=.01) significantly improved pressure pain thresholds and CPM responses at arm and leg sites compared to the control group.

CONCLUSIONS

PNF, isotonic, and isometric exercises could lead to local and global EIH effects. The improvement in CPM response following PNF and isotonic exercises suggested that the EIH mechanisms of different resistance exercises may be attributed to the enhancement of the endogenous pain modulation via the motor-sensory interaction from the additional eccentric and dynamic muscle contraction.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCtr202111090819166165; https://tinyurl.com/2ab93p7n.

Proprioceptive Neuromuscular Facilitation Neck Pattern and Trunk Specific Exercise on Trunk Control and Balance—an Experimental Study

Background

Most stroke survivors continue to live with disabilities and may require physical rehabilitation to control the trunk and balance during the post-stroke period. The cause of lack of trunk control and balance among stroke patients is the weakened trunk muscle strength.

Purpose

To study the effect of proprioceptive neuromuscular facilitation (PNF) neck pattern and trunk-specific exercise on trunk control and balance among stroke patients.

Setting

The study was conducted at the medical wards of Saveetha Medical College and Hospital, Chennai, India.

Participants

Sixty patients with stroke who met the inclusion criteria participated in the study.

Research Design

This is a quasi-experimental study.

Intervention

PNF trunk-specific exercise was administered to the experimental group for 45 min of 28 sessions, which contained 15 min of stretching exercise and 30 min trunk-specific exercise. The control group received routine hospital care services.

Main Outcome Measures

The study’s primary outcome was balance and trunk control, measured by the Berg Balance Scale (BBS) and Trunk Impairment Scale (TIS) before the intervention and at the end of the intervention of 28 days.

Results

Within-group analysis, paired t test showed a significant improvement comparing the trunk control and balance score before (13.40±1.04 & 25.40±1.81) and after (15.03±0.96 & 27.07± 1.48) the intervention in the experimental group (p < .001). Between-group analysis, both the experimental and control group post-test mean score of TIS (15.03±0.96 &13.70±1.15) and BBS (27.07±1.48 & 25.30±1.73) showed significant difference (p < .001).

Conclusion

PNF neck pattern and trunk-specific exercise used in this study effectively improved balance and trunk control among patients with stroke.

Impact of Proprioceptive Neuromuscular Facilitation Technique for Early Rehabilitation to Restore Motor Impairments in a Classic Case of Left Middle Cerebral Artery Stroke

An abrupt hemorrhage or ischemia causes acute onset of stroke. The characteristic feature of hemiplegia is the loss of voluntary movement with the alteration of muscle tone, reflexes, and sensation. In this case, we present a 56-year-old man who suffered from right hemiplegia, facial palsy, and expressive aphasia. The MRI of the brain revealed a hemorrhagic transformation of acute infarct in the left frontoparietal-temporo-occipital lobe. The patient was managed immediately by medical interventions. The physiotherapy treatment was initiated after the stabilization of acute symptoms at an early stage. This case report details the management of the patient with physical therapy and highlights the advantages of exercise therapy, particularly the proprioceptive neuromuscular facilitation technique for enhancing the patient's condition by incorporating physiotherapy protocol from an early stage.

Effectiveness of Pelvic Proprioceptive Neuromuscular Facilitation Techniques on Balance and Gait Parameters in Chronic Stroke Patients: A Randomized Clinical Trial

Background Stroke is the second leading reason for death and the third most common reason for disability. Stroke is a source of possible substantial harm and is often more disabling than lethal. Common stroke defects include stiffness, tiredness, loss of balance on the afflicted side, as well as gait impairment, resulting in an inability to sustain postural alignment. Pelvic proprioceptive neuromuscular facilitation (PNF) is a physical rehabilitation that combines functionally dependent diagonal activity patterns with neuromuscular facilitator strategies to improve motor behaviour, endurance, and muscle activity and control. This protocol was created to describe the experimental study design for evaluating the combined impact of pelvic PNF and task-oriented exercises in chronic stroke patients to improve balance and gait parameters. Aim and objective The purpose of our study is to investigate the effectiveness of pelvic PNF as well as task-oriented exercises on balance, gait parameters, and in pelvic asymmetry. Methods The participants (n=30) were stroke survivors who fulfilled the inclusion criteria for research and were divided into two groups. The regimen lasted four weeks and took 30 minutes each day. Patients were evaluated at the beginning and end of their treatment. In both groups, pre- and post-intervention outcome measures were recorded and the data was analyzed. Result Following four weeks of rehabilitation, subjects showed remarkable improvement in balance, gait parameters, and pelvic inclination in both groups, i.e., pelvic PNF and task-oriented exercises in group A and task-oriented exercises in group B, but Group A showed a major improvement in outcome measures. A p-value of less than 0.05 was considered significant. Despite the fact that both treatment regimens were successful for the patient, pelvic PNF combined with task-oriented exercises exhibits a statistically significant difference from task-oriented exercises. Conclusion Pelvic PNF along with task-oriented exercises proved to be beneficial and can help in the restoration of balance and gait parameters as a result of normalisation in the geometry and symmetry of the pelvis in stroke patients. The pelvis, which is a connecting link between the trunk and lower limbs, plays a crucial role in balance and also in lower limb performance exclusively in gait.

Proprioceptive Neuromuscular Facilitation-Based Physical Therapy on the Improvement of Balance and Gait in Patients with Chronic Stroke: A Systematic Review and Meta-Analysis

The present study aims to determine the potential benefits of PNF on balance and gait function in patients with chronic stroke by using a systematic review and meta-analysis. Systematic review in the following databases: MEDLINE/PubMed, Physiotherapy Evidence Database (PEDro), Cochrane Library and Google Scholar. Studies up to September 2020 are included. A systematic database search was conducted for randomized control trials (RCTs) that investigated the effects of PNF intervention in patients with chronic stroke using balance and gait parameters as outcome measures. The primary outcomes of interest were Berg Balance Scale (BBS), Functional Reach Test (FRT), Timed Up and Go Test (TUG) and 10-Meter Walking Test (10MWT). Nineteen studies with 532 participants were included, of which twelve studies with 327 participants were included for meta-analysis. When the data were pooled, PNF made statistically significant improvements in balance with BBS, FRT and TUG (p < 0.05) or gait velocity with 10MWT (p < 0.001) when compared to the control. This review indicates that PNF is a potential treatment strategy in chronic stroke rehabilitation on balance and gait speed. Further high-quality research is required for concluding a consensus of intervention and research on PNF.

Electromyographic analysis of pelvic floor muscles during the execution of pelvic patterns of proprioceptive neuromuscular facilitation-concept: An observational study

OBJECTIVE

To assess the effect of pelvic patterns of proprioceptive neuromuscular facilitation (PNF-concept) on pelvic floor muscles (PFM) recruitment, as well as the electromyographic activity of muscles synergic to the pelvic floor in healthy women.

METHODS

Observational study conducted with 31 women aged between 18 and 35 years, with mean age of 23.3 ± 3.2 (22.1-24.4). PFM activity was monitored by surface electromyography during the combination of isotonics technique of four pelvic patterns of PNF-concept (i.e., anterior elevation, posterior depression, anterior depression, and posterior elevation). The electromyographic signal was analyzed using root mean square amplitude. Two-way repeated measures analysis of variance was performed to analyze differences in PFM activity between types of contraction (i.e., concentric, isometric, and eccentric) and the four pelvic patterns.

RESULTS

PFM activity did not differ among the four pelvic pattens. However, PFM activity was significantly different between the combination of isotonics technique and baseline, F(1.6, 48.2) = 71.5; p < 0.000, with a large effect size (partial ƞ² = 0.705). Concentric (22.4 µV ± 1.1), isometric (17.3 µV ± 0.6), and eccentric (15 µV ± 0.5) contractions of combination of isotonics technique increased PFM activity compared with baseline (10.8 µV ± 0.4) in all pelvic patterns. By analyzing the electromyographic activity of the muscles synergistic to the pelvic floor, there is effect of the interaction of the type of contraction, the pelvic pattern of the PNF concept, and the synergistic muscles on the myoelectric activity of the external anal sphincter, F(3.2, 96.5) = 5.6; p < 0.000, with a large magnitude of effect (partial ƞ² = 0.15). In the anterior elevation pattern, the muscles synergistic to the pelvic floor present synergy in phase with the PFM, and in the posterior patterns there was a decrease in the activity level of all synergistic muscles, without changing the activity level of the PFM.

CONCLUSION

PFM activity did not differ among the four pelvic patterns of PNF-concept. Nonetheless, the combination of isotonics technique showed a significant effect on PFM compared with baseline, with greater PFM activity during concentric contraction. Pelvic patterns of PNF-concept may be used to increase PFM recruitment in young healthy women.

Effectiveness of proprioceptive neuromuscular facilitation and myofascial release techniques in patients with subacromial impingement syndrome

PURPOSE

To compare the effectiveness of proprioceptive neuromuscular facilitation and myofascial release technique in patients with subacromial impingement syndrome on pain, range of motion, muscle strength, quality of life, functionality and disability.

METHODS

Thirty patients were randomly divided into two groups: proprioceptive neuromuscular facilitation group (n = 15) and proprioceptive neuromuscular facilitation combined with myofascial release technique group (n = 15). Both treatment methods were performed 3 times a week for 4 weeks. Pain severity was assessed by Visuel Analog Scale, range of motion by a goniometer, muscle strength by digital hand dynamometer, quality of life by Nottingham health profile, functionality by arm, shoulder and hand problems questionnaire, disability by shoulder pain and disability index. All measurements were used before and after treatments. Pain severity, range of motion and muscle strength were also evaluated after the first session.

RESULTS

After the treatment, shoulder pain, range of motion, muscle strength, functionality and disability were improved in two groups (p < 0.05). Proprioceptive neuromuscular facilitation showed improvement in pain, whereas myofascial release technique improved pain, physical activity, emotional state, sleep and total dimensions of life quality (p < 0.05). Proprioceptive neuromuscular facilitation was more effective in reducing activity pain, whereas myofascial release technique was more effective in increasing flexion, external and internal rotation range of motion, flexion and abduction muscle strength after the first session (p < 0.05).

CONCLUSIONS

The combined application of proprioceptive neuromuscular facilitation and myofascial release technique has a more acute and cumulative positive effect on pain, range of motion, muscle strength, functionality, disability and quality of life in patients with subacromial impingement syndrome.

What to stretch? - Isolated proprioceptive neuromuscular facilitation stretching of either quadriceps or triceps surae followed by post-stretching activities alters tissue stiffness and jump performance

To overcome a possible drop in performance following longer stretch durations (>60 s), post-stretching dynamic activities (PSA) can be applied. However, it is not clear if this is true for isolated proprioceptive neuromuscular facilitation (PNF) stretching of different muscle groups (e.g., triceps surae and quadriceps). Thus, 16 participants performed both interventions (triceps surae PNF + PSA; quadriceps PNF + PSA) in random order, separated by 48 h. Jump performance was assessed with a force plate, and tissue stiffness was assessed with a MyotonPro device. While no changes were detected in the countermovement jump performance, the PNF + PSA interventions resulted in a decrease in drop jump performance which led to a large magnitude of change following the triceps surae PNF + PSA and a small-to-medium magnitude of change following the quadriceps PNF + PSA. Moreover, in the triceps surae PNF + PSA intervention, a decrease in Achilles tendon stiffness was seen, while in the quadriceps PNF + PSA intervention, a decrease in the overall quadriceps muscle stiffness was seen. According to our results, we recommend that especially triceps surae stretching is avoided during warm-up (also when PSA is included) when the goal is to optimise explosive or reactive muscle contractions.

Electroneurographic Evaluation of Neural Impulse Transmission in Patients after Ischemic Stroke Following Functional Electrical Stimulation of Antagonistic Muscles at Wrist and Ankle in Two-Month Follow-Up

The available data from electroneurography (ENG) studies on the transmission of neural impulses in the motor fibers of upper and lower extremity nerves following neuromuscular functional electrical stimulation (NMFES) combined with kinesiotherapy in post-stroke patients during sixty-day observation do not provide convincing results. This study aims to compare the effectiveness of an NMFES of antagonistic muscle groups at the wrist and ankle and kinesiotherapy based mainly on proprioceptive neuromuscular facilitation (PNF). An ENG was performed once in a group of 60 healthy volunteers and three times in 120 patients after stroke (T0, up to 7 days after the incident; T1, after 21 days of treatment; and T2, after 60 days of treatment); 60 subjects received personalized NMFES and PNF treatment (NMFES+K), while the other 60 received only PNF (K). An ENG studied peripheral (M-wave recordings), C8 and L5 ventral root (F-wave recordings) neural impulse transmission in the peroneal and the ulnar nerves on the hemiparetic side. Both groups statistically differed in their amplitudes of M-wave recording parameters after peroneal nerve stimulation performed at T0 and T2 compared with the control group. After 60 days of treatment, only the patients from the NMFES+K group showed significant improvement in M-wave recordings. The application of the proposed NMFES electrostimulation algorithm combined with PNF improved the peripheral neural transmission in peroneal but not ulnar motor nerve fibers in patients after ischemic stroke. Combined kinesiotherapy and safe, personalized, controlled electrotherapy after stroke give better results than kinesiotherapy alone.

The Effects of Elastic Band Exercises with PNF on Shooting Speed and Accuracy in Ball Hockey Players during the COVID-19 Pandemic

The coronavirus pandemic has affected life and left one of the strongest negative effects on sport. The aim of our study was to evaluate how a simple exercise performed with elastic resistance during the COVID-19 pandemic, when athletes cannot train, affects the basic shooting characteristics of ball hockey players. Extra-league ball hockey players (N = 30, age 19-37 years) were randomly divided into an experimental group, which performed elastic resistance exercises with Proprioceptive Neuromuscular Facilitation (PNF) elements for eight weeks, and a control group, which did not perform any exercises. Before the start of the experiment and after it was completed, the speed and accuracy of shooting were measured. In experimental group, there was no decrease after 8 weeks in the shooting speed, and in the control group, there was a statistically significant decrease. There was a deterioration in the accuracy of shooting in both groups; however, in the experimental group, the deterioration was not significant. The results show that even three simple exercises with elastic resistance according to the PNF concept performed 10 times per day for eight weeks can maintain the level of basic skills of ball hockey players-the speed and accuracy of shooting-even when no other training is performed.

Proprioceptive Neuromuscular Facilitation Kinesio Taping Improves Range of Motion of Ankle Dorsiflexion and Balance Ability in Chronic Stroke Patients

This study aimed to determine the effect of a proprioceptive neuromuscular facilitation (PNF) pattern Kinesio taping (KT) application on the ankle dorsiflexion range of motion (DF-ROM) and balance ability in patients with chronic stroke. This crossover study included 18 patients with stroke. The subjects were randomly assigned to three interventions: barefoot, ankle KT (A-KT), and PNF-KT. The A-KT was applied to the gastrocnemius and tibialis anterior (TA) muscles, and subtalar eversion. The PNF-KT was applied on the extensor hallucis, extensor digitorum, and TA muscles. DR-ROM was measured using the iSen™, a wearable sensor. Balance ability was assessed based on static balance, measured by the Biodex Balance System (BBS), and dynamic balance, measured by the timed up and go (TUG) test and dynamic gait index (DGI). Compared with the barefoot and A-KT interventions, PNF-KT showed significant improvements in the ankle DF-ROM and BBS scores, TUG, and DGI. PNF-KT, for functional muscle synergy, improved the ankle DF-ROM and balance ability in patients with chronic stroke. Therefore, the application of PNF-KT may be a feasible therapeutic method for improving ankle movement and balance in patients with chronic stroke. Additional research is recommended to identify the long-term effects of the PNF-KT.

Effects of Two Foot-Ankle Interventions on Foot Structure, Function, and Balance Ability in Obese People with Pes Planus

Obese people are prone to foot deformities such as flat feet. Foot management programs are important to prevent them. This study investigated the effects of two foot-ankle interventions on balance ability, foot arch, ankle strength, plantar fascia thickness, and foot functions in obese people with pes planus for four weeks. The experiment was designed as a randomized controlled trial. Twenty-four participants who met the inclusion criteria were selected, and they were randomly assigned to either a short foot group (SFG) or proprioceptive neuromuscular facilitation group (PNFG) according to foot-ankle intervention. Two interventions were commenced three times a week for 20 min over four weeks. The tests were conducted at two intervals: pre-intervention and at four weeks. The tests were conducted in the following order: the patient-specific functional scale test (PSFS), an ultrasound of the plantar fascia, the navicular drop test, balance test, and the four-way ankle strength test. Two groups showed significant differences in balance ability, foot arch, ankle strength, plantar fascia thickness, and foot functions between pre-test and post-test (p < 0.05). PNFG had significantly higher dorsiflexor and invertor strength than SFG (p < 0.05). SF and PNF interventions were effective to improve balance ability, foot arch, ankle strength, plantar fascia thickness, and foot functions in obese people with pes planus. Additionally, PNF intervention is more beneficial in increasing the dorsiflexor and invertor strength compared to SF intervention.

Acute response on general and sport specific hip joint flexibility to training with novel sport device

The study objective is to test general- and sport-specific adaption during a single training on the Flexibility Trainer. The device is designed to trigger residual muscle tone decreases of the hip-joint muscles by providing (nearly) isokinetic resistance during a full range of motion strength training in adduction/abduction and flexion/extension direction. Static hip flexion and abduction as well as kinematics of double side kicks were analysed on 15 participants before and after training (or rest for controls) to assess general flexibility and sport-specific movement range. Tests were recorded by a Vicon® motion capturing system. Static hip flexion and abduction as well as leg vector spreading angles (VSA) at different nodes of the kick were selected to determine adaptions of active and passive flexibility. Normalised hip joint moments, movement velocities and VSA were calculated to evaluate the training with the device. ANOVAs with 4-repeated measures and Friedman tests were performed to identify time differences and Bonferroni post-hoc test to identify between-subject effects. Significant differences were found for both static flexibility tests (Flexion = 13.65%; Abduction = 9.94%) and the VSA at specific action phases (≤15.15%). Results indicate that short-term adaptions when training with the Flexibility Trainer are exceeding comparable literature showing improved flexibility and sport-specific performance.

Post-stroke BDNF concentration changes following proprioceptive neuromuscular facilitation (PNF) exercises

Background:

Brain-derived neurotrophic factor (BDNF) plays an important role in repairing normal as well as in the injured brain. Physical exercise may have a positive impact on the release of BDNF.

Objective:

PNF is a neurophysiological approach that facilitates the stimulation of central and peripheral nervous systems. In this study, our aim was to assess the levels of BDNF as well as functional recovery before and after the intervention of PNF in patients with acute stroke.

Methods:

A total of 208 patients with first time confirmed stroke were recruited and assessed for stroke severity, type, mini-mental state exam (MMSE), functional independence measure scale, and BDNF levels before and after PNF intervention. BDNF levels were also assessed in healthy individuals for control values.

Results:

A significant decline in levels of BDNF was observed after in stroke. BDNF levels in patients (with different risk factors) with diabetes, hypertension and DM+ HTN, alcohol, and smoking history were 8.8 ± 4.04 ng/mL, 8.86 ± 4.68 ng/mL, 8.65 ± 3.26 ng/mL, 8.51 ± 4.26 ng/mL, and 8.9 ± 3.4 ng/mL, respectively. A decline in BDNF levels was observed in accordance with the severity of stroke in both ischemic and hemorrhagic stroke with the least level being in severe stroke (NIHSS >15 and ICH >3). Despite the type of stroke and the presence of risk factors, a significant improvement in BDNF levels and FIM scale scores was seen in all subjects who received PNF exercises.

Conclusion:

Thus, PNF is efficient in improving functional level in acute stroke irrespective of the type of stroke and risk factors.

Comparison of the Intrinsic Foot Muscle Activities between Therapeutic and Three-Dimensional Foot-Ankle Exercises in Healthy Adults: An Explanatory Study

Background: In recent years, a three-dimensional ankle exercise has been proposed as a practice for strengthening the intrinsic foot muscles, however this topic still requires further research. This study aimed to compare the activities of the intrinsic muscles in healthy participants during 3D foot–ankle exercises, namely, short foot (SF), and toe spread out (TSO). Methods: Prior to the experiment, 16 healthy adults were trained on how to perform SF, TSO, and 3D foot–ankle exercises for an hour. Once all participants passed the foot–ankle exercise performance test, we randomly measured the activity of the intrinsic foot muscles using electromyography while the patients were performing foot–ankle exercises. Results: The abductor hallucis (AbH), extensor hallucis longus (EHL), and flexor hallucis brevis (FHB) activities showed significant differences among the exercises for intrinsic foot muscle strengthening (p < 0.01). Additionally, the AbH/AdH (adductor hallucis) ratio showed significant differences among the exercises for strengthening the intrinsic foot muscles (p < 0.01). Conclusions: Our results showed that the 3D extension exercise is as effective as the therapeutic exercise in terms of the AbH and FHB activities, and the AbH/AdH ratio. On the contrary, the 3D flexion exercise showed superiority in terms of the EHL activity.

Effects of EMG-triggered FES during trunk pattern in PNF on balance and gait performance in persons with stroke

BACKGROUND

EMG-triggered functional electrical stimulation (EMG-triggered FES) is one of the effective method for improving task performance and providing movement re-learning of central nervous system. Proprioceptive neuromuscular facilitation (PNF) is a traditional manual therapy that is used as a method to regain normal movement by providing specific training methods.

OBJECTIVE

The purpose of this study was to investigate the effect of EMG-triggered FES during trunk pattern in PNF on trunk control, balance, and gait of stroke patients.

METHODS

Forty participants were randomly allocated to EMG-triggered FES during PNF trunk pattern group (n = 20) and PNF trunk pattern group (n = 20). This study was a pretest-posttest with a control group design for duration of 4weeks (30 min/5 times/1 week). Outcome measures involved trunk impairment scale (TIS), Berg balance scale (BBS), and dynamic gait index (DGI).

RESULTS

In the experimental group and control group, TIS, BBS, and DGI score was significantly increased after intervention. However, there was no significant difference between the two groups in the comparison of the experimental group and the control group according to the amount of change before and after the training.

CONCLUSIONS

The results of this study showed that PNF trunk pattern affected the trunk control for stroke patients, and increased trunk control ability was effective in improving balance and walking. In addition, it was found that the EMG-triggered FES applied to the PNF trunk pattern affected the trunk control.

Immediate effects of the respiratory stimulation on ventilation parameters in ischemic stroke survivors: A randomized interventional study (CONSORT)

BACKGROUND

Post-stroke brain damage, which affects the central control of respiration, leads to various respiratory disorders. They can be caused by the weakening of the respiratory muscles and chest movements, which can indirectly contribute to an impairment of the ventilation function. The aim of the study is an objective assessment of the effect of a single-session intervention of respiratory stimulation through Proprioceptive Neuromuscular Facilitation (PNF) on chosen respiratory parameters and the following comparison of these changes with a group in which positioning was used (intra- and intergroup comparison).

METHODS

This was a randomized interventional study evaluating the respiratory parameters depending on the applied respiratory stimulation in patients after ischemic stroke. The patients qualified to participate in the study were randomly assigned to 1 of 2 groups: PNF-treated group - in which respiratory stimulation through PNF was used, PNF untreated group - in which positioning was used. The research procedure consisted of several stages. First, an interview was conducted with each participant and basic data was collected. Then, spirometry was conducted, after which each patient underwent a single-session intervention according to their assigned group. Finally, the patients were given another spirometry examination. The main outcomes will be to compare the results of a spirometry test (FVC, FEV1, FEV1/ FVC%, PEF) before and after single-session intervention and between groups.

RESULTS

Based on the inclusion and exclusion criteria for the study, 60 patients took part in the measurement. The values of FEV1/FVC% were higher in PNF-treated group than in PNF-untreated group, if the post-intervention measures (P = .04) are considered. The difference between the pre- and post-intervention results of the FEV1/FVC% values in PNF-untreated group was substantially lower than in PNF-treated group (P = .001).

CONCLUSION

A single application of respiratory stimulation through PNF positively affect air flow in the respiratory tract. Application of PNF stimulation contributed to an increase in the FEV1/FVC% parameter. However, no positive changes were noted in the other parameters, which would provide proof of the beneficial effect of facilitation on the respiratory system function.

The effect of the contract-relax-agonist-contract (CRAC) stretch of hamstrings on range of motion, sprint and agility performance in moderately active males: A randomised control trial

Background

Although stretching is done routinely to prevent injury during explosive sport activities, there is some concern that effective stretching might negatively impact on performance.

Objective

This study's main objective was to investigate the impact of a specific stretch, the contract-relax-agonist-contract (CRAC) stretch, in which the muscle to be stretched, namely, the hamstrings, is actively contracted and then relaxed. This is followed by the antagonist muscle (the quadriceps) contracting. Secondly, the impact of the stretch on performance was examined.

Methods

A randomised control trial was used. Forty healthy active males between 21 and 35 years old were assigned to either receive three repetitions of CRAC or rest. Hamstring flexibility and the Illinois Agility Test were the primary outcome measures.

Results

The intervention was effective in improving hamstring flexibility by 37% immediately post-application and was maintained for eight minutes thereafter. It had no significant effect on agility or sprint times.

Conclusion

CRAC, when applied to stretch the hamstring muscles of active males, resulted in a large increase of active knee extension range of motion, without decreasing performance. Therefore, CRAC appears to be a safe and effective method of increasing the length of the hamstrings pre-sport activity and should be utilised by sports physiotherapists if deemed necessary. It was also shown to be beneficial following the initial assessment.

The Effectiveness of PNF Versus Static Stretching on Increasing Hip-Flexion Range of Motion

Clinical Scenario: Stretching is applied for the purposes of injury prevention, increasing joint range of motion (ROM), and increasing muscle extensibility. Many researchers have investigated various methods and techniques to determine the most effective way to increase joint ROM and muscle extensibility. Despite the numerous studies conducted, controversy still remains within clinical practice and the literature regarding the best methods and techniques for stretching. Focused Clinical Question: Is proprioceptive neuromuscular facilitation (PNF) stretching more effective than static stretching for increasing hamstring muscle extensibility through increased hip ROM or increased knee extension angle (KEA) in a physically active population? Summary of Key Findings: Five studies met the inclusion criteria and were included. All 5 studies were randomized control trials examining mobility of the hamstring group. The studies measured hamstring ROM in a variety of ways. Three studies measured active KEA, 1 study measured passive KEA, and 1 study measured hip ROM via the single-leg raise test. Of the 5 studies, 1 study found greater improvements using PNF over static stretching for increasing hip flexion, and the remaining 4 studies found no significant difference between PNF stretching and static stretching in increasing muscle extensibility, active KEA, or hip ROM. Clinical Bottom Line: PNF stretching was not demonstrated to be more effective at increasing hamstring extensibility compared to static stretching. The literature reviewed suggests both are effective methods for increasing hip-flexion ROM. Strength of Recommendation: Using level 2 evidence and higher, the results show both static and PNF stretching effectively increase ROM; however, one does not appear to be more effective than the other.

Is it possible to stabilize the trunk using rhythmic stabilization in the upper limb? A cross-sectional study of asymptomatic individuals

Objective: The study aim was to evaluate the immediate effect of rhythmic stabilization on local and distant muscles involved in a functional reach. Method: Prospective, observational cross-sectional study. Eight right-handed and non-impaired individuals (4 females and 4 males) aged 18-24 years (21.5 ± 1.58 years) were evaluated. Bilateral electromyographic recording of the biceps brachii, triceps brachii, multifidus lumbar, and rectus abdominis muscles was performed during three different tasks. Task 1 involved functional reach, while Task 2 involved rhythmic stabilization followed by a functional reach. Task 3 was similar to Task 2, but with 3 repetitions before a functional reach. Results: The results showed no difference between the tasks or sides. However, an interaction was observed between each side and muscles, with greater activation of the right multifidus lumbar muscle. Conclusion: Rhythmic stabilization during the task of reaching promotes an increase of multifidus activity ipsilateral to its application. Thus, this particular technique of proprioceptive neuromuscular facilitation can be useful for improving stability of the trunk and can be used in clinical practice for this purpose. Level of Evidence: 5.

The Efficacy of the proprioceptive neuromuscular facilitation (PNF) approach in stroke rehabilitation to improve basic activities of daily living and quality of life: a systematic review and meta-analysis protocol

INTRODUCTION

Proprioceptive neuromuscular facilitation (PNF) is a widely used rehabilitation concept, although its efficacy has not yet been demonstrated in stroke survivors. The aim of this systematic review is to identify, assess and synthesise the potential benefits of using PNF to improve the activities of daily living (ADL) and quality of life (QoL) of individuals with stroke.

METHODS AND ANALYSIS

A systematic electronic search will be conducted in MEDLINE, Embase, CENTRAL and PEDro. We will include randomised or quasi-randomised controlled trials of PNF interventions conducted in stroke survivors up to April 2017. Two review authors will independently select relevant studies and will extract data using the Cochrane handbook for systematic reviews of interventions approach and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). The methodological quality will be assessed by using the PEDro scale. Finally, with the permitted numeric data, we will carry out a meta-analysis.

ETHICS AND DISSEMINATION

Ethical considerations will not be required. Results will be disseminated in a peer-review journal. This systematic review aims to examine the effects of PNF (neurophysiological approach) in order to clarify its efficacy in improving ADL and QoL in the rehabilitation process of stroke survivors.

PROSPERO REGISTRATION NUMBER

CRD42016039135.

Synergistic Effects of Proprioceptive Neuromuscular Facilitation and Manual Lymphatic Drainage in Patients with Mastectomy-Related Lymphedema

Purpose: Manual lymphatic drainage (MLD) and proprioceptive neuromuscular facilitation (PNF) are potential therapeutic strategies to reduce mastectomy-induced edema. The purpose of this study was to investigate whether the combination of these therapies would induce synergistic effects to treat lymphedema-related complications and to analyze a possible physiological mechanism involved in the observed effects.

Methods: A total of 55 patients diagnosed with mastectomy-induced lymphedema were recruited and randomized into three experimental groups: PNF group (n = 17), MLD group (n = 20), and PNF + MLD group (n = 18). They were subjected to designated rehabilitation program three times a week for 16 weeks. ROM (flexion of the shoulder joint), edema size, arterial blood flow velocity, and degree of pain and depression were measured every 4 weeks over experimental period.

Results: Lymphedema volume, VAS pain scale, and Beck depression scale were decreased in PNF and MLD groups for 16 weeks in a time-dependent manner. In combination, a greater reduction of these variables was observed over 16 weeks compared to each PNF and MLD. While axillary arterial blood circulation rate in the affected extremity was increased in both PNF and PNF + MLD groups over 16 weeks, this value was not increased in MLD group throughout the experimental period. A greater reduction of scales of VAS pain and Beck Depression Inventory (BDI) was observed in PNF + MLD group after the 16 week-treatment, as compared to each PNF and MLD group. Pearson's coefficients test demonstrated that there are significant correlation of depression against pain (r = 0.616, p < 0.01), ROM (r = −0.478, p < 0.01), and lymphedema size (r = 0.492, p < 0.01).

Conclusion: The combination of MLD and PNF induces potent synergistic effects on edema volume, shoulder range of motion (ROM), pain, and depression in patients with lymphedema. In addition, an increased rate of axillary arterial blood flow in PNF-treated patients provide a potential physiological mechanism by which local arterial pulsation in the affected extremity plays a positive role in the treatment of lymphedema. Therefore, it is suggested to incorporate an element of PNF into traditional MLD method to facilitate treatment process for patients with lymphedema.

Can chronic stretching change the muscle-tendon mechanical properties? A review

It is recognized that stretching is an effective method to chronically increase the joint range of motion. However, the effects of stretching training on the muscle-tendon structural properties remain unclear. This systematic review with meta-analysis aimed to determine whether chronic stretching alter the muscle-tendon structural properties. Published papers regarding longitudinal stretching (static, dynamic and/or PNF) intervention (either randomized or not) in humans of any age and health status, with more than 2 weeks in duration and at least 2 sessions per week, were searched in PubMed, PEDro, ScienceDirect and ResearchGate databases. Structural or mechanical variables from joint (maximal tolerated passive torque or resistance to stretch) or muscle-tendon unit (muscle architecture, stiffness, extensibility, shear modulus, volume, thickness, cross-sectional area, and slack length) were extracted from those papers. A total of 26 studies were selected, with a duration ranging from 3 to 8 weeks, and an average total time under stretching of 1165 seconds per week. Small effects were seen for maximal tolerated passive torque, but trivial effects were seen for joint resistance to stretch, muscle architecture, muscle stiffness, and tendon stiffness. A large heterogeneity was seen for most of the variables. Stretching interventions with 3- to 8-week duration do not seem to change either the muscle or the tendon properties, although it increases the extensibility and tolerance to a greater tensile force. Adaptations to chronic stretching protocols shorter than 8 weeks seem to mostly occur at a sensory level.

A randomized controlled trial on the long-term effects of proprioceptive neuromuscular facilitation training, on pain-related outcomes and back muscle activity, in patients with chronic low back pain

BACKGROUND

The role of exercise therapy in improving pain-related clinical outcomes and trunk muscle activity in patients with chronic low back pain (CLBP) has been widely reported. There is little information on the effect of proprioceptive neuromuscular facilitation (PNF) training in patients with CLBP. The purpose of the present study was therefore to investigate the persistence of the effects of PNF training on pain intensity, functional disability, patient satisfaction, health-related quality of life (HRQOL) and lower back muscle activity in patients with CLBP.

METHODS

Forty-two participants with CLBP were randomly assigned either to 4-week PNF training or to a control group receiving a Low back pain educational booklet. Pain-related outcomes, including pain intensity, functional disability, patient satisfaction, HRQOL and lumbar erector spinae (LES) muscle activity, were measured before and after the intervention, and at a follow-up session 12 weeks after the last intervention session.

RESULTS

Compared with the control group, after undergoing a 4-week PNF training intervention, participants showed a significant reduction in pain intensity and functional disability, and improved patient satisfaction and HRQOL (p < 0.01). These effects were still significant at the 12-week follow-up assessment (p < 0.01). LES muscle activity in the PNF training group was significantly increased throughout the measurement periods compared with controls (p < 0.01).

CONCLUSIONS

The study found that 4-week PNF training has positive long-term effects on pain-related outcomes, and increases lower back muscle activity in patients with CLBP.

Prophylactic stretching does not reduce cramp susceptibility

INTRODUCTION

Some clinicians advocate stretching to prevent muscle cramps. It is unknown whether static or proprioceptive neuromuscular facilitation (PNF) stretching increases cramp threshold frequency (TF_c ), a quantitative measure of cramp susceptibility.

METHODS

Fifteen individuals completed this randomized, counterbalanced, cross-over study. We measured passive hallux range of motion (ROM) and then performed 3 minutes of either static stretching, PNF stretching (hold-relax-with agonist contraction), or no stretching. ROM was reassessed and TF_c was measured.

RESULTS

PNF stretching increased hallux extension (pre-PNF 81 ± 11°, post-PNF 90 ± 10°; P < 0.05) but not hallux flexion (pre-PNF 40 ± 7°, post-PNF 40 ± 7°; P > 0.05). Static stretching increased hallux extension (pre-static 80 ± 11°, post-static 88 ± 9°; P < 0.05) but not hallux flexion (pre-static 38 ± 9°, post-static 39 ± 8°; P > 0.05). No ROM changes occurred with no stretching (P > 0.05). TF_c was unaffected by stretching (no stretching 18 ± 7 Hz, PNF 16 ± 4 Hz, static 16 ± 5 Hz; P = 0.37).

DISCUSSION

Static and PNF stretching increased hallux extension, but neither increased TF_c . Acute stretching may not prevent muscle cramping. Muscle Nerve 57: 473-477, 2018.

Correct the smile of a child by neuromuscular facilitation technique: An interesting case report

Bell's palsy (BP) in children is a rare case with no documented evidence regarding its rehabilitation management. Till date, individuals with BP are being treated with electrical stimulation are proportionately greater than other conventional means such as facial exercise and massage. These conventional modes of treatment have proved to have less incidence of synkinesis with more benefits. Here, we report a case of a 7-year-old boy diagnosed clinically to have right idiopathic facial nerve paralysis, who underwent 14 days of facial proprioceptive neuromuscular facilitation exercises along with facial therapeutic massage. Documented improvements in facial grading system reveal promising outcomes. Hence, we propose the above technique might improve the functional outcome in the children with BP.

Robot-Assisted Rehabilitation of Ankle Plantar Flexors Spasticity: A 3-Month Study with Proprioceptive Neuromuscular Facilitation

In this paper, we aim to investigate the effect of proprioceptive neuromuscular facilitation (PNF)-based rehabilitation for ankle plantar flexors spasticity by using a Robotic Ankle-foot Rehabilitation System (RARS). A modified robot-assisted system was proposed, and seven poststroke patients with hemiplegic spastic ankles participated in a 3-month robotic PNF training. Their impaired sides were used as the experimental group, while their unimpaired sides as the control group. A robotic intervention for the experimental group started from a 2-min passive stretching to warming-up or relaxing the soleus and gastrocnemius muscles and also ended with the same one. Then a PNF training session including 30 trials was activated between them. The rehabilitation trainings were carried out three times a week as an addition to their regular rehabilitation exercise. Passive range of motion, resistance torque, and stiffness were measured in both ankles before and after the interventions. The changes in Achilles tendon length, walking speed, and lower limb function were also evaluated by the same physician or physiotherapist for each participant. Biomechanical measurements before interventions showed significant difference between the experimental group and the control group due to ankle spasticity. For the control group, there was no significant difference in the 3 months with no robotic intervention. But for the experimental group, passive dorsiflexion range of motion increased (p < 0.01), resistance torque under different dorsiflexion angle levels (0°, 10°, and 20°) decreased (p < 0.05, p < 0.001, and p < 0.001, respectively), and quasi-static stiffness under different dorsiflexion angle levels (0°, 10°, and 20°) also decreased (p < 0.01, p < 0.001, and p < 0.001, respectively). Achilles's tendon length shortened (p < 0.01), while its thickness showed no significant change (p > 0.05). The robotic rehabilitation also improved the muscle strength (p < 0.01) and muscle control performance (p < 0.001). In addition, improvements were observed in clinical and functional measurements, such as Timed Up-and-Go (p < 0.05), normal walking speed (p > 0.05), and fast walking speed (p < 0.05). These results indicated that the PNF-based robotic intervention could significantly alleviate lower limb spasticity and improve the motor function in chronic stroke participant. The robotic system could potentially be used as an effective tool in poststroke rehabilitation training.

Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review

Recently, there has been a shift from static stretching (SS) or proprioceptive neuromuscular facilitation (PNF) stretching within a warm-up to a greater emphasis on dynamic stretching (DS). The objective of this review was to compare the effects of SS, DS, and PNF on performance, range of motion (ROM), and injury prevention. The data indicated that SS- (-3.7%), DS- (+1.3%), and PNF- (-4.4%) induced performance changes were small to moderate with testing performed immediately after stretching, possibly because of reduced muscle activation after SS and PNF. A dose-response relationship illustrated greater performance deficits with ≥60 s (-4.6%) than with <60 s (-1.1%) SS per muscle group. Conversely, SS demonstrated a moderate (2.2%) performance benefit at longer muscle lengths. Testing was performed on average 3-5 min after stretching, and most studies did not include poststretching dynamic activities; when these activities were included, no clear performance effect was observed. DS produced small-to-moderate performance improvements when completed within minutes of physical activity. SS and PNF stretching had no clear effect on all-cause or overuse injuries; no data are available for DS. All forms of training induced ROM improvements, typically lasting <30 min. Changes may result from acute reductions in muscle and tendon stiffness or from neural adaptations causing an improved stretch tolerance. Considering the small-to-moderate changes immediately after stretching and the study limitations, stretching within a warm-up that includes additional poststretching dynamic activity is recommended for reducing muscle injuries and increasing joint ROM with inconsequential effects on subsequent athletic performance.

Magnitudes of gluteus medius muscle activation during standing hip joint movements in spiral-diagonal patterns using elastic tubing resistance

The aim of this study was to simultaneously quantify electromyographic (EMG) activation levels (% maximum voluntary isometric contraction [MVIC]) within the gluteus medius muscles on both moving and stance limbs across the performance of four proprioceptive neuromuscular facilitation (PNF) spiral-diagonal patterns in standing using resistance provided by elastic tubing. Differential EMG activity was recorded from the gluteus medius muscle of 26 healthy participants. EMG signals were collected with surface electrodes at a sampling frequency of 1000 Hz during three consecutive repetitions of each spiral-diagonal movement pattern. Significant differences existed among the four-spiral-diagonal movement patterns (F3,75 = 19.8; p < 0.001). The diagonal two flexion [D2F] pattern produced significantly more gluteus medius muscle recruitment (50 SD 29.3% MVIC) than any of the other three patterns and the diagonal one extension [D1E] (39 SD 37% MVIC) and diagonal two extension [D2E] (35 SD 29% MVIC) patterns generated more gluteus medius muscle recruitment than diagonal one flexion [D1F] (22 SD 21% MVIC). From a clinical efficiency standpoint, a fitness professional using the spiral-diagonal movement pattern of D2F and elastic tubing with an average peak tension of about 9% body mass may be able to concurrently strengthen the gluteus medius muscle on both stance and moving lower limbs.

Task complexity and maximal isometric strength gains through motor learning

This study compared the effects of a simple versus complex contraction pattern on the acquisition, retention, and transfer of maximal isometric strength gains and reductions in force variability. A control group (N = 12) performed simple isometric contractions of the wrist flexors. An experimental group (N = 12) performed complex proprioceptive neuromuscular facilitation (PNF) contractions consisting of maximal isometric wrist extension immediately reversing force direction to wrist flexion within a single trial. Ten contractions were completed on three consecutive days with a retention and transfer test 2‐weeks later. For the retention test, the groups performed their assigned contraction pattern followed by a transfer test that consisted of the other contraction pattern for a cross‐over design. Both groups exhibited comparable increases in strength (20.2%, P < 0.01) and reductions in mean torque variability (26.2%, P < 0.01), which were retained and transferred. There was a decrease in the coactivation ratio (antagonist/agonist muscle activity) for both groups, which was retained and transferred (35.2%, P < 0.01). The experimental group exhibited a linear decrease in variability of the torque‐ and sEMG‐time curves, indicating transfer to the simple contraction pattern (P < 0.01). The control group underwent a decrease in variability of the torque‐ and sEMG‐time curves from the first day of training to retention, but participants returned to baseline levels during the transfer condition (P < 0.01). However, the difference between torque RMS error versus the variability in torque‐ and sEMG‐time curves suggests the demands of the complex task were transferred, but could not be achieved in a reproducible way.

This study examines the effect of task complexity on the acquisition, retention, and transfer of increases in maximal strength and decreases in force variability, which is novel. Simple agonist‐only contractions are compared to a more complex reversal contraction pattern as used during proprioceptive neuromuscular facilitation (PNF). The goal was to determine if the more complex contraction pattern interferes with the strength gains and reduced variability by impeding the development of agonist‐antagonist coordination.

Use of post-isometric relaxation in the chiropractic management of a 55-year-old man with cervical radiculopathy

This case report chronicles the successful management of a 55-year-old patient diagnosed with cervical radiculopathy using spinal manipulative therapy and cervical paraspinal post-isometric relaxation stretches.

Acute effects of three different stretching protocols on the wingate test performance

The purpose of this study was to examine the acute effects of different stretching exercises on the performance of the traditional Wingate test (WT). Fifteen male participants performed five WT; one for familiarization (FT), and the remaining four after no stretching (NS), static stretching (SS), dynamic stretching (DS), and proprioceptive neuromuscular facilitation (PNF). Stretches were targeted for the hamstrings, quadriceps, and calf muscles. Peak power (PP), mean power (MP), and the time to reach PP (TP) were calculated. The MP was significantly lower when comparing the DS (7.7 ± 0.9 W/kg) to the PNF (7.3 ± 0.9 W/kg) condition (p < 0.05). For PP, significant differences were observed between more comparisons, with PNF stretching providing the lowest result. A consistent increase of TP was observed after all stretching exercises when compared to NS. The results suggest the type of stretching, or no stretching, should be considered by those who seek higher performance and practice sports that use maximal anaerobic power.

Electromyographic activity of scapular muscles during diagonal patterns using elastic resistance and free weights

PURPOSE/BACKGROUND

Abnormalities in glenohumeral rhythm and neuromuscular control of the upper trapezius (UT), middle trapezius (MT), lower trapezius (LT) and serratus anterior (SA) muscles have been identified in individuals with shoulder pain. Upper extremity diagonal or proprioceptive neuromuscular facilitation (PNF) patterns have been suggested as effective means of activating scapular muscles, yet few studies have compared muscular activation during diagonal patterns with varying modes of resistance. The purpose of this study is to determine which type of resistance and PNF pattern combination best elicits electromyographic (EMG) activity of the scapular muscles.

METHODS

Twenty one healthy subjects with no history of scapulohumeral dysfunction were recruited from a population of convenience. Surface electrodes were applied to the SA, UT, MT and LT and EMG data collected for each muscle as the subject performed resisted UE D1 flexion, UE D1 extension, UE D2 flexion and UE D2 extension with elastic resistance and a three pound weight.

RESULTS

No significant differences were found between scapular muscle activity during D1 flexion when using elastic resistance and when using a weight. UT, MT and LT values were also not significantly different during D2 flexion when using elastic resistance vs. using a weight. The activity of the SA remained relatively the same during all patterns. The LT activity was significantly greater during D2 flexion with elastic resistance than during the D1 flexion and D1 extension with elastic resistance. MT activity was significantly greater during D2 flexion with elastic resistance as compared to all other patterns except D2 flexion with a weight. UT activity was significantly greater during flexion patterns than extension patterns.

CONCLUSIONS

The upper extremity PNF pattern did significantly affect the mean UT, MT and LT activity but was not found to significantly affect SA activity. The type of resistance did not significantly change muscle activity when used in the same diagonal patterns.

The effects of an active-assisted stretching program on functional performance in elderly persons: a pilot study

This study examined the impact of an eight-week active-assisted (AA) stretching program on functionality, mobility, power, and range of motion (ROM) in elderly residents of a residential retirement community. Seventeen volunteers (4 male, 13 female; 88.8 ± 5.36 years) were randomly assigned to an AA or control group. The AA group performed 10 different AA stretches targeting the major joints of the body twice weekly for eight weeks. Controls attended classes requiring limited physical activity. All participants were assessed using four flexibility and six functional tests, one week before and after the eight-week training period. A fully randomized repeated-measures ANCOVA with pretest scores as a covariate was used to detect differences between groups across time. The AA group demonstrated significant increases in ROM for most of the joints evaluated (p < 0.05) and significant increases in all performance measures (p < 0.05). Controls showed no improvements in functional or ROM measures (α = 0.05). Additionally, the AA group showed significantly better performance outcomes across the training period than controls. We conclude that our eight-week flexibility program effectively reduces age-related losses in ROM and improves functional performance in elderly persons with insufficient physical reserves to perform higher-intensity exercises.