1. PNF for Chronic Low-back Pain
James Luker

2. Background
Hides et al (1992), (1994) first established that ultrasound was a valid method of measuring multifidus CSA, and that this muscle is atrophied ipsilaterally in LBP patients
O’Sullivan, Twomey, and Allison (1997) showed that retraining transversus abdominis w/multifidus decreased back pain long-term
Hides, Jull and Richardson (2001) reported a decrease in back pain recurrence rate at one-year with a similar training program
What can PNF do for us in this population?

3. PNF Techniques
Pelvic D1/D2
Scapular D1/D2
Rhythmic stabilizations

4. Indications for Use Low-back pain
Poor recruitment/use of spinal stabilizers/deep core
General strengthening of peri-spinal muscles

5. The Intervention Effects of Different Treatment for Chronic Low Back Pain as Assessed by the Cross-sectional Area of the Multifidus Muscle
PNF vs. NJF (Neuromuscular joint facilitation) vs. NJF + pelvic floor exercises
13 subjects mean age 23.6 with LBP for >6 months
Front lower pelvic pattern of PNF used (Presumably D1), traction + resistance given in opposition to PNF pattern.
CSA of multifidus measured with ultrasound during maximal contraction
NJF+PF > NJF > PNF for maximal CSA

6. The Effects on the Pain Index and Lumbar Flexibility of Obese Patients with Low Back Pain after PNF Scapular and PNF Pelvic Patterns
30 minute PNF-pattern based exercise session 3x/week for 4 weeks
Scapular/Pelvic D1/D2 exercise patterns.
Control group strengthening exercises 3x/week for 4 weeks
30 obese males with LBP
Lumbar ext ROM increased significantly and ODI decreased significantly in PNF group, relative to baseline and control group

7. The Effects of Combination Patterns of Proprioceptive Neuromuscular Facilitation and Ball Exercise on Pain and Muscle Activity of Chronic Low Back Pain Patients
PNF pattern exercise vs. ball exercise
PNF group “sprinter/skater posture” in parallel with PNF in various positions. Ball group pelvic tilts/leg lifts/marching following Janda’s basic program
40 subjects with CLBP mean age 34.7
Both groups showed stat sig. lower VAS after 6 weeks, with PNF>ball.
Both groups showed higher muscle activity (EMG) over time for TA/ES, PNF>Ball at 6 weeks though not stat sig.

8. Effects of Two 4-Week Proprioceptive Neuromuscular Facilitation Programs on Muscle Endurance, Flexibility, and Functional Performance in Women With Chronic Low Back Pain 
86 women mean age 40.1 with CLBP
4 weeks of training, 3 groups: Rhythmic stab training, isotonic exercises, control.
PNF group: 10s alternating trunk flex/ext isometric contractions, 3x15 at max resistance.
Isotonic group: Alternating trunk flex/ext concentric/eccentric 3x15 max resistance.
Measures taken at baseline, 4 weeks, 4 weeks post, and 8 weeks post.
Both exercise groups showed decreased ODI scores, increased lumbar mobility, increased lumbar muscle endurance, Isotonic > PNF

9. ????
PNF is not well studied
Low-power studies usually
Some current studies show that other modes of exercise are more effective
Much more hands-on than traditional therex – some patients may prefer this while others may not

10. Summary
PNF techniques including scapular/pelvic patterns and rhythmic stabilization can be effective in treating CLBP
Few current studies comparing PNF to other treatment modes
Useful as an option if other treatments are stalling
Further study useful to tease out more specific indications/techniques

11. References
The Intervention Effects of Different Treatment for Chronic Low Back Pain as Assessed by the Cross-sectional Area of the Multifidus Muscle
The Effects on the Pain Index and Lumbar Flexibility of Obese Patients with Low Back Pain after PNF Scapular and PNF Pelvic Patterns
The Effects of Combination Patterns of Proprioceptive Neuromuscular Facilitation and Ball Exercise on Pain and Muscle Activity of Chronic Low Back Pain Patients
Effects of Two 4-Week Proprioceptive Neuromuscular Facilitation Programs on Muscle Endurance, Flexibility, and Functional Performance in Women With Chronic Low Back Pain 

12. References
Hides, J., Jull, G., Richardson, C. (2001). Long-Term Effects of Specific Stabilising Exercises for First-Episode Low Back Pain. Spine, 26(11): E243-E248
Hides, J., Cooper, D, Stokes, M. (1992). Diagnostic imaging for the measurement of the lumbar multifidus muscle in normal young adults. Physiotherapy Theory and Practice, 8:19-26.
Hides, J., Stokes, M., Saide, M., Jull, G., Cooper, D. (1994). Evidence of Lumbar Multifidus Muscle Wasting Ipsilateral to Symptoms in Patients with Acute / Subacute Low Back Pain. Spine, 19 (2) :
O’Sullivan, P., Twomey, L., Allison, G. (1997). Evaluation of Specific Stabilising Exercise in the Treatment of Chronic Low Back Pain With Radiologic Diagnosis of Spondylosis or Spondylolisthesis