DOI Number: 10.5958/0973-5674.2017.00051.
Effectiveness of Proprioceptive Neuromuscular Facilitation as
an Adjunct to Eccentric Exercises in
Subacromial Impingement
Akshata Sanjeev Jain1, S Anandh2, Amrutkuvar Pawar3
1
BPT Student, 2Professor, 3Lecturer, Krishna Institute of Medical Sciences,
Faculty of Physiotherapy, Karad, Satara, Maharashtra
ABSTRACT
Background: Shoulder pain is the third most common musculoskeletal condition. Shoulder Impingement is
the most frequent cause of pain and overhead limitation in the shoulder area which can hamper the activities
of daily living of an individual. So the present study was conducted to find out effect of Proprioceptive
neuromuscular facilitation as an adjunct to eccentric exercises in subacromial impingement.
Method: An Comparative study was conducted at Krishna College of Physiotherapy , Karad. 40 subjects
with age group between 25-60 years were taken. In Group A (20) subjects were treated with Proprioceptive
Neuromuscular Facilitation and Eccentric exercises along with conventional treatment and In Group B (20)
subjects were treated only with Eccentric exercises and conventional treatment.
Results: Statistical analysis was done using paired and unpaired”t” test, Mann Whitney test and Wilcoxon
matched pairs signed rank test. The results showed statistically significant improvement in pain ,overhead
reach, endurance and functional status of shoulder in group A (experimental group) as compared to group
B (p<0.001).
Conclusion: Present study concluded that PNF as an adjunct to eccentric exercises was more effective than
eccentric exercises alone in reducing pain, improving overhead reach, improving endurance and improving
functional status of shoulder .
Keywords: Proprioceptive neuromuscular facilitation (PNF), Eccentric exercises, Subacromial
Impingement(SAIS)
INTRODUCTION pain is the third most common musculoskeletal
condition. Rotator cuff injury is found to be more
The term “Impingement syndrome” was popularised
common in males4.
by Neer in1972 as a clinical entity in which the rotator
cuff was pathologically compressed against the anterior Eccentric strength training,first introduced in
structures of the coracoacromial arch, the anterior third 1984 by Stanish et al5 have for many years been used
of the acromion,the coracoacromial ligament and the AC successfully to treat other tendinopathies6-8. Eccentric
Joint2. The prevalence of shoulder symptoms have been exercises involves lengthening of the musculo-tendinous
reported to range from 35%3 and age and sex matched unit while a load is applied to it9. The current most
incidence of shoulder pain was 9.5 per 1000 .Shoulder common therapeutic exercise regimen for the treatment
of tendinopathy involves mechanically loading the
Corresponding author: painful and abnormal tissue with the use of eccentric
Ms. Akshata Sanjeev Jain exercises. Eccentric exercises is found to increase
BPT Student, Krishna Institute of Medical Sciences, the collagen synthesis in tendinopathies specially the
Faculty of Physiotherapy, Karad- 415110, Satara, peritendinous type I collagen which corresponds with
Maharashtra. Email id: akshatajain16@yahoo.com the reduced pain levels.Other proposed mechanisms
Indian Journal of Physiotherapy and Occupational Therapy. April-June 2017, Vol. 11, No. 2 142
include pain habituation as a result of several weeks months 5) Positive 3 tests out of the following:- a)
of pain provoking eccentric exercises, Neuromuscular Neer’s impingement test, b)Hawkins test, c)Jobe’s test,
benefits through central adaptation of both agonists and d)Speed’s test ,e) Painful arc – 60o-120o
antagonist muscles10 and increase in tendon stiffness11.
Exclusion Criterias were as follows: 1) Recent
Proprioceptive Neuromuscular Facilitation is history of surgery on particular shoulder 2) History of
an approach to therapeutic exercise that combines Rheumatoid arthritis, fracture around shoulder complex
functionally based diagonal patterns of movement 3) History of any Recent shoulder Injury 4) Any
with techniques of neuromuscular facilitation to evoke congenital abnormalities around the shoulder
motor responses and improve neuromuscular control
5) Frozen shoulder 6) Uncooperative subjects.
and function12.These techniques are utilized to assist
with initiating range of motion, increasing range of Subjects with subacromial impingement were
motion,decreasing pain, teaching a motion,strengthenin assessed by Visual Analogue Scale (VAS), Overhead
g,promoting stability,facilitating proprioception,increasi reach by measuring tape, Endurance by modified pull up
ng endurance and restoring function13.These techniques test and functional scores will be obtained by shoulder
include the proper manual contacts, resistance, quick pain and disability index (SPADI).Measurement of pain,
stretch, irradiation, traction and approximation, verbal overhead reach and endurance were made on all subjects
commands and visual cues14. PNF is a neurophysiologic on the first day before intervention and after 3 weeks of
approach to therapeutic exercises that can be used intervention.
during all phases of shoulder rehabilitation to address
multiple impairments and functional losses.PNF applies Procedure
neurophysiologic principles of the sensory and motor
The study protocol was presented in front of protocol
system to coordinate and efficiently perform purposeful
and Institutional Ethics Committee of KIMSDU,
movements of the shoulder15.
Karad.Subjects with Subacromial Impingement were
Thus there exists a need of incorporating regimens approached,purpose of the study was explained and
along with the strengthening exercises like eccentric written informed consent was taken from those willing
exercises which may help in relieving pain and reducing to participate.
functional disability along with improvement of
For Both the groups, Following treatment
endurance and long term effectiveness.
was given was given in common as a part of the
Thus this study is designed to find out whether conventional treatment:
Proprioceptive neuromuscular facilitation is beneficial
1.Cryotherapy in the form of cryopack applied
in achieving additional therapeutic effects when applied
over the painful area of shoulder for 15 minutes.
with the eccentric strengthening exercises.
2.Ultrasound: Pulsed ultrasound for 8 minutes with
MATERIALS AND METHOD
a device that was operated at a frequency of 1 MHz, and
This was a Comparative study which was conducted an intensity of 1.5 W/cm2
to evaluate effect of Proprioceptive Neuromuscular
3. Eccentric exercise program
Facilitation among 2 groups of subjects. The subjects
who meet the inclusion and exclusion criteria and Eccentric exercises for Rotator cuff muscles and
willing to participate in the study were included.We deltoid were given using theraband with subjects in
had approached and assessed 40 subjects as our study standing position. The subjects were asked to hold
population. The participants were explained about one end of the theraband with the other end under
the study and the evaluation procedure. The informed the corresponding foot & then asked to perform the
consent was obtained from the individuals. Inclusion shoulder movements of flexion, extension, abduction,
Criterias were as follows :1) Both male and female adduction and rotations against the desired resistance.
participants willing to participate in the study,2)Age During each exercise, the Subjects were asked to quickly
Group - 25-60 yrs, 3)VAS score more than 5 during move in the desired direction and consequently slowly
Arm Elevation. 4)Pain in the shoulder for atleast 3 returning to the starting position. Each movement was
143 Indian Journal of Physiotherapy and Occupational Therapy, April-June 2017, Vol. 11, No. 2
performed for 3 Sets of 15 repetitions each with a rest rotation, GH external rotation.18.Each movement was
period of 60 seconds between each set16 performed for 3 sets of 5 repetitions.
GROUP A (Study group) 3. Subjects were instructed to actively move
through the PNF flexion-abduction-external rotation
Proprioceptive Neuromuscular facilitation was
diagonal pattern for 3 sets of 10 repetitons with
given:-
manual facilitation at the end of the session.
1.Scapular PNF
GROUP B
Scapular PNF was applied in two diagonal patterns,
Subjects in the Group B received Therapeutic
Anterior elevation and posterior depression with 3 sets
Ultrasound,Cryotherapy And Eccentric exercises. The
of 10 repetition.
intervention was given for 5 days per week for a total
Anterior elevation duration of 3 weeks for both the groups. (Total- 15
sessions) After the end of the 15 sessions, the subjects
Subjects were in the side lying position. The scapula were assessed for the outcome measures.
was gently be moved into a posterior depressed position
taking up the slack and thus applying a quick stretch.The FINDINGS
subject were asked to anteriorly elevate the scapula
Statistical analysis was done manually as well as
against appropriate resistance. Movement is a diagonal
using the statistics software INSTAT so as to verify the
arc up towards the patient’s nose17.
result obtained .Intragroup analysis of Nonparametric
Posterior Depression Data (Pain,Endurance, SPADI scores) was done using
Wilcoxon matched pairs test and Mann Whitney test
The subject will be placed in side-lying position was used for the intergroup analysis of nonparametric
with the movement occurring down to the ipsilateral data. Intragroup & Intergroup analysis of parametric
ischial tuberosity17. Data(Overhead Reach) was done using Paired &
Unpaired T test respectively.
2. Contract Relax – Glenohumeral (GH)
Flexion: RESULT
The limb was moved (active or passive) toward Age of the subjects in this study was between 25-60
the point of limitation. years.There was no significant difference between mean
• The subject performs an isotonic contraction into age of the subjects in two groups .Mean age group A
available GH flexion. was 42.95 years and that Group B was 43.35.
• Isometric contraction for 7-9 seconds into the
antagonist pattern (GH extension). Table1: Baseline characteristics of subjects
• Patient relaxes (2-3 secs).
Groups Gender Mean age Side affected
• Passive movement into the new range of the agonist
pattern (GH flexion) for a stretch of 10-15 seconds. Group A Male=12,Female=8 42.95 years Left=7,Right=13
• Repeat until no further gain can be achieved. Group B Male=11,Female=9 43.35 years Left=5,Right=15
• This technique was performed for other motions
at the shoulder including GH abduction, GH internal Table 2:Comparison of values of Visual analogue
scale
Pre- treatment Post-treatment
Group ‘p’
Mean ± SD Median Mean ± SD Median
A 6.9 ± 0.646 6.950 3.17 ± 1.018 3.200 <0.0001
B 6.83 ± 0.7116 6.850 5.30 ± 0.8395 5.350 <0.0001
P 0.7148 <0.0001
Intra group analysis of VAS score revealed statistically reduction in pain post interventionally for both the
Indian Journal of Physiotherapy and Occupational Therapy. April-June 2017, Vol. 11, No. 2 144
groups.Group A (p<0.0001), Group B (p<0.0001). Pre interventional analysis showed no significant difference
between group A and group B (p= 0.7148). Post intervention analysis showed significant difference between Group
A and Group B (p<0.0001).
Table 3: Comparison of values of Overhead reach
Pre- treatment Post-treatment
Group ‘p’
Mean ± SD Median Mean ± SD Median
177.44 ± 4.487 187.02 ± 4.892
A 176.55 185.95 <0.0001
B 175.51 ± 3.128 176.20 179.585 ± 4.031 180.10 <0.0001
P 0.1238 <0.0001
Intra group analysis of Overhead Reach values revealed statistically increase in Overhead Reach post
interventionally for both the groups Group A (p<0.0001), Group B (p<0.0001).. Pre interventional analysis showed
no significant difference between group A and group B (p=0.1238 ). Post intervention analysis showed significant
difference between Group A and Group B (p<0.0001).
Table 4: Comparison of values of Endurance
Pre- treatment Post-treatment
Group ‘p’
Mean ± SD Median Mean ± SD Median
A 8.1 ± 3.259 8.00 15.6 ± 4.248 16.00 <0.0001
B 6.7 ± 2.296 6.00 9.7 ± 2.940 9.00 <0.0001
P 0.1474 <0.0001
Intra group analysis of Endurance score revealed statistically reduction in pain post interventionally for both
the groups.Group A (p<0.0001), Group B (p<0.0001). Pre interventional analysis showed no significant difference
between group A and group B (p= 0.1474). Post intervention analysis showed significant difference between Group
A and Group B (p<0.0001).
Table 5: Comparison of values of SPADI
Pre- treatment Post-treatment
Group ‘p’
Mean ± SD Median Mean ± SD Median
A 84.6 ± 8.905 83 34 ± 9.171 32 <0.0001
B 83.45 ± 7.451 82.50 62.3± 11.810 60.50 <0.0001
P 0.8817 <0.0001
Intra group analysis of SPADI score revealed DISCUSSION
statistically reduction in pain and functional disability
Subacromial impingement syndrome in the shouder
scores post interventionally for both the groups. Group
is characterised by pain and overhead limitation due to
A (p<0.0001), Group B (p<0.0001). Post intervention
encroachment of the subacromial space and subsequent
analysis showed significant difference between Group
inflammation of the tendon of the rotator cuff and
A and Group B (p<0.0001)
subacromial bursa1.It is one of the common causes of
shoulder pain and disability and can severely hamper
the daily living of an individual19.The purpose of this
145 Indian Journal of Physiotherapy and Occupational Therapy, April-June 2017, Vol. 11, No. 2
study was to evaluate the effectiveness of proprioceptive Proprioceptive neuromuscular facilitation is an
neuromuscular facilitation as an adjunct to eccentric advanced form of flexibility training that involves both
exercises in subacromial impingement. the stretching and contraction of the muscle group being
targeted. PNF is effective in increasing the range of
The average mean age of participants in Group
motion because of the reciprocal activation of agonist
A was 42.95 ± 13.30and Group B was 43.35 ± 11.35,
and antagonist. It provides the greatest potential for
which showed there is no significant difference in age
muscle tendon as it lengthens the Golgi organ. When
of subjects in both groups (t = 1.1023 & p = 0.9190)
PNF (contract relax technique) is applied, the patient is
which was done by unpaired t-test. The total number
told to contract the muscle in internal rotation against the
of participants included were 40,out of which 23 were
resistance. Therefore, as the muscle tension develops,
males and 17 were females. Group A had 12 males and
the GTO fibers inhibit alpha motor neurons activity and
8 females and Group B had 11 males and 9 females. Out
decreases tension in the muscle tendon. Inhibition is the
of 40 subjects, 12 had left side SAIS and 28 had right
state of decreased neuronal activity and altered synaptic
side SAIS.
potential which reflexively diminishes the capacity
Overuse was the most common cause of shoulder of a muscle to contract. As the capacity of muscle to
pain and disability found in the subjects included in the contract decreases, the arm is moved to external rotation.
study. Likewise, the antagonists are contracted and agonists
are relaxed and again, tension is developed. This GTO
Wilcoxon matched pairs and Paired t test was monitors the excessive tension during muscle contraction
used to analyse the effect of Ultrasound, Cryotherapy and thus inhibits the excessive contractions21. Similarly
and Eccentric exercises which showed that there was the scapular pattern acts in the similar way by reciprocal
significant improvement in Pain, Overhead Reach, activation of the scapular stabilisers16.
Endurance, and Functional status of Shoulder Post
treatment. The result from the statistical analysis of present
study supported alternative hypothesis which stated that
It is been suggested eccentric exercises expose there will be beneficial effect to the subjects treated with
the tendon to a greater load than concentric exercises Proprioceptive Neuromusular Facilitation along with
and proposed an eccentric exercise program as the ultrasound therapy, Cryopack and Eccentric Exercises.
best mechanism for the strengthening the tendon. The
possible mechanisms for pain reduction may be related CONCLUSION
to increase in fibroblast activity, increase in type 1
Subjects treated with proprioceptive neuromuscular
collagen fibres, Remodelling of the tendon by muscle
facilitation as an adjunct to eccentric exercises was more
lengthening, Increase of sarcomeres in series and
effective than eccentric exercises alone in reducing
neuromuscular adaptation20
pain, improving overhead reach, improving endurance
Wilcoxon matched pairs & Paired t test was used and improving functional status of shoulder in subjects
to analyse the effect of Proprioceptive Neuromuscular with subacromial impingement
facilitation as an adjunct to Eccentric exercises which
Source of Funding: The source of funding for
showed that there was significant reduction in pain,
study is KIMSDU, Karad.
Overhead Reach,Endurance , and disability (p<0.0001)
post treatment. Conflict of Interest: There is no conflict of
interest.
Comparison of Pain, Overhead Reach, Endurance
and functional disability between two groups was done Ethical Clearance: Ethical clearance was taken
using Mann-Whitney test & Unpaired T test to find from institutional ethical committee of KIMSDU.
effectiveness between two groups
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