RESEARCH ARTICLE

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
Pattanasin Areeudomwong1,2*, Witchayut Wongrat1, Nertnapa Neammesri1 &
Thanaporn Thongsakul1
1

Department of Physical Therapy, School of Health Science, Mae Fah Luang University, Chiang Rai, Thailand

Research Center of Back, Neck, Other Joint Pain and Human Performance, Khon Kaen University, Khon Kaen, Thailand

Abstract
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 signicant reduction in pain intensity and functional disability, and improved patient satisfaction and
HRQOL (p < 0.01). These effects were still signicant at the 12-week follow-up assessment (p < 0.01). LES muscle
activity in the PNF training group was signicantly 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.
Keywords
proprioceptive neuromuscular facilitation; chronic low back pain; booklet; long-term effect; quality of life
*Correspondence
Pattanasin Areeudomwong, Department of Physical Therapy, School of Health Science, Mae Fah Luang University, Chiang Rai, 57100.
Thailand.
Email: pattanasin.are@mfu.ac.th

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1165

Introduction
Low back pain (LBP), one of the most common musculoskeletal problems, carries a high individual, community and global socioeconomic burden (Hoy et al.,
2012). Over four-fths of the world population
Musculoskelet. Care (2016) 2016 John Wiley & Sons, Ltd.

experiences LBP at least once in their lives (Rubin,

2007). The prevalence of chronic low back pain
(CLBP), dened as pain localized between the 12th
rib and the inferior gluteal folds for 3 months or more,
with no specic pathology, is 23% in patients with LBP

Areeudomwong et al.

Long-term effects of PNF training in CLBP patients

(Balagu et al., 2012). A number of factors have been

proposed as potential causes of LBP, including disturbances in trunk proprioception and back muscle weakness (Lee et al., 1999, 2010; van Tulder et al., 2000).
Thus, treatment interventions which improve trunk
proprioception and back muscle function may improve
clinical and physiological outcomes, and enhance the
quality of life, and well-being of patients.
Exercise therapy is suggested as a rst-line treatment
for CLBP (Bekkering et al., 2003). Exercise interventions, aimed at facilitating abdominal and back muscle
performance and enhancing proprioception, could improve clinical outcomes in CLBP patients (George et al.,
2013; Kofotolis & Kellis, 2006; Kofotolis et al., 2008; Lee
et al., 2014). Proprioceptive neuromuscular facilitation
(PNF) training is widely used by physical therapists to
treat CLBP patients (George et al., 2013; Kofotolis &
Kellis, 2006; Kofotolis et al., 2008; Lee et al., 2014) in order to promote or augment neuromuscular responses
by stimulating proprioceptors (Adler et al., 2014). The
PNF patterns are spiral and diagonal directions which
are accordance with topographic arrangement of the
muscle being used in activities and sports (Adler et al.,
2014). PNF training has been suggested to facilitate muscle performance through its movement patterns. (Adler
et al., 2014; Westwater-Wood et al., 2010), so it may be
more appropriate than conventional single-direction
exercise training for increasing human performance
and reducing LBP symptoms (Kofotolis & Kellis, 2006).
Several PNF training techniques have been proposed
for CLBP patient applications (George et al., 2013;
Kofotolis & Kellis, 2006; Kofotolis et al., 2008; Lee
et al., 2014; Voight et al., 2008). Three commonly used
techniques are rhythmic stabilization (RS), a combination of isotonics (COI) and chop and lift (CL)
(George et al., 2013; Kofotolis & Kellis, 2006; Kofotolis
et al., 2008; Lee et al., 2014; Voight et al., 2008).The RS
technique is primarily used for managing conditions
where muscle weakness is a major factor, and where
stabilization can stimulate the agonist movement pattern (Adler et al., 2014). The COI technique is used
to improve the ability to perform controlled movements, and to address deciencies in strength and
range of movement (Adler et al., 2014). The CL technique is another PNF technique used to promote trunk
movement involving the use of bilateral limbs (Adler
et al., 2014; Voight et al., 2008).
Previous studies have reported that PNF training can
decrease pain intensity and functional disability,

increase trunk range of movement and improve trunk

muscle activation, in CLBP patients (George et al.,
2013; Kofotolis & Kellis, 2006; Kofotolis et al., 2008).
Interestingly, Kofotolis & Kellis (2006) and Kofotolis
et al. (2008) found that after 4 weeks of PNF training,
there were persistent benecial effects in terms of reduced pain, improved functional ability and trunk
range of movements over 8 weeks after the intervention
had ceased.
Regarding the biopsychosocial model of CLBP management, improvement in patient functional ability cannot be thought of simply as a result of biomedical
changes, but instead as combined changes in biomedical
and psychosocial aspects (Sanders et al., 2013; Truchon,
2001). Koumantakis et al. (2005) suggested that exercise
therapy may provide not only physiological changes,
but also psychosocial benets to CLBP patients. Numerous LBP studies also proposed that the increase in functional ability after therapeutic exercises was associated
with positive effects on psychosocial outcomes such as
quality of life, patient satisfaction (Puntumetakul et al.,
2013) and activity-related fear (Marchand et al., 2015).
We therefore considered it important to evaluate, as secondary outcomes, psychosocial variables in the present
study, to take into account whether there were improvements after PNF training in CLBP patients.
To date, no studies have investigated the benecial
effects of a PNF training course, and the persistence
of these effect, on health-related quality of life
(HRQOL) (Jirarattanaphochai et al., 2005a), patient
satisfaction (Kamper et al., 2010) [both of which are
common assessment measures in the LBP literature
(Bombardier, 2000)] and lower back muscle activity
in patients with CLBP. Therefore, the objective of the
study was to investigate the effects of 4 weeks of applied
PNF training on pain intensity, functional disability,
HRQOL, patient satisfaction and lumbar erector spinae
(LES) muscle activity in patients with CLBP, and the
persistence of these effects after a further 12 weeks.

Methods
Study design
The study, conducted at the Physical Therapy Laboratory at Mae Fah Luang University, Thailand, was an
assessor-blind, randomized, controlled trial, with three
measurement points, including baseline testing, repeat
testing at the end of 4-week intervention and 12-week
follow-up.
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Areeudomwong et al.

Participants
Male or female patients (N = 42) with chronic, nonspecic LBP, aged 1850 years (35.4 10.3 years and
36.2 9.9 years for PNF training and control groups,
respectively), with pain intensity measured by at least
two numerical rating scale scores, were asked to participate in the study. The patients were recruited by an advertisement by the Physical Therapy Department of
Mae Fah Luang University Hospital and Nanglae and
Thasud primary hospitals in Chiang Rai, Thailand.
Prior to participation, the patients were screened using
an illness history interview and a physical examination
by a medical doctor who was unaware of the proposed
intervention. Patients were excluded from the study if
they were pregnant, had a previous history of spinal
surgery, neurological decits, specic LBP (including
facet joint syndrome, disc herniation and sacroiliac
joint dysfunction), cancer or other autoimmune diseases, screened by using plain radiography and clinical
tests, including sensory and motor assessments, straight
leg raise, Valsalva maneuvre test, facet quadrant test
and sacroiliac provocation tests (Laslett et al., 2005).
In addition, those who already received regular PNF
training or had been given an LBP educational booklet
were also deemed to be inappropriate for inclusion in
the study. The eligible patients gave written informed
consent prior to participation in the study, which was
approved by the Ethic Committee for Human Research
at Mae Fah Luang University (REH 58078), based on
the Declaration of Helsinki.
Sample size determination
A formula of repeated measures analysis of variance
(ANOVA) was used to estimate the sample size on
the basis of pain intensity using a numerical rating scale
ranging from 0 to 10, where 0 represents no pain and
10 represents the worst imaginable pain (Mannion
et al., 2007), at the 12-week follow-up and assuming a
signicance level of 5%, power of 90% and attrition
rate of 30%. A total sample size of 42 was required to
detect a clinically meaningful difference between
groups of two points on a numerical rating scale for
patients with CLBP (Farrar et al., 2001).
Treatment intervention
Eligible participants were randomly divided into two
groups (PNF training and control groups) by block
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Long-term effects of PNF training in CLBP patients

randomization, with block sizes of two, four and six.

Allocation results were concealed in sealed and opaque
envelopes with consecutive numbering. Eligible participants were randomly allocated to the control (N = 21)
and test (N = 21) groups. The allocation was undertaken by a research assistant who was not aware of
treatment and evaluation processes.

PNF training group protocol

The design of the 4-week PNF training sessions was
modied from the studies of Kotofolis & Kellis (2006)
and Voight et al. (2008). The participants were asked
to attend the Physical Therapy Laboratory for training
sessions ve times a week for 4 weeks, with each session
lasting about 30 min. Participants undertook three sets
of 15 repetitions for each PNF intervention, with rest
intervals of 30 seconds between the sets, and 60 seconds
after completing 15 repetitions for each movement pattern. The programme was divided into three phases.
The rst phase, week 1, focused on teaching the patient to be able correctly to alternate isometric contractions of the trunk exor and extensor muscles against
maximum resistance, provided by the physical therapist, while in a sitting position for 10 seconds
(Kofotolis & Kellis, 2006) (Figure 1A).
The second phase, week 2, focused on training the
participant to be able to perform alternating concentric
and eccentric contractions of trunk agonists, without
relaxation; this included a 5-second resisted concentric
trunk exion, followed by a 5-second resisted isometric
contraction in exion and then a 5-second resisted eccentric contraction of trunk exion (Kofotolis & Kellis,
2006) (Figure 1B).
The last phase, weeks 3 and 4, was aimed at promoting trunk movement in rotational and diagonal directions using bilateral diagonal limb movements, with
maximal resistance provided by the physical therapist.
The upper limbs alternately performed the CL movement sequences as described by Adler et al. (2014)
and Voight et al. (2008) (Figure 1C).

The LBP educational booklet (control

group)
The control group received an LBP educational booklet, as proposed by Coudeyre et al. (2007). The booklet
provided information about anatomy and the
causes of LBP, an active self-management approach

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Long-term effects of PNF training in CLBP patients

Figure 1. Rhythmic stabilization (A), combination of isotonics (B) and chop and lift (C) proprioceptive neuromuscular facilitation training
techniques

to LBP encouraging the patient to identify

postures/movements that are painful, activity for enhancing recovery, and rehabilitative exercises. The participants were assigned to perform, and practise,
exercises, according to the recommendations of the
booklet, in their homes on a daily basis. They were
asked to record their activities in a logbook for 4 weeks,
to monitor their compliance.
On completion of the 4-week intervention, participants in both groups were asked to stop the interventions completely, and the effects of the intervention
were evaluated. Another follow-up evaluation took
place after a further 12 weeks.

Measurements
All outcome measures were evaluated by a trained assessor who was blinded to the participants group
allocation.

Primary outcome
The pain intensity was assessed using the 11-point numerical rating scale (range, 010), where 0 represents

no pain and 10 represents the worst imaginable pain

(Mannion et al., 2007). Participants marked the numerical value on the segmented scale, to indicate a level
of pain. A clinically meaningful difference for the 11point numerical rating scale is a reduction of approximately two points for patients with CLBP (Farrar
et al., 2001).

Secondary outcomes
Secondary outcomes comprised functional disability,
HRQOL, patient satisfaction and LES muscle activity.
The Thai version of the RolandMorris Disability Questionnaire (RMDQ) was used for the assessment of functional disability (Jirarattanaphochai et al., 2005b). This
24-item questionnaire evaluates physical disability specic to LBP. The participants were asked whether any
statements characterized them on evaluation day. The
total score was calculated by adding up the number of
items answered with a yes, which ranged from 0 (no
disability) to 24 (maximum disability). The Thai
RMDQ showed high reliability (internal consistency
=0.710.93). A clinically meaningful difference on the
RMDQ is three points (Bombardier et al., 2001). The
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Areeudomwong et al.

HRQOL was assessed using the Thai version of the

Medical Outcomes Study 36-Item Short-Form Health
Survey, version 2.0 (SF-36v2) (Jirarattanaphochai
et al., 2005a). This monitors eight quality-of-life domains integrated into two summary scales: the physical
component summary (PCS), consisting of physical
functioning, physical role, bodily pain and general
health, and the mental component summary (MCS),
consisting of vitality, social functioning, emotional role
and mental health. Raw scores of all domains were
transformed into standardized scores, with a common
mean score of 50 and a standard deviation of 10. In
the Thai SF-36v2, the total score is between 0 and 100,
with 0 representing severe impairment and 100
representing no impairment (Ware et al., 2000), and
this showed high reliability (Cronbachs alpha: PCS,
0.93; MCS, 0.92; range, 0.720.93 for eight domains)
(Jirarattanaphochai et al., 2005a) and high construct validity (Lim et al., 2008). Patient satisfaction with treatment intervention were evaluated using the 11-point
Global Perceived Effect Scale, ranging from 5 (vastly
worse) to 0 (no change) to +5 (completely recovered)
(Kamper et al., 2010).
LES muscle activity was measured by surface electromyography (MP 36, BIOPAC Systems, Goleta, CA,
USA). After skin preparation to achieve 5 k of skin
impedance, four pairs of surface electrodes were afxed
on the left and right LES muscles. Details of electrode
placement were in line with a previous study
(Cholewicki et al., 1997). The ground electrodes for

Long-term effects of PNF training in CLBP patients

each pair were placed on the ipsilateral iliac crests

(Figure 2). The electromyogram signals were sampled
at 1000 Hz, with a gain of 1000, a 30500 Hz bandwidth
and an 85 dB common-mode rejection ratio. The participants were asked to perform a modied Biering
Srensen test (Coorevits et al., 2008). They were asked
to lie prone on an examination couch, with the superior
border of the anterior iliac crest positioned at the edge
of the couch and a small chair supporting the upper
body. Three belts were used to strap participants lower
body and legs to the couch, at the level of the buttock,
knees and ankles. The assessor then asked them to raise
the upper body to a position of horizontal alignment
with the legs and to maintain the unsupported upper
body in this position for 5 seconds. The root mean
square (RMS) values of the right and left LES muscles
were recorded during the test. This test was repeated
three times, with a 1-min rest period between the tests
to avoid muscle fatigue (Ng et al., 1997). The RMS value
during the middle 5 seconds for each test was normalized with its respective initial value, and the normalized
average RMS value for each muscle was computed.

Statistical analyses
Data were presented as means, standard deviations and
95% condence intervals. SPSS version 16.0 (IBM Corporation, Armonk, NY, USA) was employed for data
analyses. The ShapiroWilk test found that all data
were normally distributed. A 2 3 (group time)

Figure 2. Locations of electrode attachment of the lumbar erector spinae muscles

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Long-term effects of PNF training in CLBP patients

repeated measures ANOVA was then applied to examine between-group differences for each variable. Posthoc tests for multiple comparisons with Bonferroni adjustments were used for pairwise comparisons between
conditions when a signicant interaction effect was
found. The signicance level was set at p < 0.05.

each of which each had 21 participants. Figure 3 shows

the progress of the study. There was no loss to followup. The compliance rate of participants performing
the exercises in the LBP educational booklet was 94%.
The baseline characteristics of PNF training and control
groups are presented in Table 1 and all characteristics
were similar between the groups.

Results
The study was undertaken between April and October
2015. Seventy patients were initially recruited following
advertisement but, after screening, only 42 eligible participants entered the study. Twenty-four patients were
excluded from the study with other specic LBP conditions such as facet joint syndrome, disc herniation and
sacroiliac joint dysfunction, measured by clinical tests
and plain radiography, and four others declined to participate before the study began. The 42 participants were
randomly divided into PNF training and control groups,

Pain intensity
A signicant group time interaction effect was detected (F(2,24) = 8.47; p < 0.001). The PNF training
group presented with a signicantly greater reduction
in pain intensity than the control group after the 4week intervention (p < 0.01). The PNF training group
was also found to have clinically reduced pain intensity
compared with the control group at the 12-week
follow-up period (mean difference = 2.31 0.55;
p < 0.001) (Table 2).

Figure 3. Flow of the participants

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Long-term effects of PNF training in CLBP patients

Table 1. Baseline characteristics of the participants

Characteristics

PNF training
group (n = 21)

Control group
(n = 21)

35.4 10.3
15 (71.4)
162.5 10.5
55.6 7.3
9.2 6.2

36.2 9.9
16 (76.2)
163.7 9.4
55.8 8.5
10.0 7.2

Age (year), mean SD

Gender, n (% female)
Height (cm), mean SD
Weight (kg), mean SD
Low back pain duration
(month), mean SD

PNF, proprioceptive neuromuscular facilitation; SD, standard

deviation

the control group at the 12-week follow-up period

(mean difference = 3.08 0.39; p < 0.001) (Table 2).
Patient satisfaction
A signicant group time interaction effect on patient
satisfaction was also found (F(2,24) = 7.65; p = 0.003).
The PNF training group demonstrated a signicantly
greater improvement in patient satisfaction than the
control group after the 4-week intervention and at the
12-week follow-up assessment (p < 0.01) (Table 2).

Table 2. Comparison between proprioceptive neuromuscular facilitation (PNF) training (n = 21) and control (n = 21) groups on pain
intensity, functional disability, patient satisfaction and health-related quality of life
PNF training group,
mean SD

Control group,
mean SD

PNF training group versus control group,

mean SD (95% CI)

4.08 1.19
1.46 1.20
1.54 1.56

4.15 1.41
3.08 1.50
3.85 1.21

NS
1.62 0.53 (0.52 to 2.71)*
2.31 0.55 (1.17 to 3.44)**

RolandMorris Disability Questionnaire (scores)

Baseline
4.54 0.78
4-week assessment
1.69 0.63
12-week follow-up
1.69 0.86

4.85 1.57
3.92 1.26
4.77 1.09

NS
2.23 0.39 (1.43 to 3.04)**
3.08 0.39 (2.28 to 3.87)**

Patient satisfaction (scores)

Baseline
4-week assessment
12-week follow-up

0
1.54 0.52
1.38 0.51

0
0.85 0.69
0.69 0.63

NS
0.69 0.25 (0.20 to 1.89)*
0.69 0.22 (0.23 to 1.16)*

Physical component summary of SF-36v2 (scores)

Baseline
44.66 3.75
4-week assessment
54.41 3.85
12-week follow-up
53.72 3.26

43.42 6.38
45.86 5.43
44.16 5.55

Mental component summary of SF-36v2 (scores)

Baseline
47.54 8.15
4-week assessment
49.91 5.45
12-week follow-up
49.53 5.24

47.59 8.18
49.95 8.01
48.36 8.08

Variables

Pain intensity (scores)

Baseline
4-week assessment
12-week follow-up

NS
8.54 1.85 (4.73 to 12.35)**
9.55 1.78 (5.38 to 13.28)**

NS
NS
NS

CI, condence interval; NS, non-signicant; SD, standard deviation; SF-36v2, Short-Form Health Survey, version 2.0
* p < 0.01; ** p < 0.001 for the difference between groups at each time point

Functional disability

HRQOL

The effect of the signicant group time interaction on

functional disability was observed (F(2,24) = 21.67;
p < 0.001). The PNF training group demonstrated a signicantly reduced functional disability than the control
group after the 4-week intervention and at the 12-week
follow-up (p < 0.001). The PNF training group showed
a clinically reduced functional disability compared with

The PCS of HRQOL was signicantly improved after

receiving PNF training (F(2,24) = 52.60; p < 0.001).
However, there was no signicant difference in the
MCS between the groups at 4 weeks or 12 weeks. The
PNF training group showed signicantly greater PCS
than the control group at the 12-week follow-up assessment (p < 0.001) (Table 2).

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Long-term effects of PNF training in CLBP patients

Back muscle activity

Discussion

Group time interaction effects on LES muscle activation were detected (F(2,24) = 69.74; p < 0.001 and F
(2,24) = 9.36; p = 0.001 for right and left LES muscles,
respectively). The PNF training group showed signicantly greater improvements in the normalized LES
activity level on both sides at each follow-up assessment than those of the control group (p < 0.01)
(Figure 4).

The purpose of the present study was to investigate the

4-week PNF training effects, and the persistence of
achieved clinical or physiological changes that occur
after stopping the training for 12 weeks, in terms of
pain intensity, functional disability, HRQOL, patient
satisfaction and LES activity in patients with CLBP.
The major ndings of the study were that PNF training is effective not only in reducing pain intensity and

Figure 4. Normalized right lumbar erector spinae (LES) activation (A) and normalized left LES activation (B) at baseline, the 4-week intervention and the 12-week follow-up in proprioceptive neuromuscular facilitation (PNF) training (n = 21) and control (n = 21) groups. MVIC,
maximum voluntary isometric contraction* p < 0.01; ** p < 0.001 for the difference between groups at each time point

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Areeudomwong et al.

functional disability, and improving patient satisfaction, the physical component of HRQOL and back
muscle activity after the 4-week intervention, but also
after stopping the intervention for 12 weeks.
Impaired function or weakness of lumbar extensor
muscles has previously been found in CLBP patients
(van Dien et al., 2003). Ineffective activation of the
LES muscle, which is one of muscles contributing to
providing lumbar stability during sustained posture
and movements, may result in the development of
LBP (Cholewicki & Valvliet, 2002; MacDonald et al.,
2006; Richardson & Jull, 1995). Brumagne et al.
(2000) highlighted that LBP patients have a less rened
position sense because of altered lumbar vertebral muscle spindle afference providing impaired proprioception. Thus, poor activation of the LES muscle and
impaired proprioceptors of lumbar muscle activation
may lead to lumbar instability (Richardson and Jull,
1995; van Dien et al., 2003). Neurophysiological researchers have proposed a link between LBP development and a disturbance in mechanoreceptors, and
possibly also an association with an impairment of
the superior proprioception centres (Loeser & Melzack,
1999; Yamashita et al., 1990). Hence, the treatment interventions which restore lower back muscles and proprioceptive function may decrease CLBP.
The present study found that PNF training reduced
pain intensity after a 4-week intervention. This is in line
with the studies of Kofotolis & Kellis (2006) and Kofotolis
et al. (2008), reporting a signicant reduction in pain
intensity in female CLBP patients after receiving a 4-week
PNF training programme. Interestingly, the PNF training
group provided a clinically greater reduction in pain
intensity compared with controls at the 12-week
follow-up (mean difference = 2.31 0.55; p < 0.001).
It is plausible that the PNF training in the present study also
enhanced the level of LES activation, providing improved
lumbar stability in both static and dynamic conditions.
This may contribute to the signicant reduction in pain
intensity found after receiving 4 weeks of PNF training.
Patients in the PNF training group showed a statistically and clinically signicant decrease in functional
disability, persisting to the 12-week follow-up (mean
difference = 3.08 0.39; p < 0.001). This is consistent
with the previous studies (Kofotolis & Kellis, 2006;
Kofotolis et al., 2008) showing a persistent effect of
the PNF intervention. van Dien and colleagues
(2003) stated that there was functional impairment of
the trunk muscles, including the lower back muscle,
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Long-term effects of PNF training in CLBP patients

leading to a reduced ability to control the trunk movements in LBP patients actively. Control of trunk movements in daily activities may require continuous trunk
proprioceptive feedback and neuromuscular \readjusttment (George et al., 2013). The PNF training in the
present study employed RS, COI and CL techniques
to train CLBP patients, in order to improve functional
ability. These techniques employ rotational and diagonal movement patterns which are consistent with the
topographic arrangement of the muscles being used
in activities and sport (Adler et al., 2014). PNF training
may be used to target all aspects of muscle training,
such as sustained isometric contraction to promote stability (RS technique), and muscle co-contraction and
promotion of muscle mobilization (COI and CL techniques) to improve human movement and joint functions (Adler et al., 2014; Westwater-Wood et al., 2010).
In the present study, the PNF group showed a significant improvement in the PCS of HRQOL after 4 weeks
of intervention, and at the 12-week follow-up
assessment, compared with the control group. These
improvements were associated with a signicant
enhancement of functional ability and patient satisfaction. Wilson & Cleary (1995) suggested a relationship
between functional ability and HRQOL; however, it is
possible that the interventions used in the present study
were prescribed based on a biomedical framework rather
than a strict biopsychosocial framework may only affect
pain and physical activity rather than mental health.
The ndings of the present study may not be applicable to other specic LBP diseases. The present study
included only CLBP because the prevalence of this
condition is fairly high (Balagu et al., 2012) and we
intended to observe the sole responses of CLBP patients
after receiving PNF training. It is plausible that PNF
training aimed at facilitating the activation of more
trunk muscles in rotational and diagonal patterns, to
strengthen these muscles (Adler et al., 2014;
Westwater-Wood et al., 2010) may provide positive
effects in other specic LBP populations. The effectiveness of PNF training in managing other specic LBP
diseases is unclear and warrants further evaluation.
The present study had a number of strengths. Firstly,
the study was of a randomized, controlled design, with
blinded assessor to reduce measurement bias. This
study design is commonly used in clinical trials and reduces selection and measurement bias (Suresh, 2011).
To our knowledge, this was the rst study to reveal
the effectiveness of PNF training to improve quality

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Long-term effects of PNF training in CLBP patients

of life and patient satisfaction as well as to increase LES

activity in CLBP patients. The study also provided
evidence of positive lasting effects of PNF training on
these outcomes 12 weeks after training ceased. In addition, all participants participated throughout the study
period, so the ndings were not compromised by the
effect of participant attrition. However, there were some
limitations to the study. First of all, it only considered
the effect of PNF training on the activity of the LES
muscle. Future studies should consider other lumbar
stabilization muscles (e.g. the transversus abdominis,
oblique abdominals or upper erector spinae), to examine whether they improve lumbar stabilization function
after PNF training. The LBP educational booklet was
used as a control intervention in the study. A comparison with other conventional or exercise interventions
may give a better insight into the effectiveness of PNF
training on clinical outcomes in CLBP patients. In
addition, the ndings of the present study only refer to
chronic non-specic CLBP population of working age.
Future studies should investigate the effectiveness of
PNF training in other age groups. Finally, the present
study did not measure the outcomes related to proprioception, so further studies should explore this effect.

Clinical implications
The present study provides support for the ongoing
incorporation of PNF training into LBP management
programmes. It demonstrated the effectiveness of a
4-week PNF training period to reduce pain intensity and
functional disability as well as improve patient satisfaction
and quality of life, and meaningfully increase lower back
muscle activation in CLBP patients over the short- and
long term, compared with the usual LBP educational
booklet. The ndings of the study may therefore extend
our knowledge of the benecial effects of PNF training
on physiological outcomes and patient satisfaction in
clinical practice in patients with CLBP.

Conclusion
In conclusion, the present study found that the effects
of a 4-week PNF training assessment were still present
at the 12 week follow-up. The improvements in pain
intensity, functional disability, patient satisfaction and
physical aspect of HRQOL were retained in patients
with CLBP. LES muscle activation also improved
signicantly after PNF training.

Acknowledgments
The researchers would like to thank all participants for
their excellent cooperation. They are also grateful to Dr
Susan Laurie Stewart from Northumbria University,
UK, for proofreading the article. The study was supported by grants from Mae Fah Luang University,
Chiang Rai, Thailand.
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