|Year : 2015 | Volume
| Issue : 2 | Page : 170-175
Effect of proprioceptive neuromuscular facilitation stretch and muscle energy technique in the management of adhesive capsulitis of the shoulder
Hariharasudhan Ravichandran1, Janakiraman Balamurugan2
1 Department of Physical Medicine and Rehabilitation, Global Hospitals and Health City, Chennai, Tamil Nadu, India
2 Department of Physiotherapy, School of Medicine, University of Gondar, Ethiopia
|Date of Web Publication||6-May-2015|
Department of Physical Medicine and Rehabilitation, Global Hospitals and Health City, Chennai 600 100, Tamil Nadu
Aims: To determine the efficacy of Proprioceptive neuromuscular facilitation (PNF) technique and muscle energy technique (MET) in limiting pain and disability among subjects with adhesive capsulitis of shoulder. Settings and Study Design: A single centre experimental design study was done. A total 132 male subjects were screened. After fulfilling inclusion and exclusion criteria, with convenient sampling 60 subjects were selected for the study. Mean age of Groups A and B subjects were 46 and 50 years respectively. Double blinded baseline and post interventional (after 2 weeks) assessment was performed. Intervention includes Proprioceptive neuromuscular facilitation technique for group A and Muscle energy technique for group B. Outcome measures were recorded using University of Pennsylvania shoulder score (1st subset) and shoulder flexion, abduction, external rotation and internal rotation range of motion using an universal goniometer. Results: Inter group comparison were analyzed using Independent t test and one way analysis of variance was used to analyze pre intervention, and post interventional results after 1 and 2 weeks respectively. The level of significance will be set at P < 0.05. Proprioceptive neuromuscular facilitation technique achieved significance in improving ROM and showed satisfactory results in university of Pennsylvania shoulder score when compared with muscle energy technique. Conclusion: Proprioceptive neuromuscular facilitation technique was effective in relieving pain, restoring ROM and restoring function among subjects with adhesive capsulitis.
ةيلضعلا ةقاطلا ةليسو عم ةنراقملاب قيمعلا سحلا لابقتسلا يلضعلا يبصعلا زيفحتلا ةليسو مادختسا.قصلالا فتكلا لصفمل قصلالا باهتللاا جلاع ىف ةيلضعلاو
ةنراقملاب )PNF( قيمعلا سحلا لابقتسلا يلضعلا يبصعلا زيفحتلا ةيلاعف ىدم ديدحت :ةساردلا فده نم نوناعي نيذلا ىضرملا نيب نيب زجعلاو مللأا نم دحلا يف )MET( ةيلضعلا ةقاطلا ةليسول.فتكلا لصفمل قصلالا باهتللاا
ريياعم ءافيتسا دعبو .روكذلا نم 132 ىلع دحاو زكرم ىف ةساردلا ءارجإ مت :ةساردلا جهنمو ميمصت 50 و 46 نيب مهرامعا حوارتت ادرف 60 نم نوكتت ةحيرم ةنيع رايتخا مت ،ءانثتسلااو نيمضتلا لخدتلا لمشيو .مييقتلا نم نيعوباسأ دعب( يلخادت رخآو ىمعأ جودزمل ساسلأا طخ ذيفنت متو .اماع ةعومجملل ةيلضعلا ةقاطلا ةليسوو A ةعومجمل قيمعلا سحلا لابقتسلا يلضعلا يبصعلا زيفحتلا دعب ايئاصحا نيتعومجملا نيب ةنراقملا تمتو اينافلسنب ةعماج مادختساب جئاتنلا سيياقم ليلحت متو .B .0 < P يف ةيئاصحلاا ةيمهلأا ىوتسم نييعت متو ىجلاعلا لخدتلا نم نيعوبسا
ةنراقملاب لضفا ةيجلاع جئاتن قيمعلا سحلا لابقتسلا يلضعلا يبصعلا زيفحتلا ةليسو تققح :جئاتنلا.فتكلا لصفمل قصلالا باهتللاا جلاع ىف ةيلضعلا ةقاطلا ةليسول
باهتللاا جلاع ىف قيمعلا سحلا لابقتسلا يلضعلا يبصعلا زيفحتلا ةليسو مادختسا نا :جاتنتسلاا قصلالا باهتللاا جلاع ىف ةيلضعلاو ةيلضعلا ةقاطلا ةليسو نم ةيلعاف لضفا فتكلا لصفمل قصلالا.قصلالا فتكلا لصفمل
Keywords: Adhesive capsulitis, goniometer, muscle energy technique, proprioceptive neuromuscular facilitation technique
|How to cite this article:|
Ravichandran H, Balamurugan J. Effect of proprioceptive neuromuscular facilitation stretch and muscle energy technique in the management of adhesive capsulitis of the shoulder. Saudi J Sports Med 2015;15:170-5
|How to cite this URL:|
Ravichandran H, Balamurugan J. Effect of proprioceptive neuromuscular facilitation stretch and muscle energy technique in the management of adhesive capsulitis of the shoulder. Saudi J Sports Med [serial online] 2015 [cited 2022 Jan 22];15:170-5. Available from: https://www.sjosm.org/text.asp?2015/15/2/170/156363
| Introduction|| |
Adhesive capsultis describes the common shoulder condition characterized by painful and limited active and passive range of motion (ROM).  Earlier in 1934 Codman introduced the term periarthritis shoulder.,  later in 1945 Neviaser revised the name as adhesive capsultis based on radiographic appearance with orthography, he suggested that adhesion of capsule of glenohumeral joint limits overall joint space volume.  Some of the more common terms that are synonymous to adhesive capsulitis of the shoulder are periarthritis shoulder, frozen shoulder, stiff and painful shoulder, scapulohumeral periarthritis, tendonitis of short rotators, adherent subacromial bursitis.  In the literature, confusion abounds on the subject of adhesive capsulitis, and there is no consensus on the name of this clinical entity. Confusion in terminology probably reflects the confusion in the definition, pathology, etiology and treatment of this clinical entity.  Adhesive capsulitis is reported to affect 2-5% of the general population,  increasing to 19% with type 2 diabetes and thyroid diseases.  The condition is most commonly reported between the ages of 40 and 65 years.  Based on the etiology adhesive capsulitis can be classified as primary or secondary. Primary adhesive capsulitis is an idiopathic condition, where the exact underlying cause is unknown.  Adhesive capsulitis associated with a known underlying disorder is considered to be secondary.  Hannafin described adhesive capsulitis in four stages, Stage I: Preadhesive stage in which lining of the joint (synovium) is inflamed depicts little or no restriction of glenohumeral motion, Stage II (Freezing stage): A cute adhesive synovitis with proliferative synovitis and scar formation of the underlying capsule, Stage III (Frozen stage): Marked stiffness due to scar formation in the capsule with loss of axillary fold, Stage IV (Thawing stage): Chronic stage presenting with fully mature adhesions with notable restriction of ROM. In Stages II and III of frozen shoulder, ROM is significantly restricted.  Restriction of movement is in the capsular pattern, that is, external rotation is most limited, followed by limitation in abduction and internal rotation respectively. 
For adhesive capsulitis, along with physiotherapy following are the treatment approaches that are commonly being used more or less effectively; rest, oral prednisone, corticosteroid injections, capsular distention, manipulation under anesthesia, arthroscopic capsular release. While many physical therapy techniques have been employed in the management of shoulder disorders, few have been proven to be effective in randomized controlled trial. Physical therapy is often the first line of management for adhesive capsulitis of the shoulder, yet to date efficacy of individualized techniques has not been established.  One of the major difficulties in assessing efficacy is success criterion. Often the success is defined by return of "normal" motion rather than pain-free functional motion. It may be implausible for conservative treatment to rapidly restore full pain-free functional motion, considering the presence of dense fibrotic capsulo ligamentous complex tissue and the months of collagen remodeling required to regain soft tissue length. With respect to physiotherapy, a variety of interventions are used; these include application of hot or cold modalities, ultrasound therapy, interferential therapy, transcutaneous electrical nerve stimulation, active and passive ROM exercise, stretching exercises, mobilization techniques etc.  The overall goal of physiotherapy in adhesive capsulitis is to relieve pain, to restore ROM and to restore functions.
In order to determine a research agenda, that is, relevant to physiotherapy treatment, we conducted a study on adhesive capsulitis, comparing proprioceptive neuromuscular facilitation (PNF) technique with muscle energy technique (MET).
Proprioceptive neuromuscular facilitation stretch is a technique commonly used in clinical environments to enhance both active and passive ROM with the ultimate goal being to optimize motor performance and rehabilitation. The literature regarding PNF has made the technique, the optimal stretching method when the aim is to increase ROM, especially in a short term changes. In general, an active PNF stretch involves a shortening contraction of the opposing muscle to place the target muscle on stretch; this is followed by an isometric contraction of the target muscle. Literature stated that, PNF can be used to supplement daily stretching is employed to make quick gains in ROM.  Limited studies have proven PNF techniques to be most effective for producing much improvement in ROM.  On the other hand, MET is a direct hands-on therapy originally developed by Dr. Fred Mitchell, Sr. Osteopathic Physician. It is a noninvasive technique that can be used to stretch or lengthen muscle and fascia that lack flexibility.  MET targets the soft tissues primarily, but it also makes a major contribution towards joint mobilization. MET not only increases ROM of joints, but also increases the extensibility of muscle by means of a mechanism expressed as "increased tolerance to stretch."  In a quest to find out which of these technique exhibit profound outcomes in our clinical set up this study attempts to compare the efficacy of PNF stretch technique and MET intervention among subjects with shoulder adhesive capsulitis.
| Methods|| |
A total of 132 males with clinically diagnosed shoulder adhesive capsulitis reporting to Orthopedic Unit of Global Health City and Hospitals, Chennai, India. Two examiners screened the subjects for inclusion and exclusion criteria, subjects with posttraumatic immobilization of shoulder, cognitive impairments, surgeries and arthroscopy of shoulder within 3 months, cervical pathology neoplasm in or around shoulder and reflex sympathetic dystrophy were excluded. Sixty subjects were recruited for the study. Hospital ethical committee clearance was obtained. The purpose and procedures were explained to the subjects, and informed consent was obtained.
A detailed physical examination of the involved shoulder was done, and baseline assessment was recorded. The subjects were randomized into Group A (n = 30) receiving PNF technique and Group B (n = 30) receiving MET.
Postinterventional assessments were performed by a senior physiotherapist. Outcome measures were measurement of ROM using a universal goniometer and university of Pennsylvania (1 st subset) shoulder score to measure the extent of subjects pain, satisfaction, and function.
Measuring range of motion
The ROM of the affected shoulder was assessed actively with a universal goniometer. The measurements were taken for shoulder flexion, extension, abduction, internal rotation and external rotation.
University of Pennsylvania (1 st subset) shoulder score
The 1 st subset of UPSA contains three items that measure the subject's level of pain, satisfaction and function. It contains 3 pain items it contains three pain items that address pain with the arm at rest by the side, pain with normal activities, and pain with strenuous activities. All are based on a 10 point numeric rating scale with end points of "no pain" and "worst possible pain." Therefore, a subject can be awarded 30 points for absence of pain.
The subject's satisfaction with the function of the shoulder is also assessed with a numeric rating scale. The end points chosen were "not satisfied" and "very satisfied." Scoring is based on the number circled by the subject. Therefore, the subject can achieve 10 points for this section.
Self-assessment of function is based on a 20 items questionnaire with a four category Likert scale for responses. Scoring for this section is calculated in the following ways; 3 points are awarded if the subject "can perform the activity without difficulty," 2 points for "some difficulty" 1 point for "much difficulty" and 0 for "cannot do at all." Therefore, the subject can achieve 60 points if he can perform every item without difficulty. Because some items may not be applicable to all subjects, the response option "did not do before the injury" is included. When the subject chooses this response option or leaves an item blank, an average of the items that were responded to is multiplied by 3 (maximum score for each item), to yield the maximum possible score achievable by that subject. The score for each relevant item is then added, and this total raw score is divided by the total achievable maximum score for all relevant items, to yield a percentage of the points assigned to this category. This percentage is multiplied by 60 points, to yield the final functional score. ROM and University of Pennsylvania shoulder score (1 st subset) was assessed for both Group A (PNF) and Group B (MET) subjects prior to the study, at the end of 1 st week and at the end of 2 nd week that is, on the day of completion of the study.
Group A was treated with proprioceptive neuromuscular technique. D2 PNF pattern was used.
D2 proprioceptive neuromuscular facilitation flexion ,
In supine position, the subject's head and neck in a comfortable position, as close to neutral as possible. The involved upper extremity was positioned in shoulder extension, adduction and internal rotation; elbow extension; forearm pronation; wrist and finger flexion with forearm lying across the umbilicus. One hand of the therapist grasps the dorsum of subject's hand using a lumbrical grip. Other hand grasps the subjects forearm close to the elbow. Therapist stands in a stride position by the subject's shoulder with his one foot forward. Therapist starts with weight on his front foot and lets the subject's motion pushes therapist's weight towards back foot.
Therapist applies stretch to the subject's involved shoulder through his proximal grip by a rapid traction and rotation. Distal grip gives traction to the wrist. The subjects were commanded to "open their hand and turn it toward their face" or "lift their arm up and out."
D2 proprioceptive neuromuscular facilitation extension
The starting position begins as described for completion of D2 flexion. Therapist placed the index and middle fingers of one hand in the palm of subject's hand. Other hand grasps the subjects forearm on the volar surface or distal humerus. Complete the pattern in shoulder extension, adduction, internal rotation; elbow extension; forearm pronation and wrist, fingers flexed. Forearm should cross the umbilicus and therapist applies stretch. The subjects were commanded to "squeeze therapist fingers, and pull down and across your chest." D2 PNF pattern of flexion and extension was applied for 8 repetitions per set, 2 sets per session, 1 session per day, 5 days a week for 2 weeks with each repetition maintained for duration of 5-10 s.
Group B was treated with MET for flexion, abduction, extension and rotation restrictions.
Muscle energy technique for glenohumeral joint restricted flexion
Therapist stood in front of the subject and placed one hand over the top of the subject's involved shoulder at the superior part of the scapula and cup the glenohumeral joint to palpate for motion. The other hand and forearm supported the subject's flexed elbow and flexed the humerus at the glenohumeral joint in the sagittal plane up to the initial point of resistance. The subjects were directed to extend the elbow against equal counterforce applied by the therapist. The force was maintained for 3-5 s, and then the subjects were allowed to relax for 2 s, take up the slack and then repeat.
Muscle energy technique for glenohumeral joint restricted extension
Therapist stood in front of the subjects and placed one hand over the top of the subject's involved shoulder at the superior part of the scapula and cups the glenohumeral joint to palpate for motion. Used the other hand to support subject's flexed elbow and directed the patient to push the elbow anteriorly.
Muscle energy technique for glenohumeral joint restricted abduction
Therapist stood in front of the patient, placed one hand over the top of subject's involved shoulder, cups the glenohumeral joint to palpate for motion and directed the subjects to press the elbow towards their body.
Muscle energy technique for glenohumeral joint restricted internal rotation
Therapist stood facing the patient. Carefully place the dorsum of the subject's hand of the involved side against the subjects back. Therapist placed his one hand over the top of shoulder and superior part of the scapula and other palm protecting anterior side of the shoulder capsule and then placed his other hand, posterior to the subject's flexed elbow. Directed the subject to "press their elbow against his fingers."
Muscle energy technique for glenohumeral joint restricted external rotation
Therapist stood behind the subject. Placed his hand superior to the subject's involved glenohumeral joint. Placed his forearm of the other hand medial to the subject's flexed forearm with his hand supporting the patient's hand and the wrist and then directed the subjects to internally rotate the arm by pressing the hand.
Muscle energy technique was applied for 5 repetitions per set, 5 sets per session, 1 session per day, 5 days a week for 2 weeks with each repetition maintained for the duration of 7-10 s.
| Data analysis and results|| |
The baseline characteristics of 60 male subjects included in the study were the mean age of Group A subjects are 46 years, and Group B were 50 years. In Group A among 30 subjects, 17 had type II diabetes and 21 subjects had right shoulder involvement and in Group B among 30 subjects 15 had type II diabetes and 18 had right side shoulder involvement.
Changes in range of motion
The mean and standard deviation of ROM of affected shoulder of Group A and B measured at baseline, after 1 week and postinterventional (at the end of 2 weeks). Mean baseline of flexion in Group A and B were 91.30 and 94.80 respectively. Postinterventional mean of flexion in Group A and B were 128.26 and 113.13 respectively. Mean baseline of extension in Group A and B were 32.03 and 29.56 respectively. Postinterventional mean of extension in Group A and B were 50.93 and 42.16 respectively. Mean baseline of abduction in Group A and B were 54.66 and 52.00 respectively. Postinterventional mean of abduction in Group A and B were 128.26 and 72.43 respectively. Mean baseline of internal rotation in Group A and B were 43.10 and 40.46 respectively. Postinterventional mean of internal rotation in Group A and B were 64.03 and 51.70 respectively. Mean baseline of external rotation in Group A and B were 31.13 and 27.13 respectively. Postinterventional mean of external rotation in Group A and B were 64.03 and 35.66 respectively [Table 1]. Intergroup comparison of Group A and group B obtained by independent t-test showed significant P values for flexion (0.013) and extension (0.001) after 2 weeks. Meanwhile, P values of abduction, external rotation, and internal rotation are highly significant (0.000). One-way ANOVA for overall changes in ROM among Group A following treatment with PNF technique in adhesive capsulitis between weeks and within weeks are highly significant. One-way ANOVA for overall changes in ROM among Group B following treatment with MET in adhesive capsulitis between weeks and within weeks was highly significant for extension and abduction only. Multiple Scheffe for week wise comparison of ROM in Group A after 2 weeks was significant only for abduction, external rotation and internal rotation only. For Group B extension and abduction alone achieved high significant [Table 2].
|Table 2: Inter‑group comparison of ROM of Group A and B obtained by independent t‑test|
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Changes in University of Pennsylvania (1 st subset) shoulder score
University of Pennsylvania (1 st subset) shoulder score for Group A and B obtained by Friedman test showed significant improvement in pain and function after 2 weeks, (highly significant). Week wise comparison of University of Pennsylvania (1 st subset) shoulder score obtained by Wilcoxan for both groups. There is a significant improvement in pain and function after 2 weeks except for 1 st week in Group B is less significant. Intergroup comparison on university of Pennsylvania (1 st subset) shoulder score obtained by Mann-Whitney U-test is significant after 1 st and 2 nd week of treatment. The mean rank of Group A is better than Group B [Table 3].
|Table 3: Intergroup comparison of University of Pennsylvania shoulder score (1st subset) values of Group|
A and B
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| Discussion|| |
The results of this study supported the hypothesis that both PNF technique and MET are effective in improving the shoulder ROM in subjects with adhesive capsulitis. On further analysis, it also supported that there is a significant difference in effectiveness of PNF technique and MET. Subjects treated with proprioceptive neuromuscular technique demonstrated significant improvement in terms of pain relief, restoration of ROM and early return to ADL. The mechanism by which proprioceptive neuromuscular technique caused improvement in shoulder ROM and function could be elongation of tissues, which could be the probable reason helping to improve ROM and function. Panjabi explains that every movement segment depends on three subsystems; the passive, the active and the neural subsystem, which stresses the diagonal pattern of movement in PNF technique. 
The reason for MET not so effective in improving shoulder ROM and function in adhesive capsulitis could be attributed to the conclusion of the study conducted by Buchmann et al., 2005. They concluded that postisometric relaxation (MET) seems to reach mainly the muscular parts of the treated motion segment and less to the other parts such as affiliated joint capsule, ligaments, and fascia.  MET requires the subject to create a force by activating the targeted musculotendinous unit against a precisely directed counterforce by the therapist, followed by relaxation and a passive stretch applied by the therapist, hence this technique failed to achieve considerable changes at the level of joint capsule to improve ROM.
Proprioceptive neuromuscular facilitation technique is aimed at relaxing tense muscles and restricted joints to make quick gains in ROM. Previous studies by Etnyre and Abraham, 1986; Magnusson et al., 1996; Ferber et al., 2002; Funk et al., 2003; Wallin et al., 1985 confirmed that joint ROM can be increased significantly by PNF stretching.  The study of Shimura and Kasai shows clearly that PNF pattern of exercise is benefit for initiating movements.  Thus, our study validates the use of PNF technique in improving quality of life and recovery from adhesive capsulitis.
| Conclusion|| |
Our study findings indicate that the application of PNF for the glenohumeral joint in adhesive capsulitis subjects results in relieving pain, restoring ROM and function. MET showed less significant effect when compared with highly significant and most effective PNF technique. We conclude that PNF stretch techniques can increase ROM in subjects with adhesive capsulitis. Our study recommends use of PNF stretch as an adjunct to the existing treatment techniques in adhesive capsulitis of shoulder to optimize subject's quality of life and participation in social roles pertaining to family life, leisure, work, education, and community service at appropriate stages in the life cycle.
| Acknowledgments|| |
We are grateful and thankful to Dr. Clement Joseph, Arthroscopic Surgeon and Sports Medicine, Global Health City, Chennai, India and Dr. V. Vijayanarasimhan, Orthopaedic Surgeon, Sree Balaji Medical College and Hospital, Chromepet, Chennai, India. I would like to express my gratitude to all the therapists and PT assistants involved in patient treatment and data collection.
| References|| |
Kelley MJ, McClure PW, Leggin BG. Frozen shoulder: Evidence and a proposed model guiding rehabilitation. J Orthop Sports Phys Ther 2009;39:135-48.
Codman EA. The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston: Thomas Todd; 1934.
Neviaser RJ, Neviaser TJ. The frozen shoulder. Diagnosis and management. Clin Orthop 1987;223:59-64.
Neviaser JS. Adhesive capsultis of the shoulder: Study of pathological findings of periarthritis shoulder. J Bone Joint Surg 1945;27:211.
Donatelli RA. Physical Therapy of Shoulder. 3 rd
ed. Newyork: Churchill and Livingstone; 1997.
Aydeniz A, Gursoy S, Guney E. Which musculoskeletal complications are most frequently seen in type 2 diabetes mellitus? J Int Med Res 2008;36:505-11.
Balamurugan J, Raj RV, Raja PR, Nagaraj S, Preethi S. Total end range time and Maitland's antero-posterior glide mobilization in frozen shoulder of type II diabetic subjects. Int J Pharm Ind Res 2012;2:366-70.
Lee M, Haq AM, Wright V, Longton EB. Periarthritis of the shoulder: A controlled trial of physiotherapy. Physiotherapy 1973;59:312-5.
Harrast MA, Rao AG. The stiff shoulder. Phys Med Rehabil Clin N Am 2004;15:557-73.
Iannotti JP, Gerald RW. Disorders of the Shoulder: Diagnosis and Management. Philadelphia: Lippincott Williams and Wilkin; 1999.
Hannafin JA, Chiaia TA. Adhesive capsulitis. A treatment approach. Clin Orthop Relat Res 2000;372:95-109.
Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am 1989;71:1511-5.
Vermeulen HM, Rozing PM, Obermann WR, le Cessie S, Vliet Vlieland TP. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: Randomized controlled trial. Phys Ther 2006;86:355-68.
Gupta S, Raja K, Manikandan N. Impact of adhesive capsulitis on quality of life in elderly subjects with diabetes: A cross sectional study. Int J Diabetes Dev Ctries 2008;28:125-9.
Susan SA, Dominiek B, Math B. PNF in Practice: An Illustrated Guide. 3 rd
ed. Germany; 2008. p. 77-103.
Mahieu NN, Cools A, De Wilde B, Boon M, Witvrouw E. Effect of proprioceptive neuromuscular facilitation stretching on the plantar flexor muscle-tendon tissue properties. Scand J Med Sci Sports 2009;19:553-60.
Goodridge JP. Muscle energy technique: Definition, explanation, methods of procedure. J Am Osteopath Assoc 1981;81:249-54.
Hariharasudhan R, Balamurugan J. A randomized double-blinded study of effectiveness of strain counter-strain technique and muscle energy technique in reducing pain and disability in subjects with mechanical low back pain. Saudi J Sports Med 2014;14:83-8.
Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 4 th
ed. Philodelphia; 2003. p. 117.
Panjabi M, Abumi K, Duranceau J, Oxland T. Spinal stability and intersegmental muscle forces. A biomechanical model. Spine (Phila Pa 1976) 1989;14:194-200.
Buchmann J, Wende K, Kundt G, Haessler F. Manual treatment effects to the upper cervical apophysial joints before, during, and after endotracheal anesthesia: A placebo-controlled comparison. Am J Phys Med Rehabil 2005;84:251-7.
Decicco PV, Fisher MM. The effects of proprioceptive neuromuscular facilitation stretching on shoulder range of motion in overhand athletes. J Sports Med Phys Fitness 2005;45:183-7.
Shimura K, Kasai T. Effects of proprioceptive neuromuscular facilitation on the initiation of voluntary movement and motor evoked potentials in upper limb muscles. Hum Mov Sci 2002;21:101-13.
[Table 1], [Table 2], [Table 3]