Bioscience Biotechnology Research Communications Vol 14 No (4) Oct-Nov-Dec (2021)

Medical Communication

Effectiveness of Hold Relax Proprioceptive Neuromuscular

Facilitation Technique in Total Knee Arthroplasty

Mohammad Miraj,1,2* Msaad AlZhrani,1 Ahmad Alanazi,1 Fuzail Ahmad,1 Faizan Kashoo,1
Abdul Rahim Shaik,1 Mohamed Seyam,1 Deepak Kumar,2,3 Achal Pathak,3 Kamran Afzal,4
Ahmad Abdullah A Alsaleh,4 Mazen AlQahtani5 and Mehrunnisha Ahmad6
1
Department of Physical Therapy and Health Rehabilitation, College of Applied
Medical Sciences, Majmaah University, AlMajmaah 11952, Saudi Arabia
2
Department of Applied Health Sciences, AIHMS, New Delhi, India
3
Department of Physiotherapy, Santosh University, Ghaziabad, India
4
Department of Basic Sciences, College of Medicine, Majmaah University, AlMajmaah 11952, Saudi Arabia
5
College of Applied Medical Sciences, Al Mareefa University, Riyadh 13713, Saudi Arabia
6
Department of Nursing, College of Applied Medical Sciences, Majmaah University, AlMajmaah 11952, Saudi Arabia

ABSTRACT
Proprioceptive Neuromuscular Facilitation (PNF) is a popular flexibility training, which involves stretching and contraction of the target
muscle group. PNF stretching is effective among athletes for improving passive range of motion, flexibility, and performance. Patients
who undergo total knee replacement surgeries exhibit pain, swelling, decreased range of motion, muscle weakness, and stiffness. This
study aimed to investigate the effect of the hold relax PNF technique to improve the balance and muscle strength in subjects with a
bilateral knee replacement. Sixty four patients were selected based on inclusion/exclusion criteria. The patients were allocated into two
groups by random allocation. The experimental group A (n=32) received the Hold Relax PNF technique with conventional treatment
whereas, the control group B (n=32) received only conventional treatment as a part of the Home Exercise Program (HEP). Outcome
measures used for evaluation included the Visual Analogue Scale (VAS), Manual Muscle Testing (MMT), and Berg Balance Scale
(BBS) Score for measuring pain, muscle strength, and balance respectively. Students t-test showed significant differences between
variables mean scores from two groups after three weeks of intervention. There was a statistical significant (t(32) = 2.38, p = 0.02)
change in the mean scores of VAS in the experimental group (mean difference pre-post=3.19) as compared to control group ( mean
difference pre -post=3.19) with Cohen's d = 2.744588. Similarly for MMT(t(32) = 0.415, p = 0.005) and BBS scores (t(32) = 2.628,
p = 0.035). The result of the study suggests that the Hold Relax PNF technique is more effective than conventional treatment alone
in decreasing pain as well as increasing balance and muscle strength in bilateral knee replacement patients.

KEY WORDS: PNF(Hold Relax), Knee Arthroplasty, Home Exercise Program.

INTRODUCTION of private healthcare has led to changes in payment policies

which has caused post-TKA rehabilitation primarily been
Total knee arthroplasty (TKA) procedures have expanded transferred to home health and outpatient settings. Knee
dramatically in last one decade due to aging population with arthroplasty is a surgery that replaces the weight-bearing
rising lifestyle diseases, resulting in increased prevalence surfaces of the knee joint to relieve pain and impairment,
of Osteoarthritis, especially in Knees. The exponentially most typically been used to treat osteoarthritis apart from
growing health insurance linked with increasing penetration other knee illnesses including RA and psoriatic arthritis.
Knee replacement surgery can be conducted in two ways:
partial or total. A knee replacement might be more accurately
termed as knee resurfacing because only the surfaces of the
Article Information:*Corresponding Author: m.molla@mu.edu.sa
Received 25/10/2021 Accepted after revision 30/12/2021
bone are replaced (Lauermann et al., 2014, Varacallo, Luo,
Published: 31st December 2021 Pp- 1919-1923 and Johanson, 2021).

1919
This is an open access article under Creative Commons License,
Published by Society for Science & Nature, Bhopal India.
Available at: https://bbrc.in/ DOI: http://dx.doi.org/10.21786/bbrc/14.4.80
Miraj et al.,
Whether comparing rehabilitation received in different consequence of the direct trauma from the surgical incision.
venues or analyzing different physical therapy (PT) The hold relax PNF technique is one of the most popular
procedures, numerous studies have indicated that techniques and helps to develop muscular strength and
rehabilitation is related with improved post-TKA results. endurance joint stability, mobility, neuromuscular control,
Following total knee arthroplasty, the mainstay of and coordination all of which are aimed at improving the
rehabilitation is achieving maximal feasible knee range overall functional ability of people (Hindle et al., 2012;
of motion (ROM) and achieving specified functional Koca et al.,2014; De Carvalho et al.,2017). However, not
goals (TKA) (Koca et al.,2014; Yang et al.,2019; Han et many evidence-based researches are present, where the
al.,2021). ROM is one of the most important outcomes Hold Relax PNF technique has been used in patients with
after TKA since patients with less than 105° of knee flexion total knee arthroplasty(Kim Kang and Kim,2018; Han
have difficulty going up and down stairs or getting out et al.,2021). Hence, the present research study aims to
of a low chair, and is a major sign of patient discontent explore the application of PNF stretch for changes in pain,
(Han et al.,2021). muscle strength, and balance and therefore on the overall
functionality of the lower extremity following total knee
Literature review suggests that different strategies and arthroplasty.
techniques are being used for improving range of motion in
comparison to other strategies used primarily on healthy or Material and Methods
elderly individuals (Oh 2013; Rhyu, Kim and Park, 2015; De
Carvalho et al.,2017). The Proprioceptive Neuromuscular The study design was a randomized controlled trial (pretest-
Facilitation technique(popularly called as PNF) is one posttest experimental control group design), where the
such popular technique been used to increase ROM and patients were recruited from Rehabilitation Center, College
flexibility (Hindle et al.,2012). Originally developed by Dr. of Applied Medical Sciences, Majmaah University located
Herman Kabat in year 1940, the technique mainly works at Al-Majmaah city. Necessary approval was taken from the
on the principle of raising neuro-inhibition mechanism for Institutional review board, Majmaah University. The study
releasing muscular spasm and elongating muscle length, was commenced in Sept 2020 and was completed in May
or increasing neuro-excitation mechanism for boosting 2021. A total of 64 subjects between the age of 42 to 73
muscle strength. It comprises of 3 main techniques namely, years were included in the study who fulfilled the inclusion
Hold Relax (HR), Contract Relax (CR), and Contract Relax criteria of patients diagnosed with OA knee as well as
Agonist Contract (CRAC)(Gonzalez, Gomez and Garcia, undergoing bilateral TKR. The exclusion Criteria included
2012). knee flexion more than 110 degrees or thigh girth more than
55 cm, poor cognition, CNS or PNS neuromuscular disease,
The effect of PNF stretching on both joint restriction received operation in recent 3 months, joint infection and
improvements is less well understood. Likewise, balance loosening, revision total knee arthroplasty, or complication
impairment, which is again one of the major problems during follow up. Those who met the study's eligibility
encountered by the patients after knee replacement is due requirements and gave their consent to participate were
to the weakness of quadriceps muscles, which is further a finally chosen to participate in the study.

Table 1. Showing treatment protocol for experimental and control group.

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 Miraj et al.,
The minimum sample size of 60 participants was required findings (Table 1, p≥0.05). The treatment for both groups
using statistical power of 80%, the effect size of 0.20, and continued for 3 weeks with readings measured for all the
a level of significance of 0.05 to measure the effectiveness outcome variables at 0 weeks (Baseline line) and 3rd week
of the technique used in the study. In the present study, 32 (Table3,4 and 5).
patients were recruited who fulfilled the inclusion criteria
subjects were then randomly assigned into experimental
(n=32) and control groups (n=32). While the Experimental Table 3. Showing VAS Score between group A and group B
group A(n=32) received PNF along with conventional
treatment, the control group B, (n=32) received only
conventional treatment. The outcome measures used for VAS Score Group A Group B T score(p-value)
evaluation were Manual Muscle Testing (MMT) and Berg
Balance Score (BBS) were used for measuring muscle Week 1 6.68(0.54) 6.83(0.79) NS
strength and balance respectively. Week 3 2.77(0.75) 4.61(0.58) 2.38(0.02*)

The Hold relax PNF technique is one of the key PNF

Visual Analogue Scale (VAS) readings were measured
techniques. In this method, the muscle under treatment is
for both the groups at Week 1 followed by 3 weeks of
lengthened to the point of limitation or to the extent that
intervention in both groups. It was observed that while
is comfortable for the subject. The subject then performs
significant improvement was observed in both groups but
a pre-stretch, end range, an isometric contraction for 5 to
on intergroup comparison Group A fared better than group
10 seconds followed by voluntary relaxation of the tight
B(p=0.02*) (Table 3).The outcome measures of Manual
muscle(Oh 2013). The Conventional treatment protocol
Muscle Testing for both the legs for both the groups at week
which was the Home exercise Program(HEP) was illustrated
1 and Week 3 are depicted in Table 4. Regarding the MMT
in Table 1(Minshull et al., 2014; Kim et al 2018). The
measurement between the two groups A and B, about both
protocol was same as described in an earlier published
the limbs (Right and Left leg) it was observed that over the
research, (Alaca et al 2015). The physiotherapist sat in front
3 weeks both groups witnessed a significant change in the
of the patient on a low-height stepper with one hand placed
muscle strength, however, group A demonstrated a greater
on the lower quadriceps muscle as well as another hand
gain in strength in both rights (T score = 1.8 and 0.33,
placed on the lower tibia anteriorly. Command was given
p<0.05**) and left leg (T-score =1.031 and 0.4, p<0.05**)
to the subject to perform knee extension against resistance
respectively(Table 4).
and was asked to hold for 6 to 10 seconds followed by
relaxation as per detailed protocol given in Table1.
In Table 5, within a group as well as an intergroup
comparison for groups A and B were measured for the BBS
Statistical analysis: Using the Statistical Package of Social
scale. The table shows a statistically significant difference
Science (SPSS) version 22.0, the data were checked for
over the 3 weeks both within the groups (T value (Gp.
normality assumptions using the Kolmogorov–Smirnov
A, t score = 24.04 and Gp. B=10.22, p<0.05**) as well
test (Chicago, IL). The normally distributed data were then
as between the groups with Gp. A showing significant
analyzed for mean, SDs, t-values, and p values to conclude
improvement in BBS as compared to Group B(t score =
group comparisons. The unpaired t-test score was used to
2.628, p<0.05**) (Table 5).
compare participant characteristics and demographic data
between groups.
The purpose of the present study was to investigate the
effectiveness of the hold relax PNF technique to improve
balance and muscle strength in subjects with a bilateral knee
Table 2. Showing baseline characteristics of the patients in replacement. The result suggests that there was a significant
both group A and B improvement in PNF group A when compared with the
conventional group B. Visual analog Scale (VAS), Manual
Characteristics Group A Group B muscle testing (MMT), and Berg Balance Score (BBS) were
(n =32) (n =32) found to be statically significant in both the groups, however
in the PNF group A, there was a significant decrease in pain
Gender (M: F) 22: 10 18: 14 along with a significant increase in MMT and BBS score
Mean Age 65.54(7.2) 65.06(6.87) than the conventional group as their mean and standard
deviations suggested (p<0.05**, Table 3,4 and 5).
Mean BMI 29.54(4.53) 31.22(5.88)
Baseline Active Flexion 41(11.89) 48(12.44) The results of the study draw an analogy from the study
Baseline Passive flexion 48(14.53) 52(13.54) conducted by De Carvalho et al. (2017) where two exercise
Baseline Knee Circumference 41.56(3.31) 42.74(2.94) protocols were compared for postural balance among elderly
women. They found the PNF group showed a significant
Results and Discussion reduction in most of the stabilometric parameters. Similarly,
the BBS score in the experiment group was also found better
The baseline characteristics values for the demographic than the control group thus concluding that women in the
characteristics for all the participants are depicted in Table PNF group demonstrated better improvement in postural
2 with no significant differences observed between the two static stability using evaluation of various stabliometric
groups in terms of baseline demographic data and clinical parameters. Likewise, significant improvement was

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS Effectiveness of Hold Relax Proprioceptive 1921

Miraj et al.,
also noticed for dynamic balance using functional test inhibition, which inhibits - motor neurons of contracted
performance. muscle and synergist in interneuron and activates antagonist
by transmitting tendon tension to the anterior horn of
It is suggested that the hold relax PNF technique more the spinal cord via 1 b afferent nerve fiber (Minshull et
effectively increases muscle activity with decreased al.,2014). Concentric contraction generates reciprocal
muscle fatigue. This could be because during hold relax inhibition, which activates -motor neurons of contracted
PNF, isometric contraction of the muscle causes autogenic muscles and synergists while inhibiting antagonists during
agonist contraction (Cha, Cho and Choi, 2014).

Table 4. Showing the manual muscle testing (MMT) score for both groups A and B

MMT Group A (n=32) Group B (n=32) T score

Mean SD Mean SD (p-value)

WEEK 1 Right Leg F 3 0.365 2.8*8 0.342 NS
E 2.31 0.479 2.63 0.5 NS
WEEK 3 Right Leg F 3.94 0.443 3.75 0.447 1.192(p=0.008**)
E 3.75 0.447 3.69 0.602 .333(p=0.062**)
MMT Group A n=32 Group B n=32 T score
Mean SD Mean SD (p-value)
WEEK 1 Left Leg F 3.06 0.443 3.06 0.25 NS
E 2.44 0.629 2.69 0.479 NS
WEEK 3 Left Leg F 3.94 0.443 3.75 0.577 1.031(p=0.043*)
E 3.81 0.403 3.75 0.447 .415*(p=0.005**)

**significant at 0.05 level

Table 5. Showing Berg balance scale (BBS) score for both groups A and B

** significant at 0.05 level, mean and SD of BBS (week 1 and week 3) for both groups A and B

The findings gain credibility by yet another study conducted band exercise program using proprioceptive neuromuscular
by Kim, Kang, and Kim(2018) in Korea where PNF exercises facilitation (PNF) was evaluated to measure isotonic
were found to improve range of motion, pain, and functional strength of abductor's muscles in the lower extremity. It
activity among TKR patients. However, the present study was found that PNF-based band exercises significantly
differs from the Korean study using the outcome measures improved the peak explosive muscular power in the isotonic
since the authors measured the improvement by objective contraction of the lower limb abductors. It was hypothesized
indices including the MMT and BBS scores. In yet another that the PNF facilitates certain physiological changes
study by Rhyu, Kim, and Park (2015), a six-week elastic which potentiate the functioning of both the central and

1922 Effectiveness of Hold Relax Proprioceptive BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

 Miraj et al.,
peripheral vestibular system and thereby are responsible Strength Cond Res. 26: 1045–1051.
for the therapeutic results. Han HS, Kim JS, Lee B. et al.(2021) A high degree of
knee flexion after TKA promotes the ability to perform
The perception of articular position and mobility is critical high-flexion activities and patient satisfaction in Asian
for maintaining strength and balance as reduced articular population. BMC Musculoskelet Disord 22, 565 (2021).
sensitivity contributes to balance impairments in both the https://doi.org/10.1186/s12891-021-04369-4
aged and osteoarthritic individuals (Jette et al. 2020). These
Hindle KB, Whitcomb TJ, Briggs WO, Hong J(2012)
imbalances are caused by decreased articular mobility. Both
Proprioceptive Neuromuscular Facilitation (PNF): Its
pain and decreased proprioception have an adverse effect
on the joint increasing the risk of falling. In the present Mechanisms and Effects on Range of Motion and Muscular
study, using hold relax PNF Technique in the experimental Function. J Hum Kinet. 31:105-113. doi:10.2478/v10078-
group, had brought out significant change(p=0.035*) in 012-0011-y
Berg Balance Score(BBS) thereby proving its efficacy Kim CH, Kang TW, Kim BR(2018) Effects of
post arthroplasty (Table 5). This suggests that PNF might proprioceptive neuromuscular facilitation exercise on the
improve both neuromuscular control as well as joint stability range of motion, pain and functional activity of total knee
bring better control in both static and dynamic balance arthroplasty patients. PNF and Movement.16(1):75–83.
(Gong 2020). There are some limitations to this study. doi.org/10.21598/JKPNFA.2018.16.1.75
The trial was limited to the Rehabilitation Department Koca I, Boyaci A, Tutoglu A, Boyaci N, Ozkur A (2014) The
of Majmaah University and generalizability of the study
Relationship between Quadriceps Thickness, Radiological
cannot be justified. The study used only bilateral TKR
Staging, and Clinical Parameters in Knee Osteoarthritis. J
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patients with bilateral TKR as compared to conservative
The differential effects of PNF versus passive stretch
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Epub 2013 May 20. PMID: 23688197.
The authors are grateful to the Deanship of Scientific Oh YT(2013) Effect of Hold Relax technique for college
Research, AlMajmaah University via group No. RGP- students with hamstring shortening. Journal of Korean
2019- 35 for funding through Vice Deanship of Scientific Society of Physical Medicine. *(3) : 433-441 https://doi.
Research Chair. org/10.13066/kspm.2013.8.3.433
Rhyu HS, Kim SH, Park HS(2015) The effects of band
Declaration of Interest Statement: The authors report no exercise using proprioceptive neuromuscular facilitation
conflicts of interest. on muscular strength in lower extremity. Jour Exer
Rehab;11(1) :36 -40.
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