Proprioceptive Neuromuscular Facilitation & SMT Adverse Events

The Chiropractic Forward Podcast: Evidence-based Chiropractic Advocacy

CF 349: Proprioceptive Neuromuscular Facilitation & SMT Adverse Events Today we’re going to talk about Proprioceptive Neuromuscular Facilitation & SMT Adverse Events But first, here’s that sweet sweet bumper music

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OK, we are back and you have found the Chiropractic Forward Podcast where we are giving evidence-based chiropractic a little personality and making it profitable. We’re not the stuffy, elitist, pretentious kind of research. We’re research talk over a couple of beers. So grab you a bushel. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. I’m so glad you’re spending your time with us learning together. Chiropractors – I’m hiring at my personal clinic. I need talent, ambition, smarts, personality, and easy to get along with associates. If this is you and Amarillo, TX is your speed, send me an email at [e-mail] If you haven’t yet I have a few things you should do.

• Go to Amazon and check our my book called The Remarkable Truth About Chiropractic: A Unique Journey Into The Research. It’s excellent resource for you and is categorized into sections so the information is easy to find and written in a way that is easy to understand for everyone. It’s on Amazon. That’s the Remarkable Truth About Chiropractic by Jeff Williams.
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You have found yourself smack dab in the middle of Episode #349 Now if you missed last week’s episode, we talked about SMT Research Review & Mobile Phones And Cancer Make sure you don’t miss that info. Keep up with the class.

On the personal end of things…..

Welp, what can I say, some days you’re the nail and some days you’re the hammer. Today, my friends, I’m the hammer. What the hell does that mean you might ask. Well, this is a slight departure from chiropractic clinic talk for a brief minute but I got some ‘splainin’ to do. In the VoiceOver realm, there are about 5 big national agencies that rep the big talents. The ones you mostly hear on the TVs and elsewhere.

One of those agencies is called DPN out in Los Angeles. I have been talking with DPN for a bit and trying my best to make things happen. Well, it all came together today and I was signed by DPN. Now here’s why that’s so cool. The Big 5 agencies have access to the biggest voice gigs in the country. I already have about 9 regional agents buut they don’t get the big boy gigs like the nationals get.

For example, DPN reps the national voice for Ford trucks and that dude makes north of $1 million per year. THAT’s what I’m talking about, friends. Now that doesn’t mean I’m about to be a multi-millionaire and all that good stuff. It just means I now have access to those gigs and a real opportunity to land them. So it’s all pretty exciting around the Williams Estate today. It’s electric you might say. In the clinic, our old nurse prac is out and our new medical team is in. We are up and running and killing it already and super excited about it.

We went from full time salary position to hourly without health benefits for this first year.

Which means we save thousands and are super excited to be profitable on the medical side and staying that way despite the transition. Change is stressful but this is a good change and will be huge in the long-term. The team we have coming in is outstanding and growth minded. We are going to have some bumps along the way but sometimes, you just gotta jump in and get going. Which is waht we’re doing today. Seems like for the first time in about a year or two, we have all similar personalities, all goign in the right direction, all getting along and enjoying each others’ company. And that’s gold. It’s the sweet spot.

Something I’ve been doing lately that will offer up some opportunities in the future: at the suggestion of one of our MCM Mastermind members, Vanessa, my wife and I started playing the points and miles game. With spends as high as we see in our offices, points and miles can add up very quickly. I travel a lot for business and we have an overhead of about $60,000-$65,000 per month here at the clinic. So, you can see how we might stack up the point fast and score some free airline tickets and hotel packages. If you’re interested in a free course to learn all about how to do it, go to https://10xtravel.com and click on Start With Our Free Course at the top of the page. I don’t get a thing out of it. No affiliate link or anything like that. But, if you decide to get a card, holler at me and I’ll send you a referral link so I can get some points out of that. Deal? Alright, let’s jump into the research this week shall we?

Item #1

This first one comes to us from our Parker intern. Mr. Austin Moya went and found this after I did a resisted ROM move on a patient that had a locked facet and SMT was just not going to happen. So, thank you to Austin for making us all just a little bit smarter. It was done by Kinet et al in 2012 and published in Journal of Human Kinetics. Remember, the citations can be found at chiropracticforward.com under this episode.

Hindle KB, Whitcomb TJ, Briggs WO, Hong J. Proprioceptive Neuromuscular Facilitation (PNF): Its Mechanisms and Effects on Range of Motion and Muscular Function. J Hum Kinet. 2012 Mar;31:105-13. doi: 10.2478/v10078-012-0011-y. Epub 2012 Apr 3. PMID: 23487249; PMCID: PMC3588663.

Why They Did It

Proprioceptive neuromuscular facilitation (PNF) is common practice for increasing range of motion, though little research has been done to evaluate theories behind it. The purpose of this study was to review possible mechanisms, proposed theories, and physiological changes that occur due to proprioceptive neuromuscular facilitation techniques

How They Did It

Four theoretical mechanisms were identified: autogenic inhibition, reciprocal inhibition, stress relaxation, and the gate control theory.

What They Found

The studies suggest that a combination of these four mechanisms enhances range of motion. When completed prior to exercise, proprioceptive neuromuscular facilitation decreases performance in maximal effort exercises. When this stretching technique is performed consistently and post-exercise, it increases athletic performance, along with range of motion. Little investigation has been done regarding the theoretical mechanisms of proprioceptive neuromuscular facilitation, though four mechanisms were identified from the literature. As stated, the main goal of proprioceptive neuromuscular facilitation is to increase range of motion and performance. Studies found both of these to be true when completed under the correct conditions.

Wrap It Up These mechanisms were found to be plausible; however, further investigation needs to be conducted. All four mechanisms behind the stretching technique explain the reasoning behind the increase in range of motion, as well as in strength and athletic performance. Proprioceptive neuromuscular facilitation shows potential benefits if performed correctly and consistently. So, if someone has a locked up facet, do you just hammer through that neck regardless of the pain the patient is in? If you’ve got extrapment of synovial folds, which can happen from sustained awkward sleeping positions, does it make sense to hammer through it on the first visit? Or do a little resisted ROM and stretching? I vote resisted ROM and stretching. The patients do well with it, they see immediate ROM improvement, and you didn’t give them an experience they had to figure out how to survive. Then you got them in the office the next day and they were probably much easier to hands on adjust by that point. If I’m guessing.

Item #2

The last one this week is called, “Adverse Events After Cervical Spinal Manipulation – A Systematic Review and Meta-Analysis of Randomized Clinical Trials” by Pankrath et al and published in Pain Physician in May of 2024 and that’s the hot one, people!

Pankrath N, Nilsson S, Ballenberger N. Adverse Events After Cervical Spinal Manipulation – A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Pain Physician. 2024 May;27(4):185-201. PMID: 38805524.

Why They Did It Cervical manipulations are widely used by physiotherapists, chiropractors, osteopaths, and medical doctors for musculoskeletal dysfunctions like neck pain and cervicogenic headache. The use of cervical manipulation remains controversial, since it is often considered to pose a risk for not only benign adverse events (AEs), such as aggravation of pain or muscle soreness, but also severe AEs such as strokes in the vertebrobasilar or carotid artery following dissections. Studies finding an association between cervical manipulation and serious AEs such as artery dissections are mainly case control studies or case reports.

These study designs are not appropriate for investigating incidences and therefore do not imply causal relationships. Randomized controlled trials (RCTs) are considered the gold standard study designs for assessing the unconfounded effects of benefits and harms, such as AEs, associated with therapies. Due to the unclear risk level of AEs associated with high-velocity, low-amplitude (HVLA) cervical manipulation, the aim of this study was to extract available information from RCTs and thereby synthesize the comparative risk of AEs following cervical manipulation to that of various control interventions.

How They Did It

Systematic review and meta-analysis.

Methods: A systematic literature search was conducted in the PubMed and Cochrane databases. This search included RCTs in which cervical HVLA manipulations were applied and AEs were reported. Two independent reviewers performed the study selection, the methodological quality assessment, and the GRADE approach. Incidence rate ratios (IRR) were calculated. The study quality was assessed by using the risk of bias 2 (RoB-2) tool, and the certainty of evidence was determined by using the GRADE approach.

What They Found Fourteen articles were included in the systematic review and meta-analysis. The pooled Incidence rate ratios indicates no statistically significant differences between the manipulation and control groups. All the reported AEs were classified as mild, and none of the AEs reported were serious or moderate.

Wrap It Up

In summary, HVLA manipulation does not impose an increased risk of mild or moderate AEs compared to various control interventions. However, these results must be interpreted with caution, since RCTs are not appropriate for detecting the rare serious AEs. In addition, future RCTs should follow a standardized protocol for reporting AEs in clinical trials.

Alright, that’s it. Keep on keepin’ on. Keep changing our profession from your corner of the world. The world needs evidence-based, patient-centered practitioners driving the bus. The profession needs us in the ACA and involved in leadership of state associations. So quit griping about the profession if you’re doing nothing to make it better. Get active, get involved, and make it happen. Let’s get to the message. Same as it is every week.

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The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!

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Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

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About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine (FIANM) and Board Certified Diplomate of the American Board of Forensic Professionals (DABFP) – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

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