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Effects of aquatic PNF lower extremity patterns on balance and ADL of stroke patients

January 2015
Journal of Physical Therapy Science 27(1):213-5

DOI:10.1589/jpts.27.213

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PubMed

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CC BY-NC-ND 4.0

Authors:

[Purpose] This study investigated the effect of aquatic proprioceptive neuromuscular facilitation (PNF) patterns in the lower extremity on balance and activities of daily living (ADL) in stroke patients. [Subjects] Twenty poststroke participants were randomly assigned to an experimental group (n = 10) or a control group (n = 10). The experimental group performed lower extremity patterns in an aquatic environment, and the control group performed lower extremity patterns on the ground. Both exercises were conducted for 30 minutes/day, 5 days/week for 6 weeks. Balance was measured with the Berg Balance Scale (BBS), Timed Up and Go Test (TUGT), Functional Reach Test (FRT), and One Leg Stand Test (OLST). Activities of daily living were measured with the Functional Independence Measure (FIM). A paired t-test was used to measure pre- and post-experiment differences, and an independent t-test was used to measure between-group differences. [Results] The experimental and control groups showed significant differences for all pre- and post-experiment variables. In the between-group comparison, the experimental group was significantly difference from the control group. [Conclusion] These results indicate that performing aquatic proprioceptive neuromuscular facilitation patterns in the lower extremity enhances balance and ADL in stroke patients.

Available via license: CC BY-NC-ND 3.0

Content may be subject to copyright.

Eects of aquatic PNF lower extremity paerns on

balance and ADL of stroke patients

Eu n-Kyung Kim, MSc

, Dong-Kyu LEE, MSc

2)*

, young-mi Kim, MSc

Department of Physical Therapy, Graduate School of Physical Therapy, Daegu University, Republic

of Korea

Department of Physical Therapy, Yeol-Lin Hospital: 570-15 Songchung-Dong, Gwangsan-Gu,

Gwangju 504-704, Republic of Korea

Abstract. [Purpose] This study investigated the effect of aquatic proprioceptive neuromuscular facilitation

(PNF) patterns in the lower extremity on balance and activities of daily living (ADL) in stroke patients. [Subjects]

Twenty poststroke participants were randomly assigned to an experimental group (n = 10) or a control group (n =

10). The experimental group performed lower extremity patterns in an aquatic environment, and the control group

performed lower extremity patterns on the ground. Both exercises were conducted for 30 minutes/day, 5 days/week

for 6 weeks. Balance was measured with the Berg Balance Scale (BBS), Timed Up and Go Test (TUGT), Functional

Reach Test (FRT), and One Leg Stand Test (OLST). Activities of daily living were measured with the Functional

Independence Measure (FIM). A paired t-test was used to measure pre- and post-experiment differences, and an

independent t-test was used to measure between-group differences. [Results] The experimental and control groups

showed signicant differences for all pre- and post-experiment variables. In the between-group comparison, the

experimental group was signicantly difference from the control group. [Conclusion] These results indicate that

performing aquatic proprioceptive neuromuscular facilitation patterns in the lower extremity enhances balance and

ADL in stroke patients.

Key words: Proprioceptive neuromuscular facilitation, Balance, Activities of daily living

(This article was submitted Jun. 19, 2014, and was accepted Aug. 3, 2014)

INTRODUCTION

Stroke is a neurological disease caused by the cutoff of

normal blood supply due to vessel rupture or thrombosis,

and it causes brain tissue damage. Motor, sense, recogni-

tion, language, and perception decits are typical symp-

toms of the disease, depending on the affected areas, size,

and the cause of damage

. Stroke patients mainly experi-

ence motor disorders and degeneration of balancing ability

due to unbalanced posture; this is caused by asymmetric

arrangement and hemiplegia, and this disrupts independent

activities of daily living (ADL)

The ability to balance is an individual’s ability to main-

tain the center of gravity within a base region, keeping the

body in a balanced state

. Stroke patients lack balancing

ability and show degeneration of physical function due to

a reduction in walking and activity caused by an inappro-

priate posture, proprioception malfunction, and abnormal

muscle tension

. To resolve balance problems caused by

stroke, the Brunnstrom approach, Bobath approach, or pro-

prioceptive neuromuscular facilitation (PNF) is used; such

methods focus on enhancing physical functions and balance

by improving active motor control

PNF utilizes a typical helical or diagonal pattern to

stimulate proprioceptive sensation promote a nerve root

response, enhancing functional movement

5, 6)

. It improves

muscle strength, exibility, and balance; by applying it on

the non-paretic side, force is transferred to the paretic side,

effectively promoting muscle activity

Davis

suggested aquatic PNF lower extremity patterns

for reinforcing muscular strength and enhancing muscle re-

education. Song and Kim

applied aquatic PNF lower ex-

tremity patterns to patients who had a stroke, which stimu-

lated proprioceptors, thus improving control and function

of the nerve roots while enhancing balance.

In an aquatic environment, the buoyancy allows limbs to

be moved more easily with little strength, enhancing coor-

dination of motion

. Water resistance also enables the body

to move, helping increase muscle strength, joint movement,

and balance

10)

. Multiple studies had reported PNF lower

extremity patterns during ground-based exercise for stroke

patients, but few had reported aquatic PNF.

This study aimed to investigate the effects of aquat-

ic PNF lower extremity patterns on balance and ADL of

stroke patients.

J. Phys. Ther. Sci.

27: 213–215, 2015

*Corresponding author. Dong-Kyu Lee (E-mail: ldkpt@

hanmail.net)

This is an open-access article distributed under the terms of the Cre-

ative Commons Attribution Non-Commercial No Derivatives (by-nc-

nd) License <http://creativecommons.org/licenses/by-nc-nd/3.0/>.

Original Article

J. Phys. Ther. Sci. Vol. 27, No. 1, 2015214

SUBJECTS AND METHODS

Six months after receiving a stroke diagnosis via either

computed tomography or magnetic resonance imaging, 20

patients were randomly assigned to a control group (n = 10;

5 males and 5 females) or an experimental group (n = 10;

5 males and 5 females); the control group was assigned to

conduct PNF lower extremity patterns on the ground, and

the experimental group was assigned to conduct PNF lower

extremity patterns in water. All participants scored >24

points on the Mini-Mental Status Examination (MMSE),

could perform assignments, were capable of walking 10 m

independently, and were classied as >4 on the Brunnstrom

scale. All participants were informed and provided in-

formed consent before the experiment. The protocol was

approved by the Institutional Review Board of Nambu Uni-

versity and was conducted in accordance with the ethical

standards of the Declaration of Helsinki. The general fea-

tures of the participants are listed in Table 1. The age of the

experimental group was 69.1 ± 3.2 years, height was 167.6 ±

8.2 cm, weight was 67.9 ± 5.9 kg, and time since stroke on-

set was 9.8 ± 1.3 months. The age of the control group was

68.0 ± 3.1 years, height was 165.9 ± 6.9 cm, weight was 66.7

± 6.7 kg, and time since stroke onset was 10.3 ± 1.4 months.

The experimental group conducted PNF lower extrem-

ity patterns using the rhythmic initiation (RI) method

110 cm below the water surface; the water temperature was

31–33 °C. Exercises were performed in a supine posture af-

ter simple stretching; subjects wore a body ring between L

and S

and a neck collar. The control group conducted PNF

lower extremity patterns on the ground in a supine posture

after simple stretching. The RI method starts from passive

exercise, proceeds to active resistance exercise, and helps

increase coordination, motor sensation, and balance. The

PNF lower extremity patterns consisted of patterns D

and

. The D

pattern ends at either exion-adduction-exter-

nal rotation knee exion or extension-adduction external

rotation knee extension. The D

pattern ends at either ex-

ion-adduction external rotation knee exion or extension-

adduction-external rotation knee extension. PNF lower

extremity patterns were conducted 30 minutes/day, 5 days/

week for 6 weeks.

Balance was measured with the Berg Balance Scale

(BBS), Timed Up and Go Test (TUGT), Functional Reach

Test (FRT), and One Leg Stand Test (OLST). The BBS con-

sists of 14 items and can be categorized into sitting, stand-

ing, and postural changes. Scores in each category range

from 0–4, with 56 possible total points; higher scores indi-

cate better balance. The TUGT measures the time required

to stand up from a chair and shuttle back and forth between

the chair and a spot in front of the subject three times. The

FRT measures the distance one can reach with an arm from

a standing posture. The OLST measures how long one can

stand on one foot with the eyes open without placing the

other foot on the ground.

ADL were measured with the Functional Independence

Measure (FIM), which consists of 13 items related to mobil-

ity and 5 related to recognition. The items were scored on

a scale of 1–7 with 126 possible total points; higher scores

indicate better independence.

Data were analyzed using SPSS 12.0 (SPSS, Chicago, IL,

USA) for Windows. Descriptive statistics were used for the

general features of the participants. A paired t-test was used

to determine pre- and post-experiment differences, and an

independent t-test was used to determine between-group

differences. Statistical signicance was set at α = 0.05.

RESULTS

The changes in the result of the BBS, TUG, FRT, OLST,

and FIM are listed in Table 2. The experimental and control

groups showed signicant differences for all pre- and post-

experiment variables (p < 0.05). In the between-group com-

parison, the experimental group was signicantly different

from the control group (p < 0.05).

DISCUSSION

The purpose of this study was to investigate the effects

of aquatic PNF lower extremity patterns on balance and

ADL of stroke patients. The experimental group showed

a signicant improvement in balance and ADL after the

aquatic PNF (p < 0.05) and had signicantly better bal-

ance and ADL relative to the control group (p < 0.05). This

is consistent with previous studies. For example, perfor-

Table 1. General characteristics of subjects

EG (n=10) CG (n=10)

Gender (male/female) 5 / 5 5 / 5

Age (years) 69.1 ± 3.2

68.0 ± 3.1

Height (cm) 167.6 ± 8.2 165.9 ± 6.9

Weight (kg) 67.9 ± 5.9 66.7 ± 6.7

Paretic side (right/left) 5 / 5 5 / 5

Onset (months) 9.8 ± 1.3 10.3 ± 1.4

Mean±SD, EG: experimental group, CG: control group

Table 2. Comparison of the results of the BBS, TUG, FRT,

OLST, and FIM between the experimental and control

groups

Group Pre Post D-value

BBS EG 42.8 ± 1.6

44.9 ± 1.7* 2.1 ± 1.7*

CG 39.9 ± 2.0 40.6 ± 1.7* 0.7 ± 0.8

TUGT EG 21.9 ± 1.3 20.1 ± 1.9* −1.8 ± 1.3*

CG 20.4 ± 1.0 19.7 ± 1.0* −0.7 ± 0.6

FRT EG 17.7 ± 0.9 19.0 ± 1.4* 1.3 ± 0.9*

CG 16.7 ± 0.6 17.2 ± 0.4* 0.5 ± 0.6

OLST EG 4.3 ± 0.8 5.7 ± 1.1* 1.4 ± 0.9*

CG 3.4 ± 0.5 4.1 ± 0.7* 0.6 ± 0.7

FIM EG 82.3 ± 2.5 87.5 ± 3.7* 5.2 ± 5.3*

CG 80.1 ± 1.2 81.4 ± 1.4* 1.3 ± 1.3

Mean±SD, *p<0.05, D-value: difference value, EG: experimen-

tal group, CG: control group, BBS: Berg Balance Scale, TUGT:

Timed Up and Go test, FRT: Functional Reach test, OLST: One

Leg Stand test, FIM: functional independence measure

215

mance of 10 weeks of aquatic proprioception exercise by

seniors enhanced their motor abilities

11)

. In addition, Kim

and Lee

12)

PNF reported that aquatic lower extremity pat-

terns enhanced balance in healthy adults. Moreover, Song

and Kim

reported that aquatic PNF effectively affected

the balance of stroke patients. These results indicate that

aquatic PNF lower extremity patterns help enhance the bal-

ance of stroke patients. PNF, used as a gradual resistance

exercise that employs a helical pattern, maximizes motor

unit recruitment through proprioceptive stimulation

5, 13)

Aquatic PNF promotes the maximum usage of muscle -

bers due to the intense circumstances caused by buoyancy

and turbulence; moreover, the water acts as a form of resis-

tance, stimulating proprioception and thus helping to im-

prove postural control and balance

8, 13, 14)

The most common method for examining the ADL of

stroke patients is to use the FIM. In the present study, the

experimental group showed signicant enhancement of

ADL after the aquatic PNF (p < 0.05). Suomi and Collier

15)

reported that the ADL of arthritis patients were enhanced

after conducting aquatic exercise, and Sato et al.

16)

reported

that the ADL of abnormal adults were enhanced after con-

ducting water exercise. Similar to other studies, enhance-

ment of ADL was observed after conducting aquatic exer-

cise in the present study. The enhancement of ADL was the

result of enabling movement with even a small amount of

force. This was due to the assistance of the water buoyancy

and decreased gravity, reducing the burden on muscles and

joints

10, 15)

. To promote functional recovery, the paretic side

was spontaneously enabled, thus enhancing the ADL and

improving functional independence

15, 16)

. The movements

also stimulate shortened muscles, promoting a training ef-

fect and enhancing ADL

17)

A limitation of this study was that it utilized a small

number of participants, and it was not conrmed that the

positive effects persisted. Future research should address

these things when investigating the effect of aquatic PNF

lower extremity patterns in stroke patients.

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Oct 2023

Gian Lisuari Adityasiwi

AbstrakLatar belakang: Stroke adalah suatu penyakit tidak menular yang sebagian terjadi pada serebrovaskular akut. Stroke dapat menjadi penyebab kecacatan jangka panjang bila proses rehabilitasi yang dilakukan tidak optimal. Pemulihan pasien pasca stroke agar dapat pulih optimal adalah dengan diberikan latihan oleh fisioterapis. Salah satu intervensi Fisioterapi adalah hidroterapi berupa aquatic therapy. Aquatic therapy atau yang dikenal dengan terapi di dalam kolam renang merupakan tindakan rehabilitasi yang digunakan untuk mengoptimalkan kemandirian fungsional seseorang dengan gangguan neurologi. Tujuan PKM : meningkatkan pemberdayaan masyarakat dengan hidroterapi untuk peningkatan fungsional pasien pasca stroke. Metode : Kegiatan pengabdian kepada masyarakat dilakukan bulan Maret sampai Juni 2023 dengan sasaran kader dan Masyarakat di Kelurahan Suryodiningratan Yogyakarta dilakukan dengan pretest pengetahuan tentang stroke dan hidroterapi, Pemberian Edukasi tentang penanganan pasca stroke dengan hidroterapi, Simulasi hidroterapi dan post test. Jumlah Populasi adalah 31 responden diambil secara acak 12 orang. Hasil pretest adalah 75% peserta mengalami penurunan tekanan darah dan adanya peningkatan pemahaman sebanyak 91,67%. Setelah diberikan penyuluhan dan pelatihan hidroterapi selama 45 menit. Kesimpulan : Kegiatan Pelatihan Mengenai Hidroterapi untuk Kader Kelurahan Suryodiningratan dapat menurunkan tekanan darah bagi pasien resiko stroke yang memiliki riwayat hipertensi dan menunjukan adanya pengetahuan mengenai tindakan fisioterapi dengan diberikan hidroterapi.

A Study of the Clinical Test of Sensory Interaction and Balance

Article

Full-text available

Jul 1993

The ability to maintain an upright position during quiet standing is a useful motor skill. The Clinical Test of Sensory Interaction and Balance is an inexpensive, easily administered test that provides information about the ability to stand upright under several sensory conditions. Three groups of neurologically asymptomatic (AS) adults, divided by age into younger, middle-aged, and older groups, participated in the study. A fourth group comprised subjects diagnosed with vestibular disorders. Timed performances under six different conditions were compared across groups. Subjects with vestibular disorders were significantly impaired on performance when compared with age-matched AS subjects. Older AS and vestibularly impaired subjects had greater variation in their scores than did younger AS subjects. This test is a useful screening tool for examining static standing balance.

PNF Training and Physical Function in Assisted-Living Older Adults

Article

Oct 2002

The impact of proprioceptive neuromuscular facilitation (PNF) on physical function in assisted-living older adults (73-94 years old) was studied. A 5-week pretraining period consisting of weekly visits by trainers to participants preceded a 10-week training period of warm-up, PNF exercises, and cool-down. Training progressed from 1 set of 3 repetitions to 3 sets of 3 repetitions. Assessments were conducted at baseline (T1), postpretraining (T2), and posttraining (T3). Eleven of 14 volunteer participants completed the study. Physical function was assessed by range of motion (ROM), isometric strength, and balance and mobility measures. Repeated-measures ANOVA identified 6 measures (sit-to-stand, shoulder- and ankle-flexion ROM, and hip-extension, ankle-flexion, and ankle-extension strength) with statistically significant differences. With the exception of hip-extension strength, these measures were statistically significant from T2 to T3 in post hoc univariate tests. Results indicate that PNF flexibility training can improve ROM, isometric strength, and selected physical-function tasks in assisted-living older adults.

Comparison between Aquatic and Ground Environments of Rhythmic Initiation for Postural Control

Article

Dec 2012

[Purpose] The purpose of this study was to examine the effects of aquatic and ground exercises on postural control in normal young adults. [Subjects] Thirty normal adult subjects participated in the study, and 10 adults were assigned to each exercise group, i.e., the aquatic exercise group, ground exercise group, and control exercise group (n=10). The subjects performed exercises using the rhythmic initiation technique in 2 different environments, i.e., on land and in water. Outcomes were measured when the subjects performed exercises under the following 4 conditions: (1) with the eyes kept open, (2) with the eyes kept closed, (3) with the eyes kept open and simultaneous galvanic vestibular stimulation (GVS), and (4) with the eyes kept closed and simultaneous GVS. [Results] The balance index significantly improved in the aquatic exercise group after training under all experimental conditions, excluding the condition with the eyes kept closed and simultaneous GVS. The balance index significantly improved in the ground exercise group after training under all experimental conditions, excluding the condition with the eyes closed. The balance index of the subjects in the control group did not improve significantly under any condition. [Conclusion] The results of this study showed that aquatic exercise and ground exercise training improve postural control in normal young adults.

Reduced Ambulatory Activity after Stroke: The Role of Balance, Gait, and Cardiovascular Fitness

Article

Nov 2005

Holm Thieme

Comparison of 2-year effects of once and twice weekly water exercise on activities of daily living ability of community dwelling frail elderly

Article

Oct 2008

Previous research suggests that water exercise improves the activities of daily living (ADL) ability of the frail elderly, but the specific frequency and intensity of such programs is unclear. This study aims at comparing the effects of once- and twice-weekly water exercise on the ADL ability of frail elderly receiving nursing care for 2 years. The design is a prospective randomized longitudinal study. Participants were assigned to two different exercise groups (Group 1 and Group 2). Group 1 participated in a 60-min exercise session once a week, for 2 years, while Group 2 attended the session twice a week. Exercise sessions were divided into a 10-min warm-up on land and 50 min of exercise in water. The 50-min water exercise program consisted of 20 min walking, 10 min ADL exercise, 10 min stretching and strength exercises, and 10 min relaxation in water. ADL ability and lower muscle strength were measured before the beginning of exercise and 6 months, 1 year, and 2 years after the program had started. Significant group differences occurred for bathing transfer and stair climbing at the 2-year measurement. These results suggested that at least twice-weekly water exercise was necessary to maintain the ADL ability and KEX of the frail elderly during the 1-year water exercise period and for one additional year afterward.

Cardiorespiratory Responses of Healthy Subjects to Calisthenics Performed on Land Versus in Water

Article

Aug 1992

This study evaluated the oxygen consumption (VO2) and heart rate response curves for standardized upper- and lower-extremity exercise on land and in water. Forty healthy subjects performed one upper-extremity and one lower-extremity exercise at three selected cadences on land and in water. Steady-state heart rate was determined by electrocardiographic radiotelemetry and expressed as a percentage of age-predicted maximal heart rate (% APMHR). Percentage of age-predicted maximal heart rate was used as the criterion measure of relative exercise intensity. Oxygen consumption was determined by the open-circuit method. Results indicated systematic increases in VO2 from 2 to 9 metabolic equivalents (METs) (1 MET = 3.5 mL O2.kg-1.min-1) and % APMHR from 45% to 73% with increased cadence. The VO2 responses were highest during water exercise, whereas % APMHR was greater during land exercise. Based on the magnitude of the responses, water calisthenics appear to be of sufficient intensity to elicit training adaptations. Training studies are needed to document these changes.

Aquatic Therapy for Patients with Rheumatic Disease

Article

Dec 1990
RHEUM DIS CLIN N AM

Roxane L. McNeal

Aquatic therapy is justifiably a rapidly expanding, beneficial form of patient treatment. The goals established at the initial and subsequent evaluations usually are met as quickly and as sensibly as possible. Understanding the theory of water techniques is essential in implementing an aquatic therapy program. The success of the program, however, will always depend on the pleasure and benefits achieved by the patients. Remember, rheumatic patients most likely will need to modify their previous daily functioning. Patients need to be aware of the long-term ramifications of the disease process and understand how treatment and care may be altered during various stages of exacerbation and remission. Patient education is critical in ensuring individual responsibility for the changes that must be made when not supervised by a professional. Aquatic therapy is a step in molding a positive lifestyle change for the patient. The patient can be encouraged to be fitness oriented and, at the same time, exercise in a manner that is safe, effective, and biomechanically and physiologically sound. The environment, hopefully, also will be conductive to family and social interaction that ultimately encourages the compliance of long-term exercise programs.

Therapeutic exercise in the management of rheumatic diseases

Article

Sep 1987
J Rheumatol Suppl

J V Basmajian

In spite of the wide use of therapeutic exercise in the management of musculoskeletal diseases such as chronic arthritis, there are few controlled studies that establish its effectiveness. Only active contraction can increase muscle strength. Exercises in the horizontal plane or of limbs supported by the buoyancy of water can be carried out with relative ease by people with weak muscles or painful joints. The benefits of exercise programs can be classified as improving general fitness, increasing joint mobility and reconditioning. Whether the large amount of money currently being spent on exercise programs is truly cost-effective is an important question relating to health policy that requires an answer.

A technique of resistive exercise in the treatment pool

Article

Nov 1971
PHYSIOTHERAPY

B C Davis

Effectiveness of Water Exercise on Postural Mobility in the Well Elderly: An Experimental Study on Balance Enhancement

Article

Sep 1996

The fear of falling may cause elderly people to limit their movement. As movement errors are known to facilitate the acquisition of motor skills, the elderly may inadvertently cause the loss of postural skills by constraining their movements, and hence avoid potential movement errors. It was hypothesized that by having elderly individuals exercise in a risk-free environment-water was utilized in this experiment-their postural capabilities would improve. Four groups of elderly subjects (80 +/- 5.8 years old) were placed into four groups: Water Exercisers; Land Exercisers; Water Sitters; and Land Sitters. Each group met twice per week for 45 minutes for 5 weeks of simple exercises or socializing in the designated medium. The distance each individual could reach (Functional Reach, FR) was measured at the end of each week. Initially, each group was at risk (FR < 10 inches) for falling Statistical testing showed that the Water Exercisers (WE) increased their FR almost every week; the Land Exercisers (LE) increased only during the first week; and the Water Sitters (WS) and Land Sitters (LS) did not increase at all. The FRs after 5 weeks were 13.4 +/- 1.6 (WE), 11.3 +/- 1.5 (LE), 9.6 +/- 1.3 (WS), and 9.3 +/- 0.71 (LS) inches for each group, respectively. The data showed that the postural capabilities in these elderly people, as measured by the FR, were enhanced by the production of movement errors that was facilitated in a water environment (in the case of the Water groups) or the initiation of a novel exercise program (Land Exercisers). Alternative explanations, and implication of these results, are discussed.

Effects of aquatic PNF lower extremity patterns on balance and ADL of stroke patients

Abstract

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