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40 © 2018 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow
The effect of proprioceptive
neuromuscular facilitation techniques
on trunk control in hemiplegic
subjects: A pre post design
Jeba Chitra, Diker Dev Joshi
Abstract:
BACKGROUND: Impaired trunk control is common in most of the hemiplegic patients during subacute
stage that interferes with daily activities and worsens quality of life (QOL) of patients.
PURPOSE: The purpose of the study was to investigate the effect of proprioceptive neuromuscular
facilitation (PNF) techniques on trunk control and QOL in subjects with hemiplegia.
DESIGN: This was a pre‑post design.
SETTING: The study was conducted at a tertiary care hospital in Belagavi.
PATIENTS: Totally, 16 hemiplegic patients were recruited between the age group 18–65 years
having trunk control test score ≥50 and were given PNF techniques.
INTERVENTION: PNF techniques for 45 min, three times in a week for 4 weeks.
MEASUREMENTS: Patients were assessed at baseline using Trunk Impairment Scale (TIS) and
Stroke Specic‑QOL (SS‑QOL) and reassessed after 12 sessions.
RESULTS: Statistical analysis was done using paired t‑test. PNF showed signicant results (P < 0.05)
for both outcomes, i.e., TIS and SS‑QOL scale.
CONCLUSION: The study concludes that PNF techniques are benecial in improving trunk control
and QOL in hemiplegic population. Hence, this costless technique, which does not require any
equipment, can be regularly incorporated to all hemiplegic patients in any setup or at home.
Keywords:
Conventional exercises, proprioceptive neuromuscular facilitation, stroke
Introduction
Stroke is defined by the World Health
Organization as a clinical syndrome
consisting of rapidly developing clinical
signs of focal (or global in case of coma)
disturbance of cerebral function lasting
more than 24 h or leading to death with
no apparent cause other than a vascular
origin.[1] In India, the annual incidence rate
of stroke is 124/100,000 populations, and
the prevalence is 136/100,000 population
in urban area and 165/100,000 in rural
population. Stroke is mainly of two types:
ischemic and hemorrhagic. Ischemic type
occurs from thrombus, embolism, or
conditions that cause lack of cerebral blood
flow.[2] whereas hemorrhagic strokes occur
as a result of rupture of a cerebral vessel or
trauma. Hemorrhage results in increased
intracranial pressure with injury to brain
tissues and restriction of distal blood flow.[3]
The common feature of any stroke
irrespective of its type includes contralateral
sensory impairment, contralateral
hemiplegia in acute phases which progresses
to hemiparesis by time, pain, loss of motor
Address for
correspondence:
Dr. Diker Dev Joshi,
KLEU Institute of
Physiotherapy, Belgaum,
Karnataka, India.
E-mail: joshidiker@
gmail.com
Submission: 17-07-2017
Accepted: 10-10-2017
Department of
Neurophysiotherapy,
KLEU Institute of
Physiotherapy, Belgaum,
Karnataka, India
Original Article
Access this article online
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Website:
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DOI:
10.4103/PJIAP.PJIAP_12_17
How to cite this article: Chitra J, Joshi DD. The
effect of proprioceptive neuromuscular facilitation
techniques on trunk control in hemiplegic subjects:
A pre post design. Physiother - J Indian Assoc
Physiother 2017;11:40-4.
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Chitra and Joshi: Proprioceptive neuromuscular facilitation for trunk control in hemiplegics
Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 11, Issue 2, July-December 2017 41
control, alterations in tone, abnormal synergy patterns,
abnormal reflexes, altered coordination, lack of postural
control, and balance.
Trunk control is the ability of the trunk muscles to
allow the body to remain upright, adjust weight shift,
and perform selective movements of the trunk so as to
maintain the center of mass within the base of support
during static and dynamic postural adjustments.[4‑6]
Loss of trunk control is commonly observed in patients
with stroke.[7] As stroke patients lose their ability to
perform postural adjustment and maintain postural
alignment because of spasticity, weakness, loss of
equilibrium and righting reactions, trunk assumes
asymmetrical posture.[8] Despite evidence demonstrating
the importance of trunk performance after stroke,
therapies aimed at improving trunk function are
limited.[9] Dean and Shepherd reported on the beneficial
effects of practicing reaching tasks beyond arm’s length
on sitting ability and quality, reaching, and standing up,
both in acute and chronic phase of stroke.[10,11] Physical
therapy approaches aim to improve the strength and
normalize the tone of the patients using motor relearning
approach, neurophysiological approach, and a mixed
approach.[12]
Proprioceptive neuromuscular facilitation (PNF) is an
approach based on the principle that all human beings,
including those with disabilities, have untapped existing
potential.[13] The PNF approach to treatment uses the
principle that, control of motion proceeds from proximal
to distal body regions. Facilitation of trunk control,
therefore, is used to influence the extremities.[14]
The basic facilitation procedures provide tools for
the therapist to help the patient gain efficient motor
function. This effectiveness does not depend on having
the conscious cooperation of the patient. PNF techniques
have shown to increase trunk mobility and strength.[15]
PNF is commonly used to improve gait of patients with
hemiplegia. Various PNF procedures involving trunk
have been used, depending on the affected site.[16] The
trunk impairment scale(TIS) which assesses static and
dynamic sitting balance and trunk coordination is used
to check motor impairment of the trunk after stroke.
Adequate reliability and validity of the TIS for stroke
patients has been reported.[17]
After stroke, focus is being given to upper and lower
limbs whereas trunk area which is responsible for
supporting extremity motions does not get enough care.
Trunk PNF is a technique that is used to improve trunk
control in hemiplegics. There is dearth in evidence on
effect of PNF technique being helpful in improving trunk
control. Hence, the need arises to examine the effect of
PNF techniques on trunk in hemiplegic subjects. The
objective of the study was to evaluate the effect of trunk
PNF techniques in trunk control of stroke patients.
Methodology
The primary data were collected from tertiary health‑care
hospital by enrolling subacute stroke population referred
from neurology department tertiary care hospitals.
The subjects included were as follows:(i) Subjects with
first stroke and<6 months duration,(ii) Males and
females of age group: 18–65years(iii) Mini‑Mental State
Examination score more than 24,(iv) Trunk control
Test≥50, and (v) Currently not receiving any other
type of therapeutic intervention. The exclusion criteria
were as follows:(i) Known case of brain tumor, head
injury, or infective conditions of brain or hemisection
of spinal cord,(ii) History of diagnosed musculoskeletal
disorders of the trunk. The duration of the study was
12months(from March 2016 to February 2017).
Outcome measures
Trunk impairment scale
The starting position is patient sitting on the edge of a
bed or treatment table without back and arm support.
The knee angle is kept 90°. The arms rest on the legs. If
hypertonia is present in hemiplegic arm the position of
the arm is taken as the starting position. The head and
trunk are in a midline position. If the patient scores 0 on
the first item, the total score for the TIS is 0. Each item of
the test can be performed three times. The highest score
counts. No practice session is allowed. The patient can
be corrected between the attempts. The tests are verbally
explained to the patient and can be demonstrated if
needed.
Stroke‑specic quality of life
It is a self‑report scale containing 49 items in 12 domains:
Items are rated on a 5‑point Likert scale. Patients must
respond to each question of the SS‑QOL with reference
to the past week. There are 3 different response
sets(e.g. total help/couldn’t do it at all/strongly
agree). Patients must respond to each item using the
corresponding response set. Higher scores indicate better
functioning. Scoring of each item is done by labeling 1–5
depending on the patient ability. It is valid and reliable
scale.[18]
Procedure
Ethical clearance was obtained from the Institutional
Ethical Committee; the purpose of the study was
explained. All subjects were screened for inclusion
and exclusion criteria before their recruitment in the
study. A written informed consent was obtained from
the study subjects. All the subjects diagnosed with
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Chitra and Joshi: Proprioceptive neuromuscular facilitation for trunk control in hemiplegics
42 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 11, Issue 2, July-December 2017
Discussion
The present study aimed to evaluate trunk PNF
techniques in improving trunk control in stroke
patients. Trunk control test was taken for inclusion
criteria. Scores >50 were included as it is associated
stroke undergoing medical treatment in the Neurology
department of Tertiary Care hospitals were screened
using the Trunk control test scale. After finding their
suitability as per the inclusion criteria, they were
requested to participate in the study and 4 weeks
intervention was given. Atotal of 16 stroke patients were
recruited in the study and were given PNF exercises.
Participants were given techniques for 45 min with
a 1 min rest after every exercise. The effect was then
observed on TIS and quality of life(QOL) in subacute
stroke patients after 12 sessions.
Intervention
Trunk proprioceptive neuromuscular facilitation
This technique is given by placing the subject in
supine lying position or sitting position by following
methods:
a. Chopping and lifting
• Chopping: Bilateral asymmetrical upper extremity
extension is used for trunk flexion
• Lifting: Bilateral asymmetrical upper extremity
flexion with neck extension is used for trunk
extension.
b. Bilateral leg patterns for the trunk
• These combinations used bilateral, asymmetrical,
lower extremity patterns to exercise trunk
muscles.
• Trunk Lateral flexion
For lateral trunk flexion, bilateral leg flexion or
extension patterns with full hip rotation were
given
• The treatment was given for 45 mins with about
1min rest after completion of each pattern. Each
pattern was repeated for three times.
Data analysis
Kolmogorov–Smirnov test was used to assess the
normality of the distribution. As all the variables
followed a normal distribution(P >0.05), t‑test was
applied. IBM Corp. Released 2012. IBM SPSS Statistics for
Windows, Version 21.0. (Armonk, NY: IBM Corp.) was
used for the analysis of study. P < 0.05 was considered
statistically significant.
Results
Twenty‑five(n= 25) individuals with subacute stroke
were assessed for compatibility with the eligibility
criteria. The flow of the participants is shown in Figure1.
Sixteen individuals met the eligibility criteria and
agreed to participate in the study[Table1]. Participants
showed significant improvement in pretest and
posttest scores for TIS and stroke specific‑quality of
life(SS‑QOL) with mean difference being‑5.38 in TIS
and‑16.56 in SSQOL as well as in all 3 components of
TIS [Tables2 and 3, respectively].
Subacute stroke patients assessed for eligibility
(n = 25)
Excluded (n = 9)
-not meeting inclusion criteria (n = 9)
Participants included in the study (n = 16)
Pre-intervention score of TIS and SSQOL recorded
PNF exercises for 45 min for
3 days/week for 4 weeks (n = 16)
Post-intervention score of TIS and SSQOL was recorded
Data analysis using SPSS version 21
Figure 1: Methodology ow chart
Table 2: Comparison of pre‑and post‑test scores for
outcome measures
Outcome
measures
Mean±SD Mean
difference
P
Pre Post
TIS 6.81±3.78 12.18±5.16 5.77 0.0001*
SSQOL 111.93±27.37 128.5±32.39 16.57 0.0001*
*P<0.05. TIS=Trunk Impairment Scale, SSQOL=Stroke‑Specic Quality of
Life, SD=Standard deviation
Table 3: Comparison of pre‑and post‑test scores with
respect to subscales of Trunk Impairment Scale
Subscales of
TIS
Mean±SD Mean
difference
P
Pre Post
Static sitting
balance (7)
3.68±1.74 5±1.41 1.32 0.0005*
Dynamic sitting
balance (10)
1.87±1.99 4.31±2.96 2.44 0.0001*
Coordination (6) 1.25±0.93 2.68±1.44 1.43 0.0013*
*P<0.05. TIS=Trunk Impairment Scale, SD=Standard deviation
Table 1: Demographic characteristics of the subjects
Characteristics Mean±SD
Age 52.43±7.29
Gender (male/female) 12/4
Weight (kg) 59.37±5.65
Height (m) 1.61±0.03
BMI (kg/m2)22.81±2.01
Duration since stroke (months) 2.31±1.15
BMI=Body mass index, SD=Standard deviation
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Chitra and Joshi: Proprioceptive neuromuscular facilitation for trunk control in hemiplegics
Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 11, Issue 2, July-December 2017 43
with recovery of walking whereas patients scoring 40
failed to do so.[19]
In our study, static sitting balance showed significant
improvements with mean difference of 1.32. This could
be due to the fact that PNF can improve functional
independency through treatment that emphasizes
symmetry between affected and unaffected side.[20] In a
previous study, movement analysis of trunk found that
selective trunk muscle control, particularly the lower
trunk muscle activity was minimal in patients with
stroke, and as PNF recruited the lower trunk muscles
it would have improved the static sitting balance.[21]
Visual, proprioceptive, and auditory input are important
to help a patient regain good sitting balance[22] and as
PNF techniques included all inputs, it may have led to
improved sitting balance.[23]
In present study, PNF techniques led to significant
improvement in dynamic sitting balance using technique
like chopping and lifting. This could be due to increased
interaction between the two sides of the body with
diagonal and spiral motor patterns. The coordination
component of TIS also showed statistically significant
result. The irradiation from unaffected side would
have facilitated the affected side thus improving the
coordination component.[5]
The probable mechanism by which PNF could have
worked is by facilitating the neuromuscular mechanism,
by stimulating the proprioceptors. Kabat reported that a
greater motor response can be attained when employing
facilitating techniques in addition to resistance.
Facilitation resulted from a number of factors such
as application of stretch, use of particular movement
patterns, and use of maximal resistance to induce
irradiation.[24] These facilitatory techniques might help
to facilitate trunk motion and stability thus enhancing
the motor control and motor learning, thereby improving
the performance of participants in post treatment group
showed on TIS. Astudy done by Shimura stated that in
PNF, sensory inputs from the periphery leads to stronger
excitation of the cortical areas, leading to variations in
the thresholds of a number of motor neurons, which
was reflected in the motor evoked potentials.[25] This
was further supported by a meta‑analysis done by
Shinde and Ganvir[26] which reported that the amount
of sensory input coming from the periphery was greater
in PNF position than in normal position, which induces
changes in the excitability of the pyramidal tract and the
final motor pathways.
The techniques of PNF like rhythmic initiation,
slow reversal and agonistic reversal might have
helped to normalize the tone of affected side trunk
muscles, lengthening the contracted structures, relax
the hypertonic muscles, initiating the movements,
strengthening the weak muscles and improving the
control of the pelvis.[27] All these effects might directly or
indirectly aid in improving the trunk control. The study
by Dickstein etal. showed similar results using three
exercise therapy approaches where they found pattern of
muscle tone improvement in the PNF treatment group.[28]
The PNF approach uses the principle that control of
motion proceeds from proximal to distal body regions.
Facilitation of trunk control, therefore, is used to
influence the extremities. The result of the present study
found improvement in trunk performance in terms
of static sitting balance and dynamic sitting balance
and coordination. There were few limitations in this
study. Variables that could be relevant predictor of the
functional outcome, such as socioeconomic condition
and premorbid housing were not evaluated. Neither the
patients nor the physiotherapist were blinded. Further
studies can be conducted by adding a control group.
Studies to find the correlation between trunk Impairment,
age, BMI and other variables can be carried out.
Conclusion
The present pre‑post study concludes that Trunk PNF
is beneficial in improving trunk control and QOL in
hemiplegic population. Hence this technique, which
doesn’t require any equipment or extra cost, can be
regularly incorporated to all hemiplegic subjects in any
setup or at home.
Acknowledgment
We would like to thank Dr.Sanjiv Kumar,
Dr.Jorida Fernandes, Deepak Joshi, and Asmita Tari for
their constant support throughout the study duration.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
References
1. TruelsenT, BeggS, MathersC. The Global Burden of Cerebrovascular
Disease. Geneva: World Health Organisation; 2000.
2. BanerjeeTK, DasSK. Epidemiology of stroke in India. Neurol
Asia 2006;11:1‑4.
3. O’Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation.
NewDehli: FA Davis; 2013.
4. DaviesPM. Problems associated with the loss of selective trunk
activity in hemiplegia. In Right in the Middle. Berlin, Heidelberg:
Springer; 1990. p.31‑65.
5. RyersonS, LevitK. Functional Movement Reeducation:
AContemporary Model for Stroke Rehabilitation. NewYork:
Churchill Livingston; 1997.
6. EdwardsS. An analysis of normal movement as the basis
[Downloaded free from http://www.pjiap.org on Saturday, February 24, 2018, IP: 105.112.112.154]
Chitra and Joshi: Proprioceptive neuromuscular facilitation for trunk control in hemiplegics
44 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 11, Issue 2, July-December 2017
for the development of treatment techniques. Neurological
Physiotherapy. A Problem‑Solving Approach. Philadelphia:
Churchill Livingstone; 1996. p.5‑40.
7. Karthikbabu S, SolomonJM, Manikandan N, RaoBK,
ChakrapaniM, NayakA. Role of trunk rehabilitation on
trunk control, balance and gait in patients with chronic stroke:
Apre‑post design. Neurosci Med 2011;2:61.
8. ZakariaY, RashadU, MohammedR. Assessment of malalignment
of trunk and pelvis in stroke patients. Egypt J Neurol Psychiatry
Neurosurg 2010;47:599‑604.
9. DursunE, HamamciN, Dönmez S, Tüzünalp O, CakciA. Angular
biofeedback device for sitting balance of stroke patients. Stroke
1996;27:1354‑7.
10. Dean CM, ShepherdRB. Task‑related training improves
performance of seated reaching tasks after stroke. Arandomized
controlled trial. Stroke 1997;28:722‑8.
11. DeanCM, ChannonEF, HallJM. Sitting training early after stroke
improves sitting ability and quality and carries over to standing
up but not to walking: Arandomised controlled trial. Aust J
Physiother 2007;53:97‑102.
12. PollockA, BaerG, LanghorneP, PomeroyV. Physiotherapy
treatment approaches for the recovery of postural control and
lower limb function following stroke: Asystematic review. Clin
Rehabil 2007;21:395‑410.
13. Adler S, Beckers D, Buck M. PNF in Practice: An Illustrated Guide.
New Dehli: Springer Science & Business Media; 2007.
14. VerheydenG, VereeckL, TruijenS, TrochM, HerregodtsI,
LafosseC, et al. Trunk performance after stroke and the
relationship with balance, gait and functional ability. Clin Rehabil
2006;20:451‑8.
15. Trueblood PR, Walker JM, Perry J, Gronley JK. Pelvic exercise
and gait in hemiplegia. Phys Ther 1989;69:18‑26.
16. ArboixA, OliveresM, García‑Eroles L, Maragall C, MassonsJ,
TargaC, et al. Acute cerebrovascular disease in women. Eur
Neurol 2001;45:199‑205.
17. VerheydenG, VereeckL, TruijenS, TrochM, LafosseC, SaeysW,
et al. Additional exercises improve trunk performance after stroke:
Apilot randomized controlled trial. Neurorehabil Neural Repair
2009;23:281‑6.
18. WilliamsLS, WeinbergerM, HarrisLE, ClarkDO, BillerJ.
Development of a stroke‑specific quality of life scale. Stroke
1999;30:1362‑9.
19. Bohannon RW, CassidyD, WalshS. Trunk muscle strength is
impaired multidirectionally after stroke. Clin Rehabil 1995;9:47‑51.
20. Kim Y, KimE, GongW. The effects of trunk stability exercise
using PNF on the functional reach test and muscle activities of
stroke patients. JPhys Ther Sci 2011;23:699‑702.
21. TysonSF, HanleyM, ChillalaJ, SelleyA, TallisRC. Balance
disability after stroke. Phys Ther 2006;86:30‑8.
22. DhimanNR, ShahM, ShahGL, JoshiD, GyanpuriV. Relationship
between independent sitting balance and type of stroke in patients
with left sided hemiparesis. Int J Physiother Res 2014;2:324‑8.
23. HamaS, YamashitaH, ShigenobuM, WatanabeA, HiramotoK,
TakimotoY, et al. Sitting balance as an early predictor of functional
improvement in association with depressive symptoms in stroke
patients. Psychiatry Clin Neurosci 2007;61:543‑51.
24. Knott M, Voss DE. Proprioceptive Neuromuscular Facilitation:
Patterns and Techniques. New York: Hoeber Medical Division,
Harper and Row; 1968.
25. 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.
26. ShindeK, Ganvir S. Effectiveness of trunk proprioceptive
neuromuscular facilitation techniques after stroke:
Ameta‑analysis. Natl J Med Allied Sci 2014;3:29‑34.
27. Khanal D, SingaravelanRM, KhatriSM. Effectiveness of
pelvic proprioceptive neuromuscular facilitation technique on
facilitation of trunk movement in hemiparetic stroke patients.
JDent Med Sci 2013;3:29‑37.
28. DicksteinR, HochermanS, PillarT, ShahamR. Stroke rehabilitation.
Three exercise therapy approaches. Phys Ther 1986;66:1233‑8.
[Downloaded free from http://www.pjiap.org on Saturday, February 24, 2018, IP: 105.112.112.154]