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Effectiveness of Pelvic Proprioceptive
Neuromuscular Facilitation Techniques on
Balance and Gait Parameters in Chronic Stroke
Patients: A Randomized Clinical Trial
Manali A. Boob , Rakesh K. Kovela
1. Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, IND 2.
Physiotherapy, Nitte Institute of Physiotherapy, Nitte (Deemed to be University), Mangalore, IND
Corresponding author: Rakesh K. Kovela, rakeshkrishna.pt@gmail.com
Abstract
Background
Stroke is the second leading reason for death and the third most common reason for disability. Stroke is a
source of possible substantial harm and is often more disabling than lethal. Common stroke defects include
stiffness, tiredness, loss of balance on the afflicted side, as well as gait impairment, resulting in an inability
to sustain postural alignment. Pelvic proprioceptive neuromuscular facilitation (PNF) is a physical
rehabilitation that combines functionally dependent diagonal activity patterns with neuromuscular
facilitator strategies to improve motor behaviour, endurance, and muscle activity and control. This protocol
was created to describe the experimental study design for evaluating the combined impact of pelvic PNF and
task-oriented exercises in chronic stroke patients to improve balance and gait parameters.
Aim and objective
The purpose of our study is to investigate the effectiveness of pelvic PNF as well as task-oriented
exercises on balance, gait parameters, and in pelvic asymmetry.
Methods
The participants (n=30) were stroke survivors who fulfilled the inclusion criteria for research and were
divided into two groups. The regimen lasted four weeks and took 30 minutes each day. Patients were
evaluated at the beginning and end of their treatment. In both groups, pre- and post-intervention outcome
measures were recorded and the data was analyzed.
Result
Following four weeks of rehabilitation, subjects showed remarkable improvement in balance, gait
parameters, and pelvic inclination in both groups, i.e., pelvic PNF and task-oriented exercises in group A
and task-oriented exercises in group B, but Group A showed a major improvement in outcome measures. A
p-value of less than 0.05 was considered significant. Despite the fact that both treatment regimens were
successful for the patient, pelvic PNF combined with task-oriented exercises exhibits a statistically
significant difference from task-oriented exercises.
Conclusion
Pelvic PNF along with task-oriented exercises proved to be beneficial and can help in the restoration of
balance and gait parameters as a result of normalisation in the geometry and symmetry of the pelvis in
stroke patients. The pelvis, which is a connecting link between the trunk and lower limbs, plays a crucial role
in balance and also in lower limb performance exclusively in gait.
Categories: Neurology, Physical Medicine & Rehabilitation, Therapeutics
Keywords: pelvic inclination, gait velocity, proprioceptive neuromuscular facilitation, berg balance scale, palpation
meter
Introduction
Stroke is defined as "rapid growing clinical signs of localized disruption of brain activity, with complaints
persisting 24 hours or more or fatal consequences, with no evident explanation other than the vascular
origin" [1]. In India, stroke is the most widely recognized reason for mortality and disability; the estimated
updated overall prevalence of stroke in impoverished areas is 84-262/100,000, while in metropolitan centres
it is 334-424/100,000 [2]. According to recent demographic estimates, the prevalence rate is 119-145/per
100,000 people [2]. The type of stroke has a substantial impact on patient survival; hemorrhagic strokes
1 2
Open Access Original
Article DOI: 10.7759/cureus.30630
How to cite this article
Boob M A, Kovela R K (October 24, 2022) E ffectiveness of Pelvic Proprioceptive Neuromuscular Facilitation Techniques on Balance and Gait
Parameters in Chronic Stroke Patients: A Randomized Clinical Trial. Cureus 14(10): e30630. DOI 10.7759/cureus.30630
account for the majority of deaths, with mortality rates ranging from 37% to 3% at one month, while
ischemic strokes have a mortality rate of just 14.7% at one month [3].
Common stroke defects include stiffness, tiredness, and loss of balance on the afflicted side, as well as gait
impairment resulting in an inability to sustain postural alignment [4]. The pelvic region is recognized as a
vital critical location during static and dynamic postural shifts, allowing the body to retain momentum and
modify weight variations [5]. Brunnstrom discovered, after studying a significant number of hemiplegic
patients, that an almost stereotyped series of events occur during rehabilitation following a cerebrovascular
injury [6]. A motor function deficit is indicated by hemiplegia on the contralateral side of the injury [7].
Spasticity is a motor condition marked by a velocity-dependent increase in muscle tone and increased
stretch resistance; the greater and faster the stretch, the stronger the spastic muscle's resistance [6].
Spasticity is often associated with other neurologic impairments, especially paresis, which makes assessing
its effects and treatment outcomes more difficult [6].
There are several techniques and interventions suggested for stroke patients such as proprioceptive
neuromuscular facilitation (PNF), strength training programs, task-oriented training, training with visual
feedback, a sensory-motor training program, balance training, robotic-assisted locomotor training,
locomotor training, Intervention to manage spasticity like PNF, application of a cold pack, massage,
electrical stimulation, etc. [3-8]
PNF stands for proprioceptive neuromuscular facilitation, any of the sensory receptors that offer
information about the body's movement and location are referred to be proprioceptive, the term
"neuromuscular" describes both nerves and muscles are involved, facilitation is the method of developing
smoother patterns [9]. PNF is a physical rehabilitation technique that combines functionally dependent
diagonal activity patterns with neuromuscular facilitator strategies to improve motor behaviour, endurance,
and muscle activity and control [10]. The discovery of this approach was made possible by Kabat, Knott, and
Voss' revolutionary work in the 1940s and 1950s [10]. Interpersonal feedback is used in conjunction with
some PNF procedures, such as joint approximations, traction, irradiation, and overflow, to enhance muscle
activation and motor performance [11].
Task-oriented training is the method of carrying out essential practical exercises or tasks to develop well-
organized and efficient motor skills [12]. Task-oriented programming is focused on current motor learning
models and the processes paradigm of motor control [12].
Materials And Methods
After receiving consent from the institutional ethics committee of the Datta Meghe Institute of Medical
Sciences, deemed to be a University (approved number: DMIMS(DU)/IEC/2021/371) the research was
conducted in the neuro-physiotherapy Outpatient Department (OPD), Sawangi, Wardha. The participants
were chosen from the neuro-physiotherapy departments of the Acharya Vinoba Bhave Rural Hospital in
Sawangi, Meghe, Wardha, Maharashtra, as well as the Ravi Nair Physiotherapy College.
Patients who met the inclusion and exclusion criteria and underwent the necessary evaluation were chosen
for this research. The inclusion criteria were patients who experience a period of recovery at least six months
after the initial stroke events, patients between 40 to 75 years of age, both males and females, patients who
can sit independently, patients with stages 4-5 on Brunnstrom grading, patients with pelvic asymmetry, and
patients capable of following commands. The exclusion criteria were patients suffering from severe arthritis,
patients with any cognitive dysfunction, patients who have undergone any type of spine or lower limb
operation in the span of the last one month, any other neurological abnormalities that impair sensory
function, any other cardiopulmonary deficits, patients having fixed deformities or contractures in the spine
and lower limb, patients with any type of spine or lower limb fractures or dislocations, patients who are
already in a trial. The material required for the study was a printed copy of the data collection sheet,
informed consent, a printout of the Berg Balance Scale (BBS), palpation meter, plinth, pillow, obstacles,
wobble/balance board, staircase, measuring tape, stopwatch, and chalk. Patients signed written informed
consent forms after the objectives and the study approaches were explained to the patients.
The participants diagnosed with chronic stroke were randomized through simple random sampling and
allocated through the sequentially numbered, opaque, sealed envelope (SNOSE) technique into Group A and
Group B. Group A was given pelvic PNF along with task-oriented exercises for lower extremities and Group B
was given only task-oriented exercises for the lower limb. Outcome measures were assessed before the
beginning of the study and after the completion of the study. Pre- and post-outcome measures were taken
by using a palpation meter, BBS, and gait parameters by the assessor who was blinded and aware of the
outcome measures. Treatment was planned for 30 minutes each day for six days per week for four weeks. The
enrollment, allocation, follow up and analysis are represented in Figure 1.
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FIGURE 1: Flow diagram of the study procedure
Outcome measures
Palpation Meter (PALM) Device
The Palpation Meter allows an examiner to test for skeletal asymmetry. The PALM combines the objectivity
and reliability of calliper and inclinometer readings with the simplicity and proprioceptive benefits of
palpation. Between the two palpating fingers, the calliper measures the distance in millimetres. The
inclinometer measures the angle between two palpating fingers in degrees. The height difference between
the two landmarks may be measured in centimetres and inches using a special slide rule calculator. The
picture of the palpation meter is shown in Figure 2. A demonstration of the palpation meter is shown in
Figure 3.
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FIGURE 3: A demonstration of using a palpation meter to check for
pelvic asymmetry
(A) palpation of the patients' ASIS; (B) measurement of pelvic inclination with palpation meter; (C) calliper dial; (D)
palpation meter calculator
Berg Balance Scale (BBS)
The BBS is a popular clinical scale for assessing a person's dynamic and static state of equilibrium. For
practical balancing tests, BBS is commonly known as the gold standard. The test lasts approximately 15-20
minutes and consists of 14 fundamental balance exercises. The ultimate result is the summation of all
scores.
Gait Parameters
Stride length: The distance between two successive heel strikes of a similar foot is known as stride length,
which is made up of two-step lengths. Cadence refers to the number of steps done in a certain period. Gait
velocity by 10-metre walk test is a performance indicator that measures walking speed in m/s over a small
distance. Intervention
Interventions
Intervention for Group A
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Rhythmic initiation, slow reversal (dynamic reversal), and stabilizing reversal were given for 15 minutes, six
days a week for four weeks, coupled with task-oriented lower extremity activities for 15 minutes. Each
technique lasted for five minutes with enough rest time offered for each person based on their comfort level.
These treatments were performed on the afflicted side, with the hips flexed to 100° and the knees flexed to
45°, these treatments were performed to aid with an anterior pelvic elevation and posterior pelvic
depression [5]. A cushion supported their neck. The physiotherapist positioned themself behind the
patients, following the plane of the patient’s pelvic movements. For anterior elevation, the therapist's hands
were placed just on the subject's anterior iliac spine, and for posterior depression, they were placed on the
patient's ischial tuberosity. "Pull up" was employed to help with pelvic anterior elevation, and "push down"
and "sit into my hands" helped with pelvic posterior depression [5]. Rhythmic initiation was commenced
after the patient voluntarily relaxed, after which the therapist would move the patient passively, later
proceeding with assisted movement, then active movement, and finally active-resisted movement. Slow
reversal involves a dynamic concentric contraction of strong agonists immediately followed by a dynamic
concentric contraction of weak antagonists. Stabilizing reversal is a technique that involves alternate
isotonic contractions with enough resistance to keep the body from moving. The therapist permits just a
very slight movement in response to the dynamic command. The treatment included PNF features, including
placement, manual touch, stretching, resistance, and vocal instructions.
Intervention for Group B
For four weeks, Group B was provided with just task-oriented lower-limb activities for 30 minutes each day,
six days per week. Activities for group B include reaching toward an object across the table while standing
with symmetrical weight distribution over both legs, standing on a wobble board, forward walking, backward
walking, obstacle crossing, walking on an uneven surface, stair climbing, and walking on a ramp. Pre- and
post-outcome measures were taken by using PALM, BBS, and gait parameters by the assessor who was aware
of the outcome measures. The intervention of groups A and B are shown in Figures 4-5.
FIGURE 4: Pelvic PNF demonstrated in the patient
PNF: proprioceptive neuromuscular facilitation
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FIGURE 5: Shows task-oriented exercises.
A) obstacle crossing; (B) standing on a wobble board; (C) dragging a foot and placing it on objects; (D) forward
walking and backward walking on the parallel bar.
Statistical analysis
Data collected were analyzed using descriptive statistical analysis, including a chi-square test, the student's
paired and unpaired t-test, and software from the Statistical Package for Social Science (SPSS) 27.0 version
(IBM Corp., Armonk, NY) and GraphPad Prism 7.0 version (GraphPad Software, San Diego, CA) with p-value
less than 0.05 declared the threshold of effectiveness. The frequency percentages were utilised to
characterise qualitative data, while the mean and standard deviation would be used to illustrate quantitative
data. The paired t-test was used to compare the effects of pelvic PNF and task-oriented against task-
oriented approaches on balance and gait characteristics in patients with continuing stroke. If the data did
not follow a normal distribution, the Wilcoxon sign rank test was used.
Results
The effects of the intervention on various outcome measures, including the Berg Balance Scale, stride
length, cadence, gait velocity, and pelvic inclination measure, are shown in Table 1 and Figures 6-15,
respectively. Table 1 highlights the importance of comparing and post-intervention results for groups. along
with the statistical analysis and a mean difference of the variables that were pre-measured. The findings
indicate that both groups are statistically significant, but that group A's post-treatment measures are more
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significant than those of group B. This revealed that group A's protocol would be more appropriate.
Outcome Measure
Group A Group B Mean difference
Pre-treatment Post-treatment t-value Pre-treatment Post-treatment t-value Group A Group B t-value
BBS 27.73±5.59 46.80±3.78 19.49; P=0.0001, S 28.20±5.21 37.13±4.15 10.82; P=0.0001,S 19.06±3.78 8.93±3.19 7.91; P=0.0001,S
Stride length 38.66±9.11 57.13±7.43 12.14; P=0.0001,S 38.46±10.21 46±9.62 7.11; P=0.0001,S 18.46±5.89 18.46±5.89 5.89; P=0.0001,S
Cadence 43.73±15.12 77.86±14.05 16.65; P=0.0001,S 41.20±14.10 56±13.40 8.78; P=0.0001,S 34.13±7.93 14.80±6.92 7.28; P=0.0001,S
Gait velocity 0.09±0.02 0.11±0.03 7.69; P=0.0001,S 0.09±0.01 0.09±0.01 6.82; P=0.0001,S 0.022±0.012 0.008±0.004 3.92; P=0.001,S
Pelvic inclination 2.58±0.74 1.30±0.55 19.50; P=0.0001,S 2.88±0.70 2.29±0.69 6.72; P=0.0001,S 1.28±0.25 0.58±0.33 6.35; P =0.0001,S
TABLE 1: Significance of comparing pre- and post-intervention results for groups
s: significant
FIGURE 6: BBS score comparison between two groups before and after
treatment
BBS: Berg Balance Scale, SD: standard deviation
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FIGURE 13: Evaluation of the mean difference between gait velocity
(m/s) in two groups
SD: standard deviation
FIGURE 14: Pelvic inclinometer measure (cm) comparison between two
groups before and after treatment
SD: standard deviation
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FIGURE 15: Evaluation of the mean difference between pelvic
inclinometer measure(cm) in two groups
SD: standard deviation
Discussion
Transient ischemic strokes were once suggested to be brief, focal neurologic impairments of vascular origin
that lasted or less than 24 hours. If a cerebral impairment persisted for longer than seven days, it was
considered a stroke. The phrase "reversible ischemic neurological impairment" was used to describe
neurological abnormalities that persisted for between 24 hours and seven days when it was proven that the
majority of incidents lasting for this time period were associated with cerebral infarction and should be
classified as stroke. The previously used phrase was removed from the clinical vocabulary. As a result, the
views of stroke in North America and the World Health Organization diverged, with one
emphasizing indications of infarction and the other clinical symptoms [13,14]. PNF exercises are particularly
efficient in producing voluntary contraction and enhancing functional activities in stroke patients,
according to research by Chaturvedi et al [15]. Kumar et al. (2012) PNF's effect on stride length and
functional capacities in the hemiplegic. According to studies, hemiplegic patients' gait characteristics and
functional skills are significantly impacted by pelvic PNF [16].
The study involves 15 participants in groups A and B. The study's findings illustrate the effect of pelvic PNF
and task-oriented lower extremity exercises for chronic stroke patients. The group that received pelvic PNF
together with task-oriented lower-limb exercises improved much more than the group that received simply
task-oriented lower-extremity activities. Pelvic PNF combined with task-oriented lower extremity exercises
was assigned to group A, while task-oriented lower extremity activities were assigned to group B. Five
outcomes were utilized in both groups to determine if there was a meaningful recovery or improvement in
the patient's condition. On the beginning and final days of the protocol, the outcome measure was
evaluated. The Berg Balance Scale and gait variables such as stride length, cadence, gait velocity, and the
PALM device for evaluating pelvis misalignment were all utilized to determine the results. The Berg Balance
Scale result was computed using a 14-point scale, stride length in cm, cadence in the number of steps per
minute, gait velocity in m/s, and pelvic inclination in centimetres.
The Berg Balance Scale (BBS) was administered to the participants in groups A and B. This is a clinical scale
for evaluating static and dynamic balance. Group A had a t-value of 19.49, which was higher than group B's
t-value of 10.82. Both groups exhibited substantial improvement, while group A demonstrated more impact
than group B. The p-value interpretation was significant. The average t-value difference between the two
groups was 7.91. Kim et al. examined the effect of aquatic coordinated movement using the PNF pattern on
the balance and gait variable where 20 stroke survivors were randomly assigned to one of two groups:
experimental or control. Neurodevelopmental therapy was given to both groups of patients, whereas the
experimental group used the PNF to conduct synchronized movements underwater. When compared to the
control group, the experimental group significantly improved on the BBS, Functional Reach Test, Ten-Meter
Walk Test, and Timed Up and Go Test [17].
The stride length of group A patients improved their performance more than group B patients after a four-
week treatment. Group A had a higher t-value than group B. The t-value mean difference was 5.89 and the p-
2022 Boob et al. Cureus 14(10): e30630. DOI 10.7759/cureus.30630 13 of 15
value was significant. Patni conducted research to examine the effectiveness of pelvis PNF and hip extensor
strength activities on locomotor variables in hemiplegics, with Group A receiving pelvic PNF training and
Group B receiving hip extensor strength training. The findings of this study showed that PNF approaches
had a substantial impact on gait metrics in hemiplegic individuals [7]. PNF is a way of treating
neuromuscular impairment by enhancing the movement of resources, particularly through stimulating
proprioceptors [7-18].
The cadence was assessed pre and post-treatment and which was significant in both groups but the outcome
of group A is more efficient. Khanal et al. investigated the impact of the pelvic PNF approach on trunk
movement stimulation in 30 individuals with hemiplegia who were allocated into two groups randomly. The
experimental group underwent pelvic PNF, whereas the control group received truncal exercises. Both
groups also got therapy in the form of tonal control and range of motion activities for the afflicted limbs. The
intervention was delivered daily for at least four weeks, five days a week. Following therapy, there was an
enhancement in outcome variables such as trunk performance, and trunk lateral flexion range of motion as
measured by an inclinometer, balance, and gait metrics [19].
To begin calculating gait velocity, a 10 m distance is measured in the hallway. The patient is then asked to
walk at his or her normal pace without falling, and the timeframe is recorded in seconds. The velocity was
then calculated, and the distance covered was calculated as 10 m divided by the time it took to complete the
distance. Readings were recorded on Day 1, prior to the start of therapy, and they were nearly identical in
both groups. Post-intervention both the groups are significant but the group A value is greater than B. The
mean difference in t-values is 3.92, and the mean difference in p-values was significant. Dubey et al.
analyzed the effects of hip muscle strengthening, gait speed, and activities of daily living after stroke on the
trunk and lower extremity mobility function. The experimental class received pelvic stability exercises
whereas the control class received normal therapy for 60 minutes three to four times a week for
approximately six weeks. Pelvic stabilization training has been believed to enhance hip muscular strength,
gait velocity, and control of the trunk and lower extremities in stroke patients [20].
Comparing groups, A and B before and after therapeutic interventions, the mean difference in pelvic
inclination between them was 1.28 0.25 and 0.58 0.33. The p-value was 0.0001 and the mean t-value
difference was 6.35. There was a remarkable decrease in the value of pelvic inclination in group A. Petrone
et al. conducted research to evaluate the Palpation Meter's accuracy and dependability. This study included
15 healthy subjects and 15 afflicted subjects with suspected lower limb discrepancy (LLD). The clinician used
the PALM to measure the pelvic height difference. A simply standing anteroposterior radiograph of each
patient's pelvis was collected, and the pelvic difference from the radiograph was measured to compare with
PALM values. ICCs (intraclass correlation coefficients) were computed. The results of PALM compared with
radiographs show that the evaluating pelvic tilting and inclination discrepancies, the PALM is a dependable,
valid, and accurate tool [21].
The research was limited in that it was only done on a small population. This shows that a larger population
needs to participate in the same study to see whether PNF combined with task-oriented activities is useful
for stroke patients. There was no prolonged monitoring of patients, and the study only lasted a few weeks. In
future research, the number of therapy sessions should be increased for a quicker recovery.
Conclusions
The main objective of this research is to investigate the combined therapeutic efficacy of pelvic PNF
techniques as well as task-oriented approaches to balance and gait parameters, as well as in the treatment of
pelvic asymmetry in a stroke survivor. The study's outcome measures are the PALM device, BBS, and gait
parameters. The PALM device was used to check pelvic asymmetry, which was the most reliable instrument
used in the study rather than the traditional radiographic measurement. BBS helped to assess the
balance and gait parameters; an increase in cadence led to a rise in the individuals' average stride length,
resulting in an improved gait pattern. The impactful output of this research shows that the pelvic PNF
technique with task-oriented activities of the lower limb in chronic stroke patients was more beneficial than
only task-oriented activities. This results in improving their balance, gait parameters, and pelvic asymmetry.
The recovery of the patient was faster, which improved their personal quality of life. An outcome of this
research was the learnings gleaned from both therapies. The data were examined with a paired t-test and
reported as a research article.
Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Institutional ethics
committee of Datta Meghe Institute of Medical Science (Deemed to be University) issued approval
DMIMS(DU)/IEC/2021/371. The Institutional Ethics Committee in its meeting held on 31 May 2021 has
approved the following research work proposed to be carried out at RNPC Sawangi (Meghe), Wardha. This
approval has been granted on the assumption that the research work will be carried out in accordance with
ethical guidelines prescribed by Central Ethics Committee on Human Research (C.E.C.H.R.). Animal
2022 Boob et al. Cureus 14(10): e30630. DOI 10.7759/cureus.30630 14 of 15
subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conf licts of
interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any
organization for the submitted work. Financial relationships: All authors have declared that they have no
financial relationships at present or within the previous three years with any organizations that might have
an interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
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