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Effectiveness of Pelvic Proprioceptive Neuromuscular Facilitation Techniques on Balance and Gait Parameters in Chronic Stroke Patients: A Randomized Clinical Trial

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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.
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Received 09/18/2022
Review began 09/24/2022
Review ended 10/04/2022
Published 10/24/2022
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Boob et al. This is an open access article
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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 2: Palpation meter (PALM) device
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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 7: Evaluation of the mean difference between BBS score in two
groups
BBS: Berg Balance Scale, SD: standard deviation
FIGURE 8: Stride length (cm) comparison between two groups before
and after treatment
SD: standard deviation
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FIGURE 9: Evaluation of the mean difference between stride length (cm)
in two groups
SD: standard deviation
FIGURE 10: Cadence (m/s) comparison between two groups before and
after treatment
SD: standard deviation
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FIGURE 11: Evaluation of the mean difference between cadence (m/s) in
two groups
SD: standard deviation
FIGURE 12: Gait velocity (m/s) comparison between two groups before
and after treatment
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-
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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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2022 Boob et al. Cureus 14(10): e30630. DOI 10.7759/cureus.30630 15 of 15
... Another study [105] highlighted that pelvic proprioceptive neuromuscular facilitation (PNF), in addition to task-oriented training, is more effective at improving both standing balance and gait than task-oriented training alone in stroke patients. PNF has positive effects as it improves the functions of muscles and tendons by stimulating the proprioceptive sense, which enhances muscle strength, flexibility, and balance [92]. ...
... In addition, PNF has positive effects when applied to the neck [92,106], as resistance during neck exercises also affects body trunk muscles [92]. Another study [105] highlighted that pelvic proprioceptive neuromuscular fac tion (PNF), in addition to task-oriented training, is more effective at improving both st ing balance and gait than task-oriented training alone in stroke patients. PNF has pos effects as it improves the functions of muscles and tendons by stimulating the proprio tive sense, which enhances muscle strength, flexibility, and balance [92]. ...
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Objective: The purpose of this scoping review is to provide valuable insights for clinicians and researchers for designing rehabilitative interventions targeting the trunk and core for individuals who have experienced traumatic events, such as stroke or spinal cord injury, or are grappling with neurological diseases such as multiple sclerosis and Parkinson’s disease. We investigated training methods used to enhance balance, trunk control, and core stability. Methods: We conducted an extensive literature search across several electronic databases, including Web of Science, PubMed, SCOPUS, Google Scholar, and IEEE Xplore. Results: A total of 109 articles met the inclusion criteria and were included in this review. The results shed light on the diversity of rehabilitation methods that target the trunk and core. These methods have demonstrated effectiveness in improving various outcomes, including balance, trunk control, gait, the management of trunk muscles, overall independence, and individuals’ quality of life. Conclusions: Our scoping review provides an overview on the methods and technologies employed in trunk rehabilitation and core strengthening, offering insights into the added value of core training and specific robotic training, focusing on the importance of different types of feedback to enhance training effectiveness.
... Principally utilized in the rehabilitation following neural damage [16,17], PNF has demonstrated efficacy in ameliorating motor function impairments resulting from neurological injuries [18]. It has also been applied in musculoskeletal rehabilitation, especially vital in the recuperation from conditions such as low back pain, rotator cuff injuries, and frozen shoulder [19][20][21]. ...
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Objective This study conducts a rigorous meta-analysis of existing literature to rigorously examine the efficacy of Proprioceptive Neuromuscular Facilitation (PNF) in ameliorating functional deficits associated with Chronic Ankle Instability (CAI). Methods Literature searches were conducted in multiple databases including China National Knowledge Infrastructure (CNKI), VIP, Wanfang, China Biology Medicine disc (CBM), PubMed, EBSCO (Medline, CINAHL, SPORTDiscus, and Rehabilitation & Sports Medicine Source), Embase, ScienceDirect, ProQuest, Cochrane Library, and Web of Science for randomized controlled trials assessing the effects of Proprioceptive Neuromuscular Facilitation interventions on patients with Chronic Ankle Instability. The publication timeframe spanned from the inception of each database until April 10, 2024. Meta-analysis was performed using STATA 12 software on the included studies. Results ① A total of 12 randomized controlled trials were included, encompassing 405 patients with Chronic Ankle Instability, demonstrating a generally high methodological quality of the literature.② Meta-analysis results indicate that compared to the control group, Proprioceptive Neuromuscular Facilitation (PNF) significantly enhanced the balance ability of patients with Chronic Ankle Instability as measured by the Y Balance Test (YBT) (Weighted Mean Difference (WMD) = 3.61, 95% CI [2.65, 4.56], z = 7.42, P<0.001) and the Star Excursion Balance Test (SEBT) (WMD = 5.50, 95% CI [3.80, 7.19], z = 6.36, P<0.001), with improvement in all eight directions of SEBT balance ability surpassing that of the control group (P<0.05); muscle strength around the ankle (SMD) = 0.19, 95% CI [0.03, 0.36], z = 2.26, P = 0.024), with both Plantar flexion and Dorsal flexion muscle strength improvements exceeding those of the control group (P<0.05); Visual Analog Scale (VAS) (WMD = -1.39, 95% CI [-1.72, -1.06], z = 8.23, P<0.001); Ankle instability questionnaire (WMD = 2.91, 95% CI [1.92, 3.89], z = 5.78, P<0.001).③Descriptive analysis results showed that the differences in Inversion Joint Position Sense and Dorsiflexion range of motion between the PNF and control groups were not statistically significant (P>0.05), however, the effects of PNF training persisted for a certain period even after cessation of treatment. Conclusion Proprioceptive Neuromuscular Facilitation (PNF) can significantly improve balance, muscle strength, and pain in patients with Chronic Ankle Instability (CAI). While PNF has shown improvements in joint position sense and dorsiflexion range of motion for CAI patients, with effects that remain for a period thereafter, these improvements were not significantly different when compared to the control group. Further research is required to substantiate these specific effects.
... A positive result suggests an upward scapular rotation, while a negative result shows a downward scapular rotation. [26][27][28] Change in Fugl-Meyer Assessment of Upper Extremity (FMA-UE) score ...
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Background: Stroke is a neurological disability produced by vascular-related acute focal injury to the central nervous system and is one of the leading causes of disability in adults, and it is frequently accompanied by motor skill loss. Patients suffering from hemiplegia after a stroke are more prone to have fall and are more likely to experience further injury due to irregular gait, diminished muscular strength, and functional impairment. In the affected upper limb of the hemiplegic stroke, spasticity in the shoulder girdle causes scapular malalignment, which reduces the functional mobility and stability of the upper limb. This is reflected as the reduced reciprocal arm swing during walking, which is further reinforced by an abnormal synergy pattern on the affected side. Proprioceptive neuromuscular facilitation (PNF) is a treatment strategy that stimulates motor activity and enhances control and function of the neuromuscular system. This research protocol is intended to assess and evaluate the effects of applying scapular and upper limb PNF along with conventional physiotherapy treatment to subacute-stroke patients on their scapular alignment, upper limb function, and gait. Methods: A total of 40 individuals in total will be allocated equally into two groups, group-A (experimental) and group-B (control). Both groups will be receiving treatment for six weeks with five sessions per week. Each patient will be examined both before and after therapy using the Palpation Meter (PALM), the Fugl-Meyer Assessment of Upper Extremity (FMA-UE), 10-Meter Walk Test, Handheld dynamometer (10MWT), and Dynamic gait index (DGI). After six weeks of therapy, the results will be assessed and the data will be analyzed before and after the intervention using a paired t-test to discover within-group differences in measurements. Conclusions: This physiotherapy method may be used in the management of stroke patients if our study's hypothesis is found to be valid. Registration: CTRI ( CTRI/2023/05/052930 , 19/05/2023).
... 7 Pelvis Stabilization exercise will include Pelvic Proprioceptive neuromuscular Facilitation (PNF). 8 Pelvic motions like anterior elevation, posterior depression, posterior elevation, and anterior depression will be performed. Rhythmic initiation technique of PNF will be used to perform patterns with further progression into combinations of isotonics, dynamic reversal, stabilizing reversal followed by contract relax and hold relax technique. ...
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Cerebellar ataxia is caused by several hereditary or acquired aetiologies that eventually lead to abnormalities in the cerebellum. Patients with cerebellar ataxia may experience balance issues, eye movement abnormalities, limb incoordination, gait instability, and speech impairment as a result. The available treatment options for cerebellar ataxia are rather limited, causing many patients to struggle with daily activities. Although the success rate of a range of therapeutic interventions has been determined, evidence-based exercise guidelines for the treatment of balance disorders and associated problems in people with cerebellar ataxia are currently unavailable. Thus, physiotherapists must explore novel approaches to successfully manage the symptoms of ataxia and further improve the quality of life of patients. The current study protocol will provide new insight as no article available to date has looked at trunk and pelvis stabilization exercise programme as an intervention for treating cerebellar ataxia. We hereby propose a study, which aims to investigate the impact of conventional exercises and trunk and pelvis stabilization exercises along with conventional exercises on subjects with Cerebellar ataxia in a two-arm randomized controlled trial on improving SARA, TIS, BBS, Barthel Index, WHOQOL The total participants will be divided into two-arm parallel groups and the intervention will be given for complete 6 weeks, 5 days in a week. The outcome measure will be evaluated at baseline and the end of 6 weeks. The results will be evaluated after 6 weeks. If the hypothesis of our study proves to be effective, then this physiotherapy intervention could be included in the management of cerebellar ataxia
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O acidente vascular encefálico (AVE) é a predominante causa de déficits cognitivos e incapacidades, no qual é responsável por 5,2% de todas as mortes em todo o mundo. Os objetivos são esclarecer sobre a importância da facilitação neuromuscular proprioceptiva do paciente com sequelas de acidente vascular cerebral. É um estudo integrativo de literatura, na qual foi utilizado artigos publicados nos anos 2016 a 2023 em português e inglês. Os artigos foram buscados na Scientific Electronic Library Online (SciELO), BVS, PubMed, Literatura Latino-Americana em Ciências da Saúde (LILACS), PEDro. Foram utilizados casos clínicos em acordo com a proposta metodológica evidenciando detalhadamente o método FNP no tratamento. O fisioterapeuta atua na reabilitação de pacientes com acidente vascular encefálico, por conta das sequelas da patologia que acomete a região motora e sensitiva, marcha, força muscular e propriocepção, sendo de suma importância porque ajuda a minimizar danos e evitar complicações secundárias.
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O gerenciamento de impressão nos relatórios financeiros trata-se de um mecanismo para alterar a percepção do usuário das informações contábeis direcionando-os para compreensão desejada pela administração da firma. Em cenários de recuperação judicial os relatórios financeiros podem ser utilizados como instrumento legitimador da condição da firma ou da cadeia de eventos que a direcionou a esta condição. Esta pesquisa tem como objetivo verificar se há evidências características de gerenciamento de impressão nos relatórios da administração de companhias abertas listadas na B[3] que entraram no processo de recuperação judicial no período entre 2014 e 2019. O conjunto de dados analisados são de empresas que obtiveram homologação do seu pedido de recuperação judicial no período citado com relatórios da administração divulgados no site da CVM. Foram analisados 66 relatórios de 11 empresas nos períodos de 3 anos antes e 3 anos depois do processo de recuperação judicial. Para análise foram adotadas duas métricas de gerenciamento de impressão, o TOM e o Índice de Facilidade de Leitura de Flesch (IFLF). Os dados foram analisados descritivamente e por instrumentos de correlação não paramétricos. O resultado da análise evidenciou que existe alteração no gerenciamento de impressão (TOM) das narrativas contábeis com tendência a neutralidade do terceiro ano para o primeiro ano antes do processo de recuperação judicial das firmas analisadas. O resultado da pesquisa possibilitou considerar que as empresas tendem a reduzir o TOM positivo das narrativas contábeis a medida em que se aproximam de um cenário de recuperação judicial, e que passado este cenário existe uma tendência de retorno ao gerenciamento de impressão dos relatórios. Os resultados deste estudo contribuem ainda para percepção dos agentes do mercado acerca de possíveis alterações das narrativas dos relatórios contábeis das empresas quando seus indicadores tendem a cenários de dificuldades financeiras.
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Background: Brain-derived neurotrophic factor (BDNF) plays an important role in repairing normal as well as in the injured brain. Physical exercise may have a positive impact on the release of BDNF. Objective: PNF is a neurophysiological approach that facilitates the stimulation of central and peripheral nervous systems. In this study, our aim was to assess the levels of BDNF as well as functional recovery before and after the intervention of PNF in patients with acute stroke. Methods: A total of 208 patients with first time confirmed stroke were recruited and assessed for stroke severity, type, mini-mental state exam (MMSE), functional independence measure scale, and BDNF levels before and after PNF intervention. BDNF levels were also assessed in healthy individuals for control values. Results: A significant decline in levels of BDNF was observed after in stroke. BDNF levels in patients (with different risk factors) with diabetes, hypertension and DM+ HTN, alcohol, and smoking history were 8.8 ± 4.04 ng/mL, 8.86 ± 4.68 ng/mL, 8.65 ± 3.26 ng/mL, 8.51 ± 4.26 ng/mL, and 8.9 ± 3.4 ng/mL, respectively. A decline in BDNF levels was observed in accordance with the severity of stroke in both ischemic and hemorrhagic stroke with the least level being in severe stroke (NIHSS >15 and ICH >3). Despite the type of stroke and the presence of risk factors, a significant improvement in BDNF levels and FIM scale scores was seen in all subjects who received PNF exercises. Conclusion: Thus, PNF is efficient in improving functional level in acute stroke irrespective of the type of stroke and risk factors.
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Background: Most hemiplegic patients who suffer from stroke experience restrictions on mobility at home and in the community, and they especially have difficulty with independent walking. Proprioceptive Neuromuscular Facilitation (PNF) is one approach commonly used to improve the gait of patients with hemiplegia. Various PNF procedures have been used, depending on the affected site. Among these PNF techniques is facilitation of pelvic motion to improve control of the pelvis.Hence the study was done to compare the effects of pelvic PNF exercises and Hip extensor strengthening exercises on gait parameters of chronic hemiplegic patients. Materials and Methods: 30 subjects were conveniently divided into either of the two groups namely Pelvic PNF Group (Group A) and Hip extensor strengthening Group (Group B). Subjects in Group A received a protocol of 3 PNF techniques for 3 days a week for a total duration of 4 weeks (12 sessions). These procedures were done to facilitate anterior elevation and posterior depression of pelvis in a side lying position. Subjects in Group B received a protocol for hip extensor strengthening exercise (HESE) program. Each session consisted of 3 sets of 15 performances of the 3-step program lasting about 30 min, with 30 seconds of relaxation time between the sets. The measurements of the variables i.e. Gait speed, Cadence, Stride Length, Step Length was taken twice, one at the beginning of the study (Pre) and one at the conclusion of the 4 week duration (Post).The pre post measurements of outcome measures were analysed. Results: Following 4 weeks of Pelvic PNF exercises and Hip extensor strengthening exercises, there was a statistically significant increase in Gait parameters in all domains. However the increase was statistically more significant in the experimental group (Pelvic PNF) as compared to the control group (HESE). Conclusion: Pelvic Proprioceptive Neuromuscular Facilitation technique is more effective than Hip extensor strengthening exercises in improving gait parameters such as stride length, gait velocity and cadence in chronic hemiplegic patients.
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Background: Pelvic instability is a common occurrence during standing and walking post stroke. Inappropriate muscle activation and poor movement control around the pelvis lead to difficulty in mobility and daily functioning. Purpose: The purpose of the study was to examine the effects of pelvic stability training on the movement performance of trunk and lower limb, hip muscles strength, walking speed and daily activities after stroke. Methods: This randomized controlled trial involved 34 patients aged 56 (11) years with the post stroke duration being 31 (22) weeks. Patients with medical stability, an ability to follow verbal instructions, independent sitting balance and supervised walking capacity were included. The experimental group (n = 13) underwent the pelvic stability training and the control group (n = 13) were subjected to standard physiotherapy for 1 h a day, 3 times a week for over 6 weeks in a stroke rehabilitation setting. Trunk Impairment Scale 2.0 (TIS 2.0), Fugl Meyer Assessment of Lower Extremity (FMA-LE), hip muscles strength (lb.), gait speed, pelvic tilt and modified Barthel Index (MBI) were the outcome measures. Results: All the measures between both groups were similar at baseline except TIS 2.0 and FMA-LE. Following training, pelvic stability group showed statistically significant improvement (p < 0.05) except MBI and substantial mean changes in the measures of TIS 2.0 (2.12), FMA-LE (5.12), hip strength (lb.) for flexors (4.6), extensors (2.8), abductors (2.58), adductors (2.9), gait speed (0.05 m/s) and MBI (7.74) as against standard physiotherapy group. Conclusion: Pelvic stability training was found to be beneficial in improving the trunk and lower extremity movement control, hip muscles strength, gait speed and daily activities in stroke.
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The purpose of this study was to evaluate the effects of core strengthening combined with pelvic proprioceptive neuromuscular facilitation (PNF) on trunk impairment, balance, gait, and functional ability of chronic stroke patients. Twenty-three participants with chronic stroke were recruited and randomly allocated to one of the two groups: core strengthening combined with pelvic PNF (group 1, n=13), and pelvic PNF with trunk flexibility exercises (group 2, n=10). Intervention was given to both groups for 60 min per session 5 times per week for 4 weeks. Performance of both groups was evaluated on Trunk Impairment Scale, Tinetti Performance Oriented Mobility Assessment (Tinetti-POMA), Balance Evaluation Systems Test (Mini-BESTest), Wisconsin Gait Scale, and Barthel Activities of Daily Living Index prior to and after the completion of the intervention. The comparison between postintervention scores of Tinetti-POMA between group 1 (18.76±1.78) and group 2 (16.8±1.87) and Mini-BESTest group 1 (16.15±1.28) and group 2 (14.7±1.41) showed significant difference (P=0.018). The results indicated that core stabilisation combined with pelvic PNF was more effective for improving trunk impairment, balance and gait of chronic stroke patients.
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[Purpose] To investigate the effect of coordination movement using the Proprioceptive Neuromuscular Facilitation pattern underwater on the balance and gait of stroke patients. [Subjects and Methods] Twenty stroke patients were randomly assigned to an experimental group that performed coordination movement using the Proprioceptive Neuromuscular Facilitation pattern underwater and a control group (n =10 each). Both the groups underwent neurodevelopmental treatment, and the experimental group performed coordination movement using the Proprioceptive neuromuscular facilitation pattern underwater. Balance was measured using the Berg Balance Scale and Functional Reach Test, and gait was measured using the 10-Meter Walk Test and Timed Up and Go Test. To compare in-group data before and after the intervention, paired t-test was used. Independent t-test was used to compare differences in the results of the Berg Balance Scale, Functional Reach Test, 10-Meter Walk Test, and Timed Up and Go Test before and after the intervention between the groups. [Results] Comparison within the groups showed significant differences in the results of the Berg Balance Scale, Functional Reach Test, 10-Meter Walk Test, and Timed Up and Go Test before and after the experimental intervention. On comparison between the groups, there were greater improvements in the scores of the Berg Balance Scale, Functional Reach Test, 10-Meter Walk Test, and Timed Up and Go Test in the experimental group. [Conclusion] The findings demonstrate that coordination movement using the Proprioceptive Neuromuscular Facilitation pattern under water has a significant effect on the balance and gait of stroke patients.
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Developing countries like India are facing a double burden of communicable and non-communicable diseases. Stroke is one of the leading causes of death and disability in India. The estimated adjusted prevalence rate of stroke range, 84-262/100,000 in rural and 334-424/100,000 in urban areas. The incidence rate is 119-145/100,000 based on the recent population based studies. There is also a wide variation in case fatality rates with the highest being 42% in Kolkata. Stroke units are predominantly available in urban areas that too in private hospitals. Intravenous (IV) and intra-arterial thrombolysis (IA) are commonly used in India. In the on-going Indo USA National stroke registry the rate of IV thrombolysis is 11%. Stroke rehabilitation is not well developed in India due to lack of personnel. Organised rehabilitation services are available in the country but they are mainly in private hospitals of the cities. Even though India is a leading generic drugs producer still many people can't afford the commonly used secondary prevention drugs. As a first step the Government of India has started the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS). The government is focusing on early diagnosis, management, infrastructure, public awareness and capacity building at different levels of health care for all the non-communicable diseases including stroke. An organised effort from both the government and the private sector is needed to tackle the stroke epidemic in India.
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[Purpose] The purpose of this study was to determine the effects of core stabilization exercise on dynamic balance and gait function in stroke patients. [Subjects] The subjects were 16 stroke patients, who were randomly divided into two groups: a core stabilization exercise group of eight subjects and control group of eight subjects. [Methods] Subjects in both groups received general training five times per week. Subjects in the core stabilization exercise group practiced an additional core stabilization exercise program, which was performed for 30 minutes, three times per week, during a period of four weeks. All subjects were evaluated for dynamic balance (Timed Up and Go test, TUG) and gait parameters (velocity, cadence, step length, and stride length). [Results] Following intervention, the core exercise group showed a significant change in TUG, velocity, and cadence. The only significant difference observed between the core group and control group was in velocity. [Conclusion] The results of this study suggest the feasibility and suitability of core stabilization exercise for stroke patients.
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Abstract: Background: As the pelvic motion comes from trunk muscles, a specific use of pelvic pattern not only exercises the pelvis for mobility and stability but also facilitate trunk motion and stability.Objective: To determine the effect of Pelvic Proprioceptive Neuromuscular Facilitation(PNF) technique on facilitation of trunk movement in hemiparetic stroke patients.Interventions: Thirty hemiparetic stroke patients were randomly divided into two groups. The experimental group received pelvic PNF while the control group received conventional physiotherapy in the form of truncal exercises for 30 minutes. Along with these both group received regular physiotherapy in the form of tonal management and range of motion exercises for the affected limbs for 30 minutes. Intervention was given once in a day for five days/week for four weeks.Outcome Measures: Trunk Impairment Scale (TIS), Trunk Lateral Flexion Range of Motion (TLF ROM), and Tinetti Test (TT). Results: Post-intervention, both the groups shows improvement on trunk performance, range of motion, balance and gait but the experimental group shows more improvement than control group [changes in mean score between group comparison for TIS 3.4 (1.8); TLF ROM for affected and non-affected side 0.734 & 3.666 (0.267 & 2.533); Balance 3.534 (2.266) and Gait 2.2 (1)]. The level of significance was set at p < 0.05 and highly significance at p < 0.01. Key words:Inclinometer, Pelvic Proprioceptive Neuromuscular Facilitation, Stroke, Tinetti Test, Trunk Impairment Scale, Trunk Lateral Flexion Range of Motion
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Proprioceptive Neuromuscular Facilitation (PNF) has been found effective for treating patients with a wide range of diagnoses. This richly illustrated guide presents an approach based on the concepts set out by Dr. Herman Kabat and taught by Margaret Knott. This fully revised third edition demonstrates how the principles of the International Classification of Functioning, Disability and Health (ICF) and aspects of motor learning and motor control (from "hands-on" to "hands-off" management) are applied in modern PNF evaluation and treatment. In addition, the section on Activities of Daily Living has been expanded with new photos and more in-depth explanatory text. Featuring a new, fresh design and layout, this edition presents the philosophy, basic procedures and treatment patterns of PNF in a clearly structured way. It provides a systematic and easily accessible guide to learning and understanding PNF as a practical tool and using it to full effect in patient treatment.