|Year : 2017 | Volume
| Issue : 2 | Page : 40-44
The effect of proprioceptive neuromuscular facilitation techniques on trunk control in hemiplegic subjects: A pre post design
Jeba Chitra, Diker Dev Joshi
Department of Neurophysiotherapy, KLEU Institute of Physiotherapy, Belgaum, Karnataka, India
|Date of Submission||17-Jul-2017|
|Date of Acceptance||10-Oct-2017|
|Date of Web Publication||19-Jan-2018|
Dr. Diker Dev Joshi
KLEU Institute of Physiotherapy, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
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 Specific-QOL (SS-QOL) and reassessed after 12 sessions.
RESULTS: Statistical analysis was done using paired t-test. PNF showed significant results (P < 0.05) for both outcomes, i.e., TIS and SS-QOL scale.
CONCLUSION: The study concludes that PNF techniques are beneficial 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
|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
|How to cite this URL:|
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 [serial online] 2017 [cited 2018 Jun 24];11:40-4. Available from: http://www.pjiap.org/text.asp?2017/11/2/40/223698
| 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. 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. 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.
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 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.,,
Loss of trunk control is commonly observed in patients with stroke. 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. Despite evidence demonstrating the importance of trunk performance after stroke, therapies aimed at improving trunk function are limited. 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., 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.
Proprioceptive neuromuscular facilitation (PNF) is an approach based on the principle that all human beings, including those with disabilities, have untapped existing potential. 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.
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.
PNF is commonly used to improve gait of patients with hemiplegia. Various PNF procedures involving trunk have been used, depending on the affected site. 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.
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: 18–65 years (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 12 months (from March 2016 to February 2017).
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-specific 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.
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 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. A total 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.
Trunk proprioceptive neuromuscular facilitation
This technique is given by placing the subject in supine lying position or sitting position by following methods:
- 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.
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 1 min rest after completion of each pattern. Each pattern was repeated for three times.
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 [Figure 1]. Sixteen individuals met the eligibility criteria and agreed to participate in the study [Table 1]. 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 [Table 2] and [Table 3], respectively].
|Table 3: Comparison of pre-and post-test scores with respect to subscales of Trunk Impairment Scale|
Click here to view
| 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 with recovery of walking whereas patients scoring 40 failed to do so. 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.
 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. Visual, proprioceptive, and auditory input are important to help a patient regain good sitting balance  and as PNF techniques included all inputs, it may have led to improved sitting balance.
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.
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. 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. A study 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. This was further supported by a meta-analysis done by Shinde and Ganvir  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. All these effects might directly or indirectly aid in improving the trunk control. The study by Dickstein et al. showed similar results using three exercise therapy approaches where they found pattern of muscle tone improvement in the PNF treatment group.
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.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Truelsen T, Begg S, Mathers C. The Global Burden of Cerebrovascular Disease. Geneva: World Health Organisation; 2000.
Banerjee TK, Das SK. Epidemiology of stroke in India. Neurol Asia 2006;11:1-4.
O'Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation. New Dehli: FA Davis; 2013.
Davies PM. Problems associated with the loss of selective trunk activity in hemiplegia. In Right in the Middle. Berlin, Heidelberg: Springer; 1990. p. 31-65.
Ryerson S, Levit K. Functional Movement Reeducation: A Contemporary Model for Stroke Rehabilitation. New York: Churchill Livingston; 1997.
Edwards S. An analysis of normal movement as the basis for the development of treatment techniques. Neurological Physiotherapy. A Problem-Solving Approach. Philadelphia: Churchill Livingstone; 1996. p. 5-40.
Karthikbabu S, Solomon JM, Manikandan N, Rao BK, Chakrapani M, Nayak A. Role of trunk rehabilitation on trunk control, balance and gait in patients with chronic stroke: A pre-post design. Neurosci Med 2011;2:61.
Zakaria Y, Rashad U, Mohammed R. Assessment of malalignment of trunk and pelvis in stroke patients. Egypt J Neurol Psychiatry Neurosurg 2010;47:599-604.
Dursun E, Hamamci N, Dönmez S, Tüzünalp O, Cakci A. Angular biofeedback device for sitting balance of stroke patients. Stroke 1996;27:1354-7.
Dean CM, Shepherd RB. Task-related training improves performance of seated reaching tasks after stroke. A randomized controlled trial. Stroke 1997;28:722-8.
Dean CM, Channon EF, Hall JM. Sitting training early after stroke improves sitting ability and quality and carries over to standing up but not to walking: A randomised controlled trial. Aust J Physiother 2007;53:97-102.
Pollock A, Baer G, Langhorne P, Pomeroy V. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke: A systematic review. Clin Rehabil 2007;21:395-410.
Adler S, Beckers D, Buck M. PNF in Practice: An Illustrated Guide. New Dehli: Springer Science & Business Media; 2007.
Verheyden G, Vereeck L, Truijen S, Troch M, Herregodts I, Lafosse C, et al.
Trunk performance after stroke and the relationship with balance, gait and functional ability. Clin Rehabil 2006;20:451-8.
Trueblood PR, Walker JM, Perry J, Gronley JK. Pelvic exercise and gait in hemiplegia. Phys Ther 1989;69:18-26.
Arboix A, Oliveres M, García-Eroles L, Maragall C, Massons J, Targa C, et al.
Acute cerebrovascular disease in women. Eur Neurol 2001;45:199-205.
Verheyden G, Vereeck L, Truijen S, Troch M, Lafosse C, Saeys W, et al.
Additional exercises improve trunk performance after stroke: A pilot randomized controlled trial. Neurorehabil Neural Repair 2009;23:281-6.
Williams LS, Weinberger M, Harris LE, Clark DO, Biller J. Development of a stroke-specific quality of life scale. Stroke 1999;30:1362-9.
Bohannon RW, Cassidy D, Walsh S. Trunk muscle strength is impaired multidirectionally after stroke. Clin Rehabil 1995;9:47-51.
Kim Y, Kim E, Gong W. The effects of trunk stability exercise using PNF on the functional reach test and muscle activities of stroke patients. J Phys Ther Sci 2011;23:699-702.
Tyson SF, Hanley M, Chillala J, Selley A, Tallis RC. Balance disability after stroke. Phys Ther 2006;86:30-8.
Dhiman NR, Shah M, Shah GL, Joshi D, Gyanpuri V. Relationship between independent sitting balance and type of stroke in patients with left sided hemiparesis. Int J Physiother Res 2014;2:324-8.
Hama S, Yamashita H, Shigenobu M, Watanabe A, Hiramoto K, Takimoto Y, 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.
Knott M, Voss DE. Proprioceptive Neuromuscular Facilitation: Patterns and Techniques. New York: Hoeber Medical Division, Harper and Row; 1968.
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.
Shinde K, Ganvir S. Effectiveness of trunk proprioceptive neuromuscular facilitation techniques after stroke: A meta-analysis. Natl J Med Allied Sci 2014;3:29-34.
Khanal D, Singaravelan RM, Khatri SM. Effectiveness of pelvic proprioceptive neuromuscular facilitation technique on facilitation of trunk movement in hemiparetic stroke patients. J Dent Med Sci 2013;3:29-37.
Dickstein R, Hocherman S, Pillar T, Shaham R. Stroke rehabilitation. Three exercise therapy approaches. Phys Ther 1986;66:1233-8.
[Table 1], [Table 2], [Table 3]