|Year : 2022 | Volume
| Issue : 1 | Page : 9-12
Effectiveness of proprioceptive neuromuscular facilitation techniques in improving balance in poststroke patients: a systematic review
College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, USA
|Date of Submission||07-Jan-2022|
|Date of Decision||08-Feb-2022|
|Date of Acceptance||14-Mar-2022|
|Date of Web Publication||29-Mar-2022|
College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE
Source of Support: None, Conflict of Interest: None
Stroke patients require rehabilitation programs to improve their functioning and quality of life. Proprioceptive neuromuscular facilitation is a widely used rehabilitation technique in clinical facilities. However, previous studies have not completely clarified its effectiveness. This study aimed to evaluate the effectiveness of proprioceptive neuromuscular facilitation in improving balance and mobility in stroke patients through clinical research and literature review. Our findings show that proprioceptive neuromuscular facilitation techniques effectively improve balance and mobility in stroke patients. However, there is little evidence supporting its superiority over the other rehabilitation methods.
Keywords: balance; mobility; PNF; stroke
|How to cite this article:|
Li YF. Effectiveness of proprioceptive neuromuscular facilitation techniques in improving balance in poststroke patients: a systematic review. Brain Netw Modulation 2022;1:9-12
|How to cite this URL:|
Li YF. Effectiveness of proprioceptive neuromuscular facilitation techniques in improving balance in poststroke patients: a systematic review. Brain Netw Modulation [serial online] 2022 [cited 2022 Oct 3];1:9-12. Available from: http://www.bnmjournal.com/text.asp?2022/1/1/9/340139
| Introduction|| |
Acute stroke remains the leading cause of mortality and disability worldwide. According to the latest data from the Global Burden of Diseases in 2019 published in Lancet, stroke ranked as one of the top 10 diseases with increased global burden (GBD 2019 Viewpoint Collaborators, 2020). Forecast projections based on data from the American Heart Association demonstrated that an additional 3.4 million people would suffer from stroke during their lifetime in the USA, even up to the year 2030, which represents 3.9% of the adult population in the USA, and the prevalence would increase by 20.5% compared to that in 2012 (Ovbiagele et al., 2013; Virani et al., 2020). Recovery from acute stroke impairment is generally incomplete and post-stroke patients are also at a high risk for falls and impaired functional independence due to decreased cognition, sensation, motor function, and balance (Dunbar et al., 2018; Mansfield et al., 2018). Therefore, the American Heart Association highly recommended that rehabilitation management should be provided throughout the spectrum of post-stroke patient care, and the main rehabilitation goal should be to improve the motor function and balance of those patients to reduce their risk for falls in daily life and increase their independence when performing activities of daily living (Winstein et al., 2016; Gittler and Davis, 2018). Previous studies have clarified that various types of exercises, such as trunk training (Van Criekinge et al., 2019), core stability exercise (Gamble et al., 2021), and progressive resistance exercise (Vahlberg et al., 2017), were the commonly used rehabilitation approaches to improve balance level and mobility (Denissen et al., 2019).
Proprioceptive neuromuscular facilitation (PNF) is one of the most wildly used exercise training programs, which can be combined with different kinds of exercise patterns to improve the training effects. These include combining pelvic PNF with core strengthening (Sharma and Kaur, 2017), using PNF in stair gait training (Seo et al., 2015), and using PNF during lower limb aquatic therapy for stroke patients (Kim et al., 2015a). In addition, PNF has an influence on stretching and in improving the range of motion of the affected joints (Adler et al., 2008; Wang et al., 2016; Konrad et al., 2017). PNF facilitated cortical adaptation and organization due to its diagonal movement patterns, promoting motor re-learning and recovery of balance ability (Smedes and Giacometti da Silva, 2019). Regarding the influence of PNF on balance and mobility, PNF was reported to be a potential functional oriented rehabilitation approach for post-stroke patients to decrease their fall risk while improving their motor function and balance, so that they can go back to their homes safely and perform their social roles better (Stucki, 2005). However, there is a lack of systematic review on the effect of PNF in post-stroke patients. Meanwhile, evidence-based practice in this field is necessary for both physical therapists and stroke patients.
Therefore, this systematic review aimed to evaluate the efficacy of PNF techniques in improving balance and mobility in stroke survivors to provide evidence for clinical practice.
| Data and Methods|| |
We used MeSH to define proper terms and advance search to create the following query: ((PNF* OR Proprioceptive Neuromuscular Facilitation) AND (stroke)) AND (balance or mobility).
We searched the PubMed and CINAHL databases, narrowing the publication time from 2000 to 2022. English language and human research were used as constraints.
The participants were post-stroke patients; PNF was used for the intervention; and the primary outcome must contain balance or mobility evaluation.
Non-human research; PNF was not used for stroke patients; and abstract-only papers, reviews, study protocols, or articles without available full texts.
We used the PEDro scale (de Morton, 2009) as an article assessment tool to evaluate the quality of article once it was included in the review.
| Results|| |
We generated the characteristics of the studies included in the review and presented them in [Table 1].
Proprioceptive neuromuscular facilitation improves mobility in stroke patients
A randomized controlled study (Ribeiro et al., 2013) compared the outcomes of gait training based on PNF techniques and conventional treadmill training with partial weight-bearing in stroke patients. The outcomes were measured by motor function charts (Stroke Rehabilitation Assessment of Movement and motor functional independence measure) and gait analysis. While both treatments significantly improved the patients’ motor functions, the PNF increased the patients’ ankle dorsiflexion during the swing phase in the gait cycle. In line with these findings, Ribeiro et al. (2014) demonstrated a significant increase in the patients’ motor functions based on the functional independence measure, indicating that PNF could be an excellent rehabilitation method for stroke survivors. Another randomized controlled trial compared the effectiveness of PNF with electroacupuncture (Li et al., 2019). Each group underwent a 4-week treatment course, including a 20-minute session daily. They received three courses of treatment in 12 weeks, and the outcomes were measured after each course. The patients were followed up at 6 months after the last course. While both the electroacupuncture and PNF groups showed significant improvements in the outcomes, the combination of the two treatment methods had the best outcomes based on the Fugl-Meyer assessment and modified Barthel Index scores. Consistent with these findings, a systematic review by Guiu-Tula et al. (2017) showed that PNF improved mobility and function in stroke patients. A clinical trial conducted by Junior et al. (2019) verified the effectiveness of virtual reality combined with PNF treatment on motor performance in stroke survivors. The results of the combination treatment were also compared to the virtual reality and PNF groups. Motor performance measured by the Fugl-Meyer assessment scale significantly increased after the intervention in all three groups, although no significant difference was seen. The PNF treatment improved balance and passive movement, indicating its potential benefits over virtual reality.
Based on all of these studies, it has been recommended to incorporate PNF methods in any functional training program for the rehabilitation of stroke patients.
Proprioceptive neuromuscular facilitation improves balance in stroke patients
PNF is an effective way for stroke patients to recover their balance. In a clinical trial by Kim et al. (2015b), 20 subjects were divided evenly into a control group receiving conventional treatment and an experimental group treated with the PNF techniques. The outcomes were measured using balance tests, such as the Berg balance scale, functional reach test, time yp and go test, and 10-m walk test. While both groups showed significant improvement following the intervention, the balance recovery was better in the experimental group than in the control group. Hence, coordination movement training using PNF methods significantly improved the balance in stroke patients. Hwangbo and Don Kim (2016) confirmed these findings in a randomized clinical trial involving 30 subjects. PNF for neck movement was compared with traditional rehabilitation methods by measuring the Trunk Impairment Scale and Berg Balance Scale. Significant differences in the outcomes between the two groups indicated that the PNF techniques were better than traditional rehabilitation exercises in terms of balance improvement and trunk function recovery in stroke patients.
PNF methods improve balance even when combined with other treatment methods. Cayco et al. (2017, 2019) reported a few cases, demonstrating the benefits of PNF on improving balance and motor function in chronic stroke patients. After a 6-week intervention, the Mini-BESTest, Sit-to-Stand test, and 10-meter walk test results of these patients all significantly improved, indicating that PNF improved balance and diminished the risk of falls in stroke patients.
| Discussion|| |
We performed a thorough literature search on PNF and found that most studies focused on stretching mainly related to musculoskeletal disorders. However, studies (reviews or clinical trials) on PNF related to stroke are limited. Therefore, this review was more likely needed to identify new research questions (Pautasso, 2013). While most of the existing literature suggested the benefits of PNF for stroke patients, this article specifically explored its effectiveness in improving balance and mobility in stroke patients. Based on the results, PNF techniques significantly recovered balance and mobility in stroke patients. However, there is little evidence of its superiority over other rehabilitation methods or conventional training methods. Besides, the existing literature barely focused on factors such as the stroke subtype, onset time, or severity of the disease, all of which may influence the effectiveness of the PNF in stroke patients. Therefore, future studies should evaluate the influence of these factors on the effectiveness of PNF in stroke patients.
| Conclusions|| |
PNF techniques, commonly used in rehabilitation facilities, effectively improve balance and mobility in stroke survivors. However, there is insufficient evidence of its superiority over other rehabilitation methods. Further researches are required to evaluate its effectiveness in larger sample sizes and specific stroke populations.
YFL contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript.
Conflicts of interest
The author declares no conflicts of interest.
Editor note: YL is an Editorial Board member of Brain Network and Modulation. He was blinded from reviewing or making decisions on the manuscript. The article was subject to the journal’s standard procedures, with peer review handled independently of this Editorial Board member and his research group.
Open access statement
This is an open access journal, and articles are distributed under the terms of the Creative Commons AttributionNonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
| References|| |
Adler SS, Beckers D, Buck M (2008) PNF in practice: an illustrated guide: Springer, Berlin, Heidelberg.
Cayco CS, Gorgon EJR, Lazaro RT (2017) Effects of proprioceptive neuromuscular facilitation on balance, strength, and mobility of an older adult with chronic stroke: a case report. J Bodyw Mov Ther 21:767-774.
Cayco CS, Gorgon EJR, Lazaro RT (2019) Proprioceptive neuromuscular facilitation to improve motor outcomes in older adults with chronic stroke. Neurosciences (Riyadh) 24:53-60.
de Morton NA (2009) The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 55:129-133.
Denissen S, Staring W, Kunkel D, Pickering RM, Lennon S, Geurts AC, Weerdesteyn V, Verheyden GS (2019) Interventions for preventing falls in people after stroke. Cochrane Database Syst Rev 10:CD008728.
Dunbar SB, Khavjou OA, Bakas T, Hunt G, Kirch RA, Leib AR, Morrison RS, Poehler DC, Roger VL, Whitsel LP, American Heart Association (2018) Projected costs of informal caregiving for cardiovascular disease: 2015 to 2035: a policy statement from the American Heart Association. Circulation 137:e558-e577.
Gamble K, Chiu A, Peiris C (2021) Core stability exercises in addition to usual care physiotherapy improve stability and balance after stroke: a systematic review and meta-analysis. Arch Phys Med Rehabil 102:762-775.
GBD 2019 Viewpoint Collaborators (2020) Five insights from the Global Burden of Disease Study 2019. Lancet 396:1135-1159.
Gittler M, Davis AM (2018) Guidelines for adult stroke rehabilitation and recovery. JAMA 319:820-821.
Guiu-Tula FX, Cabanas-Valdés R, Sitjà-Rabert M, Urrútia G, Gómara-Toldrà N (2017) The Efficacy of the proprioceptive neuromuscular facilitation (PNF) approach in stroke rehabilitation to improve basic activities of daily living and quality of life: a systematic review and meta-analysis protocol. BMJ Open 7:e016739.
Hwangbo PN, Don Kim K (2016) Effects of proprioceptive neuromuscular facilitation neck pattern exercise on the ability to control the trunk and maintain balance in chronic stroke patients. J Phys Ther Sci 28:850-853.
Junior V, Santos MS, Ribeiro N, Maldonado IL (2019) Combining proprioceptive neuromuscular facilitation and virtual reality for improving sensorimotor function in stroke survivors: a randomized clinical trial. J Cent Nerv Syst Dis 11:1179573519863826.
Kim EK, Lee DK, Kim YM (2015a) Effects of aquatic PNF lower extremity patterns on balance and ADL of stroke patients. J Phys Ther Sci 27:213-215.
Kim K, Lee DK, Jung SI (2015b) Effect of coordination movement using the PNF pattern underwater on the balance and gait of stroke patients. J Phys Ther Sci 27:3699-3701.
Konrad A, Stafilidis S, Tilp M (2017) Effects of acute static, ballistic, and PNF stretching exercise on the muscle and tendon tissue properties. Scand J Med Sci Sports 27:1070-1080.
Li F, Sun Q, Shao XM, Xie JJ, Liu HB, Xu Y, Yang WD (2019) Electroacupuncture combined with PNF on proprioception and motor function of lower limbs in stroke patients: a randomized controlled trial. Zhongguo Zhen Jiu 39:1034-1040.
Mansfield A, Inness EL, McIlroy WE (2018) Stroke. Handb Clin Neurol 159:205-228.
Ovbiagele B, Goldstein LB, Higashida RT, Howard VJ, Johnston SC, Khavjou OA, Lackland DT, Lichtman JH, Mohl S, Sacco RL, Saver JL, Trogdon JG, American Heart Association Advocacy Coordinating Committee and Stroke Council (2013) Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke 44:2361-2375.
Pautasso M (2013) Ten simple rules for writing a literature review. PLoS Comput Biol 9:e1003149.
Ribeiro T, Britto H, Oliveira D, Silva E, Galvão E, Lindquist A (2013) Effects of treadmill training with partial body weight support and the proprioceptive neuromuscular facilitation method on hemiparetic gait: a randomized controlled study. Eur J Phys Rehabil Med 49:451-461.
Ribeiro TS, de Sousa e Silva EM, Sousa Silva WH, de Alencar Caldas VV, Silva DL, Costa Cavalcanti FA, Lindquist AR (2014) Effects of a training program based on the proprioceptive neuromuscular facilitation method on post-stroke motor recovery: a preliminary study. J Bodyw Mov Ther 18:526-532.
Seo K, Park SH, Park K (2015) The effects of stair gait training using proprioceptive neuromuscular facilitation on stroke patients’ dynamic balance ability. J Phys Ther Sci 27:1459-1462.
Sharma V, Kaur J (2017) Effect of core strengthening with pelvic proprioceptive neuromuscular facilitation on trunk, balance, gait, and function in chronic stroke. J Exerc Rehabil 13:200-205.
Smedes F, Giacometti da Silva L (2019) Motor learning with the PNF-concept, an alternative to constrained induced movement therapy in a patient after a stroke; a case report. J Bodyw Mov Ther 23:622-627.
Stucki G (2005) International Classification of Functioning, Disability, and Health (ICF): a promising framework and classification for rehabilitation medicine. Am J Phys Med Rehabil 84:733-740.
Vahlberg B, Cederholm T, Lindmark B, Zetterberg L, Hellström K (2017) Short-term and long-term effects of a progressive resistance and balance exercise program in individuals with chronic stroke: a randomized controlled trial. Disabil Rehabil 39:1615-1622.
Van Criekinge T, Truijen S, Schröder J, Maebe Z, Blanckaert K, van der Waal C, Vink M, Saeys W (2019) The effectiveness of trunk training on trunk control, sitting and standing balance and mobility post-stroke: a systematic review and meta-analysis. Clin Rehabil 33:992-1002.
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, et al. (2020) Heart Disease and Stroke Statistics-2020 Update: a report from the American Heart Association. Circulation 141:e139-e596.
Wang JS, Lee SB, Moon SH (2016) The immediate effect of PNF pattern on muscle tone and muscle stiffness in chronic stroke patient. J Phys Ther Sci 28:967-970.
Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD, American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, et al. (2016) Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 47:e98-e169.