A Study to Assess the Effects of Proprioceptive Neuromuscular Facilitation of Trunk In Improving Trunk Balance of Patients with Stroke

Stroke is a complex pathology with many clinical presentations with unique impairments and activity limitations. Physiotherapy has a massive impact on quality of life of a stroke survivor. Proprioceptive neuromuscular facilitation (PNF) is a rehabilitation technique used to stimulate the neuromuscular system in an effort to excite proprioceptors (sensory organs in muscles, tendons, bones, and joints) in order to produce a desired movement. It has a greater impact on trunk control. The aim of the study is to evaluate the effect of proprioceptive neuromuscular facilitation of trunk in improving balance of trunk in stroke patients.Twenty stroke patients within the age between 60 to 70 years, were recruited for study. All patients were assigned proprioceptive neuromuscular facilitation of trunk for 4 weeks. Pre and post test scores were analysed. Inclusion criteria are patients with 60-70 years of age of both the genders with stroke duration of at least 6 months. Exclusion criteria are recurrent stroke with severe spasticity, perceptual disorders and uncorrected vision problems, any symptomatic cardiac failure, patients with other neurological disorders or musculoskeletal problems, impaired cognitive function. Both pre-test and post-test measures were analysed statistically using the data analysis computed with SPSS. The outcome measures used is TIS. Statistical analysis showed signi(cid:977)icant improvement in trunk balance after the treatment of proprioceptive neuromuscular facilitation of trunk for 4 weeks in stroke patients. Result showed signi(cid:977)icant improvement in the PNF treatment in trunk balance after the treatment of proprioceptive neuromuscular facilitation of trunk. The study concluded that the trunk balance can be improved in stroke patients after performing the proprioceptive neuromuscular facilitation of trunk for 4 weeks.

Stroke, proprioceptive neuromuscular facilitation (PNF), trunk balance, trunk impairment scale (TIS) ABSTRACT Stroke is a complex pathology with many clinical presentations with unique impairments and activity limitations. Physiotherapy has a massive impact on quality of life of a stroke survivor. Proprioceptive neuromuscular facilitation (PNF) is a rehabilitation technique used to stimulate the neuromuscular system in an effort to excite proprioceptors (sensory organs in muscles, tendons, bones, and joints) in order to produce a desired movement. It has a greater impact on trunk control. The aim of the study is to evaluate the effect of proprioceptive neuromuscular facilitation of trunk in improving balance of trunk in stroke patients.Twenty stroke patients within the age between 60 to 70 years, were recruited for study. All patients were assigned proprioceptive neuromuscular facilitation of trunk for 4 weeks. Pre and post test scores were analysed. Inclusion criteria are patients with 60-70 years of age of both the genders with stroke duration of at least 6 months. Exclusion criteria are recurrent stroke with severe spasticity, perceptual disorders and uncorrected vision problems, any symptomatic cardiac failure, patients with other neurological disorders or musculoskeletal problems, impaired cognitive function. Both pre-test and post-test measures were analysed statistically using the data analysis computed with SPSS. The outcome measures used is TIS. Statistical analysis showed signi icant improvement in trunk balance after the treatment of proprioceptive neuromuscular facilitation of trunk for 4 weeks in stroke patients. Result showed signi icant improvement in the PNF treatment in trunk balance after the treatment of proprioceptive neuromuscular facilitation of trunk. The study concluded that the trunk balance can be improved in stroke patients after performing the proprioceptive neuromuscular facilitation of trunk for 4 weeks.

INTRODUCTION
Stroke is also referred as a cerebrovascular accident with clinical signs of cerebral dysfunction, with symptoms lasting for 24 hours or longer1 (Guiu-Tula et al., 2017). In critical situation it may even lead to death (Banerjee et al., 2001). Stroke is a neurologic dysfunction of sudden onset, resulting from disruption of function of the cerebrovascular system (Sylaja et al., 2018). A stroke occurs due to rupture or blockage in the blood vessels of the brain (Renjen, 2015), preventing the blood and oxygen reaching the brain's tissues leading to the death of the brain cells within minutes without oxygen (Adler et al., 2008;Jijimol et al., 2013).
Acute neurologic symptoms are a medical emergency which demands immediate transportation to the casualty of an acute-care hospital for evaluation and treatment. Proprioceptive neuromuscular facilitation is a technique used to stimulate the neuromuscular system which excites the proprioceptors to induce a movement which has a greater impact on selective trunk control over the pelvis (Hosseinifar, 2016).

Aim/ Objectives
Aim of study is to assess the effects of proprioceptive neuromuscular facilitation of trunk in improving trunk balance of patients with stroke.

Research Design and Methodology
An experimental study design was conducted with 20 stroke patients who falls within the age group of 60 to 70 years, who ful illed the inclusion criteria.

Procedure
In this experimental study, 20 stroke patients who signed the written informed consent were enrolled in this study. All the subjects were screened for selection criteria. The subjects who ful illed the eligibility criteria can be included for the study. The trunk balance of the patients was initially assessed by means of trunk impairment scale (Dickstein et al., 2000). Patients were treated with proprioceptive neuromuscular facilitation of trunk training which includes task-speci ic activities. The duration of the treatment is 30 minutes per day It is continued for 3 days per week. Total duration of treatment is for 4 weeks. After 4 weeks of treatment the patients were again assessed for functional outcome of the trunk by trunk impairment scale (Hsieh et al., 2002). The proprioceptive neuromuscular facilitation of trunk consists of 10 minutes of each of the techniques. They are the rhythmic initiation technique, slow reversal technique, and technique of reversal of agonists. The techniques were applied to the pelvic region to improve the movements of the pelvis (Michaelsen, 2001).

Trunk Impairment Scale (TIS)
The Impairment scale for trunk is a 4-point ordinal scale (Karatas et al., 2004). It is a tool which is used to assess the balance of stroke patients (Verheyden et al., 2004). It is used to assess the trunk control and the trunk co-ordination (Rose et al., 2017;Hsieh et al., 2002).

Rhythmic Initiation
It is a progression of 1) initial passive movement 2) active-assistive movement and 3)active movement through the agonist pattern.

Rhythmic Stabilization
It is an isometric contraction of the agonist followed by an isometric contraction of the antagonist (Hosseinifar, 2016).

Repeated Contraction
It is an isotonic contraction against maximal resistance both concentrically and eccentrically throughout the range of motion (Guiu-Tula et al., 2017).

Slow Reversal
It is an isotonic contraction of the agonist which is followed immediately by an isotonic contraction of the antagonist (Hosseinifar, 2016).

Slow Reversal-Hold
It is an isotonic contraction of the agonist followed immediately by an isometric contraction (Guiu-Tula et al., 2017).
Each of the PNF techniques were repeated for 10 minutes.

Data Analysis
Descriptive Statistics

Inferential Statistics
• Intra Group Analysis

Null Hypothesis
There is no signi icant difference of the PNF in Trunk Control in Stroke patients.

Alternate Hypothesis
There is signi icant difference of the PNF in Trunk Control in Stroke patients.
Level of signi icance, α = 0.05   Table 2 shows the comparison of pre and post test scores of effects of proprioceptive neuromuscular facilitation of trunk in terms of statistical analysis which includes mean score, pearson correlation, p and t test values, etc. The table reveals that the post test scores have been comparatively increased which indicates the prognosis in the treatment of PNF of trunk in improving trunk balance.

RESULTS AND DISCUSSION
As per the result of Intra-Group Analysis (i.e., within group), it is concluded that PNF is effective in terms of TIS in improving trunk control.

CONCLUSIONS
The result showed that proprioceptive neuromuscular facilitation of trunk is more effective in improving trunk balance of patients with stroke.