International Journal of Science and Research (IJSR)

ISSN: 2319-7064
SJIF (2019): 7.583

Effect of Proprioceptive Neuromuscular Facilitation

[PNF] Technique for Knee & Ankle Muscles on
Lower Limb Performance in Subacute Stroke
Dr. Apeksha Hemant Shirsath1, Dr. Bhawani Rana2, Dr. Kalyani Nagulkar3
Guide, DUPCOP Physiotherapy College, Jalgaon (MH), India

Assistant Professor, DUPCOP Physiotherapy College, Jalgaon (MH), India

Associate Professor, DUPCOP Physiotherapy College, Jalgaon (MH), India

Abstract: Background: Gait dysfunction is one of the most serious consequences of stroke due to lower limb impairments. Which
results into increased falls, sit to stand disability and restricted mobility leading to individual’s poor quality of life and functional
dependency. Thus, the significant predictor of mobility after the stroke is the knee and ankle muscle strength. Aim: To find out the
effect of proprioceptive neuromuscular facilitation [PNF] technique for knee and ankle muscles on lower limb performance in subacute
stroke – an experimental study. Objectives: To study the effect of PNF technique on knee and ankle muscles. To improve the balance
and functional training in subacute stroke patients. Methodology: Using a Convenience sampling method, a sample of 20 subacute
stroke patients were recruited. An Experimental study was carried out at two tertiary care hospitals and the statistical data was analyzed
at Dr. Ulhas Patil College of Physiotherapy, Jalgaon. A protocol of 10 days treatment sessions was given to all the patients. Protocol
unified PNF Rhythmic stabilization technique utilizing alternating isometric contractions of both agonist and antagonist against
resistance. Five Times Sit to Stand Performance Test [5 STS], Modified Emory Functional Ambulation Profile [mEFAP], Postural
Assessment Scale for Stroke [PASS] were used to measure the lower limb performances. Results: The paired t test value was 8.61, 8.51
and 5.06 in 5 STS test, PASS and mEFAP(s) with the p value less than 0.05 in each test showed the significant difference in average pre
and posttests scores respectively. Conclusion: Hence, we emphasized a potential role of Rhythmic Stabilization showing an effective
method for improving balance and walking ability in subacute stroke patients.

Keywords: PNF, RHYTHMIC STABILIZATION, PASS, mEFAP, 5 STS test

1. Introduction enhance muscular strength, flexibility, and balance PNF

approach helps to stimulate proprioception of the muscles,
A stroke is a medical condition in which poor blood flow to tendons, and joints.2
the brain causes cell death. The initial first six months is
defined as the subacute phase of stroke1.Prevalence of stroke PNF consist of therapeutic exercises that use a series of
in India is approximately 200/1,00,000 population.8Stroke facilitation and synergy patterns in an effort to get muscle
results in movement problems like spasticity, atypical strengthening and neuromuscular re-education.3PNF
pattern of movement which leads to functional limitations includes various techniques that are essential to induce
and disability.4Hemiplegia or hemiparesis is most common facilitation, inhibition, strengthening, and relaxation of
presentation of stroke. And Gait dysfunction is one of the muscle groups in order to promote functional movements. 5
most serious consequences of stroke.4
Various studies have suggested that knee muscle strength
During gait, the sequential flow of motor activity is and bulk decreases significantly after stroke, which gets
disrupted.6Similar to gait, sit to stand transition usually gets directly impacted on the gait speed, gait performance,
affected in the individuals with stroke.7After stroke, the functional performance and sit to stand transfer ability
recovery of gait capacity is an important factor to ensure among stroke survivors.1For which knee muscle stabilization
increased quality of life and functional independence.2Lower and functional performance in stroke patients, rhythmic
limb impairment is associated with increased falls, sit to stabilization technique has shown significant improvement
stand ability and restricted mobility. The significant in strength, endurance, flexibility, stability, balance and
predictor of mobility after stroke is the knee and ankle functional performance.1
muscle strength.1
“Rhythmic Stabilization” technique utilizes alternating
There are numerous therapeutic approaches which are isometric contractions against resistance. This technique is
developed based upon a neurodevelopmental approach, useful in maintaining a co-contraction of antagonistic
neuro physiological approach, motor learning and motor muscles against maximal resistance which builds up
control to enhance the function, PNF is one approach excitation and further helps to increase active and passive
commonly used to improve functional performances.1 range of motion, strength, stability, and balance, as well as
to control pain.5
PNF is defined as method of promoting or hastening the
response of the neuromuscular mechanism through There are various intervention techniques to improve gait,
stimulation of the proprioceptors.5To improve function and balance and sit to stand performances. From which
Volume 10 Issue 3, March 2021
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: SR21208145959 DOI: 10.21275/SR21208145959 46
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2019): 7.583
Rhythmic Stabilization is an effective intervention to Inclusion Criteria:
improve gait, balance and sit to stand disabilities. Therefore, 1) Single unilateral stroke < 6 months.
this study aims to find out the most effective intervention for 2) Grade 2 & higher of Brunnstorm‟s voluntary control of
stroke patients. And hence, we assumed that rhythmic affected lower extremity.
stabilization for the knee and ankle muscle may improve the 3) Patient should be ambulatory before the current episode
functional performance of the lower limbs in stroke of the stroke.
patients.1 4) Able to understand instructions.
5) MMSE score >24.
2. Need for Study 6) Individuals with age group between 31 to 80 years old
were taken.
Cerebral stroke causes a significant deterioration of patients 7) Both the genders were included.
functioning and worsening his/her quality of life. Many
interventions have focused on improving physical walking Exclusion Criteria:
and balance ability in patients with stroke. However, 1) Severe cardiopulmonary disease.
hemiparetic/stroke patients often show imbalanced gait 2) Orthopedic arthritic condition interfering with walking.
caused by asymmetric upper & lower limb movement and 3) Behavioral problems (that interfere with treatment).
unstable left & right balance.
Intervention:
Sanjiv Kumar and Shiva Prasad Tiwari et.al [2014] 1) Following the inclusion and exclusion criteria, all
determined the significant improvement in function by the participants received 10 days of intervention of PNF
effect of PNF technique for knee muscles on lowerlimb Rhythmic Stabilization for the Knee and Ankle muscles
performances in subacute stroke patients. of stroke patients.
2) Here, PNF Rhythmic Stabilizationutilize alternating
However, we have not come across any literature showing isometric contractions of agonist & antagonist against
effect of PNF technique for knee and ankle muscles to resistance.
improve balance and functional activities among subacute 3) For Knee:
stroke patients in Jalgaon district of Maharashtra. Hence, the  Subjects were placed in supine lying position with the
study was conducted to find the out the effect of PNF knee joint maintained in flexion at an angle of 30, 60,
technique for knee and ankle muscles in improving & 90 degrees respectively.
lowerlimb performance among subacute stroke patients from  The examiner has to place their hands above & below
Tertiary Care Hospitals, Jalgaon. The study shall be useful individual‟s knee joint & manually apply the
for the growing body of literature thereby helping to take resistance in a Rhythmic fashion to distal & proximal
necessary measures for the same. parts of thigh and lower leg respectively.
 Resistance was increased slowly, first for knee
Aim extension and when subjects strongly resists, the
To find out the effect of proprioceptive neuromuscular examiner changes the hands to resist knee flexion
facilitation [PNF] technique for knee & ankle muscles on with simultaneous verbal commands.
lower limb performance in subacute stroke – an  Subjects were encouraged to maintain a given
experimental study position against manual resistance without
performing any movement.
Objectives
 To study the effect of PNF technique on knee and ankle 4) For Ankle:
muscle performances in subjects with subacute stroke  Subjects were placed in supine lying position with
patients. ankle joint at the edge of the table.
 To improve the balance and functional training in  Theexaminer has to placetheir hand one below the leg
subacute stroke patients. and manually apply the resistance in Rhythmic
fashion with the other hand to the dorsum aspect of
3. Materials & Methodology ankle for plantar flexion.
 As the resistance increases slowly,the examiner
 Study Design: An Experimental Study. thenchanges the hand placementto resist dorsiflexion.
 Sample Size: A total of 20 subacute stroke patients were  And asks patient to maintain the position without
recruited of both genders. performing the movement.
 Study Place: The study was conducted from two tertiary
care hospitals& thestatistical data was analyzed at Dr. Outcome Measures
Ulhas Patil College of Physiotherapy, Jalgaon. 1) Modified Emory Functional Ambulation Profile
 Study Duration: The study was carried out for a period [mEFAP]
of 6 months with a protocol of 10 Days treatment 2) Postural Assessment Scale for Stroke [PASS]
sessions per patient. 3) Five Times Sit to Stand Performance Test.
 Materials: Pen, pencil, marker,chair, measuring tape,
cello tape, stopwatch, Two small rectangular obstacles
and one large trash can.

Volume 10 Issue 3, March 2021

www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: SR21208145959 DOI: 10.21275/SR21208145959 47
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2019): 7.583
Procedure

Interpretation: The above table & graph shows the gender

distribution of the study samples. The 70% males and 30%
females were included in the study.

Table 3
Gender
Groups Total
Male Female
Side Right 5 2 7
Left 9 4 13
4. Statistical Analysis & Results Total 14 6 20

Table 1
Variable Groups Frequency Percentage
31-40 3 15.00
41-50 3 15.00
Age 51-60 4 20.00
61-70 4 20.00
71-80 6 30.00

Interpretation: The above table& graph shows the Side

affected according to the gender of study samples. In the
males 35.71% of them affected right side and 64.28% of
them affected left side. In the females 33.33% of them
affected right side and 66.66% of them affected left side.

Table 4
Outcome Time Mean SD Mean Diff. t value p Value
Interpretation: The above table & graph shows the age Pre-Test 38.46 14.24
distribution of the study samples. The 15% of the samples 5STS (s) 15.27 8.61 0.000
Post Test 23.19 8.80
have the age between 31-40 years of age, 15% in the 41-50
years, 20% in the 51-60 years, 20% in the 61-70 years and
30% of them in the age group 71-80 years of age.

Table 2
Variable Groups Frequency Percentage
Male 14 70.00
Gender Female 6 30.00
Total 20 100.00

Interpretation: The pre-test average score of 5 STS was

38.46 with SD of 14.24. The post-test average score of 5
STS was 23.19 with SD of 8.80. The Paired t test value of

Volume 10 Issue 3, March 2021

www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: SR21208145959 DOI: 10.21275/SR21208145959 48
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2019): 7.583
the paired t test was 8.61 with the p value 0.000. The p value The sample size consisted of 20 subjects. We have
less than 0.05, shows the significant difference in the performed Rhythmic Stabilization among subacute stroke
average pre and post-test 5 STS scores. patients to improve their Knee and Ankle muscles for
balance and gait training as we found those patients were
Table 5 affected also with balance impairment and gait training. The
Outcome Time Mean SD Mean Diff. t value p Value study also showed that Rhythmic Stabilization has
Pre-Test 27.50 4.46 significant improvement in strength, endurance, flexibility,
mEFAP (s) 8.50 8.51 0.000
Post-Test 36.00 0.00 stability, balance as well as functional performance. The
result of the current study concluded that there was a
significant difference found among pre & post interventions
of PASS, 5STS, mEFAP scores.

Sanjiv Kumar and Shiva Prasad Tiwari et. al. in

(2015)determined improvement in sit to stand performance
and also improvement in balance and gait outcomes through
their study. Maximal resistance applied during contraction
leads to storage of elastic energy, which enhances the force
production in contracting muscles. As force production is
directly related to motor unit activation. Maximum no. of
motor units are activated, resulting in improvement in sit to
stand. Walker JM, Surhurg PR et. al (1999) showed
significant improvements in strength, endurance and balance
because of Rhythmic Stabilization.
Interpretation: The pre-test average score of PASS was
In present study, we found significant improvement in the
27.50 with SD of 4.46. The post-test average score of PASS
five times sit to stand test, which signifies there was a
was 36 with SD of 0.00. The Paired t test value of the paired
significant improvement in knee and ankle muscle strength
t test was 8.51 with the p value 0.000. The p value less than
after the training. The reflex activities of the GTOs and
0.05, shows the significant difference in the average pre and
improvement in function may also be influenced by
post-test PASS scores.
centrally generated motor commands due to repeated
training, which leads to learning. Verbal command that was
Table 6 provided during the training acts as the augmented feedback
Outcome Time Mean SD Mean Diff. t value p Value
Pre-Test 5.37 4.87
and also adds to promote learning. This is enhanced with the
mEFAP (s) 2.33 5.06 0.000 observation by participants, and use of manual contact.
Post-Test 3.04 2.84

Truebload PR, Perry L et. al (1989)Improved performance

in functional activities in their study, which is in accordance
with the results from previous studies, which showed
significant improvements in strength, endurance and balance
because of rhythmic stabilization.Kajal Patel et. al in 2015
reported that neuromuscular spindle gets activated during
prolonged PNF stretch and isometric contractions of
stretched agonists muscles. The increase in tension created
gives better improvement in calf flexibility.

Kim Kang et. al (2014) in their study confirmed that a PNF

rhythmic stabilization regimen was effective in improving
walking and balance ability.During PNF stretch and
isometric contraction of stretched agonists for extended
period may cause activation of its neuromuscular spindle.
Interpretation: The pre-test average score of mEFAP (s)
The increase in tension created during the isometric
was 5.37 with SD of 4.87. The post-test average score of
contraction of the prelengthened agonist contracts
mEFAP (s) was 3.04 with SD of 2.84. The Paired t test value
concentrically. Hence PNF stretching is more effective and
of the paired t test was 5.06 with the p value 0.000. The p
thus helps improving calf flexibility.
value less than 0.05, shows the significant difference in the
average pre and post-test mEFAP (s) scores.
Various studies have suggested that lower extremity strength
training can improve the functional performance in
5. Discussion individuals with stroke. Whereas in our study we found
improvement in strength and function because of the
The present study was conducted to find out the effect of rhythmic stabilization. However, in contrast to our study
PNF technique in improving lower limb performances other studies reported that increase in strength does not show
among subacute stroke patients in Jalgaon. improvement in ambulation. Sanjiv Kumar and Shiva
Prasad Tiwari et. al. in (2015)study suggests that the gain
Volume 10 Issue 3, March 2021
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Licensed Under Creative Commons Attribution CC BY
Paper ID: SR21208145959 DOI: 10.21275/SR21208145959 49
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2019): 7.583
in strength occurs after the training in stroke patients, and  This study was focused only on walking and balancing
strength training does not associate with increase in activity.
spasticity.  Subjects with sub-acute stroke patients were taken into
consideration.
The components of mEFAP includes the task required for
overall functional ambulation profile, which suggests that 8. Future Scope
the given treatment enhances the ability of the patient to
undertake the activities of daily living (ADL) thus In further studies, Rhythmic Stabilization and Stabilizing
contributing to improved quality of life in hemiparetic Reversals techniques can be combined and used in a variety
patients. of patient positions, static or dynamic, depending on the
level of independence with functional mobility and on the
Charles Benaim et. al (1999) conducted a study in France, goal of treatment.
stated that Postural assessment is a key point of the
rehabilitation program in stroke patients. During the first
week after stroke has been found to be important indicator
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Paper ID: SR21208145959 DOI: 10.21275/SR21208145959 51