Background: - Trunk muscles are imperative in supporting the body in sustained antigravity poses such as sitting and standing. It also serves as a stabilizing agent for the upper limb during the execution of voluntary movements. Very few studies are published that support the role of Proprioceptive Neuromuscular Facilitation (PNF) and Manual Perturbation (MP) exercises in the facilitation of trunk control and enhancing the lower extremity functions and mobility among the sub-acute stroke patients. Thus, through this study, an attempt was made to examine and compare the effects of the MP exercises and PNF exercises on the trunk control mechanism and lower extremity functions among sub-acute stroke survivors. Methodology/ Subject Selection: A double-blinded randomized clinical trial was carried out by recruiting 30 subjects from both genders in the subacute phase attained stroke survivors with a history of first ever stroke, who’s age ranged between 50 to 70, who can able to walk with or without support. All the study participants were informed in detail about the study protocols and written consent was taken before the recruitment for this study. All the study subjects were randomly allotted into 2 groups, i.e., MP and PNF, and received interventions for a total of 8 weeks. Before the interventions, trunk stability was measured by the Trunk Impairment Scale (TIS), Lower Extremity Stability and mobility function were measured by the Dynamic Gait Index (DGI), timed up and go (TUG) test, and Gait parameters (Cadence, Affected and Non-Affected Side Step Length and Stride Length). Results: A paired t-test was used to compare differences between pre-and post-intervention, and independent t-tests were used to compare the groups. Both the groups showed improved trunk Stability and lower Extremity function for the affected limb step length (A-LSL) and Unaffected Limb Step Length (UA-LSL) components. No statistically significant difference was found between the two groups at the post-intervention level. Conclusion: The MP and PNF are equally efficient in improving trunk stability and lower extremity functions except the TUG & unaffected side step length. Thus, if both approaches are used instantaneously, a better result can be obtained in a shorter duration. Indexed Keywords: Stroke, Trunk Control, Lower Extremity Function, Manual perturbation, Proprioceptive Neuromuscular Facilitation.
A stroke is characterized as paralysis or weakness of one side of the body, including the upper limb, lower limb, and trunk. Individuals with stroke present with altered muscle tone, abnormal synergy patterns, visual changes, altered coordination, and minimization in postural control and balance [1, 2].
The trunk provides background stability during mobility. It provides stability to aid through the core muscles for postural control and activities of breathing, speech, balance, upper limb, and lower limb functions, along with the ability to do ADLs and ambulation.[3] Trunk muscles play a vital role in supporting the human body in antigravity postures as well, such as sitting and standing, and also help in the stabilization of proximal body parts during voluntary limb movements.[4] In contrast, hemiplegic subjects show limited trunk movement concerning the gravity following trunk weakness. Hence the upper and lower limbs go into a spastic synergic pattern [5]. Good trunk stability is essential for maintaining balance as well as extremity use during daily functional activities.) [6] Poor recovery of trunk muscles, which results in severe disability and also a reduction in the activities of daily living (ADL), leads to postural instability and disequilibrium thus affecting gait & functional independence. [7]
Perturbation is a disturbance of motion or a change in the static state of equilibrium. [8] Manual perturbation is a treatment approach that works through external postural perturbation, internal postural perturbation, and perturbation through some voluntary tasks. External perturbation includes ‘lean and release' perturbations where participants lean forward, backward, left, or right on the physiotherapist's hands and are released suddenly (during stable tasks); a push or pull from the physiotherapist; or a trip with the physiotherapist's foot (during mobile tasks). (Manual perturbation training is vital in restoring reactive balance and improving functions and mobility. [9]
Internal perturbations occur while the patient is performing an anticipated activity and is not controlling their center of mass adequately. It’s the patient’s lack of control of movement, poor coordination, lack of center of mass awareness, and lack of adequate motor response that leads to the center of mass approaching or falling outside of their base of support. [10]
Perturbation through voluntary tasks is an exercise aimed at improving the control of fall-prevention reactions when one loses balance. Perturbation through voluntary tasks involves whole-body movements, and these movements have similar benefits to other exercises, such as walking, and may, over time, also improve strength and conditioning. [10]
Perturbation through voluntary tasks can potentially improve multiple aspects of physical health simultaneously. Each task can be modified to increase or reduce the difficulty, depending on the participant’s abilities. [11] [12]
Proprioceptive neuromuscular facilitation (PNF) is an approach to enhancing motor learning to improve motor function and facilitate maximal muscular contraction. In PNF, patterns of diagonal and rotational exercises in nature are used to improve ADL functions and mobility. Techniques such as rhythmic initiation, slow reversal, and agonistic reversal are used; PNF is one of the well-established treatment techniques incorporating functional diagonal movement patterns in the rehabilitation of subjects with stroke. [13] PNF techniques focus on the stimulation and facilitation of proprioceptors to increase demand on the neuromuscular mechanism to obtain and simplify their responses. [14] [15]
The Conventional physiotherapy rehabilitation plan, essentially conventional physical therapy based on ADL skills, included:
Passive range of motion exercises, stretching, Active assistive exercises, Active exercises, Resistive exercises, Exercises in different functional positions, Weight-bearing exercises, Weight shifting exercises, and reaching exercises in sitting, kneeling, and standing.
Bridging: simple bridging and progressed to one leg bridging and bridging with Vestibular ball, Truncal exercises, forward and backward lean with assistance, Upper and lower trunk rotation, Flexion of the trunk on the vestibular ball, Flexion, and extension of the trunk in sitting and standing.
Gait training: Gait training was done with the parallel bar as well as without the parallel bar and mirror for the feedback [16] [17] [18] [19].
Inclusion and Exclusion Criteria
|
Inclusion Criteria, |
Exclusion Criteria |
|
First-time stroke,
Sub-acute cases,
Both male and female,
50-70 age group,
Ambulatory patients (with or without support), All types of strokes, Normal cognitive function (MMSE),
MMSE ≥24,
Able to follow commands and |
Bed-ridden patients,
Acute cases,
Chronic cases,
Patients with cognitive and perceptual disorders,
Vestibular disorder,
Sensory loss in the lower limb,
Musculoskeletal disorder in the lower limb affecting standing and walking in a patient, |
Sample Size: 30 subjects, 15 subjects in each group, wherein
Group A: 15 (Manual Perturbation Training and Conventional Therapy) and
Group B: 15 (Proprioceptive Neuromuscular Facilitation and Conventional therapy).
Materials used
Outcome Measures: MMSE, Trunk Impairment Scale, TUG, Dynamic Gait Index, Gait Parameters. Data collection sheet, Inch tape, Consent form, Marker, Stationeries, Obstacles of the same size: boxes, cones, Armchair, Stopwatch, Assessment form, Chart papers, Colour (laundry blue), Mattresses, and Foam.
Variables
Independent Variables,
PNF exercises
Manual perturbation exercises and
Dependent Variables,
Trunk control
Balance
Mobility and
Gait parameters
Figure.1 patient performing walking around the obstacles a component in DGI
The treatment procedures are as follows:
Manual Perturbation Training [9, 25, 26]
1) External perturbation
2) Internal perturbation
Position: Sitting/ Quadruped/ Kneeling/ Standing
Proprioceptive neuromuscular facilitation: - [13, 14, 15, 20, 21]
1) Diagonal patterns – Trunk
Pelvic pattern
Position: side-lying
Lower extremity - Position: Supine/ Sitting – Techniques- D1/ D2 Flexion and D1/D2 Extension
1) Rhythmic initiation
Passively done for 2 weeks
Active assisted for the next 2 weeks
Active for 1 week
Active resisted in the last 3 weeks
Trunk: Flexion/ Extension -Position: Sitting
Pelvis: Anterior Elevation/ Anterior Depression/ Posterior Elevation/ Posterior Depression - Position: Side-lying
Lower extremity: D1 Flexion/Extension, D2 Flexion/Extension- Position: Supine/ Sitting
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