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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018



Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018



Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018



Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018



Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018



Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata



Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018



Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018



Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018



Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011



Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2024 | Month : June | Volume : 18 | Issue : 6 | Page : YE01 - YE04 Full Version

Effect of Proprioceptive Neuromuscular Facilitation Technique on Balance in Stroke Patients: A Narrative Review

Published: June 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/67918.19475

Siva Sankar Kalita, BC Sarma, Simi Hazarika, Abhijit Dutta

1. PhD Scholar, Department of Paramedical Sciences, Assam down town University, Guwahati, Assam, India. 2. Associate Professor, Department of Paramedical Sciences, Assam down town University, Guwahati, Assam, India. 3. Assistant Professor, Department of Physiotherapy and Rehabilitation, Assam down town University, Guwahati, Assam, India. 4. Professor and Dean, Department of Paramedical Sciences, Assam down town University, Guwahati, Assam, India.

Correspondence Address :
Dr. BC Sarma,
Associate Professor, Department of Paramedical Sciences, Assam down town University, Guwahati-781026, Assam, India.
E-mail: sarmabc27@gmail.com

Abstract

Stroke, or Cerebrovascular Accident (CVA), is a condition that impairs the brain by rupturing blood vessels or by obstructing blood arteries with blood clots, causing a significant deterioration in the patient’s functioning and worsening their Quality of Life (QOL). Stroke patients are prone to falls and fall-related complications after a stroke, which are associated with balance disorders leading to activity limitations, increased dependency, affecting social and community participation, QOL, longer treatment duration, and slow prognosis. Balance disorders and fall risks after a stroke hinder stroke rehabilitation, so it is essential to improve balance for better results in stroke rehabilitation. Over the last decade, the Proprioceptive Neuromuscular Facilitation (PNF) technique has shown potential for improving balance in stroke patients. A systematic literature search was conducted, and the findings were critically reviewed and thematically analysed.

Keywords

Cerebrovascular accident, Proprioceptive neuromuscular facilitation, Quality of life, Stroke rehabilitation

Introduction
Stroke is defined by the World Health Organisation (WHO) as “rapidly emerging clinical signs of localised disruption of brain activity, with symptoms persisting for 24 hours or more, or leading to fatal consequences, with no evident explanation other than of vascular origin” (1). A stroke is a condition that impairs the brain by rupturing the blood vessels that supply oxygen and nutrients, or by obstructing the blood arteries with blood clots (2). As a result of these occurrences, various parts of the body may experience weakness, reduced sensitivity, limited movement, and coordination issues, resulting in speech abnormalities, loss of control of anal and visceral sphincters, vision disturbances, and impaired balance or coordination (3). The trunk is considered a central key point enabling the body to stay upright and adjust weight shifts during static and dynamic postural changes. Following a stroke, one side of the limbs is affected, but trunk muscles are impacted on both sides, leading to inadequate trunk rotation, difficulties in maintaining balance and gait (4). Balance is defined as an individual’s ability to keep the centre of gravity within a specific region, thereby maintaining a balanced body state (5). As postinjury symptoms, stroke patients encounter challenges with balance and postural adjustments. Due to asymmetric posture and decreased body balance and weight-shifting ability, their postural sway increases, and the centre of gravity shifts to the non paretic lower limb (6). The ability to balance is crucial for hemiplegic patients who have suffered a stroke, and its improvement is a primary goal for both patients and their family members (7). Various approaches, such as functional methods, neurodevelopmental treatments for motion control, Proprioceptive Neuromuscular Facilitation (PNF) utilising diagonal movement patterns, and dual-task training, are employed to enhance the balance and gait of stroke patients (8). PNF enhances muscle and tendon functions by stimulating the proprioceptive sense, thereby improving muscle strength, flexibility, and balance (9). Stroke patients are susceptible to falls and associated complications, including fractures, decreased confidence and mobility, and longer rehabilitation periods. Studies suggest that cognition and balance are significant risk factors for falls, often inadequately addressed in clinical practice (10). Balance disorders, fall risks, and fear of falling post-stroke hinder rehabilitation efforts, making it imperative to improve balance through rehabilitation programmes incorporating balance training, muscle strengthening, and flexibility training. Such programmes effectively enhance gait, balance, and the perception of falling among stroke patients (11). Over the past decade, the PNF technique has been increasingly utilised to improve motor function, muscular strength, flexibility, coordination, and balance in stroke patients, showing consistent enhancements across various studies. Integrating the PNF technique more extensively into therapeutic regimens for stroke patients can lead to reduced fall-related complications, shorter treatment durations, decreased dependency, improved prognosis, and enhanced social and community participation. The aim of this review is to assess the effectiveness of the PNF technique on balance in stroke patients, either individually or in combination with other treatment modalities.
Material and Methods
Search strategy: To gain a comprehensive understanding of the effect of the PNF technique on balance in stroke patients, a systematic search of peer-reviewed articles published after 2013 was conducted. Databases such as PubMed, Scopus, Web of Science, and Google Scholar were utilised, employing medical subject headings terms and free-text keywords like PNF, stroke, CVA, and balance. From the 90 articles identified, 25 were selected based on inclusion and exclusion criteria and reviewed in-depth.

Inclusion criteria:

• Articles published between 2013 and 2023.
• Studies that evaluated the effect of the PNF technique on balance in stroke patients.
• Randomised Controlled Trials (RCTs), cohort studies, meta-analyses and systematic reviews.
• Articles published in the English language.

Exclusion criteria:

• Articles not directly related to the effect of PNF on balance in stroke patients.
• Non English articles.

An Overall Review of Proprioceptive Neuromuscular Facilitation (PNF) Technique

The PNF is a technique historically used to restore muscular function, coordination, balance, and joint mobility. In a study by Kim K et al., coordination movements using the PNF pattern efficiently work on the paralysed side muscles, improving posture and balance, consequently enhancing walking ability. PNF emerges as a suitable therapy method for stroke patients facing gait issues due to decreased weight support and balancing ability (8). Asghar M et al., suggested that incorporating PNF into the routine treatment of stroke survivors enhances balancing capabilities. PNF, rooted in motor development and neuroplasticity concepts, elevates Brain-derived Neurotrophic Factor (BDNF) levels, aiding in brain tissue repair and enhancing the functional capabilities of post-stroke patients (12). In a systematic review by Yan-Fei Li, existing literature indicates that PNF techniques significantly enhance balance and mobility in stroke patients. However, there is limited evidence of its superiority over other rehabilitation techniques or conventional training methods (13). Vaidya A, in his study on PNF, concluded that PNF is more effective for improving gait and balance post-acute stroke, measuring gait with the Dynamic Gait Index (DGI) and balance with the Berg Balance Scale (BBS) (14). Chaturvedi P et al., concluded that PNF exercises are specialised and standardised exercises involving the neck, trunk, scapula, upper and lower extremities, along with audiovisual cues, distinguishing them from other exercises. PNF may have positive effects on functional outcomes by enhancing neuroplasticity. PNF exercises can be implemented from the first day, even in moderate to severe strokes (15).

Comparing PNF with other therapeutic techniques, PNF often proves superior or at least equally effective in enhancing post-stroke balance. Several studies reported that both PNF and traditional therapy improved balance, yet the PNF group showed quicker progress. While PNF as a standalone intervention shows promise, combining it with other rehabilitation strategies, such as Virtual Reality (VR) or mirror therapy, could offer an exciting avenue for potential synergistic effects. This could be attributed to providing multimodal sensory feedback, enhancing neuromuscular re-education, and balance. In a comparative study, dos Santos Junior VA et al., compared different treatment strategies (PNF, VR, or PNF/VR) for improving sensorimotor function recovery after a stroke and observed motor function improvement in the upper limb across all groups. They noted improvement in the motor function of the lower limb in the VR group and in balance in the PNF and PNF/VR groups. They believe this improvement may be linked to the strengthening of the proximal musculature promoted by PNF exercises, where pelvic and scapula diagonal exercises aid in stabilising the trunk (16). Additionally, the potential of PNF in reducing fall risk among stroke patients is particularly noteworthy. Post-stroke falls are common and can lead to further complications, including fractures, decreased confidence and mobility, and extended rehabilitation duration. By enhancing static and dynamic balance, PNF not only contributes to functional recovery but also enhances the safety and confidence of stroke survivors, reducing treatment duration. Cayco CS et al., in a study, demonstrated that a PNF programme coupled with principles of neuroplasticity is safe and effective in improving motor outcomes, showing positive effects on balance, strength, mobility, and reducing fall risk in older individuals with chronic stroke (17). A number of studies have shown that PNF techniques significantly enhance postural stability in stroke patients. Patients undergoing PNF training exhibited improved static and dynamic balance scores compared to those who did not. In addition to balance, functional mobility is crucial for daily activities, and PNF has been shown to improve functional mobility, closely correlating with balance improvements. In a meta-analysis, Shinde K and Ganvir S observed that trunk PNF patterns are effective in enhancing trunk control in stroke patients, with post-treatment results indicating improvements in static and dynamic sitting balance and coordination as assessed by the Trunk Impairment Scale (18). The specific PNF patterns that have shown effectiveness, such as the spiral and diagonal techniques, deserve special attention because the biomechanical rationale behind these patterns mimics functional movements, potentially leading to better neuromuscular coordination and re-learning. The repetition of functional movement patterns can significantly facilitate the journey back to daily independence for many stroke survivors. Kim CH and Kim YN established that symmetrical reciprocal combined scapular and pelvic PNF patterns are effective for improving motor control in the gait pattern (19). In a study, Lee DK and Hwang TY concluded that aquatic PNF patterns effectively improved balance, gait ability, and depression in patients with chronic stroke (20). Lim CG demonstrated in his study that PNF pattern exercises using sprinter and skater techniques may enhance balance and gait function in stroke patients (21). Kang TW and Kim BR conducted a study, and the results suggested that the chopping pattern of PNF is effective in improving hemispatial neglect, enhancing balance, and activities of daily living in stroke patients (22). A key takeaway from the review is the flexibility of PNF across different stages of post-stroke rehabilitation. The adaptability of PNF, evidenced by its effectiveness in both acute and chronic post-stroke phases, marks it as an essential tool for therapists. This flexibility is significant given the variability in recovery trajectories among stroke patients; some patients may show rapid improvement while others may require longer periods. In a systematic review with meta-analysis, Nguyen PT et al., suggested that PNF-based physical therapy has statistically significant effects on improving balance and gait speed at least six months post-stroke. For trunk control at the chronic stage in stroke patients, utilising PNF pelvic, neck, sprinter, and skater patterns in various positions with isotonic, dynamic reversal, stretching, reversal stabilisation, or resisted techniques can offer a strategy for implementing clinical practice for balance and gait functions (23). Jeong WM et al., in a study, applied PNF lower leg taping and treadmill training to patients with hemiplegia resulting from a stroke, concluding that taping and treadmill training based on the PNF concept are considered useful programmes for improving gait and balance abilities in hemiplegic patients (24). Pachruddin I et al., concluded in a study that PNF focuses on movement with diagonal and spiral patterns congruent with movements used in daily activities. PNF exercises influence standing balance ability in post-stroke patients, and physiotherapists in hospitals or clinics can select PNF exercises as a modality to enhance standing balance ability in post-stroke patients (25). Shirsath AH et al., in a study, stated that the rhythmic stabilisation technique of PNF significantly improves strength, endurance, flexibility, stability, balance, as well as functional performance in stroke patients (26). The evidence presented in the last decade emphasises the potential of PNF in restoring balance in stroke rehabilitation (27). However, limited studies have been completed that demonstrate the definite treatment protocol and long-term effects of PNF techniques on balance in stroke patients. Therefore, long-term effects are an area that requires further evaluation. A summary has been provided in (Table/Fig 1) (1),(2),(3),(4),(5),(6),(7),(8),(9),(12),(13),(14),(15),(16),(17),(18),(19),(20),(22),(23),(24),(25),(26),(27). Despite the significantly positive evidence from this study, it is crucial to acknowledge the methodological conflicts present across the studies, as these differences can impact results and interpretations. Larger, more standardised trials would provide clearer insights into the true extent of PNF’s benefits.
Conclusion
The PNF technique consistently illustrated positive effects on improving balance in stroke patients. Numerous studies emphasised that the PNF technique, when compared to conventional rehabilitation exercises, showed significant improvements in static and dynamic balance, functional mobility, and overall quality of life. However, the degree of improvement varied across studies and depended on various factors such as the severity of the stroke, the duration and frequency of PNF interventions, and the specific PNF patterns applied. Future investigations should aim for greater standardisation, explore long-term outcomes, and establish PNF’s position relative to other rehabilitation strategies.
Acknowledgement
The first author would like to express his gratitude to Dr. BC Sarma, Faculty of Paramedical Sciences, Assam down town University for the continuous support and motivation of his research. He would also like to thanks Simi Hazarika and Dr. Abhijit Dutta Sir for their contribution in his study.
Reference
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Boob MA, Kovela RK. Effectiveness of pelvic proprioceptive neuromuscular facilitation techniques on balance and gait parameters in chronic stroke patients: A randomised clinical trial. Cureus. 2022;14(10):e30630. Doi: 10.7759/ cureus.30630.   [CrossRef]
2.
Thorawade S, Solankhi C. Effect of eye movement with PNF neck movement on balance and functional mobility in subacute stroke patients. International Journal of Health Sciences and Research. 2023;13(5):59-71. Doi: https://doi. org/10.52403/ijhsr.20230509.   [CrossRef]
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Dinesh M, Thenmozhi P, KalaBarathi S. Proprioceptive neuromuscular facilitation neck pattern and trunk specific exercise on trunk control and balance- An experimental study. Int J Ther Massage Bodywork. 2022;15(4):09-17. Available from: https://doi.org/10.3822/ijtmb.v15i4.727.   [CrossRef]  [PubMed]
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Sharma V, Kaur J. Effect of core strengthening with pelvic proprioceptive neuromuscular facilitation on trunk, balance, gait, and function in chronic stroke. J Exerc Rehabil. 2017;13(2):200-05. Available from: https://doi.org/10.12965/ jer.1734892.446.   [CrossRef]  [PubMed]
5.
Kim EK, Lee DK, Kim YM. Effects of aquatic PNF lower extremity patterns on balance and ADL of stroke patients. J Phys Ther Sci. 2015;27:213-15.   [CrossRef]  [PubMed]
6.
Seo KC, Park SH, Park KY. The effects of stair gait training using proprioceptive neuromuscular facilitation on stroke patients’ dynamic balance ability. J Phys Ther Sci. 2015;27:1459-62.   [CrossRef]  [PubMed]
7.
Seo KC, Kim HA. The effects of ramp gait exercise with PNF on stroke patients’ dynamic balance. J Phys Ther Sci. 2015;27(6):1747-49.   [CrossRef]  [PubMed]
8.
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DOI and Others
DOI: 10.7860/JCDR/2024/67918.19475

Date of Submission: Oct 09, 2023
Date of Peer Review: Dec 23, 2023
Date of Acceptance: Feb 02, 2024
Date of Publishing: Jun 01, 2024

Author declaration:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 09, 2023
• Manual Googling: Jan 09, 2024
• iThenticate Software: Feb 01, 2024 (18%)

Etymology: Author Origin

Emendations: 6
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