Earticle

Purpose: The purpose of this study was to demonstrate the effects of a stepwise proprioceptive neuromuscular facilitation (PNF) pattern therapy in weightbearing positions on the balance and walking functions of a patient with subacute stroke. Methods: The patient was a 78-year-old man with right post-stroke hemiparesis who had decreased balance and gait function. During the baseline and withdrawal phases, no intervention was applied; however, in the intervention phase, the patient received a stepwise PNF pattern therapy in weight-bearing positions. Results: During the intervention phase, the LOS improved by 296.51% (from 2482.13 ㎟ to 626 ㎟), and walking speed improved by 18.70% (from 0.75 ㎧ to 0.64 ㎧). The LOS and 10MWT values appeared to be clinically significantly improved after the intervention. In addition, the scores of the BBS and ABC scales improved by 100% (from 36 points to 18 points) and 56.52% (from 720 points to 460 points), respectively. Conclusion: These findings suggest that a stepwise PNF pattern therapy may be helpful in enhancing the balance and walking function of a patient with subacute stroke. Further studies are required to validate the results of this study.

Purpose: Patients with tibial fractures can have functional problems with balance and gait, as well as lower extremity muscle weakness. This case report aimed to describe the effect of hip joint strengthening exercises using proprioceptive neuromuscular facilitation (PNF) on balance and gait and lower limb function in a patient with tibia fracture. Methods: One patient diagnosed with tibial fracture was treated for seven weeks with the basic procedure, pattern, and technique of PNF for a hip joint strengthening exercise. Results: The results of pre- and post-intervention treatment showed improvements in physical function and structure in the clinical tests, including the manual strength test; the modified Ashworth scale; sensory evaluation; balance, sit-to-stand, and gait performance; and evaluation of lower limb function. Conclusion: Based on the results of this study, it is suggested that the use of theory-based proprioceptive neuromuscular stimulation for hip joint strengthening exercises positively affects patients' functional improvement in tibial fracture patients, and this may be used as a therapeutic exercise method for those with orthopedic problems in the lower extremities. One limitation of this study was that it was performed on only one tibia fracture patient, which makes it difficult to extend the treatment effects to all patients with this condition.

Purpose: The purpose of this study was to investigate the effects of a neck exercise using a proprioceptive neuromuscular facilitation (PNF) neck flexion and extension pattern on body balance in a progressive range of positions (supine, prone on elbow, and sitting), on numbness in the upper extremities, and on neck flexion motions in cervical myelopathy patients. Methods: One participant who was diagnosed with cervical myelopathy participated in this study. A reversal design (A-B-A’) was used. The A and A’ were the baseline period (no intervention), and B was the intervention period. The intervention used a neck extension pattern with a hold-relax technique and a neck flexion pattern with a combination of isotonic techniques in the supine position. Then, neck flexion and extension patterns were applied together with a reversal technique for stabilization, followed by a neck extension pattern with a combination of isotonic techniques in the prone position on the elbows. Finally, a neck flexion and extension pattern was used with a stabilizing reversal technique, and a neck extension pattern was applied with a combination of isotonic techniques in the sitting position for 60 minutes per day, 3 times per week for 8 weeks. To measure balance, numbness, and neck motion during neck flexion, the one-leg stand test and the visual analogue scale were used. Results: The right and left one-leg stand tests showed increased balance ability in the intervention phase. Upper extremity numbness was decreased in the intervention phase, and neck flexion motion was increased in the intervention phase. These increases were maintained after the intervention (Baseline Ⅱ). Conclusion: These results suggest that a neck exercise using a PNF neck pattern with additional techniques in a progressive range of positions has a positive effect on cervical myelopathy patients for balance, numbness, and neck motion.

Purpose: The purpose of the present study was to compare the effects of proprioceptive neuromuscular facilitation (PNF) and static stretching on weight distribution and flexibility for trunk flexion. Method: Sixty participants who had no musculoskeletal disorders were recruited from a local university within six months of this study. The participants were randomly assigned to a PNF stretching group (N=30) and a static stretching group (N=32). For the pre-and post-measurement design, the left-right weight distribution, anterior-posterior weight distribution, and finger-to-floor distance (FFD) were measured before and after the stretching interventions. Result: The FFD results were significantly improved after the interventions, regardless of the group differentiation (p<0.05). The PNF stretching intervention significantly increased the differences between anterior and posterior weight distribution compared to the static stretching group (p<0.05). Conclusions: Both the PNF and static stretching interventions could improve flexibility for trunk flexion mobility. Although the PNF intervention improved the weight distribution in the anterior-posterior direction, further research is required to investigate the various PNF interventions on left-and-right and anterior-posterior weight distribution.

Purpose: The purpose of this study was to obtain detailed and quantified data concerning the effects of plantarflexor muscle fatigue induced in the non-paretic side on the spatial and temporal gait parameters of the bilateral lower extremities during walking in stroke patients. Methods: This study was conducted on 20 patients with chronic stroke. The load contraction fatigue test was applied to induce muscle fatigue in the non-paretic plantarflexor muscle. Step length, stride length, double support, gait velocity and cadence, and functional ambulatory profile (FAP) score in the bilateral lower extremities were measured using a gait analysis system in order to investigate changes in temporal and spatial gait parameters caused by muscle fatigue on the non-paretic side. The statistical significance of the results was evaluated using a paired t-test. Results: A review of the results for gait parameters revealed a significant increase in double support (p<0.05) and a significant decrease in step length, stride length, gait velocity and cadence, and FAP score (p<0.05). Conclusion: These results indicate that the muscle fatigue in the non-paretic side of the stroke patients also affected the paretic side, which led to a decrease in gait functions. This implies a necessity to perform exercise or training programs in a range of clinical aspects not causing muscle fatigue.

Purpose: This study investigates research trends in the Proprioceptive Neuromuscular Facilitation (PNF) and Movement journal. Methods: This study analyzes the frequency of keywords and their coincidences with medical subject headings (MeSH) over 15 years in 315 papers from volume 1, issue 1 to volume 15, issue 3 of a journal published by the Korean Proprioceptive Neuromuscular Facilitation Association. The research types and levels are also analyzed, and the journals are classified by subject, diagnosis, application of PNF, and technique used when PNF is applied. All of the variables are classified in five-year units and their trends are examined. Results: A total of 315 papers were published in 40 issues, and 1190 keywords were used over 15 years. The most frequently used keyword was “PNF.” For the keywords that coincided with the MeSH, there were 235 (19.74%) complete coincidence words, 167 (14.03%) incomplete coincidence words, and 788 (66.21%) complete incoincidence words. Thus, the number of complete incoincidence words was the largest. For research types, there were 196 (61.90%) experimental studies, which was the most studied research type. For research levels, there were 155 (49.21%) Level 3 studies (non-randomized trial), which was the research level with the largest number of papers. Normal people were the most common subjects (121 cases, 38.41%), and the number of papers that did not use PNF was 187 (59.37%), which was larger than those that used PNF. The most frequently used combination technique was isotonics when PNF was used. Conclusion: Basic data on PNF-related research was obtained by analyzing papers published over the past 15 years. This information can be used to suggest future directions for PNF research.

Purpose: The purpose of this study was to survey the operation and development direction in KPNFA. Method: The participants of this study consisted of physical therapists who had a KPNFA membership. The satisfaction levels for each item (KPNFA impression, educational programs, and clinical application) were measured using a 5-point Likert scale. The survey was performed during June and July 2018. The total questionnaire was comprised of 648 samples. For the data analysis, descriptive statistics and Spearman correlation analysis were used to compare the general characteristics and all items. Results: In the questionnaire, the impression of KPNFA was 69.21, the instructor specialization in the educational programs was 74.22, and helpful interventions for clinical application scored 74.96. KPNFA’s image is competitive; friendly items scored the highest, and operation suitability and communication scored the lowest. The most important factor of the educational program was the quality of the instructors. The most helpful item was the education intervention program. The nervous system was applied to the patient with the highest response. The age of subjects showed a significant positive correlation with KPNFA impression, KPNFA branch impression, and branch problem solving. The work duration of subjects showed a significant negative correlation with instructor specialization. A regular member duration of subjects showed a negative correlation with teaching method, instructor specialization. Conclusions: The KPNFA survey was performed for the first time. In the future, this data will be utilized as the basis for KPNFA policy.

Purpose: The purpose of this study was to investigate whether the respiratory function of patients with stroke was different on the ground and under water. Methods: We recruited 14 adults who had experienced a stroke (12 male, 2 female) for our study. We measured forced vital capacity, forced expiratory volume at one second, maximum inspiratory pressure, and maximum expiratory pressure when the participants breathed on the ground and under water. On the ground, the participants were safely supported using a table and chair and were measured in a standing posture. For measuring under water, the participants were immersed in water in a standing position to clavicle height. The participants were measured while standing, and the assistant supported them when they needed help. The collected data were analyzed by a paired t-test. Results: Forced vital capacity and forced expiratory volume at one second were significantly lower in water than on the ground when breathing at maximum. Maximum inspiratory pressure was not significantly different when standing on the ground or in water, but maximum expiratory pressure was significantly higher in water than on the ground. Conclusion: It has been confirmed that the hydrostatic pressure affecting stroke patients immersed in water affects the forced expiratory volume at one second while reducing the forced vital capacity and increasing the maximum expiratory pressure.

Purpose: The purpose of this study was to investigate the effect of climbing training combined with coordinative locomotor training on muscle thickness in normal adults and to provide basic data regarding its applicability to clinical practice. Methods: Coordinative locomotor and climbing training was conducted three times per week for six weeks. Each exercise session consisted of ten minutes of warm-up and 40 minutes of the main exercise. A post-test was conducted six weeks after the training began, and a follow-up test was done two weeks after the training ended. Results: There were significant differences in the participants’ external and internal oblique abdominis muscles over time (p ＜0.05). There were also significant interactions in the external and internal oblique abdominis muscles over time and according to group (p＜0.05). Conclusion: The findings indicate that coordinative locomotor training with climbing had positive effects in normal adults, including increased thickness of the external and internal oblique abdominis muscles. The findings hold value for patient rehabilitation and clinical applications and interventions using coordinative locomotor training in combination with climbing.

Purpose: The purpose of this study was to examine test-retest reliability and criterion-related validity of a trunk stability robot when measuring the weight-bearing symmetry static sitting and standing in stroke patients. Methods: For 27 stroke patients, weight-bearing symmetry was assessed twice, 7 days apart. The intraclass correlation coefficient (ICC2,1) and minimal detectable change (MDC) were used to examine the level of agreement between test and retest. The criterion-related validity of weight –bearing symmetry was demonstrated by Spearman correlation of modified Barthel index (MBI), the sit to stand test (STS), the timed up & go Test (TUG), and the function in sitting test (FIST). Results: the test–retest agreements were excellent for the weight-bearing symmetry of static sitting (ICC2,1: 0.90) and standing (ICC2,1: 0.89). It all showed that the acceptable MDC for the weight-bearing symmetry of static sitting and standing was 0.11 and 0.16, respectively (highest possible score<20 %), indicating that the measures had a small and acceptable degree of measurement error. The weight-bearing symmetry of static sitting was significantly correlated with the TUG(r=-0.45) and FIST(r=0.46)(p<0.05); the weight-bearing symmetry of static standing was also significantly correlated with MBI (r=0.65), TUG (r=-0.67), FIST (r=0.61)(p<0.01), and STS (r=-0.47)(p<0.05). Conclusion: The weight-bearing symmetry of static sitting and standing assessed by the trunk stability robot showed highly sufficient test-retest agreement and mild-to-moderate validity. It could also be useful for clinicians and researchers to evaluate balance performance and monitor functional change in stroke patients.

Purpose: This study aimed to determine the effects of various wheelchair handling directions on the upper limb muscle activities of wheelchair attendants while climbing a ramp. Methods: For the study participants, healthy males over 20 years of age were chosen, and the order of the direction of wheelchair handle grip was determined using a randomized method. The handling directions for pushing the wheelchair up a ramp included a general grip with ulnar deviation, a medial grip with wrist pronation, and a neutral grip with a neutral wrist. The muscle activities in the participants’ upper limbs were measured using surface electromyography. For statistical data processing, SPSS 18.0 was used to perform repeated measures ANOVA in order to compare the muscle activity among the intervention groups. A contrast test was also conducted among the participants. The significance level (α) was set to 0.05. Results: There was a significant difference between groups using a general grip and a medial grip in the biceps brachii, triceps brachii, and flexor carpi radialis muscles (p<0.05). There was also a significant difference between using a general grip and a neutral grip in the biceps brachii and flexor carpi radialis muscles (p<0.05), and there was a significant difference between using a medial grip and a neutral grip in the biceps brachii and extensor carpi radialis brevis muscles (p<0.05). Conclusion: In this study, the wheelchair assistants’ wrist muscle activity was the lowest with a neutral grip while ascending a ramp. Accordingly, this study proposes that wheelchair assistants push wheelchairs up ramps with a neutral grip.

Purpose: The purpose of this study was to evaluate the relationship between foot pressure and upper arm PNF exercise conducted with elastic bands while standing. Methods: Eighteen asymptomatic patients consented to participate in the study. Foot pressure was measured in the standing position using the Gaitview system for proprioceptive neuromuscular facilitation stretching (PNF) using a right upper arm pattern. Resistance strength was varied based on the type of elastic band used (red=medium, green=heavy, and blue=extra heavy). Statistical significance of the results was evaluated using a repeated one-way ANOVA, and the Bonferroni method was used for the ad hoc test (SPSS ver. 18. for Windows). Results: A significant difference was observed in fore-foot, rear-foot, and everage pressure after upper arm PNF exercise. However, there was no significant difference according to the type of elastic band. Conclusion: Based on the results of this study, an upper arm PNF exercise with and without resistance may affect foot pressure in the standing position.

Purpose: Visual information is one of the most important factors for postural balance. The purpose of this study was to investigate the effect of visual deprivation on the lower extremities and trunk muscle activity on an unstable surface during quiet standing. Methods: Fifteen healthy males from a university population participated in this study. Surface electromyography of the rectus abdominis, the erector spinalis, the vastus femoris oblique, the semitendinosis, the tibialis anterior, and the medial gastrocnemius was measured using EMG equipment (Telemyo 2400, Noraxon, USA). The participants were asked to maintain postural balance on an unstable surface (Balance pad, Airex, USA) for 30 seconds with eyes open and with eyes closed during quiet standing. The Wilcoxon test was used to compare the muscle activity of the lower extremities and the trunk between open and closed eyes on an unstable surface. Results: The muscle activity of the trunk and the lower extremities was increased more with eyes closed than with eyes open on the unstable surface during quiet standing. Conclusion: The findings from this study suggest that visual information could alter lower extremity and trunk muscle activity. Therefore, visual deprivation can be used as a method to improve postural balance.

Purpose: This study aimed to compare the impact of proprioceptive neuromuscular facilitation leg patterns emphasizing hallux abduction (PNF-LPHA) on the intrinsic foot muscles of participants with hallux valgus (HV) using the toe-spread-out exercise (TSO). Methods: The present study recruited 12 individuals with HV. All the participants voluntarily agreed to participate in the study after hearing explanations of its purpose and process. All participants performed the TSO, PNF-LPHA 1, and PNF-LPHA 2. The participants’ abductor hallucis (AbH), adductor hallucis (AdH), extensor hallucis longus (EHL), and flexor hallucis brevis (FHB) activity was measured, and the ratio of AbH:AdH was measured during the three interventions using electromyography. Additionally, the participants’ AbH thickness was measured by ultrasonography. An intraclass correlation coefficient (ICC) was used to verify the intra-rater reliability of ultrasonography at rest and during contraction. Results: The intra-rater reliability was excellent at rest and during contraction (ICC3,1=0.90 and ICC3,1=0.83, respectively). There were no statistically significant differences in the activity of the AbH, the ratio of AbH: AdH, and the thickness of AbH between the TSO and PNF-LPHA2 groups. Additionally, EHL activity was significantly higher in the PNF-LPHA2 group than in the TSOgroup. Conclusion: PNF-LPHA 2 can be recommended as a method to optimize AbH and EHL activity, the ratio of AbH:AdH, and the thickness of AbH in individuals with HV.

Purpose: The purpose of this study was to investigate the effects of a modified constraint induced movement therapy (mCIMT) using proprioceptive neuromuscular facilitation (PNF) on the upper extremity function and activities of daily living (ADLs) in patients with subacute stroke. Methods: Fourteen participants with subacute stroke were randomly assigned to a group using both mCIMT and PNF or a group using mCIMT alone. Each group underwent twenty sessions (1 h/d, 5 d/wk) for 4 weeks. Patients were assessed with the action research arm test (ARAT), the Fugl-Meyer assessment for the upper extremities (FMA-UE), the Modified Barthel Index (MBI), and motor activity logs (MALs; amount of use [AOU] and quality of movement [QOM]). Results: Both the experimental group and the control group showed significant intragroup improvement in the ARAT, FMA-UE, MBI, and MAL-AOU (p<0.05). The group using both mCIMT and PNF exhibited greater improvement in the ARAT, FMA-UE, MBI, and MAL-AOU than did the group using mCIMT alone. Statistical analyses showed significant differences in the ARAT (p=0.01), FMA-UE (p=0.01), MBI (p=0.00), and MAL-AOU (p=0.01) between the groups. Conclusion: This study applied mCIMT combined with PNF for subacute stroke patients, and the results showed significant improvements in the patients’ upper extremity function and ADLs. Therefore, mCIMT using PNF may be more effective than mCIMT alone in improving upper limb function and ADLs in patients with subacute stroke.

Purpose: The purpose of this study was to evaluate and compare the effects of inspiratory muscle training with chest expansion exercises on pulmonary function, maximal inspiratory pressure, and gait in individuals with stroke. Methods: The participants in this study included 36 stroke patients. These patients were randomly divided into three groups: an inspiratory muscle training (IMT) with chest expansion (CE) group (n=12), an IMT group (n=12), and a control group (n=12). Participants in the IMT with CE group underwent IMT and CE exercises 5 times per week for 30 minutes over 4 weeks, whereas those in the CE group and the control group received IMT and conventional physical therapy, respectively, for the same duration. The investigator measured the patients’ pulmonary function, maximal inspiratory pressure, and gait endurance. Results: After the intervention, the change values for the forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), maximal inspiratory pressure (MIP), and six-minute walk test (6MWT) in the IMT with CE group and the control group were significantly greater than those of the control group (p<0.05). Similarly, after the intervention, the change values of the FVC, FEV1, PEF, MIP, and 6MWT in the IMT with CE group were significantly greater than those in the IMT group (p<0.05). Conclusion: These findings suggest that IMT with CE could be used to increase pulmonary function, maximal inspiratory pressure, and gait endurance in stroke patients.

Purpose: The aim of the present study was to investigate the effect of a PNF orofacial exercise program on diadochokinesis in subacute stroke patients with dysarthria. Methods: Thirteen subacute stroke inpatients with dysarthria were recruited for the study. All participants were randomly assigned to two groups: an experimental group (n=7) and a control group (n=6). The experimental group performed a PNF orofacial exercise program, and the control group carried out an orofacial self-exercise. Both groups received the treatments 30 minutes per day, 5 days per week, for 4 weeks. The outcome measures were assessed before and after the intervention, including an alternating motion rate (AMR) and sequential motion rate for diadochokinesis. Results: After the intervention, both groups showed significant improvement in diadochokinesis (p<0.05). In the change values for both groups, the experimental group showed a more significant improvement than the control group did in /pə/ of AMR (p<0.05). Conclusion: These findings suggest that PNF orofacial exercise programs may have positive effects on the improvement of diadochokinesis in subacute stroke patients with dysarthria.

Purpose: This study provides a treatment for central nervous system development in patients with chronic stroke by investigating changes in the upper limb function over time. The correlations among the activities, participation, and environmental factors of the international classification of functioning (ICF), disability and health are also examined. Methods: The subjects of this study are 18 patients with chronic stroke who were hospitalized and treated at 00 hospital in the Chungcheongbuk-do province. Their upper extremity functions are evaluated using the manual function test (MFT). The activities, participation, and environmental factors are evaluated using the ICF generic form. The correlations between the total scores of the affected and unaffected sides and the ICF items are analyzed using the Pearson correlation analysis. The significance level is p<0.05. Results: When the correlations between the activities and participation areas of ICF and the total score of the affected side of MFT were examined, significant correlations (p<0.05) were found in the following items: changing basic body position (D410), lifting and carrying objects (D430), moving around using equipment (D465), using transportation (D470), washing oneself (D510), caring for body parts (D520), and dressing (D540). When the correlations between the activities and participation areas of ICF and the total score of the unaffected side of MFT were examined, significant correlations (p<0.05) were found among writing (D170), speaking (D330), eating (D550), and drinking (D560). In addition, when the correlation between the environment area of ICF and the total score of the unaffected side of the MFT were examined, significant correlations (p<0.05) were found between products and technology for personal use in daily living (E115) and immediate family (E310). Conclusion: The MFT of patients with chronic stroke is closely correlated with the activities, participation, and environmental factors of ICF. This result suggests that ICF can be used as a useful tool to comprehensively evaluate the abilities of the patient, including the upper extremity function.

Purpose: This study analyzes the predictive power of upper extremity activity and the activities of daily living in patients with stroke using an easy-to-use evaluation tool. Methods: The Fugl-Meyer assessment (FMA) of the upper extremity and action research arm test (ARAT) are performed, and the Korean modified Barthel index (K-MBI) is measured. The predictive power of the upper extremity activity level and the daily activity level are analyzed using regression analysis. The statistical significance level is 0.05. Results: The coefficient of determination, R2, for predicting the ARAT using FMA was high at 0.88, but the regression equation for predicting the K-MBI using the FMA and ARAT did not show a statistically significant difference. Conclusion: The assessment of the upper extremity should be performed at the activity level, as well as the impairment level. The assessment for predicting the activities of daily living should be carried out for each level of the international classification of functioning (ICF), disability, and health, which can be linked to daily life, in addition to the assessment of the upper arm. Future research should conduct more diverse analyses using the ICF assessment tools at various levels.