Received Date: July 9th, 2014
Neurol Res Ther Accepted date: July 30th, 2014
Open Access Published date: August 1st, 2014
http://dx.doi.org/10.14437/NRTOA-1-101 Reasearch Evelim Leal De Freitas, NRTOA 2013, 2:1
Effects of PNF Method for Hemiplegic Patients with Brachial
Predominance after Stroke: Controlled and Blinded Clinical Trial
Karen Rocha De Moraes, Evelim Leal De Freitas*, Dantas Gomes, Samantha Souza Possa and Luciana Barcala
Health Departament, Nove De Julho University, São Paulo, Brazil.
Abstract: In stroke, ninety percent of survivors have Keywords: Hemiplegic; Proprioceptive Neuromuscular
Facilitation (PNF); Stroke; Upper limb function
motor sequelae, being the main one is hemiplegia or hemi
paresis, respectively defined as total or partial paralysis of
Corresponding Author: Evelim Leal De Freitas,
the movements of one side of the body, interfering directly
Health Departament, Nove De Julho University, São Paulo,
on the balance and Activities of Daily Living (ADLs). The
Brazil.
hemiplegia or paresis are prevalent in the upper limb
disability, so this study will address this impairment. The
Proprioceptive Neuromuscular Facilitation (PNF) method Introduction
is applied to restore motor deficits promoting the return of Stroke is characterized by a total or partial reduction
function and independence of the patients in ADLs. The of blood flow in a particular area of the brain. The
aim of this study was to evaluate the effectiveness of the neurological deficits resulting from stroke vary according to
PNF method in relation to functional performance, being the location of the vascular injury, time of inadequate
assessed by two scales: the Functional Independence perfusion and the existence of collateral circulation. Thus,
Measure and Fulg-Meyer Assessment. Twenty these events may result in loss of strength, sensitivity, ability
predominantly brachial hemiplegic individuals after stroke to move and control of several corporal areas, in addition to
inserted in physical therapy treatment twice a week (one result in disorders of speech, loss of balance or coordination,
hour each session) were selected. visual disturbances, and loss of control of the anal and vesical
sphincters [1].
The subjects were randomly divided into two groups, one Specifically, the stroke is a disease of the upper motor
staying with conventional physical therapy and the other neurons and may result in loss of voluntary control regarding
group receiving application of 30 minutes of exercise of the motor movements. As the upper motor neurons do decussation
PNF method during the conventional physiotherapeutic (cross), a disorder of voluntary motor control at one side of the
session. The scales were applied before and after 20 body may reflect damage to the upper motor neurons on the
sessions of intervention. The study found that the PNF opposite side of the brain. In this case, hemiplegia is the most
presents significant results in the recovery of upper limb common motor dysfunction as a result of injury of the
hemi paretic patient functionality. opposite side of the brain [2].
Copyright: © 2014 NRTOA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, Version 3.0, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Citation: Evelim Leal De Freitas(2014), Effects of PNF Method for Hemiplegic Patients with Brachial Predominance after Stroke: Controlled and
Blinded Clinical Trial. Neurological Research and Therapy 2:101
http://dx.doi.org/10.14437/NRTOA-1-101 Page 2 of 6
Hemiplegia is characterized by loss of motor control The choice of the PNF method was by aim increased
at one side of the body, leading to typical disability to move strength, flexibility, coordination, as well as selective
the upper and lower limbs, spasticity, stereotyped synergies of rehabilitation of movements occurring learning movement,
motion with sensorial deficit and loss of balance reactions and reinforced through repetition. This occurs because the
protection. The balance reactions assist maintain and restore technique recruits the three planes of motion (for example:
our balance while performing all activities, especially when extension, abduction and internal rotation of shoulder), in a
there is risk of falls [3]. single motion executed. Figure.1 illustrates this movement
pattern.
With the presence of hemiplegia, the patient has difficulty to
move its trunk in relation to gravity, regardless of what type of
muscle activity required. The absence of proximal stabilization
(trunk) profoundly influences the members, since the upper
and lower limbs can be moved only in spastic synergy and the
distal spasticity is further increased as the patient attempts to
compensate the loss of attachment when it attempts to move
yourself against gravity [4].
The PNF method used for treating hemiplegia is a Figure 1. Movement pattern of PNF. Adler et al. [5].
therapeutic option that can alleviate complications imposed by
the chronicity of hemiplegia, allowing greater functional The aim of the present study was to evaluate the
independence, besides decreasing the risk of falls and effectiveness of the PNF on recovery of functional
consequently improving the quality of life of hemiplegic [5]. performance in daily life activities , being a complaint
(unanimous) of hemi paretic individuals post stroke. The is
PNF techniques are mainly based on stimulation of also a complaint so lodged in rehab, however, there are
proprioceptors to increase demand to the neuromuscular devices such as walkers, canes and orthotics, that assist this
mechanism to obtain and simplify their responses. The function, therefore, the prevalence of complaints of activities
treatment by these techniques is very understandable and with upper limbs.
involves the application of its principles in all phases of
rehabilitation [3]. The PNF method is a technique with a
treatment philosophy [5].
Methodology
The study is a randomized controlled trial, conducted
For the quantitative assessment, physiotherapy adopts
in the private school of Physical Therapy of Nove de Julho
scales that punctuate the sensory motor activities and their
University (UNINOVE) during the years 2011 and 2012. It
functional capacity, providing therapeutic strategies and
was approved by the Ethics Committee of UNINOVE under
developments in rehabilitation [6].
protocol # 323650 in accordance with the Resolution 196/96.
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Citation: Evelim Leal De Freitas(2014), Effects of PNF Method for Hemiplegic Patients with Brachial Predominance after Stroke: Controlled and
Blinded Clinical Trial. Neurological Research and Therapy 2:101
http://dx.doi.org/10.14437/NRTOA-1-101 Page 3 of 6
We selected twenty predominantly brachial - An Illustrated Guide [5] and under the guidance of a
hemiplegic adult patients of both genders, with a diagnosis of researcher specialized in the technique.The proposed
stroke and complaints of functional limitations of the upper intervention for both groups had a total of 12 sessions, being
limb impaired by stroke. This functional limitation was performed twice a week during six weeks, lasting 60 minutes
assessed by scoring two scales, the Fugl-Meyer Assessment each session. The evaluations were performed by same
(FMA) and the Functional Independence Measure (FIM). We researcher, i.e., the pre and post Scale Fulg-Meyer, MIF, and
excluded patients with not controlled associated diseases, the intervention of IG. Both researcher and patients were
structural deformities and lack of collaboration in the sessions. blinded to the treatment proposed for each group.
Patients agreed to participate as volunteer in the study and
Statistical analysis
signed a consent form.
For the analysis of adherence to the Gaussian curve it was
The evaluation of ADLs by the two scales was
used the Kolmogorov-Smirnov (KS) test. Data were described
performed before and after the intervention purposed by this
as mean and standard deviation or median and interquartile
study. The FMA verifies seven functional items of both upper
range according to its normality. For parametric variables it
and lower limbs. This study assessed only the four items of the
was used unpaired t test in the comparison inter groups and the
upper limb that include passive mobilization and pain,
paired t test for within group comparison. For nonparametric
sensitivity, upper limb motor function and coordination/speed.
variables were used Mann Whitney and Wilcoxon tests for
comparison inter and within group respectively. For
The FIM was applied using individual interviews
correlation analysis it was used the Spearman test. For the
conducted by an examiner trained for this procedure. Were
analysis it was used the software Minitab 14 and was
questioned ADL's related to self-care and sphincter control,
considered statistical significant a p value <0.05
transfers, locomotion, communication and social cognition, for
a total score ranging between a minimum of 1 and a maximum Results
of 7, respectively classifying the individual as dependent to Table 1 shows the anthropometric data of each group.
independent. Table 1: Anthropometric characteristics of the sample studied.
Conventional Group PNF Intervention group
After the pre intervention evaluation, the selected Age (years) 63 ± 9.16
patients were randomly divided into two groups by a lottery 61.1 ± 5.72
with a sealed envelope. The first group (control group; CG) Height (cm) 165 ± 4.9
was submitted to conventional physical therapy treatment that 164.2 ± 7.08
included muscle stretching exercises, joint mobilization, Body mass (kg) 70.2 ± 6.82
fitness tonic, resistive training for muscular strengthening, as 67.9 ± 11.68
well as static and dynamic balance training. The second group Body mass index (kg/m2) 30.8 ± 6.09
(PNF intervention group; IG) performed 30 minutes of 28.45 ± 8.81
conventional physical therapy and another 30 minutes of Injury time (months) 14.2 ± 5.59
upper limb exercises by PNF method, as shown in Table 1. 14 ± 5.14
The exercises of the PNF method were previously selected Right:left hemi paresis 6:4
from a book: PNF - Proprioceptive Neuromuscular Facilitation 5:5
Volume 2 • Issue 1 • 101 www.aperito.org
Citation: Evelim Leal De Freitas(2014), Effects of PNF Method for Hemiplegic Patients with Brachial Predominance after Stroke: Controlled and
Blinded Clinical Trial. Neurological Research and Therapy 2:101
http://dx.doi.org/10.14437/NRTOA-1-101 Page 4 of 6
The results show that in both groups (CG and IG) The PNF was choose due to technique providing in
individuals presented higher control of the functionality in the the same movement strengthening and functionality, different
upper limbs. This reflects an increase in the ability to perform from conventional physiotherapy which carries out first
ADLs and increased functional independence, since the upper strengthening exercises and second functional exercises.
limbs are responsible for a greater number of ADLs.
To verify the effectiveness of the PNF, other studies
Table 2 shows the median values and interquartile also have applied pop associated with conventional
range of the FMA score and FIM level, both for evaluating the physiotherapy comparing only with the conventional
functionality. Compare the pre- and post-intervention data for physiotherapy. As shown in the study of Modesto [7], they
both groups (CG and IG) with the results of the scales. Both verified that there was no difference between groups in
groups showed improvement in functional independence and relation to muscle strength and activities of daily living. These
when analyzing the effectiveness of the type of treatment data are consistent with the results of the present study.
(conventional or PNF) there was no difference between groups
(CG x IG). Thus, both techniques are effective for functional Studies such as of Franco et al. [8] indicate that the
recovery of the hemi paretic upper limb after stroke. technique to gain muscular strength, muscular endurance and
range of motion as well as obtaining relaxation of the
Table 2: Functional evaluation. antagonist pattern are contributing factors to the functionality.
Conventional Group PNF Intervention Group Dean et al. [9] reports the use of the technique in the presence
Pre Post p of spasticity, which generates changes in morphological,
Pre Post p physiological and biomechanical characteristics of the muscle,
FIM 2.5[2-4] 4.0 [2-6] 0.006 promoting pain relief and increased range of motion.
2.0[2-4] 4.0[2-6] 0.001
FMA 23.5 [17-26] 31[21-42] 0.002 Marques and Nogueira [10] compared PNF
17[13-25] 38.5[14-48] 0.003 associated with Functional Electrical Stimulation (FES) with
FIM: Functional Independence Measure (level); FMA: Fugl- FES alone and found that both were effective for the gain of
Meyer Assessment (score); Value expressing median and functional capacity, reduction in muscle tone of the paretic
interquartile range; *p<0.05. upper limb and improvements in the ability to perform
activities of daily living.
Discussion
The present study presents positive outcome in both Kim et al. [11] evaluated the influence of the PNF in chronic
interventions. However, even if the PNF was associated with hemi paretic in relation to the stability of the trunk through a
the thirty minutes of conventional physiotherapy, which reaching test and by muscle activating by electromyography. It
adopted only mobilizations, stretching and fitness of the was noted that the PNF showed positive results when
muscular tonus, which are preparatory activities for improved compared to using only the exercises with ankle weight. In the
applicability of functional training and strengthening present study, both strengthening activities and functional
exercises. training techniques were positive.
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Citation: Evelim Leal De Freitas(2014), Effects of PNF Method for Hemiplegic Patients with Brachial Predominance after Stroke: Controlled and
Blinded Clinical Trial. Neurological Research and Therapy 2:101
http://dx.doi.org/10.14437/NRTOA-1-101 Page 5 of 6
Lacerda et al. [12] found similar results on the effect Conclusion
of physiotherapy associated with PNF for the postural stability This study suggests that the PNF method is effective
of hemi paretic subjects, which was reflected in the risk of for functional rehabilitation of the upper limbs in hemiplegic
falls. Ribeiro et al. [13] compared two different methods of patients after stroke and may be an alternative to the physical
treatment in the recovery of postural and gait symmetry in therapy sessions. Thus, physiotherapy may adopt one more
hemi paretic subjects with stroke sequelae: PNF and treadmill treatment technique with positive effects in rehabilitation, in
training with partial weight bearing. These authors observed order to modify therapy sessions, for which individuals not
that both methods provided significant improvements, accustomed nor lose the motivation to perform the exercises.
especially in asymmetry, differing only with respect to the
ankle, and the subjects undergoing treatment with PNF
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