Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2019;-:-------

REVIEW ARTICLE

Effectiveness of the Proprioceptive Neuromuscular

Facilitation Method on Gait Parameters in Patients
With Stroke: A Systematic Review
Emer Gunning, MSc,a Marcin K. Uszynski, PhDb,c
From the aPhysiotherapy Department, Mullingar Regional Hospital, Westmeath; bFaculty of Education and Health Sciences, School of Allied
Health, University of Limerick, Limerick; and cMultiple Sclerosis Society of Ireland, Western Regional Office, Galway, Ireland.

Abstract
Objective: To review the current evidence for the effectiveness of proprioceptive neuromuscular facilitation (PNF) techniques on gait parameters
in patients with stroke.
Data Sources: The electronic platforms of CINAHL, MEDLINE, PubMed, and the Physiotherapy Evidence Database were searched using the
relevant search terms.
Study Selection: Intervention studies that had gait parameters as an outcome and in which PNF techniques were used in a poststroke population
were reviewed. The studies were reviewed by both authors and a consensus was reached. The literature search identified 84 studies. Following
screening, there were 5 studies that met the inclusion criteria for this review.
Data Extraction: Data were extracted from the studies by both authors and independently reviewed. Methodological quality was assessed with the
Physiotherapy Evidence Database scale of randomized controlled trials and with the Quality Assessment Tool for Quantitative Studies for
nonrandomized controlled trials.
Data Synthesis: Treatment using the PNF method led to a statistically significant improvement in gait outcome measures in patients with stroke
in all the studies. Three of the studies also found that groups treated with PNF techniques had a significantly greater improvement in outcome
measures than groups that received routine physiotherapy treatment.
Conclusions: Although some limitations were identified in the methodological quality of the studies, current research suggests that PNF is an
effective treatment for the improvement of gait parameters in patients with stroke. Further research is needed to build a robust evidence base in
this area.
Archives of Physical Medicine and Rehabilitation 2019;-:-------
ª 2018 by the American Congress of Rehabilitation Medicine

The proprioceptive neuromuscular facilitation (PNF) approach been used in rehabilitation of stroke patients4; however, it remains
was originally developed in the 1940s by Dr Herman Kabat and an area that is underresearched, and the existing evidence for its
Margaret Knott, when it was used to treat patients suffering from efficacy is often ambiguous.5
poliomyelitis.1 Following its development, the PNF concept A review of the current evidence and guidelines on the use of
evolved into a rehabilitation approach used for a number of con- PNF was completed. The Scottish Intercollegiate Guidelines
ditions of neurologic and musculoskeletal origin.2 Voss, Ionta, and Network6 report that there is insufficient evidence to recommend
Meyers3 defined PNF as “methods of promoting or hastening the one treatment approach over another for patients with stroke, and
response of the neuromuscular mechanism through stimulation of therapists should select their treatment approach according to the
the proprioceptors.” The PNF approach consists of an overarching needs of the patient. According to guidelines from Winstein et al,7
philosophy, a defined set of basic principles and procedures, and a it has not been established that neurophysiological approaches
description of techniques for use in rehabilitation.2 It has long such as PNF are more effective than other treatment approaches
for motor retraining after an acute stroke. This guideline suggests
that neurophysiological approaches may be considered but further
Disclosures: none. studies are needed to establish their efficacy.

0003-9993/19/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.11.020
2 E. Gunning, M.K. Uszynski

There are currently 3 narrative reviews that looked at the clinical trials9 and has fair to good levels of reliability for rating
overall efficacy of the PNF concept as a rehabilitation approach. the quality of randomized controlled trials (RCTs).10 The PEDro
Smedes et al2 completed a review of the evidence on the effec- scale has been used in previous systematic reviews in rehabilita-
tiveness of PNF techniques in a variety of subject populations, tion.11,12 The final study by Morreale at al13 was not an RCT and,
including patients with neurologic, musculoskeletal, geriatric, and therefore, was assessed with the Quality Assessment Tool for
pulmonary disorders. In the second narrative review, Westwater- Quantitative Studies.14 This tool meets acceptable standards of
Wood et al5 evaluated the evidence on the effectiveness of PNF validity and reliability15 and is suitable for use in quantitative
techniques for functional rehabilitation and increasing range of studies. It has been used in previous systematic reviews in
movement in neurologic and nonneurologic patients. Finally, rehabilitation.16,17
Chaturveti4 carried out a review of the effectiveness of PNF for
functional recovery of patients with stroke. All of the reviews
reported that PNF has been used safely in many different patient
populations and demonstrates positive results. However, they also
Results
highlighted a need for studies of high methodological quality.
Smedes et al2 reported that the results of studies using PNF on Study selection
gait-related outcome measures in different patient groups show a
The search produced 12 studies. Of these, 2 studies18,19 were
positive result on step frequency and gait speed. To our knowl-
excluded because they used PNF in combination with other
edge, there has been no review of the literature that specifically
treatments within the same experimental group; thus, the results of
investigated the efficacy of PNF techniques on gait parameters in
the trial could not be attributed to PNF treatment alone. Three
people with stroke.
additional studies20-22 were excluded because they used PNF in-
terventions in all study arms, in other words, there was no group
that did not receive PNF for comparison of effect. Finally, 2
Method studies23,24 were excluded because they did not include a control
group. There were 5 remaining studies that met the criteria for
Search strategy inclusion in the systematic review.13,25-28 Of these studies, 4 are
RCTs, and the fifth13 is a prospective multicenter blinded inter-
A literature search was conducted in June 2018. Electronic plat- ventional study. A description of the search using a Preferred
forms and databases including CINAHL, MEDLINE, PubMed, Reporting Items for Systematic Reviews and Meta-Analyses flow
and Physiotherapy Evidence Database (PEDro) were searched diagram is available in figure 1.
using a combination of search terms related to stroke, PNF, and
gait parameters. The search strategy used is presented in table 1.
Bibliographies of identified studies were manually searched for Population of studies
additional references, and a gray literature search was conducted
using Internet search engines and websites. The sample sizes in the RCTs ranged in number from 18-40. None
of these studies reported a power calculation to inform the number
of people needed to show a significant effect of treatment. The
Study selection study by Morreale et al13 was a larger multicenter trial with 340
patients. Of the 5 studies, 3 studies25-27 had patients with chronic
The following criteria were used to include studies for the review:
stroke (>6mo poststroke), and 2 studies13,28 had patients who
(1) published clinical trials that have an experimental group
were <6 months poststroke.
receiving PNF treatment and a control group, (2) studies including
a stroke population, (3) studies using outcome measures related to
gait, and (4) studies in English. Types of intervention
Both authors of this review conducted the searching, screening,
and data extraction independently. The authors then met to Although all of the included studies used PNF as the primary
compare findings and discuss discrepancies. When disagreements intervention, the treatment techniques in individual studies
occurred, they were discussed and resolved without need for a varied. In the study of Stephenson et al,25 the intervention
third party. group received PNF mat activities, including resisted pelvic
and lower extremity movement patterns, and gait training. The
gait training involved resistance applied to the patient’s
Methodological quality pelvis during weight shifting, followed by manual resistance
To evaluate the quality of the studies, the PEDro rating scale was applied at the pelvis during continuous walking. Gait training
used. When interpreting the scores, studies of high quality score was also used by Seo et al,26 where the intervention group
between 6 and 10, studies of fair quality score between 4 and 5, received PNF-based walking exercise on a ramp. This inter-
and studies of poor quality score 3 or below.8 The scale is vention involved PNF gait training with resistance applied and
considered a valid measure of the methodological quality of walking on a ramp in opposition to pressure applied by
the therapist.
In the trial carried out by Kumar et al,28 the intervention group
List of abbreviations:
received 3 PNF techniques of rhythmic initiation, slow reversal,
BWSTT body weightesupported treadmill training and agonistic reversal for pelvis. A combination of PNF tech-
PEDro Physiotherapy Evidence Database
niques was also used by Ribeiro et al,27 where the intervention
PNF proprioceptive neuromuscular facilitation
group received basic PNF procedures and movement patterns in
RCT randomized controlled trial
standing and sitting. The treatments included resisted sit and rise,

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Poststroke proprioceptive neuromuscular facilitation 3

Table 1 Search terms

No. of
Platform Databases Search Terms Limiters Items
EBSCO CINAHL (MM “strokeþ”) OR (stroke) OR (CVA) OR (cerebrovascular accident) AND (MM Articles in English 32
“neuromuscular facilitation”) OR (PNF) OR (proprioceptive neuromuscular
facilitation) AND (MM “gaitþ”) OR (MM “gait analysis”) OR (walking) OR
(gait) OR (mobility)
EBSCO MEDLINE (MM “strokeþ”) OR (stroke or CVA or cerebrovascular accident) AND (MM Articles in English 23
“muscle stretching exercises”) OR (PNF or proprioceptive neuromuscular
facilitation or proprioceptive neuromuscular technique) AND (MM “gaitþ”)
OR (gait or walking or stepping or mobility)
PubMed (stroke or CVA or cerebrovascular accident) AND (PNF or proprioceptive Articles in English 20
neuromuscular facilitation) AND (gait or walking or mobility or stepping)
PEDro Stroke, proprioceptive neuromuscular facilitation, gait Articles in English 7

standing weight transfer with resisted pelvic movement, and therapy and can tolerate it.29 Not all of the studies met this
resisted pelvic movement during gait. recommendation with their described intervention.
In the final study by Morreale et al,13 the PNF group received PNF
techniques and postural alignment. The PNF intervention consisted of Control groups
a bedside and out-of-bed intervention with proximal joint passive/
active mobilization according to Kabat’s schemes. No further detail is In 4 of the studies,13,25,27,28 PNF was compared directly with other
described in this study as to the exact PNF treatment used. Because of treatments. In the first of these, it was reported that treatment with
this variation in the interventions used in the studies, it is difficult to PNF resulted in significantly more improvement in gait outcome
make direct comparisons between them, but the main element of all of measures than conventional exercises. In the description of the
the interventions was use of PNF techniques. conventional exercises by Kumar,28 the types of exercise and overall
The dose of treatment also differed between studies (table 2). treatment duration are given; however, the number of repetitions and
The recommended dose of rehabilitation therapy following stroke intensity of the exercises are not described. This has limitations as a
is a minimum of 45 minutes of each appropriate therapy at least 5 comparator arm in an RCT because of the potential for inconsis-
days a week for as long as the patient continues to benefit from tency and difficulty in reproducing the treatment. In the study by

Fig 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.

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4 E. Gunning, M.K. Uszynski

Table 2 Summary
Study Sample Intervention Outcome Measures Results
Stephenson 18 subjects with PNF group: PNF mat activities Measured preintervention and Both PNF and BWSTT
et al25 chronic stroke and gait training  30 min postintervention improve gait velocity,
RCT (>6mo)  3 times/wk  4 wk Gait velocity: 10-m walk test, gait cadence, and Wisconsin
BWSTT group: BWSTT  20 min cadence, Wisconsin Gait Scale, Gait Scale vs control
 3 times/wk  4 wk Perry’s classification system group (P<.05)
Control group: no intervention
Seo et al26 40 subjects with PNF group: 30-min PNF-based Measured preintervention and PNF-based walking on a
RCT chronic stroke walking exercise on a ramp postintervention ramp improved temporal
(>6mo)  5 times/wk  4 wk Gait performance: temporal, and spatial parameters
Control group: 30-min walking spatial, and functional and improved functional
exercise on a ramp  5 ambulation performance ambulation performance
times/wk  4 wk measured using GAITRite system vs control group (P<.05)
Kumar et al28 Convenience PNF group: 3 PNF techniques  Measured preintervention and PNF group improved in
Two-group sample of 30 30 min  3 d/wk  4 wk postintervention stride length, cadence,
pretest- subjects Control group: stretching, Stride length, cadence, gait gait velocity, and
posttest (<6mo strengthening and weight- velocity, functional mobility: Rivermead Mobility Index
design poststroke) bearing  30 min  3 d/wk Rivermead Mobility Index vs control (P<.05)
 4 wk
Ribeiro et al27 Convenience PNF group: basic PNF Measured pre- and Both groups improved in
RCT sample of 23 procedures and facilitation postintervention STREAM, motor FIM, and
subjects patterns in standing and Functional Ambulation Category, symmetry ratio of swing
(>6mo sitting  30 min  3 times/ NIHSS, Muscle tone: MAS, time (P<.05)
poststroke) wk  4 wk STREAM, FIM (motor); Gait: PNF group only improved in
TPBWS group: gait trainer with Qualisys System maximum ankle
treadmill and manual dorsiflexion during swing
assistance  30 min  3 phase (P<.05)
times/wk  4 wk
Morreale13 340 patients post Early PNF: (starting day 1 Measured at baseline, at 3 mo and MRS and BI improved in all
Prospective first time poststroke) 45 min daily PNF at 12 mo groups (P<.05) with
multicenter subcortical and 15 min postural Disability, MRS, BI, safety, some more improvement
blinded ischemic alignment and positioning immobility-related adverse in the early groups (not
interventional stroke Early CTE: (starting day 1 events, 6MWT, MI, MMSE, Beck statistically significant)
study poststroke) 45-min guided Depression Inventory 6MWT improved in all
movements during an groups (P<.05)
attention task and 15 min At 12 mo early groups
postural alignment and improved more in 6MWT
positioning than delayed groups
Both early groups then had (P<.05)
2.15 h/d of their assigned
treatment from 5th-60th day
poststroke. Then 1.30 h/d of
treatment for a mean of 38
wk in total.
Delayed treatment group: 60
min of postural alignment
and positioning in the first 4
days. They were then
randomized into the PNF or
CTE groups to continue
treatment for the rest of the
trial.
Abbreviations: 6MWT, 6-minute walk test; BI, Barthel Index; MAS, Modified Ashworth Scale; MI, myocardial infarction; MMSE, Mini-Mental State Ex-
amination; MRS, Modified Rankin Score; NIHSS, National Institutes of Health Stroke Scale; STREAM, Stroke Rehabilitation Assessment of Movement;
TPBWS, treadmill training with partial body-weight support.

Morreale at al,13 PNF and cognitive therapeutic exercise groups comparator arm because it is an approach that consists of different
both showed significant improvement with no difference between types of treatment techniques, and its protocol is not described in
the groups. Cognitive therapeutic exercise has limitations as a enough detail to allow replication of the treatment.

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Poststroke proprioceptive neuromuscular facilitation 5

record of the outcome measures used relating to gait in the studies

Table 3 PEDro rating scale for included RCTs
is presented in table 2. Because of this variation in outcome
Kumar Ribeiro Stephenson Seo measures, results cannot be directly compared, but a comparison
Study et al28 et al27 et al25 et al26 can be made of the overall improvements in gait parameters. All
Eligibility criteria Yes Yes Yes Yes studies reported results in terms of statistical significance, and,
Random allocation No Yes Yes Yes although sample sizes were generally small, statistically signifi-
Concealed No No No No cant differences were found in all the studies. None of the studies
allocation reported minimal clinically important difference, a significant
Groups similar at Yes Yes Yes Yes consideration in person-centered care, because it measures the
baseline changes that are meaningful for the patient.30
Subject blinding No No No No Stephenson et al25 reported a significant improvement in gait
Therapist blinding No No No No velocity and cadence in both the PNF group and the BWSTT
Assessor blinding No No Yes No group in comparison with the control group. Only the PNF group
Key outcomes No No Yes No had a significant improvement in the Wisconsin Gait Scale
85% compared with the control group. Seo et al26 reported that, in
All subjects No Yes Yes No temporal parameters, both the PNF and the control group
received improved their step time, with the PNF group improving signifi-
treatment cantly more than the control group. In terms of double support,
Between-group Yes Yes Yes Yes stance phase, and mean velocity, only the PNF group showed a
statistics significant improvement post treatment. For the spatial parame-
Point measure and Yes Yes Yes Yes ters, both groups improved in step length, with significantly more
variability improvement in the PNF group. Only the PNF group had signif-
Total Score 3 5 7 4 icant improvements in heel-to-heel base of support and step/
extremity ratio. Only the PNF group also had a significant
improvement in Functional Ambulation Performance. This dem-
onstrates that the PNF group had significantly more improvement
PNF showed slightly more improvement than body weighte in temporal and spatial gait parameters and functional ambulation
supported treadmill training (BWSTT) in 2 studies.25,27 BWSTT performance than the control group.
is an appropriate choice of treatment for a comparison because it Kumar et al28 found that both the PNF and the control group
has been recommended with level A evidence in recent stroke improved their stride length, cadence, gait velocity and Functional
guidelines to facilitate recovery of mobility in patients with Mobility Index. The PNF group had a significantly greater
stroke.7 A favorable result for PNF in comparison with BWSTT improvement in all measures than the control group. Significant
could be interpreted as evidence that it is also an effective treat- changes were also found in the trial by Ribeiro et al.27 This study
ment for recovery of mobility in patients with stroke. reported that both groups improved significantly in the Stroke
In the study by Seo et al,26 PNF with walking on a ramp was Rehabilitation Assessment of Movement and symmetry ratio of
compared with walking on a ramp only. The addition of the PNF swing time. The only gait parameter in which the PNF group
treatment was the only difference between the groups, and, therefore, showed a greater improvement than the control group was in
the improved outcomes in this group could be attributed to the PNF maximum ankle dorsiflexion during swing phase.
treatment. However, it could be argued that it was the combination of Finally, Morreale et al13 found that scores on the 6-minute
2 treatments (walking on a rampþPNF) that led to greater improve- walk test significantly improved in all groups. They found that
ment in the PNF group and not PNF treatment alone. at 12 months, the groups that began rehabilitation within 24 hours
of their admission (early groups) improved more than the groups
Quality of the studies that began rehabilitation 4 days after admission (delayed groups),
but there was no difference in improvement of 6-minute walk test
The scoring of the quality of the studies with the PEDro scale is scores between the PNF and control groups.
detailed in table 3. It suggests that 1 of the studies28 is of low
quality, 2 of the studies26,27 are of fair quality, and 1 study25 is of
high quality. The most common reasons for lower scores in the
assessment of these studies are the lack of concealed allocation
Discussion
and blinding of the therapists, subjects, and assessors. Analysis of The aim of this review was to assess the effectiveness of the PNF
the final study by Morreale et al13 with the Quality Assessment approach on gait parameters in patients poststroke. Five studies
Tool for Quantitative Studies suggested that the global rating for were narratively analyzed and the results reviewed. The method-
study methodology is strong. The study scored a strong rating in 4 ological quality of the included studies is variable, with most
out of 6 categories. The remaining 2 categories are scored as studies scoring a fair or high rating on the PEDro scale, 1 study
moderate because the study participants were aware of the study scoring a strong rating on the Quality Assessment Tool for
objectives and the study did not describe the validity and reli- Quantitative Studies, and only 1 study scoring a low-quality rating
ability of the outcome measures used. on the PEDro scale. Four of the 5 studies were RCTs, and sample
sizes were generally low.
Outcome measures All of the studies reviewed found that treatment using the
PNF approach led to a statistically significant improvement in
All of the studies used outcome measures related to gait. However, gait outcome measures in patients with stroke, with most of the
these outcome measures were different in every study. A full studies finding that the PNF group improved more than the

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6 E. Gunning, M.K. Uszynski

control group. The findings must be interpreted carefully because Conclusion

these studies had small sample sizes and varying methodological
quality; therefore, we cannot conclude that PNF is superior to The current research suggests that PNF is an effective treatment
other treatments. The best quality study with the largest sample for the improvement of gait parameters in patients with stroke. In
size13 did not show that PNF was more effective than the control each of the reviewed studies, there was a statistically significant
treatment. However, it did show that PNF improved gait improvement in gait parameters in patients with stroke with the
parameters and might be as effective as alternative physiotherapy use of PNF. Therefore, PNF techniques should be considered by
treatments. therapists as part of their treatment program for suitable patients.
With the available evidence suggesting that the PNF approach The results of this systematic review were affected by the small
is an effective intervention for the improvement of gait parameters study numbers and varying methodological quality. Further
in patients with stroke, its benefits over alternative treatments research is needed to build a robust evidence base in this area.
should be considered. Many therapists will have a basic level of
knowledge of PNF from their core training program, and further
training is available to certify therapists as PNF practitioners if Keywords
desired. In the current health care climate, cost of treatment is a Gait; Muscle stretching exercises; Rehabilitation; Stroke
necessary consideration in choice of intervention. PNF may pre-
sent a more cost-effective intervention than treatments such as
BWSTT because there is no requirement to invest in expensive
equipment for the PNF approach.
Corresponding author
Emer Gunning, MSc, Physiotherapy Department, Mullingar
Regional Hospital, Longford Road, Robinstown, Mullingar, Co,
Study limitations Westmeath, Ireland, N91NA43, 00449394947. E-mail address:
This review was limited by the number of studies available for emergunning@hotmail.com.
inclusion. Limitations of the review also included the small
sample size in the majority of the included studies and treatment
protocols and outcome measures that varied in each study, Acknowledgment
meaning that the results cannot be pooled for meta-analysis.
We thank Blathin Casey, BSc, PhD, of National University of
Ireland, Galway, for assisting in proofreading the article and
Recommendations for future research making recommendations on the final editing.

Future studies should include RCTs of high methodological

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