ASPI | Afarand Scholarly Publishing Institute; Turkey

ISSN: 7687-2645. Journal of Clinical Care and Skills. 2023;4(4):207-211. 10.58209/jccs.4.4.207

Effect of Proprioceptive Neuromuscular

Facilitation Exercises on Muscle Strength
in Stroke Patients
ARTICLE INFO ABSTRACT
Aims Stroke is a localized and sudden neurological disorder in the brain that can decrease
Article Type muscle strength. This study aimed to determine the effect of Proprioceptive Neuromuscular
Original Research Facilitation exercises on the muscle strength of stroke patients.
Materials & Methods This pre-post clinical trial with a randomized control group was
Authors conducted in 2017-2018. Patients with stroke were referred to the Neurology Department
Najafi Doulatabad Sh.1 PhD of Shahid Beheshti Hospital in Yasuj City, Iran. Sixty eligible stroke patients were selected
Afrasiabifar A.1 PhD through convenience sampling and assigned to intervention and control groups using random
Parandvar Y.1* MSc block allocation. Data were collected through a muscle strength questionnaire at baseline,
immediately post-intervention, and four weeks after the last intervention. Statistical analysis
was performed using SPSS 21 software, employing Wilcoxson and Mann-Whitney U.
Findings There was no statistically significant difference in muscle strength between the
research samples before and immediately after the intervention. However, one month after
the intervention, a statistically significant difference was reported between the two groups
How to cite this article (p<0.05). The difference in the mean muscle strength was significant in the test group (p=0.001).
Najafi Doulatabad Sh, Afrasiabifar Conclusion Implementing proprioceptive neuromuscular facilitation techniques improves
A, Parandvar Y. Effect of Propri- muscle strength in stroke patients.
oceptive Neuromuscular Facilita-
tion Exercises on Muscle Strength Keywords Proprioceptive Neuromuscular Facilitation; Muscle Strength; Stroke
in Stroke Patients. Journal of Clinical
Care and Skills. 2023;4(4):207-211.
CITATION LINKS
[1] Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990 and ... [2] A
comparative analysis of machine learning classifiers for stroke prediction: A ... [3] Application
of deep learning in detecting neurological disorders from magnetic resonance images: A
survey on the detection of Alzheimer’s disease, ... [4] Epidemiology of stroke in ... [5] Heart
disease and stroke statistics-2017 update: A report from the American heart ... [6] Аcute
stroke and type 2 ...[7] Range of motion exercise to improve muscle strength among ... [8]
Intensive therapy induces contralateral white matter changes in chronic stroke patients
with Broca’s ... [9] Effectiveness of Motor Interventions in Improving the Motor Abilities of
Post-stroke Patients: A Systematic ... [10] Proprioceptive Neuromuscular Facilitation
(PNF): Uts mechanism and effects on range of motion and ...[11] Effectiveness of the
proprioceptive neuromuscular facilitation method on gait parameters in patients with
stroke: A systematic ... [12] Effectiveness of Rhythmic Stabilization Technique (Pnf) with
Conventional Physiotherapy in Osteoarthritis (Oa) ... [13] Effects of proprioceptive
neuromuscular facilitation on balance, strength, and mobility of an older adult with chronic
stroke: A ... [14] Effect of proprioceptive neuromuscular facilitation stretching on physical
1
Department of Nursing, Faculty of fitness: A critical ... [15] Effect of mirror therapy on walking ability in patients with ... [16]
Nursing, Yasuj University of Medical
Sciences, Yasuj, Iran
Comprehensive textbook of nursing ... [17] Duration of maintained hamstring flexibility after
a one-time PNF-crca stretching protocol in ... [18] Comparison of Two different applications
of proprioceptive neuromuscular facilitation techniques to increase upper-extremity muscle
*Correspondence
Address: Department of Nursing, ... [19] Ischemic lesion volume correlation with functional outcome after PNF application in
Faculty of Nursing, Yasuj Univer- middle cerebral artery stroke ... [20] The effects of band exercise using proprioceptive
sity of Medical Sciences, Shahid Mo- neuromuscular facilitation on muscular strength in ... [21] Effectiveness of PNF stretching
tahari Boulevard, Yasuj, Iran. Postal
Code: 75913446499 versus static stretching on pain and hamstring flexibility following moist heat in individuals
Phone: +98 (74) 33322017 ... [22] The comparison of neuromuscular facilitation exercises and traditional exercise
Fax: +98 (74) 33337937 therapy programs in the treating of patients with chronic ... [23] The immediate effect of
y.parandvar@gmail.com
diaphragm taping with breathing exercise on muscle tone and ... [24] Overflow using
proprioceptive neuromuscular facilitation in post-stroke ... [25] Effects of aerobic physical
Article History exercise on neuroplasticity after stroke: ... [26] Effect of 8-week combined training (resistance
Received: November 19, 2023 and proprioceptive neuromuscular facilitation) on fatigue and quality of life in ... [27] Clinical
Accepted: December 7, 2023 evidence of exercise benefits for ...
ePublished: December 15, 2023

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Effect of Proprioceptive Neuromuscular Facilitation Exercises on Muscle Strength in Stroke Patients 208
Introduction suggested further studies for more credible results
[14].
Stroke is one of the primary factors leading to
disability, cognitive decline, and mortality worldwide Furthermore, considering that despite various
[1]. This disease is considered the second leading research on the effects of PNF on other disorders and
cause of disability and the third leading cause of diseases, there is limited research on its impact on
death [2]. According to the World Health Organization stroke patients, and sometimes these results are
(WHO) report, every 4 to 5 minutes, one person dies contradictory. Additionally, the review of existing
due to a stroke [3]. The prevalence of this disease in literature indicates that local approaches have
Iran is reported as 283 cases per hundred thousand received less attention. Thus, this study aimed to
individuals [4]. Annually, more than 400 thousand investigate the effect of deep neuromuscular
individuals are discharged from hospitals following facilitation exercises on muscle strength in stroke
the occurrence of acute conditions of stroke, resulting patients.
in varying degrees of physical disorders and
disabilities [5]. Materials and Methods
The reduction in motor ability and pain are among Design and sampling
this disorder's most common clinical symptoms [6], This pre-post clinical trial with a randomized control
resulting from tissue damage in the brain. The group was conducted in 2017-2018. Patients with
decrease in muscular strength can be significant stroke were referred to the Neurology Department of
enough to impede the performance of daily activities. Shahid Beheshti Hospital in Yasuj City, Iran. The
Therefore, professional, social, and quality-of-life research sample included 60 patients who met
activities will also be affected, leading to significant criteria such as personal satisfaction and awareness
economic and social implications [7]. for participation, a minimum of 4 months to 2 years
Clinical evidence indicates that physical activity after since the onset of stroke, aged 60 to 90 years, absence
a stroke leads to motor improvement and structural of orthopedic and neurological diseases, ability to
changes in the brain [8]. Exercise interventions in the communicate, and muscle strength less than 3.
elderly have also successfully enhanced physical Participants were selected using non-probability and
function and the exercises have a protective effect in convenience sampling methods and were randomly
alleviating functional limitations, including mobility, divided into 30 experimental and control groups
disability, and fall prevention. Therefore, researchers based on block randomization. The required sample
are striving to leverage exercise and rehabilitation size was estimated to be 27 participants in each
activities to improve functional outcomes in stroke group using the Cohen formula for comparing the
survivors [9]. Among suitable rehabilitation strategies difference between the two means of the outcome
in this context, incorporating stretching exercises is variable score (d=μ1-μ2) with a standard deviation of
noteworthy to enhance the patient's muscle muscle strength of 1.05, according to a similar study
flexibility. Proprioceptive Neuromuscular [15] and considering a confidence level of 95%, a test

Facilitation (PNF) exercises are a stretching method power of 80%, and the maximum clinically significant
that improves muscles' elastic properties and difference (effect size). Finally, 30 participants in
positively affects both passive and active range of each group were determined based on the 10%
motion [10]. statistical decline (n=60).
Results of the systematic review by Gunning and Instruments
Uszynski have demonstrated that using the PNF The muscle strength of participants in both groups
method significantly improves walking outcome was assessed before the intervention using the
measures in stroke patients. Furthermore, these Muscle Strength Measurement Questionnaire (MMT)
results indicated that groups undergoing treatment in three parameters: muscle grade, percentage of
with PNF techniques showed significant normal muscle strength, and muscle scale, scored on
improvement in outcome measures compared to a scale of 0-5. A score of 5 indicates complete
groups receiving conventional physiotherapy contraction strength against gravity and resistance
treatment [11]. Jacob also indicated that PNF is with natural muscle strength. A score of 4 indicates
significantly more effective than regular good muscle strength but not complete against
physiotherapy in reducing pain, increasing flexibility, gravity, with resistance being approximately average
and enhancing independence in functional mobility or partial weakness. A score of 3 indicates moderate
for patients with knee osteoarthritis [12]. weakness and sufficient muscle strength only against
Furthermore, the study by Cayco et al. demonstrated gravity. A score of 2 indicates the ability to move but
that PNF effectively improves balance, strength, and unable to overcome gravity, signifying severe
movement in patients with stroke [13]. Majhi, in their weakness. A score of 1 indicates minimal contractile
critical analysis study, concluded that despite reports strength (muscle contraction is weak but palpable,
of the positive impact of PNF on the strength, balance, with no observable movement) or very severe
and movement of individuals, some other studies weakness. A score of 0 indicates the absence of
have reported no effect or adverse effects. They movement. Individuals with a muscle strength score

Journal of Clinical Care and Skills Fall 2023, Volume 4, Issue 4

209 Najafi Doulatabad et al.
of three or fewer were included in the study. The reach a new point in the range of motion immediately
reliability and validity of muscle strength or after a pause of about 2 to 3 seconds [17].
measurement are confirmed in medical science The muscle strength of the patients in both the test
reference books [16]. and control groups was assessed using the Muscle
Procedure Strength Questionnaire administered by the
After obtaining approval from the Ethics Committee researcher before starting the exercises,
and registering in the clinical trial center, the purpose immediately, and four weeks after completing the
of the study was explained to the participants, and last exercise session. The assistant researcher and
written informed consent was obtained. Emphasis statistical advisor were unaware of the sample
was placed on voluntary withdrawal at any study grouping in the data analyst step.
stage and the confidentiality of information. No costs Analysis Method
or harm were imposed on the patients, and the Data were analyzed using SPSS 21 software through
Helsinki Declaration principles were followed descriptive statistics (tables and charts, central
throughout the research process. Based on the tendency indices, dispersion indices) and inferential
protocol, the intervention was implemented for eight statistical tests (Kolmogorov-Smirnov, Mann-
weeks, consisting of two sessions per week, each Whitney, Wilcoxon) considering a 95% confidence
lasting 30 to 45 minutes (16 sessions over two level and p<0.05.
months) in the experimental group. The control
group did not receive any intervention and only Findings
received routine treatments. There was no sample dropout (n=60) and no
For the implementation of PNF techniques, the significant difference in sociodemographic
following joint patterns were used: parameters between the two patient groups (p=0.1).
1. Upper Limb Joint Patterns: Both groups were in the 60 to 90 years age range.
D1 Flexion Pattern: Flexion, abduction, external 56.7% of the research sample was male, and the rest
rotation (opening and closing of the elbow) were female. The majority of participants (35%)
D1 Extension Pattern: Extension, adduction, internal were unemployed. The majority (40%) had
rotation (opening and closing of the elbow) elementary education. 80% of the participants in the
D2 Flexion Pattern: Flexion, adduction, internal intervention group and 70% in the control group
rotation (opening and closing of the elbow) were residents of urban, and the rest were residents
D2 Extension Pattern: Extension, abduction, external of villages. 30% of the intervention group and 23.3%
rotation (opening and closing of the elbow) of the control group were single. 70% of the
2. Lower Limb Joint Patterns (Subsequent intervention group and 76.7% of the control group
Movements): were married or divorced. In both groups, 55% of the
D1 Flexion Pattern: Flexion, abduction, external samples had a positive family history of stroke.
rotation (knee open and closed) 61.7% of the samples had a stroke in the right
D1 Extension Pattern: Extension, adduction, internal hemisphere and 38.3% in the left hemisphere. 61.7%
rotation (knee open and closed) had left-sided body paralysis, and 38.3% had right-
D2 Flexion Pattern: Flexion, adduction, internal sided paralysis.
rotation (knee open and closed) There was no statistically significant difference in
D2 Extension Pattern: Extension, abduction, external muscle strength between the research samples
rotation (knee open and closed) before and immediately after the intervention.
The researcher initially positioned the participant in However, one month after the intervention, a
a balanced posture; in this position, the muscles were statistically significant difference was reported
stretched as much as possible. The exercises were between the two groups (Table 1).
performed in a way that initially involved a non- The difference in the mean muscle strength was
active or active stretch applied for 10 to 20 seconds, significant in the test group (p=0.001; Table 2).
and the targeted muscle or muscles were gradually
Table 1. Comparison (Mann-Whitney U) of muscle strength mean
moved to the end of the range of motion. This position scores before and after intervention in test and control groups
was maintained for moments. In the second stage, a Parameter Experimental group Control group p-Value
contraction against the therapist's resistance was Muscle grade
performed immediately or after a rest of about 2 to 3 Before 1.0±9.7 2.0±2.1 0.2
After 2.0±8.7 2.0±4.8 0.1
seconds. This contraction can be isometric or static, One month after 3.0±3.8 2.1±4.0 0.001
or with less probability; it may be shortening and Percentage of Normalcy
concentric. The duration of this contraction was 3 to Before 12.0±28.3 13.0±31.4 0.4
6 seconds. In this stage, the target muscle was gently After 19.0±45.0 37.1±5.3 0.1
One month after 59.2±5.2 37.2±8.4 0.001
relaxed through the "autogenic inhibition" or Scale
"reversed tension reflex" mechanism and was Before 2.0±1.4 2.0±2.6 0.5
prepared for further stretching. In the third stage, the After 2.0±7.6 2.0±4.6 0.5
target muscle or muscles were stretched again to One month after 3.0±4.7 2.0±6.8 0.001

Journal of Clinical Care and Skills Fall 2023, Volume 4, Issue 4

Effect of Proprioceptive Neuromuscular Facilitation Exercises on Muscle Strength in Stroke Patients 210
Table 2. Comparing (Wilcoxon test) differences in muscle strength before and after the intervention in the experimental and control group
Parameter T3-T2 T3-T1 T2-T1
p-Value Difference p-Value Difference p-Value Difference
Experimental
Muscle grade 0.001 0.5 0.001 1.4 0.001 0.9
Percentage of Normalcy 0.001 14.5 0.001 31.5 0.001 17
Scale 0.001 0.7 0.001 1.3 0.001 0.6
Control
Muscle grade 0.999 0 0.2 0.2 0.05 0.2
Percentage of Normalcy 0.9 0.3 0.06 6.8 0.007 6.5
Scale 0.2 0.2 0.05 0.4 0.1 0.2

Discussion alterations in the connection between motor neurons

Stroke is a common neurological disorder that can lead to increased coordination and recruitment of
significantly impact the quality of life of affected motor units, enhancing force production and stable
individuals due to functional impairments. This study force application. The result is an improvement in
investigated the effect of neuromuscular facilitation muscle strength [26]. Therefore, stretching exercises
exercises on stroke patients' muscle strength. can improve stroke patients' muscle weakness,
The results indicated no statistically significant walking ability, and overall performance [27].
difference in muscle strength (muscle grade, This study also has limitations, such as not examining
percentage of normalcy, and muscle scale) among the long-term sustainability of the exercise effects. It
stroke patients before the intervention. Furthermore, would be beneficial to address this aspect in future
findings revealed no statistically significant research endeavors. One of the strengths of this
differences immediately after the intervention in the research is its effort to propose an empowering
muscle strength parameters based on manual solution for stroke patients to control and manage
measurements. It is possible that excessive fatigue the symptoms of the disease. As improving muscle
immediately after exercise and quick muscle strength and daily life activities is a primary goal in
assessment without sufficient rest opportunities controlling stroke, it is recommended that healthcare
could contribute to this observation. However, a professionals, especially nurses, focus on various
statistically significant difference was observed approaches, including neuromuscular facilitation
between the two groups one month after the exercises, in the care and management of physical
intervention. This implies that muscle strength in all issues in stroke patients. Since these exercises are
three parameters showed an increasing trend in the non-invasive, cost-effective, and free of side effects,
intervention group one month after the intervention, nurses can take effective steps by performing and
suggesting a potential rehabilitation effect. Tonak et teaching these techniques to stroke patients,
al. have demonstrated that Proprioceptive enhancing their overall health. Thus, the results of
Neuromuscular Facilitation increases muscle this study can be employed as a complementary and
strength in the arm and forearm in studied samples. non-pharmacological intervention in the
Chaturvedi & Tyagi's study also emphasized the rehabilitation or disability management process for
improvement in the condition of stroke patients after stroke patients.
performing PNF exercises [19].
Additionally, the current study's findings align with Conclusion
the results of other research studies. For instance, Neuromuscular facilitation exercises improve stroke
improvement in muscle strength, flexibility, and patients' muscle strength. Based on these results,
balance, as observed in the study by Rhyu et al. [20]. enhancing muscle strength in the daily activities of
Similar improvements in hamstring flexibility stroke patients leads to overall improvement.
compared to static stretching with moist heat were
reported in the research conducted by Meena and
Acknowledgments: The authors express gratitude to
colleagues [21]. Furthermore, Rezasoltani et al. [22] patients, their families, nurses, and everyone who
demonstrated increased muscle strength and collaborated to conduct this study.
reduced pain. Wang et al. also indicated a decrease in Ethical Permissions: This study was approved by the
the average muscle tone and stiffness in the lower Ethics Committee of the Yasuj University of Medical
limbs of chronic stroke patients, although this change Sciences (IR.YUUMS.REC.1395.9). It was also registered on
was deemed insignificant [23]. Oliveira et al. also the Clinical Trials website (IRCT2016043027676N1).
suggest a positive impact of PNF on muscle activity in Conflicts of Interests: There are no conflicts of interest.
patients with hemiplegia after a stroke [24]. Authors' Contribution: Najafi Dolatabad S (First Author),
Introduction Writer/Main
Exercise can enhance brain function and reduce
Researcher/Methodologist/Discussion Writer (32%);
nerve damage. Additionally, it can modify the Afrasyabifar A (Second Author), Assistant
excitability of neurons and neurotrophic factors in Researcher/Methodologist/Statistical Analysis (20%);
neural networks after a stroke, consequently Afroughi S (Third Author), Research
influencing neural plasticity [25]. On the other hand, Assistant/Methodologist/Statistical Analysis (16%);

Journal of Clinical Care and Skills Fall 2023, Volume 4, Issue 4

211 Najafi Doulatabad et al.
Parandvar Y (Fourth Author), Assistant proprioceptive neuromuscular facilitation on balance,
Researcher/Methodologist/Introduction Writer/ strength, and mobility of an older adult with chronic stroke:
Discussion Writer (32%) A case report. J Bodyw Mov Ther. 2017;21(4):767-74.
Funding/Support: This study has been extracted from a 14- Majhi, M, Mondal S. Effect of proprioceptive
master's thesis in nursing. All expenses related to this neuromuscular facilitation stretching on physical fitness: A
research have been provided by the University of Medical critical analysis. GSC Adv Res Rev. 2021;6(1):71-5.
Sciences in Yasuj, Iran. 15- Mazlom SR, Bahrami M, Hasanzadeh F, Gh& Ehari K.
Effect of mirror therapy on walking ability in patients with
stroke. J Birjand Univ Med Sci. 2015;22:134-44. [Persian]
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