Journal of Bodywork & Movement Therapies xxx (2016) 1e8

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Journal of Bodywork & Movement Therapies

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Effects of proprioceptive neuromuscular facilitation on balance,

strength, and mobility of an older adult with chronic stroke: A case
report
Christopher S. Cayco a, Edward James R. Gorgon a, *, Rolando T. Lazaro b
a
Department of Physical Therapy, College of Allied Medical Professions, University of the Philippines Manila, Pedro Gil Street, Malate, Manila 1004,
Philippines
b
Department of Physical Therapy, Samuel Merritt University, 450 30th Street 3726, Oakland, CA 94609, USA

a r t i c l e i n f o a b s t r a c t

Article history: This study described the effects of a proprioceptive neuromuscular facilitation (PNF) program on balance,
Received 4 July 2016 strength, and mobility in an older adult with chronic stroke. The patient was male, aged 69 years, with
Received in revised form right hemiplegia for 17 years, and had diminished balance, balance confidence, lower extremity (LE)
13 October 2016
strength, and gait velocity. He received 1 h of PNF-based therapy thrice a week for six weeks. Outcome
Accepted 23 October 2016
measures were: Mini-BESTest, limits of stability (LOS), Activities-Specific Balance Confidence Scale (ABC),
Five Time Sit-to-Stand Test (FTSST), Upright Motor Control Test (UMCT), and 10 Meter Walk Test
(10 MWT). The patient improved on the Mini-BESTest (25/28, from 21/28), FTSST (27.47 s, from 30.27 s),
UMCT knee extension (moderate, from weak), and 10 MWT (0.82 m/s, from 0.67 m/s); and positive
changes in LOS dimensions. PNF was effective in enhancing balance, strength, and mobility in an older
adult with chronic stroke and may mitigate falls risk in this population. More research is needed to
determine its impact in a larger sample of older people with chronic stroke.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction increased physical activity have been found to be effective in

Falls are a common and serious problem in adults with stroke or
cerebrovascular accident (CVA) and who belong in the older age
groups (Weerdesteyn et al., 2008). Post-stroke falls are usually
caused by residual impairments including balance and gait deficits,
impaired sensory processing and decreased strength (Weerdesteyn
et al., 2008). Balance and mobility deficits may persist years beyond
discharge from inpatient rehabilitation (Lim et al., 2012) and ac-
count for high incidences of falls in chronic stroke (>6 months)
(Harris et al., 2005). In people with chronic stroke, approximately
70% of fall incidents occur at home (Schmid et al., 2013) while
39e90% have been reported during walking (Weerdesteyn et al.,
2008). Falls can lead to serious adverse outcomes including bone
fractures, decreased physical activity, social deprivation, re-
strictions in activities of daily living and greater mobility deficits
(Schmid et al., 2013; Weerdesteyn et al., 2008). Exercise and
* Corresponding author.
E-mail addresses: cscayco1@up.edu.ph (C.S. Cayco), ergorgon@up.edu.ph
(E.J.R. Gorgon), RLazaro@samuelmerritt.edu (R.T. Lazaro).
treating the impairments associated with an increased falls risk in
adults with stroke and the older population (Sherrington et al.,
2011).
Current evidence suggests that physical therapy (PT) is effective
in improving mobility and functional outcomes even late after the
onset of stroke (Ferrarello et al., 2011; Van Peppen et al., 2004).
Given the diversity of patient needs and post-stroke disability, no
single approach has been demonstrated to be superior in improving
outcomes (Jette et al., 2005; Pollock et al., 2014; Veerbeek et al.,
2014). Proprioceptive Neuromuscular Facilitation (PNF) is one
approach that has been used conventionally in post-stroke reha-
bilitation. PNF is a form of neuromuscular re-education involving
stimulation of the sensory receptors to provide information about
body position and movement in order to facilitate a desired motion
(Adler et al., 2008). Although originally underpinned by the reflex
theory (Jette et al., 2005), PNF techniques have since evolved to
incorporate contemporary principles of neuroplasticity. The phi-
losophies of PNF share related concepts with principles of neuro-
plasticity (Kleim and Jones, 2008) (see Fig. 1). Concepts such as use
of movement to promote improvement and avoid deterioration,
task specificity, relevance of the task to the patient, and high

http://dx.doi.org/10.1016/j.jbmt.2016.10.008
1360-8592/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Cayco, C.S., et al., Effects of proprioceptive neuromuscular facilitation on balance, strength, and mobility of an
older adult with chronic stroke: A case report, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.10.008
2 C.S. Cayco et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e8

Fig. 1. Similarities between the PNF philosophy and principles of neuroplasticity showing an overlap in concepts applied such as use of movement to prevent deterioration in
movement and improve movement; focus of therapy on the specific task to be improved; and sufficient repetition, intensity, and highlighting of salient features of activities and
exercises to elicit positive changes in movement.

repetitions and practice intensity to foster change in movement are
common to both PNF and neuroplasticity principles. The use of PNF
patterns and positions suggests a stronger sensory excitation at the
cortical level leading to increased number and improved threshold
of motor neurons (Westwater-Wood et al., 2010) which could result
in improved range of motion, strength and balance reactions. The
concept of irradiation, in which muscular activity spreads across
different muscle groups during certain patterns, can be used to
improve function, strength and motor learning (Adler et al., 2008).
Few studies have demonstrated how a PNF program might
improve multiple falls risk factors such as impaired balance, lower
extremity (LE) strength, and mobility in older adults with chronic
stroke. Generally positive treatment outcomes in chronic stroke
have been attributed to PNF such as improved gait (Akosile et al.,
2012; Kim et al., 2015a, 2015b; Ribeiro et al., 2013; Wang, 1994)
and balance (Kim et al., 2015a, 2015b; Seo et al., 2015; Seo and Kim,
2015). However, published studies have been limited in that: (1) the
focus of outcome measurement had been restricted to either bal-
ance or ambulation/gait only (Akosile et al., 2012; Kim et al., 2015a,
2015b; Ribeiro et al., 2013, 2014; Seo et al., 2015; Seo and Kim, 2015;
Wang, 1994); and/or (2) the interventions were carried out in non-
weight bearing positions or aquatic environments only and not
oriented to the demands of upright posture and walking during
which most falls have been reported to occur (Akosile et al., 2012;
Kim et al., 2015a, 2015b; Wang, 1994). This study therefore aimed to
describe the effects of a PNF program on the balance, strength, and
mobility of an older adult with chronic stroke.
2. Methods
The University of the Philippines Manila's Research Ethics Board
approved the study protocol. The participant was part of a larger
study that investigated the effects of PNF in improving selected
impairments and activity limitations in older people. The partici-
pant provided written informed consent.
2.1. Participant
The participant was recruited from a university-based pro-bono
outpatient PT clinic. He was selected using purposive sampling and
met the following inclusion criteria: aged 60 years or older; diag-
nosed with CVA of longer than six months duration; cleared by a
physician to undergo outpatient PT; co-morbidities controlled by
medication; had impaired balance and ambulation, whether or not
dependent on an assistive device; and able to follow simple com-
mands and instructions.
The participant was a 69-year-old male who sustained a left-
sided CVA 17 years ago resulting in right hemiplegia. He received
conventional PT comprising electrotherapy and therapeutic exer-
cises for one year immediately after the stroke. After the episode of
care, he was able to take steps without physical assistance but had
impaired balance and required supervision because his walking
was unsafe. He resumed outpatient PT one year ago when he joined
a stroke support group that facilitated his referral to PT for impaired
balance and restricted ambulation. Since then, he had been
receiving 1 h of outpatient PT consisting of task-oriented training
for only once a week because of financial constraints. His other
forms of physical activity included joining a student-led exercise
group once a week and going to the public pool with assistance
from another person.
During initial examination, he required supervision when
walking on both even and uneven surfaces, stairs, and crowded
areas. He had no known history of falls but he substantially limited
his activities and participation. He took maintenance medication
for hypertension and prevention of prostate enlargement, and
required the use of prescription eyewear. He had no other known
co-morbid conditions and had no significant problems related to
muscle tone or sensation. However, he walked with decreased foot
clearance on the hemiparetic side and limited trunk movement,
and compensated for short step length by shuffling his steps to
increase cadence. He was able to respond appropriately to

Please cite this article in press as: Cayco, C.S., et al., Effects of proprioceptive neuromuscular facilitation on balance, strength, and mobility of an
older adult with chronic stroke: A case report, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.10.008
 C.S. Cayco et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e8
multiple-step instructions.
The participant had impaired balance (see Table 1) and
increased risk of falling forward and left sideways (see Fig. 2A). He
also had diminished balance confidence, decreased functional
strength of the LE muscle groups, and slow gait speeds (see Table 1)
that further supported his substantial fall risk. The muscle groups
required for the stance phase of gait such as the knee extensors had
impaired strength and activation (see Table 1). The participant also
showed decreased trunk flexor and extensor strength when resis-
tance was applied posteriorly in both sitting and standing. Testing
of PNF pelvic patterns showed decreased passive and active motion
of the pelvis, and poor coordination of the LE with trunk and core
muscles. He exhibited gait deviations while walking: decreased
arm swing and trunk movement; decreased step length; wide base
of support; decreased hip, knee, and ankle movement during the
swing phase of gait; and hyperextension of the knee during the
stance phase of gait. The participant's poor balance appeared to be
caused by impaired strength and activation of the trunk, pelvis, and
LE muscles, and decreased balance confidence. The impairments in
trunk and pelvic muscle activation are important to address in PNF
as a stable trunk is necessary in improving control of the extrem-
ities (Adler et al., 2008). The participant's goal for PT was to improve
ambulation on both even and uneven surfaces, prevent falling, and
decrease the amount of supervision he needed from his caregiver.
2.2. Assessment
Examination and treatment sessions were conducted at the
same clinic. A trained independent assessor performed the baseline
and post-treatment assessments. The Mini-BESTest and Limits of
Stability (LOS) of the BASIC Balance Master® (Natus Medical Inc.,
Pleasanton, CA, USA) were used to measure changes in balance. The
Mini-BESTest is a 14-item clinical test with excellent validity and
reliability for community-dwelling adults with chronic stroke
(Tsang et al., 2013). The cut-off scores for fall-risk in patients with
stroke is 16.5 (Tsang et al., 2013) and normative value for healthy
adults from ages 60e69 is 24.7 (O'Hoski et al., 2014). The BASIC
Balance Master® LOS is a force plate system used to quantify re-
action time (RT), movement velocity (average speed of center of
gravity movement based on the middle 90% of the distance) (MVL),
endpoint excursion (percentage of distance achieved on initial
movement) (EPE), and directional control (movement based on a
straight line from the center of pressure to target) (DCL) (Pickerill
and Harter, 2011). It has acceptable validity and reliability for pa-
tients with mild stroke (Chien et al., 2007) and is an accurate pre-
dictor of falls in the older population. As an important determinant
of accidental falls in patients with chronic stroke (Pang et al., 2007),
Table 1
Pre-test, post-test and change scores on balance and balance confidence, lower extremity strength, and mobility assessments after 18 sessions of PNF-based PT.
Score on baseline Score on completion of PNF
examination program
Mini-BESTest 21/28 25/28
ABC, % 77.50 71.25
UMCT-F Strong Strong
UMCT-E Weak Moderate
FTSST, s 30.27 27.47
Self-selected gait velocity, 0.50 0.57
m/s
Fast gait velocity, m/s 0.67 0.82
ABC ¼ Activity-specific Balance Confidence scale; FTSST ¼ Five Time Sit-to-Stand Test; MCID ¼ minimal clinically important difference; MDC ¼ minimal detectable change;
UMCT-E ¼ Upright Motor Control Test e knee extension; UMCT-F ¼ Upright Motor Control Test e knee flexion.
Please cite this article in press as: Cayco, C.S., et al., Effects of proprioceptive neuromuscular facilitation on balance, strength, and mobility of an
older adult with chronic stroke: A case report, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.10.008
3
balance confidence was measured with the Activities-Specific Bal-
ance Confidence Scale (ABC). The ABC is a valid and reliable 16-item
self-report measure for patients with stroke (Botner et al., 2005),
with 0% representing no confidence and 100% representing com-
plete confidence. The questions were translated and modified to
match the setting's geographic and cultural differences (e.g. icy
sidewalks was translated to wet walking surfaces).
Changes in functional LE strength were documented using the
Five Time Sit-to-Stand Test (FTSST) and Upright Motor Control Test
(UMCT). The FTSST, a valid and reliable clinical test for adults with
stroke, determines general LE strength through the fastest time it
takes an individual to stand up consecutively for five times from a
seated position with the arms kept across the chest (Mong et al.,
2010). Sit-to-stand performance has been found to be related to
sensation, balance, and psychological status (Lord et al., 2002). The
knee flexion (UMCT-F) and extension (UMCT-E) components of the
UMCT were selected for the ability to represent total-limb control
(Perry et al., 1995). Because the test is administered in standing, the
UMCT considers problems arising from limb posture and patterns
of muscle coordination (Perry et al., 1995), and simulates the de-
mands of the stance and swing phases of gait (Ade et al., 2012).
Changes in UMCT grade indicate a change in the functional strength
of the hemiparetic LE (Ade et al., 2012).
Functional mobility, represented by self-selected and fast gait
velocities, was assessed using the 10 Meter Walk Test (10 MWT).
The 10 MWT is a valid and reliable clinical test for patients with
stroke (Mong et al., 2010; Tyson and Connell, 2009). The average of
three trials for self-selected gait velocity first, then for fast gait
velocity after, was taken. Gait velocity correlates with functional
ability and balance confidence, and predicts future health status,
risk for falls, and fear of falling (Fritz and Lusardi, 2009). Together,
UMCT and gait velocity scores are able to differentiate between
household and community ambulators in patients with chronic
stroke (Joa et al., 2015).
Results were analysed descriptively using available minimal
clinically important difference (MCID) and minimal detectable
change (MDC) of the outcomes. MCID is the minimal amount of
change that is meaningful to the patient (Kovacs et al., 2008). MDC
is the smallest amount of change that likely reflects true change
and helps clinicians determine whether the change score repre-
sents real and reliable change (Kovacs et al., 2008). Together, the
MCID and MDC may be used to interpret the clinical relevance of
the results (Kovacs et al., 2008). The following MCID and/or MCD
values were applied in this study: Mini-BESTest, MCID ¼ 4 points
(Godi et al., 2013), MDC ¼ 3.5 points (Godi et al., 2013); ABC,
MDC ¼ 13 points (Steffen and Seney, 2008); FTSST, MCID ¼ 2.3 s
(Meretta et al., 2006); self-selected gait velocity, MDC ¼ 0.18 m/s
Change score from baseline MCID/MDC
examination
4 MCID ¼ 4 (Godi et al., 2013)
MDC ¼ 3.5 (Godi et al., 2013)
6.25 MDC ¼ 13 (Steffen and Seney,
2008)
2.8 MCID ¼ 2.3 (Meretta et al., 2006)
0.07 MDC ¼ 0.18 (Hiengkaew et al.,
2012)
0.15 MDC ¼ 0.13 (Hiengkaew et al.,
2012)
4 C.S. Cayco et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e8

Fig. 2. LOS assessment using the Balance Master at pre-test (A) and post-test (B). Grey shaded areas represent performance range outside of normal; green bars indicate per-
formance within normal range; red bars indicate performance outside of normal range; numerical values are given at the top of each bar. After 18 sessions of PNF-based program,
reaction times, movement velocities, endpoint excursions, and directional control during movement improved. (For interpretation of the references to colour in this figure legend,
the reader is referred to the web version of this article.)

(Hiengkaew et al., 2012); and fast gait velocity, MDC ¼ 0.13 m/s
(Hiengkaew et al., 2012).
2.3. Intervention
The participant received one-on-one PNF-based therapy lasting
for 1 h, three times a week, for six weeks (18 treatment sessions).
Sessions were divided into resisted mat exercises and resisted
walking training (see Table 2). The treatment protocol was based on
the guiding principles of PNF: resistance, irradiation, manual con-
tact, body position, verbal commands, vision, traction or approxi-
mation, stretch, timing, and patterns (Adler et al., 2008). An expert
in the PNF approach affiliated with the Kaiser Permanente Medical
Center in California, USA, provided independent validation of the
treatment program contents. The first author who received specific
training in PNF from the Kaiser Permanente Medical Center

Please cite this article in press as: Cayco, C.S., et al., Effects of proprioceptive neuromuscular facilitation on balance, strength, and mobility of an
older adult with chronic stroke: A case report, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.10.008
 C.S. Cayco et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e8 5

Table 2
PNF-based exercises, rationale, and progression to improve balance, strength, and mobility of an older adult with chronic stroke.

Exercise Rationale Progression

Pelvic anterior elevation Improve pelvic motion during swing phase of gait; facilitate stepping and LE lifting motions RI to DR
Pelvic posterior depression Improve pelvic motion during terminal stance phase of gait; facilitate weight-bearing motions of LE RI to DR
LE flexion-adduction with Improve strength and activation of muscles groups required for swing phase of gait RI to DR
knee flexion
LE extension-abduction Improve strength and activation of muscles groups required for stance phase of gait; improve weight bearing RI to DR
with knee extension
Rolling from supine to side Strengthen trunk, neck, and hip muscles Start in side lying progressed
lying to start in supine
Pelvic bridging Promote weight bearing through feet without danger of falling; improve selective control of trunk flexors and Bridging on two legs to
LE muscles bridging on one leg
Stabilizing reversals in Improve control and strengthen trunk and LE muscle groups Increase in repetitions and
standing duration
One leg stance Promote weight bearing in stance and improve pelvic and hip motion in swing phase of gait Increase in repetitions and
duration
Resisted forward walking Promote forward weight shifting, hip hyperextension and lateral motions, knee stability, and ankle motions; Increase in repetitions and
improve trunk control; improve control of LE muscle groups required for swing phase of gait duration
Resisted backward walking Promote posterior weight shifting; improve trunk control and hip hyperextension in swing phase of gait Increase in repetitions and
duration
Braiding Train ability to maneuver narrow spaces; improve control of lateral muscles of trunk and LE Increase in repetitions and
duration

DR ¼ dynamic reversals; LE ¼ lower extremity; RI ¼ rhythmic initiation.

primarily administered the intervention (14 of 18 treatment ses-
sions). Due to a family crisis that required the first author to take a
leave of absence, another physical therapist who had been trained
by the first author in PNF treatments carried out four of the ses-
sions. The second physical therapist received sufficient orientation
regarding the participant's intervention program. All treatment
sessions were videotaped and reviewed as a way of ensuring that
each session was consistent with the planned intervention program
for the participant.
Resistance was adjusted depending on the participant's
response so that motion was smooth and coordinated (Adler et al.,
2008). Hand placement, traction, approximation, and stretch were
used to give information about the proper direction of movement
through stimulation of tactile and kinaesthetic receptors. Exercises
were repeated 10e20 times up to tolerance. As performance
improved, these procedures were progressed to increase the diffi-
culty of the exercises such as through increasing resistance and
changing the position. Treatment required no specialized equip-
ment and only rubber mats, a treatment table, and parallel bars
were needed.
Different PNF techniques were used in response to the partici-
pant's needs. Rhythmic initiation (movement of limb or body
through the desired range starting with passive motion and pro-
gressing to active resisted movement) was used to teach the
movements. Stabilizing reversals (alternating isotonic contractions
with enough resistance to prevent motion), dynamic reversals
(active motions changing from one direction to the opposite), and
combination of isotonics (combined concentric, eccentric and sta-
bilizing contractions of one muscle group) were used to improve
the strength and coordination of the movement (Adler et al., 2008).
Exercises included pelvic patterns, LE patterns, mat activities,
and sitting exercises. Exercises were performed as described by
Adler and associates (see Fig. 3). Pelvic motion and stability are
needed for proper trunk and LE function (Adler et al., 2008).
Because of decreased passive and active pelvic motion, anterior
pelvic elevation and posterior pelvic depression were included to
facilitate trunk and LE motion, activation, and stability (Adler et al.,
2008). LE flexion-adduction with knee flexion and extension-
abduction with knee extension patterns in both supine and side
lying were used to improve strength and coordination of the trunk
and muscle groups involved in the swing and stance phases of gait.
Bilateral LE patterns were done by the fourth week as a progression
to unilateral LE patterns by simultaneously facilitating movement
of both legs toward the same direction to place more demand on
the trunk (Adler et al., 2008). Mat activities included bridging and
rolling (see Fig. 3B and D). Bridging was initially done bilaterally in
order to improve stability of the body and challenge balance, co-
ordination, and strength (Adler et al., 2008). It was progressed later
to unilateral bridging. Rolling from supine to side lying and vice
versa was done to strengthen the trunk muscles and improve co-
ordination of the LE with the trunk. Rolling was progressed to
include dynamic reversals by the fourth week of the intervention.
Upright weight bearing and walking training activities were
done between parallel bars for safety and support (see Fig. 4).
Stabilizing reversals in sitting and standing were held for about 6 s
and repeated up to tolerance. One leg stance was initially held for
10 s and repeated until fatigue. Forward and backward walking
focused on facilitating exaggerated weight shifting onto one limb
followed by practicing the swing phase of the opposite limb.
Assistance was initially given to guide the movement of the pelvis
and was later changed to manual resistance as progression. The
movement was further exaggerated by instructing the participant
to take high steps during the swing phase. Braiding which consisted
of alternating tandem stance and side stepping was included to
improve lateral reactive stepping. Walking exercises were pro-
gressed by decreasing the amount of support and increasing the
amount of resistance until maximum resistance was tolerated
without holding on to parallel bars. Walking exercises were prac-
ticed until tolerance for up to 30 min each session. The participant
was encouraged to practice the exercises at home with supervision
by his caregiver as often as tolerated.
3. Results
The participant completed all 18 sessions. No adverse events
were documented during the entire episode of care. The participant
performed bilateral LE patterns, unilateral bridging, one leg stance,
resisted forward and backward walking, and braiding by the end of
the sixth week. All dimensions of the LOS improved, markedly in
the forward and left sideways directions relative to the low baseline
values (see Fig. 2B): RT was shorter in the forward and left sideways
directions; MVL became faster in all directions; EPE increased in the
forward, backward, and left sideways directions; and DCL improved
in all directions. Table 1 contains details of the participant's

Please cite this article in press as: Cayco, C.S., et al., Effects of proprioceptive neuromuscular facilitation on balance, strength, and mobility of an
older adult with chronic stroke: A case report, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.10.008
6 C.S. Cayco et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e8

Fig. 3. Examples of PNF mat-level exercises to improve trunk and lower extremity function: facilitation of anterior elevation of pelvis (A), unilateral pelvic bridging (B), facilitation of
lower extremity flexion-adduction with knee flexion (C), facilitating rolling using lower extremity patterns (D).

Fig. 4. Examples of PNF exercises to improve balance and walking: stabilizing reversals in sitting (A), stabilizing reversals in standing (B), holding one leg stance with resistance at
pelvis (C), forward walking with resistance at anterior pelvis (D).

Please cite this article in press as: Cayco, C.S., et al., Effects of proprioceptive neuromuscular facilitation on balance, strength, and mobility of an
older adult with chronic stroke: A case report, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.10.008
 C.S. Cayco et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e8
performance on the rest of the outcome measures. Cumulative
score on the Mini-BESTest increased significantly by 4 points, with
specific improvements in backward and lateral stepping reactions.
He demonstrated clinically meaningful change in LE strength with a
2.8-s difference on the FTSST, while knee extension strength spe-
cifically changed from weak to moderate on the UMCT-E. Clinically
meaningful change was observed in fast gait velocity at 0.15 m/s,
but not in self-selected gait velocity. Although there was a decrease
of 6.25 points on the ABC, the participant reported feeling an
overall improvement in his strength and movement. The partici-
pant's trunk and pelvis were also observed to activate in a more
coordinated manner during movement.
4. Discussion
Results of the study show that PNF improved balance, LE
strength, and gait velocity in an older adult with chronic stroke.
Findings are consistent with published literature which show im-
provements in functional ambulation, gait, and balance in patients
with stroke following exposure to PNF with weight bearing and
walking components (Akosile et al., 2012; Ribeiro et al., 2014; Seo
et al., 2015). The positive changes may be attributed to specific
principles used in developing the treatment program such as
specificity of training, salience, and increasing the intensity and
frequency of treatment compared to his prior therapy. These
principles of PNF show some similarities to the current theories of
stroke rehabilitation, neuroplasticity specifically (Kleim and Jones,
2008). PNF techniques have evolved as understanding of the
neurophysiological basis of movement also evolved. This is the first
report to the author's knowledge that attempts to connect PNF with
contemporary motor control concepts as a basis for changes after
rehabilitation. The intervention was based on the participant's
therapy goal and results of assessment (e.g. pelvic patterns were
used to address trunk activation; backward walking was used to
improve posterior weight shifting and ambulatory ability). The
frequency and intensity of exercises were safe and in line with
published recommendations (Lohse et al., 2014) to promote
changes in motor function post-stroke. The increased amount of
activity from the participant's usual once a week outpatient therapy
to thrice weekly may have played an important role in producing
gains from therapy. There is strong evidence of the positive rela-
tionship of dose and responses independent of post-stroke time
(Lohse et al., 2014). The participant was able to ambulate on uneven
surfaces with supervision immediately after the intervention
period. The participant's high motivation was important to his
successful adherence to the treatment.
The improvements in stepping reactions on the Mini-BESTest
and in all dimensions of the LOS suggest an improvement in bal-
ance. LOS in patients with stroke have been associated with sym-
metrical weight bearing which is important for balance control
(Kwon and Jeong, 2000). Asymmetrical load on a limb reduces the
likelihood that steps will be initiated with that limb (Lakhani et al.,
2011). We hypothesize that the increased symmetry in the partic-
ipant's weight bearing led to improved stepping reactions. The
emphasis on shifting weight onto one extremity during resisted
walking exercises may have contributed to improvements in LOS
and weight bearing symmetry. These improvements are important
because “compensatory” or reactive balance control is essential for
maintaining balance to prevent falling (Maki and McIlroy, 1997).
The participant did not have clinically significant improvements in
balance prior to enrolment in this study which suggests that PNF
and increased amount of therapy may have contributed to the
observed changes.
Scores on the FTSST and UMCT-E after the intervention also
suggest an improvement in LE strength which may have further
Please cite this article in press as: Cayco, C.S., et al., Effects of proprioceptive neuromuscular facilitation on balance, strength, and mobility of an
older adult with chronic stroke: A case report, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.10.008
7
contributed to the improvements in balance. Although the MCID for
the FTSST used in this study was based on people with vestibular
disorders (Meretta et al., 2006) due to the lack of available values
for people with stroke, the results still indicate improvement from
baseline. Interestingly, the participant also showed a significant
improvement in gait velocity which was not seen in the only pre-
vious study that implemented a similar PNF program comprising
both non-weight bearing and weight bearing components (Ribeiro
et al., 2014). This difference may be explained by the longer dura-
tion of each session and higher total number of sessions in the
present study.
The non-significant decrease in ABC score may suggest that PNF
did not benefit the participant's balance confidence. The exercises
focused more on physical function and lacked interventions spe-
cifically targeting self-efficacy in performing upright activities.
Additionally, the intervention protocol did not expose the partici-
pant to varying environmental factors outside of the clinical setting.
It would be difficult to ascertain the true extent of the influence of
the positive physical changes, as improvements in physical function
may not always be reflected in balance confidence (Liu-Ambrose
et al., 2004). Patient education and practice in varying environ-
mental contexts may be incorporated in the PNF intervention
protocol in the future in order to address balance confidence.
Positive changes were observed despite the participant being an
older adult with chronic stroke. PNF makes use of tactile and pro-
prioceptive input (Westwater-Wood et al., 2010), and verbal cues
and instruction to facilitate movement. The participant had intact
sensation and cognition, and no underlying conditions that could
limit his performance of the exercises. These factors enabled
adequate progression of exercise intensity and provision of chal-
lenging motor tasks to the participant. These are all vital compo-
nents of contemporary motor control approaches (Kleim and Jones,
2008). Future studies should endeavor to substantiate the benefits
of PNF using stronger research designs both in adults with stroke
and those with other neurological conditions. It would be inter-
esting as well to explore the effects of PNF on patients with
cognitive issues or more complex health problems interacting with
the stroke. Further, the intervention protocol, which was developed
and validated following the guiding principles of PNF, can be
potentially applied in a larger study. While some degree of indi-
vidualization may be necessary, such as in determining appropriate
intensity and repetition of each exercise component, the tech-
niques would still be aligned with the guiding principles of PNF and
therefore consistent with the treatment philosophy.
Findings of this study need to be considered with its limitations.
Given the study design, findings are not meant to be generalized to
all patients with chronic stroke but rather to form the basis for the
hypothesis that PNF may be effective for this population. The
participant had no obvious impairment in sensation and cognition,
and no significant co-morbid conditions that could interact with
stroke-related impairments, and this could further impact on the
study's generalizability. Also, this study did not document the
participant's physical activity outside of the intervention, including
adherence to exercise at home. Lack of follow-up outcome assess-
ment precluded description of retention of observed changes
following cessation of the intervention. Finally, as an intervention,
PNF requires specialized training to be effectively administered and
this might limit its applicability in routine clinical practice.
5. Conclusion
In conclusion, this study showed that PNF was safe and effective
in improving stepping reactions and LOS in an older adult with
chronic stroke with persisting balance impairment. Although no
improvement in balance confidence occurred concurrently,
8 C.S. Cayco et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e8
positive changes were demonstrated in the participant's functional
LE strength, trunk and pelvis activation, and gait velocity that were
important in alleviating risk of falling. The implications of using
PNF as part of a PT program targeting multiple modifiable di-
mensions of falls risk in older adults with chronic stroke warrant
further investigation.
Conflicts of interest
None declared.
Acknowledgements
The study was funded by the National Institutes of Health (NIH)
through a Student Researcher Grant 2014 (project number: NIH
2014-014) for Christopher Cayco. The funder had no role in study
design; data collection, analysis, and interpretation; manuscript
preparation and writing; and decision to submit the article for
publication. The authors thank Stephen Schmidt for the expert
advice in validating the PNF-based intervention; Adjannie Ishtar
Estuita for providing independent assessment; Charlemaine Deane
Perez for contributing as implementer of the intervention protocol;
and Alma Labro for the assistance in project management.
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