Proprioceptive neuromuscular facilitation to improve motor outcomes in older adults with chronic stroke

Patient’s information

The study included 4 new cases of older adults (mean age - 64.75 years) with chronic stroke (>6 months post-stroke) receiving therapy from an outpatient clinic in an urban, metropolitan setting from September 2016 to May 2017. We also present the findings from another participant (labelled XXX in this paper) which was published as a case report6 to relate the changes noted in the 4 new cases. All patients were medically stable and referred to physical therapy. Patients had varying severity, chronicity, and presentations of stroke and were at risk for falls (Table 1). Patients were deemed to have a high risk for falls due to older age, history of stroke, poor mobility and physical inactivity, presence of chronic medical conditions such as diabetes or osteoarthritis, or risk for falls based on their baseline balance assessments. Figure 1 shows the general study timeline.

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Figure 1

General time line of intervention of 4 cases that received proprioceptive neuromuscular facilitation.

Case 1

A 65-year-old male who sustained a left sided stroke 18 years ago resulting in right hemiparesis. He began consistent therapy only one year before the current study due to financial constraints. His prior therapy consisted of weekly one hour sessions of task-oriented strengthening, balance, and gait training. He joined regular therapist-led weekly group exercises at the same clinic.

Case 2

A 62-year-old male who sustained his second right-sided stroke a year prior to participating in the study. The first stroke occurred 10 years earlier. He received prior therapy focusing on balance and functional ambulation using a quad cane, however, he did not use the cane outside of therapy. He primarily used a wheelchair propelled by his caregiver inside the house and in the community. He was able to stand from his wheelchair with close guarding to walk with a cane for about 10 steps before reporting fatigue and fear of falling.

Case 3

A 63-year-old female with a left-sided stroke 9 months prior to the start of the study. She received outpatient therapy a month prior to the current study. She walked with a quad cane with close guarding at home and contact guarding in the community. Although she performed basic activities of daily living by herself, she had multiple instances of near falls at home and in the community while standing or walking.

Case 4

A 69-year-old female with a left-sided stroke 9 years prior to the current study. She reported multiple instances of falls at home during walking and activities of daily living. She received therapy prior to the study and was ambulatory at home and used a wheelchair for community ambulation. She had impaired balance, lower extremity strength, decreased ankle range of motion, decreased gait speed, and had low self-efficacy in walking and performing tasks without assistance.

Clinical findings

All of the 4 new cases received treatment based on a similar framework published in an earlier study6 following the principles of proprioceptive neuromuscular facilitation and modern principles of neuroplasticity.5 Motor outcomes were assessed at baseline and after 18 intervention sessions by a trained independent assessor using standardized assessment tools as reported in a previously published case report.6 Lower extremity strength was measured using the Upright Motor Control Test (UMCT) and the Five Time Sit-to-Stand Test (FTSST), balance confidence was measured using the Activities-specific Balance Confidence scale (ABC), balance was measured using the Mini-Balance Evaluation Systems Test (Mini-BESTest) and Limits of Stability test (LOS) on the NeuroCom® Balance Master® (Natus, Pleasanton, CA, USA), and mobility was measured using the 10-meter walk test (10MWT). Pertinent clinical findings are presented in Table 1 and results of the pre-test are presented in Table 3.

Therapeutic intervention

Each case received 18 one-hour sessions (3 times a week for 6 weeks) of individualized treatment at an out-patient clinic from a licensed physical therapist who received specialized training in administering proprioceptive neuromuscular facilitation (Figure 1). Treatment were performed as described in Adler 2008.8 Interventions were based on the baseline assessment, and followed a similar intervention framework of a previously published study.6 Interventions are summarized in Table 2.

Resisted mat exercises included pelvic and lower extremity patterns, pelvic bridging, rolling, and sitting (Figure 2 a-b). Exercises were repeated 5-20 times up to tolerance, and modified based on response. Exercises difficulty was modified by changing the position, increasing intensity of the exercise, changing practice environments, or by changing amount of support. Manual resistance was applied during functional activities to facilitate performance.

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Figure 2

Proprioceptive neuromuscular facilitation mat exercises consisting of: A) lower extremity flexion-adduction with knee flexion and B) pelvic bridging with resistance

Hand placement, traction, approximation, and stretch to stimulate mechanoreceptors and guide movement were emphasized. Verbal and visual cues were given to facilitate correct movement. Proprioceptive neuromuscular facilitation techniques were used to elicit specific responses, and target specific goals (Table 2).

Gait training consisted of balance exercises in standing, resisted gait training, or walking in different directions. Balance exercises included stabilizing reversals with resistance at the pelvis or shoulders, and one-legged standing (Figure 3a-b). Difficulty was increased by changing amount of support or applying manual resistance on different areas while the patient holds the position. Resisted gait involved resistance at the anterior or posterior pelvis to facilitate forward or backward walking respectively (Figure 3c). Weight shifting was emphasized by asking the patient to hold the position for 5–6 seconds followed by instructions to exaggerate each step. Walking in different directions included forward, backward and sideward walking, and cross-over steps, and were progressed by increasing the duration or changing the environment (inside or outside the clinic).

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Figure 3

Proprioceptive neuromuscular facilitation gait exercises consisting of A) one leg stance with resistance B) stabilizing reversals and C) resisted backwards gait.

Although there were similar exercises such as lower extremity patterns and gait training, there were individualized differences in the plans of care of each case. For example, practicing stairs was emphasized if this was a therapy goal, or more exercises targeting impairments (pelvic and trunk weakness) or confidence were included if these were limiting movement more.

Follow-up and outcomes

All cases completed 18 sessions of intervention with no adverse outcomes. Each case showed varied degrees of change in their lower extremity strength, balance, confidence, and mobility. Significance of changes in outcomes were analysed descriptively using available minimal clinically important difference and minimal detectable change as described in a previous study.6 Summary of pretest and posttest results are found in Table 3.

Cases 2 and 3 showed a change of one level on their UMCT-extension scores. No change in the UMCT-flexion scores was seen in any of the cases. Cases 2, 3, and 4 also showed significant change in their FTSST scores. Case 4 no longer used her cane to stand from sitting at posttest. Case 1 showed no significant change in strength in both the UMCT and the FTSST. Improvements in lower extremity strength were consistent with improvements in Case XXX.

Cases 2, 3, and 4 showed significant changes on the Mini-BESTest. Case 2 showed improvement in the reactive balance components of the test, while case 3 showed improvement in the mobility components. All cases also showed varied positive changes in LOS (improved reaction time, end-point excursion, movement velocity, and directional control). Balance confidence for cases 3 and 4 increased, while there was a decrease in case 2. Despite variety in ABC scores, all cases reported general positive changes in functional status. Cases 2 and 4 still required a wheelchair when ambulating outdoors, but both were able to walk indoors with a cane and supervision. Case 3 no longer required supervision when walking both indoors and outdoors. Improvements in balance, specifically in reactive balance and LOS, were consistent with case XXX.

Lastly, cases 2 and 3 markedly improved in gait velocity. Case 2 showed improvement in both self-selected and fast velocity, while case 3 showed improvement in fast velocity. These changes in gait velocity are consistent with case XXX.