448 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No.

A Study to Evaluate the Effect of Proprioceptive

Neuromuscular Facilitation Stretching on Balance and Gait in
Spastic Diplegic Cerebral Palsy: An Interventional Study

Mansi Dabhi1, Shweta Rakholiya2

1
MPT Neuromuscular Science, School of Physiotherapy, RK University, Rajkot, 2Assistance Professor, School of
Physiotherapy, RK University, Rajkot

Abstract
Background: Cerebral Palsy is a static, non-progressive disorder that results from brain insult or injury
during any of the prenatal, perinatal and postnatal stages. Proprioceptive neuromuscular facilitation
integration pattern stimulates the proprioceptors with in the muscle and tendon to enhance the performance,
flexibility and balance. It is generally effective in maintaining the reaction of exercise unit by increasing the
co-ordination which react to the stimulation in muscular strength and flexibility. AIM: To evaluate the effect
of Proprioceptive neuromuscular facilitation Stretching on balance and gait in spastic diplegic cerebral palsy.

Method: Total 30 Spastic diplegic cerebral palsy subjects were assessed as per Selection criteria of the
study. Consent form taken from children’s parents. They were randomly divided into group-A (n=15) and
group-B (n=15). spastic diplegic cerebral palsy were assessed for baseline outcome measures Pediatric berg
balance, WeeFIM scale ,10 Meter walk test on day 1 and after 4 week.

Group-A was given conventional treatment and Propioceptive neuromuscular facilitation stretching which
include hold -relax and contract- relax for 6-second hold and 10 repetitions for 5 days/week for 4 weeks.

Group-B was given conventional treatment. Statistical analysis was done using SPSS Software.

Conclusion: Neuromuscular facilitation stretching along with conventional therapy is more effective to
improve the balance and gait in spastic diplegic cerebral palsy.

Keywords: spastic diplegic cerebral palsy. Proprioceptive neuromuscular facilitation technique, Gait,
Balance

Introduction difficulties are caused because of problems in the brain.1

Cerebral palsy is a well-recognized neurodevelopment
“Cerebral” refers to the brain, and “Palsy” refers
condition beginning in early childhood and persisting
to muscle weakness/poor control. Cerebral palsy (CP)
through the lifespan.2
is a term used to describe a problem with posture and
movement that makes certain activities difficult. Someone These disorders are attributed to nonprogressive
who has cerebral palsy has problems moving his or her disturbances that occurred in the developing infant
muscles; this is not because of muscles or nerves, these brain or fetal. The motor disorders of CP are often
accompanied by disturbances of perception, sensation,
cognition, communication, and behavior, by epilepsy
Corresponding Author:
and by secondary musculoskeletal problems.3
Dr. Shweta Rakholiya,
Assistant professor, School of Physiotherapy, The spastic CP type is described by exaggerated
RK University, Rajkot. (M): 9724779333 deep tendon reflexes, increased muscle tone, muscle
Mail ID: shweta.rakholiya@rku.ac.in weakness, and gait affection. Nearly 70–77% of CP
 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 449

cases were spastic CP.4 Spastic diplegia (SD) is a motor Selection Criteria:
impairment in the upper extremities as well as the lower
Inclusion Criteria:
extremities. The constrained capacity to generate force
result in activity limitation more than the spasticity did.6 · Children diagnosed as Spastic Diplegic cerebral
palsy.
In spastic diplegic children, abnormal gait patterns
can result from disturbance of balance, muscle weakness, · Age bsetween 5-12 years and both gender.
spasticity and skeletal deformities.7,8
· Gross motor function level I and II.
These patterns are characterized by lack of mobility
in the lumbar spine, pelvis and hip joints and show · Written consent from their parents.
asymmetric pelvic motion during walking. A lot of the
· Spasticity range between 1 and 1+ grade
ambulatory children with spastic diplegia were able to
according Modified Ashworth scale.
attain a walk in the form of a crouch gait with flexed
hips, knees and ankles.9 · Able to follow simple verbal instructions.

The overall pooled prevalence of cerebral palsy Exclusion Criteria:

per 1000 children surveyed was 2.95 (95% CI 2.03–
3.88). Sub-group analysis for rural, urban and mixed · Uncooperative subjects.
rural-urban study population demonstrated the pooled · Uncontrolled epilepsy.
prevalence as 1.83 (95% CI 0.41–3.25), 2.29 (95% CI
1.43–3.16) and 4.37 (95% CI 2.24–6.51) respectively.10 · Receiving botulinum toxin injections or surgery
no earlier than 6 months before project start.
Proprioceptive neuromuscular facilitation
integration pattern stimulates the proprioceptors with · Presence of shortening or deformities of the
in the muscle and tendon to enhance the performance, ankle, knee and/or hip joints that prevented the children
flexibility and balance. It is generally effective in from keeping their feet on the ground.
maintaining the reaction of exercise unit by increasing
Procedure:
the co-ordination which react to the stimulation in
muscular strength and flexibility. The proposal is approved by Ethical clearance for
the study was obtained from the Ethics Committee,
The facilitated progression due to PNF procedures
School of Physiotherapy, RK University and CTRI
follows a hierarchical process from mobility to stability
(Clinical trial registry – India).
then controlled mobility to skillful movement. Studies
have stated that PNF stretching is effective in improving Written consent was taken from subjects’ parents
muscle strength, flexibility, posture coordination and who fulfilled selection criteria and were willing to
gait. participate in the study.

Method On the first visit, spastic diplegic cerebral palsy

was assessed for baseline outcome measure WeeFIM,
· Study Design: interventional Study
Pediatric berg balance and 10 meter walk test.
· Study Setting: Morbi City
Group A (n=15): conventional Physiotherapy and
· Sampling Technique: Purposive Sampling Proprioceptive neuromuscular facilitation stretching
which include hold -relax and contract- relax for
· Study Population: Spastic diplegic cerebral
6-second hold and 10 repetitions and 2 minutes rest in
palsy
between, for 5 days/week for 4 weeks.
· Sample Size: 30 Subjects
Group B (n=15): conventional Physiotherapy.
· Study Duration: 6 months
 450 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7

Result following statistical tests:

Data Analysis: For, Pediatric Balance Scale and WeeFIM:

Descriptive statistics were used to describe sample Intra Group: Wilcoxon signed-rank Test
characteristics. The significance level selected was 0.05.
Inter Group: Mann-Whitney U Test
Statistical Analysis:
For, 10MWT:
All the statistical analysis was done by statistical
package for the social science (SPSS) Statistical Intra Group: Paired T Test
software version 21.0 for windows. The pre and post
Inter Group: Un-paired T Test
value were collected from both the group before and
after intervention. Statistics was performed by using the

TABLE 1: GROUP A INTRAGROUP ANALYSIS

MEAN SD
OUTCOME T/Z Value P Value
Pre Post Pre Post

PBS 29.80 32.20 1.69 1.82 Z Value=3.456 0.001

WeeFIM 77.46 79.20 2.89 3.028 Z Value=3.341 0.001

10MWT 0.498 0.433 0.0013 0.015 T Value=5.727 0.000

The mean average for PBS improved from 29.80(pre) to 32.20(post). Similarly, for WeeFIM the mean average
improved from 77.46(pre) to 79.20(post) and for 10MWT mean average improved from 0.498(pre) to 0.433(post).
As per data reflects that P value is lesser than 0.05 which shows significant difference in PBS, WeeFIM and 10MWT
IN Group A.

TABLE 2: GROUP B INTER GROUP ANALYSIS

MEAN SD
OUTCOME T/Z Value P Value
Pre Post Pre Post

PBS 30.53 30.60 2.29 2.38 Z Value=0.332 0.739

WeeFIM 80.40 80.20 1.88 1.52 Z Value=0.690 0.590

10MWT 0.049 0.059 0.049 0.052 T Value=0.332 0.924

The mean average for PBS from 30.53(pre) to 30.60(post) was not significantly improved. Similarly, for
WeeFIM the mean average was not improved from 80.40(pre) to 80.20(post) and for 10MWT mean average from
0.049(pre) to 0.059(post) was not significantly improved. As per data reflects that P value is more than 0.05 which
shows significantly not improved in PBS, WeeFIM and 10MWT.
 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 451

TABLE 3: INTRA GROUP ANALYSIS

MEAN SD
OUTCOME Z Value P Value
Group A Group B Group A Group B

PBS 4.66 0.66 1.496 0.798 4.546 0.000

WeeFIM 5.26 0.200 2.016 1.146 3.3451 0.000

10MWT 0.052 0.050 0.0065 0.0045 4.253 0.001

The mean average for PBS is 4.66(post) and joints, and turn human movements into patterns for
0.66(post) respectively for group A and B. similarly for various uses such as exercise intervention. Improvement
WeeFIM the mean 5.26(post) and 0.200(post) for group of balance ability might have resulted from facilitation
A and B. and the mean average for 10MWT is 0.52(post) of proprioceptive sense, leading to change in various
and 0.050(post) respectively for group A and B. As per supports leads to increase in stability of joints.
data reflects that P value is lesser than 0.05 which shows
PNF have various exercises aim to improve stability
significant difference between both groups.
and mobility components, once the desired stability
components are achieved it mobility component further
Discussion
helps to improve function.
The results of the present study showed that
conventional physical therapy and Propioceptive Logeshwari Selvaraj [2018] conducted study
neuromuscular facilitation stretching is more effective to in which Proprioceptive Neuromuscular facilitation
improve Gait, Balance and Functional independence in technique on trunk were Trunk exercise and PNF
spastic diplegic cerebral palsy. Thus, the null hypothesis techniques was perfume on spastic hemiplegic cerebral
is rejected. palsy and concluded that the PNF technique exercises
improved significantly better performance in their
The probable mechanism by which PNF could have activities of daily living.
worked is by facilitating the neuromuscular mechanism,
by stimulating the proprioceptors. Chandan Kumar [2016] conducted study on
Comparison between Task - Oriented Training and
PNF increases the ROM by increasing the length Proprioceptive Neuromuscular Facilitation Exercises on
of muscle and the neuromuscular efficiency. The Lower Extremity Function in Cerebral Palsy. Concluded
physiological mechanism for increasing the ROM and that both Task-Oriented Approach and Proprioceptive
strength may be due to autogenic inhibition, reciprocal Neuromuscular Facilitation Exercises are beneficial in
inhibition, and stress relaxation so, it helps to lengthening improving lower extremity function in children with
the contracted structures, relax the hypertonic muscles, cerebral palsy.
initiating the movements, strengthening the weak
muscles and improving the control of the pelvis. Further recommendation:

The reason for better balance and lower extremity · Study can be done with other type of PNF
function in PNF group may be due to the way it utilizes technique
the different proprioceptive information for stimulating
· Study can be done on other type of cerebral
nerve and muscles function by utilizing distinct helical
palsy or on other type of neurological conditions like
form pattern which is based on functional components
stroke.
to aid reaction of motor system located in muscles and
 452 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7

Conclusion Dec;8(1):41.

This study concluded that proprioceptive 8. Tang-Wai R, Webster RI, Shevell MI. A Clinical
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Conflict of Interest: Nil Incidence. :7.Journal of phydiatic Sci.2009 (11)25-
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