PNF in hemiplegic gait

[estherderu]

A lot of years ago(25 or so)

I was part of a practicle clinical study into the differences in effect of using NDT/Bobath or PNF with hemiplegic patients.
Nothing was ever published but I can tell you that:
1. Patients all preferred PNF because it made them work harder, the "therapists language" was easier to understand. By this I mean, the licht "stearing touch" or the percievable "push against".
2. patients percieved themselves as becoming stronger
3. they also liked the fact that they were working hard and not being "steared/pushed" around.

I often think we tend to forget the patient themselves in our pursuit of quality treatment.

Esther

[gcoe]

Hi Esther

This sounds like an interesting study. If your recall of the findings is right and the findings are sound then it provides some valuable insights into patients experiences

I agree that research can downplay patients experiences. We don’t ask our patients enough about their views on therapy. Incorporation of patient participation in planning, carrying out and reviewing research as consumers and the inclusion of well conducted qualitative research can make clinical research more thorough.

2. patients percieved themselves as becoming stronger

It doesn’t surprise me that patients perceive themselves as becoming stronger. Maybe they were becoming stronger! The Bobath approach doesn’t really address strengthening – in fact traditionally Bobath therapists are quite averse to strengthening and believe bad things come from such activity. In contrast PNF is primarily used in hemiplegia to strengthen. After much research and debate it appears that weakness is may well be the most important impairment in hemispheric stroke. So that is one up for techniques that employ strengthening. However does that mean PNF is the most effective form of strengthening? There is an absence of evidence here. In contrast there is a wealth of support for progressive resistance training and some evidence for FES and also for biofeedback (Ada, Dorsch, & Canning, 2006).

3. they also liked the fact that they were working hard and not being "steared/pushed" around.

This seems a really important psychological issue. Working hard may feel empowering and in my experience PNF oriented therapists tended to be less concerned with controlling functional movement but letting the patient practice this following performing PNF. In contrast the Bobath experience is of having one’s movement controlled in which only the therapist knows how to facilitate this. This shifts the locus of control off the patient and on to the all powerful therapist. Patients are not really permitted to experience practicing their own movement and learning to improve performance through the usual experiences such as self initiated repetition and learning from ones mistakes. This has always struck me as one of the more unfortunate aspects of the Bobath approach, and is contrary to good motor learning theory.

In the end we need to be aware of what are the most important outcomes for patients. This can be debated but a common desirable considered now is being able to walk at sufficient speed, endurance, and dexterity to safely and confidently walk in the community. Does PNF have any supporting evidence for this or any other walking outcome? I could only find one rather old study of rather dubious quality (Dickstein, Hocherman et al. 1986). The outcomes of that study showed no real superiority or inferiority of PNF to traditional approach and Bobath.

A number of more recent approaches appear to help (Dickstein 2008). However I think on the whole we need to be mindful that our effect on improving functional outcomes in stroke is quite modest. Finding treatments that are effective enough to improve participation in the community is proving to be difficult. Personally I don’t think the long term direction is going to be to clinging to past techniques based on simplistic models of movement science and lacking evidence of effectiveness.


Ada, L., Dorsch, S., & Canning, C. G. (2006). Strengthening interventions increase strength and improve activity after stroke: a systematic review. Aust J Physiother, 52(4), 241-248.
Dickstein, R. (2008). Review article: Rehabilitation of gait speed after stroke: A critical review of intervention approaches. Neurorehabilitation and Neural Repair, 22(6), 649-660.
Dickstein, R., Hocherman, S., Pillar, T., & Shaham, R. (1986). Stroke Rehabilitation: Three Exercise Therapy Approaches (Vol. 66, pp. 1233-1238).