Tahzeeb Mazhar  ( University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan. )
Ayesha Jamil  ( University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan. )
Faiza Sharif  ( University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan. )
Momna Asghar  ( University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan. )

The study was conducted at University of Lahore Teaching Hospital and Sir Ganga Ram Hospital, Lahore, using non-probability convenience sampling. Thirty-eight patients of Parkinson’s disease were allocated by randomisation into two groups. PNF Group (group A) performed proprioceptive neuromuscular facilitation incorporated with conservative treatment, while for the conventional therapy group (group B) only conservative treatment was followed. Berg Balance Scale, Freezing of Gait questionnaire, and Functional Independence measure were used as outcome measuring tool. Berg balance scale values were significantly improved in group A at 12th week as compared to group B. Freezing of gait and functional independence was more significantly reduced in group A at sixth and 12th week as compared to group B. Hence, it is concluded that Proprioceptive neuromuscular facilitation combined with routine treatment regime improves balance, gait, and function of Parkinson’s patients more effectively as compared with routine treatment protocol only.

 

Keywords: Balance, Functional Independence, Gait, Parkinson disease, Proprioceptive Neuromuscular Facilitation.

 

Trial registration: Trial protocol of this study is prospectively registered in US clinical trials registry (ID#NCT05154552).

 

DOI: 10.47391/JPMA.6710

 

Submission completion date: 25-06-2022

 

Acceptance date: 23-02-2023

 

Introduction

 

Parkinson’s disease (PD) is a deteriorating disease of the central nervous system (CNS). It is a complex neurodegenerative disorder which leads to a lot of impairments, like tremors, bradykinesia, rigidity, and postural imbalance, which causes the individual to lose their independence. To improve the activity level and quality of life of the patient, a complete therapeutic exercise programme is required along with comprehensive medical management.¹

According to a study conducted in Canada, it is generally accepted that Parkinson’s disease ranges from one to two per thousand individuals in the whole population and affects 1% of the population above 60 years of age.² In Pakistan, more males were affected by Parkinsonism and it is common in sixth and seventh decades of life.³

The clinical characteristics of Parkinson’s disease patients can be highly variable, due to which it can be divided in different subtypes which are: tremor dominant type, postural instability type and gait impairment type, or indeterminate.⁴ The important motor symptoms of Parkinson disease include tremors, bradykinesia, rigidity, postural problems, gait disturbances, micrographia, speech problems, and alteration of eye movements and blinking disturbances. Non-motor symptoms include hallucinations, hyposmia, depression, anxiety, dysphagia, sleep disturbances, and different problems in the sensory system.⁵

Proprioceptive neuromuscular facilitation (PNF) is an impressive approach for rehabilitation that is used nowadays. This study incorporated three PNF techniques including rhythmic initiation, slow reversal, and agonistic reversal. These PNF techniques will be applied along with the conventional therapeutic exercises to see its effectiveness on patient’s recovery and independence, so that PNF can be added to routine treatment protocol to enhance patient’s recovery based on the results of the current study.

 

Patients/Methods and Results

 

A single blinded randomised control trial was conducted in the department of physiotherapy at University of Lahore Teaching Hospital and Sir Ganga Ram Hospital, Lahore, Pakistan, from October 2021 to February 2022 using non-probability convenient sampling. All the ethics and rules were followed throughout the trial that were formulated by the ethical review board of The University of Lahore. The sample size was calculated as 38 (19 in each group), using FOGQ as outcome measure after adding 20% dropout.⁶

 

Inclusion and exclusion criteria: Thirty-eight Parkinson’s patients (Table 1) of  both genders aged between 60 and 85 years, diagnosed and referred by the neurologist were included in the study.⁸ All the patients were on a consistent drug programme for at least two weeks as per prescription.⁹

 

 

Patients who were between stage 1 and 3 of  Hoehn and Yahr staging system were included in the trial.¹⁰ Patients with cognitive deficits that showed scores of less than 26 on the Mini-Mental State examination and patients with moderate and severe depression with scores of less than 17 on the Beck Depression Inventory (BDI) scale⁹ were excluded from the study. Individuals suffering with diseases of CNS other than Parkinson’s disease, and patients who had undergone total hip replacement surgery were also excluded from the study.¹⁰

After signing consent forms, baseline assessments were performed on all the patients who fulfilled the eligibility criteria. Berg balance scale (BBS) was used to evaluate balancing capabilities of participants. Freezing of Gait Questionnaire (FOG-Q) was used for evaluation of gait. Functional independence measure (FIM) scale was used to evaluate functional status of participants.⁸ After baseline testing, participants were assigned randomly into PNF group/group A (routine physiotherapy and PNF) and conventional therapy group/group B (routine physiotherapy only). Outcome assessors were not aware of group assignment.

In the Experimental group, physiotherapy routine treatment regime along with PNF was performed. Conventional physiotherapy was in accordance with the European Physical therapy guidelines¹¹ for Parkinson’s disease. PNF based exercises included pelvic patterns (pelvic interior elevation and posterior depression), PNF lower extremity D1 Flexion and PNF lower extremity D1 extension. These patterns were performed unilaterally from first to third week and progressed to both limbs from fourth week onwards. Three techniques of PNF were performed, beginning with rhythmic initiation, at sixth week slow reversal technique and agonist reversal technique were performed and continued up to 12th week.¹² Routine physical therapy treatment protocol (45 minute) was given to control group/group B participants. The rehabilitation programme was performed for three days per week. Treatment protocol was performed for 12 weeks on alternate days (36 sessions).¹¹ Patients were re-evaluated on the outcome measuring scales at the end of sixth week (t1) and then after treatment i.e. after 12 weeks (t2). The screening, detailed neurological examination, assessments of outcome measures and intervention were performed by different researchers.

Data interpretation was done by using statistical package for social sciences version 24. After fulfilling the parametric assumptions (Kolmogorov-Smirnov), non-parametric tests were applied. Mann-Whitney U test was used to determine mean difference of variables between groups. Within group differences were measured with the help of Friedman test.

Parkinson’s patients improved significantly for balance (p value<0.001), freezing of gait (p value<0.001), and functional status (p value<0.001) within both the groups (Table 2). However, Berg balance scale values were significantly improved (P value<0.05) in group A undergoing PNF at 12th week as compared to group B without PNF (Table 3). Freezing of gait was more significantly reduced in group A at sixth and 12th week as compared to group B (P value<0.001) (Table 3). Also, Functional independence was more significantly improved (P value<0.001) in group A as compared to the other group at both sixth and 12th week (Table 3).

 

 

 

Conclusion

 

Proprioceptive neuromuscular facilitation incorporated with conventional physiotherapy is more effective in enhancing balancing capabilities (P value<0.05), freezing of gait (p value<0.001), and function (p value<0.001) in Parkinson’s disease patients as compared to conventional physical therapy alone.

 

Acknowledgments: We are grateful to the dean of University of Lahore (AHS department) Dr Ashfaq Ahmad and HOD, Dr Asadullah Arslan for their help and support. We also acknowledge the efforts of all the study participants.

 

Disclaimer: None.

 

Conflict of Interest: None.

 

Source of Funding: None.

 

References

 

1.      Mosley PE, Moodie R, Dissanayaka N. Caregiver burden in Parkinson disease: a critical review of recent literature. J Geriatr Psychiatry Neurol 2017; 30: 235-52.

2.      Postuma RB, Berg D. Prodromal Parkinson's disease: the decade past, the decade to come. Mov Disord 2019; 34: 665-75.

3.      Khealani B, Baig S. Clinical spectrum of Parkinson's disease from Pakistan. Singapore Med J 2006; 47: 1075-9.

4.      Ffytche DH, Creese B, Politis M, Chaudhuri KR, Weintraub D, Ballard C, et al. The psychosis spectrum in Parkinson disease. Nat Rev Neurol 2017; 13: 81-95.

5.      Horsager J, Andersen KB, Knudsen K, Skjærbæk C, Fedorova TD, Okkels N, et al. Brain-first versus body-first Parkinson’s disease: a multimodal imaging case-control study. Brain 2020; 143: 3077-88.

6.      Silva‐Batista C, de Lima‐Pardini AC, Nucci MP, Coelho DB, Batista A, Piemonte MEP, et al. A randomised, controlled trial of exercise for Pparkinsonian individuals with freezing of gait. Mov Disord 2020; 35: 1607-17.

7.      Asghar M, Fatima A, Warner S, Khan MHU, Ahmad A, Siddique K. Effectiveness of proprioceptive neuromuscular facilitation on balance in chronic stroke patients. Rawal Med J 2021; 46: 212-5.

8.      de Carvalho EL, Queiroz IP, Queiroz IP, de Souza Batista IM, dos Santos Maciel T, da Silva Arêas FZ. Effects of proprioceptive neuromuscular facilitation on the functional independence measure in patients with Parkinson’s disease. MTP & Rehab J 2015; 13: 299.

9.      Serrao M, Pierelli F, Sinibaldi E, Chini G, Castiglia SF, Priori M, et al. Progressive Modular Rebalancing System and Visual Cueing for Gait Rehabilitation in Parkinson's Disease: A Pilot, Randomised, Controlled Trial With Crossover. Front Neurol 2019; 10: 902.

10.    Modestino EJ, Reinhofer A, Blum K, Amenechi C, O’Toole P. Hoehn and Yahr staging of Parkinson’s disease in relation to neuropsychological measures. Front Biosci (Landmark Ed) 2018; 23: 1370-79.

11.    Serrao M, Chini G, Caramanico G, Bartolo M, Castiglia SF, Ranavolo A, et al. Prediction of Responsiveness of Gait Variables to Rehabilitation Training in Parkinson's Disease. Front Neurol 2019; 10: 826.

12.    Erra C, Mileti I, Germanotta M, Petracca M, Imbimbo I, De Biase A, et al. Immediate effects of rhythmic auditory stimulation on gait kinematics in Parkinson’s disease ON/OFF medication. Clin Neurophysiol 2019; 130: 1789-97.