Immediate Effect of chest proprioceptive neuromuscular facilitation (PNF) and chest wall joint mobilization on hemodynamic status of acute ischemic stroke patients in Intensive care unit (ICU): A comparative study.

Post stroke brain damage is the common cause of long-term dysfunction in stroke patients. In India the cumulative incidence of stroke ranged from 105 to 152/100,000 persons per year, and the crude prevalence of stroke ranged from 44.29 to 559/100,000 persons in different parts of the country during the past decade . To minimize dysfunction and optimize long-term function, various physiotherapeutic interventions are instituted in acute stage, which help in assisting the neurological, musculoskeletal and cardiorespiratory system.

In acute post injury stage, patients with severe neurological injury are usually intubated with tracheostomy tube, are on mechanical ventilation, given vasoactive support, sedated and is often paralyzed to prevent secondary brain damage due to improper amount of gas exchange. Respiratory complications are most common in neurological insult  like aspiration pneumonia, neurological pulmonary oedema, or as a result of mechanical ventilation and immobilization lead to complication like abnormal breathing pattern and restricted chest wall movement etc.

As respiratory system in stroke patients is affected by because of neurological insult. There is decrease in chest wall movement on paretic side of stroke patients .

There are various physiotherapeutic techniques to improve the respiratory function.  According to literature chest PNF and chest wall joint mobilization are techniques which change rate and depth of breathing and assist in improving muscle activity.

In PNF (Proprioceptive Neuromuscular Facilitation) muscle is stretched passively and constricted alternately. Respiratory neuromuscular facilitation is used to depict externally applied proprioceptive and tactile stimuli that produce reflex respiratory movement response. In healthy individuals, type I and type II fibers are equally numerous in diaphragm, but intercostal muscles have more prevalence of type II fibers. In chest PNF there are various faciliatory stimuli i.e., Intercostal stretch (IC), higher thoracic spine vertebral pressure, lower thoracic spine vertebral pressure, anterior stretch lift to posterior basal area, mild manual pressure, perioral pressure, and abdominal co-contraction are all facilitatory stimuli.

Out of all the facilitatory techniques Intercostal stretching in chest PNF aids in improvement of breathing patterns and respiratory muscle function. Intercostal stretch aid in improving chest wall elevation, chest expansion, and diaphragm excursion, which helps to increase intrathoracic lung volume and high flow rate percentage. Chest PNF can increase ventilation of patients in acute stage of stroke with decreased consciousness. It has been reported that there is an increase in minute ventilation and oxygen saturation after neurophysiological facilitation which is of clinical significance.

Joint mobilization is a manual therapy technique which is used to give passive movements to joint capsules and soft tissue to restore arthrokinematics of the joint. The sustained stretch mobilization is used to increase range of motion as it changes viscoelastic structures. Also, rib cage joint mobilization used clinically as it increases the inspiratory capacity by restoring chest wall movements. Thoracic spine joint mobilization can improve chest expansion , inspiratory muscle strength and pulmonary function.

Joint mobilization when applied to T6 and T12 vertebrae increases the lower trapezius strength due to articular reflexogenic effects. Thus, inspiratory muscle activity may be improved through articular reflexogenic effects of rib cage joint mobilization, increase rib cage flexibility, and increased respiratory muscle length.

Null hypothesis (H0):  There is no significant difference in the immediate effect on hemodynamic status between chest proprioceptive neuromuscular facilitation (PNF) and chest wall joint mobilization among ischemic stroke patients in the Intensive Care Unit (ICU).

Alternate hypothesis(H1): There is a significant difference in the immediate effect on hemodynamic status between chest proprioceptive neuromuscular facilitation (PNF) and chest wall joint mobilization among ischemic stroke patients in the Intensive Care Unit (ICU).