{'fraction_non_alphanumeric': 0.030077691453940066, 'fraction_numerical': 0.020754716981132074, 'mean_word_length': 4.76888604353393, 'pattern_counts': {'":': 0, '<': 8, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Article J Effects of Proprioceptive Neuromuscular Facilitation and Treadmill Training on the Balance and Walking Ability of Stroke

Korea Purpose: The purpose of this study was to investigate the effects of combined training using proprioceptive neuromuscular facilitation (PNF) patterns and treadmills on the balance and walking ability of stroke patients. Methods: Twenty-three stroke patients were randomized into a control group (n=11), receiving only treadmill training and an experimental group (n=12) receiving combined training. The use of both PNF exercise and treadmill were implemented in the combined training. Interventions were performed 5 times a week for 6 weeks. Balance ability was measured by a timed up and go (TUG) test. Walking ability was measured by a 10-meter walk test (10MWT) and a 6-minute walk test (6MWT). A paired t-test was used to compare differences between pre- and post-intervention and independent t-tests were used to compare between groups. Results: Changes in TUG, 10MWT, and 6MWT before and after interventions were significantly different for both the experimental group and the control group (p<0.05). In addition, within-group changes in the TUG, 10MWT, and 6MWT were more effective in the experimental group than in the control group (p<0.05). Conclusion: Combined training using PNF techniques and treadmills may be useful in improving the balance and walking ability of stroke


INTRODUCTION
Stroke is a high incidence neurological disorder caused by an interruption of blood flow in the brain. 1 Depending on the degree of the injury and the area of the brain affected, a stroke can affect consciousness, sensory perception, language, cognitive skills, or motor skills. 2 In addition, abnormal patterns coordinating muscle tone, muscle timing, and movement resulting from a stroke can affect a person's balance and walking ability. 3 Losing one's mobility is the greatest loss for stroke patients. 4 Recovering the ability to walk is an important rehabilitation goal 5 and is one of the greatest concerns for the patient, family, and therapist. 6 However, most stroke patients have a slower gait cycle because of the difficulty in moving their affected extremity 7 and thus, find it chal-lenging to maintain balance when walking due to their asymmetric step and shorter stride. 8 Balance is the ability to maintain one's center of gravity within the base of support and to control proper body positioning by responding to various external environments. 9 The ability to maintain one's balance while walking is another important rehabilitation goal. 10 Balance ability can be divided into static balance, which allows a steady stand on a fixed support surface, and dynamic balance, which can be sustained when there is external stimulation and agitation of the support surface. Dynamic balance is an essential factor in walking. 11 PNF is a technique that improves movement function by stimu-control and gait pattern. Wang 20 showed that PNF pelvic exercises resulted in changes in walking speed and rate in stroke patients.
Trueblood et al. 21 applied the PNF pelvic exercise to examine the effect of pelvic movement on the walking ability of stroke patients.
Kim et al. 22 when applying PNF pelvic and lower extremity exercises, showed a change in the balance ability of stroke patients.
The use of a treadmill is more effective than ground gait training.
It reduces rigidity and improves the walking ability of stroke patients by enabling symmetrical walking while in a weight bearing state. 23 A treadmill also constantly stimulates the calf muscles, which helps to improve balance and walking ability. 24 Based on the central pattern generator theory, a treadmill activates afferent inputs by spinal level neurons and serves as a walking control for limb movement, weight shift, and posture alignment. 25 The pelvis and scapula are key points for the control of gait pattern. 19 Previous studies have been applied only to the pelvis 20,21,26 or patterns of coordinated exercises involving the upper and lower extremities. 27,28 The purpose of this study was to investigate the effect of the combination of PNF and treadmill training on the balance and walking ability of stroke patients.

Study design
This study was a single-blind randomized clinical trial that included 23 patients with hemiplegia due to stroke. The patients were randomly assigned to a treadmill training group (n =11) and a combined training group (n =12).
Timed up-and-go test (TUG) time, 10-m walk test (10MWT) score, and 6-minute walk test (6MWT) score were identified as the primary outcomes.

Subjects
This study was conducted on 23 patients at hospital D in city J for 6 weeks in January and February 2017. The subjects were inpatients aged 55 to 65 years, who had been diagnosed with hemiplegia due to stroke within the last 1 to 2 years. Inclusion criteria were: being able to independently walk 10 m, obtaining a score of 24 or greater on the mini mental state examination-Korea (MMSE-K) in order to be able to understand and follow the researcher's instructions, and signing a consent form indicating that they fully understood the goals and procedures of this study. They were randomized into a control group (n =11), receiving only treadmill training, and an experimental group (n =12), receiving combined training (Table 1).

1) TUG
TUG is a simple test that can quickly measure mobility and balance with an intra-rater and inter-rater reliability correlation coefficient of r= 0.98-0.99. Beginning with a 'start' command, TUG measured the time that the subject took to rise from a 46-cm height armchair, walk 3 m, turn around as fast as possible in the direction of the affected side, walk back to the chair, and sit down. 29

2) 10MWT
The 10MWT is a measure of one's walking ability with an intra-rater and inter-rater reliability correlation coefficient of r= 0.95-0.96. 30 Beginning with a 'start' command, the 10MWT measured the time required for the subject to walk 10 m on a course that was a total distance of 14 m. Tape, at 2 m and 12 m, indicated the start and end of the 10-m walking distance. The first and last 2 m of the course were used for acceleration and deceleration and were not timed. 31

3) 6MWT
The 6MWT measures walking endurance 32 with an intra-rater and

Training program
In this study, the 40-minute training programs for both groups oc-

Data analysis
Statistical analyses were performed using the SPSS/PC for Windows version 18. The Shapiro-Wilk test was used to check the normal distribution of the data. The paired t-test was performed to compare differences in balance ability and walking ability within groups before and after interventions. The independent t-test was performed in order to compare the differences between the experimental and control groups. The level of significance was set at α= 0.05.

Comparison of TUG changes
Within-group changes in the TUG test were significantly different, in both the experimental group (p < 0.05) and the control group (p < 0.05)( Table 2), with the experimental group showing greater improvement than the control group (p < 0.05)( Table 3).

Comparison of 10MWT changes
Within-group changes in the 10MWT were significantly different, in both the experimental group (p < 0.05) and the control group (p < 0.05)( Table 2), with the experimental group showing greater improvement than the control group (p < 0.05)( Table 3).

DISCUSSION
In this study, 23 patients with hemiplegia due to stroke were randomly sorted into a treadmill training group (n =11) and a com- In this study, we used TUG, 10MWT, and 6MWT, all with high intra-rater reliability, to evaluate the balance and walking ability of hemiplegic patients due to stroke. 29,30,33 The findings of this study may be helpful in predicting the stroke patients' balance and walking abilities and their eventual return to independence. In this study, the TUG test was used to evaluate the dynamic and static bal- tients. These studies wish to suggest a more positive outcome using these PNF patterns, compared to the present study by more closely approximating the gait pattern. However, Bobath 19 suggested that development of normal trunk control ability is essential and that interventions to stabilize the trunk, reducing muscle atrophy, and allowing for free limb movement, should precede additional interventions such as the scapular and pelvic PNF patterns.
In this study, both the combined and treadmill training groups showed improvement in balance and walking ability. The symmetrical reciprocal combined scapular and pelvic PNF patterns reestablished motor control for the gait pattern. Treadmill exercises with increased trunk stability may have had a positive impact on balance and walking ability.
This study was effective in improving balance and walking ability by applying PNF exercises and treadmill training programs to hemiplegic stoke patients, therefore, we consider this combined program to be useful for these patients.