J. Phys. Ther. Sci.

24: 1243–1246, 2012

Impact of PNF-based Walking Exercise on a Ramp

on Gait Performance of Stroke Patients

KyoChul Seo, PhD, PT1), JeonHyeng Lee, PhD, PT2), SangYong Lee, PhD, PT3)
1) Department of Physical Therapy, College of Rehabilitation Science, Daegu University
2) Department of Physical Therapy, Daegu Health University: 7 Taejeon-dong Buk-gu Daegu city 720-
722, South Korea. TEL: +82 10-9468-9378, FAX: +82 53-320-1248. E-mail: coordi18@naver.com
3) Department of Physical Therapy, Youngdong University

Abstract. [Purpose] The present study examines how PNF-based walking exercise on a ramp affects gait perfor-
mance of stroke patients. [Methods] Forty stroke patients were randomly divided into an experiment group and a
control group. For the former group, patients went through a half-hour of training therapy and a half-hour of PNF-
based walking exercise on a ramp. For the latter group, patients went through 30 minutes of training therapy and a
half-hour of walking exercise on a ramp. All participants had five training sessions each week for four weeks. For
measurement, a GAITRite system was used to examine temporal parameters, spatial parameters, and functional
ambulation performance before and after the training. [Results] Regarding temporal parameters, step time, double
support, and stance phase decreased more significantly in the experiment group than in the control group after the
walking exercise on a ramp, while mean velocity increased significantly. In terms of spatial parameters, step length,
and heel-to-heel base of support increased significantly in the experiment group after the walking exercise, and
step-to-extremity ratio decreased significantly in the same group. Lastly, FAP rose more significantly in the experi-
ment group than in the control group following the walking exercise on a ramp. [Conclusion] The experiment results
showed that PNF-based walking exercise on a ramp is effective in enhancing gait performance. It is expected that the
same exercise can be applied to patients of other types of neurological disorders to improve their gait performances.
Key words: Strokes, Proprioceptive Neuromuscular Facilitation, Ramp gait
(This article was submitted Jul. 2, 2012, and was accepted Jul. 29, 2012)

INTRODUCTION Kim7) reported that walking speeds increased along with

Stroke patients’ gait requires high energy consumption
and physiological burden indexes, and due to changes in
movements coordinated among the head, trunk, and pelvis
and stability1), plantar pressure caused by weight shifts of
the paretic side increase in the lateral direction and decrease
in the anteroposterior direction, significantly affecting the
patients’ gait ability2). Therefore, gait ability is an important
part of rehabilitation in stroke patients. Indeed, in elderly
patients and hemiplegic patients, gait abilities become an
important rating scale to see individuals’ functional condi-
tions, and their disabilities are minimized through gait
training3).
Treatment programs for active recovery of stroke
patients’ functions considerably affect the improvement of
their gait functions. These programs include slope way gait
training. Slope ways are essential facilities used in place of
stairways for disabled persons, elderly persons, and pregnant
women who cannot use stairways, and they are in a trend
of being universalized4). Slope way gait training is also
provided as a program to prevent injuries by falls and as a
rehabilitation exercise program after injuries5). In studies of
slope way walking in normal adults, Yun et al.6) reported
that lower extremity muscle activity increased and, Yi and
treadmill slope angles. In a study on stroke patients, Hesse et
al.8) reported that strides and walking speeds increased along
with treadmill slope angles.
Methods of improving stroke patients’ gait function
include proprioceptive neuromuscular facilitation (PNF)9).
This method stimulates proprioceptive organs in muscles
and tendons to improve functions, increase muscle strength,
flexibility, and balance, and increase coordination10), and
thus this method is effective for training motor units to react
maximally11). Thus far in studies of PNF in hemiplegic
patients, PNF lower extremity patterns have been used
to show improvement in step lengths, walking time, and
walking speeds12–15).
The aim of the present study was intended to examine
the effects of slope way gait training applied with the PNF
technique, which is effective in reinforcing muscle strength
and retraining muscles necessary for independent gaits in
hemiplegic patients on gait ability in hemiplegic patients.
SUBJECTS AND METHODS
Subjects
This study was conducted in a hospital located in Daegu
1244 J. Phys. Ther. Sci. Vol. 24, No. 12, 2012
Metropolitan City, from January 1 to January 31, 2012. Forty
stroke patients who had been diagnosed with the disease
by computed tomography (CT) or magnetic resonance
imaging (MRI) at least six months previously were allocated
randomly and equally to an experimental group and a control
group. A sufficient explanation of this study was given to
them, and they consented to participate in the study.
Only those whose mini-mental state examination Korean
version (MMSE-K) scores were 24 or higher were selected,
in order to recruit those patients who were able to walk
independently, who did not need drug treatment to mitigate
spasticity, who were without flexion contracture of the hip
or knee joint, or lower-part flexion contracture of the ankle
joint, and who could understand and follow the researchers’
instructions. The general characteristics of both groups are
shown in Table 1.
Methods
The experiment group and control group went through
the walking exercise five times a week for four weeks. The
therapy room was kept soundproof, and the indoor temper-
ature was kept at 26±1 °C to maintain a stable condition
of paralysis. Participants of both groups had a 30-minute
walking training each day on a specially designed ramp that
was 10 m by 0.8 m and tilted 10°.
Prior to the walking exercise, participants in both
groups received a half-hour of general physical therapy that
consisted of a joint exercise, muscle strengthening exercise,
and a stretching exercise. Then the experiment group went
through a half-hour of PNF-based walking exercise on a
ramp conducted by a therapist in the therapy room.
The experimental group stood in front of a gait training
machine to receive knee joint flexion, hip joint flexion,
adduction, and external rotation training of the affected side
from the therapist as part of PNF gait pattern training. In
this case, the therapist held the leg above the ankle in the
experimental group with one hand and the anterior medial
region with the other hand. Then, the therapist issued an
oral instruction saying, “Raise your ankle and bend your
lower extremity over the diagonal line.” Throughout the
movement, the therapist continuously applied resistance
against the movement16). The patient performed a walking
exercise on the ramp in opposition to the therapist’s
pressure. Meanwhile, the control group performed half-hour
of walking exercise on the ramp without the PNF pattern.
To analyze temporal parameters, spatial parameters, and
functional ambulation performance (FAP) of the patients, a
GAITRite system (CIR Systems, Inc. Clifton, NJ, USA) was
used, an electronic walking plate (8.3 m by 0.89 m) that has
13,824 sensors (Φ 1 cm) ve
rtically installed at an interval of 1.27 cm to measure
components of a gait in an objective and reliable manner17).
A sufficient explanation was given to participants of both
groups, and the participant were given a 10-minute break
before measurement. The participants stood upright to
measure the length of the leg between the back of the major
trochanter and the outer ankle bone. To ensure accuracy, the
length was measured twice by different examiners, and the
Table 1. General characteristics of subjects
  EG (n=20) CG (n=20)
Sex (male/female) 10/10 10/10
Age (years) 61.5 ± 2.8 61.5 ± 3.2
Height (cm) 164.1 ± 2.1 165.8 ± 4.3
Weight (kg) 64.1 ± 3.2 65.8 ± 6.2
Paratic side (right/ left) 10/10 10/10
Onset duration (months) 5.1 ± 4.8 6.1 ± 4.3
Values are mean ± SD
average value was used for the GAITRite software. Partici-
pants were asked to walk at a comfortable and constant pace.
They started walking 3 m before the plate, following the
assessor’s oral instruction, walked over the walking plate,
and stopped 3 m after the plate. This was repeated three
times to calculate the average. To prevent accidents, one of
the assessors walked beside patients at a distance that did not
affect the patient’s walking.
For data analysis, SPSS Win 12.0 was used. T-test for
corresponding samples was conducted to compare temporal
and spatial parameters and the FAPs of the two groups before
and after the exercise. For comparative analysis between the
groups before and after the training, a t-test for independent
samples was also conducted. The significance level (α) was
set at 0.05.
RESULTS
Regarding the temporal parameters, both groups showed
a significant decrease in step time after the exercise (p<0.05).
Also a significant difference was observed between the two
groups after the exercise (p<0.05). Regarding double support
and the stance phase, only the experiment group showed a
significant decrease following the exercise (p<0.05). The
difference between the values of the two groups changed
significantly after the exercise (p<0.05). In terms of mean
velocity, only the experiment group showed a significant
increase (p<0.05), and the difference between the values
of the two groups changed significantly after the exercise
(p<0.05) (Table 2).
Meanwhile, regarding the spatial parameters, both groups
showed a significant increase in step length after the walking
exercise (p<0.05). Also, significant change was observed in
the difference of values between the two groups (p<0.05).
The heel-to-heel base of support and the step-to-extremity
ratio showed a significant decrease only in the experiment
group after the walking exercise (p<0.05), and the difference
between the values of the two groups showed a significant
change after the training (p<0.05). In terms of FAP, only
the experiment group showed a significant increase after the
training (p<0.05), and significant change was observed in
the difference between of the two groups (p<0.05) (Table 2).
DISCUSSION
The present study applied a PNF-based walking exercise

Table 2. Comparison of gait ability of experimental and control subjects
EG
Before therapy
Step time (sec) 1.3 ± 0.1
Temporal Double support (%) 18.2 ± 4.2
parameters Stance phase (%) 75.1 ± 5.4
Mean Velocity (sec) 0.4 ± 0.1
Step length (cm) 25.8 ± 2.0
Spatial
H-H BOS (%) 13.4 ± 2.2
parameters
S/E ratio (%) 0.5 ± 0.1
FAP (score) 66.1 ± 2.5
Mean ± SE, *Significant difference compared with before therapy at <0.05. a Significant difference in gains between the two group
at p<0.05. EG: Experimantal group; CG: Control group; H-H BOS: Heel-to-Heel Base of support. S/E ratio: Step/Extremity ratio.
FAP: Functional ambulation performance.
on a ramp for hemiplegia patients in two groups: an exper-
iment group and a control group. The experimented lasted
four weeks, and changes in the gait parameters between
before and after the walking exercise were observed.
Regarding the temporal parameters, patients in the
experiment group showed a significant decrease in step time,
double support, and stance phase compared with the control
group, and the mean velocity rose significantly following the
exercise. Regarding the spatial parameters, patients in the
experiment group showed a significant increase in step length
and step-to-extremity ratio after the walking exercise, while
the heel-to-heel base of support decreased significantly. It
is attributed to that the use of lower-limb pattern promoted
proprioceptive muscular nerves, which in turn, facilitated
walking on the ramp and led to active muscular contraction
of the lower limbs and the trunk. These enhanced temporal
and spatial gait parameters and the overall gait performance.
Holden et al.18) examined temporal and spatial parameters
of the gait in 61 patients with neurological disorders, and
reported a range of test-retest reliability between 0.95 and
0.97, and quite a high range of inter-subject correlation
reliability (between 0.98 and 1.00).
Yun and Kim19) showed in a study that walking on a ramp
decreased step length and widened step width in order to
elderly people to maintain balance. Wall et al.20) claimed
that in walking on an upward ramp, flexion of the hip and
knee joint increased during a transition period between the
last swing phase and the initial stance period. Also, walking
on a ramp led to an increased chest wall in the frontal plane
and cross section, and it also affected pace of walking21).
Sun et al.22) reported that walking on ramp leads to a slower
pace and a greater step width. Kim23) examined hemiplegia
patients and showed that walking exercise on a treadmill
slope enhanced FAP. Hesse et al.8) applied walking exercise
on a treadmill for stroke patients, and reported that the
exercise increased step width and velocity and mitigated
asymmetry in step width. These findings are in accordance
with the outcomes of this study.
Comparison of FAP between the two groups showed that
it changed more in the experiment group than in the control
group after the exercise. This suggests that even though the
1245
CG
After therapy Before therapy After therapty
1.0 ± 0.1*a 1.3 ± 0.1 1.2 ± 0.2*a
14.3 ± 3.7*a 18.6 ± 3.8 17.1 ± 3.5a
70.4 ± 3.0*a 74.5 ± 1.2 72.6 ± 2.1a
0.7 ± 0.2*a 0.5 ± 0.1 0.6 ± 0.1a
33.7 ± 5.7*a 26.1 ± 5.3 29.3 ± 3.7*a
10.3 ± 1.8*a 13.6 ± 2.6 12.3 ± 1.8a
0.6 ± 0.3*a 0.5 ± 0.2 0.5 ± 0.1a
74.7 ± 4.6*a 64.3 ± 3.2 69.6 ± 2.8a
participants’ FAP scores are lower than an ordinary level,
their gait performance improved in terms of temporal and
spatial parameters.
Nelson et al.24) proposed using FAP to evaluate a
person’s overall gait performance as well as its components.
Freedland et al.25) reported that there is a significant FAP gap
between ordinary people and Parkinson’s disease patients.
Gretz et al.26) conducted a study to show that FAP scores can
be used as a data to estimate gait performance of adults with
Down’s syndrome.
The present study showed that the PNF-based walking
exercise on a ramp enhanced gait performance of stroke
patients. Data on temporal parameters and spatial param-
eters and FAP score could be useful for doctors in validating
the effect of rehabilitation. Also, it could be used to estimate
functional performance and living quality of stroke patients
and provide objective data to evaluate training progress and
treatment results of patients with gait disorders.
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