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Table of Contents    
Year : 2017  |  Volume : 65  |  Issue : 1  |  Page : 183-184

Trunk proprioceptive neuromuscular facilitation influences pulmonary function and respiratory muscle strength in a patient with pontine bleed

Department of Physiotherapy, School of Allied Health Sciences, Manipal Hospital, Bengaluru, Karnataka, India

Date of Web Publication12-Jan-2017

Correspondence Address:
Suruliraj Karthikbabu
Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Bengaluru - 560 017, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.198193

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How to cite this article:
Dubey L, Karthikbabu S. Trunk proprioceptive neuromuscular facilitation influences pulmonary function and respiratory muscle strength in a patient with pontine bleed. Neurol India 2017;65:183-4

How to cite this URL:
Dubey L, Karthikbabu S. Trunk proprioceptive neuromuscular facilitation influences pulmonary function and respiratory muscle strength in a patient with pontine bleed. Neurol India [serial online] 2017 [cited 2020 Aug 7];65:183-4. Available from:


A 38-year-old female patient presented with progressive headache and vomiting following a pontine bleed. She was admitted to the intensive care unit owing to raised intracranial pressure (ICP) of 38 mmHg with a communicating hydrocephalus. The patient was managed by an external ventricular cerebrospinal fluid (CSF) drainage. She complained of double vision with gaze-induced nystagmus, facial sensory loss, and muscle weakness on the right side. She had breathing difficulty during speaking in a semi-reclined position. Her pulmonary function test (PFT) suggested an impaired respiratory function with reduced forced expiratory volume 1 (FEV1, 37% predicted value) and forced vital capacity (FVC, 32% predicted value). The FEV1 and FVC ratio of 1.61 suggested a restrictive pulmonary dysfunction. On respiratory muscle strength examination,[1] there was a reduction in the maximum inspiratory pressure (MIP) to 8.6 cm H2O and maximum expiratory pressure (MEP) to 11.3 cm H2O. The involvement of extrapyramidal connections to the cortex was demonstrated as truncal ataxia and hypotonia. The strength of shoulder and hip muscles was 3+/5 on Medical Research Council grading. She required a constant supervision while she was in a balanced standing position. The scores of 12/28 on the Tinetti balance assessment and 49/100 on the modified Barthel's index indicated the presence of a greater risk of falling and severe functional dependency.

The proprioceptive neuromuscular facilitation (PNF) techniques such as chop and lift trunk patterns were administered along with the standard physical therapy and breathing control training. Lift and chop are the bilateral asymmetrical flexion and extension patterns of upper extremities with trunk extension and flexion, respectively [Figure 1]. During lift and chop trunk patterns in the sitting position, inhalation and exhalation were stressed. These exercises were practiced 10 times per se ssion, twice a day for 4 weeks in addition to gaze stability and balance exercise. Following 4 weeks of exercise training, the values of MIP and MEP increased to 31.33 and 13.33 cmH2O, respectively. In addition, there was an improvement in the FEV1:FVC (forced vital capacity) ratio (0.77), FEV1 (69% predicted value), and FVC (79% predicted value). The balance ability and daily functioning showed an improvement, as measured by the Tinetti balance assessment (21/28) and modified Barthel index (82/100).
Figure 1: Chop and lift trunk patterns

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Stroke affects the respiratory function due to a change in breathing pattern, impaired respiratory muscle activity, and decreased ventilatory capacity. Corticobulbar pathways in the pontine area, medullary centers, and deep nuclei of cerebellum have modulatory effects on the respiratory responses. Pontine bleed not only disrupts the automatic respiration (metabolic) but also effects the voluntary respiration (behavioral).[2] Unilateral lesions of the corticobulbospinal and corticospinal connections results in paralysis of hemi-diaphragm and internal intercostal muscles allowing asymmetrical involvement of the respiratory system and a poor voluntary ventilation. In addition, the inactive oblique abdominal muscles places the thoracic cage into an elevated position, thus resulting in an insufficiency of the diaphragmatic activity; reduced FEV1, FVC, FEV1:FVC ratio, MIP, and MEP.[3]

The chop and lift trunk patterns might have enhanced the neurophysiological drive to the intercostal, diaphragmatic, and abdominal muscles, that may have resulted in more movement awareness and thoracic wall compliance.[4] The stretch on the respiratory muscles also resulted in greater force generation because the zone of apposition in the diaphragm was efficiently oriented. The probable reason for the improvement in the balance and daily activities could be due to the spatiotemporal recruitment of trunk muscles influencing the distal mobility of the lower extremities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

American Thoracic Society/European Respiratory Society. ATS/ERS statement on respiratory muscle training. Am J Respir Crit Care Med 2002;166:531-3.  Back to cited text no. 1
Lanini B, Bianchi R, Romagnoli I, Coli C, Binazzi B, Gigliotti F, et al. Chest wall kinematics in patients with hemiplegia. Am J Respir Crit Care Med 2003;168:109-13.  Back to cited text no. 2
Teixeira-Salmela LF, Parreira VF, Britto RR, Brant TC, Inacio EP. Respiratory pressures and thoraco-abdominal motion in community dwelling chronic stroke survivor. Arch Phys Med Rehabil 2005;86:1974-8.  Back to cited text no. 3
Voight ML, Hoogenboom BJ, Cook G. The chop and lift reconsidered: Integrating neuromuscular principles into orthopedic and sports rehabilitation. J Sports Phys Ther 2008;3:151-9.  Back to cited text no. 4


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