stroke is a neurological disease caused by the cutoff of normal blood supply due to vessel 
 rupture or thrombosis , and it causes brain tissue damage .
motor , sense , recognition , 
 language , and perception deficits are typical symptoms of the disease , depending on the 
 affected areas , size , and the cause of damage1 .
stroke patients mainly experience motor disorders and degeneration 
 of balancing ability due to unbalanced posture ; this is caused by asymmetric arrangement and 
 hemiplegia , and this disrupts independent activities of daily living ( adl)2 . the ability to balance is an individual s ability to maintain the center of gravity within 
 a base region , keeping the body in a balanced state3 .
stroke patients lack balancing ability and show degeneration of 
 physical function due to a reduction in walking and activity caused by an inappropriate 
 posture , proprioception malfunction , and abnormal muscle tension4 . to resolve balance problems caused by stroke , the 
 brunnstrom approach , bobath approach , or proprioceptive neuromuscular facilitation ( pnf ) is 
 used ; such methods focus on enhancing physical functions and balance by improving active 
 motor control5 .
pnf utilizes a typical helical or diagonal pattern to stimulate proprioceptive sensation 
 promote a nerve root response , enhancing functional movement5 , 6 .
it improves muscle 
 strength , flexibility , and balance ; by applying it on the non - paretic side , force is 
 transferred to the paretic side , effectively promoting muscle activity6 .
davis7 suggested aquatic pnf lower 
 extremity patterns for reinforcing muscular strength and enhancing muscle reeducation .
song 
 and kim8 applied aquatic pnf lower 
 extremity patterns to patients who had a stroke , which stimulated proprioceptors , thus 
 improving control and function of the nerve roots while enhancing balance . in an aquatic environment
, the buoyancy allows limbs to be moved more easily with little 
 strength , enhancing coordination of motion9 .
water resistance also enables the body to move , helping increase 
 muscle strength , joint movement , and balance10 .
multiple studies had reported pnf lower extremity patterns during 
 ground - based exercise for stroke patients , but few had reported aquatic pnf .
this study aimed to investigate the effects of aquatic pnf lower extremity patterns on 
 balance and adl of stroke patients .
six months after receiving a stroke diagnosis via either computed tomography or magnetic 
 resonance imaging , 20 patients were randomly assigned to a control group ( n = 10 ; 5 males 
 and 5 females ) or an experimental group ( n = 10 ; 5 males and 5 females ) ; the control group 
 was assigned to conduct pnf lower extremity patterns on the ground , and the experimental 
 group was assigned to conduct pnf lower extremity patterns in water .
all participants scored 
 > 24 points on the mini - mental status examination ( mmse ) , could perform assignments , were 
 capable of walking 10  m independently , and were classified as > 4 on the brunnstrom scale . 

the 
 protocol was approved by the institutional review board of nambu university and was 
 conducted in accordance with the ethical standards of the declaration of helsinki .
the 
 general features of the participants are listed in table 1table 1.general characteristics of subjectseg ( n=10)cg ( n=10)gender ( male / female)5 / 55 / 5age ( years)69.1  3.268.0  3.1height ( cm)167.6  8.2165.9  6.9weight ( kg)67.9  5.966.7  6.7paretic side ( right / left)5 / 55 / 5onset ( months)9.8  1.310.3  1.4meansd , eg : experimental group , cg : control group .
the age of the experimental group was 69.1  3.2  years , height was 167.6  
 8.2  cm , weight was 67.9  5.9  kg , and time since stroke onset was 9.8  1.3 months .
the age 
 of the control group was 68.0  3.1  years , height was 165.9  6.9  cm , weight was 66.7  
 6.7  kg , and time since stroke onset was 10.3  1.4 months .
meansd , eg : experimental group , cg : control group the experimental group conducted pnf lower extremity patterns using the rhythmic initiation 
 ( ri ) method 110  cm below the water surface ; the water temperature was 3133  c .
exercises 
 were performed in a supine posture after simple stretching ; subjects wore a body ring 
 between l5 and s1 and a neck collar .
the control group conducted pnf 
 lower extremity patterns on the ground in a supine posture after simple stretching .
the ri 
 method starts from passive exercise , proceeds to active resistance exercise , and helps 
 increase coordination , motor sensation , and balance . the pnf lower extremity patterns 
 consisted of patterns d1 and d2 .
the d1 pattern ends at 
 either flexion - adduction - external rotation knee flexion or extension - adduction external 
 rotation knee extension .
the d2 pattern ends at either flexion - adduction external 
 rotation knee flexion or extension - adduction - external rotation knee extension .
pnf lower 
 extremity patterns were conducted 30 minutes / day , 5 days / week for 6 weeks .
balance was measured with the berg balance scale ( bbs ) , timed up and go test ( tugt ) , 
 functional reach test ( frt ) , and one leg stand test ( olst ) .
the bbs consists of 14 items and 
 can be categorized into sitting , standing , and postural changes .
scores in each category 
 range from 04 , with 56 possible total points ; higher scores indicate better balance .
the 
 tugt measures the time required to stand up from a chair and shuttle back and forth between 
 the chair and a spot in front of the subject three times .
the frt measures the distance one 
 can reach with an arm from a standing posture .
the olst measures how long one can stand on 
 one foot with the eyes open without placing the other foot on the ground .
adl were measured with the functional independence measure ( fim ) , which consists of 13 
 items related to mobility and 5 related to recognition .
the items were scored on a scale of 
 17 with 126 possible total points ; higher scores indicate better independence .
data were analyzed using spss 12.0 ( spss , chicago , il , usa ) for windows .
descriptive 
 statistics were used for the general features of the participants . a paired t - test was used 
 to determine pre- and post - experiment differences , and an independent t - test was used to 
 determine between - group differences .
the changes in the result of the bbs , tug , frt , olst , and fim are listed in table 2table 2.comparison of the results of the bbs , tug , frt , olst , and fim between the 
 experimental and control groupsgroupprepostd - valuebbseg42.8  1.644.9  1.7 * 2.1  1.7*cg39.9  2.040.6  1.7 * 0.7  0.8tugteg21.9  1.320.1  1.9*1.8  1.3*cg20.4  1.019.7  1.0*0.7  0.6frteg17.7  0.919.0  1.4 * 1.3  0.9*cg16.7  0.617.2  0.4 * 0.5  0.6olsteg4.3  0.85.7  1.1 * 1.4  0.9*cg3.4  0.54.1  0.7 * 0.6  0.7fimeg82.3  2.587.5  3.7 * 5.2  5.3*cg80.1  1.281.4  1.4 * 1.3  1.3meansd , * p<0.05 , d - value : difference value , eg : experimental group , 
 cg : control group , bbs : berg balance scale , tugt : timed up and go test , frt : 
 functional reach test , olst : one leg stand test , fim : functional independence 
 measure .
the experimental and control groups showed significant differences for all 
 pre- and post - experiment variables ( p < 0.05 ) . in the between - group comparison ,
the 
 experimental group was significantly different from the control group ( p < 0.05 ) .
meansd , * p<0.05 , d - value : difference value , eg : experimental group , 
 cg : control group , bbs : berg balance scale , tugt : timed up and go test , frt : 
 functional reach test , olst : one leg stand test , fim : functional independence 
 measure
the purpose of this study was to investigate the effects of aquatic pnf lower extremity 
 patterns on balance and adl of stroke patients .
the experimental group showed a significant 
 improvement in balance and adl after the aquatic pnf ( p < 0.05 ) and had significantly 
 better balance and adl relative to the control group ( p < 0.05 ) .
for example , performance of 10 weeks of aquatic proprioception exercise by 
 seniors enhanced their motor abilities11 . 

in addition , kim and lee12 pnf reported 
 that aquatic lower extremity patterns enhanced balance in healthy adults .
moreover , song and 
 kim8 reported that aquatic pnf 
 effectively affected the balance of stroke patients .
these results indicate that aquatic pnf 
 lower extremity patterns help enhance the balance of stroke patients .
pnf , used as a gradual 
 resistance exercise that employs a helical pattern , maximizes motor unit recruitment through 
 proprioceptive stimulation5 , 13 .
aquatic pnf promotes the maximum usage of muscle fibers 
 due to the intense circumstances caused by buoyancy and turbulence ; moreover , the water acts 
 as a form of resistance , stimulating proprioception and thus helping to improve postural 
 control and balance8 , 13 , 14 .
the most common method for examining the adl of stroke patients is to use the fim . in the 
 present study ,
the experimental group showed significant enhancement of adl after the 
 aquatic pnf ( p < 0.05 ) .
suomi and collier15 reported that the adl of arthritis patients were enhanced after 
 conducting aquatic exercise , and sato et al.16 reported that the adl of abnormal adults were enhanced after 
 conducting water exercise .
similar to other studies , enhancement of adl was observed after 
 conducting aquatic exercise in the present study .
the enhancement of adl was the result of 
 enabling movement with even a small amount of force .
this was due to the assistance of the 
 water buoyancy and decreased gravity , reducing the burden on muscles and joints10 , 15 . to promote functional recovery , the paretic side was spontaneously 
 enabled , thus enhancing the adl and improving functional independence15 , 16 .
the movements 
 also stimulate shortened muscles , promoting a training effect and enhancing adl17 .
a limitation of this study was that it utilized a small number of participants , and it was 
 not confirmed that the positive effects persisted .
future research should address these 
 things when investigating the effect of aquatic pnf lower extremity patterns in stroke 
 patients .
 [ purpose ] this study investigated the effect of aquatic proprioceptive neuromuscular 
 facilitation ( pnf ) patterns in the lower extremity on balance and activities of daily 
 living ( adl ) in stroke patients . [ subjects ] twenty poststroke participants were randomly 
 assigned to an experimental group ( n = 10 ) or a control group ( n = 10 ) . 
 the experimental 
 group performed lower extremity patterns in an aquatic environment , and the control group 
 performed lower extremity patterns on the ground . 
 both exercises were conducted for 30 
 minutes / day , 5 days / week for 6 weeks . 
 balance was measured with the berg balance scale 
 ( bbs ) , timed up and go test ( tugt ) , functional reach test ( frt ) , and one leg stand test 
 ( olst ) . 
 activities of daily living were measured with the functional independence measure 
 ( fim ) . 
 a paired t - test was used to measure pre- and post - experiment differences , and an 
 independent t - test was used to measure between - group differences . 
 [ results ] the 
 experimental and control groups showed significant differences for all pre- and 
 post - experiment variables . in the between - group comparison , the experimental group was 
 significantly difference from the control group . [ conclusion ] these results indicate that 
 performing aquatic proprioceptive neuromuscular facilitation patterns in the lower 
 extremity enhances balance and adl in stroke patients . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION