Effects of proprioceptive neuromuscular facilitation on spine joint position sense in adolescent idiopathic scoliosis: A case report

Introduction. Adolescent idiopathic scoliosis (AIS), described as a complex three-dimensional spinal deformity, is thought to affect neurophysiological processes that result in a loss of proprioceptive input. The main purpose of this case study is to investigate the effect of Proprioceptive Neuromuscular Facilitation (PNF) on spine joint reposition (JR) sense in a 20-year-old with AIS. Methods/Case Description. The subject was a 20-year-old college student with moderate dextrothoracic and levolumbar scoliosis. She has structural scoliosis-related impaired posture, as evidenced by findings of impaired JR sensation in all directions, postural deviations, and patient-reported deformity perception using the Walter Reed Visual Assessment Scale. She was seen 4 times a week for 3 weeks. Results. The most recent radiographs analyzed by a radiologist revealed that the curvature of the thoracic spine had decreased from 38° to 32° and the curvature of the lumbar spine had decreased from 26° to 24°. There were also improvements noted in JR sensation, postural deviation, and deformity perception. Discussion. Incorporation of PNF in the patient’s plan of care may have positively contributed to improvement in JR sense of the spine, postural symmetry, and deformity perception. Future studies should examine the other components of proprioception, the effect of PNF in subjects with greater or more severe curvature, and information on joint position perception in healthy subjects.


Introduction
Adolescent idiopathic scoliosis (AIS), defined as a complex threedimensional (3D) spinal deformity (Tambe et al., 2018), with most instances occurring between the ages of ten and sixteen, is postulated to influence aberrant neurophysiological processes that occur in the nervous system (Barton & Weinstein, 2018). Due to these changes, primary and secondary postural control deteriorates, reducing proprioceptive information Liu, 2019). Since proprioception is crucial for normal joint function, assessing it is critical. Since proprioceptive deficits occurred in patients with AIS, showing significantly larger repositioning errors than in healthy individuals, it is best to measure joint reposition (JR) sense, which is defined by one's ability to repeat predetermined target positions (Lau et al., 2022;Swinkels & Dolan, 2000).
Proprioceptive Neuromuscular Facilitation (PNF) is an intervention that works by stimulating the proprioceptors found in the skin, joints, muscles, and tendons to improve the response of the neuromuscular mechanisms, such as mobility, muscular strength and endurance, joint stability, balance, and neuromuscular control (Takasaki et al., 2020). This approach includes diagonal patterns and sensory cues (i.e., proprioceptive, cutaneous, visual, and auditory stimuli) to initiate or increase motor responses. One of the initial thoughts behind this intervention considers the idea that muscles with strong diagonal patterns (antagonists) encourage responsiveness in weaker muscle groups (agonists) (Adler et al., 2008). PNF, originally developed by Dr. Herman Kabat and his colleagues in the 1940s to aid patients with poliomyelitis in regaining their strength and mobility, has evolved through time as a therapeutic approach and is now intimately related to the concepts of neuroplasticity, as well as motor control and motor learning. According to Singh et al. (2020), PNF enhances post-stroke brain-derived neurotrophic factor (BDNF) concentration, which promotes neuroplasticity. Neuroplasticity refers to the concept that the brain may rearrange and make new connections in response to environmental and behavioral changes. By employing certain movement patterns and muscle contractions to stimulate and improve the connection between the brain and the muscles, PNF makes use of the concepts of neuroplasticity to improve neuromuscular performance. Also, modern theories of motor learning and control have also impacted the development of PNF. These principles stress the significance of motor learning and the development of new motor skills via practice and feedback. These ideas are applied by PNF to assist people in learning new movement patterns and improving their motor control. Zito et al. (2020) assert that in those with movement disorders, PNF has been demonstrated to enhance motor learning and control.
In recent years, PNF has been increasingly used in scoliosis rehabilitation and has been shown to be effective in reducing spinal curvature and scoliosis-related pain; as well as improving balance, trunk symmetry, and postural control (Czaprowski et al., 2019;Han et al., 2022;Kwon et al., 2018;Zago et al, 2018;Zheng et al., 2021). Guided by the principle of neuroplasticity, PNF utilizes specific patterns of movement and muscle contractions to stimulate the muscles and enhance communication between the brain and the muscles which can help improve spinal alignment and reduce pain in patients with scoliosis. Still, despite an increase in studies investigating the effectiveness of PNF in the conservative management of subjects with idiopathic scoliosis, the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) advocates employing physiotherapy scoliosis-specific exercise (PSSE) techniques that combine 3D posture correction mechanisms to treat AIS.
The Schroth method, which is founded on sensorimotor and kinesthetic principles, is the most researched and recognized specific exercise for scoliosis among all PSSE approaches (Kocaman et al., 2021). Proprioceptive stimulations (i.e., muscle contractions during elongation and corrections) and exteroceptive stimulations (i.e., therapist touch, verbal commands, and mirror control) are used to improve scoliotic posture during postural and breathing exercises, which are remarkably similar to the PNF hallmarks. In contrast, the Schroth technique first applies 3D principles of correction prior to applying the primary principles of correction. But, before putting these basic principles of correction into practice, the Schroth technique makes five assumptions about the pelvic adjustments which make sure that the pelvis is in the best possible alignment with the trunk (Berdishevsky et al., 2016). The Schroth technique has five guiding principles: autoelongation (detorsion), deflection, derotation, rotational breathing, and stabilization. The patient learns how to de-collapse the concave portions of the trunk and how to minimize the prominences through the application of these concepts. By targeting all dimensions of the spinal deformity, the Schroth therapeutic intervention, as compared to non-surgical therapy alone, significantly improved Cobb angle regression and improved adolescents' quality of life (QOL) for up to 6 months after the intervention (Berdishevsky et al., 2016).
There is mounting evidence that the Schroth Method is effective and beneficial for treating scoliosis, notably in terms of reducing spine curvature and improving postural alignment, pulmonary function, and quality of life in patients with scoliosis. The efficacy of the Schroth Method in treating adolescents with idiopathic scoliosis was examined in a study by Zapata et al. (2018). According to the research, adolescents with idiopathic scoliosis who underwent the Schroth Method had their spinal curvature reduced, their postural alignment improved, and their pain levels decreased. Furthermore, the long-term efficacy of the Schroth Method in treating AIS was examined in a different study by Schreiber et al. (2016). According to the research, six-months of Schroth PSSE added to the standard of care (observation or bracing) improved curve severity in adolescents with idiopathic scoliosis compared to the standard of care alone. The study also showed that the Sum of Curves also decreased over time. In a systematic review and meta-analysis published in 2019 by Burger et al., the Schroth Method's efficacy in treating patients with AIS was assessed. According to the review, Level II evidence suggests that Schroth exercises have a significant effect on reducing the Cobb angle and improving the quality of life in adolescents with idiopathic scoliosis. Additionally, a study by Negrini et al. (2021) compared the effectiveness of the Schroth Method with other exercise-based rehabilitation programs for scoliosis. The study found that the Schroth Method effectively reduced spinal curvature and improved quality of life in patients with scoliosis and was more effective than other exercise-based rehabilitation programs.
However, to date, the impact of both PNF and PSSE on the changing proprioceptive neural mechanisms remains inconclusive in the literature. Thus, the main purpose of this case study is to share the results of PNF on spine JR sense with the scientific community. The second aim is to share the results of PNF on the angle of trunk rotation (ATR), posture, and deformity perception in AIS.

Subject History and Systems Review
The subject provided verbal consent to the use of her medical records for this case report. She is a 20-year-old college student who was radiographically diagnosed with mild dextrothoracic and mild levolumbar spinal curvature diagnosed when she was 13 years old. The following are pertinent radiologic findings: (1) S-Shaped Structural Scoliosis; Moderate dextroconvex curving of the thoracic spine from T6 to T11 with a Cobb's angle of 38°. Peak angulation is T9 level. There is also mild leftward rotation and (2) Moderate levoconvex curving of the lower thoracic down to the lumbar spine from T11 to L4 with a Cobb's angle of 26°. Peak angulation is at L1-L2. There is also mild rightward rotation. Past medical history included tuberculous meningitis 6 years ago.
Systems review indicated no impairments in integumentary, cardiovascular and pulmonary and neuromuscular systems. Review of systems also indicated no impairments in the gastrointestinal, genitourinary and immunologic systems.
The subject currently displays moderate dextrothoracic and moderate levolumbar spinal curvature, as determined by the radiologist's interpretation of the subject's most recent radiographs ( Figure 1). The curvature was seen in the thoracic spine from levels T6 to T11, with a Cobb angle of 38°, and the maximal angulation appearing at T9 level; there is also a mild rotation to the left. The lower thoracic spine also has moderate curvature from T11 to L4, with a Cobb angle of 26°, and the L1-L2 level showing the most angulation; there is also a slight rotation to the right. Despite claiming to be pain-and discomfortfree, the subject admitted that when she looked into a full-length mirror, she felt anxious since her left and right shoulders were asymmetrical.

Clinical Impression 1
The subjective history reveals that the subject has a past radiographic diagnosis of structural scoliosis, which is the most prevalent kind of scoliosis, and is distinguished by a rigid lateral curvature of the spine that also contains a component of rotation (Kontopanou et al., 2022). The ocular inspection (OI) reveals structural scoliosis-related impaired posture with observable postural deviation while sitting, standing, and lying down. In the anterior view, the subject has an elevated right shoulder, a prominent left rib cage, a higher right hip, and a prominent right scapula in the posterior view. Palpation, thoracolumbar range of motion (ROM), thoracolumbar manual muscle testing (MMT), special tests, and leg length discrepancies (LLD) were only conducted to rule out other conditions. Measurements of JR error using TiltMeter -Advanced Level & Inclinometer (Carlos Hernandez, Version 4.0.1), ATR using Scolioscreen (Kevin Lau, Version 5.9.2), posture parameters using PostureScreen Mobile (PostureCo, Inc., Version 13.4), and deformity perception using the Walter Reed Visual Assessment Scale (WRVAS) made up the bulk of the examination plan.

Examination
A form was used to collect descriptive information. The clinical characteristics of the subject were also questioned and recorded. Examination (and reexamination) results can be found in Tables 1-5. The radiograph was taken in the upright position (without sole/brace) and served as the basis for the Cobb angle measurement. An increasing degree of Cobb indicates an increase in the severity of the spinal curvature (Negrini et al., 2018). The primary outcome measurement was the JR sensation. The secondary outcome measurements to determine the effectiveness of treatment are the ATR, posture, and deformity perception. The subject was examined at the baseline, after the 6th session, and 3 weeks later.  The measurement of lumbar spine flexion and extension range of motion was evaluated with the TiltMeter, an iPhone application that possesses good to excellent intra-rater (MDC95[Intra-rater analysis] = 5.82° to 8.18°) and inter-rater (MDC95[Inter-rater analysis] = 7.38° to 8.66°) reliability and concurrent validity (ICC = ≥0.85) (Pourahmadi et al., 2016). To evaluate the reposition sensation of the spine, active position reproduction was measured for flexion (at 30° for thoracal and lumbar), extension (at 15° for thoracal and lumbar), and right-left lateral flexion (at 20° for thoracal and 15° lumbar). Measurements were made between T1-T12 in thoracal and T12-S1 in lumbar spine (Abboud et al., 2018;Noh et al., 2015). The subject was positioned with eyes closed and covered with a blindfold, arms crossed on the body, feet on the ground in the sitting position, and hip-knee flexion at 90° ( Figure  2). To ensure familiarization, the procedure was demonstrated and then the subject was allowed to practice. For each movement, the subject was asked to stay in the reference position for three seconds and come to the upright position and then go back to the reference position. The absolute difference in degrees between the two positions was noted as the reposition error (RE). Each test was repeated 5 times, and the average was calculated (Swinkels & Dolan, 2000). The decrease in RE was evaluated as an improvement in the sense of repositioning. Additionally, it was found that the subject's RE scores were greater than those of healthy cases.  The ATR measurement was performed by using the smartphone with application and casing (Scolioscreen) in the Adam's forward bending test position (AFBT). Scolioscreen yields an accurate and precise mean ATR of 12.6° (SD = 5.0) in relation to the gold standard of the orthopedic surgeon using the Scoliometer, which recorded a mean ATR of 12.5° (SD = 4.9). Accuracy testing using measurements by the orthopedic surgeon and the parents with Scoliometer and Scolioscreen results in an excellent Pearson correlation coefficient of 0.97 and 0.92, respectively. All the ICCs, both intra-and inter-observer, reached a value over 0.92. The standard error of measurement (SEM) between observers was 0.23° (van West et al., 2022). For this case, the Scolioscreen was applied in the same manner as the Scoliometer would be applied and measurements were made between T9 and L1 -L2 (Coelho et al., 2013).
PostureScreen Mobile software is a valid and reliable application used for evaluating the changes in the posture (ICC ≥ 0.75) (Boland et al., 2016). For this case, frontal and sagittal plane posture assessment scores were calculated by marking reference points on the photographs taken from the front, back, and both sides of the subject in the application. The green plumb line, which is solely used for educational reasons and depicts the imaginary straight line extending from the top of the head to the floor, serves as a reference point for the sagittal plane. While the red plumb line depicts the landmarks' horizontal offset (Figure 3). Total displacement values in the anterior, posterior, and lateral directions for postural impairment were recorded in cm. The decrease in the total displacement values was evaluated as an improvement in the postural parameters. Photographing, positioning, and determination of reference points of the subject were standardized using validated posture assessment with digital photography (Stolinski et al., 2017). The Walter Reed Visual Assessment Scale (WRVAS), which has high internal consistency and correlates with the degree of curvature, is recommended for clinical use because it is easy to use and score (ICC = 0.906; Cronbach's alpha = 0.9) (Pineda et al., 2006). It is used to understand the visual change caused by scoliosis and to evaluate the treatment results under seven headings. Each deformity is scored from 1 to 5; 1 is the best and 5 is the worst (Çolak & Kuru Çolak, 2020). For this case, this scale was filled by the researcher and the subject. The difference between the WRVAS (dWRVAS) scores by the researcher and the subject was obtained before and after the treatment. The decrease in the difference was evaluated as an improvement in deformity perception.

Clinical Impression 2
The results of the examination support the fact that the subject has structural scoliosis-related impaired posture by revealing findings of impaired JR sensation and ATR, present postural deviation, and existing deformity perception (Tables 4 -5). The subject's RE, which was assessed using TiltMeter in the thoracic and lumbar regions, received average scores of 3.6 and 2.4 in flexion, 1.8 and 1.6 in extension, 3.4 and 4 in lateral flexion to the right, and 2.2 and 2.8 in lateral flexion to the left, respectively. ATR obtained using the Scolioscreen during AFBT in levels of peak spinal angulation was 4 and 11, respectively. Current postural deviation, as evaluated by the PostureScreen Mobile, included shifts of 4.51 cm to the front, 3.32 cm to the left, 6.44 cm to the right, and shifts of 8.10 cm to the back. Finally, there is only a single difference between the subject's perception of deformity (WRVAS: 15/35) and the researcher's (WRVAS: 14/35).

Interventions
In the first interview before the program, the subject was informed about the postures one should pay attention to and avoid in daily life using spinal posture awareness and control, proper breathing pattern using the Active Cycles of Breathing Technique (ACBT) (Woravutrangkul et al., 2010), muscle relaxation techniques, and the benefits and purposes of the exercise.
The subject received a personalized exercise program designed to correct and stabilize the spine in three dimensions while considering the subject's curvature pattern. The program consisted of 12 sessions lasting 45-60 minutes each over 3 weeks, 4 days per week. The exercise program was applied to improve the subject's condition. Additionally, while incorporating components of the Schroth Method, all exercises were founded on the fundamental ideas, practices, and philosophies of PNF (Table  6 & Figure 4) (Adler et al., 2008). The contract-relax (CR) technique, rhythmic initiation (RI), and combination of isotonics (COI) applied to the subject's treatment were additional PNF approaches employed. To enhance the passive range of motion of the agonist, the contract-relax (CR) technique was used, which involves resisting an isotonic contraction of the restricting antagonist before relaxing and progressing into the new range. To help in the initiation of motion, improve coordination and sense of motion, normalize the rate of motion by increasing it, teach the motion, and assist the subject in relaxing, rhythmic initiation (RI), which is characterized by the rhythmic motion of the limb or body through the desired range, starting with passive motion and progressing to active resisted movement, was used. Lastly, to enhance the strength and control in the newly acquired range of motion, the combination of isotonics (COI) was applied. Correcting for spine alignment Supine Using both legs, the left-side pelvis was raised using COI through a bilateral flexion pattern of the lower limbs. The subject was also instructed to raise her LUE in flexion-abduction-external rotation.
Step The first exercise is considered as the starting position whereby the participant lies down with the arms perpendicular to the trunk and elbows extended at 90° angle for 60-seconds ( Figure 4a). During this step, the subject is prepared on the exercise sequencing and the need to incorporate proper breathing technique.

PNF Component Schroth Component Subject Position Procedure
The second exercise serves as a starting point for steps 2-4. (Figures 4b, c, d). The subject was required to lie on the side of major spinal convexity and complete one cycle of ACBT. The subject was then prompted to change hand position by doing shoulder flexion-abduction-external rotation. Finally, the subject is instructed to combine hip extension-adduction-external rotation with the prior exercise.
Bilateral lower limb patterns (flexion to the right and extension to the left) were performed by the subject while supine with a stable chest, along with CR and asymmetrical breathing techniques (Figure 4e, f, g, h, i). The subject had to hold muscle contraction for 6 seconds three times in a row before actively increasing ROM; this set was repeated three times at 10-second intervals.
The last phase of mobilization included 10 active lower-limb movements toward mobilization and asymmetrical breathing: 5 slow inspirations and expirations.
The eighth exercise had the subject lying in a hook-like position and having the instructor push both her pelvis down onto the bed as she relaxed her abdominal muscles (Figure 4j). The instructor held the iliac crest with both hands and provided resistance to the front side while verbally directing the subject to press her pelvises down while trying posterior tilting simultaneously.
The amphibian position was used in the ninth exercise, in which the left leg performed flexion-adduction-external rotation with knee flexion and the left arm performed flexion-abductionexternal rotation to stabilize the lumbo-pelvic system, elevate the scapular and pelvic bones on the left, depress the scapular and pelvic bones on the right, and align the thoracic and lumbar spines so that they arch towards normal. Furthermore, to diminish lumbar spine tilt, the patterns were used with COI, allowing for manual contact on the left leg (Figure 4k).
The tenth exercise was performed while lying down. Additionally, the subject's left-side pelvis was elevated employing COI via the bilateral leg flexion pattern, engaging both legs (Figure 4l). The subject was also instructed to extend her left arms in flexion-abduction-external rotation in order to address the lumbar spine deviations and correct the thoracic spine alignment.
The eleventh exercise was performed while the subject was sidelying, with the right leg performing extension-abduction-internal rotation and the left arm performing flexion-abduction-external rotation in a closed-kinetic-chain exercise that brought the left arm up to the edge of the bed to stretch it (Figure 4m). To establish an anterior elevation pattern, COI was used to lower the right pelvis and elevate the left pelvis, while the right leg and pelvis performed extension-abduction-internal rotation, the left leg and pelvis performed flexion-abduction-external rotation.  The twelfth and thirteenth exercises emphasized correcting the subject's posture in a narrow base of support, which is prevalent in sitting and standing positions (Figures 4n, o). The levolumbar curvature of the spine and right pelvic elevation were repositioned to their normal orientations using an anterior pattern on the left pelvis and COI. In addition, the subject's right arm is positioned extension-abduction-internal rotation, with the subject holding on the bed surface or chair handle to lower the raised right shoulder while correcting the left-arched thoracic spine.
The parameters adopted were those recommended by published literatures (Table 8) (Hindle et al., 2012;Lee, 2016;Stępień et al., 2017). To prevent discomfort and steadily improve stability, postures transitioned from having wider supporting planes to having narrower ones during the exercise sessions. The number of repetitions, sets, and duration of contraction were increased as appropriate. No adverse effect was noted.

Outcomes
The Cobb measurement, which determines the magnitude of the spinal curve, is important in measuring the treatment's effectiveness (Negrini et al., 2018). Though the exercise intervention was only implemented for a total of 12 sessions, the most recent x-ray results analyzed by a radiologist revealed that the curvature of the thoracic spine had decreased from 38° to 32° and the curvature of the lumbar spine had decreased from 26° to 24°. Thus, PNF may provide positive effects in reducing spinal curvature. Additionally, treatment efficacy was measured by a multidimensional evaluation of posture.
The angles of trunk rotation in the subject, which were assessed using the Scolioscreen at 4° in the thoracic region (T9) and 11° in the lumbar region (L1-L2), revealed no change in either location. Given that there is no > 3° increase in ATR measurement that would prompt the subject to receive a coronal plane radiograph to confirm curve progression, it was concluded that the retention of ATR in this case report is clinically important (Larson et al., 2018). Accordingly, it would be premature to draw any conclusions about whether PNF may effectively reduce the ATR given that the approach showed promising outcomes in reducing spine curvature as indicated in the reduction of Cobb angle.
The use of systems such as photography in the evaluation of postural changes is increasing (Moreira et al., 2020). Using the PostureScreen Mobile application, it was observed that the baseline posture mean displacement of the subject in this case report was higher than the healthy peers (Bogdani & Pano, 2016). At the end of the treatment, there was a decrease in the total postural displacement in the anterior, right-left lateral, and posterior directions of the subject. Therefore, it was concluded that PNF is effective in postural correction.
Proprioception improvement affects body image perception. To assess this, the researcher evaluated the difference between the WRVAS scores of the physiotherapist and the subject. Because there is a decrease in the dWRVAS score, it was concluded that PNF has positive effects on the deformity perception of a subject with AIS.

Discussion
Based on the outcomes, it was concluded that PNF may positively contribute to JR sense of the spine, improve postural symmetry, and be beneficial for deformity perception.
The alignment and position of various spinal structures must be closely controlled to maintain posture. However, very little is understood about this regulatory system, whose disruption may lead to spine deformity such as AIS. Several causes of AIS, including genetic, environmental, hormonal, metabolic, biochemical, and neurological variables, have been postulated, even though its etiopathogenesis is still unknown (Lau et al., 2022). Research has revealed a link between the onset of idiopathic scoliosis and a few proprioception-related gene abnormalities, including Runx3 and Piezo2 (Blecher et al., 2017). Moreover, several studies reported that persons with AIS had proprioceptive abnormalities when compared to non-scoliotic peers (Lau et al., 2021;Le Berre et al., 2017;Assaiante et al., 2012). These results suggest a possible etiological link between AIS and proprioception.
The capacity of a person to adjust body parts or fine-tune movements while doing functional tasks might be negatively impacted by abnormal proprioception (Dąbrowska et al., 2020;Sim et al., 2018). Effective proprioception is necessary to maintain an appropriate spinal position in either a static or dynamic position (Machida, 2018). Thus, proprioception assessments should be taken because of the critical role that proprioception plays in healthy joint function. Position sense or movement sense tests are the two standard ways to evaluate proprioception (Swinkels & Dolan, 2000). Since scoliosis is an alignment problem of the spine, it may be more connected to an insufficiency in the sense of positionthe awareness of the relative orientation of body components in spacerather than a sensation of movementthe perception of velocity and acceleration. For this reason, the evaluation of the angular error in position reproduction known as the joint reposition (JR) sense, is optimal .
Most striated muscles in the musculoskeletal system of many animals, including mammals, contain a significant number of proprioceptive mechanoreceptors (Kokkorogiannis, 2004). Many molecular pathways that control their development, connection, and operation have been discovered in recent years. The Golgi tendon organ (GTO) and the muscle spindle are the two most common forms. However, the morphology, location, measured input, effect, and other characteristics among these types vary. The capacity to perceive the biomechanical environment, swiftly trigger a brain response in specific sensory afferent fibers, and finally, control local muscle tension-forming the muscle spindle and GTO reflex arches-are shared by both organs (Proske & Gandevia, 2012). Exercise is undoubtedly used to enhance JR sensation through proprioceptor muscle spindle stimulation (alpha gamma activation), as these mechanoreceptors are found in greater abundance in facet joints and discs as well as the muscle groups of the spine (Groh et al., 2021;Puntumetakul et al., 2018). This also illustrates how the erector spinae, psoas, and quadratus lumborum are targeted during activities to enhance thoracal and lumbar RE (Akyurek et al., 2022).
The specific principles employed in designing the treatment program, such as salience, specificity of training, and increasing intensity and frequency of therapy, may also be responsible for the favorable improvements in JR sense. The purpose of using PNF approaches, which include manual facilitation, is to develop functional movement by facilitating, inhibiting, strengthening, and relaxing muscle groups through concentric, eccentric, and static muscle contractions. The treatment approach is always positive, holistic, and intended to help the subject achieve their highest level of function through treatment on the level of body structures, the level of activity, as well as on the level of participation, in keeping with the underlying philosophy of PNF that everyone without exclusion has untapped existing potential (Adler et al., 2008). PNF techniques have advanced with knowledge of the neurophysiological underpinnings of the movement. The intervention was based on the participant's therapeutic goal and the findings of the assessment (e.g., trunk patterns were used to address spinal curvature through elongation and derotation). Since movement is how we engage with the world around us, all sensory and cognitive processes may be thought of as inputs that influence how our bodies will move in the future. For rehabilitation, motor learning and some elements of motor control are essential. One of the key elements of every interaction is the exchange of information which encompasses all forms of therapy. Without information, patients are severely limited in mastering new tasks. This is especially important during the early phases of motor learning and the rehabilitation process when the patient frequently cannot rely on internal stimuli owing to the impairment. In these circumstances, the role of the therapist and facilitation techniques like PNF take on greater significance as sources of external stimulus.
By activating proprioceptors, it can increase the activity in motor centers, thus the weaker muscle groups (agonists) on the convex side of the curve are excited to their fullest potential when muscular synergism is properly applied. The PNF approach puts the patient in the best posture and corrects their spine and pelvis making them able to perform ADLS in this position. Based on these findings, it can be concluded that PNF provides positive effects to improve a sense of reposition in the spine in subjects with moderate structural scoliosis.
The use of PNF for the management of scoliosis is supported by an increasing number of publications (Yoon et al., 2021;Stępień et al., 2017), although further study is required to determine its significance and clinical utility. Furthermore, this report has several limitations that should be considered. For this case study, only the proprioceptive component of position sense (with JR) could be assessed. Research is needed on proprioception's other facets and outcomes in subjects with more severe curves. Due to a lack of information on joint position perception in healthy persons, the absence of a blind assessor to eliminate bias, and the lack of a follow-up assessment, complete data could not be obtained. Additionally, the study's time constraints was a major drawback. The absence of an evaluation of the researcher's own measurement errors to guarantee the reliability of the measurements is another limitation of this study.
In this case study, the correct sensory information of the spine needed to maintain upright postural control was gained using PNF. The strategy improved the perception of postural symmetry and deformity by creating accurate sensory inputs, in addition to improving the strength and length of the spinal muscles. Because proprioception is essential for managing the trunk's motor control, a quantitative proprioception assessment should be addressed in subjects with AIS. Additionally, for researchers to establish the effects of PNF techniques, broader implementation in scoliosis rehabilitation is required.