Children with spastic diplegic cerebral palsy often experience upper extremity impairments, including reduced coordination, muscle control, and functional hand use, which limit independence in daily activities. Proprioceptive Neuromuscular Facilitation (PNF) and Task-Oriented Training (TOT) are commonly used rehabilitation approaches to improve motor function; however, evidence comparing their individual and combined effects on upper extremity function remains limited.
This randomized controlled trial aims to compare the effects of PNF alone, TOT alone, and a combined PNF plus TOT intervention on upper extremity function in children with spastic diplegic cerebral palsy. Sixty-three children aged 6 to 12 years with Gross Motor Function Classification System (GMFCS) levels I to III will be randomly assigned to one of three intervention groups. Each group will receive supervised 45-minute treatment sessions, three times per week for six weeks.
Upper extremity function, functional independence, and joint range of motion will be assessed at baseline, mid-intervention (3 weeks), and post-intervention (6 weeks) using the Melbourne Assessment of Unilateral Upper Limb Function (MA2), Pediatric Evaluation of Disability Inventory-Functional Skills Scale (PEDI-FSS), and goniometric measurements. The findings of this study are expected to provide evidence regarding the most effective rehabilitation approach for improving upper extremity function in children with spastic diplegic cerebral palsy.
Children aged 6 to 12 years.
Clinical diagnosis of spastic diplegic cerebral palsy.
Gross Motor Function Classification System (GMFCS) Levels I-III.
Ability to understand and follow simple verbal instructions.
Orthopedic surgery involving the upper or lower extremities within the previous 6 months.
Botulinum toxin injections administered within the previous 6 months.
Severe visual, hearing, or cognitive impairments that would interfere with assessment or treatment.
Uncontrolled epilepsy or other unstable neurological or medical conditions.
Parallel
Proprioceptive Neuromuscular Facilitation (PNF)
Procedure/SurgeryParticipants will receive Proprioceptive Neuromuscular Facilitation (PNF) exercises for the upper extremity using diagonal movement patterns (D1 and D2 flexion and extension). Treatment is designed to facilitate neuromuscular activation, improve muscle strength, coordination, proprioception, and functional upper limb movement. Each participant will receive supervised 45-minute treatment sessions, three times per week for six weeks.
Task-Oriented Training (TOT)
Procedure/SurgeryParticipants will perform structured, goal-directed functional upper extremity activities including reaching, grasping, releasing, object manipulation, stacking, and other task-specific exercises. The intervention emphasizes repetitive practice of meaningful functional tasks to improve motor control, upper limb function, and independence in daily activities. Sessions will last 45 minutes, three times per week for six weeks.
Combined Proprioceptive Neuromuscular Facilitation and Task-Oriented Training
Procedure/SurgeryParticipants will receive a combined intervention consisting of Proprioceptive Neuromuscular Facilitation (PNF) followed by Task-Oriented Training (TOT) within the same treatment session. The intervention integrates upper extremity PNF diagonal movement patterns with repetitive task-specific functional activities to enhance neuromuscular control, motor learning, upper limb function, and functional independence. Each supervised session will last 45 minutes and will be delivered three times per week for six weeks.
Upper Extremity Function
Upper extremity function will be assessed using the Melbourne Assessment of Unilateral Upper Limb Function, Second Edition (MA2). The MA2 evaluates movement quality, dexterity, accuracy, fluency, and range of motion during functional upper limb tasks. Higher scores indicate better upper extremity function.
Functional Independence in Activities of Daily Living
Functional independence will be assessed using the Pediatric Evaluation of Disability Inventory-Functional Skills Scale (PEDI-FSS). The instrument measures the child's capability to perform age-appropriate self-care and functional activities. Higher scores indicate greater functional independence.
Upper Extremity Range of Motion
Active range of motion of the shoulder, elbow, and wrist joints will be measured using a standard universal goniometer. Measurements will be recorded in degrees to evaluate changes in joint mobility following the intervention.
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