DOI: https://doi.org/10.52756/ijerr.2024.v39spl.008 Int. J. Exp. Res. Rev., Vol.

39: 109-117 (2024)

Comparison between Task-Oriented Training and Proprioceptive Neuromuscular Facilitation

Exercise on Upper Extremity Function in Spastic Cerebral Palsy

Srilakshmi1, Arun Selvi1, Mahesh Kumar P.G.2*, Hari Hara Subramanyan P.V.2, Shenbaga Sundaram
Subramanian3, Thamer A. Altaim4, Shadi Abdelbaset Alkhob5 and Riziq Allah Mustafa Gaowgzeh6
1
Faculty of physiotherapy, Dr. M. G. R. Educational and Research Institute, Chennai, India; 2Faculty of
Physiotherapy, Meenakshi Academy of Higher Education and Research, Chennai, India;3Chettinad School of
Physiotherapy (CSP), Chettinad Academy of Research and Education (CARE), Chettinad Hospital and Research
Institute (CHRI), Kelambakkam, Tamil Nadu 603103, India;4Department of Physical Therapy, Faculty of Allied
Health Sciences, Al-Ahliyya Amman University, Amman 19328, Jordan;5Department of Physical Therapy, Faculty of
Applied Medical Science, Jerash University, Jerash, Jordan; 6Department of Physical Therapy, Faculty of Medical
Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
E-mail/Orcid Id:
SL, srilakshmi.physio@drmgrdu.ac.in, https://orcid.org/0000-0003-2112-2720; AS, arunselvi.physio@drmgrdu.ac.in, https://orcid.org/0000-0002-
5197-7781; MKPG, mahesh@maherfpt.ac.in, https://orcid.org/0000-0002-2465-9462; HHSPV, hari.fpt@maher.ac.in, https://orcid.org/0000-0001-
5487-5281; SSS, dr.subramanian@care.edu.in, https://orcid.org/0000-0002-6150-0928; TAA, thamerpt@live.co.uk, http://orcid.org/0000-0001-6527-
4289; SAA, Shadi_raul@hotmail.com, https://orcid.org/0009-0009-4565-3818; RAMG, rizikjoresearch@gmail.com, https://orcid.org/0000-0003-
4199-2600

Article History: Abstract: This research investigates and compares the impacts of task-oriented
Received: 14th
Feb., 2024 training and proprioceptive neuromuscular facilitation (PNF) on the motor function of
Accepted: 20th May, 2024 the affected arm in children diagnosed with spastic cerebral palsy (CP). The study
Published: 30th May, 2024
addresses the need for effective interventions to address the motor challenges in this
Keywords: population. Thirty participants were randomly assigned to either Group A (task-
Cerebral palsy, Motor oriented training) or Group B (PNF training) in a two-month comparative study
impairment, Spastic, conducted in special schools. Both groups participated in daily 40-minute sessions
Proprioceptive Neuromuscular
five days a week for eight weeks. Pre and post-tests, utilizing the Assistive Hand
Facilitation (PNF), Upper
extremity function, Task- Assessment (AHA-22) and Manual Ability Measure (MAM-16), were administered to
oriented training evaluate outcomes. The analysis revealed no significant differences in post-test scores
between Group A and Group B, indicating comparable effectiveness of both
How to cite this Article:
Srilakshmi, Arun Selvi, Mahesh Kumar P.G,
interventions in improving upper extremity function in children with spastic cerebral
Hari Hara Subramanyan P.V., Shenbaga palsy. This study contributes valuable insights into therapeutic approaches for
Sundaram Subramanian, Thamer A. Altaim,
Shadi Abdelbaset Alkhob and Riziq Allah enhancing motor function in children with spastic cerebral palsy. Both task-oriented
Mustafa Gaowgzeh (2024). Comparison
between Task-Oriented Training and training and proprioceptive neuromuscular facilitation emerge as effective
Proprioceptive Neuromuscular Facilitation methodologies, providing healthcare professionals and educators with evidence-based
Exercise on Upper Extremity Function in
Spastic Cerebral Palsy. International Journal options for optimizing outcomes in this population. These findings hold international
of Experimental Research and Review,
39(spl.) 109-117. relevance, offering a foundation for informed decision-making in the selection of
DOI:
https://doi.org/10.52756/ijerr.2024.v39spl.008
interventions for children with spastic cerebral palsy across diverse global contexts.

Introduction recognized neurodevelopmental condition (Khanna et al.,

Cerebral palsy (CP) is a persistent motor disorder 2023; Khant et al., 2023; Arun et al., 2024) commencing
resulting from non-progressive brain lesions acquired in early childhood and enduring throughout the lifespan,
during rapid brain development, characterized by muscle initially reported by Little in 1861. CP is a developmental
fibrillations or paralysis (Krigger, 2006). It is a well- disorder emerging in early childhood with functional
*Corresponding Author: mahesh@maherfpt.ac.in 109
 Int. J. Exp. Res. Rev., Vol. 39: 109-117 (2024)
limitations stemming from central nervous system Assessment (AHA), designed for children with unilateral
disorders (Bax et al., 2005). It encompasses a diverse upper limb dysfunction, demonstrates validity and
group of early-onset, non-progressive neuromotor reliability, particularly in hemiplegic CP or obstetric
disorders affecting the developing fetal or infant brain brachial plexus palsy cases (Krumlinde-Sundholm et al.,
(Oskoui et al., 2013; Ketelaar et al., 2001). Children with 2007). The Manual Ability Measure (MAM) is a task-
CP experience upper limb motor deficits, impacting oriented and patient-oriented outcome tool measuring
activities such as reaching, grasping, and prehension, manual ability. Specifically, the MAM-16, a self-
thereby affecting self-care, education, and social reporting measure assessing unimanual and bimanual
interaction (Song, 2014). The most common form of CP function, has demonstrated good validity and reliability
is spastic, presenting with additional clinical signs like through Rasch analysis (Chen et al., 2005).
limited range of motion, diminished selective control, and
muscle weakness (Kulinski et al., 2023). The severity of Methodology
gross motor function limitations in children with cerebral This study employed a rigorous comparative design
palsy is significant (Chrysagis et al., 2009), restricting featuring a pre-and-post methodology conducted within
their engagement in physical activities and posing health specialized schools over an extensive two-month period
risks due to constrained motor actions or skills (Krigger, dedicated to thorough data analysis. The sample size
2006). In 2001, the United Cerebral Palsy Foundation comprised 30 individuals meticulously selected based on
estimated 764,000 diagnosed cases in the United States, stringent inclusion and exclusion criteria, utilizing a
with approximately 8,000 new cases annually, simple random sampling method to stratify participants
emphasizing the prevalence of bilateral spastic CP (66%– into two groups, denoted as Group A and Group B.
73%) over unilateral cases (26%–34%) (Allsopp et al., Before the study commencement, parents of the subjects
2008). The task-oriented approach recognizes movement received a comprehensive explanation of the research
as an interaction between various brain systems objectives and their informed consent was obtained
organized around a goal and constrained by the through signed consent forms. The initial data collection
environment (Kolit et al., 2023). It encompasses phase involved acquiring demographic details, including
interventions like (Blundell et al., 2003), treadmill and gender, age, hemiparetic side, and causative factors, with
ground walking, bicycling, endurance and circuit training a steadfast commitment to maintaining confidentiality.
(Rensink et al., 2009). sit-to-stand exercises, and reaching Group A underwent a regimen of task-oriented training,
tasks to enhance balance (Marda et al., 2023). encompassing bilateral and unilateral activities focused
Emphasizing functional arm tasks such as grasping on hand grip, coordination, finger strength, and joint
objects and constraint-induced (movement) therapy weight bearing. These activities included drumming for
(CIMT) (Shih et al., 2023), this patient-focused approach improved hand grip and dexterity, age-appropriate play
(Song et al., 2014) targets functional activities of the for enhanced overhead activities and coordination, scissor
affected arm in children with CP (Ahl et al., 2005). cutting and pasting for hand function and finger strength
Proprioceptive Neuromuscular Facilitation (PNF) and a ball game for hand grip strength and overhead
integration patterns stimulate proprioceptors in muscles activities. Unilateral activities in Group A involved
and tendons, effectively maximizing the exercise unit's holding a drinking cup to strengthen the upper limb,
reaction (Kumar et al., 2016; Basak and Biswas, 2016; ). progressing to increased water quantity, and
Utilizing maximum resistance in spiral and diagonal carrying/dragging wooden blocks to improve joint weight
movements, PNF promotes a larger neuromuscular bearing. In contrast, Group B received proprioceptive
response and exploration of postural reflex and prioritizes neuromuscular facilitation (PNF) exercises comprising
eccentric muscle contraction, which is particularly D1 and D2 patterns for flexion and extension. D1 flexion
beneficial for hemiplegic patients (Chen et al., 2005; involved shoulder flexion, adduction, external rotation,
Lindquist et al., 2011; Olubukola et al., 2021). When elbow flexion or extension, forearm supination, wrist
addressing hand function impairment, the goal is to flexion, radial deviation, and finger/thumb flexion,
enhance the functional use of hands for everyday tasks, adduction. D1 extension covered shoulder extension,
recognizing the collaborative nature of bimanual abduction, internal rotation, elbow flexion or extension,
performance (Basak and Dutta, 2016; Nikolovska et al., forearm pronation, wrist extension, ulnar deviation, and
2023). Evaluation instruments often test one hand at a finger/thumb extension, abduction. D2 flexion and
time, assessing maximum capability rather than actual extension patterns similarly targeted specific joint
performance (Sporea et al., 2023). The Assisting Hand movements. These exercises aimed to enhance

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neuromuscular facilitation and joint mobility in the upper Table 1 shows a comparative analysis of the Assistive
extremities. Both interventions were administered for 40 Hand Assessment (AHA) scores between Group A and
minutes per day, five days a week, over eight weeks. Pre- Group B in both pre-test and post-test evaluations. In the
and-post assessments were conducted at the outset and pre-test phase, Group A exhibited a mean score of 49.00
conclusion of the two-month study, employing the with a standard deviation (SD) of 3.27, while Group B
Assistive Hand Assessment (AHA-22) and the Manual showed a mean score of 50.00 with an SD of 3.27. Post-
Ability Measure (MAM-16). Stringent comparisons and test results demonstrated significant improvement, with
analyses were undertaken on the gathered data, both Group A achieving a mean score of 74.60 (SD = 3.45)
within and between the groups, to derive meaningful and Group B attaining a mean score of 75.60 (SD = 3.45).
insights, thus providing a comprehensive understanding The t-tests revealed no statistically significant differences
of the effectiveness of task-oriented training and between the groups in either the pre-test or post-test,
proprioceptive neuromuscular facilitation exercises in emphasizing comparable advancements in assistive hand
improving arm functions in children with spastic cerebral function (* p < 0.05).
palsy. Table 2 elucidates the Comparative Analysis of the
Manual Ability Measure (MAM-16) scores between
Results and Discussion Group A and Group B during pre-test and post-test
The collected data were tabulated and analyzed using evaluations. In the pre-test phase, Group A displayed a
both descriptive and inferential statistics. All the mean score of 51.40 (SD = 3.29), while Group B
parameters were assessed using Statistical Package for exhibited a mean score of 50.26 (SD = 3.41). Post-test
Social Science (SPSS) version 19. Paired t-test was results demonstrated substantial improvement, with
adopted to find the statistical difference within the groups Group A achieving a mean score of 65.00 (SD = 2.97)
& Independent t-test (Student t-test) was adopted to find and Group B attaining a mean score of 65.80 (SD = 2.78).
the statistical difference between the groups.
Table 1. Comparison Of the Assistive Hand Assessment Score Between Group – A and Group – B.
GROUP A GROUP B
AHA MEAN SD MEAN SD t-TEST SIGNIFICANCE
PRE TEST 49.00 3.27 50.00 3.27 0.837 .410*
POST TEST 74.60 3.45 75.60 3.45 0.792 .435*

Figure 1. Comparison of the Assistive Hand Assessment Score Between Group – A

And Group – B In Pre-Test and Post-Test.

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The t-tests indicated no statistically significant
differences between the groups in either the pre-test or Table 3 underscores the intra-group dynamics within
post-test, underscoring comparable enhancements in Group A by comparing Assistive Hand Assessment
manual ability (*p < 0.05). (AHA) and Manual Ability Measure (MAM-16) scores
Table 2. Comparison of the Manual Ability Measure (Mam-16) Score Between Group – A And Group
– B In Pre-Test and Post-Test.
MAM 16 GROUP A GROUP B t-TEST SIGNIFICANCE
MEAN SD MEAN SD
PRE-TEST 51.40 3.29 50.26 3.41 1.188 .245*
POST TEST 65.00 2.97 65.80 2.78 0.760 .453*

Figure 2. Comparison of The Manual Ability Measure (Mam-16) Score Between

Group – A and Group – B In Pre-Test and Post-Test.

Table 3. Comparison of AHA and Mam-16 Score Between Pre-Test and Post Test Within Group – A.
GROUP – A PRE TEST POST TEST t-TEST SIGNIFICANCE

MEAN SD MEAN SD
AHA* 49.00 3.27 74.60 3.45 93.926 .000**
MAM – 16* 51.40 3.29 65.00 2.97 24.333 .000**

Figure 3. Comparison of AHA and Mam-16 Score Between Pre-Test and Post-Test Within
Group – A.
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between pre-test and post-test phases. In the pre-test, The study results indicate that there is no statistically
Group A demonstrated an AHA mean score of 49.00 (SD significant difference in post-test scores (AHA and
= 3.27) and a MAM-16 mean score of 51.40 (SD = 3.29). MAM) between Group A and Group B, with a p-value
Post-test outcomes revealed remarkable improvements, exceeding 0.05. Consequently, the null hypothesis,
with AHA scores surging to a mean of 74.60 (SD = 3.45) suggesting no divergence in outcomes between the two
and MAM-16 scores rising to a mean of 65.00 (SD = groups, is accepted. A closer examination of the mean
2.97). The t-tests exhibited highly significant differences values for the Assistive Hand Assessment (AHA-22) in
(p<0.001) for both AHA and MAM-16 scores within Table 1 reveals post-test mean scores of 74.6 for Group A
Group A, accentuating the substantial advancements in (Task-Oriented Training) and 75.6 for Group B
assistive hand function and manual ability over the (Proprioceptive Neuromuscular Facilitation Exercise).
intervention period.
Table 4. Comparison of AHA and Mam-16 Score Between Pre-Test And Post-Test Within Group – B.

PRE TEST POST TEST

t-TEST SIGNIFICANCE
GROUP – B MEAN SD MEAN SD
AHA 50.00 3.27 75.60 3.45 93.926 .000
MAM – 16 50.26 3.41 65.80 2.78 22.101 .000
Within Group B, Table 3 delineates the intragroup The comparison yields a p-value greater than 0.05,
comparison of pre-test and post-test scores for both the indicating no significant disparity between the two
Assistive Hand Assessment (AHA) and Manual Ability groups in terms of post-test mean values for AHA-22.
Measure (MAM-16). In the pre-test phase, Group B Thus, the null hypothesis is accepted, signifying
exhibited an AHA mean score of 50.00 (SD = 3.27) and a comparable improvements in assistive hand function for
MAM-16 mean score of 50.26 (SD = 3.41). Post-test both intervention approaches (Nshimiyimana et al.,
results manifested substantial progress, with AHA scores 2023). Similarly, the analysis of mean values for the
increasing to a mean of 75.60 (SD = 3.45) and MAM-16 Manual Ability Measure (MAM-16) in Table 2 elucidates
scores rising to a mean of 65.80 (SD = 2.78). T-tests no significant difference in post-test mean scores between
underscored highly significant differences (p < 0.001) for Group A (Task-Oriented Training) and Group B
both AHA and MAM-16 scores within Group B, (Proprioceptive Neuromuscular Facilitation Exercise).
affirming significant advancements in assistive hand The post-test mean values for Group A and Group B are
function and manual ability following the intervention.

Figure 4. Comparison of AHA and MAM-16 Score Between Pre-Test and Post Test
Within Group – B.

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65.0 and 65.8, respectively, with a p-value exceeding circuit training program focused on functional activities,
0.05. Consequently, the null hypothesis is accepted, resulting in sustained functional performance
emphasizing comparable advancements in manual ability improvement in children with CP. Moreover, Jong-Hoon
for both groups. The study findings suggest that task- Moon et al. (2017) emphasized the positive impact of
oriented training in Group A and proprioceptive task-oriented training on hand dexterity, supporting the
neuromuscular facilitation exercise in Group B yield current study's findings. Poonam Chaturvedi et al. (2020)
comparable outcomes in terms of assistive hand function demonstrated the effectiveness of PNF techniques in
and manual ability. The acceptance of the null hypothesis improving functional activities of daily living (Talgeri et
implies that the two interventions are equally effective in al., 2023). The neuromuscular mechanisms of PNF,
enhancing the targeted outcomes, providing valuable explained by the author, shed light on its impact on
insights for therapeutic interventions in similar contexts motor-evoked potentials (Shimura and Kasai, 2002).
(Shahid et al., 2023). Upper limb impairment is a
prevalent challenge affecting nearly 50% of children with Conclusion
cerebral palsy (CP), exerting a substantial impact on their The study's conclusion underscores the viability and
ability to engage in daily activities. This impairment, efficacy of both task-oriented training and PNF exercises
particularly in children with spastic hemiplegic CP, in enhancing upper extremity functions in children with
manifests early in life and can significantly limit activity spastic CP. Task-oriented training, incorporating daily
and participation. Motor control issues, coupled with and play activities, not only improves motivation but also
inefficient movement patterns, pose obstacles to promotes active participation. PNF exercises featuring
manipulative function, leading to difficulties in diagonal patterns prove effective in mitigating
performing specific tasks. The consequences extend dysfunction in the affected arm. Crucially, the versatility
beyond the affected children to impact their parents and of both Task-Oriented Training and PNF extends beyond
caregivers, underscoring the need for effective CP, holding promise for various neurological conditions
interventions to ameliorate upper limb function (Raina et such as stroke, Parkinson's disease, multiple sclerosis,
al., 2005; Oh et al., 2023). This study delves into the and balance disorders, thereby offering potential
comparative efficacy of task-oriented training and applications for individuals at heightened risk of falls. In
proprioceptive neuromuscular facilitation (PNF) summary, this research provides valuable insights into the
exercises in addressing upper extremity function in comparable effectiveness of task-oriented training and
children with spastic CP (Schneiberg et al., 2010). The PNF exercises in addressing upper limb function among
investigation spans interventions over eight (8) weeks, children with spastic cerebral palsy. The implications
with outcomes measured through the Assistive Hand extend to broader neurological contexts, highlighting the
Assessment (AHA-22) and Manual Ability Measure potential of these interventions in diverse rehabilitation
(MAM-16). The findings unveil that both task-oriented settings.
training and PNF exercises result in significant
Acknowledgment
improvements in upper limb functions. Notably, the post-
The author wishes to thank all the participants for
test scores for AHA-22 and MAM-16 exhibit marked
providing support in conducting the research.
enhancements in both groups. Importantly, statistical
analyses confirm the absence of significant differences in
Conflict of Interest
post-test scores between Group A (task-oriented training)
Nil
and Group B (PNF exercise), leading to the acceptance of
the null hypothesis. This study's outcomes align with References
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DOI: https://doi.org/10.52756/ijerr.2024.v39spl.008
116
 How to cite this Article:
Srilakshmi, Arun Selvi, Mahesh Kumar P.G, Hari Hara Subramanyan P.V., Shenbaga Sundaram Subramanian, Thamer A. Altaim, Shadi
Abdelbaset Alkhob and Riziq Allah Mustafa Gaowgzeh (2024). Comparison between Task-Oriented Training and Proprioceptive
Neuromuscular Facilitation Exercise on Upper Extremity Function in Spastic Cerebral Palsy. International Journal of Experimental
Research and Review, 39(spl.) 109-117.
DOI : https://doi.org/10.52756/ijerr.2024.v39spl.008

*Corresponding Author: mahesh@maherfpt.ac.in 117