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Case report

Effectiveness of surge faradic stimulation and proprioceptive neuromuscular facilitation for rehabilitation of hemiplegic hand in hemiplegic cerebral palsy: a case report

Effectiveness of surge faradic stimulation and proprioceptive neuromuscular facilitation for rehabilitation of hemiplegic hand in hemiplegic cerebral palsy

Namrata Sant1, Rinkle Hotwani1, Yash Kulkarni1, Aniruddha Thorat1, Pallavi Palaskar1,&


1Mahatma Gandhi Mission (MGM), School of Physiotherapy, Aurangabad, India



&Corresponding author
Pallavi Ratnaparkhi, Mahatma Gandhi Mission (MGM), School of Physiotherapy, Aurangabad, India




Hemiplegic cerebral palsy presents with unilateral impairment of upper and lower limbs, resulting in spasticity and impaired hand function in daily activities. A 4-year-old patient presented with right upper limb spasticity with difficulty in hand function. There are various physical therapy approaches like passive stretching, task-oriented approach, etc. used in cerebral palsy but have not shown satisfactory results. The current study incorporates proprioceptive neuromuscular facilitation-irradiation along with surge faradic therapy, a combination of physical treatment that works on muscle spasticity and strength. No study has been studied for this combination of therapies for the reduction of spasticity in cerebral palsy patients. Hence, this study aims at the effectiveness of combined surge faradic stimulation and PNF irradiation on hand functions in hemiplegic cerebral palsy patient. Outcome measures used in the study are TCMS to assess trunk control, MAS to assess spasticity and QUEST to assess hand function skills before and after physiotherapeutic intervention. Present study concluded that surge faradic stimulation and PNF irradiation given for wrist extensors has improved hand function skills, decreased spasticity and improved trunk control in hemiplegic cerebral palsy.



Introduction    Down

Cerebral palsy is described as non-progressive disturbances that occurred in the developing fetal or infantile brain that impair a person's ability to control body movement and posture, cognition, communication, perception and behavior, occurs in two to six of every 1,000 births. There are many types of cerebral palsy from which spastic hemiplegic cerebral palsy is one of the type and seen in 35 to 40 percent of cases [1]. The upper motor neuron lesion leads to spasticity, which is one of the most common symptoms. Spasticity is the result of a loss of inhibitory control of higher centers at the level of spinal arch. It is presented as significantly increased muscle tone and muscle tightness, which results in a limited range of motion and joint mobility [2]. In hemiplegic cerebral palsy, flexor synergy is commonly seen in the upper extremity. The components of flexor synergy are scapular elevation, shoulder flexion, adduction and internal rotation, elbow flexion, forearm pronation, wrist flexion and thumb adduction along with finger flexion in turn leads to difficulty in performing daily activities like, opening of hand for holding objects such as brushes, glass, pencil as well as dressing [3]. To prevent long-standing impairments of upper extremity flexion and to facilitate forearm supination along with wrist and finger extension, physiotherapeutic intervention is important. There is ample amount of literature available on the treatment of hemiplegic hand in cerebral palsy, but this report has concentrated on the precision of treatment protocol according to patients need, which include the combination of surge faradic stimulation and Proprioceptive Neuromuscular Facilitation (PNF) irradiation. Hence, this report aims at the effectiveness of combination of surge faradic stimulation and Proprioceptive Neuromuscular Facilitation (PNF) irradiation in improving function of hemiplegic hand in hemiplegic cerebral palsy patients.



Patient and observation Up    Down

Patient information: this report is presenting a 4-year-old male, left-handed by dominance, complaints regarding the difficulty in using the right hand for bilateral hand activities like buttoning-unbuttoning, closing-opening water bottles, catching-throwing ball and unilateral activities like difficulty using right hand for lifting glass, drinking water. The patient had preterm normal vaginal delivery at 32 weeks of gestation in view of the leakage of amniotic fluid from the sac, did not cry immediately after birth with APGAR score 7 at 1 min and 9 at 5 min, birth weight 2210 grams, admitted for 10 days in the Neonatal Intensive Care Unit (NICU) for oxygen support, diagnosed as Respiratory Distress Syndrome (RDS). During the stay, the patient showed the symptoms of neonatal jaundice, managed with phototherapy. At the physical therapy outpatient department, the patient presented with weakness of the right upper limb and difficulty in un-fisting and opening of hand, right-sided asymmetry, poor trunk control, right hand fisted with significant impairment of hand activities, increased tone and spasticity in the shoulder and elbow flexors, supinator´s, wrist flexors, impaired bimanual activities, independent unilateral activity of the right hand is challenging.


Clinical findings: on examination, spasticity grades according to the Modified Ashworth Scale (MAS) in the elbow and wrist flexors were 2, supinators were 1+. On observation, in quiet standing, the patient presented with right shoulder adducted, internally rotated, elbow flexed, pronated, wrist flexed with fingers flexed and thumb adducted. Goniometry was used to measure the active range of motion (AROM) and passive range of motion (PROM) that found decreased range of shoulder flexion and external rotation, elbow extension, forearm supination, wrist extension [4,5]. The quality of upper extremity skills test (QUEST) used for the assessment of hand function. This measure evaluates quality of upper extremity function in four domains: dissociated movement, grasp, protective extension, and weight-bearing. It is designed to be used with children who have neuromotor dysfunction with spasticity and has been validated with children from 18 months to 8 years of age [6]. Trunk control measure scale (TCMS) is used for assessing trunk control in neuromotor dysfunction, which has good validity and reliability [7].


Timeline: as shown in Figure 1 the patient had difficulty regarding the difficulty in using the right hand for bilateral hand activities like buttoning-unbuttoning, closing-opening water bottles, catching-throwing ball and unilateral activities like difficulty using right hand for lifting glass, drinking water this led to compromised quality of life.


Diagnostic assessment: all MRI scans and blood reports during patient's ICU stay were analyzed, more reliance was on physical findings. The diagnostic challenge was finance. Patient was lower middle class and was not able to afford expensive scans.


Therapeutic intervention: as shown in Table 1 [8-17]. Physiotherapeutic protocol designed as per patient need, which includes 45 min of session, 6 days a week. Intervention such as goal-directed exercise program, surge faradic stimulation, PNF irradiation, neurodevelopmental techniques for gross and fine motor activities of hand was followed for the patient.


Follow-ups and outcomes: Table 2 represents the outcome measures demonstrating the pretreatment and posttreatment status of patient [4-7]. Figure 2 represents post treatment outcomes.


Patient perspective: patient was adherent to the treatment the patients' caregiver was impressed and satisfied with post treatment outcomes.


Informed consent: verbal and written consent was obtained from caregiver.



Discussion Up    Down

This study evaluated the efficiency of PNF irradiation and surge faradic stimulation in improving upper limb function and coordination in a child with hemiplegic cerebral palsy. Surge faradic stimulation is effective in improving muscle function, decreasing muscle tone and increasing range of motion in children with hemiplegic cerebral palsy during physical therapy program [12]. Surge faradic stimulation assist the weak muscle to contract maximally, recruiting all possible muscle fibers without undergoing fatigue. Also, electrical stimulation of the hand and fingers leads to an improved sensorimotor outcome immediately after the intervention [13]. These positive effects are related to increase in blood flow to the area due to vasodilatation, voluntary muscle contraction, increase in metabolism and removal of waste products leading to more blood supply and nutrients to muscle as well as reeducation of muscle action the extent of muscle atrophy [14].


There is ample evidence on PNF training in cerebral palsy for improving lower limb coordination [15]. Another study showed PNF training to chronic stroke patients that concluded that it decreases muscle stiffness and abnormally increased muscle tone [16]. The positive effects of PNF irradiation are related to concepts of facilitation and inhibition, stretch reflex and neurophysiologic phenomenon, which includes principles as facilitatory means an impulse causing the recruitment and discharge of additional motor neurons in the spinal cord, resulting in increased excitability of muscle. Inhibitory means any stimulus that causes motor neuron to drop away from the discharge zone and away from the spinal cord, resulting in decreased excitability and spasticity of muscle. It is also related to stretch reflex, which involves 2 types of receptors, muscle spindle and golgi tendon, co-activation of both results in isolated muscle contraction through alpha motor neurons. In our study, principles of PNF used are-resistance, irradiation and reinforcement and manual contact. Their effects showed increased ability of the muscle to contract, increased motor control, improved awareness of movement and increased strength of muscle. The irradiation technique in healthy subjects revealed to elicit muscle response at distance, ipsilateral and contralateral to the stimulus. Clinically, its use allows muscle contraction when there is some impediment in exercising a body segment directly. Thus, PNF techniques help improve trunk control and QOL in hemiplegic population [17,18].



Conclusion Up    Down

So, it can be concluded that by giving surge faradic stimulation with irradiation, PNF is effective in improving hand functional skills in hemiplegic cerebral palsy patients.



Competing interests Up    Down

The authors declare no competing interests.



Authors' contributions Up    Down

All the authors have read and agreed to the final manuscript.



Tables and figures Up    Down

Table 1: physiotherapeutic intervention plan followed for the patient

Table 2: the outcome measure pre-treatment and post treatment status of patient

Figure 1: pre-treatment

Figure 2: post-treatment



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