Article

Case report

Effectiveness of surge faradic stimulation and

proprioceptive neuromuscular facilitation for
rehabilitation of hemiplegic hand in hemiplegic
cerebral palsy: a case report
Namrata Sant, Rinkle Hotwani, Yash Kulkarni, Aniruddha Thorat, Pallavi Palaskar

Corresponding author: Pallavi Ratnaparkhi, Mahatma Gandhi Mission (MGM), School of Physiotherapy, Aurangabad,
India. ratnaparkhipallavi@gmail.com

Received: 12 Aug 2021 - Accepted: 08 Feb 2022 - Published: 10 Feb 2022

Keywords: Hemiplegia, hand rehabilitation, surge faradic, stimulation, case report

Copyright: Namrata Sant et al. PAMJ Clinical Medicine (ISSN: 2707-2797). This is an Open Access article distributed
under the terms of the Creative Commons Attribution International 4.0 License
(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Cite this article: Namrata Sant et al. Effectiveness of surge faradic stimulation and proprioceptive neuromuscular
facilitation for rehabilitation of hemiplegic hand in hemiplegic cerebral palsy: a case report. PAMJ Clinical Medicine.
2022;8(32). 10.11604/pamj-cm.2022.8.32.31198

Available online at: https://www.clinical-medicine.panafrican-med-journal.com//content/article/8/32/full

Effectiveness of surge faradic stimulation and Abstract

proprioceptive neuromuscular facilitation for
rehabilitation of hemiplegic hand in hemiplegic Hemiplegic cerebral palsy presents with unilateral
cerebral palsy impairment of upper and lower limbs, resulting in
spasticity and impaired hand function in daily
Namrata Sant1, Rinkle Hotwani1, Yash Kulkarni1, activities. A 4-year-old patient presented with right
Aniruddha Thorat1, Pallavi Palaskar1,& upper limb spasticity with difficulty in hand
1 function. There are various physical therapy
Mahatma Gandhi Mission (MGM), School of
approaches like passive stretching, task-oriented
Physiotherapy, Aurangabad, India
approach, etc. used in cerebral palsy but have not
& shown satisfactory results. The current study
Corresponding author
incorporates proprioceptive neuromuscular
Pallavi Ratnaparkhi, Mahatma Gandhi Mission facilitation-irradiation along with surge faradic
(MGM), School of Physiotherapy, Aurangabad, therapy, a combination of physical treatment that
India works on muscle spasticity and strength. No study
Article
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
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,
Namrata Sant et al. PAMJ-CM - 8(32). 10 Feb 2022. - Page numbers not for citation purposes.
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
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)
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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.
Namrata Sant et al. PAMJ-CM - 8(32). 10 Feb 2022. - Page numbers not for citation purposes.
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
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 facilitate+ory means an impulse
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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
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
The authors declare no competing interests.
Authors' contributions
All the authors have read and agreed to the final
manuscript.
Tables and figures
Table 1: physiotherapeutic intervention plan
followed for the patient
Namrata Sant et al. PAMJ-CM - 8(32). 10 Feb 2022. - Page numbers not for citation purposes.
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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Table 1: physiotherapeutic intervention plan followed for the patient
Intervention Protocol
Bridging, abdominals and obliques, sitting on Swiss ball, weight shifts on tilt board,
side sitting - reach outs, superman - swiss ball, quadripud - postero-lateral reach
Goal-directed exercise
outs, assisted prone planks
programme
Stretching (all major muscle groups- hamstrings, hip flexors and adductors, ankle
plantarflexors), with 30 seconds hold and repeated for 5 times
Frequency-30-contraction each day, intensity- as tolerable by and the patient,
duration-treatment of 10 minutes-each day along with 10 secs on and 3 secs off
Surge faradic
period for 6 weeks, applied to wrist extensors in the sitting position with the elbow
stimulation
in 90% and wrist in the neutral position, with Inactive electrode at C7 vertebra and
active electrode, pen to stimulate wrist extensors
Resistance is applied for elbow flexion in pronation, external rotation of the
PNF irradiation
shoulder, which facilitates the recruitment of wrist and finger extensors
Theraband activity, pegboards, theraputty, wheel barrow walking, spring activities,
Gross and fine motor clay activity, scribbling, beads and string, smiley ball, turning pages, folding pages,
activities paper cutting with scissors, picking up marbles, opening and closing of water bottle,
using hand spray for watering plants, etc
Splinting Advise static cock-up splint for night time dynamic cock up splinting for day time

Table 2: the outcome measure pre-treatment and post treatment status of patient
Outcome measure Pre-assessment Post-assessment
QUEST (quality of Total score: 56.15, dissociated Total score: 86.17, dissociated movements
upper extremity skills movements-90.6, grasps- 34, weight 87.5, grasps- 83.33, weight bearing- 78,
test ) bearing-50, protective extension- 50 protective extension-95.83
MAS (modified Shoulder and elbow flexors-2, Shoulder and elbow flexors-1, supinators-1,
ashworth scale for supinators −1+, wrist flexors-2 wrist flexors-normal
hypertonia)
TCMS (trunk control Total score: 26/58 static sitting Total score: 48/58 static sitting balance:
measure scale) balance: 10/20, dynamic sitting 16/20, dynamic sitting balance: 23/28,
balance: 11/28, dynamic reaching dynamic reaching 9/10
5/10

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Figure 1: pre-treatment

Figure 2: post-treatment

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