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.

Cerebral palsy (CP) is the most common cause of childhood physical disability and is characterized by permanent disorders of movement and posture resulting from non-progressive injury to the developing brain. Although children with spastic diplegic CP primarily present with lower-limb involvement, many also experience impaired upper extremity function, including reduced muscle coordination, impaired selective motor control, weakness, and limitations in reaching, grasping, and object manipulation. These impairments restrict participation in self-care, education, play, and other daily activities.

Task-Oriented Training (TOT) is an evidence-based rehabilitation approach that emphasizes repetitive practice of meaningful, goal-directed functional activities to promote motor learning and improve participation. Proprioceptive Neuromuscular Facilitation (PNF) is another therapeutic approach that enhances neuromuscular activation, proprioceptive input, and coordinated movement patterns through specific diagonal movement techniques. While both interventions have demonstrated beneficial effects in children with cerebral palsy, limited evidence directly compares their isolated and combined effects on upper extremity function in children with spastic diplegic CP.

This study is a three-arm randomized controlled trial designed to compare the effectiveness of PNF alone, TOT alone, and combined PNF plus TOT. A total of 63 children aged 6-12 years with spastic diplegic cerebral palsy (GMFCS levels I-III) will be recruited and randomly allocated to one of the three intervention groups using block randomization.

Participants will receive supervised physiotherapy sessions lasting 45 minutes, three times per week for six weeks. The PNF group will perform upper extremity D1 and D2 diagonal movement patterns. The TOT group will perform structured functional activities including reaching, grasping, releasing, stacking, and object manipulation. The combined intervention group will receive both PNF and TOT within the same treatment session.

Outcome measures will include:

Melbourne Assessment of Unilateral Upper Limb Function (MA2) to assess upper limb movement quality.

Pediatric Evaluation of Disability Inventory-Functional Skills Scale (PEDI-FSS) to evaluate functional independence in self-care.

Goniometric measurements of shoulder, elbow, and wrist range of motion.

Assessments will be performed at baseline, three weeks, and six weeks by trained assessors. Statistical analyses will compare changes within and between groups to determine whether combined therapy provides greater improvements than either intervention alone.

The results of this trial are expected to strengthen the evidence base for pediatric neurorehabilitation and assist clinicians in selecting the most effective physiotherapy approach to improve upper extremity function and functional independence in children with spastic diplegic cerebral palsy.

Inclusion Criteria:

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. Medically stable and able to participate in physiotherapy sessions. Parent or legal guardian willing to provide written informed consent.

Exclusion Criteria:

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. Fixed upper extremity contractures or musculoskeletal deformities preventing participation in the intervention.

Participation in another structured upper extremity rehabilitation program during the study period.

Failure to obtain informed consent from a parent or legal guardian.

Individual participant data (IPD) will not be shared to protect participant confidentiality and privacy, as the informed consent process did not include permission for public data sharing. De-identified aggregate study results will be published in peer-reviewed journals and presented at scientific conferences. Requests for additional information regarding the study methodology or summary findings may be considered by the principal investigator in accordance with institutional policies and ethical guidelines.

Outcome assessments will be performed by an assessor who is blinded to participants' group allocation. Due to the nature of the physiotherapy interventions, participants and treating physiotherapists cannot be blinded.