Constraint Induced Movement Therapy and Bimanual Intensive Therapy for Children
With Hemiplegic Cerebral Palsy
Cathy Howes, PT, MS
Introduction
Cerebral palsy (CP) is the most common pediatric physical disability with the incidence for congenital hemiparesis rising.1 Intervention for children with hemiplegic CP involves promoting increased use and function of the weak upper limb (UL). Constraint induced movement therapy involves constraining the unimpaired UL with a cast or other device so that the child is encouraged to use the involved upper extremity for performing play and functional tasks. The cast is worn for 3-24 hours per day for 10 days to 3 weeks depending on the protocol followed.
In the mid 2000’s a paradigm shift occurred which explored bimanual coordination challenges in children with hemiplegic CP. Charles and Gordon introduced another intervention known as hand-arm bimanual intensive training (HABIT or BIT).2 This intervention involved extensive targeted practice provided in a child-friendly manner without using a physical constraint on the involved UL.2 Activities requiring bimanual coordination are then practiced such as play, dressing, ADL’s.2 I completed a research paper (EBP Paper) to explore and discuss the two interventions in depth.
I was interested in comparing these two interventions for my Capstone to determine “best practice” for treating the weak UL of children with hemiplegic CP. I was particularly curious as I have been involved, with my work colleagues, in participating in a camp that provides mostly CIMT and some BIT for children with hemiplegic CP. Thus my PICO question was: For children with hemiplegic cerebral palsy between the ages of 2-16, is use of constraint induced movement therapy versus bimanual therapy more effective in improving upper limb function?
This has been a current, well-researched topic over the last three years with level 1 evidence including 8 randomized controlled trials, 2 systematic reviews and 1 meta-analysis that I was able to review (Evidence Table).
Products
The literature review and the camp were a perfect melding as student volunteers require education about the topic to better intervene with the children during camp. I was inspired to synthesize the literature review to develop a Powerpoint with voicethread (http://voicethread.unc.edu/). This can be accessed by clicking on the link, typing in your onyen and searching constraint in the browser. The students will view this prior to camp. To measure learning and understanding of the concepts associated with CIMT and BIT a PRE and POST Test was developed (Pre -Post Test). I developed an Outcomes Measures Table (Outcome-Measures Table) that explored in more detail, the most commonly utilized outcome measures reported in the literature.
Outcomes
To measure the effectiveness of the products, I developed an evaluation form ( Evaluation form). As camp doesn’t begin until June, I was unable to seek real time feedback, but will use this when camp starts. I did seek feedback from 4 students who were kind enough to view and listen to my PPT with voicethread, take the pre and post-tests, view the Outcome Measures Table and provide me feedback on my project evaluation form. All participants felt the Capstone was beneficial and liked the Outcomes Measures Table summary. A useful piece of feedback may have been to include video of intervention with a child with hemiplegic CP. This would be a nice addition to the project which I may pursue in the future.
Thank You
I would like to take the opportunity to publicly acknowledge and thank Dr. Prudence Plummer, Dr. Katie Ollendick and Dr. Margo Haynes for their invaluable insight, guidance and support during the development and completion of this project. A big thank you to Holly Holland, OTR/L camp director and student volunteers who donate their time and energy to positively impact the lives of children with hemiplegic cerebral palsy.
References
1. Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: Incidence, impairments and risk factors. Disabil Rehabil. 2006;28(4):183-191. doi: 10.1080/09638280500158422.
2. Charles J, Gordon AM. Development of hand-arm bimanual intensive training (HABIT) for improving bimanual coordination in children with hemiplegic cerebral palsy. Dev Med Child Neurol. 2006;48(11):931-936. doi: 10.1017/S0012162206002039.
8 Responses to “Constraint Induced Movement Therapy and Bimanual Intensive Therapy for Children with Hemiplegic Cerebral Palsy”
Cathy Howes
Margo, Thanks for the kind words and all the support and feedback. I agree that treatment videos would enhance the student’s strategies and understanding of ways to work with the child. Let’s identify a few kids in camp and do it this year! Cathy
Margo Haynes
Your finished product (power point with voice thread) turned out lovely – job well done! I know it will be a great introduction for the students participating in the CIMT camp this summer. You reviewed the CIMT and BIT research and skillfully showed how these two interventions blend together in a camp situation. I liked the section where you talk about the interventions that will be carried out at CIMT camp. Providing treatment strategies for the students will help them as they prepare for the 10 day camp and the valuable work that they will provide to help the children. As you stated on the home page, several short treatment video clips (1-2 minutes) would definitely be appropriate to place in your presentation. One example would be to demonstrate 1-2 strategies that a therapist would use to address grasp and release. This specific intervention is difficult to show by pictures alone. The power point with voice thread has a very nice flow and you could bring your presentation to completion with a 2-3 minute video clip of the children participating in a camp activity – all that great play!
Cathy Howes
Hi Marion, Thanks for the positive feedback. If you want to volunteer for camp to get a better feel, let me know. We are always seeking volunteers to work with the campers and mentor the students. It does run over a weekend! It is a very rewarding and enriching experience for all involved. Cathy
Marian Stein
Cathy,
You did an excellent job on the voice thread and power point. I have many patients that have come to this summer camp and it is a wonderful opportunity for the patients and the parents. I hope this instructional piece helps with the training of the volunteers. I loved how complete and concise your page was on the website.
Marian
Cathy Howes
Casey, Thank you for your insightful comments. I think it will be a nice adjunct to help the student volunteers become familiar and/or review concepts. I’m looking forward to see it in operation in June. If anyone is interested in finding out more about camp, please contact me. We still need more student volunteers! cathy
Casey Poff
Cathy,
Terrific job on your capstone project!
As someone who has volunteered as a student at this CIMT camp for the past two years, I think this PowerPoint and voice thread will be a great addition to the pre-camp training! It is an excellent introduction to CIMT and BIT for those who are unfamiliar with these interventions, and a great review for those who may have been introduced to (or have minimal experience with) the interventions.
I am looking forward to seeing this implemented at camp this summer and hearing the feedback from the other student volunteers! Great work, Cathy!
Casey
Cathy Howes
Delane, Thanks for your feedback. This has become a great experience for our department and our Peds OT has made us all passionate about treating these children free of charge in a camp setting. Not only do the children with hemiplegia benefit, but the parents are able to network and the student volunteers rave about how valuable an experience it was. Since I was interested in the topic, it just really flowed and I enjoyed the experience of creating useful products to benefit the camp and assist with educating the students. All the best! Cathy
delane clark
Cathy,
This semester in PHYT 885 I’ve taken a closer (though not as close as you) look at constraint induced movement therapy (CIMT), so for me, your capstone posting couldn’t have come at a better time. From animal research to adults to children, CIMT seems like an effective intervention. I was less familiar with bimanual intensive training (BIT), so it was nice to learn more about it and understand that it can be effective, too. The review you cited by Novak et al. really highlighted to me that for children with cerebral palsy (CP), CIMT and BIT are interventions we should give strong consideration. Out of the 21 of 131 interventions backed by strong evidence and given a grade of “green light go”, CIMT and BIT were two of them. The information you provided gave me a very comprehensive perspective. With your materials, I was able to move from a clear and concise summary of the research evidence to clinical implications to a great overview of what to expect as a CIMT/BIT camp volunteer. Your capstone has prompted me to reach out to an OT in my area to learn more about the CIMT summer camp she offers. It’s been great to interact and to learn from your contributions over the last four semesters. Best wishes for everything post tDPT program!
Delane