Intensive Therapy Approaches for Children with HemiplegiaTerryl B Rosenberg PT DPT and Teressa Reidy MS/OTR

What is Constraint Induced Movement Therapy?

Constraint Induced Movement Therapy (CIMT) is a therapeutic intervention for people with hemiplegia in which intense practice of active movement of the involved upper extremity is promoted by restraining the non-involved upper extremity. CIMT may lead to the improvement in how children use their affected upper extremity in functional tasks of daily living at home, school and in the community/play settings.

What is Bimanual Intensive Therapy (BIT)?

BiManual Intensive Therapy is a child friendly intensive intervention to improve bimanual hand use. Children with hemiplegia have impairments in bimanual coordination beyond their unilateral impairments. BIT is intensive structured practice of both hands in cooperation, and has been found to be as efficacious as restricted restraints.

What are these intensive therapy approaches?

Both of these intervention techniques aim to improve the affected hand in daily tasks to stabilize or steady objects while the dominant hand manipulates them. The affected upper extremity can also become an assist or a manipulator in some children. The goal is to improve the use of two hands cooperatively to complete bimanual tasks of daily living by strengthening and improving the dexterity of the affected hand to the child’s maximal abilities.

Neither of these treatment techniques will change the handedness of the child or completely reverse motor impairments.

What is the method of constraint?

Studies report using a bivalve cast, splint, mitten, or sling.The Children’s age, parental preference, availability of materials, insurance reimbursement and the therapists’ preference may guide the use of materials.

Who was CIMT developed to help?

This rehabilitation technique was originally designed for adults with hemiplegia from chronic stroke. Researchers and clininical providers applied similar elements and methodology of the adult studies to a pediatric form for children.

Who was BIT developed to help?

BIT was developed as a child friendly intensive practice model to improve use of both hands in cooperation for children with hemiplegia.

Who can benefit from these intensive services?

Research has supported the use of CIMT and BIT for children with congenital and acquired central nervous system injury with resultant hemiplegia such as cerebral palsy, traumatic brain injury, stroke and genetic disorders. Emerging case reports describe positive trends using this intervention with peripheral injuries such as Brachial Plexus Injury.Factors including age, cognition, focus, behavior, extent of sensorimotor involvement, location and size of lesion can impact participation in these types of programs. Research reports various levels of parental involvement in treatment.

What are the key components of CIMT and BIT?

CIMT:

  • Constraint of the non-affected limb via cast, sling, mitt glove, etc.
  • Massed, shaping and repetitive practice in child friendly environments
  • Gradually increasing task demands and the level of challenging of activities to build new motor skills

BIT:

  • Structured and Intensive Massed practice of bimanual tasks in child friendly environments
  • Parts and Whole Skill practice
  • Gradually increasing task demands and the level of challenging of activities to build new motor skills and improve use of both hands in cooperation
  • Verbal and other types of cues to use both hands in cooperation

What age is the best time to complete these interventions?

A growing number of randomized controlled trials and clinical trials support the use of CIMT with children as young as 16 months old. New case studies are reporting positive effects with children less than one year old. Randomized controlled trials support this intervention for children through adolescence and are demonstrating effects lasting at least 6 months post intervention. Consistent clinical observation has reported that perhaps CIMT is most beneficial for children 4 years and younger and BIT is better for older children who can follow directions. However, this is has not been adequately investigated and it may depend on the individual child to determine which intervention is optimal.

There are many studies to support efficacy of both CIMT and BIT.

Who might benefit from CIMT or BIT?

Unlike adult protocols there is no pre-requisite range of motion needed for pediatric CIMT or BIT. In general children may need a modified protocol if they have:

  • Severely limited UE movement in Bilateral UE
  • Contractures that would limit participation
  • Self Injurious Behavior
  • Severe Vision Limitations
  • Are non-ambulatory

Children may not be appropriate for this intervention if they have active or uncontrolled seizures. Consultation/clearance of a neurologist is recommended.

What is the intervention protocol and reaction of the child?

Children may be frustrated at first because of their involved limb not available for routine tasks but with success in movement tasks, most reportedly adapt quickly. Therapists will guide the child and provide a just right challenge for therapeutic activities as well as guide the family in adapting tasks to make the child more successful at home using his or her affected arm and hand. The child may no longer experience failure moving his or her affected arm and may be more motivated to use his or her affected hand during play or self care.

What is the role of the family?

The families can help identify what activity routines are important parts of their children’s lives. They collaborate with therapist to set appropriate goals and problem solve ways that the affected hand can be used as a helper hand in two handed activities.

With training, the families can coach and assist their children to problem solve and practice using the affected extremity in practical, everyday activities in the home, community, school and play. Progress is made on goals identified as important by children and caregivers.

What is the role of the PT/OT? Who is the interventionist?

The therapy staff should be familiar with CIMT and BIT. The therapist should be familiar with hemiplegia and co-morbidities. The therapist/interventionist will provide structured practice in a child friendly way. The therapist sets goals with the family and is a resource, consultant and provider of education about the intervention. The therapist will also provide documentation of effectiveness through use of standardized tests and measures specific to hand impairments.

There is evidence to support that parents and caregivers can assist with the intervention and this would be determined on an individual case basis.

What are the Advantages and Disadvantages of both therapy techniques?

  • Both interventions use intensity of practice and this is a key element to the reported improvements.
  • The use of cast or restraints may take the burden of repeated cues to use the affected extremity.
  • The cast or glove is a short duration for a long term gain.
  • Research shows both retain significant gains.
  • Both interventions may need to be repeated over time to maintain benefits.
  • Both approaches recognize that the family can assist with improving and promoting use of the affected extremity.
  • Both interventions provide opportunities for the child to choose activities.
  • Both interventions provide positive reinforcement including verbal praise, stickers, and increased motivation with each success.
  • There is no evidence that one approach is better than the other.

What is the method of payment? Does insurance cover this approach?

Some insurances and medical assistance programs are beginning to cover intensive therapy models. Families should discuss use of therapy benefits with the therapy provider to limit out of pocket expenses. To assist with reimbursement, a letter of medical necessity may be provided to third party payers with an outline of the compelling evidence of effect on hand function with these approaches for children with hemiplegia. This letter can be drafted by your therapists and/or physician.

What is the best dosage?

Some evidence reports multiple times per week over two to several weeks is required for optimal outcome (greater than the conventional prescribed schedule). Evidence shows that 90 hours of CIMT or BIT result in longer retention of benefits.

In a clinical setting what other adjunctive treatments may be used?

A therapist may use the following techniques in conjunction with CIMT or BIT therapy approaches: electrical stimulation, taping, aquatics, commercially available gaming and robotics.

What are the guidelines for future research?

Future research is needed to determine if any specific model demonstrates superiority over others, the impact of age, and how dosing and training environments matter.

References:

Case-Smith, J., DeLuca, S. C., Stevenson, R., et al. (2012). Multicenter randomized controlled trial of pediatric constraint-induced movement therapy: 6-month follow-up. American Journal of Occupational Therapy, 66(1), 15–23.

Coker, P., Lebkicker, C., & Harris, L. (2009). The effects of constraint-induced movement therapy for a child less than one year of age. Neurorehabilitation, 24, 199–208

Gordon, AM., Schneider, JA., Chinnan, A., and Charles, JR., (2007) Efficacy of a Hand–Arm Bi-Manual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: a randomized control trial. Developmental Medicine and Child Neurology Volume 49, Issue 11

Gordon et al, (2011) Bimanual Training and CIMT in Children with Hemiplegic CP, A Randomized Trial. Neurorehabilitation and Neuro Repair

Lowes et al, (2013) Pilot Study of the Efficacy of Constraint-Induced Movement Therapy for Infants and Toddlers with Cerebral Palsy Physical & Occupational Therapy in Pediatrics, Early Online:1–18, 2013

Novak, I., McIntyre, S., Morgan, C., et al. (2013). A systematic review of interventions for children with cerebral palsy: State of the evidence. Developmental Medicine and Child Neurology

Reidy, T., Naber, E. & Tsai, T. (2013). Novel and Complementary Therapy Strategies: Critical Issues and Opportunities for Combining with Pediatric CIMT. In A Handbook of Pediatric Constraint-Induced Movement Therapy (P-CIMT): A Guide for Occupational Therapy and Health Care Clinicians, Researchers and Educators. Edited by S. Ramey, P.Coker-Bolt & S. Deluca, AOTA Press. Bethesda, MD

Sazkewski, Gordon, and Eliasson. (2014) The State of Evidence for Intensive Upper Limb Therapy Approaches. J of Child Neurology