Constraint Therapy With Progressive Incorporation of Bimanual Therapy Significantly Improves Hand Function in Children With Unilateral Brain Injury

PURPOSE: The purpose of the study was to examine the efficacy of a combined constraint and bimanual therapy protocol in an intensive occupational therapy (OT) program for improving hand function in children with unilateral brain injury. We tested the hypothesis that the combined constraint and bimanual therapy protocol would improve bimanual use of the affected upper extremity, motor function of the affected upper extremity, functional goal performance in daily routines, and caregiver satisfaction. Constraint-induced movement therapy and bimanual therapy are among the most effective hand therapies for children with unilateral brain injury. These therapies have shown equivalence in most studies, although bimanual therapy may more effectively improve functional hand use. Since these therapies train different aspects of hand use, they may have synergistic effects on hand function. To improve functional hand skill in children with unilateral brain injury has been an important area of OT service. Therefore, the need to develop an evidence-based, effective OT protocol to work with this population is important and necessary.

DESIGN AND METHOD: We used an experimental design. Children (N = 20) with unilateral brain injury participated in an intensive OT program with combined constraint and bimanual therapy for 6 wk, 5 days/wk, 6 hr/day. During the first 2 wk, children wore a mitt over the less-affected hand and engaged in functional and play activities with the affected hand. Starting in Week 3, bimanual play and functional activities were added progressively so that by Week 6, children engaged in 2 hr of constraint, followed by 4 hr of bimanual therapy. Children were recruited from our day hospital OT program and from the community. Children were ages 5–10 yr, with decreased use of one upper extremity due to hemiplegia or hemiparesis as a result of cerebral palsy, traumatic brain injury, stroke, or other diagnosis. Participants were required to be able to follow verbal directions, have previous experience attending a day care center or center-based program or school, and have active movement of all joints of the affected upper extremity. Hand function was measured before, after, and 2 mo after therapy with the Assisting Hand Assessment (AHA), Fugl–Meyer Upper Extremity (FM–UE), and Canadian Occupational Performance Measure (COPM). One-way analysis of variance was used to examine changes in outcome measures from before to after therapy and to follow-up.

RESULTS: Therapy improved bimanual use (AHA; p < .001), motor function of the affected upper limb (FM–UE; p < .001), functional goal performance (COPM Performance; p < .001), and caregiver satisfaction (COPM Satisfaction; p < .001). For all measures, the intervention produced a clinically meaningful improvement that was maintained 2 mo later. Repeated doses further enhanced improvements.

CONCLUSION: This combined modified constraint and bimanual therapy protocol in an intensive OT program for improving hand function in children with unilateral brain injury shows promising results in improving bimanual use of the affected upper extremity, motor function of the affected upper extremity, functional goal performance in daily routines, and caregiver satisfaction.

IMPACT STATEMENT: In children with unilateral brain injury, combined constraint and bimanual therapy causes clinically meaningful, lasting improvements in functional hand use. These findings provide evidence for the efficacy of this OT program.

References

Aarts, P. B., Jongerius, P. H., Geerdink, Y. A., van Limbeek, J., & Geurts, A. C. (2011). Modified constraint-induced movement therapy combined with bimanual training (mCIMT–BiT) in children with unilateral spastic cerebral palsy: How are improvements in arm–hand use established? Research in Developmental Disabilities, 32, 271–279. https://doi.org/10.1016/j.ridd.2010.10.008

Aarts, P. B., van Hartingsveldt, M., Anderson, P. G., van den Tillaar, I., van der Burg, J., & Geurts, A. C. (2012). The Pirate group intervention protocol: Description and a case report of a modified constraint-induced movement therapy combined with bimanual training for young children with unilateral spastic cerebral palsy. Occupational Therapy International, 19, 76–87. https://doi.org/10.1002/oti.321