Group Constraint-Induced Movement Therapy for

Children With Hemiplegic Cerebral Palsy: A Pilot Study

Wen-Chi Wu, Jen-Wen Hung, Chiung-Yi Tseng, Yi-Ching Huang

MeSH TERMS
! activities of daily living
! cerebral palsy
! hemiplegia
! motor skills
! movement
! restraint
! physical

OBJECTIVE. We investigated the feasibility and effectiveness of group-based constraint-induced movement therapy (CIMT) for children with hemiplegic cerebral palsy in a clinical setting.
METHOD. Seven children received CIMT together under the guidance of two occupational therapy practitioners, 2.5 hr/day, 5 days/wk for 4 wk. We used the Grasping and VisualMotor Integration subtests of the
Peabody Developmental Motor Scales to assess the primary outcome and the Functional Skills and
Caregiver Assistance Scales of the Pediatric Evaluation Disability Inventory to assess the secondary outcome. Children were examined at preintervention, postintervention, and 1- and 3-mo follow-up.

RESULTS. Children demonstrated significant improvement on all outcome measures after intervention (all
ps < .05, effect sizes 5 .39.84), and effects were maintained at 3-mo follow-up.
CONCLUSION. This preliminary study revealed that group-based CIMT for children with hemiplegic cerebral palsy may be a feasible and effective alternative to individual CIMT in clinical practice.
Wu, W.-C., Hung, J.-W., Tseng, C.-Y., & Huang, Y.-C. (2013). Group constraint-induced movement therapy for children
with hemiplegic cerebral palsy: A pilot study. American Journal of Occupational Therapy, 67, 201208. http://dx.
doi.org/10.5014/ajot.2013.004374

Wen-Chi Wu, MA, OTR/L, is Occupational Therapist,

Department of Rehabilitation, Kaohsiung Chang Gung
Memorial Hospital, Kaohsiung, Taiwan.
Jen-Wen Hung, MD, is Assistant Professor, Department
of Rehabilitation, Kaohsiung Chang Gung Memorial
Hospital, Chang Gung University College of Medicine,
123 Dapi Road, Niaosong District, Kaohsiung City 833
Taiwan; hung0702@adm.cgmh.org.tw
Chiung-Yi Tseng, MD, is Physician, Department of
Rehabilitation, Kaohsiung Chang Gung Memorial
Hospital, Kaohsiung, Taiwan.
Yi-Ching Huang, OTR/L, is Occupational Therapist,
Department of Rehabilitation, Chang Gung Memorial
HospitalChiayi, Chiayi, Taiwan.
Wen-Chi Wu and Jen-Wen Hung contributed equally to
this paper and should be considered as first authors.

The American Journal of Occupational Therapy

erebral palsy (CP) is a disorder of movement and posture control resulting

from a nonprogressive lesion to an immature brain (Bax, 2005). It is the
leading cause of childhood disability. Hemiplegia occurs in 25%33% of
children with CP, in whom upper-extremity (UE) involvement is usually more
noticeable than lower-extremity involvement (Colver & Sethumadhavan,
2003). Children with hemiplegia have motor impairments, sensory impairments, or both in the affected limbs (Exner, 2005; Fedrizzi, Pagliano, &
Andreucci, 2003). As a result, they have never learned to use their affected limbs
effectively and then demonstrate developmental disregard or nonlearned use of
their affected limbs (Deluca, Echols, Law, & Ramey, 2006; Taub, Ramey,
DeLuca, & Echols, 2004).
Many intervention methods have been developed to compensate for the
deficits in UE function and activity limitations of children with hemiplegia (Boyd
et al., 2010; Exner, 2005; Sakzewski, Ziviani, & Boyd, 2009). Constraintinduced movement therapy (CIMT) was initially developed to treat adults with
hemiplegia (Wolf, Lecraw, Barton, & Jann, 1989). In CIMT, the less affected
UE is restrained while the affected UE receives intensive training of unimanual
skills. Recently, CIMT was also used with children (Aarts, Jongerius, Geerdink,
van Limbeek, & Geurts, 2010; Brogardh & Sjolund, 2006; Charles, Wolf,
Schneider, & Gordon, 2006; Crocker, MacKay-Lyons, & McDonnell, 1997; de
Brito Brandao, Mancini, Vaz, Pereira de Melo, & Fonseca, 2010; Deluca et al.,
2006; Eliasson, Sundholm, Shaw, & Wang, 2005; Sakzewski et al., 2011;
Taub et al., 2004). Despite CIMTs moderately positive effect on motor
function of the affected UE and disability in clients with hemiplegic CP,
concerns have been raised regarding its appropriateness in the pediatric
201

population (Gilmore, Ziviani, Sakzewski, Shields, & Boyd,

2010). The high intensity of training and restriction of the
less affected hand can result in frustration and irritability
for children.
Another concern is that CIMT is labor intensive; it is
usually carried out one-on-one with a therapist in a series
of 2- to 6-hr training sessions (de Brito Brandao et al.,
2010; Deluca et al., 2006; Eliasson et al., 2005; Taub
et al., 2004). Most facilities do not have enough therapists to deliver such time-consuming treatment (Page,
Levine, Sisto, Bond, & Johnston, 2002). In addition,
insurance payment systems may not adequately reimburse
for such intensive training. For example, in Taiwan insurers reimburse 50 min of an intervention session; longer sessions result in no additional payment. Therefore,
the original CIMT delivery model requires modification
before it can gain acceptance in clinical practice.
The CIMT group approach may be more practical
than individual therapy given its potential to reduce total
staffing hours needed for treatment implementation
(Leung, Ng, & Fong, 2009). Because few studies have
applied pediatric group-based CIMT in clinical practice,
we aimed to investigate the feasibility and effectiveness of
delivering group-based CIMT to children with hemiplegic CP in a clinical setting.

Method
Research Design
We conducted a quasi-experimental, one-group preinterventionpostintervention and follow-up trial. The
Chang Gung Memorial Hospitals Institutional Research
Ethics Committee approved this study. Informed consent
was obtained from the participants and their parents.
Participants
Participants were recruited from the pediatric occupational therapy service in a tertiary hospital in southern
Taiwan. The inclusion criteria were diagnosis of hemiplegic CP; between ages 2 and 14 yr; and Manual Ability
Classification System (Eliasson et al., 2006) scores of I, II,
or III. We excluded children who had severe paralysis in
the affected UE, a visual problem that would interfere
with the intervention or testing, orthopedic surgery, or
botulinum toxin injection in the affected UE during the
past 6 mo.
Instruments
Peabody Developmental Motor ScalesSecond Edition.

We used two subscales of the Peabody Developmental

Motor ScalesSecond Edition (PDMS2; Folio & Fewell,
202

2000)Grasping (PDMSG) and VisualMotor Integration (PDMSV)to examine the fine motor function of the affected UE as the primary outcome. The two
subscales consist of 98 items, and every item was rated on
a 3-point scale: 0 5 unable or unwilling to do the motion;
1 5 able to do the motion but not reach the standard; and
2 5 the motion reaches the standard. No Chinese version
of the PDMS2 was available. Using the U.S. version,
Wang, Liao, and Hsieh (2006) found that the composite
scores of the PDMS2 had good testretest reliability
(intraclass correlation coefficients [ICCs] 5 0.881.00),
and responsiveness coefficients ranged from 1.7 to 2.2
when tested with Taiwanese children with CP. Some
participants in our study were older than 71 mo, which is
the upper limit suitable age for testing children with
the PDMS2. Because the fine motor skills of the participants affected UEs were below those expected of
a 71-mo-old child, we chose to use the PDMS2 as one
of the evaluation tools in this study. Because the norm
references for Taiwanese healthy children are not yet
obtainable, we used the raw scores for data analysis.
Pediatric Evaluation of Disability Inventory. Participants
functioning in daily living activities was assessed with
the Pediatric Evaluation of Disability Inventory (PEDI;
Haley, Coster, Ludlow, Haltiwanger, & Andrellos, 1992)
as the secondary outcome. The PEDI consists of a semistructured interview with parents to assess a childs
functional skills and need for caregiver assistance in
performing self-care, mobility, and social function tasks.
The Functional Skills Scale measures the childs ability to
perform specific functional skills. The child receives
a score of either 1 (has ability) or 0 (has not yet demonstrated ability/unable) on each item. The Caregiver Assistance Scale measures the caregivers typical amount of
assistance provided to complete basic functional activities
(scoring: 5 5 independent; 4 5 supervision; 3 5 minimal
assistance; 2 5 moderate assistance; 1 5 maximal assistance;
0 5 total assistance). In our study, we assessed only selfcare domains.
Although the PEDI was designed primarily for
assessing functional performance in children 6 mo7.5 yr
old, it has also frequently been used with children with
CP who are >7.5 yr old but have functional ability below
that expected of typically developing 7.5-yr-old children
dman & O
berg, 2006; Ohata et al., 2008). The PEDI
(O
provides scaled scores, which are obtained by transforming the logit estimates for the entire normative
sample to a 0100 distribution to represent the functional performance of children without adjustment for
age; the higher the score is, the better the performance
(Haley et al., 1992). Therefore, we used scaled scores for
March/April 2013, Volume 67, Number 2

further analysis. The PEDI has high internal consistency

(Cronbachs as 5 .90.99) and excellent testretest reliability (ICCs 5 .982.998) when tested with Taiwanese
children with CP (Chen, Hsieh, Sheu, Hu, & Tseng, 2009).
Intervention
This study was conducted during weekdays over 4 consecutive wk during the summer recess. We recruited 8
children with hemiplegia to receive CIMT as a group.
Each participant wore a thermoplastic short UE splint on
the less affected UE during the intervention session. The
group intervention program was delivered for 2.5 hr daily,
5 days/wk for 4 wk. All children were treated together
during the whole treatment session under the guidance of
an occupational therapist and an occupational therapy
assistant. The occupational therapist designed the program, monitored participants performance, and modified
activities for participants as required. The occupational
therapy assistant took the major role of implementing
the training program under the occupational therapists
supervision.
Each session started with stretching and weightbearing exercise of the affected UE for 15 min, followed by
hand function activities (40 min), eating and drinking
activities (40 min), and games (55 min). A 35 min break
took place between each intervention component. The
hand function activity training focused on the more affected UE and followed the principles of shaping and
repetitive task practice. The eating and drinking activity
training was designed as a teatime activity. Using their
affected UE, participants were asked to put napkins on
the table; cooperate to place the cups, dishes, spoons, and
forks on the napkins; and then practice skills for drinking
and eating. For the eating and drinking activity training,
participants used different utensils in accordance with
their different levels of affected hand function. Finally,
participants were required to clean the table together.
During the last 55 min of the session, children were
divided into two groups by age (with age 6 as the cutpoint)
to play games. The occupational therapist led the younger
group, and the occupational therapy assistant led the older
group. The games (i.e., ball games, card games, board
games, block games, puzzles) were designed to be either
cooperative or competitive in nature to promote participants motivation.
Before intervention, both therapists discussed and
set each participants treatment goal on the basis of the
baseline evaluation results. The hand function training
program was designed according to each participants
specific problems along with personal factors such as age,
cognitive level, and affected side. No home program inThe American Journal of Occupational Therapy

struction was offered to parents; we instead urged parents

to encourage their child to wear the splint at home. All
participants returned to their previous individual conventional occupational therapy after completing the 4-wk
group CIMT.
Data Collection
All participants were assessed on four occasions
preintervention, postintervention, at 1-mo follow-up, and
at 3-mo follow-upby the occupational therapist, who
designed the intervention program. Parents were interviewed at the same time points to assess on a 5-point
scale how much of the time their child used the affected
UE at home (scoring: 0 5 never; 1 5 less than 25% of the
time; 2 5 26%50% of the time; 3 5 51%75% of the
time; or 4 5 more than 75% of the time). Six activities
were observed: eating, grooming, bathing, dressing upper
body, dressing lower body, and toileting. Sum scores were
obtained for a maximum score of 24. The parents perspectives were also obtained postintervention. The two
practitioners also provided feedback to the physiatrist,
who supervised the project, after the intervention to give
their subjective view of the intervention model.
Data Analysis
Descriptive statistics were used to describe participant
demographics. We used Wilcoxon signed-ranks tests to
analyze preintervention and postintervention data to
reveal any significant change in outcome measures after
intervention. To determine whether possible effects
remained constant for 3 mo, we also used Wilcoxon
signed-ranks tests to compare the results between
postintervention and 1-mo and 3-mo follow-up. We
also calculated effect size to index the magnitude of
intervention effect. Hedges g was used because of the
small sample size. Hedges gs of .2 are considered small;
.5, medium; and .8, large (Cohen, 1988). We conducted all statistical analyses using SPSS 13.0 (SPSS
Inc., Chicago). The significance level was set at .05 for
all tests.

Results
Eight participants (4 boys, 4 girls; mean age 5 6.54 yr,
standard deviation 5 3.13) were recruited to receive
CIMT together as one group. One boy withdrew in the
1st wk because of transportation problems; 7 participants completed all treatment and measurement sessions. The baseline data of the study participants are
shown in Table 1.
Table 2 and Figures 1 and 2 show the improvement
in fine motor skills and daily living activities function
203

Table 1. Study Participants Data

Child

Affected Side

Gender

Age, Yr:Mo

MACS

Right

Male

2
3

Right
Right

Female
Male

5:6

6:1
10:0

II
III

Left

Male

6:5

III

Left

Female

2:4

III

Left

Female

4:2

II

Left

Female

11:3

III

Note. MACS 5 Manual Ability Classification System; I 5 the child can

independently manipulate different objects that require speed and accuracy
without limitations; II 5 the child can manipulate most of the objects and
has independent performance but may show reduction in the speed or
quality of movement; III 5 the child has diminished ability to manipulate
objects and may need assistance to prepare or modify the activity to be
performed.

after the intervention. Fine motor skills of the affected

UE improved significantly after intervention on the
PDMSG (p 5 .016, Hedges g 5 .67) and PDMSV
(p 5 .018, Hedges g 5 .84), and the effect size was
medium to large. In the PEDI self-care domain, participants Functional Skills (p 5 .018, Hedges g 5 .39)
and Caregiver Assistance (p 5 .018, Hedges g 5 .76)
scores also significantly improved postintervention, with
a small to medium effect size. No significant change was
found between postintervention and the 1- and 3-mo
follow-up in PDMSG, PDMSV, and PEDI Caregiver
Assistance Scale scores. However, we observed a small
decline in these scores at the 3-mo follow-up. Participants Functional Skills Scale scores improved at followup (1-mo follow-up, p 5 .042; 3-mo follow-up, p 5
.028).
Spontaneous use of the affected UE increased
significantly postintervention and was maintained
throughout the follow-up period (p 5 .018, Hedges
g 5 1.13), although it tended to decrease over time (see
Table 2 and Figure 2). No adverse events were seen
during the intervention period. All participants tolerated wearing the UE splint on their less affected UE
during treatment, but most children did not wear the
splint at home, according to parents report.

Practitioners and Parents Opinions

The two occupational therapists cooperated to provide
treatment. They approved the model of two practitioners
leading one group. They found that children were more
willing to receive CIMT in a group than in individual
therapy. Although the practitioners conducted the 7-child
group successfully, they suggested a participant:practitioner ratio of 23:1 as optimal. In other words, they
recommended that two practitioners guide a group of
46 children. They further suggested recruiting participants for a group who had similar functional limitations
and age range to make it easier to design and conduct
the program. They also recommended that each treatment session last no more than 2 hr and incorporate
short breaks throughout the entire training session because children may lose their attention or motivation
during longer periods.
All parents appreciated the effect of the group-based
CIMT. They observed improvement in their childs
function and frequency of use of the affected UE. Most
parents reported that they did not encourage their child
to wear the UE splint at home.

Discussion
This pilot study supports the feasibility of applying
group-based CIMT to children with hemiplegic CP in
a clinical setting. In addition, children receiving groupbased CIMT had significant gains in manual performance
of the affected UE and self-care function postintervention.
The spontaneous use of the affected UE also increased.
According to previous research, restraint and intensive, repetitive training may affect participants motivation to use CIMT (Charles et al., 2006; Gilmore et al.,
2010), and the high labor demand may prohibit use of
CIMT in the clinical setting (Page et al., 2002). Therefore, increasing participants motivation and decreasing
the CIMTs manpower demand are important for successful implementation of CIMT.
Group intervention may fulfill these requirements.
Small-group intervention has already been applied in

Table 2. Outcome Measures Pre- and Postintervention (N 5 7)

Outcome Measure

Preintervention,
M (SD)

Postintervention,
M (SD)

Z (p)

Hedges g

1-Mo Follow-Up,
M (SD)

3-Mo Follow-Up,
M (SD)

PDMSG (range 5 052)

37.14 (7.88)

42.14 (5.98)

22.41 (.016)

0.67

43.29 (5.91)

42.86 (6.09)

PDMSV (range 5 0114)

PEDIFS (range 5 0100)

83.57 (20.78)
50.01 (7.92)

102.57 (21.54)
53.17 (7.38)

22.38 (.018)
22.37 (.018)

0.84
0.39

106.43 (20.93)
54.89 (7.18)

105.86 (22.19)
55.51 (7.56)

PEDICAS (range 5 0100)

50.93 (11.55)

60.01 (10.70)

22.37 (.018)

0.76

60.66 (8.85)

58.64 (8.69)

Use scores (range 5 024)

5.43 (5.09)

12.00 (5.45)

22.37 (.018)

1.13

11.43 (4.83)

10.86 (4.60)

Note. M 5 mean; PDMS2 5 Peabody Developmental Motor ScalesSecond Edition; PDMSG 5 Grasping subscale of the PDMS2; PDMSV 5 VisualMotor
Integration subscale of the PDMS2; PEDI 5 Pediatric Evaluation of Disability Inventory; PEDIFS 5 Functional Skills Scale of the PEDI; PEDICAS 5 Caregiver
Assistance Scale of the PEDI; SD 5 standard deviation; use scores 5 spontaneous use of the affected upper extremity.

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March/April 2013, Volume 67, Number 2

Figure 1. Trend in Peabody Developmental Motor ScalesSecond Edition (PDMS2) scores at preintervention, postintervention, and 1- and
3-mo follow-up.
Note. PDMSG 5 Grasping subscale of the PDMS2; PDMSV 5 VisualMotor Integration subscale of the PDMS2.

general pediatric rehabilitation for UE functional

training. The group therapy setting allows participants
to observe and learn from one another, as well as to
support each other and collaborate when confronting
difficulties. In addition, children are more willing to
engage in repetitive actions while playing games in
a group than when in an individual therapy session
(Exner, 2005). Moreover, in some games, more players
create greater benefit than just one child facing the
therapist. Therefore, the group therapy appeared to
help children overcome the difficulties and frustration
of performing CIMT.
Page et al. (2002) reported that most therapists may
find it difficult to develop an intensive protocol that is
both engaging and challenging. Because few experienced
therapists may be available in a clinical setting, we arranged
for an experienced therapist and a therapist assistant to
lead one group. The experienced therapist designed the
program, monitored participants daily performance, and
modified the tasks for the participants as required, and
the occupational therapy assistant primarily implemented
the training program. Both therapists supported this model
as valid and workable.

Previous group-model studies for participants who

had either a stroke or CP have used the small-group format
(Aarts et al., 2010; Brogardh & Sjolund, 2006; Charles
et al., 2006; Leung et al., 2009), and the participant
therapist ratio ranged from 2:14:1; thus, we developed
this 8-child group led by two therapists model. After
the intervention, the two therapists recommended a 4- to
6-child group led by two therapists model (participant:
therapist ratio of 2:13:1) as more optimal. The group
training program should cohere with the personal factors
and needs of each participant; therefore, we recommend
that participants with similar functional limitations and age
range be recruited for a specific group.
The duration of each CIMT session varies widely among
studies, ranging from 2 to 6 hr per session (Aarts et al., 2010;
Charles et al., 2006; de Brito Brandao et al., 2010; Deluca
et al., 2006; Eliasson et al., 2005; Sakzewski et al., 2011;
Taub et al., 2004). Because our occupational therapy room
was open from 8:30 a.m. to 12:00 p.m. and then again
from 1:30 p.m. to 5:00 p.m., we thought training sessions
would have to be <3 hr to be practical. Considering
childrens attention and motivation limits, we suggested
limiting each session to 2 hr with frequent short breaks.

Figure 2. Trend in Pediatric Evaluation of Disability Inventory (PEDI) scores and spontaneous use of the affected upper extremity at
preintervention, postintervention, and 1- and 3-mo follow-up.
Note. PEDIFS 5 Functional Skills Scale of the PEDI; PEDICAS 5 Caregiver Assistance Scale of the PEDI.

The American Journal of Occupational Therapy

205

In Taiwan, the general principles of insurance payment are based on the number of children being treated
and the duration of each session. Although payment
increases with treatment duration, payment will usually
not be extended beyond 1 hr. This payment principle
discourages treatment sessions of longer duration. In our
group CIMT, therapists could treat similar numbers of
children as in conventional individual therapy and
therefore obtain similar payment for 2- to 3-hr sessions.
This intervention format could promote the greater acceptance of CIMT in clinical practice.
The participants showed significant improvement in
manual performance of the affected UE as well as great
improvement in self-care functioning. Parents also commonly reported that the children used the affected hand
more postintervention. These results are compatible with
those of individual CIMT programs (Crocker et al., 1997;
de Brito Brandao et al., 2010; Deluca et al., 2006; Taub
et al., 2004) and illustrate that group CIMT may be
a practical and cost-efficient method.
At the 3-mo follow-up, the participants showed a
small but nonsignificant decline in function and use of the
affected UE. This finding was in line with those of previous CIMT studies (Aarts et al., 2010; Charles et al.,
2006; Taub et al., 2004). We were not able to determine
whether maintaining the intervention effect depended on
the total training dosage. In previous studies, the total
training dosage of each CIMT course ranged from 54 to
120 hr (Aarts et al., 2010; Charles et al., 2006; de Brito
Brandao et al., 2010; Eliasson et al., 2005; Sakzewski
et al., 2011; Taub et al., 2004). The total training dosage
depends on the frequency and duration of the intervention;
the optimal training dosage has yet to be determined.
According to our results, the total training dosage of 60 hr
seemed effective. If the premise is an intervention time
of 2 hr/session, a 6-wk intervention period to deliver
intensive training during a school recess (i.e., summer
or winter) is suggested. With regard to the retention
of training effects, we could likely implement CIMT
2 times/yr, each for 6 wk, to coincide with the winter
and summer recesses.

measures in our studies were also limited. Because some

participants were older than the suitable age range for the
PDMS2 and PEDI and the norm references for
Taiwanese healthy children are not obtainable, we used
the raw scores, rather than age-specific norm-referenced
scores, for data analysis. The improvement might be
the result of maturation, especially for young children.
Moreover, we assessed only the manual function of the
affected UE and participants performance of self-care.
Assessing other health-related domains, such as participation, and including participants perspectives may broaden
occupational therapists understanding of the overall effect of
group-based CIMT.

Limitations
The weakness of our study was that it had a small number
of participants and was not a randomized controlled trial.
In addition, the assessments were not performed by a
blinded therapist. Future randomized controlled trials
with participants of a wide age range and with a variety of
manual abilities, and with assessors blinded to the type of
intervention, would be useful to determine the effectiveness of this intervention protocol. The outcome

We thank the parents and children who agreed to participate this study. We also thank Keh-Chung Lin, of
the School of Occupational Therapy, National Taiwan
University College of Medicine, and Division of Occupational Therapy, National Taiwan University Hospital,
for his valuable comments on this work. In addition, we
thank Chin-Kai Lin of the Graduate Institute of Early
Intervention, National Taichung University of Education,
for his assistance with statistical analyses.

206

Implications for Occupational Therapy Practice

The results of this study have the following implications
for occupational therapy practice:
Group-based CIMT is a feasible and effective intervention for children with hemiplegic CP.
Group-based CIMT can increase the motivation of
children with CP to engage in intensive, repetitive
training and decrease CIMTs demands on therapists.
Group-based CIMT had similar effects as individual
CIMT programs: It can improve manual performance,
use frequency of the affected UE, and self-care
functioning.

Conclusion
This preliminary study demonstrated that group-based
CIMT can be implemented in clinical practice to improve
both manual performance and frequency of functional use
of the affected UE in self-care activities in children with
hemiplegic CP. The results will provide insights for designing a large-scale, randomized trial to clarify the efficacy
of group-based CIMT. In future studies, we recommend
the use of two therapists to lead a 4- to 6-child group in
training delivered 2 hr/day, 5 days/wk for 6 wk, during the
winter and summer school recesses. s

Acknowledgments

March/April 2013, Volume 67, Number 2

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