Running Head: CIMT IN CHILDREN WITH CP

Evaluating the effectiveness of constraint induced movement therapy on upper extremity dysfunction in
children with hemiplegic cerebral palsy.

Brynnan Halsey, OTS and Kaitlin Huntington, OTS

University of Utah

CIMT IN CHILDREN WITH CP

Introduction
Cerebral palsy (CP) is defined as a group of early-onset, non progressive neuromotor disorders
that develop in the fetal or infant brain due to an abnormality or biological incident such as fetal stroke,
lack of oxygen or even a traumatic brain injury. CP presents with a variety of issues that range from
muscular movement or muscle tone to intellectual function. Every CP case presents differently and the
severity of the disorder varies. According to a review on the prevalence of cerebral palsy by Oskoui,
Coutinho, Dykeman, Jette, and Mara (2013) CP is one of the top causes for disability in children and
occurs in about 2.11 per 1000 live births. The most common type of CP is hemiplegic cerebral palsy
(Gordon et. al, 2011). Hemiplegic CP can present with a variety of motor and sensory deficits that can
affect one or both limbs (Wu, Hung, Tseng, & Huang, 2013). Often, the upper limbs are affected more
frequently than the lower limbs (Choudhary et. al., 2005).The severity of deficits will vary with each
individual case. These deficits greatly reduce the individuals ability to complete functional and bimanual
movements that are important for independent occupations such as self-care, leisure, play, and even future
vocational opportunities.
Over the last decade, two main interventions emerged to help improve upper extremity (UE)
function in the affected limb to help improve bimanual movements in children with hemiplegic CP. One
of the interventions is constraint induced movement therapy (CIMT). CIMT involves the restraint of the
unaffected limb, usually with a mitten or cast, to prevent movement so that focus can be concentrated on
using the affected UE to complete unimanual tasks and increase function of that limb (Gelkop et al.,
2015) CIMT is a very time and labor intensive intervention. Most single treatment sessions can last up to
six hours at a time, which can be a burden on the child as well as their caregiver. Another issues that
arises with this type of intervention is that many facilities do not have enough therapists that can dedicate
time to these long sessions. Also, therapists have a hard time getting reimbursed by insurance companies.
Insurance companies often have strict time parameters for therapy sessions that the intensive CIMT
training may not fall into (Wu et al. 2013).

CIMT IN CHILDREN WITH CP

CIMT as a treatment option for adults is widely accepted; however, that CIMT is not child
friendly. The need for a child-friendly version of CIMT is not just because of their attention span, but
there are safety concerns too. Children who are constrained 90% of their waking hours have a
significantly increased fall risk requiring maximal attention by their parents at all times (Gordon, Charles,
& Wolf, 2005). There is also a level of frustration that is expected when initiating use of the affected arm
and adults have better meta-cognition to work through those feelings. Typically adults are involved in
CIMT because of their own motivations whereas the children are involved as a result of their parents
decisions. Both of these components affect the level of frustration felt by the child and a task that is too
frustrating can be psychologically invasive (Gordon, et al., 2005). A modified CIMT for children with
hemiplegic CP is being tested for effectiveness. Modified CIMT keeps the repetitive practice and shaping
aspects of adult CIMT but seeks to make it more related to children (Gordon, et al., 2005).
The second intervention used with children with hemiplegic CP is hand-arm intensive bimanual
therapy (HABIT). HABIT is just as time and task intensive as CIMT, but instead of constraining the
unaffected arm the children use both limbs freely to practice bimanual movements (Gordon et al. 2011).
Currently, both interventions are being used equally to treat individuals in the population with hemiplegic
CP. Further research is being conducted to establish whether one intervention is more effective than the
other.
The research question is, is CIMT an effective intervention to increase the affected UE function
in children with hemiplegic cerebral palsy? As previously mentioned, hemiplegic CP can hinder the
childs ability to complete bimanual movements that are important in many activities of daily living.
Inability to complete these tasks of daily living can greatly reduce the childs overall independence.
CIMT is strenuous on the child as it utilizes long hours over multiple weeks of constraint of the
unaffected limb and can be psychologically invasive, while using the affected limb to complete an intense
regime of activities to help improve limb function. Not only is the CIMT intervention time intensive for
the child but it is also time and labor intensive for the therapist. It is also a major commitment for parents

CIMT IN CHILDREN WITH CP

who are expected to complete CIMT exercises with their child at home. CIMT requires a lot of time and
energy from all those involved in the intervention so it is important to know if it is effective in increasing
UE function in the the affected limb. If it is effective, then increased function in both upper limbs can
improve the childs ability to complete bimanual movements and hopefully increase the childs overall
independence.
Methods
Pubmed and CINHL databases were consulted to find articles pertaining to the question, is CIMT
an effective intervention for children with hemiplegic cerebral palsy? The key terms used to search the
databases included: children CIMT, kids CIMT, cerebral palsy, children, and CIMT. It was noted
that the keyword children had more results than kids did. In Pubmed, search bounds of 5 years was
applied and found 43 articles. In CINHL, search bounds of 10 years was used and found 13 articles.
Initially, the review documents were examined to help orient to the topic. After reading the
reviews, different abstracts of experimental and nonexperimental designs were read to evaluate if CIMT
was utilized with children with unilateral CP. A useful technique discovered was to find one suitable and
relevant article from the search in the database and then examine the reference list of that article to find
other suitable and relevant articles.
In total, 12 articles were read and summarized in an effort to decide if CIMT is an effective
treatment for children with unilateral cerebral palsy. When reading the articles the quality was judged by
sample size, we deemed it important to see the effects on outcomes on both the individual and group
level. Mixes of large random control trials (100+) down to single case studies were read on the topic.
While judging quality of articles it was also important to note if the researchers were examining a single
variable. Research validity of the whole study was judged by internal, external, and measurement validity.
Results
Of the 12 articles consulted one was a review, one was a single blind matched pair comparison
trial, five were randomized control trials, two were non-experimental descriptive studies, one case study,

CIMT IN CHILDREN WITH CP

and two quasi experimental. Levels of evidence 1-5 were represented in the research compilation. There
was one article meriting a first level of evidence, five level two, two level three, one level four, and three
level five. RCTs PEDro scale rating ranged between five and nine.
For further details of the articles reviewed see table 1.
Gordon (2011) found bimanual training (HABIT) in addition to mCIMT with sufficient intensity
improved UE function in affected arm, the HABIT treatment improved bimanual coordination and skills
were transferred to unpracticed activities. This article was a review (evidence level one) and covered
more than 100 participants in CIMT/bimanual training since 1997.
Geerdink, Aarts, & Geurts, (2012) used a RCT (evidence level two) to compare CIMT-BiT to
conventional therapy in two groups and also accessed impacts of the motor learning curve. Age
significantly affected the learning scale and children who are five years or older may require more than 54
hours of mCIMT to be effective, even still age does not affect the long-term retention. This RCT scored a
five on the PEDro scale.
In a single blind, matched pairs, comparison trial (evidence level three) conducted by Sakzewski,
Ziviani, & Boyd (2011), participants were matched for age, gender, side of hemiplegia, and upper-limb
function were randomized into pairs, one member of the pair participating in CIMT and the other in
bimanual training. Both groups improved range of motion and older children who selected their own
goals were much more engaged in therapy. It is also thought that kids with left hemiplegia are more likely
to achieve best response. Bi-T changed most in grasp and release of items, while the most changes in the
CIMT group were with hand-to-hand transfer and target accuracy
A single blind RCT (evidence level two) by Choudhary et al. (2012) found modified CIMT to be
doable, accepted, and effective in children to increase activity (rather than addressing impairments) and
improve functioning in occupations. The results suggested that the four week duration of mCIMT is
effective in improving upper limb functions in children with hemiplegic cerebral palsy . This RCT
merited a nine on the PEDro scale.

CIMT IN CHILDREN WITH CP

A RCT follow up (non-experimental, evidence level 4) conducted by Aarts, Jongerius, Geerdink,
Limbeek, & Geurts (2010) found that the increased function in upper extremity was not to the level of
spontaneous use. Researchers are also concerned with the theory base of CIMT- learned non-use. In
children, they may have never learned to use the limb previously making developmental disregard a
more appropriate term and examining more the impact of motor learning in mCIMT .
Gordon, Charles, & Wolf (2005) sought to define mCIMT more specifically in literature
describing the child friendly methodology. This descriptive study (evidence level four) demonstrated that
CIMT can be successfully modified for children ages 4-14 with hemiplegic CP. The mCIMT methodology
keeps repetitive practice and shaping aspects of adult CIMT but still needs more research so mCIMT can
be applicable to other etiologies of hemiplegia in children.
Brandao, Gordon, & Mancini (2012) conducted a RCT (evidence level two) to determine if CIMT
or HABIT was more effective in increasing UE function in children with CP. The study concluded that
both interventions were effective with this population, but there was no significant difference that one
intervention was more effective than another. This study was evaluated and given a eight on the PEDro
scale.
Wu et al. (2013) administered a quasi-experimental study (evidence level three) to determine if
CIMT conducted in a group setting was as effective as CIMT conducted at a one to one level for children
with CP. They concluded that group CIMT was as effective in increasing UE function as traditional
administered CIMT. Wu and colleagues suggest that more research will be needed with a larger sample
size to validify findings.
A single case study (evidence level four) conducted by Sutcliffe, Gaetz, Logan, Cheyne, &
Fehlings (2007) determined that CIMT resulted in increased function of the affected UE in children with
CP as well resulted in cortical reorganization. Cortical reorganization could help increase retention of
increased UE function.

CIMT IN CHILDREN WITH CP

Gelkop et al (2015) also administered a RCT (evidence level two) to compare effectiveness of
shorter sessions of CIMT vs. HABIT in increasing UE function in children with CP. Similar to the
findings of Brandao et al. (2012), they found that shorter CIMT and HABIT interventions were both
effective interventions to treating UE function, but results were inconclusive that one intervention was
significantly more effective than the other. This study was evaluated and received a score of eight on the
PEDro scale.
A RCT (evidence level two) by Eliasson, Shaw, Berg, & Krumlinde-Sundholm (2011) looked at
the effectiveness of eco-CIMT on UE function in children with CP. Eco-CIMT is CIMT conducted in an
environment that a child is familiar with such as at home or in a school setting and the intervention is
carried out by a parent or caregiver coached by an occupational therapist. Eliasson and colleagues
concluded that ecological factors could impact effectiveness of CIMT. They also found the UE function
increased with the intervention. This study was evaluated and given a score of six on the PEDro scale.
Gordon et al. (2011) used a quasi-experimental study (evidence level three) to evaluate the
effectiveness of shorter series of CIMT compared to shorter series of HABIT on UE function in children
with CP. Similarly to findings by authors Brandao et al. (2012) and Wu et al, (2013), Gordon and
colleagues found CIMT and HABIt both increased UE function, but neither was more effective than the
other. They also concluded that shorter series of both interventions was as effective as traditional series.
Discussion
According to results, the level of evidence ranged between one and five with a majority falling
between one and three and the RCTs reviewed had a PEDro rating between five and nine A common
consensus from the articles read was that CIMT is an effective intervention to increase upper extremity
function in children with hemiplegic CP (Gordon et al. 2011; Eliasson et al, 2007; Gelkop et al., 2015;
Suttcliffe et al., 2007; Wu et al., 2013; Brandao et al., 2012). A benefit of CIMT is the increased activity
with affected upper limb, which improves ability to complete bimanual tasks involved with activities of
daily life (Gordon, 2011; Brandao et. al, 2012; Gelkop et al. 2015). CIMT can result in cortical

CIMT IN CHILDREN WITH CP

reorganization that can lead to more permanent changes and increased retention (Sutcliffe et al, 2007).
CIMT intervention is more effective when done in a familiar setting with familiar people (Eliasson et al.,
2011). There is a call for involvement from parents, families, and caregivers creating a sense of
consistency children benefit from. The hours demanded by CIMT require parents to continue intervention
in the home increasing probability that a parent will be involved in intervention needed to perform at
home. An added benefit of CIMT is the family involvement and support it elicits, focusing on the childs
continual growth at home.
However, there is a need to modify CIMT to make it more children friendly. Initially CIMT was
created for adults recovering from a stroke. Adults were able to see the constraint as a necessity for
treatment and were able to give informed consent, whereas a child might not fully understand the purpose
of the constraint. As it is, CIMT is invasive and includes physical restraints that could create an increase
fall risk and psychological stresses. Modified CIMT is still being tested for how many hours and what
level of intensity is required to be effective (Suttcliffe et al, 2007; Gelkop et al., 2015; Eliasson et al.,
2011).
When searching for articles there could have been articles overlooked about a better treatment
alternative due to the nature of the focused search on CIMT. Using a less specific search could broaden
the represented view and opinion. It would also be beneficial to see further research regarding
generalizability of mCIMT. Can other children who are hemiplegic but not from CP benefit from mCIMT
too? In the 12 articles read for this report the longest retention mentioned was 8 weeks, it would be
interesting to see if the benefits from mCIMT treatment last longer than 8 weeks. We could have been
more specific in our desired outcome. If the child is at a level where they have pretty good gross motor
function, developing fine motor skills would be a desired outcome. If a more specific outcome was
chosen, potentially a more significant difference in the gains made with CIMT and HABIT interventions
could be observed.

CIMT IN CHILDREN WITH CP

After reviewing the information in the articles found, it has been concluded that CIMT is an
appropriate and effective intervention for treating children with upper extremity dysfunction due to
hemiplegic CP. The levels of evidence for the majority of the articles used, were between levels one and
three. The RCTs used had a PEDro scale range between five and nine. The high level of evidence and the
high PEDro scale range for the RCTs used, suggests that it is reasonable to perform CIMT intervention;
the benefits outweigh the risks. There is a need for further research to determine if CIMT should be
performed as the primary intervention for all individuals within this population.

CIMT IN CHILDREN WITH CP

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Brandao, M., Gordon, A., & Mancini, M. (2012). Functional impact of constraint therapy and bimanual
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Occupational Therapy, 66(6), 672-681.
Choudhary, A., Gulati, S., Kabra, M., Singh, U., Sankhyan, N., Pandey, R., & Kalra, V. (2012). Efficacy
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