Constraint-induced movement therapy in children with unilateral cerebral palsy

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Read Full Text: Constraint-induced movement therapy in children with unilateral cerebral palsy
Journal: Cochrane Database of Systematic Reviews
Year Published: 2019
Ranked 78th on our 2017-2021 list of the 100 Most Influential OT Journal Articles
CEU Podcast: CIMT and OT with Catherine Hoyt (CE Course)

If you’re like me, you’ve disregarded CIMT as a specialized intervention for specialized OTs in some far-away specialty clinic.

But trust me: no matter the population you work with, you should be following this research.

CIMT is perhaps the most-studied OT intervention—and it can teach all of us valuable lessons about:

  • Neuroplasticity,
  • Intensity, and
  • The future of OT in general :slight_smile:

Next week, I’m excited to welcome Catherine Hoyt, PhD, OTD, OTR/L, to the podcast to discuss how you can leverage the principles behind this intervention in your OT practice.

Intro to this article

Clocking in at 277 pages, this week’s article is a Cochrane Review—meaning it’s at the tip-top of the evidence pyramid.

We recently discussed cerebral palsy (CP) in another systematic review, so for this one, I’ll skip right to the info on CIMT.

What is CIMT?

Constraint Induced Movement Therapy (CIMT) is simpler than you may think. It has two key components:

  1. Restraint of the less affected limb.
  2. Intensive, structured upper limb therapy.

However, there is a lot of variation within these two components. Restraints used in studies have included:

  • Splints
  • Mitts/gloves
  • Slings
  • Casts

Additionally, the duration of restraint has ranged from 1 hour per day all the way up to 24 hours per day. And the intervention has been studied with individuals as well as in groups—and carried out in home, clinic, inpatient, and camp settings.

How does the intervention work?

When used to treat children with cerebral palsy, there are two main mechanisms that lead to positive results:

  1. Overcoming Development Disregard. This is a learned under-utilization of the affected limb in favor of the stronger limb.
  2. Activating Activity-dependent Cortical Reorganization. This is the activity-dependent neuroplasticity that we’ve learned to look for in our green-light pediatric OT interventions.

Why was this specific article written?

While there is increasing clarity around the effectiveness of CIMT, there are also lingering questions about the most effective format for this intervention.

So, the authors sought to update a 2007 Cochrane review. Their goal: “Evaluate the effect of CIMT in the treatment of the more affected limb in children with unilateral CP.”

What were the methods?

The authors looked for randomized controlled trials (RCTs), cluster-RCTs, and clinically controlled trials that compared different versions of CIMT to another treatment.

To be included in this review, the study’s participants had to be diagnosed with CP and aged from birth to 19 years old.

The authors paid close attention to the dosage of CIMT, and they calculated the total hours of treatment using the following formula:

Therapist-led intervention + parent-led intervention + other intervention + forced use

Outcome measures were included in the authors’ analysis only if the measures had a reported reliability and validity for CP.

Here are the included outcome measures by area:

Bimanual

  • Kids‐Assisting Hand Assessment
  • Hand Assessment for Infants (HAI)

Unimanual

Manual ability

  • ABILHAND-Kids
  • Children’s Hand‐use Experience Questionnaire (CHEQ)
  • Birmingham Bimanual Questionnaire

Individualized measures of performance

Self‐care

Body function

  • Grip Strength
  • Modified Ashworth Scale ‐ Elbow
  • Modified Ashworth Scale ‐ Wrist
  • Two‐point discrimination
  • Passive Range of Motion
  • Modified Tardieu Scale

Participation

Quality of life

  • Cerebral Palsy Quality of Life Questionnaire for Children (CP QOL)
  • CP QOL ‐ Child/Caregiver report
  • KIDSCREEN‐52
  • Pediatric Quality of Life Inventory (PEDSQOLTM) 4.0
  • PEDSQOLTM 3.0 ‐ Cerebral Palsy Module
  • PEDSQOLTM ‐ Infant Scale

Parenting and family measures

Other

  • Pediatric Arm Function Test
  • School Function Assessment
  • Besta Scale
  • Video Observations Aarts and Aarts
  • Alberta Infant Motor Scales

Results

36 trials with a total of 1,264 participants were identified.

Dosage of CIMT in the studies

The mean total amount of CIMT provided was 129 hours.

On average, 56 hours of the CIMT was provided by a therapist.

The average length of CIMT programs was 4 weeks.

(So, assuming participants received therapy 5 days per week, that would amount to about 3 hours of therapy per day over 4 weeks.)

Models of practice

This refers to the guide for provision of therapy. 12 studies reported using motor learning as a model of practice. 11 studies reported using shaping.

Effects of the intervention

CIMT versus a low-dose comparison (like low-dose OT)

There was low-quality evidence that CIMT was more effective than a low-dose comparison at improving bimanual performance (per the Assisting Hand Assessment).

CIMT was more effective than a low-dose comparison for improving unimanual capacity (per the QUEST).

The average total dose of the low-dosage comparison was 7.9 hours.

CIMT versus a high-dose/dose-matched comparison

CIMT was not more effective than high-dose comparisons or comparisons where the dosage was the same.

Conclusions and discussion

This review found weak evidence that, compared with a low-intensity intervention, CIMT is more effective at improving bimanual performance and unimanual capacity.

However, it is no more effective than another intervention that is carried out intensively.

Therefore, the outcomes of this study support implementation of a well defined, time-limited, goal-directed block of CIMT or bimanual therapy.

It is important for clinicians to recognize that CIMT does not appear to result in improvement at the body structure level (i.e., by impacting grip strength, muscle stiffness, or spasticity). Furthermore, evidence around improvement in participation and quality of life is also lacking at this point.

Discussing the results of this review with family:

It is important that families and children understand the outcomes of this review. CIMT does appear to be safe as an optional “green light” intervention for children with CP.

But, families should understand:

  • The specific nature of the benefit (hand function)
  • The possible magnitude of the benefit
  • The availability of other high-dosage options
  • The uncertainty of how long-term the benefits are
  • The need to continue to monitor UE function and occupational performance, as another round of high-intensity treatment (or other alternative) may become necessary
  • Not all children respond to CIMT

Takeaways for OT practitioners

(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)

1. This is a master class in the “intensity matters” principle of neuroplasticity.

The research behind CIMT is so important for us to follow, because it emphasizes the importance of intensity.

Unfortunately, our therapy here in the US is often structured in low doses over long periods of time. But, when we utilize an intensive model, it is easier to not only meet the neuroplasticity principle of “intensity,” but also ensure that the other 9 principles of neuroplasticity fall in place behind it. It is easier to focus on a few salient goals, achieve lots of repetitions, etc.

If you are a pediatric OT, I highly recommend listening to my conversation with Michelle DeJesus. What really stuck with me is how she worked to modify her practice in traditional OT settings to align more closely with neuroplasticity principles and the common elements of green light pediatric interventions.

2. Conversations with children and their families are incredibly important for choosing the right intervention.

With exponentially expanding research, an increasingly important part of our job is helping families understand their treatment options and the research behind each.

Luckily, things like the cerebral palsy interventions traffic light give us a great starting point to consider the child’s goals and collaborate in finding the best treatment match.

If you haven’t listened to our conversation with Dr. Iona Novak, a leading CP researcher, I highly recommend it. She provides excellent insight on her discussions with families.

3. CIMT is a bellwether for other OT interventions, and we need to keep watching the research.

As one of the most-studied OT interventions, CIMT is something we should all continue learning about. In many ways, it is trailblazing our understanding of how much intensity—and what type—we must deliver to create a tangible change for our patients.

Even since 2018, a lot of new research has been published, and I’m excited to talk about it with Catherine on the podcast next week.

Here’s the full APA citation for this article:
Hoare, B. J., Wallen, M. A., Thorley, M. N., Jackman, M. L., Carey, L. M., & Imms, C. (2019). Constraint-induced movement therapy in children with unilateral cerebral palsy. The Cochrane database of systematic reviews, 4(4), CD004149.

Earn one hour of continuing education by listening to the podcast on this article!!

In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Catherine Hoyt. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!

What questions/thoughts does this article raise for you?

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I’ve been thinking about CIMT after an OT friend brought up her discomfort using CIMT with her infant who likely has CP. I think this intervention, while effective at increasing mobility, raises questions around a child’s right to autonomy and consent. I’ve been having this conversation with others and many have said that the mitt - rather than restraint - approach feels kinder to kids who are too young to consent to the restraint.

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I’m SO GLAD you brought this up right away! Isn’t just the name “constraint induced” the worst! Someone needs to rebrand this treatment…

The research I am looking seems to indicate that constraint type DOES NOT matter- so if a family is more comfortable using a mitt they should!

And, honestly, it seems to me the INTENSITY OF PRACTICE is the active ingredient of change so if a bimanual therapy is available, they could consider that as well. (But, I don’t know if this exists for infants?)

@catherine8 have you had conversations about this?

Thanks, again, @meg2 for raising this important issue.

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I agree with you @meg2. Last year, we conducted a mini modified CIMT camp for a few young kids (3-6 years). Instead of doing a plaster cast and immobilizing the whole UE, we sewed mitts for our kids and attached velcro. We even had different colored and patterned mitts for all of them. Though this did not work as a solid restraint, the kids accepted those better and were more willing to use them for periods of time in between other play activities.

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This is so cool to hear @sanchala.

I think the other benefit of mitts/slings/splints is it makes the treatment more accessible. Few therapists are comfortable casting, which limits the availability of this effective treatment.

One more thought on this @meg2. As, I’ve been listening to podcasts, etc. about CIMT this week, it seems that therapists who undertake the effort to get trained in casting for kids easily become biased to its impact. (Which seems to happen with all of our interventions that include intensive training.) I just have not seen the research that says it is more effective.

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This is a very thought-provoking article for all of us. CIMT, as we all know is rather difficult to implement for both adults and children if it is to be used in its original form. Many centers have CIMT summer camps for children that meet many principles of neuroplasticity. I used to wonder if these intense focused interventions were really beneficial if not continued later on by parents. I think this article validates the time-limited focused aspect of CIMT camps.
In the Conclusions part, it is stated-The outcomes of this study support implementation of a well defined, time-limited, goal-directed block of CIMT or bimanual therapy.

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Interesting point to bring up @meg2. My main response is that we do a lot of things with children for their benefit that they may not seem to initially love (like tummy time, vaccinations, eye patches, learning healthy habits with food/sleep, learn multiple languages). All of those things serve to help children learn and grow to reach their individual potential. Children who participate (both older and younger) do REALLY well with CIMT. Children accommodate to the constraint within a few minutes and then really just ignore it. The brain has such incredible plasticity and opportunity to grow in the first years of life, and intensive interventions (beyond CIMT too, like CO-OP or interventions for ASD), are more effective than seeing children briefly (like one hour/week) for a long time. I view this as an opportunity to help the child learn to recognize and use their body, at a time when their brain and body is most able to learn it.

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I see your point, @catherine8, especially when we are talking about infants. And I totally agree about the apparent effectiveness of intensive interventions for bursts at at time! I think @meg2 's push is for CIMT to be the least restrictive (mitt versus cast) and aligning with the parent’s values. I think the research supports this? What do you think?

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I think that is an interesting question, thinking about casting vs a mitt (see the baby CHAMP study that compared this!), and agree that this is something to think about… I think, like with most things, there are pros/cons. If I recall correctly, the baby CHAMP found that parents/caregivers did not have a strong preference between the cast or the mitt, but also, there wasn’t a strong difference in outcomes between the cast or the mitt, the variable that made the difference was intensity of intervention. Interestingly, in a recent podcast by AOTA about CIMT, the leading therapists in this research communicated a preference for the cast because it was easier on the children to adjust to, rather than having to adjust to the constraint every morning when it was donned.

Research with healthy adults, and children who have broken their arm, indicate that wearing a cast for a month does not negatively affect development of motor skills of the dominant upper extremity (but may temporarily, very temporarily, reduce grip strength).

When CIMT was first being tested in adults and children, I think more therapists spent more time in their training on splinting/casting than we do now.

That said, why do a cast if it is hard for therapists and isn’t needed? Something to think about, and consider as future iterations of the intervention are tested.

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Great summary of the CIMT article. Please know that I have a lot to reflect on here. In my past private pediatric practice, I refrained from using CIMT having thought of it as a method that could frustrate a child or an adult. Emotionally, I wondered if forcing the use of a lesser functioning body part would set up a disconnect between the limb and the person’s brain emotionally. Focusing on the deficit surrounding performance didn’t fit my style of clinical intervention. Focusing on a person’s strengths, positivity, and win-win relationship to function were some of the basis for selecting treatment. I am certified as an Interactive Metronome Therapist with the acronyms of CIMT as well. I found that adding something to help the brain with processing timing, motor planning, and sequencing a task, the mental/motor processing training was the most effective intervention I had ever used. The results of IM have outperformed all other interventions I used throughout my years treating brain conditions. However, I also have found that the frequency and intensity of treatment matter to recovery time. Studies have shown that brain plasticity responds best with repetition especially when the movement is integrated into the brain with the outcome producing a more efficient and simple motor task sequence. My personal reading comprehension deficit resolved as a 46-year-old as a result of using the therapy I still use with children and adults with multiple brain conditions, but not all. I love that the results have stood the test of time, as I have not lost the reading skills that allowed me the confidence to return to grad school. Educating parents and seeing the joy when the child archives unexpected goals is very rewarding. One example that stands out happened with one of my clients in the 90s. A 10-year-old child with CP was able to roller skate for the first time. I now expect bigger outcomes after watching what interventions brought a huge impact on an individual’s confidence and functional performance. Noteworthy here, three of the children having learning challenges went on to become Marines. There were a few exceptions where the intervention was not having the hopeful outcome as most of my clients. The benefits for the majority of my clients have outweighed the interventions previously provided over the years prior to these most recent two decades of practicing OT. In my experience working ‘top-down’ and assisting the brain with input through the natural pathways of the brain, via the middle ear structures and activating the vagus nerve, has cut therapy time and cost down significantly with lasting outcomes feels better as a clinician than seeing someone briefly over longer periods of time with skills that disappear over time after stopping treatment. I think future research should include the factors of short-term effects, long-term sustainability, and generalization of the newly integrated cognitive and functional abilities where confidence in the task can be measured. If we want to use treatments that have proved even at an anecdotal level of research, then higher education should meet practitioners in the setting where these outcomes are happening. Practitioners, even those of us with a Master’s degree would welcome a doctoral student to help collect the necessary data and get the approval of the committee to approve a research study project. There are best practice interventions out here with research available but need to have updated OT lenses looking at the process from beginning to end using the right tools of measure to capture all the positive life skill changes as they happen. We would find what to spend time and insurance dollars on and what not to bother with. Functional win-win therapy outcomes are still a great philosophy to carry into future treatment and research. Can a child write their name in an OT session and in the classroom? Is the child applying this new writing skill to other tasks helping them to complete assignments in and outside the classroom? Has the writing skill been followed into the next grade or is there a need for additional OT intervention? That is how we have tracked goals traditionally. My expectations for goals have been raised higher after working with elementary-age children who have shown more than once, that the outcomes were better than I thought possible by the end of the school year. A 3rd grader and a 5th grader were pulled out of class into the first-grade level math and reading hallway group. I saw these two only providing the training for 30 minutes once weekly for the entire year. By the end of the year, these two boys tested at the top of their respective class levels. They surpassed the children in their general class in Math and Reading. Another example of a teenager with CP that I used the same therapy twice weekly in the clinic, went from C’s to straight A’s, poured herself a glass of orange juice from the refrigerator for the first time, gained the confidence to raise her hand in class, and was able to zip and button a pair of blue jeans by herself like her peers. We didn’t work on pouring juice or zipping pants. We worked on brain recovery using brain plasticity to be able to tap and clap using her hands and feet on triggers that eventually overcame spasticity, a barrier to her independence in so many areas of her life. I love OT and the recent two decades have been the most exciting and rewarding of the 45 years I have been in practice.

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I agree with the discussion above about making the restraints the least restrictive as well as honoring the child’s voice and not having it be a forced intervention.

When I was working as a school based therapist, I would occasionally have parents/outpatient therapists pushing for a student to use CIMT while at school. From a school based perspective, this research would lead me to advocate against using CIMT during the school day- especially considering the social emotional implications that came along with it. Students who were otherwise independent with self care tasks and most classroom activities having to lose some of that independence for a time as well as ‘looking’ different while wearing the restraint which typically led to students being uninterested/unwilling to engage anyways.

The other piece that stuck out for me from Sarah’s conclusions was- “Furthermore, evidence around improvement in participation and quality of life is also lacking at this point.” With participation/quality of life being the heart of OT, this alone would have me be hesitant to recommend the use of CIMT as a treatment option.

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Wow! Such great points, @Genny I’m so glad you weighed in.

Your call out about the lack of evidence around quality of life is really important. In fact I had that down as possible question to ask @catherine8 about in our interview, but ran out time.

I had two thoughts on this.

1.) This totally aligns with the trends we’ve seen in Dr. @iona Novak’s studies where the evidence around participation outcomes is lacking.

2.) It is a good reminder that we can’t assume that things l like hand function gains will translate to higher level participation gains. We always need to take time to actually practice goal areas!

I’m already thinking I need to have Dr. Novak back on the podcast to get her take on this!

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Also, I agree with your take on the situation as a school based therapist. Unless the child was involved in a research study, where that fidelity to a certain protocol was needed the evidence does not seem to support that that level of constraint is needed. I would definitely be on the phone with that outpatient therapist… But, also sensitive to the family’s wishes…

Also, curious to hear @catherine8’s take on this :slight_smile:

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Sorry one more thought, @Genny! I hope you still listen to my convo with Catherine that comes out next week.

I think the main takeaway from this research is the growing body of evidence behind high-intensity treatments of a limited duration that are highly goal directed.

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I get that @Genny, and totally agree, we need to know more! I think a major challenge to reviewing this (or any literature) in rehab, is that is impossible to be blinded, so it therefore also impossible to have the highest level of evidence. In reading the studies with children who have had CIMT, and personal experience, the older children have requested to do it. They agree to wear a cast full time, even at school, despite it being difficult and needing different accommodations, because they know it is for a short time and potentially will quickly increase their independence dramatically afterwards.

In very young children, it is difficult to measure changes in participation/QoL, but parents do report those changes on the Abilhand Kids, and Pediatric Motor Activity Log (PMAL), which is based on priorities that the parents have identified (think COPM).

While there is much evidence yet to collect, there is about 20 years of research supporting pediatric CIMT, stemming from adult CIMT research going back about 30 years. One of the most devastating things is the slow translation of evidence based practice to clinical care, which is on average 20 years. We still need to know more about dosage (currently being tested), what diagnoses are best suited for a full vs modified CIMT (or CIMT + HABIT) protocol, but I do think, as therapists, we have to do our best to offer families with the option to participate in interventions that have the chance to help their child.

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Thank you for floating this article/review! I had the chance to participate in the launch of an OP Peds CIMT program during a FW Level 2 experience. Reading through the article, review and discussion is giving me great things to think about and reflect upon. We casted, a skill I don’t personally have yet, and am happy to see in the discussion the efficacy of mitts w/velcro. To the points about potential resistance from the child, one of the clever things my CI did was create a social story with our young client’s favorite children’s show character also having a CIMT cast, to help him acclimate to the cast and CIMT process during the first week; it was a hit with both he & his mom. The biggest point from my FW experience and this article combined I’m still contemplating is the conclusion point of “goal-directed” - being able to identify and address the best goals for the CIMT experience for the unique client, in a time-bound set of services.

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