Running Head: EFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 1

Evaluating if the implementation of CIMT in school-aged children with hemiparesis

improves ADL function

Brady Donner, McCall Halvorson, Jessica Smith

University of Utah
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 2

Introduction

Children with hemiparesis often struggle with activities of daily living (ADL).

Hemiparesis can be caused by a variety of conditions including cerebral palsy (CP), stroke

(CVA), and traumatic brain injury (TBI), amongst others and can cause unilateral weakness and

difficulty with control of the affected limb. This makes interactions with their peers, accessing

their education, self-care, and meeting normal developmental milestones difficult. These issues

can be exasperated when the weakened limb is neglected because of difficulties involved with

using it. Often with effort from the child, function of the affected limb can be improved by

simply using the extremity. Different treatments have been used by occupational therapists,

including bimanual treatment, which have proven to be effective in rehabilitating children with

hemiparesis. One promising treatment for hemiparesis which is being used by occupational

therapists is constraint induced movement therapy (CIMT).

CIMT is a therapy method that restricts movement of the unaffected limb, forcing the

patient to use the affected limb. After the unaffected limb has been casted or placed in a sling,

the affected limb is treated by forcing use through repetitive tasks (Reidy et al., 2012). Through

the strengthening of the neurological mechanisms, movement and manipulation of the affected

limb becomes easier. As the affected limb becomes stronger, more complex movements are

practiced. This therapeutic treatment gives the child access to unimanual and bimanual function,

which is important to work, play, and completing activities of daily living such as dressing and

hygiene practices.

Over the past several years, mounting evidence-based research has been done to see if

CIMT is an effective treatment. The evidence that is in favor of CIMT is pertinent to

occupational therapists who often work with upper extremity conditions. While much evidence
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 3

exists on the intervention, there are few systematic reviews on the information. The purpose of

this systematic literature review is to compile the evidence of whether or not CIMT is an

effective treatment for occupational therapists to use with children with hemiparesis to improve

their ADL function.

Methods

Search Strategy

Articles for this paper were searched for using Google Scholar, PubMed and Eccles

Library databases. The following search keywords were used in a variety of combinations:

children, CIMT, constraint induced movement therapy, pediatric, hemiplegia, hemiparesis, and

adolescents. Initial search yielded approximately 1,800 articles.

Study Selection Criteria

Inclusion criteria included:

 Persons were under the age of 18 with hemiparesis/hemiplegia due to any non-

progressive condition

 CIMT was used as the experimental variable

 Outcome measures were aimed at ADL function

 Article was published in a peer reviewed journal

 Article fell between current date and 11 years prior

Exclusion criteria included:

 Articles not in English

 Articles focused on persons over the age of 18

 Articles over 12 years old

Quality Evaluation
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 4

Using these criterion, we narrowed our original list of approximately 1,800 articles to 42

that focused on our specific research question. Reviewers collaborated using a community

document in review of each individual article. Reviewers focused on randomized control trials

(RCT), using only a few articles with lower levels of evidence. Of the RCTs used in this study,

lowest PeDRO scale score used was 5/10. Other articles included three Level III and one Level

V; these articles were included because of the uniqueness of the information they brought to the

body of evidence. After evaluation, 12 articles were found and chosen for inclusion in the

systematic review. Dates for the articles reviewed ranged from the current date to 11 years prior.

Results

de Brito Brandao, Gordon, and Mancini (2012) compared the functional abilities of 16

children, 3-10 years old with hemiplegic CP before and after the implementation of CIMT or

HABIT (hand-arm intensive bimanual training) interventions that were randomly assigned.

Overall this study showed improvements of functional self-care capabilities and improved child

independence within both the CIMT group and the HABIT group. A unique aspect of this study

was the inclusion of the parents’ perceptions of their child’s functional goal improvements

during self-care and other activities and how these activities were impacted by CIMT or

HABIT. While inclusion of parent perspectives were considered positive, they were also related

to a limitation of this study; due to the young age of many of the participants, the COPM was not

able to be used with the children, but rather with the parents. The parents, therefore, chose

functional goals for their children, most of which were tailored to bimanual functional abilities,

and therefore, the HABIT group had more success in their functional goals.

Deppe et al. (2013) conducted a single-blind randomized control trial comparing CIMT

to bimanual training (BiMT) in 47 children (age 3.3-11.4 years) with non-progressive

AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 5

hemiplegia. The study found that those participants who received 60 hours CIMT (followed by

20 hours BIMT) resulted in more increase in functional abilities than BIMT alone. The strengths

of this study include sample size and randomization of participants into experimental and control

groups. Limitations of this study include the fact that the experimental group did not receive pure

CIMT only treatment, as well as a lack of long term follow up.

Sakzewski (2011) also found CIMT in combination with bimanual training resulted more

improvements than in CIMT or BIMT used independently. This study examines 63 children aged

5-16y with congenital hemiplegia. Strengths of this study include study design (single blind,

matched pairs, RCT), sample size (when compared to similar studies), and the inclusion of

persons with a slight intellectual impairment (which previous studies excluded). Limitation listed

of this study is the lack of a true control group.

Sterling (2013) examined the effect of CIMT/BIMT on gray matter of the brain. This

study examined 10 children with congenital hemiplegia ages 2-7. The study found that in

addition functional improvements, there was a significant increase in gray matter in the brain in

participants who completed CIMT training. One other significant finding from this study was

that when participants were given a choice of using either the affected hand or non-affected hand

they chose the affected 14.9% pre-treatment compared to 50.8% post treatment. Limitations of

this study include small sample size (n=10), no control group, no random assignment and it did

not address the long-term effects of CIMT/BIMT on gray matter in the brain.

An RCT by Geerdink, Aarts, and Geurts, (2013) found similar findings when combining

CIMT with BIMT in comparison to usual care. In this study, 50 children with unilateral spastic

cerebral palsy were examined before and after CIMT implementation. This study was unique in

the fact that it specifically looked at the learning curve of children. It found that children in the
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 6

study over 5 y.o. took longer to reach learning threshold than children under 5 y.o., indicating

that older children would benefit more from a longer CIMT training period than younger

children. Limitations of this study were the small sample size (possibly affecting significant

findings) and the fact there was some variation related to age in completing the box and block

test (one of the assessments used in this study).

Another implementation of CIMT that was studied in the articles reviewed was group

versus individual CIMT. Wu, Hung, Tseng, and Huang (2013) conducted a quasi-experimental

(one group pre, post and follow up) study with seven children ranging 2-14 years of age. In the

study, participants received CIMT in a group setting. At the conclusion of the study, findings

were compared to previous individual CIMT implementation. They found group CIMT to be as

effective as individual CIMT, but being more cost effective due to the fact a therapist could see

more than one client at a time. This was one of the first studies to examine this variable relating

to CIMT treatment. Limitations of this study included a small sample size, participants were not

randomly assigned, wide age range of participants, and assessments were not performed by a

blinded therapist.

El-Kafy, Elshemy, and Alghamdi (2014) did an experimental randomized control study

comparing a child-friendly form of modified CIMT with a non-structured conventional exercise

program for 30 children (4 to 8 years old) with congenital hemiparesis. The CIMT intervention

group wore a constraint sling for 6 hours per day (2 hours in clinic and 4 hours at home), 5 days

per week for 4 weeks. Results of QUEST (Quality of Upper Extremity Skills Test) scores show

significant differences between and within both groups. All children improved lost motor skills,

however, the CIMT intervention groups’ improvements were considerably greater. Unique to

this study was the additional use of shaping (dividing each task into small portions that the
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 7

subject could practice with) to further the CIMT program. Results found that a child-friendly

form of CIMT paired with shaping appears to improve UE function within this population. The

researchers did not list any limitations for this study.

Charles, Wolf, Schneider, and Gordon (2006) conducted a single-blinded study of 22

children with hemiplegic CP (4-8 years old) that were randomly assigned into an intervention

group or a delayed-treatment control group. The study was to compare the implementation of a

CIMT program on the involved upper extremity (UE) function with a group not currently

receiving any type of therapy for affected arm. CIMT was administered through age appropriate

games and functional tasks. This study tested functionality of the involved limb immediately

after intervention and tested again to measure retention of functionality. Although both groups

showed functional improvements over time, the CIMT treatment group sustained the UE (hand

and arm) function of their affected limb throughout a six-month evaluation period. Limitations

for this study include a small sample size.

Pidcock, Garcia, Trovato, Schultz, and Brady (2009) performed an analysis of previously

conducted studies about child-friendly forms of CIMT implemented post stroke, and how CIMT

should or could be applied within pediatric practice. The authors analyzed the articles and

concluded that CIMT when applied to children with hemiparesis appears to result in measurable

positive outcomes that will persist up to 6 months post intervention. The authors also discussed

the importance of early intervention with CIMT in relation to neural plasticity. This article is a

helpful tool when trying to understand the basis of CIMT intervention (the pros and cons), as

well as gaining insight into the progression of CIMT within rehabilitative practice. Some

limitations of CIMT discussed in this article include: children in these studies are susceptible to

observer bias, inadequate numbers of subjects to demonstrate reliable statistical significance and
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 8

lack of methodological consistency.

Aarts et al. (2010) conducted a randomized control trial with 52 children with unilateral

spastic cerebral palsy ages two and a half to eight. The participants were assessed before and

after the intervention was given. In the intervention the children spent the first six weeks with

their unaffected arm restrained and they were given functional training for three hours per day,

three times per week. During the last two weeks of the intervention, they focused on bi-manual

goal directed play, exercises, and ADLs. The control group was given normal therapy for 1.5

hours per week and parents were instructed to encourage the children to use the affected are 7.5

hours per day. Eight weeks later both groups were given a follow up assessment. The results

showed that the CIMT-BIT group had significantly greater improvements than the control group

did. The limitations included small sample size, the participants had relatively good arm and

hand capacity, and the control group had less interaction and dedication from their therapist than

the CIMT-BIT group did. These limitations make the generalizability of the study weaker.

Case-Smith et al. (2012) ran a randomized control trial with 18 children ages three to six

years old with unilateral CP. The participants were randomly divided into two groups. Both

groups received CIMT however one group received it for six hours per day and the other group

received therapy for only three hours per day. Both groups wore a cast on the unaffected limb for

the first 18 days of the intervention. While they were restrained they were given intense

treatment to help them gain use of their affected limb and it was given in a natural environment

and individualized to each participant. A pre assessment was given to get a baseline. For the last

three days the participants were given more practical bimanual interventions that related directly

to their ADLs. Six months after intervention was completed a post assessment was given and

both groups kept their significant improvements in ADL function. The results found that there
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 9

was not a significant difference between the three and six hour groups and therefore, it is

unnecessary to have the extra time in therapy. The limitations of this study were its small sample

size. Participants were at different levels at baseline, which may have affected the results. A

larger sample size would have decreased the likelihood of a negative effect on the outcomes. The

study also does not manipulate the CIMT protocol, which limits the amount of information

added to the field.

Reidy et al. (2012) conducted an experimental pre post design mixed pragmatic trial with

29 children with hemiplegia ages 1.6 – 19 years old. Children were split into two groups

including three and six hour groups. They were given a pre intervention assessment and then

their affected limb was casted and worn 24 hours per day and 7 days a week. The two groups

were given 16 days of CIMT and five days of bimanual training. Treatment sessions began with

preparatory activities like range of motion and moved into ADLs. After the cast was removed,

bimanual training consisted of bilateral functional activities. The results showed no difference

between the two groups, but both groups had significant ADL functioning improvements. One

limitation of this study was that the participants had different conditions, which caused their

hemiparesis. Also because of staff turnover the procedures changed overtime.

Discussion

Overall, CIMT was found to be a successful intervention for hemiparesis in

children. Twelve articles were analyzed, all of which found strong associations between

functional improvements associated with CIMT interventions.

CIMT Effectiveness

Multiple studies addressed the effectiveness of CIMT compared to bimanual training

therapies. Findings were synonymous across these articles; revealing that bimanual training
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 10

therapies were the most effective at increasing the functionality bimanually, but that CIMT

proved the most effective in regards to improvements of unimanual functioning of the involved

limb. Many of the studies suggested that a combination of CIMT and BIMT (or HABIT)

interventions would be the most effective in regards to improvement of long-term functional

gains.

Limitations, Considerations and Strengths

Some limitations of CIMT studies found across these articles include: not all

experimental groups were randomized controls, many of the studies involved small sample sizes

leading to inadequate demonstrations of statistical significance, children in these studies are

typically susceptible to observer bias, and not all studies are comparing and addressing the same

situations or populations.

Some strengths of these articles include: there were a high number of RCT studies

analyzed, the findings were consistent, and a variety of treatment duration times were assessed.\

Some additional considerations include: CIMT intervention within a group setting is

advisable for child populations, the use of a sling rather than a cast as a restrictive device may be

more child friendly, and age, and severity of injury or deficits should be considered before

implementing CIMT as an intervention option.

CIMT Clinical Considerations

There were many clinical considerations for pediatric CIMT studies. For instance,

rehabilitation professionals should choose CIMT or HABIT/BIMT based on their own expertise

and on the specifics of the client and activity demands. There have been positive associations

between implementation of CIMT protocol (both at home and in the clinic), and the focus on

continued training and use of impaired limb. The use of either a sling or a cast were both shown
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 11

to be effective applications for constraint of the unaffected limb within CIMT, however, a sling

(which is less restrictive and for fewer hours at a time) is likely more suitable for use within

pediatric populations. Implementation of CIMT intervention within in a group setting is

advisable, due to the supportive and competitive interactions between children. While keeping

the rest of these suggestions in mind, it is important to note that this intervention may NOT be

advisable for ALL children with hemiparesis/hemiplegia (age and severity of hand injury should

be considered).

Conclusion

Based on the findings from the articles we analyzed, a child-friendly form of CIMT has

shown to be effective for improving upper extremity functional abilities (including ADL

abilities) of the involved limb for children with hemiparesis. It is also recommended, that a

combined approach of both CIMT and some form of bimanual training therapy will present with

the most long-term bimanual functional improvements.

Based on American Heart Association (AHA) Levels of Evidence, the treatment

reviewed for this paper would be classified as a class I, level A. This classification was given

based on the large number of RTCs, the consistency of findings across these articles, and with

the researchers recommendations for this therapy to be used with child populations.

Information about child friendly versions of CIMT is relevant and necessary for

occupational therapists because furthering and sustaining the child’s use of a paretic arm can

have vast and impressive upper extremity functional improvements. These studies have shown

that forced use of the paretic limb can lead to functional improvements that will allow for greater

unimanual and bimanual function, which will create opportunities for children to improve

occupational skills.
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 12

References

Aarts, P. B., Jongerius, P. H., Geerdink, Y. A., Limbeek, J. v., & Geurts, A. C. (2010).

Effectiveness of modified constraint-induced movement therapy in children with

unilateral spastic cerebral palsy: A randomized control trial. Neurorehabilitation and

Neural Repair, vol? 509-518. doi:10.1177/1545968309359767

Case-Smith, J., DeLuca., S. C., Stevenson, R., & Ramey, S. L. (2012). Multicenter randomized

controlled trial of pediatric constraint-induced movement therapy: 6-month follow-up.

American Journal of Occupational Therapy, 66, 15–23. doi: 10.5014/ajot.2012.002386

Charles, J. R., Wolf, S. L, Schneider, J. A., & Gordon, A. M. (2006). Efficacy of a child-friendly

form of constraint-induced movement therapy in hemiplegic cerebral palsy: A

randomized control trial. Developmental Medicine and Child Neurology, 48, 635-642.

DOI: 10.0117/S0012162206001356

de Brito Brandao, M., Gordon, A. M., & Mancini, M. C. (2012). Functional impact of constraint

therapy and bimanual training in children with cerebral palsy: A randomized controlled

trial. American Journal of Occupational Therapy, 66(6), 672-681. DOI:

10.5014/ajot.2012.004622

Deppe, W., Thuemmler, K., Fleischer, J., Berger, C., Meyer, S., & Wiedemann, B. (2013).

Modified constraint-induced movement therapy versus intensive bimanual training for

children with hemiplegia – a randomized controlled trial. Clinical Rehabilitation, 27(10),

909-920. doi:10.1177/0269215513483764

El-Kafy, E. M. A., Elshemy, S. A., & Alghamdi, M. S. (2014). Effect of constraint-induced

movement therapy on upper limb functions: A randomized control trial. Scandinavian

Journal of Occupational Therapy, 21, 11-23. DOI: 10.3109/11038128.2013.837505

AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 13

Geerdink, Y., Aarts, P., & Geurts, A. C. (2013). Motor learning curve and long-term

effectiveness of modified constraint-induced movement therapy in children with

unilateral cerebral palsy: A randomized controlled trial. Research in Developmental

Disabilities, 34(3), 923-931. doi:10.1016/j.ridd.2012.11.011

Pidcock, F. S., Garcia, T., Trovato, M. K., Schultz, S. C., & Brady, K. D. (2009). Pediatric

constraint-induced movement therapy: A promising intervention for childhood

hemiparesis. Topics in Stroke Rehabilitation, 16(5), 339-345. DOI: 10.1310/tsr1605-339

Reidy, T. G., Naber, E., Viguers, E., Allison, K., Brady, K., Carney, J., ... & Pidcock, F. (2012).

Outcomes of a clinic-based pediatric constraint-induced movement therapy program.

Physical and Occupational Therapy in Pediatrics, 32(4), 355-367. DOI:

10.3109/01942638.2012.694991

Sakzewski, L., Ziviani, J., Abbott, D. F., Macdonell, R. A. L., Jackson, G. D., & Boyd, R. N.

(2011). Randomized trial of constraint-induced movement therapy and bimanual training

on activity outcomes for children with congenital hemiplegia. Developmental Medicine

and Child Neurology, 53, 313-320. DOI: 10.1111/j.1469-8749.2010.03859.x

Sterling, C., Taub, E., Davis, D., Rickards, T., Gauthier, L. V., Griffin, A., & Uswatte, G. (2013).

Structural neuroplastic change after constraint-induced movement therapy in children

with cerebral palsy. Pediatrics, 131(5). doi:10.1542/peds.2012-2051

Wu, W., Hung, J., Tseng, C., & Huang, Y. (2013). Group constraint-induced movement therapy

for children with hemiplegic cerebral palsy: A pilot study. American Journal of

Occupational Therapy, 67(2), 201-208. doi:10.5014/ajot.2013.004374

AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 14

Study Design Population Outcome Findings

Measures

Deppe, W., Level of 47 children with Melbourne Examines the

Thuemmler, evidence: 1 unilateral CP or assessment of effectiveness of
K., Fleischer, other non unilateral Upper CIMT + BIMT
J., Berger, Pedro Scale: progressive Limb Function and versus BIMT alone
C., Meyer, 7/10 hemiplegia Assisting Hand
S., & Assessment CIMT has greater
Wiedemann, effect on isolated
B. (2013). Parent functions of the
questionnaire on hemiplegic arm than
self care abilities BiMT
from Pediatric
Evaluation of Both CIMT and
Disability BiMT were equally
Inventory effective in
(secondary encouraging
measure) effective use of the
affected limb

Children with greater

deficit to begin with
had greater
impromentents than
those with a lesser
deficits

Geerdink, Y., Level of 50 children with Box and block test Examines the
Aarts, P., & evidence: 1 unilateral spastic relationship between
Geurts, A. C. CP, age 2.4-8 years Long term effects CIMT and learning
(2013) Pedro Scale: were measured curve in children
6/10 with:
AHA (eval of the Age had the greatest
spontaneous use of effect on speed of
the affected hand dexterity gain with
in a semi- the affected upper
structured extremity
observation)
ABILHAND-Kids Younger children
(evaluate manual (<5 years) reached
skills through a their learning
parents threshold fast than
questionnaire) children over 5 years
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 15

Older children may

benefit more from a
longer CIMT
treatment

Age did not effect

the long term
benefits of CIMT

Sakzewski, Level of 63 children age 5- Outcomes across Examined the

L., Ziviani, evidence: 1 16 with congenital all domains of the differences between
J., Abbott, D. hemiplegia World Health CIMT alone and
F., Pedro Scale: Organization’s BIMT
Macdonell, 8/10 International
R. A., Classification of CIMT had superior
Jackson, G. Functioning, outcomes compared
D., & Boyd, Disability and with bimanual
R. N. (2011). Health training for
Melbourne unimanual capacity
Assessment of
Unilateral Limb Gains were
Function assessed maintained by BiMT
unimanual at 26 weeks
capacity of the
impaired limb and BiMT had more
Assisting Hand effect on bimanual
Assessment improvements
evaluated
bimanual Suggestion that
coordination at future studies should
baseline, 3 and 26 begin with CIMT,
weeks followed with BiMT
to maximize
outcomes

Sterling, C., Level of 10 children with MRI assessing the Examined the
Taub, E., evidence: 3 congenital changes in grey functional and
Davis, D., hemiparesis age 2- matter in the brain biological effects of
Rickards, T., 7 3 weeks before, CIMT in children
Gauthier, L. immediately
V., Griffin, before and CIMT lead to a
A., & immediately significant increase
Uswatte, G. following CIMT in gray matter in the
(2013). brain
At each of the 3
testing occasions CIMT may promote
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 16

parents more additional

participated in a adaptations of
scripted, structured ipsilateral motor
interview to assess pathways
spontaneous use of
the affected limb

Wu, W., Level of 7 children age 2-14 Measured Testing feasibility of

Hung, J., evidence: 3 years with functional skills, group- based CIMT
Tseng, C., & diagnosis of caregiver for children with
Huang, Y. hemiplegic CP and assistance scores hemiplegic CP
(2013). a Manual Ability and spontaneous
Classification use of affected Groups based CIMT
System score of I, limb in children with
II, or III hemiplegic CP was
an effective
alternative to
individualized CIMT

Functional skills and

caregiver assistance
scores improved in
the PEDI self care
domain

Found that children

were more willing to
receive CIMT in
group setting than on
their own

Recommended 2
practitioners for 4-6
children

Results of group
CIMT
implementation were
similar to
individualized CIMT

de Brito Experimental Inclusion criteria This study used the CIMT and HABIT
Brandao, M., Randomized for participants in Manual Ability interventions had a
Gordon, A. Control Trial this study: Classification positive impact on
M., & (RCT) participants must System (MACS) - the functional self-
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 17

Mancini, M. have normal (on a scale from I - care skills and

C. (2012). 16 children cognition, must V) to test independence of
with have a diagnosis of participants’ hand children with
hemiplegia hemiplegia function. hemiplegic CP, as
(10 males, 6 with at least a 50% well as had a positive
females) difference on timed Parents were impact on the child’s
(3-10 years) motor tasks interviewed by self satisfaction with
between their two main author to performing the
8 children - arms (on the assess their child’s activities.
HABIT Jebsen-Taylor Test (participant) daily
(Hand-Arm of Hand function - functioning; the Rehab professionals
Bimanual excluding writing author used the should choose CIMT
Intensive test portion of this PEDI (Pediatric or HABIT based on
Training) assessment), and Evaluation of their own expertise
participants must Disability and on the specifics
8 children - be able to extend Inventory), and the of the client and
CIMT wrist at least 20° COPM (Canadian activity demands
(Constraint- and fingers 10° Occupational
Induced from full flexion. Performance
Movement Measure)
Therapy) assessments.

Level of Mixed analysis of

Evidence: 1 variance – to
compare group
Pedro Scale: functional means
6/10 scores pre- and
post-
interventions

El-Kafy, E. Experimental Inclusion criteria: The Pediatric Arm This study found that
M. A., Randomized children must have Function Test a child-friendly form
Elshemy, S. Control Trial a DX of congenital (PAFT) tested of a modified CIMT
A., & (RCT) hemiparetic CP unilateral and (with shaping) shows
Alghamdi, (confirmed by bilateral functional improvement of UE
M. S. (2014). 30 MRIs obtained ability scores (this function in children
congenitally from medical is a valid and with congenital
hemiparetic records); age 4-8 reliable test). hemiparesis.
children (4-8 years old; have a
years) MAS (Modified The Quality of
Ashworth Scale) of Upper
Level of 1, 1+, or 2; hand Extremity Skills
Evidence: 1 function levels Test (QUEST)
within II, III, and includes a pre- ,
Pedro Scale: IV according to immediately post-
5/10 MACS (Manual & 3 months post-
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 18

Ability treatment
Classification assessments.
System); ability to
extend wrist at The Manual
least 20° and Ability
fingers 10° from Classification
full flexion. System (MACS)
test participants’
Exclusion Criteria: hand function on a
visual problems; scale from I-V.
balance problems;
botulinum toxin in
UE within past 6
months of study;
fixed contractures;
previous CIMT or
similar therapy; or
UE surgeries that
could interfere with
intervention.

Charles, J. Single- Inclusion criteria: Jebsen-Taylor Test A child-friendly

R., Wolf, S. blinded (1) ability to extend of Hand Function modified version of
L, Schneider, Randomized wrist at least 20° (to test movement CIMT appears to be
J. A., & Control Study and fingers 10° efficiency and efficacious in
Gordon, A. (RCT) from full flexion; dexterity). improving movement
M. (2006). (2) a 50% efficiency of the
22 Children difference of Fine motor involved UE in a
with affected and subtests of the carefully selected
hemiplegic unaffected arm on Bruininks- subgroup of children
CP (8 females the Jebsen-Taylor Oseretsky Test of with hemiplegic CP.
14 males) Test of Hand Motor Proficiency.
(mean age 6 Function; (3) Treatment group
yr. 8 months; scored within 1SD Sensibility sustained
age range 4-8 of mean on measured with improvement over
years) Kaufman Brief two-point the 6 month
Intelligence Test; discrimination evaluation period.
Level of (4) willingness to (TPD).
Evidence: 1 travel to and This intervention
participate in study. Hand grip may NOT be
Pedro Scale: measured with advisable for ALL
5/10 Exclusion Criteria: hand-held children with
(1) additional dynamometer. hemiplegia (age and
health problems in severity of hand
addition to CP; (2) Modified injury should be
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 19

seizures; (3) visual Ashworth scale considered)

problems; (4) used to assess
severely increased muscle tone.
muscle tone; (5)
previous UE
surgery; (6) dorsal
rhizotomy; (7)
botulinum toxin
therapy in past 6
months; (8)
intrathecal
baclofen; (9)
balance problems.

Pidcock, F. Article n/a This article Pidcock did not

S., Garcia, analysis discussed the use perform a research
T., Trovato, of various study for this article,
M. K., No measurement tools but this article is a
Schultz, S. population. that have been helpful tool when
C., & Brady, successfully used trying to understand
K. D. (2009). Level of in other studies the basis of CIMT
Evidence: 5 related to CIMT: intervention and the
pros and cons that
Quality of Upper may be associated
Extremity Skills with it, as well as
Test (QUEST)- gaining some insight
Dissociated into the progression
movement of CIMT already
subscale. within health care.

Assisting hand
assessments
(AHD)

Reidy, T. G., Pre- and Post- Inclusion: Canadian This states that there
Naber, E., test design previously received Occupational is no difference
Viguers, E., 29 children services from a Performance between doing a
Allison, K., with clinical CIMT Measure (COPM) daily three or six
Brady, K., hemiplegia program located hour treatment. They
Carney, J., ages 1.6 – 19 in a pediatric day Melbourne are equally effective.
Salorio, C., years old. rehabilitation Assessment of CIMT is an effective
Pidock, F. Level of center Unilateral Upper treatment for
(2012) evidence: 3 (retrospective) or Limb Function improving bimanual
were referred to the (MAUL) hand skills.
CIMT program by
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 20

their primary Assisting Hand

physician, Assessment
physiatrist, (AHA)
outpatient physical
or occupational Quality of Upper
therapist, or by Extremity Skills
self-referral Test (QUEST)

Exclusion:self
injurious behaviors,
inability to
passively extend
their elbow past
90◦ prohibiting
participation in
tabletop activities,
bilateral UE
weakness,
contractures in the
less
affected side
limiting ability to
be properly
positioned in a cast,
inability to engage
in activities and
participate in
reciprocal
interactions with
therapists,
uncontrolled
seizures, inability
of the family to
commit to the
program, or age
under 1 year

Case-Smith, Randomized Inclusion: Eighteen AHA: measures This study compared

J., DeLuca, Controlled children ages 3–6 the a 3 hour regiment of
S. C., Trial yr diagnosed with child’s ability to CIMT with a 6 hour
Stevenson, unilateral use the affected and found that the 3
R., Ramey, Population: CP were recruited. hand to assist the hour treatment can
S. L. (2012) Eighteen All children had unaffected produce an
children ages central nervous hand in a variety of equivalent benefit to
3–6 yr system bimanual activities the 6 hour treatment.
AFFECT OF CIMT ON ADL FUNCTION IN CHILDREN 21

diagnosed lesions clinically This finding can save

with judged to have QUEST: measures the clients time and
unilateral occurred before upper-extremity money.
CP were 1 mo of age. movement
recruited. All Exclusion: the use patterns and hand
children had of botulinum function in
central toxin within the children with CP
nervous past 6 mo, previous ages
system participation 18 mo–8 yr.
lesions in a formal CIMT PMAL: a parent-
clinically program, the report tool of the
judged to presence of major child’s
have occurred uncontrolled frequency and
before seizures or quality of use of
1 mo of age. comorbid medical the affected upper
conditions, or extremity.
the presence of
Level of visual impairment.
evidence: 1

Pedro Scale:
6/10

Aarts, P.B., Randomized Inclusion Outcome Findings:All

Jongerius, P. Control requirements: CP Assessments: assessments showed
H., Geerdink, Study. with a unilateral or AHA, significant
Y. A., The bilateral spastic ABILHAND-Kids, improvements
Limbeek, J. population movement Melbourne, including ADLs.
v., Geurts, A. was children impairment, 2.5-8 COPM, and GAS.
C. (2010) ages 2.5-8 years old, MACS
who had CP score of I,II,III
with Exclusion:
unilateral Intellectual
spastic disability, inability
movement to combine school
impairment. with intervention,
and inability to
Level of walk
evidence: 1 independently.

Pedro Scale:
6/10