Journal of Interprofessional Education & Practice 15 (2019) 88–93

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Journal of Interprofessional Education & Practice

journal homepage: www.elsevier.com/locate/jiep

Modifying constraint induced movement therapy for diverse populations T

a,∗ a a
Nicole Whiston (MS, OTR/L) , Teressa Garcia Reidy (MS, OTR/L) , Erin Naber (PT, DPT) ,
Joan Carney (Ed.D)a, Cynthia Salorio (PhD, ABPP)a,b
a
Fairmount Rehabilitation Programs, Kennedy Krieger Institute, 1750 E. Fairmount Ave, Baltimore, MD, 21231, USA
b
Johns Hopkins University School of Medicine, Baltimore, MD, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Aims: This paper aims to describe a modified constraint induced movement therapy (mCIMT) protocol used
Hemiplegia within a comprehensive interdisciplinary day rehabilitation program for a multi-needs population, propose a
Cerebral palsy methodology for selecting participants for this protocol, describe the collaboration between professions within
Constraint induced movement therapy this intervention protocol, and provide a case report of outcomes of 5 participants.
Intensive therapy
Methods: In this retrospective chart review of participants enrolled in an interdisciplinary outpatient re-
Upper extremity
habilitation program, 5 participants met inclusion criteria of an average of at least 30 min of mCIMT each day
Interdisciplinary rehabilitation
and at least 10 days of casting during admission. Assessment measures and classification scales included the
Canadian Occupation Performance Measure, Manual Ability Classification Scale, Gross Motor Function
Classification Scale, Quality of Upper Extremity Skills Test, Assisting Hand Assessment and Mini-Assisting Hand
Assessment.
Results: Improvement was observed for all participants across all measures. Exploratory analysis revealed sig-
nificant change from pre-to post-intervention on the COPM in both average performance (p < .05) and overall
satisfaction (p < .05). Significant improvement across time points was also seen on the QUEST (p < .05).
Conclusions: This modification of an effective intervention for children with cerebral palsy gives children who
have a lower baseline skill set or who have additional mobility, communication, and cognitive needs the op-
portunity to receive intensive upper extremity training.

1. Introduction
Research supports the use of Constraint Induced Movement Therapy
(CIMT) as an effective therapeutic intervention to improve bilateral
upper extremity (UE) skills for children with hemiplegic cerebral
palsy.3,21,26 CIMT is utilized with increased frequency as an interven-
tion technique for children with varying levels of manual ability33 and
has demonstrated effectiveness with heterogeneous populations of
children with hemiplegia both in group and individual settings.1,8,22,30
Intensive Bimanual Training (IBT) has also demonstrated improved
coordination, upper limb function, and performance capacity in chil-
dren with cerebral palsy.2,21 Compared to standard care, both intensive
approaches have begun to demonstrate superior outcomes.14
Traditional CIMT models include parameters in which a child's
uninvolved arm is continuously constrained, typically with a cast, for a
period of time. Therapy is provided daily, several hours a day, for ap-
proximately 21 days.7,30 Modified approaches use a removable con-
straint such as a splint, removable cast, mitt or glove, and range in
treatment time from 12 to 96 h total for 2–6 h per day over the course of
2–10 weeks.21
Despite the growing body of evidence for both CIMT and IBT, these
interventions are primarily utilized with participants with higher
baseline hand function. In a search of the current literature, the ma-
jority of children completing this intervention met program-specific
grasp and range of motion pre-requisites and had minimal to no mo-
bility, communication, or cognitive difficulties.6
In a comprehensive review of interventions used for children with
cerebral palsy, Shierk and colleagues (2016) reported that research
using CIMT protocols most frequently included participants with a
Manual Ability Classification Scale (MACS) score of II, followed by
those with MACS of I. Comparatively speaking, there is far less pub-
lished evidence for use of CIMT intervention for children with more
impaired hand skills; a search of the current literature revealed very
few studies that use intensive upper extremity training with children
with MACS levels III and higher.8
In the handful of studies that reported Gross Motor Functional

∗
Corresponding author.
E-mail address: whiston@kennedykrieger.org (N. Whiston).

https://doi.org/10.1016/j.xjep.2019.02.005
Received 20 November 2018; Received in revised form 13 February 2019; Accepted 18 February 2019
2405-4526/ © 2019 Elsevier Inc. All rights reserved.
N. Whiston, et al.
Table 1
Participant characteristics and intervention received.
Participant Age Gender Diagnosis Affected Arm MACS/Mini-
MACS Level
1 2:3 Male Spastic Hemiplegic CP Right 3 4
2 3:0 Male Spastic Quadriplegic CP Right 3 3
3 4:2 Male Hemispherectomy Right 3 2
4 5:0 Male Right Hemiplegia Right 3 3
5 9:11 Female Spastic Hemiplegic CP Right 2 1
Classification Scale (GMFCS)27 levels, participants who completed
CIMT intervention were limited to levels I and II.16,31,32,34 There is little
data reported on use of intensive upper extremity training with children
with greater mobility limitations classified as GMFCS level III or
higher.8
In modified CIMT (mCIMT), structured skill practice is a key ele-
ment, despite the variations in intensity, duration of constraint, and
type of constraint. This intervention has been expanded to include in-
dividuals who would not tolerate the multiple hours of constraint per
day due to age and ability.13 These modified approaches have a de-
creased duration of casting and daily therapy, and may take place in
non-traditional settings such as schools.17 In addition, the service pro-
viders have included not only therapists, but also family members.13
In a clinical setting, participants with hemiplegia, especially those
with greater severity of hand impairment, may also have cognitive or
behavioral challenges. In addition, individuals referred to CIMT pro-
grams who have hemiplegia due to an injury or acquired brain injury
may also present with decreased cognitive abilities. Emerging evidence
examining modified and traditional approaches in children with ac-
quired brain injury is promising but limited to smaller group stu-
dies.4,5,10,20,22
Research on the use of CIMT within a larger interdisciplinary pro-
gram for children with additional mobility, communication, or cogni-
tive deficits is scarce and limited to preliminary pilot studies or clinical
reports. There is a lack of interdisciplinary programs described in the
literature at this time. Most protocols reported are executed exclusively
by educators, physical therapists or occupational therapists with little
cross over or collaboration. To date, no published protocols include the
disciplines of speech language pathology, special education and psy-
chology collaborating to provide therapy to the child receiving con-
straint induced movement intervention.
Significant descriptions about modifications, treatment considera-
tions, and adaptations to CIMT are not extensively reported in the ex-
isting literature. Clinicians who strive to provide evidence based
treatment may find it hard to decide when and with whom to imple-
ment traditional and modified approaches of CIMT. Translating the
evidence into clinical practice with a varied and complex caseload can
present a real challenge for the occupational or physical therapy
practitioner.
This paper has two objectives: (1) describe an evidence based
modified CIMT intervention protocol used within an interdisciplinary
rehabilitation program and (2) to propose a methodology for de-
termining use of modified CIMT to address asymmetrical UE dysfunc-
tion in a multi-needs population. In addition, a case report of a small
group of participants who have completed the protocol will be pre-
sented.
2. Methods
2.1. Participants
Institutional Review Board Approval was obtained from Johns
Hopkins University. This retrospective chart review extracted demo-
graphic data, functional status, and assessment results of clinical cases
admitted to a comprehensive interdisciplinary day rehabilitation
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Journal of Interprofessional Education & Practice 15 (2019) 88–93
GMFCS Days of Average amount of time wearing Days of Bimanual
Level CIMT constraint per day (minutes) Therapy
19 46.5 3
19 46.3 0
14 51.4 5
15 40.3 11
12 53.8 1
program who participated in a modified CIMT intervention as part of
their occupational therapy treatment between August 2014 and August
2017. A total of 19 cases met these criteria.
Cases were excluded from this dataset if they had less than an
average of 30 min of mCIMT each day (n = 1), had fewer than 10 days
of casting during admission (n = 7), or had incomplete records (n = 6).
Clinical inclusion criteria was minimal but included the following:
• Seizure free or well controlled seizures for at least 3 months prior to
starting the program
• Tolerates at minimum 1 h of casting and mCIMT a day
• Tolerates 3–5 h of interdisciplinary therapy per day
Five cases met inclusion and exclusion criteria and were analyzed.
Participants varied widely in age and functional abilities at baseline.
Most participants had hemiplegic cerebral palsy and were MACS level
3. Table 1 describes the participants in greater detail.
2.2. Measures
During the initial evaluation period and again at discharge, parti-
cipants enrolled in mCIMT underwent the following standardized as-
sessments by the occupational therapist and physical therapist.
Assessment selection was consistent with those used in other research33
and clinical CIMT programs.22
The Canadian Occupation Performance Measure (COPM) is a semi
structured interview to assess participation by capturing parent goals
and functional changes to assure intervention is client centered.25
Change scores of 2 points have been verified to be clinically significant
on the COPM.25
The Manual Ability Classification Scale (MACS) is a 5-point classifi-
cation system describing how 4–18 year old children with cerebral
palsy use both hands to interact with objects based on observation and
caregiver input.12 The Mini-MACS is a similar classification system used
with children 1–4 years old.11
The Gross Motor Function Classification Scale (GMFCS) is a 5-level
system which describes the gross motor skills of children with cerebral
palsy based on the child's functional ability, their use of assistive de-
vices or wheeled mobility, and the quality of their movement.27
The Quality of Upper Extremity Skills Test (QUEST) is a standardized
assessment that examines how each hand and arm functioned in-
dependent of each other specifically assessing dissociated movements,
grasps, protective extension, and weight bearing for children 18 months
to 8 years of age.9
The Assisting Hand Assessment (AHA) is a semi-structured play ses-
sion that assesses bilateral hands skills in children with hemiplegic
cerebral palsy from 18 months to 12 years.24 Change scores of 5 points
of logit AHA-unit scale have been verified to be clinically significant on
the AHA.23
The Mini-Assisting Hand Assessment (Mini-AHA) is a semi-structured
play session that assesses bilateral hand skills in children with hemi-
plegic cerebral palsy from 8 months to 18 months old.18
To ensure fidelity and uniformity of the protocol, all therapists in-
volved in assessment and intervention completed required trainings and
an annual competency checklist. In addition, all clinicians were
N. Whiston, et al.
supervised by a senior therapist until deemed competent in casting,
assessment, and intervention.
2.3. Procedures
2.3.1. Program description
Kenendy Krieger Institute's Focused Interdisciplinary Therapy (FIT)
is a rehabilitation program provided in an outpatient day hospital set-
ting. It offers children and adolescents between ages 8 months and 21
years old with persistent, disabling conditions intensive therapy that
targets specific therapeutic goals. The interdisciplinary team includes
pediatric rehabilitation physicians, physical therapists (PT), occupa-
tional therapists (OT), speech and language pathologists (SLP), neu-
ropsychologists, nurses, and special educators.
Patients enrolled in the FIT program receive a developmentally
appropriate, multi-disciplinary evaluation with a comprehensive bat-
tery of assessments at the start of the program from all treating dis-
ciplines. During intervention, all practice is function and play based
while highly repetitive and carried out in a variety of contexts. Children
receive a combination of individual and group therapy services to help
them achieve the goals set by them, the family and therapeutic team.
Educational services are also provided, so that a child may keep up with
his or her schoolwork while participating in the program, and to fa-
cilitate integration of newly acquired skills from therapeutic program
into the school setting. The specific frequency and duration of therapy
varies according to the child's age, abilities, and goals for therapy;
however, children enrolled typically receive interdisciplinary therapy
and special education services three to 6 h per day, five days a week, for
four to six weeks.
Team meetings are held weekly. At the start of the program an in-
terdisciplinary treatment plan is developed based on evaluation results
and discussion of the best of plan of care by the treatment team. The
treatment plan is documented in the medical record and shared with
families. Patient progress and needs are discussed every other week or
more frequently if needed during rehabilitation rounds. Feedback on
patient progress, intervention strategies, improvements, and ways to
promote cross disciplinary goals in all sessions is discussed.
Opportunities for co-treatment by multiple disciplines are available as
needed. Individual therapists or groups of therapists provide training to
parents throughout the program.
Skill practice is cross functional and community oriented. For ex-
ample if a child is learning to use a new augmentative communication
device, accessibility options may be discussed by the OT and SLP,
trialed in SLP first, practiced within self-care or play activities in OT
sessions, and then introduced to the classroom staff for educational
activities. The OT may address specific goals such as improving grip
strength to hold the device with the affected hand, carrying the device
from place to place with two hands or working on using his or her index
finger for access. At a team meeting the OT may discuss with the team
the best way to utilize two hands or the child's affected hand when he or
she is accessing the device across therapy sessions.
Based on emerging evidence supporting the adaption of CIMT pro-
grams for varying populations,5,28,30 clinicians in this program created
a modified CIMT protocol to use with participants enrolled in the FIT
program. Although they did not meet established criteria for traditional
CIMT protocols, clinicians identified patients who still needed to en-
gage in repetitive, progressive, focused UE therapy to improve self-care
and bimanual skills. After the completion of comprehensive evaluations
and conferencing by staff (see Fig. 1), modified CIMT could be added to
a child's treatment plan.
2.4. Intervention
Modified CIMT intervention takes place during the participant's
scheduled occupational therapy time and occasionally during other
functional times such as lunch time, music group, or cooking group
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Journal of Interprofessional Education & Practice 15 (2019) 88–93
where upper extremity and fine motor training were targeted.
There was a wide variation in the amount of constraint based
therapy and bimanual focused therapy provided in occupational
therapy sessions, as each participant received a custom protocol based
on the participant's needs, parent's goals, and therapist's clinical rea-
soning.
During weekly team meetings and informal meetings with inter-
disciplinary staff the OT educated the team on strategies to promote
affected hand and bimanual hand use.
The amount of constraint therapy was impacted by participant at-
tendance, how soon after a participant's initial evaluation the therapist
initiated mCIMT, and the need for repetitive practice with functional
bilateral tasks. Table 1 describes the parameters of the mCIMT inter-
vention for each participant.
During unimanual focused training, when the participant wore the
constraint, the therapist focused on refining range of motion, grasp and
release, coordination, strength, and motor control through age appro-
priate activities from toy cars and form board puzzles, to crafts and
games. Adjunct treatments including robotic devices or electrical sti-
mulation to target and strengthen specific muscles or movement pat-
terns were used with one older participant as well.
During bimanual focused training, the therapist focused on use of
both hands together in symmetrical and asymmetrical patterns through
age appropriate self-care and play activities from playing with dough
and construction blocks to playing sports and cooking.
The reason for choosing a modified protocol also varied. A majority
of the participants were better suited for a modified protocol since they
had other therapy needs beyond the scope of occupational and physical
therapy practice that were better addressed by all practitioners si-
multaneously. Some participants had a complex medical history or co-
morbidities (n = 4), impaired mobility (n = 3), or decreased cognitive
skills (n = 2) which impacted their ability to tolerate traditional CIMT.
One participant was older and had age appropriate independence, so
activities of daily living would have been restricted with prolonged or
continuous casting.
Fig. 1 describes the decision making process used clinically for
participants when choosing whether traditional CIMT or mCIMT pro-
gram would be more appropriate.
2.5. Data analysis
Performance across participants for each outcome measure was
examined qualitatively by comparing individual performance pre- and
post-intervention, and examining whether participants demonstrated
general and clinically significant improvements. For the COPM, in-
dividual goals were examined, as was the average total score for per-
formance and satisfaction at each time point. Exploratory statistics were
used to examine group-based change on the COPM total average score
for performance and satisfaction, and the QUEST total score. The AHA
was not examined statistically as not all participants received the same
version. To account for the small sample size and lack of normality,
exploratory Wilcoxon Signed-Rank Tests were used to compare group
pre- and post-intervention scores. Group-based analysis was completed
using SPSS version 24.19
3. Results
Improvement was observed for all participants across all measures.
Table 2 reports participant scores for each outcome measure pre and
post mCIMT intervention. Overall, the COPM showed a mean change in
performance of +2.62 (SD ± 0.78) and mean change in satisfaction of
+2.94 (SD ± 1.17). The QUEST showed a mean change of +10.17
(SD ± 3.18) from initial to discharge. The mean AHA scores improved
+5.33 (SD ± 0.44) points on a logit-based scale. The mean mini-AHA
scores improved +25.5 (SD ± 3.5) points on a logit-based scale.
Table 3 presents the goals identified by parents and the change in
N. Whiston, et al. Journal of Interprofessional Education & Practice 15 (2019) 88–93

Fig. 1. Decision tree for selecting traditional or modified CIMT intervention.

perceived performance and satisfaction from admission to discharge. (Z value −2.02, p < .05).
Across all goals on the COPM, 96% had a raw score increase for per-
formance, and 88% had a raw score increase for satisfaction. In addi-
4. Discussion
tion, 79% of goals had a clinically significant increase for performance,
and 75% showed clinically significant improvement in satisfaction.
This case report describes the use of a modified CIMT protocol ad-
Exploratory analysis revealed significant change from pre-to post-
ministered within an interdisciplinary day rehabilitation program in
intervention on the COPM in both average performance (Z value
children whose age, diagnosis, and impairments would typically pre-
−2.02, p < .05) and overall satisfaction (Z value −2.02, p < .05).
clude CIMT as an intervention. We also propose a decision tree for se-
Significant improvement across time points was also seen on the QUEST
lecting participants that is rooted in current evidence and clinical

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N. Whiston, et al. Journal of Interprofessional Education & Practice 15 (2019) 88–93

Table 2 In this small sample, parent-selected goals on the COPM fell in a

Participant scores on outcomes measures pre and post intervention. variety of categories reflecting the complex heterogeneous needs of
Participant COPM Average QUEST (Global AHA (Logit AHA- their child and the importance of interdisciplinary approach. Goals
score) units) related to upper extremity use including awareness, motor control,
Performance Satisfaction desensitization, and strength made up only 42% of the goals identified.
While this was the majority, it is important to note that at least half of
Pre Post Pre Post Pre Post Pre Post
the goals identified were in areas of mobility (21%), communication or
1 3.00 5.50 3.17 6.00 40.22 50.66 28a 57a cognition (29%), and self-care (8%). In contrast, our prior study sug-
2 2.75 5.50 2.75 5.50 30.26 34.95 16a 38a gested that goals from caregivers of children enrolled in a traditional
3 4.50 7.67 4.17 8.17 38.45 45.36 16 21 CIMT program are predominantly related to mobility, self-care and fine
4 4.00 8.00 4.40 8.20 53.47 63.43 60 66
5 4.00 4.67 3.67 5.00 49.28 67.13 54 59
motor manipulation.29 Often the mobility goals were related to upper
extremity function such as carrying objects from place to place or
a
Participants were assessed using Mini-AHA. crawling for younger participants. Of the 219 goals reported in that
cohort of 41 participants, only 8 goals were related to cognition and
experiences. This can be used by clinicians and in the design of larger communication.
studies using this intervention protocol. Collaboration with the participant's existing medical team is im-
The preliminary findings from this case series suggests that children portant as side effects of treatment are not widely understood.
may receive a lower dosage of CIMT and still demonstrate functional Participants who may have a more complex medical history including
gains, making it a potential treatment technique for a variety of settings seizures would benefit from close monitoring by their established
including school, outpatient, or home. Previous studies17 have reported medical providers as some incidences of increased seizure activity have
feasibility of a modified protocol combining CIMT and bimanual been reported in the literature.8
training in a school setting with positive results. This modification of an effective intervention for children with
The flexibility of a modified protocol allows therapists to use CIMT cerebral palsy gives children who have a lower baseline skill set or who
within the context of an interdisciplinary team working towards re- have additional mobility, communication, and cognitive needs the op-
mediating global deficits in children with neurological disorders. Larger portunity to receive intensive upper extremity training that might not
gains in bilateral hand function may be seen using an interdisciplinary be possible within the parameters of traditional CIMT admission cri-
approach rather than a single discipline due to the incorporation of teria. It should be noted that this protocol, despite its modification of
cross functional skill practice. Training other team members how to casting intensity, was not a “watered down” intervention. Focused task
facilitate or encourage specific bilateral hand skills within treatment practice and progressively more difficult functional and play based
sessions leads to increased repetition of skill practice and improved unimanual and bimanual tasks were an essential part of treatment.
ability for a child to generalize a skill, ultimately increasing the use of Emerging evidence highlights the importance of this structured skill
that skill at home or in school with other adults and peers. The in- progression to improve UE skills on functional abilities with secondary
corporation of physical therapy, speech therapy, special education, and effects including significant changes to cortical motor maps.15
psychology facilitates gains that are not limited to upper extremity use.
Improvements in gross motor skills, mobility, communication, social 4.1. Limitations
interaction skills, academic knowledge, and coping increase overall
participation in a wide variety of roles and environments. This report has several limitations. First, this case report reflects the

Table 3
COPM performance and satisfaction scores pre and post intervention.
Participant Goal Performance Satisfaction

Pre Post Change Pre Post Change

a
1 Transition supine to sit independently 2 4 2 2 5 3a
Stepping in gait trainer 4 5 1 4 6 2a
Moving or scooting towards a toy 1 5 4a 1 5 4a
Active grasp with affected hand 2 6 4a 3 7 4a
Strength to stabilize with affected hand 4 6 2a 4 6 2a
Communicating needs appropriately 5 7 2a 5 7 2a
2 Use of affected arm to stabilize 1 6 5a 1 6 5a
Awareness of affected arm 4 8 4a 4 8 4a
Reaching across midline with affected arm 5 6 1 5 6 1
Pull to stand 1 2 1 1 2 1
3 Improved affected thumb mobility 4 7 3a 2 8 6a
Desensitization of affected arm 5 8 3a 4 9 5a
Awareness of affected arm 5 9 4a 5 10 5a
Communicating needs appropriately 4 7 3a 5 6 1
Decrease social anxiety 4 6 2a 4 6 2a
Use of affected arm to stabilize 5 9 4a 5 10 5a
4 Self-care 2 8 6a 5 10 5a
Appropriately managing frustration 1 5 4a 1 1 0
Communicating needs 3 7 4a 1 10 9a
Learning new skills 8 10 2a 10 10 0
Developmental progression 6 10 4a 5 10 5a
5 Washing hair 3 5 2a 3 5 2a
Walking with heel-toe pattern 5 4 −1 5 5 0
Increased control of affected hand 4 5 1 3 5 2a
Percentage of goals with clinically significant change 79% 75%

a
Denotes clinically significant change of ≥2 on the COPM.

92
N. Whiston, et al.
experience of a single clinical team serving a small group of participants
with this intervention. Larger trials with more participants and at var-
ious institutions would be useful in testing this protocol. In addition,
statistical analysis examining the impact of MACS, GMFCS, and cog-
nitive function on outcomes with mCIMT was not possible in this small
sample.
5. Conclusions
This study is a first step in presenting a modified CIMT protocol that
can be used within an interdisciplinary rehabilitation service delivery
model to serve a larger population with a wide variety of needs. It
provides a novel decision making tree to aide clinical and research
teams in selecting non-traditional candidates for this intervention.
Clinically this intervention showed promising preliminary results
with children who were non-traditional candidates. In a clinical setting,
children with the following characteristics may benefit from this
modified protocol to improve bilateral upper extremity function:
• Children who rely on use of unaffected arm for primary means of
mobility or to use/learn to use a communication device
• Children who were learning to walk with or without a device
• Older school-age children who are already independent with activ-
ities of daily living and may not be agreeable to continuous casting
but could benefit from intensive, focused therapy
•
Children who are medically complex
• Children who due to cognition, limited play skills, limited social
skills or behavior would not tolerate a constraint for 24 h a day
Funding
The authors have no funding to report.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.xjep.2019.02.005.
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