Research Article

Efficacy of Constraint-Induced Movement

Therapy Versus Bimanual Intensive

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Training on Motor and Psychosocial
Outcomes in Children With Unilateral
Cerebral Palsy: A Randomized Trial
Kai-Jie Liang, Hao-Ling Chen, Chen-Wei Huang, Tien-Ni Wang

Importance: Emerging research has demonstrated that constraint-induced movement therapy (CIMT) and
bimanual intensive training (BIT) show promising effectiveness for children with unilateral cerebral palsy (UCP).
Considering that neurorehabilitative programs have always been designed with long training periods, psychosocial
outcomes have received scarce attention and thus have not been investigated sufficiently.

Objective: To compare the efficacy of CIMT and BIT with 36-hr interventional dosages for both motor and
psychosocial outcomes.

Design: Randomized trial.

Setting: Community.

Participants: Forty-eight children with UCP, ages 6 to 12 yr.

Intervention: Both CIMT and BIT delivered via individual intervention for 2.25 hr/day, twice a week, for 8 wk.

Outcomes and Measures: The Melbourne Assessment 2, Pediatric Motor Activity Log–Revised,
Bruininks–Oseretsky Test of Motor Proficiency, ABILHAND–Kids measure, and Parenting Stress Index–Short Form
were administrated at pretreatment, midterm, posttreatment, and 6 mo after intervention. An engagement
questionnaire for investigating the child’s engagement in the intervention was used to collect the perspectives of
the children and the parents weekly.

Results: Children with UCP who received either CIMT or BIT achieved similar motor improvements. The only
difference was that CIMT yielded larger improvements in frequency and quality of use of the more affected hand
at the 6-mo follow-up. Similar child engagement and parental stress levels were found in the two groups.

Conclusions and Relevance: This study comprehensively compared the efficacy of motor and psychosocial
outcomes for 36-hr dosages of CIMT and BIT. The promising findings support the clinical efficacy and feasibility of
the proposed protocols.

What This Article Adds: The core therapeutic principle of CIMT (i.e., remind the child to use the more affected hand)
may be more easily duplicated by parents. Parents may have overestimated their child’s engagement and given
relatively higher scores; therefore, occupational therapists should also consider the opinions of the children themselves.
Liang, K.-J., Chen, H.-L., Huang, C.-W., & Wang, T.-N. (2023). Efficacy of constraint-induced movement therapy versus bimanual intensive training
on motor and psychosocial outcomes in children with unilateral cerebral palsy: A randomized trial. American Journal of Occupational Therapy,
77, 7704205030. https://doi.org/10.5014/ajot.2023.050104

hildren with unilateral cerebral palsy (UCP) dem-
C onstrate unimanual motor impairment that is due
to a disturbance in the developing brain. Constraint-
induced movement therapy (CIMT) and bimanual
intensive training (BIT) have been developed for this
population to ameliorate their upper limb functions
and to further improve participation in daily activities
(Sakzewski et al., 2014). Over the past decade,

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JULY/AUGUST 2023, VOLUME 77, NUMBER 4 1
cumulative studies on CIMT and BIT have indicated
that these well-defined and intensive training models
are more promising than the usual care (Hoare et al.,
2019; Ouyang et al., 2020). Current research has con-
tinuously focused on comparing the effectiveness of
these neurorehabilitative programs and beneficial
components to establish optimal intervention plans
for children with UCP (Hoare et al., 2019; Simon-
Martinez et al., 2020; Walker et al., 2022).
Previous studies have tried to identify whether
CIMT or BIT is more effective than the other. The re-
sults demonstrated similar improvements from these
two neurorehabilitative programs in various outcomes,
such as motor performance, daily participation, and
quality of life (Hoare et al., 2019; Sakzewski et al.,
2012). However, two knowledge gaps that warrant
further investigation were identified. First, those previ-
ous findings were generally based on comparisons of
conventional high-dose neurorehabilitation programs
with intensive designs of at least 60 to 90 training
hours. Because the feasibility and practicality of those
high-dose programs presented significant challenges,
several studies have made modifications to improve
their clinical accessibility by reorganizing or decreasing
the intervention hours (Amjad et al., 2016; Chen et al.,
2019; Wu et al., 2020). Nevertheless, the differences
in efficacy between these modified CIMT and BIT
programs have not been investigated sufficiently.
To the best of our knowledge, only one study has
compared the effectiveness of CIMT and BIT with
fewer training hours (2 hr/day, 6 days/wk, for 2 wk,
24 hr in total; Amjad et al., 2016). The results of that
study showed that CIMT yielded more improvement
than BIT did in unilateral performance, such as in
grasp and dissociated movements. However, the study
used nonequivalent dosages for the two interventional
programs. The CIMT group received an extra 6 hr of
constraint of the less affected hand to force use of the
more affected hand. Thus, the more beneficial out-
comes of CIMT might have been a result of the extra
hours of forced use. Also, bimanual outcomes and
motor improvement progress were not included in
Amjad et al.’s (2016) study. To fill the first knowledge
gap, a longitudinal randomized controlled trial with an
equal dosage design and comprehensive measurements
covering unimanual and bimanual outcomes is
needed.
Second, psychosocial outcomes, including the child-
ren’s engagement and parental stress levels, have not
been compared between the CIMT and BIT programs.
It is known that programs that are based on neuro-
plasticity and motor learning theories generally consist
of intensive and repetitive practice; maintaining the
child’s engagement in the training activities presents
another challenge (Mancini et al., 2013). Because
engagement in an intervention is rated as one of
the influential characteristics determining treatment
outcomes (Cramer et al., 2011), it is particularly im-
portant for clinicians and researchers to investigate a
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JULY/AUGUST 2023, VOLUME 77, NUMBER 4
child’s engagement in the neurorehabilitative clinic.
On the basis of literature review, the comprehensive
measure of engagement is suggested to include con-
cepts of extrinsic motivation, intrinsic motivation, and
basic psychological needs (Tatla et al., 2015), and it is
recommended that engagement should be measured
from different perspectives (Wright & Majnemer,
2014). However, because of the lack of sound stan-
dardized assessments for investigating engagement,
this issue has rarely been addressed; furthermore,
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this issue has been addressed only with the use of
qualitative or anecdotal documents in a previous
neurorehabilitative study (Mancini et al., 2013). In ad-
dition, unlike adult clients, who are self-motivated to
regain lost functions, children with cerebral palsy (CP)
often participate in training programs to meet their
parents’ expectations. The potential conflicts between
a parent’s and a child’s expectations may lead to par-
enting stress. Lin et al. (2011) demonstrated that the
intensive and intrusive constraint principles led to
deterioration in the interactions between parents and
their children. Thus, understanding and comparing
the parental stress level for these modified protocols is
also important.
The aim of this study was to investigate and com-
pare the efficacy of 36-hr dosage–matched CIMT and
BIT programs on motor and psychosocial outcomes.
To demonstrate the progress of motor improvement
precisely and the parental stress status continuously,
unilateral and bilateral motor performance and
parental stress levels were evaluated four times: at pre-
intervention, midterm of intervention (after 18 hr of
training), postintervention (after 36 hr of training),
and follow-up (6 mo after training). In addition, we
documented the children’s engagement weekly from
both the children’s and the parents’ perspectives to
investigate their engagement status throughout the
whole intervention period.
Method
Participants
Children were recruited from the Cerebral Palsy
Association of R.O.C., medical centers, and special
education systems in Taipei and New Taipei City in
Taiwan. Those who met the following inclusion crite-
ria were included: (1) congenital UCP; (2) ages 6 to
12 yr; (3) active extension at the wrist and metacarpo-
phalangeal joint of the more affected hand ≥10 ;
(4) no excessive muscle tone (Modified Ashworth Scale
score ≤2 at any joints of the upper limb) before treat-
ment; (5) the ability to follow instructions according to
medical documents, parental reports, and clinical ob-
servation; and (6) no injections of botulinum toxin
type A or operations on the hand within 6 mo.
Design and Procedure
Eligible participants were randomly allocated to either
the CIMT group or the BIT group using a web-based
2
randomization tool. The allocation sequence was gen-
erated by the corresponding author (Tien-Ni Wang),
and information was delivered to the attending thera-
pist directly. A sample size of at least 21 children for
each group was suggested, given a large effect size
(d 5 .80), a power of .80, and a one-sided Type 1
error of .05. The effect size was determined by the
findings of primary outcomes in a previous study
that compared the efficacy of CIMT with that of BIT
(Amjad et al., 2016). Considering the possibility of a
10% to 20% dropout rate, we initially recruited 25 pa-
tients for each intervention group. Motor outcomes
were performed at pretreatment, midterm (18 hr),
posttreatment (36 hr), and 6 mo after the intervention.
All motor measures were conducted by three trained
occupational therapists masked to the study design.
Each therapist was trained to properly administer the
outcome measures on the basis of the careful review of
written instructions and repeated practice. Rater com-
petence, defined as the ability to implement and score
the assessments accurately and independently, was
evaluated by a senior certified occupational therapist
(Tien-Ni Wang). Psychosocial outcomes included the
weekly assessments of the child’s engagement as well
as parental stress level at pretreatment, midterm, post-
treatment, and 6 mo after the intervention. The study
was approved by the National Taiwan University
Ethics Committee and was registered with Clinical-
Trials.gov (NCT02808156).
Interventions
To address existing challenges regarding the highly
intensive protocol, a child- and family-friendly inter-
vention approach was implemented in this study. The
approach was child-friendly in that training activities
were provided according to each child’s hand function
to fit the child’s preferences. A playful atmosphere was
emphasized. The CIMT and BIT programs were also
conducted in the child’s natural environment (home
or school) to facilitate the generalizability of treatment
effects to real-world function. The approach was also
family-friendly in that the interventions were arranged
and distributed with appropriate training dosages that
were easy to merge into the participants’ daily sched-
ules. The optimal training hours were decided on the
basis of a literature review and a pilot survey to esti-
mate the feasible intervention intensity for the families
with school-age children (Chen et al., 2019; Jackman
et al., 2020). The final intervention dosage that fit their
family schedules and daily routines was 2.25 hr/day, twice
a week, for 8 wk (a total of 36 hr of intervention).
The two intervention sessions were scheduled, one on
a weekday with only a half day of school and one on
the weekend. Participants could continue their usual
rehabilitation care during the study period.
The intervention was provided by certified occupa-
tional therapists who had completed a 2-day training
program on both the CIMT and BIT protocols. Inter-
ventional dialogue for each training section was
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JULY/AUGUST 2023, VOLUME 77, NUMBER 4
documented and supervised by a senior certified
occupational therapist to ensure the fidelity of the
protocols. The principles of shaping and repetitive
task practice were applied in both groups. Shaping is
a training method in which a motor or behavioral
objective is approached in small steps by successive
approximations (e.g., a task is gradually made more
difficult for a person’s motor capabilities), and repeti-
tive task practice involves functional tasks that are
performed continuously over a specific period. The
therapists graded the intervention tasks according to
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each child’s hand function and gave appropriate feed-
back to enhance motor learning. Types of target
movements, including grasp, release, carry, stabiliza-
tion, and in-hand manipulation, were identified
according to a comprehensive literature review
(Charles & Gordon, 2006). Finally, the tasks of each
intervention protocol were chosen with consideration
of the child’s specific upper limb impairments and the
appropriate level of difficulty, as well as the child’s
preferences. The 2.25 hr of training were divided into
four to five sessions (30 min per session) to fit the
children’s attention span. A short break (5–10 min)
was allowed between sessions. Each training session
usually included one treatment activity that integrated
developmentally appropriate games for each partici-
pant, such as board games, card games, manipulation
activities, crafts, and ball games. During the therapeu-
tic sessions, parents were welcome to observe and
learn about the training activities. There was no extra
assignment outside the therapy sessions, but the chil-
dren in both groups were encouraged to use their
more affected hands in daily activities.
The major difference between the CIMT and BIT
groups was that, in the CIMT group, the focus was
on training the more affected hand with constraint of
the less affected hand, whereas in the BIT group, both
hands were involved in the activities. In the CIMT
group, to reduce the negative emotional response and
relieve parental stress, the therapist used verbal in-
structions and gentle physical guidance (holding the
child’s hand) instead of a glove or splinting to con-
strain the less affected hand (Chen et al., 2019).
Because of the different characteristics of the CIMT
and BIT interventions, the more affected hand in the
BIT group was more often the assisting hand, whereas
in the CIMT group, it was more often the task hand.
Outcome Measures
Motor Outcomes
Motor outcomes included two assessments for unilat-
eral performance and two for bilateral performance.
Each contained one test of observation-based motor
capacity and one self-report of daily motor functions.
We used the Melbourne Assessment 2 (MA–2) and
Pediatric Motor Activity Log–Revised (PMAL–R) to
measure the children’s unilateral movement skills and
daily function, and we used the Bruininks–Oseretsky
Test of Motor Proficiency, Second Edition (BOT–2),
3
and the ABILHAND–Kids measure to examine the
children’s bimanual coordination and bimanual daily
activities.
The MA–2 was developed to evaluate the unilateral
upper limb movement quality in children ages 2.5 to
15 yr with neurological impairment (Randall et al.,
2014). Versions in several languages are available on
the official website. Each child was asked to perform
14 functional tasks, which were videotaped for subse-
quent scoring of four subscales. Items were scored
according to each element of movement measured and
categorized into four corresponding subscales measur-
ing (1) range of movement (ROM); (2) accuracy of
reach and placement; (3) dexterity of grasping, releas-
ing, and manipulation; and (4) fluency of movement.
Each subscale was scored on a 3-, 4-, or 5-point ordi-
nal scale using specifically developed criteria. Final
scores assigned to each subscale were converted into
percentage scores by dividing them by the maximum
possible score. The MA–2 has sound psychometric
properties with high test–retest reliability (rs 5
.92–.98), good concurrent validity, and large respon-
siveness (Wang et al., 2017). We used the PMAL–R, a
questionnaire-based assessment, to evaluate the spon-
taneous use of the affected upper limb in 22 daily
activities (Uswatte et al., 2012). Each activity was rated
by parents or caregivers on 6-point ordinal scales (0 5
not used, 5 5 normal) with 0.5-point increments pos-
sible. The ratings were provided for two subtests: how
often (HO), which measured the amount of use of the
affected hand, and how well (HW), which measured
the quality of use of the affected hand. Higher scores
indicate that a child used the affected hand more fre-
quently than, or similarly to, an age-matched child.
The PMAL–R was developed for children with CP and
has high internal consistency (Cronbach’s a 5 .93),
sound test–retest reliability (r 5 .89), and fair concur-
rent and predictive validities (rs 5 .31–.48; Lin et al.,
2012; Uswatte et al., 2012). The BOT–2 is a standard-
ized assessment that is frequently used in upper limb
neurorehabilitation effectiveness studies for children
with CP (Bruininks & Bruininks, 2005). It has been re-
ported to have excellent test–retest reliability (r 5 .99),
good internal consistency (Cronbach’s a 5 .92), and
sound construct validity (Deitz et al., 2007; Wuang &
Su, 2009). Subtest 3 of the BOT–2, manual dexterity,
uses goal-directed activities that include reaching,
grasping, and bimanual coordination with small objects
to investigate a child’s upper limb manual function.
The point scores of manual dexterity (range 5 0–45)
were used for analysis. The ABILHAND–Kids ques-
tionnaire is a Rasch-based assessment completed by the
caregivers. Versions in several languages are available
on the official website. Caregivers were instructed to
rate their child’s difficulty in performing 21 daily
activities on a 3-point response scale (0 5 impossible,
1 5 difficult, 2 5 easy). The ABILHAND–Kids dem-
onstrated good construct validity, internal consistency
reliability (r 5 .94), and test–retest reliability (r 5 .91;
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JULY/AUGUST 2023, VOLUME 77, NUMBER 4
Arnould et al., 2004). The logit score (i.e., the conver-
sion of the ordinal score into a linear measure of
ability) was used.
Psychosocial Outcomes
Psychosocial outcomes included the child’s weekly
engagement and parental stress level at pretreatment,
midterm, posttreatment, and 6 mo after the interven-
tion. The Engagement Questionnaire (EQ) was used to
investigate the participants’ engagement in the thera-
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peutic programs. The items in the EQ were modified
from existing questionnaires (Green & Wilson, 2012)
to contain the concepts of basic psychological needs,
extrinsic motivation, and intrinsic motivation. In this
study, the EQ was modified into two versions to repre-
sent the participants’ engagement from both the
children’s and parents’ perspectives (e.g., Do you look
forward to the next session? vs. Do you think your child
looks forward to the next session?). Items on the EQ
are rated from 1 (strongly disagree) to 5 (strongly
agree), and the total score ranges from 0 to 30, with
higher scores indicating better engagement. Finally,
the Chinese version of Parenting Stress Index–Short
Form (PSI–SF) was used to measure the stress level of
the parents. It includes 36 items rated from 1 (strongly
agree) to 5 (strongly disagree). High scores on the
PSI–SF indicate lower stress in the parent. The PSI–SF
demonstrated sound internal consistency (Cronbach’s
a 5 .86–.95) and construct validity (Weng, 2011).
Statistical Analysis
We evaluated baseline differences between the two
groups by using an independent t test and x2 test.
Normality was verified using the Shapiro–Wilk test
and inspection of the histograms for symmetry. Inter-
nal reliabilities were examined for each measure by
calculating Cronbach’s a. To conduct parametric sta-
tistics, we applied a Box-Cox transformation to the
parameters of range of motion, the accuracy of the
MA–2, and the PMAL–R. Outcome measures were
compared between groups by fitting a linear mixed
model including random intercepts, group, time, and
Time × Group interactions as independent factors, as
well as potential covariates. Covariates were retained if
the model fit showed a lower corrected Akaike infor-
mation criterion value. The level of significance was
set at p < .05. For significant main effects and interac-
tions, we conducted post hoc analyses using t tests
applying Bonferroni corrections for multiple compari-
sons in case of significant trends (<.10), as this allowed
us to capture tendencies immediately after the inter-
vention (Simon-Martinez et al., 2020). We calculated
the effect sizes of the Group × Time interaction and the
main effect of time from the F values, according the
Cohen’s h2p formula: h2p 5 (F × dfbetween-subjects)/
((F × dfbetween-subjects) 1 dfwithin-subjects) (Cohen, 1973).
To explore children’s engagement across treatment
4
sessions, we used a linear mixed model, as well as a simple
line graph, to present each week’s scores on the EQ.
Results
Fifty children were randomly assigned to the CIMT
group or the BIT group, and 48 children completed
the study. One child in the CIMT group dropped out
because of injections of botulinum toxin during the
intervention, and one child in the BIT group dropped
out because of issues with transportation. All 48 par-
ticipants completed the 36-hr intervention within 8
to 10 wk. Each participant was assigned one specific
certified occupational therapist; a total of 17 certified
occupational therapists provided interventions for this
study. No adverse events were reported throughout
the study. The recruitment process is described in
Figure 1. There were no significant group differences

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Figure 1. Description of recruitment following CONSORT guidelines.

Note. BIT 5 bimanual intensive training; CIMT 5 constraint-induced movement therapy; CONSORT = Consolidated Standards of Re-
porting Trials.

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Table 1. Demographic Characteristics of the Study Participants
Characteristic CIMT (n 5 24)
Age, mo, M (SD) 97.75 (27.14)
Male, n (%) 11 (46)
Affected side: right, n (%) 14 (58)
MACS, n
I 5
II 12
III 7 7
Note. BIT 5 bimanual intensive training; CIMT 5 constraint-induced movement therapy; MACS 5 Manual Ability Classification System.
in baseline scores for any measures (Table 1). The in-
ternal reliabilities of all measures were excellent, with
Cronbach’s a values of .87–.94 for the MA–2, .88–.92
for the PMAL–R, .81 for the BOT–2, .93 for the
ABILHAND–Kids, and .95 for the PSI–SF.
Table 2 shows the means for each group at each
time point for the unilateral and bilateral motor out-
comes. For the unilateral motor outcome, the results
of the mixed-effect model showed a significant Group ×
Time interaction on the HW and HO subtests of the
PMAL–R at the 6-mo follow-up, favoring CIMT. There
were no significant Group × Time interactions on the
MA–2 at any time point. We found main effects for
time on all subscales of the MA–2. Post hoc analysis re-
vealed initial improvements on three subscales (range
of movement and fluency) of the MA–2 at midterm as-
sessment but not the accuracy and dexterity subscales
of the MA–2, which reached significant improvement
at posttreatment. All improvements on the MA–2 were
retained at the 6-mo follow-up. For the bilateral motor
outcome, there were no significant Group × Time in-
teractions on the BOT–2 and ABILHAND–Kids. Both
groups showed initial significant improvements on the
BOT–2 at midterm assessment and on the ABILHAND–
Kids at posttreatment. These improvements were retained
at the 6-mo follow-up.
For the psychosocial outcomes, the PSI–SF showed
no significant interaction or time effects, reflecting that
the parents’ stress did not differ between groups and
was stable during the interventions. The weekly scores
on the EQ, completed by the children and parents, are
presented in Figure 2. The CIMT and BIT groups
showed similar trends on the child and parent versions
of the EQ. In addition, the parent version of the EQ
yielded consistently high weekly scores throughout
the intervention. The child version of the EQ yielded
relatively lower EQ scores in the beginning but contin-
uous increases during the 8 wk of intervention.
Discussion
The study findings showed that, whether they received
CIMT or BIT, children with UCP achieved similar
motor improvements in both unilateral and bilateral
motor performance. Overall, there were small
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JULY/AUGUST 2023, VOLUME 77, NUMBER 4
BIT (n 5 24) p
96.92 (24.87) .91
16 (67) .15
14 (58) 1.00
6 .94
11
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differences in motor effectiveness between the two
programs, and such differences only appeared at the
6-mo follow-up: At this evaluation, the CIMT group
demonstrated greater improvements than the BIT
group on the HO and HW of the PMAL–R,
indicating that CIMT led to a higher frequency and
quality of use of the more affected hand in daily activi-
ties. Children in both groups steadily maintained high
engagement throughout the whole intervention period,
and the parental stress levels were consistently static.
These positive psychosocial outcomes provided evi-
dence to support our design of clinically friendly
features for the two proposed intervention programs.
The between-groups differences were found only
for the scores on the HO and HW of the PMAL–R at
the 6-mo follow-up, with the CIMT group showing
greater improvement. The findings, consistent with
previous high-dose effectiveness studies (Gelkop et al.,
2015; Hoare et al., 2019), suggested that both CIMT
and BIT yielded similar improvements in motor per-
formance within the interventional process (from
baseline to midterm and from baseline to immediately
after the intervention). However, at the 6-mo follow-
up, CIMT demonstrated additional benefits for daily
use of the more affected hand as measured by the
PMAL–R. This result indicated that children in the
CIMT group might have had more potential for trans-
ferring learned abilities to daily motor function than
the children in the BIT group. In addition, the charac-
teristics of CIMT might provide another explanation
for this result. The core therapeutic principles of
CIMT, including intensive use of the more affected
hand and forbidden use of the less affected hand, were
easy to duplicate for the caregivers in their daily rou-
tines. Thus, in the long run, we found additional
benefits of using the more affected hand in daily
routines.
The unimanual CIMT approach had more favor-
able results for unilateral daily use at the 6-mo follow-
up; however, the same result was not found for the
BIT group for bimanual motor outcomes. This might
be explained by the fact that, for the BIT group, even
if parents were exposed to the bimanual protocol, they
would intuitively still focus on the child’s more af-
fected hand (Ferre et al., 2017). By observing the
6
Table 2. Estimated Marginal Means of Outcome Measures at Each Time Point, and Statistical Comparison
M (SD) Group Difference, p Time
Variable Main
and Pretreatment Posttreatment 6-Mo Follow- Effect,
Group (T1) Midterm (T2) (T3) Up (T4) T1–T2 T1–T3 T1–T4 Post Hoc
Unilateral Outcomes
MA–2 ROM
CIMT 66.20 (19.82) 71.60 (19.37) 72.07 (20.81) 73.46 (20.77) .26 .10 .12 T2, T3, T4
>T1
BIT 66.36 (23.35) 68.98 (24.47) 68.98 (22.70) 70.06 (24.83)

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MA–2 Accuracy
CIMT 81.67 (24.82) 84.33 (22.22) 85.50 (21.68) 84.17 (22.05) .67 .90 .47 T3, T4
BIT 77.67 (25.51) 79.33 (23.76) 81.17 (23.10) 80.83 (24.91) > T1

MA–2 Dexterity
CIMT 46.27 (18.49) 47.15 (19.78) 50.88 (21.15) 48.68 (22.01) .62 .43 .77 T3 > T1
BIT 45.83 (25.99) 47.81 (25.21) 48.68 (24.84) 47.59 (26.18)
MA–2 Fluency
CIMT 55.95 (16.33) 59.13 (18.14) 62.50 (17.22) 64.09 (16.79) 1.00 .67 .09 T2, T3, T4
BIT 58.13 (19.41) 61.31 (18.05) 63.69 (19.45) 62.30 (19.75) >T1

PMAL–R
How Often
CIMT 1.47 (0.86) 1.72 (0.96) 1.93 (0.89) 1.97 (0.85) .51 .28 .01* T2, T3, T4
>T1
BIT 1.81 (1.36) 1.92 (1.18) 2.11 (1.27) 1.90 (1.13)
How Well
CIMT 1.77 (1.11) 1.94 (1.07) 2.07 (1.07) 2.29 (1.08) .93 .60 <.01* T3, T4
BIT 2.06 (1.47) 2.22 (1.29) 2.31 (1.35) 2.08 (1.32) >T1

Bilateral Outcomes
BOT–2
CIMT 15.04 (8.18) 16.25 (8.24) 16.46 (8.27) 16.62 (8.05) .71 .78 .29 T2, T3, T4
BIT 15.46 (6.78) 16.33 (7.34) 17.12 (6.91) 18.00 (7.59) >T1

ABILHAND–Kids
CIMT 0.91 (1.47) 1.38 (1.46) 1.37 (1.32) 1.35 (1.58) 0.23 0.66 0.67 T3, T4 >
BIT 1.02 (2.47) 1.13 (1.84) 1.62 (2.14) 1.59 (2.18) T1

PSI–SF
CIMT 128.67 (24.02) 128.79 (23.78) 127.58 (24.53) 128.29 (23.78) 0.79 0.32 0.16 —
BIT 130.50 (20.99) 131.25 (21.53) 131.75 (23.16) 133.46 (23.79)

Note. BIT 5 bimanual intensive training; BOT–2 5 Bruininks–Oseretsky Test of Motor Proficiency, Second Edition; CIMT 5 constraint-
induced movement therapy; MA–2 5 Melbourne Assessment 2; PMAL–R 5 Pediatric Motor Activity Log–Revised; PSI–SF 5 Parenting
Stress Index–Short Form; ROM 5 range of movement.
*p < .05.

therapists’ interventional strategies, parents learned
the instructions that directed the child to use both
hands together. However, they might not have been
sensitive enough to notice the role of the more affected
hand in different bimanual tasks, or they may have
lacked the motor knowledge to enhance bilateral coor-
dination. Thus, parents in the CIMT group seemed to
be able to extend and expand improvements in daily
functional use of the more affected hand, whereas pa-
rents in the BIT group did not demonstrate this
influence.
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JULY/AUGUST 2023, VOLUME 77, NUMBER 4
To our knowledge, this study is the first to compare
and track children’s weekly engagement in CIMT and
BIT from both the children’s and parents’ points of
view. No significant differences were found between
the two protocols; thus, the results of both groups
were merged together for analysis. For engagement
from the children’s perspective, it is interesting that,
despite the high average score, both groups demon-
strated relatively lower engagement in the beginning,
although it gradually increased over the following
weeks. These findings echoed those of previous
7
Figure 2. Scores on the EQ During Weekly Interventions: (A) Parents and (B) Children.

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Note. BIT 5 bimanual intensive training; CIMT 5 constraint-induced movement therapy; EQ 5 Engagement Questionnaire.

qualitative studies, which stated that children might
show marked frustration and complain in the early
stages of the intensive neurorehabilitative program
(Mancini et al., 2013). This study further provides
quantitative evidence to confirm and support the exist-
ing qualitative documents. Moreover, on the basis of
our clinical observation, there might be a potential
psychosocial difference between the two groups in the
child’s self-efficacy. In the CIMT group, therapists
provided more assistance or grading because the chil-
dren were required to use the more affected hand as
their task hand during entire sessions—a requirement
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JULY/AUGUST 2023, VOLUME 77, NUMBER 4
they might not have been familiar with. Unlike the
BIT program, in which children used the more
affected hand as their assisting hand, the CIMT pro-
gram’s challenges might, as stated earlier, negatively
affect children’s self-efficacy. Measurements reflecting
self-efficacy should be considered in future work.
In addition, the consistently high engagement
scores over the whole intervention period supported
our child-friendly design in terms of gentle constraint
and providing training activities that fit the children’s
preferences. Regarding engagement from the parents’
perspective, it is noted that the scores on the parent
8
version of the EQ remained steady and high for the
whole intervention period. The relatively higher scores
of parents on the weekly EQ may suggest that they
overestimated their child’s engagement during the in-
tervention. These findings should remind clinicians
and researchers that children have different percep-
tions of interventional engagement (Kennedy et al.,
2012). Thus, the opinions of the children themselves
should be considered simultaneously in future work.
Regarding the parental stress level, similar scores
on the PSI–SF were found for both groups at each
evaluation visit, indicating that the parents demon-
strated stable emotional statuses. These findings
supported our modification of existing neurorehabili-
tative protocols to make them family-friendly. The
protocols in this study were arranged as intervention
delivery schedules of 2.25 hr/day, twice a week, for
8 wk, to fit the ecological features of local families’
routines, which did not increase parental stress. Previ-
ous studies have also demonstrated that, for children
with CP as well as their caregivers, training implemen-
tation at home for 2 hr/day is more preferable to, and
more comfortable than, training for 3 to 4 hr/day
(Eliasson et al., 2005; Gelkop et al., 2015; Wu et al.,
2020). Because parental stress levels influence parents’
well-being and children’s development, delivering
intervention protocols that do not increase parents’
burden is important.
To understand motor improvement progress dur-
ing the interventions and whether these changes were
retained after the interventions, this study imple-
mented evaluations at four time points (pretreatment,
18-hr midterm, 36-hr posttreatment, and 6-month
follow-up). For the unilateral outcome, both groups
showed initial improvements at the 18-hr midterm on
two subtests (range of movement and fluency) of the
MA–2 and the HO of the PMAL–R but not on the
dexterity and accuracy subtests of the MA–2 or HW
of the PMAL–R. These initial improvements indicated
that 18 hr of intensive training could lead to signifi-
cant motor improvements on the basic components of
motor abilities, as well as the frequency of daily use.
Nonetheless, improvements in advanced motor skills
and quality of daily use did not appear until the end
of the 36-hr training program. For bilateral outcomes,
Subtest 3 of the BOT–2 reached significant improve-
ment after 18 hr of training, whereas the ABILHAND–
Kids measure needed 36 hr for improvements to
appear. The initial improvements after 18 hr of
intensive training indicated that the child’s more af-
fected hand could play a better role as the assisting
hand in performing bilateral activities. Bilateral daily
motor function improved later, after completion of
the 36-hr training program. These promising results
suggest that children who received either CIMT or
BIT would demonstrate motor improvements after 36 hr
of training, and some even after 18 hr. Given the
intensive protocols that demand large amounts of
resources and high costs, understanding the
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JULY/AUGUST 2023, VOLUME 77, NUMBER 4
possible minimum dosage to yield changes for dif-
ferent motor prospects is vital (Ilieva & Ilieva,
2020).
Despite the promising results, several limitations
of this study need to be considered. First, we did not
stratify participants by age or Manual Ability Classifi-
cation Scale level to investigate the differences between
CIMT and BIT because of the various sample sizes
in each stratified group. Future research with larger
sample sizes to examine treatment effects within strati-
fied groups is recommended to further clarify
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the effects of age and motor status. Second, subjective
questionnaires (e.g., PMAL–R and ABILHAND–Kids)
were used to investigate daily use of the upper limbs
in this study. Because it is difficult to blind parents to
the content of interventions, the parents may have had
a bias that was based on the intervention their children
received. Therefore, future studies should include an
objective measure such as an accelerometer for explor-
ing real-world hand use to validate the study findings.
Implications for Occupational
Therapy Practice
The study results have the following clinical implica-
tions for occupational therapy practice:
䊏 Motor improvements in basic skills appeared af-
ter 18 hr of intensive training, whereas improve-
ments in advanced motor skills were achieved
after 36 hr of training. Occupational therapists
could provide at least 36 hr of CIMT or BIT to
achieve improvements in both basic and ad-
vanced motor skills.
䊏 CIMT yielded greater improvements than BIT
on frequency and quality of daily use of the
more affected hand at the 6-mo follow-up, indi-
cating that, for parents, the core principle of
CIMT (i.e., remind the child to use the more af-
fected hand) might be easier to duplicate than
those of BIT. Thus, occupational therapists
should provide more guidance and education
for parents when implementing BIT.
䊏 In interventions, occupational therapists should
consider the opinions of not only the parents
but also the children themselves.
Conclusion
To our knowledge, this study is the first to compare
the efficacy of the motor and psychosocial outcomes
of CIMT and BIT, with a relatively smaller 36-hr
dosage. We found small differences in motor and psy-
chosocial performance between the CIMT and BIT
groups. The only major difference was that CIMT
yielded better frequency and quality of daily use of
the more affected hand at the 6-mo follow-up, which
might imply that the therapeutic principle of CIMT
(i.e., remind the child to use the more affected hand)
was easier for the parents to imitate than those of BIT.
The possible minimum dosage to yield changes has
9
been established for different motor prospects. Eigh-
teen hours of intensive training can achieve motor
improvements in basic skills, whereas improvements
in advanced motor skills require 36 hr of training. For
psychosocial outcomes, children in both groups exhib-
ited similarly high levels of engagement, and their
parents showed stable stress levels during the whole
intervention period. However, the children and their
parents reported different perceptions of treatment en-
gagement, indicating that the opinions of the children
themselves should be considered simultaneously in fu-
ture work. In summary, promising results for motor
and psychosocial outcomes were found in this study
for our child- and family-friendly CIMT and BIT
protocols.
Acknowledgments
We thank the children and their families for partici-
pating in this study. This project was supported in
part by the Ministry of Science and Technology
(MOST 110-2314-B-002-061 to Tien-Ni Wang and
MOST 110-2628-E-002-004 to Hao-Ling Chen).
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Kai-Jie Liang, PhD, is Postdoctoral Researcher, Department of
Occupational Therapy and Graduate Institute of Behavioral Sciences,
Chang Gung University, Taoyuan City, Taiwan. At the time this article
was submitted, Liang was PhD Student, School of Occupational
Therapy, College of Medicine, National Taiwan University, Taipei City,
Taiwan.
Hao-Ling Chen, PhD, is Associate Professor, School of Occupational
Therapy, College of Medicine, National Taiwan University, and
Occupational Therapist, Department of Physical Medicine and
Rehabilitation, National Taiwan University Hospital, Taipei City, Taiwan.
Chen-Wei Huang, MS, is Occupational Therapist, Department of Physical
Medicine and Rehabilitation, Chi Mei Medical Center, Chiali Branch, Tainan
City, Taiwan.
Tien-Ni Wang, PhD, is Professor, School of Occupational Therapy, College
of Medicine, National Taiwan University, and Occupational Therapist,
Department of Physical Medicine and Rehabilitation, National Taiwan
University Hospital, Taipei City, Taiwan; tnwang@ntu.edu.tw
11