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Objective: To compare efficacy of constraint-induced movement therapy (Baby-CIMT) with bimanual therapy (Baby-BIM) in infants at high risk of unilateral cerebral palsy., Study Design: This was a single-blind, randomized-comparison-trial that had the following inclusion criteria: (1) asymmetric brain lesion (2) absent fidgety General Movements, (3) Hammersmith Infant Neurological Examination below cerebral palsy cut-points, (4) entry at 3-9 months of corrected age, and (5) >3-point difference between hands on Hand Assessment Infants (HAI). Infants were randomized to Baby-CIMT or Baby-BIM, which comprised 6-9 months of home-based intervention. Daily dose varied from 20 to 40 minutes according to age (total 70-89.2 hours). Primary outcome measure was the HAI after intervention, with secondary outcomes Mini-Assisting Hand Assessment and Bayley III cognition at 24 months of corrected age., Results: In total, 96 infants (51 male, 52 right hemiplegia) born median at 37-weeks of gestation were randomized to Baby-CIMT (n = 46) or Baby-BIM (n = 50) and commenced intervention at a mean 6.5 (SD 1.6) months corrected age. There were no between group differences immediately after intervention on HAI (mean difference [MD] 0.98 HAI units, 95% CI 0.94-2.91; P = .31). Both groups demonstrated significant clinically important improvements from baseline to after intervention (Baby-BIM MD 3.48, 95% CI 2.09-4.87; Baby-CIMT MD 4.42, 95% CI 3.07-5.77). At 24 months, 64 infants were diagnosed with unilateral cerebral palsy (35 Baby-CIMT, 29 Baby-BIM). Infants who entered the study between 3 and 6 months of corrected age had greater change in HAI Both Hands Sum Score compared with those who entered at ≥6 months of corrected age (MD 7.17, 95% CI 2.93-11.41, P = .001)., Conclusions: Baby-CIMT was not superior to Baby-BIM, and both interventions improved hand development. Infants commencing intervention at <6 months corrected age had greater improvements in hand function., Competing Interests: Declaration of Competing Interest This study is funded by the Australian National Health and Medical Research Council (NHMRC project grant no. 1078877). The NHMRC has provided people support for the following team members: a Research Fellowship (RB, 1105038) Early Career Fellowship (KW, 631712). ACE was supported by Swedish Research Council (grant nos. 521-211-2655 and 521-2011-456), Stockholm City Council (2011-2117), Foundation Olle Engkvist Byggmästare and Foundation Frimurarna Barnhuset., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Congenital hemiplegia is the most common form of cerebral palsy (CP). Children with unilateral CP show signs of upper limb asymmetry by 8 months corrected age (ca) but are frequently not referred to therapy until after 12 months ca. This study compares the efficacy of infant-friendly modified constraint-induced movement therapy (Baby mCIMT) to infant friendly bimanual therapy (Baby BIM) on upper limb, cognitive and neuroplasticity outcomes in a multisite randomised comparison trial., Methods and Analysis: 150 infants (75 in each group), aged between 3 and 6 months ca, with asymmetric brain injury and clinical signs of upper extremity asymmetry will be recruited. Children will be randomised centrally to receive equal doses of either Baby mCIMT or Baby BIM. Baby mCIMT comprises restraint of the unimpaired hand using a simple restraint (eg, glove, sock), combined with intensive parent implemented practice focusing on active use of the impaired hand in a play-based context. In contrast, Baby BIM promotes active play requiring both hands in a play-based context. Both interventions will be delivered by parents at home with monthly home visits and interim telecommunication support by study therapists. Assessments will be conducted at study entry; at 6, 12 months ca immediately postintervention (primary outcome) and 24 months ca (retention). The primary outcome will be the Mini-Assisting Hand Assessment. Secondary outcomes include the Bayley Scale for Infant and Toddler Development (cognitive and motor domains) and the Hand Assessment of Infants. A subset of children will undertake MRI scans at 24 months ca to evaluate brain lesion severity and brain (re)organisation after intervention., Ethics and Dissemination: Full ethical approvals for this study have been obtained from the relevant sites. The findings will be disseminated in peer-reviewed publications., Trial Registration Number: Australian and New Zealand Clinical Trials Registry: ACTRN12615000180516, Pre results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

This study aimed to compare efficacy of two dosages of modified constraint induced movement therapy (mCIMT) and bimanual therapy on upper limb and individualized outcomes for children with unilateral cerebral palsy. This secondary analysis included two separate randomized trials that compared equal doses (high or low) of mCIMT to bimanual therapy; Study 1 (full dose--60 h) n=64 and; Study 2 (half dose--30 h) n=18 for children aged five to 16 years with unilateral cerebral palsy. Outcomes for both studies included the Melbourne Assessment of Unilateral Upper Limb Function, Assisting Hand Assessment, Jebsen Taylor Test of Hand Function and Canadian Occupational Performance Measure which were administered at baseline, three and 26 weeks. Mixed linear modelling was used to compare between dose (e.g. "full dose" to "half dose" of either mCIMT or bimanual therapy) on outcomes at three and 26 weeks post-intervention. There were no significant differences between groups at baseline, however, on average the half dose mCIMT group was younger with better hand function compared to the other groups. The full compared to half dose mCIMT group achieved greater gains in bimanual performance at three weeks and dexterity and quality of movement at 26 weeks. There were no between group differences for bimanual therapy doses. Half dose groups receiving either mCIMT or bimanual therapy did not make significant within group gains on any upper limb motor outcome, however gains in occupational performance were clinically meaningful. These results suggest that a half dose (30 h) of either mCIMT or bimanual therapy may not be sufficient to impact upper limb outcomes, but made clinically meaningful gains in occupational performance for school aged children with UCP., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background and Objective: Children with unilateral cerebral palsy present with impaired upper limb (UL) function affecting independence, participation, and quality of life and require effective rehabilitation. This study aims to systematically review the efficacy of nonsurgical upper limb therapies for children with unilateral cerebral palsy., Methods: Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, the Cochrane Central Register of Controlled Trials, and PubMed were searched to December 2012. Randomized controlled or comparison trials were included., Results: Forty-two studies evaluating 113 UL therapy approaches (N = 1454 subjects) met the inclusion criteria. Moderate to strong effects favoring intramuscular injections of botulinum toxin A and occupational therapy (OT) to improve UL and individualized outcomes compared with OT alone were identified. Constraint-induced movement therapy achieved modest to strong treatment effects on improving movement quality and efficiency of the impaired UL compared with usual care. There were weak treatment effects for most outcomes when constraint therapy was compared with an equal dose (amount) of bimanual OT; both yielded similar improved outcomes. Newer interventions such as action observation training and mirror therapy should be viewed as experimental., Conclusions: There is modest evidence that intensive activity-based, goal-directed interventions (eg, constraint-induced movement therapy, bimanual training) are more effective than standard care in improving UL and individualized outcomes. There is little evidence to support block therapy alone as the dose of intervention is unlikely to be sufficient to lead to sustained changes in UL outcomes. There is strong evidence that goal-directed OT home programs are effective and could supplement hands-on direct therapy to achieve increased dose of intervention.

Introduction: Children with congenital hemiplegia often present with limitations in using their impaired upper limb which impacts on independence in activities of daily living, societal participation and quality of life. Traditional therapy has adopted a bimanual training approach (BIM) and more recently, modified constraint induced movement therapy (mCIMT) has emerged as a promising unimanual approach. Evidence of enhanced neuroplasticity following mCIMT suggests that the sequential application of mCIMT followed by bimanual training may optimise outcomes (Hybrid CIMT). It remains unclear whether more intensely delivered group based interventions (hCIMT) are superior to distributed models of individualised therapy. This study aims to determine the optimal density of upper limb training for children with congenital hemiplegia., Methods and Analyses: A total of 50 children (25 in each group) with congenital hemiplegia will be recruited to participate in this randomized comparison trial. Children will be matched in pairs at baseline and randomly allocated to receive an intensive block group hybrid model of combined mCIMT followed by intensive bimanual training delivered in a day camp model (COMBiT; total dose 45 hours direct, 10 hours of indirect therapy), or a distributed model of standard occupational therapy and physiotherapy care (SC) over 12 weeks (total 45 hours direct and indirect therapy). Outcomes will be assessed at 13 weeks after commencement, and retention of effects tested at 26 weeks. The primary outcomes will be bimanual coordination and unimanual upper-limb capacity. Secondary outcomes will be participation and quality of life. Advanced brain imaging will assess neurovascular changes in response to treatment. Analysis will follow standard principles for RCTs, using two-group comparisons on all participants on an intention-to-treat basis. Comparisons will be between treatment groups using generalized linear models., Trial Registration: ACTRN12613000181707.

Aim: The aim of this study was to determine whether constraint-induced movement therapy is more effective than bimanual training in improving the quality of life of children with unilateral cerebral palsy (CP)., Method: Sixty-three children (mean age 10y 2mo [SD 2y 6mo]; 33 males, 30 females) with CP of the spastic motor type (n=59) or with spasticity and dystonia (n=4) were randomly allocated to two groups. The children were assessed as Manual Ability Classification System level I (n=16), II (n=46), or III (n=1). Each group received 6 hours of daily intervention (either constraint-induced movement therapy [CIMT] or bimanual training [BIM]) for 10 days over a 2-week period (total intervention time 60h). Children aged 9 years and older completed the Cerebral Palsy Quality of Life Questionnaire for Children (CPQOL-Child) and those aged 8 years and older completed the KIDSCREEN-52. All parents completed proxy versions of each measure. Assessments were made at baseline and at 3, 26, and 52 weeks after the end of the intervention., Results: Thirty-five children completed the CPQOL-Child and 41 completed the KIDSCREEN-52. No changes in social or emotional well-being were reported by children in either group. Children and parents from both groups reported a significant improvement in their or their child's feelings about functioning as well as participation and physical health on the CPQOL-Child. The parents of children receiving CIMT reported positive and sustained changes in their child's social well-being (CPQOL-Child). The CIMT group showed significant improvements in physical well-being, psychological well-being, and moods and emotions (KIDSCREEN-52) at 3 weeks post intervention, which were maintained over the study period., Interpretation: Intensive goal-directed upper limb training programmes using either CIMT or BIM achieved domain-specific changes in quality of life relating to feelings about functioning and participation and physical health. A condition-specific quality of life compared with a generic measure may be better able to detect changes in quality of life in children with unilateral CP., (© The Authors. Developmental Medicine & Child Neurology © 2012 Mac Keith Press.)

Objective: To determine if constraint-induced movement therapy (CIMT) is more effective than bimanual training to improve occupational performance and participation in children with congenital hemiplegia., Design: Single-blind randomized comparison trial with evaluations at baseline, 3, and 26 weeks., Setting: Community facilities in 2 Australian states., Participants: Referred sample of children (N=64; mean age ± SD, 10.2±2.7y, 52% boys) were matched for age, sex, side of hemiplegia, and upper-limb function and were randomized to CIMT or bimanual training. After random allocation, 100% of CIMT and 94% of the bimanual training group completed the intervention., Interventions: Each intervention was delivered in day camps (total 60 h over 10d) using a circus theme with goal-directed training. Children receiving CIMT wore a tailor-made glove during the camp., Main Outcome Measures: The primary outcome was the Canadian Occupational Performance Measure (COPM). Secondary measures included the Assessment of Life Habits (LIFE-H), Children's Assessment of Participation and Enjoyment, and School Function Assessment., Results: There were no between-group differences at baseline. Both groups made significant changes for COPM performance at 3 weeks (estimated mean difference =2.9; 95% confidence interval [CI], 2.3-3.6; P<.001 for CIMT; estimated mean difference=2.8; 95% CI, 2.2-3.4; P<.001 for bimanual training) that were maintained at 26 weeks. Significant gains were made in the personal care LIFE-H domain following CIMT (estimated mean difference=0.5; 95% CI, 0.1-0.9; P=.01) and bimanual training (estimated mean difference=0.6; 95% CI, 0.2-1.1; P=.006)., Conclusions: There were minimal differences between the 2 training approaches. Goal-directed, activity-based, upper-limb training, addressed through either CIMT or bimanual training achieved gains in occupational performance. Changes in participation on specific domains of participation assessments appear to correspond with identified goals., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Aim: To determine if constraint-induced movement therapy (CIMT) is more effective than bimanual training (BIM) in improving upper limb activity outcomes for children with congenital hemiplegia in a matched-pairs randomized trial., Method: Sixty-three children (mean age 10.2, SD 2.7, range 5-16 y; 33 males, 30 females), 16 in Manual Ability Classification System level I, 46 level II, and 1 level III and 16 in Gross Motor Function Classification level I, 47 level II) were randomly allocated to either CIMT or BIM group day camps (60 hours over 10 days). The Melbourne Assessment of Unilateral Upper Limb Function assessed unimanual capacity of the impaired limb and Assisting Hand Assessment evaluated bimanual coordination at baseline, 3 and 26 weeks, scored by blinded raters., Results: After concealed random allocation, there was no baseline difference between groups. CIMT had superior outcomes compared with BIM for unimanual capacity at 26 weeks (estimated mean difference [EMD] 4.4, 95% confidence interval [CI] 2.2-6.7; p < 0.001). There was no other significant difference between groups post-intervention. Both groups demonstrated significant improvements in bimanual performance at 3 weeks, with gains maintained by BIM at 26 weeks (EMD 2.3; 95% CI 0.6-4.0; p = 0.008). Interpretation  Overall, there were only small differences between the two training approaches. CIMT yielded greater changes in unimanual capacity of the impaired upper limb compared with BIM. Results generally reflect specificity of practice, with CIMT improving unimanual capacity and BIM improving bimanual performance. Considerable inter-individual variation in response to either intervention was evident. Future research should consider serial sequencing unimanual then BIM approaches to optimize upper limb outcomes for children with congenital hemiplegia., (© The Authors. Journal compilation © Mac Keith Press 2011.)

Objective: To delineate characteristics of best responders in a randomized trial comparing constraint-induced movement therapy (CIMT) to bimanual training for children with unilateral cerebral palsy., Design: Secondary analysis of a single-blind matched-pairs randomized comparison trial., Setting: Community sporting facilities in 2 Australian capital cities., Participants: Children (n=64; mean age, 10.2±2.7y; 52% boys), matched for age, sex, side of hemiplegia, and upper-limb function, were randomized within pairs to CIMT or bimanual training. Sixty-one children who completed CIMT (n=31) or bimanual training (n=30) were included in this study., Interventions: Each intervention was delivered in day camps (total 60h over 10d) using a novel circus theme with goal-directed training., Main Outcome Measures: Change between baseline, 3, and 26 weeks on the Melbourne Assessment of Unilateral Upper Limb Function (MUUL>7.4%), Assisting Hand Assessment (AHA>4 raw score points), and Canadian Occupational Performance Measure (COPM>2 points) defined best responders., Results: Poorer baseline hand function predicted a best response for unimanual capacity of the impaired upper limb (MUUL) immediately postintervention; however, at 26 weeks the odds of achieving a favorable outcome were 21 times greater for CIMT than bimanual training. A favorable response for bimanual performance (AHA) was predicted by immediate change in Jebsen-Taylor hand function test scores. Age (older), left-sided hemiplegia, and lower-baseline COPM performance scores significantly predicted favorable individualized outcomes., Conclusions: Secondary analysis of a randomized trial directly comparing 2 upper-limb training models, found children with poorer hand function benefited most. Favorable outcomes for bimanual performance were associated with gains in movement efficiency and older children with left-sided hemiplegia achieved more favorable gains in perceived occupational performance., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Aim: This study explores the relationship between unimanual capacity and bimanual performance for children with congenital hemiplegia aged 5 to 16 years. It also examines the relationship between impairments and unimanual capacity and bimanual performance., Method: Participants in this cross-sectional study attended a screening assessment before participating in a large, randomized trial. They comprised 70 children with congenital hemiplegia (39 males, 31 females; mean age 10 y 6 mo, SD 3 y); 18 were classified in the Manual Ability Classification System level I, 51 in level II, and one in level III. Eighteen were in Gross Motor Function Classification System, level I and 52 in level II. Sixty-five participants had spasticity and five had dystonia and spasticity. Fifteen typically developing children (7 males, 8 females; mean age 8 y 8 mo, SD 2 y 7 mo), matched to study participants for age and sex, were recruited as a comparison group for measures of sensation, grip strength, and movement efficiency. Outcome measures for unimanual capacity were the Melbourne Assessment of Unilateral Upper Limb Function (MUUL), and the Jebsen-Taylor Hand Function Test (JTHFT). The Assisting Hand Assessment (AHA) evaluated bimanual performance. Upper limb impairments were measured using assessments of stereognosis, moving two-point discrimination, spasticity, and grip strength., Results: There was a strong relationship between unimanual capacity (MUUL) and bimanual performance (AHA; r=0.83). Linear regression indicated MUUL and stereognosis accounted for 75% of the variance in AHA logit scores. Sensory measures were moderately correlated with unimanual capacity and bimanual performance. Age, sex, and grip strength did not significantly influence bimanual performance. There was no difference between children with right- and left-sided hemiplegia for motor performance., Interpretation: Findings of our study confirm a strong relationship between unimanual capacity and bimanual performance in a cohort of children with congenital hemiplegia. However, the directionality of the relationship is unknown and therapists cannot assume improvements in unimanual capacity will lead to gains in bimanual performance.

Background: Congenital hemiplegia is the most common form of cerebral palsy (CP) accounting for 1 in 1300 live births. These children have limitations in capacity to use the impaired upper limb and bimanual coordination deficits which impact on daily activities and participation in home, school and community life. There are currently two diverse intensive therapy approaches. Traditional therapy has adopted a bimanual approach (BIM training) and recently, constraint induced movement therapy (CIMT) has emerged as a promising unimanual approach. Uncertainty remains about the efficacy of these interventions and characteristics of best responders. This study aims to compare the efficacy of CIMT to BIM training to improve outcomes across the ICF for school children with congenital hemiplegia., Methods/design: A matched pairs randomised comparison design will be used with children matched by age, gender, side of hemiplegia and level of upper limb function. Based on power calculations a sample size of 52 children (26 matched pairs) will be recruited. Children will be randomised within pairs to receive either CIMT or BIM training. Both interventions will use an intensive activity based day camp model, with groups receiving the same dosage of intervention delivered in the same environment (total 60 hours over 10 days). A novel circus theme will be used to enhance motivation. Groups will be compared at baseline, then at 3, 26 and 52 weeks following intervention. Severity of congenital hemiplegia will be classified according to brain structure (MRI and white matter fibre tracking), cortical excitability using Transcranial Magnetic Stimulation (TMS), functional use of the hand in everyday tasks (Manual Ability Classification System) and Gross Motor Function Classification System (GMFCS). Outcomes will address neurovascular changes (functional MRI, functional connectivity), and brain (re)organisation (TMS), body structure and function (range of motion, spasticity, strength and sensation), activity limitations (upper limb unimanual capacity and bimanual motor coordination), participation restrictions (in home, school and recreation), environmental (barriers and facilitators to participation) and quality of life., Discussion: This paper outlines the theoretical basis, study hypotheses and outcome measures for a matched pairs randomised trial comparing CIMT and BIM training to improve outcomes across the ICF., Trial Registration: ACTRN12609000912280.

Aim: This systematic review aimed to compare the validity, reliability, evaluative validity, and clinical utility of upper limb activity measures for children aged 5 to 16 years with congenital hemiplegia., Method: Electronic databases were searched to identify assessments that measure upper limb activity available for use and for which published validity and reliability data for the population are obtainable. Assessment items were coded according to the International Classification of Functioning, Disability and Health (ICF) categories to determine if at least 35% of the assessment items fell within the activity component of the ICF. Assessments that met these criteria were included in the review., Results: Thirty-eight measures were identified, and five met the inclusion criteria. The best measure of unimanual capacity was the Melbourne Assessment of Unilateral Upper Limb Function (MUUL); however, the Shriners Hospital Upper Extremity Evaluation (SHUEE) and the Quality of Upper Extremity Skills Test (QUEST) could also be considered, depending on the type of information required. The performance-based measure of bimanual upper limb activity in children with hemiplegia with the best psychometric properties was the Assisting Hand Assessment (AHA). The ABILHAND-Kids is a parent-report, performance-based questionnaire with excellent clinical utility and psychometric properties., Interpretation: Clinicians may choose to use more than one of these measures to detect changes in unimanual or bimanual upper limb activity.

Objective: This qualitative study explored the experiences of children participating in modified constraint-induced movement therapy (CIMT) within a circus-themed day camp., Methods: Individual semi-structured interviews were performed with 32 children (15 girls, 17 boys; mean age 10.1 years) to gain insights into their experience of CIMT. Interviews were audio recorded, transcribed verbatim and independently read by two authors to identify common themes., Results: Three themes emerged from the data: children's experience of wearing the glove employed in the modified CIMT, their reactions to the camp format and the gains they made during the camp., Conclusion: The results highlighted the need to achieve a balance between the frustration of participating in modified CIMT and what was seen as motivators to sustain involvement. Findings are interpreted in the context of self-determination theory and remind clinicians to ensure interventions consider autonomy, competence and relatedness.