Anda di halaman 1dari 9



Constraint-Induced Movement
Therapy in Children Aged 5 to 9
Years With Cerebral Palsy: A Day
Camp Model
Ashley M.E. Thompson, MHSc; Serena Chow, MScOT; Cathy Vey, BScOT; Meghann Lloyd, PhD
Carleton University (Ms Thompson), Ottawa, Ontario, Canada; University of Ontario Institute of Technology (Dr Lloyd),
Oshawa, Ontario, Canada; Grandview Childrens Centre (Ms Chow and Ms Vey), Oshawa, Ontario, Canada.

Purpose: To examine the effectiveness of a modified form of constraint-induced movement therapy (mCIMT)
in the context of a day camp model in 6 children aged 5-9 years with spastic hemiplegic cerebral palsy.
Methods: Before, 1 week after, and 3 months after 9 consecutive days of mCIMT, participants were assessed
using the Quality of Upper Extremity Skills Test (QUEST) and assessments of range of motion and grip strength.
Caregiver perceptions were assessed using the Pediatric Evaluation of Disability Inventory (PEDI) and a parent
questionnaire. Results: Significant improvements were observed on the grasps and protective extension
subsections of the QUEST after the intervention. Increased social function was also observed as measured
by the PEDI. All improvements were maintained at the 3-month follow-up assessment. Analysis of individual
participants yielded additional information on clinically significant improvements as a result of the mCIMT
intervention. Conclusions: The day camp model of mCIMT was effective in inducing lasting and meaningful
changes in the children with hemiplegic cerebral palsy. (Pediatr Phys Ther 2015;27:7280) Key words: cerebral
palsy/hemiplegia, child, evaluation of disability, motor skills, upper limb
Cerebral palsy (CP) encompasses a group of movement and posture disorders caused by a nonprogressive
but permanent abnormality in the fetal or infant brain.1
The development of the brain is interrupted by an interfering event that damages or otherwise influences the
expected patterns of maturation; the result may be a lesion

Pediatric Physical Therapy
C 2015 Wolters Kluwer Health | Lippincott Williams &
Wilkins and Section on Pediatrics of the American Physical Therapy

Correspondence: Ashley M.E. Thompson, MHSc, Carleton University, 1125 Colonel By Dr, Ottawa, ON K1S 5B6, Canada (
Grant Support: This study was supported by grants from the Grandview
Childrens Centre Foundation, Oshawa, Ontario, Canada.
At the time this article was written Ashley Thompson was a student at the
University of Ontario Institute of Technology, Master of Health Sciences,
Oshawa, Ontario, Canada.
The authors declare no conflict of interest.
DOI: 10.1097/PEP.0000000000000111


Thompson et al

or a malformation in the immature brain.1-3 Although the

causes of these abnormalities vary,4 CP occurs on average
in 1 of 500 children,5 making it the most common pediatric physical disability.6,7 The most common form of CP
is spastic hemiplegic CP, which is characterized by rigid
movements as well as asymmetric motor impairment.7-9 In
hemiplegia, one side of the body is more impaired than the
other; the upper limb is typically more affected than the
lower limb.10 The impairments experienced by children
with hemiplegic CP affect many aspects of their daily lives;
these limitations ultimately interfere with proper motor
development in multiple ways. Independence while performing self-care tasks, ability to fully participate in play
and other group settings, and overall daily function are
some of the areas in which children with hemiplegic CP
experience difficulties.11
Constraint-induced movement therapy (CIMT) is a
form of rehabilitative therapy that involves constraining the less-affected limb, while simultaneously training the more-affected limb.12 The originally proposed
Pediatric Physical Therapy

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

recommendations were to restrain the less-affected limb

for 90% of the individuals waking hours, and to perform
intensive movement therapy with a trained therapist for 6
hours per day over a 2-week period.12 However, in the
population of children with spastic hemiplegic CP, researchers must contend with unique challenges; the intensity of the traditional CIMT therapy may be too great
to retain the attention of young children.13,14 The therapy
should ideally include a variety of child-geared activities
as well as intermittent breaks to maximize compliance and
effectiveness.13-17 In addition, original guidelines for CIMT
would require between 60 and 84 hours of physical therapy
per week, rendering traditional CIMT costly, both financially and in terms of therapists time. Thus, the original
form of CIMT may not be an economically feasible and sustainable therapeutic model for children with CP. As such,
researchers have been challenged to modify CIMT for children affected by spastic hemiplegic CP. Many studies have
used modified forms of CIMT, using alterations in the intensity and/or duration of the therapeutic technique.15,17-20
Modified CIMT (mCIMT) has yielded improved functional outcomes for children with CP21 that are at least as
good as traditional CIMT.22 In children with hemiplegic
CP, mCIMT has been shown to increase the spontaneous
use of the affected limb in day-to-day tasks and self-care
activities (eg, dressing, feeding, and toileting),17,19 and improve motor performance measured by standardized motor
assessments.21,23 In many studies, the improvements were
maintained several months later.15-17,19,20,21 This suggests
that a less intensive form of CIMT may produce positive
effects in children and be more economical and less timeintensive for families.
In addition, many recent studies have successfully implemented CIMT in nonclinical settings.15-17,22,24 The importance of transferring the shaping and practice of CIMT
to more natural settings is gaining attention in the field,
as many recent studies have implemented home exercise
programs into the interventions.24-27 These studies have
demonstrated that CIMT implemented in a natural setting can improve the spontaneous use of the affected limb,
improve coordination and precision, and improve participants abilities to perform self-care activities. In one study
the home and clinic environments were specifically compared for providing CIMT, and although participants in
both groups improved, the participants in the home group
improved more.24 When compared with a home setting,
a day camp model of CIMT additionally offers peer interaction, which has yielded positive social outcomes for
youth.14 More research is needed to support the effectiveness of mCIMT applied in natural settings for children with
spastic hemiplegic CP. Furthermore, the importance of implementing CIMT in a natural setting is supported by the
World Health Organizations International Classification
of Functioning, Disability and Health (ICF),28 which describes the reciprocal relationship between the individual
and the environment, and the way in which this interaction
contributes to the individuals overall health condition and
functional status.
Pediatric Physical Therapy


According to the ICF, disability must be considered
in the context of body structures and functions, personal
and environmental factors, activity, and participation.28
These factors interact with one another and contribute to
the overall health condition and function of an individual.
The activity of the child refers to what he or she is able
to do, and participation refers to what the child actually
does outside the therapeutic setting.28 The goal of any intervention is to increase the activity of the child, such that
participation may improve. By improving the ability to perform upper limb tasks in a lasting way, CIMT is promoting
functional changes that permit children with hemiplegic
CP to increase their participation in various tasks outside
of therapy. Intervention in a natural setting accounts for
the importance of the individuals environment and might
facilitate the transfer of any learned skills into daily functioning.
The objective of the current study was to determine
whether a 2-week day camp model of CIMT, delivered
by highly trained camp counselors supported by occupational therapists (OTs), was effective in improving functional outcomes for children aged 5 to 9 years with spastic
hemiplegic CP. We hypothesized that restraining the lessaffected upper limb for 7 hours per day during a day camp
taking place over 9 days would induce functional benefits for the more-affected limb after the intervention. We
also hypothesized that the improvements observed in the
more-affected limb as a result of mCIMT would persist at
the 3-month follow-up assessment. Finally, we hypothesized that conducting mCIMT in a day camp setting would
yield positive social outcomes for participants.
The current study involved a preassessment that took
place 1 week before the intervention, a 9-day intervention
during which participants wore a splint on the unaffected
arm for 7 hours per day and participated in activities that
promoted the use of the affected arm, a postassessment
that took place 1 week after the intervention, and a 3month follow-up assessment. Children with hemiplegic
CP between 5 and 9 years of age were recruited through
fliers that advertised the camp on bulletin boards at the
Childrens Treatment Centre (CTC) where the camp took
place; the camp was also advertised to other CTCs in the
area. Potential participants were also directly informed of
the study by OTs at the CTC.
This study was approved by the Universitys Research
Ethics Board and the CTCs Ethics Committee. Inclusion
criteria for the study required that participants have a diagnosis of spastic hemiplegic CP and be between 5 and 9 years
of age. Participants had to be able to walk independently
CIMT Camp for Children With CP 73

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

without an ambulation aid, have the cognitive and social

ability to participate in a camp setting, and be willing
to travel to the CTC for the duration of the camp, for
the intake assessment, and for the 3 assessment sessions.
Exclusion criteria included (1) any orthopedic (correctional) surgery on the affected upper limb and/or (2) dorsal
rhizotomy. Regardless of any secondary conditions or any
other impairment or symptoms present, all interested children who satisfied the above criteria were included in the
study. A total of 6 children took part in the study (4 boys
and 2 girls; mean age = 6 years, 4 months). Informed consent from a parent/guardian of each child as well as child
assent was obtained for all participants during an intake
session; during this session, additional information about
each participant was gathered on a supplemental form, and
participants were fit for a splint.
Participants were enrolled in a day camp (Cast
Camp) where mCIMT was administered for 7 hours per
day; Cast Camp took place over a 2-week period during
the summer, for a total of 9 days (a holiday took place on
the Monday of the first week). Each participant was given
C splint to be worn on the unaffected hand. The
a Benik
model selected was the W323 with Volar Pan extension;
this splint effectively immobilizes the wrist, fingers, and
thumb of the restrained hand (Figure 1). This splint was
chosen because of its ability to prevent the children from
flexing and extending the wrist, as well as to prevent finger
extension and all thumb movements. The splint was worn
only during camp hours and was applied and removed by
camp staff each day.

C Splint Model W323 with Volar Pan extension. This

Fig. 1. Benik
figure is available in color in the article on the journal website,, and iPad.


Thompson et al

All children who attended the camp were participants

in the study (no children other than the 6 in the study
attended camp for these 2 weeks); all children wore the
splint and received mCIMT. The camp was led by 3 counselors, all of whom were university students (entering either the third or fourth year of undergraduate studies) and
were required to undergo a 2-week intensive orientation
and training session at the CTC; this training prepared the
counselors to act as camp counselors for children with various physical and developmental disabilities. In addition, 2
of the 3 camp counselors, including the camp coordinator,
were involved in Cast Camp in 2011; the camp coordinator
was further involved in Cast Camp in 2010. The counselors
for Cast Camp additionally underwent two 1-hour training
sessions with OTs at the CTC to prepare to effectively deliver CIMT in a day camp setting. Occupational therapists
at the CTC dropped in to the camp daily to ensure that
CIMT was being effectively delivered by the camp counselors. The daily visits were arranged using sign-up sheets
at the CTC; various OTs working at the CTC volunteered
to drop in to the camp each day around 10 AM. The length
of the visits varied depending on the needs of the camp (ie,
questions or problems that arose), with visits lasting from
10 minutes to 1 hour. The OTs spent this time observing
the staff, providing direction regarding how to give the
children the correct amount of support, answering questions, and working with the children directly. In addition,
1 of the OTs directly involved with this project dropped in
to the camp more informally each afternoon to observe and
answer any questions. This OT was also available on-call at
all times during the camps duration in case any problems
requiring the assistance of an OT arose. All activities performed during the camp were planned by camp counselors,
supported by OTs, and specifically selected to promote the
use of the affected hand. Gross manipulation tasks as well
as precision tasks were emphasized in the daily activities;
examples of the activities included finger painting, crafts,
and team-building activities. Counselors also monitored
all feeding times and provided a motivating environment
in which children were encouraged to use their affected
hands as much as possible. The activities changed from
day to day but always included both free play in an outdoor setting (that included a park) and structured play
(eg, sports, games, and crafts) that were all performed by
the children using their affected hand (the splinted hand
was allowed to be used as an assisting hand when tasks
were more challenging or clearly bimanual in nature ie,
stabilizing a lunch bag with the splinted hand to unzip the
bag using the affected hand). Camp counselors used verbal cues to discourage the use of the splinted hand and to
encourage the use of the affected hand during both structured and unstructured play. The splint restricted motion
of the unaffected hand such that the unaffected arm could
only be used for stability and gross movements; still, consistent reminders and encouragement to use the affected
hand in a dominant manner were provided by the camp
counselors throughout each day of the camp. In the current study, mCIMT was administered in a day camp setting
Pediatric Physical Therapy

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

for 7 hours per day for 9 consecutive weekdays, for a total

of 63 hours of CIMT; as such, these conditions are fairly
close to the originally proposed guidelines of 6 hours per
day for 14 days, but represent a more cost-effective model
of CIMT.
Outcome Measures
Several assessments were used in this study, all selected to evaluate the function of the affected hand or to
determine the parents perceptions of the childrens function. An OT, who was not the primary OT for any of the
participants, conducted all assessments. Previous studies
have used a wide variety of assessments to measure improvement after CIMT; however, a common aspect of most
studies is the selection of assessments that directly measure
motor function as well as those that examine qualitative
improvements in daily life (eg, increased use of the limb,
self-care, independence, and social ability).17,19-21,27,29-30
The assessments used in the current study were chosen
based on the variety of areas that they collectively assess
(eg, gross motor, fine motor, social ability, and mobility),
as well as for their use in previous studies using CIMT for
children with CP.15,16,23,25,29,30
The primary assessment used in this study to evaluate
upper limb function was the Quality of Upper Extremity
Skills Test (QUEST).34 The QUEST is a standardized assessment of motor performance used to evaluate a childs
ability to complete a variety of tasks; all items are graded as
a yes/no, with a yes meaning that each child can perform
the task completely.34 The QUEST is scored on a basis
of 100 points, and includes items assessing upper limb
movements, grasping and manipulating objects, balance,
and protective extension skills.34
The assessments used to evaluate caregiver perceptions of each childs function included the Pediatric Evaluation of Disability Inventory (PEDI)35 and a questionnaire
developed by the OTs at the CTC based on the Canadian Occupational Performance Measure.36,37 The PEDI is
a questionnaire that is completed by the childs caregiver;
this measure is also scored on a basis of 100 points. The
PEDI is used to measure the ability of the child to participate in self-care tasks (eg, dressing and feeding), mobility capabilities (eg, indoor and outdoor movements),
and social function abilities (eg, communication and social play).35 The CTC questionnaire is used to assess any
changes observed in the frequency and/or spontaneity of
the use of the affected limb; and furthermore to assess the
childs ability to perform a variety of self-care tasks, and
includes both the parents evaluations of the importance
of the child improving in each area and their levels of satisfaction with the childs current level of performance for
each task. Each item is assessed on a scale of 1 to 10, with
scores closer to 10 indicating a higher level of performance,
importance, or satisfaction.
Additional tests included measures of range of motion, grip strength, and assessment of spasticity using the
Modified Ashworth Scale,38 and the level of impairment
using the Gross Motor Function Classification System
Pediatric Physical Therapy

(GMFCS)39 and the Manual Ability Classification System

Range of motion measures included elbow and wrist
flexion/extension, finger and thumb flexion/extension,
and shoulder rotation. Grip strength in both hands was
measured using a modified sphygmomanometer (using a
sphygmomanometer); the device consists of a
hand-held pump containing water connected to a pressure
gauge that measures grip strength in pounds per square
inch (psi) when squeezed (the maximum possible score is
15.5 psi). Participants were seated, with the shoulder in the
neutral position and the elbow flexed at a 90 angle when
grip strength measurements were taken. Three successive
measurements were taken in the unaffected limb and then
the affected limb; a rest period of about 15 seconds was
given between trials, which was the time required to read
and record the score.
The OT completed the Modified Ashworth Scale on
the elbow joint of the affected limb during each of the 3
assessment sessions. The GMFCS level was established by
the OT conducting the assessments, and the MACS level
was established by asking the caregivers of each participant
to select, from a list of 5 descriptions, the level that best
described the childs overall function.
Data Analysis
The Friedman test was used for the QUEST data as
well for grip strength and the caregiver reports on the
CTC questionnaire. Nonparametric post-hoc analyses were
done using the Wilcoxon signed rank test, and Bonferroni corrections were used for multiple comparisons. The
Wilcoxon signed rank test was further used to analyze
results from the PEDI and the independent reports given
from camp counselors and caregivers on the performance
section of the CTC questionnaire (these assessments were
only administered on 2 occasions). Observed power and
effect sizes were calculated for all statistical tests, and are
reported with the results section. All data handling and
analyses were performed using SPSS version 19.0.41
Characteristics of each participant can be found in
Table 1. Considerable variability was present in the sample;
therefore, each child was used as his or her own control and
analyzed individually for many of the measures employed.
Motor Outcomes
Table 2 shows the QUEST scores for all participants.
Significant differences were observed on the protective
extension subsection of the QUEST over time ( 2 (2) =
8.316; P = .016; observed power = 0.833; partial 2 =
0.589) (Figure 2). Post-hoc analysis with Wilcoxon signed
rank tests was conducted using a Bonferroni correction,
resulting in a significance level set at = 0.017. A
trend toward improvement on the protective extension
CIMT Camp for Children With CP 75

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

Participant Information

level (I-V)

level (I-V)

MAS at Elbow
Pre-, Post-, and
3-mo Follow-up
Assessment (0-4)


Age, yr









1, 2, 2
NT, 2, 1
2, 1, 1

Yes (2011)
Yes (2011)







3, 3, 2
0, 0, 0
0, 0, 0

Yes (2011)


Learning disabilities; sensory
integration disorder; social
isolation; difficulty transitioning
from preferred activities to less
preferred; angry (sometimes
physical with outbursts; impulse
control difficulties)
Learning disabilities
Febrile seizures; difficulty keeping
up with other children in
physical activities

Abbreviations: GMFCS, Gross Motor Function Classification System; MACS, Manual Abilities Classification System; MAS, Modified Ashworth Scale; NT,
not tested.

QUEST Scores by Participant and by Section
QUEST Section
Total score

Dissociated movements


Weight bearing

Protective extension


3-mo follow-up assessment
3-mo follow-up assessment
3-mo follow-up assessment
3-mo follow-up assessment
3-mo follow-up assessment







Abbreviation: QUEST, Quality of Upper Extremity Skills Test.

a Participant 4 did not complete the weight bearing section at 3-month follow-up assessment, as he did not comply with the assessors requests.

subsection observed immediately after the intervention (Z

= 2.214; P = .027) was not statistically significant.
As a group, the participants experienced significant
improvements in the grasps subsection of the QUEST
( 2 (2) = 7.684; P = .021; observed power = 0.91; partial
2 = 0.712) (Figure 3). No statistically significant improvements were observed in post-hoc analyses using Wilcoxon
signed rank tests. No significant changes were observed in
the dissociated movements or weight bearing subsections of the QUEST, or in the overall QUEST scores.
No significant improvements in grip strength or range
of motion of the affected or unaffected limb were observed
after CIMT.

Thompson et al

Caregiver Reports
On the PEDI, caregivers responses indicated a significant improvement in social function skills after the intervention (Z = 2.201; P = .028; observed power > 0.999;
Cohens d = 2.55). No significant changes were observed
in any of the other categories of the PEDI.
On the CTC questionnaire, no significant changes
were observed in the caregiver responses over time or on
the satisfaction section of the questionnaire over time. In
each individual category of the CTC questionnaire, however, at least 3 of the 6 caregivers satisfaction responses
increased between the initial assessment and the 3-month
follow-up; the only exception to this was in the frequency
Pediatric Physical Therapy

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

Fig. 2. Median protective extension scores on the Quality of

Upper Extremity Skills Test with standard deviation.

cally significant improvements in grasping ability that persist months later.29,30 More efficient grasping capabilities
would allow children to perform more efficiently a variety
of functional tasks, including self-care tasks such as feeding and dressing, and might allow increased participation
in other activities such as play.
Trends toward improvement in the protective extension sub-section of the QUEST occurred regardless of
GMFCS or MACS level. As activities performed at the camp
did not specifically address protective extension skills an
increase in the spontaneous use of the affected limb could
have reasonably contributed to improved protective extension scores. Children with CP often experience impairments in balance42 ; these impairments can lead to falls,
further supporting the relevance of the current finding of
improved protective extension skills.
The improvements observed on the QUEST
are consistent with previous research, demonstrating improvements on standardized tests of motor
performance16,17,19-21,23,30,43 ; however, those studies
found varying degrees of improvement on various motor
assessments.16-18,27,29 Ultimately, individual differences
may affect the improvements observed on standardized
tests of motor performance.
Like our findings, previous studies have consistently
shown that grip strength and active range of motion in
the unaffected limb are not hindered after CIMT.15,21,23,31
Previous studies have also reported nonsignificant results
for change in grip strength in the affected limb after a CIMT
Caregiver Reports

Fig. 3. Median grasps scores on the Quality of Upper Extremity Skills Test with standard deviation. Participant 4s scores are
excluded from analysis.

of use subsection, where only 2 of the 6 caregivers reported increased satisfaction. In the spontaneity of use
subsection, 5 of the 6 caregivers reported increased satisfaction after the intervention.
The results from the current study support findings
of prior clinical studies demonstrating mCIMT to be effective in children with hemiplegia.20,22,23 The results further
support previous research demonstrating that mCIMT can
be successfully applied outside a clinical setting, yielding
positive outcomes for youth.15,17,24-26

Caregivers reported through the PEDI a significant

increase in social function after the intervention, supporting our hypothesis related to positive social outcomes;
previous studies have also reported increased social
function after the CIMT intervention.28,46 Gilmore et al14
examined participants opinions of a day-camp model
of CIMT, and found that they enjoyed being in a place
where others were like them; participants felt motivated
as a result of this. Increased feelings of self-confidence,
self-esteem, and motivation may have resulted from
the camp setting, leading to improved social function.
This represents a developmental gain that can positively
influence many other areas of a childs life, including
home, school, and community environments. Three of the
6 caregivers reported improved independence for their
children in self-care tasks after the intervention. These results are consistent with previous research demonstrating
caregiver perceptions of childrens improved ability to use
the affected limb after CIMT.16,18,20,22,32

Motor Outcomes
The finding of improvement in the grasps area of
the QUEST supports previous research findings of statistiPediatric Physical Therapy

Despite demonstrating a variety of benefits of mCIMT,

this study also identifies some of the methodological issues of clinical studies employing CIMT in the pediatric
CIMT Camp for Children With CP 77

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

population affected by CP. Inconsistent results have been

reported in prior studies of mCIMT in children32,47 ; some
authors suggested that personal factors such as age, level
of impairment, and level of motivation ought to be considered when applying the CIMT intervention in this
population.17,30,44,48,49 The current study included children aged 5 to 9 years, which to the knowledge of the
researchers, is among the smallest age ranges reported for
this type of study. Although the narrow age range led to a
small sample size, we believe a smaller age range will ultimately yield more generalizable results for this age group.
Another potential limitation of the current study was that
parents enrolled their children into the study, and parents
who seek out these types of positive rehabilitative opportunities for their children may create a biased sample.
ICF. The ultimate goal of CIMT is to improve the
childs capacity to perform daily activities using the affected
limb. In this study, these skills were intentionally practiced
in a natural setting to facilitate the transfer of these skills to
daily life. Although the children were undergoing a form
of therapy, they were also engaged in fun activities while at
the camp, and had the opportunity to interact with other
children who were facing similar challenges. The ICF28
considers these environmental and personal factors important when providing treatment programs for children
with CP. Although all children did not experience the same
benefits from the CIMT intervention, not all children experienced difficulties in the same areas. Although the benefits
varied within our sample, all children experienced some
improvement in functional outcome. If children are better
able to perform even one activity, they may participate in
that activity more frequently.
Statistical Versus Clinical Significance: Individual
Differences. Although several of the primary motor assessments yielded important clinical outcomes as a result of the
intervention, many of the measures did not reach statistical
significance. For example, when asked about their satisfaction with their childs overall function on the CTC questionnaire, at least 50% of the parents reported increased satisfaction at the 3-month follow-up on 6 of the 7 measures.
In addition, 83.33% of the parents reported increased satisfaction with respect to their childs spontaneity of the use
of the affected limb. This indicates that important clinical changes are being observed, as caregivers are reporting
increased satisfaction in a variety of functional areas. Because the ultimate objective of the current study was to
promote functional benefits for this population as a result
of mCIMT, these parental reports are important and should
not be ignored. Several explanations are possible for the
lack of statistically significant results; in the current study,
the limited sample size and the heterogeneity within the
sample are the most likely explanations for the lack of statistically significant results on certain measures. Within the
sample, participants experienced different levels of mobility, functioning of the hemiplegic limb, and comorbidities.
Our results show the importance of considering the personal factors of each child, outlined by the ICF,28 that
have the potential to influence the outcome of the therapy.

Thompson et al

The results further support the need to consider clinical

changes in this population as opposed to exclusively examining statistically significant changes in group means.
This is particularly important when examining interventions for children with spastic hemiplegic CP, as a large
amount of variability exists within this population.1,3,4
Suggestions for Future Research
In the future a control group should be included,
and investigators should attempt to recruit larger numbers
of children within a narrow age range. Studies employing CIMT in the future should consider the importance of
applying such techniques in a natural environment, and
should also consider conducting a cost analysis to determine the economic efficiency of the day camp model of
mCIMT compared with mCIMT conducted in a clinical
Questionnaires about daily functioning might be best
in a semistructured interview as caregivers may interpret
questions differently. For example, 5 parents in this study
reported improved spontaneous use of the affected limb
after 3 months, but only 2 reported an increase in frequency
of use. This may or may not represent an incongruent set
of responses.
Finally, several investigators have examined the combined effects of botulinum toxin-A and upper limb therapy
for children with spastic hemiplegic CP.51,52 In the future
investigators should consider examining the potential benefits of employing CIMT in conjunction with botulinum
toxin A.53,54
The day camp model of mCIMT used in the current
study provides an effective setting for children with spastic hemiplegic CP. The current study demonstrated the
effectiveness of a day camp model of CIMT in inducing
lasting functional benefits for children with spastic hemiplegic CP. This intervention, considered within the context
of the ICF model, improved the activity and participation
levels of participants.
1. Bax M, Tydeman C, Flodmark O. Clinical and MRI correlates
of cerebral palsythe European cerebral palsy study. JAMA.
2006;296(13):1602-1608. doi:10.1001/jama.296.13.1602.
2. Mercuri E, Rutherford M, Cowan F, et al. Early prognostic indicators of outcome in infants with neonatal cerebral infarction:
a clinical, electroencephalogram, and magnetic resonance imaging study. Pediatrics. 1999;103(1);39-46.
BlPXNpdGU%3d#db=fth&AN=1592836. Accessed June 12, 2013.
3. Cowan F, Rutherford M, Groenendaal F, et al. Origin and timing of
brain lesions in term infants with neonatal encephalopathy. Lancet.
2003;361(9359):736-742. doi:10.1016/S0140-6736(03)12658-x.
4. Robinson MN, Peake LJ, Ditchfield MR, Reid SM, Lanigan A, Reddihough DS. Magnetic resonance imaging findings in a populationbased cohort of children with cerebral palsy. Dev Med Child Neurol.
2009;51(1):39-45. doi:10.1111/j.1469-8749.2008.03127.x.
Pediatric Physical Therapy

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

5. Blair E, Watson L. Epidemiology of cerebral palsy. Semin Fetal Neonatal Med. 2006;11:117-125. doi:10.1016/j.siny.2005.10.010.
6. Stanley F, Blair E, Alberman E. Cerebral Palsies: Epidemiology and
Causal Pathways. Cambridge, MA: Cambridge University Press;
7. Reid SM, Carlin JB, Reddihough DS. Rates of cerebral palsy in
Victoria, Australia, 1970 to 2004: Has there been a change?
Dev Med Child Neurol. 2011;53(10):907-912. doi:10.1111/j.14698749.2011.04039.x.
8. Hagberg B, Hagberg G, Beckung E, Uvebrant P. Changing panorama
of cerebral palsy in Sweden. VIII. Prevalence and origin in the
birth year period 1991-94. Acta Paediatr. 2001;90(3):271-277.
9. Platt M, Cans C, Johnson A, et al. Trends in cerebral palsy among
infants of very low birth weight (<1500 g) or born prematurely
(<32 weeks) in 16 European centres: a database study. Lancet.
10. Sakzewski L, Ziviani J, Boyd R. Systematic review and meta-analysis
of therapeutic management of upper-limb dysfunction in children
with congenital hemiplegia. Pediatrics. 2009;123(6):e1111-e1122.
11. Brady K, Garcia T. Constraint-induced movement therapy (CIMT):
pediatric applications. Dev Disabil Res Rev. 2009;15(2):102-111.
12. Taub E, Crago JE. Constraint-induced movement therapy: a new
approach to treatment in physical rehabilitation. Rehabil Psychol.
1998;43(2):152-170. doi:10.1037/0090-5550.43.2.152.
13. Brown JK, Rensburg FV, Lakie GWM, Wrigh GW. A neurological
study of hand function of hemiplegic children. Dev Med Child Neurol.
2008;29(3):287-304. doi:10.1111/j.1469-8749.1987.tb02482.x.
14. Gilmore R, Ziviani J, Sakzewski L, Shields N, Boyd R. A
balancing act: childrens experience of modified constraintinduced movement therapy. Dev Neurorehabil. 2010;13(2):88-94.
15. Bonnier B, Eliasson A, Krumlinde-Sundholm L. Effects of constraintinduced movement therapy in adolescents with hemiplegic cerebral
palsy: a day camp model. Scand J Occup Ther. 2006;13(1):13-22.
16. Aarts P, Jongerius P, Geerdink Y, van Limbeek J, Geurts A.
Effectiveness of modified constraint-induced movement therapy
in children with unilateral spastic cerebral palsy: a randomized
controlled trial. Neurorehabil Neural Repair. 2010;24(6):509-518.
17. Cope SM, Liu X, Verber MD, Cayo C, Rao S, Tassone JC. Upper limb function and brain reorganization after constraint-induced
movement therapy in children with hemiplegia. Dev Neurorehabil.
2010;13(1):19-30. doi:10.3109/17518420903236247.
18. Charles JR, Lavinder G, Gordon AM. Effects of constraintinduced therapy on hand function in children with hemiplegic cerebral palsy. Pediatr Phys Ther. 2001;13(2):68-76.
2001&spage=68&issn=0898-5669. Accessed June 12, 2013.
19. Charles JR, Gordon AM. A repeated course of constraintinduced movement therapy results in further improvement.
Dev Med Child Neurol. 2007;49(10):770-773. doi:10.1111/j.14698749.2007.00770.x.
20. Fergus A, Buckler J, Farrell J, Isley M, McFarland M, Riley B.
Constraint-induced movement therapy for a child with hemiparesis: a case report. Pediatric Phys Ther. 2008;20(3):271-283.
21. Taub E, Ramey S, DeLuca S, Echols K. Efficacy of constraintinduced movement therapy for children with cerebral palsy with
asymmetric motor impairment. Pediatrics. 2004;113(2):305-312.
22. Taub E, Griffin A, Uswatte G, Gammons K, Nick J, Law CR.
Treatment of congenital hemiparesis with pediatric constraint-

Pediatric Physical Therapy

















induced movement therapy. J Child Neurol. 2011;26(9):1163-1173.

DeLuca S, Echols K, Law C, Ramey S. Intensive pediatric constraintinduced therapy for children with cerebral palsy: Randomized,
controlled, crossover trial. J Child Neurol. 2006;21(11):931-938.
Rostami HR, Malamiri RA. Effect of treatment environment on modified constraint-induced movement therapy results in children with
spastic hemiplegic cerebral palsy: a randomized controlled trial.
Disabil Rehabil. 2012;34(1):40-44. doi:10.3109/09638288.2011
Naylor CE, Bower E. Modified constraint-induced movement
therapy for young children with hemiplegic cerebral palsy:
a pilot study. Dev Med Child Neurol. 2005;47(6):365-369.
Chen C, Kang L, Hong W-H, Chen F-C, Chen H-C, Wu C. Effect of
therapist-based constraint-induced therapy at home on motor control, motor performance and daily function in children with cerebral palsy: A randomized controlled study. Clin Rehabil. 2013;27(3):
236-245. doi:10.1177/0269215512455652.
Hsin YJ, Chen FC, Lin KC, Kang LJ, Chen CL, Chen CY. Efficacy of constraint-induced therapy on functional performance and
health-related quality of life for children with cerebral palsy: a
randomized controlled trial. J Child Neurol. 2012;27(8):992-999.
World Health Organization. The International Classification of Functioning, Disability and Health. WHO; 2001.
classifications/icf/en. Accessed June 11, 2013.
Lin KC, Wang TN, Wu CY, et al. Effects of home-based
constraint-induced therapy versus dose-matched control intervention on functional outcomes and caregiver well-being in children with cerebral palsy. Res Dev Disabil. 2011;32(5):1483-1491.
Case-Smith J, DeLuca SC, Stevenson R, Ramey SL. Multicenter randomized controlled trial of pediatric constraint-induced movement
therapy: 6-month follow-up. Am J Occup Ther. 2012;66(1):15-23.
Stearns GE, Burtner P, Keenan KM, Qualls C, Phillips J. Effects of
constraint-induced movement therapy on hand skills and muscle
recruitment of children with spastic hemiplegic cerebral palsy. Neurorehabilitation. 2009;24(2):95-108. Accessed June 12, 2013.
Huang H, Fetters L, Hale J, McBride A. Bound for success: a systematic review of constraint-induced movement therapy in children
with cerebral palsy supports improved arm and hand use. Phys Ther.
2009;89(11):1126-1141. doi:10.2522/ptj.20080111.
Eliasson A, Krumlinde-Sundholm L, Shaw K, Wang C. Effects of
constraint-induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model. Dev Med Child Neurol.
2005;47(4):266-275. doi:10.1017/S0012162205000502.
DeMatteo C, Law M, Russell D, Pollock N, Rosenbaum P, Walter
S. The reliability and validity of the Quality of Upper Extremity Skills Test. Phys Occup Ther Pediatr. 1993;13(2):1-18.
Berg M, Jahnsen R, Frslie KF, Hussain A. Reliability of the Pediatric
Evaluation of Disability Inventory (PEDI). Phys Occup Ther Pediatr.
2004;24(3):61-77. doi:10.1300/J006v24n03_05.
Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock
N. The Canadian Occupational Performance Measure: an outcome
measure for occupational therapy. Can J Occup Ther. 1990;57(2):8287. doi:10.1177/000841749005700207.
Cusick A, Lannin NA, Lowe K. Adapting the Canadian Occupational Performance Measure for use in a paediatric clinical trial.
Disabil Rehabil. 2007;29(10):761-766. doi:10.1080/09638280600929
Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987;67:206-207. http:
// Accessed June
12, 2013.

CIMT Camp for Children With CP 79

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.

39. Rosenbaum PL, Palisano RJ, Bartlett DJ, Galuppi BE, Russell DJ.
Development of the Gross Motor Function Classification System for cerebral palsy. Dev Med Child Neurol. 2008;50:249-253.
40. Eliasson A, Krumlinde-Sundholm L, Rosblad B, et al. The Manual
Ability Classification System (MACS) for children with cerebral palsy:
Scale development and evidence of validity and reliability. Dev Med
Child Neurol. 2006;48:549-554. doi:10.1017/S0012162206001162.
41. SPSS [computer program]. Version 19.0. Chicago, IL: SPSS Inc; 2011.
42. Chambers HG. Treatment of functional limitations at the knee in ambulatory children with cerebral palsy. Eur J Neurol. 2001;8(Suppl 5):
59-74. doi:10.1046/j.1468-1331.2001.00039.x.
43. Aarts P, Jongerius P, Geerdink Y, van Limbeek J, Geurts A. Modified constraint-induced movement therapy combined with bimanual
training (mCIMTBiT) in children with unilateral spastic cerebral
palsy: How are improvements in arm-hand use established? Res Dev
Disabil. 2011;32:271-279. doi:10.1016/j.ridd.2010.10.008.
44. Charles JR, Wolf SL, Schneider JA, Gordon AM. Efficacy of a childfriendly form of constraint-induced movement therapy in hemiplegic
cerebral palsy: a randomized control trial. Dev Med Child Neurol.
2006;48(8):635-642. doi:10.1111/j.1469-8749.2006.tb01332.x.
45. Gordon AM, Charles J, Wolf SL. Efficacy of constraint-induced
movement therapy on involved upper-extremity use in children
with hemiplegic cerebral palsy is not age-dependent. Pediatrics.
2006;117(3):e363-e373. doi:10.1542/peds.2005-1009.
46. de Brito Brandao M, Mancini MC, Vaz DV, Pereira de Melo
AP, Fonseca ST. Adapted version of constraint-induced movement therapy promotes functioning in children with cerebral palsy:
a randomized controlled trial. Clin Rehabil. 2010;24(7):639-647.
47. Wolf SL. Revisiting constraint-induced movement therapy: are
we too smitten with the mitten? Is all nonuse learned? And


Thompson et al








other quandaries. Phys Ther. 2007;87(9):1212-1223. doi:10.2522/ptj

Lavinder G, Taub E, Gentile AM. Constraint-induced therapy in children with hemiplegic cerebral palsy. Abstract of Poster Presented at
Combined Sections Meeting. Seattle, WA: 1999.
Wang TN, Wu CY, Chen CL, Shieh JY, Lu L, Lin KC. Logistic regression analyses for predicting clinically important differences in
motor capacity, motor performance, and functional independence
after constraint-induced therapy in children with cerebral palsy.
Res Dev Disabil. 2013;34(3):1044-1051. doi:10.1016/j.ridd.2012.11
Graham HK, Aoki KR, Autti-Ramo I, et al. Recommendations for
the use of botulinum toxin type A in the management of cerebral
palsy. Gait Posture. 2000;11(1):67-79. doi:10.1016/S0966-6362(99)
Lowe K, Novak I, Cusick A. Low-dose/high-concentration localized
botulinum toxin A improves upper limb movement and function
in children with hemiplegic cerebral palsy. Dev Med Child Neurol.
2007;48(3):170-175. doi:10.1017/S0012162206000387.
Wallen M, OFlaherty SJ, Waugh MCA. Functional outcomes of
intramuscular botulinum toxin type A and occupational therapy in the upper limbs of children with cerebral palsy: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88(1):1-10.
Bjornson K, Hays R, Graubert C, et al. Botulinum toxin for spasticity in children with cerebral palsy: a comprehensive evaluation.
Pediatrics. 2007;120(1):49-58. doi:10.1542/peds.2007-0016.
Speth LAWM, Leffers P, Janssen-Potten YJM, Vles JSH. Botulinum toxin A and upper limb functional skills in hemiparetic cerebral palsy: a randomized trial in children receiving
intensive therapy. Dev Med Child Neurol. 2005;47(7):468-473.

Pediatric Physical Therapy

Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.