Cincinnati Children’s Hospital Medical Center

1. Cincinnati Children’s Hospital Medical Center Ohio Occupational Therapy Association October 16, 2008

2. Constraint-Induced Movement Therapy for Children By: Pamela Little-Hayes, OTR/L Amy Klein, OTR/L, MS, MPP Co-Authors: Allison Allgier, OTR/L Division of Occupational Therapy, Physical Therapy, Therapeutic Recreation

3. Research Review-Pediatrics

4. Impact of Pediatric Research • Lessons learned: • Constraint seems to lead to improved UE use • The various protocols, outcome measures, and types of constraints don’t allow us to say that any one protocol or type of constraint is better than any other • We cannot tell whether the effectiveness is due to the use of a constraint or the increased intensity of services and practice • Research supports the importance of family involvement and increased home program compliance

5. CCHMC Guideline Development • Factors that were considered in developing guidelines for intervention using CIMT included: • Evidence-based • Ability of intervention to meet the needs and abilities of children and families/ Family Centered • Intervention protocols fit with CCHMC’s current provision of care for outpatient occupational therapy • Intervention protocols are reimbursable by most public and private insurers • Because the evidence related to intervention protocols is equivocal, we recommend the use of one of the two following protocols that best meet the above factors.

6. Protocol 1 (Based on Elliason et al 2005) Protocol 2 (Based on Willis et al 2002) Duration of Intervention 8 weeks 4 weeks Daily Constraint Wear 2 hours per day 24 hours per day Daily Structured Practice with Caregiver 2 hours per day while wearing constraint No additional practice required but 2 hours daily practice with caregiver encouraged Method of Constraint Ace Wrap Pedi-wrap Splint / Glove Removable Cast Removable Cast Frequency of Therapy 1 time per week 1 time per week CCHMC Guidelines

7. Exclusion Criteria • Inability to participate in purposeful play or functional activities. • Contractures that limit functional arm use • Family that do not agree to follow through with home program activities. • Children under the age of 12 months have been following a modified version of the pathways.

8. Choosing the Protocol Parents Choose! • The treating therapist educates the parents regarding protocol options. • The parents then select the model that they feel will work best for their child and their family. • “Clients who perceive that they are actively involved in treatment decisions generally have better outcomes.” (Adams 2006) • A number of studies have found that a key predictor of compliance is perceived self efficacy. (Chen 1998, Stenstrom 1996)

9. Using The Power of Play • Intervention principles are based on those described by Eliasson (et al 2005) using these three concepts to guide treatment sessions and home programming. • Provide motivation to use the impaired hand by using the child’s inner drive to PLAY. • Select activities of an appropriate level of difficulty so the child can be successful while developing new skills. • Provide opportunities for lots of repetition

10. Assessment

11. CCHMC Assessment Development • The assessments are completed before and after CIMT • Assessments were selected based on the following: • Clinical utility of assessments (assessments provide the treating therapist with useful information) • Reliability and validity as outcome measures • Can be completed within 60 to 90 minutes • All CCHMC OTs can be trained to complete assessments (training requires less than one day; no certification required)

12. OT Framework Standardized Assessment Occupational Profile Canadian Occupational Performance Measure (COPM) Performance of Activities Shriners Hospital Upper Extremity Evaluation (SHUEE) Manual Ability Classification System (MACS) Gross Motor Function Classification System (GMFCS-E&R) Client Factors Range of Motion Modified Ashworth Scale Activities of Daily Living Contextual Factors Confidence Scale CCHMC Assessments

13. Guidelines for Developing CIMT Home Exercise Program • Focus on one specific skill each week (e.g., grasp, release, shoulder flexion), making sure to select emerging skill areas and activities that are meaningful to the child and family (use COPM results). • Pick five activities that target the chosen skill to be practiced during each 2-hour daily CIMT HEP session. • Encourage caregivers to incorporate other activities into their HEP time as well. • Parent should demonstrate competency with at least one activity each week.

14. Sample Activity Log for Constraint Induced Play at HomeDeveloping Pincer Grasp

15. Treatment sessions • Each week during the treatment session: • update home program, • problem solve concerns with parents, • model interventions, have parent demonstrate • check fit and function of constraint.

16. Discussing the Challenges of Constraint Motivation Tolerating the constraint Parent follow through Negative behaviors Choosing material and type of constraint

17. Problem Solving and Questions