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Intensity-based rehabilitation of the upper extremity in children with congenital hemiplegia Andrew M. Gordon, Ph.D., TC, Columbia Univ Jeanne Charles, PT, MSW, Ph.D. Emory University. Overview. Hemiplegic cerebral palsy Benefits of practice Constraint-induced movement therapy Limitations

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Intensity-based rehabilitation of the upperextremity in children with congenitalhemiplegiaAndrew M. Gordon, Ph.D., TC, Columbia Univ Jeanne Charles, PT, MSW, Ph.D. Emory University



  • Hemiplegic cerebral palsy
  • Benefits of practice
  • Constraint-induced movement therapy
  • Limitations
  • Bimanual control in hemiplegia
  • Hand-arm intensive bimanual therapy (HABIT)
  • Specificity of practice
  • What next?
impaired hand function in hemiplegic cp

Impaired Hand Function in Hemiplegic CP

Symptoms Include:

Abnormal muscle tone

Posturing into wrist flexion, ulnar deviation, elbow flexion and shoulder rotation

Reduced strength

Tactile and proprioceptive disturbances

Developmental non-use


Development of hand function a 13 year perspective

Eliasson, Forssberg, Hung, Gordon. (2006) Pediatrics Oct;118(4):1226-1236


400 gm

  • -- 200 gm

Gordon et al. 1999



Children with hemiplegic CP have impairments in anticipatory prehensile control

Children with hemiplegic CP show improvement in hand function with extended practice.


Basic Science

  • Mott-Sherrington (1895)
  • Munk (1909)
  • Ogden and response in small increments (successive approximations; Franz, 1917)
  • Tower, Berman, Taub
  • Merzenick, Nudo, Jones, Shallert, Kleim

Adult Stroke

  • First human studies of forced use: Ostendorf and Wolf (1981), Wolf et al. (1989)
  • First human studies of CI therapy: Taub et. al. (1993)
  • For review see Wolf et al. (2002) The Neurologist, 8:325.-38.
  • Extremity Constraint-Induced Therapy Evaluation (EXCITE) multi-site randomized clinical trial (Wolf et al. 2006 JAMA)
children with hemiplegia
Children with Hemiplegia

Studies of Forced Use/CI Therapy:

  • Yazukawa (1990): Am. J. Occ. Ther., 44: 840-846
  • Crocker et al. (1997) Am. J. Occ. Ther, 51:824-833
  • Charles, Lavinder, Gordon (2001) Ped. PT,13: 68-76
  • Pierce et al. (2002) Arch Phys Med Rehabil. 83: 1462-3.
  • Sterr et al. (2002) Arch Phys Med Rehabil. 83: 1726-31.
  • Glover et al. (2003) Pediatr Rehabil. 5:125-31.
  • Willis et al. (2002) Pediatrics. 110: 94-6.
  • Eliasson et al. (2003) Dev Med Child Neurol. 45: 357-9.
  • Karman et al. (2003) Head Trauma Rehabil. 18: 259-67.
  • DeLuca et al. (2003) Phys.Ther. 2003;83: 1003.-1013.
  • Taub et al. (2004) Pediatrics. 113: 305-12.
  • Charles et al. (2006) DMCN (8): 635-42
  • Gordon et al. (2006) Pediatrics 117(3): 363-73
  • Bonnier et al. (2006) Scan. J Occ Ther 13(1): 13-22
  • DeLuca et al. (2006) J of Child Neuro (1):81-91
  • Taub et al.(2007) Dev Neurorehab (10)1: 3-18
  • Sutcliffe et al. (2007) J Child Neurol. 2007 Nov;22(11):1281-7.
  • Wallen et al. (2007) Dev Neurorehabil. 15;:1-10
  • Charles and Gordon (2007) DMCN (10): 770-73
  • For Review, see:
  • Charles, J, Gordon, AM, (2005) Neuroplasticity 12(2-3): 245-61
  • Hoare et al.(2007) Clinical Rehab. 21:675-85
  • Eliasson, AC, Gordon, AM. In: AC Eliasson and P. Burtner (Eds.) Improving Hand Function in Children with Cerebral Palsy. Clinics in Developmental Medicine, London: MacKeith Press (2008).
  • Gordon, AM, Friel, K. In: J. Hermsdorfer and DA Nowak (Eds) Sensorimotor Control of Grasping: Physiology and Pathophysiology. Cambridge University Press (In Press)
problems applying adult ci therapy to children
Problems Applying Adult CI Therapy to Children
  • CI Therapy is too intensive and not-child friendly--may cause undue frustration, safety concerns and family burden.
  • Focuses on overcoming “learned nonuse”. Children may have “developmental non-use”, whereby they may be asked to use their limb unimanually for the first time --motivation, frustration.
modified cit

Modified CIT

We modified CI therapy and applied it to children with hemiplegic CP age 4-13 years.

Randomized clinical trial of 22 children with hemiplegic CP age 4-8 yrs.

Determine the efficacy of CI therapy in this population

Determined predictors of outcome

Examined Relationship between age and outcome in hemiplegic CP age 4-13 yrs

Compared efficacy of modified CI therapy in children 4-8 yrs. and 9-13 yrs.


Inclusion criteria are based on 3 main factors:

  • Criteria used in adult CIMT studies
  • Case studies of forced use and CIMT in children
  • Extensive experience working with children in clinical and laboratory settings

Inclusion Criteria:

4-13 years old with congenital hemiplegia

Active wrist and finger extension

Show >50% in timed motor performance between the two hands

Ability to lift arm

Normal cognitive ability


Exclusion Criteria

  • Seizures
  • Visual problems that would interfere
  • Severe spasticity
  • Other health problems
  • Too mild/severe
  • Orthopedic surgery in affected limb
  • Dorsal Rhizotomy
  • Botulinum Toxin within last 6 months
  • Intrathecal Baclofen
  • Balance problems
modified ci therapy for children
Modified CI Therapy for Children

Essential considerations include:

  • Maintaining the two major elements of adult CI therapy (repetitive part practice and whole task practice).
  • Be as closely aligned with the methodology employed in the EXCITE trial as possible.

2005 Arch Phys Med Rehab

  • Group setting
  • sling worn 6 hours per day for 10 out of 12 consecutive days
  • Movement Science Program, Teachers College, Columbia University
  • Functional and play activities
  • 1:1 interventionist/child ratio
  • Supervisor/ Team Meetings
  • Repetitive (part) Practice
  • Task (whole) Practice
  • Feedback: Positive Reinforcement
  • Home practice
  • Logs

Charles et al (2005) APMR


Task Selection

Specific activities were selected by considering

a) uni-manual movements with identified deficits

b) child preference for activities that have similar potential for improving identified movements

Constraints were adapted to allow success and removed as skill progresses.

ci therapy measures
CI Therapy Measures
  • Jebsen-Taylor Test of Hand Function ( 6 timed tasks)
  • Subtest of Bruininks-Oseretsky (8 timed bi/uni-manual tasks)
  • Pediatric Caregiver Survey (14 bimanual task items)
  • Pre-test, 1 week, 1 month, 6 month post-tests
  • Blind evaluation

CI Therapy Intervention Practice

  • Sling worn 60 hours
  • Overall intensity: 58% (35 hours)
  • Repetitive practice: 33%
  • Whole task practice: 67%
  • Home practice during intervention: 5.7 hrs / 10 days
  • Home practice after intervention: 7.3 hrs / week (6 months)

Initial severity of impairment and number of re-directions during testing accounted for 73.5% of the variance in improvement

is the efficacy of ci therapy age dependent
Is the efficacy of CI therapy age-dependent?
  • Compared CI therapy in younger (4-8 yrs) and older (9-13 yrs) children

CI Therapy Results

Time (s)


One Week


One Month


Six Month


Gordon et al. (Pediatrics 2006)

is ci therapy a one time intervention
Is CI therapy a one-time intervention?
  • We examined the efficacy of a second dosage of CI therapy 12 months after the first dosage.

Charles and Gordon (2007) DMCN


CI Therapy Results

Charles and Gordon (2007) DMCN

summary of cimt
Summary of CIMT
  • Intensive unimanual practice associated with CI therapy is of benefit for some children.
  • The benefit can be seen in both younger and older children
  • Efficacy may be dependent on initial severity and ability to attend to task.
  • A repeated dose results in further improvement—not a one-time miracle.
limitations of ci therapy in children
Limitations of CI therapy in children
  • CI therapy was developed to overcome learned non-use in adults-- children with hemiplegia must overcome “developmental non-use.”
  • Restraining a child’s non-involved extremity (especially with casts) is potentially invasive. The practice elicited with CI therapy is the key element of improved motor performance (Sunderland and Tuke 2005).
  • Unilateral restriction of limb use in kittens reduces topographic distribution, branch density and presynaptic bouton density on the side of restricted use (Martin et al.2004).
  • CI therapies are frequently conducted without regard for realistic expected functional outcomes.
  • We propose that rather than defining increased unimanual use of the involved extremity as the therapeutic goal, the goal should be to increase functional independence by improving use ofboth hands in cooperation. CI therapy does not directly target this goal!
summary of bimanual control
Summary of bimanual control
  • Even “less affected” hand is affected.
  • Many bimanual movements may have never been practiced.
  • Impaired ability to coordinate both hands together (Hung et al. 2004).
  • Unlike unilateral impairments, these bimanual coordination problems may underlie some of the functional limitations these children experience.
  • During bimanual movements the non-involved hand could provide a template for the involved hand when movements are either performed sequentially (Gordon et al. 1999, 2006, Raghavan et al. 2006) or simultaneously (Utley et al. 2004, Steenbergen et al. 2008).
how would you build your own intervention based on what we know
How would you build your own intervention based on what we know?
  • Make it functional and meaningful (e.g., Ketlaar et al. 2001, Ahl et al. 2005).
  • Make practice intense and structured!
  • Training specificity (e.g., bimanual cyclical training in stroke, Rose and Winstein 2004, Caraugh and Summers 2005, ICARE).
  • Balance activity across limbs since competition between hemispheres may influence corticospinal projections (Martin 2005, 2008, Eyre et al. 2007, Gordon & Friel In Press).
  • Utilize principles of motor learning (practice specificity, types of practice, feedback).
  • Utilize principles of neuroplasticity (practice-induced brain changes arising from repetition, increasing movement complexity, motivation, and reward). e.g., (e.g., Nudo 2003, Kleim et al. 2003)
  • Make it FUN!!!
  • No restraint
  • Same duration as CIMT
  • Bimanual activities (e.g., cards, wrapping presents, video games, ball throwing, zipping a jacket)

Task Designation

  • Stabilizer
  • Active/passive assist
  • Manipulator
  • Homologous/non-homologous
  • Part (homologous and non-homologous) practice
  • Whole task practice

Charles and Gordon, (2006) Dev Med Child Neurol Nov;48(11):931-6.


Table 1: Bimanual Activities

Charles and Gordon, (2006) Dev Med Child Neurol Nov;48(11):931-6.

  • Start with an easy task to build confidence
  • Agree upon how each hand will be used (e.g., reaching on more affected side)
  • View each movement as an opportunity for practice
  • Think about how you hand objects, placement, positioning, etc.
  • Minimize verbal prompting (i.e., use your left hand…)
  • Always give positive reinforcement, KR
  • Use whole and part practice
  • Mix fine and gross activities
  • Progress skills using spatial and temporal constraints
  • Use kinematic mirroring, examples
  • Group vs. individual activities
  • Establish clear criteria for progressing
  • Homologous vs. non-homologous movements?
  • Planning problems—how to sequence two hands
  • Keep fun!!!
  • HABIT is much harder to do than CIMT—the interventionist must do the work of the restraint!
habit measures
HABIT Measures
  • Assisting Hand Assessment (AHA)Movement Efficiency
  • Kinematic measures of draw-opening
  • Pediatric Caregiver Survey (10 bimanual and 10 uni-manual tasks) Functional/Environmental
  • Bruininks-Oseretsky, Jebsen-Taylor
  • Pre-test, 1 week, 1 month
  • Blind evaluation

Charles and Gordon, (2006) Dev Med Child Neurol Nov;48(11):931-6.

habit intervention practice
HABIT Intervention Practice
  • Bimanual practice= 60 hours
  • Overall intensity: 74% (44 hours)
  • Repetitive practice: 17%
  • Whole task practice: 83%

Gordon et al. Dev Med Child Neurol. (In Press)


HABIT Results

Gordon et al. Dev Med Child Neurol. (In Press)

drawer opening
Drawer Opening

Hung, Charles & Gordon (2004)

Gordon et al. Dev Med Child Neurol. (In Press)


Week Post

Month Post

both cimt and habit yield improvements in unimanual and bimanual movement
Both CIMT and HABIT yield improvements in unimanual and bimanual movement


1 week

1 week



1 month

1 month

Accelerometry (% involved hand use)

1 week


1 month

Gordon et al. Dev Med Child Neurol. (In Press)

  • Intensive bimanual training leads to improved bimanual control.
  • Question the use of constraints as “solve-all”
  • Practice is the most important ingredient.
future work
Future Work
  • Hone in on effects of age, severity, lesion location
  • Similar improvements for children with ipsilateral versus contralateral control.
  • More rigorous RCT of CIMT versus HABIT with stratified randomization
  • Dosage
  • Side effects
  • Goal attainment
  • Determine key ingredients
  • Real-world environments
Research Assistants/graduate students

Jennifer Schneider

Simone Gill, OT

Megan Dayton, OT

Geraldine Dapul, MA

Ya-Ching Hung, PT, Ed.D.

Electra Petra

Ashley Chinnan

Blind Evaluators

Mjugin Kim, PT

Pamela Cohen, MA

Electra Petra, OT

Yocheved Bensinger, PT

Peter Fisher, PT

Ivona Kedzierska, PT

Lorraine Fierro, PT

Gudrun Dierdmeyer PT

Anna-Christin Viking OT

Ellen Romein, OT

Sandeep Prabhu


Lena Krumlinde-Sundholm PhD, Karolinska Institute

Steve Wolf, Emory University

Volunteers Supported by:



Thrasher Research Foundation