A Practical Guide to Implementing

Constraint Therapy and Bimanual

Training

Sophie Lam-Damji, OT Reg. (Ont.)

Linda Fay, OT Reg. (Ont.)
Yvonne Ng, OT Reg. (Ont.)

Holland Bloorview Kids Rehabilitation Hospital

150 Kilgour Road, Toronto, ON M4G 1R8
Tel: 416-425-6220 Toll Free: 800-363-2400
Fax: 416-425-6591 Email: [email protected]
www.hollandbloorview.ca
 Table of Contents
Title
Page
About the authors, acknowledgements, disclaimer 3-5

Introduction and purpose of manual 6

What is the evidence? 7-9

How to assess a child for constraint therapy 10-11

How to implement constraint therapy and bimanual training

 Individual and group based programming 12-14
 Sample camp schedule 15-16

How to constrain the unaffected limb

 Does the type of constraint matter? 17
 Types of constraints 18-20
 How to select the appropriate constraint 21
 Case example 23
 Advantages and disadvantages of removable 24-25
and non-removable constraints

How to provide developmentally appropriate programming

 Preschool to 2 years 26
 2 years to 4 years 27
 5+ years 28

How to provide systematically and progressively graded 29-38

activities for constraint therapy
 Examples of activities and how to systematically and
progressively grade the activities

Appendix A: Excerpt from Constraint Therapy Handbook 39-41

References 42-48

© 2016 Holland Bloorview Kids Rehabilitation Hospital

Sophie Lam-Damji, Linda Fay and Yvonne Ng 2
 About the authors
Sophie Lam-Damji is a staff occupational therapist at Holland Bloorview Kids
Rehabilitation Hospital with almost 20 years of experience working with
children. She holds a Lecturer Status Appointment at the University of
Toronto and completed her Masters with the University of Manitoba. She is a
casual employee in the Bloorview Research Institute and has collaborated on
research projects evaluating the effectiveness of constraint therapy using
fMRI and MEG imaging. Having a strong interest in the treatment of children
with hemiplegic cerebral palsy she initially developed practice guidelines for
constraint therapy in the Child Development Program and co-developed the
constraint and bimanual therapy summer camp. She has presented on
constraint therapy at provincial and national conferences. She can be
reached at [email protected]

Linda Fay is a staff occupational therapist at Holland Bloorview Kids

Rehabilitation Hospital with over 20 years of clinical experience working with
children. She holds a Lecturer Status Appointment at the University of
Toronto and completed her Masters with the University of Manitoba. She is a
casual employee in the Bloorview Research Institute and has collaborated on
research projects evaluating the effectiveness of constraint therapy using
fMRI and MEG imaging. She also co-developed the constraint and bimanual
therapy summer camp, and has presented on constraint therapy at
provincial and national conferences.

Yvonne Ng is a staff occupational therapist at Holland Bloorview Kids

Rehabilitation Hospital and holds a Lecturer Status Appointment at the
University of Toronto. She is presently pursuing her Masters with the
University of Manitoba. She has an interest in the treatment of children with
cerebral palsy, provides constraint therapy in clinical practice, and
co-developed the constraint therapy and bimanual training summer camp.

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 Acknowledgements
We gratefully thank Dr. Darcy Fehlings for her mentorship, time and support
in the development of this manual.

Thank you to the Centres for Leadership at Holland Bloorview in providing

funding and support for clinician time in the writing of this manual.

Thank you to the clinicians in the community who generously gave their time
to provide us with input in the final stages of this manual.

Thank you to Linda D’Arpino, student OT for helping to format this manual.

Disclaimer
This manual contains recommendations based on recent evidence and the
authors’ clinical experience with constraint and bimanual therapy for children
with hemiplegic cerebral palsy.

This manual was developed for healthcare providers to use as a guide to

provide practical suggestions to implement constraint and bimanual therapy
and does not constitute professional clinical advice. Healthcare providers
are required to exercise their own clinical judgment in using the manual and
application of any information contained in this manual should be based on
individual/client/patient needs, the relevant circumstances, and local
context. Neither Holland Bloorview nor any of the authors and/or
contributors of the manual are providing treatment services through the
information contained in this manual. Moreover while every effort has been
made to ensure the accuracy of the content of the Manual at the time of
publication, neither Holland Bloorview, nor any of its agents, appointees,
directors, officers, employees, contractors, members, volunteers or related
parties: (i) give any guarantee to the completeness or accuracy of the
information contained herein; and (ii) TO THE EXTENT PERMITTED BY
APPLICABLE LAW, ACCEPT ANY LIABILITY OR RESPONSIBILITY FOR THE USE

© 2016 Holland Bloorview Kids Rehabilitation Hospital

Sophie Lam-Damji, Linda Fay and Yvonne Ng 4
 OR MISUSE OF THE MANUAL BY ANY INDIVIDUAL OR ENTITY, INCLUDING
FOR ANY LOSS, DAMAGE, OR INJURY (INCLUDING DEATH) ARISING FROM
OR IN CONNECTION WITH THE USE OF THE MANUAL IN WHOLE OR IN
PART.

Publication date: November 8, 2016

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Sophie Lam-Damji, Linda Fay and Yvonne Ng 5
 Introduction

Children with hemiplegic cerebral palsy (HCP) have trouble using their
affected arm and hand on one side of their body. Evidence from randomized
controlled trials, clinical controlled trials, and systematic reviews has shown
constraint therapy improves hand and arm movement in children with HCP.
1,5,6,8
The development of constraint therapy as an emerging best practice at
Holland Bloorview started in 2005 when constraint therapy was initially
offered on an individual client basis. Subsequently in 2008, Holland
Bloorview developed the summer constraint and bimanual therapy camp.

Though constraint therapy has high levels of evidence to support its

effectiveness we have noticed a challenge in accessing this treatment
throughout Ontario. We receive numerous questions from children
treatment centres and community therapists on how to implement constraint
therapy in their setting. Examples of questions include; how can we provide
intensive constraint therapy? what types of constraint should we use? and
can we make constraint therapy enjoyable? To address this gap we created
this manual for occupational therapists that provides a “how to” approach for
implementing constraint therapy.

Purpose of the manual

The purpose of this manual is to provide occupational therapists with

practical suggestions on how to implement evidence-based modified
constraint induced movement therapy (mCIMT) and bimanual training (BIM)
into clinical practice for children with hemiplegic cerebral palsy. The manual
illustrates Holland Bloorview’s current practices on mCIMT and BIM.
Although mCIMT has been used with children with acquired brain injury
(ABI) and adults with stroke this manual focuses on children with hemiplegic
cerebral palsy.

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 What is the evidence?
What is constraint therapy?

Children with hemiplegic cerebral palsy (HCP) often have weakness, poor
selective motor control, and sensory impairments affecting one side of their
body.1,2 They learn early it is more efficient and effective to use their
unaffected limb often disregarding or ignoring their affected limb in daily
activities; a phenomenon described by DeLuca as developmental disregard.3
Children with HCP often will have challenges with activities such as self-care,
productivity, and leisure. The goal of occupational therapy is to promote
improved independence in self-care, productivity, and leisure activities while
integrating the affected hand in day-to-day bimanual activities to achieve
increased functional independence, increased participation, and increased
quality of life.4

Many different interventions are used for children with HCP. In the past 10
years, evidence for modified constraint induced movement therapy (mCIMT)
has increased exponentially, and has been shown to be an effective
treatment for children with HCP.5 A Cochrane review found positive results
from mCIMT, and a systematic review found mCIMT improved the frequency
of use of the affected limb.6,7 Several RCTs found mCIMT improved
participants’ use of the affected limb in bimanual activities, increased the
amount of use of the affected limb, and improved quality of use of the
affected limb for functional activities.8-11 Furthermore, a case study found
clinical improvement, and cortical reorganization following three weeks of
constraint therapy.12

An expert consensus13 described mCIMT as an intensive intervention with

the following features:

1. Constraint of the unaffected upper limb (regardless of the type of

constraint being used) and,
2. Intensive structured training (regardless of type of training being
used)

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 Research findings on mCIMT

There is no definitive guideline for the optimal amount of hours for constraint
therapy (i.e. dosing); however, most studies adopt a total dose of 60 hours
or more.8,9,14,37 The dosing, the type of constraint, where the training takes
place, the format of the training, and the frequency at which mCIMT is
repeated are all important components that need to be considered.13,14

Important components of mCIMT

 The dosing
 The Type of constraint
 Where the training takes place (i.e. clinic, rehab facility, home)
 The format of the training (i.e. individual vs. group )
 The Frequency at which mCIMT is repeated

More recently, bimanual training (BIM) has been paired with mCIMT. BIM
has also been established as an effective treatment for children with HCP.5
BIM addresses the limitations of mCIMT, which is primarily a unilateral
treatment, by maintaining the same intensity and the same structured
practice associated with mCIMT.15 A study found BIM to improve both the
quality and quantity of movement of the affected limb in bimanual upper
extremity use.16

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 A study comparing mCIMT and BIM with the same intensities found both
mCIMT and BIM demonstrated similar improvements in hand function.14 A
systematic review and other studies comparing mCIMT and BIM found
significant improvements in both types of intervention for improving
impaired arm function and overall functional performance.17,18,19 In addition,
the mCIMT group made significant improvements in unimanual performance,
while the BIM group made significant improvements in bimanual
performance.17,18,19 This suggests mCIMT should be paired with BIM to
achieve optimal results for children with HCP who present with difficulties in
both unimanual and bimanual hand functions.19,20 A study combining mCIMT
and BIM demonstrated more frequent and more effective use of the affected
limb, and better performance in self-care and leisure tasks. 21

In addition to motor impairments children with HCP often face sensory

deficits affecting motor function and motor control.22 Presently, there is
insufficient literature to guide clinicians on the management of sensory
deficits in children with HCP. Future research on the treatment of sensory
deficits could explore the benefits for children with HCP.

Who would benefit from constraint therapy?

There is very little guidance from the literature on who would most benefit
from constraint therapy.13 We do know mCIMT is a treatment for children
with one sided weakness, and all various forms of mCIMT result in positive
changes.

In our clinical experience mCIMT has been an effective treatment for those
children who have developmental disregard, and who have impaired
strength, impaired sensation, and impaired motor control.

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 How to assess a child for constraint
therapy?
Assessment

Prior to assessment, the Manual Ability Classification System (MACS)23

is used to describe how a child uses their hands to handle objects in daily
activities. The MACS helps to classify a child’s usual upper limb function.

At Holland Bloorview, children are assessed prior to starting mCIMT, one

week after the completion of mCIMT, and six months after the start of
mCIMT. These assessments provide information on the effectiveness of
mCIMT.

While there are many assessments one can use, the following is a list of
assessments used by the OTs in the Child Development Program at Holland
Bloorview. These assessments were chosen based on the evidence to date
and using the World Health Organization’s International Classification of
Functioning, Disability and Health framework.24

We recognize this is a lengthy list of assessments, and for some OTs

completing every assessment is not feasible for many reasons (i.e. time
constraints, lack of resources, etc.). Given the literature and our clinical
experience, assessment should minimally include a measure of:

 Unilateral function
 Bimanual function
 Participation

Unimanual function

The Quality of Upper Extremity Skills Test (QUEST)25 is utilized as a

measure of upper extremity function to evaluate a child’s quality of
movement in four domains: dissociated movements, grasp, weight bearing,

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 and protective extension. Scoring only the affected limb is recommended to
better evaluate changes in the affected limb.26

Grip strength is recorded using a sphygmomanometer. Efficiency is

assessed using the Jebsen-Taylor Hand Function Test (JTHFT)27 which
provides a timed evaluation of hand function using simulated activities of
daily living.

Sensory function is assessed using the Semmes Weinstein monofilaments

to measure tactile registration by producing standardized tactile stimuli of
increasing intensity. Stereognosis is tested through tactile identification of
familiar objects. Proprioception is evaluated by accurately identifying wrist
and digit joint position. A proprioception testing protocol comprising a static
and a dynamic component with and without vision to assess joint-position
sense recovery has been utilized as part of research protocols at Holland
Bloorview.28

Bimanual function

The Assisting Hand Assessment (AHA)29 measures how effectively the

affected limb is used in bimanual performance.

Participation

The Children’s Hand-use Experience Questionnaire (CHEQ)30 is a web-

based questionnaire used with children ages 6 to 18 years to assess the
experiences in using the affected hand to perform tasks. For younger
children ages 2 to 8 years, the Acquire c Therapy Motor Activity Log
(Acquire C Mal)31 can be used to examine how often and how well the
affected limb is used for functional activities. The Canadian Occupational
Performance Measure (COPM)32 is used to identify client and family goals
for occupational performance. Goal Attainment Scaling (GAS)33 is an
alternative option to measure participation.

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 How to implement constraint therapy?
Individual mCIMT

In individual mCIMT, a client is seen initially by an OT to assess if s/he is a

candidate for constraint therapy. If the decision is made to proceed, the OT
together with the parent and the child establish goals and decides on a type
of constraint.

Constraint Schedule/Dosing: The child participates in a 12-week block of

occupational therapy at a frequency of once per week with each session
being one hour. If the client utilizes a removable intermittent constraint s/he
wears the constraint for a total of two to four hours per day over six weeks.
If the client uses a non-removable constraint, s/he wears the constraint for
three weeks. See types of constraints under “how to constrain the
unaffected upper limb” on page 17.

Staffing: The OT develops a mCIMT program that offers intensive repetitive

practice with progressive and systematically graded activities. This program
can be carried out by an occupational therapy assistant (OTA) under the
supervision of the OT.

Activities: The mCIMT program provides intensive, repetitive, systematic,

and progressive practice of motor and sensory skills, while including a
strength, and speed component (see section on how to provide
systematically and progressively graded activities for constraint therapy on
page 29). The mCIMT program is followed by intensive bimanual training,
which includes integration of learned unilateral skills into bilateral activity
practice. The OT actively monitors the program and modifies the program as
needed.

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 Group based mCIMT and BIM

At the time of print there were no studies comparing the efficacy of

individual mCIMT to group based mCIMT, however, group based mCIMT has
several advantages (see table below).35 At Holland Bloorview, the mCIMT
and BIM camp is offered annually for two weeks in the summer. A 1:2 ratio
of staff to children is used as this is ideal to maximize the advantages of a
group based mCIMT and BIM approach while maintaining close monitoring
and attention to providing intense, repetitive and progressive practice.36

Advantages of group based mCIMT and BIM

 Simulating a more natural collaborative environment similar to

schools
 Peers providing each other with support and motivation34,35
 A group can be more cost effective to implement

Constraint Schedule/Dosing: One week prior to the start of camp the

participants wear a non-removable cast. This cast is bi-valved on the first
day of camp and made into a removable constraint. Participants attend the
camp daily for four hours per day. During the first week of camp the
participants wear the constraint for three hours and for the second week of
camp they wear the constraint for up to 1.5 hours during the day.

Staffing: Staffing includes OTs, OTAs, volunteers, social workers, music

therapists, magicians and aquatic lifeguards. Social workers provide client
and parent support, and disability awareness intervention. Using a multi
professional approach provides enriching activities that are fun and
enjoyable while participating in mCIMT.

Activities: Camp activities are developed using the model of motor learning
and motor control and are embedded within an activity-based framework
during the camp. The activities are progressively and systematically graded
to ensure success but are also challenging enough for the child to practice
motor movements. A home program is provided for additional practice. See
figure 1 (page 15) and figure 2 (page 16) for the typical camp schedule.

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 Duration of wearing
Week of camp Objective
constraint

Goal: 3 hours wear

Development of
Week One time unilateral skills

Integrating learned
Goal: 1 to 1.5 hours
Week Two unilateral skills into
wear time
bimanual activities

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 Legend:
Figure 1. Typical camp schedule week 1

U=unilateral activities, clients use

only the affected limb during
activity

B=bilateral activities, clients

integrate learned unilateral skills
into bimanual practice

Circuits=timed fine motor

stations for practice of specific
selective motor control and speed

Sensory= sensory activities for

practice of stereognosis, spatial
awareness, two point
discrimination

ADL =practice of identified goals,

which are primarily bimanual

Interactive Computer Play=

activities using iPads, and virtual
reality system to practice
unilateral skills

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 Legend: Figure 2. Typical camp schedule week 2
U=unilateral activities,
clients use only the affected
limb during activity

B=bilateral activities, clients

integrate learned unilateral
skills into bimanual practice

Circuits=timed fine motor

stations for practice of
specific selective motor
control and speed

Sensory= sensory activities

for practice of stereognosis,
spatial awareness, two point
discrimination

ADL =practice of identified

goals, which are primarily
bimanual

Interactive Computer
Play= activities using iPads,
and virtual reality system to
practice unilateral skills

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 How to constrain the unaffected limb
Does the type of constraint matter?

At the time of print, there were no studies directly comparing types of

constraint with similar amounts of practice.13 All studies using various
constraints demonstrate improvements. When choosing a constraint factors
therapists should consider the following: safety, comfort, climate, fabrics and
hygiene (see figure 3 below).13 Additionally, our clinical experience suggests
the type of constraint selected should also depend on child characteristics,
upper extremity motor function, and the goal(s) of constraint therapy.

Figure 3. Factors to consider when choosing a constraint.

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 Types of constraints

Review of the literature suggests there are many different types of

constraints being used, and they can best be categorized as either
removable or non-removable.13,38 Removable constraints are predominantly
utilized for short periods of practice during the day, while non-removable
constraints are worn at all times for a defined period of time.

Examples of removable constraints include volar thermoplastic splints

inhibiting use of fingers and thumb, gloves with a thermoplastic insert, long
mitts, or bivalved casts (see figure 4 on page 19 and 20). An example of a
non-removable constraint is a water resistant lightweight fiberglass below
elbow cast that encloses the fingers and thumb in a neutral position and is
worn for a defined amount of time (see figure 5 on page 20).

How to constrain the unaffected upper extremity

We recommend the following for both removable and non-removable

constraints:

 Position the wrist in slight extension (i.e. 10 degrees to minimize

migration of the constraint distally)
 Enclose the fingers with metacarpal phalangeal and proximal
phalangeal joints in slight flexion, and distal phalangeal joints in
neutral
 Position the thumb in neutral alignment with forearm with open web
space
 Extends the constraint approximately ½” to 1” distal to the fingertips
to prevent the child from using the fingers for grasping.

There are many creative ways to constrain the unaffected hand. For
example, enclosing the elbow may be suitable for a child or youth who is
working on both reach and grasp. In this example the constraint extends
above the elbow and positions the elbow in 90 degrees of elbow flexion and
encloses the wrist, fingers, and thumb to prevent the child from using elbow
extension to reach and grasp with the unaffected extremity. In another
example, for a child or youth who has very little to no distal motor control

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 (i.e. hand movement) and whose goal is to improve proximal control at the
shoulder and/or elbow a constraint may consist of an elbow extension gaitor
and a “wrap” to adduct the shoulder and prevent the child from using the
shoulder on the stronger side.

Figure 4. Examples of removable constraints

Bivalved cast Mitt with thermoplastic insert

Applying a sock over a splint

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 Elbow extension gaitor and “wrap” to work on proximal control

Figure 5. Example of a non-removable constraint

Fiberglass light weight cast

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 How to select the appropriate constraint?

When choosing a constraint it is important to consider child characteristics,

the child’s occupation and the child’s environment(s) as this will help to
maximize effectiveness of mCIMT, ensure client safety, and achievement of
goals.

Factors to consider Some questions to ask

1. How old is the child?

Child factors
 Is s/he preschool aged? School aged? A
teenager?
2. Is the child usually compliant with therapy?
 What is the client’s frustration for
challenging activities?
3. Does the child frustrate easily or accept new
routines easily?
4. How will you grade activities to provide “a just
right challenge” to minimize frustration?

1. What is the child’s balance and mobility?

Physical factors 2. Is the child tripping and/or falling and/or at risk
for falling and/or tripping?
3. What is the child’s gross motor function?
 Is the child developing gross motor skills
such as crawling, walking, pulling to stand,
other?
4. Will constraint therapy impact on developing
gross motor abilities?
5. Does the child have asymmetrical upper
extremity use?
 What is the child’s unilateral arm/hand
function?
 Does the child only have proximal motor
control? Distal motor control? Or both?
6. Does the child disregard the affected arm/hand?

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 Factors to consider Some questions to ask

1. What is the child using his/her affected arm and

Child’s occupational factors hand for during the day at home, school,
preschool, and/or in the community?
2. What activities is the child presently doing in
his/her environments, need to do and/or want to
do?
3. Will constraint therapy affect independence in
daily activities and if so, how will you support
with these activities while s/he is participating in
constraint therapy?

1. Where does the child spend most of his/her day?

Child’s environmental factors 2. Who looks after the child during the day?
3. Can you teach the parent/guardian/caregiver,
teacher, assistant, daycare worker to implement
the constraint programming?

In our experience the effectiveness of mCIMT depends on:

 Family/caregiver/client commitment to the program

 Realistic achievable goals
 The acceptance of wearing the constraint
 Working with an occupational therapist for programming

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 Case example: Sam

Sam is a 4 year old boy with right hemiplegic cerebral palsy referred for constraint therapy.
He is functioning at MACS level I. Sam just started school and is independent with toileting,
dressing, and feeding. He is starting to help with bathing. He ambulates independently but
reportedly falls when running. He is having difficulty holding objects with his right hand,
and frequently does not always remember to use his right hand when needed. Having read
about constraint therapy his parents are very keen to see if this will work for Sam. On
assessment, you find he has a strong preference for using his left unaffected arm/hand, and
he requires reminders and encouragement to integrate his right hand into activities. When
asked to use his right hand he is easily frustrated. He presents with a weak ability to grasp
objects using a gross grasp, and is inconsistently able to release objects. He has difficulty
identifying objects placed in his hand when his eyes are occluded. You also notice Sam does
not tolerate gentle constraint during the assessment visit. Parents’ goals include improving
Sam’s hand strength, incorporating his right hand into daily activities, and improving his
grasp and release.

How to treat Sam using constraint therapy:

Type of constraint: Given Sam’s poor tolerance for gentle constraint and
challenging activities, a removable constraint for intermittent practice was
suggested to the parents. The removable constraint will also permit Sam to
use his stronger arm to protect himself in the event he accidentally trips or
falls. The removable constraint will enable Sam to preserve his independence
in his routine activities (i.e. toileting, bathing, mealtimes), which may help to
minimize frustration. As well, using a removable constraint will not interfere
with school activities such as printing.

Constraint schedule/dosing: You recommend using the removable constraint

for a total of two to four hours during the day for six weeks. You inquire if the
teacher at school could implement the removable constraint during times when
Sam is seated and doing fine motor activities. You also inquire if the parents
are able to commit to carrying out the constraint therapy program daily at
home. You provide the parents with a home program for implementing mCIMT
at home outside of therapy sessions. You also recommend Sam receive weekly
OT with the OTA. You develop a mCIMT program that is intensive, repetitive,

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 and offers developmentally appropriate and progressively graded activities.
Following the six week of mCIMT you provide BIM.

Advantages and disadvantages of removable and non-removable

constraints

Removable constraints

Advantages.
 A removable constraint enables practice for short periods of time
 Minimizes frustration for children who have a low tolerance for
challenging activities and/or for children with poor distal motor control
 Maintenance of independence in daily activities (i.e. mealtime and
toileting) by allowing use of the unaffected hand to complete daily
activities
 Minimizes risk of falls for clients with poor ambulation; the use of a
removable constraint during periods of seated fine motor work at a
table will greatly minimize risks of falls

Disadvantages.

× For some children using a removable constraint may make it more

challenging for the parent/ caregiver to reapply the constraint if the
child knows the constraint is removable
 If this is the case, the child may not receive the optimal amount
of dosing

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 Non-removable constraints

Advantages.

 May help to ensure dosing and compliance for some children

 For some children, the use of a non-removable constraint may
be frustrating initially, however, most children quickly accept the
constraint recognizing the constraint is not removable

Disadvantages.

× May lead to significant frustration resulting in non-compliance

especially if the child has very poor distal motor control
× May lead to a loss of independence and safety risks depending on the
child’s motoric abilities in the affected limb (i.e. limited protective
extension during a fall)
× Need to diligently check child’s skin condition and circulation daily
when using a non-removable constraint
× Increase likelihood this type of constraint can get wet and dirty which
may increase the risk of skin irritation; can use a waterproof material
to minimize this

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 How to provide developmentally
appropriate programming

Preschool ages up to 2 years:

Implementation of constraint therapy for the young child

 Use of removable constraint while seated

 Play based, individualized programming
 Consider safety as young children are developing gross motor skills
and may be at risk of falling and/or tripping
 Be creative

A removable, intermittent constraint may be considered most appropriate for

children under 2 years of age due to the necessity of using the unaffected
upper limb in the development of gross motor skills (i.e. weight bearing
during crawling, pulling to stand) as well as the early development of
bilateral integration skills. Given the above factors, a removable intermittent
constraint may be most appropriate for this very young age group.

The OT may need to be creative on how to best restrain the unaffected limb.
Creative examples of constraints include use of a long glove/mitt with a
thermoplastic insert to prevent grasp or pinning of the unaffected limb within
the sleeve. Young children are often developing their gross motor skills thus
for safety, it is recommended that the child be seated when using the
constraint. In our clinical experience, constraint therapy for the young child
can be carried out for example in his/her high chair. The duration and
frequency of constraint therapy is more customized to suit the young child’s
developing attention and interests but incorporates the core components
(see page 29) and is delivered in a play-based format. Programming
potentially could be integrated into the preschool or daycare environment
under the direction of the child’s therapist.

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 Preschool ages 2-4 years

Implementation of constraint therapy for the preschool aged child

 Use of removable constraint, possible consideration for a non-

removable constraint
 Play based, individualized programming
 Consider safety as gross motor skills may still be developing
 Be creative

As children approach preschool age some may be able to participate in a

structured group based program, however individualized programming
continues to be most often utilized due to developing attention, motivation,
and the child’s ability to participate independent of caregivers. The duration
and frequency of constraint therapy is more customized to suit the young
child’s developing gross and fine motor skills, attention, and interests. A
removable constraint may be most appropriate for this age group given the
above factors. Although the constraint therapy is customized, it should still
include the core components (see page 29) and delivered in a play-based
format. Integrating programming into the child’s preschool environment
would help to increase the dosing of mCIMT.

While a removable constraint may be the most appropriate for this age
group, a non-removable constraint may be an option for those children
whose parents are having difficulty reapplying a removable constraint. For
these children a non-removable constraint will provide optimal dosing.
Given this age group is primarily assisted with their daily activities there will
be less concern about loss of independence. Consideration for a removable
constraint is indicated in a child with balance and mobility issues due to
safety and/or the child’s inability to tolerate a non-removable constraint.

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 School aged 5+ years

Implementation of constraint therapy for the school aged child 5+

years

 Consider a group format for constraint therapy

 Encourage the child to help decide on the type of constraint, and to help
develop goals
 Consider the impact of the constraint on the child’s:
o Independence in daily activities
o Participation at school
o Social acceptance

Children and youth in this age group will be able to participate in a group
format. A group provides the added benefits of socialization, peer support,
and modeling of similar peers. These children can often follow a more
formalized program incorporating all the core components (see page 29).

Children of this age can help to make decisions towards which type of
constraint to use (i.e. removable or non-removable). Children and youth in
this age group are much more able to participate in goal setting as well as
develop a plan, and strategies to achieve their goals. For this age group,
consider the impact of the constraint on independence (such as toileting,
bathing, personal hygiene, eating), school, and possibly social acceptance.
A removable constraint may help to meet all of these needs. For example,
using a removable constraint outside of school hours (i.e. during a March
break, winter holiday, and summer) will not interfere with school
productivity such as printing, will help to maintain independence in personal
care, and address issues of social acceptance.

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 How to provide systematically and
progressively graded activities for
constraint therapy
Some common goals of constraint therapy include:
 Improve strength in the affected limb
 Improve selective motor control specifically for elbow extension,
forearm supination, wrist and finger extension, and thumb out of palm
movements
 Improve sensory awareness of the affected limb
 Improve spontaneous use of the affected limb
 Improve coordination for bimanual activities

Constraint therapy involves the following core components:

 Intensity
 Repetition
 Grading
 Shaping

Grading has been described as “task demands that are progressed with
specific rules on how the affected hand is used during an activity for success
while avoiding use of compensatory strategies”, and shaping as “practice of a
targeted movement within context of completing a task”.9 The shaping
process can be assisted through modelling the desired movement, providing
hand over hand facilitation, and fading the assistance as desired results are
achieved.38

The following are examples of activities commonly used at Holland Bloorview

during both individual and group constraint therapy and bimanual training. A
practice log (see Appendix A on page 39) may be used to track progression
of grading during therapy.

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 Activity: Painting

Objective: Reaching

Child paints on a mural mounted on a wall.

Grade down

 Child is allowed to sit to reduce postural demands

 Child moves closer to the mural
 Therapist provides active assisted facilitation to maximize elbow
extension
 Therapist implements use of adjuncts (i.e. splints)
 Mural is positioned on horizontal surface (i.e. on a table or on the
floor and incline is gradually increased)
 Therapist decreases grasp demands (i.e. vary drawing tool diameters,
secure drawing tool for child with velcro wrap, use of sponges, finger
paints)

Grade up

 Child stands for the activity

 Child stands further away from the activity
 Mural is positioned on an inclined vertical surface (i.e. on the wall)
 Therapist places drawing tools or mural at distance and height to
promote maximum elbow extension during reach
 Child is encouraged to cross midline using the affected limb to fill in
the mural, and/or when grasping colouring tools
 Increase the height of mural, length of time for the activity and size of
area to be filled in on mural
 Child is asked to use a variety of drawing tools that challenge grasp
 Therapist encourages frequent gripping and release of drawing tools to
switch colours for repeated repetitions of elbow flexion and extension

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 Activity: Pin the tail on the donkey

Objective: Sensory reach, proprioception

Child stands comfortably in front of “pin the tail on donkey” game mounted
on wall and the target is pointed out to the child. Child is blind folded, and
takes turns with a partner to accurately target tail placement.

Grade down

 Therapist provides kinesthetic feedback of location of target through

passive assist followed by asking the child to mimic the movement
 Therapist provides auditory clues/feedback to assist with targeting (i.e.
“getting warmer”, ring bell/rattle as getting closer to target)
 Child wears weighted cuff or sound bracelet in order to increase
feedback of where arm is in space
 Target size is increased
 Therapist decreases grasp demands (i.e. vary shape/thickness of tail,
secure tail for child in hand with velcro wrap)
 Child is allowed increased response time

Grade up

 Target location is varied during the game (i.e. encourage crossing

midline, approaching end range)
 Target size is decreased
 Response time is decreased and/or child is challenged to target within
allocated time
 Child is asked to grasp different tails of varying properties to challenge
grasp

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 Activity: Interactive computer play

Objective: Proprioception

Child plays Kinect or Wii games to encourage use of the affected arm for
targeting. Rehabilitation based virtual reality are available, allowing
therapists to customize parameters to grade the activity. Examples used
include SeeMe and Jintronix.
http://www.virtual-reality-rehabilitation.com/products/seeme/what-is-seeme
http://www.jintronix.com/

Grade down

 Therapist provides active assisted reaching to facilitate targeting

 Therapist applies adjuncts to facilitate targeting (i.e. elbow extension
immobilizers)
 Therapist chooses an easier game (i.e. with an increased response
time, less targets, larger targets, less busy background, not needing to
cross midline, limit active range of movement)
 Therapist allows the child to use both hands to target (i.e. baseball,
golf, and hockey stick)

Grade up

 Therapists chooses progressively more difficult games (i.e. with a

decrease response time, timed component, more targets, smaller
targets, busier backgrounds, crossing midline, targeting using a larger
range of movement and/or more ranges of movements)
 Child only uses the affected hand for playing
 Child plays with a partner

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 Activity: Card game

Objective: Forearm supination

Child sits and plays a card game involving turning cards.

Grade down

 Therapist provides support and stability in upper body/ arm and/or

allows child to stabilize his/her forearm on the tabletop to isolate
forearm supination
 Therapist provides active assisted facilitation for supination to turn
cards over
 Therapist uses adjuncts (i.e. supination strap)
 Child uses larger size playing cards, thicker and stiffer playing cards
 Timed component is removed

Grade up

 Child uses a regular deck of cards to turn cards over

 Child independently isolates forearm supination
 Timed component is added
 Child plays a game with a partner i.e. “war”

Activity: Bubbles

Objective: Wrist extension

Child sits comfortably in a chair and supports his/her affected arm on a

table. The therapist holds a bubble wand with a bubble above the child’s
wrist. The child is asked to extend his wrist to pop the bubble while keeping
his/her forearm on the table.

Grade down:

 Therapist stabilizes the child’s forearm on the table to help isolate

wrist extension

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  Therapist uses adjuncts
 Therapist provides active assisted facilitation for wrist extension to pop
the bubbles
 Therapist holds the bubble wand closer to the child’s hand to decrease
the wrist range of movement needed to pop the bubble
 Child is asked to pop the bubble with a closed hand (i.e. no finger
extension)
 Therapist uses a bubble wand that produces a bigger bubble
Remove timed component

Grade up:

 Therapist holds the bubble wand further from the child’s hand to
facilitate a greater excursion through active range of wrist extension
 Therapist uses a bubble wand that produces smaller bubbles
 Child is asked to pop as many bubbles as s/he can in a specified
amount of time
 Child is asked to place wrist over the edge of table and to lift his/her
wrist from flexion to neutral to above neutral to pop the bubble
 Child is asked to pop the bubbles with more finger extension, (i.e.
wrist and finger extension together)
 Child is asked to hold wrist and finger extension following popping the
bubbles for a specified amount of time
 Add a timed component

Activity: Squeezing sponges

Objective: Sustained grip

Child stands at a table and uses his/her affected hand to squeeze sponges
filled with water into a container/ bucket. The amount of water squeezed
out in a specified amount of time can be measured.

Grade down

 Child is allowed to stabilize wrist on the edge of the container/ bucket

to support wrist for gripping/ squeezing

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  Therapist positions wrist in neutral to slight extension to provide active
assisted facilitation for a power grasp
 Child starts initially with forearm in pronation
 Child uses non cellulose sponges that are easier to squeeze
 Therapist places sponge in child’s hand
 Use of adjuncts (i.e. elbow extension splint/gaitor to decrease flexor
pattern)
 Remove time component

Grade up

 Therapist assists the child to squeeze sponges with forearm in neutral

rather than in pronation
 Child uses cellulose sponges and smaller sponges
 The amount of sponges to squeeze is increased
 A time component is put in place (i.e. how much can you squeeze in 1
minute)

Activity: Building a tower with blocks

Objective: Grasp and release

Child sits to build a tower.

Grade down

 Child stands to build a tower for gravity assisted placement of blocks

 Therapist provides an adjunct (i.e. wrist splint)
 Therapist allows the child to stabilize his/her wrist on tabletop or an
external surface to work on isolated release
 Child is asked to pick up and release blocks into a container if unable
to stack
 Child uses larger blocks, magnetic blocks, or velcro blocks to help
stack a tower
 Remove timed component

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 Grade up

 Child sits to work on grasp and release against gravity to stack a tower
 Release is voluntary and above surface with no external stabilization
 Child uses smaller blocks.
 A timed component is put in place

Activity: Curtained box game

Objective: Sensory grasp: Stereognosis

Child sits and his/her vision is occluded (i.e. can use a blindfold, ask to close
his/her eyes, or use a curtained box). Therapist presents a number of
common items and asks the child to name the items through touch.

Grade down

 Therapist places the object in the child’s hand to facilitate grasp

 Therapist moves the object within the child’s hand if the child is unable
to grasp
 Therapist limits the number of objects presented
 Therapist provides a visual aid for reference (i.e. picture of the same
set of objects to be identified)
 Therapist gives descriptors of the objects to cue the child
 Therapist provides objects with very different characteristics (i.e. size,
shape, texture)
 Remove timed component

Grade up

 Child reaches behind the curtain and grasps the objects on his/her own
 Child moves the object within his/her own hand
 No visual aid for reference is provided
 Therapist increases the number of objects presented
 Therapist provides objects with very subtle differences
 Therapist places the objects within a medium (i.e. place the objects in
a bin of sand, uncooked beans)
 A timed component is put in place

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 Activity: Tongs pick-up game

Objective: Pinch

Child sits and uses tongs to pick up small objects to fill a container.

Grade down
 Child stands for this activity to use gravity to assist motor movements
 Therapist provides adjuncts (i.e. thumb splint)
 The objects and the container are positioned closer to the child to
decrease the number of required motor movements (i.e. straightening
elbow and pinch)
 The therapist holds the object for the child and positions the object
strategically/optimally for pinch rather than ask the child to pick up
from the tabletop
 Child picks up objects using his/her affected hand
 Therapist chooses objects that are easier to feel and thus pick up (i.e.
larger in size, firm vs. soft, rough vs. smooth, shape)
 The therapist chooses a container with a larger opening
 If using tongs, therapist gives larger tongs to enable child to use a less
refined grasp
 Timed component is removed
 Repetitions are decreased

Grade up
 Therapist positions objects and container at a further distance to
combine number of motor movements (i.e. elbow extension to reach
and pinch)
 The size of the container opening is smaller
 Therapist chooses objects that are more challenging to pick up (i.e.
smaller objects, less firm, smooth vs rough, irregularly defined shapes
defined objects)
 Child uses smaller tongs to work on a more refined grasp and pinch
pattern
 A timed component is incorporated
 Therapist increases required repetitions to incorporate endurance

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 Activity: Pickup coins game

Objective: In-hand manipulation

Child sits and picks up coins to put into a piggybank

Grade down

 Child stands to do this activity using gravity to assist with motor

movements
 Provide adjuncts as needed (i.e. thumb splint)
 Objects and piggybank are positioned closer to the child to decrease
the need to work on combined motor movements (i.e. reach and hand
skills)
 The size of the objects and slit of the piggybank can be made larger
 Child practices finger to palm translation initially (i.e. picks up coin
using a pincer grasp and moves the coin into his/her palm using
thumb and fingers)
 Timed component is removed
 Repetitions are decreased

Grade up

 Objects and piggybank are positioned further away from child to

increase the need to use more combined motor movements (i.e. reach
and hand skills)
 Child uses smaller coins and the slit of the piggybank is smaller
 Child picks up a number of coins, translates into the palm and then to
fingertips to release into piggybank
 Therapist incorporates other in-hand manipulation skills with
stabilization (i.e. child practices translation with stabilization i.e. while
holding the first coin, pick up another coin; translation and rotation).
 Timed component is used
 Increase repetitions

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 Appendix A
Excerpt from Constraint Therapy Hand Book

© 2016 Holland Bloorview Kids Rehabilitation Hospital

Sophie Lam-Damji, Linda Fay and Yvonne Ng 39
© 2016 Holland Bloorview Kids Rehabilitation Hospital
Sophie Lam-Damji, Linda Fay and Yvonne Ng 40
© 2016 Holland Bloorview Kids Rehabilitation Hospital
Sophie Lam-Damji, Linda Fay and Yvonne Ng 41
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© 2016 Holland Bloorview Kids Rehabilitation Hospital

Sophie Lam-Damji, Linda Fay and Yvonne Ng 48