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Unimanual versus bimanual therapy in children with unilateral cerebral palsy: Same, same, but different.

This article is a summary of a research paper prepared by A/Prof Brian Hoare and Dr Sue Greaves. As this is a summary of the full article, we have not included references throughout and instead listed the references at the end.  You can read the full paper here.

There is high-level evidence supporting constraint-induced movement therapy (CIMT) and bimanual therapy for children with hemiplegic cerebral palsy (CP). In this article, we discuss the concept of functional hand use and explain the differences between CIMT and bimanual therapy and how they can work together. 

Functional hand use

The pioneering work by Lena Krumlinde-Sundholm in the development of the Assisting Hand Assessment (AHA) [1] has significantly influenced our understanding of bimanual performance, hand role differentiation and functional hand use in children with hemiplegic CP. The concept of functional hand use recognises that all humans have a dominant hand and a non-dominant hand or hand role differentiation [2]. This is critical information to help guide our understanding of the focus of therapy for children with hemiplegia. 

To help this make sense, take a moment to think about which hand you brush your teeth with. Now think about brushing your teeth with your other hand. Would it feel unnatural or even impossible? The hand you use to brush your teeth is your dominant hand. Brushing your teeth with your non-dominant hand is awkward and unnatural. It is not “functional”. So why is it that children with hemiplegic CP are often prompted to do things that are unnatural, or perform one-handed tasks with their more affected limb? Using this approach, it is unlikely you will see any carryover into a child’s usual daily routines when you are not there. If you need to prompt, touch or tap a child’s arm for them to use it, it’s more than likely that the task may be one-handed (so they will use their dominant hand) or they don’t understand how to use the hand for this task. The aim of therapy for children with hemiplegia to help them learn how to use their more affected arm and hand in tasks when they need to. 

In all humans, the dominant and non-dominant hand do not perform the same role. The dominant hand is used for high precision tasks such as writing and tool use, whereas the non-dominant hand plays a more supportive, assisting role [2]. This differentiation is greatly exaggerated following damage to one side of the brain in early life, with the more impaired upper limb adopting the role of a helping or assisting hand, regardless of expected or perceived hand dominance. The concept of hand role differentiation may become distorted in upper limb rehabilitation programs where successful outcomes are often measured by a child’s “best ability” to use their more impaired arm and hand in unimanual, dominant hand activities. 

Constraint-induced movement therapy (CIMT)

The fundamental principle of CIMT is the intensive practice of the more impaired limb [3]. This aims to reverse or prevent the very early behavioural adaptation that takes place in children with hemiplegic CP who demonstrate a strong early hand or limb preference, known as developmental disregard. 

The intensive spontaneous use of the more impaired limb also aims to drive neuroplasticity, prevent secondary musculoskeletal impairment and improve function. It is now recommended that developmentally appropriate models of CIMT are implemented when asymmetric hand use is first observed, commonly at three to five months of age.

CIMT involves placing a constraint on a child’s less impaired upper limb (e.g. cast, mitt, sling) to facilitate spontaneous and repetitive use of the more impaired limb in a range of unimanual activities, specifically targeted to the child’s individual ability and developmental level. The constraint replaces the need for repetitive physical and/or verbal prompts to use the more impaired limb. The skill of the therapist and/or caregiver is to maintain the child’s interest and motivation, grade the level of task difficulty and to provide as many opportunities as possible for intensive practice of unimanual goal-related actions e.g. reach, grasp, hold, release. 

Using CIMT, children practice dominant hand actions with their assisting or non-dominant hand. It is not possible for them to practice and learn how to use their more impaired hand for assisting hand actions. Therefore, for some children, it is difficult for them to understand how to transfer the improvements seen following CIMT into their usual play or daily activities.

Bimanual Therapy

We define bimanual therapy as “the process of learning bimanual hand skills through the repetitive use of carefully chosen, goal-related, two-handed activities that provoke specific bimanual actions and behaviours”.

Bimanual therapy aims to provide the opportunity for children to practice and learn bimanual skills and strategies that are targeted to a child’s individual ability. In simple terms, through practice and repetition of carefully chosen bimanual activities, children are able to learn how to use their more affected arm/hand as an assisting hand. This requires careful consideration of toy properties that trigger children to recognise when and how to use two hands to complete an activity. It is simply not possible for children with hemiplegia to practice and learn these skills when a restraint (mitt, glove, cast) is placed on the dominant hand.

Constraint or bimanual therapy for my child? 

We suggest that the best way to determine the most appropriate therapy for your child is to consider the nature of your child’s goals. CIMT can be used to target unimanual actions (reach, grasp, hold, release). Once these actions are established, bimanual therapy should be used so that children can learn how to use these actions in bimanual activities to achieve success and independence. 

As the research suggests, there is no “one size fits all” or superior approach for the treatment of the upper limb in children with hemiplegia. Both unimanual and bimanual therapies are effective if provided to the right child, at the right time. Remember, goals first, therapy second. 

For further information on this topic, please visit the Cochrane Library. 

To access our online parent forum on this topic, and many other topics, please visit the CPToys education library at https://parent.cptoys.org/videos 

References

  1. Krumlinde-Sundholm L, Eliasson AC. Development of the Assisting Hand Assessment: A Rasch-built measure intended for children with unilateral upper limb impairments. Scandinavian Journal of Occupational Therapy. 2003; 10(1): 16-26.
  2. Krumlinde Sundholm L. On the other hand: About successful use of two hands together. Conference proceedings from the Third International Cerebral Palsy Conference. Developmental Medicine and Child Neurology. 2009; 51(Suppl. 2): 39.
  3. Taub E, Miller NE, Novack TA, Cook EW, Fleming WC, Nepomuceno CS, et al. Technique to improve chronic motor deficit after stroke. Archives of Physical Medicine and Rehabilitation. 1993; 74(4): 347-354.