Date Presented 04/05/19
We examined whether an OT regimen that combines modified constraint-induced unimanual therapy with bimanual therapy can improve hand function in children with unilateral brain injury. We also examined the optimal order of each therapy type. We found that combined unimanual and bimanual intensive OT improves motor and functional upper-extremity use in these children. Improvement appears to be independent of the order in which the therapies are combined.
Primary Author and Speaker: Ka Lai Au
Contributing Authors: Julie Knitter, Susan Morrow-McGinty, Talita Campos, Jason Carmel, Kathleen Friel
PURPOSE: To examine whether an occupational therapy regimen that combines modified constraint-induced unimanual therapy with bimanual therapy in a clinical setting can improve hand function in children with unilateral brain injury. We also examined the optimal order of each therapy type. Several randomized clinical trials have demonstrated that intensive unimanual or bimanual therapy produce similar amounts of improvement in hand function in children with unilateral brain injury. Some studies have identified therapeutic benefits unique to each type of therapy. The goal of this study was to test the efficacy of combined unimanual and bimanual intensive therapy, and to determine the optimal schedule for delivering the combination of therapies. Improving functional hand skill in children with unilateral brain injury is a critical goal in occupational therapy. Therefore, the need to develop evidence based effective Occupational Therapy protocols to work with this population is important.
DESIGN: Experimental design. Forty children (13 females) with unilateral brain injury, age range 7.4 ± 2.2 years, were recruited from our day hospital OT program and from the community. Children were with decreased use of one upper extremity due to hemiplegia or hemiparesis as a result of cerebral palsy, traumatic brain injury, stroke or other diagnoses. Participants were required to be able to follow verbal directions, and have active movement of all joints of the affected upper extremity.
METHOD: Children participated in intensive unimanual and bimanual therapy, delivered in an occupational therapy day program for 6 weeks (5 days per week, 6 hours per day). Children were randomized to receive a 3-week block of unimanual therapy followed by a 3-week block of bimanual therapy (n=13), or a 3-week block of bimanual therapy followed by a 3-week block of unimanual therapy (n=13). These two groups of children were compared with group of children (n=14) who had received a combination of the two therapies for the same duration of 6 weeks, 5 days a week, 6 hours a day (unimanual during the first two weeks, then in each subsequent therapy week, one hour of bimanual therapy was substituted for an hour of unimanual therapy). To assess the effects of therapy, hand function was tested before, after, and two months after therapy with the Assisting Hand Assessment (AHA), Box and Blocks test (BBT), and the Canadian Occupational Performance Measure (COPM). We conducted Analysis of Variance (ANOVA) to statistically compare outcomes among the groups.
RESULTS: All three groups of children showed statistically significant, clinically meaningful improvements in bimanual use of the affected upper extremity (AHA; 4.3-point average improvement, p<0.01), skill of the affected upper extremity (BBT; 2.4-point average improvement, p<0.01), and functional goal performance (COPM Performance; 2.4-point average improvement, p<0.01) and satisfaction (COPM Satisfaction; 2.9-point average improvement, p<0.01) after six weeks of therapy. There were no differences in improvement among the three groups, meaning that all three protocols produced equal amounts of improvement in hand function.
CONCLUSION: Combined unimanual and bimanual intensive occupational therapy improves motor and functional upper extremity use in children with unilateral brain injury. Improvement appears to be independent of the manner in which the therapies are combined.
IMPACT STATEMENT: These findings provide evidence for the efficacy of this Occupational therapy regimen. Combined unimanual and bimanual therapy produces clinically meaningful improvements in functional hand use. Improvement appears to be independent of the order in which the therapies are combined.
References
Cohen-Holzer, M., Katz-Leurer, M., Meyer, S., Green, D., Parush, S. (2017). The Effect of Bimanual Training with or Without Constraint on Hand Functions in Children with Unilateral Cerebral Palsy: A Non-Randomized Clinical Trial. Phys Occup Ther Pediatr. 20;37(5), 516-527. doi:10.1080/01942638.2017.1280871.
Cohen-Holzer, M., Sorek, G., Kerem, J., Katz-Leurer, M. (2017). The impact of combined constraint-induced and bimanual arm training program on the perceived hand-use experience of children with unilateral cerebral palsy. Dev Neurorehabil. 20(6), 355-360. doi:10.1080/17518423.2016.1238017.
