Hand skills and how they develop in infants are so intricate and fascinating. I worked only a brief stint in early intervention, so my exposure to working with infants has been limited. I love babies, but I have always thought I would have to be more seasoned to be a therapist to infants. My fresh out of the gate, type A, overachieving new grad self struggled with the fact that one can hardly make babies do what you want them to do! Now that I’ve had some time to learn how to finesse and scaffolding activities for older kids, I think I would have a better go with babies too.
This article was interesting to me because I loved the idea of constraint induced movement therapy when I learned about it. Not because I love restricting a child’s movement, but the concept just makes good sense to me.
What I love even more about this article, though, is that they were detail oriented. They don’t argue that CIMT and mCIMT don’t benefit children with cerebral palsy. However, they specifically wanted to know how it might impact outcomes for infants with CP.
Journal American Journal of Occupational Therapy (SNIP score 1.121)
Article Title Effectiveness of Modified Constraint-Induced Movement Therapy Compared with Bimanual Therapy Home Programs for Infants with Hemiplegia: A Randomized Controlled Trial
- 1A Systematic review of homogeneous RCTs
- 1B Well-designed individual RCT
- 2A Systematic review of cohort studies
- 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
- 3A Systematic review of case control studies
- 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
- 4 Case series (and low-quality cohort and case control study) [This study was a cross-sectional study]
- 5 Expert opinion without explicit critical appraisal
Methods Health professionals recruited parents through public health services. Children could be included if…
- They had a formal diagnosis of spastic hemiplegic CP from a physician
- They were 8-16 months old (no older than 18 months at the end of treatment)
- Could follow simple and age-appropriate instructions
Researchers excluded children with additional medical issues and those who demonstrated no difference in the function between their two hands. Study authors randomly assigned children to either a modified Constraint Induced Movement treatment group or a Bimanual Therapy group. Thirty three infants and their families participated in 8 weeks of individualized daily one-hour play sessions 7 days per week. Occupational therapists visited the families once per week and guided parents on ways to promote the child using his/her affected hand during play.
Intervention
Children in the mCIMT group wore a soft, custom-made mitt and participated in activities to promote unilateral hand use. The children in the BIM group completed activities to encourage symmetrical and asymmetrical hand use. All children had sufficient head control, and treatments were done with the child sitting (floor or high chair) and given trunk support if needed.
During weekly visits, the OT’s ensured that parents knew to provide positive reinforcement for desired actions when performed. The professionals also guided parents on the activities they should complete the following week. The researchers required parents to complete a daily log with details of the play sessions.
Measures
Researchers used the Mini-AHA, which is an infant version of the Assisting Hand Assessment. This assessment uses criterion reference to measure the effectiveness of 8-18 month olds with hemiplegia’s use of their affected hand (Chamudot, R. et al, 2018, p. 2). Evaluators observe infants playing with specific toys which promote the use of bilateral hands. The scores on the Mini-AHA are not influenced by age.
Researchers also developed a Functional Inventory as a means to measure the results the treatment program had on gross motor and hand function for infants 7-18 months old. The FI has 31 items and is divided into Gross Motor Skills, Unilateral Hand Use and Bilateral Hand Use (Chamudot, R. et al, 2018, p. 3). The authors found high internal consistency for the initial total FI score, post-treatment total FI score and the three categories.
Parent Completed Measures
Parents completed the Dimensions of Mastery Questionnaire which measures infants’ mastery of motivation (Chamudot, R. et al, 2018, p. 4). Parents also provided information about pregnancy and labor in addition to demographic information.
Findings
Parents in the mCIMT group completed an average of 48.4 hours (out of 60 total for the intervention), and parents in the BIM group completed 45.0 hours on average.
Investigators found there was a significant main effect with large effect sizes of time on all of the outcome measures (Chamudot, R. et al, 2018, p. 6). Children in both groups demonstrated higher scores after treatment. When investigators assessed the interaction of time with treatment and effects of treatment, the results were insignificant. Researchers found significant and equal improvement gross motor function from analysis of the FI.
Authors investigated the interaction between motivation (from the parent reported scores on the DMQ motivation questionnaire) and performance. They did find one significant interaction with a medium effect size. Children in the mCIMT group (though not those in BIM) who scored low on the Object Oriented Persistence subscale of the DMQ at baseline, showed significantly greater improvements.
Authors posited that perhaps children with lower motivation to engage in tasks with their hands may benefit more from mCIMT than children with similar physical presentation but high motivation to engage objects with their hands prior to treatment.
Things to Consider
The authors mentioned that there was no control group that did not receive treatment to compare to the interventions. However they also mentioned that this practice could be viewed negatively because early intervention can have such a large impact on children’s development. To deny them treatment in this crucial window intentionally could reap long lasting detriment.
Important to note is that this article specifically sought to determine what difference, if any, investigators would find in comparing two treatment interventions for infants with spastic hemiplegia. There is evidence indicating the benefits of CIMT and mCIMT for children older than two years. So, it is important to differentiate and consider the differences between infants and older children when selecting treatment interventions.
References
Chamudot, R., Parush, S. Rigbi, A. Horovitz, R., & Gross-Tsur, V. (2018). Effectiveness of Modified Constraint-Induced Movement Therapy Compared with Bimanual Therapy Home Programs for Infants with Hemiplegia: A Randomized Controlled Trial. American Journal of Occupational Therapy 72 (6): 7206205010. https://doi.org/10.5014/ajot.2018.025981
