CP-Care - Module 4 - Physiotherapy

IO2 Module 4
Physiotherapy
CP-CARE - 2016-1-TR01-KA202-035094
(01.12.2016 – 30.11.2019)

Unit 1 – Therapeutic Exercises

What are therapeutic exercises?
Therapeutic exercise is the systematic, planned performance of
bodily movements, postures, or physical activities intended for
individuals.

Aims of therapeutic exercises
Remediate or prevent impairments.
Improve, restore or enhance physical function.
Prevent or reduce health-related risk factors.
Optimize overall health status, fitness, or sense of well-being.
Principle of overload.

Who is eligible for therapeutic exercises?
Neuromuscular Musculoskeletal
Delayed motor development
Muscle weakness/reduced
torque production
Impaired balance, postural
stability or control
Decreased muscular endurance
Incoordination, faulty timing Limited range of motion due to
Ineffective/inefficient functional
movement strategies
Restriction of the joint capsule
Pain
Restriction of periarticular
connective tissue
Decreased muscle length
Joint hypermobility
Faulty posture
Pain

Types of therapeutic exercises
Range of Motion (ROM) Exercises
Active exercises
Active-assistive
exercises
Passive exercises
Stretching exercises
Strengthening exercises
Endurance exercises
Proprioceptive neuromuscular facilitation exercises
Balance and coordination exercises

Range of Motion Exercises
What is it?
Range of motion exercises are regularly repeated exercises that
straighten or bend one or more joints of the body and move them
in all the directions that a joint normally moves.

What are the key ingredients of it?
The main purpose of these exercises is to keep the joints flexible.
They can help prevent joint stiffness, contractures, and deformities.

When should we start?
If there are risks such as muscle weakness, hypertonia-hypotonia,
deformity or contracture, should be started as early as possible.
This can be done during the play/game.

How to apply?
Plan the exercise in the game according to the level of ability
of the individual.
Plan the exercise in the game according to the level of ability
of the individual.
Adequate practice must be performed before starting the
exercise to avoid undesired movements.
It should be done 3-5 times a day, 10-15 times for each joint.

Active exercises
What is it?
It is the exercises individuals can perform and resist by
themselves.

What are the key ingredients?
Maintain physiological elasticity and contractility of the participating
muscles.
Provide sensory feedback from the contracting muscles.
Provide a stimulus for bone and joint tissue integrity.
Increase circulation and prevent thrombus formation.
Develop coordination and motor skills for functional activities.

Whenever a patient is able to contract the muscle actively and
move a segment with or without assistance.

How to apply?
Exercise should be planned according to the clients’ ability level.
Adequate practice must be performed before starting the exercise
to avoid undesired movements.
Be sure to consult your physiotherapist
before starting the exercise

Active-assistive exercises
What is it?
These are exercises made with help so that the individual can
perform part of the movement.

Maintain physiological elasticity and contractility of the
participating muscles.
Provide sensory feedback from the contracting muscles.
Increase circulation.
Increase muscle activity and strength.

When the individual:
• has weak musculature and is unable to move a joint
through the desired range (usually against gravity).
• has active movement restriction.
• aimed to facilitate typical movement.
https://www.youtube.com/watch?v=Rk4k75hsT-k

How to apply?
Plan the exercise based on individuals ability level
The movement should be assisted as much as the individual
needs.

Passive exercises
What is it?
These are exercises done by someone else when the individual is
unable to move the body parts or when it is not desired to move
them (i.e. surgical-injury).

Maintain physiological elasticity and contractility of the
participating muscles
Inhibition of deformity and contracture
Increase circulation
Assisting movement awareness (proprioceptive awareness)
Inhibition of pain
Helping the process of recovery from injury or post-surgery

When an individual
• has an acute and inflammatory condition (2-6 days after
injury)
• can not actively act in complex conditions such as coma
consciousness closure

How to apply?

Stretching exercises
Types of stretching:
 Static: with manually or mechanically
 Dynamic: with muscle contraction (with spring and swing
movements)
What is it?
Exercises are made to increase the range of motion of the joints
when there is limitation in joint movements.

Increasing range of motion
Improving mobility and comfort
Prevention of muscle and tendon injuries
Prevention of deformity
Improvement in relaxation

When an individual
• has a functional restriction due to soft tissue adhesions,
contracture and scar tissue
• has a deformity
• has muscle imbalance
• is protected from injury
to minimize the individual's pre- and post-exercise pain

How to apply?
to avoid undesired movements.
It should be done 3-5 times a day, 15-30 second for each joint.

Strengthening exercises
What is it?
The exercises that increase muscle strength.

What are the key ingredients of?
Enhanced muscle performance: restoration, improvement or
maintenance of muscle strength
Increased strength of connective tissues: tendons, ligaments,
intramuscular connective tissue
Decreased stress on joints during physical activity
Reduced risk of soft tissue injury during physical activity
Possible improvement in balance
Enhanced physical performance during daily living

When an individual’s
• muscle strength is to be increased
• independence in functional activities is to be increased
• energy saving to be improved
• balance, posture and flexibility are to be increased

How to apply?
Appropriate resistance must be determined for the individual
It should be done 3 times a week, 20-30 minute

Endurance exercises
What is it?
Endurance exercise is characterized by having a muscle contract and
lift or lower a light load for many repetitions or sustain a muscle
contraction for an extended period of time.

Low intensity multiple repetitive muscle contractions
Extended time period
Increased cardiovascular and muscle adaptation
Soft touch reinforcement

• muscle contractions are required to be of low intensity and
very repetitive
• cardiovascular and muscle adaptation are to be increased
• soft tissue is to be strengthened
• performance in the daily living activities must be increased

How to apply?
Appropriate repetition must be determined for the individual
2-4 weeks to increase the cardiovascular and muscle adaptation

Proprioceptive neuromuscular facilitation
exercises
What is it?
Proprioceptive exercises are designed to reveal movement
patterns with sensory stimulus such as touch, stretching,
pressure, sight and hearing.

Increasing muscle strength
Providing relaxation
Increasing independence in functional activities
Restoring functional ROM and increasing strength

• muscle strength increases and loosening of muscle tone is
desired
• independent functional activity is increased
• soft tissue has been injured or was subjected to invasive
surgery
• range of motion is increased

How to apply?
to avoid undesired movements

Balance and coordination exercises
What is it?
These are the exercises that provide the harmony between the
different parts of the body while performing the movements that
the individual targets against a constant position or against
external forces.

Provide goal-oriented movements
Create sensory and motor memory
Ensure safety

When the target motor movement is desired in the individual.

How to apply?
The movement should be assisted as much as the individual
needs.
https://www.youtube.com/watch?v=UCJ2jbqyeBk

Clinical Application
When to use/start?
Every single child with Cerebral Palsy is different, his or her
condition is unique. This means that the application should be
initiated as early as possible.

How to apply?
The patient may be consulted by a physiotherapist and apply
treatment at the following places
• Rehabilitation centres
• Early intervention centres
• Acute care centres
• Clinics
• Hospitals
• Fitness centres
• Home

Risk factors could be:
• cardiovascular diseases
• pulmonary diseases
• rotational problems
• chronic kidney disease
• diabetes mellitus
• osteoporosis
• severe deformities/contracture
• congenital abnormalities or disorders
• epilepsy/convulsion
• severe pain
• subluxation

The effect of therapeutic exercises on daily living
activities:
• increases muscle strength and flexibility
• increases balance, coordination
• provides of cardiovascular stability
• provides of pulmonary stability
• stimulates correct posture
• corrects the psychological condition
• increases sleep quality
• reduces chronic pain
• saves energy

References
 Therapeutic exercise. ClinTechSmall AnimPract. 2007 Nov: 22(4):
155-9.PMID:18198783
 Dodd KJ, Taylor NF, Damiano DL A systemic review of the
effectiveness of strength-training programs for people with
cerebral palsy. Achieves of Physical Medicine and Rehabilitation
(2002)83.
 Olama KA (2011) Endurance exercises versus treadmill training in
improving muscle strength and functional activities in hemiparetic
cerebral palsy. The Egyptian Journal of Medical Human Genetics
(2011)12,193-199.
 https://revalidatiegeneeskunde.nl/sites/default/files/attachments/
Wetenschap/Promoties/2017/maaike_eken_thesisindesign_eken_
definitief_vkl.pdf

Unit 2 – Electro Physical Agents
What is an electro physical agent?
Devices and/or agents which increases muscle strength,
circulation and body awareness by stimulating muscles through
electrical current, that can also be used at home.
 To increase the contractibility of muscles.
Electrical stimulation is performed by
applying it to the motor points of a
specific muscle.

Unit 2 – Electro Physical Agents

Different electrode types are available according to targeted muscle
groups.
pen electrode snap electrode

Who is eligible for electric stimulation?
Individuals with:
• Weak specific muscle group
• Incomplete joint movements
• Need for relaxation of the hypertonus in specific
muscles
• Need of post-op rehabilitation
• No active seizures

Left side is weaker.
Electrical stimulation is
used to improve the left side.
When should we start stimulation?
The client should consult a physiotherapist before stimulation is
applied
It should be part of an active rehabilitation process

These can be used in combination with other
physical agents (hot packs and cold packs).
Models of electro physical agents
EMG Biofeedback
Muscle strengthening (NMES, FES)
Muscle relaxation: stimulation of opposite muscle (NMES)
Transcutaneous Electrical Nerve Stimulation (TENS)

Muscles Strength Relaxation Function
Tibialis Anterior XX - XXX
Gastrocnemius X XXX X
Quadriceps Femoris XXX X XX
Haistring X XXX -
Gluteus Maximus XXX - XX
Elbow Extension XXX - XXX
Elbow Flexion X XXX -
Wrist Extension XXX X XX
Wrist Flexion X XXX XXX
Elbow Supination XXX - XXX
Elbow Pronation - XXX X
XXX: Often XX: Sometimes X: Rare
NMES
FES
TENS
NMES
(on opposite muscles)
Cold Pack
Hot Pack
FES
EMG
Biofeedback

EMG Biofeedback
Device receives the amount of muscle contraction through the
electrodes.
According to that information, the device gives auditory and
visual signals.
The activity of muscles decrease or increase according to the
signals.

Neuromuscular
Electrical Stimulation
(NMES)
Functional Electrical
Stimulation (FES)
Muscle Strengthening
Transcutaneous
Electrical Nerve
Stimulation (TENS)

Electrodes are
put on weak muscles
Neuromuscular electrical stimulation (NMES)
NMES is used to increase muscle strength.
Triggers / stimulates muscle contraction.

Functional Electrical Stimulation (FES)
Improves specific movement of weak muscles during function.

Transcutaneous Electrical Nerve Stimulation (TENS)
Relaxation of muscles and soft tissues
Stimulation of muscles via sensorial receptors

In this photo electrodes are put on the opposite part of the spastic muscle
Electric stimulation for muscle relaxation
Relaxation is obtained by stimulating opposite muscles.

References
 https://www.ncbi.nlm.nih.gov/pubmed/26420473
https://www.ncbi.nlm.nih.gov/pubmed/22447997
 http://ryma.cinvestav.mx/ronihm/project/biofeedback-
exergames-to-guide-and-evaluate-isometric-exercises/
 https://www.braceworks.ca/2012/08/28/devices/lower-
limbs/afo/functional-electrical-stimulation-in-children-and-
adolescents-with-cerebral-palsy

Unit 3 – Pulmonary Rehabilitation in Clients with
Cerebral Palsy

What is pulmonary rehabilitation?
It is a program of exercise and awareness to improve pulmonary
functions
Exercise part of the programme:
• helps to manage breathing problem
• increases stamina (energy)
• decreases breathlessness
The awareness part of the program teaches:
• to be ‘in charge’ of breathing
• to learn how to pace the breathing with the activities
• when to take the medication (inhalation, puffers)

Who Is Eligible For Pulmonary Rehabilitation?
Individuals with:
• Respiratory muscle weakness
• Need of increased ventilation
• Lack of mobility
• Respiratory issue
• Respiratory distress syndrome (infants)

Methods Of Pulmonary Rehabilitation In Clients With CP
General
Positioning
Exercise
Supporting Inspiration Supporting Expiration
Postural Drainage
Chest Percussion and Chest Wall Vibrations
High Frequency Chest Wall Oscillations
Positive Expiratory Pressure (PEP)
Holistic Care
Parent/carer involvement Positioning Health Promotion

Positioning
Encourages normal development of the chest
Reduces pulmonary stress
Provides upright body position and facilitate for optimal
pulmonary function and normal chest development

Exercise
Suggested exercises to get secretions moving
Reduced mobility is one of the biggest problems. Any passively
small movement can be enough to get secretions moving.
According to the level of function, there is always an appropriate
way to obtain some movement.

Inspiration through the nose
with abdominal movement
Expiration through the lips
Supporting Inspiration
Exercise 1 For improving inspiration
Diaphragmatic Breathing
• To improve chest wall expansion
• To improve exercise performance
• To decrease the energy consumption

Inspiration
through
the nose
Expiration
through the
pursed lips
Exercise 2 For improving expiration
Pursed Lip Breathing
• Improves breathing
• Keeps the airways open longer
• Decreases the effort of breathing
• Prolongs expiration to slow the breathing rate
• Relieves shortness of breath
• Provides general relaxation

Supporting Expiration
• Coughing
A cough is consist of a deep inspiration followed by a forced
expiratory manoeuvre
• Suction
If there is no effective cough but copious secretions, airway
suction is necessary for clearing the secretions
• Balloon inflating
• Blowing
Candle, small pieces of papers, pompoms
• Floating ball activity

Chest Percussion
• Passive and effective for mobilizing secretions
• Is to force to move secretions into larger airways
• Must not be firm, fast and painful
• Rhythmically clapping on the chest wall over the area being
drained
Precautions for individuals with low bit weight, low gestational age
and with osteoporosis!!!
Percussion for 3 or 5 times
Don`t do percussion over the spine, sternum,
stomach, liver or kidneys.
Cup-shaped
hand position
Cup-shaped
w/3 position
Silicone
nipple

Chest Wall Vibrations
Gentle, shaking pressure
Vibrate as the client exhales slowly through pursed lips
After each vibration, if possible encourage the individual to
cough and expectorate
Must be avoided if softening of long bones and deformities of the
thorax and pelvis occur.

Active Cycle Of Breathing Techniques (ACBT)
• Combines airway clearance with the promotion of ventilation
• More effective in sitting or gravity assisted positions
Flower breathing
Imagine smelling in a flower breathing
through the nose breathe out through the
mouth
Drinking something with
straw

High Frequency Chest Wall Oscillations (WEST)
for Clearing The Secretion in the Airways
The generator sends air, which causes the vest to inflate and
deflate rapidly
After using the vest for five minutes, the individual coughs
Sessions last about 20 to 30 minutes

Positive Expiratory Pressure (PEP)
After inspiration, expiration is done through resistance.
• Helps to move secretions from lung and airway
• Breathes through a mask or a handheld mouthpiece
Bubble PEP
Flutter PEP by facemask
PEP by mouthpiece
Threshold PEP
Thera PEP
The Cornet
Acapella

References
 Braverman J. M.: Airway Clearance Dysfunction Associated with
Cerebral Palsy:An Overview. Advanced Respiratory 2001, 800-
426-4224.
 https://on.cff.org/2NKbMwK
 Evans PM, Ewans SJW, Alberman E.: Cerebral Palsies: Why We
Must Plan For Survival. Arch Dis Child. 1990, 65:1329-1333.
 Webber BA.: The Brompton Hospital Guide to Chest
Physiotherapy. 5th ed. London: Blackwell Scientific Publications,
1990.
 Prassad S.A.: Paediatric Respiratory Care. 1995, 67-71.
 http://www.cerebralpalsy.org/about-
cerebralpalsy/treatment/therapy/respiratory-therapy
 http://geoface.info/ef8714/anatomy-of-lungs-lobes
 http://bronchiectasis.com.au/paediatrics/airway-clearance
 http://www.medicalexpo.com/prod/salvia-lifetec/product-69904-
514928.html

 http://bronchiectasis.com.au/paediatrics/airway-
clearance/acapella
 https://www.physio-
pedia.com/Positioning_the_Child_with_Cerebral_Palsy
 http://physiotherapystudybd.blogspot.com/2018/04/postural-
drainage-positions.html

Unit 4 – Facilitation of Typical Movement

The movements in client with CP
The tension that is in muscle during relaxation
The ability of muscles to work together by protecting
appropriate resistance
Provides to continue typical posture and movement

Typical movement
Skill of achieving the most efficient and economical movement or
performance of a given task

Atypical movement
An activity that is done with more effort than is needed to reach
target without maintaining proper body alignment.

Facilitating, standing from sitting
The Facilitation
What is the facilitation?
Assisting the individual by hands to make the movement

What are the principles?
Matching individuals’ abilities
Giving direction to child with hands how to move
Child should be active
Decreasing the amount of assisting as individuals achieves
Using sensory inputs to improve motor performance
(proprioceptive, visual, vestibular, auditory, tactile)

When should we start facilitation?
As early as possible according to the clients’ needs
https://www.youtube.com/watch?v=OT7MyXC8dmQ

What types of facilitation?
Core stabilisation by reaching
Facilitation of typical movement
Facilitating movement in the appropriate sequence and to continue.

Facilitation of client in flexion
Increased flexion in body at sitting

Facilitation of client in extension
Extension in
trunk and legs
Extension facilitation of trunk by using arms
Devices can be used
(ball, roller, bench, mat)

Facilitation of child while walking
Child in flexion
while standing
Holding arms closer to the trunk, shoulders a little bit back: to
make his body more vertical
https://www.youtube.com/watch?v=LRc7ABIZf3s

Facilitation of a client with hypotonia
Positioning of hypotenuse child to increase the tone,
providing the midline and giving proprioceptive stimulation

References
 Doç. Dr. Bülent Elbasan, FTRS35-Pediatride Fasilitasyon
Yöntemler, Gazi Üniversitesi SBF Fizyoterapi Rehabilitasyon
Bölümü Ders Notları
 British Bobath Tutors Association, Website document, Module 1
Understanding human movement analysis, 2016

What is tone ?
The ability of muscles to work together while performing
proper resistance
Allows to have and maintain a normal posture and
movement
Go to: Module 0 Unit 3

Types of tone
Hypertonicity
High abnormal muscle tone
Decreasing the ability of muscle relaxation and
ıncreasing of muscle strain
Tone increases with the active movement and
the quality and persistence of the movement
deteriorates
Spasticity
The resistance of the muscle against a passive
movement increases depending on the speed
of the movement
It causes stiffness and deformity of the muscle
https://www.youtube.com
/watch?v=_vikQgf1Epc

Hypotonicity
Low abnormal muscle tone
The tension and strength of the
muscle decreases
It causes flexibility and weakness
Fluctuating tone
Variable muscle tone
The individual is hypotonic while
resting and hypertonic while
performing active movements
Especially, this is observed in
dyskinetic Cerebral Palsy
Involuntary movements
of a diskinetic CP
https://www.youtube.com/watch?v=tRZb8RepkFE

Management of the tone problems in
physiotherapy
Proprioceptive exercise
Weight bearing and transfer
Movement
Approximation
Tapping

Proprioceptive exercises
Proprioception is the sense of the position, movement
and location in the space.
It is needed for the right and coordinated movement.

Weight bearing and transfer
Weight bearing has been reported to reduce contracture.
It can be applied with tilt-tables, and standing frames
through a prolonger stretch
Increase the quality of movement by weight transfer and transfer
https://www.youtube.com/watch?v=ijfDATxPtto

Functional Movement
It causes variation of muscle tone (increasing/decreasing)
with active movement, proper positioning, proprioceptive
input and weight-bearing.

Approximation
It is applied passively
Increases stability and muscle tone
Especially, it is used for individuals with hypotonic and
dyskinetic CP
https://www.youtube.com/watch?v=h_fNcHjzkJs

Tapping
It is applied on the tendon or muscle belly
It facilitates voluntary contractions
https://www.youtube.com/watch?v=zAmWiuYLylM

www.physio-pedia.com/Spasticity
Lance JW. The control of muscle tone, reflexes, and movement:
Robert Wartenberg Lecture. Neurology.
www.cerebralpalsy.org/about-
cerebralpalsy/treatment/therapy/physical-therapy
Michelle H. Cameron - Physical agent in Rehabilitation from
Research to Practice
www.physiopedia.com/Neurology_Treatment_Techniques
References

Unit 6 – Treadmill training with partial weight
bearing

What is treadmill training with partial body weight
support?
This method of
• Increasing quality pf gait
• gait enhancement
is based on the principle of
• stepping through a treadmill while providing partial body
weight support
• Stabilizing the body with a harness system

Key Ingredients of Treadmill Training With Partial Body Weight
Support
Variable speed and inclination settings are selected based upon
the each patient`s ability
The ultimate goal is to improve walking
10%-40% of body weight support
To promote effective weight transfer onto bilateral lower
extremities

Who is eligible for treadmill training with partial
body weight support ?
Suitable for a client with CP
• with neuromotor impairment
• lack of mobility
• reach to typical pattern in walking
There is no age limit but it should be used with physiotherapist
consultation especially until 4 years old

When should we start treadmill training with partial
body weight support ?
If your gait has been affected.
If you need to:
• Regain endurance,
• Increase walking parameters
• Control of your lower limbs, and cardiovascular health.
• Ask to your physiotherapist to start at most appropriate time.

Types of treadmill training with partial weight bearing
Robotic-Body Weight Supported Treadmill Training
A motorized computer controlled device that generates passively
guided, symmetrical lower extremity trajectories that are consistent
with a normal physiological gait pattern.
• Reduces manual labour of PT
• More repetition
• More consistent force
It is also referenced in literature as:
• Driven Gait Orthosis (DGO)
• Lokomat (Manufacturer)
• RAGT (Robot Assisted Gait Training)

Types of treadmill training with partial weight bearing
Conventional Body Weight Supported Treadmill Training
• Safety- Risk of falling during training decreased/eliminated
• Can decrease likelihood of developing compensatory
mechanisms in abnormal gait.

Risk Factors
There are no specific side effects but according to the people
who have used:
• The harness is uncomfortable to wear
• Some who do not enjoy walking on a treadmill.

References
 Visintin M, Barbeau H, Korner-Bitenski N, Mayo NE. A new
approach to retrain gait in stroke patients through body weight
support and treadmil stimulation. Stroke 1998: 29:1122-8.
 Hakgüder A. Body weight supported treadmil training in stroke
rehabilitation. Turkish J PhyMed Rehabil 2007: 53(1)
 Van de Crommert HW, Mulder T, Duysens J. Neural control of
locomotion: sensory control of the central pattern generator and
its relation to treadmill training. Gait Posture 1998:7(3): 251-63
 https://www.strokengine.ca/wp-content/uploads/2015/02/BWS-
Patient-Family-Information1.pdf
 https://www.cincinnatichildrens.org/service/o/ot-pt/litegait
 https://pediatricapta.org/includes/fact-sheets/pdfs/Body-Weight-
Supported-Treadmill.pdf

Unit 7 – Goal oriented/directed therapy

What is goal oriented/directed therapy ?
It is a client-centred goal setting method.
Therapy method to help children with cerebral palsy to learn
activities needed for daily life

Therapy goals could be:
Gross motor function
Fine motor function
Self care activity
Playing
School activities
Principles of goal oriented/directed therapy
Focus on the client’s individual goals
Child/family and physiotherapist work together for goal setting
Goals should be based on activity and participation.
Activities needed for daily life
Daily or regular practice is important for success

He has difficulty
wearing shoes
Choosing the goals
Define activities that the child has difficulty to do
The selected activities should make sense for the child
Should represent daily living activities
https://www.youtube.com/watch?v=Gq95txBoMRE

Examples of goals:
Playing football
Put on clothes
Riding bicycles
Highly motivated
to play football

Setting the therapy goal
Who is eligible for goal oriented/directed therapy ?
This method can be applied to all individuals with CP.
Useful for clients who have motor, social, emotional, cognitive
problems.
When to use
While assessing child needs
While determining meaningful
activities for the child
While setting therapy goals with
child and parent.
For more information
See Module 0 Unit 3

References
 https://research.cerebralpalsy.org.au/about-cerebral-
palsy/interventions-and-therapies/goal-directed-training-gdt-for-
children-with-cerebral-palsy/
 Stevens, A., Köke, A., Weijden, T., & Beurskens, A. (2017). Ready
for goal setting? Process evaluation of a patient-specific goal-
setting method in physiotherapy. BMC health services research,
17(1), 618.
 http://www.bcchildrens.ca/our-services/your-visit/during-your-
visit/patient-family-centred-care

Unit 8 - Constraint Induced
Movement Therapy (CIMT)

What is it?
A therapy technique that improves upper extremity function
in Hemiplegic Cerebral Palsy.
Using affected
hand for hold
and release

Using affected side intensively; grasp, release, reach
Aims of CIMT
Restrain the less affected limb
Intensive use of the affected limb

Models of CIMT
Classic/Traditional Modified Baby

Edward Taub, 1997
Charles Jr. And collegeaus 2006
Traditional CIMT Modified CIMT Baby CIMT
Usually used for adults Child friendly
Further modification of
modified CIMT
Restrain the less affected
limb for %90 of waking
hours for 2 to 3 weeks
Different types of
restraint (bandage, splint,
mitt/glove)
30 minutes per day, six to
seven days per week, for
two six-week periods
separated by a six-week
break; a third period might
be needed later on
6 hours daily therapy for 2
to 3 weeks
Restrain of the less
affected limb for 2
hrs/day/ for 8 weeks
Babies’ attention spans are
short, and even 30-minute
sessions are commonly
divided into two segments
Total of 126 hours of
therapy
Weekly checks Training focus is the infant’s
self-initiated actions
Total of 112 hours of
practice
Ann-Christin Eliasson and Lena
Sjöstrand, Baby- CIMT Manual,
Karolinska Institutet, 2013

Playing with less
affected hand
Exploring and reaching toys with
affected hand
Baby CIMTModified CIMT

Who is eligible?
Modified CIMT Baby CIMT
Children who have: Children who don't have:
Babies who
have:
Developmental disregard
(lack spontaneous use of
the affected hand)
Contractures that significantly
limit functional arm use
Babies at risk of
developing
unilateral CP
Impaired basic hand skills
but has some finger
movements
Dystonia that prevents the child
from having any controlled
movement with the affected
upper extremity
Enough activity to
positivity participate in play
Carers who are able to
actively do intensive home
based program

When should we use CIMT ?
If the child doesn’t use affected hand
spontaneously
As early as possible
If the child can follow simple
commands
Asymmetric hand use is first observed
(commonly at 3-5 months)
if baby uses one hand more than the
other
baby begins to be interested in objects
and tries to grasp them
Baby CIMT
Grasping,
reaching
with affected
hand, arm.
Using,
affected
hand in
daily life.
Modified
CIMT

How to apply ?
mass practice is essential, not only
restraint
the practice should occur in the
infants’ everyday environment
plan the activities based on child’s
ability level
stimulate to use the involved hand
by toys, things
never pay attention to the restraint
device
provided by the parents under
therapist supervision during weekly
home visits
start to session as soon as the
restraint is placed on
start with easy activities
make sure you have enough
toys/things, play ideas when the
restraint is placed on
Reach, hold and
releasing with
affected side
Playing toy with
affected hand

 Apply in child’s natural environment
 Play
 Use daily life activities (cooking, feeding) have fun
Eating with
affected hand
Throwing balls
with affected
hand
Examples for restriction

Risk factors of CIMT
Having some boundaries:
• can decrease the child’s self-confidence
• does not make movement ‘normal’
• it is not enough alone to increase bimanual coordination
Playing, exploring toys
with affected hand.

References
 Tervahauta MH1, Girolami GL2, Øberg GK3, Efficacy of constraint-
induced movement therapy compared with bimanual intensive
training in children with unilateral cerebral palsy: a systematic
review, Clin Rehabil. 2017 Nov;31(11):1445-1456. doi:
10.1177/0269215517698834. Epub 2017 Mar 20.
 Chen YP1, Pope S2, Tyler D2, Warren GL2, Effectiveness of
constraint-induced movement therapy on upper-extremity
function in children with cerebral palsy: a systematic review and
meta-analysis of randomized controlled trials, Clin Rehabil. 2014
Oct;28(10):939-53. doi: 10.1177/0269215514544982. Epub
2014 Aug 14.
 Leanne Sakzewski, Jenny Ziviani, Roslyn N. Boyd, Efficacy of
Upper Limb Therapies for Unilateral Cerebral Palsy: A Meta-
analysis, Paediatrics January 2014, VOLUME 133 / ISSUE 1

 Hoare BJ1, Imms C, Rawicki HB, Carey L., Modified constraint-
induced movement therapy or bimanual occupational therapy
following injection of Botulinum toxin-A to improve bimanual
performance in young children with hemiplegic cerebral palsy: a
randomised controlled trial methods paper., BMC Neurol. 2010
Jul 5;10:58. doi: 10.1186/1471-2377-10-58.
 Ann-Christin Eliassona,⁎, Linda Nordstranda, Linda Eka, Finn
Lennartssonb,c, Lena Sjöstranda, Kristina Tedroffa, Lena
Krumlinde-Sundholma, The effectiveness of Baby-CIMT in infants
younger than 12 months with clinical signs of unilateral-cerebral
palsy; an explorative study with randomized design, Research in
Developmental Disabilities 72 (2018) 191–201
 Ann-Christin Eliasson and Lena Sjöstrand, Baby- CIMT Manual,
Karolinska Institutet, 2013
 http://marazoemia.net/wp-
content/uploads/2013/05/Mia12mosWatermelon-.jpg
 https://i.ytimg.com/vi/vFYyiSqKs0s/maxresdefault.jpg

Unit 9 - Bimanual Upper Limb
Therapy

What is it ?
A therapy technique to improve the use of both hands together (at
the same time) in activities of daily life
wearing shoes washing hands using both hands

12
Using both hands at the same time in daily life activities
Key features of bimanual upper limb therapy
specific activities are chosen
activities should be carefully planned

Who is eligible?
Hemiplegic/unilateral, diplegic and quadriplegic cerebral palsy who
experience movement difficulties in their hands
Trying to eat himself with movement difficulties in his hands

Proper toy for bilateral hand use
Usage:
• more suitable for children older than 12 months
• children who have spontaneous use of affected hand
• children who can grasp, hold and release
• children who can understand and follow instructions

One hand holding the cup, other hand putting things into it
 intensive program (at least 6 hrs/day for 2 weeks or
more)
 occupational therapist should help to set goals for
therapy and to carefully plan the therapy
 should include individual sessions with an occupational
therapist

Implementation for daily living activities
Structured task practice is essential
Bimanual functional activities
Be challenging
Fun and motivation
more affected hand holding less affected hand doing the activity

CIMT BIMANUAL THERAPY
Start as early as possible
More suitable when older
than 12 months
Should have the ability for
grasping and releasing
Should have spontaneous use
of the affected hand (s)
Can be applied at home,
school etc.
It should include individual
sessions to practice

References
 Leanne Sakzewski, Jenny Ziviani, Roslyn N. Boyd, Efficacy of
Upper Limb Therapies for Unilateral Cerebral Palsy: A Meta-
analysis, Pediatrics January 2014, VOLUME 133 / ISSUE 1
 Hoare BJ1, Imms C, Rawicki HB, Carey L., Modified constraint-
induced movement therapy or bimanual occupational therapy
following injection of Botulinum toxin-A to improve bimanual
performance in young children with hemiplegic cerebral palsy: a
randomised controlled trial methods paper., BMC Neurol. 2010
Jul 5;10:58. doi: 10.1186/1471-2377-10-58.
 Hoare, B., Imms, C., Villanueva, E., Rawicki, H. B., Matyas, T., &
Carey, L. (2013). Intensive therapy following upper limb
botulinum toxin A injection in young children with unilateral
cerebral palsy: A randomized trial. Developmental Medicine and
Child Neurology, 55(3), 238-247.

 Deppe, W., Thuemmler, K., Fleischer, J., Berger, C., Meyer, S., &
Wiedemann, B. (2013). Modified constraint-induced movement
therapy versus intensive bimanual training for children with
hemiplegia – A randomized controlled trial. Clinical Rehabilitation,
27(10), 909-920.
 Gelkop, N., Burshtein, D. G., Lahav, A., Brezner, A., Al-Oraibi, S.,
Ferre, C. L., & Gordon, A. M. (2015). Efficacy of constraint-
induced movement therapy and bimanual training in children with
hemiplegic cerebral palsy in an educational setting. Physical &
Occupational Therapy in Pediatrics, 35(1), 24-39.
 https://www.neurorhb.com/wp-content/uploads/2016/04/terapia-
habit.jpg

CP-Care project partners
• Gazi University (Turkey)
• PhoenixKM BVBA (Belgium)
• Bilge Special Education And Rehabilitation
Clinic (Turkey)
• Spastic Children Foundation Of Turkey
(Turkey)
• Serçev- Association For Children With
Cerebral Palsy (Turkey)
• Asociacion Espanola De Fisioterapeutas
(Spain)
• National Association Of Professionals Working
With People With Disabilities (Bulgaria)

CP-CARE curriculum, learning material,
handbook by www.cpcare.eu is licensed
under a Creative Commons Attribution-
NonCommercial 3.0 Unported License.
Based on a work at www.cpcare.eu
Permissions beyond the scope of this
license may be available at www. cpcare.eu
This project (CP-CARE - 2016-1-TR01-
KA202-035094) has been funded with
support from the European Commission.
This communication reflects the views only
of the author, and the Commission cannot
be held responsible for any use which may
be made of the information contained
therein.

CP-Care - Module 4 - Physiotherapy

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