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Running Head: MCIMT & NDT IN KIDS WITH CP

The Effect of Combined Modified Constraint Induced Movement Therapy and

Neurodevelopmental Therapy on Activities of Daily Living for Children with Cerebral Palsy

Shea Aldana

Molly Augustine

Keely Gove

Lauren Lundstrom

University of Utah
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MCIMT & NDT IN KIDS WITH CP
The Effect of Modified Combined Constraint Induced Movement Therapy and
Neurodevelopmental Therapy on Activities of Daily Living for Children with Cerebral Palsy

According to the Center for Disease Control and Prevention (2018), Cerebral Palsy (CP) is
the most prevalent childhood motor disability, affecting between 1.5 to 4 per 1,000 children
worldwide. Cerebral Palsy can develop as a result of a wide variety of prenatal complications.
As a result of CP, children may experience global impairment at a motor, cognitive, and
developmental level. Factors that can affect functional ability include muscle rigidity, spasticity,
and weakness as well as problems with coordination, learning disabilities, and speech disorders.
Children with CP may also experience a wide variety of other comorbid conditions which
additionally exacerbate their ability to participate in daily occupations.
Current studies involving children with CP and/or motor developmental delays have
shown significant improvements in function can be achieved through Neurodevelopmental
Treatment (NDT) or Constraint Induced Movement Therapy (CIMT). In general, the more
intense therapies involving CIMT or NDT tend to have better results (Geerdink, Aarts, & Geurts,
2013; Lee et al., 2017). However, Gordon, Charles, and Wolf (2005) found that the intensity of
CIMT has been shown to cause children increased frustration due to the duration of using the
impaired limb, negatively affecting a child’s self- esteem. This also correlates with a higher rate
of non-compliance with treatment regimens as well as reported caregiver burden. In their study
of 38 children with hemiplegic CP, they found that Modified Constraint Induced Movement
Therapy (mCIMT), a less time-intensive form of CIMT, had positive results in improving overall
function and had a high rate of intervention completion. Few studies have explored the
effectiveness of combined treatment involving mCIMT in combination with NDT therapeutic
handling on the affected upper extremity. In 2012, Haynes and Phillips conducted a case study
involving two infants with CP on the effects of combined mCIMT and NDT. Results were
promising and both infants maintained improvements one year post treatment.
In this proposed study, we aim to determine the effectiveness of NDT therapeutic
handling in combination with mCIMT on participation in activities of daily living (ADL) and
satisfaction in children with CP between the ages of 4 -12 years old.

Aim 1: Determine the effects of combined mCIMT and NDT on ADL performance in children
ages 4-12 with CP as compared to CIMT alone.
Hypothesis: Combined mCIMT and NDT will increase ADL performance significantly more than
mCIMT alone as measured by the Canadian Occupational Performance Measure - Participation
(COPM-P), Assessment of Motor and Process Skills (AMPS), and the Pediatric Arm Function Test
(PAFT).
Aim 2: Determine the effects of combined mCIMT and NDT on ADL satisfaction in children
ages 4-12 with CP as compared to CIMT alone.
Hypothesis: Combined mCIMT and NDT will increase ADL performance satisfaction significantly
morethan mCIMT alone as determined by the Canadian Occupational Performance Measure -
Satisfaction (COPM-S) and on open-ended interview.
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MCIMT & NDT IN KIDS WITH CP
Review of the Literature

Treatment of Cerebral Palsy

Treatment for children with CP requires a multidisciplinary approach incorporating

pediatricians, neurologists, physical and occupational therapists, speech-language pathologists,

teachers, parents, and children. In occupational therapy (OT), the primary focus of care is to

improve fine and gross motor function in the affected limb(s) as well as utilize adaptive

equipment to increase participation in meaningful daily occupations. As a result, children are

better able actively participate in their community, cope with difficult emotions, and gain

independence. This in turn reduces caregiver strain and increases parent/guardian satisfaction

in seeing an improvement in their child’s abilities within a physical, social, and mental context.

Existing Interventions

Modified Constraint Induced Movement Therapy. Constraint induced movement

therapy is a treatment intervention that involves restraining the unaffected limb, which forces

the individual to utilize the affected side in order to overcome learned non-use and increase

plasticity in the brain. Constraint induced movement therapy is currently thought of as the

“gold standard” for care for children with CP. Modified CIMT takes the same principles that are

used in typical CIMT, however is easier for families to comply with (Gordon, Charles, & Wolf,

2005).

Vaghela (2014) conducted a study comparing mCIMT versus CIMT in children with

spastic hemiplegic CP between ages three to five. The group receiving CIMT had the unaffected

limb restrained 90% of waking hours along with hand exercise, passive stretching, shaping, and

repetitive task practice for 6 hours per day. The second group received mCIMT, restraining the
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MCIMT & NDT IN KIDS WITH CP
unaffected arm only 1 hour per day along with hand exercise, passive stretching, and playing

activities for 1 hour per day. Although the group that received CIMT demonstrated greater

improvement, the fact that both groups improved further supports the efficacy of mCIMT and

its potential to be effective when combined with other therapeutic techniques.

Rostami et al. (2012) tested the effect that CIMT in a virtual environment had on upper-

extremity function of the affected limb in children aged 6-11. While both groups showed

improvement, the combined CIMT and VR group had significantly greater improvements in

upper-limb function than those in the other groups that did not combine these two therapies.

This study speaks to the benefits of combining treatment modalities to create a new “gold

standard” for care. Modified Constraint Induced Movement Therapy has the potential to be an

even more effective intervention for children with CP when combined with other interventions

that have been proven effective in increasing motoric ability and quality of life.

Neurodevelopmental Treatment. Neurodevelopmental Treatment is another

intervention that has been shown to be effective in treating motor dysfunction in children with

CP. Neurodevelopmental Treatment is a type of manual therapy that has been in practice for

nearly 80 years (Case-Smith & O’brien, 2015). This treatment seeks to improve functional

mobility for children with CP by promoting normal movement patterns through hands-on

guiding at specific pressure points. Neurodevelopmental treatment scaffolds off of these

reflexes in order to help individuals have more typical patterns of movement until they are able

to accomplish the movements without the guidance of a therapist. Neurodevelopmental

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MCIMT & NDT IN KIDS WITH CP
treatment continues to be used in order to treat a variety of neuromotor conditions, especially

CP (Lee, et al., 2017).

One study of importance to occupational therapy (OT) looked at the effects of NDT on

daily functioning. Tekin, Kavlak, Cavlak, and Altug (2018) looked at the effect of NDT on postural

control, balance, and activities of daily living (ADL) functioning in children with diparetic and

hemiparetic CP. They found that an 8-week NDT intervention, focusing on posture and balance,

had significant effects on gross motor, balance, seated postural control, and independence with

ADL functioning. These findings are of interest to the field of occupational therapy, as they

highlight the idea that improved motor skills made from participating in NDT can be generalized

to daily functional self-care tasks.

Objective

The proposed intervention of combined mCIMT and NDT protocol will expand current

research in both of these well-known intervention areas. This new intervention may provide OT

practitioners with a treatment program that will optimize both motor control and ADL

functioning for children with CP that will be manageable for families to comply to. Currently,

there is only one case study that combines mCIMT and NDT, however results are very promising

and both infants retained results after one year (Haynes & Phillips, 2012).

In the new study, we hypothesize that the combined treatment will build off of the

current knowledge and improve overall performance in ADLs, satisfaction, and quality of life for

children living with CP and their parents. This study may influence the practice of OT in the

future if the proposed intervention is equally as effective as CIMT alone, but is easier to apply
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to a family’s daily life. This may mean NDT and mCIMT treatment will become the new gold

standard in OT treatment for children with CP.

Methods

Participants

Participants will be recruited through clinician's referral at Shriners Hospital, Primary

Children’s Hospital and the University of Utah Life Skills Clinic. We will recruit at least 25

participants in order to run appropriate statistics, accounting for some attrition. Inclusion

criteria are: medically diagnosed with CP, ages 4-12 years old, and able to attend 85% of

therapy sessions with a parent/guardian who is willing to participate. Exclusion criteria

includes: participant who has received Botulinum Toxin injection within the last 6 months and

parent/guardian is unwilling or unable to participate in therapy.

Design

The proposed 2-group RCT mixed methods study will consist of both quantitative and

qualitative outcomes. Participants will be randomly assigned to a control or treatment group

with pre and post assessments. The intervention group will receive 7 weeks of therapy involving

NDT and mCIMT jointly for 3 hours, three times a week. Trained therapists will provide NDT on

the affected not constrained arm in order to encourage proper movements during a variety of

tasks throughout therapy. An eighth week of therapy will be provided wherein only NDT will be

used to help reintegrate the unaffected arm with the affected arm into functional activities and

occupations. Those in the control group will receive 8 weeks of standard CIMT treatment.

Measures
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MCIMT & NDT IN KIDS WITH CP
The following assessments will be used to measure upper extremity function, ADL

function, and occupational satisfaction.

Pediatric Arm Function Test

The Pediatric Arm Function Test (PAFT) involves behavioral observation of how children

use their more-affected arm during structured play in the laboratory or clinic. Consisting of 17

unilateral and 9 bilateral upper-extremities activities, finger movement, plan of arm movement

and posture in which activity is done, are observed and recorded for both dominant and

nondominant upper extremities. After the testing session, trained raters evaluate the more-

affected arm motor capacity from a video utilizing the Functional Ability scale. The PAFT was

developed to evaluate the aspects of arm function in children ages 2-12 and was shown to be a

valid and reliable measure for children with CP (Uswatte, et al., 2012).

Assessment of Motor and Process Skills

The Assessment of Motor and Process Skills (AMPS) is an occupational therapy-specific

assessment of the quality of a client’s ADL performance. After observing a client complete at

least two AMPS tasks, each rater uses the AMPS manual to score the 16 ADL motor skill and 20

ADL process skill items. Each ADL skill item is scored using a 4-point ordinal rating scale based

on the global criterion of competence. Results are compounded to a Global Functional Level

associated with independent, minimal assistance or maximal assistance (Merritt, 2011). The

AMPS has been standardized on more than 46,500 individuals world-wide. It has been shown to

be a valid and reliable measurement across age, gender, ethnic groups and world regions

(Hayase, et al., 2004).

Canadian Occupational Performance Measure

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MCIMT & NDT IN KIDS WITH CP
The Canadian Occupational Performance Measure(COPM) is an individualized outcome

measure designed to assess clients’ perception of their occupational performance and

satisfaction with that performance. The COPM enables clients to identify goals for OT and

engage in the therapy process (Donnelly, O’Neil, Bauer, & Letts, 2017). This assessment is

commonly used in pediatric intervention helping parents engage in the therapeutic process

with their children and providing progress measures through pre/post assessments.

Open-Ended Interview

We also plan to obtain information regarding the parent/guardian’s perception of

therapy treatment and recovery through an open-ended interview. Questions will be asked

regarding ease of therapy, benefits seen at home, and overall satisfaction of therapy

interventions.

Procedures

Before beginning the study, participants will be lead through an assent and consent

process with at least one parent/guardian willing to participate in the study as well to help fill

out surveys and questionnaires. If a parent/guardian refuses to consent or if a child refuses to

assent even with a parent/guardian’s consent, the child will not be enrolled in the study. After

the consent and assent process has been completed, participants will be administered the PAFT

and AMPS by blinded therapists. The COPM will also be given by a blinded therapist with both

the participants and parent/guardian present and participating as appropriate. All assessments

will be administered pre- and post- intervention. Following the 8th week of treatment, the

parents/guardians and participant, if able, will also complete an open-ended interview, which

will be recorded, allowing them to provide feedback on their perception of the treatment and
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MCIMT & NDT IN KIDS WITH CP
recovery. Participants will receive $5.00 for each assessment completed (PAFT, AMPS, COPM,

and open-ended interview).

Human Participant Protection

Institutional Review Board (IRB) approval will be obtained through the University of

Utah IRB. The study involves participants from vulnerable populations including children with a

disability. In order to protect participants, they will be led through the informed consent and

assent process with the child and parent/guardian by a research assistant who is not directly

affiliated to the family’s healthcare team. Participants will receive information that their

decision to participate in this study will have no effect on their relationship with their current or

future healthcare providers. They will also be informed that should they choose to drop out,

there will be no repercussions to their healthcare, and they may continue receiving therapy and

healthcare services independently of the study. Risks involved with the study are those similar

to receiving typical OT services including physical strain from exercising and discomfort from

the constraint device. Participants may also experience some emotional discomfort typical for

discussing personal challenges and performance.

Data Analysis Plan

Descriptive statistics will be run for the participant demographic information.

Researchers will analyze independent t-scores between the control and intervention group for

the four quantitative assessments (PATH AMPS, and COPM). Statistical significance will be set

to p < 0.05. The feedback interviews will be transcribed and coded for common themes by two

trained research assistants (RA) using grounded theory techniques. Finally, themes will be
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MCIMT & NDT IN KIDS WITH CP
compared between the two RAs and interrater reliability will be determined by the average

percent of themes per participant that they had the same.

References

Case-Smith, J., & O’Brien, J. C. (2015). Occupational therapy for children and adolescents. St.

Louis, MO: Elsevier.

Center of Disease Control and Prevention. (2018). Cerebral Palsy. Retrieved from

https://www.cdc.gov/ncbddd/cp/data.html

Donnelly, C., O’Neill, C., Bauer, M., & Letts, L. (2017). Canadian Occupational Performance

Measure (COPM) in primary care: A profile of practice. American Journal of

Occupational Therapy 71(6), 1-8. doi: 10.5014/ajot.2017.020008

Geerdink, Y., Aarts, P., & Geurts, A. C. (2013). Motor learning curve and long-term effectiveness

of modified constraint-induced movement therapy in children with unilateral cerebral

palsy: A randomized controlled trial. Research in Developmental Disabilities, 34(3), 923-

931. doi:10.1016/j.ridd.2012.11.011

Gordon, A. M., Charles, J., & Wolf, S.L. (2005) Methods of constraint- induced movement

therapy for children with hemiplegic cerebral palsy: Development of a child-friendly

intervention for improving upper-extremity function. Archives of Physical Medicine and

Rehabilitation, 86(4), 837-844. doi: 10.1016/j.apmr.2004.10.008

Hayase, D., Mosenteen, D. A., Thimmaiah, D., Zemke, S., Atler, K., & Fisher, A. G. (2004). Age-

related changes in activities of daily living (ADL) ability. Australian Occupational Therapy

Journal, 51, 192–198. doi: 10.1111/j.1440-1630.2004.00425.x

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Haynes, M. P., & Phillips, D. (2012). Modified constraint induced movement therapy enhanced

by a neuro-development treatment-based therapeutic handling protocol: Two case

studies. Journal of Pediatric Rehabilitation Medicine, 5(2), 117–124. https://doi-

org.ezproxy.lib.utah.edu/10.3233/PRM-2012-0203

Lee, K. H., Park, J. W., Lee, H. J., Nam, K. Y., Park, T. J., Kim, H. J., & Kwon, B. S. (2017). Efficacy of

intensive neurodevelopmental treatment for children with developmental delay, with or

without cerebral palsy. Annals of Rehabilitation Medicine, 41(1), 90–96.

http://doi.org/10.5535/arm.2017.41.1.90

Merritt, B. K. (2011). Validity of using the Assessment of Motor and Process Skills to determine

the need for assistance. American Journal of Occupational Therapy, 65(6), 643-650. doi:

10.5014/ajot.2011.000547

Rostami, H. R., Arastoo, A. A., Nejad, S. J., Mahany, M. K., Malamiri, R. A., & Goharpey, S.

(2012). Effects of modified constraint-induced movement therapy in virtual

environment on upper-limb function in children with spastic hemiplegic cerebral palsy:

A randomized controlled trial. Neuro Rehabilitation, 31, 357-365. doi: 10.3233/NRE-

2012-00804

Tekin, F., Kavlak, E., Cavlak, U., & Altug, F. (2018). Effectiveness of neuro-developmental

treatment (Bobath concept) on postural control and balance in cerebral palsied children.

Journal of Back and Musculoskeletal Rehabilitation, 31(2), 397–403.

Uswatte, G., Taub, E., Griffin, A., Rowe, J., Vogtle, L., & Barman, J. (2012). Pediatric Arm

Function Test: Reliability and validity for assessing more-affected arm motor capacity in
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children with cerebral palsy. American Journal of Physical Medicine & Rehabilitation,

91(12), 1060-1069.

Vaghela, V. (2014). To study the effects of MCIMT versus CIMT for young children with spastic

hemiplegic cerebral palsy: A comparative study. Indian Journal of Physiotherapy &

Occupational Therapy, 8(2), 136-141.