Bimanual upper limb therapy

Bimanual upper limb therapy is usually provided by occupational therapists and other similarly qualified rehabilitation specialists or allied health professionals.

Occupational therapists at Cerebral Palsy Alliance offer bimanual upper limb intervention and can help a family decide if this intervention is the right choice for their child.

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Fees may apply for occupational therapy assessment and intervention and will depend on the provider, the type of bimanual upper limb therapy and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing and therapist travel.

Equipment – Therapists will support the family to use readily available resources in the child’s familiar environments as much as possible.

Ask health care providers if you are eligible for funding to assist with occupational therapy fees and any equipment required. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

This intervention takes time and children need multiple opportunities to practice the recommended bimanual activities.

Recommended programs include:

• Individual sessions with an occupational therapist, involving one hour appointments once or twice a week, for up to eight weeks¹. This will be combined with a home program
• Home programs supervised by the family or carers provide practice each day to achieve the intensity needed to achieve goals
• Intensive group programs may involve therapy for six hours a day for two weeks, followed by a home program. Occasionally, intensive programs with a magic² or circus³ theme are available to provide intensive bimanual therapy

Most everyday activities are easier to complete with two hands together - for example, catching a ball, putting on a shirt, using a knife and fork, and tying shoelaces. Children with hemiplegic cerebral palsy often have difficulty performing activities that rely on the coordinated use of both hands, because of movement difficulties in the affected (hemiplegic) hand.

• Children with poor hand and arm ability may be encouraged to use their affected hand and arm to support objects during two-handed activities.
• Children with a better ability to use their arm and hand might be encouraged to develop dexterity when grasping, manipulating and releasing objects with their fingers.

To be effective, this therapy requires specialist strategies. Children will require frequent contact with a therapist to ensure they have adequate direction, support and feedback. This is for both individual and group-based bimanual upper limb therapy. The therapist will also help a family learn to use bimanual upper limb therapy so that it can be carried out in the child’s familiar environments.

Another upper limb intervention for children with hemiplegic cerebral palsy is called constraint-induced movement therapy. It is equally effective if completed at the right intensity. The decision about which intervention to choose will depend on the goals for therapy, whether a child is able to tolerate the interventions, the child’s and family’s preferences, as well as the resources required. Studies⁴ have reported the use of these interventions together but no clear evidence yet exists as to whether combining is better than using just one of the interventions.

• Hemiplegic cerebral palsy is also known as unilateral cerebral palsy
• Bimanual upper limb therapy is sometimes called bimanual training, bimanual occupational therapy or HABIT (hand-arm bimanual intensive therapy)
• Bimanual upper limb interventions can be used with children with diplegic and quadriplegic cerebral palsy who experience movement difficulties in their hands. Bimanual upper limb interventions can also be used with children aged under 18 months. No research evaluating this intervention has been completed with these groups of children however.

An occupational therapy assessment is necessary to help set goals for therapy and to carefully plan the therapy.

The second type of assessment is to measure the outcome of bimanual upper limb therapy to ensure that it has been effective for meeting an individual’s needs and goals. The occupational therapist, together with the child and family will decide on the most suitable measure.

Typical assessments and outcome measures for this intervention are:

• Kids-Assisting Hand Assessment (AHA) and Mini-AHA (for infants) – measure how well a child with hemiplegic cerebral palsy uses their affected hand during two-handed play activities
• Canadian Occupational Performance Measure (COPM) – measures change on everyday activities that people have identified as a problem
• Goal Attainment Scaling (GAS goals) – measures whether a person’s goals are achieved

We searched the allied health and medical literature to find research evaluating the outcomes of bimanual upper limb therapy for children with hemiplegic cerebral palsy.

The search aimed to find the best available evidence about whether this intervention improved a child’s ability to use his or her affected arm to complete everyday activities and achieve functional goals.

There are three main findings from the research. Firstly, high-level research from randomised controlled trials (RCTs)^4-8 provides moderate quality evidence that bimanual upper limb therapy is effective for improving upper limb function of children with hemiplegic cerebral palsy if provided at adequate intensity. Secondly, bimanual upper limb therapy is as effective as an alternative, equally intensive intervention such as constraint-induced movement therapy^{4, 6-9} for improving upper limb function, self-care or parent perception of change and may be more effective for achieving children’s individual goals. Finally, an intensive block of bimanual upper limb therapy is more effective than the same number of hours of conventional therapy distributed over a longer period¹⁰.

Bimanual upper limb therapy is more effective than standard care

Two moderate quality randomised controlled trials (RCTs)^5-7 compared the outcomes of children who had bimanual upper limb therapy with children who had standard care. In these studies, the children who participated in bimanual upper limb therapy had intensive therapy and those who received standard care had little or no therapy for the upper limb. These studies provide low-quality evidence that bimanual upper limb therapy is more effective than standard care for improving bimanual upper limb function. The results are less certain for unimanual function and self-care but also suggest that bimanual intervention is more effective than usual care.

Bimanual upper limb therapy and constraint-induced movement therapy achieve similar benefits

Some of the studies compared bimanual upper limb therapy with constraint-induced movement therapy. Constraint-induced movement therapy is also an intensive intervention and is known to be effective for children with hemiplegic cerebral palsy. Five randomised controlled trials were included in a good quality systematic review⁴. Two additional, high quality, randomised controlled trials^8-9 have been published more recently. Together, these studies provide moderate to high quality evidence that children receiving either of these interventions improved. Bimanual interventions may improve goal achievement more than constraint-induced movement therapy. There was no difference, however, in the amount of improvement for upper limb function, self-care or parent perception of change between bimanual upper limb therapy and constraint-induced movement therapy. Looking at this evidence together shows that either of these interventions is effective for improving outcomes for children with hemiplegic cerebral palsy.

Bimanual intervention has some advantages over a distributed model of conventional therapy

One study¹⁰ compared an intensive block of bimanual upper limb intervention consisting of 90 hours carried out over 2 weeks, with a distributed model of conventional therapy, which was 90 hours distributed over 5 months. The study provided moderate quality evidence that the intensive bimanual therapy was more effective than an equal number of hours of conventional therapy distributed over a long period for improving bimanual upper limb ability and social participation. There was no difference between groups for self-care ability, which improved in both groups and unilateral upper limb outcomes, which did not change in either group.