Cerebral palsy (CP) is a public health problem that affects 2-3 per 1000 children. Up to 75 %
of children with cerebral palsy will have motor impairments that can lead to lifelong
disability, therefore there is a need for effective treatment of these motor impairments. A
body of evidence shows that intensive motor therapies can improve arm and hand (upper limb)
motor function in children with CP. Constraint induced movement therapy (CIMT) is one of the
motor therapies with the strongest evidence base for its effectiveness. Our team has
developed an innovative CIMT protocol to treat upper limb impairments due to CP. This
protocol combines 1) high dosage of motor treatments, (up to 3-6 hours of therapy per day for
20 days); 2) constraint of the unaffected arm, 3) the incorporation of behavior motivation
techniques to encourage the child to perform increasingly complex motor tasks; 4) treatment
within the home to promote generalization of the motor behaviors; and 5) a post-therapy
treatment plan for the parents to continue after the formal CIMT protocol is done. In a
recent randomized controlled trial, we tested the effect of this CIMT protocol on upper limb
function in children with hemiplegic CP. Children who received CIMT at the 30-hour and
60-hour doses had significantly better function immediately post-treatment than children who
received usual and customary care. This difference persisted at 6 months after treatment for
the children who received the 60-hour dose. These results provide clear evidence that the
higher therapy dose resulted in greater sustained improvement of upper limb function.
Through our work in this and other clinical trials, we recognized that our treatment protocol
delivered in the home cannot be delivered to children who live in rural areas beyond the
reach of our therapists or in urban communities whose families are unable to have therapists
work in their homes for 20 days. This limitation disproportionately affects families who live
in medically resource poor areas. To address this barrier to access, we propose to modify our
CIMT protocol so it can be used for telehealth delivery. Rehabilitation by telehealth has
drawn considerable attention in the adult stroke world. A small number of trials in adult
stroke patients and a small pilot trial in pediatric patients with upper limb weakness have
shown that upper limb rehabilitation by telehealth is feasible and can be as effective as
that delivered in the clinic.
Based on this emerging evidence, we will test the feasibility of our CIMT protocol adapted
for telerehabilitation. In a related study, we will refine our CIMT by soliciting the input
of families and children who have undergone CIMT treatment, and the input of expert treating
therapists and assessors regarding our protocol. In the current study, we will test this
refined protocol in a pilot sample of five to seven children ages 1-10 years who have
hemiplegic CP. We will evaluate whether the remotely delivered treatment maintains fidelity
to the original version delivered in person; whether the treatment is feasible to deliver,
and whether it is acceptable to families, therapists, and assessors. In addition, we will
evaluate whether the remote assessment of fine and gross motor skills is feasible, reliable,
and acceptable. These measures will be assessed by questionnaires, observation of assessment
recordings, scoring of the outcome measure, and interviews of parents of and participating
children (the primary stakeholders), as well as feedback from study assessors.
Our long-term goal is to implement effective, accessible, intensive upper-limb interventions
for children with hemiparesis, using delivery methods that are accessible, available, and
feasible for families representing socioeconomic, geographic, and racial/ethnic diversity.
This clinical research study is an important step toward clinical implementation through
translation of an evidence-based intervention to a potentially more accessible, practical and
equitable delivery method for families of children with CP.