Early Hand Therapy for Kids with Cerebral Palsy
Cerebral Palsy
Difficulties in motor (movement) function and development related to a brain problem early in life is called cerebral palsy. These difficulties often become more obvious throughout childhood.
Children with cerebral palsy can have a broad range of abilities. Each child's experience is unique. Some children with cerebral palsy may find certain movements harder than others in part because of the location and nature of brain changes. Experts agree that what parents do during this time does not cause cerebral palsy. There are other factors at play that we do not fully understand.
Hemiplegic Cerebral Palsy
Hemiplegic cerebral palsy describes children who experience challenges moving one side of their body. For these children, hand and arm movements can be particularly difficult. A child’s weaker hand is often called the “assisting hand”. This terminology has been chosen because the weaker hand usually helps (assists) the stronger hand with movements.
Triplegic Cerebral Palsy
Children with triplegic cerebral palsy also have a hand asymmetry, or one hand and arm that is stronger than the other. Triplegic cerebral palsy describes children who experience challenges moving three limbs: both legs and one hand and arm.
Hand & Arm Movements
Hand, wrist, and finger movements are often called “fine motor” skills because they use small muscles and small movements. Children may learn these skills in a predictable pattern, because one skill builds on another. Children may learn different skills at different times. Every child is different.
Child development is often monitored with developmental milestones. Milestones describe most – but not all – things children can do at a certain age. Children may not learn skills at the predicted age. That is okay. Each child will learn in a way that suits them.
Challenging Hand & Arm Movements
Children with CP often keep hands fisted and arms close to their body. These are flexed positions. Moving out of flexion may be difficult. These are often the movements learned in therapy. Depending on each child, they may work on straightening their elbow, turning their palm up (by rotating the forearm), straightening their wrist, opening their hand, and/or pulling their thumb away from the palm.
Preferred Hand & Arm
Almost all children, with or without cerebral palsy, develop a preferred (dominant) hand. The other hand is less preferred (non-dominant). The dominant hand is quicker and more skilled. The non-dominant hand is most often used for holding and stabilizing. These hand preferences usually become evident around 2 years of age.
For children with CP, there may be a greater difference between hands. This difference may be noticed at an earlier age. The assisting hand may be called a “helper hand” or “assisting hand” because it is rarely used on its own. By developing skills on the assisting side, a child’s hand and arm may become more skilled and used more.
Early Hand Therapy
Early intervention is for young children with cerebral palsy. Children under the age of 2 years may have increased potential for brain plasticity. With increased brain plasticity, there may be greater improvements in how the brain controls movement.
By improving hand and arm function early, children may have an improved developmental trajectory. A ‘developmental trajectory’ tracks how children progress as they age. Therapy may ‘boost’ a child’s developmental trajectory to be closer to typical development.
Types of Hand Therapy
Two types of hand therapy are supported by research evidence: constraint-induced movement therapy (CIMT) and bimanual therapy. Both therapies can help improve hand and arm skills, and one is not better than the other. An occupational therapist (OT) is often responsible for designing hand therapy.
CIMT and bimanual therapy are both “evidence-based.” This means research supports use of these therapies. In research studies, children have improved use of their assisting hand/arm after CIMT and after bimanual therapy. Some children improve more than others. Researchers are trying to learn why this is.
Bimanual Therapy
During bimanual therapy, a child uses both hands together (“bimanual”). A child may practice things like clapping, holding a cup with two hands, or opening a book. These actions normally use two hands. Each hand may do the same movement, like in clapping. Or each hand may do a different movement, like holding a container while the other hand takes the lid off.
Constraint-Induced Movement Therapy (CIMT)
During CIMT, a child’s preferred hand is wrapped up (“constrained”) so it can’t be used. This encourages children to use the assisting arm and hand. An OT usually designs structured practice with one-handed activities like touching toys, reaching for objects, or picking up food. For CIMT, practice focuses on using just the assisting arm and hand.
Types of Constraints
There are many options to wrap up the preferred hand. A soft mitt or clipped sleeve are simple options. If these options don't work for a child, an OT can design a splint or soft case to “hide away” a child’s preferred hand. The most important thing is that the constraint is safe and tolerable.
Safety of Constraint
Research has shown that constraining the preferred hand is not harmful. The development of a child’s preferred side will not be affected by constraint. A child’s skin may be irritated by the constraint that is used. If this happens, a child's therapy can try other ways to “hide away” the preferred arm.
Skills Learned in Hand Therapy
During therapy, each child will focus on skills that suit her/his development and abilities. With the assisting hand, children may focus on reaching, pre-grasping, grasping, holding, releasing, and manipulating. Manipulating is moving an object with the fingers and hand. The object can be on a surface or held in the hand (in-hand manipulation). Children may be encouraged to reach across their body, towards the preferred side. This is called crossing midline, and can be challenging for children with CP.
A child may practice two-handed skills. Two-handed skills include reaching, holding, and transferring objects between hands. Sometimes hands do the same action (‘symmetrical’ actions), like clapping. Sometimes hands do different actions. One hand may hold or stabilize an object while the other hand does an action, like holding a container with one hand and opening it with the other. Or both hands do actions, like pouring from cup to cup.
Activities may engage a child’s senses. Often the focus is on senses of touch, sight, and sound. These senses inform movement. For example, if an object looks squishy, you pick it up more gently. Using information from the senses, or “sensory processing”, can be more challenging for children with cerebral palsy. Children need practice using their senses to learn how adjust movements for a variety of objects. Sensory play may include things like water play, handling textured balls, or poking play doh.
