When you first look at Brianna Robinson, you might not realize that she has cerebral palsy. She does a lot of the same things most other 2 1/2-year-old girls do: she walks and runs, plays with dolls and eagerly reaches for favorite treats. But look closer and you notice that while Brianna enjoys a lot of the same games and activities as other kids her age, she tends to do them with just one hand. The type of cerebral palsy Brianna has causes hemiplegia, in which one side of the body is weaker and less coordinated than the other. In Brianna's case, her right side is affected to the point where, until very recently, it was almost impossible for her to grasp anything with her right hand.
For small children, inability to use one hand or another is challenging, but nowhere near as problematic as it is for adults, who are expected to type, prepare their own meals and perform an enormous range of tasks that are quite difficult to execute with a single hand. Brianna's parents wanted her to get a head start on developing her right hand, so last year, they began immobilizing her left hand with a splint a few hours a day to encourage Brianna to use her right hand. Pleased with the progress they saw, they became very interested when Brianna's private physical therapist recommended a new program at Kennedy Krieger called Constraint-Based Movement Therapy. This is a three-week program that involves applying a cast to the child's stronger arm and at least four hours of daily therapy designed to strengthen and increase functional use of the weaker arm.
"Kids with CP and other forms of hemiparesis realize early on that it's more difficult for them to use their affected arm," says Dr. Frank Pidcock, a Kennedy Krieger specialist in pediatric rehabilitation medicine and the medical director of the program. "They learn to rely on their better arm and neglect the weaker side. But the brain is capable of being shaped by sensory input. This technique capitalizes on the brain's ability to develop connections that we believe can lead to new, functionally useful skills."
Last year, Dr. Pidcock attended a lecture presented by Dr. Edward Taub, who pioneered the use of this type of therapy in adults recovering from strokes. He soon came to believe that Kennedy Krieger's large population of children with cerebral palsy could benefit from similar techniques with the goal of stimulating the development of emerging skills rather than regaining lost skills, as in the case of adults whose hemiparesis stems from strokes. Kennedy Krieger's Specialized Transition Program (STP), which provides coordinated, intensive, daily outpatient therapy services for children using a community reintegration model, was seen as an ideal location for this type of program.
Dr. Pidcock and Specialized Transition Program Director Joan Carney began assembling the team for the constraint-based program as well as adapting STP's facilities to accommodate the younger group of children that the constraint program was expected to attract. "Most of the kids who normally come to STP are school-age," Carney says. "We had to stock up on some more age-appropriate games and activities as well as find smaller chairs and tables."
Families interested in enrolling their children in Kennedy Krieger's Constraint-Based Movement Therapy program come for an initial evaluation to determine what degree of function they currently have in their weaker arm. The children must be able to initiate 10 degrees of motion in their wrists or fingers to be eligible. Because casting an arm can affect a child's balance, children must also be old enough to walk or use a wheelchair. Then, Dr. Pidcock and the program's therapists develop a set of child-specific goals and strategies. "The actual therapy itself has two parts," says Dr. Pidcock. "The first involves temporarily constraining the less-affected side with a cast that extends from above the elbow to the finger tips. The second and probably more important piece is shaping, or stimulating, the more affected side by using customized, increasingly difficult activities that will often be incorporated into play."
If a child qualifies for the program, they are evaluated by therapists at STP who, in conjunction with the child's parents, develop a customized therapy program. On the first day of their enrollment in the program, the child receives a cast on the more functional arm that can be removed by therapists or parents if there are medical concerns or if the child finds it uncomfortable. After children are casted, they come to STP for three weeks of therapy led by physical therapist Jennifer Keiber and occupational therapist Kim Obst. "The first two days can be rough," Obst says. "You have to find out what the child's interests are and intertwine those into therapy."
Keiber and Obst work hard to develop age- and interest-appropriate activities that encourage the use of children's non-dominant hands. Depending on the child, activities could include throwing a ball, stacking blocks and taking books on and off library shelves.
As the program attracts more participants, the team hopes to improve its resources. Specifically, they would like to add a sand and water table to provide sensory play and therapy for younger patients, in addition to touch screen monitors and related software to interest older ones.
According to Keiber and Obst, it's impossible to produce dramatic improvements in just three weeks. But the children they've worked with have experienced increased strength in their weaker limbs, better movement patterns, more purposeful use of the non-dominant hand and are more likely to use that hand or arm without prompting. The key to more significant improvement is continuing therapy at home. Prior to patients' discharge, they and their families are given a home-based program to follow and asked to return for follow-ups one, three, six and 12 months after discharge to make adjustments to the program and measure progress. Additional "doses" of intensive constraint-based therapy may be needed to reinforce gains as children get older. One family has already arranged for their child to return for a repeat session.
"We give parents suggestions for activities to try at home for at least a half an hour each day," says Obst. "The kids we've seen the most improvement in are those whose parents have been able to keep up that routine."
That's the strategy the Robinson family has followed. Since Brianna left the program in April, her parents have made sure she spends at least a couple hours each day wearing a splint on her stronger hand, while her weaker hand participates in structured activities. "When she started the program, it was like her right arm wasn't even there," says Brianna's mother Beth. "She'd walk around with it tucked inside her shirt. Now she has more of a natural, open palm. She's even held a bat with both hands. She knows it's not OK to not use "Righty."
Brianna's progress is typical of that of most of the children who have gone through the program, says Carney. "Many of these children came to us essentially ignoring their weaker arms. By the time they leave, they're initiating more. You can see the spark that leads them to use the arm more and more, without us there to encourage them."