Cerebral Palsy: Constraint-Induced Movement Therapy for Children
Guest: Dr. Patty Coker – Dept of Health Professions, Occupational Therapy, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: Dr. Patty Coker is Assistant Professor of Occupational Therapy in the College of Health Professions. Dr. Coker, you have a very interesting area of research. Tell us about it.
Dr. Patty Coker: Well, I’m doing an exciting study. We started the study in 2006. It’s a therapy intervention for children with cerebral palsy that have one-sided weakness. So, they have a diagnosis of hemiparesis.
Dr. Linda Austin: Let’s define some of those words, first of all. All of us have grown up hearing about cerebral palsy, what exactly is it?
Dr. Patty Coker: Cerebral palsy is a movement disorder. By definition, there’s a static lesion in the brain. What it looks like, clinically, in children is that they have difficulty moving their arms and legs. They have problems with posture. They sometimes have problems controlling their head movements. It can affect their speech and their vision. And, many times, these lesions occur while the baby is in the mother’s womb. It can occur during the birth process, and it can occur shortly after birth.
Dr. Linda Austin: So it’s really a grab bag term, probably covering a lot of different ways that there could be some damage to the brain that leads to abnormal movement.
Dr. Patty Coker: Yes.
Dr. Linda Austin: What gave you the idea for this particular study? And tell us exactly what it is that you’re trying to explore with this.
Dr. Patty Coker: I’ve worked with children with special needs for the last 20 years. I started my career as a special education teacher, came back to MUSC for a degree in occupational therapy and began working here 11 years ago. One of the groups of children I found to be most interesting were children that had a diagnosis of cerebral palsy. Very early on, I really wanted to find ways to help them overcome some of the movement problems that they had. Some of the early research I looked at was on constraint-induced movement therapy.
Dr. Linda Austin: Now what does that mean, constraint-induced movement therapy?
Dr. Patty Coker: Constraint-induced movement therapy is a therapy intervention that was first pioneered for use with adults recovering from stroke. The research that was done primarily in the 1980s was for adults that had a weakness on one side of their body. Because of that weakness, they wouldn’t use that weaker arm and leg. They would adopt a one-sided approach and neglect the weaker side. So, constraint therapy requires a restraint that is actually worn on the stronger arm. This amounts to a forced use, or therapeutic use, of the weaker arm in lots of different activities.
Dr. Linda Austin: So you thought you’d apply this, then, to cerebral palsy?
Dr. Patty Coker: So, in the 90s, the research on adults recovering from stroke using constraint therapy was very successful. There was some research that started coming out for children with cerebral palsy. For children with a one-sided weakness with cerebral palsy, the diagnosis is hemiparesis. They show many clinical signs very similar to adults recovering from stroke that could have really detrimental effects as they’re growing up. The one limb that’s weaker doesn’t grow at the same rate, so they have discrepancies in the size of their arms and legs.
Dr. Linda Austin: Is that because of the original problem, or is that from just underuse?
Dr. Patty Coker: It’s really from disuse, and underuse, especially with children that are born with a static lesion that only affects one side of their body. If they have that type of cerebral palsy, they tend to not use their one limb. And during growth spurts, the limb that is used more often grows at a faster rate. You see more muscle bulk. You see the bones growing at a faster rate. And so the limb that’s not used as much tends to not grow at the same rate.
Dr. Linda Austin: So, paint us a picture in words, what are the constraints like, and what is the program about?
Dr. Patty Coker: Well, we started a program here, at MUSC, in 2001. We were one of the earliest programs in the country to adopt a constraint program using a little a modified approach. Our approach involves constraint of the stronger arm for five consecutive days. The child receives therapy intervention for six hours a day with some type of intensive, fun developmental activities where we really target specific motor movements that the child has difficulty with, improving their shoulder strength, their ability to grab things, and their ability to pinch with the weaker hand.
We started the program in 2001. It was in conjunction with an educational course for our occupational and physical therapy students. So, not only were we providing constraint therapy for children with hemiparesis, we were also educating our occupational and physical therapy students on how to provide therapy intervention.
Dr. Linda Austin: Does this constraint therapy work for kids with cerebral palsy?
Dr. Patty Coker: Well, since the 1990s, there have been over 30 published studies that have shown that constraint therapy is highly effective. And there have been significant changes in the amount of use of the weaker arm, as well as the quality of movements of the weaker arm in overall function. And our study has focused on not only the movements in the upper extremity, we’ve also looked at the overall posture of the child, and their gate, or ambulation; how they walk after constraint therapy.
Dr. Linda Austin: What makes this a study, as opposed to a therapy program for the child?
Dr. Patty Coker: Our program was unique in that we modified traditional constraint programs. Traditional constraint programs for adults required the adult to wear the constraint on the stronger arm for 90 percent of the waking day for up to 21 days. But when researchers began to try constraint therapy with children, they realized that children cannot tolerate that kind of intensity. So then, programs tried to modify constraint approaches to meet the developmental needs of children. The literature points out that there are a lot of different modified approaches. So, we wanted to look and see if our modified approach, which really changed the amount of constraint therapy the child was receiving, would show changes in the motor function of children, as well as their posture and gait.
Dr. Linda Austin: It sounds like it has.
Dr. Patty Coker: Oh, it’s been great. I think as we explore our model, we’re looking at a model that not only provides effective treatment intervention for children with hemiparesis, it’s also cost effective. Our children are making gains in upper extremity motor function; the amount of use of the weaker upper extremity; the quality of their motor patterns in their arm; their gait. And, at this point, it’s free to our participants. Constraint therapy can be extremely expensive. We’re the only constraint program in the state of South Carolina. And, the programs offered in other states have to pay for it, or try to get insurance to pay for it. It can run between $15,000 and $40,000 for a three-week program.
Dr. Linda Austin: How quickly can you begin to see positive results from the program?
Dr. Patty Coker: Typically, I start seeing results after the second full day of restraint. When the child is engaged in repetitive task activities that really target motor weaknesses on the affected side, the weaker side, I can see changes by the beginning of the third day. And parents also notice changes. They’ll come in and say that after they left the program, their child was able to use two hands to carry a tray, was able to go downstairs without using the handrail, and without falling. So, they notice changes pretty quickly.
Dr. Linda Austin: Very exciting. If a parent listening to this wants to have their child enrolled in the study, what should they do?
Dr. Patty Coker: We’ve set up a website. The camp is called Camp Hand to Hands. The website is www.camphandtohands.com, the thought being that you’re taking a child using only one hand, and getting them to use two hands, so Camp Hand to Hands.
Dr. Linda Austin: Camp implies that they’re there, what, all day?
Dr. Patty Coker: This is not a sleepover camp. They arrive at 9:00 in the morning, and the day ends at 3:00 in the afternoon. Each child that comes is assigned an occupational and physical therapy student, which provides two-to-one activities with a child for the entire day. We have licensed occupational and physical therapists that supervise the students and help set up the therapy programs.
Dr. Linda Austin: Dr. Coker, you’re doing fantastic work. Congratulations.
Dr. Patty Coker: Thank you.