Ep. 2 Play that Works: Engaging & Effective OT Motor Interventions for Kids with CP

What if you could help children with cerebral palsy make significant motor gains with half the therapy hours while keeping both parents and kids engaged? Pediatric occupational therapists Dr. Michele Alaniz and Dr. Lacy Wright dive into the OT research comparing constraint-induced movement therapy and bimanual intensive training, revealing which approach might have the long-term edge for your pediatric therapy practice. Along the way, you'll hear Michele's inspiring OT story about a former client who now rides mountain bikes after successfully using constraint-induced movement therapy, discover practical pediatric occupational therapy strategies to overcome initial child resistance and laugh at Lacy's epic "Failed It" implementing the Zones of Regulation. This episode delivers evidence-based strategies to transform your interventions and elevate your pediatric therapy outcomes when working with kids with CP.

We share our own thoughts in the Research Review and encourage you to read the article too.

Liang, K.-J., Chen, H.-L., Huang, C.-W., & Wang, T.-N. (2023). Efficacy of constraint-induced movement therapy versus bimanual intensive training on motor and psychosocial outcomes in children with unilateral cerebral palsy: A randomized trial. American Journal of Occupational Therapy, 77, 7704205030. https://doi.org/10.5014/ajot.2023.050104 

Keywords: Occupational therapy; evidence based practice; OT ideas; OT; Peds OT; pediatric occupational therapy; cerebral palsy; CP; motor skills

Stay informed, stay curious, and stay playful!

Email us at IdeasAtPlayPodcast@gmail.com

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Transcript

Michele: Welcome to Ideas at Play, where we discuss pediatric research and help you apply the ideas to your daily practice. Each week, we'll review evidence-based ideas to make you a better therapist. I'm Dr. Michele Alaniz, Director of Pediatrics at a rehab hospital in Southern California. And with me is my good friend and former coworker, Lacy.

Lacy: That's me, I'm Dr. Lacy Wright, an occupational therapy professor in Kansas City. We're peds OTs who love research and making it fun. We've helped thousands of therapists just like you to become more informed, more playful, and more effective in their sessions.

Michele: Today we'll be discussing how to improve motor skills in kids with CP. Let's get started.

Lacy: But first, we have some exciting news, we are coming out with a weekly [00:01:00] newsletter. If you love what you hear in today's episode, sign up for our weekly newsletter where we provide a quick summary of the research and links to any products or places we discuss in this episode. Email us at ideasatplaypodcast@gmail.com.

Michele: And now let's get started with Nailed It or Failed It. This is our segment where we discuss what worked and what didn't work in our practice this week. Because if you're pushing for the just right challenge, sometimes you're going to nail it and sometimes you're going to fail it. Lacy, you're up first with your failed it for the week.

Lacy: Yes, Michele. Sadly, I have an epic fail for this week. So, I was working with one of my fantastic Fieldwork Level 2 student to implement a version of the Zones of Regulation. For those who are not familiar with the Zones of Regulation, it is a very visual and concrete curriculum that helps clients understand how they are feeling by identifying which colored zone they are in.  Then, based on their zone, metacognitive or sensory-based action steps are provided to acknowlege how they are feeling and provide supports. So, we're working in a supported workplace for adults with intellectual and developmental disabilities. And we really want to have a system in place [00:02:00] that uses common terminology so we can identify when one of our workers is having a hard time or just needs a little bit more support for the day. Now, our program, our workplace, is set up so that there are different work tasks in the workplace that are color-coded to different colors. For example, there's one group working on janitorial training, and they're working in what we call the orange zone. And there's another group working on packaging cat treats in the quote-unquote green zone. You can probably tell where I'm going with this already. So, my student and I made customized Zones of Regulation visuals using emojis per our client's request. It looked great. We took it to the library and printed out these big, beautiful posters. And we were so excited. Then we go to roll out the program and we ask, “What color zone are you in?” And they all reply with [00:03:00] their work zone colors. The janitorial group shouts out, orange zone! Which, as you know, does not correspond with any of the Zones of Regulation colors. And on top of it, there's a few clients working on the cat treats, the green zone, and they're perpetually reporting that they are in the green zone, and it completely fell flat.

Michele: Complete fail.

Lacy: So, yeah, I need to figure out what to call this now. Like, we're thinking like color categories, but that's not catchy.

Michele: That's actually terrible.

Lacy: I know, uh, color feelings. Feelings? Color? I don't know. Help me out. Can you please send, me ideas? For now, I just cut off the top, um, of my poster and it looks a little bit bare. I would love to reprint it. so yeah,

Michele: Okay. Listeners, if you have a better idea for Lacey for instead of Zones of Regulation, instead [00:04:00] of what did you call it? Colored categories. If you have a better idea than that, which I'm sure you do, please email her and help, uh, help a friend out on this one.

Lacy: I need it. Clearly. Okay, Michele, help us out. Take me out of my embarrassment. I hope you have a great Nailed It for this week. 

Michele: I think I do. I think I do. You know, last week we were talking about social modeling and I totally nailed it with my social connection group. I have these four kids that I work with who are just learning how to make friends and be a friend. And we've been really struggling with them to teach them different concepts and one of the hardest one is a concept of fair play, where you get to decide who's going to go first or whose idea are we going to go with? Cause everyone has different ideas. So we've been introducing the concept of rolling a dice. These kids can't quite do the rock, paper, scissors kind of thing. It's that's a little bit too complex, but the rolling the dice is at the just right level for them. And we've been teaching them how to use it, but [00:05:00] I really wanted them to incorporate it into just their own mindset so we don't have to prompt them. So I had the idea that we were going to make a movie. So I brought in the kids and I said, guys, we're going to make a movie. “Who wants to be the star? Who wants to be the cameraman?” Everyone got assigned roles. And then they did a movie of how to use the fair play strategy correctly. And then we did another movie of what happens if you don't. And we had a really exaggerated falling apart and one of the kids was filming it. So it was a little bit dicey on the filming, but the kids loved it so much. And they wanted to watch it over and over again. And they wanted to show their parents. And then the next week when they came back, boom, they're using the fair dice, the fair play strategy on their own without any prompting. So nailed it!

Lacy: Cool. That's great. So you made a movie they taught themselves and then they loved it so much they just kept re-teaching themselves the skill. And they came back.

Michele: That's it exactly.

Lacy: Great. Good job, Michele.

Michele: [00:06:00] Thanks. 

Michele: And our next segment is the research review where we break down the latest in pediatric research, explore how to apply it to your sessions. This week, Lacy has an article about motor skills for kids with CP and parent stress. Lacy, tell us about your article.

Lacy: Have a great article for us this week. Michele, it's called Efficacy of Constraint Induced Movement Therapy Versus Bimanual Intensive Training on Motor and Psychosocial Outcomes in Children With Unilateral Cerebral Palsy: A Randomized Trial.

Michele: Well, Lacy, that title is a real banger.

Lacy: It is riveting, right? And so long. So, um. It was so long I counted up the words, to be dorky, and it's actually 24 words. I think it's the longest title I've ever written, and for kicks, I went back to your long title last [00:07:00] week, and yours was 19 words, and I thought that that was the longest one ever, so, mark it down. Episode 2. 24 words for our title. 

Michele: It's a new record.

Lacy: See if we ever beat it.

Michele: So why did you pick this article with this amazingly long title?

Lacy: Well, I didn't pick it for the title, but it's a recent article. It came out of AJOT, 2023. And I like it because, we’ve worked with lots of kids with CP. And the authors were really interested in figuring out how they could lower the dose or the number of hours required

Michele: I like it

Lacy: for constraint-induced movement therapy and bimanual intensive therapy. Constraint-induced movement therapy has been researched quite a bit, but it always has tons of hours. 

Michele: Yeah. I mean, I wanted to just jump in and say, for the listeners that might not know constraint induced movement therapy is when you lock down the good arm to force the [00:08:00] use of the affected arm. It's an interesting dilemma because sometimes the affected arm, is not strong enough for protection. If they fall to, like, extend to protect them. So we have to be mindful of that with our kids, or sometimes the non-affected limb still has some delays, even though it might not be as impaired.

Lacy: Yeah, the article takes a look at that and it compares it to bimanual intensive training and bimanual intensive training is a therapy where the therapist chooses activities where the child is forced to use two hands to do it. Such as like opening up a water bottle, right? Like you, you can't just do it with one hand. You have to stabilize it somehow. 

Lacy: So, the author doesn't go in depth too much about the protocols for these two therapies. The author assumes that the reader has familiarity with it, but does say that both of these have a lot of research backing it up. Michele, have you ever tried one of these with a [00:09:00] kiddo?

Michele: I have tried both of these, actually with two different kiddos. I tried the constraint one with a younger child that I was working with and he just needed to work on his his hand, his arm was doing pretty good, but we could not make progress with the dexterity. And so we wanted to try just. Putting a mitten on the uninvolved hand and actually his grandmother, sewed it for us and custom made it.

Lacy: Oh,

Michele: And then, you know, we worked really heavily on the affected hand while that mitt was on. And it was interesting because just recently, a couple of weeks ago, I ran into this grandmother and her grandson who I used to treat, who's a teenager now, and he rides mountain bikes at school. That's his sport. And she was talking about how much grip strength it takes and the control to like switch the gears. And I was so [00:10:00] proud of how he's grown up and used it.

Lacy: Oh, that's such an awesome story. I love when they come back and you get to hear about how they've progressed so wonderfully. So you said you've done the other one too, the bimanual intensive training.

Michele: Yeah, I did that with a kiddo who had involvement on both sides. So one side is more involved in the other, but I didn't want to restrain one side because he still really needed to develop skills in it. And so I worked with the parent who was very involved. And I worked with the school district OT. I was able to consult with her as well, so we pushed it into the classroom as well as at home, and we got some pretty good outcomes with that, and in fact, if the listeners want more specific protocol, I am thinking of a study that I used to model that intervention after, and it had specific activities listed in it, so just shoot us an email, and I'm happy to share that article with you so that you can get those specifics.

Lacy: Excellent. Thanks for those examples, Michele. [00:11:00] Okay. Back to this article. So, the authors used protocols established in the literature for both constraint-induced movement therapy, also called CIMT, and bimanual integration therapy called BIT. Naturally, the researchers wanted to figure out how to use these protocols to improve motor skills. And the other thing that was unique I touched on earlier is reducing the number of hours. They got down to 36 hours in their study as opposed to the 60 to 90. The other part of this article that I actually like even more is that they were looking at psychosocial measures. They measured parent stress and child engagement. And I love what they said about parent stress, where a lot of times the parents are enrolling a child in a program or trying to find a program to help their child. The child doesn't usually have that natural buy-in that adult clients tend to have. There's this gap where the parents want so badly for the child [00:12:00] to be engaged and do all the activities and the kid is just showing up and doesn't really understand the why and the what behind it so that can cause a lot of stress, especially for parents. So I'm really glad that we have research that is looking, at motor skills but also looking at some of these other psychosocial factors and dynamics.

Michele: Yeah, I like that they include that too. The child that I was working with was really unhappy about it. In the beginning, it took him a while to adjust to it. And if they hadn't been totally on board, I think they would have given up right away because it was stressful. You know, he was crying. He was trying to rip it off. You know, he didn't want it. It was hard for him. And. Eventually, he got used to it, and it was no big deal, and we were able to make the gains, but I think looking at how parents are impacted by the interventions that we're choosing is super important.

Lacy: Yeah, definitely. 

Michele: Okay, Lace, now that we understand what the intervention is, tell us, what did they actually do in the study?

Lacy: So this study took [00:13:00] place in Taipei and the researchers recruited 50 kids in their study, ages 6 to 12 years old and all of these kids had unilateral cerebral palsy. So one side was much more affected than the others they broke them into two different intervention groups. One was the constraint-induced movement therapy group and the other was the bimanual intensive training group. And they had the kids do the protocol for each of their different interventions for 2. 2 hours a day. so a little over two hours, for two days a week for eight weeks. So it's a lot, but it's for a short duration over time, 16 visits overall.  I loved how they talked about how they fit these chunks of therapy into the family routines so that it was more manageable for the families to carry it out. And it was in the school and the home setting. The other thing that they shared was They didn't just work nonstop for a little over two hours with the kids. They broke it into [00:14:00] 30 minute chunks and then had five-minute breaks in between. And they worked on activities that had a lot of upper extremity and hand skills, such as grasping, releasing, carrying items, stabilizing, and in hand manipulation. Within those 30 minute chunks, at least one of the 30 minutes was spent doing developmentally appropriate games. And they described this as being board games, card games, crafts, ball games. The big thing that they did clarify, though, was that the constraint-induced movement therapy group did not have a splint or a cast or any sort of physical restraint around the arm. Instead, they used what they called gentle physical guidance, which was just holding a kid's hand. And they did this to reduce parent stress and negative emotions around it. So I thought that was really interesting, that they didn't actually have a physical barrier because that's always what's made me a little bit hesitant to use constraint-induced movement therapy. [00:15:00] Because I'm, I'm never quite sure what that thing should be. Um, I know some therapists make like a soft cast and I'd never really had those supplies. 

Michele: Yeah, I like that they did that too. Although I could see how that might be hard for implementation for a parent, um, who might not have the skill of like how to do it, you know, in a way that's not triggering. I know that I've done it before where I just had them pull their arm into their shirt, you know, so instead of having the arm out, yeah, something easy like that, or you could do it with a jacket and again, like not have the arm out. You could just keep it on the inside and then zip up the jacket. If you don't have anything fancy to restrain it with, you could even do it as like a dress up game. Where you're like, okay, we're going to put on our, like our one-armed Superman costume or whatever. And then restrain it that way to make it more fun.

Lacy: hmm. I was thinking about just having like a designated, I don't know, like tennis ball or something that the kid would have to hold in their hand to give it a [00:16:00] job rather than just holding hands. It. It sounds a little awkward, like holding a kid's hand for two hours, like sounds really sweaty too.

Michele:It does sound sweaty! I do like though that they, I like that they, um, broke it up and I can see how like in a clinical practice how you could do this where you could do one hour in your session and then the parent would be assigned to do an hour at home. So I could see how it could be feasible in real-life practice.

Lacy: Yeah, definitely. The parents observed the sessions, but they actually didn't do any at home, which is interesting. Cause I've seen other articles where it's very home driven if it's not like an inpatient setting. 

Michele: So, Lacy, it sounds like a pretty cool study. What did they actually find?

Lacy: So they had some great outcomes. They looked at motor skill and motor skill coordination, And they saw how that affected arm or hand ended up performing and how the two hands ended up performing [00:17:00] together. And groups saw good improvement across the board, when they checked in.

Michele: But the big question is, who won? Which one had the biggest improvement?

Lacy: They both had equal improvement with motor skills.

Michele: I hate a tie!

Lacy: Okay, but there is one that is an edge winner. So the researchers took measurements throughout this study. They did a pre test, checked in at midpoint, four weeks into it. A post-test, and then a follow up six months later. And at the six month follow up only, the constraint-induced movement therapy was just a little bit better. And the researchers hypothesized that it was easier for parents to understand the intervention protocol and just say, use the affected one more. Rather than, Oh, do activities with two hands together. Like it was just easier for parents to conceptualize that and keep practicing.

Michele: Yeah, that [00:18:00] makes sense. It takes a lot more creativity to do the two handed approach than it does to just try to use the other one. Um, so it sounds like C. I. M. T. came out with the penalty kicks and won it.

Lacy: It did this time. The other thing that they measured, again, going back to that parent stress and the child engagement, parent stress through this whole thing was very low and did not change. So, I think using those embedded routines and, being mindful of parent stress. The parent and child engagement was the most interesting part. The parents had buy in the whole time, and it remained really high on their chart. The child engagement, though, as you said with your own experience, the child was not into it and did not buy in initially. But with each subsequent session, the child rated their improvement and their eagerness to return as a little bit [00:19:00] higher each time. So that goes to show anticipate maybe some bumps initially, and then it'll improve. The other thing that the author suggested was to include the child as much as you can, as soon as you can, ask them about what kinds of activities, explain why it's important, get their buy in as fast as possible. 

Michele: Okay, so let's go through and do our three question wrap up that we end our research review segment with every time, where we talk about the population, the key ingredients, and the mechanism of action. So, Lacy, we talked about the population. Remind us again.

Lacy: These were children ages 6 to 12 years old with unilateral cerebral palsy.

Michele: Okay, great. And then the key ingredients, which are the things that we need to keep in mind if we're going to implement this in our research review in our regular practice. What are those key ingredients?

Lacy: So the key ingredients are different depending on the protocol that you choose. The constraint-induced movement therapy, you're trying to get the affected [00:20:00] arm to do as much as possible while restraining the unaffected side. With the bimanual integration therapy, you're doing activities that are forcing the child to use both hands together. You also want to get buy in from the child. It needs to be fun, so you can hit that 18 to 36 hours of therapy total. It's also important to embed the therapy into the family's routines as much as possible and focus on those fine motor activities, upper extremity activities, and developmentally appropriate fun games.

Michele: Yeah, that makes sense. And then let's talk about the mechanism of action, which helps us to understand why this study actually worked.

Lacy: Yeah, so this study goes back to that motor learning theory.

Michele: Love a little motor learning theory!

Lacy: So that includes high repetition where you're doing the same activities or similar activities over and over and over again so that you're [00:21:00] tapping into that child's neuroplasticity. The article also talks about the importance of that just right challenge where you're continually trying to challenge the child little by little to push towards progress. And that's it for our research review. Try out one of these protocols in your therapy practice and tell us all about it. 

Lacy: Alright,up next, we have people, places, and products, where we shine a spotlight on something that is making our therapy hearts happy. Michele, you have a product for us today. Tell us all about it.

Michele: I do, and I know on our last episode, we shouted out to students and it was a student that actually first brought this product into the clinic for us to try. And then we ended up buying one ourselves. It's this cool little light box. Um, if you've worked with kids with low vision before, you might've heard of a light box.It's basically just a table that's got a backlight on it. So anything you put on it [00:22:00] has high contrast, but the low vision ones are super expensive. And this is one that you could get at Target for $25.

Lacy: Wow!

Michele: Yeah, it's cool. So it's like this little table, it's backlit, and then you can push the button and change the colors. So it might be like a, just like a white light, or it could be blue or green or orange. And then you put things on top of it and it draws the child's attention to it. 

Lacy: So what do you put on top of it?

Michele: Well, it comes with these overlays. So some of them are like pictures and then they have these little shapes that you can put on the picture to, to build the picture on the light table, or it has letters that you can use, but as an OT, you know, we use anything on something like this. And I was working with a little girl who is not low vision, but she does have pretty involved autism and gets a little bit stuck sometimes where she seems like she's not happy, but we can't figure out how to pull her out of [00:23:00] whatever thing that she's gotten stuck on. So I brought out the light box. She loves spinning things. I got those little suction baby spinners. Have you seen these before?

Lacy: Uh, I think so.

Michele: They suction to the window and then you push it and it spins around. So they're. Yeah, they're designed for babies, but I pop those onto the light box and she was mesmerized and she got so happy and she started playing with it and it was cool because I'm also trying to work on imitation with her so that she can learn some new skills and generally that's very difficult. But in this case, because she was so motivated, she was watching me push the button to change the color of the light box and then she was doing it. And it ended up being a really good session just with this cute little light box.

Lacy: Oh, that's awesome. I would love to see that in action sometime. And I'm going to have to look up those baby spinners.

Michele: Well, I'll be sure [00:24:00] to put it on our social media so that people can see what I'm talking about. You can check us out on under IdeasAtPlay and see what I'm talking about.

Lacy: If you've got questions, we've got answers, email us at ideasatplaypodcast@gmail.com or DM us on social media and we may include your question in a future episode.

Michele: This week is our first question, and it comes from Megan. Megan wants to know, “I work with kids on developing their leisure skills, and I love using sports in my sessions. Do you have any ideas on how to support developing basic sports skills so our kids can be successful participating in their community programs?”  Oh, I love this question!

Lacy: Yes.

Michele: It has to do with inclusion, and it has to do with, um, following the child's lead on what they love, and it's using something that's really, uh, exciting and motivating [00:25:00] with your kids in your session. So, great question, Megan.

Lacy: Oh, and leisure skills. I feel like as therapists, we often overlook those leisure skills. So I love where you're going with this, Megan.

Michele: You know what this reminds me of? Remember when we did that group, that Adventure Together group where we had the kids come in and we were working with them on different leisure activities. So like one time we did soccer, right. And I contacted the local place and said, what are some of the drills you do in your soccer practices? And they gave us some ideas. Cause we had no idea neither of us play soccer.

Lacy: I don't play soccer.

Michele: So we worked with the kids for four weeks in the clinic where we were introducing these ideas, these soccer drills, and just making it the just right challenge for each of the kids so they could do it.

Lacy: Mm

Michele: And then at the end, we went on that field trip to the arena they gave us a group lesson and we were able to go in with the kids and the parents came and they were able to do all of these skills that we've been practicing in the clinic. But they were able to do [00:26:00] it successfully at this community program. And it was so exciting for them.

Lacy: So fun. I love those field trips. Getting out. We did soccer. We did yoga once. I think we did a painting class.

Michele: Music. Don't forget about the rhythm circle we did. Uh, yeah, it's really fun because we got exposed to a lot of things that we had never done before. It's not about being an expert. It's just about figuring out what the kid is interested in and then being able to scaffold the tasks so they could be successful.

Lacy: Yeah. I would say having a really good community partner at the end and could help us scaffold those activities. So we were planning with the end in mind and then working backwards to make sure that our kids were successful when they went out. That was really important with the program.

Michele: Yeah, and even, you know, sometimes that's not available to you, but what you could do [00:27:00] is have the parents go to the practice ahead of time and see if they could videotape what they're doing at the practice and then they could use that video and show it to their child over the weeks and then bring it into your session so you could see what they're doing and just backwards engineer it that way because I mean, of course, we all want good community partners, but sometimes they just can't be had. So that might be one way of doing it.

Lacy: Mm hmm. Yeah, I love that example of how it could work individually, too. Different sites don't always have a group that can facilitate this, but it can definitely work one on one with the same parameters. 

Michele: So hopefully that helped Megan. Give it a try and let us know how it turned out.

Lacy: This week we reviewed constraint induced movement therapy and bimanual integration therapy. Remember the steps. Work with your child on those upper extremity and hand activities such as grasp, release, carrying by manual [00:28:00] integration, but also include those occupation-based activities that are developmentally appropriate with those board games, card games, and last but not least, involve the client child as much as possible in the intervention to get their buy in from the start.

Michele: Thank you for listening to Ideas At Play. If you learn something new from today's podcast, be sure to leave a rating and review. It really helps others find our podcast so we can all be evidence-based therapists. If you want more ideas for your sessions, you can find us on Instagram under ideas at play or email us at ideasatplaypodcast@gmail.com. 

Lacy: Until next time, stay informed, stay curious, and stay playful.

Out-take

Lacy: It's something like 60 to 90 hours is like the dose for constraint induced movement [00:29:00] therapy. So when I kept thinking about all these hours, the Justin Bieber song kept coming into my head, the 10, 000 hours, right? Kids are going to be an expert. 

Michele: There is always room for Bieber in therapy.