Ask the Hand Specialist – Two year old with hemiplegic cerebral palsy is resisting constraint therapy

Ask the Hand Specialist - Hemiplegic Cerebral Palsy and Constraint TherapyMy 2 1/2 year old daughter has left side hemiplegic cerebral palsy due to a stroke. Since five months old, we have been doing some form of Constraint Induced Movement Therapy (CIMT). Over the past six months, my daughter has become very resistant to constraint therapy, so that the length of CIMT sessions has been reduced to only a few minutes on most days. Are children less resistant to the Hand-Arm Bimanual Intensive Therapy (HABIT) because it is a bilateral therapy? How intense is the therapy on a daily basis? I’m not sure if HABIT focuses specifically on the type of exercises performed during therapy or if it’s the duration of therapy or both. I live outside of Boston. Are there practitioners outside of New York who have experience with HABIT? My daughter responds well to therapy, and we are trying very hard to get her over this hurdle, since CIMT has worked well for her.

HABIT consists of functional bimanual training. This is one of many ingredients potentially used in physical therapy and occupational therapy, although rarely with the intensity provided in a day camp experience. There are practitioners outside of New York, but I am not aware of any closer to Boston than New York. A good clinician can get it started but home training would be needed to obtain the necessary intensity.

I have a 2 year old as well, and what you are describing is “terrible two’s”. The world is a confusing place at that age, and they are learning to negotiate choice. Why children prefer not to use the affected hand is complex, and probably differs from individual to individual. But using the affected side is really, really hard. Young children can’t articulate that directly, but in the few instances older children have articulated why they prefer not to use it, they say “it doesn’t feel right.” Think of what it would feel like to use your hand after sitting on it for a while–that would be an estimation of what it feels like (weak without appropriate sensation). HABIT is not likely less frustrating in this regard. But they are more likely to use the affected hand (without being told so) if provided a task they want to do that requires two hands. In our day camp model for older children, we have novelty and the possibility to mix and match interventionists based on the child’s personality. Parents don’t have this luxury. I would suggest a combination of special activities only performed during “home therapy” sessions, a reward system, and lots of compassion for how hard what you are asking really is.

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