To constrain or not to constrain, and other stories of intensive upper extremity training for children with unilateral cerebral palsy


Dr Andrew M Gordon, Department of Biobehavioral Sciences, Box 93, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027, USA. Email:


Impaired hand function is among the most functionally disabling symptoms of unilateral cerebral palsy. Evidence-based treatment approaches are generally lacking. However, recent approaches providing intensive upper extremity training appear promising. In this review, we first describe two such approaches, constraint-induced movement therapy (CIMT) and bimanual training (hand–arm bimanual intensive therapy). We then summarize findings across more than 100 participants in our CIMT/bimanual training studies since 1997. We show that (1) at high intensities, CIMT and bimanual training improve dexterity and bimanual upper extremity use; (2) bimanual training may allow direct practice of functionally meaningful goals, and such practice may transfer to unpracticed goals and improve bimanual coordination; (3) 90 hours of CIMT and bimanual training leads to greater improvements than 60 hours of the same treatments; (4) higher doses may be required for bimanual training; (5) increased dosing frequency and shaping may be needed for older children; and (6) combined CIMT/bimanual approaches may be useful, but require sufficient intensity. Together these findings suggest that dosage (treatment amount and frequency), more so than ingredients, may well be the key to successful training protocols, especially for older children. Such rehabilitation efforts should be ‘child-friendly’, and as least invasive as possible, especially because these approaches may be provided throughout development.