Ellie's mother contacted our clinic to investigate CIMT as a potential treatment option for her 2 year old daughter who developed left sided hemiplegia as a result of an acquired brain injury at birth which led to a diagnosis of hemiplegic cerebral palsy. Ellie's mother reported that Ellie was slower to achieve her developmental milestones as a result of her hemiplegia. Ellie had achieved walking despite this, and her lower limb was continuing to improve. However, Ellie's progress with her hand and arm had been slower and Ellie was becoming more resistant to traditional therapies. Following an initial telephone consultation Ellie attended the clinic for her initial assessment with one of our specialist CIMT therapists, Natalie.
On initial assessment Ellie presented with the following problems:
- Left sided upper limb weakness
- Neglect of her left arm with a preference to use her right hand for all activities
- Difficulty sustaining grip around an object
- Difficulty fully opening her hand
- Increased muscle tone (stiffness) causing tightness in her forearm and hand
- Hypersensitivity to touch or handling (disliked left arm being handled)
The initial assessment with Ellie determined that she did have movement in her left upper limb with lots of encouragement. Despite increased muscle stiffness Ellie had good range of movement in her left arm. Following discussion with Ellie's mother it was recommended that Ellie undergo an intense course of CIMT aimed at improving her hand function.
Ellie's CIMT Programme
Ellie attended our clinic in Manchester for a 2 week programme. Ellie responded very well to the casting applied on day one and settled in well.
Initially it was difficult to sustain Ellie's attention as she was easily distracted by other toys, however we soon learned which toys were her favourite and which we could use to stimulate use of her upper limb. It was useful having Ellie's mum present during the sessions to provide extra encouragement and cheerleading or the occasional hug if Ellie got frustrated. Ellie particularly enjoyed play doh, and role play activities e.g. playing with the tea party set or kitchen play. Ellie also liked sensory and messy play finding items hidden in the box of shredded paper.
By the end of week one we were able to see noticeable differences in the activity in Ellie's left arm. Ellie was able to hold a small spoon and take it to her mouth as well as small snacks, something she would previously never have been able to do with her left hand.
During the second week Ellie continued to show improvements and she was able to pick up a larger variety of objects independently, carry them and release them. She was able to hold a roller and paint with her left side as well as showing more efficient movement patterns throughout her arm.
At the end of the two week programme once the cast was removed Ellie automatically involved her left hand in activities without prompting. She was able to pick up heavier items with two hands. Ellie blew bubbles with the wand in one hand and held the bottle in her left hand herself. We were all really pleased with outcome and progress in such a short space of time and how quickly Ellie adapted to the cast.
Ellie was provided with a new removable cast which she was able to wear under supervision of her mother on leaving the programme. This was to continue to use the principles of CIMT in order to progress her skills further. CIMT can considerably increase a child's function, however it is not a 'quick fix' and Ellie will continue to need on-going therapy input to maximise her potential in future.
Feedback from Ellie's Mother:
"We decided on CIMT after Ellie had been having physio for about a year. Up until that point she was showing consistent improvement, but then she seemed to plateau, and we thought it wold be worth trying something fairly drastic to try and kick start the improvement again. We live in South East London, but CIMT was the closest place we could find offering constraint induced movement therapy. We had the treatment when Ellie was 2½."
"Our CIMT therapist Natalie was really good at motivating Ellie and adapting activities to make them more beneficial for her. It's hard for a two year old to stay focused on a task for long, and because the therapy room is full of toys and equipment, we found Ellie kept wandering off and finding other things to play with - usually things that weren't much good for her left hand! But Natalie was really patient and would find ways of making sure Ellie was using her left hand in some way, whatever she was doing. Our sessions were from 9am until 12, with the option of a break in the middle, although we never needed the break because Ellie enjoyed herself so much! She was fine during the sessions but very tired afterwards and usually slept on the way back."
"There was a pretty dramatic improvement in the 'before' and 'after' scores on the measurements that Natalie took. The first time my family saw Ellie after the treatment they could see big differences straight away. It's been really helpful having the cast to use at home, and I think I'm seeing Ellie improve more, the more we use the cast. She wears it for at least an hour a day, and we have a few toys that she's only allowed to play with when she has the cast on, which means she looks forward to wearing it."