Guidelines for Provision of Modified Constraint- Induced ......Guidelines for provision of Modified...

Guidelines for provision of Modified Constraint Induced Therapy - Revised September 2011

© Margaret Wallen of 37 Previously of The Children’s Hospital at Westmead

Guidelines for Provision

of

Modified Constraint-Induced Therapy

(ModCIT)

for Children with

Cerebral Palsy



Contents

Page

Introduction 3

Outline of modCIT intervention 6

Implementation of modCIT by families 6

Role of therapists in implementing modCIT 7

A. Preparation for modCIT with the family

B. Formulation of the intervention programme to achieve family goals

7

8

The primary goals of intervention

Framework for therapy intervention – motor learning principles, formal and informal sessions, demonstration, manual guidance, strengthening, grading, rewards.

8

8

C. Weekly occupational therapy appointments

D. Providing a home programme

11

11

E. Providing and monitoring a log book 12

Frequently asked questions 12

General ideas for implementing modCIT 13

Adapting toys, games and other items 14

Activity ideas 16

Case example – Maddy 24

Resources 28

Example of a daily log book 34

Reference list 36



Introduction Constraint-induced therapy is the umbrella term used to describe upper limb intervention for people with hemiplegia, including children with hemiplegic cerebral palsy, whereby the unaffected arm is constrained to encourage use of the affected arm. The constraint is usually accompanied by an adjunct intervention to maximise the use of the affected side. In early studies, constraint was achieved by a plaster of Paris cast applied 24 hours per day, 7 days a week for 2 to 3 weeks, depending on the study (Crocker, MacKay-Lyons, & McDonnell, 1997; Taub, Landesman Ramey, DeLuca, & Echols, 2004; Willis, Morello, Davie, Rice, & Bennett, 2002). Parents and therapists articulated that constraining a child’s unaffected arm using casts was not acceptable to them. They postulated that long periods of constraint may be frustrating for the child, difficult for families, and perhaps detrimental to the development of a child’s unaffected limb. Interventions deviating from traditional models of constraint-induced therapy, but which are considered more child and family friendly and clinically feasible, are generally referred to as modified constraint-induced therapy. The guidelines herein were developed in response to increasing interest in constraint-induced interventions and based on i) research literature, both randomised trials and other designs, ii) informally seeking the views of parents of children with hemiplegic cerebral palsy and iii) those of experienced paediatric occupational therapists. The guidelines for modified constraint-induced therapy involve wearing a mitt on the unaffected hand for 2 hours a day for 8 weeks whilst engaging in adjunct therapy. This form of modified constraint-induced therapy was based on work by Eliasson and colleagues (2005). This particular programme of modified constraint-induced therapy (modCIT) was evaluated in a randomised trial published as: Wallen, M., Ziviani, J., Naylor, O., Evans, R., Novak, I., & Herbert, R. D. (2011). Modified constraint-induced therapy for children with hemiplegic cerebral palsy: A randomized trial. Developmental Medicine and Child Neurology, 53, 1091-1099. DOI: 10.1111/j.1469-8749.2011.04086.x In this randomised trial, modified constraint-induced therapy was compared to a block of intensive occupational therapy with 50 children with spastic hemiplegic cerebral palsy who were aged between 19 months and 8 years. This trial provided useful information to discuss with families in making decisions about various upper limb options as follows. Intervention effectiveness

The results of the trial indicated that there was no difference between interventions on the primary outcome (Canadian Occupational Performance Measure; COPM; (Law et al., 2005)) or any other measures – Assisting Hand Assessment (Krumlinde-Sundolm, Holmefur, Kottorp, & Eliasson, 2007), Goal Attainment Scaling (GAS; (Kiresuk, Smith, & Cardillo, 1994)), Pediatric Motor Activity Log (Wallen, Bundy, Pont, & Ziviani, 2009), modified Ashworth Scale (Bohannon & Smith, 1987), modified Tardieu Scale (Gracies et al., 2010) or a parent questionnaire (developed for this study). Either intervention –



modified constraint-induced therapy or intensive occupational therapy as implemented in this trial resulted in meaningful change on the COPM. It is important to bear in mind, however, that these interventions were not compared with a control group who received no intervention. Clinical judgement must be used in communicating the implications of these results to families. Intensity of intervention, rather than constraint, appears to be the effective component of intervention. Intervention therefore could be selected in collaboration with the family, based on what best suits the child and family - their needs, preferences and resources, for instance. Adverse events The only potential difference between interventions was that 5 of the 25 children in the modified constraint-induced therapy group experienced difficulties carrying out the therapy, compared with 1 of 25 children in the intensive occupational therapy group. These difficulties were manifest as frustration and refusal to cooperate. Acceptability of interventions Most families (25%) did not find modified constraint-induced therapy “easy” to implement. Most families in the modified constraint-induced therapy (96%) and intensive occupational therapy (96%) groups found the intervention “worthwhile” or “very worthwhile”. Generalisation of findings

Generalisation of findings to other caseloads. Findings should only be expected to

apply to children who are similar to those included in the study. Those children met the following criteria:

had spastic hemiplegic CP

were aged between 18 months and 8 years

achieved at least 10o active wrist extension and/or finger extension in the affected upper limb

possessed functional passive range of movement (120o shoulder flexion and abduction; 30–120o elbow movement; neutral wrist and finger extension; minimum 45o supination)

were capable of cooperating for assessment and therapy

had access to weekly occupational therapy

had parents who indicated a commitment to participating in an intensive intervention and, for clinical purposes, in pre-treatment and follow up assessments.

Generalisation of findings to other environments.

Therapy was successfully implemented in a variety of paediatric environments including specialist cerebral palsy services, tertiary paediatric hospitals, local hospitals, non-government organisations, private practice, community health centres etc, by occupational therapists with a range of paediatric experience (6 months to 28 years).

Written therapy guidelines almost identical to those contained in this document were provided to therapists. Email and telephone support were provided to these therapists if requested. No other education was provided to therapists implementing the therapy. It could be expected, therefore, that modCIT could be carried out by occupational therapists in a variety of settings.



Intervention integrity

Interventions should be carried out in a similar manner to that in the study if similar results are expected to be achieved, i.e., intervention integrity should be maintained. The key features of intervention, which should be incorporated into modified constraint-induced therapy, are as follows.

Goal setting. Each family completed a COPM (Law et al., 2005) which then guided development of specific goals using GAS (Kiresuk et al., 1994). These goals were therefore meaningful and motivating to families and it is possible that using such an individualised, family focused approach to planning intervention may impact on outcomes.

Provision of written functional goals and also of movement goals to family.

Frequency and intensity of modified constraint-induced therapy, that is, a mitt worn on the unaffected hand for 2 hours per day (in minimum sessions of 30 minutes) for 8 weeks, during which time the child participated in structured intervention developed according to the principles outlined in these therapy guidelines

Nature of adjunct therapy carried out while the mitt is worn. Again, the therapy

should be developed according to principles outline in these therapy guidelines – this intervention is occupational therapy, is goal driven, using motor learning principles following a task analysis.

Weekly occupational therapy sessions to provide support, monitor progress and

upgrade activity challenge, troubleshoot difficulties, provide demonstration of home programme and provide family and child with incentive and support to continue with home programme.

Home programme. A home programme, developed according to the principles of Novak et al., (2009) was a formal part of intervention.

Log book. A daily diary noting the timing of therapy and associated comments was completed. This was to assist therapists in monitoring implementation of the home programme and also may have provided an incentive for families to complete the home programme.

The child must be accompanied for safety and to: prevent frustration; ensure success; target therapy; facilitate activity progress and completion; and upgrade difficulty.

The following therapy guidelines were those evaluated as part of the randomised trial outlined above.



Outline of modCIT intervention ModCIT consists of two parts: constraint and therapy whilst constraint is in place. i) Constraint. This involves constraining the use of the unaffected hand with a mitt for

2 hours per day for 8 weeks. The mitt may be worn in smaller blocks of time over the day (with a minimum duration of 30 minutes) to fit in with the child’s and family’s routines. Wearing the mitt (constraint) “forces” the child to use the affected arm. The mitt is made of colourful fabric and consists of a mitten, with the fingers encased in a separate section which is adjoined to the thumb. A flat thermoplastic insert on the volar aspect of the mitt prevents grasp and release. A Velcro or zipper opening on the dorsum or ulnar border allows the hand to be placed in the mitt and the mitt is fastened at the wrist with a concealed button. The precise style and materials used in constructing the mitt is less important than being appealing, comfortable, preventing grasp and release, and being difficult for the child to remove themselves. See photographs below.

ii) Therapy whilst constraint is in place. Families are asked to provide therapy

activities for the 2 hours that the mitt is worn each day. This therapy may be conducted by parents, extended family, in child care or at school.

Implementation of modCIT by families Families participating in modCIT are asked to:

Commit to carrying out the modCIT, that is, facilitating their child to wear the mitt for 2 hours per day along with 2 hours of therapy activities

Attend 2 assessments. o The first, prior to beginning intervention is to identify the goals for therapy (using

COPM and goal setting) and to establish the level of ability prior to intervention. The Assisting Hand Assessment (AHA; (Krumlinde-Sundolm et al., 2007)) is useful to determine the child’s movement strengths and weaknesses and also as a measure of the outcome of intervention.

o The second assessment should be scheduled in the period after completion of intervention to repeat the COPM (Law et al., 2005), GAS (Kiresuk et al., 1994),



AHA (Krumlinde-Sundolm et al., 2007) and other outcome measures used to determine the outcome of intervention

Attend weekly, 1-hour, occupational therapy appointments. The purposes of these appointments are to:

o Provide practical support to families for carrying out modCIT o Monitor the implementation of the modCIT with families and provide ongoing

revisions of therapy to maintain appropriately graded activities o Troubleshoot difficulties if they should arise o Demonstrate and review appropriate therapy intervention, giving detailed written

ideas for therapy activities

Complete a daily logbook recording the times spent wearing the mitt and the amount and type of therapy provided.

Role of therapists in implementing modCIT The therapist has 4 critical roles in implementing modCIT: A. Preparation for modCIT with the family B. Formulation of the intervention programme to achieve family goals B. Weekly occupational therapy appointments C. Providing a home programme

A. Preparation for modCIT with the family

Undertaking involvement in modCIT is an important and significant decision for families. They should be guided through a process prior to implementation to help them to be thoroughly prepared. The family’s routine and commitments must be considered with them to determine the most effective way of integrating the wearing of the mitt into daily life. The following are some questions to consider with the family in establishing the home programme: What is the family’s daily and weekly routine and how can mitt wear and therapy be

integrated into the family’s lifestyle? How long is it anticipated that the child can tolerate wearing the mitt during one

session? How long would they normally engage in structured play sessions? Is this a suitable

time frame for one session of wearing the mitt? Who will do the therapy while the child is wearing the mitt? Can this be shared during

the week or separated for the week and weekend? Can extended family, child care, and/or school be involved? If so, what preparation and

liaison will be required? What rewards might be important for a child to use to motivate him/her to complete a

session of mitt wear? How will siblings be involved in, or how will they be distracted or otherwise engaged

during, modCIT? Others who are involved with providing the daily therapy will also require preparation and support, for example a pre-school visit may be necessary.



B. Formulation of the intervention programme to achieve family goals

The primary goal of intervention is to:

Increase the use of the affected arm in functional activities particularly those identified as priorities by the family using the COPM (Law et al., 2005) and GAS (Kiresuk et al., 1994).

This may be achieved by:

Increase awareness of the affected arm

Increase spontaneous use of the affected arm

Increase motor control of the affected arm

Improved use in bimanual activity

Framework for therapy intervention

Intervention is broadly activity-based, founded on Motor Learning Principles (Eliasson, 2005; Poole, 1991; Valvano, 2004). In order to implement this intervention therapists need to:

Be clear about the child’s and family’s goals. The COPM should be used to identify

occupational performance difficulties that the family considers as priorities to target for therapy. These difficulties can be formed into objective goals for intervention using GAS. These goals are integral to planning therapy with the family. Many goals will relate to bilateral activities, whereas therapy during modCIT must be largely unilateral or using the unaffected/mitted hand as a gross assist. It is important, however, to know the child’s and family’s goals in order to plan the changes to unilateral function required to support these bilateral activities.

Identify the strengths and weaknesses of the child’s upper limb abilities. This knowledge is necessary to plan the specific movement patterns which can be built upon to achieve identified goals. It may be beneficial to complete the AHA and also to videotape the goals established at baseline. This enables a task analysis of each goal so that the therapist can establish:

o The individual movements required to achieve the goals, o Which abilities and movement patterns the child already possesses and o Which abilities and movement patterns the child needs to focus on

For example, if a child wants to be able to catch a ball and he/she can only achieve active supination to 45 degrees, one focus of therapy could be on improving supination to mid position. Activities that facilitate active voluntary supination would be one component of the treatment plan.

Be positive about mitt wear and therapy, set up the implementation of therapy to be fun and “special”.

Implementation may need to be a combination of ‘formal’ (involving motor learning principles) and where necessary, ‘informal’, to fit in with daily routines and to maintain the child’s motivation. Most of the emphasis on therapy should be on implementing modCIT in a formal manner.



Formal. A ‘session’ might consist of:

A brief warm up if some preparation of the affected arm is considered appropriate. This may involve, for example, strengthening, stretching and weight bearing. Other ideas are to involve the child in gross motor activities which involve both arms but maintaining the unaffected hand in the mitt, for example, an obstacle course including crawling, rolling, safe climbing, etc; throwing and catching balls.

A selection of activities, carefully chosen to achieve desired movement patterns, and having the following properties:

o Essentially unilateral activities using the affected arm as the primary arm. As upper limb function is predominantly bilateral, however, it is useful to consider activities whereby the unaffected/mitted arm may be used as an assisting arm within the limits of wearing the constraint.

o Involve children in carrying out self-generated voluntary actions. o Are repetitive (that is, involve practise) (Eliasson, 2005; Poole, 1991; Valvano,

2004) of desired movement patterns (may be several activities to achieve this as well as repeating one activity). If this is difficult to achieve then the priority will remain on facilitating active, spontaneous and voluntary movement.

o Fun and motivating – to engage the child fully and maximise learning.

Frustration must be avoided. o Challenging enough to capture attention and maintain motivation but allow the

child to achieve success. Consider how activities can be graded, for example: focussing on stability then more skills based; gross to finer arm and hand skills; large/gross arm movements moving to activities focused on reach, grasp and release, and moving onto in-hand manipulation.

o Feedback - this is critical to the therapeutic process. Feedback can be verbal guidance, which is directed to assisting the child to complete activities and is ongoing during the session. It should be positively framed; for example, ‘let’s see if you can do it this way’, ‘turn your hand around a little more’, ‘come just a bit closer’, ‘let go now’ etc, rather then correcting or giving criticism. Feedback should also reward small approximations of success, either verbally or in other ways (cheering, clapping or contact).

Demonstration, imitation, manual guidance, strengthening and grading are also critical considerations in implementing modCIT.

Demonstration1of movement patterns (Buccino, Solodkin, & Small, 2006; Pomeroy et al., 2005) may assist a child to learn that pattern. For instance, show your hand moving into supination to grasp an object, demonstrate the use of a digital grasp, show how your own wrist looks as it extends to touch an object on the dorsal surface and to grasp an object, then ask the child to imitate the same action. Manual guidance can be important to give a child the sense of a required movement and the sense of that movement without compensatory patterns of movement. For instance, after demonstrating supination, ask the child to copy you and manually guide them to complete this action. Follow this up with activities which require them to voluntarily

1 It is hypothesised that demonstrating an action with the hand using an object stimulates the mirror neuron system and enhances learning of that task.



complete a supination task. Another example is to manually guide a child to achieve shoulder flexion (perhaps with supination) by assisting the arm to flex whilst using your other hand to maintain trunk alignment or prevent shoulder elevation. Strengthening (Arnould, Penta, & Thonnard, 2007) is an important part of achieving

improved upper limb function. Strength is necessary for maintaining a desired movement, for example, a sustained grasp to stabilise a piece of Lego to interlock with another piece. Strength is also important to achieve resisted movement, for instance in pulling down pants, or pushing off a shoe. Movement against resistance is essential for developing strength (Damiano, Dodd, & Taylor, 2002; Stewart & Wallen, 2008). Consider how strength can be incorporated into activities or become one of the reasons for choosing an activity, for example, play dough, lego blocks, activities stuck with Velcro, tug-o-wars with taking and releasing objects, squeezy bath toys. Grading. Carefully grading activities is important to allow a child to achieve success,

mastery and motivation for trying new tasks, promoting a sense of achievement. Grading of a task may include:

o Gradually increasing the number of times/steps the child does (e.g. sustaining a tripod grasp to complete a 2-block tower then build up to a 10 block tower).

o Reducing/ fading the amount of assistance, cues or prompting that the child receives (e.g. hold the base of the tower and give verbal prompts then build up to the child doing it independently).

o Gradually decreasing the amount of time that the child takes to complete the activity.

o Changing the complexity of the task - start with simple then make the task more and more challenging as the child progresses (e.g. start with Duplo to build a tower then build up to wooden blocks).

Wrap up –include a short bilateral activity, which may be considered a reward, immediately after the mitt is taken off at the end of the session, to reinforce to the child the bilateral nature of most upper limb activities and the use of both hands together.

Rewards for completing a session may be useful in maintaining motivation. Rewards

may be given at the end of each session, or accumulated over the session and given to the child at the end of each session, or alternatively may be accumulated over a number of sessions.

Informal sessions are those when the mitt is worn whilst completing daily self-care, play or productivity related activities, for instance, playing in the sand pit, in the bath, whilst eating/finger feeding, using a computer, playing games, helping to cook, playing outside, water play, bucket of water with objects in it (some that float, some that sink) etc. These activities are generally not carefully selected specifically for the child’s level of ability and it remains essential that an adult be involved to facilitate a child’s participation in these activities to ensure success and enjoyment. This type of activity is sometimes called “massed practice”, that is, the upper limb is still being used but not necessarily to achieve specific movement patterns.



C. Weekly occupational therapy appointments

It is very important that these sessions are well planned so the time can be used most effectively to support the family. The central focus for these sessions is to provide input and ideas on upgrading/continuing the daily therapy programme. This should include carrying out therapy activities, demonstrating activities with the child, observing family completing therapy activities, constructing a written home programme which should be explained and demonstrated, and lending appropriate toys and resources.

Sessions should also be structured to include time for:

Reviewing the child’s progress over the week.

Providing suggestions for difficulties encountered.

Providing valuable support and encouragement for efforts of the child and family over the week.

Reviewing completion of the logbook (mentioned below). Families report these sessions are critical to the achievement of modCIT. Families require input for devising activities which are appropriate and varied for completing at home. They also appreciate that the pressure is off them during the session for carrying out the therapy, and that the mitt-time during therapy reduces mitt-time at home for that day.

D. Providing a home programme

The therapy that families complete must be guided by a carefully developed home programme. The following principles have been adapted from work by Novak and Cusick (2009). Develop an effective relationship with the family. Ensure you have a positive and

supportive attitude. Listen to the families needs, preferences and take time to become familiar with their routines, commitments and time constraints. Work collaboratively to develop some implementation strategies, for example to develop a library of ideas, or to construct a timetable of mitt-time and therapy activities. Constructing the home programme. The therapy should be motivating and fun to do,

with a range of interesting and varied activities. The activities provided should practice desired movements and actions in a way that is fun, but challenging to the degree that promotes the motivation of the child. Give families a number of options to achieve aims and give them permission to adapt them using other resources. It may be useful to write specific ideas down each week perhaps with pictures of activities and ways to use activities. It is a good idea to offer to lend families target activities for a week and also to encourage them to visit toy libraries. This may be a useful option for obtaining toys for siblings to encourage them to be supportive of the modCIT programme. Support the implementation of the programme. It is imperative to demonstrate

activities, to discuss why they have been selected and to observe parents carrying them out. Keep the number of new concepts to only 3 or 4 each session. Give the family feedback on how they are going. Families really appreciate understanding the rationale for selecting activities so they can adapt other activities independently.



E. Providing and monitoring a log book

A log book to record amount of time spent wearing the mitt and completing therapy on a daily basis is an integral part of implementation of this programme of modCIT. It is important to show interest in and review the logbook. Apart from monitoring therapy time and activities it is hoped that the need to present a completed log book to a therapist will act as an incentive to complete daily therapy. An example of a page of a log book is included as a resource at the end of these guidelines.

Frequently asked questions

Can casting or splinting be used to supplement the therapy as part of modCIT? Splinting and casting was not allowed as part of the study, however, clinical decisions can be made for individuals based on each child’s presentation and goals when modCIT is implemented in typical clinical practice. What if the family is not managing to have 2 hours per day to wear the mitt?

Re-consider the routine and see if there are times when the mitt can be worn informally, for example, in the bath, when eating, or when playing. Keep encouraging the family to wear the mitt and keep recording the time spent. Ask the family to seek support from other family members, childcare etc. Can mitt wear be increased at other times, for example on weekends to make up for short falls at other times? Yes, but some time each day is preferable in the first instance. What if the child keeps getting the mitt off?

Re-consider the fastenings and whether modifications can be made. Consider use of more incentives for time the mitt is worn. Start with rewarding short periods and increase the length. What if the family gives up? Be reassured that you and they have made a determined effort. Can the child be left to wear the mitt without adult involvement?

No. It is imperative that children enjoy their time in the mitt and have success with doing activities. It is essential that frustration be avoided. Further, it is important to have an adult to upgrade the difficulty of tasks as progress is achieved. Can the time the mitt is worn during the weekly therapy sessions count as part of the daily 2 hours?

YES!



General ideas for implementing modCIT Reinforce a positive attitude towards modCIT and develop a consistent terminology with

the family about the time the mitt is worn eg “mitt-time” Suggest families enlist others’ support for completing the modCIT, for example, have a

special dad’s time each day or week, ask grandparents, child carers etc to assist. Consider options for obtaining activities to keep the child motivated while wearing the

mitt, for example cheap toys from the “$2 shop”, using local toy library, borrowing from friends, putting special toys away in the weeks before modCIT and only using when the mitt is worn.

Trawl toy cupboards and kitchen cupboards for activities and items which may be adapted to be therapeutic, encourage families to do the same.

Consider options for motivating and encouraging the child’s participation and acceptance of the mitt. For example, rewards put into place after each session so that the child knows when mitt wearing time is over for the day. Have special activities performed only when mitt is worn, for example, play dough, painting or cooking activities.

Use a timer to give a concrete indication to the child as to how much longer the session is and how much he/she has already completed.

Use a ‘special’ or ‘magic box’ of toys which are only played with when the mitt is worn or at the end of a session.

Timetable – some families find it very helpful to plan the day or week ahead. That is, they schedule time for mitt wear and also list the activities for the time the mitt is worn. It is then a simple matter of following the timetable. The timetable will help to ensure there is a variety of activities and to ensure that activities which achieve the various movement goals are included.

Consider the child’s ‘good times’ when planning modCIT, for instance after sleeps, avoiding tired and hungry times, consider when siblings may be present.

It may be useful to get two similar children together who are wearing mitts for added support for the children and for the families.

Consider making items for children to then complete at the next session, for instance use easy-to-hold paint sponges to paint fish for magnetic fish or do a painting to be the base for a collage.

Spend time with the child to find out what they believe would make it fun to wear the mitt, what treats they would enjoy etc. Showing them you are integrating their preferences into therapy may increase motivation. Ask families for the types of activities the child enjoys and any that they avoid.

It may be necessary to modify handles of some items to allow appropriate use eg paintbrush handles, Bradflex on wooden spoon handles used in cooking activities.

Consider how siblings are going to be integrated into modCIT, for instance: involve them in modCIT, have them wear a mitt, or choose toys/activities which will keep them away from the modCIT session if this is more appropriate.

It may be a challenge to keep the mitt on and to think of sufficient variety of appropriate activity to use. Provide lots of praise and positive feedback to the child during and after activities. Be prepared to offer rewards, even small ones, to motivate the child.

Therapy DOES NOT have to be at a tabletop, this depends on the child. It is not always developmentally appropriately to confine a child to a table. Have activity stations set up where child has some choice of the ordering of activities. Have parts of an activity hidden/set up in various parts of a treatment space. Child can integrate upper limb movements into mobility.

Remember: Setting up and packing away/cleaning up are all part of the “therapy”.



Adapting toys, games and other items

It is amazing how toys, games, activities and other items can be adapted and used to make them suitable to achieve movement aims. Following is a list of principles to consider when selecting and adapting therapy activities to achieve specific movement aims Shoulder

Flexion and abduction ROM – activities can be placed at different positions or handed to a child in differing positions for them to obtain using shoulder movement. Manual guidance may be necessary to facilitate a larger ROM or to prevent the overuse of compensatory patterns.

Strength – activities can be set up on a vertical surface and/or at varying heights for completion thus requiring maintenance of shoulder flexion and/or abduction.

Functional patterns of upper limb movement eg

Reaching to opposite shoulder (required for taking off sleeve) – objects can be handed to the child at the opposite shoulder or alternatively ask child to release objects from their hand into your hand or a container placed at the opposite shoulder.

Reaching towards feet (required for pulling down/pulling up pants). Placing activities on the floor alongside a child seated in a chair will reinforce the shoulder and elbow patterns required for activities such as pulling down pants. Consider using a feely box, bucket of water with toys in it to be retrieved (an air filled ‘floatie’ around the wrist may encourage strength when reaching into the bucket), game pieces placed on the floor.

Elbow extension. Many children use their arms within a small range of their body. Many activities can be used to encourage elbow extension by considering where objects are placed to retrieve or where child is required to release them. Consider where the child is seated in relation to fixed objects, move seat away from an object or across a table. Also consider manual guidance to prevent body movement to achieve a reach and to facilitate an increased active elbow extension. Remember to encourage elbow extension at many different planes i.e. with shoulder flexed, extended, abducted, reaching down, with shoulder rotation and encouraging supination, wrist extension. Supination. This is a movement pattern which commonly requires development. Objects may be placed or handed to the child in a way where an appropriate degree of supination is required to grasp or release the object. Consider combining some degree of supination with other movement patterns such as elbow extension and shoulder flexion and reaching towards the opposite shoulder. Manual guidance is very useful for encouraging supination. Wrist extension. Many children have weak wrist extension and wrist control which interferes with efficient grasp and release patterns. The child’s forearm can be placed on the tabletop and an activity piece slid towards them to encourage wrist extension in order to enable them to grasp the object. Activities on an inclined or vertical or elevated surface are also useful for encouraging wrist extension. In preparation for these activities demonstration and imitation can be used, as can the use of some resistance.



Grasp and release. Careful evaluation is required to enable grasp and release to be upgraded. This may involve training components of grasp and release, for instance simply training hand opening, open-hand weight bearing, placement of the open hand (eg on a switch) and maintaining the hand open, without any object requiring grasp and release. It may require facilitating the grasp and release in arm positions that are not functional but which may be upgraded as the grasp and release improves. Manual guidance can be very helpful to facilitate and provide sensory feedback to the child about the desired pattern of grasp and release. Demonstration and imitation can be useful tools to use to encourage a child at a higher level of grasp to complete digital grasps and correct thumb position in a grasp. When the movement goal is developing or refining digital grasp, differing sized object may be used and activities requiring resistance while maintaining the digital grasps should be incorporated (eg squeezing play dough, pulling cotton wool held by the therapist). Finger isolation This is a higher-level movement goal and is an important component of digital grasps, finger dexterity and leading towards in-hand manipulation. Ideas to encourage finger

isolation range from pushing/pointing with the tips of each finger, finger gym exercises whereby the child is encouraged to move each finger separately, grasping objects between the thumb and each of the finger tip, manual guidance to maintain the ulnar fingers in flexion to encourage the radial fingers to grasp/point/poke, stabilising an object (eg dowel) in ulnar fingers to encourage radial fingers to grasp/point/poke. These activities can be upgraded to those that facilitate in-hand manipulation such as high-level finger gym, practice of the components of in-hand manipulation (eg finger to palm translation and palm to finger translation with and without stabilisation, rotation and translation of objects),



Activity Ideas Notes:

Set up and pack away can be considered part of the sessions and be therapeutic e.g. wipe down tabletops, mirrors, windows, washing items, putting rubbish in bin and washing/drying hands. These activities can also be graded and varied, e.g. wipe down table using Enjo mitt, large sponges, thick dishcloths, thin Chucks wipes.

Use the placement of the activity to encourage desired movements, especially consider handing objects to child to facilitate, for example, wrist extension, supination, shoulder movement in wide ranges including reaching to the opposite shoulder.

Many activities will require a parent or therapist to be actively involved to stabilise, set up etc to allow the child to participate. An adult may be required to place an object in the hand and facilitate release to allow a large arm movement. It is acceptable and encouraged to hold an object or complete a section of a task if it assists the child to assist a movement, for example, to hold half a toy egg to allow the child to pull the other half away.

Place objects in affected body space and incorporate activities that move in and out of this body space.

Trawl through work and home kitchen and toy cupboards to find toys, games, activities and items which can be used or adapted to achieve movement goals.

These lists of specific activities for use in carrying out modCIT are very broadly ordered starting with those that are simpler for children to achieve. Examples are given for upgrading some of these activities.

Bubble blowing, child can simply pop bubbles in the air or may be able to hold bubble wand in their hand.

Water play – as simple as sponges and floating toys to push under water and pop up again. Use a big bucket/basin, bubbles, funnel, measuring spoons and cups, jugs, corks, sieve, items that float and those that sink, waterwheel. Can water plants using items such as cups/jugs from the water play.

Shaving cream. Draw on a tabletop, mirror or glass door. Noughts and crosses, drawing, pre-writing skills, rainbows etc. Can place small objects in the foam, use foam stamps. Put foam on child’s supinated hand to encourage supination. Using a window: place parent on other side and child can achieve reach in different positions by ”placing” foam on parents nose. Use shaving cream on the bath sides and tiles, shower screen. Really useful to have child assist with cleaning up shaving cream by using a damp cloth.

Finger painting – see shaving cream for ideas and can place small pieces of pasta, paper, legumes, cotton balls etc into the paint. Also allocate each finger a colour and each finger can only be dipped in this colour or the colour placed on the fingertip (supination). Dot pictures such as caterpillars and flowers. To grade, can start with fist prints, move to open hand prints and then individual finger prints.

Painting with sponges (use different items from home, eg cotton balls, dishcloths cut into interesting shaped pieces). May place sponge in child’s hand to simply encourage large arm movement and arm placement. Also paint rollers are useful. Place paper on vertical, incline or horizontal.



Quoits – can place in child’s hand and facilitate release to encourage large arm movements and arm placement. Hand to child so supination is required. Place pole of base horizontally to encourage supination. Ask child to retrieve from a range of positions including opposite shoulder. Can hide pieces in a room and ask child to find to complete placing on pole. Lie on back and take quoits backwards over head to place on stick. Retrieve from behind head and place on unaffected arm. Take from unaffected arm to replace quoits

Play Twister

Potato printing – on horizontal or vertical surface, turn potato upward to have paint applied (to encourage supination). Can place in child’s hand.

Batting balloon with hand, try to keep in the air, encourage hitting with hand open and turned palm upwards. Hold bat (assists sustained grip) to bat balloon to keep it in the air.

Larger balls – roll between people, attempt to roll between goals, knock over tower of blocks, aim for target

Button pressing noisy toys

Switch toys – can mount switch to facilitate supination, shoulder movement, elbow extension etc. Grading- big red switch to jelly bean switches to Specs switches. Adapt to hold switch down for on, or touch to turn on and turn off.

Play cards – from the simple eg matching pairs, Memory, Snap, Fish to the more complex, eg Black jack, 500 etc. Make the motor component as simple as sliding cards across a table, slide the card off the edge of the table using different fingers, or difficult - take the card from the pile using thumb with different fingers, turn the cards over on the table top. The cards can be lined up around a table to make it simpler to slide cards off table. Card stands could be used.

Theraputty, Polydough or Playdough – see recipe attached

o Make as simple as “squashing ants” – squashing small balls of dough; “catching snakes” – pushing down on a playdough sausage/snake; pushing objects down which are placed in the dough by another, eg other coloured dough, dough cutters,

marbles, game pieces. Grading: squash balls with fist open hand index finger

and other fingers. Squash on floor (uses body weight) squash on table squash against window/mirror (hardest)

o squeeze large ball of dough through all fingers

o squeeze between thumb and individual fingers

o Pick off small pieces with thumb and different fingers and shape into balls

o Squeeze these balls with thumb and different fingers

o Hold hand out straight and try to pick up these balls between each pair of fingers. Carry between fingers and release onto another spot. Pick up balls and hold two or three at a time between different fingers.

o Roll playdough into a sausage and use alternate fingers to push down to make indentation. Then use thumb with alternate fingers to squeeze between each of the indentations made.

o Pick up small items and push into dough and pull out. Use toothpicks, chopsticks, golf tees, match sticks to stick into dough, oasis or styrofoam

o Lots of other playdough play, use cookie cutters, roll out to make sausages and coils, etc.

Gruesome Goo – fun to make and play with. Recipe and ideas attached.



Use a light bat or cardboard roll to keep a balloon in the air, or to bat a suspended balloon or ball which is suspended from clothes line in a stocking or orange bag. Grading- balloon

stocking filled with plastic bags beach ball volleyball.

Have a bag of bath toys to play with in the bath, including sponge shapes and letters, squeezy toys, toys that float and sink.

Place bath mitt on child’s hand for them to soap up and wash body parts in the bath

Jelly beans – can sort these into colours either on a table top or in plastic cups. May simply slide jelly beans on tabletop, use grasp/release or use large plastic tweezers or ice tongs to assist. Place each colour in its own zip-lock bag and use as a treat for a great mitt sessions.

Squeezing toys such as squeezy glitter pens

Tiny firm foam shapes with a hole are available from bargain shops. These can be used for a myriad of activities. They float and can be caught and thread onto a skewer which is stabilises in oasis or playdough. They can be stuck to shaving cream. They can be colour and shape matched, sorted in like pieces, play matching patterns and thumb to finger opposition practiced.

Sand play. Hide objects in sand, use spades to retrieve, have funnels, sieves, forks etc. Can wet sand and encourage building. Consider using rice, seeds, beans instead of sand.

Bouncy men: three coloured pegs resting in pegboard and which when pushed bounce out. Hand to child for replacement so as to facilitate supination, digital grasp and shoulder movement. Hand to child with their forearm stabilised on tabletop to encourage wrist extension.

Music session. Put on favourite CD and use different instruments to make music. Examples: maracas of water bottles and different fillings (chick peas, sand, rice, marbles), drums of saucepan lids and wooden spoons, buy cheap shakers and bell instruments from budget shops. Also hitting object eg spoon, shaker, against object held by another person, so that a range of movements can be facilitated from the child making contact with the other person’s “instrument”. Instruments can be placed in child’s hand.

Use egg cartons as a container. Objects such as pom-poms, blocks, golf balls, playdough balls, ping-pong balls etc can be placed with precision in the different compartments. Place the carton in different positions to encourage shoulder flexions, abduction, reach to floor etc.

Open flap books

Gum ball machine – ball is placed into machine to activate music.

Small table-top see-saw. Item placed on one end and child pushes on other end to launch item into air.

Very lightweight scarf which when thrown in air floats down slowly. Child catches scarf and places in container.

Socks. Ask child to collect socks from socks drawer into a container. Child can hide them around the house as a game for others to find. When found, hand them to child to replace in container. Alternatively hide the socks for child to find. Container can be placed at different positions to encourage different shoulder/wrist movements. Socks can be given to/taken from child to encourage supination.



Play with plastic tea-sets and cooking utensils, may use water. Set up a Teddy Bear’s Picnic, feed teddies, pour tea etc.

Sticker chart. This can be mounted on the wall and the child can place their own stickers on the chart for example; within a session, at the end of each activity or at the end of every 10 minutes.

Soft toys in buckets, pull out one at a time, line up and replace.

Sesame Street musical cube. Plays music and manipulating knobs on each face of cube alters the music.

“Feely bag/box” with toys of various sizes and weights to retrieve

Fishing game ie catching fish with a magnet at the end of a string, consider build up of handle of fishing rod.

Matchbox and other cars, running down ramps, sorting, playing on road mat. Have races by rolling matchbox cars down tubes eg glad wrap rolls. Cars which pull backwards to create movement are useful.

Eggs which split in two pieces to reveal matching shapes. The child will require assistance to stabilise one side to pull the other apart. Can place just one half back in the egg carton and then find the matching half to join together.

Make plaster moulds to paint – may need built up paint brush handles, or use sponges or fingers to paint. May be appropriate for child to spoon or pour plaster into moulds for use in a subsequent week. Spare plasters can be sent home.

Chocolate dipping. A great activity is to melt chocolate and dip marshmallows, dried apricots, grapes, etc in it, place on a tray to set. The child may use the thumb with different fingers to pick up and dip the items. You may also hand the items to child to achieve supination, shoulder flexion/extension etc. Can involve the child in preparing for the activity also, eg placing marshmallow and other items in bowls, pressing microwave buttons, stirring chocolate as it melts (may use built up wooden spoon). Child can lick finger achieving finger extension and supination also! At the end of session child can hand out chocolates and can pack them away to take home.

Squeaky toys requiring squeezing to make the noise.

Posting different types of balls through a large cylinder (ie. Postal tubes) tied onto the side of a chair or leg of a table with a large bucket underneath, use balls with bells in them, large and small marbles, ping pong balls, tennis balls – varied widths to encourage finger grasps or open hand stretch and wide grasp depending on ability

Connect 4 – use thumb with different fingers. Give counters to child in different positions to encourage wrist extension, supination, shoulder movement. To upgrade, pick up counters, translate into palm to pick up another, then bring out one at a time. It is not necessary to worry about playing the game correctly for smaller children, they also love to see the pieces fall out the bottom at the end of a ‘game’.

Drawing using large implements and large movements. Make rainbows, draw lines between matching items eg: flower and butterfly, teacup and saucer, bee and hive, hat and head, etc. Use a whiteboard and whiteboard markers for this also which reduces the surface resistance. Try upgrading the resistance with the surface used (whiteboard, paper,



blackboard) the incline of the surface and the implement (whiteboard marker, textas, crayons, chalk).

Jumping bugs – available from Socrates. Press down on bugs, they suction to tabletop and jump up.

Skittles – setting up the skittles can involve supination, shoulder movement. Use blocks, empty water bottles etc

Throwing balls, bean bags and quoits at a target or in a bucket.

Ball relays – hold balls or bean bags on supinated hand and relay to a container.

Table soccer ie jig placed on table to give an edge and goal area. Blocks of wood are used to prevent ball entering the goal area.

Craft Shape punchers

Wear the mitt for a snack, spillproof drink and finger food – pieces of fresh or dried fruit, chunks of cheeses, rice biscuits, small chunks of sandwich

Sound block – 2 cubes which when the pictures on the sides are matched up, they make an accompanying sound.

Magnets. Large u-shaped magnets or magnetic wands with little magnetic balls are available. Be inventive with using this to attract paper clips, magnetic items from other games etc.

Computer games and activities that require dragging or clicking or modified access to activate. May increase size of pointer, slow speed of mouse etc.

Velcro fruit – wooden fruit which is cut in half and held together with Velcro. A play knife can be used to ‘cut’ the fruit or the fruit can be held by another so the child can pull apart and replace the pieces.

Cook Speckled Bubble Bars – recipe attached

Use kitchen tongs to pick up pom-poms (from craft shop), cotton balls or other similar objects to glue onto a picture (eg wool on a sheep, centre of flowers), or to dab paint onto a painting. The tongs are good to develop grip strength. Try holding them both ways, that is, with thumb closer to end or with little finger closer to end, and also doing activities on an inclined/vertical surface as well as a tabletop. Use small tongs with finger tips to pick up small objects eg pasta, cotton wool, sultanas, dried apricots

Buy cheap magnetic letters and numbers and use on a magnetic board. Can sort these by colours, by letters, into the alphabet and order letters, can match with a written letter etc. This is good for shoulder and elbow strength and control. Consider handing the letters to your child from different directions as well as starting some on the magnetic board and sliding them into place.

Larger building bocks – sort into colours and place in towers, make a castle, train tracks, practice copying simple shapes as follows but can make up more complex ones also.

Kerplunk – use the marbles and sticks in the set up and clean up.

Dominos – pieces may be slid or grasp/released into place



Make pasta necklace (or use other materials). You will need to hold ‘string’. Use string with sticky tape tied around the end to make it rigid or use plastic tubing which is firmer

Shape sorters

Modify craft activities to allow child to complete. Consider special celebrations for themes eg Easter, Fathers Day.

Make caterpillar or sheep from cotton wool balls, tongs can be used to handle the cotton wool or they can be coloured.

Draw a large picture with discrete sections which can be filled in with different media eg: cotton wool balls (tearing them apart is good for strength), scrunched paper balls, pieces of pasta, pieces of cut up cellophane or coloured paper, paint, collect leaves, twigs, nuts etc from the garden (with mitt on!). Pictures could be an umbrella, beach ball, clown face, butterfly. Child can spread glue either with paintbrush (adapted handle) or glue stick. The paper can go on an easel, table top or vertical surface.

Small sandbags or freezer bags filled with dried bean, rice etc and use as an old fashioned orange race. Can also hide these and make a game of finding them and placing them in a bucket. Make the container size smaller to develop finer control of release.

Stamps with knobs (eg from Educational Experience), great to do on horizontal or vertical surface

Keyboards – musical, electronic, tiny roll-out fabric light touch electronic piano.

Game whereby beads are strung on wire attached to a baseboard

Games where the hand is placed inside to retrieve other smaller toys, for example soft pelican which has a gullet full of small stuffed fish.

Jumping frogs - aim for a container, race across floor, use different fingers.

Pegboards – use different fingers to move pieces. Can play memory game with this, that is, one player makes a pattern of colours and allows opponent 10 seconds to view then hides. The opponent then attempts to copy the colour pattern. May do designs. Can mount board in different positions eg vertical

Play with hand puppets. May make these first, out of paper bags. See examples attached.

Play with finger puppets

Puzzles with handles - Puzzle can be mounted on an inclined surface. Puzzle pieces can be handed to the child to encourage supination, wrist extension, shoulder range of movement.

Handy little items to have to encourage finer grasps are: buttons, counters, golf tees, toothpicks, skewers, tiny teds, minipegs and flattened marbles (used in vases). These can be sorted, pressed into foam or playdough, posted. Use to practice translation and stabilisation

Ice cream container or shoe box with slots cut into it – child places coins and buttons into slot and then opens container to remove. Use thumb opposed to different fingers. Make



this into a game, for instance, a reward for each “I spy” correct answer, or give child 3 pieces to put in for every 10 mins of mitt wear – use a timer to reinforce this. Then give a special treat if a certain number of pieces are collected over the day. Can incorporate translation and stabilisation into this activity.

Pegs: squeeze pegs onto a container and onto each other. Importantly take them off to put away. Consider placing a container around shoulder height to put pegs on or to release into. Copy patterns or play memory game with this, that is, one player makes a pattern of colours and allows opponent 10 seconds to view then hides. The opponent then attempts to copy the colour pattern. Can use thumb opposed to differing pegs and can build in translation, rotation and stabilisation tasks. Make spider or octopus by placing pegs on icecream or other container, inverting and gluing eyes and other features on the container.

Stack ‘em game (Crown Andrews). Child needs to gently place pieces onto a board without it toppling over.

Pop-Up Pirates – child place sword into pirate’s barrel until he pops up.

Games such as Battleships, Trouble, Monopoly, Scrabble, Snakes and Ladders –use different fingers to manipulate pieces, also pick up more than one piece in hand, using translation and release one at a time.

Spray toys such as small water spray bottles and water pistols.

Jig saw puzzles and try to pick up pieces between thumb and different fingers.

Lego with pieces stabilised on a Lego board

Use kitchen and/or ice tongs to pick up and release objects eg blocks, cotton wool balls

Pick up small objects eg kidney beans, smarties with thumb and different fingers and release into a small mouthed container eg drink bottle, film canister.

Face washer – place on table top with corner stabilised under heel of hand. Use fingers to ‘walk” face washer into hand – make sure all fingers get a turn. Try with the washer damp.

Marbles – flick with thumb and different fingers. Hold hand out straight and try to pick up

between each pair of fingers as for playdough. Consider using them to encourage in hand manipulation ie picking up one, translating into the palm for stabilisation with the ulnar fingers against the palm. Roll them through obstacles placed on table top. When putting them away, encourage grasp between thumb and middle finger as well as with index finger. Give them to child with arm on the tabletop to encourage wrist to extend and also to turn palm to the side or supinated to grasp them.

Jacks –pick up and replace between thumb and different fingers; Hold hand out straight and try to pick up Jacks between each pair of fingers as for playdough

Pick up sticks

Barrel of Monkeys

Finger Gym ideas for older children and those with minimal impairment. Can make up a “kit” for these to be kept together and used everyday.

o Turn hand palm up - touch tip of thumb to tip of each finger in turn, straighten all fingers in between turns. Then, squeeze each finger to thumb firmly.

o Lie hand palm down on table top, keep palm down and then lift thumb and each finger off table top in turn, then try to keep each finger lifted for a couple of second.

o Place hand curved like a crab on table top, rest of hand off the table. Straighten thumb and each finger to lift them off the table in turn.



o Place heel of hand on table with fingers all elevated, sequentially/rhythmically bring each finger down on table top always starting with little finger (racing horse)

o Hand above table – deliberately and rhythmically bring thumb, index, middle, ring and little finger (in this order) down firmly on table top.

o Using different sizes barrels “walk” fingers up and down eg pencil, wooden spoon, chop stick, dowel

o Use pencil – turn it around in finger

o Turn hand palm up and grasp object (eg small block, plastic counter) between thumb and each finger in turn then release each into a small container placed about shoulder level.

o Rubber bands – position around thumb and one finger and stretch and release with thumb and finger opposed; stabilise one end and grasp the other with thumb and different fingers. Try to keep hand still whilst doing this, so the fingers are doing the moving. Also place smaller rubber band across two fingers and stretch fingers apart sideways



Maddy is a 4 year old with right sided spastic hemiplegic cerebral palsy. She is mildly affected with the following scores:

Modified Ashworth Scale: 1 = slight increase in muscle tone manifested by a catch and

release or by minimal resistance at the end of the range of motion when the affected part is moved in flexion or extension

Manual Abilities Classification System: III

Gross Motor Function Classification System: I The discrepancy between the MACS and the MAS is due to a substantial learned non-use. Maddy has good capacity to use her arm but frequently does not. She also has significant weakness especially of grip strength and wrist extension, and limited supination. The goals identified on the COPM and GAS included: 1. To push her affected arm through a t-shirt sleeve 2. To pull up undies using both hands 3. To hold a pop-up top drink bottle with both hands and drink without spills 4. To pull on socks with both hands 5. To pull on shoes with both hands A task analysis of these goals, considered in conjunction with assessment of Maddy’s capacity lead to the nomination of the movement (therapy) goals. These goals were given to Maddy’s family along with the goals identified by GAS to assist them in interpreting the home programme and planning daily therapy for Maddy. On the following pages are: 1. The therapy goals which were given to Maddy’s family 2. A plan for an occupational therapy session 3. An example of a list of home programme ideas given to Maddy’s family each week.

These activities were discussed with the family and when appropriate were demonstrated. As well, ideas for implementing these activities to achieve the movement goals were discussed. This weekly list also included one generic reminder for modifying/customising activities to achieve Maddy’s movement goals.

Case Example Maddy



Aims of therapy for Maddy

Increase arm and especially grip strength

Increase sustained grasp

Increase strength of full arm extension

Increase supination (turning palm upwards)

Improve finger dexterity which includes finger to thumb grips and the ability to move objects within her hand.

Improve wrist extension strength

1 Therapy goals given to Maddy’s family



Modified constraint induced therapy. Maddy Week 3

Activity Implementation Playdough Demonstrate range of activities to increase gross and finger grip strength

Hand pieces to Maddy to encourage wrist extension and supination

Kerplunk Ask mum to place sticks in place prior to starting game. Maddy to pick up marbles from towel on tabletop with thumb and index; and thumb and middle fingers to place in top of game. Maddy to take turns to remove sticks Involve Maddy in putting away marbles. Hand them to Maddy to encourage supination and wrist extension (ie ask Maddy to place forearm on table and roll/hand them to her. Place container at various heights and position to encourage shoulder movement.

Balloon Game whereby balloon is kept in the air with a supinated hand (includes shoulder movement). Use very light bat to bat between players (grip strength, sustained grip)

Craft – make sheep of cotton wool Mount pre-drawn outline of sheep on wall (encourage shoulder, wrist and elbow extension). Ask Maddy to paint glue in outline using built up paint brush (encourages grip strength and shoulder movement). Encourage tripod grip to pick up and place cotton balls on glue. Try using tweezers For legs of sheep, hold cotton ball so Maddy can pull cotton balls apart and make finer ‘wool’.

Pop-Up Pirate game For grip strength. Hand pieces to Maddy to encourage a variety of shoulder movements, and to encourage wrist extension and supination. When putting the pieces away, hold container in different places to encourage functional reaching patterns (eg at opposite shoulder, near feet, behind and to the side etc)

Quoits Have pre-hidden in room. Maddy to find quoits and replace on quoit-pole which is held at different angles and heights to encourage shoulder movement and supination. Maddy to remove quoits from quoit-pole and hand back at different heights, play tug-o-war.

2 Occupational therapy session plan



A few ideas for Maddy

(Home programme)

Remember to use the clean up as part of mitt time, ie wipe down table, wash hands, place garbage in bin, wash sponges and squeeze out and lay out to dry etc.

Painting with sponges (use different items from home, eg cotton balls, dishcloths cut into interesting shaped pieces). Put paper on wall to encourage shoulder movement.

Skittles/10-pin bowling – rolling a ball into empty water bottles, or stacks of blocks. Maddy can build the blocks or set up water bottles.

Connect 4. Give the pieces to Maddy at different shoulder heights and in ways to encourage her to turn her hand palm up, and also to encourage wrist extension (ie with forearm on table top). Another idea is to help Maddy to secure a piece in her palm using the ring and little fingers and the to grasp a second piece with her thumb and index/middle fingers.

“Feely bag/box” with toys of various sizes and weights to retrieve. Can Maddy identify them before bringing out of bag? Ask her to ‘show’ them to you with her palm up, before placing down. To replace, hand them to her at different shoulder positions, and to encourage her to turn her palm up and to encourage wrist extension. Change the objects in the feely bag to make a new adventure every day. Some can be edible treats!

Wear the mitt for a snack – spillproof drink and finger foods – chunks of fresh or dried fruits, sandwich cut into chunks, chunks of cheese, large pieces of pasta, rice biscuits. Also can wear to eat treats eg marshmallows, jelly beans, Maltesers (placed on a towel to prevent rolling) etc.

3 Home programme ideas



Resources

Contents:

Speckled bubble bar – recipe

Gruesome goo – recipe

Playdough recipe

Hand puppet pattern – cat

Hand puppet pattern – lamb

Example of daily log



Speckled Bubble Bars

1½ cups marshmallows

60g butter

2½ cups Rice Bubbles

½ cup 100’s & 1000’s

1. Line an 18 x 28 cm shallow tin with Glad Bake.

2. Place butter in pan. Stir over low heat until melted. Remove from heat. Add marshmallows and stir until melted. This is easy to do in microwave.

3. Place Rice Bubbles and 100’s & 1000’s in a large bowl. Pour in marshmallow mixture and mix well.

4. Pour mixture into prepared tin; smooth surface. Allow to cool and set (about 1 – 2 hours).

5. When cool, cut into bars.

6. Enjoy!! Makes 24



Gruesome Goo

Place cornflour and a few drops of food colouring in a bowl. Slowly add the water and mush the mixture together by hand.

Plunge hands into the goo and mess with your goo.

Squeeze a handful hard then stop squeezing and open your hand.

Get hold of some kitchen utensils (e.g colander, strainer, slotted spoon, pasta spatula etc) and see how the goo works when you push it through the holes or try to spoon it around

Pick up a blob and roll it to make a solid ball. Stop and let the ball rest.

Put some little toys in the goo and retrieve them

2 cups of cornflour

food colouring 1 cup water.



PLAYDOUGH 2 cups Flour 2 tablespoons Cream of Tartar ½ cup salt 2 cups of water 2 tablespoons oil food colouring Combine dry ingredients in a large saucepan. Combine all wet ingredients in a jug, add to dry ingredients and mix well. Cook over a medium heat stirring constantly until it forms a ball (using a wooden spoon is probably the best). (You will find quite a bit sticks to the saucepan, don’t worry about trying to get it all out just scrape as much as you can). Scoop the hot playdough onto a plate or the bench and allow to cool before you start kneading (it can be quite hot). Then knead into a ball. If you find it sticky add a bit more flour and knead it in. Wrap in plastic. You can store like this or also put it into an air tight container. You can store in or out of fridge.



modCIT

DAILY LOG Child’s Name: Start date: This Daily Log is a very important part of implementing this therapy and I am very grateful for your efforts to keep it up to date and bring it with you to each visit. On the following pages please complete (see example below):

The date

Where the therapy was conducted

How much time is spent each day wearing the mitt and doing therapy).

Please record the number of minutes for each day. If the therapy is carried out at different times during the day, please note each time separately. See the example following.

Comments: This might include information like:

o Your child’s response wearing the mitt and doing the therapy

o Any changes you note over the period of therapy

You may ask family, friends, school, child-care or preschool to assist with the therapy. If this is the case, please ensure that the log book is completed for these instances also. If you have any questions or concerns please contact: on tel: Example of completing the Daily Log:

Daily Log – Week 1

Date Wed August 1st Place worn Home, Gran’s

Time in therapy OR time mitt was worn (if in mitt group)

Morning = 45 mins; afternoon = 1 hour 20 mins

Comments (Child’s response, changes noted) Enjoyed therapy, opening and closing hand more to grasp toys, reached to other side to pick up spoon. The bath toys, marbles and play dough were great activities to encourage the right movements.

PLEASE TURN OVER TO START THE DAILY LOG



Daily Log – Week 1

Date Wed August 1st Place worn Home, Gran’s

Time mitt was worn Morning = 45 mins; afternoon = 1 hour 20 mins

Comments (Child’s response, changes noted) Enjoyed therapy, opening and closing hand more to grasp toys, reached to other side to pick up spoon. The bath toys, marbles and play dough were great activities to encourage the right movements.

Date Place worn

Time mitt was worn

Comments (Child’s response, changes noted)

Date Place worn

Time mitt was worn


Date Place worn

Time mitt was worn


Date Place worn

Time mitt was worn


Date Place worn

Time mitt was worn


Date Place worn

Time mitt was worn




Reference List

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Bohannon, R. W., & Smith, M. B. (1987). Interrater reliability of a Modified Ashworth Scale of muscle spasticity. Physical Therapy, 67(2), 206-207.

Buccino, G., Solodkin, A., & Small, S. L. (2006). Functions of the mirror neuron system: implications for neurorehabilitation. Cognitive and Behavioral Neurology, 19(1), 55-63.

Crocker, M. D., MacKay-Lyons, M., & McDonnell, E. (1997). Forced use of the upper extremity in cerebral palsy: A single-case design. The American Journal of Occupational Therapy, 51(10), 824-833.

Damiano, D. L., Dodd, K., & Taylor, N. F. (2002). Should we be testing and training muscle strength in cerebral palsy? Developmental Medicine and Child Neurology, 44(1), 68-72.

Eliasson, A. C. (2005). Improving the use of hands in daily activities: Aspects of the treatment of children with cerebral palsy. Physical and Occupational Therapy in Pediatrics, 25(3), 37-60.

Eliasson, A. C., Krumlinde-Sundolm, L., Shaw, K., & Wang, C. (2005). Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy: An adapted model. Developmental Medicine and Child Neurology, 47(4), 266-275.

Gracies, J. M., Burke, K., Clegg, N. J., Browne, R., Rushing, C., Fehlings, D., . . . Delgado, M. R. (2010). Reliability of the Tardieu Scale for assessing spasticity in children with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 91(3), 421-428.

Kiresuk, T. J., Smith, A., & Cardillo, J. E. (1994). Goal Attainment Scaling: Applications, theory, and measurement. New Jersey: Lawrence Erlbaum Associates.

Krumlinde-Sundolm, L., Holmefur, M., Kottorp, A., & Eliasson, A. C. (2007). The Assisting Hand Assessment: Current evidence of validity, reliability and responsiveness to change. Developmental Medicine and Child Neurology, 49(4), 259-264.

Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock, N. (2005). COPM Canadian Occupational Performance Measure (Vol. 4th). Ottawa, ON: CAOT Publications ACE.

Novak, I., Cusick, A., & Lannin, N. (2009). Occupational therapy home programs for cerebral palsy: Double-blind, randomized, controlled trial. Pediatrics, 124(4), e606-e614.

Pomeroy, V. M., Clark, C. A., Miller, J. S., Baron, J. C., Markus, H. S., & Tallis, R. C. (2005). The potential for utilizing the "mirror neurone system" to enhance recovery of the severely affected upper limb early after stroke: a review and hypothesis. Neurorehabilitation and Neural Repair, 19(1), 4-13.

Poole, J. L. (1991). Application of motor learning principles in occupational therapy. American Journal of Occupational Therapy, 45(6), 531-537.

Stewart, K., & Wallen, M. (2008). There is little evidence on the effect of upper limb strengthening in children with cerebral palsy, from http://www.otcats.com/topics/Strengthening_CAT_FINAL_Nov_30_2009.html

http://www.otcats.com/topics/Strengthening_CAT_FINAL_Nov_30_2009.html



Taub, E., Landesman Ramey, S., DeLuca, S., & Echols, K. (2004). Efficacy of constraint-induced movement therapy for children with cerebral palsy with assymetric motor impairment. Pediatrics, 113(2), 305-312.

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