Bimanual upper limb therapy

Last update: 12 Sep 2016

Bimanual upper limb therapy helps children with hemiplegic cerebral palsy learn to use both hands together to complete everyday activities
To be of benefit, an intensive block of therapy is necessary

Who is it for?

Bimanual upper limb therapy may be suitable for children with cerebral palsy who have the following characteristics:
Type of cerebral palsy : Hemiplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.

Mobility : GMFCS I, GMFCS II, GMFCS III

Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

GMFCS Level I
Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

GMFCS Level II
Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

GMFCS Level III
Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

GMFCS Level IV
Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

GMFCS Level V
Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.

See full glossary

Arm ability : MACS I, MACS II, MACS III

Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

MACS Level II
Handles most objects but with somewhat reduced quality and/or speed of achievement.

MACS Level III
Handles objects with difficulty; needs help to prepare and/or modify activities.

MACS Level IV
Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

See full glossary

Communication ability : CFCS I, CFCS II

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

CFCS Level II
Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

CFCS Level III
Effective Sender and Receiver with familiar partners.

CFCS Level IV
Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

See full glossary

Movement disorder : Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

See full glossary

Bimanual upper limb therapy is usually provided by occupational therapists and other similarly qualified rehabilitation specialists or allied health professionals.

Occupational therapists at Cerebral Palsy Alliance offer bimanual upper limb intervention and can help a family decide if this intervention is the right choice for their child.

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Fees may apply for occupational therapy assessment and intervention and will depend on the provider, the type of bimanual upper limb therapy and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing and therapist travel.

Equipment – Therapists will support the family to use readily available resources in the child’s familiar environments as much as possible.

Ask health care providers if you are eligible for funding to assist with occupational therapy fees and any equipment required. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

This intervention takes time and children need multiple opportunities to practice the recommended bimanual activities.

Recommended programs include:

  • Individual sessions with an occupational therapist, involving one hour appointments once or twice a week, for up to eight weeks1. This will be combined with a home program
  • Home programs supervised by the family or carers provide practice each day to achieve the intensity needed to achieve goals
  • Intensive group programs may involve therapy for six hours a day for two weeks, followed by a home program. Occasionally, intensive programs with a magic2 or circus3 theme are available to provide intensive bimanual therapy

More about bimanual upper limb therapy

Bimanual upper limb therapy is an intensive intervention for children with hemiplegic cerebral palsy who experience movement difficulties in one hand. It uses carefully planned, repeated practice of two-handed, or bimanual, games and activities to improve a child’s ability to use their hands together. Successful programs are intensive as well as fun and motivating for the child.

  • This therapy is used with children of all ages who have some ability to use their hemiplegic arm and hand. In the research literature, children from 18 months old to 16 years old have participated in this intervention.
  • Family commitment to intensive therapy and to completing a home program is necessary for successful outcomes.
Most everyday activities are easier to complete with two hands together - for example, catching a ball, putting on a shirt, using a knife and fork, and tying shoelaces. Children with hemiplegic cerebral palsy often have difficulty performing activities that rely on the coordinated use of both hands, because of movement difficulties in the affected (hemiplegic) hand.
  • Children with poor hand and arm ability may be encouraged to use their affected hand and arm to support objects during two-handed activities.
  • Children with a better ability to use their arm and hand might be encouraged to develop dexterity when grasping, manipulating and releasing objects with their fingers.
To be effective, this therapy requires specialist strategies. Children will require frequent contact with a therapist to ensure they have adequate direction, support and feedback. This is for both individual and group-based bimanual upper limb therapy. The therapist will also help a family learn to use bimanual upper limb therapy so that it can be carried out in the child’s familiar environments.
Another upper limb intervention for children with hemiplegic cerebral palsy is called constraint-induced movement therapy. It is equally effective if completed at the right intensity. The decision about which intervention to choose will depend on the goals for therapy, whether a child is able to tolerate the interventions, the child’s and family’s preferences, as well as the resources required. Studies4 have reported the use of these interventions together but no clear evidence yet exists as to whether combining is better than using just one of the interventions.
  • Hemiplegic cerebral palsy is also known as unilateral cerebral palsy
  • Bimanual upper limb therapy is sometimes called bimanual training, bimanual occupational therapy or HABIT (hand-arm bimanual intensive therapy)
  • Bimanual upper limb interventions can be used with children with diplegic and quadriplegic cerebral palsy who experience movement difficulties in their hands. Bimanual upper limb interventions can also be used with children aged under 18 months. No research evaluating this intervention has been completed with these groups of children however.

Assessments

There are two types of assessments which are required when undertaking bimanual upper limb therapy.
An occupational therapy assessment is necessary to help set goals for therapy and to carefully plan the therapy.

The second type of assessment is to measure the outcome of bimanual upper limb therapy to ensure that it has been effective for meeting an individual’s needs and goals. The occupational therapist, together with the child and family will decide on the most suitable measure.

Typical assessments and outcome measures for this intervention are:

Best available research evidence

We searched the allied health and medical literature to find research evaluating the outcomes of bimanual upper limb therapy for children with hemiplegic cerebral palsy.

The search aimed to find the best available evidence about whether this intervention improved a child’s ability to use his or her affected arm to complete everyday activities and achieve functional goals.
There are three main findings from the research. Firstly, high-level research from randomised controlled trials (RCTs)4-8 provides moderate quality evidence that bimanual upper limb therapy is effective for improving upper limb function of children with hemiplegic cerebral palsy if provided at adequate intensity. Secondly, bimanual upper limb therapy is as effective as an alternative, equally intensive intervention such as constraint-induced movement therapy4, 6-9 for improving upper limb function, self-care or parent perception of change and may be more effective for achieving children’s individual goals. Finally, an intensive block of bimanual upper limb therapy is more effective than the same number of hours of conventional therapy distributed over a longer period10.

Bimanual upper limb therapy is more effective than standard care

Two moderate quality randomised controlled trials (RCTs)5-7 compared the outcomes of children who had bimanual upper limb therapy with children who had standard care. In these studies, the children who participated in bimanual upper limb therapy had intensive therapy and those who received standard care had little or no therapy for the upper limb. These studies provide low-quality evidence that bimanual upper limb therapy is more effective than standard care for improving bimanual upper limb function. The results are less certain for unimanual function and self-care but also suggest that bimanual intervention is more effective than usual care.

Bimanual upper limb therapy and constraint-induced movement therapy achieve similar benefits

Some of the studies compared bimanual upper limb therapy with constraint-induced movement therapy. Constraint-induced movement therapy is also an intensive intervention and is known to be effective for children with hemiplegic cerebral palsy. Five randomised controlled trials were included in a good quality systematic review4. Two additional, high quality, randomised controlled trials8-9 have been published more recently. Together, these studies provide moderate to high quality evidence that children receiving either of these interventions improved. Bimanual interventions may improve goal achievement more than constraint-induced movement therapy. There was no difference, however, in the amount of improvement for upper limb function, self-care or parent perception of change between bimanual upper limb therapy and constraint-induced movement therapy. Looking at this evidence together shows that either of these interventions is effective for improving outcomes for children with hemiplegic cerebral palsy.

Bimanual intervention has some advantages over a distributed model of conventional therapy

One study10 compared an intensive block of bimanual upper limb intervention consisting of 90 hours carried out over 2 weeks, with a distributed model of conventional therapy, which was 90 hours distributed over 5 months. The study provided moderate quality evidence that the intensive bimanual therapy was more effective than an equal number of hours of conventional therapy distributed over a long period for improving bimanual upper limb ability and social participation. There was no difference between groups for self-care ability, which improved in both groups and unilateral upper limb outcomes, which did not change in either group.

Date of literature searches: May 2016

  1. Hoare, B., Imms, C., Villanueva, E., Rawicki, H. B., Matyas, T., & Carey, L. (2013). Intensive therapy following upper limb botulinum toxin A injection in young children with unilateral cerebral palsy: A randomized trial. Developmental Medicine and Child Neurology, 55(3), 238-247.
  2. Green, D., Schertz, M., Gordon, A. M., Moore, A., Schejter Margalit, T., Farquharson, Y., et al. (2013). A multi-site study of functional outcomes following a themed approach to hand-arm bimanual intensive therapy for children with hemiplegia. Developmental Medicine & Child Neurology, 55(6), 527-533. doi: 10.1111/dmcn.12113.
  3. Sakzewski, L., Ziviani, J., Abbott, D. F., Macdonell, R. A., Jackson, G. D., & Boyd, R. N. (2011). Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Developmental Medicine & Child Neurology, 53(4), 313-320. doi: 10.1111/j.1469-8749.2010.03859.x.
  4. Sakzewski, L., Ziviani, J., & Boyd, R. N. (2014). Efficacy of upper limb therapies for unilateral cerebral palsy: A meta-analysis. Pediatrics, 133(1), e175-e204.
  5. Gordon, A. M., Schneider, J. A., Chinnan, A., & Charles, J. R. (2007). Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: A randomized control trial. Developmental Medicine and Child Neurology, 49(11), 830-838.
  6. Facchin, P., Rosa-Rizzotto, M., Visona Dalla Pozza, L., Turconi, A. C., Pagliano, E., Signorini, et al. (2011). Multisite trial comparing the efficacy of constraint-induced movement therapy with that of bimanual intensive training in children with hemiplegic cerebral palsy: Postintervention results. American Journal of Physical Medicine & Rehabilitation, 90(7), 539-553. See abstract
  7. Fedrizzi, E., Rosa-Rizzotto, M., Turconi, A. C., Pagliano, E., Fazzi, E., Pozza, L. V. D., & Facchin, P. (2013). Unimanual and bimanual intensive training in children with hemiplegic cerebral palsy and persistence in time of hand function improvement: 6-month follow-up results of a multisite clinical trial. Journal of Child Neurology, 28(2), 161-175. See abstract
  8. Deppe, W., Thuemmler, K., Fleischer, J., Berger, C., Meyer, S., & Wiedemann, B. (2013). Modified constraint-induced movement therapy versus intensive bimanual training for children with hemiplegia – A randomized controlled trial. Clinical Rehabilitation, 27(10), 909-920. See abstract
  9. Gelkop, N., Burshtein, D. G., Lahav, A., Brezner, A., Al-Oraibi, S., Ferre, C. L., & Gordon, A. M. (2015). Efficacy of constraint-induced movement therapy and bimanual training in children with hemiplegic cerebral palsy in an educational setting. Physical & Occupational Therapy in Pediatrics, 35(1), 24-39. See abstract
  10. Bleyenheuft, Y., Arnould, C., Brandao, M. B., Bleyenheuft, C., & Gordon, A. M. (2015). Hand and Arm Bimanual Intensive Therapy Including Lower Extremity (HABIT-ILE) in children with unilateral spastic cerebral palsy: A randomized trial. Neurorehabilitation & Neural Repair, 29(7), 645-657. See abstract
Find out about CP Check-Up™

Cerebral Palsy Alliance offers a service called CP Check-Up™ which provides ongoing surveillance of the health and well-being of our clients aged 0-18 years.
The information on this page was developed using the best research evidence combined with the expertise of clinicians and people with cerebral palsy and their families. It is provided to help people with cerebral palsy, their families and caregivers, clinicians and service providers make decisions about suitable interventions. This information is intended to support, but not replace, information exchanged, and decisions made, between people with cerebral palsy, their families and health professionals.