Constraint and bimanual therapy

“hand” book

Name:

Holland Bloorview Kids Rehabilitation Hospital

150 Kilgour Road, Toronto, ON M4G 1R8
T 416-425-6220 T 800-363-2440 F 416-425-6591
E [email protected] www.hollandbloorview.ca

A teaching hospital affliated with the University of Toronto

Introduction

What is constraint and bimanual therapy? How do I get started?

Children with hemiplegia have one hand that Your therapist will fit your child with a constraint
functions better than the other hand. Constraint and to be worn on the unaffected hand. The type of
bimanual therapy has been shown to improve the constraint and the length of time the constraint
motor control and use of the affected hand. The goal will be worn will be determined by your therapist.
of this therapy is to improve the use of the affected This constraint prevents the child from using
hand in two handed activities. their unaffected hand to encourage use of the
affected hand.
What is the purpose of this handbook?
This handbook provides parents and caregivers with Practice log and goal setting
examples of activities that can be completed during Your therapist may do assessments and set goals
the child’s home therapy program. The activities with you prior to using the constraint and after using
encourage use of their affected hand in reaching, the constraint. Your therapist may have you fill out a
grasping and two handed activities. practice log to provide necessary feedback.

This handbook includes activities that can be Before starting the activities, you may want to do
completed while the child is wearing the constraint ‘warm-ups’ by stretching your child’s arm and hand.
and also includes bimanual activities that involve
the use of both hands together.

This handbook should be used under the

guidance of your therapist.

When doing the activities, try to:

Straighten the elbow and if Pick up objects using thumb, Rotate your forearm by turning
possible bend the wrist and index and middle finger rather palm up to face the ceiling.
fingers up while keeping the than the whole hand (or it may
wrist in line with the arm. be easier to have your child pick
up the object from your hand
instead of from the table top).
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© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 1
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
One-handed activities

 Position objects, toys, game pieces to  Place rings on a post. Move the location and
encourage elbow straight when reaching. height of the post so your child has to reach in
Encourage reaching in different directions: different directions.
above shoulder, out to side, in front with
elbow straight.

 Pop bubbles. Aim for wrist extension  Push down on a switch toy or a toy with a large
(fingers pointed up). Your child should try push button. Place the toy away from your
to pop bubbles using the pointer finger only child so s/he has to reach for it.
and pinch the bubbles with pointer finger
and thumb.

 Sensory Bin. Fill a container with dried beans,  Shaving cream on mirror or bathtub wall.
rice, pasta, etc. Hide some of your child’s Have your child sit or stand a distance away
small toys in the box or bag. Let them move from the wall so they have to straighten their
their hand around in the box to find their toys. elbow. Let them draw in the shaving cream
To make this harder, your child can close their (this is also a great opportunity to practice
eyes or use an eye covering. drawing shapes or printing their name).

 Sensory activities with a blindfold can include  Play with a toy wand or light saber.
having your child match different fabrics
using their affected hand, identifying letters
or numbers that you draw on their affected
hand. You can also ask your child to “touch
your nose, touch your head” etc.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 2
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
One-handed activities Continued

 Water play. In a suitable container (e.g. plastic  Musical instruments. Play the drum or
box or small wading pool) have your child triangle. Place the instrument a distance away
move a toy under the surface of the water so your child has to straighten their elbow.
(e.g. a boat, small plastic toy, etc.). Scoop Practice reaching in different directions.
water using a cup (something easy to hold)
and pour the water into another bucket.
The bucket should be placed on the side of
your child’s weaker arm as this will encourage
forearm rotation.

 Wave a large ribbon in the air (it can be  Flashlight designs. In a dark room, have your
attached to a stick) or large bubble wand. child wave a flashlight to make pictures on the
Focus on large movements in all directions. wall. Encourage a straight elbow.

 Knock over bowling pins on the floor or off  Play catch with a “Velcro hand.” Your child can
the table. Put them far away so your child has help remove the ball from the Velcro and
to reach for them. Have your child push them throw the ball.
with the palm of their hand.

 Throw a small ball and catch it if possible.  Hit a large, light ball off of a stand (“T-ball”).
Your child can hit with the front or back of
their hand, or use a racquet or bat. This may
require HOH (hand over hand) assistance.
Racquet sports include tennis, badminton.
Encourage elbow extension.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 3
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
One-handed activities Continued

 Toss bean bags or small ball (that fits into your  R

 oll an extra-large ball. Your child should
child’s hand) into a basketball net or bucket. keep it in control with elbows straight, wrist
Have the net at least at your child’s shoulder in line with arm, fingers open and thumb
height. Progress from dropping them in to out of palm.
tossing/throwing. Keep elbow straight.

 Have
 your child sit on a towel and use only    ush a filled large box or laundry basket.
P
their hands and arms to push themselves Try to keep elbow straight.
backwards for a distance.

 Pull a rolling cart/suitcase or push a filled  H

 elp out with chores around the house
grocery cart (your child may need assistance such as wiping tables, cleaning windows,
with steering). dusting, washing the car, etc. Any chore
that encourages your child to keep their
elbow straight.

 Everyday activities such as opening a door,  P

 lay cards. Position the cards a distance
turning the tap on/off, turning on/off light away to encourage your child to reach with
switches, opening/closing cupboard doors. a straight elbow. Play games that encourage
your child to turn the cards up so their palm
faces the ceiling.

 Video games that involve reaching such as  G

 ym equipment. Resistive exercises,
Wii and Kinect, as well as using a keyboard lifting weights, pushing weighted objects.
or tablet. Supervision suggested.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 4
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
One-handed activities Continued

 Using an exercise band, have your child hold  Wall pushups. Stand in front of a wall an arm’s
the band and hold the other end securely in length away. Place arms (both or only the
their weaker hand. Try to stretch the band affected arm) on the wall with:
with their elbow straight. You can also tie • elbow straight
one end to a doorknob and have your child • wrist in line with arm
hold the other end with his/her weaker hand • fingers pointing to ceiling
to stretch the band while keeping the elbow • thumbs out of palm
straight.
 Do wall pushups by bending and
straightening the elbow. Do not move the feet.
Repeat.

© PhysioTools Ltd © PhysioTools Ltd

S
 tack blocks.   Stack cones or nesting boxes

 Place large wooden beads on a post. Adult  Place pegs into pegboard. Begin with large
may have to help steady the post. pegs and then decrease the size as accuracy
and grasp develop.

 Self-feed. Finger foods or use of utensils.  Carry

 a bag or purse using the
affected hand.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 5
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
One-handed activities Continued

 Squeeze putty, playdough or stress ball.  S

 queeze sponges filled with water. Start with
a sponge in a bucket of water, place sponge
over an empty bucket and squeeze out water.
Continue until first bucket is empty. Also can
squeeze washcloth in bath or dishtowel to
wipe counter.

 Rubber
 stamps. Use stamps that have a post   
Coloring/painting/printing on a vertical
to grab onto. Encourage pushing into an ink surface, chalk board or table top.
pad and then on to the paper. Use a vertical
surface if possible.

 Play a piano or use a computer to move  Pop bubbles on bubble/packing wrap.

the fingers. Encourage your child to use only
one finger on a key and “hide” his/her
other fingers.

 Put coins into a piggy bank slot or checkers  P

 ut small objects such as blocks, beads,
into game slot (e.g. Connect Four). marbles, game pieces into containers with
various sized openings. Inserting pennies in
a piggy bank. Progress to using salad tongs
or tweezers.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 6
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
One-handed activities Continued

 Squeeze clothes pegs. Find ones that are  F

 rog jump. Plastic frogs that jump when you
easier or harder to squeeze. Place them on the push on their “tail.”
edge of a cardboard box

 Games/board games. Some can be adapted  T

 urn over cards using the affected hand.
to use one or two hands. Roll the dice, spin Thick cards and bigger cards are easier.
the spinner and move game pieces where
appropriate. E.g. Wiggle Giggle, chess/
checkers, Pop Up Pirate, Candyland, Guess
Who or Kerplunk.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 7
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
Two-handed (bimanual) activities

 Weight bearing activities. Weight should be on P

 lay on a play structure. Climbing/holding
the affected hand while the non-affected hand onto both rails, monkey bars, swing.
plays. Side sitting, prone (on tummy), 4-point
(hands and knees) reaching for toys, doing
puzzle, reading book, etc.

 Cut paper. Stabilize paper with affected hand.  String beads (large or small).

 Ride a bike/scooter. Buckle the helmet.  Throw a large ball that requires two hands:
shooting basketball, volleyball.

 Carry a box, large stuffed animal or a tray.  Jump rope.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 8
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
Two-handed (bimanual) activities Continued

 Swimming. Use both arms to swim, holding  Play Zoom Ball. Child holds the straps at one
onto a pool noodle or flutter board. Swim end while you hold the other straps. Ask your
strokes with both arms. child to pull the straps apart to “zoom” the ball
over to you.

 Getting dressed. Push arms through sleeves,  Gymnastics, yoga and taekwondo.
socks, pants. Do up fasteners: zippers,
buttons, snaps and shoelaces.

 Hula hoop. Hold with two hands and place  Tug of war with a scarf, rope, towel, sheet.
it over a post. Roll hula hoop, reach out to
catch it. Play tug of war or ‘row row row your
boat’ while holding on to the hula hoop with
both hands.

 Mealtime and snack time. Use a knife and  Sit on a towel and have the child use both
fork to cut up food. Open a food container. hands and arms to push himself/herself
Twisting cap of bottle. Peel fruit. Remove backwards for a short distance.
wrapper from food. Remove and insert straw
into drink box.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 9
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
Two-handed (bimanual) activities Continued

 Household chores. E.g. sweep, wash and dry  Cook. Chop, slice, spread, pour, roll, grate, mix
dishes, set the table, fold laundry, garden or or use a rolling pin.
shovel snow.

 Grooming activities. E.g. put up a ponytail,  Grocery shopping. E.g. push cart, take
put on nail polish, cut finger nails, put money out of wallet, pack groceries and carry
toothpaste on a toothbrush, floss teeth, wash groceries in both hands.
hair, put on jewelry.

 Sports such as basketball, hockey, tennis,  Tool use. E.g., hammer, screwdriver, nuts and
baseball or volleyball. bolts. Supervision suggested.

 Electronic games such as Wii or Kinect. 

Using game controllers.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 10
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
Additional activities

As suggested by your child’s therapist (including any specific bimanual goal identified by child/family):

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© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 11
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft
Practice log

Name: Date (week of):

Activities Time spent Constraint Comments

on: Y/N?
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Recipient assumes all liability for damages, which may arise from recipient’s use of the licensed work. Holland Bloorview will not be liable
to recipient or any other party for any loss, claim or demand made by recipient, or made against recipient by any other party, due to or arising
from recipient’s use of the licensed work, except to the extent permitted by law when caused by the negligence or wilful misconduct of
Holland Bloorview.

© 2015 Holland Bloorview Kids Rehabilitation Hospital Constraint and bimanual therapy “hand” book | 12
Linda Fay, Sophie Lam-Damji, Yvonne Ng, Laura Thompson,Temine Fedchak, Megan Lynch
Clip art images used with permission from Microsoft