Established care
Constraint-induced therapy and bimanual training
CIMT, modified CIMT, HABIT, hand–arm bimanual intensive training
For a child who uses one hand much more than the other, these are among the best-evidenced interventions in paediatric neurology — and both work, for different things.
Either a medicines regulator has licensed it for this use, or clinical practice guidelines recommend it on the strength of controlled trials. This is the standard everything else on the scale is measured against — and for most children, the treatments at this level are the ones that will actually change their day.
Where it stands, condition by condition
The same therapy can be well supported for one problem and completely untested for another. This is the single most common place families are misled.
| Condition | Evidence | What that means here |
|---|---|---|
| Unilateral cerebral palsy — hand function | Established care | Strong randomised evidence for both approaches. Guideline-recommended. |
| Bilateral cerebral palsy | In clinical trials | Bimanual approaches are used; constraint has less rationale when both hands are affected. |
| Acquired hemiplegia | Established care | Same principle, applied after stroke or injury. |
What it is
Constraint-induced movement therapy restrains the stronger hand — with a mitt, glove or cast — so the child is obliged to use the weaker one, combined with intensive structured practice.
Bimanual training (HABIT) does the opposite: both hands are used together in activities that genuinely need two hands, so the weaker hand learns its role as assistant or stabiliser.
Both are delivered in concentrated blocks — typically many hours over two to three weeks, often in a camp or play format rather than a clinic room.
How it is meant to work
Children with one weaker hand stop trying to use it, and the pathway weakens further. This is called developmental disregard, and it is learned rather than fixed.
Constraint interrupts that habit; bimanual training rebuilds the two-handed coordination that daily life actually requires.
What has actually been tested
- Randomised trials have compared the two directly. Both improve hand function; the differences are in what improves.
- Constraint tends to produce larger gains in what the affected hand can do on its own. Bimanual training tends to transfer better to two-handed everyday tasks.
- Intensity matters more than the brand. A low-dose version delivered an hour a week is not the intervention that was tested.
- In practice many programmes combine them: a constraint block followed by bimanual work.
What we still do not know
- The best age to start, and whether earlier blocks produce lasting advantage.
- How often to repeat a block.
- Which children respond best — predictors are not reliable.
Risks and costs
- Frustration and distress if the constraint is imposed without preparation or play framing.
- Temporary loss of independence while the stronger hand is restrained, which matters for school-age children.
- The practical obstacle is delivery: these programmes are demanding for families and short-staffed services.
Questions to ask before you agree
A centre that is doing good work will welcome these questions and answer them in writing.
- Which of the two suits my child's goals, and why?
- What is the total dose in hours, over how many weeks?
- How will the gains be maintained afterwards?
More in this section
Early detection and early intervention
The single highest-value thing in this whole field, and the one least often discussed in clinics selling treatment. Cerebral palsy can be identified in the first months of life, and that is when therapy does the most.
Established careGoal-directed, task-specific training
Not a brand of therapy but the principle underneath the ones that work: the child practises the actual task they are trying to learn, with enough repetition to matter.
Established carePhysiotherapy and strength training
Well supported when it is built around function and genuinely loaded — much weaker when it is passive stretching and generic exercise.
Established careOccupational therapy
The discipline that works on what the child actually does all day — dressing, eating, writing, playing, getting through a school morning.
Established careSpeech, language and communication
For a child who cannot speak clearly, giving them a way to communicate is among the most consequential interventions available — and the fear that it will stop them talking is unfounded.
Established careSpasticity and tone management
Medical and surgical treatment of tone, which works best when it is tied to a functional goal rather than to a number on a tone scale.
In clinical trialsTechnology-assisted rehabilitation
Useful mainly as a way of delivering more practice, not as a treatment in its own right — and that distinction decides whether it is worth the money.
In clinical trialsNamed physiotherapy approaches
Families are usually asked to choose between brands. The evidence says the brand matters far less than whether the session is active, goal-directed and repeated often enough.
In clinical trialsSensory therapies
Two things are sold under one word. Manualised Ayres Sensory Integration has been tested in trials; the sensory add-ons sold around it mostly have not.
Established careVision and cerebral visual impairment
The most commonly missed problem in children with brain injury. A child who cannot interpret what they see is often described as inattentive, uncooperative or more delayed than they are.