Bimanual Training Research Articles

Muscle Recruitment and Coordination following Constraint-Induced Movement Therapy with Electrical Stimulation on Children with Hemiplegic Cerebral Palsy: A Randomized Controlled Trial.

ObjectiveTo investigate changes of muscle recruitment and coordination following constraint-induced movement therapy, constraint-induced movement therapy plus electrical stimulation, and traditional occupational therapy in treating hand dysfunction.MethodsIn a randomized, single-blind, controlled trial, children with hemiplegic cerebral palsy were randomly assigned to receive constraint-induced movement therapy (n = 22), constraint-induced movement therapy plus electrical stimulation (n = 23), or traditional occupational therapy (n = 23). Three groups received a 2-week hospital-based intervention and a 6-month home-based exercise program following hospital-based intervention. Constraint-induced movement therapy involved intensive functional training of the involved hand during which the uninvolved hand was constrained. Electrical stimulation was applied on wrist extensors of the involved hand. Traditional occupational therapy involved functional unimanual and bimanual training. All children underwent clinical assessments and surface electromyography (EMG) at baseline, 2 weeks, 3 and 6 months after treatment. Surface myoelectric signals were integrated EMG, root mean square and cocontraction ratio. Clinical measures were grip strength and upper extremity functional test.ResultsConstraint-induced movement therapy plus electrical stimulation group showed both a greater rate of improvement in integrated EMG of the involved wrist extensors and cocontraction ratio compared to the other two groups at 3 and 6 months, as well as improving in root mean square of the involved wrist extensors than traditional occupational therapy group (p<0.05). Positive correlations were found between both upper extremity functional test scores and integrated EMG of the involved wrist as well as grip strength and integrated EMG of the involved wrist extensors (p<0.05).ConclusionsConstraint-induced movement therapy plus electrical stimulation is likely to produce the best outcome in improving muscle recruitment and coordination in children with hemiplegic cerebral palsy compared to constraint-induced movement therapy alone or traditional occupational therapy.Trial registrationchictr.org ChiCTR-TRC-13004041

Tactile deficit and its adaptability associated with intensive bimanual therapy and tactile training in children with unilateral spastic cerebral palsy

Tactile deficit and its adaptability associated with intensive bimanual therapy and tactile training in children with unilateral spastic cerebral palsy

Caregivers as interventionists: a randomized trial of home‐based intensive bimanual training in young children with hemiplegia

Caregivers as interventionists: a randomized trial of home‐based intensive bimanual training in young children with hemiplegia

Changes in kinematic performance between structured and unstructured practice during intensive bimanual training for children with unilateral cerebral palsy

Changes in kinematic performance between structured and unstructured practice during intensive bimanual training for children with unilateral cerebral palsy

Intensive upper limb intervention with self-management training is feasible and promising for older children and adolescents with unilateral cerebral palsy

This study explored the feasibility and preliminary effectiveness of a short (one week) intensive intervention combining Constraint Induced Movement Therapy (CIMT) and bimanual training (BiT) to improve upper limb capacity and bimanual performance guided by individual goal setting in children and adolescents with unilateral cerebral palsy aged 8–18 years. Self-management training was added to the intervention to maximize the effect of training and to empower the participants in self-monitoring the effective use of their affected hand. Functional goals (Canadian Occupational Performance Measure), unimanual capacity (Box and Block Test), bimanual performance (ABILHAND-Kids, Children's Hand-use Experience Questionnaire (CHEQ)) and amount of use (Video Observation Aarts and Aarts – determine developmental disregard (VOAA-DDD-R)) were measured at baseline, one week and four months post intervention. Twenty children (mean age 9.5 years) participated. Repeated measures ANOVA was used to measure effects over time. Compared to baseline, there were significant improvements on all outcome measures. The largest effect sizes were found for the COPM-performance and COPM-satisfaction (Cohen's d=2.09 and d=2.42, respectively). The effect size was large for the ABILHAND-Kids (d=0.86), moderate for the CHEQ (d=0.70) and Box and Block Test (d=0.56), and small for the VOAA-DDD-R (d=0.33). All effects were retained at the four months post intervention assessment. The results of this study indicate that one-week (36h) intensive CIMT-BiT combined with self-management training is a feasible and promising intervention for improving the capacity of the upper limb and its use in bimanual activities in older children and adolescents with unilateral CP.

Strain Gauge Sensors Implemented in a New Female Torso Model Have Increased Student's Motivation and Confidence in Gynecologic Bimanual Examination on Clinical Skill Training

A good mannequin is needed to improve the quality of clinical skill learning. A strain sensors gauge can be applied into gynecologic bimanual examination mannequin. This study compared a new strain gauge sensors mannequin and non-sensor mannequin for gynecologic bimanual examination training in undergraduate medical student. We made a new female torso model implemented with strain gauge sensors in the definitive landmark, then used this new mannequin for gynecologic bimanual examination training in undergraduate medical student, and evaluated using questioner. We observed 4 parameters: mannequin appearance, student’s self confidence to palpate uterus and ovary, and student’s learning motivation. The new model improved student’s confident to palpate ovary (p&lt;0.05) and student’s motivation (p&lt;0.001) compared to non-sensor mannequin. In contrast, the gross appearance of the new mannequin was inferior (p&lt;0.05). However, there was no difference in defining the uterus position during examination (p&gt;0.05) in both mannequins. A new female torso model with strain gauge sensors can be applied for gynecologic examination training.

Bilateral primary motor cortex circuitry is modulated due to theta burst stimulation to left dorsal premotor cortex and bimanual training

Motor preparatory and execution activity is enhanced after a single session of bimanual visuomotor training (BMT). Recently, we have shown that increased primary motor cortex (M1) excitability occurs when BMT involves simultaneous activation of homologous muscles and these effects are enhanced when BMT is preceded by intermittent theta burst stimulation (iTBS) to the left dorsal premotor cortex (lPMd). The neural mechanisms underlying these modulations are unclear, but may include interhemispheric interactions between homologous M1s and connectivity with premotor regions. The purpose of this study was to investigate the possible intracortical and interhemispheric modulations of the extensor carpi radials (ECR) representation in M1 bilaterally due to: (1) BMT, (2) iTBS to lPMd, and (3) iTBS to lPMd followed by BMT. This study tests three related hypotheses: (1) BMT will enhance excitability within and between M1 bilaterally, (2) iTBS to lPMd will primarily enhance left M1 (lM1) excitability, and (3) the combination of these interventions will cause a greater enhancement of bilateral M1 excitability. We used single and paired-pulse transcranial magnetic stimulation (TMS) to quantify M1 circuitry bilaterally. The results demonstrate the neural mechanisms underlying the early markers of rapid functional plasticity associated with BMT and iTBS to lPMd primarily relate to modulations of long-interval inhibitory (i.e. GABAB-mediated) circuitry within and between M1s. This work provides novel insight into the underlying neural mechanisms involved in M1 excitability changes associated with BMT and iTBS to lPMd. Critically, this work may inform rehabilitation training and stimulation techniques that modulate cortical plasticity after brain injury.

The neural correlates of bilateral upper limb training after stroke: a systematic review

Background:Recovery of upper limb (UL) function after stroke is poor with only a third of stroke survivors regaining some functional use. Bilateral training (BT) of the ULs is a promising intervention but its underlying mechanisms are unclear. BT involves practicing identical movements with both UL (e.g. carrying a box, lifting two cups) and is not to be confused with bimanual training where both limbs perform different movements (e.g. tying shoelaces). It is important to understand how BT affects both UL motor recovery and neuroplasticity in order to assess its potential as a therapeutic intervention. This is the first review of the effects of BT on motor recovery and neuroplasticity together. Purpose: This systematic review aimed to elucidate the mechanisms underlying BT by determining (i) the effects of functional changes by BT on neuroplasticity and (ii) the relationships between changes in UL function and changes in neuroplasticity as a result of BT. Methods: The complete holdings of 11 databases were searched up until December 2014.Trial registers and reference lists of included studies and reviews were checked. Quantitative studies of any design employing BT with both UL motor and neurophysiological outcomes involving adult stroke survivors were included. Studies not available in English or in full text were excluded. Two independent reviewers selected studies, extracted data and reviewed methodological quality using the Effective Public Health Practice Project (EPHPP) tool. The EPHPP tool was selected from four reviews. Where a decision could not be made between the two reviewers, a third reviewer was sought and consensus reached through discussion. Results: From 41,438 records, eight studies comprising 164 participantswere included. The global rating formethodological quality was ‘strong’ for two studies, ‘moderate’ for two studies and ‘weak’ for the remaining four. Considerable heterogeneity of participants, modes of BT, comparators and measures meant pooled outcome analysis was not possible. The variation in modes of BT included: in-phase and anti-phasemovements, functional tasks involving objects and movements only, mechanically coupled and free movement, auditory cued and self-paced movements. The most common outcomemeasure usedwas theUL section of the Fugl–Meyer whichwas used in six studies; however some studies used different subsections. Functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) were used in three and five studies respectively, employing a wide range of measures. Only five studies reported neural correlates of BT, but findings were inconsistent. No clear pattern of neuroplasticity associated with BT was apparent from this review. Conclusion(s): Current evidence from this systematic review indicates that the neural correlates of BT after stroke are currently unknown and need to be examined systematically to understand the therapeutic potential of different modes ofBT. Future research needs to identify effective training modes of BT, match the optimal mode to people with specific stroke lesions anduse appropriate outcomemeasures. Implications: Physiotherapists should use their clinical reasoning when using BT, considering various modes of delivery in conjunction with patients’ UL impairments and functional goals.

Hand and Arm Bimanual Intensive Therapy Including Lower Extremity (HABIT-ILE) in Children With Unilateral Spastic Cerebral Palsy

Background. Intensive bimanual training results in more improvement in hand function in children with unilateral spastic cerebral palsy (USCP) than lower intensity conventional interventions. However, it is not known whether combined upper and lower extremity training in an intensive protocol is more efficacious for upper and lower functional abilities than conventional therapies provided in usual customary care. Objective. To determine the efficacy of Hand and Arm Bimanual Intensive Therapy Including Lower Extremity (HABIT-ILE) for children with USCP. Methods. Twenty-four children with USCP were randomized into 2 groups: an immediate HABIT-ILE group (IHG, initially receiving HABIT-ILE, 10 days = 90 hours), and a delayed HABIT-ILE group (DHG), which continued their conventional/ongoing treatment for an intended total duration of 90 hours. In phase 2, children in the DHG were crossed over to receive HABIT-ILE and children of the IHG were followed in their ongoing conventional therapy. Children were assessed using the Assisting Hand Assessment (AHA, primary outcome), the ABILHAND-Kids, and the Pediatric Evaluation of Disability Inventory. Dexterity (Box and Blocks Test [BBT]) and pinch strength were also measured. Locomotor abilities were assessed with Six-Minute Walk Test (6MWT, primary outcome) and ABILOCO-kids. Social participation was measured with the Assessment of Life-HABITs. Results. A 2 (groups) × 3 (test sessions) analysis of variance indicated significant improvements for primary outcomes (AHA, P < .001; 6MWT, P = .002) and all secondary assessments except BBT, step length and bodyweight distribution following HABIT-ILE, but not conventional therapy. Conclusion. The findings suggest that combined upper and lower extremity in an intensive training protocol may be efficacious for improving both upper and lower extremity function in children with USCP.

The Influence of a Constraint and Bimanual Training Program Using a Variety of Modalities, on Upper Extremity Functions and Gait Parameters Among Children with Hemiparetic Cerebral Palsy: A Case Series

ABSTRACTAim: To assess the influence of an intensive combined constraint and bimanual upper extremity (UE) training program using a variety of modalities including the fitness room and pool, on UE functions as well as the effects of the program on gait parameters among children with hemiparetic cerebral palsy. Methods: Ten children ages 6–10 years participated in the program for 2 weeks, 5 days per week for 6 hr each day. Data from the Assisting Hand Assessment (AHA) for bimanual function , the Jebsen–Taylor Test of Hand Function (JTTHF) for unimanual function, the six-minute walk test (6MWT), and the temporal-spatial aspects of gait using the GAITRite walkway were collected prior to, immediately post and 3-months post-intervention. Results: A significant improvement was noted in both unimanual as well as bimanual UE performance; A significant improvement in the 6MWT was noted, from a median of 442 meter [range: 294–558] at baseline to 466 [432–592] post intervention and 528 [425–609] after 3 months (p = .03). Conclusion: Combining intensive practice in a variety of modalities, although targeting to the UE is associated with substantial improvement both in the upper as well as in the lower extremity function.

Efficacy of Constraint-Induced Movement Therapy and Bimanual Training in Children with Hemiplegic Cerebral Palsy in an Educational Setting

ABSTRACTWe examined the efficacy of modified constraint-induced movement therapy (CIMT) and hand-arm bimanual intensive therapy (HABIT) in a special education preschool/kindergarten in Israel. Twelve children (1.5–7 years) with congenital hemiplegic cerebral palsy were randomized to receive modified CIMT (n = 6) or HABIT (n = 6). Occupational and physical therapists administered usual and customary care for 8 weeks; children then crossed over to receive CIMT or HABIT 2 hr/day, 6 days/week for 8 weeks from their occupational therapist. The Assisting Hand Assessment and Quality of Upper Extremity Skills Test were administered 2 months prior to the intervention, immediately before, immediately after intervention, and 6 months after the first baseline assessment. Both groups demonstrated no change during baseline and comparable improvement following CIMT and HABIT (p < .001), which was maintained at 6-month follow-up. Results suggest that modified CIMT and HABIT provided in school-based settings can lead to improvements in quality of bimanual skill and movement patterns.

The state of the evidence for intensive upper limb therapy approaches for children with unilateral cerebral palsy.

Children with unilateral cerebral palsy experience difficulties with unimanual and bimanual upper limb function, impacting independence in daily life. Targeted upper limb therapies such as constraint-induced movement therapy, bimanual training, and combined approaches have emerged in the last decade. This article reviews the scientific rationale underpinning these treatments and current evidence to improve upper limb outcomes and goal attainment. Intensive models of therapy achieved modest to strong effects to improve upper limb function compared to usual care. Dose-matched comparisons of bimanual and unimanual training demonstrated similar gains in upper limb outcomes. The optimum timing, dose and impact of repeat episodes of intensive upper limb therapies require further investigation. Characteristics of children who achieve clinically meaningful outcomes remain unclear. Key components of intervention include collaborative goal setting with families and intensive repetitive, incrementally challenging, task practice. Choice of treatment approach should be governed by child/family goals and preferences, individual, and contextual factors.

Efficacy and Task Structure of Bimanual Training Post Stroke: A Systematic Review

Background: Bimanual training has been shown to be as effective as, but not superior to, unimanual paretic upper extremity (UE) training interventions in improving paretic UE function and use post stroke. However, it is still unclear whether different training interventions or task structures within bimanual interventions may differentially affect the outcomes. Objective: The objectives of this review were to (1) systematically determine the efficacy of bimanual training in relation to the International Classification of Functioning, Disability and Health model components and (2) explore the structure of current bimanual training interventions. Method: A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eleven studies were accepted for review. Results: Three main types of bimanual training emerged: functional task training (FTT), bilateral training with rhythmic auditory cues (BATRAC), and robot-assisted training (RAT). Bimanual training is generally efficacious overall in improving paretic UE movement in individuals with subacute and/or chronic stroke as compared with other interventions. FTT, BATRAC, and RAT showed no significant differences compared with conventional therapy. Bimanual training may have greater proximal control benefits but fewer benefits in terms of subjects’ perceived amount and quality of use as compared with constraint-induced movement therapy. Conclusion: There were not enough data to draw any conclusions about the effects of bimanual task symmetry or commonality of goal.

Selective modulation of left primary motor cortex excitability after continuous theta burst stimulation to right primary motor cortex and bimanual training

Bimanual movement training (BMT) enhances the excitability of human preparatory premotor and primary motor (M1) cortices. We have shown that activity in M1 is enhanced after BMT involving simultaneous activation of homologous muscles (in-phase). Potential neural mechanisms underlying this effect could be input from premotor areas (i.e. dorsal premotor cortex (PMd)) and/or the homologous M1 representation. Recently, we showed that increasing PMd activity using theta burst stimulation (TBS) followed by BMT enhanced the corticospinal excitability of M1 compared to BMT alone. The purpose of this study was to investigate the effects of continuous TBS (cTBS) to right hemisphere M1 (rM1) on the homologous wrist extensor representation in left M1 (lM1), and its potential combined effects when followed by BMT. We used transcranial magnetic stimulation (TMS) to measure cortical excitability of extensor carpi radialis (ECR) representation at multiple time points in three conditions: (1) BMT, (2) cTBS to rM1 or (3) cTBS to rM1 and BMT. The combination of cTBS to rM1 and BMT resulted in an increased shift in the centre of gravity (CoG) compared to either intervention alone, along with an increased muscle topographical representation up to 60min when cTBS to rM1 was combined with BMT compared to cTBS to rM1 alone. These results suggest that modulation of M1 may reduce ongoing interhemispheric inhibition (or increase facilitation indirectly) to the opposite homologous M1 region in healthy individuals via transcallosal or subcortical connections. Critically, this work may guide rehabilitation training and stimulation techniques that modulate cortical plasticity after brain injury.

Improvement of Upper Extremity Motor Control and Function After Home-Based Constraint Induced Therapy in Children With Unilateral Cerebral Palsy: Immediate and Long-Term Effects

ObjectiveTo investigate the long-term effects of home-based constraint induced therapy (CIT) on motor control underlying functional change in children with unilateral cerebral palsy (CP). DesignRandomized controlled trial. SettingHome based. ParticipantsChildren with unilateral CP (N=45; aged 6–12y) were randomly assigned to receive home-based CIT (n=23) or traditional rehabilitation (TR) (n=22). InterventionsBoth groups received a 4-week therapist-based intervention at home. The home-based CIT involved intensive functional training of the more affected upper extremity during which the less affected one was restrained. The TR involved functional unimanual and bimanual training. Main Outcome MeasuresAll children underwent kinematic and clinical assessments at baseline, 4 weeks (posttreatment), and 3 and 6 months (follow-up). The reach-to-grasp kinematics were reaction time (RT), normalized movement time, normalized movement unit, peak velocity (PV), maximum grip aperture (MGA), and percentage of movement where MGA occurs. The clinical measures were the Peabody Developmental Motor Scales, Second Edition (PDMS-2), Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), and Functional Independence Measure for children (WeeFIM). ResultsThe home-based CIT group showed a shorter RT (P<.05) and normalized movement time (P<.01), smaller MGA (P=.006), and fewer normalized movement units (P=.014) in the reach-to-grasp movements at posttreatment and follow-up than the TR group. The home-based CIT group improved more on the PDMS-2 (P<.001) and WeeFIM (P<.01) in all posttreatment tests and on the BOTMP (P<.01) at follow-up than the TR group. ConclusionsThe home-based CIT induced better spatial and temporal efficiency (smoother movement, more efficient grasping, better movement preplanning and execution) for functional improvement up to 6 months after treatment than TR.

Verification of additional merits of a bimanual-coordinated rehabilitation robot using near-infrared spectroscopic technology

Using our designed robot, previous work has confirmed that bimanual training induced greater oxygenated-hemoglobin concentration than unilateral-limb training. However, the inter-hemispheric asymmetry of oxygenated-hemoglobin concentration was not compared between the bimanual and unilateral-limb patterns. To confirm the merits of our designed robot based on cerebral hemoglobin activation, 18 healthy subjects performed bimanual and unilateral-limb tasks in active-resisted mode and active-assisted mode for the right and left control sides (determines from that which limb provides a larger force). Analyses of variance were performed to compare the laterality index (LI) of two hemispheres between the two control sides, and to compare oxygenated-hemoglobin concentration between the different training patterns. The difference of LI between the two control sides was distinct in unilateral-limb patterns (p = 0.029) but not obvious in bimanual patterns. As for the oxygenated-hemoglobin, active-resisted tasks induced a higher concentration than active-assisted tasks in the left control side (p = 0.048). Results demonstrated that the proposed bimanual training induced the functional integrity of two hemispheres, and the robot is favorable for improving bimanual movement-coordination function. Additionally, active-resisted tasks had a higher difficulty level than active-assisted task. Therefore, the robot has a potential for delivering strength enhancement training in bimanual patterns.

Improvements in hand function after intensive bimanual training are not associated with corticospinal tract dysgenesis in children with unilateral cerebral palsy

Unilateral cerebral palsy (CP) results from damage to the developing brain that occurs within the first 2 years of life. Previous studies found associations between asymmetry in the size of the corticospinal tract (CST) from the two hemispheres and severity of hand impairments in children with unilateral CP. The extent to which CST damage affects the capacity for hand function improvement is unknown. This study examines the association between an estimate of CST dysgenesis and (1) hand function and (2) the efficacy of intensive bimanual training in improving hand function. Children with unilateral CP, age 3.6–14.9 years, n = 35, received intensive bimanual training. Children engaged in bimanual functional/play activities (6 h/day, 15 days). Peduncle asymmetry, an estimate of CST dysgenesis, was measured on T1-weighted magnetic resonance imaging scans. Hand function was measured pre- and post-treatment using the assisting hand assessment (AHA) and Jebsen–Taylor test of hand function (JTTHF). AHA and JTTHF improved post-treatment (p < 0.001). Peduncle asymmetry was correlated with baseline AHA and JTTHF (p < 0.001) but not with AHA or JTTHF improvement post-training (R 2 < 0.1, p > 0.2). An estimate of CST dysgenesis is correlated with baseline hand function but is a poor predictor of training efficacy, possibly indicating a flexibility of developing motor systems to mediate recovery.

Effects of a Mirror-Induced Visual Illusion on a Reaching Task in Stroke Patients

Background. Although most mirror therapy studies have shown improved motor performance in stroke patients, the optimal mirror training protocol still remains unclear. Objective. To study the relative contribution of a mirror in training a reaching task and of unilateral and bimanual training with a mirror. Methods. A total of 93 stroke patients at least 6 months poststroke were instructed to perform a reaching task as fast and as fluently as possible. They performed 70 practice trials after being randomly allocated to 1 of 5 experimental groups: training with (1) the paretic arm with direct view (Paretic-No Mirror), (2) the nonparetic arm with direct view (Nonparetic-No Mirror), (3) the nonparetic arm with mirror reflection (Nonparetic Mirror), (4) both sides and with a nontransparent screen preventing visual control of paretic side (Bilateral-Screen), and (5) both sides with mirror reflection of the nonparetic arm (Bilateral-Mirror). As baseline and follow-up, patients performed 6 trials using only their paretic side. Primary outcome measure was the movement time. Results. We found the largest intervention effect in the Paretic-No Mirror condition. However, the Nonparetic-Mirror condition was not significantly different from the Paretic-No Mirror condition, while the Unaffected-No Mirror condition had significantly less improvement than the Paretic-No Mirror condition. In addition, movement time improved significantly less in the bimanual conditions and there was no difference between both bimanual conditions or between both mirror conditions. Conclusion. The present study confirms that using a mirror reflection can facilitate motor learning. In this task, bimanual movement using mirror training was less effective than unilateral training.

From specific training to global shift of manual preference in Kung Fu experts.

Manual preference and intermanual performance asymmetry have been approached from a multidimensional and dynamic perspective. A point of interest from that approach is the role of lateralized motor experiences on handedness. In this study, intermanual performance asymmetry in sport-specific movements and manual preference in daily living tasks were compared between Kung Fu athletes and novices. Analysis of movement time in the performance of interlaterally symmetric and asymmetric movement patterns showed smaller intermanual performance asymmetry in experts. Analysis of manual preference using the Edinburgh Handedness Inventory indicated that experts presented predominantly weak or moderate strength of right hand preference. Novices, conversely, were found to have predominantly strong right hand preference. These results suggest that extensive bimanual training by experts leads to a global shift of manual preference, affecting hand selection in distinct tasks.

Efficacy of Upper Limb Therapies for Unilateral Cerebral Palsy: A Meta-analysis

Children with unilateral cerebral palsy present with impaired upper limb (UL) function affecting independence, participation, and quality of life and require effective rehabilitation. This study aims to systematically review the efficacy of nonsurgical upper limb therapies for children with unilateral cerebral palsy. Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, the Cochrane Central Register of Controlled Trials, and PubMed were searched to December 2012. Randomized controlled or comparison trials were included. Forty-two studies evaluating 113 UL therapy approaches (N = 1454 subjects) met the inclusion criteria. Moderate to strong effects favoring intramuscular injections of botulinum toxin A and occupational therapy (OT) to improve UL and individualized outcomes compared with OT alone were identified. Constraint-induced movement therapy achieved modest to strong treatment effects on improving movement quality and efficiency of the impaired UL compared with usual care. There were weak treatment effects for most outcomes when constraint therapy was compared with an equal dose (amount) of bimanual OT; both yielded similar improved outcomes. Newer interventions such as action observation training and mirror therapy should be viewed as experimental. There is modest evidence that intensive activity-based, goal-directed interventions (eg, constraint-induced movement therapy, bimanual training) are more effective than standard care in improving UL and individualized outcomes. There is little evidence to support block therapy alone as the dose of intervention is unlikely to be sufficient to lead to sustained changes in UL outcomes. There is strong evidence that goal-directed OT home programs are effective and could supplement hands-on direct therapy to achieve increased dose of intervention.