Innovations in Occupational Therapy

An innovative therapy helps children develop new motor pathways to improve use of a weakened arm.

Fighting Back: Darby Strong and Riccardo Pirrone

During her intensive three-week therapy program, Darby Strong gained strength and function in her left arm through her hard work and the expertise of occupational therapist Riccardo Pirrone.

A staccato rhythm fills an exercise room at Seattle Children’s Hospital as Riccardo Pirrone, an occupational therapist, shows Darby Strong and Devon Yamane how to hit a speed bag.

Thwack-a-ta, thwack-a-ta, thwack-a-ta, THWACK!

“Now, who wants to give it a try?” Pirrone says to the two young girls.

Darby shyly steps to the bag and takes a few awkward swipes, but only with her left hand. When it’s Devon’s turn, she swings only with her right. Why? Because both girls are wearing casts on their other arms – all part of a new treatment called constraint induced therapy (CIT) for children with hemiparesis.

Hemiparesis is a condition in which the limbs on one side of the body have severe weakness and limited function, making everyday tasks such as eating and dressing a challenge. Conventional therapy for children with hemiparesis involves an hour or two of physical and occupational therapy per week. In between, these children typically neglect their weak arm.

“They forget about it in large part because it’s not useful to them,” says Laura Crooks, who leads the Rehabilitation Medicine Department at Children’s.

Creating new motor pathways

Fighting Back: Wendy McGrath

Occupational therapist Wendy McGrath helped introduce constraint induced therapy to Seattle Children’s to help children and teens improve function in an upper extremity weakened due to strokes, brain tumors, cerebral palsy or other injuries to the brain.

During the three-week CIT session, each patient’s strong arm is immobilized with a shoulder-to-fingertip cast forcing them to use their weak arm 24/7. Through constant use of their weak arm, patients create new motor pathways in the brain that help them gain strength and function on their weak side and ultimately use both arms more equally.

Besides eating, playing, etc., with the cast on, they come to Children’s Monday through Friday for three hours of highly varied occupational therapy each day. Activities range from music to art to cooking to board games. Swimming is the only time the cast is removed.

“Families tell us that their children are doing things with both hands now. They’re not letting that weak arm just hang there,” says Wendy McGrath, an occupational therapist who helped introduce CIT at Children’s.

A week and a half into her therapy, Devon buckled her own seatbelt for the first time with her right hand.

“We’re talking real, practical changes,” says her mother, Juliette Yamane. “Devon wants to be more independent in her day-to-day life, and we’re thrilled with the progress she has made.”

“We're talking real, practical changes. We're thrilled with the progress Devon has made.”

Juliette Yamane, Devon's mom

Meeting a great need

Fighting Back: Dr. Michael Astion

Dr. Michael Astion, a speed-bag enthusiast and physician at UW Medicine, volunteers his time to teach patients in the CIT program how to “work the bag.”

CIT has been used for many years to treat adult stroke victims but is a relatively new treatment for children. Children’s began offering CIT five years ago after hearing about the treatment’s success at the University of Alabama, which pioneered the use of CIT in children. “The more we looked into it, the more we learned about how well CIT worked and about how many families wanted us to start a program here,” McGrath says.

A grant from the Christopher Reeves Foundation paid for McGrath and fellow occupational therapist Betsy Chappelle to train at Alabama. “We were part of the first group ever trained there,” McGrath says.

When they returned, they ran “camps” once or twice a year that helped three or four patients at a time, but they couldn’t keep up with demand from families eager to participate. To increase access, they trained 40 communitybased therapists to offer CIT in their practices.

Last year, Children’s hired Pirrone, who works with two children three weeks at a time year-round, making Children’s the only place in the region offering CIT on a regular basis.

“The need is so great,” Crooks says. “We have families who wait months and months to get into the program.”

Donations make it possible

Funds from a charitable endowment have supported the CIT program’s growth by purchasing games, art supplies, etc., and enabled McGrath and Chappelle to train the communitybased therapists. The endowment also helped Chappelle receive training to assess children after they complete the program.

So far, preliminary results from the therapy are extremely promising. McGrath and Chappelle have presented data at several seminars showing significant improvement in 10 of 11 patients treated at Children’s in 2008. “In almost every case, kids leave therapy with more function in their weak arm than they’ve ever had before,” Pirrone says.

Even better outcomes could be on the horizon. Led by pediatrician Dr. John McLaughlin, Children’s is part of a multisite study to learn whether adding magnetic brain stimulation to CIT improves results. “The hypothesis is that combining these therapies will help the brain reduce dysfunctional signals and create the new motor pathways these children need to gain greater use of their weak arm,” Crooks says.

This research represents another possible step forward in the effort to help children like Devon and Darby lead fuller and more independent lives.