Hand-Arm Bimanual Intensive Training (HABIT)
Evidence reviewed as of before 01-01-2021
Author(s): Ogourtsova, T. (PhD OT); Steven, E. (MSc App OT); Iliopoulos, G. (MSc App OT); Deleva, V. (MSc App OT) & Majnemer, A. (PhD, OT, FCAHS)
Introduction
Hand-Arm Bimanual Intensive Training (HABIT) is a type of an intensive rehabilitation approach developed at Columbia University for children with hemiplegic cerebral palsy (CP). Unlike constraint-induced movement therapy (CIMT), which restricts the use of the unaffected hand, HABIT focuses on improving the function and use of both hands together in daily play and functional activities.
Resources
- https://www.tc.columbia.edu/cit/our-research/hand-arm-bimanual-intensive-training habit/#:~:text=Hand%2DArm%20Bimanual%20Intensive%20Therapy,both%20arms%20in%20daily%20function.
- https://www.brainrecoveryproject.org/therapies-and-development/handarm-bimanual-intensive-training/
- https://www.brainrecoveryproject.org/wp-content/uploads/2020/01/H-HABIT-Training-Manual-Hx-2.pdf
- https://burke.weill.cornell.edu/research/research-methods/hand-arm-bimanual-intensive-therapy-habit
Parent & Family Information
HABIT is a form of bimanual functional training for children with hemiplegic CP. Like constraint-induced movement therapy (CIMT), it involves intensive practice, requiring up to 90 hours of therapy. However, unlike CIMT, rather than restrain the less affected limb with a cast or sling, it focuses on coordinated use of the two hands together through play and functional activities. The activities are chosen based on each child’s specific goals and increase in difficulty as the child’s performance improves. HABIT is usually given in a group setting with an emphasis on having fun, building confidence, and social interaction.
Children with hemiplegia learn to compensate for their affected hand by using their dominant hand in most activities. Functional and play activities which involve the use of the two hands together tend to pose the biggest challenge for these children. HABIT was developed as a way to specifically address bimanual coordination impairments which are commonly seen in children with hemiplegic CP due to the difficulty in moving the affected (hemiplegic) hand. The goal of the therapy is to increase spontaneous, active use of both hands and to improve children’s functional independence in daily life activities, such as putting on a shirt, catching a ball or using a knife and a fork.
A variation of the original program (which was given in the form of a summer day camp over 2 weeks) involves delivering the training at home by caregivers as the primary interventionists. This home-based model, called H-HABIT, was proposed as a more feasible and friendly approach for younger children who may not be able to attend intensive therapy for multiple hours a day. Compared to HABIT which can consist of up to 6 hours of bimanual practice per day for 2 weeks, H-HABIT is modified to be less intense by spacing it out over a longer period of time, with only 2 hours of therapy per day.
The use of HABIT for children with unilateral spastic CP has been examined in two high quality studies.
The first study investigated the effectiveness of the home-based model of the intervention (H-HABIT) compared to lower-limb functional intensive training. The results showed an improvement in dexterity and parent perception of performance for the children receiving H-HABIT but no difference in bimanual performance or parent satisfaction between the two groups.
The second study compared HABIT to modified constraint-induced movement therapy and found similar improvement in bimanual performance and upper extremity function between the children receiving these two interventions. So while neither intervention was shown to be better than the other, the results suggest that both HABIT and mCIMT can be effective in improving outcomes for children with hemiplegic CP.
Typically, an occupational therapy (OT) assessment will be required which will be used to set goals and plan the therapy. The format, the length and frequency of the intervention can vary depending on the provider.
In the reviewed study, HABIT was provided during children’s preschool hours by OTs and therapy assistants and consisted of both individual and group sessions which took place 2 hours/day, 6 days/week, for 8 weeks.. The program was individualized for each child based on their abilities and included activities of daily living as well as a variety of games chosen to be motivating.
H-HABIT, on the other hand, was provided at home by the family for 2 hours/day, 5 days/week, for 9 weeks. Caregivers were trained to administer all home activities/assessments and received supervision via webcam monitoring. The activities chosen were aimed at improving reaching, grasping, releasing, etc. and were provided in the context of child-friendly games.
HABIT is typically provided by occupational therapists. H-HABIT is provided in the home environment by the family. The family (or caregivers) receive training prior to the start of the intervention and supervision via telerehabiilitation during the course of the program.
HABIT was initially developed as a summer day camp consisting of intensive bimanual practice 6 hours/day, for 10 days, followed by an extra 1-2 hours of practice at home, for 1 month (for a total of 90 hours). H-HABIT spaces out the 90 hours of practice over a period of 9 weeks, with 2 hours/day, 5 days a week. The treatment period and specific details can vary, however.
No side effects or risks have been reported in the literature.
HABIT is a type of bimanual intensive therapy which is used for children with hemiplegic CP who have some ability to use their affected arm/hand. The home based model of HABIT (H-HABIT) may be better suited for young children under 5. Given that the intervention takes place at home, family commitment is essential for the successful completion of the training. The reviewed study on H-HABIT included children with GMFCS levels I-II who were able to follow two-step instructions.
Information on this website is provided for informational purposes only and is not a substitute for professional medical advice.
Clinician Information
Children with unilateral spastic CP
GMFCS level I-II
One high quality RCT (Ferre et al., 2017) investigated the effects of home-based intensive bimanual training provided by caregivers on bimanual performance among children with unilateral spastic CP (GMFCS level I-II). In this high quality RCT, children were randomized to receive home-based hand-arm bimanual intensive therapy (H-HABIT) or lower-limb functional intensive training (LIFT-control); both groups received standard care. Bimanual performance was assessed using the Assisting Hand Assessment at post-treatment (9 weeks) and follow-up (6 months). No significant between-group differences were found at post-treatment.
Note: Between-group differences not reported at follow-up.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that H-HABIT is as effective as the comparison intervention (LIFT-control) in improving bimanual performance in children with unilateral spastic CP (GMFCS level I-II).
One high quality RCT (Ferre et al., 2017) investigated the effects of home-based intensive bimanual training provided by caregivers on dexterity among children with unilateral spastic CP (GMFCS level I-II). In this high quality RCT, children were randomized to receive home-based hand-arm bimanual intensive therapy (H-HABIT) or lower-limb functional intensive training (LIFT-control); both groups received standard care. Dexterity was assessed using the Box and Blocks Test at post-treatment (9 weeks) and follow-up (6 months). A significant between-group difference was found at post-treatment, favoring H-HABIT vs. LIFT-Control.
Note: Between-group differences not reported at follow-up.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that H-HABIT is more effective than a comparison intervention (LIFT-control) in improving dexterity in children with unilateral spastic CP (GMFCS level I-II).
One high quality RCT (Ferre et al., 2017) investigated the effects of home-based intensive bimanual training provided by caregivers on parent perception of functional goals (occupational performance) among parents of children with unilateral spastic CP (GMFCS level I-II). In this high quality RCT, children were randomized to receive home-based hand-arm bimanual intensive therapy (H-HABIT) or lower-limb functional intensive training (LIFT-control); both groups received standard care. Parent perception of occupational performance was assessed using the Canadian Occupational Performance Measure – Performance at post-treatment (9 weeks) and follow-up (6 months). A significant between-group difference was found at post-treatment, favoring H-HABIT vs. Lift-control.
Note: Between-group differences not reported at follow-up.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that H-HABIT is more effective than a comparison intervention (LIFT-control) in improving perception of occupational performance among parents of children with unilateral spastic CP (GMFCS level I-II).
One high quality RCT (Ferre et al., 2017) investigated the effects of home-based intensive bimanual training provided by caregivers on parent satisfaction with functional goals (occupational performance) among parents of children with unilateral spastic CP (GMFCS level I-II). In this high quality RCT, children were randomized to receive home-based hand-arm bimanual intensive therapy (H-HABIT) or lower-limb functional intensive training (LIFT-control); both groups received standard care. Parent satisfaction with occupational performance was assessed using the Canadian Occupational Performance Measure – Satisfaction at post-treatment (9 weeks) and follow-up (6 months). No significant between-group difference was found at post-treatment.
Note: Between-group differences not reported at follow-up.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that H-HABIT is as effective as the comparison intervention (LIFT-control) in improving satisfaction with occupational performance among parents of children with unilateral spastic CP (GMFCS level I-II).
CP level N/A
One high quality RCT (Gelkop et al., 2015) investigated the effects of hand-arm bimanual intensive therapy (HABIT) on bimanual performance in children with unilateral CP. In this high quality RCT, children were randomized to receive HABIT or modified constraint-induced movement therapy (mCIMT) following a baseline period of conventional therapy (occupational therapy and physiotherapy). Bimanual performance was assessed using the AHA at post-treatment (8 weeks). No significant between-group difference was found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that HABIT is as effective as the comparison intervention (mCIMT) in improving bimanual performance in children with unilateral CP.
One high quality RCT (Gelkop et al., 2015) investigated the effects of hand-arm bimanual intensive therapy (HABIT) on quality of upper limb movement in children with unilateral CP. In this high quality RCT, children were randomized to receive HABIT or modified constraint-induced movement therapy (mCIMT) following a baseline period of conventional therapy (occupational therapy and physiotherapy). Quality of upper limb movement was assessed using the QUEST (Grasp; Dissociated movement; Protective extension; Weight bearing) at post-treatment (8 weeks). A significant between-group difference was found for QUEST (Grasp), favoring mCIMT vs. HABIT.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that HABIT is as effective as the comparison intervention (mCIMT) in improving quality of upper limb movement in children with unilateral CP.
References
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Ferre, C. L., Brandão, M., Surana, B., Dew, A. P., Moreau, N. G., & Gordon, A. M. (2017). Caregiver-directed home-based intensive bimanual training in young children with unilateral spastic cerebral palsy: a randomized trial. Developmental medicine and child neurology, 59(5), 497–504. https://doi.org/10.1111/dmcn.13330
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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. https://doi.org/10.3109/01942638.2014.925027
Definitions
A group of lifelong disorders affecting a person’s movement, coordination, and muscle tone and which are the result of damage to the brain before, during, or shortly after birth.
Gross Motor Functional Classification System. It is a tool used to categorize the gross motor skills of children with cerebral palsy into 5 different levels across 5 age bands. It evaluates the child’s abilities in sitting, walking and wheeled mobility as well as the type of assistive devices needed for mobility. The levels are assigned based on the severity of the limitations, ranging from mild (level I) to severe (level V).
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