Dose of therapy. The “dose” may be more important than the method used for some therapies. As an example, constraint-induced movement therapy (CIMT) is a form of intensive therapy for individuals with hemiplegic CP in which the less-impaired hand is restrained for (typically) 14 days during which focused repetitive tasks and shaping activities are performed for 6 hours per day in order to overcome “learned [or] developmental non-use”79. Comparisons between studies suggest that more therapy (up to 90 hours over 15 days) yields more and longer-lasting benefits for individuals with hemiplegic CP. However, for both CIMT and bimanual therapy (in which coordinated use of both hands together), dose/response relationships are seen80,81. Combination with adjuncts ranging from functional electrical stimulation82 to transcranial magnetic stimulation83 or virtual reality programs84 also shows promise. There remains marked variability in individual outcomes.  In practice, the authors assume that there are diminishing returns for ever higher doses of therapy, but optimal doses, durations, and intensities (high-intensity “bursts” vs. distributed over time) are generally not known79. As such, we recommend setting realistic, measurable, individualized goals to be accomplished over defined time periods with periodic assessment of therapeutic gains vs. burden of increased care.

Types of therapy. Evidence is building to support use of specific therapies for specific indications and against efficacy for others36. Again using the example of hemiplegic CP, intensive CIMT and bimanual therapy both have evidence supporting efficacy80,81, and neurodevelopmental therapy has evidence against its efficacy. However, evidence for many treatments is limited and inadequate to make strong recommendations for or against them.  One emerging principle is that “top/down” task-oriented therapy goals may be more effective than “bottom-up” goals focused on basic functions or prerequisite skills80.

Timing of therapy: Transition points. Permanent (e.g. surgery) and long-lasting (e.g. botulinum toxin therapy) treatments intuitively alter biomechanics (e.g. decreased muscle strength in the period following multi-level orthopedic surgery 85). As such, guidelines emphasize the importance of intensive postsurgical (and post-botulinum 80) therapy 86 throughout the recovery period, while specific evidence-based protocols are only beginning to emerge 85. Early intervention. Much current policy and medical practice prioritizes early detection of CP and early initiation of therapy. Evidence has emerged to support benefits of some early interventions 87. However, early childhood brain plasticity is likely better considered a dynamic period of rapid change than an open-and-shut critical period 88. While early diagnosis and therapy may represent an opportunity, submaximal early intervention should not be seen as a reason to lose hope.