Helping Kids with Hemiplegia Summer Camp: Background Information, Handling Techniques, and a Comparison Between Constraint-Induced Movement Therapy and Bimanual Intensive Therapy

Helping Kids with Hemiplegia Summer Camp:  Background Information, Handling Techniques, and a Comparison Between Constraint-Induced Movement Therapy and Bimanual Intensive Therapy

By:  Courtney Bowers, SPT

 

Background:

I have always had a passion for working with children.  Once accepted into the Doctor of Physical Therapy Program at the University of North Carolina (UNC) at Chapel Hill, I aimed to partake in opportunities that would foster my development as a rising pediatric physical therapist.  This previous summer, I had the privilege to participate in the 2017 Helping Kids with Hemiplegia summer camp held in Chapel Hill, North Carolina.  This experience enabled me to work alongside a 4-year-old boy diagnosed with spastic hemiplegic cerebral palsy (CP) for a total of 8 consecutive days.  During this time, I learned a lot about myself as well as my future aspirations in pediatrics.  I saw firsthand how the evidence-based interventions implemented in the camp led to improvements in involved upper extremity (UE) function during age-appropriate play, successes in the attainment of a number of established camp goals, and feelings of self-confidence and accomplishment among participants.

The Helping Kids with Hemiplegia camp encompasses a modified constraint-induced movement therapy (CIMT) format, including a combination of CIMT and bimanual intensive training (BIT).  In order to satisfy my curiosity, I developed a PICO question that focused on the direct comparison between CIMT and BIT in respect to intervention effectiveness in improving function and participation in the involved UE among children with hemiplegic CP.  This clinical question was then used in the development of my Critically Appraised Topic (CAT) in the Evidence-Based Practice II course.

 

Overview/Purpose:

CP is a group of non-progressive, neurodevelopmental disorders caused by injury to the developing brain.¹ This lifelong condition is associated with limitations in activity, restrictions in participation, impaired functional capacity, and reduced quality of life.¹ CP is the most common childhood motor disability with a prevalence of 2.5 per 1000 persons.² Based on topographical classification, hemiplegia is the most common type impacting an estimated 33% of children diagnosed with CP.^1-3 Hemiplegic CP is characterized by one-sided involved, which can result in decreased range of motion, muscle stiffness, and/or weakness in the more involved UE, gait abnormalities, subsequent balance deficits, reduced executive function and/or motor planning deficits, and difficulties in fine and gross motor function.^4,5

CIMT and BIT are two commonly utilized and widely accepted rehabilitation techniques in the treatment of motor-related impairments among patients with CP.  CIMT includes the administration of a constraint, typically in the form of a cast or mitt, to the less involved UE and is coupled with intensive unimanual training of non-constrained UE.^6,7 In comparison, BIT integrates the use of both arms during functional, age-appropriate activities.^6,7

The purpose of this project was to provide prospective volunteers with the knowledge base and skill set they need in order to feel confident and prepared for the upcoming camp.  More specifically, I aimed to supply volunteers with information they could use prior to and during the camp as a reference in the form of an evidence table, the CAT developed in Evidence-Based Practice II, and an educational Voicethread.

 

Statement of Need:

The majority of camp volunteers consist of pre- and current physical and occupational students.  After speaking with some of the volunteers from last year’s camp, I discovered that several had yet to attain hands-on experience working with the pediatric patient population.  Many individuals, particularly those pursuing physical or occupational school in the future, had not had the opportunity to learn about the expected clinical presentation associated with hemiplegia, proper grading and sequencing of tasks, current evidence-based research findings related to the camp design, or simple strategies that may be helpful when a child demonstrates increased fussiness.  Although the volunteer to camper ratio is 2:1, with volunteers comprising one pre- and one current physical or occupational student, I discovered a need to prepare each and every individual despite his or her background.

 

Products:

With the goal of providing an educational supplement to be used throughout the preparation phase of the Helping Kids with Hemiplegia summer camp for volunteers, I devised an evidence table as well as a narrated Voicethread with a focus on clinical presentation in children with hemiplegia, handling and facilitation techniques, and an evidence-based overview of current CIMT and BIT concepts.  In order to optimize the effectiveness of my presentation, I consistently reassessed and critiqued the material provided on each slide to ensure its simplicity, topic relevance, and importance in accordance with my audience.  Moreover, to mitigate the effects of the “Death by PowerPoint,”⁸ I incorporated the following strategies borrowed from the National Conference of State Legislators website⁹ in the development of my Voicethread presentation:

• Simple design with appropriate contrast between font and background
• Font style and size that is legible and easily viewable
• Bullet points with key points
• Minimize text to improve readability
• Consistency in font size, color, and design template
• Empty space surrounding text
• Avoid reading the presentation

Members of my audience will be provided a PDF version to be printed for note-taking in an effort to improve attentiveness and information retention.  Lastly, my CAT will be available for review, which was used to critically appraise two current research articles that were deemed to represent the best evidence using the following clinical question: “For an 8-year-old patient with hemiplegic cerebral palsy, is constraint-induced movement therapy or bimanual intensive training more effective in improving function in the involved upper extremity?”

 

Evaluation:

In the development of my products, I received ongoing feedback from my committee members, peers, and volunteers who had participated in the 2017 camp.  This feedback was used to augment the delivery of finalized material to my audience.  Moreover, I sought feedback from my classmates in the PHYT 880 Child and Family Assessment elective during the fall semester of third year coursework, many of which had participated in the camp in prior years.  This feedback was received in the form of a survey, which will also be shared with upcoming camp volunteers to identify areas in need of modification.  Because this project is ongoing, I plan to make revisions as needed in the years to come.

 

Self-Reflection:

This experience has provided me with an abundance of opportunities to network with experienced therapists, determine personal strengths to continue building upon, identify areas in need of improvement, and grow as a future clinician.  I have received exceptional feedback from the survey results in relation to my Voicethread, and I look forward to attaining additional feedback from future volunteers.

Overall, I am very pleased with the final result of my project.  Because the camp is held in June of each year, I was unable to include pictures and supplemental video footage of Helping Kids with Hemiplegia campers in my products.  Ideally, I would have liked to incorporate a patient case within the Voicethread content in order to enhance the application of knowledge acquired.  This is a goal I hope to accomplish this year.

 

Acknowledgements:

I would like to take the time to express my gratitude to all of those with whom I had the pleasure to work with throughout this entire process.  This work would not have been possible without your ongoing commitment and support.  I would like to personally thank Holly Holland, OTR/L, and Kerry Blazek, PT, DPT, PCS, for the time and effort you both put forth on a daily basis to better serve the pediatric patient population.  Your passion for the Helping Kids with Hemiplegia camp is inspiring, and I want you to know how much I appreciate the hard work you put in to its development each year.  I would also like to thank you for the invaluable feedback you have provided throughout this semester and for giving me the opportunity to focus my capstone project on a topic that is so near and dear to my heart.  I would also like to thank my capstone advisor, Karen McCulloch, PT, PhD, NCS, for her professional guidance and assistance, which were instrumental in the completion of this project.  Finally, I am especially indebted to Dana McCarty, PT, DPT, PCS, C/NDT, who has worked so diligently to support my future career goals in pediatrics.

 

References:

1. Rosenbaum P, Paneth N, Goldstein M, Bax M. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol. 2007;49(6):480.
2. Maenner MJ, Blumberg SJ, Kogan MD, Christensen D, Yeargin-Allsopp M, Schieve LA. Prevalence of cerebral palsy and intellectual disability among children identified in two U.S. National Surveys, 2011-2013. Annals of epidemiology. 2016;26(3):222-226. doi:10.1016/j.annepidem.2016.01.001.
3. Kliegman RM, Stanton BMD, St Geme J, Schor NF. Nelson Textbook of Pediatrics E-Book, 20^th Elsevier Health Sciences, 2015:2897.
4. CHaSA – Hemiplegia. Children’s Hemiplegia and Stroke Association. 2018. Available at: http://chasa.org/medical/hemiplegia/.
5. Houwink A, Aarts PBM, Guerts ACH. A neurocognitive perspective on developmental disregard in children with hemiplegic cerebral palsy. Research in Developmental Disabilities. 2011;32:2157-2163. doi:10.1016/j.ridd.2011.07.012.
6. Sakzewski L, Ziviani J, Abbott D, et al. Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Developmental Medicine & Child Neurology. 2011;53:313-320. doi:10.1111/j.1469-8749.2010.03859.x.
7. Deppe W, Thuemmler K, Fleischer J, et al. Modified constraint-induced movement therapy versus intensive bimanual training for children with hemiplegia – a randomized controlled trial. Clinical Rehabilitation. 2013;27(10):909-920. doi:10.1177/0269215513483764.
8. McMillan D. Life After Death by PowerPoint 2012 by Don McMillan [YouTube]. 2012. Available at: https://www.youtube.com/watch?v=MjcO2ExtHso.
9. Tips for Making Effective PowerPoint Presentations. National Conference of State Legislators. 2017. Available at:http://www.ncsl.org/legislators-staff/legislative-staff/legislative-staff-coordinating-committee/tips-for-making-effective-powerpoint-presentations.aspx

 

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