| Description |
Background: Cerebral palsy (CP) is the leading cause of childhood motor disabilities, affecting approximately 1 in 345 children in the United States. Infants with CP often experience asymmetric upper extremity involvement, which can lead to lifelong motor impairments if not addressed early. Constraint-induced movement therapy (CIMT) is a proven intervention for CP, but there is a gap in evidence-based protocols for infants with asymmetric upper extremity involvement. This project addressed this gap by implementing A Positive Parent-focused training for Upper Limb Experiences with Sensory-motor feedback (APPLES), a CIMT-based therapy, in an early intervention (EI) program serving the Intermountain West. Local Problem: A needs assessment conducted in 2023 at an EI program revealed that while therapists were eager to adopt evidence-based CIMT practices, barriers such as high caseloads, limited funding, and staffing shortages hindered implementation. None of the physical therapists (PTs) or occupational therapists (OTs) surveyed in 2023 used evidence-based CIMT protocols for infants with CP (Hohnholt). This project sought to address these challenges by implementing APPLES protocol, an evidence-based intervention and evaluating its feasibility, usability, and satisfaction. Methods: This evidence-based practice quality improvement project (EBPQI) followed the Johns Hopkins Evidence-Based Practice Model. While grant and scholarship applications were pursued, the project was ultimately funded through community stakeholder contributions. These funds supported the development of physical kits designed for immediate use during the training of therapists and to be used in their clinical application with patients and families. The funding also supported the two-day training session for 15 PTs and OTs, led by experts from the Cerebral Palsy Foundation and Emory University. The training focused on bimanual and multimodal techniques to improve motor outcome in infants with CP. Post-training surveys were sent out two weeks and three months after the two-day training session; this follow-up feedback was used to evaluate the usability, satisfaction, and feasibility of the implementation in real-world practice with patients and their families participating in the early intervention program. Interventions: The intervention included a thorough review of the needs assessment and SWOT analysis to identify barriers and readiness for APPLES implementation. Multiple funding sources were identified and pursued, and with funding secured, the project lead coordinated a two-day training session, including the assembling of physical take-home kits and recruitment of volunteers to demonstrate the use of C-mitts, specialized mittens used in therapy to encourage the use of the affected hand by restricting the less-affected hand seen in Appendix A. This was followed by collecting qualitative and quantitative data through post-training surveys and follow-up interviews to assess usability, feasibility, and participant satisfaction. Results: This initiative successfully increased therapists' knowledge and confidence in applying the APPLES protocol, with key findings including high participant satisfaction, 80% (n=12) strongly agreed, and 20% (n=3) agreed that the taught interventions were relevant to their practice. In total, six physical therapists and nine occupational therapists were awarded a completion certificate after completing the two-day training session and submitting the two-week post-intervention survey. Of the 15 therapists who completed training, the three-month survey reported that 20% (n=3) used specific APPLES interventions in their practice; one therapist reports, "I have implemented a few ideas from the course but have not had a child with CP or hemiparesis to use the strategies with yet." Two additional therapists noted that they had adapted their cueing techniques and parent education approaches to incorporate the parent-involvement strategies introduced during the two-day training. They praised the evidence-based interventions for being both feasible and practical for clinical use, emphasizing their relevance to their work with families and patients. However, they also highlighted barriers to sustained implementation, including high caseloads, limited resources, and staffing shortages. Despite these challenges, therapists expressed overall satisfaction with the quality improvement initiative, appreciating the learning opportunity and its applicability to their patient population. Conclusion: This project demonstrated the feasibility and usability of the APPLES protocol in an EI program, addressing a critical gap in evidence-based interventions for infants with CP. The findings highlight the importance of early, evidence-based interventions to optimize neuroplasticity and improve long-term outcomes. Future efforts should focus on sustaining training, addressing systemic barriers, and evaluating operational outcomes of further implementation of evidence-based practices to ensure equitable access to evidence-based care for all infants with CP. |
