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Outcomes of a Camp-Based Intensive Therapy Approach to Promote Functional Independence in Children Diagnosed With Developmental Disabilities

Background: Healthy People 2010 and 2020 include the objectives “to reduce the proportion of children and adolescents who are overweight or obese” and “to increase the proportion of adolescents that meet current physical activity guidelines for aerobic physical activity and for muscle-strengthening activity” (1). Compared to their peers, children with cerebral palsy are at increased risk for overweight and obesity, which can be associated with decreased functional status and cardiovascular disease (2). In addition to impacting body weight and cardiovascular health, participation in physical activity may also prevent other secondary complications of cerebral palsy such as pressure ulcers, decreased bone density, and joint contractures (3).

Program Description: The Focused Interdisciplinary Therapy Program at Kennedy Krieger Institute offers children and adolescents with persistent, disabling conditions intensive therapy that targets specific therapeutic goals. Given high demand for enrollment in this program during summer months, a group-based model of intensive therapy is implemented. This poster reports the outcomes of three 7- to 8-year-old girls, GMFCS level 1-2, who participated in an intensive therapy group during the summer of 2013.

Campers in the group participated in three hours of group physical therapy and two hours of group occupational therapy four days per week. Physical therapy interventions were divided into an hour of yoga/stretching, an hour of cardiovascular activities (dancing, riding adaptive trikes, walking/running/jumping while playing games), and an hour of strengthening exercises (lifting and carrying weights, functional training such as sit to stand and stairs) and balance/agility activities (obstacle courses, walking on uneven surfaces, playground games, and climbing). Occupational therapy sessions focused on ADL practice, upper extremity strengthening, and promoting lifelong fitness with groups such as leisure education and practice, and nutrition and healthy meal preparation. In addition to the four days of land-based therapy, each camper participated in aquatic therapy once per week. Throughout the camp session, the campers went on weekly therapeutic outings to emphasize community-based fitness activities, such as bowling and rock climbing. At the end of the camp session, participants attended a sleepaway camp for the weekend with therapist support. Each camper was given a home exercise program at the conclusion of camp to allow ongoing progress toward functional goals, and campers were referred as appropriate to community fitness programs.

Melissa K. Trovato, MD – Director of Inpatient Rehabilitation at Kennedy Krieger Institute; Teressa Garcia Reidy, MS, OTR/L – Kennedy Krieger Institute; Erin C. Naber, BS, DPT – Kennedy Krieger Institute;

Patricia Turlington, BSc, PT – Kennedy Krieger Institute

References:1. http:///www.healthypeople.gov.

2. Hurvitz EA, Green LB, Hornyak JE, Khurana SR, Koch LG (2008). Body mass index measures in children with cerebral palsy related to gross motor function classification: a clinic-based study. Am J Phys Med Rehabil. 87(5):395-403.

3. Ayyangar R. (2002) Health maintenance and management in childhood disability. Physical Medicine and Rehabilitation Clinics of North America. 13(4):793-821.

4. Cieza, A., Geyh, S., Chatterji, S. et al. (2005). ICF linking rules: An update based on lessons learned. J Rehabil Med. 37: 212–218

5. Darrah J, Wessel J, Nearingberg P & O’Connor M (1999). Evaluation of a community fitness program for adolescents with cerebral palsy. Pediatric Physical Therapy. 11(1), 18-23.

6. Fragala-Pinkham MA, Haley SM, Rabin J & Kharasch VS (2005). A fitness program for children with disabilities. Physical Therapy. 85(11), 1182-1200.

7. Schreiber J, Marchetti G & Crytzer T (2004). The implementation of a fitness program for children with disabilities: A clinical case report. Pediatric Physical Therapy. 16(3), 173-179.

8. Oriel KN, George CL & Blatt PJ (2008). The impact of a community based exercise program in children and adolescents with disabilities: A pilot study. Physical Disabilities: Education and Related Services. 27(1), 5-20.

9. Arpino C, Vescio MF, DeLuca A, Curatolo P (2009). Efficacy of intensive versus nonintensive physiotherapy in children with cerebral palsy: a meta-analysis. Int J Rehabil Res. Nov 11: E-pub ahead of print.

Participant Age at initial

evaluation

Diagnosis MACS GMFCS Change BOT Manual

Dexterity

Change BOT Upper Limb

Change BOT Balance

Change BOT Run

Change BOT

Strength

Change % Mean

PEDSQL

COPM Goal Areas Change in COPM

Change in COPM

Satisfaction

1. Female 8 Hemiplegic cerebral palsy

2 2 3 -1 7 3 3 4.81 (d4402) manipulating, (d4459) hand and arm use unspecified, (D4551) climbing, (d4552) running, (d170) writing

2.33 3.5

2. Female 7 Developmental delay

1 1 -6 8 13 4 5 5.63 (d3504) Conversing with many people, (d170) writing, (b7300) power of isolated muscles or muscle groups, (d4402) manipulating

4.25 7.25

3. Female 8 Hemiplegia s/p stroke in 2010

3 2 -1 4 12 7 3 4.54 (b7300) power of isolated muscles or muscle groups, (d710) Basic Personal Interactions, (d4459) hand and arm use unspecified, (b7300) power of isolated muscles or muscle groups

-0.25 -0.5

Key: MACS: Manual Ability Classification System; GMFCS: Gross Motor Function Classification System

Table 1: Participant Information and Results

Outcomes: Standardized assessments completed pre and post program included sections of the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT); the Pediatric Quality of Life Inventory (PEDS-QL); and the Canadian Occupational Performance Measure (COPM). COPM goal areas identified by families were coded using the ICF-CY (World Health Organization, 2007) using the method described in Cieza et al., 2005 (4). Change in COPM pre to post program and reported in table 1. All participants had a small increase on PEDS-QL score, and improved on the gross motor sections of the BOT-2 (balance, strength, running speed, and agility). BOT-2 upper limb coordination improvements were noted in 2/3 participants, but manual dexterity actually decreased for 2/3 participants. 2/3 participants also had clinically significant changes (>2) on COPM satisfaction and performance scores.

Discussion: The literature describes a variety of approaches to address fitness in children with cerebral palsy with varying degrees of success. Most employ after-school gym programs for 1-2 hours and last 4-12 weeks (5-8). Few, if any, programs have described an intensive group-based fitness camp model. Intensive therapy approaches for children with cerebral palsy are emerging as effective in encouraging improvements in motor function (9). The optimal intensity and specificity of intervention to address fitness in youth with cerebral palsy requires further investigation.