Working in pediatric practice, particularly with neuromotor populations and medically complex children has been a lesson in patient perseverance. My experiences are marked by countless moments of trial and error which has challenged me to question conventional norms while continuing to seek out new knowledge and innovative practices. This led me to set a goal to acquire and integrate advanced knowledge in the skillful assessment and comprehensive treatment of motor control and function in children with neuromotor conditions. Each of these artifacts contribute to my journey of arriving in a place of competence and confidence with implementing individualized best practices.

Through my courses at NYU, I came to wholly recognize and value the role of evidence based practice. Prior to NYU, evidence based practice was something I had been educated on and seemingly strived to implement into my day to day treatment. However, it wasn't until my doctoral studies that I truly challenged not only my understanding but also my prioritization of evidence based practice in the context of offering the best care I knew possible, to my patients. Through these experiences, I came to realize evidence based practice does not automatically translate into best practice, as the two are not mutually exclusive. The notions posed by two of my professors, asserting "just because there isn’t evidence now, doesn’t mean the evidence doesn’t exist" (Van Lew, 2019) and "if we only practice evidence based approaches, how do we create new evidence?"(Kim,2019) continue to resonate with me. As a clinician, I feel this is an important reminder to never be confined to the conventional opinions and restrictions of what is merely available and regularly done. Conversely, I appreciate the need for sound clinical reasoning grounded in science and objective rationale. I continue to strive to strike a balance between utilizing valid and reliable methods to inform my practice while also understanding sometimes one must look outside traditional means for what is most subjectively beneficial for each patient.

I carried these lessons with me beyond the classroom, as I was able to directly apply my knowledge into practice. This would continue to prove invaluable as I began to educate myself further on pediatric upper extremity assessment and intervention. The development of my fourth artifact (UE Assessment) entailed reviewing the literature of various assessment measures, which I was now able to do with a critically trained eye in psychometric properties. However, I also recognized the need to weigh this against other factors such as our unique clinical population as well as time and cost constraints. I've come to understand that even the gold standard assessment tools are only as valid and reliable as one's ability to administer as intended, to precisely for whom it was intended. At first, I struggled to identify the singular perfect assessment to fit our practice population. As I carefully critiqued and considered the strengths and limitations of all the options available to me, I kept coming up short. That was until I realized it was the restrictions in my own vision, that was responsible for this shortcoming. I had envisioned and idealized implementing one standardized measure to more uniformly streamline our assessment processes. But trying to identify one measure to fit all our patients' needs was problematic. The challenge in an attempt to streamline the assessment process was differing situations will warrant differing approaches. There was no singular measure that was going to perfectly fit all patients, across all situations. The solution I found rather, was a blended approach, taking the best parts of each measure to arrive at a comprehensive picture. This ultimately resulted in the developing my upper extremity assessment artifact, which reflects the system our department currently utilizes.

I continued to explore applying this concept of comprehensive and complementary care and sought to expand the idea of a blended approach beyond assessment to intervention. This led me to the development of my fifth (mCIMT Guidelines) and sixth (mirror therapy) artifacts. In conducting my literature review and own continuing education, I found constraint induced movement therapy (CIMT) to be regarded as the most widely recognized and documented intervention for pediatric hemiplegia. With a solid evidence base touting its' efficacy, I determined it warranted integrating into my current practices. As the literature detailed, the protocols for CIMT varied, with several modified constraint (m-CIMT) protocols having been developed. These options both excited me and perplexed me, as I questioned where to begin. Through the AOTA course, I was able to acquire formal foundational knowledge in CIMT and was further exposed to another approach, hand arm bimanual intensive training (HABIT). As I considered either approach, I was struck by how I felt many of my patients could benefit from aspects of both. As with implementing a new assessment protocol, I was reminded of my lesson of trying to make one method fit. As the two approaches initially appeared somewhat contradictory, I knew it would not be as simple as merely combining them. But what if there was a way to expose patients to the benefits of both, I thought? The literature guided me once again, yielding early evidence for hybrid CIMT-BIT models. Initially, I had not anticipated how challenging it would be to integrate these hybrid models into our current existing practice model. A direct translation was not possible due to our time constraint of typically 3 weeks with our patients. This forced me to more deeply examine minimum effective dosages, which allowed me to effectively adapt clinical guidelines that complemented our practice model. Another challenge was identifying how to effectively ensure the recommended dosages were being implemented within the time constraints of our program, without compromising the quality of other therapies. I quickly learned this would not be possible without the collaboration, willingness and efforts of our full interdisciplinary team. Together, we were able to identify creative solutions for embedding the necessary repetition and structured practice for unimanual and/or bimanual opportunities throughout the child's day. This was of course individualized to each child, but may include things such as the PT incorporating specific bimanual play tasks as breaks between exercise reps or the speech-language pathologist emphasizing specific unimanual preference when reaching to activate a switch or grasp a toy. In addition to better supporting the child, this approach has also been an opportunity for our team to best support one another as collaborative clinicians.

As excited as I was about the prospect of the mCIMT-BIT protocol, I knew it was far from being a singular solution. For every few child I saw progress with, there were others I found mCIMT-BIT to be less feasible or simply not yielding the desired results. I went back to literature once again. This time, I sought not so much evidence, but rather innovation. I was chasing after something new and untapped; something that held promise but perhaps lacked the conclusive science to back it up just quite yet. I expanded my thinking beyond pediatric hemiplegia. I researched populations with similar impairment. Little by little, I uncovered several other approaches that seemed promising. This topic so piqued my interest, it eventually led to my conducting a formal literature review on the topic. Selecting which route I wanted to next pursue led to the development of my sixth artifact (mirror therapy). Perhaps biased by my own expsoure, I began to further explore mirror therapy treatment for pediatric populations. I recalled being a graduate student and learning of the successes my professor had when studying mirror therapy with adult stroke populations. While the literature offered guidance on practice guidelines for adults, there was minimal evidence for pediatric protocols. I knew if I was going to attempt this, I was going to have to adapt based on the guidelines of what was currently available. I recognized it would not be as simple as merely translating the adult protocols to children. I learned and understood there were additional factors including cognition, attention and motivation that posed unique barriers in the pediatric patient. As a pediatric practitioner, the ability to continually think outside the box and adapt has been amongst one of my greatest lessons. Children rarely present black and white, perfectly fitting and following a protocol. Adaptation and ingenuity are a necessity. Much to my surprise, implementing mirror therapy with the right pediatric candidate has been easier than anticipated. It has also yielded some significant gains which has made the process even more worthwhile. One of the best aspects of this approach from parent feedback has been the ability to easily integrate this technique into a home routine. I really value finding an approach that incorporate simplistic and cost-effective materials, and is easy to implement anywhere. Moreover, the ability to train children and families in a home-based mirror therapy program has been incredibly rewarding. As a therapist, I find there is such immense value and reward in empowering the patient and family to have the ability to carry out their own care.

CME training and certification is an artifact which represents a very critical and integral turning point of who I have become as a practitioner. Initially, I had reservations on incorporating an approach with a clear lack of any established scientific evidence to support its’ effectiveness. Through courses in this doctoral program, namely Advanced Assessments and Evidence Based Practice, I was able to recognize and appreciate CME's role in expanding beyond conventional norms. Proponents of CME, including that of the founder, readily acknowledge a lack of any scientific evidence to support this method of assessment and intervention. However, Cuevas (2012) offers “In 35 years of continuous practice, the lack of scientific proof regarding CME therapy results, has never been an obstacle for the parents to put their children in my hands. Only the solid progress experienced by the children treated with CME, has spread the reputation of this approach". It was the first time in my professional career I began to question the weight anecdotal report and mere clinical observation holds, in the absence of any objective scientific data to support it. I approached CME with cautious, but hopeful hesitations. But as I watched child after child respond in a way I had not previously observed, I became increasingly intrigued. The science hadn't changed, but my clinical observation - that had to count for something? Still, I do get push back from colleagues. I remember bringing up this approach during one of my courses and being challenged by peers and professors. I've learned to advocate not only for evidence-based practice, but also innovative practices. I emphasize recognizing the difference between an intervention that has inferior evidence versus one that simply does not have any evidence yet. This experience has continued to teach me the importance and need for evidence based practice. But it has also revealed how exclusive evidence based practice can become almost paradoxical. For if we confine ourselves to only the evidence of the past and present, we impede future innovation.

Collectively, these artifacts demonstrate my advanced competence in skillful assessment and comprehensive treatment of pediatric neuromotor control. I've reflected on how I let go of the notion greater knowledge automatically translates into greater skill. Advanced training and course certifications, including CME and CIMT, exhibit I have acquired the knowledge. But I also recognize my skill comes from more than merely knowing the information, but rather what I have done with that information. A person can have all the knowledge, information, evidence. But the skill comes in being able to sift through all the information, interpret it, and apply it in a meaningful and effective way. As a clinician, I strive to embody approaches as unique and diverse as the children I work with. My approach to practice strives to strike a balance between the conventional and contemporary, supplementing with complementary and alternative methods as warranted. That to me, is the mark of a skilled clinician.