Overview of Occupational Therapy Assessment and Intervention in Cerebral Palsy

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Original Editor - Ewa Jaraczewska based on the course by Teona Darchia

Top Contributors - Ewa Jaraczewska  

Introduction

Occupational therapy enables people to participate in activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want, need, or are expected to do by modifying the occupation or the environment to support their occupational engagement better.Paediatric occupational therapy programs that are family-centred meet children’s needs and focus on structured play and recreation to enhance the development of children with cerebral palsy (CP) and can be delivered in hospitals, clinics, rehabilitation and daycare centres, home care programmes, special schools, community centres or private enterprises. Occupational therapy for clients with cerebral palsy addresses problems related to movement disorders but also lifelong issues that include cognitive dysfunction and behavioural or emotional problems.This article provides an overview of the occupational therapy framework for assessing and treating children with cerebral palsy. Healthcare professionals will be offered an in-depth review of the Person-Environment-Occupation-Performance Model as an example of the occupational therapy client- and family-centred model.

Assessment

The occupational therapist can choose one from several client- and family-centred models as a framework for assessment and treatment when providing services to children with cerebral palsy. These models are

1. 1. The Person-Environment-Occupation-Performance Model – its main components are complex interactions between the person and the environment.
   2. The Person-Environment-Occupation Model- focuses on "occupational performance and its link to people, occupation, roles, the environment, work, and play as a dynamic, interwoven process".
   3. Occupational Adaptation Model- identifies occupations to allow the client to experience adaptation.
   4. The Model of Human Occupation- assists with habits and roles that guide a person’s occupational choices.
   5. The Kawa Model- tries to enable, assist, restore and maximise clients’ life experiences.

The Person-Environment-Occupation-Performance Model (PEOP)

PEOP is a client- and family-centred model emphasising occupational performance.

"Occupational performance (OP) is the performance of significant activities, tasks and roles through the complexity of the relationship between the person and the environment."

There are four domains within the PEOP model:

• Person
  • Include roles, personality, physical, cognitive, and sensory abilities, self-concept, health, and cultural background
• Environment
  • Includes social, physical, socioeconomic, and institutional environment
• Occupation
  • Includes "tasks that an individual engages in and expresses himself/herself "
• Occupational performance
  • Includes characteristics of a person and characteristics of the environment
    • Characteristics of a person include body structures (physiological characteristics), body functions (motor, cognitive, perceptual, sensory, and psychosocial functions), and values and spirituality
    • Characteristic of the environment that positively or negatively affects an individual's occupational performance

Cerebral Palsy

Cerebral palsy (CP) is a non-progressive disorder resulting from lesions that occur in an immature brain. The physical disability caused by this disorder limits a child’s ability to perform daily activities successfully due to spasticity, muscle contracture, lack of coordination, loss of motor control and poor voluntary movements.

CP and Characteristics of Domains within the PEOP Model

The four domains within the PEOP model can be impacted by cerebral palsy:

• Person: Independent participation in daily activities, productive activities, play and leisure activities requires physical, communicative, cognitive abilities and self-awareness efficacy. Individuals with cerebral palsy who demonstrate impairments in gross motor functions, manual abilities, and cognitive and communicative functions can become restricted in recreational and physical activities and demonstrate decreased intensity and variety of participation in activities and the achievement of self-efficacy and self-engagement.
• Environment: social participation affected by the social environment is based on family preferences and their capacity. Steady reliance on adults by a child with cerebral palsy reduces the feeling of freedom in a social context and the development of friendships. Yet family support through encouraging participation can help the child to develop social participation but, in certain circumstances, can limit participation due to the overprotective attitude of the parents. Physical barriers (stairs, no easy access) can affect a child's socialization with family and friends. The physical environment for school and sports activities can become limiting and discouraging.
• Occupation: Individuals with cerebral palsy prefer sedentary activities, such as board games, and passive and computer-based activities, which are mostly carried out at home and not within the community.
• Occupational Performance: Parents and friends are the main sources of social support for children with CP. When the support is limited, or there is a presence of violence, the child may lose their sense of belonging, which can impact their self-esteem and confidence.

Occupational Therapy Evaluation Using PEOP Model

" The evaluation process is focused on finding out what the client wants and needs to do, how to determine what the client can do and has done, and also identify supports and barriers to participation in everyday life."--Teona Darchia

Client's Occupational Profile

"The occupational profile is a summary of a client’s (person’s, group’s, or population’s) occupational history and experiences, patterns of daily living, interests, values, needs, and relevant contexts.” --AOTA (2020)

The occupational profile of a child with cerebral palsy includes the following components and methods of assessment:

• Occupational history/Experience
  • Semi-structured interview with the parent and/or child about the child's life experiences.
• Information about daily living/interests (leisure)
  • Canadian Occupational Performance Measure (COPM) measures a child’s perceived occupational performance in self-care, productivity, and leisure.
• Values
  • Semi-structured interview with the parent and/or child about the child’s values and interests.
• Contexts
  • Observation and semi-structured interviews with the parent and/or child to define the different environmental and personal factors specific to each child.

Client's Occupational Performance

• Occupational performance is an interaction and interdependence of a person, environment, and occupation components
• Includes daily activities, work, productive activities, and play or leisure activities.

Formal interview techniques, casual conversation, observation and analysis of the client's performance in specific occupations and evaluation of specific aspects can be used to assess occupational performance.

Synthesis of the Evaluation

• It helps to establish goals, intervention plans, and desired outcomes
• The occupational performance goal achieved through applying the PEOP model is to achieve good participation and well-being

Intervention Planning

Intervention planning is conducted in collaboration with clients, their family members, or other professionals and includes the following three steps:

1. Intervention plan
2. Intervention implementation
3. Intervention review

Intervention Plan

A broad spectrum of motor impairments, associated disabilities, and varying levels of cognitive function characterises children with cerebral palsy. This heterogeneity makes the development of the assessment tools very challenging. Clinicians cannot rely on a one-size-fits-all approach as they will likely miss a child's specific needs and abilities. Proper assessment using standardised tools is central in developing individualised treatment plans for individuals with CP. The following standardised assessment tools provide a structured and objective framework for measuring each child's abilities and limitations and help with establishing the most appropriate intervention plan:

Gross Motor Function Classification System (GMFCS):

• Allows to tailor treatment strategies and interventions to match an individual's specific functional abilities
• It helps to predict a child's likely motor progression and potential for achieving greater independence in activities of daily living. It sets "realistic expectations and provides a basis for goal setting and intervention planning".

Manual Ability Classification System (MACS):

• Provide insights into an individual's manual abilities and limitations
• Allows selection of appropriate therapeutic interventions and strategies to improve hand function and manual dexterity
• Facilitates a design of realistic, effective, and targeted interventions to address the child's unique needs

Paediatric Evaluation of Disability Inventory (PEDI):

• Assists in identifying areas of functional impairment
• Provides a comprehensive assessment of an individual's functional strengths and limitations
• Create a foundation for developing targeted and individualised intervention plans
• Enables setting achievable goals for improvement

WeeFIM:

• Helps to tailor interventions and support services to enhance functional independence and quality of life

The Vineland Adaptive Behaviour Scales:

• Measure adaptive behaviour and daily living skills in individuals with developmental and intellectual disabilities.
• Guide intervention planning by assessing the individual's adaptive functioning

Intervention Implementation

Intervention can be direct or indirect and must consider the following two elements:

• A person's interaction with the environment
  • Barriers:
    • Physical barriers (stairs, uneven path)
    • Lack of access or availability of assistive technologies
    • Attitudinal barriers (stigmas around children with CP)
    • Governmental/policy barriers (limited access to hospitals, clinics, and specialised services)
  • Context-focused therapy:
    • Changing the characteristics of the task and/or environment will enable the child to perform an activity they were unable to do previously.

• A person's participation in everyday activities:
  • Therapist must consider the developmental timeline in which children complete basic self-care tasks
  • Therapist sets age-appropriate goals
  • Therapist analyses complex tasks into a sequence of smaller steps or actions
  • Child completes small steps towards reaching the goal of completing the full task independently

General rules for applying an intervention:

• Use simple and clear verbal instructions
• Show the person what you are asking them to do
• Carry out activities together and, if necessary, use the hand-in-hand technique, which involves performing actions together, holding hands, and helping physically
• Give the person enough time to complete the activity
• Provide only as much help as the person needs
• Do not do part of the activities or tasks for the person if they cannot do it
• Use only handling strategies that do not have a negative effect on the person's muscle tone
• Choose assistive technologies that can increase the client's participation in daily activities

Intervention Review

Regular assessments allow for monitoring an individual's response to applied interventions over time, objectively measuring progress, identifying areas of improvement, and detecting any emerging challenges.The same tools used for initial assessment are applicable to monitor the effectiveness of the interventions:

MACS:

• Monitors an individual's progress over time.
• Assesses changes in manual abilities and thus evaluates the effectiveness of therapeutic interventions and rehabilitation programs.
• Allows to make data-driven adjustments to treatment plans and celebrate milestones achieved by individuals with CP.

PEDI:

• Measures the impact of various interventions and therapies

Outcome Evaluation

The assessment tools are instruments to monitor a child's progress. They can assist with the following:

• tracking changes in functional abilities
• assessing the impact of interventions
• making necessary adjustments to treatment plans
• ensuring that interventions remain aligned with evolving needs

Goal Attainment Scaling (GAS)

"Goal attainment scaling (GAS) is a method of setting and evaluating goal achievement across different patient groups."

Goal Attainment Scaling (GAS):

• Offers a structured approach to goal-setting
• Evaluates services or an individualised program based on attaining individualised goals.
• Includes discussions between the patient, family, and the multidisciplinary team about what goals are important to the individual.
• It is a reliable, sensitive and valid measure of specific and targeted clinical change which is included in daily living tasks performed by children with CP.
• Able to measure individual change over time in children with cerebral palsy.

Paediatric Evaluation of Disability Inventory (PEDI)

• Tracks changes in functional abilities over time.
• Offers a standardised framework for assessing an individual's functional progress.
• Evaluates a child with CP's level of independence or dependence in self-care activities, which include feeding, dressing, grooming, and other personal hygiene and daily living activities.
• Assesses an individual's mobility limitations and the assistance required to move safely and effectively.
• Assesses a child with CP engagement with peers, family members, and the community.

Resources

• Rehabilitation Guideline for the Management of Children with Cerebral Palsy
• Assessment Scales in Cerebral Palsy: A Comprehensive Review of Tools and Applications