Overview of Occupational Therapy for Cerebral Palsy with Case Examples

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

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Cerebral palsy (CP) is a permanent, neurodevelopmental condition that starts early in life. It affects a person's functional ability in daily life and is the leading cause of physical disability in childhood. Occupational therapy enables people to participate in meaningful activities that support their health and well-being, taking account of the physical, emotional, social and environmental factors that influence occupational performance. For children with cerebral palsy, occupational therapy focuses on developing the skills needed for activities of daily living, increasing independence, and improving quality of life.

Occupational therapy includes a range of approaches that are adapted and tailored to meet each child's unique presentation, needs and goals. An integrated care approach should be promoted for children with cerebral palsy to ensure timely and efficient interventions. Early initiation of specific therapeutic interventions can positively influence neuroplasticity in the developing brain. This article is designed for all healthcare professionals to help them appreciate the occupational therapy approach in the rehabilitation of children with cerebral palsy.

Occupational Therapy

"Occupational therapy is a client-centred health profession concerned with promoting health and wellbeing through occupation."

The Role of the Occupational Therapist

Occupational therapists support individuals to achieve meaningful participation in meaningful occupations. They tailor interventions to meet specific needs and preferences and they support people of all ages in achieving greater independence and enhancing their quality of life and well-being.

Occupations

"Occupations refer to the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do."

"Occupations are important because they define who we are, our interests, likes and our identity."

The Occupational Therapy Practice Framework (OTPF-4) categorises the following occupations:

• activities of daily living
• instrumental activities of daily living
• health management
• rest and sleep
• education
• work
• play
• leisure
• social participation

Note: OTPF-4 added Health Management as a specific occupation category.

If you're interested, you can read more about each category here.

Occupational Therapy Settings

Occupational therapists work in hospitals, clinics, rehabilitation facilities, daycare centres, home care programmes, schools, and private enterprises. Their services include (1) individual evaluation, including life experiences and interests, (2) a unique intervention plan, and (3) outcome evaluation.

Occupational Therapy Assessment

The occupational therapy assessment focuses on finding what the client wants and needs to do and identifying their resources and barriers. Occupational therapists conduct an initial assessment and continue to re-assess throughout the intervention process. The type and focus of the assessment depend on the occupational therapy practice setting, and each assessment is modified according to the client's individual needs.

Assessments can include standardised and non-standardised elements. A standardised assessment measures a child’s abilities against those of other children the same age (e.g. a cognitive assessment test or IQ test). A non-standardised assessment is an informal assessment that therapists can use to identify strengths and difficulties that can be targeted during therapy. For example, the therapist might conduct an activity analysis, where they observe the child performing a specific task. This can be a task or activity usually supported by a caregiver. The occupational therapist will analyse the task and determine which approach (adapting the task, environment, practising new skills or using patient education methods) or which combination of approaches would be most beneficial.

Occupational Therapy Interventions

According to the Occupational Therapy Practice Framework (OTPF-4), the occupational therapist can provide direct or indirect services.

Direct services: services are delivered collaboratively to clients in hospitals, clinics, workplaces, schools, homes, and communities. These direct services involve interventions conducted in face-to-face contact with the client, including in-person meetings, group sessions, or engaging with clients and their families via telehealth platforms.

Indirect services: occupational therapy practitioners consult with various entities, such as teachers, multidisciplinary teams, or community planning agencies, on behalf of their clients. For instance, they may advise school staff on promoting health through recess activities or offer guidance to organisations on inclusive design to enhance occupational performance in built and natural environments.

Occupational Therapy for Cerebral Palsy

Occupational therapy for cerebral palsy aims to address problems related to play, self-care (feeding, dressing, and grooming), and fine motor skills such as writing, cognitive, and visual-spatial problems.

Case Examples

• A child with spastic cerebral palsy presents with hyperreflexia and hypertonicity, which has caused decreased range of motion. They have difficulty performing everyday functional activities, such as walking, grasping, and reaching.
• A child with dyskinetic cerebral palsy has limited mobility and manual ability due to involuntary movements and changes in muscle tone.

For both children, occupational therapy could help to improve independence, their ability to play and learn, and increase their self-esteem, confidence and quality of life through the following approaches:

• introducing activities that focus on developing and improving the ability to perform functional and daily activities, like playing, eating, bathing, toileting, and dressing
• practising motor skills, body posture, and functional mobility activities
• introducing different assistive devices, including sitting and standing aids, wheelchairs, adapted utensils, and writing aids
• adapting the task or the environment while practising and enhancing the child's skillset

Interventions to Support Meaningful Occupations

Occupational therapy offers significant benefits for children, enhancing various aspects of their development and overall well-being and promoting engagement and participation in daily life roles. Occupational therapists choose interventions for children based on the following: (1) an analysis of the child's performance of daily life roles, (2) how the child's performance is affected by their disability, and (3) how their environment supports or limits their performance.

Family plays an essential role in the health and well-being of children. Thus, the client-centred approach in occupational therapy emphasises the participation of the patient and family in decision-making in order to set and achieve therapeutic goals and functional priorities.

In order to support meaningful occupations, occupational therapists consider: (1) the environment, (2) participation in everyday activities, (3) physical helping strategies, (4) incorporating assistive devices, and (5) sensory processing. Each of these aspects is explored below using a case study.

Environment

Occupational therapy can suggest ways to adapt the environment to support meaningful occupations.

Mia is a 6-year-old girl with spastic cerebral palsy. She uses a walker for mobility and struggles with balance and coordination. Mia loves playing with her toys and getting dressed independently, but her home environment presented several barriers that limited her ability to participate fully in daily activities. The slippery floors made it difficult for Mia to move around her house safely and increased her risk of falls. Her favourite toys were stored on high shelves, making it hard for her to access them independently. The family bathroom also lacked suitable supports or adaptive equipment, and Mia struggled to sit and rise from the toilet without help.

The occupational therapist suggested several interventions. To reduce slippery surfaces, non-slip rugs and relatively hard carpets were placed in the main areas where Mia walks, such as her bedroom and the living room. This reduced her fall risk and increased her confidence in moving around with her walker. To improve storage accessibility, Mia's toys were moved to lower shelves within easy reach, allowing her to get them independently. This fostered a sense of autonomy and allowed her to play more without adult assistance. For the bathroom, the therapist recommended installing grab bars by the toilet and attaching a toilet riser to make sitting and standing easier, and a foot support cube was provided to help Mia feel more stable when sitting on the toilet.

Participation In Everyday Activities

Occupational therapists can work with children to improve their participation in everyday activities.

Ben is an 8-year-old boy with cerebral palsy. In particular, his fine motor skills and coordination are impacted. Ben wanted to be able to dress himself in the mornings and help with small chores around the house, like setting the table. However, he was struggling with tasks that involved precise movements. He was finding it difficult to button his shirt and tie his shoes, which led to frustration and dependence on his parents. When trying to set the table, he often dropped items because of coordination difficulties.

The occupational therapist began by observing Ben's daily routine and talking to him and his family about his goals. Ben wanted to learn how to button his shirt and help set the table like his siblings, so the therapist focused on these two areas as priorities for intervention.

To develop Ben's buttoning skills, the therapist used a "Tell, Show, Do" approach. In the "Tell" stage, they used simple, clear verbal instructions to break the task into smaller steps, such as "find the button," "hold the button" and "push it through the hole." In the "Show" stage, they demonstrated the steps, showing Ben how to hold the button with both hands and align it with the buttonhole. In the "Do" stage, they used the "hand-in-hand technique" (also known as guiding via the Affolter approach), physically guiding Ben's hands as they practised buttoning together. This gave him the support he needed without the therapist taking over the task.

For chores, the therapist worked with Ben on setting the table, starting with lightweight utensils and giving him time to carry one item at a time, then gradually reducing the assistance provided to encourage him to complete the task independently. Throughout, Ben was given ample time to button his shirt and complete chores, with only as much help as needed. His family was advised not to take over tasks he could manage, allowing him to improve his skills at his own pace.

Physical Helping Strategies

An occupational therapist can introduce physical helping strategies to help children participate in everyday activities.

Alex is a 5-year-old boy with spastic cerebral palsy, which affects his posture and ability to sit upright for extended periods. His parents found that he was often slouching or sliding down in his wheelchair, which made activities like eating or drawing at the table difficult. This postural instability made it hard for him to focus on tasks and limited his participation in everyday activities, and his parents noticed that he often became frustrated during mealtimes because he struggled to stay seated and take part in family meals.

The occupational therapist assessed Alex's sitting posture and identified that he could not maintain the 90-90-90 position (hips, knees and ankles at 90 degrees). His feet were dangling and his trunk lacked support, so the therapist recommended modifications to his seating to improve stability. Alex was referred to a seating and mobility specialist, and his wheelchair was modified in two ways: a footrest was added to ensure his feet were flat and supported, which helped reduce sliding and increased his overall comfort, and a back cushion with a headrest and lateral support replaced the wheelchair's sling back to help him sit upright and keep his back against the chair.

The therapist also used physical helping strategies during mealtimes, gently guiding Alex's trunk and shoulders to maintain an upright position and positioning his head in the midline to improve focus and reduce strain on his neck. They practised sitting together, using verbal cues such as "head up, shoulders back" to encourage self-correction over time.

Finally, Alex's family was asked to continue practising this new sitting posture during meals and playtime. They were encouraged to give him time to adjust, offering gentle physical assistance only when needed to help him maintain stability and independence.

Incorporating Assistive Devices

Occupational therapists will often introduce assistive devices into treatment interventions to help children with cerebral palsy perform various daily tasks.

Lily is a 7-year-old girl with cerebral palsy, which affects her motor skills and coordination. She was struggling with tasks like feeding herself and brushing her teeth because of limited hand dexterity and muscle control. She found it difficult to grasp utensils and bring food to her mouth without spilling it, which limited her ability to feed herself, and she struggled to brush her teeth independently because she could not maintain a stable grip on the toothbrush. These challenges affected her independence, and she was relying heavily on her parents for assistance during meals and personal grooming.

After observing Lily's difficulties and discussing her needs with her family, the occupational therapist determined that adaptive utensils and grooming aids would best support her daily activities. Collaboration with other specialists, including a physiotherapist, helped confirm the choice of self-care assistive devices. The therapist introduced Lily to utensils with large, easy-to-grip handles designed for children with limited hand strength and coordination, and a weighted spoon helped her maintain control while feeding herself. For grooming, the therapist recommended an electric toothbrush with a large, cushioned handle, which reduced the need for precise hand movements and made it easier for Lily to grip and control the brush.

The therapist then worked with Lily to familiarise her with the new utensils and toothbrush. They practised using the spoon during snack time, with the therapist offering verbal cues and hand-over-hand assistance when needed and gradually decreasing physical help as Lily gained confidence and control. For brushing her teeth, Lily practised holding and turning on the electric toothbrush independently, with her parents and the therapist reinforcing the steps. The therapist also encouraged Lily's parents to allow her ample time to practise with the assistive devices during meals and daily grooming, and to help only when necessary, promoting her independence and self-confidence.

Sensory Processing

The following case example illustrates how occupational therapists can use sensory integration in their therapy sessions.

Noah is a 6-year-old boy with cerebral palsy who struggles with sensory processing. His parents noticed that he often became overwhelmed by loud noises, had difficulty with balance and coordination, and avoided tasks that required him to touch certain textures, such as dressing and feeding himself. He was easily overwhelmed by environmental stimuli like loud noises and rough textures, which affected his daily functioning and participation in group activities, and he struggled with tasks that required strength and coordination, such as moving objects or playing games involving balance. Together, these sensory challenges limited his ability to perform self-care tasks and take part in social activities at school.

Noah's occupational therapist designed therapy sessions that included a variety of sensory stimuli to help him gradually adjust to processing different sensations, using calming music, textured materials and equipment such as swings and balance beams to support his sensory processing needs. Some sessions involved sensory integration activities: in one game, Noah imitated animal movements, such as crawling like a bear and hopping like a frog, which helped him practise motor coordination while engaging in playful, sensory-rich experiences. The therapist also introduced loaded activities. These tasks involved moving objects, which provided proprioceptive input to help Noah regulate his body awareness and sensory responses. For example, he was encouraged to slide a chair under the table, put his toys into a large box and carry relatively heavy books to a shelf, activities that helped strengthen his muscles while improving sensory processing and motor planning.

To address his sensitivity to textures, Noah was gradually introduced to different textures through playful tasks, such as putting his hands into containers of rice or soft sand to find hidden toys. Over time, this helped desensitise him to touch, making daily tasks like dressing and feeding less stressful. Swinging on a sensory swing helped him improve his tolerance to movement and balance, which had previously been overwhelming, and the therapist used this activity as a calming strategy during sessions, helping Noah focus better on other tasks such as fine motor activities or following simple instructions.

Resources

• Occupational therapy for cerebral palsy
• Rehabilitation Guideline for the Management of Children with Cerebral Palsy Occupational Therapy Guideline.