Occupational therapy in the management of cerebral palsy

Occupational Therapy (OT) enables individuals with cerebral palsy to participate in activities of daily living that are meaningful to them. A family-centred philosophy is used with children who have CP. Occupational therapists work closely with families in order to address their concerns and priorities for their child.^[1] Occupational therapists may address issues relating to sensory, cognitive, or motor impairments resulting from CP that affect the child's participation in self-care, productivity, or leisure. Parent counselling is also an important aspect of occupational therapy treatment with regard to optimizing the parent's skills in caring for and playing with their child to support improvement of their child's abilities to do things.^[2][3] The occupational therapist typically assesses the child to identify abilities and difficulties, and environmental conditions, such as physical and cultural influences, that affect participation in daily activities.^[4] Occupational therapists may also recommend changes to the play space, changes to the structure of the room or building, and seating and positioning techniques to allow the child to play and learn effectively.^[5][6]

Effect of sensory and perceptual impairments

Children with CP may experience decreased sensation or a limited understanding of how the brain interprets what it sees. Occupational therapists may plan and implement sensory-perceptual-motor (SPM) training for children with CP who have sensory impairments so that they learn to take in, understand, plan and produce organized behaviour.^[7] The SPM training improves the daily, functional abilities of people with CP.^[8] Occupational therapists may also use verbal instructions and supplementary visual input, such as visual cues, to help children with CP learn and carry out activities.

For children with CP with limited movement and sensation, the risk of pressure sores increases. Pressure sores often occur on bony parts of the body.^[9] For example, pressure sores may occur when a child has limited feeling and movement of their lower body and uses a wheelchair; the tailbone bears weight when seated and can become vulnerable to pressure sores. The occupational therapist can educate the child, family, and caregivers about how to prevent pressure sores by monitoring the skin for areas of irritation, changing positions frequently, or using a tilt-in-space wheelchair.^[10]

Effect of cognitive and perceptual impairments

OT can address cognitive and perceptual disabilities, especially of the visual-motor area.^[11] For children with CP who have difficulty remembering the order and organization of self-care tasks in the morning, an occupational therapist can construct a morning routine schedule with reminders. An occupational therapist may analyze the steps involved in a task to break down an activity into simpler tasks. For example, dressing can be broken down into smaller, manageable steps. This can be done by having a caregiver lay out the clothing in order so the child knows what needs to be put on first.^[12]

Effect of motor impairments

The effect of motor impairments is significant for children with CP because it affects the ability to walk, propel a wheelchair, maintain hygiene, access the community and interact with other people. Occupational therapists address motor impairments in a variety of ways and makes use of various techniques, depending on the child’s needs and goals.^[13] The occupational therapist may help the child with gross motor rehabilitation, or whole body and limb movements, through repetitive activities.^[14][15] If the child has muscle weakness, progressive resistance exercises can improve muscular strength and endurance.^[16] Fine motor rehabilitation, or small, specific movements, such as threading the eye of a needle, can be implemented to improve finger movement and control.^[17]

Often children with CP require orthoses, such as casts and splints, to correct or prevent joint abnormalities, stabilize joints, prevent unwanted movement, allow desired movement, and prevent permanent muscle shortening.^[18][19] Orthoses may also make it easier to dress or to maintain hygiene.^[20] Lower limb splinting is specifically beneficial in providing a base of support and facilitating walking.^[21] It is equally important that the child be able to carry out daily activities and prevent joint deformities.^[22]

Children with CP have difficulties with mobility and posture. Occupational therapists often assess and prescribe seating equipment and wheelchairs. An appropriate wheelchair will stabilize the body so the child can use their arms for other activities. Wheelchairs therefore enhance independence.^[23][24][25] For children with difficulties speaking, an occupational therapist may liaise with a speech therapist, carry out assessments, provide education and prescribe adaptive equipment. Adaptive equipment may include picture boards to help with communication and computers that respond to voice.^[26]

Occupational therapists may also use neuro-developmental techniques to promote normal movement and posture and to inhibit abnormal movement and posture.^[27] Specific techniques include joint compression and stretching to provide sensory-motor input and to guide motor output.^[28] Occupational therapists can help the child promote use of a neglected arm through techniques such as constraint-induced movement therapy (CIMT), which forces use of the unused arm by placing the other arm in a sling, cast or oversized mitt.^[29] Another OT technique that may be used is neuromuscular facilitation techniques, which involves physically moving and stretching the muscles to improve function so that the child can participate in activities.^[30][31]

Spasticity is a common problem experienced by people with cerebral palsy. It can cause pain and loss of sleep, impair function in activities of daily living, and cause unnecessary complications. Spasticity is measured with the Ashworth scale. Occupational therapy targeting spasticity aims to lengthen the overactive muscles.^[32]

OT role with factors influencing participation

Barriers to participation for children with CP include difficulty accessing the community. This includes difficulty accessing buildings and using transportation.^[33][34] Occupational therapists may work with developers to ensure new homes are accessible to all people.^[35][36] Also, occupational therapists often help people apply for government and non-profit funding to provide assistive devices, such as special computer programs or wheelchairs, to children with CP.^[37] Availability of transportation services can be limited for children with CP because of many factors, such as difficulties fitting wheelchairs into vehicles and dependency on public transit schedules. Therefore, the occupational therapists may also be involved in education and referral regarding accessible vehicles and funding.^[38][39]

Occupational therapists address the community and environmental factors that affect participation in leisure activities by educating children with CP, their families, and others on available options and adaptive ways to engage in leisure activities of interest.^[40] Prejudice of others toward disability can also be a barrier to participation for children with CP with respect to leisure activities.^[41] One way occupational therapists can address this barrier is to teach the child to educate others on CP – thus reducing stigma and enhancing participation.^[42] Finally, occupational therapists take children’s preferences into consideration in terms of cosmetic appearance when prescribing or fabricating adaptive equipment and splints. This is important as appearance may affect the child’s compliance with assistive devices, as well as their self-confidence, which may impact participation. In addition to providing dedicated occupational therapy to such children, some non-profit organizations viz. Spastic Society of Gurgaon are providing comprehensive assistance which includes designing of child specific assisting devices to such children for making their lives more meaningful by enabling them to be self-reliant to the best possible extent.

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