FRAMES OF REFERENCE USED IN CEREBRAL PALSY.pptx

a brief presentation on various FOR used in pediatric occupational therapy

1. FRAMES OF REFERENCE USED IN CEREBRAL PALSY

2. CEREBRAL PALSY The term Cerebral Palsy (CP) describes a group of developmental motor disorders arising from a non progressive lesion or disorder of the brain. Damage to various areas of the brain can result in paralysis, spasticity or abnormal posture and movements. Motor issues in Cerebral Palsy can be accompanied with disturbances in sensation, cognition, perception, communication and in some cases, a seizure disorder.

3. IDENTIFIED CAUSES OF CEREBRAL PALSY

4. EARLY SIGNS OF CEREBRAL PALSY

5. TYPES OF CEREBRAL PALSY

6. CEREBRAL PALSY IS KNOWN TO CAUSE..

7. TREATMENT OF CEREBRAL PALSY

8. OCCUPATIONAL THERAPY IN CP Cerebral Palsy as a condition affects a child’s development giving rise to motor, sensory, cognitive, perceptual, hearing, vision, ADL related difficulties. A comprehensive approach is needed to manage a complex condition like Cerebral Palsy.

9. FRAMES OF REFERENCES A Frame of reference is a tool that guides the practical application of theoretical concepts. A theory is created on the basis of repeated observations and has underlying assumptions. A frame of reference customizes theoretical information so that it can be used by Occupational therapists. Frames of reference are based on one or more theories. In Pediatric OT, a FOR offers an outline of fundamental theoretical concepts relative to particular areas of function.

10. FRAMES OF REFERENCE Theories that serve as the basis for frames of reference address the strengths and limitations of the child and family. The frame of reference essentially is a blueprint for evaluation and intervention. Thus an Occupational therapist relies on a Frame of reference as a guiding tool for evaluating and planning an intervention in Cerebral palsy.

11. PRACTICE MODELS IN CEREBRAL PALSY Since children with Cerebral Palsy primarily have a difficulty with postural control and movement against gravity, therapists frequently use motor control and motor learning concepts. A Dynamic systems theory poses that movement is complex and multidimensional systems work in coordination to influence functional movement. Several principles of dynamic systems theory include a child’s ability to self-organize motor actions through repetition and practice, creating new patterns from refinement of motor actions

12. PRACTICE MODELS IN CEREBRAL PALSY The child’s physical characteristics, activity demands, environmental factors can influence the child’s functional movement. A number of Frames of references are used in the treatment of Cerebral palsy as it is a challenging condition to manage.

13. COMPONENTS OF FORs

14. FUNCTION-DYSFUNCTION CONTINUA The functional end of the continuum represents what the therapist expects the child to be able to do, whereas the dysfunctional end of the continuum represents disability. Function-Dysfunction continua come directly from the theoretical bases of frames of references and are specific to a particular FOR. FUNCTION Expected ability DYSFUNCTION Disability

15. NEURODEVELOPMENTAL TREATMENT

16. A FRAME OF REFERENCE FOR NEURODEVELOPMENTAL TREATMENT The Neurodevelopmental Treatment (NDT) frame of reference is a dynamic hands-on treatment approach guiding occupational therapists globally in their assessments and intervention of pediatric clients experiencing posture and movement impairments. The NDT framework is a client-centered, individualized, problem solving approach for managing motor skill challenges that limit a child’s participation.

17. NDT ENABLEMENT CLASSIFICATION OF HEALTH AND DISABILITY

18. NEURODEVELOPMENTAL THERAPY In NDT, through handling and movement experiences in a functional context, the therapist attempts to integrate and assimilate competing patterns of movement into a balanced interaction for movement and postural control development. Whatever function a child requires most urgently at any one stage is the priority of the established treatment goals.

19. ASSUMPTIONS OF NDT Primary problems in CP are- postural control and movement coordination When motor coordination problems are treated, overall functioning improves Sensorimotor impairments affect the whole individual A working knowledge of typical adaptive motor development and how it changes across lifespan provides the framework for assessing functions and planning intervention NDT focuses on changing movement strategies as a means to achieve the best energy efficient performance

20. ASSUMPTIONS OF NDT Movement is linked to feedback and feedforward control Intervention involves the individual ’s active initiation and participation, combined with the therapist’s manual guidance and direct handling Movement analysis is used to identify missing or atypical elements Ongoing evaluation occurs throughout every treatment session Aim of NDT is to optimize function

21. DYNAMIC SYSTEMS THEORY OF MOTOR CONTROL NDT has embraced the Dynamic Systems approach as a theoretical foundation. Collectively, diverse systems shape the production of functional movement skills. “Movement is an interactive process between multiple systems” Identification of constraints and limiting factors is necessary Each system is supported by physical and environmental elements Trial and error provides feedback Development of compensatory motor synergies are often established as a “problem-solving” strategies to their movement problems

22. SENSORY CONTRIBUTIONS IN NDT Feedforward system which anticipates and initiates movement Feedback system reacts to the environment causing motor execution NDT provides the child with enriched motor experience and opportunity to practice movements emphasizing sesnsorimotor feedback and providing possibilities for problem solving movement strategies using anticipatory motor control. EXPERIENCE -> PRACTICE -> PERMANENT CHANGE NEWLY LEARNT SKILLS -> TRANSFER OF LEARNING -> DAILY LIFE

23. FUNCTION- DYSFUNCTION CONTINUA IN NDT ROM/ Dissociation Postural alignment Postural tone Balance Co-ordination

24. EVALUATION USING NDT FRAME OF REFERENCE Postur e & Movement System integrity Child- family- environmental factors assessment Observation Observation of child’s compensatory strategies used by the child Focus on alignment, weight bearing, balance, co-ordination, ROM, muscle tone Occupational performance ADL

25. POSTULATES RELATING CHANGE Handling Adapt the environment Use handling techniques during play Use purposeful activities

26. POSTULATES RELATING CHANGE Use orthotic devices and adaptive equipment Reduce deformities and limitations

27. POSTURAL ALIGNMENT AND WEIGHT BEARING Muscle activation Sustenance Sensory input + weight bearing Deep pressure towards base of support Weight bearing relaxes the tone and prepares for active task Handling helps with weight shift during a task

28. MUSCLE TONE/ POSTURAL TONE Therapist is able to feel the child’s muscle activation and relaxation Therapist alters the handling accordingly Handling is modified in accordance to the child’s changing needs for sensory information Distal and Proximal key points of control are used during handling

29. BALANCE AND POSTURAL CONTROL Therapist must facilitate a smooth interplay between agonist and antagonist muscles Therapist must select the proper position, equipment, and therapeutic handling Postural control during functional movement activities can help the child to potentially integrate these movements into neuronal groups in the CNS Graded handling + child’s response to sensory input will develop greater strength, stability and control

30. BALANCE AND POSTURAL CONTROL Facilitation in all three planes of movement can encourage axial rotation, elongation of multiple muscular systems simultaneously, dissociation and activation of postural control synergies If therapist provides concentric and eccentric work throughout aligned joint range, motor strength and control are potentially increased and graded during functional tasks.

31. APPLICATION TO PRACTICE NDT- emphasizes to establish a purposeful relationship between sensory input and motor output. Therapeutic handling is the primary intervention technique in NDT Handling directs, regulates and organizes tactile, vestibular, proprioceptive systems Therapist can use one hand to guide the movement and the other to assist Depth of touch depends on the type of sensory input needed Therapist needs to prepare the child for facilitating active movement and inhibiting unwanted movements

32. APPLICATION TO PRACTICE Facilitation is a handling strategy designed to ease the production of appropriate and efficient posture and movement patterns. Preparation + facilitation techniques should be merged together Weight bearing and weight shifting is needed to activate motor control Deep compression to larger muscles is needed for stability and postural control Treatment of both sides of the body enhances structural alignment, body image and sensory awareness NDT should be combined with play as it is an important occupation for the child, and play can infact stimulate necessary movements

33. BIOMECHANICAL FRAME OF REFERENCE

34. BIOMECHANICAL FRAME OF REFERENCE This frame of reference is a remedial approach that focuses on improving impairments It requires handling and facilitation strategies The treatment involves techniques that limit dysfunction Therapeutic and occupation based activities are used during treatment Compensatory and adaptive strategies are used in case of loss of movement Assessment is done according to the impairment, need of orthosis, ADL performance limitation and integrity of the musculoskeletal system

35. BIOMECHANICAL FRAME OF REFERENCE The domains of concern in Biomechanical FOR are: Structural stability Low level endurance Edema control Passive range of motion Strength High level endurance

36. ASSUMPTIONS OF BIOMECHANICAL F.O.R Purposeful activities can be used to treat loss of ROM, strength, and endurance After gaining ROM, strength, endurance, client will automatically regain function Child needs to understand instructions in order to perform smooth, isolated movements as required Rest and stress- Rest is needed to heal the body, and only then can the child be engaged in movements which are needed to be performed

37. BIOMECHANICAL F.O.R Biomechanical goals can be set as per improvement needed in strength, ROM, endurance etc. Exercises + purposeful activities need to be used in treatment Games, crafts and leisure tasks can be used when repetition in movement is needed Sensory motor approaches are to be used with Biomechanical frame of reference

38. BIOMECHANICAL F.O.R for POSITIONING CHILDREN Used to assist the development of postural reactions “Sensory stimulations” develop from the interaction with the environment and autonomic responses are needed to develop postural reactions Using external supports and adaptations, including gravity eliminated activities during sessions and therapeutic handling are a major part of the practice using biomechanical FOR Therapist uses the FOR’s principles along with purposeful play to enhance function and participation

39. REHABILITATIVE FRAME OF REFERENCE

40. REHABILITATIVE FRAME OF REFERENCE Rehabilitative frame of reference: To enable a person with a physical or mental disability or chronic illness to achieve maximum function in his or her daily activities Rehabilitative FOR focuses on: Compensatory methods Assistive devices Environmental adaptations

41. REHABILITATIVE F.O.R ASSUMPTIONS Through the use of compensatory strategies, an individual can restore independence Person’s level of motivation affects the extent to which an individual regains independence Environments in which daily activities are performed influence a person’s motivation for independence Rehabilitation involves a teaching- learning process Cognitive skills are needed to learn and apply compensatory methods

42. REHABILITATIVE F.O.R Child’s capacity to function in daily activities can be changed through his or her use of compensatory methods and adaptive equipment. Thus teaching-learning process is a major part of the OT treatment Compensatory methods are taught to the child for performing ADLs, self care, play and leisure The child should demonstrate sufficient motivation in the play based strategies

43. REHABILITATIVE F.O.R The rehabilitative FOR uses daily-living, work and leisure activities as the purposeful activities for Occupational therapy treatment By encouraging the child to participate in the problem-solving strategies, the therapist helps the child to develop skills to be used outside the therapeutic milieu Reinforcers and Demonstration can be used to create an environment that supports the child’s learning. Therapist’s creativity is also important during the sessions to design play based meaningful activities

44. SENSORY INTEGRATION FRAME OF REFERENCE

45. SENSORY INTEGRATION FRAME OF REFERENCE The Sensory Integration Frame of Reference by Dr. Jean Ayers, talks about how a child’s sensory system (auditory, visual, gustatory, interoceptive, tactile, vestibular, proprioceptive) interacts with the environment and adapts itself to produce an optimal response.

46. DUNN’S MODEL OF SENSORY PROCESSING

47. SENSORY INTEGRATION IN CP ASSUMPTIONS AND NEUROBEHAVIOURAL CONCEPTS: Sensory nourishment is critical for brain function Plasticity within the CNS – through adaptive responses to environmental demands , changes occur at the synaptic level Sensory integrative processes occur in a developmental sequence The brain functions as a whole and as a hierarchically organized interactive system

48. SENSORY INTEGRATION ASSUMPTIONS ( contd ) Convergence of all the sensory input from the sensory modalities occurs at the reticular formation and has a widespread influence over the entire brain When a child experiences the “JUST RIGHT” challenging type of sensory stimulation and responds to it, an adaptive response takes place Every child has an “inner drive” to develop sensory integration through his/her participation

49. THE RIGHT SENSORY ENVIRONMENT Sensory integration therapy requires a particularly structured environment to offer the just right challenge to various sensory systems of the child as per his/her need The environment should not be over stimulating as well It should aptly suit the child’s needs

50. SENSORY INTEGRATION AND OTHER F.O.Rs S.I also requires participation in a meaningful task/ play S.I focuses on: Sensory modulation, sensory discrimination, self regulation, praxis, bilateral integration It enhances the CNS to produce better occupational performance Thus, this F.O.R is important when combined with other FOR’s in Cerebral Palsy treatment to enhance motor skills, learning, ADL and adaptive responses of the child

51. TEACHING-LEARNING METHOD

52. FOUR- QUADRANT MODEL OF FACILITATED LEARNING

53. COGNITIVE DISABILITY FRAME OF REFERENCE

54. COGNITIVE DISABILITY FRAME OF REFERENCE This frame of reference provides environmental compensations for people with severe mental disorders Considering the Allen Cognitive Levels, this FOR helps to measure the changes in the ability to function While using this frame of reference, the child’s learning capacity is matched to the demands of the activity

55. COGNITIVE DISABILITY F.O.R COGNITIVE DISABILITY LEVEL LEVEL 1: Automatic actions LEVEL 2: Postural actions LEVEL 3: Manual actions LEVEL 4: Goal-Directed actions LEVEL 5: Exploratory actions LEVEL 6: Planned actions

56. MOTOR LEARNING FRAME OF REFERENCE

57. MOTOR LEARNING FRAME OF REFERENCE This frame of reference is based on the key principle of learning theory It helps a child to acquire motor skills for functional participation “Practice” and “experience” leading to permanent changes Practice and training become a long term retention in the child Function and intervention helps to enhance independence

58. FACTORS INFLUENCING MOTOR LEARNING

59. MOTOR LEARNING INTRINSIC FEEDBACK Information generated through individual’s available sensory avenues Eg : Proprioception, vision It is the inherent information from the sensory receptors The learner compares this information to a learned reference of correct movement Feedback is used in early learning

60. MOTOR LEARNING EXTRINSIC FEEDBACK Information from an external source Extrinsic feedback can be provided by knowledge of results (KR) and knowledge of performance (KP) KR is a verbal, terminal feedback about movement outcome. Eg : Therapist saying “You reached for the ball, not the ring” KP is the information provided about the movement pattern. Eg : “You need to lean forward in your chair to reach for the cup” It aims on correcting the performance of the movement.

61. MOTOR LEARNING LEARNING VARIABLES AND PRACTICE CONDITIONS: Massed and distributed practice Whole versus Part practice Mental practice Variable practice

62. DEVELOPMENTAL FRAME OF REFERENCE

63. DEVELOPMENTAL FRAME OF REFERENCE The developmental FOR suggests that human development happens in a sequential manner Development is “Dynamic” Skill acquisition is based on previously learnt skills Therapists work on various aspects of development and help a child gain age-appropriate milestones and skills

64. BEHAVIOURAL FRAME OF REFERENCE

65. BEHAVIOURAL FRAME OF REFERENCE

66. OCCUPATIONAL BEHAVIOUR Occupational behaviour constitutes the complete developmental continuum from childhood play to adulthood work Occupational behaviour involves interaction with the environment and is shaped by the complex interaction with the environment It believes that right from birth, a child is challenged with occupations Adaptation in occupation means that the person has basic occupational skill including motor, social, selfcare, time use and play and work abilities Child once grown into adulthood must be able to assume occupational roles

67. SCOPE-IT

68. SCOPE-IT

69. SCOPE-IT Synthesis of Child, Occupational, Performance, and Environment- In Time It aims to enhance children’s occupations and Occupational performance Participation in daily living activities, enhances a child’s development SCOPE-IT considers the synthesis of the child’s occupational performance, occupational engagement and environment Therapists identify strengths, barriers, and motivational factors in the area of work, play & leisure, self care and ADL

70. SCOPE-IT ASSUMPTIONS Children are occupational and social beings The use of occupation is the underlying foundation of occupational therapy Occupational performance is influenced by personal, environmental, social, cultural, and temporal factors Occupational development occurs through a dynamic process Engagement in occupation brings about change Occupational engagement influences health and well-being.

71. OTHERS According to the child’s needs and development, the other Frames of reference that can be used in practice are: F.O.R for Social participation F.O.R to develop Handwriting skills F.O.R for Visual perception All the mentioned FORs can be used in accordance to the Model of Human Occupation(MOHO) and a client- centered approach

72. MOHO

73. REFERENCES Willard and Spackman’s Occupational Therapy- 9 th Edition Frames of Reference for Pediatric Occupational Therapy- 3 rd edition Images source: www.google.com