Occupational Performance Therapy
Occupational Performance Therapy
Evidence reviewed as of before 01-01-2021
Author(s): Ogourtsova, T. (PhD OT); Steven, E. (MSc App OT); Iliopoulos, G. (MSc App OT); & Majnemer, A. (PhD, OT, FCAHS)
Introduction
Occupational performance is the ability of a person to be actively engaged in their life activities. These can be basic tasks of self care or more complex activities, such as work or leisure. A disorder or disease can cause impairments to a person’s body structure or function (including psychological functions) and it can prevent them from executing certain activities independently and/or participating in life situations.
Occupational performance therapy involves therapists taking one of two approaches when treating occupational performance issues in children: 1) Context-focused interventions (which address environmental factors) or 2) child-focused interventions (which address personal factors).
The child-focused intervention approach focuses on body functions and structures as its starting point. Some examples of treatment for children with cerebral palsy (CP) would be applying methods to improve movement patterns, postural control and balance through different therapeutic approaches (e.g NDT). These strategies can be used in isolation or practiced during functional activities.
The context-focused intervention approach focuses on task constraints or environmental limitations (physical and social). Here, the therapist will look at how to adapt a task or eliminate barriers in the environment that could improve the child’s independence.
Both the child-focused and the context-focused approaches aim to improve activity and participation of the child but they differ in how they attempt to reach goals.
Resources
Parent & Family Information
Occupational performance is a person’s ability to participate and complete activities of daily life (self-care, leisure, work). When a person has impairments due to a disorder or disease (e.g. CP), occupational performance can be affected negatively.
Typically, occupational therapists and physiotherapists address occupational performance. A common theoretical framework used to assist therapists analyze problems and determine goals is the International Classification of Functioning, Disability and Health, Child and Youth (ICF-CY). This model identifies 2 starting points or approaches to treating occupational performance:
1. Child-based approach (personal factors)
2. Context-based approach (environmental factors)
Child-based approaches employ interventions that attempt to address impairment in the child’s body structure or physical/psychological functioning to improve occupational performance. For example, hippotherapy can help treat movement dysfunction in children with CP and improve capacities such as walking. This would then improve the child’s ability to participate in daily activities.
Context-based approaches focus on changing elements of the task and/or environment. This approach includes adaptive strategies, parent involvement, and the use of an activity-based approach.
Both approaches attempt to improve activity and participation, but they have different “starting points” to treatment.
Child-focused and context-focused therapy use different interventions to attempt to improve the occupational performance of the child. Child-focused approach will treat physical (and psychological) causes of disability to improve independence, while a context-focused approach will not. Instead, context-focus intervention may have the same outcome (greater independence and participation in daily activities) but it will change factors in the environment or barriers to a particular activity.
There are no specific child-focused and context-focused interventions. Instead treatment approach selection is left to the discretion of the therapist as well as the client and family. A child-focused approach may have greater opportunities to employ an evidence-based intervention. For example, a child with hemiplegic CP may have limitations to participating in an activity due to decreased use of their affected hand/arm. Therefore, a therapist may decide to use constraint-induced movement therapy (CIMT), a evidence-based treatment approach, to improve occupational performance.
There is no clear guidelines for clinicians to decide which starting point (child-based or context-based therapy) is most effective when treating children with CP.
The results of two high quality studies showed that when compared to standard care (typical occupational therapy/physiotherapy practices), occupational performance therapy was not more effective in improving family empowerment, family participation, parental distress, gross motor function, range of motion (lower extremities), self care, participation in daily life activities, and quality of life in families of children with CP. There was conflicting evidence for “mobility”, where one high quality randomized control trial (RCT) found that a child-focused approach was more effective than a context-focused approach, while another RCT did not find a significant difference between them.
Sessions may be completed in a health care setting or in your home with a therapist (typically an occupational therapist or physiotherapist). They will likely conduct a semi-structured interview to understand your child’s functional limitations, family concerns, and social/environmental contexts, before setting goals collaboratively.
The therapist will choose different treatment modalities depending on if they will be taking a child-focused approach or context-focused approach. The former is likely to be a more hands-on approach with your child, where treatments are targeting functional impairments (muscle tone, posture, etc.). The latter will likely involve some direct and some indirect work with a therapist. For example, activities could be practiced with a therapist to determine modifications/strategies to improve independence. Throughout the sessions the parent may receive guidance as to how to integrate strategies into daily routines, etc.
Typically an occupational therapist or physiotherapist.
Treatment periods vary based on the needs of the client and their family as well as the approach and intervention types used.
Any associated risks or side effects would be related to the specific treatment approach used (e.g. acupuncture, CIMT, etc.).
The studies reviewed examined the impact of occupational performance therapy on children from 1 -5 years of age and GMFCS levels I-V. Based on these studies, there is no strong scientific evidence that using a child-based or context-based approach is more effective at improving occupational performance for children with CP compared to traditional approaches.
Information on this website is provided for informational purposes only and is not a substitute for professional medical advice.
Clinician Information
Children with CP (unilateral/bilateral spastic, dyskinetic, ataxic, mixed)
GMFCS level I-IV
Two high quality RCTs (Law et al., 2011; Kruijsen‐Terpstra et al., 2016) investigated the effect of occupational performance therapy on family empowerment among families of children with cerebral palsy (CP) (all types, GMFCS level I-IV).
The first high quality RCT (Law et al., 2011) randomized patients (GMFCS level I-V) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure) or a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment). Family empowerment was assessed using the Family Empowerment Scale (FES; Family, Services, Community) at post-treatment (6 months). No significant between-group differences were found.
The second high-quality RCT (Kruijsen‐Terpstra et al., 2016) randomized children (GMFCS level I-IV) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure), a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment) or regular care. Parent empowerment was assessed using the FES at post-treatment (6 months) and follow-up (9 months). No significant between-group differences were found.
Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that occupational performance therapy is as effective as the comparison interventions (different occupational performance therapy approaches; regular care) in improving family empowerment among families of children with CP.
One high quality RCT (Kruijsen‐Terpstra et al., 2016) investigated the effects of occupational performance therapy on family participation among families of children with cerebral palsy (CP) (all types, GMFCS level I-IV). This high quality RCT randomized patients to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure), a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment) or regular care. Family participation was assessed using the Family Participation (FP: Daily activities; Personal activities; Sibling activities) at post-treatment (6 months). No significant between-group differences were found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that occupational performance therapy is as effective as the comparison intervention (regular care) in improving family participation among parents of children with CP.
Two high quality RCTs (Law et al., 2011; Kruijsen‐Terpstra et al., 2016) investigated the effect of occupational performance therapy on gross motor function in children with cerebral palsy (CP) (all types, GMFCS level I-IV).
The first high quality RCT (Law et al., 2011) randomized children (GMFCS level I-V) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure) or a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment). Gross motor function was assessed using the Gross Motor Function Measure-66 (GMFM-66) at post-treatment (6 months) and follow-up (9 months). No significant between-group differences were found.
The second high quality RCT (Kruijsen‐Terpstra et al., 2016) randomized children (GMFCS level I-IV) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure), a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment) or regular care. Gross motor function was assessed using the GMFM-66 at post-treatment (6 months). No significant between-group difference was found.
Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that occupational performance therapy is as effective as the comparison interventions (different occupational performance therapy approaches; regular care) in improving gross motor function in children with CP.
Two high quality RCTs (Law et al., 2011; Kruijsen‐Terpstra et al., 2016) investigated the effect of occupational performance therapy on mobility in children with cerebral palsy (CP) (all types, GMFCS level I-IV).
The first high quality RCT (Law et al., 2011) randomized patients (GMFCS level I-V) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure) or a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment). Mobility was assessed using the Pediatric Evaluation of Disability Inventory (PEDI: Mobility – Functional Skill Scale; Mobility – Caregiver Assistance Scale) at post-treatment (6 months) and follow-up (9 months). A significant between-group difference was reported in one measure of mobility (PEDI: Mobility – Caregiver Assistance Scale) at follow-up (9 months), favoring child- vs. context-focused approach.
The second high quality RCT (Kruijsen‐Terpstra et al., 2016) randomized children (GMFCS level I-IV) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure), a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment) or regular care. Mobility was assessed using PEDI (Mobility – Functional Skill Scale; Mobility – Caregiver Assistance Scale) at post-treatment (6 months). No significant between-group differences were found.
Conclusion: There is conflicting evidence (Level 4) from two high quality RCTs regarding the effects of occupational performance on mobility in children with CP. While one high quality RCT found that a child-focused approach was more effective than a context-focused approach, another RCT did not find significant between-group differences.
Note: Difference studies’ power might explain the difference in findings, where Law et al., (2011) involved a larger sample size than Kruijsen‐Terpstra et al., (2016) (i.e., n=146 vs. n=68). In addition, Law et al., (2011) provided a 9-month follow-up assessment, whereas Kruijsen‐Terpstra et al., (2016) did not evaluate participants at follow-up.
Two high quality RCTs (Law et al., 2011; Kruijsen‐Terpstra et al., 2016) investigated the effect of occupational performance therapy on self-care in children with cerebral palsy (CP) (all types, GMFCS level I-IV).
The first high quality RCT (Law et al., 2011) randomized patients (GMFCS level I-V) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure) or a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment). Self-care was assessed using the Pediatric Evaluation of Disability Inventory (PEDI: Self-care – Functional Skill Scale; Self-care – Caregiver Assistance Scale) at post-treatment (6 months) and follow-up (9 months). No between-group differences were found.
The second high-quality RCT (Kruijsen‐Terpstra et al., 2016) randomized children (GMFCS level I-IV) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure), a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment) or regular care. Self-care was assessed using the PEDI (Self-care – Functional Skill Scale; Self-care – Caregiver Assistance Scale) at post-treatment (6 months). No significant between-group differences were found.
Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that occupational performance therapy is as effective as the comparison interventions (different occupational performance therapy approaches; regular care) in improving self-care in children with CP.
Two high quality RCTs (Law et al., 2011; Kruijsen‐Terpstra et al., 2016) investigated the effect of occupational performance therapy on participation in daily life activities in children with cerebral palsy (CP) (all types, GMFCS level I-IV).
The first high quality RCT (Law et al., 2011) randomized patients (GMFCS level I-V) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure) or a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment). Participation in everyday activities was assessed using the Assessment of Preschool Children’s Participation (APCP: Play; Skill development; Active physical recreation; Social activities) at post-treatment (6 months) and follow-up (9 months). No significant between-group differences were found.
The second high-quality RCT (Kruijsen‐Terpstra et al., 2016) randomized children (GMFCS level I-IV) to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure), a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment) or regular care. Participation in daily life activities was assessed using the APCP (Play; Skill development; Active physical recreation; Social activities) at post-treatment (6 months). No significant between-group differences were found.
Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that occupational performance therapy is as effective as the comparison interventions (different occupational performance therapy approaches; regular care) in improving participation in daily life activities in children with CP.
One high quality RCT (Kruijsen‐Terpstra et al., 2016) investigated the effects of occupational performance therapy on parental distress in children with cerebral palsy (CP) (all types, GMFCS level I-IV). This high quality RCT randomized patients to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure), a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment) or regular care. Parental distress was assessed using the Nijmeegse Ouderlijke Stress Index post-treatment (6 months). No significant between-group difference was found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that occupational performance therapy is as effective as the comparison intervention (regular care) in improving parental distress among parents of children with CP.
One high quality RCT (Kruijsen‐Terpstra et al., 2016) investigated the effects of occupational performance therapy on quality of life in children with cerebral palsy (CP) (all types, GMFCS level I-IV). This high quality RCT randomized patients to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure), a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment) or regular care. Quality of life was assessed using the Question of Quality-of-Life Scale at post-treatment (6 months). No significant between-group difference was found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that occupational performance therapy is as effective as the comparison intervention (regular care) in improving quality of life in parents of children with CP.
One high quality RCT (Law et al., 2011) investigated the effects of occupational performance therapy on lower extremities’ range of motion in children with cerebral palsy (CP) (GMFCS level I-V). This high quality RCT randomized patients to receive a child-focused approach (remediation of the child’s abilities by changing the components of body function and structure) or a context-focused approach (functional performance remediation by changing constraints regarding the task and/or the environment). Range of motion (left/right: hip abduction/extension, popliteal angle, and ankle dorsiflexion) was assessed using standardized methods at post-treatment (6 months) and follow-up (9 months). No significant between-group differences were found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that occupational performance therapy is as effective as the comparison intervention (different approaches of occupational performance therapy) in improving lower extremities range of motion in children with CP.
References
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Kruijsen-Terpstra, A., Ketelaar, M., Verschuren, O., Gorter, J. W., Vos, R. C., Verheijden, J., Jongmans, M. J., & Visser-Meily, A. (2016). Efficacy of three therapy approaches in preschool children with cerebral palsy: a randomized controlled trial. Developmental medicine and child neurology, 58(7), 758–766. https://doi.org/10.1111/dmcn.12966
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Law, M. C., Darrah, J., Pollock, N., Wilson, B., Russell, D. J., Walter, S. D., Rosenbaum, P., & Galuppi, B. (2011). Focus on function: a cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy. Developmental medicine and child neurology, 53(7), 621–629. https://doi.org/10.1111/j.1469-8749.2011.03962.x
Definitions
A group of lifelong disorders affecting a person’s movement, coordination, and muscle tone and which are the result of damage to the brain before, during, or shortly after birth.
Gross Motor Functional Classification System. It is a tool used to categorize the gross motor skills of children with cerebral palsy into 5 different levels across 5 age bands. It evaluates the child’s abilities in sitting, walking and wheeled mobility as well as the type of assistive devices needed for mobility. The levels are assigned based on the severity of the limitations, ranging from mild (level I) to severe (level V).
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