Context verses child focused therapy

in cerebral palsy Dr Amit Pandey, BPt

Senior therapistSamvedna

www.samvednatrust.comFB: samvednatrust.cerebralpalsy

You tube: jjain999 you tube channel : UC5h-gRf8sFpf-k60_kwyrgg

Cont.A unique aspect of the context therapy approach is that

therapists were explicitly trained to change only the

characteristics of the task and/or environment and not to

try to change the child’s impairments.

CHILD FOCUSED THERAPY

1.Therapists identified problems such as body posture, mobility, etc. which were restricting the child’s function. They gave therapy to change these problems and practice specific movements and activities. 2. Therapists focused on changing the child’s mobility, body alignment, muscle strength and coordination.

3. Therapy also focused on improving a child’s skills through practicing movements and activities.

CONTEXT FOCUSED THERAPY

1. Parents and therapists identified activities which the child likes to do, but has difficulty doing.

2. Therapists focused on changing the activity to make it easier to do by reducing the restricting factors in the environment. Children also practiced the activities.

Context Therapy shares concepts

Functional

Task-oriented

Activity-focused interventions,

such as involvement of parents, identification of functional goals,

and a ‘top-down’ activity-based approach to assessment and

intervention,

Dynamic systems theory stresses the

importance of trying to encourage new motor

behaviors when a child starts to experiment with

different motor skills; this is referred to in

dynamic systems theory as being ‘in transition’

for new motor skills.

Dynamic system theory

Cont.Dynamic systems theory posits that motor

behaviors are organized around functional tasks or

goals and that the specific motor solution is influenced

by the spontaneous interaction of variables from three

sources.

Child characterist ics

Task demands

Environmental inf luences.

Cont.

Child characteristics represent not only the

traditional physical impairments considered

in the rehabilitation of children with CP (e.g.

muscle tone, range of motion, balance) but

also non-physical characteristics such as

motivation, attention, and cognition.

Theory Principles Implementation in context therapy

Dynamic systems Success at functional goal depends on interaction of factors within child, task and environment subsystems

Emphasis on changing task and environment rather than child

Family centered Collaborative relationship between family and health-care providers to identify goals and intervention strategies

Family involvement incorporated into assessment and intervention protocol and not left to individual therapist discretion

Service delivery model

Primary therapistOne therapist provides intervention (other therapists available for consultation)

Natural environment

Assessment and intervention ideally occurs in natural environment directly related to identified goal or task

Goal/task Parent involvement Functionally relevant goals

Therapists trained to use the Canadian Occupational Performance Measure

Identif ication Principles Implementation in context therapy

AssessmentInclude families Strength-based Focus on

identifying constraints and facilitators related to

task and environment

With family, observe and videotape child’s

current performance of each identified goal

With family, identify factors in

task/environment that are supporting or

hindering child’s success at goal

Include families

Families identify strategies with therapists

Families demonstrate present strategies; build

from there

Work at functional goals Strategies target

task/environment, not remediation of child

Remediation of impairments not allowed (e.g.

passive stretching, specific muscle

strengthening, specific motor control

strategies)

Intervention'Fail quickly’

Expect success quickly: if not successful in 2wks

re-evaluate strategies

Episodic interventions Think outside the box

Try short intense periods of intervention

followed by practice times for consolidation by

family and child Innovation encouraged

Do not assume hierarchical preference of

movement solutions Atypical (innovative)

patterns of movement accepted

Provide rationale and theoryTraining included theory and research

background

Therapist trainingProvide process

Three-step guidelines for goals, assessment, and intervention

Provide support

Support from colleagues and research team Conference calls with therapists together, personal telephone and e-mail follow-up

Evaluate process earlyTherapists sent videotapes of initial assessment to research team

Intervention monitoringEnsure fidelity of treatment

Therapist sent video of intervention process; evaluated by research team for fidelity of treatment and feedback provided

Documentation of process

Therapists and families kept logbooks of intervention process; evaluated by research team to ensure fidelity of treatment

CONTEXT FOCUSED THERAPY

1.Parents and therapists identified activities which the

child likes to do, but has difficulty doing.

2. Therapists focused on changing the activity to make

it easier to do by reducing the restricting factors in the

environment. Children also practiced the activities

Cont.Examples of task characteristics (what the child

is trying to do) are the shape, size, and weight of a ball

for the task of throwing, or the choice of the size,

shape, or texture of a writing instrument for the task of

printing, or consideration of alternative solutions such

as a computer or label maker.

Cont.Environmental considerations are the identification of physical,

social, and attitudinal influences that represent barriers to or

facilitators of successful completion of the identified task or goal.

Examples include physical accessibility, availability of assistants,

and the attitudes of persons within the child’s environment.

Context therapy emphasizes changing the

parameters of the task or environment rather than

a focus on remediation of a child’s abilities. The

assumption of this approach is that changes to the

task and/or environment will enable the child to

perform an activity that they were unable to do

previously.

Intervention protocol

Three-step process for the context therapy intervention:

Goal identification

Assessment

Intervention strategies.

BENEFITS OF CONTEXT THERAPY

a) able to participate more independently in their self-

care activities,

b) able to move more independently,

c) more engaged in general skill activities,

d) able to participate more intensely in play activities,

e) more physically active and participated in more

games.

Cont.Therapists identified innovative solutions to

parents’ concerns that resulted in a quick

resolution and achievement of the goal.

One child had difficulty independently stepping onto her school bus because of the height of the steps. Instead of working on improving the child’s quadriceps muscle strength to climb the steps, the therapist phoned

administrators in the school district, explained the problem, and requested a bus with steps that were less steep.

CHILD FOCUSED THERAPY

1.Therapists identified problems such as body posture, mobility,

etc. which were restricting the child’s function. They gave

therapy to change these problems and practice specific

movements and activities.

2. Therapists focused on changing the child’s mobility,

body alignment, muscle strength and coordination.

3. Therapy also focused on improving a child’s skills through

practicing movements and activities

Method

Therapist identified the problem of a child such as body posture, mobility ,body alignment,muscle strength and coordination.The Therapy focused on improving the child skills through practicingMovement and activities.

Message Both modality has its own benefit & draw back By utilizing both method we can have good

recovery in most of the children affected with cerebral palsy

We can divide period of rehabilitation in two part