a brief presentation on various FOR used in pediatric occupational therapy

1. FRAMES OF REFERENCE
USED IN CEREBRAL PALSY

3. 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.

4. IDENTIFIED CAUSES OF CEREBRAL PALSY

5. EARLY SIGNS OF CEREBRAL PALSY

6. TYPES OF CEREBRAL PALSY

8. CEREBRAL PALSY IS KNOWN TO CAUSE..

9. TREATMENT OF CEREBRAL PALSY
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
THERAPIES

11. 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.

12. 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.

13. 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.

14. 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

15. 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.

16. COMPONENTS OF FORs

17. 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

18. NEURODEVELOPMENTAL
TREATMENT

19. 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.

20. NDT ENABLEMENT CLASSIFICATION OF
HEALTH AND DISABILITY

21. 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.

22. 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

23. 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

24. 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

25. 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

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

27. EVALUATION USING NDT FRAME OF
REFERENCE
 Posture & 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

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

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

30. 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

31. 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

32. 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

33. 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.

34. 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

35. 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

36. BIOMECHANICAL
FRAME OF
REFERENCE

37. 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

38. 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

39. 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

40. 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

41. 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

42. REHABILITATIVE
FRAME OF
REFERENCE

43. 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

44. 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

45. 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

46. 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

47. SENSORY INTEGRATION
FRAME OF REFERENCE

48. 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.

49. DUNN’S MODEL OF SENSORY
PROCESSING

50. 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

51. 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

52. 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

53. 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

54. TEACHING-LEARNING METHOD

55. FOUR- QUADRANT MODEL OF
FACILITATED LEARNING

56. COGNITIVE DISABILITY
FRAME OF REFERENCE

57. 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

58. 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

59. MOTOR LEARNING
FRAME OF REFERENCE

60. 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

61. FACTORS INFLUENCING MOTOR
LEARNING

62. 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

63. 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.

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

65. DEVELOPMENTAL
FRAME OF REFERENCE

66. 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

67. BEHAVIOURAL
FRAME OF REFERENCE

68. BEHAVIOURAL FRAME OF REFERENCE
BEHAVIOURS
THOUGHTS
EMOTIONS
PHYSIOLOGICAL
RESPONSES
ENVIRONMENT

69. 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

70. SCOPE-IT

71. SCOPE-IT

72. 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

73. 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.

74. 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

75. MOHO

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