Context therapy approach

The team from Can Child developed and evaluated a context focused approach to intervention for young children with cerebral palsy A unique aspect of the context therapy approach is that therapists are explicitly trained to change only the characteristics of the task and/or environment and not to try to change the child’s impairments.

Although other functional approaches acknowledge the influence of the environment on a child’s motor successes and task completion, they still focus on changing the abilities of child. In the initial development of the context approach,24 we allowed therapists to include remediation of the child’s abilities as part of the intervention. From this pilot work, we learned that therapists preferred to change the child’s abilities rather than to adapt the task or environment. Thus, in this trial, we became more prescriptive in training therapists to focus on changing the task or the environment and not the child.

The underlying principle of a context based approach to intervention is that the success at achieving a goal depends on the interaction  of factors within child, task and environment subsystems. In contrast with other task / function focused approaches the emphasis is on changing task and environment rather than the child. 

Context therapy based on dynamic systems theory

The context therapy approach was developed using tenets of the dynamic systems theory as it is applied to motor development. 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 characteristics, task demands, and environmental influences.

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.

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.

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.

Assessment process

"For the assessment process, therapists videotaped the child’s performance on each goal identified. Ideally, the videotaping was done in the natural environment relevant to the goal (e.g. home, school, backyard), but in some instances, because of family and/or therapist constraints, the assessment was completed in the rehabilitation center. The parent and therapist watched the video together and identified factors within the task and the environment that were either helping or hindering a child’s performance. From this list, they identified factors that could be adapted or changed to achieve the goal as quickly as possible. Therapists used a strength-based approach, first identifying factors within the task and environment that supported a child’s attempt to complete the identified goal before identifying task and environmental constraints. Therapists sent in their first assessment video to the research team and they received personal feedback about their goals and intervention strategies from therapists on the research team.

After identifying the important task and environment factors amenable to change, the therapist and parent agreed on the intervention strategies. In many therapy approaches, specific movement patterns and strategies are the goal of treatment. In the context approach, therapists were trained to consider all movement solutions, even those traditionally thought to represent ‘abnormal’ movement patterns (e.g. W-sitting, ‘bunny-hopping’), and to build on the movement solution that the child was trying to use. Therapists asked parents to show how they were currently managing the task and to consider this as a ‘starting point’ for adaptations. Therapists were cautioned against assuming a hierarchy of ‘best solutions’, such as assuming that a child should move by crawling rather than commando creeping or that a mature pencil grasp was preferred over an immature grasp. Instead we encouraged them to find solutions that yielded success at the goal or task as quickly as possible. The therapists were taught to use a trial and error approach and to ‘fail faster’, i.e. not to wait too long for change to occur before re-evaluating the intervention strategy.

Darrah J, Law MC, Pollock N, Wilson B, Russell DJ, Walter SD, Rosenbaum P, Galuppi B. Context therapy: a new intervention approach for children with cerebral palsy. Dev Med Child Neurol. 2011 Jul;53(7):615-20. doi: 10.1111/j.1469-8749.2011.03959.x. Epub 2011 May 13. Erratum in: Dev Med Child Neurol. 2011 Aug;53(8):767. http://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2011.03959.x/full

RCT Comparing child and context therapy approaches 

Law MC, Darrah J, Pollock N, Wilson B, Russell DJ, Walter SD, Rosenbaum P, Galuppi B. Focus on function: a cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy. Dev Med Child Neurol. 2011 Jul;53(7):621-9. doi: 10.1111/j.1469-8749.2011.03962.x. Epub 2011 May 13. PubMed PMID: 21569012; PubMed Central PMCID: PMC3110988. http://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2011.03962.x/abstract

AIM: This study evaluated the efficacy of a child-focused versus context-focused intervention in improving performance of functional tasks and mobility in young children with cerebral palsy.

METHOD: A randomized controlled trial cluster research design enrolled 128 children (49 females, 79 males; age range 12 mo to 5 y 11 mo; mean age 3 y 6 mo, SD -1 y 5 mo) who were diagnosed with cerebral palsy. Children across levels I to V on the Gross Motor Classification System (GMFCS) were included in the study. Children were excluded if there were planned surgical or medication changes during the intervention period. Therapists from 19 children's rehabilitation centers were block randomized (by occupational therapist or physical therapist) to a treatment arm. Children from consenting families followed their therapists into their assigned group. Children received child-focused (n=71) or context-focused intervention (n=57) over 6 months, returning to their regular therapy schedule and approach between 6 and 9 months. The primary outcome measure was the Pediatric Evaluation of Disability Inventory (PEDI). Secondary outcome measures included the Gross Motor Function Measure (GMFM-66), range of motion of hip abduction, popliteal angle and ankle dorsiflexion, the Assessment of Preschool Children's Participation (APCP), and the Family Empowerment Scale (FES). Outcome evaluators were masked to group assignment and completed assessments at baseline, 6 months, and 9 months.

RESULTS: Ten children did not complete the full intervention, six in the child group and four in context group. GMFCS levels for children in the study were level I (n=37), level II (n=23), level III (n=21), level IV (n=21), and level V (n=26). There were no significant differences at baseline between the treatment groups for GMFCS level, parental education, or parental income. For the PEDI, there was no significant difference between the treatment groups, except for a small effect (p<0.03) on the Caregiver Assistance Mobility subscale between baseline and 9 months. The mean scores of both groups changed significantly on the Functional Skills Scales (p<0.001) and Caregiver Assistance Scales (p<0.02) of the PEDI after the 6-month intervention. There was no additional statistically significant change on the PEDI during the follow-up period from 6 to 9 months. A subgroup effect was found for age (p<0.001), with children younger than 3 years changing significantly more than older children. GMFCS level at baseline did not influence the amount of change on the PEDI scales. There were no significant differences between the treatment groups on the GMFM, range of motion measures, APCP or FES assessments. For the GMFM, there was a significant change over time from baseline to 6 months (p<0.001) and no significant change between 6 and 9 months. There was no adverse side effect as range of motion did not decrease in either group. Hip abduction increased significantly (p<0.01) at the 9-month assessment for both groups. For the APCP, significant changes for both treatment groups were found between baseline and 6 months for play intensity (p<0.04), physical activity intensity and diversity (p<0.001), and total score intensity (p<0.01).

INTERPRETATION: This study shows that child- or context-focused therapy approaches are equally effective and that frequency of intervention may be a critical component of successful intervention. Further evaluation is required to identify the various 'dose-response' relations of amount of treatment and changes in functional abilities.