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Stability at its Core: Development of an occupation-based, core stabilization, therapist

training program for children with cerebral palsy

Significance
Population and Needs
Cerebral palsy (CP) is defined broadly as “a group of disorders that affect a person’s
ability to move and maintain balance and posture” (Centers for Disease Control and Prevention
[CDC], 2021, para. 1) and is the most common childhood motor disability. It is caused by
abnormal brain development or damage to an already developing brain before, during, or within
the first year after birth, resulting in difficulty with muscle control (CDC, 2021). Morocco, a
country situated in Africa, is considered a developing country. Little data is available on the
estimated prevalence of CP within Morocco specifically; however, in developing countries, the
prevalence appears to be higher, ranging from 2-8 per 1,000 births (Abas et al., 2017). Basic
care for children with CP in Morocco is limited by poor availability of diagnostic facilities, medical
personnel experience, and lack of available medications, surgical procedures, and regular
therapy (Donald et al., 2015). This program proposal aims to address the needs of children with
CP at the Moulay Ali Institute for Rehabilitation (MAIR) clinic in Marrakech, Morocco.
Gaps in Services
Children with CP are often functionally limited by decreased core strength and control.
Core stability is defined as the ability to control the position and movement of the central portion
of the body (Ahmed et al., 2014). Poor core strength can lead to difficulty with gross motor skills,
such as balance and walking, as well as fine motor skills, such as writing or holding a utensil to
self-feed (Abd-Elfattah et al., 2021). Such occurrences reflect the commonly repeated phrase in
therapy that proximal stability is needed before distal mobility can be achieved (El Shemy,
2018). Physical and occupational therapy services can play an important role in helping children
with CP improve muscle tone, balance, and participate more independently in activities of daily
living (National Institute of Child Health and Human Development, 2021).
Additionally, the country of Morocco lacks the United States equivalent of occupational
therapy. Therefore, the MAIR clinic does not have occupational therapists or occupation-based
interventions for individuals needing neurological rehabilitation. For the purposes of
occupational therapy and this program, occupation refers to the activities that individuals
engage in every day. Occupations can occur individually, within families or groups, and within
the community and bring meaning to life. Occupations include things people need to, want to,
and are expected to do (World Federation of Occupational Therapists, 2018). In the case of
children, a major occupation is play. This program will address the gap in occupation-based
interventions related to children with CP by targeting trunk stability through occupations such as
play.
Current Programs
The majority of core-strengthening programs that are implemented and researched
originate from the physical therapy discipline. Such programs utilize treatment methods that
focus on exercises specific to core strengthening. Research results indicate that a core-
strengthening program may help to improve body structures and functions such as balance,
endurance, strength, and gait (Ali, 2019; Unger et al., 2013). Though such outcome measures
are important, these programs fail to address functional participation. According to Anaby et al.
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(2017), participation has been widely recognized as a key factor to a child’s development, well-
being, and is an important outcome of rehabilitation interventions for children with CP. It has
been shown that engagement in occupations can be motivating and improve functional
outcomes in children with CP (Lynch & Moore, 2016; O'Brien & Kuhaneck, 2020). Therefore,
though there may be little research available regarding occupation-based core strengthening
programs, occupation-based treatment is supported by the literature and may be helpful in
treating children with CP.
An Occupation-based Core Strengthening Program
This program will use evidence-based practices in combination with occupation-based
treatment to address trunk stability in children with CP. It will work to implement the basics of
OT into a clinic where there is very limited OT influence. The program will include four sessions
delivered over video conferencing where the therapists at the MAIR clinic will be trained on
trunk stability and occupation-based treatment for children with CP. While the training will
provide ideas and resources for occupation-based treatments, it will ultimately be the
responsibility of the therapist to determine the needs of the client and make treatments client-
centered. Training will include education on the use of outcome measurement tools designed to
gather information throughout the program duration. After the training sessions, the therapists
will implement the principles they learned about into their treatment with clients who have CP.
Two occupational therapy students will be available for virtual consultation when needed.
Models and Theories
Use of OT practice models and theories to guide program development will help to
ensure program success. The Model of Human Occupation (Kielhofner, 2008) and the
biomechanical model (Kielhofner, 2009) were selected in conjunction with this proposed
program. In the Moroccan culture, disabilities are seen at a surface level, meaning the
assumption is often made that people with disabilities cannot compensate for their impairments
and regain independence. The Model of Human Occupation considers an individual’s volition
and meaningful occupations in order for performance to be enhanced. The biomechanical
model addresses modifications to the task or environment to promote occupational participation
as well as areas of strength, endurance, and limitations in movement. While each client is
different, children with CP would benefit from addressing such components of the
biomechanical model which relate to posture in conjunction with occupational and motivation-
based principles, which originate from the Model of Human Occupation.
Healthy People 2030
This proposed program aims to address priority areas of Healthy People 2030. These
areas include the goals to “attain healthy, thriving lives and well-being free of preventable
disease, disability, injury, and premature death” and to “eliminate health disparities, achieve
health equity, and attain health literacy to improve the health and well-being of all” (US
Department of Health and Human Services, 2021, para. 6). This program will address these
aims by improving the quality of life for children with CP, as well as providing occupation-based
services to a population that currently does not have such services available to them.
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Innovation
Program Innovation
This program aims to implement OT principles into treatment for a population that
currently lacks OT influence. By focusing on a single population, children with CP within the
MAIR clinic, we can train the therapists on how to design occupation-based interventions.
Interventions will target core stability and will be meaningful to the client by using aspects of
play or other occupations that are of interest to the child.
Additionally, this program does not require much involvement from outside sources. The
therapists receive the training they need to create occupation-based core strengthening
treatments and are given the freedom to implement them in a way that is culturally relevant and
client-centered. OT students will be available after training for consultation, but their continued
involvement is not necessary for program sustainability.
Program Novelty and Differentiation to Existing Programs
Existing trunk stability programs for children with CP are rooted in therapeutic exercise
and aim to address areas of balance, strength, and endurance. While such programs may be
important and effective, they do not address function and are not at all related to occupations
the child may engage or have an interest in. By combining principles from these exercise-
focused programs with occupation-based interventions, participation in treatment will become
more meaningful, hopefully increasing motivation, as well as facilitating improvements in areas
of function.

Approach
Needs Assessment Results
After conducting a thorough needs assessment through careful observation and informal
interviews with the owner and therapists at the MAIR clinic, it became evident programming
would need to be centered around occupation-based care. The clinic is not staffed with any
occupational therapists and in a broader sense, as of 2015, Morocco does not have a degree
program for occupational therapy (Nafai, 2015). Due to the large-scale lack of occupational
therapy influence, occupation-based care is an unfamiliar concept. Interventions at the clinic
often resemble therapeutic exercise and rarely include meaningful occupations. In regard to the
program being proposed, positioning and exercise are currently the primary interventions being
utilized to address trunk stability in children with CP. These interventions are being used without
the incorporation of occupation and without seeing significant improvements in functional trunk
use. Given this observed gap in services, programming in this area will be beneficial to
encourage engagement and functional improvements. Additionally, interventions at the clinic
often fail to keep the client at the center of care due to the tendency to focus on impairments
rather than how rehab can lead to increased occupational participation. Although the clinic is
already an invaluable resource for the community in Marrakech, adding occupation-based and
client-centered interventions with the CP clientele will increase motivation and functional results.
Program Goals, Objectives, and Evaluations
The program has two main goals with objectives to act as stepping stones. The goals
have been created to ensure successful program implementation and are broken down as
follows:

● Goal 1: (Outcome) Therapists at the MAIR clinic will successfully implement the
core stability program with pediatric clients who have cerebral palsy.
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○ Objective 1a: (Process) Therapists at the MAIR clinic will undergo training
on how and when to provide occupation-based core stability training to
clients with cerebral palsy.
○ Objective 1b: (Outcome) Upon completion of program implementation,
MAIR clinic therapists will gain an understanding of how to individualize
the program and the importance of occupation-based care, which will be
assessed through the use of a post survey.
● Goal 2: (Outcome) Pediatric clients with cerebral palsy will have increased core
stability during meaningful occupations.
○ Objective 2a: (Process) Pediatric clients with cerebral palsy and their
parents will discuss with their therapist important occupations to focus on
during therapy.
○ Objective 2b: (Outcome) Upon completion of the program clients will
demonstrate increased occupational participation.

In addition to the goals and objectives acting as a guide for implementation, they also
provide the basis for how the program’s outcomes will be measured. Qualitative data will be
collected through semi-structured interviews with the therapists and also the client’s
parent/guardian prior to program implementation and 1 year post program implementation. See
Appendix A for the qualitative measures, which have been created for the program. Additionally,
quantitative data will be collected through the use of the Pediatric Balance Scale, which is used
to measure functional balance in pediatric clients (Akbas, 2016). This assessment will be given
prior to the child beginning the core stability program and then again immediately after the
program has been completed. See Appendix B and C respectively for details on the Pediatric
Balance Scale and the Sitting Assessment Test for Children with Neuromotor Dysfunction.
Finally, there will be an additional quantitative measure utilized, which can be found in Appendix
D. This measure uses a Likert Scale questionnaire, which will be administered to
parents/guardians of the pediatric clients. The questionnaire will provide a quantitative score
regarding the program’s influence on occupational participation.
Program Details
The program that has been developed emphasizes the importance of the MAIR clinic
therapists and their willingness and ability to implement occupation-based interventions
successfully with their clients. The dependency on therapist involvement indicates trainings are
critical and are designed to foster program buy-in and encourage the therapists to understand
the value of occupation-based care. Trainings will be held via Zoom, the teleconferencing
software, to connect the therapists in Morocco to the occupational therapy students providing
the training in Utah. The training sessions will be administered in four stages. Stage 1 will cover
core stability as it relates to CP. Stage 2 will address the importance of occupation. Stage 3 will
teach about how to incorporate occupation into interventions, while stage 4 will address
outcome measures and gathering data to track the program’s progress. The following gives a
brief overview of the training modules while Appendix E provides detailed breakdowns of what
the four stages will cover, along with handouts for the therapy team.
Stage 1 will introduce core stability and how it relates to CP. According to Shin et al.
(2017), insufficient trunk muscle postural control is the most concerning symptom of CP due to
the impact it has on gross motor control. Which affects sitting, play, and functional hand
movements, all of which are occupations or are needed for occupations. Ahmed et.al. (2014)
explains how children with CP have delayed development impacting the ability to sit
independently, which is a fundamental step in achieving upright posture against gravity. The
article goes on to say how the muscles surrounding the spine make up for the spine’s structural
weaknesses; however, due to a child with CP having impaired core muscle control the spine is
unstable and ultimately movement is impacted. Knox (2002) details abnormal postural
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responses, which help to identify impaired trunk control. They include non-purposeful or
uncontrollable distal body movements as well as non-purposeful or uncontrollable gross motor
movements. Additionally, Knox (2002) details four concepts including postural tone, proximal
stability, postural alignment, and balance all of which play an important role in trunk stability and
help with tailoring interventions to a child’s specific needs. See Appendix E for additional
information regarding core stability and CP.
Stage 2 will address the importance of occupation in treatment and functional outcomes
as a result of treatment. Research supports the use of functional participation of activities in
treatment for children with CP; however, in practice, interventions instead are often focused on
body functions and structures. Studies conducted by Novak et al. (2013) and Law et al. (2011)
support interventions that are activity-based, functional, and goal-directed as opposed to an
impairment-based approach. Ketelaar et al. (2001) found that children who participated in a
physical therapy program with an emphasis on the performance of functional activities had
greater improvements in motor abilities when compared to children who received physical
therapy focused on the normalization of the quality of movement. In accordance with these
studies, interventions and programs for children with CP may benefit from the incorporation of
occupation-based and function-based activities. Therefore, it would be important to include such
participation in functional activities into core strengthening programs designed to improve core
strength in children with CP.
Stage 3 of training will discuss how to incorporate occupation into core strengthening
interventions. With pediatric clients the occupation most valuable is often some form of play;
however, discussing meaningful occupations with the child and their family will be an important
first step. Once it is clear what is motivating for the child, interventions should include the
motivating occupation to increase engagement and maintain a client- centered approach.
Interventions including neurodevelopmental treatment (NDT), core stabilization exercise
programs, and balance training programs have all been proven to increase core stability. Pairing
interventions such as these with elements of meaningful occupations such as play is the
essence of this program. More specific intervention examples can be found in Appendix E.
Stage 4 will include training on program outcome measures and gathering data. In order
to understand the level of impact from program implementation, outcomes need to be identified
and measured. Semi-structured interviews with the client and parents will be a helpful tool to
retrieve qualitative information and measure outcomes. Therapists will gather information from
the parents about meaningful occupations to the child and the level of occupational participation
outside of therapy. See Appendix A for specific questions therapists may ask to gather the
needed information in the semi-structured interview. Therapists will also be trained in the
administration of the Pediatric Balance Scale and the Sitting Assessment Test for Children with
Neuromotor Dysfunction to provide quantitative data about balance and sitting both before and
after program implementation. Refer to Appendices B, C, and D for specific outcome measure
materials and Appendix E for outcome measure training materials.
After training is conducted, therapists will utilize the information to implement the
interventions and conduct appropriate measures with the pediatric clients who have CP and are
showing signs of trunk instability. With clients of the MAIR clinic being the participants,
marketing and recruitment for this program are minimal. After the training, the therapists will
collaborate with the occupational therapy students to decide which pediatric clients would
benefit from this program. The program will then be implemented once a week, for 30 minutes,
over the duration of 10 weeks. Outcome measures will be conducted immediately after the 10-
week period.
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Program Sustainability
For this program to be successful, it will be reliant on an ongoing relationship with the
MAIR clinic and the University of Utah Occupational Therapy department. One therapist at the
clinic in Morocco will be appointed as the onsite program lead. This therapist will be in charge of
implementation of the program with relevant clients at the clinic after the program training
period. They will also be responsible for bringing any questions or issues with implementation to
the contact personnel in Utah. The contact personnel will include two OT students who
volunteer to provide assistance as an additional learning opportunity. While the program is
detailed and includes an ongoing mentorship component, there are definitely areas where
problems could occur. First of all, training will be conducted virtually, which could bring not only
technical complications, but also difficulties with accurately demonstrating/teaching without the
benefits of being in-person. To address barriers relating to technology, Zoom Pro will be
purchased to ensure better quality virtual meetings. Trainings will also be well rehearsed and
planned to avoid confusion during demonstrations and questions will be answered promptly as
they arise. Additionally, the cultural differences and language barriers must also be taken into
account when considering possible problems. How therapy is administered, access to research
and resources, and how therapists communicate with their patients all have cultural
components, which could create barriers with program implementation. Cultural barriers to
program implementation will be addressed through creating an environment of open dialogue
and feedback between the MAIR clinic staff and the OT students assisting with implementation.
The staff is immersed in Moroccan culture and they fully understand the needs and wants of
their clients; their opinion and input are invaluable and will be fully respected and reflected in
how the program evolves.