Optimising parental engagement in early intervention physical therapy for infants with cerebral palsy - A Realist Synthesis.


To identify theories and strategies employed in early intervention physical therapy (EI) literature to engage parents in early intervention for babies with CP and evaluate what works, for whom and in what circumstances.

This review will inform the development of a larger NIHR Clinical Doctoral Research Fellowship project exploring parental engagement in EI within the NHS with the aim of developing programme theory with practical application in this context.


A realist synthesis following Pawson et al's methods (2005) was performed. This methodology enables a pragmatic and purposive approach to review.

Using specified criteria; quantitative, qualitative and theory papers were used to scope the topic.

Multiple search strategies were used, with an initial systematic search of PubMed and Embase databases (MeSH terms; Parents, Infants, Early Intervention and Cerebral Palsy).

Abstracts of 240* hits were reviewed, 34 articles were kept. References from recent systematic reviews of EI efficacy were used. And further snowballing. Contexts, mechanisms and outcomes configurations were developed.


The most common component strategy to engage parents within EI programmes was education.

There are mixed outcomes of engagement depending on the parent's context and whether the programme strategy could provide sufficient resources for parents. Many programme theories used the therapist as an expert teacher and parents as adult learners, assuming that the parent will 'carry-over' therapy into the daily routines of family life. Literature suggests that if a programme relies on complex handling techniques then successful parent engagement is less likely.

Contexts - Parents of infants with emerging cerebral palsy are more at risk of anxiety and depression, which may influence their ability to engage in therapy. Social networks and personal support may help mitigate this. Parent socioeconomic and educational status can be influential, but these are not always indicative of poor outcomes if the programme provides sufficient resources for parents.

Mechanism - Providing EI parent education to enable engagement in these contexts is likely to be most successful when mediated through trusting therapist - parent relationships; where the parent feels that the therapist genuinely cares for their baby, understands their personal circumstances and enables their contribution. Further, if parent-infant bond is supported through therapy, outcomes will be better for all parties.

Coaching, whereby parents are supported to independently therapeutically problem solve within their family environment, may create long-term outcomes where parents develop greater self-efficacy. This in turn can lead to improved parent engagement longer term.

EI experimental research, considers compliance as the most important outcome associated with parental engagement. Qualitative investigation highlights that parent engagement is more complex than this metric. Nevertheless, research suggests that if therapy dosage is low then parental engagement and consequently compliance to therapy application at home is reduced.

This realist synthesis provides some insight to help therapists to reflect upon their own practice, consider the best theories and application of logical approaches to enable optimal parental engagement.


Trust is a critical catalytic mechanism; where parents first need to believe in the therapist, then the therapy educational approach, before fully engaging. 

Funding acknowledgements

This project is being funded by Health Education England (HEE) and the National Institute for Health Research (NIHR) through the Integrated Clinical Academic (ICA) Programme Pre-doctoral Clinical Academic Fellowship (PCAF) scheme.

Additional notes

This work was presented at Physiotherapy UK 2019 and National Neonatal Therapy Study day.