Context therapy: a new intervention approach for children with cerebral palsy

Both the number and rigor of efficacy studies to evaluate intervention techniques used with children with cerebral palsy (CP) have improved in the past decade.1 Whyte and Hart2 identified three important methodological issues that researchers need to consider when designing effective intervention studies: (1) defining the population, (2) choosing appropriate outcome measures, and (3) describing the intervention in enough detail that other researchers and clinicians can replicate it. Researchers are increasingly aware of the importance of characterizing children in terms of their functional abilities and of considering the effect of the intervention in children of differing ability levels.3 The psychometric rigor and evidence of responsiveness of pediatric outcome measures have both improved in the past decade.4 However, descriptions of specific interventions remain the least developed aspect of rehabilitation intervention studies,2,5,6 and systematic reviews of specific interventions report this as a weakness of studies.7–9 Detailed treatment protocols have been used and discussed in the literature on behavioral psychotherapy for over 25 years.10 In the field of psychotherapy, these manual-based therapies or ‘manualized therapies’ require a clinician to match clients with a specific diagnosis to a treatment package that has been developed for that disorder.11 Characteristics of effective treatment protocols or manualized therapies include a theoretical justification for the treatment design, detailed descriptions of the intended patients, the intervention intensity, duration and delivery, and a description of the training and monitoring of persons providing the intervention.2,6 Advocates of manualized therapies claim that they are efficient and reduce the ‘flawed idiosyncratic decision-making of individual therapists’ (Eifert et al.,11 (p500)). For research purposes, a standardized description of an intervention increases the internal validity of outcome studies, allowing systematic evaluation of treatments across settings and sites. Critics of a manualized therapy approach, however, caution that it could encourage a ‘cookbook’ intervention and suggest that adequate flexibility must be included in the instructions to accommodate individual situations.12 Manualized therapy approaches are appearing in pediatric rehabilitation for children with autism13,14 but they are not common practice for the management of children with CP.15 Manualized therapies ensure the specificity of intervention approaches for children with motor disabilities, both in research studies and in the delivery of intervention approaches in clinical practice. This paper describes the ‘context therapy’ intervention approach developed for the clinical trial described in the accompanying paper by Law et al. The theoretical rationale for the context approach, the model of service delivery, and the training procedures are described. Examples of specific intervention solutions are provided and some identified benefits and challenges of introducing this intervention are discussed. Broad concepts of the context therapy approach have been described previously in a published treatment protocol,16 but this paper provides detailed information about the training procedures and intervention guidelines. It identifies the ‘active’ ingredients2,6 of the context therapy approach, allowing clinicians and researchers to replicate it.