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Preliminary Aquatic Physical Therapy Core Sets for Children and Youth With Neurological Disorders: A Consensus Process

Güeita-Rodríguez, Javier PT, PhD; García-Muro, Francisco PT, PhD; Rodríguez-Fernández, Ángel L. PT, PhD; Cano-Díez, Beatriz PT, PhD; Chávez-Santacruz, David PT; Palacios-Ceña, Domingo RN, PhD

Author Information
doi: 10.1097/PEP.0000000000000624
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Aquatic physical therapy (APT) is defined as “the special practice of physiotherapy, with the therapeutic intent toward rehabilitation or attainment of specific physical and functional goals of individuals using the medium of water.”1 APT programs increase the function of children and youth with neuromotor disorders and other developmental disabilities.2–4 APT has a wide range of therapeutic effects, as well as clinical benefits. APT provides an environment in which children and youth can participate with improvements in the motor skills of children with developmental coordination disorders3 and in the gross motor performance and walking parameters of children with cerebral palsy (CP),2 providing a motivating and enjoyable form of physical participation.5–8 APT often encourages independent activities and participation in comparison to land-based therapies. APT treatments can generate positive emotions improving the well-being of children with disabilities of varying severity9,10 and have a positive effect on the behavior of children with autism spectrum disorders,11,12 encouraging participation levels and enhancing adherence to treatment.

Physical therapists often assess and give advice on the management of children with neurodevelopmental disorders working in collaboration with other health care professionals to improve parent-child interactions and promote functional mobility and participation.13 The pediatric research community emphasizes the importance of working on functional objectives in the treatment of this population.14 Our project involved a process of identifying and analyzing intervention categories treated by APT in pediatrics to define specific treatment goals.

“Functioning” is defined by the International Classification of Functioning, Disability and Health (ICF) as “an umbrella term to describe what a person with a health condition does or is able to do in everyday life.”15 In 2007, the World Health Organization (WHO) published the version for children and youth. The purpose of the ICF-children and youth is to create a framework for evaluating the pertinent domains of functioning and health. This is a useful classification that can be used to promote children's participation16 for the development of ICF pediatric Core Sets (CSs)14 and for the identification of relevant goals within professional interventions, such as physical therapy.17 In 2018, the 2 classifications were merged into 1 to address all aspects of functioning across the life span.18 The ICF is a useful tool for assessing health status and describing the functional status associated with the presence of health, illness, and disability. The ICF addresses both what people can do in a standard surrounding (their level of capacity) and what they do in their usual environment (their level of performance).15

Five components of functioning are distinguished in the ICF classification: (1) body functions; (2) body structures; (3) activities and participation; (4) environmental factors; and (5) personal factors. These components are described in several chapters, with hierarchical ICF categories as the units of classification. Altogether, the ICF components make up 1685 ICF-children and youth categories, excluding personal factors (not yet classified to date). A code is assigned to each ICF category. This alphanumeric code represents the classification component with a letter (b: body functions; s: body structures; d: activities & participation; and e: environmental factors) followed by a number, which represents the chapter (ie, s7). This is followed by the second-level specification (ie, s760), and when applicable, a third- and fourth-level specification is also included (ie, s7600).

The practical application of the ICF has been challenging in clinical practice because of its complexity and the number of categories. For this reason CSs have been developed to represent shorter lists of ICF categories that cover the most relevant areas of function and disability in a specific condition or health care context.19 The CSs are a list of the most relevant ICF categories that serve as an international standard for describing functioning, and the basis on which the assessment tools should be used. Schiariti et al14 have led the development of the ICF CSs for children and youth with CP as the first ICF-based tools developed to describe the functioning of children and youth. While CSs have been developed for several chronic conditions,20 fewer CSs have been developed for specific health care contexts. Development of CSs for the specific health care context of APT would assist clinicians in identifying relevant ICF categories to describe function and appropriate measurement tools to use in the practice, education, and research related to APT. The development of each ICF CS project involves the development of a comprehensive and brief CS.20 The comprehensive CS can be applied for multidisciplinary assessment and as a “common language.” The brief CS follows from the comprehensive CS, to be used in clinical practice where only a brief assessment is necessary.21 Schiariti et al14 added the Common Brief ICF CS to describe the level of functioning of children and youth from infant to school-age to youth. This common set describes children and youth during a life span and can be applied as a minimal data set. Some authors have divided it into 3 age-specific brief CSs,14,22 including the categories of the common brief CS in addition to specific categories for each pediatric age group. These age-specific CSs can be used in clinical settings or in research to describe the categories in a particular phase of development of children and youth.

In spite of the well-described effects and benefits of APT in neuromotor disorders and other developmental disabilities, the areas of functioning that should be routinely assessed or targeted by physical therapists working in the aquatic environment are not yet known. There is no universal structure to describe the functioning of children and youth who participate in APT. ICF can be connected with APT through the creation of CSs to solve this scarcity of description of functioning in this specific health-care context. The objective of this study was to describe the CSs for children and youth with neurological disorders according to the preliminary APT consensus, presenting the most relevant ICF categories identified in the preparatory phase.


Our project started in 2012 as collaboration between the Red Española de Terapia Acuática and the Association International Aquatic Therapy Faculty, with the support of the World Confederation of Physical Therapy-Aquatic Physical Therapy International. The process was divided into 2 phases, a preparatory phase with information gathered from different studies and an international expert opinion consensus phase. The development of the preliminary APT CSs followed the methods endorsed by the WHO,20,21 which integrated evidence from various studies (preparatory phase).23 This method included (1) a systematic review of the aquatic measures and a content comparison of the measures identified (unpublished); (2) a worldwide expert 3-round survey,24 using a Delphi technique (n = 69, from 21 countries); and (3) a qualitative study,25 using “focus group” methods (n = 23, 5 groups) and individual semistructured interviews (n = 20) with the parents of children with disabilities.

After this preparatory phase was completed, international experts from a previous Delphi study24 were invited to a final consensus study to review the outcomes of the 3 preparatory studies, and to reach agreement on the final ICF-children and youth categories to be included in the APT CSs. According to the number of experts in each group in the first Delphi study,24 the higher prevalence of neurological disorders included in qualitative study,25 and the scarcity of literature on the other groups (autism spectrum disorders, psychomotor delays, and musculoskeletal disorders) in comparison to the neurological group, we decided to concentrate on neurological conditions for final consensus.

We conducted a formal and structured consensus process using an open-ended internet survey of international APT experts based on the Delphi method.26 The Delphi method is a structured process based on anonymity, iteration with controlled feedback, statistical group responses, and informed feedback.27 The aim of this method is to develop and facilitate consensus among individuals with knowledge in the matter studied, and who are recognized as “experts.”27,28

We report here on the results of the final consensus as presented in the Fourth International Conference of Evidence Based Aquatic Therapy, November 10 to 12, 2017, at Mysuru (India).

Recruitment of Expert Participants

Expert aquatic physical therapists from each WHO region were recruited if they met the following criteria: (1) physical therapists; (2) had participated in preparatory study inside a group on neurological disorder24; and (3) had over 5 years of experience working in water with children and youth with neurological disorders. Experts were required to communicate either in English or Spanish.

The initial sample included 49 experts representing 5 WHO regions.24 All had previous training and experience with ICF-children and youth and in a Delphi process. From this total of experts, 21 did not respond to the invitation to be part of this final consensus, 6 declined for personal reasons, and 6 did not respond to the first round. Finally, 16 experts participated in at least 1 of the rounds of the Delphi (15 completed both rounds, and 1 dropped out in round 2). This recruitment took place in November 2016 (Figure). There were a total of 10 responses in Spanish and 6 in English. Three WHO regions were included. Six participating countries were from the European region, 1 from the Eastern-Mediterranean region, and 3 from the American region.

Recruitment process.

Data Collection

The number of rounds used in the Delphi process varies, although it is usually 2 or 3.27 This consensus process is considered complete when there is confluence of opinion or when a degree of diminishing returns is achieved.29

The process was performed in 2 languages (Spanish and English). Each participant was granted 2 weeks to respond to each round. The primary researcher sent out reminders approximately 2 days before and 2 days after the response deadline. Participants were masked to the identities of the other participants in the Delphi process at all times. Each Delphi round lasted approximately 1.5 months, including time to respond and to analyze the data.

We developed an electronic consensus as an opinion leader perspective instead of the face-to-face consensus proposed in WHO methods for practical reasons. The iterative decision-making process and the voting process were the same as proposed by the WHO. The APT experts examined and identified the intervention categories in 2 rounds, in a structured decision-making process based on a list of categories resulting from the 3 preparatory studies. The 2 rounds are analogous steps in Delphi consensus studies for item generation and reduction for neurological disorders.30 Comprehensive and Brief Core Sets had been developed in the previous pediatric ICF CS development process, and 3 Brief Core Sets were developed to reflect the developmental stages of children and youth, following its recommendation.14,22

The iterative decision-making process included 2 consecutive parts. The first involved the selection of the ICF-children and youth intervention categories to be included in the Comprehensive CS in the second level, and in further detail at the third level (rounds 1 and 2). The second part included the selection of categories from the Comprehensive CS to be included in the Brief CSs (round 2). Consensus agreement among the experts was set at 75% or more for inclusion in the 5 CSs, referring to at least 75% of the experts including a category for it to be part of the CSs. In round 1, the categories below 40% were excluded. The categories lower than 75% and greater than 40% were considered “ambiguous” 31 and went to round 2. We used the same cutoff points as described in previous Core Set projects.14,31

The Comprehensive APT CS should include enough categories to make an exhaustive description of interventional categories. The Brief APT CS includes the fewest interventional categories possible so as to serve as a minimal standard for describing and evaluating treatments for clinical, educational, and research purposes.20 The participants did not have a predetermined number of categories required to achieve consensus. Selb et al20 have described the first part in detail. The experts were questioned in the second part to select categories from the Comprehensive CS for the creation of the Brief CSs. Since it is the first APT consensus on children and youth, specific adaptations need to be made for the ICF methodology for children. Based on the ICF CSs for children and youth with CP14 (the first pediatric ICF-based functioning tool), CSs should reflect neurodevelopmental phases. Schiariti et al elaborated 3 detached Brief CSs for children and youth below 6 years, from 6 to less than 14 years and from 14 to 18 years. Our results were divided according to the stage of development (infant, school-age, and youth) in case the age ranges for the stages of development differed with respect to countries and culture.22 A Common Brief CS was created, with categories that covered the 3 age groups. The practical application tools are available for free use at the Web site:


In the preparatory phase, the 3 studies identified 260 categories (15.4%) of 1685 ICF-children and youth categories as relevant areas of functioning to be treated by APT in children and youth. Experts included 123 different second-level categories (47.3%), and 137 third- and fourth-level categories (52.3%). Out of these categories, 94 (36.15%) categories belonged to body functions, 47 (18.08%) categories belonged to body structures, 105 (40.38%) categories were associated with activities and participation, and 14 (5.39%) categories were connected to environmental factors. The categories in the third and fourth levels, between 40% and 75% after round 2, following the hierarchy rule of the ICF, were assumed by the upper level if this was already represented.18

The consensus process resulted in a Comprehensive APT CS for children and youth with neurological disorders and included 64 different ICF categories (63 different second-level categories and 1 third-level category; Table). This level of detail was satisfactory for body functions, activities and participation, and the environmental factors; nevertheless, some intervention categories from body structures needed further detail into the third level, because the experts showed through a high response frequency (≥75%) that a specific description of the target was necessary, with further specifications for the second-level categories (eg, s7600 structure of vertebral column). No further detail was needed at the fourth level.

TABLE - Aquatic Physical Therapy Core Sets in Children and Youth With Neurological Disorders
Brief APT Core Sets
Age-Specific Brief APT Core Sets
Comprehensive APT ICF Core Set, 0-18 y, n = 64
Code ICF Category Name Common Brief, 0-18 y, n = 13 0 to <6 Infant, n = 18 >6 to <14 School-age, n = 22 >14 to 18 Youth, n = 19
Body functions
b110 Consciousness functions
b114 Orientation functions X X
b1301 Motivation X X
b140 Attention functions
b147 Psychomotor functions X
b156 Perceptual functions
b163 Basic cognitive functions
b210 Seeing functions X
b235 Vestibular functions X X X X
b260 Proprioceptive function X X
b265 Touch function
b280 Sensation of pain X X X X
b410 Heart functions
b440 Respiration functions X X X X
b445 Respiratory muscle functions X X X X
b455 Exercise tolerance functions X X
b710 Mobility of joint functions X X X X
b715 Stability of joint functions X X
b730 Muscle power functions X X
b735 Muscle tone functions X X X X
b740 Muscle endurance functions X X
b750 Motor reflex functions
b755 Involuntary movement reaction functions
b760 Control of voluntary movement functions X X
b770 Gait pattern functions
b780 Sensations related to muscles and movement functions
Body structures
s710 Structure of head and neck region
s720 Structure of shoulder region
s730 Structure of upper extremity
s740 Structure of pelvic region
s750 Structure of lower extremity
s760 Structure of trunk X X X X
s7600 Structure of vertebral column
s770 Additional musculoskeletal structures related to movement
Activities and participation
d110 Watching
d115 Listening
d130 Copying
d131 Learning through actions with object
d155 Acquiring skills
d160 Focusing attention
d161 Directing attention
d175 Solving problems
d210 Undertaking a single task
d220 Undertaking multiple tasks
d315 Communicating with—receiving—nonverbal messages
d330 Speaking
d335 Producing nonverbal messages
d410 Changing basic body position X X X X
d415 Maintaining a body position X X X X
d420 Transferring oneself X X X X
d430 Lifting and carrying objects
d435 Moving objects with lower extremities
d445 Hand and arm use X X X X
d450 Walking X X X X
d455 Moving around X X X X
d465 Moving around using equipment
d510 Washing oneself
d540 Dressing
d710 Basic interpersonal interactions
d880 Engagement in play
d9200 Play X X
Environmental context
e310 Immediate family
e355 Health professionals
e580 Health services, systems, and policies
Abbreviations: APT, aquatic physical therapy; ICF, International Classification of Functioning, Disability and Health.

These 64 categories represent 3.79% of all categories included in the ICF-children and youth classification. Of the 64 categories, 26 (40.6%) belonged to body functions, 8 (12.5%) were connected to body structures, 27 (42.1%) belonged to activities and participation, and 3 (4.6%) were associated with environmental factors. The experts agreed a Common Brief APT CS of 13 categories (6 are from body functions, 1 from body structures, and 6 from activities and participation) that comprised categories present across 3 age-specific groups.

The experts agreed to add 5 Brief APT CS aged 0 to less than 6 years categories to the Common Brief APT CS. Nine Brief APT CS aged 6 to less than 14 years categories were added. In the last age-specific group, from 14 to 18 years, 6 categories were added to the common set.

The experts were asked to create CSs capturing the key intervention categories of children and youth with neurological disorders in a concise and accurate way. The challenge for the participants was to prioritize in each round when voting for each category to keep the APT CSs practical and applicable. As expected, categories related to mobility, mental functions, muscle functions, respiratory functions, and structures of trunk were included almost unanimously by the experts.


This consensus provided an opportunity for a group of international physical therapy experts to appraise the evidence from the preparatory phase of the project and select the categories of the APT CSs for children and youth with neurological disorders. This process produced a tool that facilitates a systematic design and assessment of the APT intervention categories. In a clinical context, APT CSs in children and youth with neurological conditions may be seen as a comprehensive framework with which to guide the intervention process following the ICF. Our findings provide insights regarding the relevant practical and meaningful areas of functioning that aquatic physical therapists target their treatment interventions.

No new categories were included in this final process of preselection through the 3 preparatory studies. Five APT CSs were developed based on Schiariti et al,14 according to the developmental trajectories in children and youth to follow their growth. The Comprehensive APT CS can provide a complete description of intervention categories from 0 to 18 years. The Common APT Brief CS can enable the continuous description of intervention categories over time, as its 13 categories are included in each age-specific APT Brief CS. Moreover, each age-specific APT Brief CS enables the description of intervention categories specific to each age group.

The agreed-upon CS for physical therapy in the specific context of water for children and youth with neurological disorders includes almost half of the relevant areas of functioning described by Schiariti et al,14 in Comprehensive CS in children with CP (165 categories of functioning, 64 APT intervention categories: 47.40% functioning categories influenced by APT), with CP the most prevalent neurological pediatric disorder. The functioning pediatric project and our intervention project matched as follows: b7, neuromusculoskeletal and movement-related functions; s7, structures related to movement; and d4, mobility chapters, as expected from preparatory phase. There was consensus regarding b1, mental functions; b2, sensory functions and pain; d1, learning and applying knowledge; and d2, general tasks and demands.

Only some of Schiaritiś functioning chapters were not included in our findings regarding body structures: s1, structures of the nervous system, s3, structures involved in voice and speech. In comparison, the body functions not covered in our study were as follows: b3, genitourinary functions; b5, functions of the digestive, metabolic, and endocrine system; b6, genitourinary and reproductive system; and b8, functions of the skin and related structures. Of activities and participation, only d6 domestic life was not covered in our findings. The environment factors—e1, products and technology; and e4, attitudes—were not influenced by APT. This suggests that APT offers possibilities for higher participation levels of children and youth counting on the support of, and relationship with, family and health professionals, affecting the health services, systems and policies; whereas goals must be more specific to this environment at the level of body functions and body structures.

The highest consensus obtained in APT Comprehensive CS (27 categories, 42.18%), within the intervention components, was for the categories related to “mobility” (chapters b7, s7 with special attention to s760, and d4). They were almost entirely represented by the 4 APT Brief CSs. The “learning” categories were also emphasized in the APT Comprehensive CS (22 categories, 34.37%), including mental functions, sensory functions, and learning and applying knowledge in general tasks and demands categories (chapters b1, b2, d1, and d2). They were not covered in the age-specific APT Brief CSs, however, perhaps due to difficulty in accurately differentiating these depending on age and specific neurological disorders. Our results support the idea that active movement is the main tool during APT treatments, and its application via learning and the application of knowledge resolving tasks and demands are the main intervention categories used by aquatic physical therapists. Nevertheless, APT has to fine tune these “learning” goals according to age-specific groups and neurological disorders, creating a clear relationship with patients and parents when setting goals for APT interventions.

The categories included in the Comprehensive APT CS can all be assessed and treated by physical therapists. The next step is to study the validity and feasibility of APT CSs in children and youth with neurological disorders. An empirical cross-sectional study is being developed in study centers in WHO regions to identify the extent to which there are typical interventional APT profiles for different pediatric neurological disorders. Clinical perspectives will be recorded, using the preliminary APT CSs as a checklist.

Possible applications of this intervention categories list for children and youth with neurological disorders could be clinical aquatic therapy practice, research, education, and health administration. In day-to-day practice, APT CSs could be used for professional collaboration and multidimensional intervention plans. In research, they can be used to evaluate APT treatments and to facilitate the selection of the most appropriate outcome measure for the aim of the intervention. In education, they could be used to fine tune the program contents and in administration for improving the distribution of care.

To apply the CSs, aquatic physical therapists first have to select the type of APT CS, depending on their purpose. The list of categories included in the specific APT CS selected by the user will guide identification of “what” to measure and report, and “what” to treat by APT. It is important to realize that APT CSs are not outcome measurements in their own right, because they do not describe “how” to do it. They are an agreed list of domains that are relevant for APT treatments. Accordingly, the next step is selection of the appropriate health status measures that align with the content of APT CSs in water and on land.

This study has several limitations. First, not all WHO regions were represented, and this may have affected the results obtained. Second, some major areas of Comprehensive APT CS are not represented in the Brief APT CSs (d1, learning and applying knowledge; and d2, general tasks and demands). We expect that the validation phase, following the consensus process with clinical studies, will address these limitations, to implement the results. For these reasons, we suggest that this preliminary version of the APT CSs is used for pilot studies.


APT CSs for children and youth with neurological disorders were defined using evidence from the preparatory phase with a structured and formal decision-making consensus integrating expert opinion. Strategies should be developed for the application and implementation in practice, research, education, and health administration. The 5 CSs are preliminary and are in the process of being tested and validated. Further studies are required to investigate how to operationalize the included categories, since these 5 CSs only say “what categories” to treat in APT, but do not say “how to measure” them.


The authors thank all expert participants in the final consensus for their time and invaluable contribution, the parents involved in the project, and the managers of the aquatic physical therapy units included. We also extend a special thanks to Dr Alarcos Cieza for her support throughout the research.


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clinical competence; consensus; Delphi technique; Disability and Health; International Classification of Functioning; nervous system diseases; physical therapy modalities

© 2019 Academy of Pediatric Physical Therapy of the American Physical Therapy Association