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RESEARCH REPORT: EDUCATION

Current Physical Therapy Practice in Norway for Children With Cerebral Palsy

Størvold, Gunfrid Vinje PT, PhD; Jahnsen, Reidun Birgitta PT, PhD

Author Information
doi: 10.1097/PEP.0000000000000757
  • Free

INTRODUCTION

In Norway, more than 90% of children with cerebral palsy (CP) receive physical therapy (PT),1 most often 1 or 2 times per week.1,2 The decision-making as to what type of PT to provide should be evidence-based. If the desired outcome is for the child to learn a gross motor skill, which is an activity according to the International Classification of Functioning, Disability and Health (ICF),3 the current best practice recommendations are to use functional approaches based on motor learning theory.4–7 The purpose of this nationwide study is, therefore, to investigate to what extent learning-based approaches are implemented in the treatment of children with CP in Norway.

In compliance with systems theory, motor learning is defined as “a set of processes associated with practice or experience leading to relatively permanent changes in the capability for motor skill.”8(p497) Common features of approaches based on motor learning theory are: the setting of functional goals in partnership with the child and parents, the child is active in solving movement problems inherent in the functional goals, and repetitive and structured practice of the goal task in real-life environments.7,9–14 During practice, motor learning principles such as feedback, simplification of the task, blocked versus random practice, and the need for guiding, among others, have to be considered. (For more elaboration on motor learning principles and how they are operationalized in PT, we refer to Geijen et al14 or Storvold and Jahnsen15 for a practical description.) Although approaches have different names in the literature, which highlight different aspects, in this article we use the term “functional training based on principles of motor learning.”

Research has consistently shown the effect of functional training based on principles of motor learning on gross motor progress in children with CP16–22 and is recommended rather than the more traditional conceptual methods.16,21,22 Still, there is a delay in implementing these approaches.13

In a cross-sectional study conducted in Canada,23 PT practices for young children with CP were described based on 2 case scenarios at 2 ages (18 months and 4 years) through a structured telephone interview with physical therapists. Although an expert team identified task-specific training and functional exercises as the best practice intervention for all case scenarios, this intervention was reported only by 20% of physical therapists or less. The authors concluded that there were gaps in the incorporation of evidence-based best practice into clinical practice.23

A similar conclusion was reached by Darrah et al24 in a survey of the practice of occupational therapists and physical therapists who responded to 2 standardized scenarios. While two-thirds of the therapists indicated that they used an intervention within the activity component of the ICF to achieve a goal within that component, one-third indicated the use of an intervention within the body function component.25

Using a similar research paradigm, Anaby et al5 concluded that there were gaps between what we know and what we do in practice. They found that most physical therapists targeted the body structure and function component of the ICF and claimed that other ICF components, specifically participation, were poorly integrated into practice.5

By contrast, in a large study investigating the focus of PT for young children with CP in the United States and Canada, parents reported that interventions focused on primary impairments, to a moderate extent on secondary impairments, but also on activities and structured play activities. The authors therefore suggested that therapists addressed all components of the ICF.26

More recent studies suggest that the gap between what we know and what we do is closing.27–30 A survey of current practice in the UK found that when aiming to improve or maintain lower limb function in children at Gross Motor Function Classification System27 (GMFCS) I to III, the most frequently used PT interventions were the provision of explanations, liaison and advice to the children, their families, health professionals, and schools, and stretching. Still, 72% of the respondents reported that they frequently used functional activities.28

McCoy et al29 conducted a large study in the United States and Canada as part of the “on track study.” Although not the primary aim of the study, they reported that the focus of therapy ratings was on the secondary body structure and function domain. However, activities to improve self-initiated abilities and participation were rated as either a moderate or great extent.29 Toovey et al30 conducted a practice survey of therapists in Australia regarding training of 2-wheel bike skills in children with CP. The results suggest that the focus of the interventions was on the activity and participation domain. Functional training approaches were predominant, but intervention characteristics varied.30

No similar research has been conducted in Norway. However, functional training based on principles of motor learning is described in several intervention studies.12,15,20 Nevertheless, we are aware that conceptual methods (neurodevelopmental treatment, Vojta, Conductive Education, and Doman) also are in use, as are therapy strategies involving a large degree of handling of the children, although we do not know to what extent these methods are used.

Therefore, the main aim of our research was to investigate to what extent functional training based on principles of motor learning was the method of choice for Norwegian physical therapists when treating children with CP whose goal was to learn gross motor skills (not PT approaches physical therapists use when addressing body functions and structures or participation). We asked PTs what approaches they used when treating children with CP whose goal is to learn gross motor skills.

We hypothesized that functional training based on principles of motor learning has become the method of choice, but that conceptual methods and methods involving a large degree of handling of children are still used by therapists.

A secondary goal of the study was to investigate whether 2 important motor learning principles, the setting of specific goals and frequency of training, as well as the frequency of physical therapists' presence, the physical therapists' employment position, education, experience, and region of the country were associated with the use of functional training based on principles of motor learning.

METHODS

Design

This research project comprised 2 parts applying mixed methods. To capture the spectrum of PT practices in Norway, physical therapists were asked to describe their practice in free text to establish categories of PT approaches in part I. In part II, we used these categories in a cross-sectional national survey of current PT practice.

Participants

Part I

A convenience sample of 55 physical therapists working with children with CP who attended the national CP conference in Oslo 2019 participated.

Part II

All physical therapists who were members of the Norwegian Association of Physiotherapists subgroup for pediatric physiotherapy and who had treated children with CP during the last 5 years or who had worked as supervisors/teachers for those physical therapists, or who were researchers in the field of children with CP, were considered eligible for participation. The Association had 675 members as of November 2019.

In total, 456 physical therapists answered the questionnaire. Forty-two physical therapists answered that they did not fulfill the inclusion criteria and were therefore not included in further analyses, thus leaving 414 participants (response rate of 65.4%). Details relating to the participants are in Table 1.

TABLE 1 - Distribution of Main PT Approaches According to Health Region, Whether Specific Goals Were Usually Set, Frequency of Training, How Often the Physical Therapist Was Present, and the Physical Therapist's Education, Type of Position, and Experience
Training of Body Functions and Structures
n (%)
Manual Stimulation of Positions and Movements
n (%)
Functional Training Based on Principles of Motor Learning
n (%)
Addressing Environmental Factors
n (%)
Conceptual Methods
n (%)
Other
n (%)
Total
n (%)
Total 35 (8.5) 29 (7.0) 323 (78.0) 15 (3.6) 7 (1.7) 5 (1.2) 414 (100)
Health region
North 5 (16.7) 4 (13.3) 19 (63.3) 2 (6.7) 0 (0) 0 (0) 30 (7.3)
Central 5 (7.2) 2 (2.9) 56 (81.2) 3 (4.3) 2 (2.9) 1 (1.4) 69 (16.8)
West 9 (12.3) 5 (6.8) 55 (75.3) 0 (0) 3 (4.1) 1 (1.4) 73 (17.8)
Southeast 16 (6.7) 18 (7.5) 190 (79.5) 10 (4.2) 2 (0.8) 3 (1.3) 239 (58.2)
Goals
Specific goals 24 (7.6) 19 (6.0) 253 (80.1) 11 (3.5) 5 (1.6) 4 (1.3) 316 (81.4)
Not goals 4 (5.6) 7 (9.7) 57 (79.2) 3 (4.2) 0 (0) 1 (1.4) 72 (18.6)
Frequency of training
1 time/wk 3 (16.7) 1 (5.6) 13 (72.2) 0 (0) 1 (5.6) 0 (0) 18 (4.4)
2 times/wk 1 (3.8) 2 (7.7) 22 (84.6) 0 (0) 0 (0) 1 (3.8) 26 (6.3)
3 times/wk 11 (17.2) 2 (3.1) 44 (68.8) 3 (4.7) 1 (1.6) 3 (4.7) 64 (15.6)
4 times/wk 4 (8.9) 4 (8.9) 35 (77.8) 2 (4.4) 0 (0) 0 (0) 45 (10.9)
5 times/wk 12 (6.3) 12 (6.3) 155 (81.2) 9 (4.7) 3 (1.6) 0 (0) 191 (46.5)
6 times/wk 2 (15.4) 2 (15.4) 9 (69.2) 0 (0) 0 (0) 0 (0) 13 (3.2)
7 times/wk 0 (0) 4 (12.9) 25 (80.6) 0 (0) 2 (6.5) 0 (0) 31 (7.5)
Other 2 (8.7) 2 (8.7) 17 (73.9) 1 (4.3) 0 (0) 1 (4.3) 23 (5.6)
Physical therapist present
Every other week 0 (0) 0 (0) 22 (95.7) 1 (4.3) 0 (0) 0 (0) 23 (5.6)
1 time/wk 14 (9.4) 9 (6.0) 118 (79.2) 4 (2.7) 1 (0.7) 3 (2.0) 149 (36.2)
2 times/wk 13 (11.6) 8 (7.1) 82 (73.2) 4 (3.6) 5 (4.5) 0 (0) 112 (27.2)
3 times/wk 4 (9.3) 6 (14.0) 30 (69.8) 2 (4.7) 0 (0) 1 (2.3) 43 (10.4)
4 times/wk 1 (20.0) 0 (0) 4 (80.0) 0 (0) 0 (0) 0 (0) 5 (1.2)
5 times/wk 0 (0) 0 (0) 6 (100.0) 0 (0) 0 (0) 0 (0) 6 (1.5)
Other 3 (4.1) 6 (8.1) 60 (81.1) 3 (4.1) 1 (1.4) 5 (1.2) 74 (18.0)
Education
PT 23 (8.7) 16 (6.1) 210 (79.5) 11 (4.2) 2 (0.8) 2 (0.8) 264 (63.8)
PT + specialist/MSc/PhDa 12 (8.0) 13 (8.7) 113 (75.3) 4 (2.7) 5 (3.3) 3 (2.0) 150 (36.2)
Specialist 118 (28.5)
MSc 65 (15.8)
PhD 6 (1.5)
Position
Treatment 30 (8.6) 27 (7.8) 268 (77.2) 11 (3.2) 7 (2.0) 4 (1.2) 347 (84.4)
Not treatment 4 (6.3) 2 (3.1) 53 (82.8) 4 (6.3) 0 (0.0) 1 (1.6) 64 (15.6)
Supervision 39 (9.5)
Education 3 (0.7)
Research 1 (0.2)
Other 21 (5.1)
Experience
0-9 y 6 (7.2) 5 (6.0) 70 (84.3) 2 (2.4) 0 (0) 0 (0) 83 (20.0)
10-19 y 12 (8.3) 6 (4.2) 118 (81.9) 7 (4.9) 0 (0) 1 (0.7) 144 (34.8)
20-29 y 10 ( 9.1) 9 (8.2) 84 (76.4) 2 (1.8) 4 (3.6) 1 (0.9) 110 (26.6)
30-39 y 5 (8.3) 5 (8.3) 43 (71.7) 2 (3.3) 2 (3.3) 3 (5.0) 60 (14.5)
>39 y 2 (11.8) 4 (23.5) 8 (47.1) 2 (11.8) 1 (5.9) 0 (0) 17 (4.1)
aMultiple categories allowed. The Fischer exact test showed no differences in frequencies of the PT approaches according to the setting of specific goals, educational level, and type of position (not possible to conduct in the other cross-tabulations).

Procedure

Part I

To gain an overview of the PT approaches currently in use in Norway, all physical therapists attending the CP conference in 2019 were given a questionnaire and anonymously asked to answer 2 questions:

  1. What do you call the physical therapy approach you use when treating children with cerebral palsy whose goal is to learn a gross motor skill?
  2. Other approaches you sometimes use?

If they did not work directly with children, they were asked to name the approach they would recommend.

Part II

A web-based questionnaire (Questback) was developed on current PT practices based on the categories of approaches from part I.

Outcome Variable

On the first question (What is your main approach when treating a child with CP whose goal is to learn a gross motor skill?), we listed 6 categories (5 approaches and “other”) and only 1 response was allowed. When answering the second question (If you use more than 1 approach, name additional approaches here), multiple categories were allowed. The 6 categories were included in the descriptive analyses. To investigate the probability of using functional training based on principles of motor learning, the outcome variable was dichotomized as functional training based on principles of motor learning or other approaches.

Supplementary Information

Health region: collected as 4 categories corresponding to the 4 health regions of Norway. The 4 categories were used in the descriptive and inferential analyses.

Type of position: collected originally in 5 categories and dichotomized as having a position of treating the children directly or not treating the children directly for all analyses.

Level of education: collected as 4 categories and dichotomized as being a physical therapist (BSc) or having additional education for all analyses, as multiple categories were possible in the original variable.

Therapist's years of experience: collected on a scale and transformed into 5 categories for all analyses.

Whether specific goals for treatment usually were set: collected and used as a dichotomous variable in all analyses.

Frequency of training: collected as in 8 categories, which included in all analyses.

Frequency of physical therapists' presence: collected as in 7 categories, which were used in all analyses (Table 1).

A limited number of physical therapists pilot-tested the questionnaire and we made minor changes. The Norwegian Association of Physiotherapists subgroup for pediatric physiotherapy distributed the questionnaire through e-mail on November 1, 2019, with 2 reminders 1and 2 weeks following. The first author posted several requests to participate on a closed community on social media before, during, and after the e-mails were distributed. The e-mail list was not available to the researchers and therefore the answers were anonymous.

Data Analysis

Part I

Inductive content analysis was used to create categories of PT approaches. Two experienced physical therapists (authors) aggregated the descriptions to categories of PT approaches, with reference to the ICF. An experienced physical therapist not otherwise involved in the research project did the same. Thereafter, the 3 physical therapists discussed the categories until consensus was reached. Furthermore, the 3 physical therapists included missing categories based on both experience and literature and they ensured that one of the categories was in accordance with the best practice recommendations of functional approaches based on motor learning theory.

Part II

Sample size was calculated using an online sample size calculator (https://www.masc.org.au/stats/PowerCalculator/PowerChiSquare), for which we anticipated a power of 0.8, a medium effect size of 0.3, a significance level of .05, and 15 degrees of freedom (a 4×6-contingency table). To reach significance, a sample size was required of a minimum of 210 participants.

We used descriptive analysis for frequencies of the PT approaches and the Fisher exact test to examine whether there were differences in frequencies of the PT approaches according to the setting of specific goals, educational level, and type of position. For the remaining cross-tabulations, it was not possible to report the results of the Fischer exact test because the computational effort needed exceeded the limits provided by standard computers.

We used logistic regression to investigate whether any factor was associated with using functional training based on principles of motor learning as the method of choice.

This study was approved by the institutional research board of the Nord-Trondelag Hospital Trust.

RESULTS

Part I

In the responses to the questions, “What do you call the physical therapy approach you use when treating children with cerebral palsy whose goal is to learn a gross motor skill?” and “Any other approaches you sometimes use?” some participants gave the name of the approach. However, most participants reported the various elements of their practice. Examples of typical answers and how the answers were categorized are in Table 2. To avoid misunderstandings, some descriptions were included in parenthesis.

TABLE 2 - Examples of Names or Elements of an Approach and Final Categories of PT Approaches
Examples of Physical Therapists' Descriptions of Practice Categories of PT Approaches
Strength, coordination, and mobility training
Strength training
Balance training
Stability training
Positioning
Aerobic training
Stretching
Training of body functions and structures
(mobility/stretching, strength, fitness, balance, and stability)
Sensorimotor stimulation
Weight-bearing on affected side
Guiding in positions and mobility
Facilitation
Working for selective movements
Manual stimulation of posture and movements
(facilitation, guided active movements, and weight-bearing)
Functional training
Activity-based stimulation
Goal-directed skills training
Task-oriented training
Intensive, goal-directed, functional, specific, active
Goal-directed, activity-based, focused
Goal-directed functional training of self-prioritized skills, ADL activities
Supervision in learning functional skills
Functional training based on principles of motor learning
(goal-directed functional training, task-oriented training, and skill
training)
Customize equipment
Change the context
Supervision in preparation for participation assistive devices
Addressing environmental factors
(equipment, assistive devices, and context modifications)
Bobath, Vojta, Dynamic Neuromuscular Stabilisation Conceptual methods
(Bobath/NDT, Vojta, PETØ, Doman/Family Hope, Kosiavkin, Sensory
Integration)
Abbreviations: ADL, activities of daily life; PT, physical therapy.

Some reported the intensity only (intensive PT), the setting only (home program), or nonspecific answers such as “ordinary PT.” Such answers were not included in categories.

Part II

The majority of the physical therapists reported that their main approach when treating children with CP whose goal was to learn a gross motor skill was functional training based on principles of motor learning. A few used training of body functions and structures or manual stimulation of posture and movements as their main approach (Figure 1 and Table 2).

Fig. 1.
Fig. 1.:
Main approaches used by physical therapists when treating children with cerebral palsy whose goals were to learn gross motor skills. This figure is available in color online (www.pedpt.com).

Most of the physical therapists reported that they supplemented their main approach with multiple other approaches. However, very few used conceptual methods (Figure 2).

Fig. 2.
Fig. 2.:
Supplementary approaches used by physical therapists when treating children with cerebral palsy whose goals were to learn gross motor skills (multiple answers allowed). This figure is available in color online (www.pedpt.com).

There was little variation according to the independent variables (Table 1). However, there was a statistically significantly difference between the Northern Health Region and the Southeast Health Region regarding the probability of using functional training based on principles of motor learning as the main approach. The physical therapists with most experience had less probability of using functional training based on principles of motor learning compared with the physical therapists with less experience. There were no other associations (Table 3).

TABLE 3 - Unadjusted and Adjusted Odds Ratio for Use of Functional Training Based on Principles of Motor Learning as Main Approach
Unadjusted Associations Adjusted Associationsa
Variable OR (95% CI) P Value OR (95% CI) P Value
Health region
Southeast (reference)
North 0.45 (0.20-0.998) .049 0.35 (0.14-0.86) .02
Central 1.11 (0.56-2.19) .76 1.16 (0.51-2.65) .72
West 0.79 (0.43-1.46) .45 1.01 (0.49-2.11) .98
Experience
0-9 y (reference)
10-19 y 0.84 (0.41-1.75) .65 0.92 (0.40-2.09) .84
20-29 y 0.60 (0.29-1.25) .18 0.57 (0.24-1.33) .195
30-39 y 0.47 (0.21-1.06) .07 0.58 (0.21-1.60) .295
>39 y 0.17 (0.05-0.51) .002 0.14 (0.03-0.59) .008
Abbreviations: CI, confidence interval; OR, odds ratio.
aAlso controlled for setting of specific goals, frequency of training, how often the physical therapists were present, and the physical therapists' education and type of position.

DISCUSSION

The main aim of this mixed-methods study was to investigate whether functional PT approaches based on motor learning theory were implemented among Norwegian physical therapists when promoting gross motor skill acquisition in children with CP.

The results confirm our hypothesis that functional training based on principles of motor learning has been the method of choice among Norwegian physical therapists when treating children with CP whose goals are to learn gross motor skills. The proportion of physical therapists who used functional training based on principles of motor learning as the method of choice in this study was larger than in previous studies,5,23,24 but on the same level as that found by Toovey et al30 when investigating cycling skills. Several authors have suggested that there is a gap between what we know and what we do with regard to the implementation of functional PT approaches based on motor learning theory.5,23,28 However, the results of our study indicate that the gap may be getting smaller.

Our results also confirm that physical therapists use multiple approaches as a supplement to their main approach. This can be understood in the light of systems theory. For example, the physical therapists may identify that a body function is the limiting system for accomplishing a given skill and accordingly intervene at that component. Likewise, a physical therapist may conclude that changing the environment (context) would contribute to successful performance of the skill. The use of manual stimulation may describe the handling of children at GMFCS levels IV and V but may also be neurodevelopmental treatment-inspired treatment.

We were surprised by the very low proportion of physical therapists who used conceptual methods. Bobath/neurodevelopmental treatment has traditionally been used by a large proportion of physical therapists.23 More recent studies have reported that respectively 8% of physical therapists used neurodevelopmental treatment in Australia,30 13% in Canada,5 and as much as 39% used neurodevelopmental treatment frequently in the UK.28 However, our results suggest a fading out of neurodevelopmental treatment and other conceptual methods in their original form in favor of functional training based on principles of motor learning.

An important motor learning principle is the frequency of practice of the goal skill. It is encouraging that more than 50% of the physical therapists reported that the children practiced 5 days per week or more when trying to learn a new gross motor skill (Table 1). However, this means that both parents and assistants in school or kindergarten frequently assisted the children, as most physical therapists were only present 1 to 2 times per week.

The setting of specific goals makes it easier to structure the practice in such a way that it provides specific practice with a high number of repetitions of the goal skill. By setting the goal in close collaboration with the child and/or parents, motivation is also enhanced. Our results indicate that approximately 80% of physical therapists usually set specific goals. However, the probability of using functional training based on principles of motor learning was not related to the setting of specific goals, suggesting that physical therapists use this motor learning principle also when applying other PT approaches.

Strengths and Limitations

The thorough creation of categories in part I of the study ensured that the participants found a category that represented their main approach. The free text in part I and responses following pilot-testing led to the inclusion of some explanatory text in the categories, which further strengthened the chance that the respondents would find a category that represented their practice. Therefore, we would argue that as a whole the results are valid regarding the main question. However, as with all surveys, some misclassifications were possible and there is a chance that the physical therapists report what they ideally would do as opposed to what they actually do.

A strength of the study is the large sample size of 414 physical therapists, which exceeds the number needed as estimated by sample size calculations. A response rate of 65% is considered good. The question still arises as to whether the results can be generalized to the population of physical therapists treating children with CP in Norway. We have no reason to think otherwise regarding the main research question, but results should be interpreted carefully with regard to the possible differences according to health region and physical therapists' years of experience. There were relatively few participants from the Northern Health Region and the response rate for that region was also lower than for the rest of the country (49%). Therefore, the difference might have been due to selection bias. As there were only 17 physical therapists in the group with the most experience, it is even more important to be cautious when interpreting this result.

It is important to keep in mind that the main research question was what approach the physical therapist would use when treating a child with CP whose goal was to learn a gross motor skill, and not a general question about what approaches they used in their practice.

CONCLUSIONS

This study provides an overview of PT approaches used by physical therapists in Norway when treating children with CP whose goals are to learn gross motor skills. The results indicate that functional training based on principles of motor learning has become the method of choice as the main approach, but that most physical therapists use multiple approaches as a supplement to their main approach, although very few used conceptual methods. The results suggest a bridging of the gap between what is known and what is done in practice in this area.

To confirm the results from this survey, we suggest using a design including observation of real practice situations to be the next step.

ACKNOWLEDGMENTS

The authors thank the Norwegian Association of Physiotherapists subgroup for pediatric physiotherapy for distributing the questionnaire to the members, and Tordis Ustad, Specialist in Pediatric Physiotherapy/PhD, for her contribution in aggregating descriptions to categories of physical therapy approaches.

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Keywords:

cerebral palsy; functional training; motor learning; physical therapy

© 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association