Tool Use for Early Detection of Cerebral Palsy: A Survey of Spanish Pediatric Physical Therapists

Abstract

Purpose: 

The purpose of this study was to assess the use of diagnostic assessment tools in pediatric physical therapy practice in Spain. Best practice recommendations indicate the timely use of key assessment tools to reduce the age of diagnosis of cerebral palsy (CP).

Methods: 

Pediatric physical therapists currently working in Spain in early intervention were recruited through targeted physical therapy entities. They were invited to complete the purpose-developed electronic survey, consisting of 45 multiple-choice questions, with 5 thematic blocks.

Results: 

Results from 140 anonymous respondents were analyzed. The average reported age when CP was suspected was 12.6 months. Most used the child's clinical history (88.1%), the Alberta Infant Motor Scale (41.3%), and Vojta Assessment Procedure (32.1%) to assess and detect CP. General Movements Assessment (25.7%) and Hammersmith Infant Neurological Examination (28.4%) were used infrequently.

Conclusions: 

Currently, pediatric physical therapists in Spain rely on clinical history and outdated tools to identify children with CP.

Digital Abstract available at: https://links.lww.com/PPT/A361 (English).

Digital Abstract available at: https://links.lww.com/PPT/A362 (Spanish).

INTRODUCTION AND PURPOSE

With 2.1 cases per 1000 births, cerebral palsy (CP) is the most common childhood physical disability,¹ with the definition encompassing a group of permanent disorders in the development of movement and posture related to injury to the developing brain. Through the application of preventive measures and advances in obstetric and neonatal care, the rate and severity of CP have been decreasing in some countries and may continue to improve with the use of early detection guidelines and protocols.^2–4

A 2017 clinical review on early diagnostic tools included the release of best practice recommendations and calls from the group of international experts that a diagnosis can and should be given early with the timely use of recommended tools.⁵ The diagnosis of CP is typically provided by a physician between 12 and 24 months of age, but in some cases, it can be delayed until 42 months.^6,7 In contrast, the accurate and early use of key tools can allow for a much earlier detection of infants younger than 6 months, with the recommendations allowing for 2 pathways for infants either younger or older than 5 months. For example, for infants entering the pathway younger than 5 months (corrected for prematurity) who have been exposed to known risk factors (commonly newborn-detectable risks), the recommended assessments include magnetic resonance imaging, Qualitative Assessment of General Movements (GMA) or Test of Infant Motor Performance (TIMP), and the Hammersmith Infant Neurological Examination (HINE). Children older than 5 months of corrected age should undergo the following tests: magnetic resonance imaging, HINE and a motor test (such as the Developmental Assessment of Young Children [DAYC]), or the Alberta Infant Motor Scale (AIMS).⁵ Infants entering a high-risk pathway with newborn detectable risks are likely to already be monitored for early neurodevelopmental changes. However, more than half of children who have CP are born full term with uncomplicated births and considered healthy.⁸ As such, delayed or impaired development may not be readily detected and will most likely be identified by community clinicians, such as pediatric physical therapists (PTs). For this group of children, the pediatric PTs could play a key role in conducting assessments and evaluations of an infant to aid in detecting and referring the child for future medical diagnosis. Early detection and monitoring of infants in the community (with appropriate valid and reliable tools) for CP are essential to minimize possible sequelae through timely application of CP-specific interventions.^3,4

Cerebral palsy research in Spain has centered mainly on symptoms or comorbidities associated with CP, with a paucity of epidemiological studies.⁹ Currently, there is no national database or registry, and the concepts of early detection and early intervention are still emerging. One study indicated a range for detection of CP between 1 and 33 months in the Comunidad Foral de Navarra,¹⁰ but very little is known about the current practice with the use of early detection assessment tools or the age of diagnosis of CP in Spain.

The aim of our study was to capture the current state of practice of pediatric PTs for early detection of children at high risk of developing CP in Spain, with a focus on those working with infants younger than 1 year, and to determine the most commonly used assessment tools for the detection of CP.

METHODS

Study Design and Sample

The survey invitation was electronically distributed (between February 14, 2020, and May 1, 2020) to the main representative bodies of Spanish physical therapy such as the Spanish Society of Physical Therapy in Pediatrics (SEFIP), General Council of Physical Therapy Colleges of Spain (CGCFE), Spanish Association of Physical Therapists (AEFI), and the National Conference of Deans of Physical Therapy Faculties (CNDFF). Participants were informed about the objective of the study and provided electronic consent to the anonymous survey. The design of this study and the analytical approach followed established protocols,¹¹ which are based on weighted data to compensate for a lower response rate and thus ensure that the data reflect the true population.

Quality improvement studies used exclusively for the purposes of evaluation, management or improvement of clinical practice, or quality of life are not included in the studies that are subject to the approval of the Clinical Research Ethics Committees.

Survey Design

The survey design was adapted from Williams et al¹² and translated by the researchers into Spanish, adapting these questions to the functions and professional profile of pediatric PTs in Spain. The initial survey development by Williams et al¹² was guided by Burns et al¹³ and included pretesting and clinical sensibility testing to ensure that it met the study objectives. The Spanish version of the survey was piloted by several pediatric PTs, external to the research team, to ensure understanding of the text by future participants and distributed electronically through the Google Forms software.

The survey included a total of 45 multiple-choice questions, with different thematic blocks: 10 questions on therapists demographic data (eg, autonomous community, education, and years worked in the field), 12 questions on CP diagnosis during the first 2 years of life in their clinical practice, 9 questions on the use of neurological and motor rating scales, 4 questions on knowledge of the optimal scores of neurological assessments and motor skills, and 10 questions on the use of referral protocols and follow-up of the high-risk child (see Supplemental Digital Content 1, available at: https://links.lww.com/PPT/A363).

Analysis

The descriptive analysis was means of percentages and frequencies. The analysis was completed with R V4.0.3, R Core Team 2020 to verify the possible association between variables. It was determined to use Pearson's χ² test, using a statistical significance of P value of less than .05.

For data that were not appropriate for Pearson χ² test (ie, when the expected frequencies were <5), Fisher exact test was used. Where a statistical significance of P value of less than .05 was estimated, Cramer V was added to measure the strength of association between variables. Cramer V varies between 0 and 1, and its interpretation is of weak association with value of 0.2 and less; moderate association with value of 0.2 or 0.6 and less; and a strong association when Cramer's V is greater than 0.6.

Both the percentage of participation and the calculation of the use of detection tools were calculated using the relationship between the respondents and the total possible number of PTs targeted by this survey. The following classification was used to determine the level of use of detection tools (GMA, TIMP, HINE, DAYC, AIMS, NSMDA, and MAI): low (<25%), medium (between 25% and 75%), high (>75%).¹⁴

RESULTS

Demographic Data

Of 140 surveys completed, 109 stated that they provided intervention for infants younger than 1 year. Demographic data indicated a high percentage of female PTs (85%); mean age was 35.5 years for women, 36.0 years for men, and 35.6 years for the total sample. A representative sample of the Spanish state was obtained, leaving 2 autonomous communities as well as 2 autonomous cities without participation (Figure 1). The survey represented an estimated sample size of 17.9% of the total^15,16 number of pediatric PTs who work in early intervention and are involved in early detection processes; a low number of participants.

Fig. 1.: Distribution by autonomous communities and tools use. The percentage of participation and the use of the detection tools by communities. CC AA indicates autonomous communities.

The highest percentage (35.7%) of participants had a basic degree in physical therapy, followed by an official master's degree in pediatric physical therapy or early childhood intervention (19.3%) and doctorate degree (5.7%) (Figure 2). Almost half (49.9%) of the total participants were members of a scientific society.

Fig. 2.: Percentage of academic degree. EI, early intervention; Other, postdegree (n = 9), monographic courses (n = 2), pediatric expert (n = 2); PT, physical therapy.

The majority of participants (62.9%) carried out their clinical work in the child development and early intervention centers; 58.6% had worked less than 10 years with children younger than 6 years.

Clinical Practice: Evaluation Processes

Responses were that 59.3% of the participants had less than 50% of their workload consisting of children with CP and only 77.9% (n = 109) worked with children infants than 1 year (Figure 3). Respondents were asked to approximate the age when their patients were referred to a specialty physician to receive a diagnosis of CP, with an average age of 12.6 months, and 61.4% indicating this referral age to be when the infant was younger than 12 months. In the event that during the daily clinical practice of the pediatric PTs a child at high risk of CP was identified, only 34.3% indicated that they had a clear protocol for referral to a medical specialist. The most common referrals were to a child neurologist (38.2%), a pediatrician (24.7%), and a pediatric physiatrist (15.4%).

Fig. 3.: Approximate percentage of workload spent working with children with cerebral palsy. CP indicates cerebral palsy.

When all PTs (n = 140) were asked whether they were familiar with the GMA and HINE in relation to it aiding in the diagnosis of CP, 57 (40.7%) were familiar with GMA and 58 (41.4%) with HINE.

Physical therapists who worked with infants younger than 1 year (n = 109) were asked which evaluation tools, from a provided list,⁵ they used to aid in the detection of CP, and how often they currently used these tools in practice. Most indicated that they used the child's clinical history (n = 77, 70.6%), AIMS (n = 61, 56%), and Vojta Assessment Procedure (n = 50, 45.9%). For frequency of tool use (ie, how often they used to the tool) to detect CP, the clinical history (n = 96, 88.1%), AIMS (n = 45, 41.3%), and Vojta Assessment Procedure (n = 35, 32.1%) were most frequently used. The GMA and HINE were “never” used by 62.4% (n = 68) and 59.6% (n = 65) of PTs, respectively (Table 1). The respondents reported that they did not use these tools because of “lack of training” for GMA (n = 69, 63.3%) and HINE (n = 62, 56.8%), even though 43 (30.7%) and 44 (31.4%) of the PTs reported to have been formally trained in GMA and HINE, respectively. Other reasons for nonuse of GMA and HINE are shown in Table 1. The common enablers and barriers to implementing new assessment tools identified by the PTs are reported in Table 2. However, the PTs reported that they knew the optimal scores for the tools despite not attending any official courses (AIMS score aware: n = 90, 64.3%, HINE: n = 49, 35.0%, GMA: n = 46, 32, 9%, and TIMP: n = 16, 11.4%). The frequency of use of early detection tools for the detection of CP in infants younger than 1 year by PTs across Spain by autonomous communities is graphed in Figure 1.

TABLE 1 - Frequency of Use of Assessment Tools

Children Younger Than 1 y (N = 109)
Frequency	Usually (%)	Sometimes (%)	Never (%)
AIMS	41.3	29.3	29.3
ASQ	16.5	13.8	69.7
BSID	12.8	19.3	67.9
DAYC	0.9	3.7	95.4
Dubowitz	0.0	2.8	97.2
HINE	28.4	11.9	59.6
Clinical history	88.1	8.3	3.7
MAI	0.9	11.9	87.2
NSMDA	0.9	3.7	95.4
GMA	25.7	11.9	62.4
Vojta	32.1	27.5	40.4
TIMP	2.8	11.0	86.2
Touwen	0.9	2.8	96.3
Other	15.6	26.6	57.8
Reasons for Responding “Nonuse” of (Responders Could Select Multiple Answers)
GMA		HINE
Not trained, n = 69 Not familiar, n = 14 Lack of resources, n = 13 Out of my practice, n = 9 Not age appropriate, n = 5 Too much time to assess, n = 4 Training is too expensive, n = 1 Unsure about its effectiveness, n = 2 My center does not accept, n = 2 Limited experience with this tool, n = 2 Lack of professionals, n = 1 Late referral, n = 1 Other better tools, n = 1 Other, n = 5		Not trained, n = 62 Not familiar, n = 18 Lack of resources, n = 11 Out of my practice, n = 6 Too much time to assess, n = 5 Unsure about its effectiveness, n = 3 Limited experience with this tool, n = 2 Not age appropriate, n = 2 Lack of professionals, n = 1 Other better tools, n = 1 My center does not accept, n = 0 Training is too expensive, n = 0 Other, n = 3

Abbreviations: AIMS, Alberta Infant Motor Scale; ASQ, Ages & Stages Questionnaires; BSID, Bayley Scale of Child Development; DAYC, Developmental Assessment of Young Children; Dubowitz, Dubowitz Neurological Assessment; GMA, assessment by means of Prechtl's general movements; HINE, Hammersmith Infant Neurological Examination; MAI, Motor Assessment of Infants; NSMDA, Neuro Sensory Motor Development Assessment; Others, Assisting Hand Assessment, Brunet-Lézine Scale, Gross Motor Function Classification System, Gross Motor Function Measure, Harrison Infant Neuromotor Test, Early Attention Development Inventory, Measure of Engagement, Independence, and Social Relationships, Haizea-Llevant Development Chart, Assessment Le Métayer's Global, Normal Movement Assessment Based on Bobath Neurodevelopment; TIMP, Test of Infant Motor Performance; Touwen, Touwen Infant Neurological Examination; Vojta, Vojta Assessment Procedure.

TABLE 2 - Physical Therapists Identified Enablers and Barriers to the Implementation of New Assessment Tools

System Factors
Enablers (n = 7)		Barriers (n = 90)
Time and Funding (n = 7)		Time, Workload, and Staffing (n = 46)
Allocated time and funding for upskilling	“Several opportunities for scholarships.”—ID 114 “My service supports me in terms of attending trainings.”—ID 73 “I have days given for training.”—ID 50	Lack of time for updating, training/heavy caseload	“Limited training hours.”–ID 66 “Difficulty in training due to lack of time and financial resources.”—ID 5
		Lack of time to conduct standardized assessments even when have training	“The main barrier is time for administering the assessments.”—ID 70 “Short session time ....”—ID 40 “Inflexible schedules.”—ID 2
		Understaffed	“Lack of resources and staff.”—ID 23
		Funding (n = 28)
		Lack of funding to attend relevant training	“Cost of training ....”—ID 35 “Economic difficulties to access training ....”—ID 5
		Personal cost to attend training	“Financial issues/no permission to attend trainings during working hours.”—ID 14
		Referral and Health Pathways (n = 16)
		Long waitlists Need for screening and referral guidance Changes/lack of standardized pathways Referral to other therapists (nonphysical therapists)	“Long time to referral ....”—ID 99 “The single referral center, XXX, takes a long time to refer us the families.”—ID 111 “It would be useful to have red flags.”—ID 100 “Continuous changes in service protocols.”—ID 56 “... referral to other therapists, non-physical therapists.”—ID 17
Social Factors
Enablers (n = 37)		Barriers (n = 30)
Management/Staff and Administration (n = 9)		Management/Staff and Administration (n = 12)
Management support for best practice and continued improvement	“Service management.”—ID 77 “Manager open to participate.”—ID 15	Lack of management support	“"Everything has to be approved by the board.”—ID 51 “Lack of support from service manager.”—ID 38
		Noncollaborative attitudes	“There is no collaboration with the Health Care System.”—ID 78 “Lack of coordination with the Health System.”—ID 84
		Resistance to change	“... a change of mentality is needed.”—ID 113
		European and Spanish policies	“Spanish Official Data Protection Law.”—ID 44
Multidisciplinary Teamwork (n = 28)		Multidisciplinary Teamwork (n = 18)
Collaborative teamwork	“Collaborative colleagues.”—ID 36 “Other therapists from my service.”—ID 12	Noncollaborative teamwork	“We are following the guidelines of the rehab specialists.”—ID 46 “The rest of the team don't understand my proposals.”—ID 16
Share knowledge learnt and experiences	“The experience of my colleagues.”—ID 62	Practices developed within the team	“Family-centered practices, when developed, is a barrier.”—ID 116 “More training on family-centered practices is needed within the team.”—ID 79 “They just do neurodevelopmental treatment (NDT).”—ID 45
Social Factors
Enablers (n = 37)		Barriers (n = 30)
Multidisciplinary Teamwork (n = 18)		Multidisciplinary Teamwork (n = 18)
Peer review, support, and supervision	“Our peer-to-peer sessions.”—ID 4	Not recognized pediatric physical therapy specialty	“Pediatric physical therapist is not very widespread.”—ID 98 “I cannot just do pediatrics ....”—ID 97
Coordination among physical therapists	“Support among physical therapists.”—ID 108 “Coordination among team's physical therapists.”—ID 84	Poor communication within/between services Hierarchical structure	“Lack of indirect service time and coordination within the service.”—ID 87 “The hierarchy, ....”—ID 80
Health Professional Knowledge and Perceptions
Enablers (n = 36)		Barriers (n = 22)
Health Professional Knowledge (n = 22)		Health Professional Knowledge (n = 21)
Accessible education and continued professional development	“Specialized training.”—ID 90 “Attending to external courses.” ID—29 “Use of different apps, social networks and being connect to the field of pediatrics.”—ID 7	Health professional's knowledge of assessment tools	“Lack of external organization of trainings.”—ID 9 “ ... difficult access to the assessment tools.”—ID 35 “Assessment tools need a specific training.”—ID 53
Knowledge sharing	“Internet/work groups on the topic.”—ID 88
Guidelines and Clinical Pathways (n = 9)
Development of guidelines and clinical pathways	“Latest research.”—ID 138 “Guidelines' development.”—ID 78
Evidence-based assessment tools for early detection	“The use of assessment tools.”—ID 86
Health Professional-Patient Communication (n = 4)		Health Professional-Patient Communication (n = 1)
Provide more information to patients	“More information to families.”—ID 25	Mismatched health professional and patient involvement/expectations	“Lack of families' involvement.”—ID 102
Patient Tailored Care (n = 1)
Tailored outcomes	“Tailored and objective results.”—ID 136
Internal Drive		Clinical Considerations
Enablers		Barriers
Self-Driven/Self-Initiated (n = 13)		Case Variability and Complexity (n = 1)
Self-driven/self-initiated and autonomy	“Autonomy within my service.”—ID 81 “I can make my own decisions freely.”—ID 21	Clinical variability of cases	“I have different patient groups ....”—ID 127
Energy and drive functions	“My interest in it.”—ID 60 “My own motivation.” —ID 54 “My level of motivation.”—ID 14	Physical Possibilities (n = 7)
		Lack of adequate space/materials	“Lack of adequate space.”—ID 60

The age of the PTs was associated with the tools used for the detection of children with CP, with a moderate relationship with the Bayley Scale of Child Development-III edition (BSID3) (moderate association, V = 0.33) and with GMA (moderate association, V = 0.36). The age of the PTs was also moderately associated (moderate association, V = 0.36) with the use of BSID3, the tool most used with children with CP.

The number of years worked by the PT had a moderate association (V = 0.26) with the mean age of prognosis or diagnosis of CP, as well as frequency of use of tools for the detection of children with CP (moderate association for Ages & Stages Questionnaires—ASQ, V = 0.31; BSID3, V = 0.30; TIMP V = 0.33), with the use of tools for the evaluation of children with CP (moderate association for ASQ, V = 0.36; BSID3, V = 0.46; other tools V = 0.33) and with training in the TIMP assessment (moderate association, V = 0.33).

There is a relationship between academic training in certain tools such as DAYC (moderate association, V = 0.48) and AIMS (moderate association, V = 0.36). In addition, there is a moderate association (V = 0.36) with no training in any of the tools proposed in the survey questions. Another relationship that was found in this study was the lower mean age of reported diagnosis and the use of GMA with a moderate association (V = 0.26).

DISCUSSION

Recent evidence for the timely use of key diagnostic tools supports that the age of diagnosis can be below 12 months¹⁷ and closer to 5 to 6 months,⁵ with the triangulation of GMA, HINE, and neuroimaging providing early and accurate predictions of the medical diagnosis.¹⁸ In the absence of a national CP registry in Spain, accurate data on the age of CP diagnosis in Spain are unavailable, making benchmarking and comparison with outcomes from other countries difficult (eg, the Australian CP Register report that 26% of children receive a diagnosis at 6 months of age¹⁹). Although, based on PT responses to the current survey, it appears that some children with CP in Spain are being identified or referred for a diagnosis of CP before 12 months of age in the community setting, there are clear opportunities for improvement.

The use of the recommended (strongly recommended on the basis of moderate-high-quality evidence⁵) assessment tools for the detection of CP, the GMA and HINE, by PTs in Spain is low. Physical therapists reported that they infrequently used valid and reliable assessment tools to detect CP including the GMA (25.7%) and the HINE (28.4%). The tools most used by PTs in Spain for the early detection of children with CP were the medical history, AIMS, and Vojta Assessment. The AIMS (86% predictive of an abnormal motor outcome) is recommended as an additional assessment within pathways for CP detection (conditional recommendation based on low-moderate quality evidence)⁵; the Vojta Assessment procedure has neither established validity nor reliability and is not included within the international recommendations for detection of CP. The use of a child's medical records or clinical history seems to be a common approach from health professionals in other countries such as the United States (55%²⁰) and New Zealand (87%¹²). A review of the child's medical history can aid with CP identification when combined with valid and reliable tests.^6,21 Yet for Spain, PTs rely almost exclusively on the child's medical history, signs, and symptoms without the addition of the recommended tools. In the absence of use of recommended valid and reliable tools, early signs of CP should continue to be recognized and valued to promote early referral for diagnostic evaluation¹²; yet, increased awareness on which early clinical signs to watch for (eg, a persistent head lag beyond 4 months of age, inability to sit independently beyond 9 months of age, hand preference before 12 months of age^5,22) may be beneficial, particularly by health, child care, and education professionals based within community settings.

Use of the 2 recommended tools for the identification of CP in Spain compared with New Zealand (a study of similar methodology) indicates a higher use of the GMA (26% vs 15%) and a lower use of the HINE (28% vs 40%)¹²; however, these results may not be generalizable due the low number of participants in our study. While there is strong evidence for the use of these tools in aiding early detection^5,18 and providing prognostic value for the diagnosis of CP, the use of assessments of the motor development is also favored by therapists to provide further prognostic value within their assessments. Similar to Mendoça et al,²³ therapists in Spain commonly opted to use the BSID3 and the AIMS for motor evaluation of children with CP,²³ using at least one of the recommended tools to detect children with CP in the pathway for children older than 5 months.⁵ It is important here to note that though the focus of this survey was to capture the use of assessment tools for the detection of CP, the use of more generalized assessments such as the BSID3 and the AIMS (both having value in determining abnormal development) can aid in the broader screening for risk of all neurodevelopmental impairments or delays. There appeared to be low use of initial and eligibility screening tools such as ASQ, which means that a high number of children at risk of motor or neurodevelopmental issues (including those other than CP) may currently be overlooked in the community for follow-up assessment and intervention. Therapists with more years of clinical experience appeared to have more frequent use of valid and reliable tools, perhaps indicative of a greater level of skills and expertise; however, this also revealed a risk of disparity in practice across the profession. Providing a consensus practice approach to health care provision may help reduce potential variability and inequity in practice, as well as provide guidance and support for therapists in their decision making.

Future Directions

Currently, there is no consensus approach or practice guidelines supporting health professionals in the screening and detection of CP in Spain. The first step to accelerate change may be to initiate a network of interested pediatric allied health professionals across Spain, or a task force to work together to develop the consensus practice guidelines, and support education and training. The international recommendations presented by Novak et al⁵ provide a strong foundation for which tools (and their timing) could be used and may indicate where more awareness, training, and support for their use may be indicated in Spain. Importantly, these recommendations by Novak et al clearly outline the strength of each recommendation, along with the level of the quality of evidence of each.

Based on outcomes of our survey, there may also be a need for more education and support for PTs in Spain to not only implement evidence-based assessment tools but also avoid the use of traditional tools that are not recommended, such as Vojta Assessment, NDT's Assessment, Haizea-Llevant Development Chart, or Le Métayer's Assessment. Practice guidelines may also benefit from the inclusion and guidance around early intervention. The current wait for admittance into a free early intervention program may be up to 2 years in some regions. Without timely evidence-based intervention, we risk a reduction in function and outcomes.²⁴ In efforts to reduce disparity in practice, consensus practice guidelines must be developed with and accepted by all professionals who work with children with CP, where evaluations and follow-up appointments are scheduled in ways that support the practitioner's schedule (usually every 6 months). In this way, Byrne et al²⁵ carried out a protocol where HINE, GMA, and TIMP would be used at 3 to 4 months of age; HINE and AIMS at 6 months; and HINE and BSID3 during 9 to 12 months.²⁵ In this sense, throughout a network of 5 US high-risk infant follow-up programs, they managed to reduce the age of diagnosis of high-risk children from 19.5 months to 9.5 months of age in 1 year of implementation.¹⁷ A similar protocol could be developed in Spain, increasing training in the 2 assessment tools with the higher evidence support, GMA and HINE, and facilitating mentorship and peer review between therapists to support the use and interpretation of such tools in practice (beyond training). In relation to the implementation for the use of GMA, it has been shown that by conducting accredited training courses by several people from the services as well as the systematic recording of videos of children at risk and their subsequent analysis in group, at-risk infants can be accurately detected by their atypical movement.^26,27 While for the implementation of the HINE, only a brief amount of training is needed, including explanations of HINE item administration, scoring—including optimal scores—and demonstrations.²⁸ To this end, different institutions have sponsored free and low-cost Web-based training in GMA, HINE, AIMS, and other assessments focused on the family system to ensure that Spain continues to progress toward the recommendation set in the current guidelines.⁴ Further education opportunities for PTs in Spain could have increased research through the Spanish Association of PTs, the provision of online education modules for continuing professional development points, the provision of local education opportunities such as symposiums, and also linking therapists to opportunities for participation and membership with professional childhood academic societies such as the European Academy of Childhood Disability or the International Alliance of Academies of Childhood Disability.

Limitations

Outcomes from this study are limited by the low participation in the survey by pediatric PTs working within the neonatology and early intervention teams. Therefore, it was difficult to generalize our results about the global state of early detection within the pediatric PT population. There was also low participation in specific autonomous communities, making comparisons across regions difficult. Another limitation of this study was that this survey was aimed at pediatric PTs in Spain, so it was a minimally representative sample of all professionals who are involved in the early detection of children with CP. Future studies may choose to include neonatologists, pediatricians, and neurologists to capture a wider scope. It would be highly recommended to conduct a larger-scale survey to obtain global data, including all professional profiles related to the prognosis and medical diagnosis of CP.

CONCLUSIONS

In Spain, pediatric PTs play an important role in the detection of CP of children seen within the community. However, current data indicate a low use of key assessment tools recommended as best practice to aid in the early detection of CP in Spain. Spanish PTs completing the survey appear to rely heavily on the child's medical history, clinical signs, and outdated assessment tools, with low use of HINE and GMA (partly due to the low number of therapists trained). Therapists around the world have been challenged to make better use of resources (time and money) by focusing on the best evidence tools (GMA and HINE) and limiting use of other assessment tools for this purpose not included in the international guidelines. Although initial steps in facilitating this shift center around education, raising awareness and training in the use of best evidence tools, it is possible that the addition of a structured national approach would help earlier detection of CP in Spain.