The present study is the first to describe the broad spectrum of children referred to physiotherapy during one year in a primary health care setting in Norway. As expected, the children were heterogeneous in terms of age and cause of referral. Most were referred from child health care centres for concerns regarding motor development, asymmetry or orthopaedic conditions (including concerns for foot alignment), even though most parents reported that the problem for which their child was referred had little or no influence on their daily activities. There was a large overlap between cause of referral and the PT’s functional diagnosis when it came to motor development and asymmetry, but more than half of the children referred for orthopaedic conditions were classified as having normal findings by the PT. By far the majority achieved or partly achieved their main treatment goal and the treatment was carried out as planned.
Strengths of the present study were the systematic data collection of children receiving primary care physiotherapy services, the inclusion of parent-report, and follow-up registration of goal attainment and treatment compliance. Only 21.4% of the all children referred to primary care physiotherapy in the 12-month period was included. Reasons for not including children were mainly lack of parental consent or the PT not being able to reach the parents (for children in kindergarten or school). Initially, parental consent from both parents was required. However, we experienced that this was sometimes logistically challenging, and after six months of data collection we sought ethical approval to obtain written consent from one of the parents, given that the other parent also received written information about the project. Furthermore, the PTs had ethical concerns about including families with high burden of care and there were language barriers for non-Norwegian speaking families. Even though consent forms were available in Norwegian and English, parent-report questionnaires were available in Norwegian only. Nevertheless, we have previously reported that sex and age distribution as well as cause of referral of the children included in FYSIOPRIM were comparable to those not included (12). Moreover, given that we included new referrals, it is likely that there were few children in need for habilitation services in our material. As these children are usually followed for a long period of time, they constitute a substantial part of the physiotherapy services for children, which was not reflected in this study. There was a considerable proportion of children without follow-up data. Assessment of goal attainment and treatment compliance was not relevant for children with examination only. Furthermore, we did not find baseline differences for most demographic and clinical variables between those with and without follow-up data, but a larger proportion of children referred for orthopaedic concerns and school children had missing follow-up data, and thus we need to be cautious if drawing conclusions about these subgroups. The fact that we have follow-up data on more preterm children and children with hospital consultations the last 12 months, may indicate that our outcome results are more likely to be underestimated than overestimated, as these may be among the most vulnerable groups of children.
Children receiving physiotherapy were mostly young children aged 0–6 years, and half of the referred children were infants below the age of one year. Half of the children were referred to physiotherapy from child health care centres. In the recent years, the Unit for Physiotherapy Services in Trondheim Municipality has developed guidelines for the most common reasons for referral; i.e. infant asymmetry, in-toeing, flatfoot and toe walking (13–17). This effort was made to reduce the number of referrals that we experienced were typically developing children, so that the services could prioritise children in need of treatment. Furthermore, Trondheim Municipality has implemented a joint group consultation by PTs and public health nurses for parents and their infants at age four months. In these group consultations, the PTs address typical motor development by emphasising that every child is developing at their own pace and by illustrating how development may be affected by several factors within the child as well as the interplay between the child, the activities that the child do and environmental factors (18). We experienced these joint consultations as a way of communicating and transferring information between professionals enhancing interprofessional collaboration.
The present results showed that only examination or one consultation with the PT was enough for about one third of the included children. This may indicate that we have not totally succeeded in reducing the number of unnecessary referrals. Also, the fact that the parents reported that their child was little affected by the problem may point in the same direction and question the rationale for referral. However, the latter result may be inherent in the cause of referral and the children’s young age as most infants with asymmetry are for instance not in any pain, and the problem may not (yet) be affecting their daily life. However, an examination and reassuring of parents could still play an important role and prevent other attempts to get help or reassurance from other health care providers. It also fits well with the goal that the primary health care services should provide low threshold services (2). Nevertheless, one cannot rule out that an even closer collaboration between the PTs and the public health nurses may prevent some of these referrals. In Sweden, there is an example of implementation of a screening tool to support the nurses in clinical decision making regarding when to be concerned about motor development (5). In our study, there was a great overlap between referral causes and the PT’s functional diagnoses regarding concerns for motor development and asymmetry, indicating that different professionals in Trondheim Municipality evaluate these conditions similarly. In contrast, more than half of the referrals regarding concerns for foot alignment were classified as having normal findings by the PT. One explanation for this over-referral may be that these cases are more difficult to evaluate for the nurses and they may lack sufficient knowledge. For most foot alignment cases there is no conservative treatment to offer, but simply to observe over time and expect the condition to resolve spontaneously as the child grows older (14–16). Implementing this knowledge regarding the natural course of foot alignment among public health nurses may be a way of reducing the observed over-referrals. In Norway, there is currently a shift towards more group consultations and less individual appointments according to the updated guidelines of November 2019 for the public health care programme for children aged 0–5 years (2). Group consultations are carried out at four weeks, five months and 17–18 months of age, of which the first two may involve a PT, and at ages five, eight and 10 months, group consultations are optional. These group consultations could provide a setting for building trust, quality of relationships and collaboration between professionals, factors which are identified as key characteristics of knowledge transfer and exchange in health care (19, 20).
Of the children where physiotherapy was initiated, about 70% had six or less consultations during the six-month period. Despite the relatively low frequency of consultations, most children either achieved or partly achieved their main treatment goal, and the treatment was carried out as planned. The relatively low frequency of physiotherapy is consistent with the current notion that physiotherapy for children should be family-centred (21) and an integrated part of the child’s daily activities at home, kindergarten or school. It is also consistent with the PT’s role to guide parents and other caregivers on how to implement intervention in daily life. About 40% of the children needed continued physiotherapy services after the six-month follow-up, and numbers indicated that at least half of this children may be children with more complex problems, such as sustained motor development problems, established neurological diagnoses/syndromes and preterm born children. The latter group may be followed by a PT for surveillance even though they may not have current problems (22). It is reassuring that the main treatment goal and planned treatment for asymmetry and foot alignment adhered to our guidelines (14–17), which are based on international literature (23–26).