Effectiveness of school-based physiotherapy intervention for children

Figures & data

Figure 1. PRISMA flow diagram [19].

Table 1. Summary of school-based physiotherapy interventions in children – interventions and results.

Reference	Design, evidence level, conduct rating (level I-III) and GRADE rating	Participants	Setting	Intervention and dosage	Outcomes measured and [ICF coding]
Environmental modifications
[27]	Pre-post design Level IV Low quality/weak recommendation	Diagnosis: Developmental Coordination Disorder; typically-developing children n = 41 Age: mean age 7.85 years 23 F, 18 M	Country: South Africa School type: Mainstream primary school	Content: Health Promotion Program with aims of encouraging physical activity, providing a safe and healthy environment with appropriate equipment, collaborating with teachers to provide skills-based health education, and communicating with families to provide advice for accessing further support. Dose: nine week “whole school” initiative; physiotherapy students present at the school for 26 h per week. Delivered by: 4 physiotherapy students and their clinical educator. Target: Students, teachers, families Group 1: Participants with DCD (n = 22) Group 2: Typically-developing participants (n = 19) Both groups received the same intervention.	Within group analyses Group 1 (pre-post) Improved gross motor motor skills [d4] on Total Standard Score of MABC-2 (p < 0.0001). Improved balance [b755, b760] on balance component of MABC-2 (p < 0.0001). Improved anaerobic power [b730] on Muscle Power Sprint Test (p not reported). Group 2 (pre-post) No change in gross motor skills [d4] on Total Standard Score of MABC-2 (p = 0.69) No change in balance [b755, b760] on balance component of MABC-2 (p = 0.49). Improved anaerobic power [b730] on Muscle Power Sprint Test (p not reported). Between group analyses Greater improvement in balance (balance subscale of the MABC-2) in group 1 (p < 0.0001) compared to group 2 (p = 0.49). Greater improvement in anaerobic fitness in group 2 (p = 0.008).
Ergonomic health literacy
[28]	Individually randomised parallel-group trial Level II Moderate quality/moderate recommendation	Diagnosis: none; school children n = 194 Age: 9–11 years 110 F, 84 M	Country: Belgium School type: Mainstream primary schools	Group 1: Back education program (n = 96) Content: Education based on ten guidelines for correct posture and spinal health, delivered to one class group at a time. Dose: 6 h (6 weeks × 1 session per week × 1 h) Delivered by: Physiotherapist Target: Students Group 2: No intervention (n = 98)	Within group analyses Group 1 (pre-post) Improved back-care knowledge (p ≤ 0.011) (d = 0.84) except specific back care knowledge at the 8-year follow-up (p = 0.112) (d = 0.28). Higher pain prevalence [b280] at all test moments (p < 0.001). Higher fear avoidance beliefs for the item ‘lifting a heavy object’ (p = 0.025). Group 2 (pre-post) Improved back-care knowledge over time (p not reported). Improved spinal care behaviour [d4105, d430], most evident at 1-year follow-up (p not reported). Between group analyses Lower scores for spinal care behaviour (p ≤ 0.014) and self-efficacy (p ≤ 0.003) at the 8-year follow-up compared to previous test moments in both groups.
[29]	Case series Level IV Low quality/weak recommendation	Diagnosis: none; school children n = 206 Age 12–19 years 97 F, 109 M	Country: Portugal School type: Mainstream primary and high schools	Content: Theoretical-practical session targeting body mechanics and posture (static and dynamic) during daily activities. Dose: Single occasion, 1.5 h session Delivered by: Physiotherapist Target: Students	Improved performance of practical tasks [d4105, d430] – increase in 53.75% of students able to perform all tasks correctly (p not reported). Improved ergonomic knowledge 1 month after the intervention (p not reported). Decreased percentage of students in 8th grade with an overweight backpack [d430] (p ≤ 0.001). Increased percentage of students in 10th grade with an overweight backpack [d430] (p ≤ 0.001).
[30]	Case series Level IV Low quality/weak recommendation	Diagnosis: none; school children n = 84 Age: 10–13 years 42 F, 42 M	Country: Portugal School type: Mainstream primary school	Content: Theoretical-practical session targeting body mechanics and posture (static and dynamic) during daily activities. Dose: 1.5 h (2 weeks × 1 session per week × 45 min) Delivered by: Physiotherapist Target: Students	Improved ergonomic knowledge – improvement in theoretical test scores (mean scores improved from 7.7 to 10.83) (p ≤ 0.001). Improved performance of practical tasks [d4105, d430] – practical test scores (mean scores improved from 4.14 to 11.8) (p ≤ 0.001). No change in backpack weight [d430] following intervention (p = 0.285).
Gait training – overground
[31]	Case report Level IV Low quality/weak recommendation	Diagnosis: Cerebral palsy (diplegic) n = 1 Age: 15 years 1 F	Country: United States School type: Mainstream high school	Content: Intervention focused on progressive gait training, per the student’s IEP goals. Dose: 60 min/week of direct PT, and 30 min/month of consultative services over 3.5 years from 9th to 12th grade. Delivered by: Physiotherapist Target: Student	Improved gross motor function [d4] − 12.4% increase in GMFM score (p not reported). Improved walking tolerance and functional capacity [d450-d469] – final 6MWT distance of 152.4 m with KAFOs and 2 axillary crutches (initially able to mobilise 45.7 m with crutches; time not specified) (p not reported). Improved mobility with crutches and light assistance [d450-d469] – able to ascend and descend 26 steps with a landing; progressed to stand-by assistance (p not reported). Improved independence with personal cares and dressing [d540; d5] – including donning, doffing, and locking KAFOs. No rating scale reported (p not reported).
[32]	Case report Level IV Low quality/weak recommendation	Diagnosis: Developmental disability n = 1 Age: 8 years 1 M	Country: United States School type: Mainstream primary school with special education class	Content: Use of forward chaining procedure to teach the student to use his walker when verbally prompted. Dose: 100 min (5 days × 20 min per day); one additional day to assess maintenance. Delivered by: Physiotherapist Target: Student	Improved mobility using walker [d450–469] – able to perform sit-to-stand and walk 30 feet with only verbal or visual cues by conclusion of intervention (previously unable to stand or walk short distances without assistance from teachers).
Gait training – treadmill (no body-weight support)
[33]	RCT Level II Strong High quality/strong recommendation	Diagnosis: Cerebral palsy (spastic tetraplegic or diplegia), GMFCS I – III n = 22 Age: 13–19 years 9 F, 13 M	Country: Greece School type: Special high school	Group 1: Treadmill training (no body weight support) (n = 11) Content: Static stretching warm-up, 10 min; individualised treadmill training without body weight support, at a comfortable speed increased gradually, for a maximum of 30 min; cool-down stretches, 5 min. Dose: 27 h (12 weeks × 3 sessions per week × 45 min) Delivered by: Physiotherapists Target: Students Group 2: Usual PT (n = 11) Content: Mat activities, balance, gait training, functional gross motor tasks. Dose: 27 h (12 weeks × 3 sessions per week × 45 min) Delivered by: Physiotherapists Target: Students	Within group analyses Group 1 (pre-post) Improved gross motor function [d4] − 3.87% change in mean GMFM score (p not reported). Improved self-selected walking speed [d450] − 8.06 m/min change in mean self-selected walking speed (p not reported). Increase in mean treadmill speed [d450] from 1.76 km/hr to 3.00 km/hr (p = 0.00). Increase in mean time spent training from 12–20 mins to 23.9 − 29.8 mins (p not reported). Group 2 (pre-post) Improved gross motor function [d4] − 0.69% change in mean GMFM score (p not reported). Improved self-selected walking speed [d450] − 1.31 m/min change in mean self-selected walking speed (p not reported). Between group analyses Greater improvements in gross motor function [d4] on GMFM (p = 0.007) (d = 0.38) in group 1 [d450 – d469]. Greater improvements in self-selected walking speed [d450] (p = 0.000) (d = 1.13) in group 1 [d450 – d469]. No significant differences in spasticity between groups (p > 0.05) [b735].
Gait training – treadmill (partial body-weight support)
[34]	RCT Level II Strong Moderate quality/moderate recommendation	Diagnosis: Cerebral palsy, GMFCS II-III n = 30 Age: 6–18 years 10 F, 20 M	Country: Australia School type: Special school (primary and high school)	Group 1: Treadmill training (partial body weight support) (n = 15) Content: Graded progression with reduced body weight support, increased speed, and increased duration as appropriate. Walking harness attached to ceiling hoist. Dose: 8 h (8 weeks × 2 sessions per week × 30 min) Delivered by: Physiotherapists Target: Students Group 2: Over ground walking training (n = 15) Content: Participants used usual assistive devices and practiced walking in school corridors. Dose: 8 h (8 weeks × 2 sessions per week × 30 min) Delivered by: Physiotherapists Target: Students	Within group analyses Group 1 (pre-post) Improved walking speed [d450] − 0.051 m/s improvement in 10MWT between weeks 4 and 8 (p not reported). Improved functional capacity and walking tolerance [d450-d469] − 13.67 m improvement in 6MWT between weeks 4 and 8 (p not reported). Improved gross motor function [d4] − 6.26% improvement in GMFM (D) score and 7.4% improvement in GMFM (E) score between weeks 4 and 8 (p not reported). Group 2 (pre-post) Improved walking speed [d450] − 0.125 m/s improvement in 10MWT between weeks 4 and 8 (p not reported). Improved functional capacity and walking tolerance [d450-d469] − 15.54 m improvement in 6MWT between weeks 4 and 8 (p not reported). Improved gross motor function [d4] − 7.86% improvement in GMFM (D) score and 8.93% improvement in GMFM (E) score between weeks 4 and 8 (p not reported). Between group analyses Greater minimum distance covered in group 2 (p < 0.001) (d = 1.71). Greater average (p = 0.017) (d = 0.46) and maximum (p < 0.001) (d = 2.65) time spent walking in group 1. Greater minimum time spent walking in group 2 (p < 0.001) (d = 2.71). No significant difference between groups for change in scores in any outcome measure (GMFM, 10MWT, 6MWT) (p = 0.244–0.967).
Gait training – robotic-assisted
[35]	Pre-post design Level IV Low quality/weak recommendation	Diagnosis: Cerebral palsy (GMFCS IV/V) n = 27 Age: 5–8 years 10 F, 17 M	Country: United Kingdom School type: Special school (primary and high school)	Content: Robotic gait retraining using the Innowalk Pro – a robotic rehabilitation trainer that allows children with significant physical disabilities to mobilise in a weight-bearing position by providing assisted, guided and repetitive gait-like movements. Delivered in combination with usual physiotherapy care. Dose: 12 h (6 weeks × 4 sessions per week × 30 min) Delivered by: Physiotherapists, physiotherapy assistants, teachers and teaching assistants. Target: Students	Improved health-related quality of life [b, d, e, s] – on CPChild (p = 0.004) Improved individual goal attainment [d4] – on Goal Attainment Scale goals (p < 0.001) Improved lower limb range of motion [b710, b735] – on goniometric assessment (p = 0.004 − 0.17) Reduced lower limb spasticity [b735] – on the Modified Tardieu Scale (p = 0.02 − 0.27)
Gross motor activity training (GMAT)
[36]	Pre-post design Level IV Low quality/weak recommendation	Diagnosis: Developmental coordination disorder n = 46 Age: 6–10 years 22 F, 24 M	Country: South Africa School type: Mainstream primary schools	Group 1: Neuromotor task training (n = 27) Content: Part-task practice of components of soccer, netball, variations of tagging games, and other playground games. Dose: 13.5–18 h (9 weeks × 2 sessions per week × 45–60 min) Delivered by: Physiotherapists. Target: Students Group 2: Wii Fit (n = 19) Content: Games designed to mimic cycling, soccer, skateboarding or skiing, by encouraging weight shift in lateral and anterior directions, and stepping or humping over virtual obstacles. Games incorporating arm movements using the hand controller were also used. Dose: 9 h (6 weeks × 3 sessions per week × 30 min) Delivered by: Physiotherapists. Target: Students	Within group analyses Group 1 (pre-post) Improved gross motor skills [d4] on Total Standard Score of MABC-2 (p < 0.0001). Improved functional strength [b730] on Functional Strength Measure (p < 0.01). Improved anaerobic power [b730] on Muscle Power Sprint Test (p < 0.01). Group 2 (pre-post) No change in gross motor skills [d4] on Total Standard Score of MABC-2 (p = 0.26). No change in functional strength [b730] on Functional Strength Measure (p = 0.89). Improved anaerobic power [b730] on Muscle Power Sprint Test (p = 0.01). Between group analyses No significant difference in motor performance between groups (TSS of MABC-2) (p = 0.12). Greater improvement in functional strength (Functional Strength Measure) (p < 0.01) in group 1. No significant difference in upper limb muscle strength between groups (isometric contraction measured with dynamometer) (p not reported). No significant difference anaerobic power between groups (Muscle Power Sprint Test) (p not reported).
Gross motor activity training + multimodal education-based therapy (GMAT-MET)
[37]	RCT Level II Moderate Moderate quality/moderate recommendation	Diagnosis: Developmental Coordination Disorder n = 93 Age: 5–9 years 27 F, 66 M	Country: Australia School type: Mainstream primary schools	Group 1: Participant’s school with a school assistant (n = 37) Content: Motor retraining program, comprising fine motor (e.g., cutting and pasting), body awareness, gross motor circuit or skills practice (task-specific training of fundamental skills). Intervention delivered in small groups of 4–6 children, staff:children 1:3. Dose: 13 h (13 weeks × 1 session per week × 1 h) Delivered by: School assistant Target: Students Group 2: Participant’s school with a PT (n = 30) Content: As above Dose: 13 h (13 weeks × 1 session per week × 1 h) Delivered by: Physiotherapist Target: Students Group 3: Community clinic with a PT (n = 26) Content: As above Dose: 13 h (13 weeks × 1 session per week × 1 h) Delivered by: Physiotherapist Target: Students	Within group analyses Group 1 (pre-post) Improved motor skills [d410-d429; d450-d469; b755, b760] – on MABC and TGMD-2 (p < 0.05). Improved perceived physical competence [d4] – on PSPCSA from pre-intervention to 6 months post (p < 0.01). Group 2 (pre-post) Improved motor skills [d410-d429; d450-d469; b755, b760] – on MABC and TGMD-2 (2 (p < 0.05). Improved perceived physical competence [d4] – on PSPCSA from post-intervention to 6 months post (p = 0.01) and pre-intervention to 6 months post (p < 0.01). Group 3 (pre-post) Improved motor skills [d410-d429; d450-d469; b755, b760] – on MABC and TGMD-2 (2 (p < 0.05). Improved perceived physical competence [d4] – on PSPCSA immediately post-intervention (p = 0.01) and pre-intervention to 6 months post (p < 0.01). Between group analyses Significant improvement in motor skills in all groups on MABC (p = 0.00) (d = 0.98) & TGMD-2 (locomotor (p = 0.00) and object control (p = 0.00)) (d = 1.37) [d410-d429; d450-d469; b755, b760]. No group effect between modes of intervention (p = 0.09) for improvement in motor skills on MABC and TGMD-2. No group effect between modes of intervention (p = 0.62) for improved in perceived physical competence over time (p = 0.01) (d = 0.73) [d4].
[38]	RCT Level II Moderate Moderate quality/moderate recommendation	Diagnosis: Profound hearing impairment n = 21 Age: 6–11 years 7 F, 14 M	Country: India School type: School for the deaf	Group 1: Vestibular-specific neuromuscular training (n = 11) Content: Eye movement exercises, balance training (static stance in varied positions & walking with narrow base of support), and fundamental motor skills practice. Dose: 13.5 h (6 weeks × 3 sessions per week × 45 min) Delivered by: Physiotherapists Target: Students Group 2: Regular school activities (n = 12) No details of content or dose reported.	Within group analyses Group 1 (pre-post) Improved postural control [b755, b760] – Paediatric Reach Test (p = 0.001), Single Leg Stance test (p = 0.03), anteroposterior sway (eyes open p = 0.007, eyes closed p = 0.03), mediolateral sway eyes open p = 0.014, eyes closed p = 0.017). Improved gross motor skills [d4] – TGMD (p = 0.02), throw for distance (p = 0.042), jump for distance (p = 0.001), 15-yard dash (p = 0.001). Improved health-related quality of life on PedsQL (p = 0.01). Group 2 (pre-post) No changes in postural control [b755, b760] (p values not reported). No changes in gross motor skills [d4] (p values not reported). No changes in health-related quality of life (p values not reported). Between group analyses Greater improvement in postural control [b755, b760] (p < 0.05) in group 1. Greater improvement in gross motor skills [d4] (p < 0.05) in group 1. Greater improvement in health-related quality of life (p < 0.05) in group 1.
GMAT + progressive resistance exercise (GMAT-PRE)
[39]	Case series Level V Low quality/weak recommendation	Intellectual disability n = 2, 1 F, 1 M 18–19 years	Country: United States School type: Mainstream high school with special education program	Participant 1 Content: Therapeutic exercise, functional activities, participation in APE program, and a home program. Dose: 9 h (18 weeks × 1 session per week × 30 mins) Delivered by: Physiotherapist, in collaboration with school teachers. Target: Student Participant 2 Content: Therapeutic exercise, functional activities, instruction to school team regarding proper squat technique and teaching strategies, a home program, and continued participation in APE. Dose: 6 h (12 weeks × 1 session per week × 30 mins) Delivered by: Physiotherapist, in collaboration with school teachers. Target: Student	Participant 1 Improved lifting performance [d430] – able to perform 10–25 reps of lifting activities (previously performed 9–10 reps) (p not reported) Improved squat performance [d4101] – able to move from squat to stand and stand to squat (previously unable); able to hold squat position for 60 s (previously unable) (p not reported) Improved body mechanics for squatting [d4101] – scoring 8/8 on mechanics checklist (previously 1/8) (p not reported) Participant 2 Improved lifting performance [d430] – able to perform 15–20 reps of lifting activities (previously performed 9–15 reps) (p not reported) Improved squat performance [d4101] – able to move from squat to stand and stand to squat (previously unable); able to hold squat position for 32 s (previously unable) (p not reported) Improved body mechanics for squatting [d4101] – scoring 6/8 on mechanics checklist (previously 1/8) (p not reported)
Hippotherapy
[40]	Case report Level V Low quality/weak recommendation	Diagnosis: Cerebral palsy with mild cognitive impairment n = 1 Age: 14 years 1 F	Country: Slovenia School type: Mainstream primary school with special education program	Intervention Type 1 Content: Hippotherapy exercises on unsaddled horseback to improve motor function through muscle relaxation, balance responses and postural control. Dose: Single occasion, 45 min. Delivered by: Physiotherapist Target: Student Intervention Type 2 Content: NDT (before class) with a focus on inhibition of pathological patterns and facilitation of normal movement to induce correct motor responses. Dose: Single occasion, 45 min Delivered by: Physiotherapist Target: Student Intervention Type 3 Content: NDT (after class) with a focus on inhibition of pathological patterns and facilitation of normal movement to induce correct motor responses. Dose: Single occasion, 45 min. Delivered by: Physiotherapist Target: Student	Within group analyses Intervention type 1 (pre-post) No change in reading speed [d166] – no change in time to complete a set reading task (p not reported). Improved writing speed [d170] – faster time to complete a set writing task (p not reported). Improved accuracy of writing [d170] – fewer mistakes made in exact joining of letters (contact lineation) (p not reported). Between group analyses: No difference between groups for contact lineation (p not reported) or reading speed (p not reported).
Multimodal education-based therapy (MET)
PT COUNTS (single study comprised of the following five articles) [41] [42] [43] [44] [45]	Case series Level IV Low quality/weak recommendation	Diagnoses: Cerebral palsy (n = 103); down syndrome (n = 46); other genetic syndromes (n = 40); global developmental delay (n = 32); other (n = 75) n = 296 Age: 5–12 years 130 F, 166 M	Country: United States School type: Mainstream primary schools	Content: School physiotherapy intervention based on students’ IEP goals. Activities included practice of sitting, standing, and transitions, mobility, and physical education/ recreation. More time spent on behalf of student (consultation/collaboration, documentation, in-service, or curriculum development) as opposed to delivering direct therapy. Dose: Average of 534.4 min of PT services delivered per child in 6 months (duration of each service occasion not reported); average of 86.9 min of group service delivery, and 262.7 min of services on behalf of the student. Delivered by: Physiotherapists Target: Students, teachers	Goal Attainment Scale: GAS goals achieved: 75.68% of students achieved their primary GAS goal. [41] Improved GAS (posture/mobility): [d410-d429; d450-d469] 41% exceeded goals for posture/mobility. More minutes of service on behalf of student and self-care activities associated with exceeding expectation (p < 0.05). [43] Improved GAS (recreation/fitness): [d920; d570]. 40% exceeded goals for recreation/fitness. Greater use of functional strength, mobility for playground access, cognitive and behavioural interventions was associated with exceeding expectation (p < 0.05). [43] Improved GAS (self-care): [d5] 40% exceeded goals for self-care. Students received less PT time with no other students present (p = 0.05), less documentation time (p < 0.02) and more neuromuscular interventions (p < 0.04) than students who did not exceed expectation. [43] Improved GAS (academic): [d820] 27% exceeded academic goals. Students received more mobility interventions than students who did not exceed expectation (p < 0.03). [43] School Function Assessment: Improved SFA (Participation): [d] 51% improved on the Participation domain of the SFA (p not reported). Improved SFA (Task Support Adaptations): [e] 46% improved on the Task Support Adaptations domain of the SFA (p not reported). Improved SFA (Maintaining and Changing Position): [d410–429] 46% improved on the Maintaining and Changing Position domain of the SFA (p not reported). Improved SFA (Manipulation with Movement): [d430–449] 44% improved on the Manipulation with Movement domain of the SFA (p not reported). Mobility, sensory, motor learning, aerobic/ conditioning, functional strengthening, and playground access intervention services correlated positively with SFA outcomes, as well as higher student participation during therapy (p not reported). Services with negative correlation to SFA outcomes included group delivery, within school activities, with students not in special education, during recreation activities, and with positioning, hands-on facilitation, sensory integration, orthoses, and equipment interventions (p not reported). [45]
[46]	Case series Level IV Low quality/weak recommendation	Diagnosis: Down syndrome n = 46 Age: 5–11 years 25 F, 20 M	Country: United States School type: Mainstream primary school with special education classes	Intervention Group Content: School physiotherapy intervention based on individual goals from the students’ IEP, e.g., transfers, mobility, physical education participation, lunchtime recreation participation. Dose: Average of 11 h 50 min of services per student (20 weeks × 35.6 min per week); 8 h direct therapy (20 weeks × 24 min per week) plus 3 h and 50 min of services on behalf of the student (20 weeks × 11.6 min per week). Delivered by: Physiotherapists Target: Students, teachers	Intervention Group (pre-post) Improved GAS (posture/mobility): [d410-d429; d450-d469] 66.7% met/exceeded goals for posture/mobility (p not reported). Improved GAS (recreation): [d920] 73.7% met/exceeded goals for recreation (p not reported). Improved SFA: [d820] mean subtest scores increased by 2.2–3.7 points (p not reported).
[47]	Case report Level IV Low quality/weak recommendation	Diagnosis: Cerebral palsy (spastic hemiplegia), GMFCS I n = 1 Age: 5 years 1 M	Country: United States School type: Kindergarten at mainstream school	Content: Mobility and stability tasks relevant to goal of ascending ladder to playground. Combination of strength and endurance training, ROM and body awareness activities, to address identified constraints to function. Dose: 19 sessions (unspecified duration) Delivered by: Physiotherapist Target: Student	Improved ability to ascend ladder to access slide [d4551] (previously unable). No rating scale reported (p not reported).
Neurodevelopmental treatment (NDT)
[40]	Case report Level V Moderate quality/moderate recommendation	Diagnosis: Cerebral palsy with mild cognitive impairment n = 1 Age: 14 years 1 F	Country: Slovenia School type: Mainstream primary school with special education program	Intervention Type 1 Content: Hippotherapy exercises on unsaddled horseback to improve motor function through muscle relaxation, balance responses and postural control. Dose: Single occasion, 45 min. Delivered by: Physiotherapist. Target: Student Intervention Type 2 Content: NDT (before class) with a focus on inhibition of pathological patterns and facilitation of normal movement to induce correct motor responses. Dose: Single occasion, 45 min Delivered by: Physiotherapist. Target: Student Intervention Type 3 Content: NDT (after class) with a focus on inhibition of pathological patterns and facilitation of normal movement to induce correct motor responses. Dose: Single occasion, 45 min. Delivered by: Physiotherapist. Target: Student	Within group analyses: Intervention type 2 (pre-post) Improved reading speed [d166] – faster time to complete a set reading task (p not reported). Improved writing speed [d170] – faster time to complete a set writing task (p not reported). Improved accuracy of writing [d170] – fewer mistakes made in exact joining of letters (contact lineation) (p not reported). Intervention type 3 (pre-post) No change in reading speed [d166] – no change in time to complete a set reading task (p not reported). Improved writing speed [d170] – faster time to complete a set writing task (p not reported). Improved accuracy of writing [d170] – fewer mistakes made in exact joining of letters (contact lineation) (p not reported). Between group analyses: Greater improvement in writing speed after NDT (before class) compared to other interventions (χ^2 = 44.68; χ^2 0.05 (3) = 7.81). No difference between groups for contact lineation (p not reported) or reading speed (p not reported).
[48]	Crossover RCT Level II Strong Moderate quality/moderate recommendation	Diagnosis: Cerebral palsy (spastic; bilateral), GMFCS I – III; age-matched typically developing children n = 8 Age: 7–18 years 2 F, 6 M	Country: Germany School type: Special school (primary and high school)	Intervention group: Climbing therapy (then usual PT) (n = 4) Content: Indoor rock climbing at an orthopaedic hospital for children. Dose: 18 h (6 weeks × 2 sessions per week × 1.5 h); 4 weeks wash-out prior to study and between interventions. Delivered by: Climbing therapists. Target: Students Comparator group: Usual PT (then climbing therapy) (n = 4) Content: NDT and functional tasks Dose: 18 h (6 weeks × 2 sessions per week × 1.5 h); 4 weeks wash-out prior to study and between interventions. Delivered by: Physiotherapists Target: Students	Within group analyses – Comparator group Group 2 (pre-post) Improved self-selected walking speed, step length, and step time [d450-d469] in participants with cerebral palsy (p not reported). Improved gait kinematics on Gait Profile Score [b770] (–1.4°) (p not reported). Improved knee flexion (–4.5°) and ankle dorsiflexion (1.1°) [b770] (p not reported). Deterioration in the hip peak internal rotation [b770] (p not reported). Between group analyses No significant difference in spatiotemporal parameters of gait between groups [d450–469] (p not reported). Greater improvement in knee flexion at initial contact in the comparator group (p = 0.039) [b710].
Non-immersive virtual reality (NVR)
[36]	Pre-post design Level IV Low quality/ weak recommendation	Diagnosis: Developmental coordination disorder n = 46 Age: 6–10 years 22 F, 24 M	Country: South Africa School type: Mainstream primary schools	Group 1: Neuromotor task training (n = 27) Content: Part-task practice of components of soccer, netball, variations of tagging games, and other playground games. Dose: 13.5–18 h (9 weeks × 2 sessions per week × 45–60 min) Delivered by: Physiotherapists. Target: Students Group 2: Wii Fit (n = 19) Content: Games designed to mimic cycling, soccer, skateboarding or skiing, by encouraging weight shift in lateral and anterior directions, and stepping or humping over virtual obstacles. Games incorporating arm movements using the hand controller were also used. Dose: 9 h (6 weeks × 3 sessions per week × 30 min) Delivered by: Physiotherapists. Target: Students	Within group analyses Group 1 (pre-post) Improved gross motor skills [d4] on Total Standard Score of MABC-2 (p < 0.0001). Improved functional strength [b730] on Functional Strength Measure (p < 0.01). Improved anaerobic power [b730] on Muscle Power Sprint Test (p < 0.01). Group 2 (pre-post) No change in gross motor skills [d4] on Total Standard Score of MABC-2 (p = 0.26). No change in functional strength [b730] on Functional Strength Measure (p = 0.89). Improved anaerobic power [b730] on Muscle Power Sprint Test (p = 0.01). Between group analyses No significant difference in motor performance between groups (TSS of MABC-2) (p = 0.12). Greater improvement in functional strength (Functional Strength Measure) (p < 0.01) in group 1. No significant difference in upper limb muscle strength between groups (isometric contraction measured with dynamometer) (p not reported). No significant difference anaerobic power between groups (Muscle Power Sprint Test) (p not reported).
[49]	RCT Level II Strong Moderate quality/moderate recommendation	Diagnosis: Cerebral palsy, GMFCS III – IV n = 18 Age: 6–14 years 7 F, 11 M	Country: Hong Kong School type: Special school	Group 1: Non-immersive VR and usual PT (n = 9) Content: Computer games using a force plate, designed to target postural control. Usual care interventions not specified. Dose: 8 h (6 weeks × 4 sessions per week × 20 min) Delivered by: Physiotherapists Target: Students Group 2: Usual PT alone (n = 9) Content: Typical care (interventions not specified). Dose: Not specified. Delivered by: Physiotherapists Target: Students	Within group analyses Group 1 (pre-post) Improved dynamic balance [b755, b760] − 3.28 cm improvement in mean forward reach distance on Paediatric Reach Test (p not reported). Improved gross motor function [d4] − 0.51 increase in mean GMFM score (p not reported). Improved walking ability and functional capacity [d450-d469] − 1.43 m increase in mean walking distance on 2MWT (p not reported). Group 2 (pre-post) Improved dynamic balance [b755, b760] − 5.22 cm improvement in mean forward reach distance on Paediatric Reach Test (p not reported). Improved gross motor function [d4] − 2.04 increase in mean GMFM score (p not reported). Improved walking ability and functional capacity [d450-d469] − 10.4 m increase in mean walking distance on 2MWT (p not reported). Between group analyses No significant difference between groups on measures of dynamic balance (Paediatric Reach Test), gross motor function (GMFM), or walking ability (2MWT), at any testing moment (p > 0.001).
[50]	Case series Level IV Low quality/weak recommendation	Diagnosis: Cerebral palsy (mild – moderate hemiplegic and diplegic), GMFCS I – II n = 11 Age: 4–11 years 6 F, 5 M	Country: Spain School type: Mainstream primary school	Content: Non-immersive VR using Kinect Xbox 360. Games used to target balance, trunk movements, visual-manual coordination, and limb movements. Dose: 8 h (2 months × 2 sessions per weeks × 30 min) Delivered by: Physiotherapists Target: Students	Improved gross motor function [d4] on GMFM (p = .001). Improved quality of performance of activities of daily living [d230] on the Assessment of Motor and Process Skills (motor (p = 0.001) and process (p = 0.01)). Improved dynamic balance [b755, b760] on Paediatric Reach Test (p = 0.005). Improved walking speed [d450] on 10MWT (p = 0.029). Improved hand function [d440, d445] on most domains of Jebsen-Taylor Hand Function Test; differences between basal and follow-up mostly not significant (p not reported).
Rock climbing
[48]	Crossover RCT Level II Strong Moderate quality/moderate recommendation	Diagnosis: Cerebral palsy (spastic; bilateral), GMFCS I – III; age-matched typically developing children n = 8 Age: 7–18 years 2 F, 6 M	Country: Germany School type: Special school (primary and high school)	Intervention group: Climbing therapy (then usual PT) (n = 4) Content: Indoor rock climbing at an orthopaedic hospital for children. Dose: 18 h (6 weeks × 2 sessions per week × 1.5 h); 4 weeks wash-out prior to study and between interventions. Delivered by: Climbing therapists. Target: Students Comparator group: Usual PT (then climbing therapy) (n = 4) Content: NDT and functional tasks Dose: 18 h (6 weeks × 2 sessions per week × 1.5 h); 4 weeks wash-out prior to study and between interventions. Delivered by: Physiotherapists Target: Students	Within group analyses – Intervention group Group 1 (pre-post) Improved self-selected walking speed, step length, and step time [d450-d469] in participants with cerebral palsy (p not reported). Deterioration in gait kinematics on Gait Profile Score [b770] (p not reported). Improved hip peak internal rotation [b770] (0.1°) (p not reported). Deterioration in knee flexion and ankle dorsiflexion [b770] (p not reported). Between group analyses No significant difference in spatiotemporal parameters of gait between groups [d450–469] (p not reported).
Upper limb
[51]	RCT Level II Strong High quality/strong recommendation	Diagnosis: Cerebral palsy (spastic hemiplegia), GMFCS I – III n = 32 Age: mean age 10.43 years 15 F, 17 M	Country: Turkey School type: Mainstream primary schools (School-based intervention (1x 1h session/week) or group sessions at a rehabilitation centre (2x 1h session/week), combined with home practice)	Group 1: mCIMT (n = 16) Content: Gross motor and fine motor activities, manipulative games, puzzles, arts and crafts, board and card games, and functional activities, with use of the less affected hand restricted. Dose: 75 h face-to-face therapy (10 weeks × 3 sessions per week × 2.5 h) and home practice (1 h per day during intervention period and 2 h per day during follow-up period). Delivered by: Physiotherapists Target: Students Group 2: Bimanual Training (n = 16) Content: Fine and manipulative gross motor activities requiring the use of both hands, particularly tasks which were skilled, repetitive, and structured in nature. Dose: 75 h face-to-face therapy (10 weeks × 3 sessions per week × 2.5 h) and home practice (1 h per day during intervention period and 2 h per day during follow-up period). Delivered by: Physiotherapists Target: Students	Within group analyses: Group 1 (pre-post) Improved grip strength [b730] of more affected hand (p < 0.001) (d = 0.53), retained during follow-up (p < 0.01) (d = 0.4). Improved quality of bimanual hand use [d445] (d = 0.91–0.96). Improved quantity of use of more affected limb [d445] (p < 0.001). Improved global participation (d = 1.08) and participation in school activities (d = 1.1) (p < 0.001) [d820] on the Child and Adolescent Scale of Participation. Group 2 (pre-post) No improvement in grip strength [b730] (p > 0.05). Improved quality of bimanual hand use [d445] (d = 0.63–0.75). Improved quantity of bimanual hand use [d445] (p < 0.001). Improved global participation (d = 0.67) and participation in school activities (d = 0.69) [d820] on the Child and Adolescent Scale of Participation. Between group analyses: Greater improvement in unimanual capacity (QUEST) [d440, d445] after mCIMT (p < 0.001). Greater improvement in manual ability in everyday activities (ABILHAND-Kids) [d440, d445] after mCIMT (p < 0.001) (d1=3.75, d2=1.12).
[52]	RCT Level II Moderate High quality/strong recommendation	Diagnosis: Handwriting problem diagnosed by HPSQ n = 60 Age: 5–7 years 19 F, 41 M	Country: India School type: Mainstream primary schools	Group 1: Physiotherapeutic exercises targeting handwriting (n = 30) Content: Exercises to improve upper limb stability, visual-motor development, and fine motor skills for handwriting. Dose: 48 h (3 months × 4 sessions per week × 1 h) Delivered by: Physiotherapists Target: Students Group 2: Ergonomic advice and postural correction (n = 30) Content: Ergonomic advice on handwriting, taught appropriate writing posture Dose: 1 session (duration not reported Delivered by: Physiotherapist, parents, teachers Target: Students	Within group analyses Group 1 (pre-post) Improved handwriting proficiency [d170] on HPSQ (t = 8.413), MHA total (t = 42.17), and MHA subscale scores following intervention. Group 2 (pre-post) Improved handwriting proficiency [d170] on HPSQ (t = 6.71), MHA total (t = 34.00), and MHA subscale scores following intervention. Between group analyses Greater improvement in handwriting proficiency (HPSQ) scores in group 1 1 (p < 0.05) (d = 26.72).

GRADE: Grading of Recommendation, Assessment, Development, and Evaluation; DCD: developmental coordination disorder; MABC-2: Movement Assessment Battery for Children 2nd Edition; IEP: Individualised Education Program; PT: physiotherapy/physiotherapist; GMFM: Gross Motor Function Measure; 6MWT: 6 min Walk Test; KAFOs: knee ankle foot orthoses; RCT: randomised controlled trial; GMFCS: Gross Motor Function Classification Scale; 10MWT: 10 Metre Walk Test; CPChild: Caregiver Priorities and Child Health Index of Life with Disabilities; MABC: Movement Assessment Battery for Children; TGMD-2: Test of Gross Motor Development 2nd Edition; PSPCSA: Pictorial Scale of Perceived Competence and Social Acceptance; TGMD: Test of Gross Motor Development; PedsQL: Paediatric Quality of Life Inventory; APE: Adapted Physical Education; NDT: neurodevelopmental treatment; GAS: Goal Attainment Scale; SFA: School Function Assessment; ROM: range of motion; VR: virtual reality; 2MWT: 2 Metre Walk Test; mCIMT: modified Constraint Induced Movement Therapy; QUEST: Quality of Upper Extremity Skills Test; MHA: Minnesota Handwriting Assessment; HPSQ: Handwriting Proficiency Screening Questionnaire.

Table 2. AACPDM conduct of studies of school-based physiotherapy interventions – group design studies – Level of Evidence I-III.

Study	Evidence level/quality	1 Inclusion criteria	2 Int/con participants described	3 Measures appropriate	4 Blinded assessor	5 Statistical calculations	6 Dropout reporting	7 Controlling confounders
Ergonomic health literacy
[28]	II (4/7) moderate	No	Yes/yes	Yes	Yes	No	No	Yes
Gait training – treadmill (partial body-weight support)
[34]	II (7/7) strong	Yes	Yes/yes	Yes	Yes	Yes	Yes	Yes
Gross motor activity training + multimodal education-based therapy (GMAT-MEBT)
[37]	II (6/7) moderate	Yes	Yes/yes	Yes	Yes	No	Yes	Yes
[38]	II (4/7) moderate	Yes	Yes/no	Yes	No	No	Yes	Yes
Rock climbing /NDT
[48]	II (6/7) strong	Yes	Yes/yes	Yes	Yes	No	Yes	Yes
Non-immersive virtual reality
[49]	II (5/7) strong	Yes	Yes/no	Yes	Yes	No	Yes	Yes
Upper limb
[51]	II (7/7) strong	Yes	Yes/yes	Yes	Yes	Yes	Yes	Yes
[52]	II (4/7) moderate	Yes	Yes/yes	Yes	No	No	No	Yes

1. Were inclusion and exclusion criteria of the study population well described and followed? 2. Was the intervention well described and was there adherence to the intervention assignment? (for 2-group designs, was the control exposure also well described?) Both parts of the question need to be met to score ‘yes.’ 3. Were the measures used clearly described, valid and reliable for measuring the outcomes of interest? 4. Was the outcome assessor unaware of the intervention status of the participants (i.e., were the assessors masked)? 5. Did the authors conduct and report appropriate statistical evaluation including power calculations? Both parts of the question need to be met to score ‘yes.’ 6. Were drop out/loss to follow-up reported and less than 20%? For 2-group designs, was drop out balanced? 7. Considering the potential within the study design, were appropriate methods for controlling confounding variables and limiting potential biases used? [25].

Table 3. Cochrane risk-of-Bias tool for randomised trials (RoB-2) – conduct of studies of school-based physiotherapy interventions – group design studies – Level II Evidence.

Study	1 Risk of bias arising from the randomisation process	2 Risk of bias due to deviations from the intended interventions (Effect of assignment to intervention)	2 Risk of bias due to deviations from the intended interventions (Effect of adhering to intervention	3 Missing outcome data	4 Risk of bias in measurement of the outcome	5 Risk of bias in selection of the reported result	Overall risk of bias
[28]	Low	Low	Low	Low	Low	Low	Low
[33]	Low	Low	Low	Low	Low	Low	Low
[34]	Low	Low	Low	Low	Low	Low	Low
[37]	Low	Low	Low	Low	Low	Low	Low
[38]	Low	Low	Low	Low	Low	Low	Low
[48]	Low	Low	Low	Low	Low	Low	Low
[49]	Low	Low	Low	Low	Low	Low	Low
[51]	Low	Low	Low	Low	Low	Low	Low
[52]	Low	Low	Low	Low	Low	Low	Low

Table 4. Risk of Bias in non-randomised studies – of interventions (ROBINS-I) – conduct of studies of school-based physiotherapy interventions – non-randomised group design studies – Level IV Evidence.

Study	1 Bias due to confounding	2 Bias in selection of participants into the study	3 Bias in classification of interventions	4 Bias due to deviations from intended interventions	5 Bias due to missing data	6 Bias in measurement of outcomes	7 Bias in selection of the reported result	Overall risk of bias
[27]	Moderate	Low	Low	Low	Low	Low	Low	Low
[36]	Moderate	Low	Low	Low	Low	Low	Low	Moderate

Table 5. NHLBI quality assessment – conduct of studies of school-based physiotherapy interventions – pre-post design studies – Level IV Evidence.

Study	1 Was the study question or objective clearly stated?	2 Were eligibility/ selection criteria for the study population prespecified and clearly described?	3 Were the participants in the study representative of those who would be eligible for the test/ service/ intervention in the general or clinical population of interest?	4 Were all eligible participants that met the pre-specified entry criteria enrolled?	5 Was the sample size sufficiently large to provide confidence in the findings?	6 Was the test/ service/ intervention clearly described and delivered consistently across the study population?	7 Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?	8 Were the people assessing the outcomes blinded to the participants’ exposures/ interventions?	9 Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?	10 Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?	11 Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?	12 If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?	Quality rating
[31]	Yes	No	Yes	Cannot determine	No	Yes	Yes	No	NA	No	Yes	NA	Poor
[32]	Yes	No	Yes	Cannot determine	No	Yes	Yes	No	NA	No	Yes	NA	Poor
[35]	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Fait
[47]	Yes	No	Yes	Cannot determine	No	Yes	Yes	No	NA	No	No	NA	Poor

Table 6. NHLBI quality assessment – conduct of studies of school-based physiotherapy interventions – case series studies – Level IV Evidence.

Study	1 Was the study question or objective clearly stated?	2Were eligibility/selection criteria for the study population prespecified and clearly described?	3 Were the cases consecutive?	4 Were the subjects comparable?	5 Was the intervention clearly described?	6 Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?	7 Was the length of follow-up adequate?	8 Were the statistical methods well-described?	9 Were the results well-described?	Quality rating
[29]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Good
[30]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Good
[39]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Fair
[41–45]	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Fair
[46]	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Fair
[50]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Good

Table 7. GRADE quality of evidence table.

No.of studies	Design	Limitations (Risk of bias)	Indirectness of patients, intervention, and comparator	Inconsistency	Imprecision	Quality of evidence	Strength of recommendation
Environmental modifications
1	Pre-post (n = 1)	High	Direct	No major inconsistencies	Moderate uncertainty	Low	Weak
Ergonomic health literacy
3	Case series (n = 2) Cohort study (n = 1)	High	Direct	Some inconsistency	Moderate uncertainty	Low	Weak
Gait training – overground
2	Case report (n = 2)	High	Direct	No major inconsistencies	Moderate uncertainty	Low	Weak
Gait training – treadmill (no body-weight support)
1	RCT (n = 1)	Low	Direct	No major inconsistencies	None	High	Strong
Gait training – treadmill (partial body-weight support)
1	RCT (n = 1)	Low	Direct	Some inconsistency	None	Moderate	Moderate
Gait training – robotic-assisted
1	Pre-post (n = 1)	Medium	Direct	No major inconsistencies	Moderate uncertainty	Moderate	Moderate
Gross motor activity training (GMAT)
1	Pre-post (n = 1)	Medium	Direct	Some inconsistency	Moderate uncertainty	Low	Weak
Gross motor activity training + multimodal education-based therapy (GMAT-MET)
2	RCT (n = 2)	Low	Direct	Some inconsistency	None	Moderate	Moderate
GMAT + progressive resistance exercise (GMAT-PRE)
1	Case report (n = 1)	High	Direct	Some inconsistency	Moderate uncertainty	Low	Weak
Hippotherapy
1	Case report (n = 1)	High	Direct	Some inconsistency	Moderate uncertainty	Low	Weak
Multimodal education-based therapy (MET)
3*	Case series (n = 2) Case report (n = 1)	High	Direct	Some inconsistency	Moderate uncertainty	Low	Weak
Neurodevelopmental treatment (NDT)
2	RCT (n = 1) Case report (n = 1)	Medium	Direct	No major inconsistencies	Moderate uncertainty	Moderate	Moderate
Non-immersive virtual reality (NIVR)
3	RCT (n = 1) Case series (n = 1)	Medium	Direct	Moderate inconsistency	Moderate uncertainty	Low	Weak
Rock climbing
1	Crossover RCT (n = 1)	Low	Direct	No major inconsistencies	Moderate uncertainty	Moderate	Moderate
Upper limb
2	RCT (n = 2)	Medium	Direct	No major inconsistencies	None	High	Strong

*Including 1 study comprised of 5 articles. Total of 7 articles.

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