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Table 1 Examples of categorisation of the physiotherapist’s (PT’s) functional diagnosis, main goal for treatment and treatment plan registered as free text

From: Profile of children referred to primary health care physiotherapy: a longitudinal observational study in Norway

Categorisation Free text
PT’s functional diagnosis
 Normal findings No diagnosis; Not relevant; Normal development; None; Normal joint conditions
 Motor difficulties Bodily unrest and attention deficit; Struggles with gross motor skills; Immature movement pattern; Slightly delayed motor development according to age; Delayed fine motor development; Delayed gross motor development; Struggles in prone position; Reduced head control
 Asymmetry Infant asymmetry; Positional infant asymmetry; Neck asymmetry; Torticollis; Favorite side; Asymmetrical movement development; Lateral flexion to the right side; Asymmetry
 Foot alignment Stiff ankles, toe-walking; Intoeing; Asymmetrical running pattern and stiff ankle; Increased valgus in foot; Flexible flatfoot
 Established diagnosis/syndrome Down's syndrome; Rare diseases (not shown due to anonymity)
 Other Birth asphyxia; Pain problem; Tension headache; Stiff neck; Ankle fracture; Diffuse leg pain
Main goal for treatment
 No further follow-up Only examination; No need for follow-up; Case closed
 Normalise or optimise motor development Age-adequate motor development; Independent walking; Normal motor development; Improve independence in fine- and gross motor tasks; Improve writing; Normalise running pattern; Impact walking and running
 Achieve symmetrical movements Symmetrical motor development; Symmetrical neck position; Symmetry in neck; Equal range of motion to both sides; Full range of motion bilaterally; Become equally strong in active lateral flexion to both sides; Become symmetrical in prone position; Achieve symmetry of head movements
 Pain reduction Reduce pain in neck and back; Become pain free, become aware of tension; Reduce pain and fatigue
 Further examinations Evaluate need for follow-up; Evaluation of fine motor function as part of further assessment; Mapping of motor skills; Assessment of feet; Assessment/evaluation of fine motor function and coordination; Determine need for further follow-up/assessment; Examine the cause of intoeing and determine need for follow-up; Find the cause of asymmetry and stiffness in ankle; Examination of neck; Examination and evaluation; Consider further follow-up by PT;
 Other Maintain function; Participation in suitable and pleasurable leisure activities; Improve sleep and school day functioning; Improve range of motion in dorsiflexion of the ankle; Prevent problems due to week muscles; Avoid stiffening of shoulder; Monitor development
Treatment plan
 No need for treatment No plan for treatment; No goal for treatment; No further follow-up
 Further examinations Assessment; Examination; Observation and assessments; Mapping of causes; Observe in kindergarten; Observe in school; Evaluate motor development
 Advice/guidance of parents Guidance of mother; Guidance of parents; Guidance kindergarten/home; Talk to child, mother and school; Ensure that parents are given knowledge-based information about motor development
 Stimulation to active movements Stimulate both sides in daily activities; Stimulation on the child’s left side; Stimulate to symmetrical head control and varied positions; Stimulation; Stimulate to active rotation of the head to the left; Active lateral flection to the right in various position; Functional movements
 Adaptation of the environment and positional support Adaptation in school; Adaptation; Supine position with adequate support to promote head in midline; Facilitate prone position; Facilitate varied motor development; Support for supine position
 Stretching Stretching
 Other Normal activity level; Balance, strength and stability; Variation in position; Understand the condition; Referral to occupational therapist