Physiotherapy students promoting health and well-being of school-aged children and adolescents in North Karelia, Finland

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Abstract

Background: Physical activity is important for health and well-being for all ages. The recommendation for children and adolescents is at least 60 minutes moderate- to vigorous- intensity physical activity daily and two third of Finnish children achieve these recommendations. Schools have an important role in children’s physical activity and physiotherapists as experts in motor development, movement and mobility could contribute largely in this respect to children's health and wellbeing in school healthcare system. This article describes, how school physiotherapy was developed and organized in North Karelia in cooperation with Karelia University of Applied Sciences (Karelia), schools in the Joensuu region and the Siun sote- Joint municipal authority for North Karelia social and health services. Aim: The aim of the pilot project was to promote the health, well-being, and functional capacity of children and adolescent. The purpose of the school physiotherapy pilot was to build a school physiotherapy model for schools in the North Karelia region. Results: As a result of the school physiotherapy pilot, a model for school physiotherapy practice was created. Conclusion: School physiotherapy pilot was shown to be helpful in improving the activity levels and motor development of school-aged children and adolescents. It is hoped that school physiotherapy will develop further to promote the health and well-being, motor skills and functional capacity of children and adolescents through physical activity.

Reviews

Overall, I think this is a worthwhile article and potentially important work, and I hope that you proceed to improve and resubmit. I agree with Ralph Hammond that it seems more of a service improvement project at the moment, and that several changes are required for it to be seen as a pilot project. Consider the actual aim of your project and also the inherent purposes of doing a pilot project, is it to evaluate feasibility of rolling out such a project on a bigger or more permanent scale?

1. Complete, coherent, and well-organized presentation: The article is presented well, with effective use of language throughout. The structure is logical. There is no Discussion section, this should be added. There are some grammatical errors that would benefit from proofreading.

2. Sufficient explanation of the significance of the problem: You offer relevant contextual information and base factual background on sources that appear both trustworthy and meaningful to the topic. I am a little uncertain about the relevance of motor development, this seems somewhat outside of the scope or focus for your article. If your argument is that motor development is required for physical activity to be possible, you should perhaps offer a stronger rationale for this.

You could also consider strengthening the argument for the importance of promoting physical activity for children and adolescents, linking to studies showing how habits developed in this life phase can develop into life-long habits. There is also the potential for social and academic gains to be achieved through physical activity (see https://www.euro.who.int/__data/assets/pdf_file/0006/382335/fs-education-eng.pdf)

3. Clear demonstration of the relevance to the field (beyond the case presented): I think this is an important initiative and you deserve a lot a credit for undertaking this pilot project. It is potentially useful for the individual pupils, for society, and for the physiotherapy students as part of their learning. Perhaps you could explain if the intention is to use the results of this pilot to expand with similar parameters or if you envisage this to become part of qualified physiotherapists job roles.

4. Original contribution to the topic of physiotherapy education: See 3. Above.

5. Compelling presentation of the problem within a theoretical framework (where appropriate): You could consider expanding on the wider contextual factors, where the background is one of societies and health care systems which tend to focus on curative and interventional healthcare, rather than the promotion and protection of good health which you set out to achieve with your intervention.

6. Establishment of a relationship between the problem and other relevant literature: There is a lot of literature around integrating movement and physical activity into the classroom, and you could offer a wider basis for the potential role physiotherapists/physiotherapy students cold play here.

7. Appropriate research design and method: It is unclear how you obtained the information that shaped your results.

8. Accurate and useful interpretation: Difficult to comment on this as you give no information about how and from who you collected feedback.

9. Sound argument and analysis: Also limited due to missing information.

10. Effective conclusion about the implications for physiotherapy education, research, and/or practice: See below.

Detailed comments and feedback

Abstract

Consider the points made under each heading, then update to abstract to reflect any changes.

Introduction

  1. You have not offered a citation to support this sentence: “It has been shown that one third of adolescents report musculoskeletal (MSK) pain monthly and prevalence of MSK pain increases from childhood to adolescence.”
  2. Physical activity is not the same as motor development, how can you be sure the latter is a problem? We should be careful not to create problems if no problem exists, and of creating an intervention or treatment need when none is required.

Methods – School physiotherapy pilot

  1. You present the aim in this section, it fits better at the end of the Introduction. Consider if the aim is as you describe it, or if by undertaking a pilot project you are setting out to find out if this model is useful, viable, etc.
  2. This sentence “Physiotherapy students, who participated in this pilot , were at the end of their studies and this practice was at least their third placement.” could be made clearer, it is not obvious to the reader (at least me) how much clinical placement experience the students have under their belt at the time of taking part in the pilot.
  3. It would be useful to know the age range and overall number of the pupils involved.
  4. By this sentence “Shared reflection was perceived important for students.” did you mean important for students or someone else? Or important by students?
  5. It would be useful to know how the apparent popularity of the groups was measured (if a pupil didn’t enjoy the groups she might not openly share this),
  6. Can you clarify some aspects around this sentence: “Students were involved in health evaluations, where they provided health-promoting advice especially to overweight, obese and inactive pupils.” Did the students target only those pupils who were overweight, obese, or inactive? How was this established? Was this selective information-sharing hidden from the other pupils? There are some potential ethical issues around how this was carried out, please provide more information.
  7. The spinal assessments for scoliosis needs to be explained further, including any associated limitations. Was it the forward bend test (Adan’s test), plumb line, anything else? Was it testing for idiopathic and postural scoliosis?

Results

  1. You could offer more information about how you evaluated the project; how did you collect feedback and from who?
  2. It would also be useful to understand the cost associated with such a project, not least to be able to justify this approach on a long-term basis from a cost-benefit perspective.

Discussion

No section on this. Consider writing this section to discuss the possible implications and limitations of your pilot project, and to offer insights into the viability and value of expanding the initiative on a bigger and/or continuing basis.

Conclusion

I don’t think you have presented compelling arguments for why school physiotherapy is ‘necessary’. By “…for improving physiotherapy for school-aged children and adolescents.” you have possibly fallen into the trap of aligning the profession (physiotherapy) with an intervention. Or I might have misunderstood the intended meaning here.

1. Complete, coherent, and well-organized presentation

Thank you for submitting this article. I think this is an interesting idea and pilot study. I want to encourage you to continue with this work because I think it is of value. I certainly like the idea of the profession increasing its deployment of staff beyond traditional healthcare settings (i.e., hospitals and homes).

Currently, I think it is incomplete, because it omits to report on important governance arrangements that I would anticipate the physiotherapy school and the education school would have put in place.

It sounds like a good idea, and something that is superficially of value – but if you are to report on what you did, then it would help to provide more details, otherwise you raise more questions than you answer. I will try to give examples of what I mean, below.

I think your paper reports on a service improvement project rather than a research study. If you want this to be a research study report, you will need to add much more detail about the background thinking, research methodology and methods, evaluation measures, and points of measurement, etc, to strengthen the credibility and trustworthiness of your report. However, I don’t think this is really what you are seeking to do or report on.

If I’m right and it is a service improvement project, I still think it would help to add in more details of your thinking, the options you faced, and therefore the decisions you made; more information about governance arrangements; how you have evaluated the pilot; and, therefore, why you consider it a success. I’m sure you are, but you don’t currently demonstrate this.

I appreciate this is meant to be a short report. I like the idea and intentions of the work. I want to encourage you to re-read this report and add more details of what you were thinking about as you planned it: what decisions did you make, what safeguards did you put in place, how have you worked out that it was a success.

2. Sufficient explanation of the significance of the problem

I am not sure. You provide details of the importance of physical activity for this age group. You explain that many do not achieve it. You then suggest that physiotherapists can provide this. As this is an international journal, I did wonder if you could supply more details about the nature of physical education provision in Finland – is this provided by sports teachers or schoolteachers who have been volunteered to run physical activity sessions. As such, is this a gap in local school curriculum provision, or have you identified a gap in national level?

3. Clear demonstration of the relevance to the field (beyond the case presented)

I suggest this is implied and that physiotherapists might understand your perspective. However, policy makers and educationalists may need a sentence or two to understand why student physiotherapists can do this safely and effectively.

4. Original contribution to the topic of physiotherapy education

Yes. I think so, though I am not familiar with the literature of physical activity in primary school children, or education provision in Finland. I can see, and would agree, that physiotherapists, or the physiotherapy profession in Finland, could expand its service offer by offering a more comprehensive physical activity service in the community, beyond healthcare services, by providing primary prevention public health services. I think it would help your case, were you to say this.

5. Compelling presentation of the problem within a theoretical framework (where appropriate)

I think this needs expanding. See my previous point.

6. Establishment of a relationship between the problem and other relevant literature

More would strengthen the paper. For example, what specifically were you hoping to achieve? Is this about expanding the placement provision for student physiotherapists, filling a gap in the school’s curriculum that has been identified, or supplementing or strengthening what is already provided?

7. Appropriate research design and method

I suspect this is a service improvement project rather than a research study. If it is the latter, then much more detail about the theoretical perspective, research methodology, and research methods, including measures, are needed.

If it is a service improvement project,, it would still benefit from describing in more detail the governance arrangements, and measures of activity, to give a stronger sense of what happened, and what improvements the pilot showed. As it is, the report seems to suggest that getting physiotherapy students to run a physical activity session “works”: what is it that “worked”? Do you have any independent feedback: from students, from parents, from the teachers – to strengthen your evaluation?

For example, in the School physiotherapy pilot section you say:

“Students organized physical activity groups, e.g., exercise, motor skills training and relaxation groups”.

What sort of exercise, what motor skills training, what relaxation groups? Was this individualised, or group work? How did the students manage students with diverse needs, abilities, and motivation?

“According to students, these groups were popular amongst the pupils.”

Can you provide more evidence? If you can’t, it may be worth saying so, and suggesting that you would do so, as you roll out the pilot. Were these groups popular with literally everyone, or a large majority? Did they prefer some forms of physical activity over others? Did some just like the relaxation classes?

“Students were also involved in exercise classes with teachers, where they organized activities which developed motor skills and helped the pupils who had special needs.”

I think more detail would make this more powerful: how often did the teachers get involved, and why? Was this to help a student who was struggling with a given child, or because the teachers enjoyed the activity? Were teachers learning new skills that they planned to take on themselves? What was the incidence of children with special needs, what type of special needs, and how did the students manage this? Answers to these questions strengthen your evaluation and report.

“Students were involved in health evaluations, where they provided health-promoting advice especially to overweight, obese and inactive pupils.”

Can you describe how this was undertaken, and what governance arrangements were in place to prevent the student, with the best of intentions, from delving into personal problems? I can imagine this requires a great deal of sensitivity and could open all sorts of issues: which are worth opening up for the child but would need great care to do so safely.

“Students with school nurses also performed spinal assessments for scoliosis and if necessary, gave physiotherapeutic guidance and advice for exercises.”

This potentially expands the pilot from offering physical activity opportunities, to much more individualised and bespoke work; it might also stray into national public health schemes: all potentially worthwhile, but complex.

“Physiotherapy students also gave individual targeted advice to pupils who had musculoskeletal pain.”

Again, this might be useful opportunistic health care, but strays into becoming a specific healthcare episode of care: so, how was this managed: what governance arrangements, record keeping, etc were in place. How was the student supervised to ensure they conducted an appropriate examination and assessment, and gave appropriate advice, and were able to refer on, when necessary?

8. Accurate and useful interpretation

Limited: needs development. In the section, Results of the school physiotherapy pilot, you do not actually provide any results. Rather you say what will happen next.

9. Sound argument and analysis

Needs more reflection on the outcomes and what you think it means.

10. Effective conclusion about the implications for physiotherapy education, research, and/or practice

Limited.

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