WP 1:Effectiveness Ofastructuredintervention Forimprovingmotorskillsin Danishpreschoolchildren

Additional file1

WorkPackages1-8

WP 1:Effectiveness ofastructuredintervention forimprovingmotorskillsin Danishpreschoolchildren. Arandomisedcontrolledtrial.

Background

Therearereportsofrandomisedcontrolledtrialsindicatingthatchildren’smotorskillscanbeimprovedthroughinterventionsinpreschool,butthestudypopulationshavebeen small,theintervention periodsshort(<12 weeks),and thefollow-up periodslessthanhalf a year(1).Thus,there isan urgentneed for highqualitystudiesinvolvinglargersamplesandlongerintervention and follow-up periods(seemain body oftheprotocol).

Besidestheimportanceofa child´sactualfundamental movementskills,perceived motor competenceseemstobeimportantinsupportingphysicallyactivebehaviour,anditisthoughttobeakey motivationalfactorinsupportingengagementinphysicalactivitiesandsports(2-4).Perceivedmotorcompetenceisdefinedaschildren´sself-perceptionsabouttheircapabilitiesinphysical ormotordomains(5,6). Althoughchildren haveunrealisticperceptionsof actualcompetenceduringtheirearly years,Stoddenandcolleaguesarguethat aperceivedhighlevelofmotorskillsmightbe oneofthereasonsto engageinphysicalactivitiesduring theearly childhoodyears.Thehypothesis isthat children with lowperceptionsof competencefindphysicalactivitylessenjoyablethan theirpeerswith higherperceptionsof competence and thus are lesslikely to bephysicallyactiveandmaybedrawnintoanegativespiralof disengagement(2).

Furthermore,children with high perceptionsof competenceare likely toselectchallenging tasks,enjoythelearningprocess,exhibithigherself-esteem,exertgreatereffortto masterskills,andpersistintheface ofdifficulty(3,7).

Objectives

Theprimaryobjectiveof thisworkpackage istodeterminetheeffectivenessof an adaptablebutstructuredinterventiontoimprovemotorskillsandperceivedmotorcompetenceinpreschoolchildren.

Intervention

Seemain protocol and Appendix2.

Variables

Primaryoutcome:

Motorskillsasassessedby theMovementABC-2(asdescribedinthemainprotocol)atthe 18 month follow-up (spring 2018). At this point, the children will have received the intervention for 12 months after a six months phase-in period.

Secondaryoutcomes:

Child’sperceived physicalcompetence

Theperceived motorcompetencerelatingtoeveryday activitieswillbemeasuredbythePerceivedPhysicalCompetence(PPC)subscaleofHarterand Pike’sPictorialScaleofPerceived Competenceand SocialAcceptance(PSPCSA)forpreschool-andkindergarten-agechildren (4to 7 years)(5).The PPCsubscaleassessesthechildren’sself-perceptionsrelated to theirabilitytorun,hop,swing,climb,tieshoelaces,andskip.Oneachpictorialplate,twopictures willbedisplayedsidebyside;onepicturedepictsa childwhoiscompetentin a particulartask,andtheotherdepictsa childwhoisnotcompetent.Thechildselectsthepicturethatismostlikehim/herself.Then,thechild focusesontheselected pictureand indicateswhether

(s)heis‘‘alittlebit like’’thechildinthepictureor ‘‘alot like’’thechild in thepicture.Therange of scoresforeach item onthesubscaleis 1 (lowcompetence)to4(high competence).Theinstrumenthas an internalconsistency fortheindividualPPCsubscale forpreschoolchildrenof 0.62 (5).TheassessmentofthePPCsubscaletakes around5 minutes.

Parent-perceivedmotorcompetence

Theratingof parents’perceptionof theirchild’sathleticcoordinationcomparedtootherchildrenof thesameagehasoften been relatedto preschool-agechildren´sactualphysicalactivity(9-11). Anoften usedquestion forthisassessmentis “Comparedwithotherchildren ofthesameage and sex,howwould youdescribeyourchild’slevelof athleticcoordination?”with a responseona5-pointLikertscale,from1(muchless coordinated)to5(much morecoordinated)(10,11). This question will be included in theparentalbaselinequestionnaireandalso mailedto theparents atthetimeofthe lastfollow up before the child leaves preschool.

Lengthoffollowup

Theduration ofthefollowupis 6 to30 months,whichcoverstheperiod fromthebeginning oftheintervention untilthelastmeasurementbeforethechild leavespreschool(seeFigure 1 inthemainprotocol).

Analysesofeffect

Simpleunivariate statistics willbeusedtodescribetheoutcomesandcovariatesby preschool.Bivariateanalysisadjusted forthedesigneffectwillbedoneto determine iftherewereanyimbalances inthebaselinecovariatesamong the two groups.

Multilevellinearregressionmodelswillbe constructed to assess theeffectivenessoftheinterventiononmotorskillperformance. Thebaselinevalueoftheoutcomevariable,timesincebaseline,interventiongroupandanyimbalancedcovariateswillbeadded to themodelalongwithpreschoolandsocioeconomicstatusof theareaasrandomeffects. Theinteractionbetweenpreschoolandintervention groupwillbetested. Theassumptionsforthemodelswillbechecked.

Multilevelordinalregressionmodels will be constructed toassessthe effectiveness ofthe interventionontheparents’perceptionoftheirchild’smotorcompetence.Thebaselinevalueoftheparents’perception,timesince baseline,intervention group and imbalancedcovariateswillbeindependentvariables. Theschooland socioeconomicstatusof the areawill beentered asrandomeffectsand theinteractionbetweenschoolandinterventionwillbetested.Themodel’sassumptionswillbetested.

Theaboveanalyseswill berepeatedon a subsample ofchildrenwhowereconsidered tohavea ‘poor’levelofmotor competenceatbaseline.

Ananalysiswillbeconducted to determineifthechildren whodroppedoutof thestudyweredifferentfrom thosewho remained,based onthebaselinevalues oftheoutcomevariablesandthecovariates.

Perspectives

TheSvendborg CityCouncilhasgranted generousresourcesto educatethestaff;the staffatthepreschoolsiseagerto participate; thepreschoolteachershavecontributed tothedesignof theintervention,ensuringa sense ofownership and involvement;and thereisexperiencewithconductinglarge,clusterrandomisedcontrolledtrialsintheMunicipality. Therefore,theconditionsforimplementation of theintervention inthepreschoolsareoptimal. Consequently,ifwecannot showanimprovementinthechildren’smotorskillsusing thisframework,furtherallocation ofresourcestoprogramstoimprovemotordevelopment inpreschoolsshouldprobablybediscontinued.

Ontheotherhand,iftheinterventiondoessucceed,theprogramcaneasilybeappliedinotherDanishmunicipalitiesduetothedesign,whereeachpreschoolappliestheinterventionprinciplesin a way to suittheirindividualconditionsregardingphysicalenvironment,staffing,etc.

Finally, if theintervention improvesmotorcompetencein thechildren with thehighestneed forimprovement,targeted interventionscould beconsideredif,insomesettings,prioritizingof resourcesisnecessary.

Primaryresponsibility

Lise Hestbæk,AssociateProfessor,Departmentof SportsScienceandClinicalBiomechanics,University ofSouthernDenmark.Seniorresearcher,NordicInstitute ofChiropracticandClinicalBiomechanics.

References

1.RiethmullerAM,Jones R,OkelyAD.Efficacyofinterventionstoimprovemotordevelopmentinyoungchildren:a systematicreview.Pediatrics.2009;124(4):e782-92.

2.StoddenDF GJ,LangendorferSJ,RobertonMA,RudisillME,GarciaC,GarciaLE.Adevelopmental perspective onthe roleofmotorskill competencein physical activity:Anemergentrelationship.Quest.2008;60:290-306.

3.weissMRAA.Children'sself-perceptionsinthephysicaldomain:Between-andwithin-agevariability inlevelauracyandsourcesofperceivedompetence.Journal ofSportandExerisePsychology.2005;27:226-44.

4.BarnettLM,MorganPJ,vanBeurdenE,BeardJR.Perceivedsportscompetencemediatestherelationship between childhoodmotor skillproficiencyand adolescentphysicalactivityand fitness: alongitudinalassessment.Theinternationaljournal ofbehavioralnutritionandphysicalactivity.2008;5:40.

5.HarterS,PikeR.Thepictorial scaleof perceived competenceandsocialacceptanceforyoungchildren. Child Dev.1984;55(6):1969-82.

6.Horn T.Developmentalperspectiveson self-perceptionsinchildren andadolescents. MRW,editor.Morgantown,WV:FitnessInformationTechnology; 2004.

7.HarterS.Effetancemotivation reconsidered.HumanDevelopment.1978;21:34-64.

8.BarnettLM,RidgersND,ZaskA,SalmonJ.Facevalidityandreliability of a pictorialinstrumentforassessingfundamentalmovementskillperceivedcompetenceinyoungchildren.Journalofscienceandmedicineinsport/SportsMedicineAustralia.2015;18(1):98-102.

9.LoprinziPD,TrostSG.Parentalinfluenceson physicalactivitybehaviorinpreschoolchildren.Prev Med. 2010;50(3):129-33.

10.DowdaM,PfeifferKA,Brown WH, MitchellJA,ByunW,Pate RR.Parentalandenvironmentalcorrelatesof physicalactivityof children attending preschool. ArchPediatrAdolescMed.2011;165(10):939-44.

11.PfeifferKA,DowdaM,McIverKL,PateRR.Factorsrelated to objectively measured physicalactivityin preschoolchildren.Pediatricexercisescience.2009;21(2):196-208.

WP 2:ProcessEvaluation

Background

Therationaleforincludinga processevaluation isthatit createsthe possibilityto gaininsightinto whathappensinlocalimplementation processes.Even themostefficient effortswill,in practice,notyieldsignifi-cantimpacts iftheyare notimplemented with sufficientquality.Theinterventiontoimprovechildren´smotorskillsisdescribedingeneralinAppendix2. Itis uptolocalstakeholderstointerpretthecontent inordertofurtheroperationalizevariouskeycomponentsand thusbeable to implementtheintervention(1).

Overall,theprocessevaluation buildson theworkofMichaelQ.Patton,whichdealswithso-calledutilization-focused evaluation.Thisapproachenablesthe monitoringof activitiesand outputs to delivercontinuous and solid feedbackto those directly involved intheintervention and other keystakeholders.1Inlaterstages,theprocessevaluation willcontributetogeneratinginformationaboutintervention doseand quality,e.g.dose-delivered,dose-received,consistency,appealandfidelity.

Theprocessevaluationwillbeguided by theRE-AIMframework(2).Thisensures a holisticassessmentof interventionimpacts -focusing notsolely oneffectiveness,butalso ontheprocessof delivery and how,and towhatdegree,themain interventioncomponents areinstitutionalized.Formorethan fifteenyears,RE-AIM hasbeenwidelyused to enhancethequality,speed,andpublichealthimpactofeffortsto translateresearchintopractice.

Objective

Toassessthe implementation aspectsof theintervention toimprovemotor skills.

Variables

TheRE-AIMframeworkconsistsof fivefundamentalquestions:

Reach: Howmanyintheoveralltargetgroupcanandareactuallywillingtoparticipate in theintervention?

Efficacy:Whatkind ofmain and broadereffects aretobeexpected?Information on the positiveand negativeeffects(intentionalornot)of an intervention is included.

Adoption –setting level:Howmanypotentialsettings arewillingand/orableto participate?

Adoption – staff level: Canandwillthosewhoaresupposedto executetheintervention actuallycommitthemselves? The capacityand motivationof differentprofessionalgroupstoengageina given intervention,andspecificworkmodesandtoolsdevelopedforthis,areregardedascrucialfortheactualreachand impactofsettings-basedinterventions.Based ontheavailableevidence it must, as far as possible, be explored whichbarriersandfacilitatorsareinplay to movetheprofessional useofeffectiveinterventionsfurther.

1Stakeholdersareindividualorcollectiveactorshavinganinterestinagivenprojectand/orpotentiallybeingaffectedbyitsdeliverables.Inthisresearchprogramfocusisoninternalactorsinterestedinand/oraffectedbythedescribedintervention.Externalstakeholdersencompassallactorshavingastakeintheprogramanditsdelivery,withouttakingactivepartinanyinterventioncomponentsand activities(3).

Implementation:How consistentlyistheintervention,anditsvariousparts,delivered?Fidelityissuesof theintervention comeintofocus;if theinterventionwentas planned; whatactuallyhappened,andwhy;and if theeffectscorresponded towhatwasexpected and intended. A furtherimportantpoint isto whatdegreetheintervention ismodified overtime.

Maintenance –individualand setting level:Can a givenintervention anditseffectsbemaintainedovertime? Thispointisoftendecisive inconnection with an overallevaluationofan intervention. In relation totheindividualend user,the maintenanceissue is about the ability tokeep up changes in health-relatedhabitsand routines promoted bya given intervention.At theorganizationallevel,themaintenanceissuecenterson,for instance, thefeasibility ofmaking theinterventionpartof day-to-dayoperations.

The tablebelowillustrateshowthe RE-AIMframeworkwillbefurtherprimedinthisparticularproject.

ElementLevelDescriptionMeasureAssessment
Reach / IndividualThenumberandcharacteristicsof
(targetpopulation)participantsthatre-
ceive,orareaffectedbytheintervention / ThetargetpopulationDemographicinfor-
iscomparedtothemationonnonpartici-larger‘denominator’pantsaswellaspar-population.ticipants.
Efficacy
Adoption
/ Program
Implementation
Maintenance / SettingIndividual
(targetpopulation)(targetstaff) / Protocolfidelity,theconsistencyandskillofhowthevariousinterventioncompo-nentsaredeliveredbytargetstaff.
Satisfactionwithandunderstandingofsignificantinterven-tionoutcomesas-sessedbythetargetpopulation,togetherwiththeirnextofkin. / Barriersandfacilita-torsreportedbytar-getstaffandtargetpopulationandtheirnextofkinduringimplementation / Fieldnotesandinter-viewsexaminingim-plementationissues,withtargetstaff,reachedchildrenandtheirnextofkin.
SettingIndividual(targetstaff) / Long-termeffectsonoutcomesmeasuresattheindividuallevel
Theextenttowhichtheinterventionbe-comesinstitutional-izedaspartofthedailyroutinesandorganizationalprac-tices. / Measurestheextenttowhichinnovationsbecomeanenduringpartofthebehav-ioralrepertoireofthepreschoolsetting. / Directobservations,structuredinterviewsande-surveys

Analyses of effect

Preschoolstaff,preschoolmanagersandrelevantpartsofthemunicipaladministration andmanagementinSvendborg,willbeidentifiedandincludedintheprocessevaluation.Keymethodswillbeparticipantobservationof practice,individualandgroupinterviews and e-surveys.Thechildren’sperspectivewillbeexploredviaobservationstudiesandprotocol-basedassessmentsofthepreschool’ssocial andpedagogicalenvironments.Participantobservation andgo-alonginterviewsareappliedtocapturethechildren’sexperiences(4-6).

Thedatacollection willbegininthespringof 2016andcontinuesimultaneously withthelocalimplementation processesuntilthespring of2019.

Perspectives

RE-AIMmakesup akeycomponent inthe compiled frameworkon KnowledgeTranslation (KT)–which inhealth sciencesisgenerallydefinedas adynamicprocessthatincludessynthesis,exchangeandapplicationof knowledgetoimprovehealth and wellbeing and providemoreeffectiveservices(7-8).TheKTapproach isfurtherinformed by Knowledge-to- Action(K2A)approachesdevelopedover anumberofyearsby theCanadianInstitutesof Health Research(CIHR)(9).TogetherK2AandRE-AIMform a systematicandwelldevelopedmethodologicaltoolboxtosupportintegrationof bestavailableresearchevidencewith localcontextandpracticeand,finally,to feed backtothegeneralknowledgebase.Forthis particularproject,itisofvaluetodifferentiatebetweentwo typesofknowledgetranslationprocesses–namelyintegratedandfinalKT.Thelatter isconcernedwith promotingthefindings,experiencesand resultsoftheresearch project.Key messagesforcommunication anddissemination aredevelopedtofacilitatetransferofknowledge,targeting specificaudiences.IntegratedKT,also foundundertheheadings ofco-creationofknowledgeandcollaborativeresearch,referstotheprocesses inwhichKTisinstalledasa continued activity to ensurethatallprojectphasesarebased on thebestavailableempiricalandtheoreticalknowledgebyfacilitatingcloseinteractionbetweenresearchers,endusersandotherrelevantstakeholders(9).

ThebasicpremiseisthatKTshouldbeutility-driveninthe sensethat knowledgegenerated fromresearch(constitutingonetypeof information)isonly completewhen itinformsstakeholders onmattersofrelevanceandimportance,therebyassisting in the development,modification and planningof currentandfutureinterventions.

Primary responsibility

ProfessorJensTroelsen,Research UnitforActiveLiving,DepartmentofSportsScience andClinicalBiomechanics,SDU

AssociateProfessorThomasSkovgaard,Research UnitforActiveLiving,DepartmentofSportsScienceandClinicalBiomechanics,SDU.

References

1. Krogstrup, H.K. (2006).Evalueringsmodeller. Aarhus: Academica.
2. Glasgow,R. E.,Vogt,T.M.,Boles, S.M. (1999). Evaluating thepublic health impactof healthpromotioninterventions:TheRE-AIMframework. American Journal ofPublic Health,89(9),1322-1327.
3. Friedman,A.L.,MilesS. (2006)Stakeholders:Theoryand Practice: Theory and Practice,Oxford UniversityPress
4. Højlund, S. (2002). Barndomskonstruktioner. Påfeltarbejdei skole, SFOog på Sygehus.København:Gyldendal
5. Gulløv,E., Højlund, S. (2006). Feltarbejdeblandtbørn. Metodologiog etikietnografiskbørneforskning.København:Gyldendal
6. Ballegaard, S. A., Grøn, L.,Olesen, E.(2013).Del3:Etbrugerperspektivpå Space. In J. Troelsen (Ed.),SPACE -Rum til fysiskaktivitet. Organisatoriskevaluering og brugerperspektivpåen helhedsorienteret,forebyggendeindsats for børn og unge.Delrapport, januar 2013 (pp. 96-133).Odense:SyddanskUniversitet
7. Satterfield,J. M., Spring, B.,Brownson, R. C.,Mullen, E. J., Newhouse, R.P.,Walker, B. B.,& Whitlock, E.P.(2009). Toward a Transdisciplinary Modelof Evidence-Based Practice. The MilbankQuarterly,87(2), 368–390.
8. KesslerR., Glasgow R. E.(2011) A proposal tospeed translationof healthcare research intopractice:dramaticchangeis needed.AmJPrev Med.2011 Jun;40(6):637-44
9. Straus, S. E.,Tetroe,J., &Graham, I.(2009).Defining knowledgetranslation.CMAJ :Canadian Medical As-sociation Journal, 181(3-4),165–168.

WP 3: Motorperformanceandmusculoskeletaldisorders

Background

Intuitively,motorskillsandmusculoskeletal(MSK)disordersarelinked, but therealityis thataknowledgegap existsand theassociation between thetwo is unclear at present.MSKdisorders arenowthelargestcontributortotheglobalburden of disease(1)andtheleadingsomaticcauseofdisabilityinDenmark(2).Researchpublished over thelastdecadehasconsistentlyshownthatMSKdisordersstartearlyinlife(3-5),andthatbackpaininadolescenceleadstobackpain in adulthood(4). However,whyand howearly MSKdisordersandbackpainoriginatesisunknownbecause,sofar,studieshave mainlyfocusedon children aged12yearsorolder.Importantly,theimmediateconsequencesofpoor MSKhealth earlyinlifeappearto beextensive. Forexample,children experiencingpainmay missschoolandwithdrawfrom sportandothersocial activitiesand are atrisk ofthedeveloping negativehealthbehaviourssuchasphysicalinactivity, when compared to children with goodMSKhealth. Thismayinturnincrease theriskof lifestyledisorderslater in life such ascardiovasculardiseaseor diabetes(6,7).In addition,appropriateuse of the MSKsystem is likelyto decreasetheriskofboth overuseinjuries(8,9),whichappeartoberelativelyprevalentinyoungerchildren(10).Also, theriskoftraumaticinjuriesmightbereduced(11)andseveralmotorcontrolinterventionshavebeenshowntodecreasethe riskoftraumaticinjuriesamongadolescentsandmilitaryrecruits (12-14).

Surprisingly,theimportanceofregularmotorskills training of preschoolchildrenintermsof developingMSKproblemshasneverbeen investigated before.However,there isgoodreason tobelievethatimprovedmotorperformancemayhaveapositiveeffecton preventing problemsofMSKorigin. Firstly,several studiesof focusedmotorperformancetraininghaveshownanincreaseinmusclecontrol,coordination and balanceinadults(15-17).In addition,severalinterventions designed toimprovemotordevelopmentin young children have been shown tobeeffective(18)even atthreeyears’follow-up (19).Secondly,motorperformancetraining ofadultshasrevealedimprovedactivationoftheabdominalmusculatureespeciallywhen challenged bysuddentrunkperturbations(20, 21).This is relevant, aschildren with poorlydevelopedmotorabilities(DevelopmentalCoordination Disorder)oftenshowpooractivityinthesemusclegroups(22).Thirdly,itis likely thatmotorperformancetraining has a positiveeffectonthedevelopmentof‘normal’movementpatterns,resultinginappropriatefunctioningofmechanicaljointsandmuscleload.

Finally,studiesindicatethatimprovedmotorcontrolcanreducethefrequency ofMSKinjuriesintheextremities(12-14).

Highqualitystudiesinvestigatingthepotentialbenefitof improvedmotorskillsonMSKhealthareurgentlyneeded. A prophylacticstrategyfocusingon improvingmotorskillsinpreschoolchildren maypotentiallyreducetheprevalenceofcurrentand futureriskofMSKinjuriesand theconsequencesthereof.

Aim

Thelong-termaimistoimprovethelifecourseof MSK disordersthrough identificationoftargetareasforearlyprevention.

Objectives tobe explored in the RCT

1.To estimatetheeffectof amotorskills intervention onaberrantmovementpatternsandmusculoskeletalhealth.

Objectives tobe explored in the fullcohort

1.Todescribetheageandsexrelatedincidenceandcourse of back-,neck-andextremity-disordersina generalpaediatricpopulation from threetofifteenyears ofage.

2.To establish potential patterns of developmentofmusculoskeletaldisordersfrom threeto fifteenyearsof age.

3.To determinethepotentialrelationship betweenpoor motorperformanceand aberrantmovementpatterns.

4.To determinethepotentialrelationship betweenmotorperformanceat theendof preschoolandmusculoskeletalhealththroughouttheschoolyears.

Variables

Predictors

• Motorperformanceasdescribedunder ‘core outcomes for all WP’s’
• Movementpatterns willbeevaluated by kinematic analyses ofDrop VerticalJumpTestandStanding Broad JumpTest.

Drop VerticalJumpTest

TheDrop VerticalJumpTest (DVJ)is avalidated clinicaltest,in which kinematicsaround thekneeareassessedduringanacceleratedverticaljump froma31-cm.highbox, landing on both feetandimmediatelyfollowedbyverticaljump ashighaspossible(11). Aberrantmovements,including increased valgusmotion, highabductionloads,andincreasedinternalrotationofthehip,hasrepeatedlybeenshownasa riskfactorfor(a)anteriorcruciateligamentruptureamongfemaleathletes(11),and(b)developmentof patellafemoralpainsyndromeamongfemaleathletes(23,24)andmilitaryrecruitsof bothsexes (25).

StandingBroadJumpTest(a.k.a.HorizontalLongJump Test)

TheStandingBroadJumpTest(SBJ)isperformedbyhavingthechildstandbehinda line on thefloor,jumping as far aspossible,and thelengthofthejumpis measured. It isconsidered a simple,cheapand safetest,suitablefortheassessmentoflowerbody maximalstrength in adolescents(26).SBJ hasbeentestedonchildren as young as5 yearsof age,and found to have normallydistributedtotalscoresandgood reliability(ICC=0.88)(27).Furthermore,ithasbeenusedtomonitorchildrenwitheither loworhighmotorcompetence withsignificantdiscriminativeabilities over a5years’period(28).

Measurement equipment

The DVJ and SBJ tests will be measured using the Captury motion capture system ( The Captury is a portable 8-camera high-speed motion capture system which makes no use of any markers, suits or special hardware. A child avatar has been specially developed to be used in the present project in collaboration with Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark. The Captury has been found to be reliable compared to the Vicon motion capture system used as gold standard (unpublished data, article under preparation).

Outcome

Thepresence ofcomplaintsfromthe MSKsystem willbe reportedbySMS-track.Parentswill receivetextmessages(SMS)ona biweeklybasisinquiringaboutthechild´sMSKpainaswellasobservationsofabnormalbehaviourthepastweek.Repliesareautomaticallyregisteredandstored inanencrypteddatabase. The systemhasbeen in useinanother projectintheschoolsof Svendborg Municipalitywheremorethan95%oftheparticipatingfamiliesrespondedeachweek[32]. Avalidationstudy was undertakenin orderto determinethereproducibility oftheSMS-trackreportingwhencomparingitwithverbalreporting.ThesensitivityfortheSMS datawas0.98,specificity 0.87,positivepredictivevalue0.94andnegativepredictivevalue0.95,indicating high validityof data [33].

The SMS questions were developed on the basis of a qualitative study investigating how parents to children aged 3-6 years become aware of their children’s MSK pain. The study derived six themes: ‘wont/can’t use part of the body’, ‘physical signs’, ‘communicate it’, ‘demonstrate it with an outburst’, ‘change of behaviour’, and ‘protect the painful area’. A nominal group technique was used to generate the initial SMS questions and these were subsequently tested in a pilot study. The final SMS questions were:

Introductory SMS:

“Dear Parents.

Thank you for participating in the project Active Children in Daycare.

In the future, you will receive 1 or 2 SMS’s every second Sunday with questions about [child name] muscle and joint pain in the previous 2 weeks. Pain in muscles and joints in children can be detected in many ways. Your child may tell or show it to you, hold the area or protect it and not let anyone touch it. Maybe he/she will use the body in a different way (e.g. avoiding normal movements, limp or not use one arm). It is important that you answer all SMS’s, even if [child name] has not had any pain.

If you have any questions to the SMS’s, please contact project coordinator [name] on [telephone number].”

SMS 1 (every second Sunday):

Do you think you child have had pain from muscles or joints in the past two weeks?

Answer 1 for yes and 2 for no.

SMS 2 (only send out if answering ‘yes’ to SMS 1):

How did you detect it? (Answer with numbers. You can use multiple answer options by using a comma between the numbers, e.g. 1,2)

1. [Child name] told or showed me

2. [Child name] changed the use of his/her body/arm/leg or other body part

3. [Child name] have had a changed mood/behaviour/sleep

Both questionswill be asked during thepreschoolyears.Ifthesameproblemisreportedtwoconsecutivetimes, a researchassistantwillcalltheparentsandofferexaminationand treatmentbyanorthopaedicsurgeon at thesportsclinicatthe OdenseUniversityHospital.

Thus,thethreeoutcomesused foranalyseswillbe:

• Parent-reportedpain
• Parent-reporteddetection of problems
• MSKdiagnosesof persistentproblems

Covariates

Thefollowingcovariates willbeaccounted forwhen analysing theresults:sex,age,socioeconomicstatus,childwell-beingandparentalMSKhealth.

Length offollow-up

Theduration ofthefollow-up will be12years,whichcoversthreeyearsin preschooland nineyears inschool.

Analyses

Multilevellogistic regressionwillbeconductedtodetermineiftherewasa differenceinaberrantmovementproblemsbyintervention group afteradjusting fortimein intervention,imbalancedcovariatesfrom WP1,schooland socioeconomicstatusoftheschool.

MultilevelPoissonregression willbeconductedifthenumberofMSKdiagnosesof persistent problemsdiffersbyintervention groupafteradjustingfortimeonintervention,imbalancedcovariatesfromWP1,schoolandsocioeconomicstatusof theschool.

Theage-specific,sex-specificandage- andsex-specific incidencerate ofMSKconditionswillbecalculated.

Longitudinallatentclassanalysisandlatentclassgrowthanalysiswillbeconductedtodescribe theMSKdevelopmentalpatterns.Thesequentialmodelcomparisons(Tclassesvs.T +1classes)andchi-squaregoodness-of-fittestwillbeevaluatedusingtheparametricbootstrappingtechnique.Lastly,theassociationsbetween classmembershipandtheprevalence of related measureswillbeexaminedusing aconfirmatorylatent classanalysisapproach.

Multilevellongitudinallogisticregression analyseswillbeconductedtodetermineifpoormotorperformanceisassociatedwith aberrantmovementpatternsafteradjusting forage,sexandotherimportantcovariates. The interactionbetweentime and poormotorperformancewillbeexamined.

MultilevellongitudinalPoissonregression analyses willbeconductedtodetermineifmotorperformanceattheendof preschool is predictiveofthenumberofMSKdiagnosesthroughouttheschoolyearsafteradjusting for age,sexandotherimportantcovariates.Theinteraction betweentimeand motorperformancewillbe examined.

Perspectives

TheRCThasthepotentialtoshowtheeffectofamotorperformanceprogrammeonspecificmovementpatterns.Ofequalimportance,theprojectwillbringnew insights into theearlyphasesof MSKproblems,including howand whytheseproblemsarise and developand thetypeof problemschildrenfrom threeto15 years ofage experience.Throughthisrichdataset,wewillbeabletoidentify andrecogniseriskpatternswhich are importantforpreventing futurechronic MSKconditions.Together,thisopens‘awindowofopportunity’forimplementing targeted prophylacticstrategieswiththepotentialtoreducetheriskofcurrentandfuture MSKinjuriesandtheirassociatedindividualandsocietalburden.

Primaryresponsibility

HenrikHeinLauridsen,AssociateProfessor,Dept.ofClinicalBiomechanics,University of SouthernDenmark

References

1.Vos T,FlaxmanAD,NaghaviM,LozanoR, MichaudC, EzzatiM,etal.Yearslivedwithdisability(YLDs)for1160 sequelae of289 diseasesandinjuries1990-2010: a systematicanalysisfortheGlobalBurdenofDiseaseStudy2010. Lancet.2012;380(9859):2163-96.

2.InstituteforHealth Metrics andEvaluation (IHME).GBDCausePatterns.SeattleWI,2013.UoW. Available from:

3.JeffriesLJ,MilaneseSF,Grimmer-SomersKA.Epidemiology of adolescentspinalpain:asystematicoverviewoftheresearch literature.Spine.2007;32(23):2630-7.

4.HestbaekL,Leboeuf-Yde C,KyvikKO,MannicheC. Thecourseof lowbackpain fromadolescenceto adulthood: eight-yearfollow-upof9600twins.Spine.2006;31(4):468-72.

5.AartunE,Hartvigsen J,WedderkoppN,HestbaekL. Spinalpaininadolescents:prevalence,incidence,and course:aschool-basedtwo-year prospectivecohortstudyin1,300Danes aged11-13.BMCmusculoskeletaldisorders.2014;15:187.

6.AndersenLB,BuggeA,DenckerM,EibergS, El-NaamanB.Theassociationbetweenphysicalactivity,physicalfitnessanddevelopmentofmetabolicdisorders.Internationaljournal ofpediatricobesity:IJPO : anofficialjournal oftheInternationalAssociation for theStudy ofObesity.2011;6Suppl1:29-34.

7.Froberg K,AndersenLB.Minireview: physicalactivityandfitnessanditsrelationstocardiovasculardiseaseriskfactorsinchildren.Internationaljournal ofobesity.2005;29Suppl2:S34-9.

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29.WP 4: Motor skills influence on physical activity and overweight, and population-based motor skills

30.reference data

31.

32.Background

33.Engaging repeatedly in various physical activities in early childhood is fundamental for motor skill

34.development. However, poorly developed motor skills may also cause a propensity for choosing habitual

35.activities that are sedentary in nature and a lack of engagement in sports participation in the short and long

36.term, resulting in a vicious cycle. Physical inactivity is a principal risk factor for many poor health conditions,

37.chronic non-communicable diseases, and may ultimately influence longevity. Hence, promotion of physical

38.activity in early life is a critical public health issue. Because children do not necessarily grow out of their

39.motor skill difficulties in early childhood, it is important to closely examine the relationship between motor

40.skills and physical activity from this early stage of life. Understanding the relationship between the two

41.constitutes an essential element needed to inform health and educational authorities as to the reasons for

42.prioritizing motor skill-oriented activity in early childhood.

43.To date, the potential nature of the relationship between motor skills and physical activity in preschool-age

44.children has received little scientific attention. When reviewing the literature, it becomes readily apparent

45.that the majority of the results from past studies are based on cross-sectional data. Furthermore,

46.inconsistent and limited findings make it difficult to determine whether motor skills during early childhood

47.predict habitual physical activity or sports participation later in childhood (1-3). In fact, we are only aware

48.of one study examining the relationship between motor skills during the preschool years and physical

49.activity in later childhood that has used an objective measure of physical activity. This study found that

50.motor skills were unrelated to later physical activity; however, the study was very modest in size and had a

51.short follow-up period (9 months) (1). Randomized controlled trials carried out in the preschool setting

52.with the aim of improving motor skills in healthy preschool children have not examined short- or long-term