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Introduction: Cardiac rehabilitation is an interdisciplinary treatment in which the physiotherapist has a central role. The aim of this paper is to describe the organization of cardiac rehabilitation in Norway and to summarize the evidence with a focus on the role of the physiotherapist. Main part: A description of the phases of cardiac rehabilitation in Norway is presented. The focus is kept on the two major dominant patient groups: coronary heart disease and chronic heart failure. Additionally, the paper presents knowledge and experiences from other patient groups referred to cardiac rehabilitation. Conclusion: The physiotherapist is essential in the interdisciplinary team and is often the one following the patients over time. There is no doubt that exercise is a cornerstone of cardiac rehabilitation. However, cardiac rehabilitation is more than exercise, and the physiotherapist should have knowledge of various diagnoses to provide evidence-based follow-up.

Introduction: The paper describes a model for assessing body image in patients with obesity and binge eating disorder. The aim is to contribute to the physiotherapeutic body of knowledge concerning bigger bodies. The paper is rooted in a pilot project conducted at Nord-Trøndelag Hospital Trust. Main part: Disturbed body image is a central feature in binge eating disorder. Cognitive aspects of body image are traditionally the focal point in evaluation and treatment, although research also highlights preconscious, sensorimotor experiences, often interwoven with shame and relational interactions. A theoretical and empirical statement and a threefold model for examining body image in this patient population is described. Sum up: Rather than offering exercise-based treatment for weight reduction, physiotherapists should focus on movement as a source of strengthened contact with one's body and surroundings, in a shame-sensitive manner that encourages new relational experiences.

Introduction: Shoulder pain is one of the most common musculoskeletal complaints and the term ‘subacromial pain syndrome’ is used to describe the most common clinical subgroup. A recent practice guideline for surgery concludes that subacromial decompression should not be offered to patients with subacromial pain. Subsequently, the Norwegian Secretary of State for Health, Bent Høie, in an interview advised that this patient group should receive the most effective treatment, namely physical rehabilitation. Main section: The current paper provides an overview of evidence-based physiotherapy treatment for patients with subacromial pain and discusses relevant evidence. The paper then outlines knowledge gaps, such as the degree of supervision and the content of exercise regimes. Recommendations from leading musculoskeletal research teams suggest an increased focus on self-efficacy and self-management. With this in mind, the authors discuss future directions for treatment of shoulder pain. End section: With the more prominent role physical rehabilitation now has been given, it is necessary for the physiotherapy profession to respond honestly and responsibly. The treatment model should be further developed in line with evidence, and this might challenge the current knowledge-base of physiotherapists.

Introduction: Low energy availability (LEA) is a condition with potential severe consequences related to health and athletic performance. One such consequence is impaired bone health. The aim of this paper is therefore to describe risk- and associated factors for LEA, and the role of the physiotherapist in identification and management of the syndrome «Relative Energy Deficiency in Sport» (RED-S). Main part: A literature search identified 19 papers that were included in this paper. Both biological, psychological and sociocultural factors are associated with LEA in athletes. Athletes in weight-sensitive sports, female athletes, para-athletes, athletes with certain personality traits, recurrent non-healing injuries, and athletes with a history of dieting, stress fractures and/or menstrual disturbances seem to be at increased risk of LEA. Physiotherapists have great potential for early identification and management of RED-S by implementing and using available screening tools. Collaboration in multidisciplinary teams seems important for the reversing of LEA and its associated health- and performance consequences. Ending: Athletes who seek help from physiotherapists due to bone stress injuries and/or musculoskeletal pain might be at increased risk for RED-S. Physiotherapists therefore play an important role in identifying, and as a collaborative partner in management of the syndrome RED-S.

Nudges and incentives can be—and are—used in physiotherapy treatment to alter and steer patients’ behaviour. In this paper, we first investigate the conceptual difference between nudges and incentives. Thereafter, we conduct an ethical analysis of these two techniques for influencing behaviour, pointing to different aspects that may have ethical importance for physiotherapy practise. We conclude that while employing nudges and incentives in physiotherapy treatment raises distinct ethical issues in light of their conceptual differences, there is a common moral imperative for physiotherapists to provide and discuss the reasons for employing nudges and incentives with the public and/or the patients.

Introduction: In sport, core training has been used as a supplement to traditional training modalities. The scientific literature has significantly increased the last decade whereas core training has been embraced and conceptualized among clinicians, the fitness industry, exercise enthusiasts, and in sport. Main section: In the paper “Core training promises more than it can hold: A review of current literature and practical experience” the authors criticize the lack of scientific evidence to improve performance in sport and to prevent injuries. We support a lot of the critic, but there are sections which lack details and precision especially regarding performance in sport. Furthermore, the authors find it problematic not to include the latest decade of research in the overview. Summary: The status of knowledge is moved in the field of practice and in science, but in different speeds. Still, lack of evidence is not the same as rejecting a hypothesis. Therefore, and the question we ask is not whether an athlete should conduct core training or not, but who?

Charcot-Marie-Tooth disease (CMT) is a hereditary neuromuscular disease primarily affecting the nerves in the feet. Physical activity is reduced in persons with CMT due to several symptoms that impair gait and balance. This paper, which is based on the authors’ experience from the clinical field and an unsystematic selection from the literature, presents how CMT symptoms affect physical activity, the effects of exercise and physical activity, and recommendations for physiotherapists working with CMT patients. The research evidence in physical activity for people with CMT is sparse. However, low to moderate aerobic exercise and strength training are safe and can be recommended. Individualization is important to meet each patients’ specific needs, and should be managed together with a physiotherapist. Enjoyable and social activities in the outdoors can also be excellent arenas for physical activity, and there are several available activity aids, arrangements and organizations that can contribute to an active lifestyle for people with CMT.

Introduction: The elbow joint plays a significant role in upper extremity function. Limited elbow function may prevent the ability to perform daily life activities, physical exercise as well as impairing workability. A number of different treatment measures for rehabilitation after elbow fractures has been described in the literature, but the effects of the various measures is not known. The current paper aims to identify recommendations for rehabilitation after elbow fractures with an evidence-based practice model. Main section: This article is based on current studies on patients with elbow fractures and relevant knowledge-based medical encyclopaedias on the subject. In particular, early mobilisation is a recurring treatment measure both postoperatively and after the immobilisation period. Apart from motion exercise, the effect of immobilisation and other mentioned treatment measures on elbow function is assessed, as well as the duration and extent of the rehabilitation period. End section: The review of the literature gives no clear recommendations for rehabilitation after elbow fracture. Some recommendations seem to have a strong empirical base and the lack of knowledge is evident on several areas. In spite of this, the value of the various treatment measures should not be depreciated. Early mobilisation can be recommended both postoperatively and after the immobilisation period. Immobilisation following a fracture may not have a negative effect on joint motion and elbow function following a fracture. Individually adapted treatment is recommended and should be adapted to the patient's progression. Most elbow fractures regain their range of motion within three months, while complex injuries require longer and more extensive rehabilitation. There is a need for high quality research on rehabilitation for elbow patients.

Objective: To clarify theoretical understanding underpinning physiotherapy practice for patients with rheumatic inflammatory diseases. Methods: Physiotherapists at Lillehammer Rheumatism Hospital in Norway, and a researcher collaborated to clarify what physiotherapy practice implies. Scientific papers related to physiotherapy for rheumatic diseases were read and facilitated reflections about own clinical practice. The conversations were tape recorded and analysed after each meeting. Preliminary analyses inspired questions for further elaboration and selection of new articles to be read. Results: Physiotherapists focused earlier mainly on relieving symptoms, preventing and reducing disease-induced functional limitations. During the last 20 years, an increasing emphasis is on enabling patients to continue to work and perform regular exercise to prevent physical inactivity, loss of physical capacity, and comorbid lifestyle diseases. The physiotherapists also underlined the importance of using their “hands as instrument" in their examination and treatment. Two different ways of interpreting body, movement and function can justify physiotherapy practice; one related to disease and function capacity and the other to patients' bodily illness experiences disturbing connectivity to own body and life. Conclusion: Both objective and subjective theoretical understandings of body and functioning underpin what physiotherapy for rheumatic diseases may entangle.

Personal health responsibility has different meanings. One might mean that unhealthy lifestyles bring about disease and illness, or that the outcome of physiotherapy treatment depends on the patient’s effort. But it can also mean that we have moral obligations towards ourselves, those close to us, or the society. When these obligations are not met, personal responsibility can entail guilt and blame. The purpose of this paper is to show how the concept accommodates both the uncontroversial and the far more controversial. Therefore, there is a danger of talking past each other when discussing the topic. Since personal responsibility is a natural part of physiotherapy, through the emphasis on training and home exercises, there is reason to think about the concept.

Purpose: Prioritization guidelines are supposed to support the physiotherapists in prioritizing inquiries. NOU 2018:16 has given three national criteria for prioritization: severity, benefit and resource. The purpose of this study is to look into how the private physiotherapists evaluate the urgency of inquiries, whether the three criteria for prioritization are reflected in the physiotherapists` justifications of prioritization, and whether the local guidelines for prioritization are helpful for the physiotherapists. Design: The study has a qualitative approach. Material: 837 inquiries to physiotherapy in private practice in two municipalities. The physiotherapists gave each inquiry a priority from 1-4 using the local guidelines for prioritization. Method: The texts with the physiotherapists justifications of prioritization were analyzed using hermeneutic text analysis. The analyzed material was assessed against the local guidelines for prioritization and the national criteria for prioritization. Results: This paper presents three different results: The private physiotherapists prioritized in two different levels and not four, according to the local guidelines for prioritization. The local guidelines for prioritization are not distinct enough about how the national prioritization criteria should be used. Some priorities were not in line with national priorities. Conclusions: This study adds new knowledge about how private physiotherapists prioritize. The local guidelines for prioritization should be reevaluated to reflect the national criteria for prioritization.

Recovery as personal healing work – experiences of patients with persistent musculoskeletal pain conditions Persistent musculoskeletal conditions are frequently occurring in the population. Often these patients consult physiotherapists in primary health care. However, physiotherapists may feel falling short in helping these patients. Clinical guidelines recommend patients to do life style changes and conditioning exercises. But patients do not seem to comply well to such interventions. The purpose of this paper is to shed light on what it is like to be ill and recover from a patient perspective. The presentation is a synthesis of what is learnt over years by studying illness and recovery experiences of patient with inflammatory or medically unexplained musculoskeletal conditions. Central in patients’ illness experiences is how an unreliable, strange body disturbs daily life and makes it difficult to fulfill social roles and obligations. The patients’ recovery experiences include patients strive to refamiliarize with their body and rebuild a tolerable, but still meaningful life. Mostly, the person’s recovery is constituted by a rather bodily work of learning from movement experiences. Thus, recovery comprises processes of recreating coherence between body, daily life and social self.

Introduction: Evidence-based practice involves making decisions based on systematically collected knowledge from research, experience and users. Physiotherapists are expected to keep themselves updated within a range of fields, but the knowledge may be poorly available and difficult to translate into practice. The aim of this paper is to describe the process and share experiences from working with guidelines for evidence-based practice within paediatric physiotherapy in Trondheim Municipality. Main part: Through FYSIOPRIM, which is a research program for physiotherapy in primary health care, we have established structures for collaboration and development in Trondheim Municipality. The collaboration between researchers and physiotherapists seems beneficial in working for evidence-based practice. We have created a 3-step model for development of guidelines, consisting of preparation, organisation and execution. We here present the various steps and discuss experiences with this work in Trondheim Municipality. Conclusion: In this process of developing guidelines, we have used a method that has worked well in Trondheim Municipality. We think this model can be transferred to other municipalities working with guidelines for evidence-based practice in primary health care. We hope that this will stimulate other municipalities to develop knowledge within paediatric physiotherapy.

Introduction: Goal setting is paramount in definitions of rehabilitation; in laws, regulations and in descriptions of clinical rehabilitation. Theoretical foundation and evidence for the use of goal setting in pediatric rehabilitation are unclear, which is ethically challenging. Main part: Goal setting serve several purposes. This paper discusses theoretical foundation, evidence and purpose for the use of goals in pediatric rehabilitation, especially in relation to meaning and play. Sum up: Goal setting is important and complicated. We need more knowledge in connection with goal setting within pediatric rehabilitation contexts.

Aim: Health-related information is easily accessible on the internet, and a high proportion of the Norwegian population use the internet for health-related queries. This paper reports from a study of how people search, evaluate and act upon this information. E-Health literacy is used as theoretical framework. Material and method: The Norwegian data is drawn from an international comparative study with a mixed method design; two surveys and qualitative interviews with 16 participants. The material is thematically analysed. Results: E-Health literacy refers to the ability to seek, appraise and apply health information from electronic sources. The participants had high competence in information seeking, but low education corresponded with low appraisal skills. The application of internet based health information did not correspond with education level. Internet searches served different purposes: uncertainty, assisting others, information needs, or sensitive topics. The participants crosschecked the information against authoritative sources; and discussed it with family, friends or health professionals. Conclusion: The participants had high competence in information seeking, but differed in capacity to appraise their finds. Physiotherapists should acknowledge patients’ internet competencies and utilise their desire to learn as a resource for treatment and empowerment.

Purpose: Presence at work may cover more than just physical presence. From this starting point, this study investigates what factors promote a sense of good presence in the workplace. This paper may contribute to the debate about absence and presence in worklife. Material: The study was conducted in threee different municipal nursing-homes, and included nine employees from these worksites. Method: Nine face-to-face in depth-interviews were analyzed by qualitative databased content analysis. Results: Good presence is described as a condition emerging from the experience: that work in itself is meaningful and creates engagement; a balance between challenge and mastery; reciprocal trust between leaders and employees; and leaders who act as facilitators and role models for good presence. Conclusion: Good presence and absence are affected by the same factors but good presence requires a greater complexity of factors. Good presence, as emerged from this study, will likely promote a sense of having a good worklife for the workers, and thereby increase the quality of service they provide, which will benefit the patients, their families and the society as a whole. Increasing presence could be a purpose in itself, independent of whether it will reduce sickness absence or not. The conditions that facilitate good presence should therefore be high-lighted in the debate about presence/absence in the workplace.

The development of the Animated Activity Questionnaire is a European project including Denmark, France, Italy, the Netherlands, Spain, England and Norway. This paper is based on data from the Norwegian part. Objective: To test a computer-animated Questionnaire (AAQ), an innovative method for assessing function in patients with hip and/or knee osteoarthritis (OA). The new method is compared with established methods for measuring function. Design: The study is a European collaborative project and has a cross-sectional design. The Norwegian part is implemented as part of the research program FYSIOPRIM. Material and methods: Patients with hip and/or knee OA and relatives were recruited from four physiotherapy clinics. Patients answered questionnaires (HOOS/KOOS ADL and AAQ) and completed performance tests. Relatives rated patient’s function using the AAQ. Five a priori hypotheses were defined for validation of AAQ (construct validity). Results: 60 patients with hip and/or knee OA and 29 relatives participated. The correlation between AAQ scores for patients and relatives was very strong (r = .80). Patients AAQ-scores correlated strong/very strong with both H/KOOS ADL (r = .74, p < .001) and with performance tests (r = - .63 to - .66, p < .001). The correlation between pain and AAQ was weaker than between pain and H/KOOS ADL, but stronger than between pain and performance tests. Conclusion: Four out of five hypotheses were met, and it is concluded that AAQ is comparable with established methods of function in patients with hip and/or knee OA (construct validity). The standardized and readily available data-animated tool AAQ may be suitable for use in clinical physiotherapy practice.

Introduction: Most stroke survivors experience gait difficulties to some extent. Regaining independent gait is an important aim in stroke rehabilitation and is closely related to activity and participation in several community areas. This paper presents an overview of studies concerning stroke survivors with gait velocity and symmetry as the main focus. Main part: Chronic stroke survivors walk more slowly than healthy individuals and their energy expenditure is 1, 5-2 times as high when walking at the same velocity. Slow gait can by being less automatic, contribute to higher energy demands, while faster gait is more energy efficient due to more coordinated movement patterns. Gait velocity can be increased through gait related endurance training and high intensive functional strength training. However, the evidence supporting that strength- and gait-related endurance training might lead to more symmetric gait patterns, is insufficient. Summary: Although gait velocity is a reliable measure of improvement of gait, it does not adequately reflect independence in complex outdoor environments. Keeping a comfortable gait speed with less muscular effort, is perhaps more important than fast walking, as this might lead to a more functional and flexible gait where the individual is able to change velocity as needed.

Introduction: Cerebral palsy (CP) is a permanent neurological disorder occurring in two per thousand children. The risk is increased among children born prematurely. The plasticity of the brain is highest from 2-3 months before and until 6-8 months after term. Still, median age for diagnosing CP is 15 months. Aim: The aim of this article is to address how physiotherapists might be able to identify and treat children at risk for CP before they are diagnosed with CP. The article is based on searches in commonly used databases over peer-reviewed papers. Result: The literature shows that children at risk for CP can be identified already at three months of age by combining examination of the quality of movements with findings from neurological examination and brain imaging. However, studies on effect of different interventions on motor development have shown inconsistent results. Recent physiotherapy interventions have shown positive results. There are several problems in studying effect of physiotherapy, due to the fact that CP is a very heterogeneous condition. Studies in the future may benefit from focusing on subgroups of children with risk for CP.

Objective: This article describes participant characteristics in health promoting groups for community-dwelling older adults, the feasibility of the exercise model and the effect on physical functioning. Design: The study is a clinical quality assurance project. Material: Fifty older adults recruited from newspapers announcements and publicity in the community performed pre testing prior to participation. Of these, twenty-eight completed post-testing after seven months of group exercise. Methods: Physical functioning was assessed by the Senior Fitness Test (SFT), the Falls Efficacy Scale-International (FES-I), and the Physical Functioning scale from Short Formular 36 (SF-36). Group exercise lasted for one hour once a week, and included strength, balance and flexibility exercises. Results: Participants mean age was 78.2 years (SD 6.2) and 80 percent were women. 38 percent had suffered a fall within the past year. 90 percent reported good health and 84 percent reported fear of falling. The compliance with the group exercise was 82.9 percent. There were no improvements in SF-36, or SFT, but a reduction in fear of falling from 23.3 to 21.6, on a scale ranging from 16 to 64 (p=0.023). Conclusion: The paper describes a low cost group exercise model and how it can be carried out as an initiative to maintain physical function in community-dwelling older adults. In order to improve physical function the group exercise of 0.7 x per week should be combined with home exercise programs or other physical activity programs.

- The effect of exercise therapy on chronic musculoskeletal pain is generally low and moderate at best. In this paper a new exercise treatment method, Neurac, is described with theoretical background, development, main content, and documentation. - Neurac is a treatment method that aims at regaining normal functional movement patterns in patients with musculoskeletal disorders, by using high levels of neuromuscular stimulation - This is an active treatment approach including four main elements: 1. Bodyweightbearing exercises utilizing the Redcord sling system, 2. Controlled vibration to selected body parts, 3. Gradual increase of resistance (work-load), 4. No pain or no increase of existing pain. - A newly developed vibration apparatus, Redcord Stimula, is often used to augment neural adaptations by a potential increase in activation of muscle spindles. The Neurac method also includes testing procedures for neuromuscular function of the kinetic chains, and the integration of «local» and «global» muscle function. - Theoretically, Neurac is based on supporting research on bodyweightbearing exercises loading the biomechanical chains. Further, based on neuroscience and clinical trials the method utilizes vibration to increase neural drive and to decrease pain. - The development of the Neurac-methodology has emerged from the S-E-T concept (Sling Exercise Therapy). The new methodology involves use of the Redcord Trainer (formerly called TerapiMaster), workstation and the vibration apparatus. - Documentation: Systematic observations in the clinic show changes after implementation, but research is needed to evaluate the efficiency of the Neurac-method as a physiotherapeutic tool.

Much attention has in the recent years been given to the concept of neuromuscular training (NMT), and it has been argued that such training should replace traditional regimes in the rehabilitation of athletes with ruptures of the anterior cruciate ligament. The present paper argues that the concept of NMT is poorly defined, that the theoretical basis of the concept and the training is unclear, and that the training is not really new. An alternative explanation of NMT is proposed, based on the literature on motor control and motor learning. It is argued that what has been presented as NMT has long been known in this literature under the name of coordination, and that the training can be described as coordination training of gradually increased complexity.

In Norway there is a rising concern for the health status of the population as the average weight in the adult population Norway has increased over the last few decades. A similar trend is found among children and adolescents in other countries, with an increasing number of overweight and obesity. This paper is a review of the probable causes of obesity in childhood and adolescents. The issue of how physical activity may affect the development of obesity is discussed, together with the risk of developing cardiovascular diseases as adults. In contrast to what has been observed in other countries an increase in average weight among children and adolescents in Norway over the last decades has not been recorded. There are several confounding factors that make it more difficult to determine the impact of physical activity on weight-control in children than in adults. Nevertheless, most studies conclude that physical activity level is an important determinant of body weight control and may to some extent reduce the risk of cardiovascular disease in adulthood. Physical activity in children and adolescents should be emphasised in the prevention of obesity and cardiovascular diseases in adulthood.