Dan Med J 62/11

d a n i s h m E d i c a l J O U R NAL

November 2015

Management of cerebral palsy varies
by healthcare region
Gija Rackauskaite1, Peter W. Uldall2, 3, Bodil H. Bech4 & John R. Østergaard1

ABSTRACTINTRODUCTION: Cerebral palsy (CP) is the most common

type of motor disability in childhood. The aim of the present
paper was to describe regional differences in the management of CP in school-aged children in Denmark.
METHODS: This was a cross-sectional study based on theDanish Cerebral Palsy Registry. The parents of 462 children
answered a questionnaire about their child’s treatment andthe family’s characteristics. Descriptive and logistic regression analyses were performed for every treatment modal­
ity, stratified by the Gross Motor Function Classification System (GMFCS) level and adjusted for family and childcharacteristics.
RESULTS: Significant regional differences were found regarding the provision of occupational therapy at all GMFCS
levels, speech therapy at GMFCS levels II-V and orthopaedic
surgery at GMFCS levels I and III-V. No regional differenceswere observed in the frequency of physiotherapy. We
found no regional differences in the severity of disability.
CONCLUSIONS: Regional differences in the management of
cerebral palsy cannot be explained by social differences ordifferences in the severity of the disability.
FUNDING: This study was funded by the Research Foundation from the Central Denmark Region and the Departmentof Clinical Medicine at Aarhus University Hospital, the Augustinus Foundation, the Bevica Foundation, the Dagmar
Marshalls Foundation, the Ludvig and Sara Elsass Foundation, and the Civil Engineer Frode V. Nyegaard’s and his
Wife’s Foundation.
TRIAL REGISTRATION: not relevant.

Cerebral palsy (CP) is the most common type of motor
disability in childhood. It affects posture and motor control and is caused by a non-progressive lesion of the developing brain. The motor disability of CP is often accompanied by disturbances of sensation, cognition,communication, perception, behaviour and/or by seiz­ure disorders [1]. Spastic CP is the most common subtype of CP, accounting for approximately 85% of cases.
The other subtypes are ataxic (4%) and dyskinetic (7%),
and some cases are unclassified (4%) [2, 3]. The severityof CP depends on both the impairment of motor function and the presence of accompanying disability.
The Gross Motor Function Classification System(GMFCS) is a validated method to evaluate the severityof motor impairment of children with CP [4]. It is used tocompare the severity of CP between populations and todesign treatment for children with CP [5]. GMFCS consists of five levels. Children at level I can walk without
limitations, but have problems with balance and coord­
ination when jumping, running or performing othermore complicated motor activities. Children at level V
are not able to walk and can only move about using awheelchair with extensive adaptations. GMFCS II-IV areintermediate levels connecting those extremes.
The treatment of motor disability in CP includes habilitation services (physiotherapy, occupational andspeech therapy), use of orthotic devices, orthopaedic
surgery and oral, intramuscular or intrathecal medication. Accompanying disorders need to be detected andtreated. At present, very few population-based studies
have investigated differences in CP management [6],and none of these studies involved multiple treatment
modalities.
Previous studies have demonstrated that both the
motor and cognitive disabilities of the child may influence the choice of treatment [7-9].
Regional differences in treatment have previously
been observed, e.g. among patients receiving a cochlear
implant [10]. Knowledge about regional differences inhealth services for patients with CP is limited. In an annual report from the Region of Southern Denmark, it
was demonstrated that the proportions of children who
received physiotherapy varied from 60% to 100% between municipalities [11]. A recent study from the UK
revealed regional variation in the healthcare services
provided to children and young people with CP regarding orthopaedic consultation, access to magnetic reson­ance imaging (MRI), recording state of spine and discussions about pain [6].
The aim of the present study was to investigate andto describe regional differences in the management of
CP in school-aged children in Denmark.
METHODS
The study is part of a cross-sectional study on treatment
and co-morbidity in 8-15-year-old children with CP. Data
were based on the Danish National Cerebral Palsy Registry (NCPR) [12], questionnaires answered by the parents
and information from Statistics Denmark.

Original
article1) Department ofPaediatrics, Aarhus
University Hospital2) The Cerebral Palsy
Registry, National
Institute of Public
Health, University ofSouthern Denmark3) Department ofChildren andAdolescence,
Rigshospitalet4) Department of
Public Health, Aarhus
University, Denmark
Dan Med J
2015;62(11):A5152

1

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d a n i s h m E d i c a l J O U R NAL

Participants and data sourcesChildren (n = 977) who were born in the 1997-2003
period were identified from the NCPR, and 893 children
were still eligible for the study after updating their civil
status in September 2011. An invitation letter wassent to the parents in the period from January 2012 toJanuary 2013.
Parents reported the use of treatment methods in
the Cerebral Palsy Treatment Questionnaire (CP-TQ),
created for the study by an expert group and tested in
23 families [13]. The SurveyXact software was used for
CP-TQ online.
The Danish Gross Motor Function Clas­si­fication
System Family Report was tested for reliability to ensure
GMFCS level classification [14].
The outcome variables included paediatrician andorthopaedic surgeon consultations during the past 12
months; evaluation by speech therapist and psychologist
ever in life; frequency of physiotherapy during the past

Dan Med J 62/11

November 2015

12 months (at least weekly or less for GMFCS levels I-II
and more than weekly or less for GMFCS levels III-V).
Occupational therapy during the same period was summarised to “received or not”. Orthoses were included if
used daily or nightly in the past three months. Ortho­
paedic surgery was defined as “operation on the legs,
arms or spine due to CP ever performed”. Botulinum
toxin (BTX) injections were included if ever received
intramuscularly.
Information regarding the number of parents (single/two), number of siblings (0 or ≥ 1), and educational
level of the parents was retrieved from the CP-TQ. The
highest educational level was used if parents had different educational levels.
The region was determined from the child’s mu­
nicipality as stated in the Danish Civil Registration
System.
The type of CP and cognitive function were ex­
tracted from the NCPR.

TablE 1
Basic characteristics of participants andnon-participants.

Child and family characteristics

Participants

Non-participants

All

Child’s age, yrs + mo., median (range)* a

12((8 + 4)-(15 + 7))

12 + 6((8 + 4)-(15 + 6))

12 + 2

Male, n (% (95% CI))

258 (56 (51-60))

267 (62 (57-67))(59)

Level I

225 (49 (44-53))

224 (52 (47-57))(50)

Level II

49 (11 (8-13))

33 (8 (5-10))(9)Level III18 (4 (2-6))

20 (5 (3-7))(4)

Level IV

87 (19 (15-22))

68 (16 (12-19))(17)

GMFCS, n (% (95% CI))

Level V79 (17 (14-21))

84 (20 (16-23))(18)

Proportion of children with IQ > 85, n; %, median (range)* b

239 (52 (47-56))

170 (39 (35-44))(46)

Right hemiplegia

105 (23 (19-27))

92 (22 (17-25))(22)

Left hemiplegia

79 (17 (14-21))

89 (21 (17-24))(19)

Spastic bilateral

210 (46 (41-50))

203 (48 (42-52))(47)

Ataxic19 (4 (2-6))

15 (4 (2-5))(4)Choreoathetotic

8 (2 (1-3))

4 (1 (0-2))(1)

Dystonic

35 (8 (5-10))

22 (5 (3-7))(6)Single parent, n (% (95% CI))

121 (26 (23-31))

146 (34 (30-39))(30)

Siblings in the family, n (% (95% CI))

343 (81 (77-85))

301 (79 (74-82))

(80)

Low

234 (54 (49-58))

281 (71 (66-75))(62)

Middle142 (33 (28-37))

83 (21 (17-25))

(27)

High

60 (14 (11-17))

31 (8 (6-11))(11)

Cerebral palsy type, n (% (95% CI))

Education level of parents* b, n (% (95% CI))

Region* b, n (% (95% CI))Southern

120 (26 (22-30)

100 (23 (19-27))(25)

Central136 (29 (25-34))

93 (22 (17-25))(26)

Northern

47 (10 (7-13))

50 (12 (9-15))(11)

Capital97 (21 (17-25))

128 (30 (25-34))(25)

Zealand

62 (13 (10-17))60 (14 (11-17))(14)

Total, n (%)

462 (52)431 (48)893

CI = confidence interval; GMFCS = Gross Motor Function Classification System.
*) p < 0.05.
a) Wilcoxon rank sum test.
b) Pearson’s chi2-test.

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Statistical analyses
The statistical software package STATA 12 was used for
all the statistical analyses. The chi-squared test was used
to compare proportions of categorical variables between participants and non-participants, and between
regions. The Wilcoxon’s rank sum test was used to compare the age of participants and drop-outs because age
was not normally distributed between drop-outs. Statistical significance was defined as p < 0.05.
Crude odds ratios were calculated with 95% confidence intervals (CI) for every follow-up and treatment
modality for the Northern, Central, Capital and Zealand
Regions, using the Southern Region as a reference group.
Odds ratios were later adjusted for other characteristics(the child’s age, gender and cognitive levels, living withsingle parent, with siblings, in a municipality with >100,000 inhabitants, and parental educational level).
After a descriptive analysis, it became clear that
school type was very strongly associated with the presence of cognitive impairment, and it was therefore excluded from further analysis to prevent multicollinearity.
Distance to the hospital was also considered a possible confounder for follow-up and hospital-based treatment, but was not included in the analysis because 45 of
the children did not undergo follow-up at any hospital.

3

The study was approved by the Danish Data
Protection Agency (ref. no. 2008-41-2927) and the
Ethical Committee of the Central Denmark Region(ref. no. M-20090016).
Trial registration: not relevant.
RESULTS
Basic characteristics of both participants and non-par­ticipants are shown in Table 1. Normal speech was reported in 56% (95% CI: 51-61%) and no understandable
speech in 19% (95% CI: 15-22%) of the participating­children.
Similar proportions of children in GMFCS levels III-V(84-95%) attended paediatric consultations in all five regions (Table 2). Only 29% of the children in GMFCS level
I had been investigated by a paediatrician during thepast 12 months in the Northern Region versus 61-76% in
the remaining Regions.
Speech therapist evaluation was performed in 71%
of all the children with CP, and the highest proportions
were found in the Capital Region for all GMFCS levels.
After adjustment, the difference remained statisticallysignificant at GMFCS levels II and III-V (Table 2).
Evaluation by a psychologist was performed in 68% of

Table 2
Regional differences in the follow-up of cerebral palsy: national and regional proportions of children, crude odds ratio and odds ratio adjusted for child’s and family’s characteristicsa.

Paediatrician in the last 12 months
GMFCS

n (%)

OR

ORadj (95% CI)

Orthopaedic surgeon in
the last 12 months

Speech therapist

n (%)

n (%)

OR

ORadj (95% CI)

OR

Psychologist
ORadj (95% CI)

n (%)

OR

ORadj (95% CI)

Level I
Southern region

29 (66*)

Ref.

Ref.

22 (51)

Ref.

Ref.

32 (73*)

Ref.

Ref.

36 (82*)

Ref.

Ref.

Central region

33 (61*)0.81

0.91 (0.37-2.25)

12 (33)0.48

0.47 (0.19-1.15)

33 (61*)0.59

0.52 (0.19-1.40)

37 (69*)0.48

0.63 (0.22-1.76)

Northern region

5 (29*)

0.22*

0.20* (0.06-0.73)

4 (24)

0.29

0.28 (0.07-1.04)

7 (41*)

0.26*

0.18* (0.05-0.69)

6 (35*)

0.12*

0.13* (0.03-0.53)

Capital region

29 (66*)1.00

1.16 (0.37-3.63)

19 (43)0.73

0.78 (0.26-2.35)

33 (77*)1.24

0.96 (0.28-3.32)

32 (73*)0.59

0.94 (0.26-3.43)

Zealand region

16 (76*)

1.66

1.97 (0.57-6.75)

5 (24)

0.30

0.29* (0.09-0.96)

11 (52*)0.41

0.33 (0.09-1.15)

11 (55*)0.27*

0.26* (0.07-0.98)

Denmark

112 (62)––68 (38)––116 (65)––

122 (68)––

Level IISouthern region

27 (84)

Ref.

Ref.

18 (56)

Ref.

Ref.

17 (55*)

Ref.

Ref.

22 (71)

Ref.

Ref.

Central region

17 (71)0.45

0.33 (0.08-1.43)

13 (54)0.92

1.02 (0.31-3.78)

18 (75*)2.47

5.68 (1.23-26.32)

17 (77)

1.39

1.59 (0.41-6.17)

0.69 (0.07-7.21)

Northern region

5 (56)

0.23

0.25 (0.04-1.78)

5 (56)

0.97

0.53 (0.08-3.41)

5 (56*)

1.03

Capital region

20 (95)3.70

2.43 (0.20-30.01)

16 (76)

2.49

2.28 (0.49-10.56)

20 (95*)16.47* 20.43* (1.76-237.6)

5 (56)

0.51

0.61 (0.10-3.68)

16 (80)1.64

1.54 (0.31-7.72)
1.16 (0.27-4.95)

Zealand region

14 (78)0.65

1.21 (0.20-7.54)

6 (35)

0.42

0.47 (0.11-1.99)

13 (81*)

3.57

8.45* (1.14-62.76)

13 (72)

1.06

Denmark

83 (79)––58 (56)––73 (72)––73 (73)–

Levels III-V
Southern region

36 (88)

Ref.

Ref.

29 (73)

Ref.

Ref.

25 (64)

Ref.

Ref.

27 (66)

Ref.

Ref.

Central region

48 (91)

1.33

1.40 (0.36-5.42)

40 (75)1.18

1.23 (0.43-3.59)

38 (74)1.64

1.93 (0.71-5.23)

26 (51)0.54

0.48 (0.19-1.26)

1.13 (0.26-4.87)

Northern region

16 (84)0.74

0.62 (0.11-3.41)

13 (68)0.82

Capital region

27 (87)0.94

0.89 (0.16-4.79)

28 (90)3.54* 8.44* (1.52-46.80)

15 (83)2.80

3.14 (0.68-14.44)

13 (68)1.12

1.40 (0.38-5.34)

29 (94)8.12*

5.88 (0.96-36.03)

18 (60)0.78

0.90 (0.26-3.16)

Zealand region

21 (95)

2.91

3.12 (0.30-31.98)

16 (73)1.01

0.73 (0.18-2.97)

17 (81)2.38

1.99 (0.51-7.82)

16 (76)

1.66

1.84 (0.48-6.98)

Denmark

148 (89)––

126 (76)––

124 (77)––

100 (62)––

CI = confidence interval; GMFCS = Gross Motor Function Classification System; OR = odds ratio; ORadj = OR adjusted for child’s and family’s characteristics.
*) p < 0.05 for difference between proportions or OR.
a) ORadj is adjusted for child’s age, gender, cognitive function and family characteristics (living with siblings, with a single parent, in a city and parental educational level).

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TablE 3
Regional differences inmanagement of cerebral
palsy: proportions ofchildren, receiving thetreatment, and odds ratio
adjusted for child’s andfamily’s characteristicsa.

Physiotherapy, at least weekly

Occupational therapy,
received in the last 12 months

Orthoses, daily or nightly
n (%)

n (%)

OR

ORadj (95% CI)

n (%)

OR

ORadj (95% CI)

OR

ORadj (95% CI)

Southern region

27 (61)

Ref.

Ref.

17 (39)

Ref.

Ref.

Central region

21 (33)0.31

0.43 (0.17-1.02)

10 (18)0.34

0.36* (0.13-0.98)

9 (20)

Ref.

Ref.

11 (19)0.93

Northern region

9 (53)

0.71

0.97 (0.29-3.25)

5 (29)

0.66

0.58 (0.15-2.22)

1.00 (0.34-2.95)

1 (6)

0.24

Capital region

21 (45)0.52

0.91 (0.30-2.76)

13 (30)0.67

0.23 (0.03-2.11)

0.72 (0.21-2.45)

1 (16)

0.76

Zealand region

11 (52)0.69

0.89 (0.29-2.73)

6 (29)

1.41 (0.35-5.70)

0.64

0.64 (0.19-2.16)

1 (5)

0.19

Denmark

89 (49)––0.19 (0.02-1.69)

51 (28)––29 (16)––Southern region

26 (79)Ref.

Central region

14 (58)

0.38

Ref.

12 (38*)

Ref.

Ref.

25 (25)

Ref.

Ref.

0.43 (0.12-1.51)

12 (50*)1.67

1.96 (0.62-6.24)

14 (61)

4.67

Northern region

7 (78)

6.53* (1.82-23.48)

0.94

0.93 (0.13-6.75)

6 (67*)

3.33

7.19* (1.03-50.0)

3 (33)

1.50

Capital region

2.43 (0.39-15.11)

16 (76)0.86

1.24 (0.26-5.97)

17 (81*)

7.08

10.99* (2.17-55.55)

10 (48)2.73

2.29 (0.53-9.88)

Zealand region

15 (83)

1.35

1.03, 0.19-5.56

12 (67*)

3.33

3.86, 0.94-15.84

5 (28)

1.15

1.42, 0.32-6.22

Denmark78 (74)––59 (57)––40 (39)

–

–

GMFCS
Level I

Level II

Levels III-V
Southern region

28 (68)c

Ref.c

Ref.c

27 (66)

Ref.

Ref.

31 (76)

Ref.

Ref.

Central region

37 (69)c

1.01c

0.96 (0.39-2.52)c

33 (61)0.81

0.76 (0.30-1.90)

46 (85)

1.67

1.82 (0.57-5.75)

Northern region

15 (75)c

1.39c

1.37 (0.37-5.04)c

16 (80)2.07

2.33 (0.57-9.41)

19 (95)5.51

4.44 (0.45-43.85)

Capital region

20 (65)c0.84c0.68 (0.20-2.31)c

25 (78)1.85

1.20 (0.32-4.46)

26 (81)1.26

0.56 (0.12-2.49)

Zealand region

16 (70)c

1.06c

0.78 (0.23-2.62)c

16 (70)1.19

1.17 (0.33-4.13)

16 (70)0.66

0.97 (0.24-3.89)

Denmark

116 (69)c––

117 (69)––

138 (82)––

CI = confidence interval; CP = cerebral palsy; GMFCS = Gross Motor Function Classification System; OR = odds ratio; ORadj = OR adjusted for child’sand family’s characteristics.
*) p < 0.05 for difference between proportions or OR.
a) ORadj is adjusted for child’s age, gender, cognitive function and family characteristics (living with siblings, with a single parent, in a city and parental
education level).
b) Only spastic and dystonic CP included.
c) More than weekly.

children. Statistically significant differences were observed only for GMFCS level I, ranging from 35% in
the Northern Region to 82% in the Southern Region(Table 2).
No regional differences were observed in provisionof physiotherapy, but statistically significant differences
existed for provision of occupational therapy (Table 3).
Regional differences in the daily use of orthoses weresignificant only for GMFCS level II (Table 3).
Botulinum toxin treatment was provided most frequently in the Zealand Region; the difference was statistically significant only for GMFCS level II. Orthopaedic
surgery was performed most frequently in the Capital
Region in GMFCS levels III-V and was observed least frequently in the Central Region in GMFCS level I (Table 3).
No statistically significant regional differences wereobserved for other treatment modalities, i.e. baclofen
pump, rhizotomy, oral spasmolytics or gastrostomy for
nutrition tube (Table 4).
DISCUSSION
For children in GMFCS level I, the management of CP differed between the five Regions in Denmark with regard

to provision of occupational and speech therapy, psychological evaluation, the number of paediatric or orthopaedic consultations and orthopaedic surgery. For children in GMFCS level II, the differences were observed inprovision of occupational and speech therapy, use of orthoses and botulinum toxin injections. For GMFCS levels
III-V, a higher rate of speech therapy, orthopaedic consultations and surgery was reported in the Capital Region. All differences remained statistically significant after adjustment for child and family characteristics.
To our knowledge, this is the first study evaluating
possible interregional differences in the management of
CP in a national sample. Swedish and Norwegian followup programmes have reported on the numbers of children receiving a particular service or treatment in every
county, but no additional statistical analyses on regional
differences are available in these reports. On the na­
tional level, the proportions of children receiving ser­vices were similar in all three Scandinavian countries[15-17].
A recent paper reported variation in healthcare forchildren with CP regarding access to orthopaedic surgeons between treatment centres in Northern England

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TablE 3, continued

Botulinum toxinb, ever received
n (%)

OR

24 (60) Ref.

ORadj (95% CI)
Ref.

22 (42) 0.47 0.56 (0.23-1.39)
8 (50)

Orthopaedic surgeryb,
ever performed
n (%)

OR

23 (58) Ref.

ORadj (95% CI)
Ref.

12 (23) 0.22 0.19* (0.07-0.52)

0.67 0.80 (0.23-2.82)

6 (38) 0.44 0.55 (0.16-1.93)

24 (59) 0.94 1.58 (0.49-5.10)

17 (43) 0.55 0.65 (0.21-2.10)

16 (76) 2.13 3.05 (0.82-11.4)

12 (57) 0.99 1.04 (0.33-3.28)

94 (55) ––70 (41) ––19 (58) Ref.

Ref.

19 (59) Ref.

Ref.

15 (75) 2.21 3.48 (0.77-15.67)
4 (50)

7 (35) 0.37 0.41 (0.12-1.47)

0.74 0.47 (0.05-4.25)

4 (50) 0.68 0.42 (0.06-3.02)

13 (76) 2.39 1.52 (0.26-8.89)

13 (72) 1.78 1.56 (0.34-7.27)

14 (78) 2.58 6.63* (1.12-39.42)

9 (50) 0.68 1.49 (0.35-6.41)

65 (68) ––52 (54) ––27 (73) Ref.

Ref.

23 (62) Ref.

Ref.

42 (82) 1.73 2.00 (0.67-5.93)

31 (61) 0.94 0.86 (0.34-2.17)

13 (65) 0.69 0.59 (0.16-2.27)

8 (40) 0.40 050 (0.15-1.67)

26 (87) 2.41 3.80 (0.78-18.39)

22 (81) 2.67 5.53* (1.27-24.02)

18 (82) 1.67 2.88 (0.62-13.30)

13 (59) 0.88 0.87 (0.26-2.93)

126 (79) –97 (62) –––[6]. In Denmark, the overall proportion of children consulted by an orthopaedic surgeon was higher than in the
North of England. For example, 61% against 76% for
GMFCS levels III-V. A wide access to orthopaedic surgeon consultation in Denmark may have reduced the regional variation in access to consultation, but did not
eliminate regional variation in the rate of orthopaedic
surgery.
The high rate of orthopaedic surgery in GMFCS
levels III-V in the Capital Region cannot be explained byclinical differences in CP children between the Regions.
When analysing data within the GMFCS III-V strata, wefound that 93% of children in GMFCS level V underwent
orthopaedic surgery in the Capital Region in contrast to
55% in the other Regions, whereas no differences wereobserved in children within GMFCS levels III and IV. This
indicates that the increase in orthopaedic surgery in the
Capital Region was restricted to the most severely affected children. We were unable to explore whether thedifference was due to preventive hip dislocation surgery
or to other types of surgery.
In Denmark, habilitation services for children withCP are provided by the municipalities. Additionally, public health insurance covers the cost of physiotherapy,
but not other habilitation services like occupational services or speech therapy for people with CP. Therefore,
regional differences in habilitation services reflect thedifferences in municipality services within and between

the different Regions. As regards the lower provision ofoccupational therapy and speech therapy, the explan­
ation may be that municipalities are unaware of theneed for these services in children with mild CP or thatthey prioritise children with the most severe disability
when habilitation services are not available for everyone
in need. We were unable to explore the reasons for regional differences in municipality services in the present
study design. The reasons for such differences havebeen analysed in a qualitative report regarding familycentred habilitation services in the Southern Region[11]. The main hurdle for implementation of familycentred care was not a lack of awareness about thechild’s habilitation needs, but a lack of clearly assigned
overall responsibility for providing habilitation services
under health, education and social services legislationsin the municipalities [10].
Regional differences in two treatment modalities(orthoses and BTX) were statistically significant in
GMFCS level II. Interpretation of these findings should
be done with caution because GMFCS II was the smallest
stratum (103 participants and only 94 children withspastic/dystonic CP). We found no regional differencesin the use of these treatment modalities in GMFCS levels
I and III-V. The findings concerning orthoses may reflecta specific problem for children in GMFCS level II, how­
ever. These children are able to walk without aids, buthave a limited walking distance, and ankle orthoses may
increase their walking distance and hand orthoses may
increase their bimanual ability. A recent study reported
a more frequent use of ankle-foot orthoses in Sweden
than the use of all kinds of orthoses in Denmark (47%versus 39% in GMFCS level II). Therefore, the availabilityof orthoses in Denmark should be explored.
The relatively low participation of parents from the
Capital Region may be a limitation and introduce selection bias. Participants from the Capital Region had theNorthern,
0.6 M
Copenhagen
Central,
1.3 M

Southern,
1.2 M

AarhusCapital,
1.3 M
Zealand,
0.6 M
Regions in Denmarkwith numbers of
inhabitants in 2015.

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TablE 4
Regional differences oftreatments, mainly usedin Gross Motor Function
Classification Systemlevels III-V: number (%) ofchildren, receiving thetreatment, and odds ratiowith 95% confidence interval, adjusted for child’sand family’s characteristicsa.

Baclofen pump or dorsal rhizotomyb

Oral spasmolyticsb

Gastrostomy

n (%)

OR

ORadj (95% CI)

n (%)

OR

ORadj (95% CI)

n (%)

OR

ORadj (95% CI)

0

–

–

6 (4)

–

–

0

–

–

0

–

–

3 (3)

–

–

2 (2)

–

–

Southern region

10 (27)

Ref.

Ref.

14 (38)

Ref.

Ref.

9 (22)

Ref.

Ref.

Central region

10 (20)0.69

0.62 (0.22-1.76)

24 (48)1.52

1.80 (0.71-4.61)

17 (31)

1.59

1.43 (0.48-4.26)

Northern region

3 (15)

0.48

0.50 (0.11-2.27)

9 (45)

1.34

1.79 (0.53-6.07)

4 (20)

0.89

0.78 (0.17-3.62)

Capital region

7 (26)

0.95

1.13 (0.30-4.23)

18 (62)

2.69

3.27 (0.95-11.27)

10 (32)

1.69

1.13 (0.28-4.52)

Zealand region

6 (27)

1.01

0.70 (0.19-2.61)

12 (57)2.19

1.47 (0.44-4.87)

2 (10)

0.37

0.13 (0.01-1.25)

Denmark

36 (23)––77 (46)––42 (25)

–

–

GMFCS
Level I
Denmark
Level II
Denmark
Levels III-V

CI = confidence interval; GMFCS = Gross Motor Function Classification System; OR = odds ratio; ORadj = OR adjusted for child’s and family’s characteristics.
a) ORadj is adjusted for child’s age, gender, cognitive function and family characteristics (living with siblings, with a single parent, in a city and parental
educational level)b) Only spastic and dystonic CP included.

same distribution regarding CP type and GMFCS level as
the drop-outs. Therefore, we assume that regional selection bias had a minimal influence on the results at thenational level, but may have introduced selection bias ininterregional analyses.
Another source of selection bias may be the low
participation of parents with a short education because
children with mild CP tended to undergo orthopaedic
surgery more often if their parents had a short education than children of parents with intermediate-level orhigh education. Therefore, the frequency of orthopaedic
surgery may be underestimated in our study at the national level. The influence of parental education on theregional differences in orthopaedic surgery was minim­
ised by adjusting the OR for parental education, and wetherefore conclude that regional differences in orthopaedic surgery exist in Denmark.
Another limitation of our study is that we only
analysed the frequency of provided therapy, not theamount of therapy or differences between specificmodalities of physiotherapy.
CONCLUSIONSRegional differences in the management of CP do exist
in Denmark, and the differences cannot be explained bysocial differences or differences in the severity of thedisability between the regions. A national follow-up programme entitled “Opfølgningsprogram for Cerebral
Parese” (CPOP) has now been launched in four regions
and is being initiated in the fifth [18]. CPOP may promote a more equal management of CP in all regions
based on national guidelines for primary and secondary
healthcare and an increased political attention at re­gional and municipal levels. CPOP now includes guide-lines for the follow-up of children’s motor function andjoint mobility, but no guidelines on treatment or comorbidity screening. Our findings indicate that the CPOP
may need to be developed further to diminish interregional differences in habilitation services and the treatment of children with CP in Denmark.
CORRESPONDENCE: Gija Rackauskaite. E-mail: gijarack@rm.dk
ACCEPTED: 7 September 2015
CONFLICTS OF INTEREST: Disclosure forms provided by the authors areavailable with the full text of this article at www.danmedj.dk
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