Effect of physical or occupational therapy on participation and functioning in children born preterm: A systematic review and meta-analysis

Effect of physical or occupational therapy on participation and functioning in children born preterm: A systematic review and meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Effect of physical or occupational therapy on participation and functioning in children born preterm: A systematic review and meta-analysis Jana-Susann Briem, Eva Trunk, Marie Babel, Heidrun Janka, Maria-Inti Metzendorf, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7231082/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Preterm born children are at a higher risk of developing motor, cognitive and behavioural impairments than term born peers. This systematic review with meta-analysis aimed to assess the efficacy of post-discharge physical or occupational therapy compared to standard of care, no treatment or any other active intervention on functioning and participation during infancy and childhood in children born preterm. Methods: We systematically searched MEDLINE, PsycINFO, CINAHL, CENTRAL, and WHO ICTRP for randomized controlled trials (RCTs) published up to April 23, 2024. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool. Certainty of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Random-effects meta-analyses were performed for clinically and methodologically homogeneous studies. Results: Thirteen RCTs involving 697 children born preterm were included, with ten studies investigating physical therapy (n=453; 0-6 years) and three studies examining occupational therapy (n=244; 3-6 years). Physical therapy interventions comprised family-centered active learning programs, group-based therapy, muscle training, and task-oriented motor intervention. Meta-analyses indicated that physical therapy may slightly enhance cognitive development during infancy (MD 0.95, 95% CI -0.3 to 2.2; low certainty). However, effects on motor outcomes were inconsistent, and evidence regarding participation and quality of life was limited and inconclusive. Occupational therapy interventions included computer-based training and parent-child interaction programs. Outcomes measured were behaviour, participation, executive functioning, and parent-child interaction. No consistent benefits were observed across studies. One small study indicated a reduction in attention (MD -8.30, 95% CI -13.40 to -3.20) and internalizing problems (MD -11.70, 95% CI -17.78 to -5.62), though evidence certainty was low and very low. No studies examined quality of life or long-term healthcare use. Conclusions: While the effects of physical therapy on motor and participation outcomes remain uncertain, physical therapy in infancy may improve cognition. Evidence for occupational therapy on participation, behaviour, and parent-child interaction is limited. Therefore, generalizable conclusions are not possible. Studies rarely address participation, quality of life, or long-term outcomes and reveal research gaps emphasizing the need for future research. PROSPERO Protocols: CRD42024562290 and CRD42024562314. preterm physical therapy occupational therapy motor development cognitive development participation parent-child interaction quality of life executive functioning systematic review Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. Introduction Preterm birth, defined as delivery before 37 completed weeks of gestation (1), continues to be a significant global medical concern. In 2020, an estimated 13.4 million newborns – accounting for 9.9% of all births worldwide - were born preterm (2). Preterm birth is associated with long-term complications that can impact preterm-born individuals throughout their entire lives, often resulting in significant lifelong disabilities (3). For instance, preterm born children are at a higher risk of developing motor, cognitive, and behavioural impairments compared to their term-born peers (4–6). These challenges not only result in personal limitations but can also hinder social participation, manifesting in difficulties in kindergarten or school, unemployment, and challenges in family life (7, 8). Currently an evidence-based guideline for long-term follow-up of preterm born infants is under development in Germany. To improve the limitations caused by preterm birth, a variety of therapeutic and support measures are available. After discharge from the NICU, physical therapy and occupational therapy are frequently prescribed, with specific interventions such as motor skill training, sensory integration therapy and neurodevelopmental treatment being carried out (9–11). Professionals as well as parental support groups considered the research question about the evidence on physical or occupational therapy of high priority. The primary aim of early physical therapy and occupational therapy interventions is to promote the children’s motor and cognitive development, improve social skills, and address other developmental needs (12, 13). Although physical and occupational therapy interventions are commonly prescribed and many parents report high satisfaction, robust evidence supporting their effectiveness, especially after hospital discharge, is lacking (11, 14). Early intervention programs to improve motor development objectively were not shown to have a lasting effect (15). This discrepancy between the lack of objective effects and the high parental satisfaction with the therapy could have several explanations. One possible reason is that the outcome measures used in studies may not align with the primary concerns of children and parents, whereas the F-words (function, family, fitness, fun, friends and future) would better capture their priorities (16). Given the significant impact of preterm birth on many areas of daily life, it is crucial to identify effective therapeutic measures that can be sustainably implemented to improve long-term outcome of preterm-born individuals. This systematic review explores the impact of physical therapy during infancy or childhood on motor development, participation, quality of life, and cognitive development in preterm born children, as well as the effect of occupational therapy during childhood on participation, behaviour, quality of life, and executive functioning. 2. Methods This systematic review addresses two research questions. In children born preterm, on the one hand, we examined the impact of physical therapy during infancy or childhood on motor development, participation, quality of life, and cognitive development, compared to standard of care, non-therapeutic interventions, or other types of physical therapy; and on the other hand, we investigated the effect of occupational therapy during childhood on participation, behaviour, quality of life, and executive functioning, compared to standard of care, non-therapeutic interventions, or other types of occupational therapy. Protocols for both research questions were published before conduct of the systematic review (PROSPERO: CRD42024562290 and CRD42024562314). 2.1 Eligibility criteria 2.1.1 Types of studies To minimize confounding we included only randomized controlled trials (RCTs). Studies were eligible if they were published or reported results in trials registries or were not completed (‘ongoing studies’) or were completed but not yet published (‘awaiting classification’). Publications lacking sufficient data for a reliable inclusion were classified as ‘awaiting classification’. We contacted authors for clarification. There were no restrictions regarding the language of publication. Studies published solely as conference abstracts were excluded due to limited information. 2.1.2 Participants / Population We included studies investigating: Children born preterm (< 37 weeks gestational age (GA), regardless of birth weight) Children born preterm AND with low birth weight (LBW < 2500g) Children born preterm AND/OR with very low birth weight (VLBW < 1500g) Children born preterm AND/OR with extremely low birth weight (ELBW < 1000g) If the study population consisted of children born full-term (≥ 37 weeks GA) or of children with LBW without detailed information on gestational age, studies were excluded. For studies with mixed populations, inclusion required separately reported subgroup data on the eligible population. 2.1.3 Intervention(s) For both physical therapy and occupational therapy, we included any therapeutic methods and concepts, provided that they were performed as a single intervention and not as part of an interdisciplinary program, such as an early intervention program. Interventions had to be conducted at least six times post-discharge by a health professional and focus on the child, with or without parental involvement. The physical therapy intervention had to start within any time before school age (0–6 years), while occupational therapy had to be conducted during preschool age (3–6 years). 2.1.4 Comparator(s) Physical and occupational therapy were not combined in analysis. Eligible comparators were: Standard of care or no treatment. Any other active monodisciplinary intervention unrelated to physical or occupational therapy (e.g. sports, choir, scouts). Any other type or mode of physical or occupational therapy methods and concepts. Standard of care must have been comparable between study groups. 2.1.5 Outcomes We aimed to focus on proxies for the F-words (function, family, friends, fun, fitness, future) (16), using motor, cognitive, and fitness measurements as indicators of function, and participation and quality of life instruments as proxies for family, friends, and fun. The main outcome set of physical therapy included: Motor development at infancy (0–3 years) and preschool age (4–6 years) measured with e.g. Alberta Infant Motor Scale (AIMS), Bayley Scales of Infant and Toddler Development – Third Edition (BSID-III), Movement Assessment Battery for Children – Second Edition (MABC-2) Cognitive development at infancy measured with e.g. with BSID-III Participation (activities of daily living, leisure activities, special educational needs) at infancy and preschool age measured with e.g. Daily Activities of Infants Scale (DAIS), Participation questionnaire, Pediatric Evaluation of Disability Inventory (PEDI) Quality of life at infancy and preschool age measured with e.g. Vécu et Santé Perçue de l’Adolescent (VSP-A), KINDL R , Pediatric Quality of Live Inventory ™ (PedsQL ™ ) We included the frequency of medical prescriptions following initial therapy as an additional outcome. The main outcome set of occupational therapy included: Participation (activities of daily living, leisure activities, special educational needs) at preschool age measured with e.g. Global School Adaption score (GSA) Behaviour (attention and internalizing problems) at preschool age measured with e.g. Strengths and Difficulties Questionnaire (SDQ), Child Behavior Checklist (CBCL) Executive functioning at preschool age measured with e.g. Developmental Neuropsychological Assessment – Second Edition (NEPSY-2)) Quality of life at preschool age measured with e.g. VSP-A, KINDL R , PedsQL ™ Additional outcomes included motor development, parent-child interaction and the frequency of medical prescriptions following initial therapy. Outcomes had to be assessed no earlier than 6 months corrected age due to limited validity at this age. Studies which did not report at least one predefined outcome were not excluded and contributed baseline information to our study pool. 2.2 Search methods A joint systematic search for both research questions was conducted. We searched MEDLINE, PsycInfo, CINAHL, Cochrane Central Register of Controlled Trials and WHO International Clinical Trials Registry Platform (ICTRP) from inception to 23 April 2024. Search strategies are reported in Additional file A1. We also screened reference lists of all included primary studies and identified systematic review articles. We performed study selection based on our predefined eligibility criteria and in accordance with the Cochrane Handbook of Intervention (17). Two reviewers independently screened titles and abstracts of identified records. Full text-articles of all doubtful and potentially eligible records were then retrieved and assessed independently by both reviewers. Disagreements in either step were resolved through discussion or consultation with a third reviewer. We used Covidence® (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia) for screening. 2.3 Data extraction Two review authors independently extracted data using a piloted data extraction form. We extracted details on general study information, trial characteristics, and participant, intervention, comparator and outcome characteristics. Discrepancies were resolved through discussion and missing data were requested from study authors. Data was extracted using Covidence® and Excel® (Microsoft®, 2018). 2.4 Risk of bias assessment Two reviewers using the Cochrane Risk of Bias 2 (RoB2) tool independently, assessed the risk of bias of outcomes from included studies. The risk of bias of each study result was classified as low, some concerns or high for each individual domain and overall. Disagreements were resolved through discussion or input from a third reviewer. 2.5 Data synthesis For dichotomous outcomes, we used the risk ratio (RR) with a 95% confidence interval (CI) as an effect measure. For continuous outcomes, we used the mean difference (MD) with 95% CIs in case results of studies referred to one scale, and the standardized mean difference (SMD) with 95% CIs for results of studies referred to different scales. We pooled data of studies with sufficiently homogeneous clinical and methodological characteristics in meta-analyses. Patient age at intervention, the assessment tool and its scale had to be comparable, with outcomes reported as mean (SD). Data reported exclusively as median were not transformed into means and were not included in meta-analysis. As we assumed that the intervention effects will be related but not the same for included studies, we used a random-effects model for meta-analysis. All studies included in our meta-analyses reported continuous outcomes, so we performed analyses using the inverse variance method under a random-effects model. We used R package meta version 7.0–0 for analysis. Statistical heterogeneity was assessed using the χ² test and the I² statistic, with heterogeneity defined as P < 0.05 for the χ² statistic, or I² ≥ 40%. We didn’t calculate the 95% prediction interval (PI) because our meta-analyses didn’t include four or more studies. Subgroup and sensitivity analyses, as well as assessments of reporting bias, were considered not meaningful due to the small number of identified studies and were not performed. 2.6 Certainty of the Evidence Two review authors independently rated the certainty of evidence of each main outcome using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, which classifies certainty of evidence as high, moderate, low, or very low (18). Certainty of evidence was downgraded for one, two or three levels in case of risk of bias, inconsistency, imprecision, indirectness, or publication bias (17). Discrepancies were resolved through discussion. Results are summarized in Summary of Findings tables. 2.7 Differences between protocol and review Following the publication of our protocol, several adjustments were made: First, if outcome data were collected at multiple time points within a study using the same measurement instrument, we decided to extract data only from the latest time point, in order to capture the longest-term effects of the interventions. Second, cognitive development was identified as a key outcome of physical therapy during data extraction and was prioritized accordingly. Third, due to limited capacities, we had initially applied a language restriction to include only studies published in English and German. However, to avoid the potential omission of relevant evidence, we subsequently re-evaluated studies that had been excluded due to language. Still, none of these studies met our inclusion criteria. 3. Results 3.1 Search The search strategy identified 10,537 database records and 1,290 records in trials registers. After removing duplicates, 8,763 titles and abstracts were screened, with 8,180 deemed irrelevant. We sought 583 full-text articles for retrieval and assessed 568 for eligibility, along with 8 additional entries from websites (Additional Files A2, A3). For the physical therapy research question, 525 reports were excluded, 11 studies (13 reports) were ongoing at the time of the search, and 11 studies (12 reports) were awaiting classification (Additional file A2). Ten studies (18 reports) were included. For the occupational therapy research question, 553 reports were excluded, one study was ongoing at the time of search and eight reports were awaiting classification (Additional file A3). Three studies (seven reports) were included. All excluded studies along with their respective reasons for exclusion are provided in Additional File A4. 3.2.1 Characteristics of included studies: Physical therapy For physical therapy, we included ten RCTs with 453 randomized preterm infants (GA 22–35 weeks) aged 0–6 years (Additional File A5, A6). Studies were published between 2012 and 2023 and were carried out in Australia, France, Spain, Switzerland, Turkey and the United States of America. The studies were categorized into four intervention groups. Five studies focused on family-centred and active learning programs for children and their parents (19–23), whereas two studies focused on group-based physical therapy for preterm born children aged 4–6 years (24, 25). Two studies (26, 27) investigated muscle training techniques and one study (28) analysed early crawling training on a mini-skateboard. Control groups received either another physical therapy concept, standard of care or no intervention. The following outcomes were assessed over a period ranging from 4 weeks to 24 months post-baseline: Motor development (19–28), participation (19, 23) and cognitive development (19–21, 23, 26). While all studies reported relevant outcomes, four were not included in data synthesis and meta-analysis due to methodological issues or incompatible data (19, 22, 25, 27). An overview of all non-poolable outcomes can be found in Additional File A7. 3.2.2 Characteristics of included studies: Occupational therapy In total, three RCTs investigating occupational therapy, involving 244 preterm-born children (GA 23–35 weeks) aged 3–6 years were included (Additional Files A5, A8). Studies were published between 2010 and 2024 and were carried out in Italy, France and the United States of America. The interventions were either a parent-child interaction therapy program (29) or computer-based programs (30, 31). Control groups received either no intervention or standard of care. The following outcomes were assessed over a period ranging from 4 weeks to 16 months post-baseline: Behaviour (29, 31), participation (31), executive functioning (30, 31), quality of life (31), and parent-child interaction (29). While all studies reported relevant outcomes, one study (30) was not included in data synthesis due to incompatible data. An overview of all non-poolable outcomes can be found in Additional file A9. 3.3 Risk of bias Detailed RoB2 assessments for all studies’ outcomes are shown in Figure F1 and F2 . Figure F1 : Risk of bias ratings per outcome and for all domains (physical therapy) Figure F2 : Risk of bias ratings per outcome and for all domains (occupational therapy) Of the 14 study results for physical therapy, 57.1% were rated as ‘low risk of bias’, 28.6% as ‘some concerns’, and 14.3% as ‘high risk of bias’. Of the six study results for occupational therapy, 83.3% were rated as ‘some concerns’ and 16.7% as ‘high risk of bias’. 3.4 Effects of interventions 3.4.1 Results physical therapy 3.4.1.1 Motor delay and cognitive delay (0–3 years) Motor delay and cognitive delay were each assessed in one study (21) including preterm infants (GA 27–31 weeks) aged 0–3 years, comparing the Explorer Baby program to neurodevelopmental treatment. The evidence is very uncertain about the effect of physical therapy on motor delay (RR 0.64, 95% CI 0.21 to 2.00, 51 participants, Additional file A10) and cognitive delay (RR 0.11, 95% CI 0.01 to 1.89, 51 participants, Additional file A10), both measured with BSID-III (32). Certainty of evidence was very low due to extremely serious imprecision. 3.4.1.2 Cognitive development (0–3 years) Cognitive development was assessed in two studies (21, 23) including preterm infants (GA 27–34 weeks) aged 0–3 years, comparing the Explorer Baby program to neurodevelopmental treatment (21) and the Preterm infant Early intervention for Movement and Participation Trial (PreEMPT) to usual physiotherapy care (23). We combined the results of these two studies in meta-analysis. The evidence suggests that physical therapy may slightly increase cognitive development (MD 0.95, 95% CI -0.3 to 2.2, I 2 = 0%, 62 participants, Additional file A10, Figure F3 ), measured with BSID-III (32). Certainty of evidence was low due to very serious imprecision. Figure F3 : Meta-analysis of cognitive development (0–3 years): Physical therapy versus control 3.4.1.3 Motor development (0–3 years) Motor development was assessed in two studies (20, 26) including preterm infants (GA 24–35 weeks) aged 0–3 years, comparing psychomotor therapy to standard of care (20, 26) and treadmill training to standard of care (26). We combined the results of these two studies in meta-analysis. The evidence suggests that physical therapy results in little to no difference on motor development (SMD − 0.14, 95% CI -0.46 to 0.19, I 2 = 0%, 142 participants, Additional file A10, Figure F4 ), measured with BSID-III (20, 32) and BSID-II (26, 33). Certainty of evidence was low due to serious risk of bias and serious imprecision. Figure F4 : Meta-analysis of motor development (0–3 years): Physical therapy versus control 3.4.1.4 Fine motor development and gross motor development (0–3 years) Fine motor development and gross motor development were each assessed in three studies (21, 23, 28) including preterm infants (GA 27–34 weeks) aged 0–3 years, comparing the Explorer Baby program to neurodevelopmental treatment (21), the PreEMPT to usual physiotherapy care (23) and crawling training on a mini-skateboard to standard of care (28). We combined the results of these three studies in meta-analysis. The evidence is very uncertain about the effect of physical therapy on fine motor development (MD -0.97, 95% CI − 3.17 to 1.23, I 2 = 64%, 89 participants, Additional file A10, Figure F5 ) and gross motor development (MD 0.44, 95% CI -2.31 to 3.19, I 2 = 70%, 90 participants, Additional file A10, Figure F6 ), both measured with BSID-III (32). Certainty of evidence was very low due to very serious inconsistency and very serious imprecision. Figure F5 : Meta-analysis of fine motor development (0–3 years): Physical therapy versus control Figure F6 : Meta-analysis of gross motor development (0–3 years): Physical therapy versus control 3.4.1.5 Participation in activities of daily living (0–3 years) Participation in activities of daily living was assessed in one study (23) including preterm infants (GA 28–34 weeks) aged 0–3 years, comparing the PreEMPT to usual physiotherapy care. The evidence is very uncertain about the effect of physical therapy on participation in activities of daily living (Mean (SD) intervention group 5.5 (0.0), control group 6.3 (1.03), 8 participants, Additional file A10), measured with DAIS (34). Certainty of evidence was very low due to very serious risk of bias and very serious imprecision. 3.4.1.6 Motor development (4–6 years) Motor development was assessed in one study (24) including preterm infants (GA 22–29 weeks) aged 4–6 years, comparing group-based physiotherapy to standard of care. The evidence is very uncertain about the effect of physical therapy on motor development (MD -10.65, 95% CI -25.07 to 3.77, 48 participants, Additional file A10), measured with MABC-2 (35). Certainty of evidence was very low due to extremely serious imprecision. 3.4.1.7 Other outcomes (0–6 years) Our systematic literature research highlighted a lack of evidence on several predefined outcomes of physical therapy (Additional file A10). In infancy, no study reported data for the outcomes participation in leisure activities or later special educational needs of preterm born children, quality of life or frequency of medical prescriptions in subsequent years. Similarly, for childhood, only motor development outcomes were reported, with no study reporting on other outcomes. 3.4.2 Results occupational therapy 3.4.2.1 Participation: special educational needs Special educational needs were assessed in one study (31) including preterm infants (GA 26–32 weeks) aged 5½ − 6 years, comparing an online working memory rehabilitation program to standard of care. The evidence is very uncertain about the effect of occupational therapy on children’s school participation (MD 0.1, 95% CI -6.1 to 6.3, 142 participants, Additional file A11), measured with the GSA score (36). Certainty of evidence was very low due to very serious risk of bias and very serious imprecision. 3.4.2.2 Behaviour Behaviour was assessed in two studies (29, 31) including 167 preterm born children (GA 23–35 weeks) aged 3–6 years, comparing a parent-child interaction therapy program to no treatment (29) and an online working memory rehabilitation program to standard of care (31). Due to clinical heterogeneity in interventions, data could not be pooled in meta-analysis. The evidence suggests that parent-child interaction therapy slightly reduces attention problems (MD -8.30, 95% CI -13.40 to -3.20, 25 participants, Additional file A11), measured with the CBCL (37), whereas the working memory rehabilitation program may result in little to no difference in hyperactivity (MD 0.4, 95% CI -0.6 to 1.3, 142 participants, Additional file A11), measured with the Goodman SDQ (38). Certainty of evidence for attention problems and hyperactivity was low due to serious risk of bias and serious imprecision. The evidence is very uncertain about the effect of occupational therapy on internalizing and emotional problems: Parent-child interaction therapy may reduce internalizing problems (MD -11.70, 95% CI -17.78 to -5.62, 25 participants, Additional file A11), measured with the CBCL (37), whereas the working memory rehabilitation program may have little to no effect on emotional problems (MD -0.2, 95% CI -1.2 to 0.8, 142 participants, Additional file A11), measured with the Goodman SDQ (38). Certainty of evidence for internalizing and emotional problems was very low due to serious risk of bias, serious inconsistency and serious imprecision. 3.4.2.4 Parent-child interaction Parent-child interaction was assessed in one study (29) including preterm born children (GA 23–35 weeks) aged 18–60 months, comparing a parent-child interaction therapy program to no treatment. Occupational therapy may improve parent-child interaction, measured with the Dyadic Parent-Child Coding System (39) (MD 20.70, 95% CI 3.97 to 37.43, 25 participants, Additional file A11), but the evidence is very uncertain. Certainty of evidence was very low due to serious risk of bias and very serious imprecision. 3.4.2.5 Executive functioning Executive functioning was assessed in two studies (30, 31), including 189 preterm born children (GA 26–32 weeks) aged 5½ − 6 years, comparing an online working memory rehabilitation program to standard of care (31) and an adaptive motion-interaction videogame platform to standard of care (30). However, only subscales were used, which do not fully capture executive functioning as defined in our main outcome set and were therefore not included in our summary of findings. One study (31) measured executive functioning of the children using the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) visuospatial and working memory indices (40) and reported a short-term effect that could not be substantiated in the long term (Additional file A9). One study (30) assessed executive functioning using the Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI-III) processing speed quotient (41) and reported a short-term effect (Additional file A9). 3.4.2.6 Quality of life Quality of life was not comprehensively assessed in any of the included studies. One study (31) including 142 preterm infants (GA 26–32 weeks) aged 5½ − 6 years, comparing an online working memory rehabilitation program to standard of care measured quality of life using the VSP-A questionnaire (42), reporting subscales on “Relationship with parents and family”, “School performance”, and “Relationship with teacher” with no clinically relevant effect (Additional file A9). As these subscales focus on specific aspects of the school and social environment, they do not fully capture overall quality of life as defined in our main outcome set and were therefore not included in our summary of findings. 3.4.2.7 Other outcomes Our systematic literature research highlighted a lack of evidence on several predefined outcomes of occupational therapy. We couldn’t identify any studies that assessed whether occupational therapy performed at preschool age improves the children’s participation in activities of daily living or leisure activities and whether there is an effect on their motor development or on the frequency of medical prescription in subsequent years (Additional file A11). 4. Discussion To the best of our knowledge, no comparable systematic review with meta-analysis including RCTs on this topic is currently available, highlighting a significant gap of aggregated evidence in both the fields of physical therapy and occupational therapy. Only a few studies have examined the impact of childhood physical and occupational therapy on various abilities and life domains of preterm-born individuals. In particular, long-term follow-up data on outcomes summarized by the F-words (function, family, friends, fitness, fun, future) are missing (16). The high heterogeneity of interventions and outcome assessment tools, as well as the mostly very low certainty of evidence, further complicates the interpretation of findings. Our findings suggest that family-centred and active learning programs for children and their parents led by physical therapists may support cognitive development in the first years of life. This is consistent with findings that emphasize the first five years of life as a critical period for neural development, during which foundational processes shape future cognitive-educational and social-functioning (43–45). The brain’s heightened neuroplasticity in this early stage allows for significant and lasting effects of targeted experiences and interventions (43–45). However, while our systematic review suggests that physical therapy may have benefits for cognitive development in infancy, its impact on motor development throughout childhood remains inconclusive. These findings align with data from early intervention programs, demonstrating positive effects on cognitive but not motor development up until preschool age (15), whereby valuable insights for clinicians are provided. In settings where multidisciplinary intervention programs are unavailable, the prescription of a physical therapy program with parental involvement may be a viable alternative. Notably, none of the reviewed studies examined physical therapy concepts that started in the second or third year of life. While some studies indicate that early family-centred physical therapy improves both cognitive function and motor skills in the short-term (46), the overall evidence remains heterogenous. A previous study suggested that family-centred physical therapy alone may not be sufficient to improve cognitive and motor development during the first year of life; however, the population in this study was not randomised (10). Consistent with the findings of our meta-analyses, which indicate that physical therapy has no clinically relevant impact on both fine and gross motor development during infancy and preschool years, other studies similarly provide no evidence that early motor difficulties and subsequent developmental outcomes in school age children can be improved through physical therapy alone (14, 47). In the German Guideline the following recommendation was made for prophylactic physical therapy during infancy: “Physical therapy on its own in infancy including and educating parents can be recommended for preterm born < 37 weeks of gestation to improve development.” Despite these findings, evidence regarding the efficacy of physical therapy for motor compensatory abilities in children aged 4–6 years remains scarce and inconclusive. Furthermore, no studies reported participation rates in leisure activities, highlighting a gap in the literature. In the German Guideline the following recommendation was made for prophylactic physical therapy during childhood: “Physical therapy during childhood for preterm born < 37 weeks is dispensable.” General conclusions about the effects of occupational therapy for preterm children at preschool age cannot be drawn due to insufficient evidence. The limited evidence from our review indicates that parent-child interaction training during early childhood may strengthen the parent-child relationship and reduce attention and internalizing problems (29). This aligns with occupational therapy approaches for other patient groups. Parent involvement in occupational therapy interventions appears highly effective and beneficial for children, making family-centred care a suitable approach in this context (48). However, there are also studies which present contrasting findings. For instance, a study on a different interaction-based intervention during the first year of life in preterm infants found no evidence for an improvement in parent-child interaction, highlighting the variability of outcomes across studies, depending on factors such as the specific intervention, the population, and the age of the preterm infants (49). In the German Guideline the following recommendation was made for prophylactic occupational therapy during childhood: “Occupational therapy focussing on parent-child-interaction can be considered to improve parent-child-interaction.” Regarding participation in school or special educational needs to clear benefits could be found (36). In the German Guideline the following recommendation was made for prophylactic occupational therapy during childhood: „Occupational therapy during childhood to improve participation and quality of life in school is dispensable.” Internet- or computer-based training programs designed to enhance cognitive functions, which were included in the studies of our review, show short-term positive effects on working memory and executive functions in preterm born children, but these benefits are not sustained long-term (30, 31). Additionally, other studies have demonstrated that short-term occupational therapeutic interventions can temporarily improve outcomes such as social development, though long-term effects were not maintained (50). It is not surprising that short term interventions fail to produce lasting effects. Given these short-term effects, it may be worthwhile to investigate whether ‘booster sessions’ could help maintain gains. So far, studies on the long-term implementation of such sessions are lacking. Occupational therapies using a top-down approach and focussing on the International Classification of Functioning, Disability and Health (ICF) framework of activity in line with the “F-words” seem to be more promising than classical bottom-up designs focussing on body-structure (48). It is important to note that interpreting our main results in the context of existing evidence is challenging due to the limited overall evidence in this field and the considerable variability among available studies in terms of studied populations, interventions, outcomes, study designs, and quality. While several systematic reviews have already addressed early interventions for preterm born children post-discharge, their methodologies differ from those of this review. Some included not only RCTs but also observational studies (46), quasi-RCTs and cluster-randomized trials (15). Additionally, their meta-analyses incorporated data reported exclusively as asymmetric medians (15, 46). The certainty of evidence of the outcomes included in this systematic review were rated as low or very low. This is primarily due to most outcomes being assessed by only one or two studies with a small number of participants. Furthermore, wide confidence intervals and a high statistical heterogeneity contributed to imprecision and inconsistency of some studies, leading to a downgrading of the certainty of evidence. Additionally, a substantial risk of bias was identified in three studies (23, 26, 31), arising from various methodological limitations in the conduct of the studies. Some studies employed highly specific measurement tools or subscales that were insufficient for a comprehensive assessment of the predefined outcomes (25, 30, 31). In other instances, the results were reported in incompatible data formats (19, 22, 27). Consequently, certain studies or outcome data were not incorporated into the evidence profile. Additionally, subgroup and sensitivity analyses, as well as assessments of reporting bias, were deemed unfeasible due to the limited number of identified studies and were therefore not conducted. Most studies focused on very or extremely preterm children, with mean gestational ages of the included infants ranging from 25 to 32 weeks (23, 25). Therefore, the findings may not be generalizable to late preterm infants. Our systematic review and meta-analysis were conducted in accordance with Cochrane methodological standards, ensuring a high-quality literature search and synthesis. Inclusion criteria were clearly predefined, and two independent reviewers carried out the review process. Any deviations from the protocol, which was published prior to this review, were transparently documented. Due to limited resources, the review initially included only studies published in English and German, potentially leading to the omission of relevant evidence. This limitation was effectively mitigated through a subsequent reassessment of studies published in other languages. At least in Germany, physical and occupational therapy are frequently prescribed for preterm children up to preschool age for various reasons. While more than 60% of preterm children receive physical therapy in the first year of life, this rate declines by school age, whereas occupational therapy use gradually increases, reaching approximately 30% by preschool age (11). Schouten et al. developed a core outcome set for physical, mental, and social functioning in collaboration with parental groups and experts (51). However, core outcome sets co-developed with preterm-born individuals and their parents for proxies of the other F-words are still lacking. Such frameworks are essential for prioritizing research on meaningful outcomes in physical and occupational therapy. Follow-up care of preterm-born individuals should encompass not only the “F” for functioning, but also fun, family, friends, fitness and future. Analysing neonatal network data for these outcomes could help identify subgroups with deficits, allowing us to prioritize future research accordingly. In most countries, there is a growing shortage of qualified therapists, making it essential to prioritize therapies for those who stand to benefit the most. At the same time, frequent therapy appointments can be burdensome for both parents and children, reducing preterm children’s leisure time – time that could otherwise be spent engaging in other F-words: fun, family, friends, fitness and getting prepared for the future. This highlights the need for a critical evaluation of the effectiveness of these therapeutic interventions. Addressing the current lack of sufficient evidence on this issue is crucial to ensure the most effective healthcare for preterm children and laying a strong foundation for their future. 5. Conclusion This systematic review with meta-analyses assessed 13 RCTs examining the effect of post-discharge physical and occupational therapy on developmental and functional outcomes in preterm children. The findings suggest that physical therapy in infancy may enhance cognitive development, although its effects on motor development remain uncertain. Occupational therapy showed no consistent benefits for behavioural outcomes, executive function, or parent-child interaction. Notably, no studies assessed long-term participation, quality of life, or healthcare utilisation. The certainty of evidence was generally low or very low due to methodological limitations and small sample sizes, restricting the reliability of the findings. These results reveal significant evidence gaps, emphasizing the need for high-quality research to improve therapeutic recommendations. For clinicians involved in follow-up care of preterm infants, the findings suggest that family-centred physical therapy could be considered where multidisciplinary programmes are unavailable. Future research should prioritise comprehensive outcome measures that align with patient and family priorities, ensuring interventions meaningfully contribute to long-term developmental trajectories. Abbreviations Abbreviation Description AIMS Alberta Infant Motor Scale BSID-II Bayley Scales of Infant Development, Second Edition BSID-III Bayley Scales of Infant and Toddler Development, Third Edition CBCL Child Behavior Checklist DAIS Daily Activities of Infants Scale GA Gestational age GRADE Grading of Recommendations, Assessment, Development and Evaluations GSA Global School Adaptation score ICF International Classification of Functioning, Disability and Health MABC-2 Movement Assessment Battery for Children, Second Edition NICU Neonatal intensive care unit NEPSY-2 Developmental Neuropsychological Assessment, Second Edition PEDI Pediatric Evaluation of Disability Inventory PedsQL TM Pediatric Quality of Live Inventory TM PreEMPT Preterm infant Early intervention for Movement and Participation Trial RoB2 Cochrane Risk of Bias 2 tool SDQ Strengths and Difficulties Questionnaire VSP-A Vécu et Santé Perçue de l’Adolescent WPPSI-III Wechsler Preschool and Primary Scale of Intelligence, Third Edition WPPSI-IV Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition Declarations Ethics approval and consent to participate (not applicable) Consent for publication (not applicable) Availability of data and materials: All data generated or analysed during this study are included in this published article and its additional files. Competing interests The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Funding This research was part of the development of an evidence-based guideline for follow-up for children born preterm (FrühTEV) and funded by GBA-Innovationsfond (01VSF23009). The funding source was not involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. 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Supplementary Files AdditionalfileA1Searchstrategy.docx.pdf Search Strategy AdditionalfileA2PRISMAFlowDiagramPTneucropped.pdf PRISMA Flow Diagram Physical Therapy AdditionalfileA3PRISMAFlowDiagramOTcropped.pdf PRISMA Flow Diagram Occupational Therapy AdditionalfileA4Listofallincludedandexcludedstudies.pdf List of included and excluded studies AdditionalfileA5Characteristicsofallincludedstudies.pdf Description of included Studies Physical Therapy AdditionalfileA6Characteristicsofincludedstudiesofphysicaltherapy.pdf Characteristics of included Studies Physical Therapy AdditionalfileA7Nonpoolableoutcomesofphysicaltherapy.pdf non-poolable Study Outcomes Physical Therapy AdditionalfileA8Characteristicsofincludedstudiesoccupationaltherapy.pdf Characteristics of included Studies Occupational Therapy AdditionalfileA9Nonpoolableoutcomesofoccupationaltherapy.pdf non-poolable Study Outcomes Occupational Therapy AdditionalfileA10Summaryoffindingsphysicaltherapy.pdf Summary of Findings Physical Therapy AdditionalfileA11Summaryoffindingsoccupationaltherapy.pdf Summary of Findings Occupational Therapy Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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control\u003c/p\u003e\n\u003cp\u003eLegend:\u003c/p\u003e\n\u003cp\u003eCI, confidence interval; PT, physical therapy; SD, standard deviation\u003c/p\u003e\n\u003cp\u003eFootnotes:\u003c/p\u003e\n\u003cp\u003e(1) Mobbs 2022: Physical therapy (Preterm infant Early intervention for Movement and Participation Trial), control (usual physiotherapy care)\u003c/p\u003e\n\u003cp\u003e(2) Altunalan 2023: Physical therapy (Explorer Baby program), control (neurodevelopmental treatment)\u003c/p\u003e\n\u003cp\u003e(3) Dumuids-Vernet 2023: Physical therapy (crawling training on a mini-skateboard), control (standard of care)\u003c/p\u003e","description":"","filename":"FigureF5MetaanalysisFinemotorPhysicaltherapy.png","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/e81688a335806702572baf1f.png"},{"id":88652627,"identity":"e27db650-8fb6-4e0d-818b-894c58ff9668","added_by":"auto","created_at":"2025-08-08 17:56:51","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":27406,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis of gross motor development (0-3 years): Physical therapy versus control\u003c/p\u003e\n\u003cp\u003eLegend:\u003c/p\u003e\n\u003cp\u003eCI, confidence interval; PT, physical therapy; SD, standard deviation\u003c/p\u003e\n\u003cp\u003eFootnotes:\u003c/p\u003e\n\u003cp\u003e(1) Mobbs 2022: Physical therapy (Preterm infant Early intervention for Movement and Participation Trial), control (usual physiotherapy care)\u003c/p\u003e\n\u003cp\u003e(2) Altunalan 2023: Physical therapy (Explorer Baby program), control (neurodevelopmental treatment)\u003c/p\u003e\n\u003cp\u003e(3) Dumuids-Vernet 2023: Physical therapy (crawling training on a mini-skateboard), control (standard of care)\u003c/p\u003e","description":"","filename":"FigureF6MetaanalysisGrossmotorPhysicaltherapy.png","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/3ee3b94d2637d38b6c40e7a2.png"},{"id":88653749,"identity":"a4737e6a-b44b-4442-a0ef-7409c9d47257","added_by":"auto","created_at":"2025-08-08 18:20:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1836766,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/088ff085-5346-4e6b-bc49-bcfefb8617c3.pdf"},{"id":88653013,"identity":"3706a04c-3643-43df-83db-ee6d100dbf05","added_by":"auto","created_at":"2025-08-08 18:04:51","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":147837,"visible":true,"origin":"","legend":"\u003cp\u003eSearch Strategy\u003c/p\u003e","description":"","filename":"AdditionalfileA1Searchstrategy.docx.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/1e75846a9bf6f4793743c991.pdf"},{"id":88652618,"identity":"24a08394-a16d-42b2-823d-414cc6fdc566","added_by":"auto","created_at":"2025-08-08 17:56:51","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":52729,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Diagram Physical Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA2PRISMAFlowDiagramPTneucropped.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/8f0ede22b5d7b6f221154c50.pdf"},{"id":88652634,"identity":"d99f25a9-4943-457e-9d8c-643ba6669a42","added_by":"auto","created_at":"2025-08-08 17:56:51","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":52777,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Diagram Occupational Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA3PRISMAFlowDiagramOTcropped.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/3392983899ee588e133addbb.pdf"},{"id":88652632,"identity":"2515ac7a-699e-44d2-92e2-43ef73603be5","added_by":"auto","created_at":"2025-08-08 17:56:51","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":849030,"visible":true,"origin":"","legend":"\u003cp\u003eList of included and excluded studies\u003c/p\u003e","description":"","filename":"AdditionalfileA4Listofallincludedandexcludedstudies.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/c361537001707f8a1f230836.pdf"},{"id":88652645,"identity":"e8b17584-aa6c-4c36-96cc-cda10ade14a6","added_by":"auto","created_at":"2025-08-08 17:56:52","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":485570,"visible":true,"origin":"","legend":"\u003cp\u003eDescription of included Studies Physical Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA5Characteristicsofallincludedstudies.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/e606ba0f0035669d291f0579.pdf"},{"id":88652625,"identity":"812e6a05-532c-4327-8762-b3c454282abf","added_by":"auto","created_at":"2025-08-08 17:56:51","extension":"pdf","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":129574,"visible":true,"origin":"","legend":"\u003cp\u003eCharacteristics of included Studies Physical Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA6Characteristicsofincludedstudiesofphysicaltherapy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/9c8f600ca46145a55c8d7e8a.pdf"},{"id":88652633,"identity":"3f8a7abc-f75f-4fe2-961d-cb29bdf84506","added_by":"auto","created_at":"2025-08-08 17:56:51","extension":"pdf","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":115079,"visible":true,"origin":"","legend":"\u003cp\u003enon-poolable Study Outcomes Physical Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA7Nonpoolableoutcomesofphysicaltherapy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/92b76f290925ce6850b96d62.pdf"},{"id":88652630,"identity":"2668db15-f5b3-468c-a8e2-2e878021fc50","added_by":"auto","created_at":"2025-08-08 17:56:51","extension":"pdf","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":62191,"visible":true,"origin":"","legend":"\u003cp\u003eCharacteristics of included Studies Occupational Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA8Characteristicsofincludedstudiesoccupationaltherapy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/91a251140346c80342ed992c.pdf"},{"id":88652626,"identity":"7aa00fa3-9321-4fda-b91e-a34473c35cdc","added_by":"auto","created_at":"2025-08-08 17:56:51","extension":"pdf","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":57031,"visible":true,"origin":"","legend":"\u003cp\u003enon-poolable Study Outcomes Occupational Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA9Nonpoolableoutcomesofoccupationaltherapy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/9ad5bde47298e0718a40ff51.pdf"},{"id":88653018,"identity":"e2f4680f-37f4-433e-b8f0-18e9c6ca174f","added_by":"auto","created_at":"2025-08-08 18:04:51","extension":"pdf","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":124171,"visible":true,"origin":"","legend":"\u003cp\u003eSummary of Findings Physical Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA10Summaryoffindingsphysicaltherapy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/8e17d8fdbe341a3af73a9eb8.pdf"},{"id":88653016,"identity":"8cf4c469-9aee-4a4e-b24d-c4b65d46b3e9","added_by":"auto","created_at":"2025-08-08 18:04:51","extension":"pdf","order_by":11,"title":"","display":"","copyAsset":false,"role":"supplement","size":114198,"visible":true,"origin":"","legend":"\u003cp\u003eSummary of Findings Occupational Therapy\u003c/p\u003e","description":"","filename":"AdditionalfileA11Summaryoffindingsoccupationaltherapy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7231082/v1/e2f887a5adfcd869d0c2cddd.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eEffect of physical or occupational therapy on participation and functioning in children born preterm: A systematic review and meta-analysis\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePreterm birth, defined as delivery before 37 completed weeks of gestation (1), continues to be a significant global medical concern. In 2020, an estimated 13.4\u0026nbsp;million newborns \u0026ndash; accounting for 9.9% of all births worldwide - were born preterm (2).\u003c/p\u003e\u003cp\u003ePreterm birth is associated with long-term complications that can impact preterm-born individuals throughout their entire lives, often resulting in significant lifelong disabilities (3). For instance, preterm born children are at a higher risk of developing motor, cognitive, and behavioural impairments compared to their term-born peers (4\u0026ndash;6). These challenges not only result in personal limitations but can also hinder social participation, manifesting in difficulties in kindergarten or school, unemployment, and challenges in family life (7, 8).\u003c/p\u003e\u003cp\u003eCurrently an evidence-based guideline for long-term follow-up of preterm born infants is under development in Germany. To improve the limitations caused by preterm birth, a variety of therapeutic and support measures are available. After discharge from the NICU, physical therapy and occupational therapy are frequently prescribed, with specific interventions such as motor skill training, sensory integration therapy and neurodevelopmental treatment being carried out (9\u0026ndash;11). Professionals as well as parental support groups considered the research question about the evidence on physical or occupational therapy of high priority. The primary aim of early physical therapy and occupational therapy interventions is to promote the children\u0026rsquo;s motor and cognitive development, improve social skills, and address other developmental needs (12, 13).\u003c/p\u003e\u003cp\u003eAlthough physical and occupational therapy interventions are commonly prescribed and many parents report high satisfaction, robust evidence supporting their effectiveness, especially after hospital discharge, is lacking (11, 14). Early intervention programs to improve motor development objectively were not shown to have a lasting effect (15). This discrepancy between the lack of objective effects and the high parental satisfaction with the therapy could have several explanations. One possible reason is that the outcome measures used in studies may not align with the primary concerns of children and parents, whereas the F-words (function, family, fitness, fun, friends and future) would better capture their priorities (16). Given the significant impact of preterm birth on many areas of daily life, it is crucial to identify effective therapeutic measures that can be sustainably implemented to improve long-term outcome of preterm-born individuals.\u003c/p\u003e\u003cp\u003eThis systematic review explores the impact of physical therapy during infancy or childhood on motor development, participation, quality of life, and cognitive development in preterm born children, as well as the effect of occupational therapy during childhood on participation, behaviour, quality of life, and executive functioning.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis systematic review addresses two research questions. In children born preterm, on the one hand, we examined the impact of physical therapy during infancy or childhood on motor development, participation, quality of life, and cognitive development, compared to standard of care, non-therapeutic interventions, or other types of physical therapy; and on the other hand, we investigated the effect of occupational therapy during childhood on participation, behaviour, quality of life, and executive functioning, compared to standard of care, non-therapeutic interventions, or other types of occupational therapy.\u003c/p\u003e\u003cp\u003eProtocols for both research questions were published before conduct of the systematic review (PROSPERO: CRD42024562290 and CRD42024562314).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Eligibility criteria\u003c/h2\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003e2.1.1 Types of studies\u003c/h2\u003e\u003cp\u003eTo minimize confounding we included only randomized controlled trials (RCTs). Studies were eligible if they were published or reported results in trials registries or were not completed (\u0026lsquo;ongoing studies\u0026rsquo;) or were completed but not yet published (\u0026lsquo;awaiting classification\u0026rsquo;). Publications lacking sufficient data for a reliable inclusion were classified as \u0026lsquo;awaiting classification\u0026rsquo;. We contacted authors for clarification. There were no restrictions regarding the language of publication. Studies published solely as conference abstracts were excluded due to limited information.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e2.1.2 Participants / Population\u003c/h2\u003e\u003cp\u003eWe included studies investigating:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eChildren born preterm (\u0026lt;\u0026thinsp;37 weeks gestational age (GA), regardless of birth weight)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eChildren born preterm AND with low birth weight (LBW\u0026thinsp;\u0026lt;\u0026thinsp;2500g)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eChildren born preterm AND/OR with very low birth weight (VLBW\u0026thinsp;\u0026lt;\u0026thinsp;1500g)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eChildren born preterm AND/OR with extremely low birth weight (ELBW\u0026thinsp;\u0026lt;\u0026thinsp;1000g)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eIf the study population consisted of children born full-term (\u0026ge;\u0026thinsp;37 weeks GA) or of children with LBW without detailed information on gestational age, studies were excluded. For studies with mixed populations, inclusion required separately reported subgroup data on the eligible population.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.1.3 Intervention(s)\u003c/h2\u003e\u003cp\u003eFor both physical therapy and occupational therapy, we included any therapeutic methods and concepts, provided that they were performed as a single intervention and not as part of an interdisciplinary program, such as an early intervention program. Interventions had to be conducted at least six times post-discharge by a health professional and focus on the child, with or without parental involvement. The physical therapy intervention had to start within any time before school age (0\u0026ndash;6 years), while occupational therapy had to be conducted during preschool age (3\u0026ndash;6 years).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.1.4 Comparator(s)\u003c/h2\u003e\u003cp\u003ePhysical and occupational therapy were not combined in analysis. Eligible comparators were:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eStandard of care or no treatment.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAny other active monodisciplinary intervention unrelated to physical or occupational therapy (e.g. sports, choir, scouts).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAny other type or mode of physical or occupational therapy methods and concepts.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eStandard of care must have been comparable between study groups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.1.5 Outcomes\u003c/h2\u003e\u003cp\u003eWe aimed to focus on proxies for the F-words (function, family, friends, fun, fitness, future) (16), using motor, cognitive, and fitness measurements as indicators of function, and participation and quality of life instruments as proxies for family, friends, and fun.\u003c/p\u003e\u003cp\u003eThe main outcome set of physical therapy included:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMotor development at infancy (0\u0026ndash;3 years) and preschool age (4\u0026ndash;6 years) measured with e.g. Alberta Infant Motor Scale (AIMS), Bayley Scales of Infant and Toddler Development \u0026ndash; Third Edition (BSID-III), Movement Assessment Battery for Children \u0026ndash; Second Edition (MABC-2)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCognitive development at infancy measured with e.g. with BSID-III\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eParticipation (activities of daily living, leisure activities, special educational needs) at infancy and preschool age measured with e.g. Daily Activities of Infants Scale (DAIS), Participation questionnaire, Pediatric Evaluation of Disability Inventory (PEDI)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eQuality of life at infancy and preschool age measured with e.g. V\u0026eacute;cu et Sant\u0026eacute; Per\u0026ccedil;ue de l\u0026rsquo;Adolescent (VSP-A), KINDL\u003csup\u003eR\u003c/sup\u003e, Pediatric Quality of Live Inventory\u003csup\u003e\u0026trade;\u003c/sup\u003e (PedsQL\u003csup\u003e\u0026trade;\u003c/sup\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eWe included the frequency of medical prescriptions following initial therapy as an additional outcome.\u003c/p\u003e\u003cp\u003eThe main outcome set of occupational therapy included:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eParticipation (activities of daily living, leisure activities, special educational needs) at preschool age measured with e.g. Global School Adaption score (GSA)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBehaviour (attention and internalizing problems) at preschool age measured with e.g. Strengths and Difficulties Questionnaire (SDQ), Child Behavior Checklist (CBCL)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eExecutive functioning at preschool age measured with e.g. Developmental Neuropsychological Assessment \u0026ndash; Second Edition (NEPSY-2))\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eQuality of life at preschool age measured with e.g. VSP-A, KINDL\u003csup\u003eR\u003c/sup\u003e, PedsQL\u003csup\u003e\u0026trade;\u003c/sup\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eAdditional outcomes included motor development, parent-child interaction and the frequency of medical prescriptions following initial therapy.\u003c/p\u003e\u003cp\u003eOutcomes had to be assessed no earlier than 6 months corrected age due to limited validity at this age. Studies which did not report at least one predefined outcome were not excluded and contributed baseline information to our study pool.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Search methods\u003c/h2\u003e\u003cp\u003eA joint systematic search for both research questions was conducted. We searched MEDLINE, PsycInfo, CINAHL, Cochrane Central Register of Controlled Trials and WHO International Clinical Trials Registry Platform (ICTRP) from inception to 23 April 2024. Search strategies are reported in Additional file A1. We also screened reference lists of all included primary studies and identified systematic review articles.\u003c/p\u003e\u003cp\u003eWe performed study selection based on our predefined eligibility criteria and in accordance with the Cochrane Handbook of Intervention (17). Two reviewers independently screened titles and abstracts of identified records. Full text-articles of all doubtful and potentially eligible records were then retrieved and assessed independently by both reviewers. Disagreements in either step were resolved through discussion or consultation with a third reviewer.\u003c/p\u003e\u003cp\u003eWe used Covidence\u0026reg; (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia) for screening.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data extraction\u003c/h2\u003e\u003cp\u003eTwo review authors independently extracted data using a piloted data extraction form. We extracted details on general study information, trial characteristics, and participant, intervention, comparator and outcome characteristics. Discrepancies were resolved through discussion and missing data were requested from study authors.\u003c/p\u003e\u003cp\u003eData was extracted using Covidence\u0026reg; and Excel\u0026reg; (Microsoft\u0026reg;, 2018).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Risk of bias assessment\u003c/h2\u003e\u003cp\u003eTwo reviewers using the Cochrane Risk of Bias 2 (RoB2) tool independently, assessed the risk of bias of outcomes from included studies. The risk of bias of each study result was classified as low, some concerns or high for each individual domain and overall. Disagreements were resolved through discussion or input from a third reviewer.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Data synthesis\u003c/h2\u003e\u003cp\u003eFor dichotomous outcomes, we used the risk ratio (RR) with a 95% confidence interval (CI) as an effect measure.\u003c/p\u003e\u003cp\u003eFor continuous outcomes, we used the mean difference (MD) with 95% CIs in case results of studies referred to one scale, and the standardized mean difference (SMD) with 95% CIs for results of studies referred to different scales.\u003c/p\u003e\u003cp\u003eWe pooled data of studies with sufficiently homogeneous clinical and methodological characteristics in meta-analyses. Patient age at intervention, the assessment tool and its scale had to be comparable, with outcomes reported as mean (SD). Data reported exclusively as median were not transformed into means and were not included in meta-analysis.\u003c/p\u003e\u003cp\u003eAs we assumed that the intervention effects will be related but not the same for included studies, we used a random-effects model for meta-analysis. All studies included in our meta-analyses reported continuous outcomes, so we performed analyses using the inverse variance method under a random-effects model. We used R package meta version 7.0\u0026ndash;0 for analysis.\u003c/p\u003e\u003cp\u003eStatistical heterogeneity was assessed using the χ\u0026sup2; test and the I\u0026sup2; statistic, with heterogeneity defined as P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for the χ\u0026sup2; statistic, or I\u0026sup2; \u0026ge; 40%. We didn\u0026rsquo;t calculate the 95% prediction interval (PI) because our meta-analyses didn\u0026rsquo;t include four or more studies.\u003c/p\u003e\u003cp\u003eSubgroup and sensitivity analyses, as well as assessments of reporting bias, were considered not meaningful due to the small number of identified studies and were not performed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Certainty of the Evidence\u003c/h2\u003e\u003cp\u003eTwo review authors independently rated the certainty of evidence of each main outcome using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, which classifies certainty of evidence as high, moderate, low, or very low (18). Certainty of evidence was downgraded for one, two or three levels in case of risk of bias, inconsistency, imprecision, indirectness, or publication bias (17). Discrepancies were resolved through discussion. Results are summarized in Summary of Findings tables.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e2.7 Differences between protocol and review\u003c/h2\u003e\u003cp\u003eFollowing the publication of our protocol, several adjustments were made:\u003c/p\u003e\u003cp\u003eFirst, if outcome data were collected at multiple time points within a study using the same measurement instrument, we decided to extract data only from the latest time point, in order to capture the longest-term effects of the interventions.\u003c/p\u003e\u003cp\u003eSecond, cognitive development was identified as a key outcome of physical therapy during data extraction and was prioritized accordingly.\u003c/p\u003e\u003cp\u003eThird, due to limited capacities, we had initially applied a language restriction to include only studies published in English and German. However, to avoid the potential omission of relevant evidence, we subsequently re-evaluated studies that had been excluded due to language. Still, none of these studies met our inclusion criteria.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Search\u003c/h2\u003e\u003cp\u003eThe search strategy identified 10,537 database records and 1,290 records in trials registers. After removing duplicates, 8,763 titles and abstracts were screened, with 8,180 deemed irrelevant. We sought 583 full-text articles for retrieval and assessed 568 for eligibility, along with 8 additional entries from websites (Additional Files A2, A3).\u003c/p\u003e\u003cp\u003eFor the physical therapy research question, 525 reports were excluded, 11 studies (13 reports) were ongoing at the time of the search, and 11 studies (12 reports) were awaiting classification (Additional file A2). Ten studies (18 reports) were included.\u003c/p\u003e\u003cp\u003eFor the occupational therapy research question, 553 reports were excluded, one study was ongoing at the time of search and eight reports were awaiting classification (Additional file A3). Three studies (seven reports) were included.\u003c/p\u003e\u003cp\u003eAll excluded studies along with their respective reasons for exclusion are provided in Additional File A4.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1 Characteristics of included studies: Physical therapy\u003c/h2\u003e\u003cp\u003eFor physical therapy, we included ten RCTs with 453 randomized preterm infants (GA 22\u0026ndash;35 weeks) aged 0\u0026ndash;6 years (Additional File A5, A6). Studies were published between 2012 and 2023 and were carried out in Australia, France, Spain, Switzerland, Turkey and the United States of America.\u003c/p\u003e\u003cp\u003eThe studies were categorized into four intervention groups. Five studies focused on family-centred and active learning programs for children and their parents (19\u0026ndash;23), whereas two studies focused on group-based physical therapy for preterm born children aged 4\u0026ndash;6 years (24, 25). Two studies (26, 27) investigated muscle training techniques and one study (28) analysed early crawling training on a mini-skateboard. Control groups received either another physical therapy concept, standard of care or no intervention.\u003c/p\u003e\u003cp\u003eThe following outcomes were assessed over a period ranging from 4 weeks to 24 months post-baseline: Motor development (19\u0026ndash;28), participation (19, 23) and cognitive development (19\u0026ndash;21, 23, 26).\u003c/p\u003e\u003cp\u003eWhile all studies reported relevant outcomes, four were not included in data synthesis and meta-analysis due to methodological issues or incompatible data (19, 22, 25, 27).\u003c/p\u003e\u003cp\u003eAn overview of all non-poolable outcomes can be found in Additional File A7.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2 Characteristics of included studies: Occupational therapy\u003c/h2\u003e\u003cp\u003eIn total, three RCTs investigating occupational therapy, involving 244 preterm-born children (GA 23\u0026ndash;35 weeks) aged 3\u0026ndash;6 years were included (Additional Files A5, A8). Studies were published between 2010 and 2024 and were carried out in Italy, France and the United States of America.\u003c/p\u003e\u003cp\u003eThe interventions were either a parent-child interaction therapy program (29) or computer-based programs (30, 31). Control groups received either no intervention or standard of care. The following outcomes were assessed over a period ranging from 4 weeks to 16 months post-baseline: Behaviour (29, 31), participation (31), executive functioning (30, 31), quality of life (31), and parent-child interaction (29).\u003c/p\u003e\u003cp\u003eWhile all studies reported relevant outcomes, one study (30) was not included in data synthesis due to incompatible data. An overview of all non-poolable outcomes can be found in Additional file A9.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Risk of bias\u003c/h2\u003e\u003cp\u003eDetailed RoB2 assessments for all studies\u0026rsquo; outcomes are shown in Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003eF1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003eF2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003eF1\u003c/span\u003e: Risk of bias ratings per outcome and for all domains (physical therapy)\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003eF2\u003c/span\u003e: Risk of bias ratings per outcome and for all domains (occupational therapy)\u003c/p\u003e\u003cp\u003eOf the 14 study results for physical therapy, 57.1% were rated as \u0026lsquo;low risk of bias\u0026rsquo;, 28.6% as \u0026lsquo;some concerns\u0026rsquo;, and 14.3% as \u0026lsquo;high risk of bias\u0026rsquo;.\u003c/p\u003e\u003cp\u003eOf the six study results for occupational therapy, 83.3% were rated as \u0026lsquo;some concerns\u0026rsquo; and 16.7% as \u0026lsquo;high risk of bias\u0026rsquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Effects of interventions\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003e3.4.1 Results physical therapy\u003c/h2\u003e\u003cdiv id=\"Sec22\" class=\"Section4\"\u003e\u003ch2\u003e3.4.1.1 Motor delay and cognitive delay (0\u0026ndash;3 years)\u003c/h2\u003e\u003cp\u003eMotor delay and cognitive delay were each assessed in one study (21) including preterm infants (GA 27\u0026ndash;31 weeks) aged 0\u0026ndash;3 years, comparing the Explorer Baby program to neurodevelopmental treatment.\u003c/p\u003e\u003cp\u003eThe evidence is very uncertain about the effect of physical therapy on motor delay (RR 0.64, 95% CI 0.21 to 2.00, 51 participants, Additional file A10) and cognitive delay (RR 0.11, 95% CI 0.01 to 1.89, 51 participants, Additional file A10), both measured with BSID-III (32). Certainty of evidence was very low due to extremely serious imprecision.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section4\"\u003e\u003ch2\u003e3.4.1.2 Cognitive development (0\u0026ndash;3 years)\u003c/h2\u003e\u003cp\u003eCognitive development was assessed in two studies (21, 23) including preterm infants (GA 27\u0026ndash;34 weeks) aged 0\u0026ndash;3 years, comparing the Explorer Baby program to neurodevelopmental treatment (21) and the Preterm infant Early intervention for Movement and Participation Trial (PreEMPT) to usual physiotherapy care (23). We combined the results of these two studies in meta-analysis.\u003c/p\u003e\u003cp\u003eThe evidence suggests that physical therapy may slightly increase cognitive development (MD 0.95, 95% CI -0.3 to 2.2, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%, 62 participants, Additional file A10, Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003eF3\u003c/span\u003e ), measured with BSID-III (32). Certainty of evidence was low due to very serious imprecision.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003eF3\u003c/span\u003e: Meta-analysis of cognitive development (0\u0026ndash;3 years): Physical therapy versus control\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section4\"\u003e\u003ch2\u003e3.4.1.3 Motor development (0\u0026ndash;3 years)\u003c/h2\u003e\u003cp\u003eMotor development was assessed in two studies (20, 26) including preterm infants (GA 24\u0026ndash;35 weeks) aged 0\u0026ndash;3 years, comparing psychomotor therapy to standard of care (20, 26) and treadmill training to standard of care (26). We combined the results of these two studies in meta-analysis.\u003c/p\u003e\u003cp\u003eThe evidence suggests that physical therapy results in little to no difference on motor development (SMD \u0026minus;\u0026thinsp;0.14, 95% CI -0.46 to 0.19, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%, 142 participants, Additional file A10, Figure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003eF4\u003c/span\u003e), measured with BSID-III (20, 32) and BSID-II (26, 33). Certainty of evidence was low due to serious risk of bias and serious imprecision.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003eF4\u003c/span\u003e: Meta-analysis of motor development (0\u0026ndash;3 years): Physical therapy versus control\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section4\"\u003e\u003ch2\u003e3.4.1.4 Fine motor development and gross motor development (0\u0026ndash;3 years)\u003c/h2\u003e\u003cp\u003eFine motor development and gross motor development were each assessed in three studies (21, 23, 28) including preterm infants (GA 27\u0026ndash;34 weeks) aged 0\u0026ndash;3 years, comparing the Explorer Baby program to neurodevelopmental treatment (21), the PreEMPT to usual physiotherapy care (23) and crawling training on a mini-skateboard to standard of care (28). We combined the results of these three studies in meta-analysis.\u003c/p\u003e\u003cp\u003eThe evidence is very uncertain about the effect of physical therapy on fine motor development (MD -0.97, 95% CI \u0026minus;\u0026thinsp;3.17 to 1.23, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;64%, 89 participants, Additional file A10, Figure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003eF5\u003c/span\u003e) and gross motor development (MD 0.44, 95% CI -2.31 to 3.19, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;70%, 90 participants, Additional file A10, Figure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003eF6\u003c/span\u003e), both measured with BSID-III (32). Certainty of evidence was very low due to very serious inconsistency and very serious imprecision.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003eF5\u003c/span\u003e: Meta-analysis of fine motor development (0\u0026ndash;3 years): Physical therapy versus control\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003eF6\u003c/span\u003e: Meta-analysis of gross motor development (0\u0026ndash;3 years): Physical therapy versus control\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section4\"\u003e\u003ch2\u003e3.4.1.5 Participation in activities of daily living (0\u0026ndash;3 years)\u003c/h2\u003e\u003cp\u003eParticipation in activities of daily living was assessed in one study (23) including preterm infants (GA 28\u0026ndash;34 weeks) aged 0\u0026ndash;3 years, comparing the PreEMPT to usual physiotherapy care.\u003c/p\u003e\u003cp\u003eThe evidence is very uncertain about the effect of physical therapy on participation in activities of daily living (Mean (SD) intervention group 5.5 (0.0), control group 6.3 (1.03), 8 participants, Additional file A10), measured with DAIS (34). Certainty of evidence was very low due to very serious risk of bias and very serious imprecision.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section4\"\u003e\u003ch2\u003e3.4.1.6 Motor development (4\u0026ndash;6 years)\u003c/h2\u003e\u003cp\u003eMotor development was assessed in one study (24) including preterm infants (GA 22\u0026ndash;29 weeks) aged 4\u0026ndash;6 years, comparing group-based physiotherapy to standard of care.\u003c/p\u003e\u003cp\u003eThe evidence is very uncertain about the effect of physical therapy on motor development (MD -10.65, 95% CI -25.07 to 3.77, 48 participants, Additional file A10), measured with MABC-2 (35). Certainty of evidence was very low due to extremely serious imprecision.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section4\"\u003e\u003ch2\u003e3.4.1.7 Other outcomes (0\u0026ndash;6 years)\u003c/h2\u003e\u003cp\u003eOur systematic literature research highlighted a lack of evidence on several predefined outcomes of physical therapy (Additional file A10). In infancy, no study reported data for the outcomes participation in leisure activities or later special educational needs of preterm born children, quality of life or frequency of medical prescriptions in subsequent years. Similarly, for childhood, only motor development outcomes were reported, with no study reporting on other outcomes.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section3\"\u003e\u003ch2\u003e3.4.2 Results occupational therapy\u003c/h2\u003e\u003cdiv id=\"Sec30\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.1 Participation: special educational needs\u003c/h2\u003e\u003cp\u003eSpecial educational needs were assessed in one study (31) including preterm infants (GA 26\u0026ndash;32 weeks) aged 5\u0026frac12; \u0026minus;\u0026thinsp;6 years, comparing an online working memory rehabilitation program to standard of care.\u003c/p\u003e\u003cp\u003eThe evidence is very uncertain about the effect of occupational therapy on children\u0026rsquo;s school participation (MD 0.1, 95% CI -6.1 to 6.3, 142 participants, Additional file A11), measured with the GSA score (36). Certainty of evidence was very low due to very serious risk of bias and very serious imprecision.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.2 Behaviour\u003c/h2\u003e\u003cp\u003eBehaviour was assessed in two studies (29, 31) including 167 preterm born children (GA 23\u0026ndash;35 weeks) aged 3\u0026ndash;6 years, comparing a parent-child interaction therapy program to no treatment (29) and an online working memory rehabilitation program to standard of care (31). Due to clinical heterogeneity in interventions, data could not be pooled in meta-analysis.\u003c/p\u003e\u003cp\u003eThe evidence suggests that parent-child interaction therapy slightly reduces attention problems (MD -8.30, 95% CI -13.40 to -3.20, 25 participants, Additional file A11), measured with the CBCL (37), whereas the working memory rehabilitation program may result in little to no difference in hyperactivity (MD 0.4, 95% CI -0.6 to 1.3, 142 participants, Additional file A11), measured with the Goodman SDQ (38). Certainty of evidence for attention problems and hyperactivity was low due to serious risk of bias and serious imprecision.\u003c/p\u003e\u003cp\u003eThe evidence is very uncertain about the effect of occupational therapy on internalizing and emotional problems: Parent-child interaction therapy may reduce internalizing problems (MD -11.70, 95% CI -17.78 to -5.62, 25 participants, Additional file A11), measured with the CBCL (37), whereas the working memory rehabilitation program may have little to no effect on emotional problems (MD -0.2, 95% CI -1.2 to 0.8, 142 participants, Additional file A11), measured with the Goodman SDQ (38). Certainty of evidence for internalizing and emotional problems was very low due to serious risk of bias, serious inconsistency and serious imprecision.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.4 Parent-child interaction\u003c/h2\u003e\u003cp\u003eParent-child interaction was assessed in one study (29) including preterm born children (GA 23\u0026ndash;35 weeks) aged 18\u0026ndash;60 months, comparing a parent-child interaction therapy program to no treatment. Occupational therapy may improve parent-child interaction, measured with the Dyadic Parent-Child Coding System (39) (MD 20.70, 95% CI 3.97 to 37.43, 25 participants, Additional file A11), but the evidence is very uncertain. Certainty of evidence was very low due to serious risk of bias and very serious imprecision.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec33\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.5 Executive functioning\u003c/h2\u003e\u003cp\u003eExecutive functioning was assessed in two studies (30, 31), including 189 preterm born children (GA 26\u0026ndash;32 weeks) aged 5\u0026frac12; \u0026minus;\u0026thinsp;6 years, comparing an online working memory rehabilitation program to standard of care (31) and an adaptive motion-interaction videogame platform to standard of care (30). However, only subscales were used, which do not fully capture executive functioning as defined in our main outcome set and were therefore not included in our summary of findings.\u003c/p\u003e\u003cp\u003eOne study (31) measured executive functioning of the children using the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) visuospatial and working memory indices (40) and reported a short-term effect that could not be substantiated in the long term (Additional file A9). One study (30) assessed executive functioning using the Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI-III) processing speed quotient (41) and reported a short-term effect (Additional file A9).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.6 Quality of life\u003c/h2\u003e\u003cp\u003eQuality of life was not comprehensively assessed in any of the included studies. One study (31) including 142 preterm infants (GA 26\u0026ndash;32 weeks) aged 5\u0026frac12; \u0026minus;\u0026thinsp;6 years, comparing an online working memory rehabilitation program to standard of care measured quality of life using the VSP-A questionnaire (42), reporting subscales on \u0026ldquo;Relationship with parents and family\u0026rdquo;, \u0026ldquo;School performance\u0026rdquo;, and \u0026ldquo;Relationship with teacher\u0026rdquo; with no clinically relevant effect (Additional file A9). As these subscales focus on specific aspects of the school and social environment, they do not fully capture overall quality of life as defined in our main outcome set and were therefore not included in our summary of findings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec35\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.7 Other outcomes\u003c/h2\u003e\u003cp\u003eOur systematic literature research highlighted a lack of evidence on several predefined outcomes of occupational therapy. We couldn\u0026rsquo;t identify any studies that assessed whether occupational therapy performed at preschool age improves the children\u0026rsquo;s participation in activities of daily living or leisure activities and whether there is an effect on their motor development or on the frequency of medical prescription in subsequent years (Additional file A11).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eTo the best of our knowledge, no comparable systematic review with meta-analysis including RCTs on this topic is currently available, highlighting a significant gap of aggregated evidence in both the fields of physical therapy and occupational therapy. Only a few studies have examined the impact of childhood physical and occupational therapy on various abilities and life domains of preterm-born individuals. In particular, long-term follow-up data on outcomes summarized by the F-words (function, family, friends, fitness, fun, future) are missing (16). The high heterogeneity of interventions and outcome assessment tools, as well as the mostly very low certainty of evidence, further complicates the interpretation of findings.\u003c/p\u003e\u003cp\u003eOur findings suggest that family-centred and active learning programs for children and their parents led by physical therapists may support cognitive development in the first years of life. This is consistent with findings that emphasize the first five years of life as a critical period for neural development, during which foundational processes shape future cognitive-educational and social-functioning (43\u0026ndash;45). The brain\u0026rsquo;s heightened neuroplasticity in this early stage allows for significant and lasting effects of targeted experiences and interventions (43\u0026ndash;45). However, while our systematic review suggests that physical therapy may have benefits for cognitive development in infancy, its impact on motor development throughout childhood remains inconclusive. These findings align with data from early intervention programs, demonstrating positive effects on cognitive but not motor development up until preschool age (15), whereby valuable insights for clinicians are provided. In settings where multidisciplinary intervention programs are unavailable, the prescription of a physical therapy program with parental involvement may be a viable alternative. Notably, none of the reviewed studies examined physical therapy concepts that started in the second or third year of life.\u003c/p\u003e\u003cp\u003eWhile some studies indicate that early family-centred physical therapy improves both cognitive function and motor skills in the short-term (46), the overall evidence remains heterogenous. A previous study suggested that family-centred physical therapy alone may not be sufficient to improve cognitive and motor development during the first year of life; however, the population in this study was not randomised (10). Consistent with the findings of our meta-analyses, which indicate that physical therapy has no clinically relevant impact on both fine and gross motor development during infancy and preschool years, other studies similarly provide no evidence that early motor difficulties and subsequent developmental outcomes in school age children can be improved through physical therapy alone (14, 47). In the German Guideline the following recommendation was made for prophylactic physical therapy during infancy: \u0026ldquo;Physical therapy on its own in infancy including and educating parents can be recommended for preterm born\u0026thinsp;\u0026lt;\u0026thinsp;37 weeks of gestation to improve development.\u0026rdquo;\u003c/p\u003e\u003cp\u003eDespite these findings, evidence regarding the efficacy of physical therapy for motor compensatory abilities in children aged 4\u0026ndash;6 years remains scarce and inconclusive. Furthermore, no studies reported participation rates in leisure activities, highlighting a gap in the literature. In the German Guideline the following recommendation was made for prophylactic physical therapy during childhood: \u0026ldquo;Physical therapy during childhood for preterm born\u0026thinsp;\u0026lt;\u0026thinsp;37 weeks is dispensable.\u0026rdquo;\u003c/p\u003e\u003cp\u003eGeneral conclusions about the effects of occupational therapy for preterm children at preschool age cannot be drawn due to insufficient evidence.\u003c/p\u003e\u003cp\u003eThe limited evidence from our review indicates that parent-child interaction training during early childhood may strengthen the parent-child relationship and reduce attention and internalizing problems (29). This aligns with occupational therapy approaches for other patient groups. Parent involvement in occupational therapy interventions appears highly effective and beneficial for children, making family-centred care a suitable approach in this context (48). However, there are also studies which present contrasting findings. For instance, a study on a different interaction-based intervention during the first year of life in preterm infants found no evidence for an improvement in parent-child interaction, highlighting the variability of outcomes across studies, depending on factors such as the specific intervention, the population, and the age of the preterm infants (49). In the German Guideline the following recommendation was made for prophylactic occupational therapy during childhood: \u0026ldquo;Occupational therapy focussing on parent-child-interaction can be considered to improve parent-child-interaction.\u0026rdquo;\u003c/p\u003e\u003cp\u003eRegarding participation in school or special educational needs to clear benefits could be found (36). In the German Guideline the following recommendation was made for prophylactic occupational therapy during childhood: \u0026bdquo;Occupational therapy during childhood to improve participation and quality of life in school is dispensable.\u0026rdquo;\u003c/p\u003e\u003cp\u003eInternet- or computer-based training programs designed to enhance cognitive functions, which were included in the studies of our review, show short-term positive effects on working memory and executive functions in preterm born children, but these benefits are not sustained long-term (30, 31). Additionally, other studies have demonstrated that short-term occupational therapeutic interventions can temporarily improve outcomes such as social development, though long-term effects were not maintained (50). It is not surprising that short term interventions fail to produce lasting effects. Given these short-term effects, it may be worthwhile to investigate whether \u0026lsquo;booster sessions\u0026rsquo; could help maintain gains. So far, studies on the long-term implementation of such sessions are lacking.\u003c/p\u003e\u003cp\u003eOccupational therapies using a top-down approach and focussing on the International Classification of Functioning, Disability and Health (ICF) framework of activity in line with the \u0026ldquo;F-words\u0026rdquo; seem to be more promising than classical bottom-up designs focussing on body-structure (48).\u003c/p\u003e\u003cp\u003eIt is important to note that interpreting our main results in the context of existing evidence is challenging due to the limited overall evidence in this field and the considerable variability among available studies in terms of studied populations, interventions, outcomes, study designs, and quality. While several systematic reviews have already addressed early interventions for preterm born children post-discharge, their methodologies differ from those of this review. Some included not only RCTs but also observational studies (46), quasi-RCTs and cluster-randomized trials (15). Additionally, their meta-analyses incorporated data reported exclusively as asymmetric medians (15, 46).\u003c/p\u003e\u003cp\u003eThe certainty of evidence of the outcomes included in this systematic review were rated as low or very low. This is primarily due to most outcomes being assessed by only one or two studies with a small number of participants. Furthermore, wide confidence intervals and a high statistical heterogeneity contributed to imprecision and inconsistency of some studies, leading to a downgrading of the certainty of evidence. Additionally, a substantial risk of bias was identified in three studies (23, 26, 31), arising from various methodological limitations in the conduct of the studies.\u003c/p\u003e\u003cp\u003eSome studies employed highly specific measurement tools or subscales that were insufficient for a comprehensive assessment of the predefined outcomes (25, 30, 31). In other instances, the results were reported in incompatible data formats (19, 22, 27). Consequently, certain studies or outcome data were not incorporated into the evidence profile. Additionally, subgroup and sensitivity analyses, as well as assessments of reporting bias, were deemed unfeasible due to the limited number of identified studies and were therefore not conducted.\u003c/p\u003e\u003cp\u003eMost studies focused on very or extremely preterm children, with mean gestational ages of the included infants ranging from 25 to 32 weeks (23, 25). Therefore, the findings may not be generalizable to late preterm infants.\u003c/p\u003e\u003cp\u003eOur systematic review and meta-analysis were conducted in accordance with Cochrane methodological standards, ensuring a high-quality literature search and synthesis. Inclusion criteria were clearly predefined, and two independent reviewers carried out the review process. Any deviations from the protocol, which was published prior to this review, were transparently documented.\u003c/p\u003e\u003cp\u003eDue to limited resources, the review initially included only studies published in English and German, potentially leading to the omission of relevant evidence. This limitation was effectively mitigated through a subsequent reassessment of studies published in other languages.\u003c/p\u003e\u003cp\u003eAt least in Germany, physical and occupational therapy are frequently prescribed for preterm children up to preschool age for various reasons. While more than 60% of preterm children receive physical therapy in the first year of life, this rate declines by school age, whereas occupational therapy use gradually increases, reaching approximately 30% by preschool age (11).\u003c/p\u003e\u003cp\u003eSchouten et al. developed a core outcome set for physical, mental, and social functioning in collaboration with parental groups and experts (51). However, core outcome sets co-developed with preterm-born individuals and their parents for proxies of the other F-words are still lacking. Such frameworks are essential for prioritizing research on meaningful outcomes in physical and occupational therapy.\u003c/p\u003e\u003cp\u003eFollow-up care of preterm-born individuals should encompass not only the \u0026ldquo;F\u0026rdquo; for functioning, but also fun, family, friends, fitness and future. Analysing neonatal network data for these outcomes could help identify subgroups with deficits, allowing us to prioritize future research accordingly.\u003c/p\u003e\u003cp\u003eIn most countries, there is a growing shortage of qualified therapists, making it essential to prioritize therapies for those who stand to benefit the most. At the same time, frequent therapy appointments can be burdensome for both parents and children, reducing preterm children\u0026rsquo;s leisure time \u0026ndash; time that could otherwise be spent engaging in other F-words: fun, family, friends, fitness and getting prepared for the future. This highlights the need for a critical evaluation of the effectiveness of these therapeutic interventions. Addressing the current lack of sufficient evidence on this issue is crucial to ensure the most effective healthcare for preterm children and laying a strong foundation for their future.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis systematic review with meta-analyses assessed 13 RCTs examining the effect of post-discharge physical and occupational therapy on developmental and functional outcomes in preterm children. The findings suggest that physical therapy in infancy may enhance cognitive development, although its effects on motor development remain uncertain. Occupational therapy showed no consistent benefits for behavioural outcomes, executive function, or parent-child interaction. Notably, no studies assessed long-term participation, quality of life, or healthcare utilisation. The certainty of evidence was generally low or very low due to methodological limitations and small sample sizes, restricting the reliability of the findings. These results reveal significant evidence gaps, emphasizing the need for high-quality research to improve therapeutic recommendations. For clinicians involved in follow-up care of preterm infants, the findings suggest that family-centred physical therapy could be considered where multidisciplinary programmes are unavailable. Future research should prioritise comprehensive outcome measures that align with patient and family priorities, ensuring interventions meaningfully contribute to long-term developmental trajectories.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAIMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlberta Infant Motor Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBSID-II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBayley Scales of Infant Development, Second Edition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBSID-III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBayley Scales of Infant and Toddler Development, Third Edition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCBCL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChild Behavior Checklist\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDAIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDaily Activities of Infants Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGestational age\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGRADE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrading of Recommendations, Assessment, Development and Evaluations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGlobal School Adaptation score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eICF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInternational Classification of Functioning, Disability and Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMABC-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMovement Assessment Battery for Children, Second Edition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNeonatal intensive care unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNEPSY-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDevelopmental Neuropsychological Assessment, Second Edition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePediatric Evaluation of Disability Inventory\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePedsQL\u003csup\u003eTM\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePediatric Quality of Live Inventory\u003csup\u003eTM\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreEMPT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreterm infant Early intervention for Movement and Participation Trial\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRoB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCochrane Risk of Bias 2 tool\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSDQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStrengths and Difficulties Questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVSP-A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVécu et Santé Perçue de l’Adolescent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWPPSI-III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWechsler Preschool and Primary Scale of Intelligence, Third Edition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWPPSI-IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWechsler Preschool and Primary Scale of Intelligence, Fourth Edition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u0026nbsp;(not applicable)\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;(not applicable)\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its additional files.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors have stated that they had no interests that might be perceived as posing a conflict or bias.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research was part of the development of an evidence-based guideline for follow-up for children born preterm (FrühTEV) and funded by GBA-Innovationsfond (01VSF23009). The funding source was not involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions\u003c/p\u003e\n\u003cp\u003eJSB: acquisition, analysis and interpretation of data, writing– original draft\u003c/p\u003e\n\u003cp\u003eET: acquisition, analysis and interpretation of data, writing– original draft\u003c/p\u003e\n\u003cp\u003eMB, JW: acquisition and analysis of data; writing– review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eLS: acquisition and analysis of data\u003c/p\u003e\n\u003cp\u003eHJ, MIM:\u0026nbsp;systematic search\u003c/p\u003e\n\u003cp\u003eSW:\u0026nbsp;conceptualization, methodology, formal analysis, supervision, writing– review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eJS: conceptualization, supervision, writing– review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe thank N. Gawehn, G. Kaiser, M. Kayser and N. Stahlmann for their support and advise during the review process.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWalani SR. Global burden of preterm birth. Int J Gynaecol Obstet. 2020;150(1):31-33\u003c/li\u003e\n\u003cli\u003eOhuma EO, Moller A-B, Bradley E, Chakwera S, Hussain-Alkhateeb L, Lewin A, et al. National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis. The Lancet. 2023;402(10409):1261-1271.\u003c/li\u003e\n\u003cli\u003eBlencowe H, Lee AC, Cousens S, Bahalim A, Narwal R, Zhong N, et al. Preterm birth-associated neurodevelopmental impairment estimates at regional and global levels for 2010. Pediatr Res. 2013;74 Suppl 1(Suppl 1):17-34.\u003c/li\u003e\n\u003cli\u003eBhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJ. Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis. 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Wechsler Preschool and Primary Scale of Intelligence \u0026ndash; Fourth Edition (WPPSI-IV). Bloomington, MN: Pearson; 2012.\u003c/li\u003e\n\u003cli\u003eWechsler D. The Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI-III). San Antonio, TX: The Psychological Corporation; 2002.\u003c/li\u003e\n\u003cli\u003eSapin C, Simeoni MC, El Khammar M, Antoniotti S, Auquier P. Reliability and validity of the VSP-A, a health-related quality of life instrument for ill and healthy adolescents. J Adolesc Health. 2005;36(4):327-336.\u003c/li\u003e\n\u003cli\u003eWachs TD, Georgieff M, Cusick S, McEwen BS. Issues in the timing of integrated early interventions: contributions from nutrition, neuroscience, and psychological research. Ann N Y Acad Sci. 2014;1308:89-106.\u003c/li\u003e\n\u003cli\u003eBrito NH, Fifer WP, Myers MM, Elliott AJ, Noble KG. Associations among family socioeconomic status, EEG power at birth, and cognitive skills during infancy. Dev Cogn Neurosci. 2016;19:144-151.\u003c/li\u003e\n\u003cli\u003eNelson CA, Sullivan E, Engelstad AM. Annual Research Review: Early intervention viewed through the lens of developmental neuroscience. J Child Psychol Psychiatry. 2024;65(4):435-455.\u003c/li\u003e\n\u003cli\u003eBernabe-Zu\u0026ntilde;iga JE, Rodriguez-Lucenilla MI, Alias-Castillo AJ, Rueda-Ruzafa L, Roman P, Del Mar Sanchez-Joya M. Early interventions with parental participation and their implications on the neurodevelopment of premature children: a systematic review and meta-analysis. Eur Child Adolesc Psychiatry. 2024.\u003c/li\u003e\n\u003cli\u003eCameron EC, Maehle V, Reid J. The effects of an early physical therapy intervention for very preterm, very low birth weight infants: a randomized controlled clinical trial. Pediatr. 2005;17(2):107-119.\u003c/li\u003e\n\u003cli\u003eNovak I, Honan I. Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Aust Occup Ther J. 2019;66(3):258-273.\u003c/li\u003e\n\u003cli\u003eBaraldi E, Allodi MW, L\u0026ouml;wing K, Wadstr\u0026ouml;m N, Smedler AC, \u0026Ouml;rtqvist M, et al. Parent-child interaction after home-visiting intervention for children born extremely preterm-A randomised clinical trial. Acta Paediatr. 2025;114(1):74-82.\u003c/li\u003e\n\u003cli\u003eSalokorpi T, Rautio T, Kajantie E, Von Wendt L. Is early occupational therapy in extremely preterm infants of benefit in the long run? Pediatr Rehabil. 2002;5(2):91-98.\u003c/li\u003e\n\u003cli\u003eSchouten E, Haupt J, Ramirez J, Sillett N, Nielsen C, Clarke A, et al. Standardized Outcome Measures for Preterm and Hospitalized Neonates: An ICHOM Standard Set. Neonatology. 2022;119(4):443-454.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"1abf7428-df93-4120-930c-c384bfff1108","identifier":"10.13039/501100002946","name":"Deutsches Zentrum für Luft- und Raumfahrt","awardNumber":"01VSF23009","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University Hospital Würzburg","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"preterm, physical therapy, occupational therapy, motor development, cognitive development, participation, parent-child interaction, quality of life, executive functioning, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-7231082/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7231082/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePreterm born children are at a higher risk of developing motor, cognitive and behavioural impairments than term born peers.\u003cstrong\u003e \u003c/strong\u003eThis systematic review with meta-analysis aimed to assess the efficacy of post-discharge physical or occupational therapy compared to standard of care, no treatment or any other active intervention on functioning and participation during infancy and childhood in children born preterm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe systematically searched MEDLINE, PsycINFO, CINAHL, CENTRAL, and WHO ICTRP for randomized controlled trials (RCTs) published up to April 23, 2024. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool. Certainty of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Random-effects meta-analyses were performed for clinically and methodologically homogeneous studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirteen RCTs involving 697 children born preterm were included, with ten studies investigating physical therapy (n=453; 0-6 years) and three studies examining occupational therapy (n=244; 3-6 years).\u003c/p\u003e\n\u003cp\u003ePhysical therapy interventions comprised family-centered active learning programs, group-based therapy, muscle training, and task-oriented motor intervention. Meta-analyses indicated that physical therapy may slightly enhance cognitive development during infancy (MD 0.95, 95% CI -0.3 to 2.2; low certainty). However, effects on motor outcomes were inconsistent, and evidence regarding participation and quality of life was limited and inconclusive.\u003c/p\u003e\n\u003cp\u003eOccupational therapy interventions included computer-based training and parent-child interaction programs. Outcomes measured were behaviour, participation, executive functioning, and parent-child interaction. No consistent benefits were observed across studies. One small study indicated a reduction in attention (MD -8.30, 95% CI -13.40 to -3.20) and internalizing problems (MD -11.70, 95% CI -17.78 to -5.62), though evidence certainty was low and very low. No studies examined quality of life or long-term healthcare use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eWhile the effects of physical therapy on motor and participation outcomes remain uncertain, physical therapy in infancy may improve cognition. Evidence for occupational therapy on participation, behaviour, and parent-child interaction is limited. Therefore, generalizable conclusions are not possible. \u003cbr\u003e\nStudies rarely address participation, quality of life, or long-term outcomes and reveal research gaps emphasizing the need for future research.\u003c/p\u003e\n\u003cp\u003ePROSPERO Protocols: CRD42024562290 and CRD42024562314.\u003c/p\u003e","manuscriptTitle":"Effect of physical or occupational therapy on participation and functioning in children born preterm: A systematic review and meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-08 17:56:46","doi":"10.21203/rs.3.rs-7231082/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd0e011d-641c-4550-8c93-ceddec3777de","owner":[],"postedDate":"August 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-08T17:56:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-08 17:56:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7231082","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7231082","identity":"rs-7231082","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}