The descriptive category A: Making it possible, is based on the biopsychosocial paradigm and takes all the interacting components in the ICF-CY  into consideration. In this descriptive category the standpoint is that the environment has to be modified in order to make it possible for the child and their families to participate in activities that are important to them. A counter point position would be that it is the child that must be adjusted, i.e. improved muscle strength or increased joint range of motion in order to manage the environmental demands. In descriptive category A the physiotherapist adopts a collaborative and empowering role which has been supported in previous studies concerning physiotherapy interventions [57–59]. This research approach, which is centred on the child and family, is based on a holistic view of the child and family with the conception of physiotherapy knowledge as the ability to interact and use professional competence in the intervention process . Jensen et al. recognized this interactive approach as a keystone in expert physiotherapy . The role of the parents is to be active partners and to help the child to incorporate new treatment-related behavior into everyday life [14, 16]. The biopsychosocial paradigm facilitates goal-setting with the focus on the child’s potential in every-day life, which are relevant according to the components activity and participation in the ICF-CY model. In this client-centred goal-setting  the power and control over interventions and evaluation are shared between the child, the family and the physiotherapist, thereby employing the paradigm of FCS [12–14], empowerment , and strategies for motor learning [27–31]. This is important for both the child and the family and will make therapy in clinical settings and in research more effective and meaningful [61–65]. The child’s motor learning process is encouraged by stimulating the child to be an active problem solver during the physiotherapy intervention, thereby enabling the child to learn motor strategies to achieve a higher degree of independence in their environment [27–32]. According to Valvano the child’s practice of meaningful tasks based on the child’s individual ability in a true environmental situation is essential for the child’s development of motor control and coordination .
In descriptive category B: Making it work, a mixed paradigm of health was identified. This is due to the influences from both the biomedical paradigm, which focuses on the impairment and is directed towards correcting the child’s disability, and the biopsychosocial paradigm, as the intervention is also directed towards making a difference in the child’s ability to participate actively in a particular environment. Valvano describes this as “an impairment-focused intervention with activity-focused goals” which has been proposed as a common combination in physiotherapy interventions for children with CP . The role of the physiotherapist derived from the descriptions interpretation of the results encompassed in this descriptive category is to train the child and family, and to give special instructions as to what they should do, i.e. the role of a coach. Research has shown that the parents and the child have little influence over the intervention and its goals when physiotherapists adopt this mixed paradigm because the goal-setting procedure and the intervention are solely physiotherapist led [57, 61–65]. This is also in accordance with the experiences of parents and children with CP in decision making in community-based paediatric physiotherapy  and with a study describing physiotherapists’ experiences of client participation in physiotherapy interventions as guidance. In adopting a mixed biomedical/biopsychosocial paradigm the physiotherapist takes full responsibility for enhancing health, avoiding risks and reducing complications without fully inviting the child and families to be active in the process. This can be recognized as an ability to follow the demands on the profession . The demands are many and sometimes divergent. The health-care system demands that physiotherapists provide good clinical services according to evidence and/or well-tried clinical practice. Moreover there may be demands for health- care cost control and cost reduction, while at the same time demands to respond to the needs and expectations of the child and family . In research these different demands may be contradicted. In descriptive category B, a major input as to how the child tackles motor problems comes from instructions given by the physiotherapist. Physical guidance can be used early in practice in order to help the child to feel the movement and to facilitate the development of the child’s action plan . However, the criticism is that optimal motor learning will not be achieved unless the child is actively engaged in solving the problem to meet the challenge of the task [27–32].
Descriptive category C: Making it normal, is embedded in a biomedical paradigm as the research intervention is directed towards the child’s disability with the innate understanding that the environment, the child’s own motivation and the family’s needs, are not adequately considered. The descriptive category C differs considerably from the descriptive categories A and B. The focus of the intervention on only specific impairment aspects implies a deductive approach [57, 59]. Different motor impairments within the spectrum of CP can be treated with different therapeutic exercises, but the transferred functional benefits of impairment-focused interventions have yet to be proven effective. Thus, strictly impairment-focused physiotherapy research interventions for children with CP may not be beneficial for the child to optimally function in daily life. According to Anttila et al.  and Damiano  physiotherapists should consider the functional task and not simply treat the impairment. In the biomedical paradigm the role of the physiotherapist is that of an expert who has full control and power over the intervention process. This authoritarian approach, centred on the physiotherapist as an authoritative expert, has been described previously as one approach in physiotherapy interventions in clinical practice [57, 58]. The physiotherapist is regarded as being the best suited to understand the full consequences of the disability and to determine the needs of others from their own perspective as opposed to those of their clients [57, 58]. The goal-setting procedure is centred on the physiotherapist  and the child and parents are marginalized and not invited to take part in the process at all. Instead of being active participants in the process the child and family are reduced to powerless recipients of medical decisions and treatment . Children’s self-confidence and self-esteem can depend on how well they understand the reason behind physiotherapy interventions, in other words, why they have to do the exercises . This is important as children’s understanding also affects their ability to use their capacity in the challenges they face in everyday life, and thus their motor learning processes. The use of biomedical impairment-focused interventions in clinical settings, the lack of FCS, and the physiotherapist’s failure to enable the child to try to change his or her movement strategy contradicts the process of motor learning [27–32].
We may assume a priori that studying relevant articles, commonly read by physiotherapists describes the underlying view of disability and health that physiotherapists use. This influences assumptions when conducting research within the area of CP, and thus different experiences of physiotherapy interventions in research can be described. The family puts their trust in the professional competence of the physiotherapist and therefore should be assured of getting the best treatment available for their child. Thus, it is vital that the physiotherapy profession continues to study physiotherapy interventions for these children with appropriately designed clinical trials . However physiotherapists are affected by their own experiences which in turn are imbedded in paradigms that affect the physiotherapists choice of research strategy, treatment and evaluation [25, 26]. The biomedical dualistic paradigm of disability and health is commonly adopted in physiotherapy research. It is useful in models of the human body, as it enables the researchers to study separate aspects of disability, and contributes to the description of its function in quantifiable terms. Thus physiotherapists’ experiences of physiotherapy interventions in research as found in this study, may be entrenched in the routines and ready-made solutions that permeate the tradition which is taken for granted .
Theory and assumptions about humans, health, the world, knowledge, science and physiotherapy together with the physiotherapists’ personal perspectives on health and disability are related to the practical and theoretical knowledge they use in their interventions in clinical practice and research [69, 70]. Higgs et al.  state that knowledge is dynamic and that theoretical and practical perspectives coexist, are interconnected and interdependent, and that they are intertwined in interventions. The physiotherapy profession has expertise in body function and structure from a functional point of view. Physiotherapists also have profound knowledge on how the disabilities associated with CP, i.e. problems in sensory-motor development and the development of cognitive functions, contribute to the child’s ability to perform the task in the environment, and they should therefore base their research interventions on this knowledge . Rosenbaum  argues that it is time to consider the developmental aspects of the child, as well as the family dimensions. This requires that physiotherapists not only should have focus on the child’s impairment in itself but also take more consideration of the child and family’s daily challenges and well-being. In research this is a challenge. However, the objective of interventions is to increase the child’s competence in their social and physical environment, and this requires the active participation of both the child and the parents [3–14, 27–32]. The family may sometimes experience the need for, in their eyes, a physiotherapy expert who will tell them explicitly what to do. This may be grounded in their previous experiences of physiotherapy as a profession that provides authoritative instruction which may result in a transfer of decision making to the physiotherapist. Thus in these cases it may be difficult to establish a true collaborative relationship both in research and in clinical practice. Such parents may need a highly competent physiotherapist who can facilitate cooperative decision making . Physiotherapists should be able to satisfy the parents’ needs for support and information using empowerment and collaboration and should not take complete control. Parents know what is best, and want the best, for their child based on their own unique view of life and parenthood, but they often require support to cope with their child’s disability and its impact on everyday life. The parents should be instructed and supervised, but they must also be encouraged as competent parents. Physiotherapists need to identify ways to help these children and their families to cope in daily life. Our standpoint is that physiotherapists should recognize that it is a professional skill to listen and learn from their clients. Furthermore we believe that the overall goal of physiotherapy interventions for children with CP is to encourage the involvement of the family and to create challenging strategies to enable the child to maximize his/her potential and autonomy in society, including the ability to solve problems and take control over their lives. Physiotherapists have to know how to create empowerment in the child and their family and together with them create new ways to control and handle limitations. The field of physiotherapy embraces knowledge within the areas of pedagogics and didactics and therefore more research concerning the pedagogical aspects of physiotherapy interventions for children with CP, is required.
Methodological aspects and limitations
In health care it is essential to recognise how phenomena can be experienced and understood in qualitatively different ways by health-care professionals [56–58]. Thus, phenomenography can be an essential tool for the exploration of theoretical foundations and conceptual parameters of the discipline of physiotherapy [57, 58]. The phenomenographic approach is an interesting though to date seldom used way of analysing previously published material. The articles analysed in this study described different therapeutic methods and treatment modalities in physiotherapy interventions in research, thus variations were expected in the way in which physiotherapy interventions were experienced. A phenomenographic analysis was used as a powerful tool to identify these variations. Once again, we want to point out that this study identifies the variations of collected experiences as they appear in the articles studied [25, 26] which may not be wholly representative of how the individual authors actually experience physiotherapy intervention in their everyday clinical practice. A critical assessment of physiotherapy interventions in clinical practice is beyond the scope of this article.
The category system of a phenomenographic study is not definitive, as the results are derived from a limited number of sources, although the variation of experiences within the investigated material can be described. Other descriptive categories, not found in this study, may have been revealed in a larger sample and other material. However, the phenomenographic approach assumes some degree of transferability and that the same descriptive categories can be found in other similar sources .
The trustworthiness of the results in a qualitative study is dependent on the researchers’ methodological skill and competence. The researchers’ understanding and awareness of the phenomenon being investigated and of the context in which the phenomenon can be experienced and understood is important [26, 73]. However, this can also be a limitation of this study. In the background section references from acknowledged researchers within the field of CP interventions and/or motor learning elucidate our understanding of the phenomenon. The first author in this present study has considerable clinical experience in treating children with CP and has shared the physiotherapeutic framework with the authors in the analysed articles. The results can be influenced by this pre-understanding, as well as our understanding of reality from our own cultural and ideological understanding of the phenomenon . The human factor is both the great strength and the fundamental weakness of qualitative research and analysis. Following the phenomenographic approach, we are convinced that when the first author read the articles she probably experienced them according to how she herself experiences the physiotherapy interventions for children with CP. We were aware of this throughout the analysis and discussed it on several occasions during the analysis process.
Triangulation is often used in qualitative research to indicate that more than two methods or sources are used in a study with a view to double- or triple-checking results. Data triangulation, i.e. the use of a variety of data sources in studying the same phenomenon, using the same method is one way of strengthening the results and increasing trustworthiness in a qualitative study . In a previously published study  we conducted a phenomenographic analysis of physiotherapists’ experiences of client participation in physiotherapy interventions. Even if there are points of similarities between the results in these studies the perspectives in the studies were not the same and the context was different. In phenomenography the experience is always related to the context  and thus triangulation has not been done.
The trustworthiness and reasonableness of a phenomenographic study are related to how well the results correspond to reality and how logical and understandable the results are . The collection of the data used in this study is documented by a detailed description of how the articles were selected in order to obtain a broad sample according to the maximum variation strategy. To ensure trustworthiness quotations were used in illustrating each descriptive category  and the articles to which they belonged are presented in the reference list [35–55]. A pragmatic criterion can be used to address practical concerns about truth in qualitative studies [26, 73]. The practical consequences of this study may be that physiotherapists conducting research within the area of children with CP recognize the different experiences of physiotherapy interventions described in this study. They can reflect over the health paradigm they use and how this may influence their research and what this may imply.