training resources
Physical Therapy in ECSE
by Catherine Franks, P.T. (1980's)
Catherine completed studies in pediatric physical therapy, earning a Masters Degree at Hahenman University in Philadelphia and later a doctorate in motor development and learning from the University of Wisconsin-Madison. Her thesis was recognized as the outstanding Masters study by the American Physical Therapy Association and later published in the Journal of Physical Therapy. Her study confirmed the hypothesis that too much physical activity and attendant fatigue negatively impacted some fine motor and attention skills associated with academic performance in the classroom.
The physical therapist in the public school setting provides both direct and indirect services to the handicapped child. When you look into the Early Childhood-Exceptional Education needs (EC:EEN) classroom you may well see evidence of both of these types of service. Over by the easel is a child with cerebal palsy painting while in a prone stander which the therapist has adjusted and adapted to fit that child, and instructed the staff in its appropriate use. In another part of the room the child with myelomeningocele (spina bifida) may be playing ball with a small group of children while using a walker. The physical therapist is directing this activity and assisting the handicapped child because this is part of his therapy treatment, working toward improving balance and weight shift. In yet another part of the room, a youngster with muscular dystrophy is helping clean up, bending over picking up blocks and placing them on a shelf. This is one of the activities suggested by the physical therapist to help maintain the child's strength.
When you move from the pre-elementary area to the elementary level, you might pass by a child with myelomeningocele who is racing down the hallway on crutches being followed by the physical therapist who is admonishing him/her to "slow down." Looking into the multihandicapped classroom you may see a child with cerebral palsy sitting in a special chair, operating a computer with an adapted switch. And at the upper elementary grade level you could come across a boy with muscular dystrophy propelling his wheelchair down the hall, laboring to keep up with the other children. If you were observing in the high school, it would become even more apparent to you that as children with physically handicapping conditions get older their needs change; therefore, the role and services of the physical therapist change to meet their needs.
Physical therapy is generally defined as the treatment of disease, injury, or disability by physical means such as heat, cold, light, electricty, water, massage, theraputic exercise, etc. In a medical clinical setting, for example, modalities of heat could include diathermy, ultrasound, hot packs, infrared, or water modalities. Water modalities include whirlpool, hubbard tank, and possibly even a theraputic pool. Electricty could be employed by using a variety of electrical stimulators. The physical therapist is primarily concerned with providing treatment to prevent or minimize disability, relieve pain, develop and improve or restore sensory and motor function, control postural deviations and establish and maintain maximum physical performance. Physical Therapy in the public schools is a medically orientated treatment program administered in an educational setting. Therapists employ a variety of thersputic exercise techniques and activities to facilitate or remediate sensory/motor development. Intervention is directed towards maximizing the child's educational potential by preventing disabilities and developing, improving or restoring sensory/motor function and relieving pain. The primary goal of intervention is to enhance the child's physical development so he/she can attain maximum benefit from the educational process. According to PL 94-142, physical therapy is defined by law as a related service or one of those services "...as maybe required to assist a handicapped student to benefit from special education ..." (APTA, 1980.)
Therapists employed by schools work primarily in a school based setting but also can work with a child at home. In the state of Wisconsin, a prescription from a physician, dentist or osteopath is required for physical therapy evaluation and/or treatment. At the present time physical therapists are not allowed to participate in school or community screening projects. In addition to being licensed by the Medical Examining Board, physical therapists must also be certified by the Wisconsin Department of Public Instruction (DPI), and this certificate must be renewed every five years unless one has life certification. It is also important if working in pediatrics to have additional education and training in treatment techniques such as Neurodevelopmental Treatment (NDT) and Sensory Integration (SI) treatment. Such training is available through workshops, short courses, summer school programs, etc.
The American Physical Therapy Association (APTA) is the professional organization to which most physical therapists belong. One may also belong to one or several sections within the APTA depending on one's area of specialty within the field. All members of the APTA are also members of their respective state chapters, in this state called the Wisconsin Physical Therapy Association (WPTA). State, national and district organizations all hold regular meetings, conferences and offer educational programs. In addition, in many areas, Pediatric Study Groups hold regular informative sessions for interested professionals working with the pediatric population.
Publications in physical therapy include Clinical Management, Totline, and Physical and Occupational Therapy in Pediatrics which are quarterly journals; Physical Therapy-Journal of the American Physical Therapy Association and state and national newsletters which are published monthly; and the "PT FORUM" and "PT BULLETIN. which are weekly publications.
To become a physical therapist one must graduate from an accredited school with a bachelor of science or a master of science in physical therapy. It is also possible to have an undergraduate degree in a related field, e.g. OT, physical education, and obtain a certificate in physical therapy after completing eighteen to twenty-four months of work at an accredited physical therapy school. Most therapists are graduates of a four year program with an additional semester for clinical affiliations. In 1990, however, this will change. Due to the advances in technology which have greatly increased the scope of physical therapy, all programs after 1990 will be five year programs plus time for clinical affiliations. Course work has heavy emphasis on sciences, consisting of classes in physics, chemistry, anatomy, physiology, kinesiology, neurology and neuroanatomy, general medicine and surgery, pathology, psychology, child development and course work in the use of physical modalities and techniques. Clinical affiliations or internships vary from school to school, but usually last about six months and are in three different settings, e.g. general hospital, pediatrics center, geriatrics center. Upon completion of the educational program the physical therapist may choose to work in an area of specialty in physical therapy such as rehabilitation, community health, cardiopulmonary, pediatrics, sports, orthopedics, geriatrics, private practice, general or industrial medicine.
All fifty states now have physical therapy practice acts which define the physical therapist's role and responsibilities. All states require a licensure examination and many require continuing education credits to maintain a license. There is at the present time no uniformity among states in granting licensure reciprocity from state to state. The state of Wisconsin requires an oral examination for licensure even if they accept the written examination from another state. They also require renewal of license every three years at the cost of eighty-five dollars. The WPTA is presently trying to get the Physical Therapy Practice Act amended to allow physical therapy treatment without physician's referral. This has already been accomplished in a number of states. While WDPI has not acknowledged it, the legislature has recently passed legislation giving PTs freedom to test and intervene in public school programs without a physicians prescription.
Physical therapists are bound to abide by the APTA Code of Ethics (see appendix) and to interpret the code, the Guide for Professional Conduct which includes Standards for Physical 'halm Services and Standards for Physical Therapy Practitioners. They must also abide by their state chapter bylaws, by their state medical practice act which is policed by a state licensing board and by their state DPI rules and regulations. Then of course they must also follow the guidelines of the school districts in which they work and/or their employing agency. According to APTA the therapist has a legal as well as an ethical obligation to document and quantify effectiveness of treatment in enhancing the child's educational process (APTA, 1980). This means keeping up to date records and at least annually, writing comprehensive progress reports for each child served. It is also the therapist's ethical responsibility to continually improve his/her physical therapy skills and those specific skills required, for working with children in an educational environment, through continuing education courses. APTA is also very explicit regarding the cooperative effort that must exist between educators and therapists if children are to get maximum benefits from educational programs. "The physical therapist should share with the educator information concerning those skills which the child needs to function optimally within the classroom. The educator should share with the physical therapist those educational concepts which the therapist can incorporate into the theraputic regime. Only through a cooperative effort will it be possible to remain consistent with programming strategies across environments." (APTA, 1980) Consistent implementation of programming will then be functionally and developmentally appropriate for the child.
Besides direct and indirect treatment which will be discussed later, physical therapists in the public schools have a number of other responsibilities. The therapist participates on M-Teams either as a member or as a consultant, to determine a child's physical abilities and disabilities and to explain the rational for physical therapy intervention. The therapist also participates in the development of the child's IEP goals and objectives and his/her educational program plan. Because physical therapy is a related service it can only be provided when it is necessary to enhance the child's special education program. A child with a physical disability who does not need or qualify for any special education programs including a specially designed physical education program is not considered to have an EEN and does not qualify to receive physical therapy. As the provider of a related service, the physical therapist cannot be a primary IEP monitor.
The physical therapist is also responsible for the instruction of school personnel and parents in proper handling and positioning techniques to allow the child to be in optimal position for learning. It is equally important that parents and school staff are taught proper lifting and transfer techniques to insure prevention of injury to either the child or the adult. Those working with children in school and at home need instructions (best if written) and demonstration by the physical therapist in the use of adaptive equipment such as pronestanders or special chairs; assistive devices like special spoons, pencil holders or page turners; and in the use and application and removal of prosthetics which are artificial limbs, and orthotics which include all braces and splints.
Physical therapists also have a valuable role as consultants to school personnel and parents about architectural barriers and adaptive equipment needed for short and long range planning, in interpreting a child's physical abilities and disabilities when the classroom teacher, adaptive and regular physical education teachers and parents are developing educational programs, and as a liaison between school, home and medical community.
Most of the physical therapists' time is spent providing direct services for the physically handicapped child. Children in Wisconsin public schools receiving physical therapy range in age from three to twenty-one years old and have a wide range of disabling or handicapping conditions, including neurological deficits such as cerebral palsy, myelomeningocele, dystrophies, sensory/motor and SI disorders; orthepedic conditions such as juvenile rhuemetoid arthritis or amputation; and medical conditions such as cystic fibrosis, heart defects or burns. Referrals for physical therapy services can be made by school personnel, physicians and other health care providers, transferring school districts and parents. The decision as to whether physical therapy will help the child to get maximum benefit from his educational program is made by the M-Team.
The question often arises as to whether a child should receive physical therapy or occupational therapy or both, and what.are the differences between the two therapies. In addressing this question, several points need to be made. First, certain specialized types of pediatric training courses, e.g., . Neurodevelopmental Treatment (NDT), or Sehsory Integration (SI) Treatment are taught to both disciplines, so both become knowedgeable of the same techniques. Second, training in areas of adaptive equipment and assistive devices, orthotic and prosthetic needs, activities of daily living (ADLs), wheelchair mobility, architectural and environmental modifications is very dependent on the school program where the physical therapist or occupational therapist was trained. What follows is a general breakdown of the responsibilities of each profession and then what responsibilities are shared by both.
OCCUPATIONAL THERAPY
Oral-Motor Dysfunction (e.g., coordination of musculature for feeding and pre-speech).
Activities of Daily Living (ADC's) and Environmental Modifications.
Muscle Tone and Strength-Trunk and Upper Extremities.
Fine Motor Development (small muscle groups) and Manual Dexterity.
Perceptual Motor Development.
These will be explained more fully in the Occupational Therapy section.
PHYSICAL THERAPY
Range of Motion (ROM)/Flexibility. An instrument called a Goniometer is used to measure how much range each joint is able to move through. When there is limitation, various techniques are used to increase ROM. Regular goniometric measurement is a must for children with muscular dystrophy as one of the goals of therapy is to prevent ROM limitation for as long as possible. The tendency towards limitation and eventual contractures is also present with cerebral palsy so frequent measurement is also advisable. It is also important to check if all components of movement are present. Frequently the diagonal or rotation component is missing, especially in the child with cerebal palsy.
Muscle Function (Tone and Strength). The Manual Muscle Test is given to establish a baseline of muscle strength. If specific muscle groups are involved as in the child with muscular dystrophy or myelomeningocele the muscle test also is given at regular intervals. Using weights, the therapists may have the child with myelomeningocele on a progressive resistive exercise program to increase strength. When there are problems with tone and general strength as with the child with cerebral palsy, the therapist may use techniques which involve movement patterns with facilitation, inhibition and resistance to movement given by the therapist.
Postural and Gait Deviations. Physical Therapists assess and use a variety of methods of remediation for such things as scoliosis, lordosis, and kyphosis which are all curvatures of the spine, club feet, leg length discrepancies or toe walking. All the children we have previously discussed would be likely to have both postural and gait problems due to the muscle imbalance that is present with all three conditions.
Ambulation. When teaching independence in mobility using crutches, walkers, wheelchairs or other special equipment it is important to do a thorough assessment. Any kind of mobility has prerequisites which must be developed before safe, independent mobility can be accomplished. A child using crutches or walker must have good upper extremity strength before he/she can begin walking; the child must also know how to fall to avoid injury. All children should have appropriate protective responses before attempting ambulation. The response most frequently referred to by therapists is the parachute which prevents the child from landing on his/her face when he/she falls. This response is often delayed with cerebal palsy.
Assessment of Architectural Barriers and Transportation Needs. Physical Therapists work with district and building administrators no school buildings are accessible to handicapped children and buses are equiped to provide safe transportation. This can range from something as simple as lowering locker hooks, to remodeling a bathroom, to working out evacuation procedures from upper floors during fire and disaster drills. It is a very necessary service for children with all types of handicapping conditions.
Gross Motor Development. Physical Therapist use a variety of instruments for assessment of motor development. Some of these are the Bruininks-Oseretsky Test of Motor Proficiency, the Peabody Developmental Motor Scales, the Brigance Diagnostic Inventory of Early Development, and a variety of checklists. When testing for SI deficits, the Southern California Sensory Integration Test is generally used. The type of assessment done will depend on the age and condition of the child. Physical Therapists often use observation, feel and analysis of the child's response. Therapists look at what the child can do, what the child can't do, what components of movement, strength and coordination are missing, what the child does abnormally and why the child does it abnormally. This is the type of assessment done with children with cerebal palsy as an example, whereas with the developmentally delayed child, criterion referrenced or competency based testing will probably be used.
BOTH PHYSICAL AND/OR OCCUPATIONAL THERAPY
Assessment and Construction of Adaptive Equipment Needs. Physical Therapists usually take care of larger equipment needs such as wheelchairs, special seating devices, standers, potty chairs, etc., while occupational therapist generally deal with feeding, ADL's, and fine motor activity adaptations. It is likely that at some time during their schooling children with cerebal palsy, muscular dystrophy and myelomeningocele will all need adaptative equipment. Initially, the child with cerebral palsy will probably have the most needs using such things as wedges, bolsters, standers, special spoons or adapted cups. By late junior high and in senior high the dystrophic child's need for special equipment increases greatly.
Assessment of Prosthetic and Orthotic Needs and Equipment. When dealing with an artifical limb, the therapist has to know the biomechanics of its operation in order to teach the child how to use it properly. The therapist also needs to know different types of splints-some aid in movement, some give stability to a joint, some reduce tone - and when a child will benefit from splinting. Some therapist make splints, but many have them made. A splint would be very common orthoses for the children we have been discussing. The child with cerebral palsy could have tone reducing foot splints or casts to decrease heel cord tone and may also have some type of splint on the hand/wrist to assist in hand function. Only the very mildest child with spina bifida would be without ankle/foot orthoses (AFO's) and a child with a higher lesion, while walking with crutches/walker, may be braced up to the chest. The older child who is no longer walking will no longer need braces so will probably only have AFO's. Frequently the child with muscular dystrophy will have AFO's in the lower elementary grades to help keep his walking as long as possible. Later as a teenager, when he is very disabled, he may need hand/wrist splints to assist him in writing, feeding, etc. Reflexes and Responses. If primitive reflexes, which are necessary at birth and are the basis for movement in the infant, are not appropriately integrated they can interfere with the child's ability to function. The classic example of this is the asymetric tonic neck reflex (ATNR). When a child turns his/her head to the side, the are on the face aide extends straight out, while the arm on the back of the head side flexes, making it difficult for the child to feed himself/herself. There are exercises and activities which help facilitate integration. Balance, equilibrium and protective responses which are needed for stability in any position are often delayed in children receiving therapy, including those discussed earlier. Working with children on a large therapy ball is one way to help remediate this delay and is an activity which most children enjoy.
Sensory Integration (SI). To be competent in testing for and remediating SI problems, therapists need additional training. Traditionally, SI problems have been associated with learning disabled children, but recent studies have shown that almost all children with motor deficits will also exhibit SI difficulties. This would appear to be appropriate if one considers the interdependence of the sensory and motor systems starting from in utero development and throughout life. For this reason therapists are incorporating SI treatment in therapy programs not only for learning disabled children, but for those receiving therapy because of cerebal palsy, myelomeningocele – particularly if the child is shunted –, and for severe developmental delay. In fact, while the learning disabled child may have been receiving SI treatment since lower elementary grades, and is usually able to be discontinued before the child reaches the secondary level, the child with myelomeningocele is often not identified as having learning and sensory integration problems until he/she is in junior high and so may need remediation into the secondary level.
Neurodevelopmental Treatment (NDT). NDT, which is primarily handling, is based on the theory that movement is a response to sensory stimulus and the input basis for early learning. Handling helps provide the appropriate sensory stimulus so the child can respond with the right movement ensuring correct motor learning. With the appropriate handling and positioning poor movement patterns are inhibited while good movement patterns are facilitated. This theory has had a major impact on the kind of therapy and the results of therapy for individuals with cerebral palsy. According to the Bobaths (1979), NDT methods can be used with both children and adults giving positive results. Therapists need additional training to be competent in carrying out NDT. This treatment also requires specialized training.
Ideally, when appropriate, children should receive both physical and occupational therapies. In rural areas however, because of staff shortages and costs this is not always feasible. When only one service is available it is important that the child's evaluation and treatment planning be done by the appropriate therapist who instructs the other therapist in carrying out the program and is available for frequent consultation. Also ideally, therapists should determine cooperatively who has the more appropriate training in areas where either could provide services. An example of this would be when working with a population of children with cerebral palsy, when only one therapy can be provided. If either the occupational therapist or the physical therapist had NDT training, the NDT trained therapist would be better able to meet the needs of those children.
Physical Therapy is losing some of its mystery in schools as many therapists are no longer plucking the child from the classroom and then silently returning him/her after 30 minutes of "treatment" in the therapy room. The APTA Practice Document encourages that therapists "... should consider utilizing the classroom as a theraputic environment in order to ensure the functional usefulness of the skills being taught and the generalization of skills to environments in which they are needed." (APTA, 1980) This allows for much greater teacher/therapist interaction and sharing which can't help but benefit the child. And considering that most therapists usually worked in the janitor's closet, storeroom or a room in the "condemed part of the building" it is certainly an improvement for them. Working in the classroom when appropriate, also allows for much more contact with other specialists who are working with the child, making the M-Team better able to operate as a team. This increased visibility on the part of the physical therapist helps other school personnel to understand more about the function of the physical therapist and allows them to use therapy services more frequently and appropriately.
At the present time in the state of Wisconsin, the DPI and local Special Education Administrators are developing new guidelines regarding elegibility for physical therapy services. Because of major funding cuts to education from both federal and state levels, it appears that eligibility for school district provided physical therapy services will be much more limited than in the past. For the most part, it does not appear that therapists have had much input at the state and local decision making levels. One hopes this changes before a final document is prepared.
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