Running Head: EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY

Examination of the Effectiveness of School based Physical Therapists Taylor Chasey Northeastern University

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY Abstract Children with disabilities are required under the Individuals with Disabilities Act of 2004, IDEA, to receive school based physical therapy if they have a need for the services. School based physical therapists are effective in helping students achieve functional gains in

mobility, however their physical therapy colleagues in other practice settings are often unable to understand what they do for students in schools. The use of evidence based practice is slowly being implemented in schools, however even with minimal use of evidence based practice, physical therapists are still able to make continued ambulation gains throughout a students school years. Students report enjoying therapy, even if it was difficult at first due to being pulled away from regular class activities. Limitations to providing physical therapy in schools such as lack of finances and a shortage of staff place an impact on being able to provide services to students, and thus the overall effectiveness a therapist can have. By cutting out the wait times that often hinder medical based care, therapy in the schools is more easily utilized by students families. After examination of multiple factors, school based physical therapy has more positive factors for its effectiveness than limitations and barriers.

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY Introduction School based therapy is a resource that many children with disabilities utilize on a daily basis. The services allow students to receive beneficial treatment throughout their school routine, and let time spent outside of school to be used doing other activities. The Individuals with Disabilities Education Improvement Act of 2004 implemented standards for education that all states and school districts in the United States are expected to uphold. These standards include a zero reject policy, ensuring the least restrictive environment, right to due process,

nondiscriminatory evaluation, an individualized education plan, parent participation, and related services (Oriel, Pemberton, and Urfer, 2004). Physical Therapy provided in the school systems falls under a childs right to an individualized education plan, or IEP. School based physical therapy could be provided in many different forms. In specialized schools for students with disabilities, there could be multiple physical therapists that serve the entire school, and have their own practice area. In public schools, there could be one physical therapist assigned to the school, or there could be one physical therapist assigned to a school district. When one physical therapist is responsible for treating students throughout a school district, it often becomes challenging for the therapist to have the right supplies or adequate space at every school. Contrarily, physical therapists in a specialized school setting often have their own clinic in the school where students will come for therapy. Regardless of the school setting, physical therapists determine a students eligibility based on their function in a variety of pre-determined areas. Using Connecticuts state guidelines as an example, students are evaluated on posture and positioning, range of motion, equilibrium and protective reaction, manipulative skills, mobility, and muscular and cardiopulmonary systems strength (Connecticut Department of Education, 1999). Many

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY conditions, such as Cerebral Palsy or Hydrocephaly, can cause dysfunctions in the previously mentioned functional areas, and thus are treated by school based physical therapists. There is a wide variety of school based physical therapy practice settings, however this

domain of the physical therapy profession is a mystery to many in the profession. Most physical therapists that are not involved in pediatrics are unsure what school based physical therapy may look like, what services are provided to students, or what students are served. The focus of this research will be to prove school based physical therapists effectiveness, and give an overview of the effectiveness to the rest of the profession. The use of evidence based practice in school therapy settings will be examined, as well as progress made throughout the school years in a study of long term services. Student perceptions of their time spent in physical therapy will be discussed to consider the students personal opinions in relation to the services they receive. This may be easily forgotten with children, especially children with cognitive delays, however patient satisfaction is always a key aspect to effective service providers. Limitations of the effectiveness of the profession will also be discussed, due to school system barriers, lack of staff, and lack of peer-professional supports. While investigating the underlying effectiveness of school based physical therapy, many facilitating and impeding factors will be discussed. The first, and potentially most crucial, in the view of the American Physical Therapy Association (APTA) is the implementation of evidence based practice. Use of Evidence Based Practice The APTA defines the use of evidence based practice as an integral part of maintaining the credibility and integrity of the physical therapy profession. Due to this, every certified physical therapist is expected to complete continuing education throughout their professional careers, and implement newly found practice techniques that have been proven to be effective

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY through research. A study was conducted to evaluate the use of evidence based practice by physical therapists in a school setting. The results of interviewing physical therapists provided an interesting insight into working in a school setting. Every physical therapist recognized the

need for evidence based practice to be implemented with the children they worked with, however many of them ran into problems when trying to actually do so (Schreiber, Stern, Marchetti, Provident, and Turocy, 2008). All of the clinicians in the study displayed a good attitude towards the implementation of evidence based practice, however many brought up obstacles that made the implementation difficult (Schreiber et al, 2008). Some of these obstacles included insufficient time, lack of workplace support, and lack of confidence in skills (Schrieber et al, 2008). These barriers to evidence based practice implementation show a limitation of the effectiveness of school based physical therapy. Without the proper support system, and colleagues to consult on implementing the findings of research into practice, it can be difficult for a clinician to find the time to research new skills or techniques, practice the skills, and implement them into clinical work with the correct patient. Much of the support needed to make evidence based practice possible, comes from co-worker support and staff in-services for therapists to share new research with each other, and thus be able to implement into the clinic. To address this problem, North Carolina has implemented the use of a Physical Therapy Consultant through the Department of Public Instruction (UNC, 2014). The role of the Physical Therapy Consultant is to develop and implement policy and guidance related to school-based physical therapy, funding issues (regarding Medicaid) and adapted physical educationthe PT consultant develops updates, disseminates and posts written resources and guidelines on best practices in school-based physical therapy, Medicaid reimbursement and APE (UNC, 2014).

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY Implementing this consulting role to school based physical therapy could be the next necessary step to allow further integration of evidence based practice into treatments, and thus give children an opportunity to be treated by the newest researched techniques. Neuro-Developmental Treatment Approach (NDT) certified physical therapists are an example of implementing evidence based practice into schools. NDT is used to help with the

management and treatment of students who have disorders of their central nervous system. One study researched if children with cerebral palsy had improvements in gait after a six-week course of treatments using NDT methods (Sluslarski, 2000). The results found an increase in stride length, step length, velocity and foot angle after the six weeks of treatment (Sluslarski, 2000). Teaching more school based physical therapists the practice techniques behind NDT could be another way to increase the use of evidence based practice, and also significantly help the ambulation of students who have cerebral palsy. Evidence based practice is crucial to uphold the integrity of school based physical therapy. There needs to be more support from school systems and colleagues to give physical therapists the resources necessary to utilize evidence based practice. Although the integration of new research into practice is still being refined, physical therapists in schools are able to utilize the knowledge they have to help many students be successful in functional gains throughout their school years. Successful Case Study Under the implementation of IDEA, students with disabilities qualify for specialty school services from the age of three to twenty two. This could mean a residential school that fosters independence for the students in a school and home setting, or a weekly day program that focuses on education and community immersion. Regardless of the specifics of the setting,

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY school based therapy provides a unique circumstance where students are able to receive therapy on a regular, weekly basis for up to nineteen years of their lives. Assuming that gains in mobility cannot be made after a child, with a chronic disability, starts to plateau may be easy. However, ONeil McCoy (2011) conducted a case study of a fifteen year old who has cerebral palsy, and was discharged from school based physical therapy in the eighth grade. Upon discharge, the student was given an exercise and stretching routine to

self-manage her functional status. Due to some functional limitations, she was re-referred to be evaluated for school based therapy her freshman year of high school, and ended up receiving treatment from a physical therapist throughout the four years of high school. Between the students freshman and senior year, her Gross Motor Function Measure scores increased from 66.4% freshman year to 78.8% senior year (ONeil McCoy, 2011). This case study displays the effectiveness of school-based physical therapy, and the successful ambulation and functional gains that are possible with adequate services for students. There is no other practice setting in physical therapy where a therapist is able to consistently be involved in so many activities of daily living, and help the student work toward functional independence. This can become even more of a positive factor if the school is also residential. School based physical therapists can make a difference throughout childrens lives, which is why physical therapists throughout all practice settings need to understand the role of a school based PT and recognize their importance throughout each stage of a child and young adults motor development. While statistics are important to be able to see the progress that can be made, it is also crucial that the students who are receiving the therapy deem the services effective.

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY Student Perceptions of Physical Therapy

Specialized school settings provide a unique circumstance where therapists are able to get to know their patients over the course of many years. This allows them to create a long lasting, trusting relationship with their patients. Fostering this relationship can be easier in specialized schools were students see therapists multiple times a week and therapy is structured into every students school day. However, in public schools, students are pulled out of class and may only see their therapist once a week, thus potentially making it more difficult for students to create relationships with their therapists. Jewell and Rousch (1995) determined how a group of students perceived therapy as part of their school day. The study interviewed 12 students, 1 female and 11 males, who ranged in ages from 8 to 20 years old (Jewell and Rousch, 1995). All of the students had physical disabilities from birth, and had physical therapy integrated as a major part of their school week (Jewell and Rousch, 1995). The findings were pulled from student surveys, and concluded that overall students found therapy enjoyable and valuable (Jewell and Rousch, 1995). Students reported that they trusted their PT, and while feeling uneasy at first due to being in activities that differed from their classmates, and having to leave class for part of the day, students ended up easily adapted to and accepted therapy as part of their school routine (Jewell and Rousch, 1995). Students positive perceptions of their time in physical therapy demonstrate to the rest of the physical therapy community that school therapists are able to make functional gains while still making therapy enjoyable. It should be stated however, that the sample of students in Jewell and Rouschs (1995) study cannot be generalized for every student. Settings and student diagnoses differ, all of which can cause unique circumstances that may or may not impact the students experience of school based physical therapy. A significant aspect to the therapists job

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY is to ensure that they are doing the best job possible to mediate external limitations and barriers placed on the ability to provide therapy. Limitations and Barriers Oriel, Pemberton, and Urfer (2004) utilized Idaho to study the barriers of school based physical therapy in a rural, isolated state. The study focused on four main barriers: financial constraints, administrative issues, personnel shortages, and a limited understanding of disability law (Oriel et al, 2004). Participants of this study were physical therapists currently working in school settings in Idaho, and were asked to complete a survey. Idaho has one hundred and fourteen school districts, of which eighty-seven employ a physical therapist (Oriel et al, 2004). However, many of these districts employ the same physical therapist, which raises the flag of a staffing shortage. Upon analyzing the responses, the study found that therapist perceptions of barriers statewide were much greater than what therapists reported actually occurring in their schools (Oriel et al, 2004). With this evidence, Oriel et al (2004) concluded that barriers to

providing physical therapy services occurred at a lesser extent than what therapists believed to be true. While barriers may not be as severe as the therapists in Idaho believe, their presence is still there. As discussed in the application of evidence based practice, the combination of a lack of overall staff and lack of support for staff that is available can create difficult circumstances for school based physical therapists. Many school based physical therapists will gladly share the obstacles they face in practice. Their frustrations can lie in the lack of resources, funding, and structure around the implementation of therapy in schools. IDEA created the resource to be available for students, however in some areas much of the follow through of the implementation has been left up to the therapists, without proper support systems in place. Implementing a

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professional as a Physical Therapy Consultant, similar to what North Carolina has done, may be a way to provide more support to working therapists. Overall Effectiveness School based physical therapy has many clear benefits and successful outcomes with students, through the obstacles that exist to providing services. As IDEA continues to develop and be implemented in schools, physical therapists will be able to work towards establishing a community in the physical therapy profession. One study examined the service utilization patterns of interdisciplinary therapies (PT, OT, and SLP) by children with disabilities, and found that long waiting times and lack of resources in medical based services can limit a childs ability to get the therapy that they need (Majnemer, 2001). Physical therapy in the school is able to bridge the health care gap of being referred to a new service provider, to then having to wait to be evaluated, only to wait to be scheduled when the provider and family schedules align. Bringing therapy to the schools also allows the children to receive therapy without the need of their parents to be free to drive them to a facility. Instead, they can receive practical, functional, and convenient therapies that relate to their activities of daily living. When examining the location of therapy, research suggests that sessions are more successful and effective in a natural educational setting rather than in an isolated therapy room (Karnish, Bruder, Rainforth, 1995). Karnish et al (1995) defined a natural educational setting as the setting where the skills would naturally occur. In order to determine if there was a difference between therapy settings, a motor evaluation was completed with three children in physical therapy, all of which ended up having superior results in the natural education setting (Karnish et al, 1995). Having easy access to a natural education setting is another reason school based physical therapy can be more effective than services in an outpatient medical setting.

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While there are clear factors pointing towards a high effectiveness by physical therapists in school, physical therapy provided through a school setting is still evolving. IDEA opened the door by allowing therapy to be provided, however by leaving the implementation up to the individual states and school districts, discrepancies are occurring and impacting patient care. A lack of evidence based practice could, overtime, lead to outdated treatment methods, and thus a lower quality of care. The lack of sufficient staff that occurs when multiple school districts employ the same therapist could lead to over worked, over tired therapists, who are on a path to being burnt out. These problems are what IDEA and the individual school districts cannot let happen. As proven by the research discussed, school based physical therapists make a significant difference in childrens lives. More states need to follow North Carolinas lead and create roles such as the Physical Therapy Consultant, to foster professional development and create a community state wide among school based physical therapists. By finding ways to fix the current problems in school based physical therapy, the professions effectiveness will be raised and students will benefit directly. Conclusion With the appropriate supports to implement more evidence based practice, an increase in staffing, and an awareness of the role/responsibility of a school physical therapist by the rest of the profession, even more children with disabilities will be able to benefit from PT services on a daily basis. Physical therapy in schools is the easiest way to contact students who need the services that a physical therapist can provide, and now, more than ever there is a need for more physical therapists to consider working in schools.

EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY References Jewell, M., & Roush, S. (1995). Students' perceptions of their school-based physical therapy. Pediatric Physical Therapy, 7(4), 162-166. Karnish, K., Bruder, M., & Rainforth, B. (1995). A comparison of physical therapy in two school based treatment contexts... an isolated therapy room or a natural educational setting. Physical & Occupational Therapy In Pediatrics, 15(4), 1-25. Majnemer, A., Shevell, M., Rosenbaum, P., & Abrahamowicz, M. (2002). Early rehabilitation service utilization patterns in young children with developmental delays. Child: Care, Health & Development, 28(1), 29-37. McCoy, J. (2011). Continued ambulation gains through high school in a student with cerebral palsy: a case report. Pediatric Physical Therapy: The Official Publication Of The Section On Pediatrics Of The American Physical Therapy Association, 23(4), 391-398. doi:10.1097/PEP.0b013e31823525c6 Oriel, K., Pemberton, C., & Urfer, A. (2006). Barriers to school based physical therapy perceptions of physical therapists in a rural state. Journal Of Allied Health, 35(2), 103E-120E. Ray, L. (2014). School based physical therapy. Retrieved from http://www.med.unc.edu/ ahs/physical/schoolbasedpt Schreiber, J., Stern, P., Marchetti, G., Provident, I., & Turocy, P. (2008). School based pediatric physical therapists' perspectives on evidence-based practice. Pediatric Physical Therapy: The Official Publication Of The Section On Pediatrics Of The American Physical Therapy Association, 20(4), 292-302. doi:10.1097/PEP.0b013e31818bc475

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EFFECTIVENESS OF SCHOOL BASED PHYSICAL THERAPY Slusarski, J. (2002). Gait Changes in Children with Cerebral Palsy Following a Neuro Developmental Treatment Course,. Pediatric Physical Therapy, 14(1), 55-56 State Connecticut Department of Education. (1999). Guidelines for physical therapy in educational settings. Retrieved from http://www.sde.ct.gov/sde/lib/sde/ PDF/DEPS/Special/PTGuidelines.pdf.

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Initially, I did not consider including this piece in my professional portfolio. I thought that I lacked an argument, and was struggling to find a way to write this paper. However, now I am happy with the end product. I was able to find multiple articles to support my claims, and was able to find a negative against my argument, and then give ways to change the negatives for the better. Since this piece is in line with the topics of my other two Unit projects and I was able to bring the paper a long way from the rough draft, I think that I would consider including this in my final portfolio.