By Kathryn R. Biel, PT, DPT
image retrieved from: www.gboe.org
I am a physical therapist. It often surprises people when I tell them that I work in a school district (a large, urban one, to be exact). I usually get the follow-up question of, “doing what?” Many people do not understand the role of physical therapists in the educational system. Those who have led a sheltered life surrounded only by typically developing children think that I must be there to work with children who are injured playing sports. Many parents of the preschool set know someone receiving some kind of service (speech therapy, occupational therapy or physical therapy), and can relate that my job is an extension of preschool services. School-based physical therapy is a related service provided through the Individualized Education Plan (IEP), which is part of the Individuals with Disabilities Education Act (IDEA). The legislation for IDEA was passed in 1990, stemming from the 1975 Education for All Handicapped Children Law. IDEA was reauthorized in 2004 and guarantees a “free and appropriate public education” for students.
This is where and why school-based physical therapy diverges from preschool therapy and pediatric outpatient-based physical therapy. School-based physical therapy is not intended to meet all of the therapeutic needs of a child. Rather, it is available to ensure that a child is able to access his or her education in a safe and efficient manner. What does that mean? It means we are looking at function. This includes how a child is transported to school, how a child can enter and exit the building, how the child can enter and exit the building during evacuation/emergency procedures, how a child moves around the school building, how a child moves around the classroom, and how a child sits in the classroom. In essence, what is the best, most efficient and safe way for a child to get to school, get around in school, and in what position will he or she receive his or her education.
School-based physical therapy generally focuses on the following skill sets: walking, running, stair climbing, walking in line, balance (one foot, with feet together), jumping, posture, strength and ball play (to participate in physical education). Strength, particularly in the postural and core muscles and muscles of the shoulder girdle is especially important. Just like a house needs a solid foundation, a child needs a strong and stable core to be able to develop the skills needed to write. In order to write a word down on paper, the following skills are needed: the strength and endurance to sit upright, stabilize the paper on the writing surface with one hand while crossing midline with the other hand, move the dominant hand in small, meaningful and controlled strokes (writing) while applying appropriate pressure and grading, listening to the instructions, reading the directions and shifting gaze from the board to the paper. If a child lacks the strength to sit upright, all of the other pieces fall apart, and the child will have immense difficulty with writing, attending and ultimately learning.
Being able to walk with a narrow base of support (follow in line), respect personal space (and not bump into everything) and navigate the stairs are skills necessary to access one’s education. For most children, with physical therapy services, these skills develop nicely in a short period of time, within 1-2 school years.
Generally speaking, PT services the children in the primary grades mostly (K, 1, 2). This is because these children, due to their gross motor delays, are still learning to navigate their environment and developing the skills in the large muscle groups that allow them to sit upright and learn. That is not to say that we never service older children. But, generally, as a child ages, the amount of physical therapy services are gradually decreased in the public school setting. This is usually due to the fact that a child is able to access his or her education through equipment and accommodations. For example, a child with cerebral palsy who is not a functional ambulator (cannot walk independently or with an assistive device more than 300 feet) will have a wheelchair. The wheelchair will be the child’s primary means of transport to and from school and within the school building. By the time the child is in fourth grade (about 10 years old), the role of the physical therapist shifts from helping the child work on walking and trunk control skills to making sure that the child has the appropriate equipment (wheelchair, adaptive chairs, adaptive toileting) and that staff is well educated in how to transfer the child in and out of said equipment. The wheelchair (for the non-ambulatory student) is the most safe and efficient way for that child to access his or her education. Physical therapists work in Consultation mode (with the staff), rather than by providing direct service, or treatment to the student.
This concept is hard for parents to understand, especially when a child has a significant diagnosis, such as cerebral palsy or muscular dystrophy. While these students benefit from physical therapy, the regulations of IDEA do not provide for maintenance therapy. Progress must be made on a yearly basis (and this progress is measured by the goals written yearly on the IEP). Yes, a child with increased muscle tone or spasticity would benefit from range of motion. However, daily range of motion is not deemed educationally relevant in most cases. This means that providing range of motion to a child’s feet and ankles does not help provide a free and appropriate education for the child. That being said, most physical therapists are more than happy to work with families to show some techniques for carryover at home.
In the public school setting, we are looking to minimize the time a child is taken out of the education setting. It is very difficult to provide PT within the classroom, although it is sometimes possible. As such, generally, physical therapy frequencies are not as high as those of speech therapy or occupational therapy. Those two therapies play a much larger role in a child’s education (the child must understand language to learn, must output some form of communication to show what he or she knows, and generally requires writing or other fine motor skills to assist in expressive knowledge).
School-based physical therapy is a wonderful adjunct to the public education process. It opens doors and removes barriers that for so long prevented physically disabled children from receiving a public education. It is meant to work in conjunction with, but not as a replacement for medically-based outpatient physical therapy.
About the Author:
I am a pediatric physical therapist. I attended school at Boston University, and received my doctoral degree from The Sage Colleges. I have worked in a variety of settings, including special education schools, a pediatric residential care facility, Early Intervention, preschool and now in the public school setting, with some brief dabbling in an adult outpatient rehab clinic. When I’m not busy treating, writing IEP’s, attending meetings and fixing wheelchairs, I am the mother to two school-aged children and wife to a very patient husband. I can often be found releasing my stress through dance and writing for my own personal blog, Biel Blather, which can be found at www.kathrynbiel.blogspot.com.
