Guest Post – School-based Physical Therapy

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.

 

Ideas for Torticollis

Torticollis can affect almost any child.  It is caused by a tight muscle called the sternocleidomastoid.  Often this can happen as a result of positioning in the womb or as a result of a child spending too much time in one position and developing plagiocephaly.  There are other reasons but these are two common ones.

It is highly recommended that you see a doctor and/or a physical therapist to make sure there are no other underlying causes for the torticollis but often the way to help with its improvement involves stretching, strengthening and functional retraining (not as scary as it sounds).

For stretching you want to be really gentle.  Whatever direction your child holds their head, you would want to gently stretch in the opposite direction.  For example, if your child prefers to look to the left and tilt their head to the right you would gently try to bring their left ear towards their left shoulder while keeping their eyes looking straight up (i.e. their head is not turned to the left or right).  You would also try to turn their head to right while keeping their body straight (don’t let their shoulders follow them).  I’m sure you can imagine that kids may not enjoy this (although it is a little easier when they are tiny) so you may want to have something they enjoy looking at in the direction you are stretching them.  You want to distract them from what you are doing.

I have also worked on strengthening by using a therapy ball.  I love to use a therapy ball for tummy time (which is important to work on with you child).  By using the ball you can move it so that your child has to use different muscles in their neck.  Their head will automatically want to right itself in the middle (prolonged torticollis can affect this ability which is why you want them to get lots of exposure to different positions).  So for the same example we were talking about above you would want to move the ball (while stabilizing your child on it) so that they have to lift their head to the left.  You can also have something really engaging to the right so they will turn their head to look at it while they are on their belly.  Don’t put it too far off to the right but just slightly so that they have success.  In the beginning only have them practice moving their head in these directions.  As they get stronger you can have them hold it for longer periods of time.

Functional retraining (my definition for this post) is to encourage your child to actively engage in looking and moving in the direction opposite of their torticollis.  So, if you normally sit on one side of them or hold them on one specific side then hold them on your other side.  If you have them sleep with their head at one end of their crib, switch it so they are lying at the other end.  By changing their positioning they will have to use different muscles to look at things and not get ‘stuck’ in the same pattern.

 

Walking – Starting at the Beginning

So I mentioned in an earlier post that we sat in on a talk on gait deviations by the Hospital for Special Surgery at our physical therapy conference this past January.  There was a lot of interesting information in it including some great treatment ideas to help us change up some of our usual activities.  I thought I would share some of the information we took away (it may be over a few different posts though).

What are the parts of walking?  There are two main pieces.  There is the stance phase (when you are standing on your leg) and the swing phase (when your leg is moving through the air to take a step).  Stance takes up about 60% of the walking cycle and swing takes up the other 40%.  This is because there is generally a portion of time that both feet are touching the ground.

Some prerequisites for walking according to Perry 1985 are:

• Stability in stance – this means the ability to maintain balance in standing, an upright head and body, and bear weight through their legs
• Swing clearance – this means that they are able to stand tall on their stance leg and bend their other leg so that they can clear their foot from the ground to avoid tripping and falling
• Pre-positioning of the foot – Right before the foot hits the ground the child should ideally be able to have their toes lifted in the air so that their foot is primed as a shock absorber when it comes into contact with the ground
• Good step length – in order to walk at a functional walking speed steps need to be of an adequate length so that enough ground is covered
• Energy conservation – Momentum is used during stance and swing to ideally position the center of gravity to minimize muscle contraction and make walking more efficient

Another prerequisite that isn’t mentioned is that a child needs to be able to sit independently in order to walk independently.  I know it seems obvious but I thought I would mention it anyway.

I found this interesting – Normal walking energy expenditure is 2.5 kcal/min.  When walking changes due to musculoskeletal or environmental changes the energy expenditure goes up.  One of the things listed below is an AFO (ankle foot orthosis).  While this increases energy expenditure compared to ‘normal’ walking it may minimize energy based on the way the child was walking before the brace was applied because it can allow for stability and the minimizing of excessive muscle contraction.

Here were some of the factors that they listed:

• AFO – increases 10%
• Backpack – increases 15%
• Stiff knee – increases 25%
• Fast walk – increases 60%
• Using crutches to keep weight off of a foot – increases 300%

These are just factors to consider when trying to help your child maximize their energy expenditure, especially in a school setting where they need energy for academics.

I’ll cover more from this talk in a later post.

 

Functional Carryover

I know I’ve been missing in action recently and I have no excuse other than life and work got a little hectic.  I’m hoping it settles down a bit because of course when I have no time to write I have lots of ideas floating around in my head!  All of us PT’s recently went to San Diego where we saw some great products that we are excited to try as well as sat in on some stupendous talks that got our creative treatment juices flowing!

One of the talks we went to was on gait deviations and I hope to do a longer post on that topic later but one of the greatest reminders I got from that talk was to work on impairments during treatment (i.e. range of motion, strength, etc) and then at the end of that treatment to work on the impairment in the way you want to use it functionally.  For example, for strengthening the hip extensors (gluts) to help with stance during walking, there are lots of ways you can target the muscles but then as you are finishing up with those exercises use one that has them standing on the leg with their hip moving towards extension and the opposite leg moving forward (as if you were taking a step).  They had kids doing sit to stand over a bolster and then twisting to hand a ball to someone else.  When they twist, the opposite leg moves into extension while the other leg is forward, just like with walking.

I loved this reminder because I have been looking at my treatments and then looking at how I can put a ‘functional twist’ on at the end.

I’d love to hear ways you have incorporated this idea.

Book Review – Out of My Mind by Sharon Draper

image retrieved from http://sharondraper.blogspot.com/2010/02/out-of-my-mind-my-newest-novel-great.html

Ok, I know I just did my first book review but this is another one I felt compelled to chat about.  Out of My Mind by Sharon Draper was another ridiculously easy read and so well communicated.  I took a moment to look up the author to see where she got her inspiration and I found this ‘interview‘ with her which I thought did a great job of describing why and how she created Melody her main character.  I’m sure many people have written about this book but I loved how it was narrated from Melody’s point of view.  In fact the book starts and ends the same way, with her introducing herself with these words:

‘….. all my words had meanings.  But only in my head.  I have never spoken one single word.  I am almost eleven years old.‘

I work with so many kids that don’t have what the world expects in terms of communication.  One of my favorite aspects of work is getting to know each child and learning how they communicate.  I have never ceased to be amazed at the senses of humor and displays of personality that are often hidden from those who don’t take the time to learn the ‘password’ into the child’s own communication.

I think AAC (alternative adaptive communication) is so important to helping children communicate in whatever method works for them.  Anyone who knows me, knows I am a talker and I can’t imagine the frustration (which is so beautifully described in this book) of not being able to say what you want to say.  Or saying it in a way that you think is so clear, only to be misunderstood by those around you.

As someone who doesn’t have these challenges, after reading this book, the closest I can come to imagining what it would be like is to picture landing in the middle of a foreign country where they don’t understand a single word I am saying.  Now combine that with being laid up physically (such as after a surgery) and needing to depend on people for your most basic needs.  Talk about frustration.

If, as people read this book, it causes them to take pause and maybe take an extra moment around children (and adults) who interact in this world in a way that is outside of your expected norms.  Maybe that extra moment will let you connect with the amazing personality that makes that person who they are, then the time you took to read this book was well worth it.

Transitions

Transitions can be hard for everyone involved.  However, its also a good skill to practice so that it can slowly become easier.  We have been trying over the last several months to try to reschedule kiddos with a different therapist when their regular therapist is going to be out.  There are some really great benefits when this is done.

• Kids are given the opportunity to use their skills with a new person (are they able to generalize outside of their comfort zone)
• There is a new set of eyes on the kiddo which may see things that the regular therapist doesn’t notice because of familiarity
• Brainstorming and idea generation can occur to keep therapy fresh
• Transitions not only benefit the child, but the parents/care takers as well. Parents become so comfortable with their therapists, that it may be more difficult for them to do the transition, than the child.
• Provides a fresh venue for the child and will often highlight challenges that the child is still having outside of the therapeutic environment because they are working with someone new and less ‘comfortable’

I know this is a short post but I thought I would share some of our observations!  That being said, I do believe in the continuity of a therapist working with a child, I just like to mix it up every once in a while because I do believe it is beneficial for all involved.

More Please – Repetition for Skill Mastery

When kids begin to learn new skills repetition is key.  This is how they learn what works and what doesn’t work and what they need to fine tune until they have mastered the key.  For some kids repetition comes naturally, for some, they may need a bit more encouragement.  Basically you need to figure out what motivates them.  Over the holidays I was hanging out with my god daughter and I couldn’t help but push her gross motor skills a bit.  (poor kid her mom is a speech therapist so she didn’t stand a chance with the two of us around!)

Some of the things we practiced were jumping, going down stairs and standing on one foot.  Jumping as you can see in the video was easy to get the repetition.  We put words to the actions, I showed her what to do and she mimicked me.  She thought it was hysterical and wanted her dad to keep saying ‘bend-jump’.  For that activity it didn’t take much to motivate her to practice the skill (she even got air a few times).  With going down the stairs, I basically showed her once or twice on the bottom two steps how to hold her hand on the wall/rail and step down and she was just so proud of herself that my cousin reported she now only wants to walk down the stairs.  Lastly, with the single leg stance we were playing with the stomp rocket so the toy itself was motivating.  She loved ‘stomping’ on it and making the rocket fly.  She even got good at putting the rocket back on the launcher (ok, she needed some help but she knew that it needed to line up).

For some kids, doing a novel activity is enough to get them to practice because they want to keep doing the new thing, especially when there is a ‘reward’ at the end (i.e. the rocket flying off the launcher).  With tasks that aren’t as novel look for ways to change it up and make it fun.  For instance, with stairs practice at the park or in the house or make little steps (using stools) that are a path they have to follow throughout the house.  Change it up and add some fun and you’d be surprised at how quickly kids will engage!

Top Ten Blog Posts of 2012

I’m sure I’m saying the same thing as everyone else, ‘I can’t believe 2o12 is over already.’  2012 had its ups and downs (mostly ups luckily) and I’m excited to see what 2013 holds both professionally and personally.  I want to thank all the people that have taken the time to read our blog.  It has been a fun year for writing and I wrote more posts in 2012 than I had in all the previous years combined!  While I was definitely better with my consistency it’s still a work in progress (as evidenced by the fact that this is my first post since December 14th).  I have loved reading all the blogs out there whether they were from parents, teachers, or other health professionals.  I have learned from all of you and enjoyed trying out your ideas (as seen in the pic above).  I’m excited to see what everyone has to share in 2013!  So again, thank you to those who follow my ramblings, here are the ones that you guys read the most this past year!

10.  A Multi-Tasking Activity

9.  DIY Weighted Lap Bag

8.  Great Songs For Therapy

7.  A Glossary of Sitting

6.  Core = More Than Just Abs

5.  What Does Low Tone Mean?

4.  DIY Lycra Swing

3.  Pool Noodles:  Check out all the things you can work on

2.  Why is W-Sitting a 4 Letter Word?

1.  Torticollis: What Is Its?

Have a safe, healthy and happy New Year and I’ll see you in 2013!

Making Exercises Meaningful for Pre-Teens

We decided the ladder was the best for our needs based on the packing that was occurring and he tolerated me taking a picture as well as the video so I couldn’t complain when it was slightly blurry!

So I spent part of the week in San Diego helping my friend and her family pack to move across the country.  While there I spent some time with my ‘nephew’ because she has mentioned that he can struggle with running sometimes.  We’ve talked about the fact that he’s a toe walker and that his calves and hamstrings are extremely tight but its hard to give out advice over the phone, and even harder for ‘mom’ to motivate him.

I already had some ideas but I watched him for a few days to see what I thought and then on my last day, I asked him if he wanted some help with his stretches and some exercises to help him possibly run faster on the football field.  He agreed so we had an impromptu work out.  I gave him 3 simple stretches for his hamstrings and calves that he can easily do while watching tv and I didn’t make them very time consuming or requiring a lot of contortions.  I had him try them out and decide if it was something he could ‘easily’ do.  He agreed.

Next we went into the backyard (mainly so we could have some space since their house was in the midst of being packed up) and we practiced jumping and bounding.  I showed him the exercise and then he tried it.  Of course he did it really fast (the way he would normally) and then I asked him if he would try going slow and concentrating on each jump/hop/bound and pausing between each one so he could really make his toes into ‘jet rockets’.  When he did, he felt and saw the difference between how high he could jump/hop and how far he could bound.  I asked him if he knew why and he said its because he was thinking about it so he was able to make his muscles work the way he wanted.  I asked him what happened if he kept practicing it while thinking about it – and he (without prompting) said eventually he would be able to do it without thinking about it!  I loved that he got the concept!

Now, I know that he’s a 10 1/2 year old boy that would rather be watching tv or playing DS but he was genuinely interested in running faster during football practice and during the game.  When I asked if he wanted me to make him a chart, pictures or a movie, he picked a movie so we filmed him doing his exercises with the explanations and then I worked my magic with iMovie and made his own personalized exercise movie.

Do I think he will do it every day? Probably not but he had some choices with the exercises as well as with the delivery of the exercises.  He also got to ask questions about why we were doing them and how practice would make it easier.  He even got to see that when we went back to make the movie, the bounding and jumping were harder because his muscles were tired.  He could relate it to learning how to play football and the time he puts in on the practice field, so that by doing these it will get easier and he will start to see results.

Now, I’ll have to check back in a month or two to see how diligent he has been but my fingers are crossed!

What ideas have you used?

How to Protect Yourself While Carrying Your Child Safely

When caring for your child, you are most likely focused on his/her safety.  Thus, caregivers often forget to ensure the proper body mechanics needed to keep themselves safe. Parents should remind themselves, however, that their health and safety are of utmost importance in maintaining their child’s well-being.

Caring for your child puts increased stress on your back, which may result in back pain or injuries.  When your child is an infant, you may be lifting approximately 7 to 10 pounds about 50 times per day.  By the time your child is 3, this number increases to about 25 to 30 pounds.  Given the increased load and repetitive lifting, caregivers are at a great risk for injury if they do not use the proper body mechanics.

So, here are a few tips to keep in mind when you are carrying for your child to make sure you are keeping your body safe.

1. Avoid stretching your arms out to reach for your child.  Instead, always get as close as possible to your child before you try to pick him up.
2. When picking your child up from the floor or a low surface, lift by bending at your knees in a squat position, rather than bending at your back.
3. When changing your child, do not lean over the surface area.  You should adjust the work surface so that she is at the level of your navel.
4. When feeding your child, keep both your and your child’s faces at even levels to prevent you from slouching over. When you are putting your child in or removing your child from a high chair, always take off the high chair tray.
5. When putting your child in or taking him out of a crib, always put the side of the crib down so you do not have to bend over it.***(NOTE- these types of cribs are no longer legal in the US.  Instead, make sure you hold your child close to your body as mentioned in number 1.)
6. When transferring your child into a bathtub, sit on the edge of the bathtub with one foot outside of the tub and one foot inside the tub.

For more information on tips to keep yourself safe when caring for your child, please click Tips For New Moms.