Stuberg, Wayne PT, PhD, PCS; DeJong, Stacey L. PT, MS, PCS
Public law 108-446 (The Education of all Handicapped Children Act, now known as the Individuals with Disabilities Education Improvement Act of 2004 or IDEA), was initially passed as PL 94-142 in 1975 and most recently reauthorized in 2004. This Act ensures children with disabilities and their families access to a free appropriate public education and improved education for children with disabilities.1,2 For more than 25 years, physical therapists have provided evaluation, program planning, consultation, and intervention for students with disabilities as an early intervention service under Part C in the home or other natural setting for children from birth through two years of age or as a related service under Part B in school settings for children ages three through 21 years. McEwen et al3 provide a comprehensive overview of Part B & C educational physical therapy services for the reader desiring more detail on the subject.
IDEA legislation recognizes the value of a goal-oriented approach and systematic monitoring of outcomes. For children with disabilities that are younger than three years,* an Individualized Family Service Plan (IFSP) is developed and reviewed every six months or more frequently if warranted. One component of the IFSP that must be included, pertaining specifically to the child, is a statement of developmentally appropriate, measurable annuals goals and a description of how the child’s progress towards meeting the goals will be measured. For each school-aged student in special education, an Individualized Education Plan (IEP) is developed and reviewed at least annually. The IEP must include a statement of measurable annual goals, including benchmarks or short-term objectives, related to meeting the child’s educational needs that result from the child’s disability. Throughout the United States, therefore, identification of measurable outcomes and periodic monitoring of progress are integral components of early intervention and special education. Despite this emphasis on outcomes, very little information is available in the literature regarding the effect of physical therapy services provided in educational settings.
King and colleagues have reported the most substantial study of the subject to date, recognizing a “critical need for documentation to support the role of therapists in providing educationally related services.”4 They reported a pilot project in 19984 and a larger study in 19995 on the achievement of individualized physical therapy objectives in children aged five to 13 years who received physical therapy services in their school setting through a publicly funded rehabilitation center in southwestern Ontario. The larger study included 50 children with various diagnoses who received speech-language services (n = 16) for communication difficulties, occupational therapy (n = 21) for classroom productivity difficulties, and physical therapy (n = 13) for mobility difficulties at school. An average of 17 physical therapy visits per child was provided during a six-month period. The authors found both clinically and statistically significant improvements in goal attainment scores (GAS) and on School Function Assessment scores,6 indicating that, on average, the children met and surpassed their goals. Although the GAS scores were individualized to the particular mobility difficulty of the child, the subcategories of (1) maintaining and changing positions, (2) manipulation with movement, and (3) recreational movement were all found to have improved significantly during the six-month intervention period and all subcategories of the School Function Assessment were found to have improved significantly at follow-up assessments conducted approximately five to six months later.
In a study of 16 children in a preschool program, Jenkins and Fewell compared sensory integration therapy to a program of group motor activities.7 Both treatment groups showed improvement in gross motor ability as measured with the Peabody Developmental Gross Motor Scale.8 No significant difference was found between gains made by the two groups. Similarly, Jenkins and Sells studied children ages three to 15 years who received direct physical therapy either once weekly or three times-per-week as part of their educational program.9 Compared with a control group receiving no therapy that did not significantly change during the 15 weeks of the study, the two treatment groups showed significant and near equal gains in gross motor ability as assessed using the Peabody Developmental Gross Motor Scale.
Individual case reports also illustrate the effectiveness of physical therapy in educational settings. Strawbridge et al10 described the use of behavior therapy combined with physical therapy to teach a child with multiple handicaps to use a walker. In an account of one child’s experience, Szabo depicted the roles of physical and occupational therapy in facilitating successful inclusion of a child with special needs in a general education classroom.11
Physical therapy as an early intervention or related service provided in homes and school districts across the country is a substantial expense to the public. Therefore, best practice concepts should be central to the programs provided for children and students. These concepts include a collaborative team approach to the planning and provision of services,12–14 service delivered in the context of the child’s daily routine,14,15 use of a service delivery model that meets the developmentally appropriate needs of the child,14,15 services provided by knowledgeable professionals,2 and services provided within an inclusive setting as appropriate.14 Discipline-specific interventions provided solely through “pull-out” services in the hallway or therapy room with the student segregated from other students or the natural routines of the school should be minimal and only be provided when justified. For the young child, these concepts extend to the provision of services within natural environments.16–18 Early intervention services were based on a family-centered, culturally competent approach using techniques with the children and families to facilitate developmental progress.18,19 Consultation and collaboration are recurrent themes of a program following best practice concepts and ensure that educational personnel work collaboratively to provide effective and comprehensive adaptations and programs for children in an inclusive environment.19
Program evaluation through the collection and synthesis of outcomes data is a critical component of assuring best practice in the delivery of educational programming. A primary purpose of this study was to develop a database method for documenting achievement of IEP/IFSP objectives in a practical and cost effective manner, which could be easily replicated in other school systems. An analysis of data collected in one school district is presented, including the extent of goal attainment and examination of several attributes of the children studied, their individualized objectives, and the physical therapy services they received.
This study was conducted in a public school district in a Midwest metropolitan area The Department of Education in Nebraska and, therefore, each school district serves as the lead agency for the provision of both early intervention and school-age related services. The school district included 18 pediatric physical therapists providing services. The mean years of experience for the therapists was 10.6 ± 9.1 (range, one to 29 years). Seventeen therapists were women, and one was a man. All therapists volunteered to participate in the project. The project received exempt status for human subject review by the University of Nebraska Medical Center Institutional Review Board as subject data were extracted without subject identifiers from the database and presented as aggregate data.
Before the initiation of the study, the therapists were given two, two-hour in-services regarding the project by the authors. The in-services included information on the purpose of the project, review of the collaborative development of IEP/IFSP behavioral objectives to include a team process versus discipline specific goals, an explanation of operational definitions of all terminology to be used as part of data collection process, and instruction on proper data recording using a standardized data form. The philosophy of service delivery reviewed in the training emphasized providing the least amount of service first, that is, consultation, before moving to greater hands-on involvement by the therapist or other caregiver. Another key concept reviewed was the importance of assuring that impairment-based goals had a clear relationship to the child’s functional participation in either the home or school environment. No reliability study was conducted as the project was developed as a quality assurance program to document the outcomes of goals for the children receiving physical therapy services. However, scoring of the IEP or IFSP attainment was done by the team and recorded by the therapist at their IEP or IFSP meeting to help assure as unbiased scoring as possible.
The nonrandom sample of convenience included 566 children receiving physical therapy as an early intervention or related service in Special Education. Data were collected for 207 students during year one, and 483 students during year two for a total of 690 IEPs and IFSPs. One hundred twenty-four of the students were included during both years. Each student had between one and five IFSP or IEP objectives that related to physical therapy. IFSP goals were written for children in early intervention, birth through age two years, with IEP goals for children in preschool and school-age.† A data collection form that included the therapist’s caseload for the school year was provided to each therapist for data recording at the beginning of the school year (Table 1). At each IEP or IFSP meeting, each objective from the previous year was scored by the team, which included the caregiver, and then the therapist recorded the score on the data collection form. The data collection forms were obtained from the staff at the end of the school year. Staff members were encouraged to complete the forms by e-mail or other reminders provided throughout the school year by their supervisor. A total of 2228 objectives were recorded for analysis.
Each objective was classified based on a number of factors, including the level of service provided (direct, consultative or integrated [a combination of the two methods]), the type of objective (impairment, functional limitation or disability), and score (objective met, progress on objective though not met, no progress). The level of service was considered “direct” if intervention was provided by the therapist through direct treatment techniques. If all programming was performed by the student, teacher, or caregiver with the therapist only providing supervision and occasional instruction, the level of service was considered “consultative.” When the intervention was provided through a combination of direct treatment by the therapist and additional programming performed by the student, teacher, or caregiver, the level of service was considered “integrated.” Every student received consultation as part of their programming with the use of “consultative” as the primary service delivery model specified when that was the only service provided. Examples of consultation included assistance with ordering of equipment or providing information to the student’s physician on issues related to the educational environment.
Direct services were provided both in and out of the classroom for children receiving Part B-related services. Examples of direct treatment activities in the classroom included assistance with use of equipment, instruction to adapt physical education activities, or assistance in accessing the educational program such as in the cafeteria or bathroom. Out-of-classroom sessions included therapeutic exercise to develop range of motion, muscle strength, balance, or motor skills. Intervention techniques ranged from neurodevelopmental treatment, practice of motor skills such as stair climbing, transfer training using school equipment, or functional skill training such as practice walking on stairs with peers during passing periods or managing food on a tray in the cafeteria during lunch.
Direct services for children receiving Part C early intervention services were provided in the natural environment, which typically was the home and included direct handling techniques by the therapist with a focus on instructing the family to enhance the family’s ability to meet the needs of their child.
Each objective was categorized according to the type of objective (impairment, functional limitation or disability).20,21 Impairment objectives addressed a loss or abnormality of physiological, psychological, or anatomical structure or function. Examples of impairment objectives included activities to improve flexibility, strength, or walking speed. Functional limitation objectives addressed a restricted ability to perform, at the level of the whole person, a physical action, activity or task in an efficient, typically expected or competent manner. Examples of functional limitation objectives included abilities to function in the environment, such as walking between classes without being late, climbing stairs during passing period, or transferring on or off the school bus with peers. Disability objectives addressed an inability to engage in age-specific, gender-specific roles in a particular social context and physical environment. Examples of disability objectives included participation in school sponsored activities such as band or participating in team sport activities.
Each child’s program was described according to the “verification category” that is, eligibility for special education services such as orthopedic impairments, other health impairments, or multiple impairments; the grade level, amount of physical therapy service authorized, and whether the therapist that scored the child’s objectives had also developed the objectives. The amount of service was recorded in hours per school year and included the amount of time authorized by the school district for the physical therapist to spend in direct contact with the child, program planning, coordination, and collaboration with school staff and parents. Time for IEP or IFSP meetings, other meetings and travel was not included.
A Microsoft Access database was developed to track the status of IEP and IFSP objective outcomes (Fig. 1).22 At each IEP or IFSP meeting, each objective from the previous year was scored by the team/treating therapist and then the therapist recorded the score on the data collection form (Table 1) that was turned in at the end of the school year to complete the database. A score of 2 was given if the objective had been met, a score of 1 if progress had been made but the objective had not been met, and a score of 0 if no progress had been made. For example, a child who was only able to walk half way from their classroom to the cafeteria when the objective stated “Given a walker and standby assistance, will walk from the classroom to the cafeteria by the end of school year” would be given a score of “1.” Data from the data collection forms were then transcribed into the database. No separate analysis was conducted to compare IFSP to IEP goal attainment as the trend of changes appeared similar across both groups. Fifteen percent of the goals were obtained from IFSPs and the remainder from IEPs.
Descriptive statistics were used to examine data trends. For the categorical variables with three or more groups, a Kruskal-Wallis (KW) one-way analysis of variance (ANOVA) on ranks was used to assess the effect of each categorical variable on the response variable and the Dunn method was used for post-hoc comparisons. The Mann−Whitney Rank Sum Test was used to analyze categorical variables with only two groups. SigmaStat 3.0 was used for all data analysis.23 An alpha level of p = 0.05 was used to determine significance. A Bonferroni adjustment was used for post-hoc comparisons of grade level and verification category due to multiple comparisons. Although data were collected on 12 verification categories, only four were used in the analysis of the variable “verification category” as 91% of the children were included in these four groups. No other group included more than 2% of the remaining objectives.
Ninety-one percent of the 2228 IFSP and IEP objectives were scored as having been met or progress made. Fifty-three percent of the objectives were scored as having been met, 38% as progress made, and 9% as no change. A significant difference was found between the three categories of objectives (KW = 14.92, df = 2, p = 0.001; Table 2). Scores for objectives written to address functional limitations and disability were equivalent. Scores for objectives written to address impairments were found to be significantly lower than scores for objectives addressing functional limitations or disability.
Table 3 lists the verification categories of the children served. The four verification categories of Other Health Impairments (diagnoses such as developmental coordination disorder, congenital heart defects, or mild juvenile rheumatoid arthritis), Orthopedic Impairments (diagnoses including spastic diplegic cerebral palsy, spina bifida or amputee), Multiple Impairments (diagnoses such as severe spastic quadriplegic cerebral palsy with mental handicap or genetic abnormality such as trisomy 18), and Mental Handicap (diagnoses such as fetal alcohol syndrome or genetic abnormalities such as trisomy 21) accounted for 91% of the IFSP and IEPs scored. ANOVA results of scores by verification category demonstrated a significant difference between categories (KW = 135.083, df = 3, p < 0.001). Post-hoc comparisons revealed the scores of students verified with Multiple Impairments were significantly below the scores of the children in the other three categories. Scores for children verified as Mental Handicap were significantly lower than scores of children in the Other Health Impairments and Orthopedic Impairments categories. There was no significant difference between the scores of children in the Other Health Impairments and Orthopedic Impairments categories.
Grade levels of the children are listed in Table 4. Scores significantly varied across grade levels (KW = 111.796, df = 4, p < 0.001). Scores of children in early intervention did not differ from the scores of children in preschool, but the scores of both groups were significantly greater than the other groups. Scores of children in elementary school were higher than middle and high school, with the scores of the latter two groups being equivalent.
Sixty-seven percent of the children were authorized to receive up to 12 hours of physical therapy services for the school year. The remaining 33% of the children received greater than 12 hours (16% received 13 to 18 hours, 15% received 19 to 22 hours, and 2% received from 23 to 32 hours, with no child receiving more than 32 hours). Twelve hours-per-year would equal 20 minutes per week of service, although it was up to the discretion of the therapist how and when the time was utilized for intervention. For example, some children received weekly contact for a limited number of hours, but the overall contact time for the year was at or below 12 hours. The amount authorized was determined collaboratively by the team, including the parent or guardian. The scores of the group receiving up to 12 hours were significantly higher than the other group (Wx = 717243.0, P < 0.001).
No difference was observed based on authorship of the objectives (Wx = 977824.5. p = 0.23). Fifty-eight percent of the objectives were written by the team or therapist who scored the objective. The remaining 42% were written by a team or therapist during the previous school year who was not involved in scoring the objective during the study period.
A significant difference was seen based on the level of service (KW = 6.7, p = 0.04). Unfortunately, however, the post-hoc analysis was not able to discriminate between the three groups despite the fact that the Dunn test is the only post-hoc method available for ANOVA results on ranks with unequal group size.23 The majority of objectives were integrated (43%) followed by the service delivery methods of direct (35%) and consultative (22%).
This study demonstrates a practical and efficient method to evaluate the provision of physical therapy in educational settings. The extent of goal achievement was studied for a very large sample of children, requiring minimal time commitment and training for the participating therapists. Previous investigators have advocated use of GAS methodology to measure achievement of individualized objectives and have described the need for orientation and extensive training prior to its use. For example, King and colleagues4,5 identified five levels of attainment, represented by scores ranging from −2 to +2. The child’s baseline level of performance was assigned a score of −2, and the expected level of performance at the end of the intervention was assigned a score of 0. Additional levels were identified to represent progress that was less than or greater than expected (−1, +1, +2). This allowed measurement of the extent to which children exceeded expectations. Scores after intervention were greater than expected, indicating that therapists may systematically underestimate the level of attainment that children are capable of achieving. In our study, objectives were given a score of 2 if they were either met or exceeded (corresponding to GAS scores of 0, +1, and +2). Thus the simplicity of the scoring scale resulted in a less precise measurement but allowed scoring of large numbers of objectives, which had already been written in IEP or IFSP format.
Any study using individualized objectives includes the possibility of bias affecting the goal setting process, the scoring process, or both. In this study, objectives for each child were identified through collaboration with the child’s IEP or IFSP team, thereby decreasing the likelihood that therapists set goals that were overly easy or overly difficult for the children to attain. Bias in the scoring process also was examined by testing for differences between objectives that were scored by the therapist who wrote the objectives, versus those objectives that were written and scored by separate therapists. No significant difference in mean score was found.
The lack of reliability or validity data on the scored objectives is a limitation of the study. Ideally, the scores written by the IEP or IFSP team would have been scored through an independent scoring mechanism including individuals who had no part in objective development as a control for bias. However, this approach was not used as these data reflect a typical service delivery setting. Although the possibility of biased scoring remains, behaviorally written objectives with specific conditions and performance criteria minimize the potential for ambiguity in the scoring process.
This study demonstrates a high rate of goal attainment for children receiving physical therapy services as part of their special education program. Thus the study provides evidence that children who receive physical therapy as an early intervention or related service consistently make progress, achieve, or exceed their goals. However, because the study did not include a control group for whom physical therapy was not provided and did not control for other services or activities, no causal relationship between the therapy and the outcomes can be implied. Nevertheless, a positive effect on the educational program of the children was demonstrated with the high attainment of IEP and IFSP objectives. Because of the limitations of the study, the results suggest that further research with more rigorous methodology is necessary to examine whether or not a high rate of educational objective attainment for children receiving physical therapy in the educational setting is a reality. Future research to more directly demonstrate efficacy of physical therapy services should include collaborative goal setting by more than one therapist to reduce bias in the goal setting process, independent scoring of objective attainment and inclusion of a control group to account for factors such as maturation, motivation or setting.
In addition to documenting objective achievement, data were collected that could aid in program evaluation, including the types of objectives (impairment, functional limitation, or disability), the level of service provided to address the objectives (direct, consultative, or a combination of the two), and the amount of physical therapy services authorized for each student to receive during the school year. These data are likely to be site-specific and thus may not be representative of service delivery in other school districts or geographical areas. However, this type of data can be used by program administrators as an indicator of the type of service being provided. If a significant amount of direct service is being provided by one staff member with the majority of goals being written at the impairment level it would raise questions as to whether best practice is being followed to allow for integration of activities into the natural environment of the student.
In our particular sample, factors that had a significant effect on goal achievement included type of objective, grade level, verification category, and amount of physical therapy services authorized. Further analysis of the impairment type objectives, which were associated with lower goal attainment, may reveal whether or not these objectives are appropriate for the educational setting and, if so, whether the intervention being provided is likely to achieve the desired effect. If an impairment level objective does not provide a functional improvement then its appropriateness is questionable, regardless of the practice setting. Analysis of grade level showed an inverse relationship between goal attainment and grade level (i.e. higher achievement in children receiving early intervention and preschool services). It is well accepted that younger children have greater plasticity or capacity for adaptation. The finding supports the premise that children receiving early intervention and preschool services may have a greater capacity to attain educational goals. Similarly, in our sample, mean scores were lower for children in the “Multiple Impairments” verification category and for those authorized to receive greater than 12 hours per school year of physical therapy services. This indicates a lower level of achievement for children with more severe disabilities, and suggests that further program evaluation may be warranted for this subgroup of children. Additional efforts may help to delineate whether goals set for the children in this group are overly ambitious, or whether improvement in goal attainment can be achieved with changes in intervention strategies, service delivery methods, amount of service provided, or the use of other strategies.
In summary, this study demonstrates a method for documentation and review of physical therapy services in educational settings and identification of factors that positively or negatively affect achievement of IFSP and IEP objectives. Use of similar databases by other school districts will provide information for further documentation of educational outcomes with varying service delivery models.
The authors would like to acknowledge the support of the physical therapy staff members at the Munroe-Meyer Institute for their work in data collection and goal to improve services for children receiving educational physical therapy services.
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* Under IDEA 2004 (Section 633), at the discretion of the state plan, children who previously received Part C services can continue to receive the early intervention services under an IFSP from their third birthday until they enter, or are eligible under state law to enter, kindergarten.2 Cited Here...
† At the time of this research, IFSPs were only used for children age birth though two years and not for children enrolled in preschool in the school district. Cited Here...
© 2007 Lippincott Williams & Wilkins, Inc.