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Student Outcomes of School-Based Physical Therapy as Measured by Goal Attainment Scaling

Chiarello, Lisa A. PT, PhD, PCS, FAPTA; Effgen, Susan K. PT, PhD, FAPTA; Jeffries, Lynn PT, DPT, PhD, PCS; McCoy, Sarah Westcott PT, PhD, FAPTA; Bush, Heather PhD

doi: 10.1097/PEP.0000000000000268
RESEARCH REPORTS
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Purpose: The main purposes were to describe individualized outcomes of students receiving school-based physical therapy and determine if goal attainment differed by gross motor ability and age.

Methods: One hundred nine physical therapists and 296 students participated. At the beginning of the school year, therapists translated students' Individualized Education Program goals into subgoals using Goal Attainment Scaling and determined students' Gross Motor Functional Classification System level. Researchers categorized goals (posture/mobility, recreation/fitness, self-care, or academics), and therapists identified students' primary goal. At the end of the school year, therapists scored the goals. Descriptive statistics and 2-way analyses of variance were conducted.

Results: Students exceeded their expected goal level for primary goals and goals categorized as posture/mobility, recreation/fitness, and self-care and made progress on academic goals. No differences were found by gross motor ability. Younger students had higher goal attainment for primary and recreation goals.

Conclusion: Students achieve individualized outcomes addressed by school-based physical therapy.

The main purposes were to describe individualized outcomes of students receiving school-based physical therapy and determine if goal attainment differed by gross motor ability and age.

Department of Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, Pennsylvania (Dr Chiarello); Departments of Rehabilitation Sciences (Dr Effgen) and Biostatistics (Dr Bush), University of Kentucky, Lexington; Department of Rehabilitation Sciences, University of Oklahoma Health Sciences, Oklahoma City (Dr Jeffries); and Department of Rehabilitation Medicine, University of Washington, Seattle (Dr McCoy).

Correspondence: Lisa A. Chiarello, PT, PhD, PCS, FAPTA, Department of Physical Therapy and Rehabilitation Sciences, Drexel University, 1601 Cherry St, Mail Stop 7502, Philadelphia, PA 19102 (lisa.chiarello@drexel.edu).

The authors declare no conflicts of interest.

Grant support: The research reported here was supported by the Institute of Education Sciences, US Department of Education, through grant R324A110204 to the University of Kentucky. The opinions expressed are those of the authors and do not represent views of the Institute or the US Department of Education. REDCap was used in the data analysis, which was supported by NIH CTSA grant number UL1TR000117.

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INTRODUCTION

In the United States, students with disabilities receive an Individualized Education Program (IEP) that includes related services to help students benefit from their education and support individualized outcomes. A major emphasis of the reauthorization of the Individuals with Disabilities Education Improvement Act (IDEA) of 2004 was on accountability: student achievement of functional and academic outcomes.1 School-based physical therapists (PTs) believe the most important factor in considering termination of physical therapy are students' achievement of their functional goals,2 which supports the importance of having explicit measurable goals. Individualized outcomes are important for evaluation of the effectiveness of school-based services and progress monitoring of student education. Individualized assessment has gained broader acceptance in recent years, especially when dealing with heterogeneous or low-incidence populations,3 and has been shown to be more responsive than standardized assessment in measuring change over time.4 Individualized outcomes guide the delivery of educational services and reflect learning that is meaningful to students' education and participation in the school environment.

Little is known about students' individualized outcomes to school-based physical therapy. One study in Canada evaluated individualized outcomes of 50 students, 5 to 12 years of age, receiving school-based physical, occupational, and speech and language therapy services using Goal Attainment Scaling (GAS).5 The goals focused on communication, school productivity, and mobility. Only 26% of the children were receiving physical therapy services, and the majority of the children were in kindergarten to second grade (66%) and had cerebral palsy (52%). After 6 months of services, 98% of the students made progress on their goals and, on average, exceeded goal expectations across all disciplines. In the United States, Stuberg and DeJong6 evaluated progress on individualized objectives of 566 children, in early intervention through high school, receiving physical therapy services from 18 therapists in a Nebraska school district. Each child had 1 to 5 objectives: 53% of the objectives were achieved, 38% had progressed, and 9% had no change. Progress on objectives for children in early intervention and preschool was higher than progress for students in elementary through high school. Students receiving special education for multiple impairments had less progress on objectives than students in other categories. Progress on objectives was lower for objectives related to impairments of body function and structures than objectives related to functional limitations and participation restrictions. These studies suggest that students receiving physical therapy services in schools make progress or achieve their individualized outcomes; yet, more research is needed to know if these results generalize across the United States.

School-based PTs, whose primary areas of expertise are motor and adaptive functions, directly support student outcomes for adaptive and functional skills7 and may indirectly support academic outcomes.8 Adaptive and functional skills specifically include posture and mobility (maintaining a position and moving from place to place), recreation and fitness (play, leisure, and physical activities), and self-care (dressing, feeding, and hygiene). Parents of 276 school-aged children with cerebral palsy (6-12 years of age) identified self-care, mobility, productivity in school, and physical recreation as their most frequent priorities for their children.9 These adaptive and functional skills enable a child to be active and participate in school activities. With regard to academics, posture and movement enable children to attend to classroom lessons, follow directions, experience actions,8 and manipulate materials for learning. Adaptive and functional skills are critical outcomes, as children's mobility, play, and self-care abilities are a foundation for daily life, fostering self-reliance, participation, and quality of life.10–12 These abilities may enable life experiences that promote the development of skills for subsequent inclusion and participation in education, employment, leisure, and social roles.13,14 School-based physical therapy's focus on adaptive and functional outcomes addresses the stated purpose of IDEA to prepare students “for further education, employment, and independent living.”1(§601,d,1,A)

The main purposes of this study were to describe the individualized outcomes of students receiving school-based physical therapy services and determine if goal attainment, as measured by GAS, differed by gross motor ability and age. A secondary objective was to explore if goal attainment differed by diagnostic groups. GAS measures individual progress toward achievement of individual goals using a set of specific goals for the student that typically includes a 5-point possible range of outcomes.15 GAS allows for more robust statistical analysis than the 3-point scale used to measure goal achievement by Stuberg and DeJong.6 Additional merits of GAS include that the measurement process is (1) criterion-referenced, making the measurement responsive to individual meaningful changes, (2) applicable for all levels of functional ability, and (3) feasible and affordable.15 GAS has been used for evaluation of pediatric rehabilitation services in many settings including schools.5,16,17 An understanding of goal attainment for students based on functional level, age, and focus of the goal will enable PTs to reflect on how students change and should provide guidance for establishing and monitoring progress on meaningful individualized outcomes.

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METHODS

Design

This study was part of a national study of school-based physical therapy services and student outcomes, PTrelatedChildOutcomes in theSchools (PT COUNTS), using a practice-based evidence design.18 Our methodology using this design has been described previously.19 For this article, a prospective, multisite, longitudinal observational design was used to describe students' individualized outcomes in a school year and through comparative analyses determine the effects of gross motor functional level, age, and medical diagnosis.

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Participants

Participants were recruited from 4 regions of the United States (Northeast, Southeast, Central, and Northwest). Details of our recruitment procedures and attrition of participants have been described by Effgen and colleagues.19 A sample of 296 students and their 109 PTs finished the study, with a complete data set of 20 weeks of documentation of physical therapy services and student outcomes assessment. Demographic characteristics of the participants are presented in Table 1. The majority of PTs were female (96%) and white (96%), with a mean age of 46 years (SD = 9.2). The majority of students were 5 to 7 years of age (58%), male (56%), and white (72%), with 78% of the students at Gross Motor Functional Classification System (GMFCS) levels I to III.

TABLE 1

TABLE 1

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Measures

The GMFCS20 is a 5-level system designed to classify children with cerebral palsy up to 18 years of age on the basis of performance in daily life. A classification is made on the basis of current gross motor function in daily activities, with emphasis on mobility and sitting. The GMFCS has evidence of content, construct, and discriminative validity and interrater reliability for children with cerebral palsy.20–22 While the GMFCS was developed for children with cerebral palsy, we wanted to have an indication of overall functional motor ability level for all students in the study. We believe that the GMFCS was the most appropriate option to describe and group the students on the basis of gross motor function. Thus, the GMFCS was used to classify all students and they were then divided into 3 groups: GMFCS levels I, II-III, and IV-V.

GAS23 is an individualized, goal-based, criterion-referenced outcome measure of change in performance of a behavior. Criteria for each level of change must be measurable and meaningful. The child's performance at baseline is assigned a value of −2, and the expected outcome following intervention is assigned a value of “0.” A value of −1 represents progress toward the expected outcome, and values of +1 and +2 represent outcomes that are possible but exceed expectations for the intervention. A value of −3 can be used to reflect that the child has regressed in function on this goal below the baseline. GAS has demonstrated content validity, interrater and intrarater reliability, and responsiveness in studies of children with cerebral palsy, motor delays, and other developmental conditions3,16,17,24,25 and has been more responsive to changes in functional performance than standardized measures.4

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Procedures

Details of the study procedures have been reported previously.19 Prior to the start of the study, therapists completed an online training module on GAS and passed a posttraining assessment. At the beginning of the study, therapists identified students' IEP goals related to participation in school activities that were supported by their physical therapy. Depending on the students' IEPs, therapists were asked to identify goals reflecting the following outcome areas of interest in this study: posture/mobility, recreation/fitness, self-care, and academics. The research team systematically reviewed the GAS goals to ensure they met the criterion for GAS format.15 Of the 498 GAS goals reviewed for this study, only 19 goals required substantial revisions. Through a consensus process, the research team confirmed the classification of these goals into the 4 outcome areas and 3 learning levels (acquisition, fluency, or generalization). If a student had more than 1 goal identified for this study, therapists were asked to select the goal that was most pertinent to the student's participation in school and to which the physical therapy services most addressed—this goal was referred to as the primary goal. Within each outcome area, students had only 1 goal. After approximately 6 months, therapists determined the student's goal attainment. Goal attainment was verified by at least 2 IEP team members for the following percentage of goals: 78% of the primary goals, 81% of the posture/mobility goals, 71% of the recreation/fitness goals, 94% of the self-care goals, and 89% of the academic goals.

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Data Analysis

Study data were collected and managed using REDCap (Research Electronic Data Capture) tools.26 GAS was summarized as a continuous variable with descriptive statistics. It was also summarized as a categorical variable with counts and percentages to provide descriptive details of student outcomes. Students were grouped on goal attainment as regressed, no change, improving (score of −1), achieving goals (score of 0), or exceeding expectations (scores of +1 or +2); achieving and exceeding goals were also combined. Analyses were conducted for the students' primary goal and for each of the goal areas. As students had 1 to 4 goals, the analysis for the primary goals reflects all the students in the study and the analyses for the goal areas reflect subsets of the students. Goal categories are described by both learning level and goal attainment. Scores were described overall, by age group (5-7 years, 8-12 years), and by gross motor function (GMFCS level I, II-III, IV-V). Two-way analyses of variance (ANOVAs), using age group and GMFCS level as factors, were used to determine differences in goal attainment between age groups, gross motor function groups, and whether an interaction existed between age and gross motor function. Post hoc 2-group comparisons were used in the event that the overall F-test was found to be statistically significant. In the event no significant effects were found despite an overall significant model, the model was rerun with only the main effects. One-way ANOVAs were used to determine differences in goal attainment by diagnostic groups. A significance level of .05 was used for all statistical tests. SAS (version 9.3, SAS Institute Inc, Cary, North Carolina) was used for all statistical analysis.

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RESULTS

Each student had 1 to 4 goals, consisting of 205 posture/mobility goals, 161 recreation/fitness goals, 82 academic goals, and 50 self-care goals. From these goals, the primary goals, 1 identified for each student (n = 296), were categorized as follows: 58% posture/mobility, 33% recreation/fitness, 5% self-care, and 4% academics.

Therapists reported that for 61% of the students, performance of the primary goal behavior was addressed and measured within a school activity or routine. Self-care goals had the highest percentage (94%), addressed and measured within a school activity or routine, and recreation/fitness goals had the lowest (47%). Sixty-five percent of the posture/mobility goals and 69% of the academic goals were addressed and measured within a school activity or routine.

For the primary goals, 56% were at the acquisition learning level, 43% at the fluency learning level, and 1% at the generalization learning level. As presented in Table 2, the percentage of goals at the acquisition learning level varied from 47% to 88% for the goal categories. The recreation/fitness category was the only goal category that had a higher percentage of goals at the fluency learning level (53%).

TABLE 2

TABLE 2

The goal attainment scores for all of the students are presented in Table 3. Students on average slightly exceeded their expected goal level for their primary goal (mean = 0.3, SD = 1.17), as well as for goals categorized as posture and mobility, recreation, and self-care. Students, on average, made progress but did not meet their expected goal level for goals categorized as academics (mean = −0.3, SD = 1.35). Table 4 presents the frequency distribution of students' level of goal attainment for each goal category. Seventy-seven percent to 98% of the students improved on their individualized goals depending on the goal category, and 50% to 76% of students achieved or exceeded their expected goal attainment.

TABLE 3

TABLE 3

TABLE 4

TABLE 4

No gross motor function by age interaction was found for the primary goal or the individual goal categories. Goal attainment was not significantly different by gross motor function for the primary goal or the individual goal categories (Table 3). Goal attainment did vary by age (Table 5) for the primary goal (F = 4.22, df = 1, P < .05). Students 5 to 7 years of age had higher goal attainment than students 8 to 12 years of age for their primary goal. For the recreation goal category, no significant effects were found despite an overall significant model. When the 2-way ANOVA was conducted without the interaction effect, goal attainment did vary by age (F = 7.96, df = 1, P < .01). Students 5 to 7 years of age had higher goal attainment for their recreation/fitness goal than students 8 to 12 years of age. Student goal attainment for the primary goal or the individual goal categories did not differ by diagnostic groupings.

TABLE 5

TABLE 5

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DISCUSSION

To our knowledge, this study is the first to examine nationwide in the United States the individualized outcomes of students receiving school-based physical therapy services. The majority of goals were related to posture/mobility and recreation/fitness, at the acquisition learning level, and were addressed and measured within the context of a school activity or routine. Students made progress, achieved their individualized goals, and many surpassed their expected functional, adaptive, and academic-related goals. Younger students had higher goal attainment than older students for their primary goal as well as the recreation/fitness goal area. These findings have implications for individualized outcomes assessment of students receiving school-based services.

The majority of the student goals were related to posture/mobility and recreation/fitness, with considerably fewer goals in the area of self-care and academics. This finding is not surprising, given the physical therapists' areas of expertise. However, it does raise concern that PTs in school-based practice may not consider their skills in supporting student outcomes in other related areas. For the self-care area, we do not know the extent this finding reflects the lack of IEP goals related to self-care or that therapists did not identify these goals to monitor for our study because other service providers focused on this area. In the area of academics, we can assume that the majority of students had academic-related goals on their IEPs. McConlogue and Quinn27 similarly found that PTs were addressing few goals related to academic tasks. While it is appropriate for therapists to address students' needs for mobility and fitness, we encourage therapists to consider using their expertise in movement and adaptive function to broadly support student academic and functional outcomes.

It is promising that the majority of goals were addressed and measured within the context of a school activity or routine, thus supporting the students' participation during the school day. This finding is contrary to that reported in previous research27 but aligned with the intent of IDEA and evidence that therapists are embracing best practice.7 However, it was surprising that a minority of the goals for recreation/fitness were addressed and measured within the context of a school activity or routine, as recess and physical education class would provide appropriate opportunities for PTs to support these goals. Therapists' inability to address and measure recreation/fitness goals in context of the school day may be due to challenges with scheduling. When our results were presented at a national conference, SoPAC 2014, school-based PTs in the audience also shared that some school personnel are not supportive of therapists providing services within the classroom. We encourage therapists and teachers to share their individual perspectives and negotiate appropriate times for therapists to collaborate with teachers and students during class activities in order to better support participation.

It was not surprising that the majority of goals were at the acquisition level of learning, followed by the fluency level. PTs focus on students learning motor skills and performing them with greater independence, speed, ease, and safety. It was interesting that recreation/fitness was the one area where there were more goals at the fluency level than at the acquisition level. This may reflect an understanding that for skills to be used effectively in the demanding physical and social environments of the school setting, students need to be able to perform the skills with greater fluency. The fact that only 1% of the skills were at the generalization level is concerning, as little attention may be given to truly ensuring that students use their skills within a variety of meaningful contexts in the school environment.

The finding that students receiving school-based physical therapy services made progress and achieved their individualized goals is positive, consistent with previous research,5,6 and suggests that these services support student outcomes. PTs were accurate in anticipating expected progress for students of varying gross motor functional levels and diagnostic categories. The results that goal attainment was not different among children with varying gross motor functional ability or diagnostic category indicate that GAS was responsive to changes that individual students made and support its use as a meaningful outcome in school-based physical therapy practice. The slightly lower level of goal attainment for goals related to academics may reflect that therapists, along with the IEP team, are not as accurate in predicting expected outcomes in this area. PTs also may not have been working on the specificity of the academic goals, although it can be assumed that other IEP team members, such as teachers, were directly supporting these outcomes.

The finding that older students had lower goal attainment for their primary and recreation/fitness goals than younger students suggests that therapists may need to reflect on what supports older students need to optimize progress. Despite the lower level of goal attainment, on average, the older students did achieve their expected goal level but did not exceed that level as the younger students did. Therapists may have underestimated the progress that younger students could make, or younger students may have received more services to support their goals. Related to our findings, Stuberg and DeJong6 found that elementary school students had higher goal attainment than students in middle and high schools. We are currently investigating the services received by the students to examine whether older students received less service time than younger students. Another consideration is that as learning is nonlinear and complex, students 8 to 12 years old may be focusing their energies and progressing in other areas of development, such as academics, and less on mobility and recreation.

We believe that meaningful intervention starts with a good outcomes assessment. Developing relevant student goals is challenging and the use of GAS may promote collaboration in identifying and monitoring goals.28 At IEP meetings, therapists can engage parents, teachers, other related services providers, and students in discussions to establish meaningful goals and set appropriate outcome levels. This process sets the stage for intervention planning. When working together, GAS can help the IEP team focus service delivery on a client-centered perspective15 and academic and functionally relevant priorities. Expert consensus recommends that goals reflect student participation in school routines and activities to assist them in benefiting from their education.29 It is important for team members to identify goals that reflect priorities for the student and to establish goals that are integrated across domains.

GAS is useful for progress monitoring and documentation of outcomes.15,30 Visual graphs of GAS outcomes can be used by teams to discuss student progress and to consider whether the intervention strategies are appropriate or need modification. For this study, we do not know the degree of collaboration in setting goals, but the use of GAS fostered collaboration in monitoring and determining goal achievement. Monitoring and documentation of student outcomes can facilitate program evaluation at a district or school level,6,16 self-evaluation and performance appraisal of PTs at the practitioner level,30 and progress monitoring at the student level and may foster greater team investment in the learning process for students.

Limitations of our study include a smaller percentage of students at GMFCS levels IV and V. We also used the GMFCS, which is validated for children with cerebral palsy,20 to classify the gross motor function of children with a range of diagnoses.

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CONCLUSION

This study documented the positive progress using GAS for elementary school students across the United States on their individualized outcomes addressed by physical therapy services. We found no effects of GMFCS level or medical diagnosis on the students' goal attainment. We found an age effect for the primary goal and goals classified as recreation/fitness, with younger students having higher goal attainment than older students. Our research team is currently examining the relationship of physical therapy services to these outcomes. In addition, qualitative research is in progress to explore the processes that therapists experience in goal development and implementation, as well as the facilitators and barriers to developing participation-based goals. We hope our research fosters others to conduct additional studies on school-based physical therapy practice so that PTs can truly provide evidence-based services. We encourage therapists to invest in outcomes assessment, collaborate with the IEP team, and develop and monitor meaningful student individualized goals using the GAS system to optimize students' educational experience.

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ACKNOWLEDGMENTS

The authors thank Dr Tracy Stoner, Dr Dianne Rios, and Julia Smarr, for assisting in data management, and Candace Brancato and Catherine Starnes, for assisting with data analysis as well as all of the school systems and physical therapists who participated in the data collection.

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Keywords:

Goal Attainment Scaling; goals; school-based physical therapy; student individualized outcomes

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