The Individuals with Disabilities Education Act (IDEA) was enacted to improve the educational outcomes for students with disabilities in accordance with the US national policy of equal opportunity and social participation for individuals with disabilities.1 The latest reauthorization in 2004 states that the IDEA's main purpose is “to ensure that all children with disabilities have available to them a free appropriate public education that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living.”1 Related services include, but are not limited to, physical therapy (PT), occupational therapy (OT), and speech services.1 Although the IDEA identifies PT as a related service that may help students with disabilities benefit from their education, it does not provide specific guidance as to the provision of PT services. This results in confusion, controversies, and variability in practice among school-based physical therapists.2,3 McEwen4 reported that determining a student's need for school-based PT services has been the “most controversial and poorly understood aspect of IDEA.”
For school-aged children, the Individualized Education Program (IEP) team makes decisions on a student's eligibility for special education and the student's need for, as well as the extent of, related services.5 The IEP team may include teachers, students, parents or guardians, related services, and other school personnel. The therapist, together with other IEP team members, can apply evidence-based practice when determining a student's need for school-based PT services. However, evidence-based practice in school-based PT has been constrained by the paucity of research, the perceived lack of direct applicability of available research, and the complex nature of team decision-making, where the physical therapist's goal is to support the educational objectives set by the team.6,7 We therefore examined school-based physical therapy practice guidelines (from here on forward referred to as “guidelines”) created by state educational agencies (SEAs) and local educational agencies (LEAs) to find guidance in determining a student's need for school-based PT services under the IDEA.
The federal government entrusts the SEAs and LEAs with the ultimate responsibility of creating and implementing policies and procedures that are consistent with the IDEA to ensure free appropriate public education for all students with disabilities.1 Thus, SEAs and, in some instances, LEAs have developed guidelines for physical therapists providing related services in their schools. Because these agencies were tasked to create policies and procedures to be implemented within their states or school districts, differences among these guidelines may arise. Despite these differences, we expect that there would be commonalities across state and local guidelines for a variety of reasons. First, SEAs and LEAs base their policies on the same regulation: the IDEA. Second, it is likely that SEAs and LEAs chose, as creators of those policies, individuals who have knowledge and expertise in the provision of special education and related services. When developing guidelines, these individuals may have consulted, in addition to the IDEA, current literature in special education and related services, such as school-based PT. Guidelines developed by individuals who considered current evidence in literature can, therefore, share similar tenets.
Finding agreement among experts via consensus is an alternative method in solving problems that are complicated, and where the evidence is lacking.8,9 We therefore examined with 2 purposes the contents of SEA and LEA guidelines that are accessible online.
The first purpose is to identify guidance from each SEA or LEA regarding the determination of the student's need for PT services; and second, to find commonalities across state and local guidelines that can serve as agreement among experts from different SEAs and LEAs. We present these findings and discuss the commonalities in relation to current PT and special education literature. Finally, we apply these commonalities into practice by developing a list of procedural requirements and questions that the IEP team can use when discussing a student's need for PT services.
School-based practitioners from any region in the United States may benefit from understanding each SEA's or LEA's guideline, the commonalities across the practice guidelines, and their application to practice. IEP teams in school districts that lack guidelines for determining a student's need for PT services can incorporate our procedural requirements and questions as a starting point during IEP meetings. Teams and therapists in states or school districts with explicit guidance for determining need for PT services can use our summary of guidance from their SEA or LEA guidelines and our discussion of the commonalities to make informed decisions during an IEP team meeting.
GATHERING THE PRACTICE GUIDELINES
The authors reviewed the most recently published guidelines that were accessible by any school-based practitioner. As such, we examined only guidelines that were available online between December 2014 and January 2015. Guidelines were initially obtained through the list of State Guidelines of School-Based PT Practice available on the Web site of the American Physical Therapy Association, Academy of Pediatric Physical Therapy's (APPT) School-Based PT Special Interest Group (SIG).10 This list was developed via School-Based SIG member submissions of guidelines from their states, and an online search. The School-Based SIG updates the list when new or revised guidelines are published. Additional guidelines were obtained through online searches on Google, Bing, and Yahoo search engines using different combinations of the following keywords and their variations: “physical therapy,” “physical therapist” or “PT”; “school-based,” “school” or “educational setting”; “practice”; and “guide” or “guideline.” The search included both SEA and LEA guidelines. LEA guidelines found in states that have SEA guidelines were excluded because of redundancy.
We found a total of 23 SEA and 2 LEA guidelines. The APPT list of guidelines yielded 23 SEA and 1 LEA guidelines, whereas our subsequent online search yielded 3 additional LEA guidelines. Two LEA guidelines from California were excluded because California has a state guideline. Of the guidelines included, 18 pertained to both PT and OT practices; 4 exclusively described PT practice; 1 pertained to OT, PT, and speech services; 1 referred to all related services; and 1 was a general special education handbook.
EXAMINATION OF THE PRACTICE GUIDELINES
We selected chapters or excerpts from each of the 25 guidelines with references to the determination of need for school-based PT under the IDEA. These included, but were not limited to, topics termed “entrance criteria,” “determining need for therapy services,” or “eligibility.” The authors also included topics referred to as “termination” or “exit criteria,” as they may help clarify the “entrance criteria.”
Guidelines that did not explicitly address determining the need for PT services were excluded from further examination. This included Alaska, New Jersey, and Washington. As a result, the authors analyzed a total of 22 SEA and LEA guidelines. Supplemental Digital Content 1 (available at: http://links.lww.com/PPT/A185) contains the 22 guidelines and Supplemental Digital Content 2 (available at: http://links.lww.com/PPT/A186) contains the excluded guidelines and the reasons for exclusion.
Each author independently examined the selected chapters and excerpts from each guideline, listing concepts that pertain to determining need for PT services. We then jointly reviewed each of our lists to ensure agreement of findings. Where only one author noted a particular concept, both authors reread the guideline to confirm or disaffirm the concept's presence. All agreed-upon concepts were then tabulated into one spreadsheet to calculate the percentage of guidelines in which they appeared (Table).
To determine a threshold at which a concept can be considered a commonality, we consulted published consensus documents in the medical field. Fink et al,9, in surveying characteristics of consensus models developed by the National Institutes of Health, stated that typical consensus is reached when two-thirds of the participants come to an agreement. Of the concepts listed in Table, 7 can be found in at least two-thirds of the guidelines (ie, in at least 14 of the 22 guidelines), and are thereby considered commonalities.
All 22 guidelines mention educational benefit and team decision as main considerations in determining the need for school-based PT; these 2 concepts are also emphasized under the IDEA. Nineteen guidelines require the need for PT expertise to include PT as a related service. Eighteen of the 22 guidelines stress that the team establishes the student's IEP goals before determining the need for PT to address any of the goals. The distinction between the medical model and school-based model of PT services was discussed in 18 guidelines. Seventeen guidelines require that the student's disability adversely affects education in order for PT to be included in the IEP, and 17 ask the team to consider the student's potential for improvement with PT intervention.
In addition to the 7 commonalities, there are 6 concepts that appeared in 1 to 6 guidelines. Although these concepts will not be discussed in detail in this article, school-based practitioners in states or school districts that mentioned these concepts should take them into consideration when determining need for PT services.
Our examination of SEA and LEA guidelines yielded 7 commonalities that are consistent with current literature and the IDEA. All guidelines echo the IDEA by stating that related services are provided for educational benefit. The Kentucky guideline states that “therapy must contribute to the development or improvement of the student's academic and functional performance.”11 The Oxford Public School District puts forth the contrapositive statement that PT is necessary if without it the “student will not have access to an appropriate education” nor “experience educational benefit.”12
The logical corollary to the concept of educational benefit is that school-based PT as a related service is distinct from medical-based PT. The Alabama guideline summarizes this commonality by describing 2 situations. First, a medical condition that does not interfere with educational performance may require medical-based PT, but not school-based PT.13 However, a medical condition that interferes with educational performance may require both medical-based and school-based PTs, in which case the “[school-based] therapist would concentrate on skills necessary to allow the student to benefit from special education.”13 This distinction is bolstered by the commonality that school-based PT may be needed only if the student's disability and resulting movement problems adversely affect a student's educational performance. Impairments need not be addressed by school-based PT unless “improvement in those impairments will increase students' educational access and success.”14 Educational benefit is not limited to academics, and it may include any other school function that the IEP team has decided is essential for the student to benefit from the educational program.4 Thus, the role of the IEP team is important in defining the educational needs of the students with disabilities.
All guidelines stress that determining the need for PT services is a team decision. This is supported by the IDEA and the PT literature as ideal practice.15 Minnesota's guideline states that if an IEP is developed with a collaborative approach, “then a decision to have a therapist provide service to a child within an isolated area of function that no other team member is helping to support would not happen.”16 In a study of IEP team meetings, Martin et al17 reported that the presence of the student and general education teacher in an IEP meeting resulted in increased discussion of student strengths and needs, and an “increased knowledge of what to do next”; whereas the presence of related service personnel increased discussions of student's interests.
The IEP team must establish the student's IEP goals prior to determining the need for related services. Creating goals first ensures that the goals relate to educational needs and are discipline free.18 To assist the student in reaching the established goals, the team chooses the service provider with the most appropriate expertise, noting that an IEP goal that falls within a physical therapist's area of expertise does not necessarily mean that PT is the right service.19 As such, another commonality states that IEP teams determine the need for the expertise of a physical therapist when considering PT as a related service for a student. Areas of PT expertise often overlap with those of other school personnel. For example, OTs share PT expertise in self-care; physical education teachers also specialize in play and recreational skills; and classroom teachers, teacher aides, and orientation and mobility personnel may assist a student in negotiating the classroom and the school environment. An APPT fact sheet suggests that the physical therapist is the practitioner of choice when “difficulty with functional posture or mobility are the primary factors interfering with other areas of development and participation.”20 Moreover, PT can be added on the IEP if the level of expertise required to achieve the student's goal necessitates the skills and knowledge of a physical therapist21 and, that other school staff cannot address the goal without PT.22 The Minnesota guideline cautions the team that duplication of services is inappropriate: PT services should not replace or increase “the frequency of support that should be provided by other primary service providers.”16
The team should also consider whether PT is likely to improve the student's ability to access education. The Kentucky, Connecticut, and Illinois guidelines add that this potential for improvement must be a result of the PT intervention, and not merely due to maturity.11,14,23 The concept of determining a student's potential emphasizes the importance of a therapist's prognostic skills. Prognosis, one of the elements of patient management outlined in the Guide to Physical Therapist Practice, is defined as the “determination of the level of optimal improvement that may be attained through intervention and the amount of time required to reach that level.”24 Prognosis must take into consideration a variety of factors, including patient demographics, disease-specific factors, and biobehavioral and medical comorbidities.25 We add that, in school-based practice, therapists should also consider school-related factors (ie, academic expectations, environmental barriers and facilitators, and availability of school support) and the student's personal factors (ie, preferences, motivation, and family support). Current literature provides some guidance on prognosis for specific diagnoses (eg, cerebral palsy, Down syndrome, and spina bifida) and their comorbidities, as well as the efficacy of various interventions.26–28 It is suggested that a therapist use the unbiased prediction of effects of PT interventions gleaned from research as a starting point, “adjusted up or down” in accordance with one's clinical judgment to determine the likelihood that a student will respond to the intervention.29
These commonalities apply to the determination of a student's need for PT services under the IDEA. This article does not address the provision of PT services under Section 504 of the Rehabilitation Act of 1973.
APPLICATION OF THE COMMONALITIES TO SCHOOL-BASED PRACTICE
The identification and discussion of the 7 commonalities among the SEA and LEA guidelines can help guide the physical therapist and the IEP team when determining the need for PT services. The commonalities suggest 2 procedural requirements and 5 decision-making questions that need to be considered. We suggest that the IEP team adheres to the 2 procedural requirements as follows:
- Determining the student with disabilities' need for PT service is a team decision.
- The team establishes the student's IEP goals prior to determining whether PT is needed to address any of the goals.
In addition, the IEP team must answer the following 5 questions during the decision-making process:
- Are the student's disabilities or performance limitations adversely affecting his/her education?
- Is the student's PT need educational, and not only medical?
- Is PT necessary for the student to benefit from his/her education?
- Does the student have potential to improve access to his/her education and achieve educational goals with PT intervention?
- Does the student require the level of expertise of a physical therapist to achieve educational goals?
Answering yes to all 5 questions indicates that PT may be an appropriate related service for the student. However, these questions do not supersede SEA or LEA guidelines, policies, or procedures; therefore, school-based therapists are advised to review their own state and school district policies. Because these questions are based on the commonalities across the guidelines, it is expected that in many cases the questions will satisfy the state and district policies; however, in some cases, the IEP team may need to modify, eliminate, or add questions in accordance with their state or school district policies.
At the time of our search, 27 states did not have practice guidelines that were accessible online, whereas an additional 3 states with guidelines did not have explicit guidance for determining the need for school-based PT services. School-based practitioners in these states may find the commonalities summarized in this article particularly helpful when participating in IEP team discussions. These commonalities may also serve as a starting point for SEAs or LEAs when developing their own PT practice guidelines.
Our search was limited to SEA and LEA guidelines that were available online. It is possible that other guidelines are available in print and where thereby excluded. Future studies may include direct outreach to special education offices in states or school districts to obtain guidelines. Additional studies may also be conducted that yield guidance on decision-making for frequency, intensity, and method of delivery of school-based PT services.
The IDEA includes physical therapy as a related service that may be provided for students with disabilities to help them benefit from their education. However, the IDEA does not provide specific guidance for the provision of school-based PT services, resulting in variations in practice across the United States. This article provides guidance when determining a student's need for school-based PT services on the basis of SEA and LEA guidelines. We found 7 commonalities across 22 guidelines. We reframed these 7 commonalities into a list of 2 procedural requirements and 5 questions that the IEP team should consider and discuss when deciding the need for school-based physical therapy services.
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