Regional Differences in School-Based Physical Therapy Practice for Students Who Made Progress on 2 Outcome Measures : Pediatric Physical Therapy

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RESEARCH REPORTS

Regional Differences in School-Based Physical Therapy Practice for Students Who Made Progress on 2 Outcome Measures

Caldwell, Michele PT, DPT, DSc; Effgen, Susan PT, PhD, FAPTA; Tezanos, Alejandro Villasante PhD; Sylvester, Lorraine PT, PhD; Jeffries, Lynn M. PT, DPT, PhD

Author Information
Pediatric Physical Therapy 34(1):p 46-54, January 2022. | DOI: 10.1097/PEP.0000000000000844

INTRODUCTION

Related services in schools, including physical therapy, are provided under the Individuals with Disabilities Education Act (IDEA).1 While school-based service provision is federally mandated, each state develops a plan to implement the IDEA within that state. Further, Individual Education Plan (IEP) teams develop individualized plans for each student leading to potential variability in service decisions for students with similar needs. Physical therapist training, common practices, and treatment philosophy vary across states and regions and may contribute to differences in school-based physical therapy (SBPT) provision.2

Kaminker et al,3 using case studies to investigate decision-making among school-based physical therapists, determined that physical therapists across the United States recommended variable amounts and frequency of SBPT. They determined physical therapists located in the Northeast recommended a higher number of sessions and recommended SBPT occurs in natural settings less often compared with the West, South, and Midwest.4 They also reported an association between geographic region and SBPT service delivery based on therapists' service recommendations and urged further research to examine the extent of and reasons for observed regional differences.

When a physical therapist makes recommendations to the IEP team, the therapist must consider dosage. Dosage includes therapy frequency, intensity of the students' output or work, time (or duration), and type of intervention, yet limited evidence exists to guide those decisions.5–7 Most data related to dosage focused on children with cerebral palsy (CP) and are not specific to a school-based setting. Cope and Mohn-Johnsen8 completed a systematic review examining the effect of dosage time and frequency on motor outcomes for children with CP and concluded insufficient evidence existed supporting different dosages. Effgen and McEwen9 appraised systematic reviews of physical therapy interventions used in school-based practice and found promising evidence supporting specific interventions for children with CP, but reported a lack of information available on the physical therapy dosage needed for optimal effectiveness.

For children with CP, researchers have started to examine service dosage to outcomes. McCoy et al10 completed a prospective study of 656 children with CP to analyze the relationship between child outcomes and therapy, including focus (type) and dosage. They found no association between therapy dosage received and child outcomes. Conversely, Storvold et al11 used a prospective cohort study designed to identify associations between physical therapy intervention, child factors, and gross motor progress and found higher service frequency was related to better outcomes. The frequency of therapy provided for children in the McCoy study was below the threshold identified as effective in the Storvold study, potentially accounting for the variation in results. For therapists to make evidence-based decisions on the most effective interventions, contexts, and dosage of SBPT services, research is needed to examine the relationships between outcomes and physical therapy services provided.

The Physical Therapy-Related Child Outcomes in the Schools (PT COUNTS) study applied practice-based evidence (PBE) methods to describe SBPT across the United States.12 Researchers collected data on student outcomes, specific physical therapy interventions used, and SBPT dosage provided for 6 months. The majority of students' primary Goal Attainment Scaling (GAS) goals, categorized as mobility, recreation, and self-care were met.13 The main activities used in SBPT were physical education (PE) and recreation, mobility, and sitting/standing transitions while primary interventions were neuromuscular, mobility, and musculoskeletal.14 Researchers also investigated the relationship between SBPT services and student outcomes using the School Function Assessment (SFA), with results showing mobility, functional strengthening, playground access interventions, sensory, motor learning, aerobic conditioning, and higher student participation correlated with better SFA outcomes.15

Therefore, this study explores the dosage and type of SBPT services provided for students who met their goals during the PT COUNTS study and examines whether relationships exist between student outcome achievement and the type and dosage of SBPT services provided by region.12

Research questions are as follows:

  1. For students who met or exceeded their primary GAS goal, do regional differences exist in the dosage and types of activities and interventions used in SBPT?
  2. For students who achieved positive progress on the SFA, do regional differences exist in the dosage and types of activities and interventions used in SBPT?
  3. Are student outcomes as measured by the GAS and SFA related to regional differences in SBPT services?

METHODS

Study Design

This study examined the results from the PT COUNTS study, a national prospective, multisite, longitudinal, observational study of SBPT services and related student outcomes using PBE.12 All participating institutions and school systems with Institutional Review Boards provided ethics approval. School-based physical therapists who assisted in data collection completed online ethics and study-specific trainings. Therapists and parents or guardians of the students provided informed consent.

Participants

Researchers recruited school-based physical therapists from public school systems through announcements at APTA meetings, APTA Pediatrics member emails, and personal contacts. Therapists must have worked in schools for at least 1 year, passed online training, and agreed to collect data for 1 year.

Student participants were on the caseloads of participating school-based physical therapists. Student inclusion criteria included being a student with a disability, receiving special education, and receiving SBPT at least monthly. Students were in kindergarten through sixth grade (ages 5-12 years) and were excluded if they had a progressive disability such as muscular dystrophy, had a planned surgery or move within the school year, or had been absent over 30% of the previous school year.

Measures

Gross Motor Function Classification System. The Gross Motor Function Classification System (GMFCS) classifies the gross motor function skills of children with CP using 5 levels that describe the differences between a student's functional gross motor mobility.16 Research has supported the classification system's content, construct, discriminative validity, and interrater reliability.16–18 In PT COUNTS, researchers used the GMFCS as a proxy description of the functional abilities of all students.12

School-Physical Therapy Interventions for Pediatrics. The School-Physical Therapy Interventions for Pediatrics (S-PTIP) is a data collection tool developed and validated for children receiving SBPT services.14,19,20 Therapists document type of service delivery (eg, individual, group, within a school activity) and time spent on behalf of the student (eg, consultation, collaboration, and documentation). Therapists also document the number of minutes spent in 14 types of activities using 5-minute time increments. The activities are grouped based on similarities into pre-functional, sitting/standing transitions, classroom activity, mobility, PE/recreation, self-care, communication, and other types of activities. Therapists document the interventions used during the therapy session from 79 possible interventions. Interventions are grouped in categories of neuromuscular, musculoskeletal, cardiopulmonary, integumentary, orthoses, mobility assistive devices, mobility, position, equipment, sensory, educational, assessment, and other interventions on the S-PTIP (https://www.uky.edu/chs/academic-programs/department-rehabilitation-sciences/physical-therapy/pt-counts).

Goal Attainment Scaling. GAS is an individualized, criterion-referenced outcome measure of change in performance.13 Therapists create behavioral criteria for change at 5 levels, with baseline performance assigned a value of −2 and expected goal achievement assigned a value of 0. A value of −1 indicates progress and values of +1 and +2 indicate student goal outcomes, which exceed the expected level. GAS is responsive to minimal clinically significant changes, can be written for all functional ability levels, and research has shown content validity, reliability, and responsiveness to change.21–23

School Function Assessment. The SFA is a standardized, criterion-referenced outcome measure designed to measure activity and participation of students with disabilities in kindergarten through sixth grade.24 Physical therapists completed Part I Participation, Part II Task Supports, and components of Part III Activity Performance: Physical Tasks.15 Part I assesses student participation in 6 settings and is scored using a 6-point Likert scale. Part II Task Supports (assistance and adaptations needed) and Part III Activity Performance: Physical Tasks (student performance) use a 4-point Likert scale. Raw scores for each part were calculated and converted to standard scores. The SFA has high internal consistency, is comprehensive, and has reported a test-retest reliability of r > 0.80.25–27

Procedures

During 2011-2012, researchers recruited school-based physical therapists in the United States. Once consented, physical therapists completed a demographic form and online training modules on the S-PTIP, GAS goal development, and SFA measures, and passed a posttest assessment scoring at least 80%. Physical therapists then viewed 2 videos of students receiving SBPT and completed the S-PTIP form, with at least 70% agreement with the researchers. Each physical therapist identified students on their caseload who met inclusion criteria. Researchers selected students using a randomized process and parents or a guardian provided consent. Effgen and colleagues12 describe detailed recruitment procedures for study participants.

At the beginning of the 2012-2013 school year, parents completed a student demographic form. Physical therapists determined a GMFCS level and scored the SFA for each student. Physical therapists wrote GAS goals based on the student's IEP and identified a primary GAS goal for the school year. Researchers systemically reviewed each GAS goal to ensure all required criteria were met as described by Chiarello and colleagues.13

During the 6-month intervention period, excluding winter and spring breaks, physical therapists completed the S-PTIP weekly for each participating student. Physical therapists recorded type of service delivery, time spent with and on behalf of the student, interventions used, and the length of time spent in each activity type. At the end of 6 months, physical therapists repeated the SFA and determined each student's GAS goal score, which was verified by at least 1 other IEP team member.12

Data Analysis

Research Electronic Data Capture (REDCap)28 was used for data entry and management and SAS 9.3 (Cary, North Carolina) for statistical analysis. Analysis included descriptive statistics for participants' demographics, S-PTIP, GAS goals, and SFA by region. Our research team conducted analysis of variance (ANOVA) to determine whether differences existed between regions regarding therapist demographics. For GAS, researchers identified 2 groups, students that met or exceeded their goal (GAS ≥ 0) or students who did not (<0) and used χ2 analysis to determine whether differences existed. For each SFA subscale, researchers calculated a pre- to postcriterion change score. For analysis, the SFA subscale criterion scores were then divided into 3 categories based on the outcomes' standard error of measurement: those with a criterion change score below −5, −5 to 5, and above 5. Those with criterion scores of −5 were considered to have regressed, and those above 5 to have improved. Researchers used analysis of covariance (ANCOVA) to examine regional differences between service minutes received, minutes in activities, and interventions provided for those students who met or exceeded GAS goals and for students who made progress on the SFA, adjusting for students' GMFCS level. Researchers ran Tukey Honestly Significant Difference (Tukey HSD) post hoc tests to indicate which regions were significantly different from the others, χ2 to analyze differences between GMFCS levels across the regions. Alpha was set at 0.05 for all statistical tests.

RESULTS

Participants

There were 109 physical therapist participants: 28 in the Southeast, 21 in the Northeast, 29 in the Central, and 31 in the Northwest (Table 1). There were no differences among regional groups with respect to therapist age, years of physical therapy practice, years as a pediatric physical therapist, years as a school-based physical therapist, and average student caseload per year. The physical therapists' mean age fell was 44 to 48 for each region.

TABLE 1 - Physical Therapist (n = 109) and Student (n = 296) Demographics
Physical Therapists Demographics
Variable Southeast, n = 28 Northeast, n = 21 Central, n = 29 Northwest, n = 31
Age
Mean (SD) 45.0 (9.27) 47.4 (8.85) 44.1 (9.79) 48.1 (8.6)
Range 27-59 29-59 27-60 28-66
Gender—female/male 28/... 20/1 27/2 30/1
Race—White/Non-White 24/4 21/... 29/... 31/...
Ethnicity—Hispanic or Latino: yes/no .../27a .../21 1/28 1/29a
Degree
Baccalaureate 16 13 14 16
Certificate ... 1 ... 1
Doctorate 4 2 5 3
Masters 8 5 10 11
Postprofessional degree
MS (or equivalent) 4 3 4 8
None 11 12 19 16
PT clinical doctorate 11 5 5 4
PT clinical masters 2 1 ... 2
PhD (or equivalent) ... ... 1 1
Time worked—full time/part time 26/2 15/6 19/10 13/18
Mean number students per year
Mean (SD) 36.8 (9.45) 34.1 (12.51) 39.5 (14.40) 33.5 (13.25)
Range 15-50 16-60 22-77 9-65
Years practiced as PT
Mean (SD) 20.1 (10.49) 22.8 (10.64) 19.3 (11.21) 23.2 (9.24)
Range 2-37 4-38 1-38 3-40
Years practiced as pediatric PT
Mean (SD) 15.5 (10.05) 18.1 (10.57) 14.6 (8.89) 17.4 (9.59)
Range 1-34 3-37 1-33 2-40
Years as school-based PT
Mean (SD) 11.3 (9.17) 14.5 (10.30) 13.3 (9.07) 13.9 (784)
Range 1-30 3-35 1-33 2-37
APTA member—yes/no 15/11+ 9/12 15/14 18/13
Student Demographics
Variable Southeast, n = 85 Northeast, n = 51 Central, n = 81 Northwest, n = 79
Age
Mean (SD) 7.2 (2.02) 7.6 (1.94) 7.2 (2.09) 7.4 (2.03)
Range 5-12 5-11 5-12 5-12
Gender—female/male 38/46 18/33 43/38 31/48
Race
Asian 4 4 2 6
Black 20 5 8 1
Multiracial 9 4 8 6
Other 3 9 6 2
White 47 29 52 60
Hispanic/Latino—yes/no 9/76 15/5 20/59 7/68
PT outside of school—yes/no 37/47a 11/40 28/53 21/56a
School-based OT—yes/no 74/11 49/2 70/11 63/16
School-based SLP—yes/no 63/22 45/6 64/17 62/17
Adaptive PE—yes/no 34/51 22/29 35/46 32/47
Spend most of the day in:
Combination 17 (20%) a 17 (33.3%) 31 (38.3%) a 21 (26.6%)a
Special classroom 44 (51.8%) 16 (31.4%) 23 (28.4%) 31 (39.2%)
Typical classroom 23 (27.1%) 18 (35.3%) 26 (32.1%) 22 (27.8%)
Gross Motor Function Classification Level
Level I 16 (18.8%) 21 (41.2%) 33 (40.7%) 43 (54.5%)
Level II/III 44 (51.8%) 17 (33.3%) 34 (42.0%) 22 (27.8%)
Level IV/V 25 (29.4%) 13 (25.5%) 14 (17.3%) 14 (17.8%)
Abbreviations: OT, occupational therapist; PE, physical education; PT, physical therapist; SLP, speech-language pathologist.
aIndicates not all participants responded.

Two hundred twenty-four of the 296 student participants met or exceeded their GAS goals: Southeast (n = 68; 80%), Northeast (n = 32; 62.7%), Central (n = 63; 77.8%), and Northwest (n = 61; 77.2%). There were no differences between student groups with respect to age, but there were differences between regions and student GMFCS levels (P = .0004). The Southeast had the highest percentage of students at GMFCS levels IV and V and the lowest percentage of students GMFCS level I.

Goal Attainment Scaling

For students who met or exceeded their primary GAS goal, regional differences existed in the dosage and types of activities and interventions used in SBPT (Tables 2, 3, and 4). Therapists in the Central region provided the highest dosage of physical therapy services (639.5 minutes), significantly greater than total minutes of service in the Southeast (P = .006) and Northwest (P = .003). Total minutes spent on behalf of the student were also higher in the Central region compared with the Southeast (P < .00) and Northwest (P = .01) regions. Group minutes in the Central region were higher for students compared with any other region (Southeast P = .031, Northeast P = .006, and Northwest P = .001).

TABLE 2 - Primary GAS Goal Achievement by Region, Whole Sample
GAS 0, +1, +2 Frequency Southeast Northeast Central Northwest Whole Sample
Yes 68 32 63 61 224
Percent whole sample 22.97% 10.81% 21.28% 20.61% 75.68%
Percent region 80% 62.7% 77.8% 77.2%
No 17 19 18 18 72
Percent whole sample 5.74% 6.42 6.08% 6.08% 24.32%
Percent region 20% 37.3% 22.2% 22.8%
Total 85 51 81 79 296
100.00%
Abbreviation: GAS, Goal Attainment Scaling.

TABLE 3 - Regional Results for Students Who Met or Exceeded Primary GAS Goal (n = 224)a
S-PTIP Variable Southeast Northeast Central Northwest
n = 68 n = 32 n = 63 n = 61
Total minutes—all activities for each student
F value = 3.16, P value = .025
504.9
(SE = 35.04)
613.9
(SE = 23.51)
639.5
(SE = 35.77)
533.3
(SE = 33.87)
Total minutes—services on behalf of the student
F value = 5.94, P value ≤ .001
227.6
(SE = 17.06)
296.7
(SE = 23.51)
323.7
(SE = 17.41)
261.2
(SE = 11.27)
Total minutes—sitting/standing/transition activities
F value = 2.95, P value = .033
124.3
(SE = 15.93)
171.8
(SE = 21.95)
168.0
(SE = 16.26)
114.5
(SE = 15.40)
Total minutes—mobility activities
F value = 3.18, P value = .025
123.1
(SE = 18.27)
210.6
(SE = 25.18)
132.6
(SE = 18.65)
163.1
(SE = 17.66)
Sum of interventions—neuromuscular
F value = 5.05, P value = .002
29.9
(SE = 1.87)
36.7
(SE = 2.57)
38.0
(SE = 1.90)
29.8
(SE = 1.68)
Sum of interventions—cardiopulmonary
F value = 2.98, P value = .032
2.8
(SE = 0.45)
1.3
(SE = 0.62)
2.0
(SE = 0.46)
1.0
(SE = 0.44)
Total minutes for group
F value = 4.36, P value = .005
81.5
(SE = 20.22)
47.5
(SE = 27.87)
142.7
(SE = 26.45)
49.5
(SE = 19.55)
Abbreviations: GAS, Goal Attainment Scaling; SE, standard error; S-PTIP, School-Physical Therapy Interventions for Pediatrics.
aS-PTIP by region: ANOVA F values and P values, mean, and standard error for those variables with significant differences between regions, P < .05.

TABLE 4 - S-PTIP by Region for Students Who Met or Exceeded GAS Goals, P Values
Southeast Northeast Central Northwest
Total minutes—all activities for each student
Southeast ... 0.066 0.006a 0.560
Northeast 0.660 ... 0.666 0.173
Central 0.006a 0.666 ... 0.033a
Northwest 0.560 0.173 0.033a ...
Total minutes—on behalf of the student
Southeast ... 0.017a <0.001a 0.156
Northeast 0.017 ... 0.352 0.217
Central <0.001a 0.352 ... 0.010a
Northwest 0.156 0.217 0.010a ...
Total minutes—sitting/standing/transition activities
Southeast ... 0.078 0.050a 0.656
Northeast 0.078 ... 0.890 0.033a
Central 0.050a 0.890 ... 0.018a
Northwest 0.656 0.033a 0.018a ...
Total minutes—mobility activities
Southeast ... 0.005 0.708 0.116
Northeast 0.005a ... 0.012a 0.123
Central 0.708 0.012a ... 0.239
Northwest 0.116 0.123 0.239 ...
Sum of neuromuscular interventions
Southeast ... 0.032a 0.002a 0.972
Northeast 0.032a ... 0.676 0.029a
Central 0.002a 0.676 ... 0.002a
Northwest 0.972 0.029a 0.002a ...
Sum of cardiopulmonary interventions
Southeast ... 0.052 0.193 0.005a
Northeast 0.052 ... 0.385 0.696
Central 0.193 0.385 ... 0.132
Northwest 0.005a 0.696 0.132 ...
Minutes of group
Southeast ... 0.318 0.031a 0.255
Northeast 0.318 ... 0.006a 0.952
Central 0.031a 0.006a ... 0.001a
Northwest 0.255 0.952 0.001a ...
Abbreviations: GAS, Goal Attainment Scaling; S-PTIP, School-Physical Therapy Interventions for Pediatrics.
aP < .05.

Researchers noted other differences between regions associated with goal attainment regarding the length of time spent on specific activities and types of interventions. Physical therapists in the Northeast provided more time on mobility activities (mean 210.6 minutes) than the Southeast (P = .005) and Central regions (P = .012) while students in the Northwest received less time in sitting/standing/transition activities (mean 114.5 minutes) compared with the Northeast (P = .033) or Central (P = .018). Further, physical therapists in the Northeast and Central regions provided more neuromuscular interventions than the Southeast (P = .032, P = .002) or Northwest regions (P = .029, P = .002). Cardiopulmonary interventions were more frequently used in the Southeast compared with the Northeast (P = .052) or Northwest (P = .005).

School Function Assessment

For students who made progress on Part I Participation, researchers identified regional differences (Table 5). Variables on the S-PTIP associated with regional differences on Part I Participation include total minutes, service minutes on behalf of the student, and group minutes, all greatest in the Central region (P = .006, P < .001, P = .002). The Central region provided more minutes of self-care activities (Southeast P = .002, Northeast P = .017, and Northwest P = .039) while physical therapists used mobility activities less frequently in the Southeast compared with the Northeast (P = .005) and Northwest (P = .009). Physical therapists in the Central region used neuromuscular interventions more than in the Southeast (P = .007) or Northwest (P = .044) regions. Physical therapists in the Northwest provided fewer minutes of PE and recreation activities (Southeast P = .004 and Central P = .005) and used more equipment interventions compared with the Southeast (P = .014) and Central (P = .015).

TABLE 5 - S-PTIP by Region for the School Function Assessment
SFA Part II: Task Supports
SFA Part I: Participation Assistance Adaptations
S-PTIP Variable F Value P Value F Value P Value F Value P Value
Total minutes—all activities for each student 4.29 .006a 1.84 .144 5.66 .001a
Total minutes—on behalf of the student 7.91 <.001a 5.62 .001a 7.67 <.001a
Total minutes—prefunctional activities 4.42 .005a 4.70 .004a 2.85 .040a
Total minutes—mobility activities 3.64 .014a 3.13 .029a 2.49 .063
Total minutes—PE and recreation 3.76 .012a 1.71 .170 3.05 .031a
Total minutes—self-care 3.74 .013a 2.55 .059 3.39 .020a
Sum—neuromuscular interventions 3.16 .027a 1.51 .215 3.40 .020a
Sum—mobility assistance interventions 2.62 .053 3.88 .011a 3.41 .020a
Sum—mobility interventions 3.95 .010a 3.98 .010a 3.54 .017a
Sum—equipment interventions 2.74 .046a 2.83 .042a 0.82 .487
Total minutes for group 5.19 .002a 1.35 .263 2.83 .041a
SFA Part III Activities: Physical Tasks
Changing and Recreational Manipulation Up and Down
Travel Maintaining Position Movement With Movement Stairs
S-PTIP Variable F Value P Value F Value P Value F Value P Value F Value P Value F Value P Value
Total minutes—all activities for each student 6.01 <.001a 3.69 .014a 0.58 .631 3.01 .033a 3.11 .031a
Total minutes—on behalf of the student 7.65 <.001a 3.25 .024a 3.14 .028a 4.76 .004a 1.31 .276
Total minutes— prefunctional activities 4.11 .009a 6.62 <.001a 2.19 .093 1.73 .164 6.34 <.001a
Total minutes— mobility activities 1.51 .216 1.72 .165 2.12 .102 2.78 .044a 3.34 .024a
Total minutes— PE/recreation activities 5.78 .001a 1.55 .204 1.35 .262 2.51 .062 0.48 .694
Sum of neuromuscular interventions 4.80 .003a 3.82 .012a 1.61 .190 5.11 .002a 4.73 .004a
Sum of musculoskeletal interventions 0.82 .485 1.01 .392 0.15 .930 0.76 .521 2.92 .039a
Sum of cardiopulmonary interventions 2.05 .111 1.08 .358 2.89 .038a 2.31 .080 0.28 .841
Sum of mobility assistance interventions 2.42 .070 3.85 .011a 2.01 .117 1.58 .199 1.49 .225
Sum of mobility interventions 1.66 .180 2.93 .036a 3.49 .018a 4.81 .003a 1.57 .204
Total minutes for group 4.15 .008a 3.20 .025a 1.29 .282 3.29 .024a 6.14 <.001a
Abbreviations: PE, physical education; SFA, School Function Assessment; S-PTIP, School-Physical Therapy Interventions for Pediatrics.
aIndicates P < .05.

Part II Task Supports assesses the student's need for assistance and adaptations. The Central region was associated with a higher dosage of total services (adaptation: Southeast P = .007 and Northwest P = .001), services on behalf of the student (assistance: Southeast P < .001, Northeast P = .012, and Northwest P = .005 and adaptation: Southeast, Northeast, and Northwest each P < .001), and group minutes (adaptation: Northeast P = .012 and Northwest P = .018). The Central region provided more minutes of prefunctional activities (assistance: Southeast P < .001, Northeast P = .012, and Northwest P = .026 and adaptation: Southeast P = .006 and Northwest P = .036) and self-care activities (adaptation: Southeast P = .004 and Northeast P = .017). Physical therapists in the Central and Northeast regions used more neuromuscular interventions (Central × Southeast P = .26, Central × Northwest P = .05, Northeast × Southeast P = .014, and Northeast × Northwest P = .025) and the Southeast provided fewer mobility interventions (Northeast P = .03, Central P = .037, and Northwest P = .003). Students received fewer minutes of PE and recreation activities in the Northwest (adaptation: Southeast P = .011 and Central P = .011).

For students with positive gains on the 5 physical tasks on the SFA Part III Activities: Physical Tasks, the Central region provided more direct service minutes for several physical tasks compared to other regions (travel: Southeast P < .001 and Northwest P = .007; maintaining and changing positions: Southeast P = .006, Northeast P = .016, and Northwest P = .0120) and provided a higher number of minutes on behalf of students for all 5 physical tasks. Physical therapists in the Northeast region provided higher total minutes for students who progressed on manipulation with movement (Southeast P = .039 and Northwest P = .043) and up and down stairs sections (Southeast P = .044 and Northwest P = .007). The Central region provided a higher number of prefunctional activities and more group time than the other regions in each area except recreational movement. Further, mobility interventions were used less in the Southeast compared with other regions for changing and maintaining position, recreational movement, and manipulation with movement (P = .0360, .0179, and .0034). It is notable that cardiopulmonary interventions associated with positive change on recreational movement, P = .0384, were higher in the Southeast compared with other regions.

DISCUSSION

The PT COUNTS study allowed researchers to compare combinations of interventions and activities used and the dosage of services related to student outcomes. While causal relationships between services and outcomes cannot be determined using the observational PBE study design, the results provide valuable information regarding the dosages, interventions, and activities that support student outcomes. Additionally, the results serve to guide future research.

There were no regional differences in the number of students who met or exceeded their primary GAS goal,29 yet when examined by those who made progress on each outcome, there were differences in the services, activities, and interventions provided. The lack of connection between the dosage of services received and student outcomes highlights the need to identify the most efficient dosage of SBPT interventions. In a systematic review of physical therapy interventions used in school-based practice, Effgen and McEwen9 note that due to the expense of SBPT services and the time services take the student away from other learning, it is crucial to identify how much physical therapy intervention is sufficient yet not excessive. Research is needed comparing the effectiveness of different dosages (frequency and duration) for achieving student outcomes.

There were no significant relationships between different service delivery contexts (in the classroom or outside the classroom) and goal attainment for students who met or exceeded their GAS goals. This unexpected finding may be due to the types of goals targeted. Chiarello et al13 reported that only 1% of identified GAS goals were at the generalization level, rather most goals were at the skill acquisition (56%) and fluency (43%) levels of learning. The targeting of goals primarily at the acquisition and fluency levels, which focus on teaching a student a new skill, may also contribute to the provision primarily of individual and away from the classroom physical therapy services.

There were regional differences in the interventions and activities associated with GAS goal attainment. For students who met or exceeded their GAS goals, students in the Central region received significantly higher total minutes, minutes on behalf of the student, and minutes of group compared with other regions. This finding contrasts with the dosage findings for the Central region.29 For example, the mean total direct minutes of SBPT for students in the Central region was 440.86 minutes while students in Central region who met or exceeded their GAS goals received an average of 639.5 minutes. Similarly, the average time spent in groups was 73.33 minutes for the Central region but was 142.7 minutes for students who made progress. Students who met or exceeded their GAS goals in the Southeast region received the lowest average dosage of total time and the lowest time on behalf of the student, yet the Southeast region had students with the most significant gross motor function limitations, perhaps accounting for the lack of progress. These results demonstrate that while overall dosage and student outcomes may not have been related, there are regional differences in dosage related to outcomes for those students who met or exceeded their GAS goals.

For those students who met or exceeded their GAS goals, regional differences exist in the time spent on transition-related activities and mobility activities with the Northeast providing the greatest dosage in each category after controlling for GMFCS level. Related to interventions used, the researchers found regional differences for 2 of the 13 S-PTIP categories.

Many of the regional differences that were significant for students who met or exceeded their GAS goals were also present for students who made progress on the SFA (see the Supplemental Digital Content, available at: https://links.lww.com/PPT/A333). The SFA, unlike GAS, is a standardized outcome measure creating a consistent ruler by which to measure progress. Overall, fewer students made progress on the SFA compared with GAS due at least in part to the large standard error of measurement of the SFA. Specifically, when examining SFA Part III Activities: Physical Tasks, students did not make progress in all task areas. We believe this is related to the focus of the student's SBPT services and the IEP goals of that particular school year.

Regional differences in total minutes spent on all activities, time spent on behalf of the student, and time in group were significant for students who made progress on Part I: Participation, Part II Task Support, and subtests of Part III Activities: Physical Tasks. For students who demonstrated positive change, students in the Central region spent the most time on self-care activities and prefunctional activities while students in the Northeast spent greater time on mobility activities.

Strengths and Limitations

Strengths of this study include a large, national sample of physical therapists who reported SBPT services weekly for 6 months, with a large sample of students. The PBE study design allowed for comprehensive examination of student outcomes, dosage of SBPT provided, and the types of services, activities, and interventions used by school-based physical therapists within the school environment.

A limitation of this study was lower representation of students at GMFCS levels IV and V, and students with progressive disabilities were not included. In addition, older students were not studied due to the age limitations of the SFA. The researchers did not delve into the data to examine specific therapist differences such as higher degrees or part time/full time employment and that relationship to student outcomes. As an observational study, there was no control or manipulation of SBPT services. While relationships and associations were identified between factors, researchers can make no causal conclusions.

CONCLUSIONS

This study suggests that students receiving SBPT make progress on both individualized goals and on standardized measures. Regional differences in services, activities, and interventions provided exist for students who made progress yet did not impact goal achievement. Across regions, physical therapists provided the majority of SBPT service time in individual therapy and separate from the classroom environment. Further research is needed to identify the most efficient and effective interventions and dosage to support student outcomes.

What This Adds to the Evidence

Students who received SBPT made progress on individualized and standardized goals across regions. Regional differences exist in the dosage interventions, and activities provided, yet goal attainment was not different.

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Keywords:

observational research; regional variability; schools; school-based physical therapy; student outcomes

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