Decision making for physical therapy service delivery in schools: a nationwide survey of pediatric physical therapists.

School-based physical therapists, as members of the Individualized Education Program (IEP) team, collaborate in decisions regarding the need for physical therapy services, including the models, contexts, frequency, and intensity of intervention. (1-10) The team creates an education program for each student. For students with physical disabilities, input from physical therapists about the motor strengths and needs of the students is often a key component of the planning process. (6,9,10)

Physical therapy, according to the Individuals With Disabilities Education Act, Part B (IDEA) 1997, is a related service, defined as one of the "supportive services ... as are required to assist a child with a disability to benefit from special education." (10)(p16)-12 Alternatively, physical therapy may be delivered for students who do not receive special education, under Section 504 of the Rehabilitation Act of 1973. (9,10) Physical therapists assist children and adolescents in "achieving the educational goals ... and accessing and participating in the educational environment." (10)(p19)

When the IEP team establishes a need for physical therapy services, intervention is planned. Models of service delivery may include direct services (individual or group, or both) and indirect services (consultation or monitoring). (6,7,10,13-19) Services may be delivered in a variety of contexts: integrated into the student's usual school activities, performed in an isolated therapy area, or a combination. (6,10,14,19-24) The frequency and intensity of service delivery also are established by the team. (20) "Frequency refers to how often a service is provided, and intensity addresses the duration of each session." (3)(p27)

Limited evidence exists to guide clinical decisions regarding models of pediatric service delivery. (24-26) Two researchers (17,27) comparing direct services with consultation found no difference in motor outcomes, but Dunn (27) found that teachers preferred the consultative model. Research appears to support integrated service delivery over an isolated approach, (4,13,14,21,24,25,28,29) provided that there are sufficient opportunities for practice, which may depend on the severity of the student's involvement, the nature of the goals, and the stage of learning of those skills. (13,28,30)

The literature is ambiguous, however, with regard to whether high-frequency, high-intensity schedules of service delivery are more effective than low-frequency, low-intensity schedules in improving motor performance. (31-36) Effectiveness of services may be related to additional factors, such as the degree of implementation of the therapists' recommendations to the teachers and other caregivers. Clinical decision making regarding the models, contexts, frequency, and intensity of service delivery appears to be a complex process influenced by many child, family, and environmental factors. (7)

Physical therapists, administrators, and teachers have made a distinction between medically necessary and educationally relevant physical therapy. (9,14,15,29) Recently, authors (9,29) have tried to diminish this dichotomy by emphasizing that physical therapy for all students should address functional needs. Still, uncertainties exist regarding how to make service delivery decisions in educational environments. From 2001 through 2004, on the online discussion group (listserve) of the American Physical Therapy Association's (APTA's) Section on Pediatrics, pediatric physical therapists have continually posted questions and expressed their struggles with making decisions regarding school-based service delivery. Insufficient evidence is available to support specific clinical choices in school settings or to define best practice, which appears to result in sonic of the variability in service delivery philosophies and models among practicing therapists. (1,10,15,24,32,33,37-45) We question whether the emphasis in current professional (entry-level) education programs on newer theories of motor development, motor learning, and motor control may lead recently trained physical therapists to make different clinical decisions than those who were trained before these concepts became popular. (4,39,45)

Survey research has begun to clarify several issues surrounding clinical decision making in school practice. (1,15,24,46) These studies have described some important aspects of current practice, but more specific guidelines will be helpful to school-based physical therapists. Effgen and Klepper (15) conducted a survey of school-based physical therapists in which they compared the respondents' reports of their actual practice with their conceptions of ideal practice, with respect to decision making, service delivery, team dynamics, and administrative support. According to the therapists' self-reports, 64% of the respondents always or usually provided direct services and 26% of the respondents always or usually provided indirect services. Service provision by 46% of the therapists was always or usually through an isolated (pull-out) format, whereas 51% of the therapists always or usually provided therapy that was integrated into the educational setting. In ideal practice, however, only 25% of the therapists thought that isolated service delivery was preferable.

Effgen (1) more recently highlighted the influence of the achievement of functional goals, the severity of the student's cognitive disability, and the degree of physical impairment in decisions regarding termination of school-based services. Sekerak et al (24) conducted interviews of 10 experienced North Carolina physical therapists who provide intervention in preschool settings and who incorporate integrated services as part of their intervention. None of the respondents reported using exclusively integrated services; the participants used a combination of integrated, isolated, and consultative models of service delivery.

In our study, we conducted a nationwide survey to explore clinical decision making for school-based physical therapy. Using 4 clinical cases of children ranging from preschool through the school-age years, we sought recommendations by physical therapists regarding the models, contexts, frequency, and intensity of physical therapy services, as well as home exercise and activity programs, adaptive physical education, and community recreation programs. We also explored factors the therapists considered important in their decision making. Our primary aim was to examine recommendations for frequency of direct therapy and context of service delivery across the cases. In addition, we analyzed the relationship between these recommendations and the respondents' years of school-based experience.

The survey results reflect the perceptions of the respondents regarding their current practice and may approximate school-based practice patterns across the country. The study can serve as a foundation for the design of future outcomes-based research that may lead to guidelines for decision making and for best practice. Information on clinical decision making by school-based physical therapists also could be beneficial for training therapists new to school practice and for promoting reflection by readers on their own practice patterns, as compared with those reported by this nationwide sample.

Method

Respondents

A survey questionnaire was mailed nationwide to all the members of APTA's Section on Pediatrics (N=1,154) who identify themselves as school-based physical therapists. They were from all 50 states and the District of Columbia. Participation was requested by those therapists who are currently working in school settings with students from 3 to 21 years of age.

Of the 1,154 mailed survey questionnaires, 2 were returned as undeliverable. Survey instruments were received from 710 therapists within 9 weeks, producing a response rate of 61.6%. Among these therapists, 630 (88.7%) indicated that they currently practice in school settings. Conversely, 80 respondents (11.3%) did not work in schools. Four questionnaires were incomplete. Thus, the results were based on the responses of 626 school-based physical therapists.

Responses were received from all 50 states and the District of Columbia. Representation by state was consistent with that of the membership of APTA's Section on Pediatrics. The states with the greatest number of respondents were: New York (n=76, 12.1%), New Jersey (n=50, 8%), Pennsylvania (n=37, 5.9%), and Michigan (n=35, 5.6%). The Northeastern region had more respondents (n=210, 33.5%) than any other region.

The participants were overwhelmingly female (n=597, 95.5%), with a mean age of 43.6 years (SD=9.7, range=23-73). Most respondents were employees of school districts (n=439, 70.1%), as opposed to independent contractors, and their mean years of experience in school settings was 11.2 years (SD=7.7, range=1-35). Professional degrees were predominantly at the bachelor's level (n=389, 62.1%). Postprofessional academic degrees were reported by 25.7% of the respondents (n=161), although 39.1% (n=245) reported a variety of nondegree postprofessional training, the most common of which was a neurodevelopmental treatment course (n=152, 24.3%). Forty-seven respondents (7.5%) reported that they were diplomates of the American Board of Physical Therapy Specialties (ABPTS) as Pediatric Certified Specialists (PCS).

Most of the respondents worked in public schools: 81.6% (n=510) in inclusive settings (children with disabilities attend their neighborhood schools, where they are in classes with children who are developing typically for some or all of their school day (7)) and 73.6% (n=460) in schools with self contained classes for children with disabilities. Other school settings included: early-intervention centers, community preschools, Head Start programs, home-based services, and private and parochial schools. A majority of therapists (n=361, 58.2%) reported working in suburban settings. The most prevalent age group of students served was 6 to 12 years (n=566, 90.6%), with 553 therapists (88.5%) serving children from 3 to 5 years of age. Table 1 contains information about the participants.

Procedure

The mailed packet included a cover letter, the survey questionnaire, and a postage-paid, addressed return envelope. Procedures to promote a high response rate were used. (47) Two weeks after the initial mailing, a follow-up postcard was sent to all 1,154 physical therapists, thanking those who had already returned the questionnaires and reminding the others to do so. The postcard indicated that those who had misplaced their questionnaires could download and print a replacement from the Internet.

Instrumentation

We developed the survey instrument in 2002 using a clinical case format. This was done in an effort to elucidate the physical therapists' thought processes for making clinical decisions. The questionnaire used in our survey was a modified version of a survey instrument used in a pilot study conducted by the primary authors (48) but never described in the peer-reviewed literature. Content validity for the survey instrument was examined using literature that supported the diagnoses and case construction; Sweeney et al (49) found that cerebral palsy and developmental delay were the diagnoses of the largest percentage of the population served by pediatric physical therapists. The survey instrument was reviewed by 3 experienced pediatric physical therapists (with over 17 years of experience each), 2 of whom were Pediatric Certified Specialists. Further evidence for content validity for the questionnaire used in our survey was provided by our review and integration of comments from participants in the pilot study among school-based physical therapists in New Jersey regarding the content and format of that survey instrument. As a result of this input, the clinical cases and the list of influential factors in decision making were modified and expanded to include more detail. The format was refined for greater visual appeal and readability, based on Dillman's principles of survey design. (47) Four school-based physical therapists pilot tested the final version of the survey instrument. All of them had completed a specialty certification program in school-based practice; 2 of them had 9 and 12 years of school-based experience (respectively), and the other 2 had fewer than 5 years of school-based experience. We reviewed the written feedback from these 4 clinicians and made subtle changes to clarify some of the case descriptions, questions, and terminology.

In our survey, 4 clinical cases were presented regarding fictitious students who had diagnoses and functional levels comparable to those often seen in children referred to school-based physical therapist. (49) After reading each case description, the respondents were asked to reply to specific questions regarding service delivery models, contexts of therapy, frequency and intensity of services, additional services they would recommend, and factors they considered important in making these decisions.

The first 2 paired cases concerned 4-year-old girls with motor delays and similar physical functional and impairment levels. In the case of "Annie," cognition was within normal limits, and, in the other case, "Beth" had moderate cognitive impairment. This pairing was designed to elucidate the impact of cognitive level on clinical decision making. To remove potential response bias for these 2 cases, the cases were counterbalanced using 2 different versions of the survey instrument; half the respondents received survey questionnaires with Annie's case presented first, and half of the respondents received survey questionnaires with Beth's case presented first.

The next 2 cases were paired by age for a boy with cerebral palsy. In the first case, "Chris" was 6 years age, and, in the second case, he was 12 years of age. Although the functional and impairment levels were slightly different, this pairing was intended to provide information on the influence of age on the respondents' recommendations. No counterbalancing was done for these 2 cases, as the sequencing of the student's 2 ages was intentional.

Data Analysis

We analyzed the data using the Statistical Package for the Social Sciences, Version 10.0 for Windows. * We used descriptive statistics to report demographic information of the participants and their recommendations related to the models, contexts, frequency, and intensity of physical therapy service delivery, as well as additional services. Factors considered important in making these decisions also were described.

We performed a 2-way analysis of variance (ANOVA) for repeated measures across the 4 cases to determine whether there were differences in the recommended frequencies of direct services for each of the 6 categories of years of respondents' school-based experience, by each of the 4 clinical cases. A significant Mauchly Test of Sphericity led to a Greenhouse-Geisser adjustment to decrease the degrees of freedom. Follow-up analyses using paired-samples t tests were done to examine the differences between the paired cases: (1) two 4-year-old girls with similar functional abilities, one with and one without cognitive impairment, and (2) the student with cerebral palsy at the 2 different ages. An independent-samples t test was performed to determine whether the order of presentation of Annie and Beth affected the recommendations for direct frequencies.

A 4 x 3 chi-square test for independence was performed to determine whether there was an association between the 4 clinical cases and the recommended contexts of service delivery (integrated, isolated, and combination). Six follow-up 2 x 3 chi-square analyses then were conducted for each pair of cases (Annie versus Beth, Annie versus Chris at age 6 years, Annie versus Chris at age 12 years, Beth versus Chris at age 6 years, Beth versus Chris at age 12 years, and Chris at age 6 years versus Chris at age 12 years), by the 3 contexts. (50,51) For this series of chi-square analyses, the assumption of independence was violated, but the differences were fairly clear and there was no practical alternative method to analyze the data. The failure to consider correlations among responses by a given therapist should tend to make the results conservative (less likely to be significant).

Four one-way ANOVAs were conducted, one for each of the 4 cases, to ascertain whether there were differences in the respondents' years of experience in school settings for each of the 3 choices for context of service delivery (integrated, isolated, and combination). For this series of analyses, a Bonferroni adjustment was used and the alpha level was established at .01. Post hoc Scheffe tests were performed on the analyses that produced significant results.

Results

Clinical Choices of Respondents

The respondents showed a strong preference for direct services (range-58.1%-94.1%) over indirect services (range=5.3%-39.9%) (Tab. 2). Direct services were defined as interventions delivered to an individual or group, or both, including consultation with the team. Indirect services were defined as consultation (about once per month) or monitoring (about once or twice per school year), without an additional recommendation for direct services. Indirect services were recommended more often for Chris at age 12 years (39.9%) than for Chris at age 6 years or the two 4-year-old girls (range=5.3%-14.6%), and few respondents indicated that they would not provide any physical therapy services (range=0.6%-6.4%). For those therapists who recommended indirect services, consultation was suggested by 11.7% (n-73) of the respondents for Annie, by 11.2% (n=70) of the respondents for Beth, by 4.8% (n=30) of the respondents for Chris at age 6 years, and by 33.2% (n=206) of the respondents for Chris at age 12 years. Monitoring was recommended by 2.9% (n=18) of the respondents for Annie, by 2.4% (n=15) of the respondents for Beth, by 0.5% (n=3) of the respondents for Chris at age 6 years, and by 6.8% (n=42) of the respondents for Chris at age 12 years.

For all 4 cases, some form of individual services was recommended by the majority of respondents. Fewer physical therapists suggested group services (Fig. 1). Among those respondents who recommended direct services for each of the 4 cases, more therapists suggested one session per week than any other frequency, with a range of 44% to 57% for individual services and a range of 52.5% to 68.3% for group services. Monthly frequencies are depicted in Table 3. The order of presentation of the first 2 cases (Annie and Beth) had no effect on the respondents' choices for frequency of direct services.

[FIGURE 1 OMITTED]

There was a difference among the recommended direct service monthly frequencies across the 4 cases (F=144.37; df=3,15; P<.001). Recommended frequencies for Beth ([bar.X]=4.47, SD=3.22) were greater than for Annie ([bar.X]=4.03, SD=3.12) ([t.sub.612]= -4.38, P<.0001, 2-tailed). Similarly, suggested frequencies were greater for Chris at 6 years of age ([bar.X]=5.74, SD=3.27) than at 12 years of age ([bar.X]-2.38, SD=2.93) ([t.sub.582]=27.79, P<.0001, 2-tailed).

There was no interaction between respondents' years of experience in school settings and case on the frequency of recommended use of direct services (F-0.74; df=3,15; P>.05), and no main effect was found for respondents' years of experience in school settings on frequency (F=1.47; df=5,572; P>.05). Among those respondents who recommended direct services for each of the 4 cases, more respondents preferred 30-minute sessions than any other duration. For individual services, 30-minute sessions were recommended by 71.5% to 76.1% of the respondents. For group services, 67.9% to 73.3% of the therapists selected 30-minute sessions. Table 4 illustrates the respondents' recommendations for session duration.

A combination of contexts of service delivery was strongly preferred by the survey participants: services delivered in both natural and isolated (pull-out) settings. Natural settings are defined as the activities and environments the child encounters in a typical school day (including the classroom, lunchroom, corridors, stairs, playground, gymnasium, and school bus, with peers and classroom staff). Isolated settings are those that are physically separate from the child's regular educational environment, such as a secluded therapy room (14,25) (Tab. 5). An association was found between the 4 clinical cases and the recommended contexts of service delivery (integrated, isolated, and combination): [[chi square].sub.(6, n=2,336)] = 210.94, P<.001). Among the 6 follow-up 2 x 3 chi-square analyses between each pair of cases, all were significant except for Annie versus Beth. The greatest difference was that proportionately fewer therapists chose isolated services for Annie and Beth, integrated services for Chris at age 6 years, and a combination of contexts for Chris at age 12 years, whereas a greater percentage of therapists chose isolated services for 12-year-old Chris.

In the case of Beth, differences were found in the respondents' years of school-based experience among the recommended contexts of service delivery (F= 11.22; df=2,599; P<.001). The therapists who selected isolated services for Beth had fewer years of experience than those who selected integrated services. Those therapists who recommended a combination of contexts had tower years of experience than those who recommended integrated services. Table 6 demonstrates the respondents' mean years of school-based experience for each recommendation.

A majority of respondents designated home exercise and activity programs for all 4 cases (Tab. 7). These activities were chosen by 407 therapists (65.2%) for Annie, by 361 therapists (58%) for Beth, by 460 therapists (73.6%) for Chris at age 6 years, and by 458 therapists (73.8%) for Chris at age 12 years.

The respondents expressed strong support for adaptive physical education and community recreation programs to augment school-based physical therapy services, or sometimes as a recommendation without physical therapy (Tab. 8). Among these therapists, 34.8% to 79.5% advocated adaptive physical education, and 65.4% to 75.8% advocated community recreation programs.

Factors Important in Decision Making

Among the factors that the therapists indicated were important in decision making for each case (Fig. 2), the student's functional level was considered very to extremely important by the largest percentage of respondents. Functional status was rated very to extremely important by 88.6% (n=552) of the respondents for Annie, by 86.7% (n=541) of the respondents for Beth, by 88.8% (n=556) of the respondents for 6-year-old Chris, and by 90.2% (n=560) of the respondents for 12-year-old Chris. The student's own goals were rated very to extremely important as follows: by 76.2% (n=475) of the respondents for Annie, by 72% (n=448) of the respondents for Beth, by 85.6% (n=535) of the respondents for Chris at age 6 years, and by 88.5% (n=550) of the respondents for Chris at age 12 years. For all 4 cases, the student's body structure and functional impairments, the family's goals, and the student's age were deemed very to extremely important by at least 58% of the respondents. The student's diagnosis, history of intervention (past experience with physical therapy services), educational setting, and prognosis were considered very to extremely important by the fewest number of participants.

[FIGURE 2 OMITTED]

The respondents were asked how frequently other factors were important in decision making in their practices (Tab. 9). They considered input from the educational team, past practice, and state policies regarding provision of related services as most important. Parental input and the family's involvement in the student's education and intervention less frequently affected the clinical judgments of these therapists. Budgetary constraints, administrative input, and personal feelings about a student were even less likely to alter service delivery decisions.

Discussion

We examined clinical decision making by school-based physical therapists across the nation. The comments offered by the members of APTA's Section on Pediatrics who responded to the survey were characterized by a high level of interest in the topic, as evidenced by a response rate of 61.6%. The therapists reported that the clinical cases were similar to those they frequently encounter in their practices. They expressed a wide range of judgments regarding the models, contexts, frequency, and intensity of service delivery, although some patterns emerged from the data.

The high incidence of recommendations for direct service was comparable to the results of the study by Effgen and Klepper. (15) Few therapists in our study chose indirect services for the two 4-year-old girls or Chris at age 6 years. However, about one third of respondents recommended consultation for Chris at age 12 years. Older children are considered less likely than younger children to benefit from direct services. (36) Additionally, older children, unless they are in self-contained classes for students with severe disabilities, are more likely than younger children to be immersed in demanding academic programs, making it difficult to schedule intervention. (6,13,14,24,25)

Sortie of our results were morel consistent than others with the findings reported in the literature, in view of the traditional medical model of pediatric physical therapy, characterized by individual, direct, hands-on intervention, (15,24,52) it is perhaps surprising that so many respondents advocated group services. Pediatric physical therapists may recognize the benefits of peer modeling, (24) and the size of caseloads also may have affected these results, but the reasons for choosing group services were not explored. As expected, a large percentage of participants endorsed home exercise and activity programs, adaptive physical education, and community recreation programs, with or without physical therapy services. These activities can help to increase physical fitness and overall health. (53) The role of physical therapists in encouraging participation in such activities is consistent with the emphasis in the Guide to Physical Therapist Practical (52) on the prevention of illness and disability and the promotion of health, wellness, and fitness.

The most commonly recommended frequency of service delivery was one session per week. This recommendation is supported by several studies that showed no benefit from higher frequencies of intervention, (31-36) although a consensus document (33,36) and a subsequent study (31) showed conflicting findings. In our study, we sought to explore frequency recommendations for various clinical cases and the factors the therapists considered when making these decisions.

The respondents suggested higher frequencies for the 4-year-old with cognitive impairment than for the 4-year-old with typical cognitive functioning. These therapists, therefore, do not subscribe to the cognitive referencing model, which contends that children with cognitive impairments are less likely to benefit from therapy than are those with typical cognitive development. (6,14,54) Research has shown that, among children with motor delay's, there is no relationship between cognitive abilities and improvements in motor outcomes. (36,55,56) The slightly higher frequencies recommended for Beth may indicate that these therapists believe that children with lower cognitive levels require more time than children with typical cognitive functioning to process and learn new motor skills.

An expected outcome was the recommended lower frequencies for Chris at age 12 years, with a mean of just over 2 sessions per month. This outcome, we believe, may be explained by the greater perceived benefit of intervention for younger students (36) and the logistical problems of scheduling services for older students who attend academic classes. (6,13,14,24,25) Among all 4 cases, the highest recommended frequency was for 6-year-old Christopher, apparently because of his relatively young age, his functional status, and the student's and family's goals.

We found that a combination of contexts was preferred in most cases, demonstrating to us that the respondents endorsed natural environments as settings for at least some portion of intervention. This finding was consistent with those of Sekerak et al (24) in their study of physical therapists employed in preschool settings. Effgen and Klepper (15) compared integrated and isolated models of service delivery and found that their respondents were divided between the 2 practices, but their survey did not offer a combination as an alternative. Some authors (4,13,14,21,24,25,28-30,46) promote service delivery in natural environments to maximize motor learning, provided that there are ample opportunities to practice, (26,29) however, natural settings do not always afford sufficient practice. Ott and Effgen (26) examined the naturally occurring opportunities to practice 3 types of gross motor behaviors (stability, mobility, and transfers) among preschoolers. The high incidence of stability skills (eg, sitting activities) made those skills appropriate to integrate into therapeutic intervention. The relatively lower incidence of mobility and transfer skills presented greater challenges to the service providers to design sufficient practice opportunities. For the younger children in our survey, for whom it may be easier to create opportunities to practice motor skills in natural contexts, few therapists chose exclusively isolated services. They were more likely to recommend isolated services for the older students, presumably because it is often problematic to integrate services for those students. (14,24,25) Although the largest percentage of respondents in our study favored a combination of contexts, the more variable recommendations for Chris at age 12 years may have reflected a perceived conflict between the enhanced motor learning associated with natural environments and the problem of therapist intrusion during academic classes.

The association between clinical case and recommended context of service delivery indicates to us that the respondents considered the ages, functional levels, and individual needs of the students when choosing how services would be delivered. We were not surprised, however, to find no association between case and context for the paired cases of Annie and Beth, suggesting that therapists would consider similar approaches to service delivery for both preschool children. Although the girls' different cognitive levels did not affect the contextual recommendations for the preschoolers, the contrasting ages of the boy with cerebral palsy did appear to influence choices for the context of service delivery. A combination of contexts was selected by proportionately more respondents for Chris at age 6 years and by fewer respondents for Chris at age 12 years. More therapists chose integrated or isolated services for Chris at age 12 years, whereas fewer therapists chose integrated or isolated services for Chris at age 6 years.

The relatively recent evidence in favor of integrated services, (4,13,14,21,24,25,28,30,46) led us to investigate whether physical therapists who are new to school practice would be more likely than traditionally trained physical therapists to recommend services in natural settings. Unexpectedly, a greater percentage of the more experienced therapists selected integrated services, as compared with isolated services, for the 4-year-old with cognitive impairment. Sekerak et al, (24) in their study of experienced therapists in preschool settings, identified a preference for a combination of integrated, isolated, and consultative service delivery. Experienced clinicians may have learned about the benefits of integrating services, whereas novice practitioners may have a greater need to concentrate on the mechanics of their clinical skills, through isolated services. School-based experience may have influenced the respondents' contextual choices for the preschooler with cognitive impairment; however, the differences in the mean number of years may not be important. Differences in mean years of experience for those physical therapists who selected the various contexts were not found for the preschooler without cognitive impairment or for the older children. Logistical issues related to the feasibility of integrating services for older students may have affected these results. (24)

As we anticipated, the respondents' decision making was strongly influenced by both the students' functional levels and the students' own goals. The emphasis on function is supported by current literature describing best practice, as well as the legal requirements under IDEA 1997. (5,7,10,13,14,20,24,15,46,57) The impact of the students' goals might have reflected the respondents' understanding of the importance of motivation, purposeful activities, and contextual programming in motor learning. (7,24,58,59)

The participants attributed a high level of influence on their decision making to the student's body structure and functional impairments but not to his or her cognitive level. These findings were consistent with the consensus of pediatric physical therapists surveyed by Bartlett and Palisano. (60) In their survey, physical therapists rated determinants of motor change among children with cerebral palsy. Muscle tone (defined by Bartlett and Palisano as "the force with which a muscle resists being lengthened" (60(p243))) and movement patterns were ranked the highest among primary impairments, and muscle and joint contractures and skeletal malalignment were ranked the highest among secondary impairments. Bartlett and Palisano considered these musculoskeletal impairments more influential than cognition. Impairment level and cognition, however, were rated highly influential in Effgen's survey. (1) These findings are contrary to the literature's emphasis on functional skills, rather than on physical impairments or cognition. Research (61-65) has shown, however, that resistive exercise programs can produce gains in muscle three among children with and without neurological impairments. Increased force is associated with improved motor performance. (61-65) This might explain why school-based physical therapists continue to focus on body structure and functional impairments. Additionally, these results may reflect the emphasis outlined in the Guide to Physical Therapist Practice (52) of the physical therapist's role in the prevention of secondary impairments, functional limitations, and disability.

Similar to the findings of Effgen's study, (1) in our survey respondents' own practices, the importance of the school administration in decision making was reported to be minimal; the importance of parental participation was reported to he moderate. Parental participation in decision making regarding related services is required by law and is the basis for family-centered intervention. (7,10,14,24,66)

Limitations and Implications for Future Research

The recommendations derived from this study reflect the clinical choices of the respondents. They are not necessarily evidence-based decisions that may be considered best practice, and they need to be appreciated within the limitations of this study. Federal regulations and current literature indicate that IEP goals should be developed first, before defining strategies to achieve these goals. (9-11,16) The survey participants, however, did not have the benefit of knowing the students' IEP objectives before determining their recommendations for service delivery. The purpose of this study was to examine the physical therapists' views, recognizing that in actual practice, service delivery decisions are made collaboratively by the entire IEP team. (1-10)

The survey was based on only 4 clinical cases, which may not adequately represent the population of students referred to school-based physical therapists. All survey participants responded to questions regarding all 4 cases. Recommendations for one case may have affected those for other cases; however, in actual practice, service delivery decisions are made from the perspective of the program plans for both current and former students in the therapists' caseloads. The large sample size and the counterbalancing of the 2 preschoolers contributed to the validity of the analyses.

Interpretation of the results should be influenced by the sampling limitations. All participants, by virtue of the selection process, were members of APTA's Section on Pediatrics. Members of a specialty section may be more likely than nonmembers to read current literature, participate in continuing education courses, earn postprofessional degrees, and complete surveys. Their recommended decision making may not reflect all practicing school-based physical therapists. The results of the study, therefore, may be skewed to reflect the judgments of the better-informed physical therapists who are Section on Pediatrics members. (1,24)

This nationwide survey explored service delivery preferences among members of the Section on Pediatrics employed in school settings. Future researchers may want to compare the clinical decisions of Section on Pediatrics members with those of nonmembers. If differences exist, more aggressive efforts will need to be made to establish and promote continuing education opportunities for members and nonmembers alike. Additional experimental research is needed in the areas of service delivery models, motor control, and motor learning to determine best practice in educational environments. Qualitative in-depth interviews may be able to explore the rationale behind clinical decision making. (24) Regional differences in practice patterns were not analyzed in this study but may be appropriate for future research. We are currently exploring regional differences in frequency recommendations through follow-up analyses using this database.

Conclusions

This nationwide study among school-based physical therapists, all of whom were members of APTA's Section on Pediatrics, reflected the respondents' perceptions of their own practice patterns. The responses were relatively consistent with current literature regarding school practice and principles of motor learning. The most prevalent recommendation for the context of service delivery was a combination of integrated and isolated models. Fewer respondents chose isolated services for the preschoolers, and more respondents chose isolated services for the 12-year-old student. The therapists reported that the students' functional levels and the students' own goals were important in their decision making. Direct services were strongly favored over indirect services. More respondents selected individual services than group services, and few selected group services for the student with cerebral palsy at 6 and 12 years of age, Frequency recommendations varied, but one 30-minute session per week was suggested by the largest percentage of respondents. Recommended direct frequencies for the 6-year-old with cerebral palsy were more than twice the frequencies for the same student at age 12 years. The participants advocated home exercise and activity programs, adaptive physical education, and community recreation programs. A comprehensive understanding of current school-based practice, combined with evidence-based research, should lead to improved services for students with disabilities.

Table 1.
Respondent Information (a)

                                        N       n       %

Currently work in school setting       710
  Yes                                          630    88.7
  No                                            80    11.3

Age (y)                                622

Sex                                    625
  Male                                          28     4.5
  Female                                       597    95.5

Years practicing as physical
  therapist                            625

Years practicing as pediatric
  physical therapist                   625

Years practicing as school-based
  physical therapist                   625

Employment status                      626
  Employee                                     439    61.8
  Independent contractor                       162    22.8
  Both                                          25     3.5

Professional (entry-level) degree      626
  BS                                           389    62.1
  Certificate                                   83    13.3
  Professional master's degree                 150      24
  Professional DPT                               4     0.6

Highest postprofessional degree        626
  Missing data                                  64    10.2
  No postprofessional degree                   401    64.1
  Postprofessional master's
    degree                                     158    25.2
  Postprofessional DPT                           1     0.2
  PhD                                            2     0.3

Pediatric Certified Specialist         626
  Yes                                           47     7.5
  No                                           579    92.5

School settings                        625
  Public school: inclusive
    setting                                    510    81.6
  Public school: self-contained
    classes                                    460    73.6
  Out-of-district school for
    children with disabilities                 117    18.7

Communities                            620
  Urban                                        171    27.6
  Suburban                                     361    58.2
  Rural                                        212    34.2

Ages of children served                625
  Birth-3 y                                    237    37.9
  3-5 y                                        553    88.5
  6-12 y                                       566    90.6
  13-17 y                                      496    79.4
  18-21 y                                      378    60.5

                                   [bar.x]    SD     Range

Currently work in school setting
  Yes
  No

Age (y)                              43.59    9.68   23-73

Sex
  Male
  Female

Years practicing as physical
  therapist                          18.51   10.61    1-51

Years practicing as pediatric
  physical therapist                 13.74    9.04    1-40

Years practicing as school-based
  physical therapist                 11.24    7.67    1-35

Employment status
  Employee
  Independent contractor
  Both

Professional (entry-level) degree
  BS
  Certificate
  Professional master's degree
  Professional DPT

Highest postprofessional degree
  Missing data
  No postprofessional degree
  Postprofessional master's
    degree
  Postprofessional DPT
  PhD

Pediatric Certified Specialist
  Yes
  No

School settings
  Public school: inclusive
    setting
  Public school: self-contained
    classes
  Out-of-district school for
    children with disabilities

Communities
  Urban
  Suburban
  Rural

Ages of children served
  Birth-3 y
  3-5 y
  6-12 y
  13-17 y
  18-21 y

(a) BS=Bachelor of Science, PhD=Doctor of Philosophy, DPT=Doctor
of Physical Therapy.

Table 2.
Recommendations for Direct Versus Indirect Service

                                                 No
                                                 Physical
                       Direct       Indirect     Therapy
                       Service      Service      Service

                       n     %      n     %      n    %

Annie                  493   79      91   14.6   40   6.4
Beth                   516   82.8    85   13.6   22   3.5
Chris at age 6 y       588   94.1    33    5.3    4   0.6
Chris at age 12 y      361   58.1   248   39.9   12   1.9

Table 3.
Monthly Frequency Recommendations

                                                       Total Direct
                                                       (Individual
                Individual         Group               + Group)

                [bar.x]   Median   [bar.x]   Median    [bar.x]   Median

Annie           2.3       1        1.7       0         4         4
Beth            2.6       2        1.9       0         4.5       4
Chris at age    5.4       4        0.4       0         5.7       4
  6 y
Chris at age    2.2       1        0.2       0         2.4       2
  12 y

Table 4.
Recommendations for Duration of Each Session (in Minutes)

                Individual                   Group

                [bar.x]   Median   Range     [bar.x]   Median    Range

Annie           28.5      30       10-60     28.9      30        5-60
Beth            28.4      30       10-60     28.4      30        5-60
Chris at age    31.4      30       15-60     29.6      30        15-60
  6 y
Chris at age    31.6      30       10-60     33.8      30        15-60
  12 y

Table 5.
Recommendations for Contexts of Service Delivery

                  Integrated   Pull-out     Combination

                   n     %      n     %      n     %

Annie             158   27.1    43    7.4   383   65.6
Beth              175   29      28    4.6   400   66.3
Chris at age       72   11.8    93   15.2   445   73
  6 y
Chris at age      152   25.6   159   26.8   282   47.6
  12 y

                               df   n       [chi square]   P

Annie x Beth                    2   1,187     4.1           >.05
Annie x Chris at age 6 y        2   1,194    54.64          <.001
Annie x Chris at age 12 y       2   1,177    82.01          <.001
Beth x Chris at age 6 y         2   1,213    80.23          <.001
Beth x Chris at age 12 y        2   1,196   113.73          <.001
Chris at age 6 y x Chris at     2   1,203    82.18          <.001
  age 12 y

Table 6.
Respondents' Years of School-Based Experience and Contexts of Service
Delivery

                     Integrated       Isolated

                     [bar.X]   SD     [bar.X]   SD

Annie                12.52     7.84    9.23     5.84
Beth                 13.33     8.07    8.96     6.76
Chris at age 6 y     12.75     7.36   11.26     8.17
Chris at age 12 y    11.95     7.58   10.83     7.36

                     Combination

                     [bar.X]   SD     F

Annie                10.65     7.73    4.66
Beth                 10.27     7.36   11.22 (a)
Chris at age 6 y     10.88     7.48    1.91
Chris at age 12 y    10.87     7.87    1.17

Table 7.
Recommendations for Home Exercise and Activity Programs

                      With Direct         With Indirect
                      Physical Therapy    Physical Therapy

                      n      %            n      %

Annie                 344    55.1          53     8.5
Beth                  325    52.3          31     5
Chris at age 6 y      439    70.2          18     2.9
Chris at age 12 y     280    45.1         173    27.9

                      With No
                      Physical Therapy    Total

                      n      %            n      %       N

Annie                 10     1.6          407    65.2    624
Beth                   5     0.8          361    58      622
Chris at age 6 y       3     0.5          460    73.6    625
Chris at age 12 y      5     0.8          458    73.8    621

Table 8.
Other Recommended Services

Adaptive Physical Education

                     With Direct    With Indirect  With No
                     Physical       Physical       Physical
                     Therapy        Therapy        Therapy

                     n      %       n      %       n       %

Annie                161    25.8     41     6.6    15      2.4
Beth                 267    42.9     50     8      16      2.6
Chris at age 6 y     468    74.9     27     4.3     2      0.3
Chris at age 12 y    288    46.4    196    31.6     8      1.3

                     Total

                     n      %       N

Annie                217    34.8    624
Beth                 333    53.5    623
Chris at age 6 y     497    79.5    625
Chris at age 12 y    492    79.2    621

Community Recreation Programs

                     With Direct    With Indirect  With No
                     Physical       Physical       Physical
                     Therapy        Therapy        Therapy

                     n      %       n      %       n       %

Annie                368    59       74    11.9    31      5
Beth                 343    55.1     53     8.5    13      2.1
Chris at age 6 y     384    61.4     23     3.7     2      0.3
Chris at age 12 y    272    43.8    181    29.2    11      1.8

                     Total

                     n      %       N

Annie                473    75.8    624
Beth                 409    65.7    623
Chris at age 6 y     409    65.4    625
Chris at age 12 y    464    74.7    621

Table 9.
Other Factors Important in Decision Making

                                   Never        Rarely       Sometimes

                                    n     %      n     %      n     %

Parental input                       0      0    14    2.3   230   37.1

Family involvement in education      8    1.3    31      5   183   29.6
  and intervention

Administrative input                30    4.8   209   33.7   283   45.6

Budgetary constraints              183   29.4   254   40.8   122   19.6

Input from educational team          0      0    10    1.6   121   19.5

Personal feelings about student    122   19.7   220   35.5   163   26.3

Past practice                        9    1.5     9    1.5   121   19.6

State policies                       9    1.5    41    6.6   128   20.7

                                   Often        Always

                                    n     %      n     %

Parental input                     266   42.9   110   17.7

Family involvement in education    283   45.7   114   18.4
  and intervention

Administrative input                86   13.8    13    2.1

Budgetary constraints               52    8.4    11    1.8

Input from educational team        288   46.4   202   32.5

Personal feelings about student     88   14.2    26    4.2

Past practice                      351   56.8   128   20.7

State policies                     218   35.3   221   35.8

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Marcia K Kaminker, Lisa A Chiarello, Margaret E O'Neil, Carol Gildenberg Dichter ([dagger])

([dagger]) Dr Dichter is deceased.

MK Kaminker, PT, MS, PCS, is Physical Therapist, Department of Student Services, South Brunswick Township Schools, 4 Executive Dr, PO Box 181, Monmouth Junction, NJ 08852 (USA) ([e-mail]). This study was conducted in partial fulfillment of the requirements for Ms Kaminker's postprofessional Master of Science degree in pediatric physical therapy at Drexel University, Philadelphia, Pa. Address all correspondence to Ms Kaminker.

LA Chiarello, PT, PhD, PCS, is Associate Professor, Hahnemann Programs in Rehabilitation Sciences, Drexel University.

ME O'Neil, PT, PhD, MPH, is Assistant Professor, Hahnemann Programs in Rehabilitation Sciences, Drexel University.

CG Dichter, PT, PhD, PCS, was Physical Therapy Consultant, Office of Education, New Jersey Department of Human Services, Trenton, NJ, at the time of the study.

Ms Kaminker provided the research concept and design, data collection and entry, and statistical analysis, and she was the primary author. Dr Chiarello served as Ms Kaminker's faculty advisor and committee chair, providing substantial assistance with the research concept and design, data entry, statistical analysis, and writing. Dr O'Neil served as a member of the thesis committee, providing feedback on the research concept and design, as well as editorial assistance with the writing. Dr Dichter assisted with the research concept and design, provided editorial feedback, and served on the thesis committee. The authors thank Edward J Gracely, PhD, and Patricia A Shewokis, PhD, who consulted on several statistical analyses; Lisa A Leifer, PT, PCS, who provided guidance on the preliminary study; and Susan K Effgen, PT, PhD, who reviewed the manuscript and offered valuable suggestions for improvement. The authors also thank all of the New Jersey pediatric physical therapists who responded to the pilot survey and all of the therapists throughout the nation who participated in this study.

The Institutional Review Board of Drexel University granted administrative approval for the study.

A poster presentation of the pilot study was given at the Combined Sections Meeting of the American Physical Therapy Association; Boston, Mass; February 20-24, 2002. The first author received the 2004 Thesis Award from the Section on Pediatrics of the American Physical Therapy Association for her master's thesis upon which this article is based at the Combined Sections Meeting of the American Physical Therapy Association; Nashville, Tenn; February 6, 2004.

This article was received August 15, 2003, and was accepted April 13, 2004.