Occupational and Physical Therapy: Strategies for the Classroom

Empowering instructional assistants to help teachers implement therapeutic strategies and

improve student achievement.

School-Based Therapy• The primary role of a school-based therapist is to assist students in benefiting from their

educational program. • Therapy provided within the educational setting must be educationally relevant and

necessary for the student to benefit from Kentucky’s educational system for all students. • Therapy must contribute to the development, or improvement, of the student’s

academic and functional performance. • Therapy within the school setting has a different orientation than therapy provided in

non-school settings. • School-based therapy involves “teaming” in which recommendations and decisions are

made based on input from all team members in order to determine a student’s total educational plan.

• School based therapists identify needs of the student and assist in providing strategies on how to best capitalize on abilities as well as minimize the impact of the disabilities in the educational environment.

• If a student has an identifiable therapy need that does not affect the student’s ability to learn, function, and profit from the educational experience, that therapy is not the responsibility of the school district.

• Therapists should always strive to provide interventions in the natural or least restrictive environment for each student receiving therapy.

What is Occupational Therapy in the Schools?

• The job of the occupational therapist (OT) who works in schools is to help children meet the every day demands of being a student. The school is one of the primary environments where the following occupations are performed daily.

Functional Visual Motor Skills• Using classroom tools (pencils, scissors, calculators, etc) and

learning materials to communicate through handwriting, keyboarding, and access to assistive technology

Sensory Motor Skills• Increasing participation using eyes, ears, nose, touch, and

movement in order to gain access to the education curriculum.

Vocational Skills• Improving on-task behaviors, completion of assignments,

organization skills, and independent work habits that leads to participation in the job and community settings.

Self Management• Performing daily living skills such as feeding, dressing, safety

awareness, and using adaptive materials when needed.

What is Physical Therapy in the Schools?

• The job of the physical therapist (PT) who in schools is to assist the student in meeting his/her educational goals and to be able to access all areas of their environment. • The goal of physical therapy in the school

system is to “level the playing field” for students with disabilities in the following ways.

Mobility

• Ability to move parts of the body • Ability to maneuver throughout their

educational environment• Ability to use walker, gait trainers, and

wheelchairs•Monitoring safety, balance, strength, and

endurance

Adaptive Equipment

• Providing appropriate equipment for sitting, standing, academic activities, and walking• Training staff on proper use and safety •Monitoring equipment for fit•

Transitions• Transferring to different positions and to

different surfaces• Determining the amount of assistance

required• Teaching proper and safe transfer

techniques•Monitoring safety, balance, and strength

Positioning

•Monitoring posture in different seating options• Utilizing adaptive equipment to support

proper positioning•Monitoring safety, balance, and endurance

Other

• Monitoring medical issues • Evacuations plan• Ordering equipment • Working with durable medical equipment

representatives • Assisting administrators in planning and

implementation issues such as building modifications and new construction• Safety and injury prevention

WHO RECEIVES OCCUPATIONAL AND PHYSICAL

THERAPY IN SCHOOLS?

 • OT and PT are a related service under Part B of the Individuals with Disabilities Education Act (IDEA) and are provided to help a student with a disability to benefit from special education. If a child has a disability as defined by IDEA and needs special education and related services to meet unique learning needs, then he / she might be eligible for OT and/or PT services. The student must be eligible for special education before being considered for our services in the schools under IDEA. Eligibility for special education does not mean automatic OT and / or PT eligibility; however, if significant concerns arise with the student, then a functional evaluation will be performed to determine if the child warrants services.

What is the OT and PT role in each educational environment?

• OT and PT services are provided across a continuum and look different for every student. A variety of service delivery models are considered in determining the best way to serve the student. Some students receive hands-on services (direct therapy) in individual and / or group sessions. Others receive services as the educator and OT and / or PT discuss strategies and work together to solve problems (collaboration and / or consultation). The amount of contact with the student may be regularly or intermittently scheduled as determined by the therapist according to the student’s need.

• The list of strategies in Appendix A can be a useful tool for the classroom prior to a referral for OT and / or PT.

Elementary School (Pre-k, Primary, Intermediate)

• From the beginning of preschool, children are developing more complex motor skills, play skills, and readiness for pre-academics. The therapist working with the student who receives OT and / or PT services may address developmental delays in above areas. Our services are delivered within the classroom setting as well as collaboration with team members who are involved in the child’s education. As the student advances to the primary and intermediate classrooms, they begin to learn self management skills and more complex academic skills. This includes being a productive member of the classroom and effectively produces class work. We provide direct therapeutic services as well as ongoing collaboration and role release services to school staff to enable the student to meet the educational goals.

Middle and High School • Once the student reaches middle and high school, they are beginning to

prepare for employment, vocational training and college. Some students are also preparing for functional life skills and community based living. At this level of education, the occupational therapists primarily provide role release (consultation) and collaboration services on the student’s behalf with the educational team.

• Physical Therapy often continues to be involved with students to address physical limitations and provide adaptive equipment throughout their school career.

How to make a referral for OT and / or PT?• To make a referral for OT or PT use the following guidelines• Make a list of your concerns and discuss with the teacher• The teacher will need to contact the OT or PT that services your

school • The OT or PT will provide the teacher with a screening form that

will need to be filled out and returned. • Upon return of the screening form, the OT and PT will determine

if a full evaluation is warranted. • If a full evaluation is warranted then the OT and PT will follow the

special education procedure for evaluation.

• OT and PT screening forms can be found in Appendix B

Therapeutic Use of Equipment

• Many times occupational and physical therapy will provide equipment to utilize in the classroom to assist the child with being a successful student. It is important to recognize the safety concerns as well as following the protocol provided to you regarding the use of the equipment.

Safety Concerns• The occupational/physical therapist will instruct on the proper

use of therapy equipment. Once a piece of equipment has been provided to the student, the teacher and instructional assistant will be trained on the proper use. This will include but is not limited to a written protocol for use as well as precautions and / or desired outcomes with the use of therapy equipment. If there are any changes in the child’s condition, functional use of the equipment, or any concerns arise, the treating therapist should be contacted as soon as possible to address these concerns.

Daily Use of Equipment • It is in the best interest of the child, if consistency is followed

for implementation of therapy equipment. Once the therapist has provided the equipment with an explanation of use and possibly a written protocol, the teacher and instructional assistant should diligently implement use of the equipment . In the case that the child shows signs of refusal of use or it seem as if changes should be made, then please contact the therapist as soon as possible. An email or phone call would be sufficient to communicate the child’s use or disuse of the equipment. The therapist could then come into the classroom and make any changes necessary.

Seating Options (1 of 4)

• Adaptive seating is utilized to assist with sitting balance, develop head control, trunk control, and core strengthening to allow students to practice functional sitting skills while engaged in school activities. This also allows them to interact better with peers and teachers.• When students are seated appropriately

displaying correct postural stability, improved fine and visual motor skills are facilitated.

Seating Options (2 of 4)• Basic chairs with armrests and/or seat belts are

utilized for students that are functional but may have balance issues. These chairs assist with promoting proper posture especially when their feet supported. • First Class Chair • Tripp Trapp Chair • Various Rifton Chairs

Seating Options (3 of 4)

• More supportive seating is utilized for students with increased physical involvement to promote proper alignment and posture.• Thera-adapt chair• Various Rifton Chairs• Tumbleform Chair• Special Tomato Chair

Seating Options (4 of 4)

Types of Seating• Move-n-sit cushion• Therapy ball chair• Lying prone on floor• Foot stools• Cube chair• Bean bag chair• Papasan chair• Stand to work

Standing and Walking Options

• Standing and walking devices are utilized to provide students a position change. Standing offers weight bearing opportunities and promotes increased bone density along with prolonged stretching of lower extremity musculature. Weight shifting, balance, endurance, and postural control are being addressed while they are standing or walking. Better breathing, increased alertness, and GI motility are also enhanced. In addition you will note better peer interaction and classroom involvement.

Standing and Walking Options

• Standers• Gait trainers•Walkers

Additional Therapeutic Equipment• Therapy benches• Adaptive desks• Toileting equipment• Changing tables•Mats• Aerobic step

Types of Assistance (1 of 4)

• Backward Chaining: Guided help with all of the task with the exception of the last or final step (i.e. buttoning a shirt, you would button all but the last button and the child will complete this step).

• Forward Chaining: Guided help with all of the task with the exception of the first step (i.e. brushing teeth, the child would open the toothpaste and then assistance would be provided for the rest of the steps).

Types of Assistance (2 of 4)

• Hand Over Hand (HOH): The child’s hand is under your hand for completion of the task.

• Hand Under Hand (HUH): The child’s hand is under your hand for completion of the task.

• Multi-Sensory Cues: Help can be provided to the student through the use of verbal, visual, and touch cues (HOH & HUH). It can also include activities that are demonstrated to the student when he or she is physically close to the assistant.

Types of Assistance (3 of 4)

• Minimum Assistance: You provide assistance for up to 25% of the task.

• Moderate Assistance: You provide assistance for 26% to 50% of the task.

• Maximum Assistance: You provide assistance for 51% to 75% of the task.

• Total Assistance: You provide assistance for the entire task or 100%.

Types of Assistance (4 of 4)

Fading Assistance - As the child progresses with a task or skill then you will decrease the level of assistance you are providing. This will enable the child to become more independent.

However, you will have to fade your amount of assistance over time.

Handwriting and Reading Strategies

• Pencils/crayons• Grips• Adaptive paper• Timers• Slant board / binder• Colored overlays• Grid paper underlay• Vertical number line• Positioning and seating

options• Word shaped boxes

• Visual focus window• EZ reader• Graph paper• Colored paper• Wikki stiks• Various handwriting

programs-including Handwriting Without Tears and Fonts

• Weighted materials• Lap tray• Highlighted lined

boundaries

UPDATING OUR KNOWLEDGE OF THE SENSORY SYSTEM

Left Side: Builds the house

Right Side: Designs the house

Our Sensory System (1 of 3)• The right and left hemispheres of the brain have different roles.• Each side of the brain controls the muscles of the other side of the body. • Learning and thinking is improved when both sides of the brain are involved in problem

solving, so nobody is totally right-brain or left-brain dominant.

Our Sensory System (2 of 3)

• The corpus callosum which is a thick band of nerve fibers is the bridge between the two hemispheres. It is also involved in eye movement, tactile localization, and maintains the balance of arousal and attention.

• The limbic system is made up of a group of structures that are important for controlling the emotional response to a given situation, memory, learning, and coordination movement.

• The thalamus receives sensory information and relays this information to other areas of the brain and spinal cord.

Everything that we do involves at least one or two senses. There are actually 7 sensory systems (taste, smell, touch,

hearing, seeing, proprioception, and vestibular input.

Vestibular: Movement

Proprioception: Body Sense

Our Sensory System (3 of 3)

Limbic System ActivityAppendix D

Snapshot of Sensory Processing Disorders

Sensory Processing Disorder – is an umbrella term for the inability to be aware of all types of sensations and making sense of the sensory input. 1. Sensory Modulation - regulating

input2. Sensory Integration - organizing and

processing input3. Sensory Defensiveness - interpreting

sensory input which results in a fight, flight, fright response

4. Sensory Registration - noticing and producing an adaptive response

What does it feel like to have a sensory processing disorder?

Appendix E and F

Focusing on Sensory Defensiveness and Sensory Regulation

• S

We will be focusing on two types:• Sensory Defensiveness: The

student may not have the ability to correctly interpret sensory input which results in a fight, flight, fright response.

• Sensory Regulation Disorder – The child will have difficulty taking in sensory information and organizing it in order to ignore unimportant information and pay attention to essential information. There are two levels:

Low Arousal/Alert Level: The child may appear tired, bored, difficult to please and/or be unaware that his or her body requires stimulating sensory input.

High Arousal/Alert Level: The child may be in constant motion, hyper, or impulsive, or may be overly-reactive to situations and is in need of calming sensory input.

Levels of Sensory Regulation

Stimulate

Calm

Benefits of Sensory Regulation Strategies (1 of 2)

• Development or reactivation of hearing, sight, taste, smell or touch• Improved hand/eye coordination• Development of language• Control of surroundings of user• Relaxation or stimulation as

needed

Benefits of Sensory Regulation Strategies (2 of 2)

• Improved socialization with peers• Increased tolerance of human touch• Increased opportunities for making own choices• Improved behavior• Lengthens teachable opportunities• Improves student success

Who can benefit from a sensory regulation strategies?

Every Student

Sensory Regulation Strategies (1 of 3)

• Brain Gym & Tool Chest (see Appendix G and H)• Alert Program• Movement Breaks (change

seat or position)• Breathing Exercises (see Appendix I)• Music without lyrics• Create Boundaries (tape,

beads, hula hoop)

• Heavy work (exercise, carry weighted objects) • Body Sock (wear while

writing or exercising)• Swing• Trampoline• Scents for calming and

alerting (pencils, markers)• Wilbarger Protocol (see Appendix J)

Sensory Regulation Strategies (2 of 3)

• Hygiene Considerations• Hydrating with water• Fidgets (see Appendix G) • Safe Place• Study carrel• Reduce visual clutter • Headphones• Resistive chewing (non-

food)

• Sensory area: room, zone, center

• Weighted Materials (vest, blanket, belt, pencil, backpack,)

• Vibration • Resistive, crunchy, sour

foods, fruit and snacks (see Appendix H)

• Work systems (folder activities

• Lighting options

Sensory Regulation Strategies (3 of 3)

Swing, Ball Chairs, Trampoline Controllable Light Source, Light Filters

AromatherapyScented Writing Tools Supervised Tasting

Weighted vests/blankets, bean bag chairs

Tactile walls, Vibration writing tools, putty

Soothing sounds (chimes, nature sounds, classical music)

Transfers (1 of 4)

•Physical therapists in the school system train students and staff on safe, effective transfer techniques. Transfer training must be customized to the student's needs, but general guidelines govern the majority of proper transfers.

Transfers (2 of 4)

• Control the Pelvis

• The pelvis is the control point for the entire body, allowing the therapist or staff member to assist the student in body mechanics and maintenance of balance. When training, the therapist will instruct the staff member to place at least one hand on the outer, lower pelvis with their arm around the back of the patient.

Transfers ( 3 of 4)

• Upper Body Management

• The upper body mechanics are vital to performing proper and safe transfers. Students who lean backwards when standing will need their assistant to place one hand in the center of their upper back to help them lean forward into the "nose-over-the-toes" position to prepare for standing. Once the student is standing, the assistant may be educated either to place their other hand over the front of the shoulder to keep the student from leaning forward, or in the armpit to provide physical support.

Transfers (4 of 4)

• Alternate Transfers• When students cannot safely transfer with the staff

member, the therapist will train the assistant on alternate transfer techniques. Sliding board transfers are used for students without the use of their legs. Sling lift machines can be used in the school for severely impaired or weak students who cannot stand. A sling is placed underneath the student in the chair and the lift mechanically lifts them, significantly reducing the physical strain on the caregiver.

Gait ( 1 of 3 )

• Definition: Gait is the manner or style of walking. There are many types of gait.

• Also Known As: walking, ambulation

Gait ( 2 of 3)

• Gait abnormalities are typically associated with a physical disease, condition, or deformity. Joint pain, limited range-of-motion of a joint, or joint deformity can cause an abnormal gait.

Gait ( 3 of 3)

• Examples include:Antalgic Gait: painful gait, a limp is adopted to avoid pain on weight bearing structures (hip, knee, ankle) Ataxic Gait: an unsteady, uncoordinated walk, a wide base of support is seen. normally due to cerebellar diseaseFestinating Gait: short, accelerating steps are used to move forward, often seen in people with Parkinson's diseaseFour Point Gait: utilized by crutch users, first on crutch, then the opposite leg followed by the other crutch and then the other leg Hemiplegic Gait: involves flexion of the hip because of inability to clear the toes from the floor at the ankle and cirumduction at the hipSpastic Gait: walk in which the legs are held close together and move in a stiff manner. often due to central nervous system injuries

Assistive Devices For Gait

• Hand Held Assist• Canes and crutches•Walkers• Gait trainers• Choosing the correct device, fitting the

device, and training on use of the device is the job of the physical therapy staff.

Exercise/Stretching Programs

• Exercise/stretching programs may involve walk training, range of motion, therapeutic exercises, and home programs to improve strength, flexibility, endurance, and independence.

• Programs can be given to students for use in PE, the classroom, or at home to assist with stretching and strengthening.

• The physical therapy staff has put together a list of suggested activities that can assist our students during the summer months.

• Thera-band and Thera-tubing is sometimes given in addition to a program and the PT staff will train students and assistance on the use of these items.

Brain Gym Exercises Appendix G

Brain Gym is a set of movement activities for the brain/body that moves a child from reacting to stress to being just right for learning.

Water – Alerts brain for learning, reduces stress, and clears thinking.Brain Buttons – , increase attention and improves visual coordination.Cross Crawls – activates both hemispheres in brain, improves balance, and helps with transitionsHook-ups - improves alertness and improves attitude.

Tool Chest ExercisesAppendix H

SHAKES AND WIGGLES

Object: movement to remove shakes and wiggles before beginning sit – down task and/or movement break to regain attention.

CHAIR PUSH UPS

Object: Prepares for writing by working shoulders and arms and movement for organizing thoughts.

Breathing Exercise Appendix I

Wilbarger Protocol Demonstration Appendix J

• The protocol is a brushing technique that is designed to fire-up the sensory receptors under the skin. These receptors then override negative sensory impulses and allows some students to have a more normalized sensory system. This is followed by gentle joint compression.

** Intervention always must be directed by a professional who has received training in the Wilbarger protocol.

Did you know that in a ¾ inch square patch on the back of your hand there are 9 feet of blood vessels, 13 yards of nerves, 9000 nerve endings, 75 pressure sensors, and 600 pain sensors?