Clinical Resources for Wheelchair Skills Training and Promoting Self-Determination, Independence and Accessibility in School-Based Physical Therapy

Caroline Lynott, SPT

 

Background

Entering into PT school, I knew I had a predilection for pediatrics, and I was able to grow my passion via my second clinical rotation in Cabarrus County School System. It was these 8 weeks spent traveling between schools and working with delightful children and their families, that I learned just how important our role is for children in the school environment. I also learned during this time that the school-based practice setting is fairly unconventional when compared to more traditional PT settings, and it can be difficult as a novice to consider all aspects of a child’s daily routine and key elements in ensuring functional independence at school. I vividly recall working with a student with Spina Bifida on wheelchair skills and struggling to consider all possible aspects of her mobility needs within the context of her school environment. Whether that be for lack of experience in that particular clinical setting or the years between now and my time spent in elementary school, ensuring her full and independent mobility at school was a challenging task.

Throughout my time leading up to PT school and through didactic and clinical work, I have also become quite interested in pediatric equipment. I have attended equipment conferences and in-services with vendors, and try to keep up-to-date with the larger companies, and their advancements in positioning and mobility technologies. I was able to participate in equipment ordering and delivery with vendors while on rotation, and experienced our role in selecting and orienting students and caregivers to their new pieces of equipment. I thus wanted to combine my interest in pediatric equipment with my passion for school-based physical therapy and pediatric intervention, which is how this project came into fruition.

Project Overview & Purpose

The ability to explore and navigate one’s environment from an early age is a critical component of physical, cognitive and psychological development.^1-4 Children who experience mobility delays of any etiology can be fundamentally limited in the opportunities afforded through independent exploration; this is what warrants introduction of augmented mobility, such as a manual wheelchair, for children who may deviate from the typical developmental sequence of independent locomotion.^1-4 Physical therapists play a critical role in family and child education, equipment selection and training, and encouraging self-determination, motivation and functional independence.^3,4 Particularly within the school environment where distances and pacing increases year after year, implementing means for augmented mobility for energy conservation as well as academic and social participation is critical to a child’s success.^3,4 Selecting and orienting children and caregivers to mobility equipment requires many considerations, particularly related to daily routines and mobility requirements. As the majority of a child’s time is spent at school, many of these considerations must be directed to school mobility and accessibility.

Thus, the purpose of this project is two fold: first, to provide an evidence-based review of the critical importance of encouraging early and independent mobility from a standpoint of childhood development; and second, to provide novices with a clinical “pocket-guide” compiling resources and tools for ensuring independent mobility and self-determination amongst manual wheelchair users within the context of the school environment.

Statement of Need

Due to the general unconventional nature of the school-based practice setting as well as the paucity of school-based research, there is an inherent need to compile helpful resources that are of clinical utility to students and clinicians alike. Most other areas of PT practice are accompanied by peer-reviewed evidence for intervention, protocols, and outcomes to assist clinicians in treating and tracking progress of their patients. Additionally, much of effective and successful PT intervention within a particular niche is derived from years of clinical experience. Thus, when limited research and resources is combined with limited clinical experience, it can be quite difficult to determine the appropriate course of action when working with children in the school setting.

School PT’s focus much more so on successful completion of functional tasks related to academics or social participation, shifting from a body structure/function approach of the ICF model to activity/participation approach. Thus, not only is it possible novices in this setting are changing their entire approach to care but they are also needing to quickly become familiar with school-based constructs and specific mobility requirements within that context with available limited resources.

Products

Two products were produced as part of this project. First, I composed a literature review of research related to the developmental benefits of encouraging early and independent mobility. I hope this review can serve as a means to improve competency in assisting children and parents through what can be a difficult transition and decision to incorporate augmented mobility in a child’s daily life.

Secondly, I created a comprehensive clinical “pocket guide” and toolkit which compiles resources for working with children who use manual wheelchairs as their means of mobility at school. The guide spans from equipment delivery to functional skill training, goal writing and incorporation of outcome measures into treatment. I have created the guide with the intention of interactive use with the student where possible for promotion of self-determination, and for use as a documentation tool via dry-erase marker. Sample photos of the printed copy of the pocket-guide can be found here.

Health Literacy Component

As a result of my product being designed for both DPT students and clinicians new to school-based PT, health literacy became of less relevance. I used this component of the project to conduct research on creation of marketing materials and ensuring readability of an educational and user-friendly guidebook. I have summarized what I obtained from my research and how I incorporated it into my pocket-guide here.

Evaluation

Throughout the entire process of writing the literature review and creating the clinical pocket-guide and toolkit, I incorporated feedback both from my committee members as well as DPT students on clinical rotation in the school system. The main components of the guidebook including the delivery checklist, skills checklist and outcome measures were created through combining my own personal experiences from my clinical rotation as well as the years of experience my committee members have in this practice setting. I have created a brief survey for colleagues and users of the guide in order to gain feedback related to the guide’s clinical utility and practicality of use.

Self-Reflection

This project has meant a lot to me in working towards my goal of one day joining a school-based rehabilitative team. I was granted the opportunity to work with skilled clinicians to create a product that hopefully will expedite novices’ competencies in this unique practice setting, while also learning a great deal in the process. There are so many aspects about a child’s day at school that we forget being so far out of school ourselves, and for a child using a manual wheelchair, considering all the various skill requirements and points of accessibility is critical for their success both academically and socially.

I also learned a great deal about myself throughout this process including my ability to communicate effectively, ask for help and respond to feedback. There were several steps along the way in creating both the literature review and the guidebook, which required me to map out my time appropriately and ensure ample time for my committee members and advisor to provide recommendations and feedback. This was also my first experience creating a document where aesthetics was an important component, and thus I learned quite a bit about creating marketing materials, and ensuring appealing visual aesthetics, and user readability. I plan to continue to build on this knowledge in future projects and continue to create helpful educational materials for parents and children throughout my career.

Acknowledgments

I would like to extend my sincerest gratitude to my Capstone project advisor Deborah Thorpe, PT, PhD as well as my two committee members Laurie Ray, PT, MPT, PhD and Sharon Antoszyk, PT, DPT, PCS. Much of my project was a collection of clinical experiences, which were steadfastly provided to me by my advisor and committee members. I am grateful to have had the opportunity to work with individuals with such deep roots in pediatric physical therapy. With the demanding environments of clinical work and academia, I am honored these individuals took time out of their day to assist me in completing this project, always being reachable via phone or e-mail. I would also like to extend a special thank you to Shelby Milller, SPT and member of our UNC PT family, who also provided feedback regarding the clinical utility of my product as she completed her rotation in the school system.

References:

1. Logan SW, Ross SM, Schreiber MA, Feldner HA, Lobo MA, Catena MA, MacDonald M, Galloway JC. Why we move: social mobility behaviors of non-disabled and disabled children across childcare contexts. Front Public Health. 2016;4(204):1-7. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5030269/pdf/fpubh-04-00204.pdf.
2. Campos JJ, Anderson DI, Barbu-Roth MA, Hubbard EM, Hertenstein MJ, Witherington D. Travel broadens the mind. 2000;1(2):149-219. DOI: 10.1207/S153270781N0102_1.
3. Butler C. Augmentative Mobility: why do it? Pediatric Rehabilition. 1991 Nov;2(4):801-815. DOI: 10.1016/S1047-9651(18)30683-1.
4. Lobo MA, Harbourne RT, Dusing SC, McCoy SW. Grounding early interventions: physical therapy cannot just be about motor skills anymore.Phys Ther. 2013 Jan; 93(1):94-103. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538987/.