Orthopedic impairments are the most common of physical disabilities. A physical disability is any condition that interferes with a student's ability to use his or her body. The term physical disabilities may be used interchangeably when referring to orthopedic impairments. In 2004 the U.S. Department of Education reported that 74,000 students between age 6 and 21 received special education services under the orthopedic impairments disability category.
According to the Individuals with Disabilities Education Improvement Act of 2004 (IDEA), orthopedic impairment is as follows: “a severe orthopedic impairment that adversely affects a child's educational performance. The term includes impairments due to the effects of congenital anomaly (e.g., clubfoot, absence of some member, etc.), impairments due to the effects of disease (e.g., poliomyelitis, bone tuberculosis, etc.), and impairments from other causes (e.g., cerebral palsy, amputations, and fractures or burns that cause contractures)” (Pierangelo & Giuliani, 2007, p. 268).
Skeletal system impairments that involve the joints, bones, limbs, and associated muscles represent the mus-culoskeletal disorders. Orthopedic impairments often are divided into three main categories to help characterize the potential problems and learning needs of the students involved. These categories are neuromotor impairments, musculoskeletal disorders, and degenerative diseases. Although neuromotor impairments involve the central nervous system (brain, spinal cord, or nerves that send impulses to muscles), they also affect a child's ability to move, use, feel, or control certain parts of the body. Clinically, they are separate and distinct types of disabilities with entirely different causes from musculoskeletal disorders, but they result in similar limitations in movement. Some examples of neuromotor impairments are spina bifida, cerebral palsy, and spinal cord injuries. Musculoskeletal disorders include defects or diseases of the bones and muscles, such as limb deficiency or club-foot. Degenerative diseases are those that affect motor movement such as muscular dystrophy.
Orthopedic impairments involve a wide range of causes and a diverse group of students. Some children have impairments caused by congenital anomalies, whereas others have experienced injuries or conditions that have resulted in orthopedic impairments. Congenital causes include cerebral palsy, osteogenesis imperfecta, joint deformity, and muscular dystrophy. Motor vehicle accidents, sports injuries, premature birth, and other injuries and conditions may cause orthopedic impairments. Burns and broken bones can result in damage both to bones and muscles. Some children have their impairments from birth, while others acquire a physical disability, so age of onset varies widely. There does not appear to be any trend toward greater incidence of orthopedic impairment in boys or girls or based on cultural or racial factors.
Some children with skeletal deformities have surgery. Others have to use various types of braces, prosthetic, and orthotic devices before, after, or in place of surgery. Others may use adapted wheelchairs. Many children identified with severe and multiple disabilities have an orthopedic impairment that must be considered when assessing and establishing services.
Evaluating children with orthopedic impairments can be complicated because there are so many different types of disabilities and causes of impairment. Most orthopedic impairments are identified before a child enters school, but sometimes they are missed or do not appear until a later age. A teacher may notice signs of poor coordination, frequent accidents, or complaints of acute or chronic pain.
The assessment must include a thorough medical evaluation of the child's orthopedic impairment by a licensed physician. Other data generally include documentation of observations and assessments of how the orthopedic impairment affects the child's ability to learn in the educational environment, as well as observations concerning mobility and activities of daily living. It is important to assess a student's social and physical adaptive behaviors through various checklists, inventories, rating scales, and interviews with those who know the child best. The severity of functional limitations must be such that they adversely impact the child's education performance.
A social history supplements the medical history, as does basic screening information on hearing, vision, speech and language skills, and development in areas such as cognition and social/emotional, or self-help behaviors. A team approach is taken for assessment and recommendations. The team that assesses a child with an orthopedic impairment must involve a parent and at least one of the child's general education classroom teacher(s). It should also include a licensed special education teacher, school counselor and/or psychologist, a licensed physician, and other profession personnel as appropriate. For example, a licensed physical therapist or occupational therapist should assess specific motor dysfunction in gross and fine motor development, neuromuscular development, daily living activities, sensory integration, and the need for adaptive equipment. The assessment also considers the permanent nature of the child's impairment. Usually the condition will not be considered an orthopedic impairment if it is not going to last at least 60 days.
More than one test always should be used to evaluate a child's needs for services. In all, the assessment must take into consideration the entire education from all angles, not just physical access to buildings, computers, libraries, or equipment that facilitates learning. For instance, a child may need to receive occupational therapy or other treatments, requiring time away from the general education classroom. Educators will need to develop adaptive strategies and adopt a hands-off approach at times to help students develop some independence. Then, too, social and peer issues also must be considered. The final evaluation should describe how the orthopedic impairment adversely affects a student's areas of development.
Children with orthopedic impairments have a wide range of characteristics that are specific to the underlying diagnosis. Therefore, it is difficult, perhaps even impossible, to generalize about the students in this category. For example, a child with a spinal cord injury could have immobility limited to one side of his or her body, just the arms or legs, or total paralysis. A child with cerebral palsy may have movement but need a wheelchair because he or she has slow, uncontrolled movements that make it difficult to walk.
It also is difficult to know prior to a thorough assessment, including input from medical professionals, what types of associated symptoms to expect. However, many students with orthopedic impairments have problems with motor skills, such as those involved in using standard writing tools, turning pages or books, or exploring and participating in typical classroom activities. Some students have associated speech impairments or multiple disabilities that may affect particular academic areas.
Some students with physical disabilities may lack common experiences and knowledge or common places, items, and activities as compared with general education students. This is due to a lack of mobility and, if their condition has existed since birth, the lack of typical childhood play and exploration. These students' social interactions often are limited because of limited motor, self-help, and self-care skills. Sometimes, standard instructional materials includes mention of objects and experiences or assumes comprehension that is beyond the experience and background of the child with an orthopedic impairment. Children with orthopedic impairments may have pain and discomfort, may sleep poorly and therefore be fatigued in class, and may be on medications. They also may miss school more frequently than other students because of their medical conditions.
Poor self-concept and poor self-advocacy skills may affect an individual student's performance or behavior. Some students with orthopedic impairments feel helpless or depressed as a result of their physical disability.
Some diseases, such as muscular dystrophy, are progressive, which means a child's need for services is likely to increase and certainly to change throughout the continuum of education. Other orthopedic impairments, particularly those caused by injury or temporary impairments from surgery, may lessen over time. Advances in medical care have allowed for better diagnosis and treatment of some disorders and diseases that cause orthopedic impairments. It is important to realize that some children with orthopedic impairments also face issues related to having both chronic and terminal illness.
More than 50 diseases and disorders are associated with orthopedic impairments. Along with subgroup types for these disorders. Spina bifida, scoliosis, cerebral palsy, and muscular dystrophy are some of the more well-known conditions that cause orthopedic impairments in children. Spina bifida is a cleft spine, or incomplete closure of the spinal column. It is the most common permanently disabling birth defect. Spina bifida occulta is the mildest and most common form; next in severity is meningocele. With this type, the spinal cord develops normally, but the meninges, or protective covering, push through the opening in the vertebrae. Meningocele can be repaired surgically. Myelomeningocele is the most severe form of spina bifida. The bones of the spinal cord do not completely form and the spinal canal is incomplete, resulting in the spinal cord and meninges protruding out of the child's back. Spina bifida may be associated with hydrocephalus.
Scoliosis is a side-to-side curvature of the spine, measured by x-ray examination as greater than 10 degrees. It makes the shoulders, hips, or both appear uneven and can cause pain in the back. Most cases of scoliosis have no known cause, and although scoliosis can occur in children with other orthopedic impairments, it normally occurs in otherwise healthy children.
Cerebral palsy (CP) includes a number of chronic disorders that impair movement control. They appear early in life and generally do not worsen as children age. Cerebral palsy affects about 500,000 people in the United States; about 8,000 infants and 1,500 preschool-age children are diagnosed with it each year. Cerebral palsy is caused by injury to parts of the brain that control the ability to use muscles. The injury can occur before birth, during delivery, or soon after birth. Early signs normally appear by the time a child is 18 months of age. The three main types of CP are spastic, where muscle tone is too high or too tight; athetoid or dyskinetic CP, which can affect the whole body with slow, uncontrolled movements and low muscle tone; and mixed CP, a combination of the symptoms from both athetoid and spastic CP. A child with mixed CP has some muscles that are too tight and others that are too loose so that some movements are involuntary and mobility is limited in other areas by stiffness.
Muscular dystrophy (MD) is a group of genetic diseases characterized by progressive muscle weakness. The muscles most affected by MD vary, as do the types of the disease. Some are ultimately fatal, such as Duch-enne muscular dystrophy, which also is the most severe form and the most common form affecting children. Although Duchenne MD results from a defective gene, it often occurs in families with no known history of the disease. Muscle weakness, rapid progression, and difficulty with motor skills are some of the characteristics of Duchenne MD. It primarily affects boys and symptoms usually begin in early childhood. There are several forms of muscular dystrophy, each with unique characteristics. For example, Emery-Dreiffus MD typically causes symptoms in late childhood and early adolescence.
Several laws ensure an inclusive education for students with physical disabilities. The Individuals with Disabilities Education Improvement Act (IDEA) was introduced in 1975 and passed in 1990. It was reauthorized in 1997 and 2004 and includes provisions for children with orthopedic impairments as defined above. Students with orthopedic impairments also may be eligible for accommodations for general classroom inclusion under Section 504 of the Vocational Rehabilitation Act, passed in 1973. In addition, the Americans with Disabilities Act (ADA), which was passed in 1990, includes provisions concerning discrimination against individuals with disabilities and requirements that school facilities are accessible to all.
Placement is a key consideration for students with orthopedic impairments. The goal is inclusion in general education classes, but some students may need services from resource rooms, special classes, schools, or residential facilities, as well as hospital or homebound programs. In 2004, the U.S. Department of Education reported that about 46% of school-age children receiving special education services under the orthopedic impairments category were educated in general education classrooms. Setting up the appropriate placement, services, and environment begins with asking the student what he or she needs and evolves through the assessment and individualized education plan (IEP) process.
Students with orthopedic impairments may present unique challenges in adapting instructional environments that call for creative solutions. Some students may be paralyzed and require assistance moving from place to place. A student may require assistance with basic self-care such as toileting. These and other needs call on teachers to perform duties that historically have not been part of their role in school. Becoming familiar with orthotics, prostheses, adaptive devices, and the specific characteristics of a student's impairment can improve the experience for student and teacher.
To assist with academic tasks, a teacher might secure papers to a student's work area with tape, clipboards, or magnets; place rubber strips or pads on work tools such as rulers and calculators to help keep them from slipping during use; and provide writing instruments that require less pressure to produce a mark, such as felt-tip pens or soft lead pencils. Communication technology can assist the student and teacher in the classroom as well.
Specialists such as physical therapists and orthopedic therapists will be involved in the educational assessment and often will have ongoing involvement in the care of students with orthopedic impairment. States may have specific qualification requirements for teachers who participate in special education programs for children with orthopedic impairments, including basic study of disabilities, anatomy, physiology, and therapeutic movement.
The varying degrees and types of physical disabilities can present special challenges to those local schools and educators who instruct students with orthopedic impairments. Providing the least restrictive environment and promoting eventual independence for students with physical disabilities requires addressing each case specifically, working in a team approach with the student, parents, and education and health professionals to provide a plan that best meets the student's needs. It is important that the teacher can carry over techniques from these professionals into the classroom.
Alliance of state laws with IDEA is an important consideration. The team must consider all applicable laws and regulations in planning for the education of a child with a physical disability. This work includes testing of students under state and federal guidelines such as the No Child Left Behind (NCLB) Act, which was signed into law in 2002 by President George W. Bush. The act revised the Elementary and Secondary Education Act, which is the primary federal law in pre-collegiate education. NCLB requires annual testing of all students in reading and math proficiency.
The NCLB Act initially allowed up to 1% of special education students to take alternate tests; in 2005 the number was raised to 3%. Students may take alternative tests if they meet certain legal criteria. Several options are available, including having different achievement criteria or taking the regular assessment with approved accommodations or modifications.
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