Special education teachers have enormous responsibilities in terms of meeting the needs of students with orthopedic and musculoskeletal disorders such as curvature of the spine, hip conditions, limb deficiency, and juvenile rheumatoid arthritis. The process of developing appropriate individualized education goals begins with educating oneself on specific characteristics of each disorder. Students with orthopedic and musculoskeletal disorders require instructional programs and physical management routines that aim to assist the student in achieving “functional outcomes in communication, mobility, socialization, work, and learning” (Snell & Brown, 2006, p.291). The purpose of this paper is first to outline teacher responsibilities in terms of meeting the needs of this population. Next the author offers a brief synopsis of educational implications for the following conditions: curvature of the spine, hip conditions, and limb deficiency. The final segment is a comprehensive look at Juvenile Rheumatoid Arthritis (JRA) including specific disabilities associated with JRA, the prominent complications, financial effects and assistance in the educational system, treatment and rehabilitation options; and the educational interventions including two appropriate individualized educational goals designed to meet the needs of the student will be presented.
Students arriving at school with orthopedic and musculoskeletal disabilities require specialized awareness and knowledge by the teacher. Often a team of professionals working together develop the instructional and physical management programs designed to insure the student receives a Free Appropriate Public Education (FAPE) in the Least Restrictive Environment (LRE) as required by federal law (Eric Digest, n.d.). The teacher serves as the team leader assisting in pulling together relevant team members and compiling necessary information for the Individualized Education Plan (IEP). Snell & Brown (2006) suggest at the beginning of each school year teachers work with therapists to address the adaptive equipment needs of the student. Checking whether the equipment still fits the student, the suitability of the equipment and determining if staff training is needed should be a priority. Furthermore, the teacher needs to look at the entire school day of the student from the bus ride to school and the bus ride home from school investigating how the student is accessing the complete educational environment including: change of classrooms, use of restroom, changing of diapers or clothing, physical education, music, library classes (2006). Exploring the student’s entire day offers the teacher valuable insight regarding the physical routines and instructional programs. Students with curvature of the spine, hip conditions limb deficiency musculoskeletal disorders and JRA will require differing adaptations and modifications. Occupational and physical therapists will most likely be included in the team of professionals serving the needs of students with orthopedic and musculoskeletal disorders (Snell & Brown, 2005).
The student with a severe curvature of the spine may have had multiple surgeries to correct the abnormality. Many of these students do not require specialized academic instruction. However, those with severe forms may need support related to movement may need support needed for mobility in the classroom and on campus. In addition, the student may have some emotional or self-concept issues. The teacher may consider addressing these issues with staff and the student’s classmates (Orthopedic and Musculoskeletal Disorders, 2010).
Hip conditions disrupt the movement of the hip limiting mobility and therefore impact the student’s ability to freely and easily move about the classroom or campus. Supportive bars, installed throughout the environment in order to make standing, sitting, or walking less debilitating. Emotional support may be needed as well for these students (Orthopedic and Musculoskeletal Disorders, 2010).
Limb deficiency is defined by Orthopedic and Musculoskeletal Disorders, 2010 as “the absence or abnormality of a limb (e.g. shortness of a limb). There are two primary categories of limb deficiency: terminal and intercalary deficiencies” (p.3).Terminal indicates the limb is partially intact. The upper portion has developed normally with the lower portion either missing or deformed. An intercalary deficiency results when all or part of the limb is missing. Students with these disorders will certainly require modification and accommodations to access school materials and the physical environment. Technology is frequently used for student to do written work, or for communication purposes. Nurses will most likely be key members of the team of educational professionals (Orthopedic and Musculoskeletal Disorders, 2010).
Osteogenesis imperfecta and arthrogryposis are disorders of the musculoskeletal system with no know cure. Osteogenesis imperfecta presents with very brittle bones that are easily and frequently broken and can be fatal. Arthrogryposis is considered a non progressing disorder. In this disorder, the child’s muscles are contracted at birth and may affect all functional movement of the arms and legs. Modifications may require multiple levels of splinting or casting. The student’s desk and school materials may require modifications for improved function and work output (Orthopedic and Musculoskeletal Disorders, 2010).
One of the most common chronic diseases found in children ages six to nine years of age is Juvenile Rheumatoid Arthritis. “JRA may lead to functional deficiency in the musculoskeletal system and blindness” (Cakmak & Bolukbas, 2005). The criteria for diagnosis of JRA includes (1) onset prior to the age of 16; (2) multiple joints involved with at least two of the following findings: limited range of motion, tenderness or pain with joint movement and elevated fever; (3) the disease is systemic and persists longer than six weeks which includes inflammation in multiple joints. JRA develops with a fever and is exclusionary of other forms of juvenile arthritis (2005). JRA causes painful swelling of the joints and stiffness and may improve, get worse or go into remission throughout the child’s life (Orthopedic and Musculoskeletal Disorders, 2010). The educational implications and complications for students with JRA include excessive absences, limited mobility and diminished strength, endurance and stamina. Because school is the occupation of the child, the needs of these students must be addressed to ensure optimum success (www.arthritis.org, 2011). Typically students when not experiencing the flare-up are to be encouraged to participate in all school activities with the accommodation of being allowed to self-limit activities in order to protect the joints. At times student with JRA take medications which must be monitored and may have side effects such as upset stomach. In these cases the student may require smaller and more frequent meals (2011).
The psychological and social impact of JRA will differ from student to student. Families are frequently stressed with worries about the child’s ability to succeed and finish school, how the student looks, and acceptance by peers, the ongoing cost of medical care, and how the child will grow into an independent and productive adult. Sibling worry they may contract the disease. These stressors can place undo hardship on the student with JRA such as feelings of isolation, inadequacy, being insecure with peers, In addition, the student may be angry or depressed because of feeling or being left out of typically developing peer activities (2010). Students with JRA should be listened to and observed for signs of depression, physical fatigue or pain. Teachers and other educational professionals can assist the student by encouraging him or her to work with strengths rather than limitations. When appropriate, the student needs to be involved in the planning and implementation of IEP goals and objectives. Whenever possible, the student should be encouraged to join in social activities and extra effort made to ensure the maximum amount of interaction with peers. The classroom should be one in which diversity and individual differences are recognized, embraced and celebrated (2010).
The student with JRA may receive modification for his or her school program by way of an Individualized education plan (IEP) which allows the student access to a team of educational professionals including the teacher, the parent, the student, OT, PT, school nurse, school psychologist, and a building administrator. This team will design and implement the IEP. PT will be one of the major contributors toward the success of the student. Cakmak & Bolukbas (2005) claim preventing growth retardation is one of the main rehabilitative strategies PT’s use when working with students with JRA. Children with JRA are at risk for a high number of falls due to weakness in muscle strength and a decrease in both fine and gross motor skills. Balance control and joint development are also cited as causal for stumbling and falling down in and out of school. Stretching and strengthening exercises need to be customized to fit in with the students home and school life. Stretches can be done in combination with therapeutic exercises. In addition, Cakmak & Bolukbas report swim therapy to be significantly beneficial for improving joint mobility (2005).
The following are two goals and objectives for a 13 year old ninth grade boy with JRA:
- Annual Goal: Johnny will be able to participate in fine and gross motor activities involving the use of shoulder, arm, hand and fingers in order to produce written work, computer access and participate in PE activities such as volleyball and table tennis.
- Objective: Johnny will participate in the following stretching program. Stretches will be administered to each joint area-shoulder, elbow, wrist, fingers. Johnny will keep records on chart given by PT. PT to do a weekly review of exercise program with Johnny.
- Stretches for 10 second hold, 5 times in each session 2 sessions per day until 6/19/11.
- Stretches for 15 second hold, 20 second relax 5 times in each session 2 sessions per day until 11/15/11.
- Stretches for 20 second hold relax 20 seconds. 10 times in each session 2 sessions per day until 1/19/12.
- Stretches for 25 second hold, relax 20 seconds 10 times in each session 2 sessions per day until 6/19/11 (2005).
- Annual Goal: Johnny will improve or maintain his ability to sit down and stand up from a chair independently through out the school day without the use of bars or assistive devices.
- Objective-Johnny will participate in the school aquatic program 3 times per week for up to 30 minutes or as tolerated.
- Johnny will swim 3 laps in the pool in 30 minutes by 6/19/11 as measured by self charting and swim coach documentation.
- Johnny will swim 5 laps in the pool in 30 minutes by 11/1511 as measured by self charting and swim coach documentation.
- Johnny will swim 8 laps in the pool in 30 minutes by 1/19/12 as measured by self charting and swim coach documentation.
- Johnny will swim 10 laps in the pool in 30 minutes by 6/19/12 as measured by self charting and swim coach documentation.
In the case of the specific student with JRA, the PT would be the qualified professional to manage the data and routines for the student. The swim coach provides the student the least restrictive environment for the student as well as highly desired peer participation. The teacher may be called upon to organize and facilitate the IEP and document student progress while collaborating with others on the team.