ORTHOPEDIC IMPAIRMENT CONCEPT AND CHALLENGES

ORTHOPEDIC IMPAIRMENT DEFINITION

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.

 ASSESSING ORTHOPEDIC IMPAIRMENTS

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.

COMMON TRAITS

As IDEA’s definition demonstrates, orthopedic impairments can stem from various causes. While most of the causes listed are fairly self-explanatory, “burns that cause contractures” warrants further explanation. The National Institutes of Health’s Medline Plus Medical dictionary defines “contracture” as “a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion.”

An evaluation is required for a disability to be classified as an orthopedic impairment. While the exact requirements for such an evaluation vary by location, this process generally includes a medical assessment performed by a doctor, detecting how the impairment may impact a child’s academic performance and observing the child in his or her educational atmosphere.

EDUCATIONAL CHALLENGES

Considering the diversity in conditions that are embodied by the orthopedic impairments category, educational challenges will differ case by case, and the strategies used in each case should focus on a student’s unique needs. Possible academic barriers include:

Non-accessible transportation

Trouble maneuvering around the classroom

Difficulty navigating school hallways

Earning mandated physical education credit

Communicating effectively 

TIPS FOR TEACHERS AND PARENTS

Parents, know your child’s rights! For instance, IDEA requires schools to provide accessible transportation to and from school, as well as within and in between school buildings. Teachers, you will want to keep in mind mobility devices (such as wheelchairs, walkers, crutches and canes) when arranging classroom furniture and assigning seats. For example, placing a student who uses a walker close to your room’s entrance is usually more practical than placing him or her in the middle of the classroom.

Navigating school hallways is an especially prevalent issue for junior high and high school students because they move from class to class throughout the day. However, an individualized education program (IEP) can indicate that a student’s schedule should be arranged to eliminate excessive walking back and forth. In addition, students can be granted access to the school’s elevator to allow them to travel safely between floors.

Solutions to the physical education requirement should correspond to the student’s particular physical abilities. A student with a more mild orthopedic impairment may be able to participate in gym class, while a doctor’s note can excuse a student with a severe limitation from participating.

Finally, the same strategies that are used to address communication difficulties in students with a range of disabilities can be helpful for students with orthopedic impairments. These include communication-based assistive technology and speech therapy

IMPLEMENTATION OF EDUCATIONAL STRATEGIES

Typically, students with orthopedic impairments have a history of chronic disability diagnosed by the medical community through routine care as infants and young children. In addition, students who are permanently injured, involving muscles, joints or bones, usually are diagnosed and receive rehabilitation services.

For most students with orthopedic impairments, the impact on learning is focused on accommodations necessary for students to have access to academic instruction. 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.

As with most students with disabilities, the classroom accommodations for students with orthopedic impairments will vary dependent on the individual needs of the student. Since many students with orthopedic impairments have no cognitive impairments, the general educator and special educator should collaborate to include the student in the general curriculum as much as possible.

In order for the student to access the general curriculum, the student may require these accommodations:

Special seating arrangements to develop useful posture and movements

Instruction focused on development of gross and fine motor skills

Securing suitable augmentative communication and other assistive devices

Awareness of medical condition and its affect on the student (such as getting tired quickly)

Because of the multi-faceted nature of orthopedic impairments, other specialists may be involved in developing and implementing an appropriate educational program for the student.

Due to the various levels of severity of orthopedic impairment, multiple types of assistive technology may be used. As with any student with a disability, the assistive technology would need to address a need of the student to be able to access the educational curriculum. For students with orthopedic impairments, these fall into two primary categories:

Devices to access information: These assistive technology devices focus on aiding the student to access the educational material. These devices include:

Speech recognition software

Screen reading software

Augmentative and alternative communication devices (such as communication boards)

Academic software packages for students with disabilities

Devices for positioning and mobility: These assistive technology devices focus on helping the student participate in educational activities. These devices include:

Canes

Walkers

Crutches

Wheelchairs

Specialized exercise equipment

Specialized chairs, desks, and tables for proper posture development

POSSIBLE REFERRAL CHARACTERISTICS

The referral characteristics for the student with an orthopedic impairment (OI) fall more into the area of physical characteristics. These may include paralysis, unsteady gait, poor muscle control, loss of limb, etc. An orthopedic impairment may also impede speech production and the expressive language of the child. It is important to note that appropriate seating/positioning of the child is of primary consideration for effective screening, evaluation and instruction.

PROGRAMMING CONSIDERATIONS

Programming may need to address such things as communication skills, academic skills, perceptual and/or motor functioning, behavior and self-sufficiency. The need for augmentative/alternative communication systems and/or assistive technology must be considered when designing the student's program. [Refer to Assistive Technology, §§ 2.03, 2.04 and 5.08 of Special Education and Related Services: Procedural Requirements and Program Standards (ADE, 2000).] The student with an orthopedic impairment must be given the opportunity to participate in physical education. Such a program may include regular or special physical education, adaptive physical education, movement education and/or motor development.