Cumberland County Schools
Physical Therapy Department
Educational Resource Center (ERC)
396 Elementary Drive
Fayetteville, NC 28301
Phone: (910) 678-2789
Fax: (910) 678-2793
Physical Therapy School Functional Evaluation
Name:
Date of Birth/Age:
Date of Evaluation:
Diagnosis:
Parents/Home Phone:
School:
Teacher/Grade:
Exceptionality:
Background Information
Medical History:
Academic History:
Reason for Evaluation:
Teacher/Parent Concerns and Observations:
Equipment
Personal (splints, wheelchair, etc.):
Classroom (desk, chair, floor sitter, prone stander, etc.):
Neuromuscular Assessment: This is an assessment of how the brain and muscles work
together to perform different activities. Postural observations describe how the body is
held in space, paying close attention to whether both sides of the body appear the same
or different. Muscle tone refers to the state of the muscle during rest and activity, such as
high tone (may also be described as tightness, spasticity, or stiffness) and low tone (also
described as floppy or soft). Range of motion describes the amount of joint movement
available.
Posture/Musculoskeletal Observations:
Functional Needs Improvement
Comments
Sitting on floor
Sitting in chair
Standing
Tone/Range of Motion/Strength: (WFL-within functional limits) (D-decreased)
(I-increased)
Right Left Comments
Range of motion
Strength
Tone
Sensory-Motor Function: This includes assessment of functional performance
on tasks involving movement, perception, and spatial organization ie
awkwardness, motor overflow, right-left confusion, mild oculomotor difficulties
and associated movements.
Gross Motor Assessment Currently there is no standardized evaluation for the
educational environment that appropriately reflects a child’s functional skills with
regards to their muscle tone. Therefore, a narrative method has been chosen to more
accurately describe the child’s abilities within the context of the school environment.
Clinical Observations: Assessment of the basic motor skills needed to function in
the school and educational environment.
Functional Needs Improvement
Maintains a sitting
position
Moves while sitting
Stands
Transitions from sitting
to standing
Transitions from
standing to sitting
Pivots while standing
Walks forward
Transitions from
standing to walking
Comments
Transitions from
walking to standing
Walks backward
Turns while walking
Walks up steps
Walks down steps
Walks on uneven
ground
Walks up slopes
Walks down slopes
Gross Motor Assessment
Criterion Referenced Testing: School Function Assessment The SFA was
designed to help collaborative teams to identify a student’s functional needs
and goals in terms that are meaningful in the elementary school environment.
The assessment is criterion referenced instead of standardized, and requires
the judgment of a person or persons who know the student well. Unlike
standardized tests, the SFA has been tested on children with a variety of
disabilities. The SFA consists of 3 parts, Participation, Task Supports and
Activity Performance. Participation examines the student’s participation in 6
school environments (Transportation; Transitions; Classroom; Mealtime;
Bathroom; Playground). Task Supports examines the student’s need for
assistance and adaptations to perform school tasks, and is divided into Physical
and Cognitive/Behavioral Activities. Activity Performance examines the
student’s performance of specific functional activities within each task area and
also is divided into Physical and Cognitive/Behavioral Activities. Each part has a
rating scale that is based on comparison to same grade peers. Ratings are always
based on the outcome of the performance (regardless of the methods the student
uses to accomplish the task). Scores indicate the student’s position on the 0-100
continuum of function (with 100 or more being where regular ed peers fall). The
following graphs help identify specific areas which are notably high or low and
where strengths and limitations facilitate or impede a task.
Test Observations:
Gross Motor Assessment
Standardized Testing:
Peabody Developmental Motor Scales 2: The PDMS 2 is a norm-referenced
standardized tool designed to evaluate the gross and fine motor skills of children
from developmental ages of 0 to 72 months. School Physical Therapists typically
use the gross motor portion of the test, which includes the following categories:
stationary skills; locomotor skills and object manipulation (ball skills). The
stationary subtest measures a child’s ability to sustain control of his or her body
within it’s center of gravity and retain equilibrium (balance). The locomotor test
measures the child’s ability to move from one location to another (creeping,
walking, running, hopping and jumping forward). The object manipulation
category measures a child’s ability to manipulate balls (catching, kicking,
throwing).
Three scores are commonly used. The percentile rank helps delineate where the
child’s score falls in relation to his peers. (for example, a percentile rank of 9 for
a raw score of 70 means that 9% of same-aged children scored below this
number). The standard score helps determine areas of strengths and weaknesses
in motor skills, allowing comparison between the subtests. The gross motor
quotient measures a child’s gross motor development based on the three areas
mentioned above. That is, a high score indicates well-developed gross motor
abilities and coordination, and a low score indicates weak movement and balance
skills.
Percentile
Rank
Standard
Score
Interpretation
Stationary
Locomotor
Object Manip.
Gross Motor
Quotient:
Test Observations:
Clinical Observations:
Mobility/Environment-Accessibility Assessment:
Transitions: Moving from one area to another, including lining up,
moving in crowded corridors or aisles, negotiating doorways, following
directions and rules.
Toileting: Tasks performed in bathroom, including managing clothing,
using diapers/catheter, flushing the toilet, taking care of personal hygiene,
and the physical acts of getting to/from the bathroom and on/off the toilet.
Gait:
Balance: Balance is the ability to maintain the body’s center of gravity
over its base of support with minimal sway or maximal steadiness.
Functional Needs Improvement
Comments
Sit to stand
Standing unsupported
Sitting unsupported
Standing to sitting
Transfers
Standing- eyes closed
Standing- feet together
Reaching forward
Retrieve from floor
Turning to look behind
Turning 360 degrees
Placing foot on stool
Standing one foot in
front
Standing on one foot
Classroom and School Grounds: Includes moving on different types of surfaces,
around obstacles, congested or narrow spaces, in a line, distances required at
school and keeping pace with peers in all school situations, including evacuating
the building as necessary.
Participation in Recreational Movement: Includes games involving physical
activity (classroom, playground, PE), running, climbing and playing on both low
and high playground equipment.
School Bus Transportation:
Summary (include how motor function, strength and physical needs impact on
education):
Physical Therapy is a related service for special education students and must be
educationally relevant. Per IDEA, school-based physical therapy is a unique, skilled
service that is provided when necessary to enable a child to benefit from his or her special
education program. School-based physical therapy services should enhance, not
duplicate teacher services in the classroom. School-based physical therapy is not
intended to replace community-based physical therapy. Parents are therefore encouraged
to seek additi8onal clinic-based therapy services when deemed appropriate by medical
professionals.
.
School-based Physical Therapist
Rating for Participation:
Extremely limited
Participation in a few activities
Participation in all aspects with constant supervision
Participation in all aspects with occasional assistance
Modified full participation
Full participation
Rating for assistance: provided by the adult
1- Extensive 2-Moderate 3-Minimal 4-No assistance
Hands on help with ……
Cueing for….
Monitoring of ….
Structures interventions of….. ie simplifying or repeating instructions,
providing extra reminders or physical monitoring
Ratings for Adaptations: help from peers, adaptive equipment, and modifications of
environment, environment, activity, program put in place and do not need regular
input from the adult.
Equipment
Seating
Desk
Changes in routines ie extra time for travel, completing work, eating
Safety Devices
Modified signals/signs
Building alterations ie ramp, adapted bathroom