17 Orthopedic Impairments

Orthopedic Impairments

 …means a severe orthopedic impairment that adversely affects a child’s educational performance. The term includes impairments caused by a congenital anomaly, impairments caused by disease (e.g., poliomyelitis, bone tuberculosis), and impairments from other causes (e.g.,cerebral palsy, amputations, and fractures or burns that cause contractures).

Center for Parent Information and Resources, (2017), Categories of Disability under IDEA. Newark, NJ, Author, Retrieved 3.28.19 from https://www.parentcenterhub.org/categories/   public domain

Table of Contents

  • Educational Orthopedic Impairment (OI)
  • Characteristics and Impact on Learning
  • Mobility
  • Instructional Strategies and Interventions
  • Assistive Technology
  • Related Service Providers
  • Cerebral Palsy
  • Spina Bifida

Educational Orthopedic Impairment (OI)

Educational Orthopedic Impairment (OI) means there is a motor disability stemming from, a medical condition such as cerebral palsy, spinal bifida, muscular dystrophy or a traumatic injury that adversely affects the child’s ability to access their education.

OI is a medical diagnosis and only becomes an IDEA disability if the OI adversely affects the students access to education. Not all students who have disabilities require specialized instruction. For students with disabilities who do require specialized instruction, the Individuals with Disabilities Education Act (IDEA) controls the procedural requirements, and an IEP is developed. The IDEA process is more involved than that of Section 504 of the Rehabilitation Act and requires documentation of measurable growth. For students with disabilities who do not require specialized instruction, but need the assurance that they will receive equal access to public education and services, a document is created to outline their specific accessibility requirements. Students with 504 Plans do not require specialized instruction, but, like the IEP, a 504 Plan should be updated annually to ensure that the student is receiving the most effective accommodations for his/her specific circumstances. (DO-I&, 2022)

Students with Disabilities and Section 504 of the Rehabilitation Act of 1973 from https://www.pacer.org/parent/504/

Characteristics and Impact on Learning

Heller and Swinehart- Jones (2003) categorize the characteristics of OI by

Types of Orthopedic Impairment

  1. Neuromotor (ex. cerebral palsy, spina bifida)
  2. Degenerative Diseases (ex. muscular dystrophy)
  3. Musculoskeletal Disorders (ex limb deficiency, juvenile rheumatoid arthritis)

Heller and Swinehart- Jones (2003) categorize the characteristics of these types of OI by the related functional limitations and psychosocial and environmental factors and how these issues impact learning.

Heller, K.W., & Swinehart-Jones, D. (2003). Supporting the Educational Needs of Students with Orthopedic Impairments. Physical Disabilities: Education and Related Services, 22(1), 3–24. from http://files.eric.ed.gov/fulltext/EJ678650.pdf

Mobility

Let’s take a closer look at the impact of mobility on the student with OI.

Many types of orthopedic or neuromuscular impairments can impact mobility. These include, but are not limited to amputation, paralysis, cerebral palsy, stroke, multiple sclerosis, muscular dystrophy, arthritis, and spinal cord injury. Mobility impairments range from lower body impairments, which may require use of canes, walkers, or wheelchairs, to upper body impairments that may include limited or no use of the upper extremities and hands.

Mobility impairments can be permanent or temporary. A broken bone or surgical procedure can temporarily impact a student’s ability to walk independently and travel between classroom buildings in a timely manner. Likewise, some students may be ambulatory with a walker for short distances within a classroom, but may need a wheelchair or scooter for longer distances.

Mobility impairments can impact students in several ways. Some students may take longer to get from one class to another, enter buildings, or maneuver in small spaces. In some cases physical barriers may inhibit entry into a building or room. Accessible transportation may also be required for students to get to fieldwork sites.

A mobility impairment may impact, to varying degrees, a student’s ability to manipulate objects, turn pages, write with a pen or pencil, type at a keyboard, and/or retrieve research materials. Medical conditions such as Arthritis or repetitive stress injuries can impact fine motor abilities and decrease endurance for longer assignments. A student’s physical abilities may also vary from day to day.

Examples of accommodations for students with mobility impairments include:

  • accessible locations for classrooms, labs, work sites, and field trips
  • wide aisles and uncluttered work areas
  • adjustable height and tilt tables
  • all equipment located within reach
  • note takers, scribes, and lab assistants
  • group lab or work assignments
  • extended exam time or alternative testing arrangements
  • computers with speech input, Morse code, and alternative keyboards
  • access to disability parking spaces, wheelchair ramps, curb cuts, and elevators
  • course and program materials available in electronic format
  • When speaking with a student in a wheelchair for more than a few minutes, sit down or move back to create a more comfortable angle for conversation.

(DO-IT, 2022)


Instructional Strategies and Interventions

Heller, K.W., & Swinehart-Jones, D. (2003). Supporting the Educational Needs of Students with Orthopedic Impairments. Physical Disabilities: Education and Related Services, 22(1), 3–24. from http://files.eric.ed.gov/fulltext/EJ678650.pdf  (includes information on characteristics, impact on learning, adaptive behavior, UDL, interventions/strategies and AT)

In order to access the general education curriculum, the focus will be on setting up an accessible learning environment. This will include seating arrangements that maximize access to learning materials.


Assistive Technology

Much of the assistive technology for students with OI will focus on access to educational materials and the learning environment. An elevator or ramp provides access to spaces when a staircase is insurmountable for someone who uses a wheelchair. Similarly, specialized hardware and software, called assistive or adaptive technology, allows people with mobility impairments to use computers. These tools allow a person with limited, uncontrollable, or no hand or arm movement to successfully perform in school and job settings. Assistive technology can allow a person with a mobility impairment to use all of the capabilities of a computer.

While it is helpful to recognize the specific limitations of an individual, it is more important to focus on the task to be completed and how his abilities, perhaps assisted with technology, can be used to accomplish the goal or task. Work closely with the person with a mobility impairment to first determine what he needs or desires to accomplish by using a computer. Specific accommodations can then be explored that provide access to software or to a specific device, such as a keyboard or mouse.

The specific need for assistive technology is unique to the individual. Trial and error may be required to find a set of appropriate tools and techniques. The person with a mobility impairment should play a key role in determining her goals and needs when selecting her assistive technology. Once basic tools and strategies are initially selected, she can test drive, discard, adapt, and refine. The end user of the technology should ultimately determine what works best.

Environmental Access

Before a person can use a computer, they need to get within effective proximity of the workstation. Aisles, doorways, and building entrances must be wheelchair accessible. Other resources such as restrooms, and classroom areas should be accessible as well. Don’t overlook a simple barrier such as a single step or narrow doorway.

Furniture

Proper seating and positioning is important for a student to access a computer, or share a table with their peers. Specialized computer technology is of little value if the student cannot physically activate these devices due to inappropriate positioning. A person for whom this is an issue should needs an  occupational therapist to ensure that correct posture and successful control of devices can be achieved and maintained.

Flexibility in the positioning of keyboards, computer screens, and table height is important. As is true for any large group, people with mobility impairments come in all shapes and sizes. It is important that keyboards can be positioned at a comfortable height and monitors can be positioned for easy viewing. An adjustable table can be cranked higher or lower, either manually or with a power unit, to put the monitor at a proper height. Adjustable trays can move keyboards up and down and tilt them for maximum typing efficiency. Be sure to consider simple solutions to furniture access. For example, wood blocks can raise the height of a table and a cardboard box can be used to raise the height of a keyboard on a table.

Keyboard Access

The keyboard can be the biggest obstacle to computing for a student with a mobility impairment. Fortunately, those who lack the dexterity or range of motion necessary to operate a standard keyboard have a wide range of options from which to choose. Pointers can be held in the mouth or mounted to a hat or headgear and used to press keys on a standard keyboard. Repositioning the keyboard to the floor can allow someone to use his feet instead of his hands for typing.

Consider using the features common in popular word processors, such as Microsoft Word, to ease text entry. The Accessibility Options control panel in current versions of Microsoft Windows contains a variety of settings that can make a standard keyboard easier to use.

A keyguard is a plastic or metal shield that fits over a standard keyboard. Holes are drilled into the guard to help an individual with poor dexterity or hand control press only the desired key without inadvertently pressing other keys. Keyguards are available from a variety of manufacturers (e.g., Don Johnston).

Alternative keyboards can be considered for a person who cannot effectively operate a regular keyboard despite changing settings or using a keyguard. For people who have limited range of motion, a mini-keyboard (Tash) may be considered. If a person has good range of motion and poor dexterity, a keyboard with extra-large keys can offer a good solution.

When physically activating a keyboard—whether through changing the settings or switching to an alternative keyboard—is not possible, evaluate the utility of a virtual keyboard. A virtual keyboard appears on the computer screen as a picture of a keyboard. A mouse, trackball, or alternative pointing system activates the keys on the screen and inserts the appropriate keystrokes into the desired program. A person can enter text by clicking on specific keys on the keyboard image. Modifier keys such as Ctrl and Alt can also be accessed, as can the function keys. Some virtual keyboards incorporate word prediction (see below) to increase entry speed and may include alternate layouts in addition to the traditional “QWERTY” layout found on standard keyboards.

When a person’s mobility impairment prevents the use of a standard keyboard or mouse, using a switch may be a possibility. Switches come in a nearly limitless array and can be controlled with nearly any body part. Switches can be activated with a kick, swipe of the hand, sip and puff by mouth, head movement, eyeblink, or touch. Even physical closeness can activate a proximity switch. These switches work in concert with a box or emulator that sends commands for the keyboard or mouse to the computer. While switch input may be slow, it allows for independent computer use for some people who could not otherwise access a computer.

Word prediction programs prompt the user with a list of likely word choices based on words previously typed. Some word prediction software automatically collects new words as they are used and considers a person’s common vocabulary when predicting words in the future.

Alternative Pointing Systems

With the advent of graphically-oriented operating systems, it is vital to have access to a mouse or an alternative pointing device. For those who lack the coordination to use a standard mouse, there are many alternatives to consider. Trackballs are a good first choice; the control surface can be easier to manipulate and the buttons can be activated without affecting the pointer position. Some trackballs offer additional buttons that add functionality such as double-clicking, click and hold, and other commands, and can be programmed to a person’s specific needs. A simple accommodation for use of a pointer by someone who can’t use his hands, but can move his feet is to place a standard mouse or trackball on the floor.

Technology is always advancing and there may be newer options availabl

Low-tech

Not all assistive technology for people with OI is computer-based. The use of such common items as adhesive Velcro to mount switches or power controls can provide elegantly simple solutions to computer access barriers. Simple items like a slant board or cup holder. Often, tools of one’s own making provide the most effective and comfortable accommodations.

(DO-IT, 2012)

Watch Video (8:12 minutes)

Students with mobility impairments talk about the assistive technology they use in educational settings. Students share information about a variety of technology such as adaptive keyboards, speech-to-text products, and more.

TheDOIT Center, (2019) Our Technology for Equal Access: Mobility Impairments [Video File], from https://youtu.be/HYz5kZgmLkE


Related Service Providers

Middleton, A.  (n.d.) Orthopedic Impairment Brochure  (good resource for general overview and Related Service Providers. The Effects of Disability section relates to adaptive behaviors and OI)

The following text is an excerpt from: Center for Parent Information and Resources, (2017), Cerebral Palsy, Newark, NJ, Author, Retrieved 4.1.19 from https://www.parentcenterhub.org/cp/  public domain

Cerebral palsy and spina bifida are two common types of orthopedic impairments. We will take look at two profiles of students with these OIs.

Cerebral Palsy- Jennifer’s Story

Jen was born 11 weeks early and weighed only 2½ pounds. The doctors were surprised to see what a strong, wiggly girl she was. But when Jen was just a few days old, she stopped breathing and was put on a ventilator. After 24 hours she was able to breathe on her own again. The doctors did a lot of tests to find out what had happened, but they couldn’t find anything wrong. The rest of Jen’s time in the hospital was quiet, and after two months she was able to go home. Everyone thought she would be just fine.

At home, Jen’s mom noticed that Jen was really sloppy when she drank from her bottle. As the months went by, Jen’s mom noticed other things she didn’t remember seeing with Jen’s older brother. At six months, Jen didn’t hold her head up straight. She cried a lot and would go stiff with rage. When Jen went back for her six-month checkup, the doctor was concerned by what he saw and what Jen’s mom told him. He suggested that Jen’s mom take the little girl to a doctor who could look closely at Jen’s development.

Jen’s mom took her to a developmental specialist who finally put a name to all the little things that hadn’t seemed right with Jen–cerebral palsy.

What is CP?

Cerebral palsy—also known as CP—is a condition caused by injury to the parts of the brain that control our ability to use our muscles and bodies. Cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles. Often the injury happens before birth, sometimes during delivery, or, like Jen, soon after being born.

CP can be mild, moderate, or severe. Mild CP may mean a child is clumsy. Moderate CP may mean the child walks with a limp. He or she may need a special leg brace or a cane. More severe CP can affect all parts of a child’s physical abilities. A child with moderate or severe CP may have to use a wheelchair and other special equipment.

Sometimes children with CP can also have learning problems, problems with hearing or seeing (called sensory problems), or intellectual disabilities. Usually, the greater the injury to the brain, the more severe the CP. However, CP doesn’t get worse over time, and most children with CP have a normal life span.

What About Treatment?

With early and ongoing treatment the effects of CP can be reduced. Many children learn how to get their bodies to work for them in other ways. For example, one infant whose CP keeps him from crawling may be able to get around by rolling from place to place. Typically, children with CP may need different kinds of therapy, including:

Physical therapy (PT), which helps the child develop stronger muscles such as those in the legs and trunk. Through PT, the child works on skills such as walking, sitting, and keeping his or her balance.

Occupational therapy (OT), which helps the child develop fine motor skills such as dressing, feeding, writing, and other daily living tasks.

Speech-language pathology (S/L), which helps the child develop his or her communication skills. The child may work in particular on speaking, which may be difficult due to problems with muscle tone of the tongue and throat.

All of these are available as related services in both early intervention programs (for very young children) and special education (for school-aged children).

Children with CP may also find a variety of special equipment helpful. For example, braces (also called ankle-foot orthoses, or “AFOs”) may be used to hold the foot in place when the child stands or walks. Custom splints can provide support to help a child use his or her hands. A variety of therapy equipment and adapted toys are available to help children play and have fun while they are working their bodies. Activities such as swimming or horseback riding can help strengthen weaker muscles and relax the tighter ones.

New medical treatments are being developed all the time. Sometimes surgery, Botox injections, or other medications can help lessen the effects of CP, but there is no cure for the condition. It’s also important to understand that cerebral palsy is not contagious, not inherited, and not progressive.  The symptoms will differ from person to person and change as children and their nervous systems mature. (Healthcommunities.com, 2007)

What About School?

A child with CP can face many challenges in school and is likely to need individualized help. Fortunately, states are responsible for meeting the educational needs of children with disabilities.

For children up to the 3rd birthday, services are provided through an early intervention system. Staff work with the child’s family to develop what is known as an Individualized Family Services Plan, or IFSP. The IFSP will describe the child’s unique needs as well as the services the child will receive to address those needs. The IFSP will also emphasize the unique needs of the family, so that parents and other family members will know how to help their young child with CP. Early intervention services may be provided on a sliding-fee basis, meaning that the costs to the family will depend upon their income.

For school-aged children, including preschoolers, special education and related services will be provided through the school system. School staff will work with the child’s parents to develop an Individualized Education Program, or IEP. The IEP is similar to an IFSP in that it describes the child’s unique needs and the services that have been designed to meet those needs. Special education and related services, which can include PT, OT, and speech-language pathology, are provided at no cost to parents. In addition to therapy services and special equipment, children with CP may need what is known as assistive technology. Examples of assistive technology include:

  • Communication devices, which can range from the simple to the sophisticated. Communication boards, for example, have pictures, symbols, letters, or words attached. The child communicates by pointing to or gazing at the pictures or symbols. Augmentative communication devices are more sophisticated and include voice synthesizers that enable the child to “talk” with others.
  • Computer technology, which can range from electronic toys with special switches to sophisticated computer programs operated by simple switch pads or keyboard adaptations.

The ability of the brain to find new ways of working after an injury is remarkable. Even so, it can be difficult for parents to imagine what their child’s future will be like. Good therapy and handling can help, but the most important “treatment” the child can receive is love and encouragement, with lots of typical childhood experiences, family, and friends. With the right mix of support, equipment, extra time, and accommodations, all children with CP can be successful learners and full participants in life.

(Center for Parent Information and Resources, CP, 2017)


Spina Bifida Juan José’s Story

This story comes to you from the Real Stories collection of the Spina Bifida Association.

I remember when the doctors told me my child had hydrocephalus and myelomeningocele and that he would not be able to do anything that another child would do. I was devastated to say the least!

Through the years, my son has proven them wrong time and time again by overcoming obstacles that having Spina Bifida can give. He spoke his first sentence at nine months old, he crawled on time, he used a wheelchair for the first time at 12 months old. My son is now an honor student in “regular” education classes and very active in wheelchair sports. He has many friends and excels in everything that he does.

About Spina Bifida

Spina bifida is one of the most common birth defects in the United States, affecting some 1,500 babies each year. 2 Spina bifida happens during the first month or so of pregnancy and means that the baby’s spine did not close completely. Damage to the nerves and the spinal cord may result.

Characteristics and Health Considerations

The effects of spina bifida vary from person to person, depending on the type involved. Children born with spina bifida occulta typically have few symptoms or adverse effects from the condition. As we mentioned, many may never even know that they have it. Those with meningocele, also a mild form, may be only minimally affected as well.

The effects of myelomeningocele, the most serious form of spina bifida, may include:

  • muscle weakness or paralysis below the area of the spine where the incomplete closure (or cleft) occurs,
  • loss of sensation below the cleft, and
  • loss of bowel and bladder control.

Educational Implications

Quite often, children with myelomeningocele will need to have a series of operations throughout their childhood and school years. School programs should be flexible to accommodate these special needs.

Many children with myelomeningocele need training to learn to manage their bowel and bladder functions. Some require catheterization, or the insertion of a tube to permit passage of urine.

The courts have held that clean, intermittent catheterization is necessary to help the child benefit from and have access to special education and related services. A successful bladder management program can be incorporated into the regular school day. Many children learn to catheterize themselves at a very early age.

In some cases, children with spina bifida who also have a history of hydrocephalus experience learning problems. They may have difficulty with paying attention, expressing or understanding language, and grasping reading and math. Early intervention with children who experience learning problems can help considerably to prepare them for school.

Successful integration of a child with spina bifida into school sometimes requires changes in school equipment or the curriculum. In adapting the school setting for the child with spina bifida, architectural factors should be considered. Section 504 of the Rehabilitation Act of 1973 requires that programs receiving federal funds make their facilities accessible. This can occur through structural changes (for example, adding elevators or ramps) or through schedule or location changes (for example, offering a course on the ground floor).

Children with myelomeningocele need to learn mobility skills, and often require the aid of crutches, braces, or wheelchairs. It is important that all members of the school team and the parents understand the child’s physical capabilities and limitations.

Families and teachers can play a key role in promoting the personal growth and independence of children with spina bifida. The foundations of that independence are laid a step at a time.
(Center for Parent Information and Resources, 2015)


Supplementary Resources


References

Center for Parent Information and Resources, (2017), Cerebral Palsy, Newark, NJ, Author, Retrieved 4.1.19 from https://www.parentcenterhub.org/cp/  public domain

Center for Parent Information and Resources, (2015), Spina Bifida, Newark, NJ, Author, retrieved 4.1.19, from https://www.parentcenterhub.org/spinabifida/#ref1  public domain

DO-IT  (2012). Working Together: Computers and People with Mobility Impairments. From https://www.washington.edu/doit/working-together-computers-and-people-mobility-impairments   CC BY-NC-SA 3.0

Heller, K.W., & Swinehart-Jones, D. (2003). Supporting the Educational Needs of Students with Orthopedic Impairments. Physical Disabilities: Education and Related Services, 22(1), 3–24. from http://files.eric.ed.gov/fulltext/EJ678650.pdf

Middleton, A.  (n.d.) Orthopedic Impairment Brochure  (good resource for general overview and Related Service Providers. The Effects of Disability section relate to adaptive behaviors and OI)

TheDOIT Center, (2019) Our Technology for Equal Access: Mobility Impairments [Video File], from https://youtu.be/HYz5kZgmLkE   CC BY

TN Department of Education. (2018, November). Orthopedic Impairment Evaluation Guide. from https://www.tn.gov/content/dam/tn/education/special-education/eligibility/se_orthopedic_impairment_evaluation_guidance.pdf


Updated 8.17.22