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Prognosis…and the difficult application of prognosis to school-based decision making.




As therapists, we are fortunate enough to have an increasing body of knowledge that helps us make decisions about a student’s prognosis. That being said, the translation of that information and its application to a student and service decision making can be challenging for a variety of reasons: lack of team understanding on your role as a school based practitioner, parental push back, and outside provider reports to mention a few. Prognosis plays a huge role with determining goals, objectives, supplementary aids and services and ultimately your dosing decision. So, let’s talk about how to work with the concept of prognosis and its application to your school-based dosing decision.


First, what do we mean by prognosis. From the Guide to PT Practice 3.0 prognosis is defined:” The determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level”. What is essential for us as therapists is to understand is the difference between what a person currently does and what that person potentially could do. Knowing prognostic factors “which have a strong enough association to be predictive of the likelihood of the outcome” (Beattie & and Nelson 2007) will help to structure your thinking about your student. So, as it relates to school practice, what might some of those factors be? Lets’ use the ICF to support a student’s prognosis.

https://www.who.int/classifications/icf/en/


Personal Factors: Age, motivation, mental health, self-efficacy (Beattie & Nelson, 2007)

Body, function and Structures: Severity of impairments, other co-morbidities and the resulting physiologic and anatomical impacts. “Intellectual ability has been found to have the highest contribution to predicting walking ability” (Chiarello, et al., 2011)

Activity: Rely on the functional scales such as the GMFCS, MACS, EDACS, CFCS and measures of cortical visual impairment if appropriate and their stability over time. (Palisano, et al., 2018).

Participation: Use ecological/authentic assessment and stakeholder interviews to understand and observe any and all participation restrictions. Follow up with a participation measure if needed.

• (Darrah, J. (2008) Using the ICF as a framework for clinical decision making in pediatric physical therapy, Advances in Physiotherapy, 10:3, 146-151, DOI: 10.1080/14038190802242046,

Goldstein, D., Cohn, E. & Coster, W. (2004) Enhancing Participation for children with disabilities: Application of the ICF enablement Framework to pediatric Physical Therapy Practice. Pediatric Physical Therapy. 114-120.


At an IEP meeting, how to approach the topic of prognosis as an element of your recommended “dose” of therapy services: some ideas to ponder.


Consider this: Using the available research (share motor curves aligned with the child’s GMFCS level), a goal with independent functional walking as its outcome is most likely not achievable at this time but I am committed to providing opportunities for your child to move as independently as possible. Using an adaptive device aligned with any activity where walking with be a meaningful way to participate, your student will have opportunities to do so. An adaptive device for activities that require walking will be included in supplementary aids and services and supported by me and other team members after being trained by me as part of your student’s IEP. We will track how often this occurs as part of data collection for the IEP year.


Consider this: For students with regressive conditions, apply the ICF in your decision making when making your prognostic assessment. Activity measures addressing the body function and structures aligned with the medical condition resulting in the regression should be used to support your recommendations.


My emphasis will be on your student’s participation in all parts of the school day in a way that allows for the his/her greatest level of independence for peer interactions, his/her sustained endurance and strength to receive educational benefit and a fluid approach to accommodations and modifications to address his/her evolving impairments that impact ADLS and other routines of the school day. I will also encourage your student’s ability to self-determine– asking for help, advising us as a team as to what his/her concerns and needs are, teaching the team on the use of his/her equipment for positioning, lifting etc. Your student’s ability to self-determine will be critical to us as an educational team and a focus of my efforts. Services will be directed toward assessing key functional skills and selecting accommodations and modifications that will allow for the greatest level of participation and training the student and staff on those supports as your student's condition warrants.


I love helping therapists problem solve dosing recommendations…a Sequoia offering! Contact me anytime at Sequoiaschoolbasedsolutions@gmail.com

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