Experiences and Opinions on School Physiotherapy Services: A Metasynthesis of Qualitative Studies

1. Introduction

Physiotherapy is an autonomous profession whose objective is to prevent, develop, and maintain movement and functional abilities in patients and communities. According to the World Confederation for Physical Therapy, the practice of the profession varies depending on the healthcare system, facilities, regulations, and resources of each country [1]. Although physiotherapy is essentially a clinical discipline, carrying out the assessment, diagnosis, and treatment of patients; it currently forms part of integrated models that also provide services in the home and the school. School physiotherapy (SP) focuses its practice on children with special motor needs during the school period [2], aiming to improve their health and functional performance at school, in connection with the home and the community [3]. Many countries have educational services which include SP for children with disabilities of pre-school and school age [4]. By integrating scientific evidence, clinical experience, and patient preferences, SP provides technical aids and curricular adaptations for children with motor, ergonomic, or postural problems [5,6].

The World Confederation for Physical Therapy recognises that the practise of the profession varies according to the competencies and healthcare system of each country [7,8]. From a paradigm of school inclusion, institutions seek cooperation between the educational, healthcare, and social sectors [9]. Schools provide a unique natural environment for physiotherapists to develop motor learning strategies, neurorehabilitation, or early intervention therapies [6]. Thus, educational centres for children with neurodisabilities usually include physiotherapy, occupational therapy, and speech therapy services [3]. Since the end of the 20th century, Spain has been committed to incorporating SP into educational guidance departments. SP focuses on the care of children with special educational needs, develops physical rehabilitation programmes, physiotherapy assessment, guidance, and treatment of motor problems [10]. Teaching in the classroom is not exempt from problems related to psychomotricity, ergonomics, or posturology, which can be prevented and treated through SP services [11]. The school physiotherapist evaluates psychomotricity, movement disorders, and body structure and function across all educational stages. At the same time, they provide guidance on physical activity [12,13], reduction of sedentary behaviour [14], musculoskeletal disorders, [15], occupational health [11], exercise in specific pathologies [16], postural health, and adapted teaching in special education settings [8,17].

The interaction between healthcare and educational development has evolved in recent years [18]. The application of therapies in schools is key for children with disabilities [19], the educational team decides the frequency, intensity, and type of intervention according to the capacities of the system. The interaction between education and health has a positive impact on the academic success and quality of life of these pupils [20]; however, it is necessary to document the strengths and weaknesses of SP services, the gap between ideal and actual practice [21], and to evaluate the effectiveness of programmes [5]. Although some studies have shown discrepancies regarding SP interventions [22,23], most agree on their benefits, such as improvement in children’s motor and social skills [24]. There is a lack of analysis, guidance, and evidence on SP interventions [25,26]. Clinical practice guides are needed [7], as well as the exploration of training in rehabilitation activities [27] and an understanding of the experiences of those involved in the process. Qualitative methodologies have proved useful in researching the experiences of physiotherapists, families, teachers, or children regarding SP for cerebral palsy [26], the use of standing frames [28], aquatic therapy [29] or spinal health programmes [30]. In order to improve the quality of care in educational settings, there is a need for a synthesis of aggregated data in order to obtain a deeper understanding of the use, development, strengths, and weaknesses of SP services. The objective of this study is to identify qualitative evidence on the experiences/opinions of physiotherapists, children, parents, and teachers concerning SP services.

2. Materials and Methods

2.1. Design

A systematic review, metasynthesis of qualitative studies, was performed.

2.2. Search Methods

Bibliographic searches were conducted on the PubMed, WOS, SCOPUS, and CINAHL databases for qualitative studies in English and Spanish, published between January 2015 and June 2025. The PRISMA 2020 declaration was used in this study [31], and the SPIDER method was used to help formulate the research question [32]. In order to perform the search, the search terms used were divided into three areas. First, the terms "school", "education", “students”, “primary and secondary education”, and “school health services”, were joined with the Boolean operator "OR". This search was performed with "physiotherapy", "physical therapy services", “physical therapist", “physical therapy speciality”, “physical therapy modalities”, and "qualitative research". After performing these searches separately, they were joined using the Boolean operator “AND”(((((((school) OR education)) AND (((((physiotherapy) OR Physical Therapy Services) OR Physical Therapist)) AND ((qualitative research). This search was supplemented by a search of grey literature.

2.3. Inclusion and Exclusion Criteria

Inclusion criteria: primary studies on the experiences and opinions of physiotherapists, parents, teachers, and children regarding SP services. Qualitative research papers or mixed methodology were included. Exclusion criteria: non-primary articles, editorials, or opinion pieces.

2.4. Search Results

A 5-stage selection process was performed: elimination of duplicates, title selection, abstract review, full paper review and reference tracking. A total of 698 studies were identified, however, only 17 articles were included in this review (Figure 1).

2.5. Data Extraction

Three authors (GGH, NSL, and SNN) independently performed data extraction, discussed the controversies found, and reached an agreement; the references of seventeen included papers were reviewed (Figure 1).

2.6. Quality Assessment

Each primary study was assessed using the Joanna Briggs Institute’s Qualitative Assessment Rating Instrument (QARI) [33]. The included articles were considered to be of high quality with respect to objectives, design, analysis, and results, providing useful knowledge on the topic (Table 1). No studies were excluded after quality assessment.

2.7. Data Synthesis and Analysis

The included studies were analysed thematically. The synthesis was undertaken by (GGH and NSL), and verified by (SNN). One independent reviewer with expertise in SP and qualitative research verified the results. The thematic synthesis included three stages [34] (Table 2), characteristics of selected studies can be seen in Table 3.

2.8. Rigour

In order to verify the validity of the review, structured abstracts of the original studies were maintained, and it was verified whether the findings were transferable to other contexts of SP application. After the thematic synthesis, the contributions of the studies to the final analytical themes were examined.

3. Results

The seventeen qualitative studies comprised a total sample of 682 participants, 194 (28.4%) pupils, 65 (9.5%) parents/relatives, 114 (16.7%) teachers, 265 (38.8%) physiotherapists, 7 (1.0%) physiotherapist aides, 10 (1.4%) educational professionals, 10 (1.4%) political positions, and 17 (2.5%) unspecified participants. Regarding their origin, there are 4 studies from South Africa, 3 from the USA, 3 from Spain, 2 from Australia, 2 from Norway, and 1 from Israel, UK, Canada and unspecified countries. Thematic synthesis is an inductive process in which three themes and eighteen sub-themes emerge (Table 4).

3.1. Clinical and School Physiotherapy: Separated by a Fine Line

SP differs from clinical physiotherapy; SP services should represent a potential for educational improvement in pupils with disabilities. Although the whole multidisciplinary team shares the same objective, it is difficult to strike a balance between physical activity, therapy, and academic work. Educators fight for education and, physiotherapists for physiotherapy, but it is a joint task where neither is more important than the other; both must coexist:

Well, what’s the most important thing here? Is it the standing? Is it the education? Is it this bit? Is it that bit?” … It’s a very fine balancing line … constant battle between therapy and education.

[28]

Physiotherapists point to a paradigm shift in SP, highlighting the difficulty of moving from a clinical model to an educational one:

I’ve been a PT for 27 years but I’ve only been in the schools for about 14. Certainly, coming from a clinic model, my first couple of years in the schools I had a really hard time to figure out how to make goals that were school-based…

[35]

The introduction of physiotherapy in schools involves living with feeling under pressure while not forgetting that the goal is to improve health and education. One therapist explained:

We’re looking at supporting students in special education and benefiting from those services; we’re looking at accessing educational environments and students participating with their peers in motor activities.

[35]

There is a lack of interaction, knowledge sharing, and communication between the clinical and academic fields, and this is perceived as a threat to the advancement of SP.

3.1.1. Lack of Specific Guidelines

SP is necessary when disabilities and motor problems negatively affect a pupil’s academic performance. A health problem that interferes with academic performance may require clinical physiotherapy and/or SP. However, as one physiotherapist notes, school settings lack protocols for action or specific tasks for physiotherapists:

I like that it gives nice clarity around the scope of work for a school-based physiotherapist.

[8]

Our review highlights the existence of distinct guidelines, competencies, functions, and registries. As one participant states, this situation confuses physiotherapists. There is a need to organise SP practise:

Sometimes because of the wording, complexity and differences between countries, PTs might feel so overwhelmed.

[8]

3.1.2. Professional Competencies and Diffuse Responsibility

Defining the professional competencies of SP poses a challenge. The ambiguity with related professions means that some essential functions that define SP are assumed by other professions. While regulations aim to standardise functions of SP, their implementation reveals gaps in accessibility, availability, and professional accountability.

Actually, it is everyone’s responsibility, so when everyone is responsible, no one takes responsibility.

[19]

3.1.3. Lack of Support: Feeling Like Outsiders

School physiotherapists report a lack of support from department heads and guidance from educational coordinators. Physiotherapists must be familiar with the school; but they are sometimes forced to adapt by taking on non-clinical activities outside of their profession duties, such as supervising recess or covering shifts for other professionals. There are no job descriptions, positions, training, or specific documentation.

Most of the focus [in our school] is on education and therapists are excluded from the decisions [physiotherapist not consulted to share their views] by the DoE. … To date we do not have job descriptions and are understaffed.

[7]

School physiotherapists may feel like outsiders in an educational system where the majority are teaching staff. Physiotherapists perceive insufficient training, fewer opportunities for professional development, and isolation.

Physiotherapy is secondary in the education system, even within the health professions… everyone needs to talk, so they [the students] receive speech therapy… everyone needs to write and hold a pencil, so who will teach them? An occupational therapist… and due to various misconceptions, the OT will also examine motor performance. So why bring in another clinician?

[19]

3.1.4. Professional Intrusion

Some policymakers expressed concern about professional boundaries. SP may overlap with occupational therapists, developmental coaches, physical education teachers, or sports coaches. Sometimes these professionals offer physiotherapy treatments for children with motor disabilities.

There is a big problem with physiotherapy professional boundaries: where do they begin and end, who needs physiotherapy, who should be referred to a physiotherapy… I mean, it is unclear to the public but also to therapists, when should a physiotherapy or occupational therapist be consulted?...

[19]

3.1.5. Pupil-Centred, Evidence Based

Beyond teachers’ opinions, school physiotherapists are trained to write measurable goals and develop evidence-based activities. As one physiotherapist with 20 years of experience in school states:

And I don’t know that there is really one great way to write goals but making sure that they’re measurable and you can actually keep data on those goals.

[35]

SP should focus on the pupil, addressing their access and mobility issues during the school day. The goals are geared toward motor development, independence in movement, gait, balance, and locomotor patterns. As one physiotherapist put it:

So, if it was a clickable link, if it was an interactive document, we could digitally find more of the information in it.

[8]

3.2. Ensuring Healthcare for Children with Specific Conditions in Schools

Children with specific conditions such as cerebral palsy, spinal cord problems, anatomical malformations, or recurring pain require physiotherapy support during their daily activities at school.

3.2.1. Care for Pupils with Cerebral Palsy

Children with cerebral palsy attend specialised schools that offer modified curricula along with therapy services. Their experiences with exercise are positive, improving their aerobic capacity, physical endurance, well-being, and participation in school and leisure activities. School physiotherapists state that they perceive improvements in motor skills, communication skills, and improved social relationships:

She was walking longer on the treadmill and riding her bike faster for longer periods.

[16]

I think that open friendliness, that it being a little bit social as well as exercise, was a great aspect of it. And so that would make it easier for them to join in.

[16]

Teachers and physiotherapists recognise the advantages of children with cerebral palsy participating in these programmes, which focus on addressing pupils’ academic and physical needs and responding to family expectations.

3.2.2. Supervising Pupils Using Standing Frames

Using standing frames for children with specific pathologies requires knowledge of their handling and complications. While classroom staff may have general skills, prolonged use, agitation, or movement of children can cause injuries or burns. Using this technology requires training for students and a multidisciplinary team; this task must be carried out by the SP.

If the children have got a lot of extraneous movement and they’re agitated, you can end up with friction burns … Sometimes it actually depends if they’ve got their second skin (dynamic lycra body suit) on, if they are tired … So you have to really know your children and know what mood they’re in as well.

[28]

3.2.3. Implementing Aquatic Therapy Programmes

The inclusion of aquatic therapy programmes in schools and special education centres provides a fun and motivating form of physical activity. Physiotherapists report improvements in muscle tone and strength, motor spasticity, and breathing in children with cerebral palsy. As the physiotherapists explain:

It is an environment where it is easier to mobilize compared to dry land conditions, so, first you see what the person can do regarding mobility in the water, and then this can be applied in the classroom or the dining room, encouraging us to reinforce this.

[29]

The sensory experience of being in the water enhances the pupils’ ability to perform other activities.

They pay more attention to conversations as soon as they get into the water, and then they react in the playground when something seems funny or interesting to them, they are more awake than before they get into the water.

[29]

3.2.4. Prevention and Treatment of Back Problems/Pain

Knowing the consequences of poor posture helps pupils change habits and motivate them to improve their ergonomics. According to teachers, information provided through physiotherapy activities allow students to improve and prevent back pain. Pupils, parents, teachers, and principals emphasise the benefits of participating in physiotherapy workshops, such as risk awareness, pain reduction, and improved well-being. One pupil expressed the following:

The workshops have helped me to change, I have truly felt that they have been useful. In my daily life, this is noticeable and little by little, the back ache that I had starts to go away.

[36]

For the pupils, the physiotherapy activities they applied most were those related to ergonomics, stretching, and proper backpack use.

I have found it very useful because before I would carry my backpack down by my bum and I would struggle, and it was hell and suddenly you said I should raise it higher, and I thought to myself “it doesn’t weigh a thing! I was very surprised.

[36]

Teachers are concerned about the lack of attention to the musculoskeletal effects of immobility, excessive technology use, dangerous play, and injury prevention. There is evidence of the effectiveness of SP programmes for this problem, but teachers do not have this training:

The teachers aren’t taught about spinal health and what’s good for children and bad.

[30]

3.2.5. Care and Prevention of Complications from Spinal Cord Injuries

Children and adolescents with spinal cord injuries face risks of spinal asymmetry, scoliosis, or hip dislocation, resulting in asymmetrical pressure distribution and an increased risk of pressure ulcers. There is a gap in prevention systems for these problems in schools. Paraplegic pupils are in need of training by physiotherapists for themselves and their peers, along with support from the school administration:

[Assistance through physiotherapists] … there should be the likes of … the help of the hospital physiotherapist, and the school, and other special schools, we will manage.

[37]

3.2.6. Applying Mind-Body Therapies

For years, the role of physiotherapy in the care of children with mental health problems has been highlighted. Mindfulness techniques, breathing practices, body awareness, and yoga have all shown benefits for child development. Teachers and pupils report that the mindfulness and body awareness work developed by physiotherapists help children concentrate. As one teacher sees it:

For example, when doing homework, they can focus more; they used to chatter a lot. They can sit better and have a better posture. Like, in sorting out arguments and stuff, they already talk about it differently, and at some point, you gotta say, “F [referring to the physical therapist] comes with this and that…” [referring to the fact that she reminds them of what they’ve learned with the physical therapist, and it’s helped them to chill out].

[38]

Guided imagery activities also help develop their imagination of other places outside the classroom. They feel like they can explore other spaces, feel other emotions, and share them in a group or at home.

3.2.7. Addressing Minor Motor Limitations

Children with Developmental Coordination Disorder (DCD) and Autism Spectrum Disorder (ASD) are not considered to have motor disabilities but have unrecognised physiotherapy needs. This represents a gap that school physiotherapists must address:

Children with DCD are not eligible for physiotherapy at school or child development centers after the age of 6.

[19]

Participants expressed concern for older children, who do not receive SP treatment beyond a certain age:

I hope older children receive services at school. I hope, but I’m not sure it happens, and I am not sure it’s enough.

[19]

3.3. The Challenge of Incorporating SP in Educational Settings

This topic covers the advantages and disadvantages, strengths and weaknesses of incorporating physiotherapists into specialised school settings.

3.3.1. Integrating Therapy Into Curriculum

The availability of specialised staff facilitates physical activity for children with high support needs. Staff shortages limit opportunities for pupils to remain physically active. As one parent notes, physiotherapists are recognised as “physical activity experts” in the school setting.

The most important thing is that the school has specialists . . . because if it didn’t then the opportunity to do physical activity would be limited.

[39]

Parents comment that their children participate enthusiastically in activities when directed or suggested by physiotherapists:

. . . if she [physiotherapist] says ‘come on I want you to get up and go and walk around the school seven times’, [name] will go ‘okay, I’ll do it eight times for you’.

[39]

3.3.2. Meeting Physiotherapy Needs in Special (and Regular) Education Schools

The school focuses on education; curricular demands prevent teachers from considering pupils’ other needs. Teachers feel they must focus on teaching and learning activities; they lack the time, capacity, or confidence to address the health needs of certain pupils.

Our work has to be done, books has to be marked, assessments have to be done and marked and moderated and all of those so we don’t have time. We can’t worry about their spines because we are worried about what they’re learning.

[40]

SP could address these demands, but it is excluded from the department’s decisions. Nor is there a perceived political commitment to change this situation beyond special education. From this premise, our review opens the challenge of incorporating SP into regular education.

Implementing this model to mainstream schools means that physical therapists should be in the general (mainstream schools), and so it’s kind of new thought, so I think it’s going to be challenging.

[8]

Policymakers believe that some treatment for children with motor disabilities should be provided in special education settings; they are skeptical about its extension into regular education.

Children with motor disabilities receive physiotherapy in special education schools. I don’t know whether to say that it is full, but certainly in special education schools there are physiotherapists who take care of these children... those in mainstream education should also receive physiotherapy at school, but it doesn’t always happen. And if not in school, then where do they get it, I don’t know.

[19]

3.3.3. Training Teachers and Other Professionals

For educational staff, it is important to attend physiotherapy sessions and practise the physiotherapist’s teachings. This way, they feel more motivated to dedicate time to certain techniques in class. For teachers, it would be advisable for the physiotherapist to train the teaching staff, consolidating what they have learned in class.

And it is perfect that in parallel to this, F [the physical therapist] is also training us teachers, so I think it is an action, and the good thing is that it is a very global intervention and that it is not isolated and so on… Yes, so I think it is important. I also think it is important that we can introduce it, as I said, in a transversal way in the curriculum, that teachers are given the tools to be able to do this.

[38]

Physiotherapists may also supervise support staff who work with children with special needs in preschools. Support staff face difficulties when handling children to prevent fractures or injuries, assisting with position changes or transferring from a wheelchair to a standing device. Support staff identify training needs for managing children with cerebral palsy, and request the participation and involvement of school physiotherapists.

I conduct 99% of the child’s training, and that doesn’t feel right. But, she’s in massive need of physiotherapy, so I do it for her [the child].

[41]

3.3.4. Integrating into Multidisciplinary Teams

The educational teams include pupils, parents, teachers, psychologists, occupational therapists, speech therapists, and physiotherapists. SP is committed to the integration and teamwork of all professionals. For educational team members, holistic care from multidisciplinary teams is the best option for children.

We’ve all got the same goals. I obviously fight for the education, physio fights for the physio, but I’m very mindful that there’s no point just doing 100% education in school. You need to have some therapy as well.

[28]

When goals are integrated, the educational team gets involved. They monitor and report on the progress of intervention strategies. As one therapist comments:

We work really hard to integrate goals … so that the teacher … or the staff can do it after we’re gone. So that they’re working on that same goal every day and not just when we’re there.

[35]

For school physiotherapists, knowing the opinions of students and parents is a key factor when it comes to involving them, setting goals, and achieving positive results in children’s treatment.

I definitely want their [students’] input [on goal development] because … if they don’t buy into it, you’re not going to go anywhere with it anyway. I like them to come up with ideas of what problems they are having with their disability and … work with them on learning what their disability is … and how we can work on it.

[42]

3.3.5. Accompanying, Treating, and Supervising in Natural Settings

Observing adolescents in different settings, such as at home or in school, is an essential part of physiotherapist interventions. SP is offered in a natural setting, with the goal of facilitating the child’s participation in school by integrating therapy into their daily lives. Another advantage is that physiotherapists can monitor the child over time, enabling the early detection of problems.

By working in a school, physiotherapists have the opportunity to monitor the children’s progress over time and detect any signs of decline before they become more serious.

[19]

3.3.6. Overcoming Setbacks and Coping with Difficulties

Working with adolescents who are in pain is a challenging and exhausting experience. SPs not only apply techniques, but also establish a therapeutic relationship focused on improving quality of life. When there is not enough time to care for all of the children, they rely on the multidisciplinary team and trained assistants.

I think you really have to collaborate with the other members of the team … we can’t be with a child all day every day. We don’t see the entire school day. We have lots of kids to serve … I think of specifically our kids who have a Physical Needs Assistant. That person is with them all day every day and is focused just on that one student.

[42]

For physiotherapists, achieving results is associated with setting goals with children, which makes them more independent and capable of making decisions.

Some of the kids are bigger than I am and they get to the stage where they - if they’ve got knee flexion contractures, if it’s uncomfortable and they don’t want to do it, then they on’t do it.

[28]

Therapists mention the need for adaptations and environmental modifications in their interventions with students. This requires quality training, including school physiotherapy in students’ practical rotations.

Related to this, some respondents from academia said it is increasingly difficult to secure good-quality rotations, especially in highly specific or innovative areas.

[44]

This quality training involves incorporating new skills and breaking out of the comfort zone that many veteran physiotherapists find themselves in. The inclusion of SPs in educational teams involves a clash of skills with other professionals. Developing specific skills in each area can help address this problem.

There will be staff that will be threatened there will be teachers that are threatened! there will be occupational therapist that is threatened… it will be a real risk to implementation of this model if it’s not done correctly.

[8]

5. Conclusions

Although there is evidence supporting various SP interventions, on its own it is insufficient to guide practice. The lack of guidelines, competencies, and clearly defined responsibilities expose SP to professional intrusion, a lack of support, and limited integration into educational teams. SP can ensure healthcare provision for children with specific pathologies and needs within schools; however, studies are needed on its impact on educational improvements and academic performance in the short and long term. The integration of SP services into educational settings continues to be a challenge. Future research should evaluate the effectiveness of most SP approaches and interventions. Understanding the opinions and experiences of participants in SP programmes provides information on the practice, and helps identify the strengths and weaknesses of these services.