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... IMPACT OF PROSTHESIS USE AND EMBODIMENT ON BALANCE CONFIDENCE, FEAR OF FALLING, AND FALLS IN INDIVIDUALS WITH UPPER LIMB LOSS OR DIFFERENCE Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Kristi L. Turner, MHS, OTR/L Copyright August 8, 2019 By: Kristi L. Turner, MHS, OTR/L All rights reserved Approved by: Elizabeth S. Moore, PhD Committee Chair Angelitta Britt-Spells, PhD, MPH, MS Committee Member Matthew J. Major, PhD Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 1 Impact of Prosthesis Use and Embodiment on Balance Confidence, Fear of Falling, and Falls in Individuals with Upper Limb Loss or Difference Kristi Turner University of Indianapolis IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 2 Abstract Background/Significance: Evidence suggests prosthesis use and prosthetic embodiment may affect balance confidence, fear of falling, and incidence of falls in individuals with upper limb loss or difference (ULL/D). Purpose: The purpose of this study was to evaluate the relationship of prosthesis use and embodiment with balance confidence, fear of falling, and incidence of falls (fallers versus non-fallers) in persons with ULL/D. Methods: Participants completed the survey online or over the telephone. A convenience sample was recruited from several sites that targeted the study population. Results: Eighty-four participants were included in the study. A nonsignificant negligible relationship was found between frequency of prosthesis use and balance confidence as well as with fear of falling. A non-significant weak relationship was found between prosthesis embodiment and balance confidence and also with fear of falling for individuals with unilateral and individuals with bilateral ULL/D. Analyses found a weak relationship between embodiment and frequency of prosthesis use in individuals with unilateral ULL/D (rs = .49, p < .001) and a strong relationship for individuals with bilateral ULL/D (rs = .72, p < .001). A significant difference was found between frequent fallers and non-fallers for balance confidence (p = .002) and fear of falling (p < .001). Discussion/Conclusion: Frequency of prosthesis use was associated with embodiment of the prosthesis; however, neither frequency of prosthesis use nor embodiment influenced the incidence of falls. Balance confidence scores were lower while scores for fear of falling were higher for fallers compared to non-fallers. This suggests these factors may be useful to identify potential fall risk in individuals with ULL/D. Keywords: Upper limb loss, upper limb difference, prosthesis, embodiment, balance, fear of falling, falls IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 3 Acknowledgments Throughout the years where I began working on my DHSc, the amount of support and assistance has been insurmountable. I want to thank my committee for taking a large amount of time out of their busy schedules with their own career and life responsibilities to help me through this dissertation. Your patience, diligence, and proficiency have been invaluable lessons to me. I hope that one day I will be as good a researcher and teacher as you all are. To my amazing family and friends, colleagues and other supporters that have supported and encouraged me along the way. Thank you for your willingness to share my study with your own clients, proofread, and give feedback even when some of you may not have known what was being talked about. Thank you for always listening intently and reminding me of what really is important. You are simply the best. To my friends and colleagues that I have gained through the University of Indianapolis, your knowledge and skill have taught me how to be a better teacher and researcher. Thank you for being the best sounding boards throughout the entire program. Knowing that we were all in it together kept me going through the more challenging times. Last but not least, thank you to all of the participants that completed my study. I know many of you completed it as a favor to me, I am so lucky to know and work with you. You are and always have been my inspiration to keep pushing forward. I am looking forward to working together for many years to come. Without all these individuals, I would not be here today and for that, I am forever in your debt. With deepest gratitude, Kristi L. Turner IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 4 Table of Contents Title Page ........................................................................................................................................ 1 Abstract ........................................................................................................................................... 2 Acknowledgements ....................................................................................................................... 33 Chapter 1: Introduction ................................................................................................................... 7 Purpose .................................................................................................................................... 8 Chapter 2: Literature Review ........................................................................................................ 99 Upper Limb Role in Balance ............................................................................................. 1010 Compensatory Movements after Upper Limb Loss .......................................................... 1111 Current Assessment and Treatment ....................................................................................... 13 Falls ....................................................................................................................................... 14 Embodiment....................................................................................................................... 1315 Chapter 3: Method .................................................................................................................... 2020 Study Design...................................................................................................................... 2020 Participants ........................................................................................................................ 2020 Data .................................................................................................................................... 2121 Instruments ........................................................................................................................ 2323 Procedures ......................................................................................................................... 2626 Statistical Analysis ............................................................................................................ 2929 Chapter 4: Results ..................................................................................................................... 3131 Chapter 5: Discussion ............................................................................................................... 3434 Chapter 6: Conclusion............................................................................................................... 4646 References ................................................................................................................................. 4747 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 5 Table 1 .......................................................................................................................................... 59 Table 2 ...................................................................................................................................... 6161 Table 3 ...................................................................................................................................... 6362 Table 4 ...................................................................................................................................... 6363 Appendix A ............................................................................................................................... 6464 Appendix B ........................................................................................................................... 104104 Appendix C ........................................................................................................................... 105105 Appendix D ........................................................................................................................... 106106 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 6 List of Tables Table 1 Descriptive Statistics of Participant Characteristics ........................................................ 59 Table 2 Correlation Results between Prosthesis Use to Embodiment, ABC Scale, and FES-I .... 61 Table 3 Correlation Results between Prosthesis Use to Embodiment, ABC Scale, and FES-I .... 62 Table 4 Sample Descritptives Comparisons of Outcomes of Frequent Fallers and Non-Fallers . 63 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 7 Impact of Prosthesis Use and Embodiment on Balance Confidence, Fear of Falling, and Falls in Individuals with Upper Limb Loss or Difference In 2005, an estimated 41,000 people in the United States lived with upper limb (UL) loss at or above the wrist level, and this number is projected to increase (Ziegler-Graham, MacKenzie, Ephraim, Travison, & Brookmeyer, 2008). Loss of an arm can cause severe disability affecting work and leisure activities and basic independence. The arms are known to play an important role in balance recovery after tripping and gait stability after perturbation (Bruijn, Meijer, Beek, & van Dieen, 2010; Pijnappels, Kingma, Wezenberg, Reurink, & Van Dien, 2010). Research with non-impaired individuals suggests that restricting one arm to their side during balance testing resulted in more severe, longer, and more frequent losses of balance (Shafeie, Manifar, Milosevic, & McConville, 2012). It is unknown whether similar balance results would be found in individuals with upper limb loss. Balance confidence is a measure of an individuals perception of their ability to perform an activity without losing balance or becoming unsteady (Powell & Myers, 1995), and has been correlated with postural control in populations such as Parkinsons disease (Lee, Altman, McFarland, & Hass, 2017; Pompeu et al, 2016). Postural control, or the ability to maintain a state of balance during any activity (Pollock, Durward, & Rowe, 2000), has been reported to improve in individuals with ULL/D who wore their prosthesis more ((Imaizumi, Asai, & Koyama, 2016). Evidence from Imaizumi et al.s study (2016) suggests that individuals with ULL/D who had improved postural control would also have improved balance. However, Major (2019) found that individuals with ULL/D generally did not exhibit low balance confidence. It is unknown whether the low balance confidence reported by individuals with ULL/D was affected by the frequency of their prosthesis use. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 8 Despite individuals with ULL/D not having low balance confidence, Major (2019) found they were more likely to experience two or more frequent falls. Individuals with ULL/D who have experienced falls may also have a fear of falling (Tajali et al., 2017). As with reported balance confidence, it is also unknown whether prosthesis use affects frequency of falls, and the relationship between prosthesis use and fear of falling has not been explored in this population. In addition, a recent study identified prosthesis use as a contributing factor that increases the likelihood of sustaining a fall in this population (Major, 2019); a follow up study found that prosthesis use increases postural demands (Major, Shirvaikar, Stine, & Gard, 2019). Currently, no studies have evaluated frequency of prosthesis use which may be a more appropriate measure of the incidence of falls. There is a gap in the literature concerning the relationship between prosthesis use and balance confidence, fear of falling, and incidence of falls in individuals with ULL/D. Another factor that may influence these variables is embodiment. Embodiment is when individuals with limb loss view their prosthesis as an extension of themselves (Dornfield et al., 2016). How often individuals wear their prosthesis and the extent they experience prosthesis embodiment may play a role in balance confidence, the incidence of falls, and fear of falling given the critical role arms play in maintaining ones functional balance during activity (Shafeie et al., 2012) and overall locomotor stability (Bruijn et al., 2010). However, to date, no studies have looked at the impact of self-reported embodiment on balance confidence, fear of falling, incidence of falls, or frequency of prosthesis use. The purpose of this study was twofold. First, this study explored the relationship between prosthesis use and balance confidence, incidence of falls, fear of falling. Second, it assessed the relationship between embodiment and balance confidence, incidence of falls, and fear of falling IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 9 in persons with ULL/D. To meet this purpose, the following primary null hypotheses were addressed: Prosthesis Use H0: there will not be a relationship between frequency of prosthesis use and balance confidence; H0: there will not be a relationship between frequency of prosthesis use and fear of falling; H0: there will not be a relationship between frequency of prosthesis use and incidence of falls; H0: there will not be a relationship between frequency of prosthesis use and embodiment. Embodiment H0: there will not be a relationship between prosthesis embodiment and balance confidence; H0: there will not be a relationship between prosthesis embodiment and fear of falling; H0: there will not be a relationship between prosthesis embodiment and incidence of falls. The following secondary hypotheses were addressed: H0: there will not be a difference between balance confidence and incidence of falls, selfreported frequent fallers and non-fallers. H0: there will not be a difference between fear of falling and incidence of falls, selfreported frequent fallers and non-fallers. Gaining a better understanding of the role prosthesis use and embodiment play in balance confidence and falls will help clinicians implement appropriate monitoring and rehabilitation IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 10 interventions to minimize the risk of falls and fall-related injuries. If these factors do affect balance confidence, incorporating measures into clinical settings can provide immediate benefit. Literature Review Losing a hand or arm can have a profound impact on an individuals quality of life due to challenges with activities of daily living, employment, and participation in leisure activities (Wijk & Carlsson, 2015). In addition, the loss or absence of an UL has the potential to impact an individuals postural control during daily tasks. Individuals with ULL/D demonstrate asymmetry toward their sound side, despite the use of a prosthesis (Major et al., 2018). In one study, individuals with transradial ULL/D had an increase in lateral tilt of their trunk and head flexion and rotation compared to healthy controls when performing functional tasks from both sitting and standing (Hussaini, Zinck, & Kyberd, 2017). However, it is unknown if these postural changes performed during functional activities affect individuals with ULL/D fall risk or fear of falling. There is sufficient evidence to support pursuing a better understanding of the relationship of the frequency of prosthesis use and embodiment with balance confidence, fear of falling, and falls in persons with ULL/D. Understanding the perception of these individuals regarding their fall risk can provide useful information for improving screening techniques and interventions. Clinically, answers to this question can lead to better fall prevention programs and minimize the risk of injury for these patients. Upper Limb Role in Balance Researchers have acknowledged the important role of the UL in postural control. It has been established that functional performance improves when the UL is used freely during clinical balance and mobility testing, (Milosevic, McConville, & Masani, 2011). Arm movement IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 11 has also been found to improve the ability to maintain and recover postural balance (Shafeie et al., 2012). Research suggests that the UL may play an important role in balance recovery after tripping and gait stability after perturbation as well (Bruijn, Meijer, Beek, & van Dieen, 2010; Pijnappels et al., 2010). More severe, longer, and frequent losses of balance occur when unable to use the UL during balance testing (Shafeie et al., 2012). When evaluating the role of the UL during trip recovery, younger adults exhibited a preventative strategy by elevating their center of mass and reducing the forward momentum of their body. In contrast, older adults reach forward as a protective response to stop a possible fall (Roos, McGuigan, Kerwin, & Trewartha, 2008). This information again highlights the importance of the UL in balance and fall risk and demonstrates how the reactions of individuals due to a loss of balance may result in a fall. Compensatory Movements after Upper Limb Loss Development of asymmetric postures, prosthesis wear, and changes in center of gravity may impair balance in individuals with ULL/D and increase the risk of falls. Studies have identified that compensatory movements in the trunk and proximal UL during reaching tasks were greater in all prosthetic users with ULL/D compared to healthy controls. Compensatory strategies most commonly used were lateral and forward trunk flexion to change the terminal device position (Metzger, Dromerick, Holley, & Lum, 2012). However, Major, Stine, Heckathorne, Fatone, and Gard (2014) found that transradial prosthesis users utilized shoulder abduction and trunk rotation to compensate for a lack of range of motion in the distal extremity of a prosthesis. Newer prosthetic users did not use a consistent movement pattern when completing tasks in repetition (Thies et al., 2017) and repeatable movements only occurred as the user gains experience with the prosthesis (Major et al., 2014). It is unknown if this variability of movement patterns and compensatory movements especially in a new prosthetic user could result IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 12 in loss of balance or falls especially as they are becoming familiar with their device. Additionally, arm amputation causes an approximate weight decrease, which may cause those with unilateral ULL/D to develop asymmetric body postures and a shifting of their center of gravity (Bertels, Schmalz, & Ludwigs, 2012). Wijk and Carlsson (2015) found when interviewing individuals with limb loss or absence at the mid-forearm level, that the prosthesis was described as beneficial for body posture and balance and without the prosthesis resulted in asymmetry of the body. This description was also supported in a study of individuals with loss of the UL at the shoulder disarticulation level. Postural asymmetry was reduced by an average of 45%, compensatory movements of the contralateral limb, increased swinging at the elbow and shoulder joint, were decreased, and there was improved body posture when wearing a prosthesis during walking (Bertels, Schmalz, & Ludwigs, 2012). However, nearly 34% of individuals with proximal ULL/D reject their prosthesis (Datta, Selvarajah, & Davey, 2004). For myoelectric and body-powered prosthetic users, rejection rates of 26% and 23% were reported (Biddiss and Chau, 2007). This lack of prosthetic wear after amputation can increase the severity of asymmetric postures over time and changes the individuals center of gravity while they are not wearing the prosthesis (Bertels et al., 2012). Although individuals with ULL/D at the shoulder disarticulation level had improved body posture when wearing a prosthesis compared to not wearing a prosthesis when walking (Bertels et al., 2012), this is not true for those with transhumeral ULL/D (Topuz et al., 2019). When gait was evaluated in individuals with unilateral ULL/D at the transhumeral level while wearing a prosthesis, they had a minimal arm swing on the side with limb loss which had a negative effect on dynamic balance compared to healthy controls (Topuz et al., 2019). Additionally, Major (2019) reported that individuals with ULL/D were more likely to fall if they IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 13 used an UL prosthesis. These studies highlight the importance of coordinating movements of both arms for stable balance and recovery (Shafeie, Manifar, Milosevic, & McConville, 2012). However, the impact a prosthesis has on postural control, balance, and fall risk is still largely unknown. Current Assessment and Treatment of Individuals with Upper Limb Loss or Difference As previously stated, there is a lack of research quantifying fall risk or fear of falling in individuals with ULL/D, and this lack of knowledge extends to the assessment and treatment of this population. Painter et al. (2009) reported that occupational therapists should assess fear of falling in older adults, as it may be one factor that is related to fall risk and activity restriction. However, when clinicians who work with this population identified key areas in rehabilitation, neither fall risk nor fear of falling were included (NiMhurchadha, Gallagher, MacLachlan, & Wegener, 2013). The findings by Major (2019) found individuals with ULL/D were nearly six times more likely to have repeated falls (2 or more) if they used a prosthesis, suggest further investigation of fall risk is warranted. In addition, appropriate and useful standardized functional performance assessments for individuals with ULL/D are lacking overall (Wright, 2009). Even the most highly rated selfreport measures for use with upper limb loss are not specific to those with ULL/D (Resnik, Borgia, Silver, & Cancio, 2017) and instruments that assess fall risk in this population are absent. Although the Trinity Amputation and Prosthesis Experience Scales (TAPES), was developed for individuals with LL amputation, it has been utilized with individuals with ULL/D and is the closest to assessing ULL/D impact on mobility. Individuals are asked to rate their perceived performance limitations during daily activities, including walking, climbing stairs, as well as during vigorous activities like running. When utilized with individuals with ULL/D, average IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 14 scores in the area of mobility restriction indicated low levels of mobility impairment (Desmond & MacLachlan, 2005); however, the TAPES does not specifically address balance confidence, fear of falling, or falls. Therefore, it is unknown how these individuals may truly be impacted by their limb loss although research suggests that individuals with ULL/D report a high incidence of falling (Major, 2019). This lack of evidence demonstrates the need for further research to understand fall likelihood in those individuals with ULL/D to assist clinicians in creating better evidenced-based interventions for this population. Balance confidence. Major (2019), reported that although confidence was high on average in individuals with ULL/D, this factor was a significant contributor to a predictive model of frequent falls (two or more), where lower balance confidence, as scored with the ActivitiesSpecific Balance Confidence (ABC) Scale, was predictive of an increased likelihood of falls. Due to the lack of literature on falls in persons with ULL/D, investigations into individuals with LL loss were used to generate rationale for studying balance confidence in this patient group of interest. Individuals with LL loss were shown to negatively influence balance confidence scores and social activity (Miller & Deathe, 2011). Balance confidence was also associated with performance, perceived mobility capability using a prosthesis, and social activity in individuals with LL amputations (Miller, Deathe, Speechley, & Koval, 2001). Similarly, the ABC Scale scores and fear of falling avoidance behavior were best at predicting future falls in older adults (Landers, Oscar, Sasaoka, & Vaughn, 2016). Just as further study is needed to describe what is contributing to a fear of falling outside of actual falls in this population, so also could information related to the fear of falling be useful in those with UL/D. Cumulatively these studies help solidify the need to study fear of falling and fall risk in those with ULL/D as this group is often expected to be otherwise high-functioning but IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 15 also have been reported to experience falls. Understanding their own perceptions of fall risk will help guide effective treatment strategies to prevent falls and subsequent injury. Falls Information is scarce in the literature on falls for those with ULL/D. In a survey of 109 individuals with upper limb loss at the wrist or higher, Major (2019) reported that 46% of these individuals experienced at least one fall and nearly a third fell more than once. The most common causes of falls were tripping and loss of balance; 30% reported falling while ascending/descending stairs and another 30% reported falling while walking outdoors (Major, 2019). Remarkably, of fallers, 31.7% indicated their most recent fall resulted in injury with 14.6% requiring medical attention or a hospital visit (Major, 2019). The impact of falls on balance confidence and fear of falling has been investigated in other populations. In elderly individuals and individuals with Parkinson's disease, those who had fallen in the past had significantly lower balance confidence scores, as measured by the ABC Scale, than those who had not fallen before (Lajoie & Gallagher, 2004; Mak & Pang, 2010). In individuals with dystonia, fear of falling scores as measured by the Falls Efficacy Scale International (FES-I), were high and ABC Scale scores were low and both worsened if there was a history of falls (Boyce et al., 2017). Additionally, Major (2019) reported the ABC Scale was associated with the likelihood of falling in individuals with ULL/D; however, other factors that may impact falls continue to be unknown. Embodiment The concept of embodiment is rooted in psychology which has recently been used in neuroscience to look at the relationship between people and their assistive device tool such as a prosthesis (Cardinali et al., 2009; Gouzien et al., 2017; Pazzaglia & Molinari, 2016). The term IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 16 embodiment has been described as a specific type of information processing and the sense of embodiment includes the feeling of ownership (De Vignemont, 2011). Embodiment has often been described in relation to the rubber hand illusion (RHI). In the RHI, one of the individuals hands is hidden from view with a screen while a rubber or prosthetic hand is placed in front of them. The individual is instructed to stare at the artificial hand while both their hand and the artificial hand are brushed simultaneously (Botvinick & Cohen, 1998). This RHI causes the individual to sense the touch of the artificial hand instead of their own (Botvinick & Cohen, 1998). Longo, Schr, Kammers, Tsakiris, and Haggard (2008) identified embodiment subcomponents in the RHI of ownership (feeling the rubber hand was part of their body), location (feeling their hand and the rubber hand were in the same spot), and agency (feeling they were able to move the rubber hand). When an individual uses a tool such as a prosthetic device, the ability to incorporate their physical body awareness with the device is necessary to interact with their environment. This connection between body perception and the tool is often called embodiment and could be one of the critical factors affecting functional recovery (Pazzaglia & Molinari, 2016). Many studies combine a short questionnaire after the RHI to capture the individuals experience in an attempt to quantify embodiment. The Embodied Sense of Self Scale (ESS) is a questionnaire that was developed to measure disturbances to the sense of self, as seen in schizophrenia (Asai, Kanayama, Imaizumi, Koyama, & Kaganoi, 2016). However, some of the challenges with identifying subjective embodiment is that the feeling of self is a concept of which we are not always aware (Asai et al., 2016). Although these studies are just a few examples of the work that has been done in relation to embodiment using the RHI, the construct of embodiment including in relation to upper limb prosthesis users continues to be difficult to IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 17 quantify. Prosthesis embodiment in individuals with upper limb loss. Embodiment is a complex experience that ranges from self-embodiment to embodiment of rubber limbs, tools, and prostheses (Giummarra, Gibson, Georgiou-Karistianis, & Bradshaw, 2008). Prosthesis embodiment is explained as the process when individuals with limb loss view their device as an extension of themselves (Dornfeld et al., 2016). Although the term embodiment is not commonly used by prosthesis users or the rehabilitation team, the extent a prosthesis user integrates their prosthesis into their life (Gouzien et al., 2017) is commonly reviewed in the rehabilitation process and captures the sense of embodiment. Canzoneri, Marzolla, Amoresano, Verni, and Serino (2013) found that individuals with ULL/D, who were long-term prosthesis users, perceived their residual limb as longer and their peripersonal space with boundaries expanded to include the area around their prosthetic hand. However, those who did not wear their prosthesis perceived their residual limb as shorter and their peripersonal space around their residual limb shrank (Canzoneri et al., 2013). When wearing a prosthesis, the reaching space is smaller than it is with a healthy limb. Despite that, individuals judged they could reach as far with their prosthesis as they could with their healthy limb. Interestingly, this overestimation was smaller with the prosthesis than the sound limb when the individual had high prosthesis integration as measured by a questionnaire on how they used and experienced their prosthesis (Gouzien et al., 2017). Studies also suggest that long-term tool use, such as a mechanical grabber, can increase performance of using the prosthesis and lead to incorporating the tool into their body representation (Cardinali et al., 2009). Murray (2004) found that although individuals with congenital limb absence did not have phantom limb sensation, they reported the sense of embodiment with their prosthesis. This study IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 18 acknowledges that prosthesis users whether due to amputation or from congenital limb absence, often provide explanations of integrating the prosthesis into their body structures (Murray, 2008). Daily upper-limb prosthesis users who embodied their prosthesis (reported the prosthesis as part of themselves and an inability to perform tasks without it), reported reduced environmental obstacles such as climate, prosthesis inadequacies, and attitudes, while those who did not use their prosthesis daily did not experience prosthetic embodiment and reported challenges in these areas (Widehammar, Pettersson, Janesltt, & Hermansson, 2017). Nico, Daprati, Rigal, Parsons, and Sirigu (2004), found that individuals who wear a more functional prosthesis (those that assist in task performance such as myoelectric or body-powered) versus aesthetic prosthesis (passive or cosmetic), may also have a greater sense of embodiment. These studies suggest that individuals who wear their functional prosthesis more frequently, have a sense of embodiment. However, it is unknown if these factors of prosthesis use and embodiment impact an individuals balance confidence, fear of falling, or fall likelihood. Embodiment and balance. Body posture is maintained by utilizing information from visual, vestibular, and somatosensory systems (Collins & De Luca, 1993). Balance and body posture is maintained by combining a feedforward system, which anticipates the motor control needed (van der Kooij, Jacobs, Koopman, & Grootenboer, 1999), with a feedback system, where the intended location of a body part is compared with its actual location through information received from multiple sensory inputs (Mergner & Rosemeier, 1998). The body schema or representation of ones own position and movement body in space (Holmes & Spence, 2004), and incoming kinesthetic information are important factors for postural control (Gurfinkel, Ivanenko, Levik, & Babakova, 1995). Although individuals with ULL/D may lack some perceptual feedback due to their loss of limb, using a prosthesis to restore their body schema IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 19 (Mayer, Kudar, Bretz, & Tihanyi, 2008) may positively contribute to postural control (Imaizumi et al., 2016). As previously mentioned, quantifying embodiment in individuals with ULL/D has mainly been reported in relation to the RHI. Embodiment subcomponents identified by Longo et al. (2008) are ownership, agency, and location. Ownership refers to the feeling that the artificial limb is part of their body, agency is the feeling of having control over the artificial limb and being able to move it, and location refers to the sense that the artificial hand and the individuals own hand were in the same space (Longo et al., 2008). It has been reported that agency can create body ownership towards external objects (Asai, 2016; Imaizumi et al., 2016). Imaizumi et al. (2016), found that frequent use of a prosthesis by individuals with ULL/D creates a greater sense of embodiment which is related to improved posture. On the other hand, infrequent use of a prosthesis led to a diminished sense of embodiment and increased postural sway or movement outside of the center of gravity. For individuals to have improved posture and embodiment and have a sense of agency rather than ownership, they need to willingly use and operate their prosthesis as well (Imaizumi et al., 2016). Although findings from Imaizumi and colleagues (2016) study suggest individuals who report they have control over their prosthesis (agency) was more important than ownership in postural control, it should be interpreted with caution given the small sample size (N = 9). Also, the study results may not be transferred to all individuals with ULL/D (Imaizumi et al., 2016). This study provides insight into the importance of agency when characterizing prosthesis embodiment and its relationship to balance confidence and falls. From the evidence, it can be hypothesized that those who have a sense of agency may also report a feeling that their prosthesis is part of their body (ownership) which leads them to wear their prosthesis more and in turn, improved stability; however, this is currently unknown. Identifying IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 20 how the frequency of prosthesis use and prosthesis embodiment affect balance confidence and falls can suggest appropriate evaluation and treatment methods to prevent potential injuries in this patient group. However, literature addressing the current research question of evaluating the relationship of prosthesis use and embodiment with balance confidence, fear of falling, and falls in persons with ULL/D is absent. Method Study Design This was a cross-sectional study that assessed the associations and potential relationships between frequency of prosthesis use, embodiment, balance confidence, fear of falling, and falls among adults with ULL/D. Participants completed an anonymous online survey, using Qualtrics (Provo, UT), an online survey platform, or completed the survey over the telephone. The survey was available to participants from September 2018 to December 2018. Prior to participant recruitment, the study was approved by the Institutional Review Board (IRB) for Social Behavioral Research from Northwestern University. Participants A convenience sample was recruited from several sites: the Amputee Coalition website, the Skills for Life Bilateral Upper Limb Loss Workshop, the Shirley Ryan AbilityLab Prosthetic and Orthotic Care Center (POCC), the Center for Bionic Medicine (CBM), the outpatient therapy center, the Shirley Ryan AbilityLab Amputee Registry, and the Northwestern University Prosthetics-Orthotics Center. In addition, snowball sampling strategy was used to identify additional participants. Participant eligibility criteria for inclusion into the study included English-speaking, at least 18 years of age, and having one or more ULL/D at the wrist level or higher. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 21 Prior to the start of the study, an a priori minimum sample size estimation was conducted using G*Power, version 3.1 (Faul, Franz, Erdfelder, Buchner, & Lang, 2009). The sample size calculation was based on a two-tailed correlation bivariate normal model between prosthesis use and balance confidence. The effect size was based on results from the study by Major (2019) which reported a correlation of .35 between prosthesis use (years) and the ABC. In addition, the following parameters were used, of .05, of .20. From this calculation, it was estimated a minimum sample size of 61 participants was needed to sufficiently power the study. Additional participants were recruited to increase statistical power of the study. Data The survey (Appendix A) consisted of the consent document and four separate instruments and/or questionnaires: sociodemographic and participant characteristic questionnaire, the ABC Scale instrument (Appendix B), the Falls Efficacy Scale International (FES-I) instrument (Appendix C), and an embodiment questionnaire (Appendix D). Sociodemographic and patient characteristic data included: age, gender, time since limb loss, level of limb loss, cause of limb loss, prosthesis type and usage, comorbidities, medications, and fall history. While it was expected that most participants would complete the survey online, participants were given the option of having the data collected by the primary researcher (K. T.) in person or over the telephone. Once the survey was closed, data were downloaded into an Excel spreadsheet, checked for errors, and formatted for data analysis. Once this was completed, the data were exported into IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY) for analysis. Operationalization of variables. Balance confidence was measured with the ABC Scale and fear of the falling was measured with the FES-I. Age and time since limb loss/difference IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 22 were measured in years. The most proximal level of limb loss reported (at or through the shoulder, between the shoulder and elbow, at the elbow, between the elbow and wrist, at wrist, and part of the hand) and prosthesis type (passive/cosmetic, body-powered, myoelectric/motorized, activity-specific, or hybrid) for this level was used, therefore only the most proximal side was included for participants with bilateral ULL/D. Individuals who reported having bilateral ULL/D at the wrist or proximal on one side and the level of partial hand on the other side were included in the bilateral ULL/D category, although only the proximal side was used for limb loss level. Categories for the cause of limb loss/difference included trauma/accident, congenital, infection, cancer, and other with the option of filling in a category not listed. Prosthesis use was determined by the number of days per week the individual reported wearing their prosthesis multiplied by the number of hours a day they reported wearing their prosthesis, giving a total number of hours of use in a week. Comorbidities were measured using the Functional Comorbidity Index (FCI). A medication was defined as something prescribed by a physician and a fall was defined as coming to rest accidentally on the ground or other lower level, other than because of lost consciousness, a violent blow, stroke, or epileptic seizure (Askham et al., 1990). Consistent with the study by Major (2019), frequent fallers were defined as reporting two or more falls and non-fallers as reporting up to one fall, to capture where falls may be a fundamental problem. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 23 Instruments The following instruments were incorporated into the survey which was completed by all study participants. Permission to use these surveys was granted by the instrument authors. Activities-Specific Balance Confidence Scale. The ABC Scale (Appendix A) is a selfreport measure in which individuals rate a variety of activities on a scale of 0 to 100 by how confident they are performing each listed activity without falling. A score of zero represents no confidence and a score of 100 represents complete confidence. An overall score is calculated by summing the individual scores for each of the 16 items and then dividing by 16, the total number of items on the scale. The final score is reported as a percent of balance confidence. The ABC Scale has been utilized with other populations including individuals with Parkinsons disease, stroke, and multiple sclerosis, older adults, and LL amputation. In individuals with LL amputation, the ABC Scale has excellent test-retest reliability (ICC = .91) and internal consistency, Cronbachs =.95 (Miller, Deathe, & Speechley, 2003). Convergent validity was demonstrated with a positive association, r = .72, 95% CI [0.56, 0.84] with the 2 Minute Walk Test and a negative association, r = -.70, 95% CI [-0.82, 0.53] with the Timed Up and Go (Miller et al., 2003). Although the ABC Scale has not been validated for those with ULL/D, both individuals with UL and LL loss have reported similar balance confidence and evidence suggests ABC Scale scores are related to falls in those with LL amputation (Wong, Chen, Blackwell, Rahal, & Benoy, 2015). Evidence also suggests ABC Scale scores are related to falls in other populations with unsteadiness such as multiple sclerosis (Tajali et al., 2017), Parkinson disease (Mak & Pang, 2009), dystonia (Boyce et al., 2017a), and community-dwelling elderly (Lajoie & Gallagher, 2004a). This may better explain the factors influencing fall risk among those with ULL/D. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 24 Falls Efficacy Scale International. The FES-I (Appendix B) is a self-report measure in which individuals rate 16 functional activities on a four-point Likert scale on how concerned they are that they might fall. A score of one means they are not at all concerned and a score of four means they are very concerned. Scores for each question are added together to calculate a total score, with a higher score signifying a greater fear of falling. The FES-I was developed to measure older adults with or without a history of fear of falling. During initial validation and development of the scale, it showed excellent internal and test-retest reliability (Cronbachs = .96, ICC = .96, respectively) in community-dwelling older adults (Yardley et al., 2005). The FES-I has excellent test-retest reliability with individuals with vestibular disorders (ICC = .94) and criterion validity with ABC Scale scores (r = -.84) (Morgan, Friscia, Whitney, Furman, & Sparto, 2013). Similar to the ABC Scale, evidence suggests the FES-I has been able to accurately predict falls in individuals with multiple sclerosis (Mazumder, Murchison, Bourdette, & Cameron, 2014). Although the FES-I has not been validated for those with ULL/D, examining the fear of falling may better explain the factors influencing fall risk among these individuals. Embodiment questionnaire. The custom-designed embodiment questionnaire (Appendix C) measured self-reported prosthetic embodiment. It consists of Likert-like scale questions which are based on a review of the literature and a questionnaire created by Imaizumi, Asai, and Koyama (2016) and a variation of Gouzien et al. (2017). There were a total of 12 questions, but individuals with bilateral ULL/D did not complete questions 2, 8, and 9 as these questions required indicating towards intact side or side of ULL/D. A high score indicated more embodiment with their prosthesis and a lower score indicated less embodiment. To establish face validity of the questionnaire, it was assessed by other experts in the field of embodiment with ULL/ as well as by Imaizumi, the lead author of the Imaziumi et al. (2016) article. Revisions and IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 25 additions were made based on feedback from occupational therapists, rehabilitation scientists, prosthetists, and biomedical engineers. All agreed the measure had adequate face validity. This is a newly created questionnaire; therefore, validity and reliability have not been fully evaluated. However, during the current study, the internal reliability of the questions was assessed using a Cronbachs alpha. For this study, a Cronbachs alpha of .70 was considered acceptable. This cutoff value was based on what is reported literature (Nunnaly, 1978; George & Mallery, 2003). The Cronbachs alpha reliability coefficient for individuals with unilateral ULL/D was = .83 and for those with bilateral ULL/D was = .81. Both these values are considered good and are above the acceptable cutoff value (George & Mallery, 2003). Functional Comorbidity Index. The FCI is an 18-item list of diagnoses that can be used in the general population to determine physical function. Individuals answer yes or no to whether they have the diagnoses listed. The score is determined by adding yes answers, with zero meaning no comorbid illness up to 18 meaning the highest number of comorbid illnesses. Understanding the effects comorbidities may impact the physical function of individuals with ULL/D can assist in determining fall risk, therefore the FCI was chosen. The FCI is a better indication of physical function compared to the Charlson Comorbidity Index and the KaplanFeinstein Index and explained more variance in physical function than these measures that are used to predict mortality (Groll, To, Bombardier, & Wright, 2005). In patients undergoing orthopedic surgery, the FCI predicted the occurrence of all adverse events and was consistently stronger in this association than the Charlson Comorbidity Index (Gagnier, Morgenstern, & Kellam, 2017). The information from the FCI in addition to the other measures utilized in this study may provide important information in evaluating individuals with ULL/D safety. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 26 Procedures Recruitment. Participants were identified through the Amputee Coalition website and the Skills for Life Bilateral Upper Limb Loss Workshop, Shirley Ryan AbilityLab POCC, the CBM, the outpatient therapy center, and the Shirley Ryan AbilityLab Amputee Research Registry. Participants who met inclusion criteria as stated above were recruited to participate in the study. The Amputee Coalition website. The Amputee Coalition is the nations leading organization on limb loss and limb difference and provides education, support, and advocacy. They are committed to preventing limb loss, improving patient care, and increasing the quality of life for individuals with limb loss and limb difference and their families. Once approval was given by this organization, study information was posted to their respective social media pages including their website and Facebook page. Skills for Life Bilateral Upper Workshop. Upon approval from the conference committee, participant recruitment and data collection were done at the national conference called the Skills for Life Bilateral Upper Limb Loss Workshop which was held in Houston, Texas in October 2018. This conference was for individuals with bilateral ULL/D and individuals with multiple limb loss, their families as well as clinicians, vendors, and researchers. In addition, study information was posted on their Facebook page. Potential participants were identified at the conference by the primary researcher or by trained clinicians. Individuals with ULL/D were approached by the primary researcher or a trained clinician to determine if they were interested in participating in the survey. If they were interested, they were given a computer or tablet to complete the consent and survey either independently or the primary researcher read the consent verbatim and recorded the participants IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 27 responses. If the individual was interested in participating in the study but was unable to complete the survey at that time, a flyer was provided with the link to the study. Individuals could access the survey from home and complete the consent form and survey on their own computer. Permission for the researcher to recruit at this conference was given once IRB approval was obtained. Northwestern University Prosthetics-Orthotics Center. Individuals with ULL/D who served as patient models as part of the clinical education program were contacted by the primary researcher. Individuals interested in participating in the study were emailed the link to the survey. If the participant preferred to participate in the study over the phone, the primary researcher scheduled a telephone meeting for obtaining consent and data collection. Shirley Ryan AbilityLab Prosthetic and Orthotic Care Center and the outpatient therapy center. Individuals were identified by clinicians in the POCC and outpatient centers. The researcher educated colleagues in the POCC and the outpatient center about the study and requested recruitment of their own clients who fit the inclusion criteria. Recruitment materials were provided to clinicians in the POCC and the outpatient clinic at the Shirley Ryan AbilityLab. These materials consisted of a flyer that was emailed or printed out that provided information about the purpose of the study, participation requirements, risks and benefits of this study, a link the participant could go to for completing the consent and survey for the study, and researcher contact information for study inquiries or concerns. Interested participants were able to utilize the link provided for consent and completing the study or could contact the primary researcher directly via the contact email or phone number provided via the recruitment flyer. A follow-up phone call or meeting could be made with the researcher to discuss the study protocol if desired by the participant. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 28 Shirley Ryan AbilityLab Center for Bionic Medicine. Potential participants who fit the inclusion criteria of having ULL/D were also be identified by the primary researcher if they have been involved in prior research studies with CBM by following up by phone or email. Interested participants could utilize the link provided for consent and completing the study or could contact the researcher directly via the contact email or phone number provided via the recruitment flyer. A follow-up phone call or meeting could be made with the researcher to discuss the study protocol if desired by the participant. Amputee Research Registry. The research registry is an IRB approved list of individuals who have been consented to be contacted for future research studies. Permission for the primary researcher to use the registry was given after the IRB approved the proposed study. Once IRB approval was obtained, individuals with ULL/D were contacted by the primary researcher via telephone or email to invite them to participate in the study. Individuals interested in participating in the study were emailed the link to the survey. If the participant preferred to participate in the study over the phone, the primary researcher scheduled a telephone meeting for obtaining consent and data collection. Informed consent. Informed consent was obtained through the online survey or verbally by the primary researcher. The informed consent document was on the first page of the survey. To be able to progress to the survey, participants had to indicate they read the informed consent document and agreed to participate in the study. For those who took the survey over the phone, the primary researcher read the consent verbatim and recorded the participants responses. Potential participants were exclude if they did not agree to the terms of the consent. If the participant agreed to the terms of the consent, the researcher continued to the survey questions. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 29 Survey procedure. Surveys were completed either online independently or researcher guided in-person or via the telephone. Individuals interested in participating in the study were given a flyer or sent an email that contained a link to the survey. The researcher guided option was provided to allow individuals who did not have access to a computer the opportunity to participate in the study. Research has shown that using different modes of data collection does not negatively impact the quality of the data collected (Revilla, 2012). Surveys completed inperson or over the phone were entered into the Qualtrics program by the primary researcher at the time the survey was completed. Each question was read verbatim as it appeared in the survey to ensure accuracy. If questions arose, further clarification was provided by the primary researcher via telephone or at the time the participant was completing the survey if the primary researcher was present. The entire process of consenting and completing the survey took between 15-20 minutes. Confidentiality. Survey participants were anonymous and no personally identifying or sensitive information was obtained from participants. All data collected from participants were considered privileged and held in confidence. Study data are stored in password-protected computers or in locked filing cabinets as applicable. In the case that study results are published, given no personal identifying data was collected, participants identities will not be indicated. The data will be destroyed after seven years or later when it is deemed no longer scientifically relevant. Statistical Analysis All data analysis was conducted using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY). All comparisons were two-tailed and an alpha level less than .05 was considered statistically significant. Data assumptions of normality were tested on the following IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 30 variables: frequency of prosthesis use, embodiment, the ABC Scale, and the FES-I utilizing the Shapiro-Wilk test and skewness/kurtosis. Prosthesis use (p < .001), the ABC Scale (p < .001), and the FES-I (p < .001) were not normally distributed. Embodiment scores in both individuals with unilateral ULL/D (p = .648) and individuals with bilateral ULL/D (p = .458) were normally distributed. Non-normally distributed data are reported as median and 25th and 75th percentiles. Normally distributed data are reported as mean and standard deviation. Although embodiment scores in individuals with unilateral ULL/D and in individuals with bilateral ULL/D were normally distributed, the continuous dependent variables used for the correlation tests were not normally distributed therefore, the non-parametric Spearman rho correlation coefficient was used. Correlation coefficient (r) strength was interpreted as follows: r < .30 very weak correlation or none; .30 < r < .50 weak correlation; .50 < r < .70 moderate correlation; and r > .70 strong correlation (Moore, Notz, & Flinger, 2013). The same variables (frequency of prosthesis use, ABC Scale, FES-I, embodiment score) were tested for normality using the Shapiro-Wilk test p values and skewness/kurtosis looking at the difference between fallers and non-fallers. Frequency of prosthesis use with non-fallers (p = .001) was not normally distributed; however, frequent fallers (p = .068) were normally distributed. There was not normal distribution with the ABC Scale in frequent fallers (p = .001), or non-fallers (p < .001) or with the FES- I in the non-fallers group (p < .001). However, in the frequent faller group, there was normal distribution (p = .052). Because the data were not normally distributed in both groups within each of the variables, the non-parametric MannWhitney U test was used to look for differences between groups. Effect sizes were calculated and interpreted using Cohens d indicating a small effect size of .20, a medium effect size of .50, and a large effect size of .80 (Cohen, 1992). IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 31 Results A total of 97 participants started the survey; however, only 84 (86.6%) completed the survey and were included in the analysis. Detailed characteristics of the 84 participants can be found in Table 1. For the overall sample, the median age of participants was 50.50 years, the majority were male, had unilateral ULL/D between the elbow and wrist caused by trauma. Primary Hypotheses Prosthesis use and balance confidence. The null hypothesis was tested that there will not be a relationship between frequency of prosthesis use and balance confidence. The alternative hypothesis was that there will be a statistically significant relationship between prosthesis use and balance confidence. Based on a Spearman rho correlation, as can be found in Table 2, a very weak positive non-significant correlation was found between frequency of prosthesis use and ABC Scale scores. The null hypothesis was accepted. Prosthesis use and fear of falling. The null hypothesis that there will not be a relationship between frequency of prosthesis use and fear of falling was tested. The alternative hypothesis was that there will be a statistically significant relationship between prosthesis use and fear of falling. Based on a Spearman rho correlation, as can be seen in Table 2, a very weak positive non-significant correlation was found between frequency of prosthesis use and FES-I scores. Therefore, the null hypothesis was accepted. Prosthesis use and incidence of falls. The null hypothesis was tested that there will not be a relationship between prosthesis use and incidence of falls (fallers and non-fallers) and the alternative hypothesis was that there will be a relationship between prosthesis use and incidence of falls. As can be seen in Table 4, results indicate there was not a statistically significantly difference in prosthesis use by incidence of falls; however, there was a medium effect size. The IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 32 null hypothesis was accepted. Prosthesis use and embodiment. The null hypothesis was that there will not be a relationship between frequency of prosthesis use and embodiment. The alternative hypothesis was that there will be a statistically significant relationship between frequency of prosthesis use and embodiment. As can be seen in Table 2, there was a medium positive significant correlation between frequency of prosthesis use and embodiment scores in individuals with unilateral ULL/D while a strong positive correlation was found between frequency of prosthesis use and embodiment scores in individuals with bilateral ULL/D. Results suggest as prosthesis use increases, embodiment scores also increase in both individuals with unilateral ULL/D and individuals with bilateral ULL/D. The null hypothesis was rejected and the alternative was accepted. Embodiment and balance confidence. The null hypothesis tested was that there will not be a relationship between prosthesis embodiment scores and balance confidence and the alternative hypothesis was that there will be a relationship between prosthesis embodiment scores and balance confidence. A very weak positive non-significant relationship was found between embodiment scores of individuals with unilateral ULL/D and ABC Scale scores and embodiment scores of individuals with bilateral ULL/D and ABC Scale scores. See Table 3 for the details. The null hypothesis was accepted. Embodiment and fear of falling. The null hypothesis that there will not be a relationship between prosthesis embodiment and fear of falling and the alternative hypothesis that there will be a relationship between prosthesis embodiment and fear of falling was tested. A very weak negative non-significant relationship was found between embodiment and fear of falling for both individuals with unilateral and bilateral ULL/D. Therefore, the null hypothesis IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 33 was accepted. Detailed results can be found in Table 3. Embodiment and incidence of falls. The null hypothesis that there will not be a relationship between embodiment between and incidence of falls and the alternative hypothesis was that there will be a relationship between embodiment and incidence of falls was tested. As can be seen in Table 4, results indicate there was not a statistically significant difference in embodiment by incidence of falls for individuals with unilateral ULL/D or bilateral ULL/D. For unilateral ULL/D there was a small effect size while there was a medium effect size for individuals with bilateral ULL/D. The null hypothesis was accepted that there was not a statistically significant difference in embodiment by incidence of falls. Secondary Hypotheses Difference between balance confidence and incidence of falls. The secondary hypothesis was tested that there will not be a difference between balance confidence and incidence of fall; the alternative hypothesis was that there will not be a difference between balance confidence and incidence of fall. Results (see Table 4) indicate there was a statistically significant difference in balance confidence by incidence of falls with non-fallers having greater confidence. A medium high effect size was also found. The null hypothesis was rejected and the alternative was accepted. Difference between fear of falling and incidence of falls. The secondary hypothesis that there will not be a difference in fear of falling by incidence of fall. The alternative hypothesis was that there will not be a difference in fear of falling by incidence of falls. There was a statistically significant difference in fear of falling by incidence of falls with non-fallers having a lower fear of falling compared to frequent fallers. There was also a large effect size. The null hypothesis was rejected and the alternative is accepted. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 34 Discussion The purpose of this study was to evaluate the relationship between the frequency of prosthesis use and embodiment with balance confidence, fear of falling, and falls in persons with ULL/D. Participant characteristics of this study align with previously published studies on this population. In the current study, the majority of participants were men (69%) with ULL/D due to trauma (54.8%) which is consistent with previous studies in which researchers reported males were more likely than women to have ULL/D from trauma (Dillingham, Pezzin, & MacKenzie, 2002; Varma, Stineman, & Dillingham, 2014). Study participants median age of 51 years for this study was similar to mean age of 43 years reported by Major (2019). Frequent fallers of the total sample made up a larger proportion of the total participants at approximately 40.1% compared to Major (2019), who had 28.6%. This may be explained by the fact that the current study also had a larger number of individuals with bilateral ULL/D, (n = 24, 28.6% of the total sample) compared to 16 individuals, 16.3% of the total sample, in the study by Major (2019). Of the individuals with bilateral ULL/D of the total sample, 45.8% had frequent falls and those with unilateral ULL/D, 38.3% had frequent falls. Because individuals with bilateral ULL/D had a higher percentage of frequent fallers than those with unilateral ULL/D, this may also explain why this study had more frequent fallers. Another explanation as to why there are more frequent fallers in this study is that Majors study also had a larger number of individuals with congenital ULL/D, (n = 47, 48.0%) compared to this study (n = 12, 14.3%). In addition, the current study had more individuals with ULL/D due to trauma, n = 46 (54.8%), higher than the study by Major (2019), n = 42 (42.9%). It is possible that individuals who were born with a limb deficiency have adapted how they perform tasks to their living environment and falling may not be as much of a concern. Those who have acquired limb loss may not have had fully adapted to their IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 35 environment. This is especially true for individuals as they are learning how to utilize their prosthesis where lateral and forward trunk flexion are commonly needed to position the prosthesis for functional tasks (Metzger, Dromerick, Holley, & Lum, 2012). These movements may create a change in their center of gravity causing them to lose their balance and potentially sustain a fall. However, the study by Major (2019) did not find etiology to be associated with frequent falls, so there is some doubt that this is the reason for the increase of frequent fallers in the current study. Additionally, the study by Major (2019) only involved online recruitment and the current study involved online and in-person (rehabilitation center, research center, and a conference). Because the primary researcher works with individuals with ULL/D and knew some of the participants, in-person recruitment may have influenced participants responses. Although the researcher read and reported the survey questions verbatim, participants may have reported falls with the anticipation that the researcher was looking for individuals who had experienced a fall in order to please the researcher. Primary Hypotheses Prosthesis use. There was not a significant relationship found between frequency hours of prosthesis use and the ABC Scale and the FES-I. Therefore, the null that there will not be a relationship between frequency of prosthesis use and balance confidence and the null that there will not be a relationship between frequency of prosthesis use and fear of falling were accepted. This indicates that neither balance confidence (ABC Scale scores) or fear of falling (FES-I) are associated with the frequency amount of time an individual wears a prosthesis. The FES-I was developed to improve the ability to assess fear of falling in more demanding social and physical activities as compared to the FES and was better at detecting differences in those who have fallen before and fall risk factors (Yardley et al., 2005). The ABC Scale was developed to also assess IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 36 fear of falling, but with more difficult activities and more detail than the FES (Powell & Myers, 1995). Although similar measures, the ABC Scale asks about confidence in becoming unsteady or losing balance which assumes that balance can be recovered, whereas the FES-I specifically asks about the concern for falling. This study had a majority of individuals who have ULL/D due to trauma and are younger which is consistent with the literature (Ziegler-Graham, MacKenzie, Ephraim, Travison, & Brookmeyer, 2008). Although both the ABC Scale and FES-I ask about a variety of activities, younger individuals may participate in activities that put them at risk for falling which was found in another study (Wong, Chihuri, & Li, 2016). If younger individuals with ULL/D do participate in risker activities, they may perceive themselves as being a confident person and not intimidated challenges. This may lead them report balance confidence and very little fear of falling. Additionally, low balance confidence and fear of falling are seen when there has been a fall in the past (Boyce et al., 2017b; Lajoie & Gallagher, 2004b; Mak & Pang, 2010). If an individual has not fallen recently, he or she may not report low balance confidence or fear of falling. It is also possible that prosthesis use may not impact ABC Scale and FES-I scores. Biddiss and Chau (2007) reported many individuals wear their prosthesis passively and Ostlie et al. (2012) reported many only wear them half of the time in everyday life and have adjusted their activities accordingly. Therefore, individuals may feel confident they will not become unsteady and will not have a fall. Another possibility a significant relationship was not seen between frequency of prosthesis use and balance confidence and fear of falling is that both the ABC Scale and the FES-I responses showed a ceiling/floor effect. Many of the respondents were at the highest confidence level on the ABC Scale and lowest scores for fear of falling for the FES-I, causing little variability, which questions the ability of these measures to detect any change. This lack of variability in these measures could be one factor no significant relationship was found. It IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 37 also cannot be ruled out that these results may also indicate that there is not a relationship between frequency of prosthesis use and self-reported balance confidence, and hours of prosthesis use and self-reported concern of falling because there are other factors that were not considered in the study. A moderate positive significant relationship was between the frequency of prosthesis use and embodiment scores of individuals with unilateral ULL/D and bilateral ULL/D. These results are similar to those reported by Imaizumi et al. (2016); individuals who wore their prosthesis more often reported more embodiment. To make a prosthetic device or tool useful to the user, the device must be worn to gain experience and skill in using the device. If a prosthetic device feels like an extension of themselves, it makes sense that the individual would wear it more. This aligns with previous findings that individuals who wore their prosthesis frequently felt prosthesis embodiment and those who were infrequent prosthesis users did not (Widehammar, Pettersson, Janesltt, & Hermansson, 2017). Although this study and previous findings suggest there may be a relationship of prosthesis embodiment and frequency of prosthesis use, the construct of embodiment continues to be a complex one and it is likely multiple factors influence prosthesis embodiment. Further investigation into the ability of the embodiment questions utilized in this survey to accurately identify prosthesis embodiment is needed as the connection between body perception and the prosthesis (embodiment) could be one of the critical factors affecting functional recovery (Pazzaglia & Molinari, 2016). Embodiment. Both the null hypothesis that there would not be a relationship between prosthesis embodiment scores and the ABC Scale (balance confidence) and that there will not be a relationship between prosthesis embodiment scores and the FES-I (fear of falling) was accepted. No significant relationships were found in individuals with unilateral ULL/D or IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 38 bilateral ULL/D in embodiment scores and the ABC Scale scores or FES-I scores. These results suggest that embodiment level of a prosthesis does not impact individuals subjective balance confidence or fear of falling. Although individuals with ULL/D may lack some perceptual feedback due to their loss of limb, using a prosthesis to restore their body schema (Mayer, Kudar, Bretz, & Tihanyi, 2008) may positively contribute to postural control (Imaizumi et al., 2016). However, for individuals to have improved posture and embodiment, they need to willingly use and operate their prosthesis willingly use and operate their prosthesis as well as have a sense of agency (control over their prosthesis) rather than ownership (Imaizumi et al., 2016). Therefore, even though there was a relationship between frequency of prosthesis use and embodiment, the sense of agency rather than ownership could be missing as agency was only asked on three of the questions. If an individual does not feel he or she has control over the prosthesis, the frequency of use may not affect balance confidence or fear of falling, which may explain why there was no relationship found. The limited variability in ABC Scale and FES-I scores as mentioned previously could be another possible explanation of why they were not associated with embodiment scores. Frequent fallers and non-fallers. For both the null hypotheses, that there was no observed difference between frequency of prosthesis use in individuals with unilateral or bilateral ULL/D who reported frequent falls or were non-fallers and that there will not be a difference in embodiment between self-reported fallers and non-fallers; were accepted. Despite that there was no statistical difference found with prosthesis use between fallers and non-fallers, the statistical difference found (p = .055) could be considered marginally significant and there was a medium effect size (d = 0.43). The effect size is an indirect way of measuring clinical significance and indicates that prosthesis use was different between frequent fallers and non- IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 39 fallers and is supported by the marginally significant results. Had the sample size been larger, there may have been enough power to show a statistical significance between the groups. This marginally significant difference and medium effect size found makes can also be supported clinically. Besides the compensatory movements required to operate a prosthesis, the mechanics of a prosthesis are not the same as a sound arm and are not able to create the appropriate actions to stop a fall. This may be further supported by the summary characteristics of the frequent faller group that showed they reported using their prosthesis more. Therefore, wearing a prosthesis more often may put these users at an increased risk of being in a situation where they might try to use the device to avoid a fall. This may also indicate why there were differences in the frequency of prosthesis use between the frequent fallers group and the nonfallers group. Because the significance was marginal and there was a medium effect size, future work to further investigate the impact prosthesis use may have on individuals with ULL/D and the potential of falls is warranted. It is known that individuals who use upper limb prostheses do not use their devices consistently throughout the day and may have multiple devices they use. Individuals reported wearing a prosthesis (80%) of the time, but only about half wore them in everyday life (Ostlie et al., 2012). This coincides with the fact that activities of daily living are often the most challenging to perform with a prosthesis (Datta, Selvarajah, & Davey, 2004) and that many wear their prosthesis passively (Biddiss & Chau, 2007). This is also in agreement with a study that looked at the correlation between electronically tracked usage data (minutes prosthesis was turned on and motors in use) of myoelectric users and self-reported prosthesis use. Researchers found that over an eight-week period participants reported wearing their prosthesis an average of two hours per day but actual prosthesis usage was only 7% of the time or 12-14 hours for the IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 40 entire eight-week period (Simon, Turner, Miller, Hargrove, & Kuiken, 2019). Although this study was only myoelectric hand prosthesis users, it reflects real-time usage of prosthetic users while at home. The large amount of prosthesis time reported in the present study (49.5 hours per week), suggests that individuals likely reported overall wear time of the prosthesis rather than the actual use of the prosthesis. It is unknown if actual use instead of wear time could impact whether an individual would fall or not, however, because usage time is less than wear time, actual use time may not have an impact. Despite this, embodiment requires the use and operation of a prosthesis as well as have a sense of agency rather than ownership (Imaizumi et al., 2016); therefore, accurate frequency of use time of the prosthesis cannot be ruled out as a possibility to make an impact in both prosthesis use and embodiment in fallers and non-fallers. Although there was no statistical difference seen between prosthesis embodiment in individuals with unilateral ULL/D and individuals with bilateral ULL/D between frequent fallers and non-fallers, there was a medium effect size (d = 0.47) with individuals with bilateral ULL/D embodiment scores. This indicates that a difference was seen between the groups and with a larger sample size, there may not have been enough power to show a statistical difference. This also further indicates the need to further investigate the relationship prosthesis embodiment has on falls. Secondary Hypotheses. The secondary null hypothesis that there will not be a difference in balance confidence between self-reported fallers and non-fallers was rejected. There was a significant difference between non-fallers and frequent fallers in ABC Scale scores indicating that fallers had lower balance confidence scores. These results agree with findings by Major (2019) suggesting that lower ABC Scale scores were associated with frequent falls. Additionally, the ABC Scale has been shown to accurately identify fall risk in a variety of other populations, including older adults (Lajoie & Gallagher, 2004b; Landers, Oscar, Sasaoka, & Vaughn, 2016), IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 41 Parkinsons disease (Mak and Pang, 2009), and lower limb amputation (Miller, Deathe, & Speechley, 2003; Wong et al., 2015) and is utilized clinically for these groups. This further indicates that the ABC Scale may be a good measurement tool for individuals with ULL/D to predict future falls. Due to the ceiling effect seen in the present study, it is reasonable to further investigate the use of the instrument with this population. The null secondary hypothesis that there will not be a difference in fear of falling between self-reported fallers and non-fallers was rejected. Statistically significant differences between frequent fallers and non-fallers in FES-I scores indicated that fallers have a higher fear of falling. This measure has been validated with other diagnoses such as multiple sclerosis (Van Vliet, Hoang, Lord, Gandevia, & Delbaere, 2013) as well as in older adults cross-culturally (Kempen et al., 2007). The ability of the FES-I to be able to identify fear of falling in individuals with ULL/D may indicate this population also experiences avoidance behavior from fear of falling. This is important since fear of falling as measured with the FES-I has been found to be a strong predictor of future falls in older adults (Landers et al., 2016). However, due to the floor effect seen in the present study, it is reasonable to further investigate the use of the instrument with this population. Limitations Limitations of this study may include recall bias, the embodiment questions, and the embodiment construct. Participants were asked about retrospective falls in the past 12 months so there is the risk of recall bias, which could have led to underreporting of falls. Although collecting self-reported fall history is less accurate than prospective monitoring of falls, in studies of older community-dwelling adults, recall of falls in the past 12 months had high specificity compared to collecting prospective fall data (Ganz, Higashi, & Rubenstein, 2005). As IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 42 mentioned previously the embodiment questionnaire has not been validated so this may indicate that the questions asked do not truly capture self-reported embodiment or the construct of embodiment is more complex than what can be measured in a question format. However, there was high internal consistency among the embodiment questions so it may be that embodiment does not indicate whether someone with unilateral or bilateral ULL/D will fall or not. Other possible limitations are the length of the survey, prosthesis use definition, and a bias to fallers. The survey length may have been a factor causing some participants (13.4%) to not complete the entire survey. However, the survey only took participants an average of 20 minutes to complete, was broken up into sections with an easy format to follow. To confirm this, the format of the survey, questions included, and length of time to complete was pilot tested by various clinicians, engineers, and individuals with ULL/D. The authors chose to measure prosthesis use as number of hours per day the participant wore their prosthesis, however we recognize that years of use and time since limb loss may have also been contributing factors to prosthesis use. In addition, as stated previously, ensuring an accurate understanding of prosthetic use versus prosthetic wear may not be truly captured in this survey format and may have not shown true relationships that may exist between frequency of prosthesis use and embodiment on falling. There is a possibility that the cohort in this study was biased to fallers or those with balance concerns due to the nature of the study and the way it was advertised. The purpose of the study was stated with the intention to better understand the impact of ULL/D on falls. Clinicians also may have chosen their clients who they knew specifically have fallen. In addition, one of the recruitment locations was at a conference specifically for individuals with bilateral ULL/D and a large number of individuals with multiple limb loss also in attendance, which may be biased to frequent fallers. Frequent fallers were higher in this study compared to previously reported by IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 43 Major (2019), which may have been due to clinicians choosing individuals with a history of frequent falls and increased number of participants with multiple limb loss which may lead to a higher number of falls. However, the other recruitment locations included all individuals with ULL/D without bias to one specific group. Clinical Significance The potential for the ABC Scale and the FES-I to be used clinically with individuals with ULL/D is a significant strength of the study. These measures each have only 16 questions and take a small amount of time to complete (5-10 minutes each), making them easy to integrate into a clinical environment. Because we recruited from a diverse population of individuals, including individuals with bilateral ULL/D and multiple limb loss, these outcome measurements may be more broadly applied to predict fall risk. Although the term embodiment is not a term used clinically, clinicians refer to this relationship by investigating the usefulness of a prosthesis to an individual. If an individual feels that a prosthesis is an extension of themselves, the psychological impact cannot be understated. Individuals often report the feeling of a prosthesis making them whole or complete. These feelings may also reinforce a positive body image and give the user confidence to participate in the activities that are meaningful to them, which is a cornerstone of rehabilitation and enhances quality of life. In fact, Rybarczyk and Bahel, (2008) found that those with poor body image have been shown to suffer from negative outcomes such as decreased life satisfaction, quality of life, increased depression, and overall psychological adjustment. This strengthens the importance of body image and the major impact ULL/D can have on self-concept and body image as arms and hands are essential in daily activities (Rybarczyk & Bahel, 2008). The relationship between prosthesis use and embodiment is an important connection to IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 44 explore not only from the potential psychosocial impact but also on functional recovery. Gouzien et al. (2017), found that individuals who wore their prosthesis more because of these same feelings of completeness were also more aware of the limitations of the prosthesis and used it accordingly. Understanding the limitations of their prosthesis may cause individuals to adjust their activities accordingly and lessen their potential for a fall. This is particularly important as 31.7% of the individuals with ULL/D who reported falls, 14.6% required medical attention (Major, 2019). Therefore, it is necessary to obtain a greater knowledge of the potential relationships between prosthesis use and embodiment and how these may impact the functional recovery, fall incidence and overall well-being of individuals with ULL/D. Future Work Although there was high internal consistency with the embodiment questions, a more careful analysis of each question is needed to evaluate its ability to capture embodiment. If trends are able to be identified to determine if some questions were better than others at capturing embodiment, further modifications may be warranted. In addition, future validation of the measure is needed for the potential to be utilized in the clinical environment. If a therapist can utilize a questionnaire to capture prosthesis embodiment, this can assist in the evaluation of functional recovery and potentially fall incidence. Because the construct of embodiment is still largely unknown, further exploration utilizing these questions in combination with other methods of measuring embodiment would be beneficial. This study also justifies the need for further evaluation to determine the validity and reliability as well as the potential of the ABC Scale and the FES-I to be used with this population in the clinical setting. Further exploration into each question individually to look for trends that may further indicate what specific areas individuals with ULL/D may find most challenging and IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 45 could provide insight on potential treatment strategies. In addition to psychometric evaluation of the ABC Scale and the FES-I as tools to be used with this population, understanding if higher balance confidence or lower fear of falling reduces the likelihood of a fall or if not falling causes the higher balance confidence and reduced fear of falling. Although it may be assumed that individuals with bilateral ULL/D or individuals with multiple limb loss may fall more, no studies currently evaluate this. Therefore, further exploration into these specific populations could assist with identifying specific fall prevention treatment programs if warranted. In addition, further investigation into these populations within this study is warranted to determine if this biased the results in the current study. Other future work to understand whether general prosthesis use or more details about the frequency of prosthesis use or other constructs such as type of prosthesis or actual usage may impact balance confidence, fear of falling, and the likelihood of falls. These results suggest that the relationship between prosthesis use and falls warrants some further exploration. As occupational therapists are the primary therapy professionals that work with individuals with ULL/D, further investigation into those services may assist in overall functional recovery. Exploration on whether individuals received therapy on how to effectively use their device in their daily routine may not only affect prosthesis use and embodiment but balance confidence, fear of falling, and falls. This could assist therapists in identifying potential areas that may require more attention in therapy especially if safety due to potential falls is a concern. Finally, there are numerous other variables that can be explored that may help further understand the relationships discussed in this study as the area of fall risk with individuals with ULL/D is largely unknown. These include gender differences, prosthesis education received, prosthesis type, level of limb loss, the cause of ULL/D, and prosthesis embodiment and empowerment. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 46 Although this list is not comprehensive, these variables may assist in a greater understanding of the relationships between prosthesis use and embodiment, fall risk, and fall incidence. Conclusion The frequency of prosthesis use was associated with more embodiment of the prosthesis. However, neither prosthesis use nor embodiment affected whether an individual fell or not. Both the ABC Scale and the FES-I were able to indicate whether individuals with ULL/D were to report retrospective falls and may be a useful tool to utilize in the clinical environment to identify potential fall risk in this population. Because internal consistency was high with the embodiment questions utilized, further validation work of these questions as well as utilizing these questions in combination with other methods of measuring embodiment to assist with helping identify prosthesis embodiment would be beneficial. Further exploration to determine the effectiveness of the ABC Scale and FES-I to indicate whether someone who has ULL/D is more likely to fall would be beneficial to ensure the appropriate interventions are utilized to maximize stability and decrease the likelihood of falls. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 47 References Asai, T. (2016). Agency elicits body-ownership: Proprioceptive drift toward a synchronously acting external proxy. Experimental Brain Research, 234(5), 11631174. https://doi.org/10.1007/s00221-015-4231-y Asai, T., Kanayama, N., Imaizumi, S., Koyama, S., & Kaganoi, S. (2016). 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Medical Engineering and Physics, 47, 137143. https://doi.org/10.1016/j.medengphy.2017.03.010 Topuz, S., Kirdi, E., Yalcin, A. I., Ulger, O., Keklicek, H., & Sener, G. (2019). Effects of arm swing on spatiotemporal characteristics of gait in unilateral transhumeral amputees. Gait and Posture, 68, 95100. https://doi.org/10.1016/j.gaitpost.2018.11.010 van der Kooij, H., Jacobs, R., Koopman, B., & Grootenboer, H. (1999). A multisensory integration model of human stance control. Biological Cybernetics, 80(5), 299308. https://doi.org/10.1007/s004220050527 Van Vliet, R., Hoang, P., Lord, S., Gandevia, S., & Delbaere, K. (2013). Falls efficacy scaleinternational: A cross-sectional validation in people with multiple sclerosis. Archives of IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 57 Physical Medicine and Rehabilitation, 94(5), 883889. https://doi.org/10.1016/j.apmr.2012.10.034 Varma, P., Stineman, M. G., & Dillingham, T. R. (2014). Epidemiology of limb loss. Physical Medicine and Rehabilitation Clinics of North America, 25(1), 18. https://doi.org/10.1016/j.pmr.2013.09.001 Widehammar, C., Pettersson, I., Janesltt, G., & Hermansson, L. (2017). The influence of environment: Experiences of users of myoelectric arm prosthesisa qualitative study. Prosthetics and Orthotics International, Special Is, 19. https://doi.org/10.1177/0309364617704801 Wijk, U., & Carlsson, I. (2015). Forearm amputees views of prosthesis use and sensory feedback. Journal of Hand Therapy, 28, 269278. https://doi.org/10.1016/j.jht.2015.01.013 Wong, C. K., Chihuri, S. T., & Guohoa, L. (2016). Risk of fall-related injury in people with lower limb amputations: A prospective cohort study. Journal of Rehabilitation Medicine, 48, 80-85. Wong, C. K., Chen, C. C., Blackwell, W. M., Rahal, R. T., & Benoy, S. A. (2015). Balance ability measured with the Berg Balance Scale: A determinant of fall history in community-dwelling adults with leg amputation. Journal of Rehabilitation Medicine, 47(1), 8086. https://doi.org/10.2340/16501977-1882 Wright, V. (2009). Prosthetic outcome measures for use with upper limb amputees: A systematic review of the peer-reviewed literature, 1970-2009. Journal of Prosthetics and Orthotics, 21(9), 362. Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005). IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 58 Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age and Ageing, 34(6), 614619. https://doi.org/10.1093/ageing/afi196 Ziegler-Graham, K., MacKenzie, E. J., Ephraim, P. L., Travison, T. G., & Brookmeyer, R. (2008). Estimating the prevalence of limb loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation, 89(3), 422429. https://doi.org/10.1016/j.apmr.2007.11.005 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Table 1 Descriptive Statistics for Sample Characteristics (N = 84) Mdn (25th, 75th) Age (years) 50.50 (39.25, 59.75) Prosthesis Use Frequency 49.50 (20.25, 89.25) Years Since Limb Loss 9.80 (2.60, 27.00) Years of Prosthesis Use 4.52 (1.50, 15.10) N (%) Gender Male 58 (69.0) Female 26 (31.0) Unilateral 60 (71.4) Bilateral 24 (28.6) Yes 25 (29.8) No 59 (70.2) Limbs missing Lower Limb Loss Level of limb lossa At or through shoulder Between shoulder and elbow At elbow Between elbow and wrist At wrist 3 (3.6) 21 (25.0) 5 (6.0) 48 (57.1) 7 (8.3) 59 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Cause of limb loss Trauma/accident 46 (54.8) Congenital 12 (14.3) Infection 18 (21.4) Cancer 6 (7.1) Other 2 (2.4) Passive/Cosmetic 8 (9.5) Prosthesis Type Body Powered 30 (35.7) Myoelectric/Motorized 38 (45.2) Activity Specific 4 (4.8) Hybrid 4 (4.8) Yes 7 (8.3) No 73 (86.9) Medication Unsure 4 (4.8) Note. aMost proximal level used for individuals with bilateral Upper Limb Loss/Difference 60 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 61 Table 2 Correlations Between Frequency of Prosthesis Use and ABC Scale, FES-I, and Embodiment (Unilateral/Bilateral) N rs p ABC Scale 84 .05 .670 FES-I 84 .02 .890 Embodiment Unilaterala 60 .49 < .001 Embodiment Bilateralb 24 .72 < .001 Note. ABC Scale = Activities-Specific Balance Confidence Scale; FES-I = Falls Efficacy Scale International IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 62 Table 3 Spearman rho Results of the Relationship of Embodiment (Unilateral/Bilateral) to ABC Scale and FES-I (N = 84) Embodiment Unilateral Embodiment Bilateral n = 60 n = 24 rs p rs p ABC Scale .203 .119 .282 .181 FES-I -.132 .316 -.370 .075 Note. ABC Scale = Activities-Specific Balance Confidence Scale; FES-I = Falls Efficacy International IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 63 Table 4 Sample Descriptives and Mann-Whitney U Test Comparison of Outcomes of Frequent Fallers and Non-Fallers (N = 84) Frequent Fallers Non-Fallers Mdn (25th, 75th) Mdn (25th, 75th) p Effect Size Prosthesis Use 65.00 (38.75, 98.00) 41.00 (16.00, 78.75) .055 0.43 Embodiment Unilaterala 43.00 (37.00, 49.00) 41.00 (34.50, 46.50) .489 0.18 Embodiment Bilateralb 37.00 (29.00, 40.00) 31.00 (28.00, 37.50) .258 0.47 ABC Scale 75.31(56.25, 94.38) 92.19 (84.69, 98.91) .002 0.73 FES-I Scale 28.00 (21.00, 39.00) 19.00 (17.00, 25.00) < .001 0.87 Note. Frequent Fallers 2 Falls; Non-Fallers = 0-1 Falls; ABC Scale = Activities-Specific Balance Confidence Scale; FES-I = Falls Efficacy International a n = 60 b n = 24 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 64 Appendix A Survey Prosthesis Use, Embodiment and their Relationship to Balance Confidence and Falls Q1 Research Study: Embodiment on Balance Confidence, Fear of Falling, and Falls in Individuals with Upper Limb Loss or Difference IRB Study Number: STU#00208178 Investigators: Kristi Turner, MHS, OTR/L and Dr. Matthew Major, PhD Supported By: Northwestern University Key Information about this research study: The following is a short summary of this study to help you decide whether to be a part of this study. The purpose of this study is to understand the impact of upper limb loss/difference on falls. You will be asked to complete a survey to help us identify ways to improve the safety of individuals with upper limb loss/difference. You will be asked to answer some questions on prosthesis use, fall history, balance confidence, fear of falling, and how you think of your prosthesis as part of your body. We will not be collecting any personal identifiable information from you and your participation is anonymous. We expect that you will be in this research study for 15-20 minutes to complete the survey. The primary risk of participation is a potential for emotional discomfort, but you have the option of not answering any question and can withdraw at any time. Although there is not a direct benefit to you participating in the study, the findings may help us improve the care for individuals with upper limb loss or difference. Why am I being asked to take part in this research study? We are asking you to take part in this research study because you are atleast 18 years of age, and have upper limb loss/difference at the wrist level or higher in atleast one arm. What should I know about a research study? Whether or not you take part is up to you. You can choose not to take part. You can agree to take part and later change your mind. Your decision will not be held against you. If you say that Yes, you want to be in this research, here is what you will do You will be asked to complete an online survey. What happens if I do not want to be in this research or if I say Yes, but I change my mind later? You can decide not to participate in this research or you can start and then decide to leave the research at any time and it will not be held against you. To do so, simply exit the survey. What happens to the information collected for the research? Efforts will be made to limit the use and disclosure of your personal information, including research study to people who have a need to review this information. We cannot promise complete secrecy. Organizations that may inspect and copy your information include the IRB and other representatives of this institution. The data collected from this survey is anonymous, does not include identifying information, and will be shared with University of Indianapolis to assist with data analysis. This survey is being hosted by Qualtrics and involves a secure connection. Terms of service, addressing confidentiality, may be viewed at https://www.qualtrics.com/privacystatement. Who can I talk to? If you have questions, concerns, or complaints talk to the Principal Investigator Dr. Matthew Major, PhD at matthew-major@northwestern.edu or (312) 503-5731 or Kristi Turner, MHS, OTR/L at turnerk@uindy.edu or (312) 238-1364. This research has been reviewed and approved by an Institutional Review Board (IRB). You may talk to them at (312) 503-9338 or irb@northwestern.edu if: Your questions, concerns, or complaints are not being answered by the research team. You cannot reach the research team. You want to talk to someone besides the research team. You have questions IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 65 about your rights as a research participant. You want to get information or provide input about this research. Consent If you want a copy of this consent for your records, you can print it from the screen. If you wish to participate, please click the I Consent button and you will be taken to the survey. If you do not wish to participate in this study, please select I do not consent or select X in the corner of your browser. Please note that this survey will be best displayed on a laptop or desktop computer. Some features may be less compatible for use on a mobile device. o I consent, begin the study o I do not consent, I do not wish to participate Skip To: End of Survey If Research Study: Embodiment on Balance Confidence, Fear of Falling, and Falls in Individuals with... = I do not consent, I do not wish to participate End of Block: Informed Consent Start of Block: Survey Q2 What is the level of your upper limb loss or difference? Please answer for both sides if the loss/difference is only on one side. At or through the shoulder Left side Right side o o Between the shoulder and the elbow At the elbow o o o o Between the elbow and the wrist o o Skip To: End of Survey If None is Equal to 2 Skip To: End of Survey If Part of the hand only is Equal to 2 Skip To: End of Survey If Prefer not to answer is Equal to 2 At the wrist Part of the hand only None Prefer not to answer o o o o o o o o IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 66 Q3 What was the cause for your upper limb loss? o Trauma/accident o Congenital (born with all or part of limb missing) o Infection (sepsis, necrotizing fasciitis, meningitis, etc.) o Cancer o Vascular disease o Other ________________________________________________ o I do not know o Prefer not to answer Q4 How long has it been since your most recent major upper limb amputation or revision? Major amputation or revision refers to a change in level of limb loss where afterwards your limb loss is now higher in your arm. If you have congenital limb difference, please mark Not Applicable. Years Months Not Applicable Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q5 Which side do you choose to use to perform most activities? Sometimes referred to as your dominant side. o Left o Right o I used both sides equally o Prefer not to answer Q6 Which side was your dominant side before you experienced upper limb loss? If you have congenital limb difference, please mark Not Applicable. o Left o Right o I use both sides equally o I do not know o Not Applicable o Prefer not to answer Q7 Do you use a prosthetic arm? o Yes o No o Prefer not to answer Skip To: Q26 If Do you use a prosthetic arm? = No Skip To: Q26 If Do you use a prosthetic arm? = Prefer not to answer 67 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 68 Q8 What type of prosthetic arm do you currently use the most? Please answer for both sides even if your limb loss/difference is only on one side. Hybrid Passive or Cosmetic Left Right o o Body Powered o o Myoelectric or Motorized o o Skip To: Q13 If Prefer not to answer was Equal to 2 Skip To: Q26 If None was Equal to 2 Activity Specific o o (combination of passive, body powered, and/or myoelectric) o o I do not know None Prefer not to answer o o o o o o IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 69 Q9 How is your prosthetic arm that you use the most held onto your body? This is commonly referred as the suspension method. Please answer for both sides even if your limb loss/difference is only on one side. Check all that apply. Left Right Harness Gel liner with pin lock OR lanyard strap Suction Osseointegration (direct attachment to the bone( I do not know None Prefer not to answer Other Display This Question: If How is your prosthetic arm that you use the most held onto your body? This is commonly referred a... = Left [ Other ] Q9a Please describe "Other" on your Left side ________________________________________________________________ Display This Question: If How is your prosthetic arm that you use the most held onto your body? This is commonly referred a... = Right [ Other ] Q9b Please describe "Other" on your Right side ________________________________________________________________ IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 70 Q10 How long have you been using the prosthetic arm that you use the most? Years Months Prefer not to answer Q11 In a usual week, how many days do you use the prosthetic arm that you use the most? Please answer for both sides even if your loss/difference is only on one side. Left Side I do not have limb loss on this side ... 7 Right Side I do not have limb loss on this side ... 7 Skip To: Q26 If I do not wear a prosthesis is equal to 2 Q12 In a usual day, how many hours do you use the prosthetic arm that you use the most? Please answer for both sides even if your loss/difference is only on one side. Left Side I do not have limb loss on this side ... Prefer not to answer Right Side I do not have limb loss on this side ... Prefer not to answer Skip To: Q26 If I do not wear a prosthetic arm is equal to 2 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q13 Please answer the following questions (Q14-Q25) about your experience with wearing the prosthetic arm you use the most. If you have more than one prosthetic arm, please refer to the prosthetic arm you most frequently use. Q14 How often do you feel stable and balanced when you wear your prosthetic arm? o Never 1 o Rarely 2 o Sometimes 3 o Often 4 o Always 5 o Prefer not to answer Q15 How would you say your trunk/torso leans when wearing your prosthetic arm? If have loss of both of your upper limbs, please select Not Applicable. o Completely towards intact side 1 o Completely towards side of limb loss 2 o Somewhat towards intact side3 o Somewhat towards side of limb loss/difference 4 o No lean towards either side 5 o Not Applicable o Prefer not to answer 71 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q16 To what extent do you feel that your prosthetic arm is a part of your body? o Not at all 1 o Partially 2 o Somewhat 3 o Mostly 4 o Completely 5 o Prefer not to answer Q17 In a usual day, how often do you have a habit of unintentionally touching your prosthetic arm? o Never 1 o Rarely 2 o Sometimes 3 o Often 4 o Always 5 o Prefer not to answer 72 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 73 Q18 How often do you feel that when something touches your prosthetic arm it touches your body? o Never 1 o Rarely 2 o Sometimes 3 o Often 4 o Always 5 o Prefer not to answer Q19 How accurately do you perceive the position and location of your prosthetic arm with your eyes closed? o Poor Accuracy 1 o Fair Accuracy 2 o Good Accuracy 3 o Very Good Accuracy 4 o Excellent Accuracy 5 o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 74 Q20 Please rate how quickly you move your prosthetic arm when you intend to move it? o Very slow 1 o Slow 2 o Moderate 3 o Fast 4 o Very fast 5 o Prefer not to answer Q21 Compared to your intact arm, how accurately do you move your prosthetic arm? If have loss of both of your upper limbs, please select Not Applicable. o Poor Accuracy 1 o Fair Accuracy 2 o Good Accuracy 3 o Very Good Accuracy 4 o As Accurately as Intact Side 5 o Not Applicable o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q22 Compared to your intact limb, how difficult is it to move your prosthetic arm? If have loss of both of your upper limbs, please select Not Applicable. o Extremely difficult 1 o Very difficult 2 o Moderately difficult 3 o Slightly difficult 4 o As easy as intact side 5 o Not Applicable o Prefer not to answer Q23 How much do you agree or disagree with the following statement: My prosthetic arm is indispensable to me or something I cannot be without. o Strongly Disagree 1 o Disagree 2 o Neither Agree nor Disagree 3 o Agree 4 o Strongly Agree 5 o Prefer not to answer 75 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q24 How much do you agree or disagree with the following statement: I use my prosthetic arm to gesture when I communicate. o Strongly Disagree 1 o Disagree 2 o Neither Agree nor Disagree 3 o Agree 4 o Strongly Agree 5 o Prefer not to answer Q25 How much do you agree or disagree with the following statement: I wear my prosthetic arm everywhere I go, I do not leave my house without it. o Strongly Disagree 1 o Disagree 2 o Neither Agree nor Disagree 3 o Agree 4 o Strongly Agree 5 o Prefer not to answer Q26 A fall is defined as coming to rest accidentally on the ground or other lower level, other than as a result of lost consciousness, a violent blow, stroke, or epileptic seizure.For questions Q27-Q31, please answer about your history of falls. Q27 How many times have you fallen in the past 6 months? 0 ... Prefer not to answer Q28 How many times have you fallen in the past 12 months? 0 ... Prefer not to answer Skip To: Q32 If How many times have you fallen in the past 12 months? = 0 76 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q29 What activities were you doing during your most recent fall? o Physical exercise/sports o Walking up or down stairs o Sit to stand or stand to sit o Walking indoors o Walking outdoors o Performing daily care (dressing, grooming, bathing, toileting) o Other ________________________________________________ o Prefer not to answer Q30 What do you believe caused you to fall during your most recent fall? o Loss of Balance o Tripped o Slipped o Pushed or Pulled o Fatigue o Dizziness o Other ________________________________________________ o I do not know o Prefer not to answer 77 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 78 Q31 Were you injured (caused you pain for more than 1 day, required you to change how you do activities or required medical attention) from your most recent fall? o Yes o No o Prefer not to answer Q32 For each of the following activities listed in questions Q33-Q48, please indicate your level of confidence in doing the activity without losing your balance or becoming unsteady from choosing one of the percentage points on the scale from 0% to 100%. If you do not currently do the activity in question, try and imagine how confident you would be if you had to do the activity. If you normally use a walking aid to do the activity or hold onto someone, rate your confidence as if you were using these supports. Q33 How confident are you that you will not lose your balance or become unsteady when you walk around the house? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 79 Q34 How confident are you that you will not lose your balance or become unsteady when you walk up or down stairs? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 80 Q35 How confident are you that you will not lose your balance or become unsteady when you bend over and pick up something off the floor? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 81 Q36 How confident are you that you will not lose your balance or become unsteady when you reach for a small can off a shelf at eye level? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 82 Q37 How confident are you that you will not lose your balance or become unsteady when you stand on your tiptoes and reach for something above your head? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 83 Q38 How confident are you that you will not lose your balance or become unsteady when you sweep the floor? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 84 Q39 How confident are you that you will not lose your balance or become unsteady when you walk outside the house to a parked car in the driveway? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 85 Q40 How confident are you that you will not lose your balance or become unsteady when you stand on a chair and reach for something? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 86 Q41 How confident are you that you will not lose your balance or become unsteady when you get in or out of a car? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 87 Q42 How confident are you that you will not lose your balance or become unsteady when you walk across a large parking lot? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 88 Q43 How confident are you that you will not lose your balance or become unsteady when you walk up or down a ramp? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 89 Q44 How confident are you that you will not lose your balance or become unsteady when you walk in a crowded place where people rapidly walk past you? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 90 Q45 How confident are you that you will not lose your balance or become unsteady when you are bumped into by people when you are walking? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 91 Q46 How confident are you that you will not lose your balance or become unsteady when you step on or off an escalator while holding the rail? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 92 Q47 How confident are you that you will not lose your balance or become unsteady when you step on or off an escalator while holding items so that you cannot hold the railing? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 93 Q48 How confident are you that you will not lose your balance or become unsteady when walk outside on icy or slippery sidewalks? o No Confidence 0% o 10% o 20% o 30% o 40% o 50% o 60% o 70% o 80% o 90% o Completely Confident 100% o Prefer not to answer Q49 For each of the following activities in questions Q50-Q65, please reply thinking about how you usually do the activity. If you use a mobility aid (wheelchair, walker, etc.), think about how concerned you are about falling when using that aid. If you currently dont do the activity (e.g. if someone does your shopping for you), please answer to show whether you think you would be concerned about falling IF you did the activity. Please pick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activity. IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q50 How concerned are you that you might fall when you are cleaning the house (e.g. sweep, vacuum or dust)? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q51 How concerned are you that you might fall when you are getting dressed or undressed? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q52 How concerned are you that you might fall when you are preparing simple meals? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer 94 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 95 Q53 How concerned are you that you might fall when you are taking a bath or shower? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q54 How concerned are you that you might fall when you are going to the shop? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q55 How concerned are you that you might fall when you are getting in or out of a chair? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q56 How concerned are you that you might fall when you are going up or down stairs? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q57 How concerned are you that you might fall when you are walking around in the neighborhood? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q58 How concerned are you that you might fall when you are reaching for something above your head or on the ground? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer 96 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q59 How concerned are you that you might fall when you are going to answer the telephone before it stops ringing? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q60 How concerned are you that you might fall when you are walking on a slippery surface (e.g. wet or icy)? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q61 How concerned are you that you might fall when you are visiting a friend or relative? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer 97 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q62 How concerned are you that you might fall when you are walking in a place with crowds? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q63 How concerned are you that you might fall when you are walking on an uneven surface (e.g. rocky ground, poorly maintained pavement)? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q64 How concerned are you that you might fall when you are walking up or down a slope? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer 98 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 99 Q65 How concerned are you that you might fall when you are going out to a social event (e.g. religious service, family gathering or club meeting)? o Not at all concerned o Somewhat concerned o Fairly concerned o Very concerned o Prefer not to answer Q66 For questions Q67-Q78, we would like to gather some basic health information. Q67 Do you have limb loss or difference in you lower limb(s)? o Yes o No o Prefer not to answer Skip To: Q72 If Do you have limb loss or difference in you lower limb(s)? = No Skip To: Q72 If Do you have limb loss or difference in you lower limb(s)? = Prefer not to answer Q68 How long has it been since your most recent major lower limb amputation or revision? Major amputation or revision refers to a change in level of limb loss where afterwards your limb loss now higher in your leg. If you have congenital limb difference, please mark Not Applicable. Years Months Not Applicable Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 100 Q69 What is the level of your lower limb loss or difference? Please answer for both sides even if your loss/difference is only on one side. At the hip Left Side Right Side o o Between the hip and the knee At the knee o o Between the knee and the ankle o o o o At the ankle Part of the foot only None Prefer not to answer o o o o o o o o Skip To: Q72 If None is Equal to 2 Q70 In a usual week, how many days do you use your leg prosthesis? Please answer for both sides even if your loss/difference is only on one side. Not Applicable Left Side Right Side o o I do not wear a prosthesis o o 1 2 3 4 5 6 7 Prefer not to answer o o o o o o o o o o o o o o o o Skip To: Q72 If Not Applicable is Equal to 2 Skip To: Q72 If I do not wear a prosthesis is Equal to 2 Skip To: Q72 If Prefer not to answer is Equal to 2 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 101 Q71 In a usual day, how many hours do you use your leg prosthesis? Please answer for both sides even if your loss/difference is only on one side. Left Side Not Applicable ... Prefer not to answer Right Side Not Applicable ... Prefer not to answer Q72 Do you regularly use a mobility aid in your home or community? If so, please select the mobility aid you use the most. o I do not use any mobility aids o Crutches o Cane o Walker o Scooter o Wheelchair o Other ________________________________________________ o Prefer not to answer IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Q73 Has a doctor ever told you that you have any of the following conditions? Please select ALL that apply. Arthritis (rheumatoid or osteoarthritis) Osteoporosis Asthma Chronic obstructive pulmonary disease (COPD), acquired respiratory disease distress syndrome (ARDS), or emphysema Angina (Chest pain) Congestive heart failure (or heart disease) Heart attack (myocardial infarct) Neurological disease (such as Multiple Sclerosis or Parkinsons) Stroke or TIA (transient ischemic attack) Peripheral vascular disease Diabetes (types I or II) Upper gastrointestinal disease (ulcer, hernia, reflux) Depression Anxiety or panic disorders Visual impairment (such as cataracts, glaucoma, macular degeneration) Hearing impairment (very hard of hearing, even with hearing aids) Degenerative disc disease (back disease, spinal stenosis, or severe chronic back pain) None 102 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS 103 Prefer not to answer Q74 Do you take any medications that may affect your balance or vision? o Yes o No o I do not know o Prefer not to answer Q75 What is your age? Prefer not to answer ... 120 years old Q76 What is your current height? If you have lower limb loss/difference and don't wear a prosthesis, please estimate. Feet Inches Prefer not to answer ... 7 ~ 11 Q77 What is your current estimated weight when not wearing your prosthesis? Prefer not to answer ... 450 lbs Q78 What is your sex? o Male o Female o Prefer not to answer Q79 Have you completed a survey about upper limb prosthetics and falls in the past two years? o Yes o No o Maybe IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Appendix B Activities-Specific Balance Confidence Scale 104 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Appendix C Falls Efficacy Scale International 105 IMPACT OF PROSTHESIS USE AND EMBODIMENT ON FALLS Appendix D Embodiment Questionnaire 106  ...

... EXPERIENCES OF CAREGIVERS WHO HAVE CHILDREN IDENTIFIED AS PICKY EATERS FOLLOWING PEER-BASED FEEDING GROUPS Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Krystin Turner, MSOTR/L Copyright 11-21-19 By: Krystin Turner, MSOTR/L All rights reserved Approved by: Jennifer Fogo, PhD, OTR Committee Chair Lisa Borrero, PhD, MPH, CPH Committee Member Karen Harpster, PhD, OTR/L Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: CAREGIVER EXPERIENCE OF FEEDING GROUP Experiences of Caregivers Who Have Children Identified as Picky Eaters Following Peer-Based Feeding Groups Krystin Turner University of Indianapolis 1 CAREGIVER EXPERIENCE OF FEEDING GROUP 2 Abstract Picky eating affects 25% of typical developing children in the United States, but has a larger impact on families. Currently, there is limited research to enable occupational therapists to discern the best therapeutic interventions for this unique population of children. The current study used a qualitative case study methodology to explore the experiences of caregivers following their childrens engagement in a peer-based feeding group. Analysis of interviews identified two general themes among caregivers: challenges with having children who are picky eaters, and benefits from their childrens participation in peer-based feeding groups for both their children and themselves. Caregivers identified stressors during mealtime, societal isolation, and child refusal to try new foods as common challenges. Mutual understanding from others, a shift in accountability, and a sense of relief were identified as benefits following their childrens participation in peer-based feeding groups. Results suggest that peer-based feeding groups offer both caregivers and children substantial benefits in overcoming common challenges associated with their childrens picky eating. Keywords: picky eater, peer-based feeding groups, occupational therapy CAREGIVER EXPERIENCE OF FEEDING GROUP 3 Experiences of Caregivers Who Have Children Identified as Picky Eaters Following Peer-based Feeding Groups Approximately 25% of typically developing US children who demonstrate difficulty with feeding are labeled as picky eaters (Aviram, Atzaba-Poria, Pike, Meiri, & Yerushalmi, 2015; Stapleton, Griffiths, & Sherriff, 2012). Although there is no consensus for the term, picky eaters are viewed as those rejecting or refusing new or non-preferred foods (Taylor, Wernimont, Northstrone, & Emmett, 2015; van Horst, 2012). Assessment and intervention for picky eaters has historically focused on quantifying and increasing the number of foods the child will eat. However, it is also important to consider the behaviors and attitudes of the child and family at the table (Boquin, Moskowitz, Donovan, & Lee, 2014). Stress experienced by both the caregivers and child during mealtime impacts all aspects of feeding. As modifications at the table are made and a child continues to limit his or her diet, the intake of healthy foods often declines leading to secondary medical concerns such as weight gain, diabetes, or cardiovascular diseases (Haszard, Skidmore, Williams, & Taylor, 2014; van der Horst, 2012). Caregiver involvement is often necessary or expected when preparing meals for and eating with a child. This social engagement of feeding and eating are considered co-occupations due to the dynamic interaction between the caregiver and child (American Journal of Occupational Therapy, 2014). That is, the performance of one has a direct impact on the performance of the other. When a child is a picky eater, both the caregiver and child can experience frustration and overall stress leading to conflict and dissatisfaction during mealtimes. As a child exhibits continued refusal behaviors, caregivers feelings of anger and stress can be exacerbated leaving caregivers with limited strategies to address these behaviors and an inability to support healthy eating (Goh & Jacob, 2012; Mitchell, Farrow, Haycraft, & Meyer, 2013). CAREGIVER EXPERIENCE OF FEEDING GROUP 4 Researchers have found that caregivers experience secondary gains and support from group interactions through the shared experiences of other caregivers (Mitchell et al., 2013). However, the overall caregiver experience following their childrens participation in peer-based feeding groups is not fully explored in the literature. This researcher sought to answer the following primary research question: What are the experiences of caregivers who have children identified as picky eaters following peer-based feeding groups? A qualitative case study methodology was used to explore the experience of caregivers following their childrens engagement in a 10-week therapeutic peer-based feeding group in a Midwestern outpatient occupational therapy clinic. Gaining a better understanding of caregivers experiences will allow therapists to tailor intervention strategies to address the needs of caregivers while also addressing childrens picky eating behaviors. Literature Review Feeding difficulties can occur beginning in infancy and last through adulthood. The presentation of these difficulties may vary for each child, but the need for oral intake and a healthy caregiver-child interaction remains consistent (Chao & Chang, 2017; Ellis, Galloway, Webb, Martz, & Farrow, 2015). Many caregivers express concern about negative behaviors at the table such as crying, pushing foods away, limited intake, or refusal to come to or stay at the table (Boquin et al., 2014). These behaviors begin to impact healthy food choices made by the child, prompting even greater caregiver concern (Bassett et al., 2008). This literature review will look closer at the dynamics of feeding including: the characteristics of a picky eater, strategies for introducing new foods, caregiver-child interactions during mealtime, developmental stage of the child, use of group therapy in other areas, and the importance of understanding the experience of the caregiver following therapeutic peer-based group intervention for their child. CAREGIVER EXPERIENCE OF FEEDING GROUP 5 Identification of Picky Eaters There is no standard definition of picky eating. The medical community is currently working to better define what characterizes children as picky eaters as several common traits have been identified. Picky eating is often described as consuming a limited variety of foods including low intake of healthy options such as fruits and vegetables (Boquin et al., 2014; Goh & Jacob, 2012). Common behaviors associated with picky eating include unwillingness to try new foods, preference for repeatedly eating the same foods, and consuming a limited number of foods from each food group (Boquin et al., 2014). Picky eating is not only classified by the foods that the child eats, but also the childs behavior and attitude at the table (Boquin et al., 2014). Individuals who are selective with food choices may be labeled as having neophobia (rejection of novel or unknown foods) or picky eating (rejection of large variety of foods either familiar or novel) (Lafraire, Rioux, Giboreau, & Picard, 2015). Recent changes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) offers a new diagnostic category entitled avoidant/restrictive food intake disorder (ARFID) (American Psychiatric Association, 2013). This diagnosis applies to children who meet one of following four categories: lack of weight gain, nutritional deficiency, need for supplemental feeding, or interference of psychosocial functioning. Exclusions from this diagnosis include: medical complications impacting feeding, food insecurity or cultural choice, and body image (anorexia or bulimia). Individuals with ARFID may demonstrate a lack of interest in eating, avoidance of foods based on sensory characteristics, or concerns about the potential adverse reaction when eating (Fisher et al., 2014; Williams, Hendy, Field, Belousov, Riegel, & Harclerode, 2015). Regardless of the diagnosis used to identify a child, picky eating can cause an increase in caregiver stress as well as nutritional concerns for the child. CAREGIVER EXPERIENCE OF FEEDING GROUP 6 Child-Caregiver Interactions Mealtime is an activity frequently shared by the caregiver and child, offering opportunities such as social communication, modeling of caregiver eating behaviors at the table, and exposure to new and sometimes healthier food choices (Bergmeier et al., 2016). Families who implement a structured mealtime and promote mealtime as a positive experience for the child exhibit less stress, especially with the presentation of new or non-preferred foods (van der Horst, 2012; Haszard et al., 2015). Initiation of a healthy mealtime at an early age can have a long-term, positive impact for the entire family (Larson, Wang, Berge, Shanafelt, & Nanney, 2016; Watts, Berge, Loth, Larson, & Neumark-Sztainer, 2018). Although research supports this structure, societal changes such as work schedules and after school activities have decreased the number of family mealtimes and meals prepared in the home (Aviriam et al., 2015; Thompson, Cummins, Brown, & Kyle, 2016). This societal transition impacts mealtime structure, reduces the opportunities for interaction between the caregiver and child, and increases foods presented out of convenience, reducing opportunities for exposure to new or non-preferred foods (Fulkerson, 2018). Caregivers of picky eaters must encourage greater oral intake to increase the volume or variety of foods their child is willing to accept, while supporting the childs craving for control over their preferred foods (Johnson et al., 2015; Power, Bindler, Goetz, & Daratha, 2010). Childrens behaviors have a direct impact on the mood of their caregivers, as well as affecting food choices presented and the feeding process (Frankel et al., 2015; Kerzner et al, 2015). Caregivers often give up on presenting new foods or begin to make contingencies as their children increasingly behave negatively or demonstrate complete refusal (Alm, Olsen, & Honkanen, 2015; Goh & Jacob, 2012; Johnson et al., 2015). To relieve stress, caregivers begin CAREGIVER EXPERIENCE OF FEEDING GROUP 7 to shift toward foods prepared in a specific way, the use of distraction such as the television, or avoidance of non-preferred foods to prevent or decrease the stress during mealtime (Boquin et al., 2014). When a child does not respond positively to these strategies and attempts, caregivers stress continues to rise. A strained relationship between caregivers and their children may inadvertently reinforce their childrens negative behaviors. Behavioral patterns such as refusal to come or stay at the table, throwing or spitting out foods, significant reduction in volume, or an increase in anxiety during mealtime are often traits displayed by a picky eater that impact caregivers responses (Mascola, Bryson, & Agras, 2010). Chao and Chang (2015) found a lack of caregiver-child interaction and inappropriate engagement with a caregiver were more common in children identified as picky eaters. When a child demonstrates difficulty with caregiver engagement, acceptance of foods may not be established even with continuous attempts. Because patterns of picky eating seldom improve without intervention, additional support may be needed to relieve stress and reestablish a mealtime routine (Stapleton et al., 2012). Weight can also be negatively affected while attempting to change feeding routine or type of food presented. A push for new foods and structured mealtime may increase behavioral reactions of refusal, leaving caregivers to encourage volume and potentially push too many daily calories of unhealthy food options (Antoniou et al., 2015; Farrow, Haycraft, & Blissett, 2015). The opposite is true for caregivers who have children identified as underweight. The stress of attempting to increase their childrens caloric intake is a daily concern and often a challenge to complete successfully. Due to the heightened stress level of caregivers, releasing control and allowing children to make food choices can be difficult (Mitchell et al., 2013). These emotions can leave caregivers having a stronger desire to encourage their children to eat more in order to CAREGIVER EXPERIENCE OF FEEDING GROUP 8 improve nutrition and gain weight (Johnson et al., 2015). This daily push impacts the caregiverchild relationship, mealtime, overall oral intake, and overall weight gain. The stress and impact on this relationship may be better understood through the caregivers experiences of the daily struggles feeding their children. Strategies to Introduce New Foods Techniques used to present new foods to children who are picky eaters vary based on the program and provider as well as the caregiver-child relationship (Holley, Farrow, & Haycraft, 2016). Most techniques utilize a variation of mealtime structure, an integration of sensory strategies with food presentation, and rely on external or social influences to support the child and caregivers during introduction of new or non-preferred foods. Development of a healthy mealtime routine is often the first step in the presentation of foods. Creating a structured mealtime includes limiting foods between meals and addressing the dynamic interaction between caregiver and child at the table. Changes may include reducing caloric drinks, limiting access to foods, and establishing consistent expectations during the mealtime (Taylor et al., 2015). Structure around a meal may also be implemented during meal preparation. That is, time spent in preparation and during mealtime allows modeling by others and sets the social expectation for all family members allowing for a sense of participation and often success (Bergmeier et al., 2016). There are many sensory characteristics of foods that impact childrens acceptance. A younger child may initiate sensory engagement with foods through visual exploration (what is the shape and color?). However, there appears to be a transition to tactile exploration of foods (how does it feel or how will it change in my mouth?) prior to adulthood (Dovey et al., 2012). For example, vegetables were found to be more difficult to accept for adults due to the texture CAREGIVER EXPERIENCE OF FEEDING GROUP 9 whereas children may reject vegetables based on look (Alm et al., 2015). Visual exposure to increase tolerance of foods can be achieved through: cooking with the child, presenting a variety of foods on the table during mealtime, or caregiver modeling while eating the foods (Dovey et al., 2012; van der Horst, 2012). Involving the child in food preparation allows for increased exposure to foods using a variety of sensory input including the look, touch, smell, and taste of both new and preferred foods (Lafraire et al., 2016). The child is able to experience foods in their natural form during initiation of the preparation and see all the changes that occur as the food is cooked (Coulthard, Palfreyman, & Morizet, 2016). With increased exposure to foods, anxiety associated with that food often decreases (Chao & Chang, 2017). The use of social rewards is often used to increase motivation for the child as well as address the behavioral challenges that impact the presentation of new food. Cooke et al. (2011) explored the differences between acceptance of a non-preferred food following multiple exposures alone and multi-exposure plus a social reward. The researchers found that social reinforcement and positive praise combined with repeated exposure was necessary to sustain a long-term behavioral change. These social rewards may be in the form of a physical object or praise from others. Physical rewards should be based on the motivation of the child. Praise and modeling can be successful with either peers or caregivers, both were found to influence the decision of a child when trying a new food (Holley, Haycraft, & Farrow, 2014). Moments of social engagement may have a secondary benefit for both the caregiver and child to improve their relationship during the mealtime. Caregiver strategies to influence exposure and acceptance of new foods may have an adverse effect if not monitored appropriately. Caregivers may use pressure to encourage CAREGIVER EXPERIENCE OF FEEDING GROUP 10 consumption of new food, desired volume of preferred foods, or greater variety of the foods presented. However, children often have a negative reaction to pressure when used to increase the volume of food, even in the absence of hunger (Ellis et al., 2016; Farrow et al., 2015; Frankel et al., 2015). For example, caregivers can negatively impact their childrens willingness to consume a wider variety of foods stating that their children will like a food when he or she says he or she doesnt like a food (Wiggins, 2014). When caregivers do not understand the impact of their verbal and social interactions, they may inadvertently continue to negatively influence their childrens eating patterns. Modification of foods or food presentation may be necessary to provide the just right challenge for the child. This initial exposure offers children preliminary experiences with food through engagement without consumption. Modifications may include: balancing the presentation of preferred and non-preferred foods on the plate, recognition of the sensory characteristics of the foods presented, and integration of mealtime structure to support the childs success and engagement with the foods. Each step may need multiple exposures to begin to increase tolerance. Caregivers providing modification and strategies for the introduction of new foods have increased success with their childs acceptance (Lafraire et al., 2016). Developmental Needs of the Child A childs developmental and social needs vary throughout childhood and adolescence. Caregiver interactions and engagement with their child often predict the childs interactions with peers (Chang, Shaw, Shelleby, Dishion & Wilson, 2017). With a younger child (2 to 6 years old), maternal modeling of trying new foods had a significant impact on desire, enjoyment, and responsiveness to new foods (Palfreyman, Haycraft, & Meyer, 2015). Developmentally, as children enter adolescence, they seek independence and begin to transition away from caregiver CAREGIVER EXPERIENCE OF FEEDING GROUP 11 control (Power et al., 2010). Due to this transition, peer interaction becomes a primary means for children to gain skills. Alm et al. (2015) found a shift during adolescence as children would rather argue with their caregiver about eating a non-preferred food than engage with the food. This change impacted social skills and attitudes as many children worry about how his or her condition affects peer interactions such as visiting a friend or going out to eat (Ruggeri, Luan, Keller, & Gummerum, 2018; Thompson, Cummins, Brown, & Kyle, 2015). Wildes, Zucker, and Marcus (2012) found one of the most important aspects for many adults who are picky eaters was the social consequences of their picky eating with peers. As children seek autonomy from his or her caregivers during adolescence, the caregivers focus may include an increased emphasis on education of healthy options paired with strategies to avoid the temptation of the unhealthy, and often preferred, food choices. Peers influence eating, which may influence a childs food choices impacting weight and body mass index (Chadwick, Crawford, & Ly, 2013; Xue, Zhang, & Wang, 2016). Cruwys, Bevelander, and Hermans (2015) reviewed 69 studies examining the relationship between social modeling and food consumption indicating that social modeling occurs on a daily basis and has a profound impact on oral intake. Social influence was not confined to familiar individuals and was often used to connect with others. Individuals in the presence of a healthy eater were more likely to choose healthy options than those eating with an unhealthy eater (Robinson & Higgs, 2013). Offering foods within a peer-based setting allows the opportunity for healthy food choices with social modeling using peer interaction. Group Therapy Group therapy opportunities may come in a variety of forms. Feeding intervention groups have shown success and support for families by offering strategies to manage behaviors CAREGIVER EXPERIENCE OF FEEDING GROUP 12 and identify foods to present for picky eating (Fraser, Wallis, & John, 2004; Haywood & McCann, 2009). Food with Fun and Fun not Fuss with Food are two programs led by early intervention specialists including caregivers and children together in a group setting to address difficulties with feeding (Fraser et al., 2004; Haywood & McCann, 2009). Caregivers participating in the group increased their understanding of strategies to be used in the home and reported a decrease in anxiety during mealtime. Peer-based groups also utilize peer interaction to support growth within a specified problem area. Donovan, Cobham, Waters, and Occhipinti (2015) completed a study of peerbased groups for children and young adolescents with social phobia. Researchers exhibited positive outcomes in reducing anxiety when including others with similar difficulties. Participants reported a better understanding of each other and a desire for similar goals. Peer engagement produced positive changes when providing feedback for children working on prosocial behaviors (van Hoorn, van Dijk, Meuwese, Rieffe, & Crone, 2014). Allowing for social engagement during group therapy has made a difference when attempting to change a shared behavior. The use of multi-family group therapy (MFGT) has successfully extinguished undesirable behaviors (Liu et al., 2015; Salaminiou, Campbell, Simic, Kuipers, & Eisler, 2017). Families described a connection during MFGT secondary to the shared history and similarities in current life situations; families felt that others who faced similar challenges created a natural support system (Liu et al., 2015). This connection, due to similar experiences such as having a child with anorexia nervosa, allowed families to discuss supportive strategies for their child they may not have otherwise considered (Salaminiou et al., 2017). Real life experiences developed during group therapy assisted with transitioning behaviors back into the home for sustained CAREGIVER EXPERIENCE OF FEEDING GROUP 13 integration into daily routines. In addition, the group setting allowed children to make independent choices within a structured environment and learn from these choices with the support of others (Liu et al., 2015). Mitchell et al. (2013) evaluated feeding programs that focused on social interactions during mealtime. During a group tailored toward caregivers, caregiver anxiety was reduced with a secondary benefit of reducing child anxiety. Participants reported that hearing the struggles of other caregivers was a relief, reducing the isolation they felt by offering both social and emotional support. As families shared with each other, a greater understanding occurred leading to an increase of knowledge of behaviors that were exhibited by other caregivers during mealtime. Although caregivers who participated in the current study were not directly involved in group therapy, their childrens participation led to similar experiences bringing the caregivers together. However, the extent to which the support is provided and how useful it is remains unknown. Conclusion Picky eating does not have an accepted universal definition and the experience varies for every caregiver (Boquin et al., 2014). There is a growing concern for the impact that picky eating has on family and the social functioning of the child due to caregiver stress during family mealtime and social gatherings (Fischer et al., 2014). Food presentation and education in a peerbased group has been shown to meet the developmental need for peer engagement and social feedback for the child (Donovan et al., 2015). As children begin to make behavioral changes with the introduction and acceptance of new foods, the dynamic of caregivers experiences with their children who are picky eaters may begin to change. Caregivers may reap similar unstructured and unsolicited benefits from their childs participation in the group therapy, but CAREGIVER EXPERIENCE OF FEEDING GROUP 14 this remains unknown. Although reduction of stress and improvements in behavior are noted, there is still a gap in knowledge to understand why these changes occur. This research study will examine the overall experience of caregivers of picky eaters following therapeutic intervention in a peer-based group setting to try to fill in this gap and better understand the role of occupational therapy in this process. Method Study Design This study incorporated a qualitative approach, using a case study methodology, to investigate the experiences of caregivers of children identified as picky eaters who have participated in a peer-based feeding group. A qualitative case study design was a fitting methodology for this study, as it prioritizes understanding a phenomenon following a naturally occurring experience (Yin, 2009). Individuals involved in this study were bound by similar experiences that brought them together as a case. Specifically, each participating caregiver had a child who participated in a peer-based feeding group. The qualitative case study design allowed multiple caregivers to share their experiences of caring for his or her child, who is a picky eater and participated in a peer-based feeding group. By engaging multiple caregivers, a broader understanding of the phenomenon was shared which allows a deeper and richer understanding of the caregiver experience (Baxter & Jack, 2008). Participants Caregivers whose children participated in a peer-based feeding group with the primary investigator at Cincinnati Childrens Hospital Medical Center (CCHMC) were eligible to participate in this study. Children who participated in the feeding group were between 4 and 15 years of age. Inclusion criteria were: (a) caregivers of children who participated in a peer-based CAREGIVER EXPERIENCE OF FEEDING GROUP 15 feeding group, (b) caregivers of children who participated in at least seven out of ten sessions of the peer-based feeding group, (c) caregivers who agreed to complete an interview within six months of their final group session. Seven caregivers completed the study. All caregivers interviewed were primary caregivers who brought their children to the feeding group for the majority of the sessions, fostering a relationship with the therapist over the course of the feeding group sessions. Six of the interviews were conducted with the childs mother and one was conducted with the childs father. Background To better understand the caregivers experiences, it is important to first understand the peer-based feeding program from which the participants were recruited. The peer-based feeding program at CCHMC only included children ages 4 to 15 years. These children were referred to occupational therapy for picky eating or ARFID and determined by the evaluating occupational therapist to have feeding difficulties. Picky eaters were identified by the limited food variety they consumed including hesitation to try any new foods (Boquin et al., 2014). Feeding groups took place within an outpatient setting at CCHMC. This studys primary investigator was the occupational therapist who led the feeding groups. During each session, the occupational therapist presented a variety of preferred and non-preferred foods to increase the childrens exposure and engagement with these foods; this exercise was designed to reduce anxiety and create a sensory experience that progresses the child toward oral consumption of new foods. Group duration was one hour per week for approximately 10 weeks. Children who participated in the group may or may not have had past therapeutic intervention for feeding concerns. However, children with secondary complications impacting feeding such as deficits in oral motor skills, limitations with peer interaction including language barrier, difficulty with self-feeding, CAREGIVER EXPERIENCE OF FEEDING GROUP 16 medical complications, inability to remain at the table, or significant food allergies were excluded from participating in the peer-based feeding program. Although only children identified as picky eaters engaged in the group experience, caregivers were also encouraged to share their experiences with the therapist regarding their childrens feeding at home throughout the duration of the peer-based feeding group. The caregivers completed a standard questionnaire a minimum of four times during the group process, responding to the following questions/prompts: (a) tell me about feeding over the last one to two weeks; (b) has your child tried any new foods?; and (c) identify any barriers that have impacted mealtime. Procedures Recruitment. Institutional Review Board approval from CCHMC and University of Indianapolis were obtained prior to starting the study. At the beginning of session seven of the feeding group, eligible caregivers were provided an information sheet by the principle investigator detailing basic information about the study. The information sheet included: (a) a general description of the study; (b) why the caregiver was being asked to participate; (c) information about the interview process; (d) the length of the study; (e) researcher contact information for questions; and (f) how to indicate a desire to participate in the study. At the end of the session, the researcher answered any caregiver questions regarding the study. Due to the potential for caregivers to feel pressured to participate in the study, caregivers were reassured that participation was completely voluntary and treatment for their child would not be impacted based on participation. CAREGIVER EXPERIENCE OF FEEDING GROUP 17 If a child had participated in a previous group and met the requirements of completion of seven sessions and their last session occurred no more than six months prior, the caregiver was contacted by the researcher via phone call or email to ask if they were interested in participating in the study. If a caregiver expressed interest, the information sheet was shared with the family by mail or email based on caregiver preference. The researcher followed up within two weeks by phone or email to discuss the study and answer any additional questions. Data Collection. Caregivers completed questionnaires during the course of their childs peer-based feeding group. Copies of the completed questionnaires were given to the caregivers either in person or by mail prior to the interview to assist with caregiver recollection of events and feelings that occurred during their childs participation in the group. Allowing caregivers to reflect on previously collected data assisted them in identifying experiences that may have occurred during the seven to ten weeks of their childs group therapy. Caregivers were encouraged to review this information prior to the interview. Based on the exempt status with the IRB, the study team obtained verbal consent from the caregivers prior to beginning, with a waiver of documentation of written consent. However, prior to initiation of the interview, the researcher offered another copy of the information sheet to the caregiver. The researcher again verbally reviewed the information sheet about the study with the caregiver to ensure his or her continued interest in participating in the study. Caregivers were also reminded that participation in this study was completely voluntary. The caregiver was given the opportunity to ask any questions at that time and the primary researcher ensured the participants questions were fully answered. CAREGIVER EXPERIENCE OF FEEDING GROUP 18 The researcher collected data using in-depth, semi-structured interviews. Three interviews were conducted face-to-face and four interviews were conducted via telephone, ranging in length from 15 to 30 minutes. Interviews were audio-recorded to ensure that all details of the data were retained for analysis purposes. Similar to grounded theory interview guides, interviews used broad questions allowing the caregiver to open up and guide the course of the interviews (Creswell, 2014). Interview questions/prompts included: (a) tell me what its like caring for a child who is a picky eater; (b) tell me about mealtimes with your child; and (c) tell me what its been like for you having your child in feeding group therapy. By allowing follow-up questions to be based off the caregiver response, the interview process provided a rich, in-depth understanding of the participants experiences as a caregiver of a picky eater. Prior to completion of each interview, the caregivers were asked if they had any additional information to share. Each caregiver was also provided with the primary researchers contact information in case they thought of additional information. No participants shared any additional information following their interviews. Data Management and Analysis Transcription of interviews was completed verbatim by the primary researcher prior to data analysis. Transcripts were de-identified and assigned an identification number for organization by the researcher. Neither audio recordings nor transcriptions contained any identifying information; both were stored under password protection on the researchers computer. The researcher engaged in reflexivity following each interview through the use of reflective journaling. Reflexivity allowed the researcher to reflect on her role as the primary therapist how this role may have biased or shaped the investigation (Creswell, 2014). Data CAREGIVER EXPERIENCE OF FEEDING GROUP 19 analysis was initiated after all interviews were transcribed. The researcher independently read through each interview transcription multiple times to gain an understanding of the information shared by each individual participant. Following this immersion in the data, margin notes were made on the transcripts to aid in the coding process, and key information about the caregivers experiences were identified. Specifically, interview content relevant to the studys research question was highlighted by assigning codes made up of unique words or phrases describing aspects of the caregiver experience. These codes were further grouped into larger categories to support the data that appeared throughout the case (Yin, 2009). Following the analysis of the individual interviews, transcripts were analyzed together using cross-case analysis in order to establish themes across all interviews (Creswell, 2013). The major themes gleaned from the categories described the key common experiences of the individuals within the larger case (Creswell, 2013). Another occupational therapist within the department at CCHMC served as a second coder and reviewed the transcripts, codes, categories, and final themes to help ensure the codes and themes developed by the primary researcher were consistent with the content of the interviews. The activities of the second coder helped to increase the credibility and authenticity of the interpretation (Yin, 2009). Finally, in a process described as member checking (Yin, 2009), overarching themes drawn from the interviews were emailed to participants providing them the opportunity to review the results and ensure that the themes correctly represented their experiences. The researcher did not receive any feedback or corrections to the derived themes. The researchers use of reflective journaling, multiple coders, and member checking improved the trustworthiness of the study validating that the caregivers perspective was maintained (Creswell, 2014). Results CAREGIVER EXPERIENCE OF FEEDING GROUP 20 Six mothers and one father completed the interview; each of these caregivers were the primary caregiver during group therapy. Three of the children were involved in the most recent feeding group, while the other four had been involved in feeding group within the last six months. The children of the caregivers consisted of five girls and two boys ranging in age from 5 to 11 years old. Four of the children had individual occupational therapy (OT) for feeding treatment prior to coming to group therapy; the remaining three had group therapy as their first feeding-related treatment with OT. Of the four children new to OT, two were previously involved in either nutritional services or behavioral psychology for feeding, but not within the last two years. One child received supplemental support for nutrition by means of gastrostomy feeding; all other children received 100% of their nutrition orally. During the in-depth interviews, participants described both the broad challenges associated with having a child who is a picky eater and the influence of the peer feeding group for the child and family. Regardless of the childrens ages during participation in feeding group, the caregivers consistently described the mealtime experiences from their childs early years of eating. The information shared by the caregivers about the challenges of managing a child who is a picky eater added important background information and understanding of caregivers past experiences. Challenges Associated with Having a Child Who is a Picky Eater With regard to managing the challenges associated with having a child who is a picky eater, themes identified by the study included: stressors during mealtime, societal isolation, and child refusal. Given the co-occupation of feeding and eating, these themes allow occupational therapists to understand the caregivers perceptions of the reactions of the child, the caregiver, the family, and others during mealtime. CAREGIVER EXPERIENCE OF FEEDING GROUP 21 Stressors with Mealtime The majority of caregivers reported implementing modifications during mealtimes which produced unanticipated experiences. Many caregivers stated they often had to abandon their belief of what mealtime should look like to adapt to the needs of their child. They indicated this seemed to occur as their child sought to gain control of the eating experience. One caregiver shared, It was so stressful! And, she wouldnt eat anything and I found myself feeding her in the bathtub because I could get her to play and eat at the same time. Caregivers knew the modifications were not normal, but they felt compelled to do whatever worked to get their child to eat. Caregivers reported that they not only modified the environment, but they also altered the type of food they offered. Altering the presentation of the food often impacted others at the table. Many caregivers noted they consistently made a separate meal for their child who was a picky eater, which reportedly increased the caregivers work and stress related to mealtime because the modifications were not always accepted by the child. One caregiver reported, We make dinner almost every nightmy daughter eats...my son never participates so we have to make sure we are making something for him. Caregivers identified that mealtime stress led to high anxiety and often arguments. Another caregiver stated, at mealtime its a constant stresswhen mealtime rolls around I get anxiety and she starts feeling thatIm not making the best choices as a parent and we end up arguing. Caregivers expressed a concern for their childs health based on the limited variety or volume of the foods accepted. They also identified a loss of control at mealtime which evolved into dietary changes in order to provide a food the child would consume, often replacing a portion of the family meal. One caregiver was able to identify this challenge, We fight almost CAREGIVER EXPERIENCE OF FEEDING GROUP 22 every single meal, because I always make something she likes and something she doesnt like Caregivers said that modifications at mealtime increased concern of malnutrition due to the lack of healthy food options accepted by the child. Caregivers did not believe the foods consumed by their child provided enough nutrients necessary for healthy growth. One caregiver explained, Its our biggest fight; and it has actually affected his health. He has high cholesterolhe never has good nutrition in him to really help him to grow or be energized. Regardless of whether the child was over or under weight, caregivers remained anxious about the childs lack of variety across all food groups and how this impacted long-term health. Caregivers were able to identify the internal struggle between making the mealtime a more pleasurable experience (decreasing the childs refusal behavior) and wanting the child to eat the foods presented to the family. The caregivers awareness that their child was still not eating the food he or she should to get the appropriate nutrients for overall health combined with their feelings of being unable to change the situation led to even greater caregiver stress surrounding the mealtime experience with their child. Societal Isolation Caregivers felt their childs apprehension with food led to a barrage of unwanted comments and advice from family members and friends. Caregivers identified that even their spouse and others living in the house lacked understanding of how to engage during mealtime. One caregiver stated, Its been difficult because my husband doesnt understandits been a long road for him to learn to be patient and let my son be in charge. Caregivers reported that the unsolicited advice from extended family did not always align with the needs of the picky eater. Another caregiver stated, now we have family saying you should just put it in front of her and make her eat. We triedwe would force her to eat and she would start vomiting and CAREGIVER EXPERIENCE OF FEEDING GROUP 23 then she would start crying hysterically. Caregivers reported they felt judged for the foods they allowed their child to eat, as well as behaviors their child displayed around mealtimes. Although caregivers identified trying to follow through with suggestions from others, their primary goal was to provide what was best for their child. One caregiver explained, People judge me and make commentsits not about them; its not about their opinion. Its about her and what she needs and my focus is on her. Caregivers expressed feeling isolated from others, because they could not go to restaurants or other public venues where eating was involved. Caregivers identified meals outside the home as stressful for both themselves and their children. The caregivers also theorized that their children felt isolated from peers during social situations and would even avoid opportunities where they felt they may need to eat. One caregiver said, His friends started picking on him some about, really you wont even eat another brand of pizza. Caregivers noted their children would not make modifications when in public and may not eat anything if the food was not preferred. A caregiver stated, You cant go to any restaurants. You have to make sure there issomething they are going to eat. The caregivers reported increased stress because they either had to avoid gatherings involving food or they had to always be prepared with a preferred food for their child who was a picky eater. Caregivers reported tension during communal activities which made outings stressful for both the family and child. This stress was shared, ...we get tears a lot, especially when it comes to social settings and we are out in public and everyone is looking at her like why are you not eating that. Child Refusal Refusal to eat non-preferred foods was a common response identified by caregivers. Caregivers reported their children exhibited a variety of behaviors around mealtime. One CAREGIVER EXPERIENCE OF FEEDING GROUP 24 caregiver recognized, it was a relief for her to be sick instead of having to eat the foods [thanksgiving]. Caregivers felt that arguments between caregiver and child shaped mealtime, which often led the child to increase food refusal. Another caregiver stated, she wouldnt try anything. It would start to cause fights between us and she would have meltdowns. One caregiver stated that her child would rather not eat than admit that she liked the new food presented, intensifying the lack of control felt by the caregiver. Caregivers speculated that the anxiety of their children was heightened during mealtime leading both the caregiver and child to have decreased patience with the situation. One caregiver shared, there have been times when, this is terrible, but I would put food in her mouth to try to get her to eat it because I was so frustrated. Influence of the Peer Feeding Group for the Child and Family Caregivers also shared their perspective on the experiences that followed their childrens participation in a peer-based feeding group. The themes that emerged included: mutual understanding, shift in accountability, and caregiver relief. Each of these themes appear to support the prior experiences of the caregiver. Initially, caregivers described the stress and lack of control they felt during mealtime and with the presentation of new food. The frustration shared by the caregivers was associated with the home, community, as well as with the individual behavior of the child. Collectively, these experiences seemed to be the impetus to bring their child to the feeding group for therapeutic intervention. It was clear from the caregivers description that having their child participate in a peer-based feeding group altered the caregivers experience. The overall perspective of the caregiver will be better understood with greater examination of these themes. Mutual Understanding from Others CAREGIVER EXPERIENCE OF FEEDING GROUP 25 Caregivers talked about the experience of having a picky eater, and how they and their children were often isolated from others during activities involving food and eating. Even though the caregivers remained in the waiting room while their child engaged in the feeding group they indicated that they felt surrounded by others who were struggling with similar daily barriers of living with a picky eater. Caregivers recognized that having this informal opportunity to speak with others was a validation of the personal struggles that mealtimes brought. One caregiver identified, You know the parent dynamic you werent really expecting to see from groupyou dont realize how much you need [support] as a parent from another parent [who has a picky eater]. Even though many caregivers felt a lack of understanding and isolation in society, having their children participate in the feeding group offered them an opportunity to share struggles and gain support and understanding from other caregivers who were having a similar experience. Caregivers also suggested that group participation allowed their children to recognize they were not alone with their struggle with picky eating, which also decreased the caregiver stress. One caregiver stated her child was excited to see other children who were picky eaters, It was great for her to see other kids that felt the same way about food that she did. Shift in Accountability Caregivers believed accountability to others was a strong motivation for their children to work toward a difficult task, such as trying a new food. They reported that their child was more willing to complete a task that was defined during the therapeutic session versus requested by the caregiver at home. One caregiver stated, the peer to peer is always going to be more beneficial than dad telling her to do it. Another caregiver stated that other kids motivated her son by asking if he completed the task he was supposed to for the therapy session. With this CAREGIVER EXPERIENCE OF FEEDING GROUP 26 shift in accountability, caregivers expressed a reduction in stress during mealtime and with the presentation of a new food because of their childs participation in the feeding group. Caregivers identified that their children were able to make modifications to their reactions to food based on modeling from peers. One caregiver stated, very different challenges and very different ways that they find success in each other. Caregivers recognized that their child enjoyed teaching others about the qualities of food they enjoyed (e.g. touch, smell, taste) which allowed practice of techniques that they would use to explore new foods at home. A caregiver stated, ...other girls in the group were kind of a little more pickyshe wanted to help them out. By helping others or learning new techniques within the group setting, caregivers identified that their child began to understand how to use strategies to try new food at home. Their childrens overall desire to try new foods was identified by caregivers as an outcome of the peer-based group. Caregivers stated their children learned new ways to handle situations from this peer engagement that were otherwise negative in the past. One caregiver commented, having children in the room, she thrives a little bit more. She has that peer aspect she likes to be the best of the group peers and so she wants to try a little bit harder. The variety of foods were noted by caregivers to increase following engagement in the group-based feeding therapy. Another caregiver explained, she was adamant when she tried new things when she was in group. We have to write this downshe was excited about it. Caregiver Relief Caregivers perspectives of their childrens engagement in a peer-based feeding group were identified as a catalyst for change in the interactions between the caregiver and child. Caregivers felt strategies provided during group therapy offered opportunities for positive CAREGIVER EXPERIENCE OF FEEDING GROUP 27 changes during mealtime. During the therapeutic group process, caregivers felt an understanding and connection with other caregivers. Caregivers also identified accountability from their child to the therapist and group as supporting change in the home. Following engagement in a feeding group, caregivers perceived a greater desire by their children to try new foods as well as opportunities to learn from others. Caregivers identified that their children now had the skill and knowledge to manage the presentation of new food in other settings. Caregivers felt that talking with other caregivers offered a different point of view within the common situation they all shared. Each family provided insight into daily struggles from a different perspective. Just as they felt their children were able to share techniques to explore new foods, caregivers felt an opportunity to offer suggestions regarding modifications for mealtimes, based on their similar experience. By reducing the amount of stress at mealtime, caregivers felt a small amount of success. One caregiver stated, Once I took it out of my hands, and she wanted to please you [therapist], she would do it without questionmealtime was definitely less stressful. Caregivers recognized the volume of food accepted may take additional time but there was relief in the fact their child would now try new foods. Now that he is out of group, when we go to dinner with my family, Im more able to get him to try something Im eatingbecause its just one bite and its not like he has to eat the whole thing Another caregiver stated that, as a parent, it was really nice to go somewherethe stress wasnt all on me, and I felt like this was the first time our family was getting help Discussion Picky eating is extremely common, impacting one-quarter of typically developing US children. Occupational therapists utilize both individual and group therapy to treat picky eating without a clear understanding of the benefits. This study sought to better understand caregivers CAREGIVER EXPERIENCE OF FEEDING GROUP 28 experiences of living with a picky eater and to understand caregivers experiences following their childrens participation in group feeding sessions. From seven caregiver interviews, the researcher found that caregivers experienced both isolation and stress associated with managing their picky eater. The isolation was tied to social situations both inside and outside the family. Caregivers felt judged by others, including their spouses, on how the picky eating was handled and the suggestions they would receive to remedy the situation. The stress caregivers felt was rooted in mealtime struggles and the modifications they often made to encourage eating with the knowledge that sometimes the modifications led to unhealthy patterns. In the current study, caregivers reflected on their choices made during mealtimes, and emphasized their feelings of frustration and at times, defeat. Mitchell et al. (2013) reviewed the literature and reported that mealtime modifications more than often increased the stress level of caregivers. The researcher highlighted that mothers of picky eaters often have higher levels of depression and anxiety. Farrow et al. (2006) also reported that among a group of 99 mothers, the most common factor associated with feeding difficulties was low selfesteem and feelings of social isolation. Caregivers reported forming bonds with other caregivers while their children participated in group feeding sessions. Compared to non-picky eaters, Chao and Chang (2015) frequently observed strained caregiver-child interactions and reactions suggesting that picky eating impacted the child-caregiver relationship even beyond mealtime. These informal caregivercaregiver interactions resulted in feelings of decreased isolation as well as opportunities for sharing the stressors of raising picky eaters. Being a part of a group, according to Jones and Bryant-Waugh (2012) reduces feelings of isolation and self-blame. Dahlsgaard and Bodie (2018) also emphasized the crucial role of shared caregiver experiences in reducing feelings of CAREGIVER EXPERIENCE OF FEEDING GROUP 29 isolation in group settings. In the current study, several caregivers indicated that these informal interactions allowed them to experience greater acceptance of their children and their own experiences knowing they were not alone in their journeys. As a result, they often felt great relief. The experience of relief was associated with the shift in responsibility of challenging their children during mealtime to the relationship between the therapist and child during the group sessions. Caregivers regularly recognized that their stress level impacted both how and when new food was presented, frequently creating additional stress and family discord. Having someone else involved with the presentation of new food reduced the burden caregivers often carried alone. By having children participate in feeding groups, it is likely that caregivers feel reprieve from the blame they self-afflict supporting a change in the caregiver-child relationship. In addition to the feelings of relief, caregivers also took comfort in knowing their children were among supportive peers and had a professional to guide them. Caregivers indicated that their children were more willing to try new food items in the group setting, that peer modeling was helpful to encourage food exploration, and that their children felt less anxiety in new situations. Many caregivers pointed to visual observation and social engagement as being important to encouraging their children to try new food. Cruwys, Bevelander, and Hermans (2015) highlighted the importance of modeling in learning new skills when similarities are perceived between individuals. Modeling of food intake for example, is a broader example of social influence that does not exist in one-on-one therapeutic support. Indeed, in the feeding groups, caregivers felt that their children shared similar struggles during mealtime, and when placed together during the groups, their anxiety levels diminished with the presentation of a new food. Also noted was that children often began to take on leadership roles supporting others CAREGIVER EXPERIENCE OF FEEDING GROUP 30 during food trials a position most of them have not experienced when being presented new foods. A Theoretical Framework for Pick Eating Behaviors Banduras social-cognitive theory (SCT) may help to explain the phenomena associated with the social and behavioral dynamics of feeding groups. Indeed, SCT suggests that individuals behaviors are shaped by their abilities to regulate behavior and modify their environments (Bandura, 2004). Bandura stated that human behavior is social, not just individual. Social dynamic, self-efficacy, and observational learning are three constructs of SCT that are relevant to the desired behavior changes identified in the current study. Caregivers in this study reported their children experienced a number of positive behavior changes through their participation in social feeding groups. These positive changes included decreased stress associated with trying new foods as well as implementing new strategies to manage their food-related stresses at home and in the community. Moreover, caregivers recognized their own positive changes following their informal interactions with other caregivers. They became more aware of their own acceptance of their situations which led to less stress and improved mealtime dynamics at home. Self-efficacy is the belief that one has the power to produce desired changes by one's action (Bandura, 2004, p. 144). Dishman, McIver, Dowda, Saunders, and Pate (2019) found that self-efficacy declined with more perceived barriers to change. By offering structured presentation of new foods and opportunities for modeling of others, group sessions often help picky eaters to overcome barriers to trying new foods and therefore would likely increase their self-efficacy. For caregivers, improvement in self-efficacy was experienced through their informal sharing with other caregivers in the waiting room. Caregivers began to recognize CAREGIVER EXPERIENCE OF FEEDING GROUP 31 strategies, through this sharing, that support greater acceptance of their childrens reactions during mealtime. Observational learning is the final SCT-related construct that may be pertinent in understanding the current study. The groups environment was explicitly established by an occupational therapist to support learning and exploration of new food. In a comprehensive review of 69 studies based on eating behaviors, Cruwys, Bevelander, and Hermans (2014) found that 64 studies demonstrated significant impact of modeling on positive eating behaviors. The review indicated that the impact of modeling had two components: 1) individuals desire to seek out appropriate response to the presentation of food; and 2) individuals need for affirmation from others. The caregivers reported that feeding group offered the ideal opportunity for children to appropriately observe others as well as obtain constructive feedback from their peers, which facilitated positive changes in the eating behaviors of the participating children. Considering these three constructs of SCT allows for a deeper understanding of why caregivers felt their children emerged with a novel willingness to accept new food following the therapeutic feeding group sessions. Caregivers also identified the transition in responsibility as a focal point that supported a breakthrough of past identified barriers of mealtime stressors associated with having a child who is a picky eater. As these barriers were removed, caregivers identified improved willingness by their child to try new foods through the introduction of peer modeling, positive affirmation, and strategies provided by others. Implications for Occupational Therapy Practice The American Journal of Occupational Therapy (2017) acknowledges the social component of feeding including: meal preparation, eating at a restaurant or other community location, or simply feeding a child. In the current study, caregivers identified feelings of stress, CAREGIVER EXPERIENCE OF FEEDING GROUP 32 isolation, and frustration when their children refused to eat with a recognition of the impact on the caregiver-child relationship during mealtime. These findings reflect treatment implications for both caregiver and child and, moreover, emphasize the need to target both when working with picky eaters. Caregivers acknowledged the leverage that peer-based support provided for their children; they also recognized the value of other caregivers in reducing their own feelings of isolation further highlighting the benefit of group sessions for families managing picky eaters. The benefit of peer support is an important component for occupational therapists to understand as an effective strategy to increase the acceptance of new food for children who are picky eaters. As children become less dependent on their caregivers, peer modeling becomes more influential in behavioral modification. In combination with a developmental assessment, an occupational therapist may determine if greater change may be seen with the support of a peer group versus individual therapy. As feeding does not happen in isolation, occupational therapy recognizes the social component involves caregiver engagement. Caregivers identified feelings of stress and isolation while raising a child who is a picky eater. During feeding groups, caregivers informally engaged with each other, finding unexpected support with other caregivers who have similar experiences. This interaction not only reduced the isolation felt by the caregiver, but also supported an exchange of novel ideas and strategies. Considerations for occupational therapy include providing structured programming for the caregiver that coincides with the peer-based feeding groups offering even greater support for the caregiver-child relationship. Given these findings, occupational therapists need to look deeper into the social aspect of feeding by assessing the developmental age of a child, caregiver stress, and the caregiver-child dynamic. The treatment of the picky eater may benefit from the multiple social components CAREGIVER EXPERIENCE OF FEEDING GROUP 33 offered by a peer-based feeding group. A combination of support for the child and caregiver may offer programming to support change in the overall mealtime experience. Limitations of the Study This researcher interviewed seven caregivers of picky eaters who had participated in feeding group sessions. The studys strengths include the variation in age of the children and the comfort level of the family with the therapist. Because this is a qualitative study with convenience sampling and a small sample size the results cannot be generalized. Although all caregivers were informed that they were not obligated to participate in the study, the interviews were completed by the therapist who provided the group-based feeding therapy. Having the same therapist provide the therapy and complete the interviews may have impacted caregivers responses. This limitation was addressed using reflective journaling, two coders, and member checking to improve the trustworthiness throughout the process with the goal of decreasing researcher bias. Future Research Future studies may consider inclusion of the children who participated directly in the group to better understand their experience of participating in peer-based feeding groups. This qualitative study is a starting point for continued research using quantitative methods to further understand the experiences of a caregiver with a child who is a picky eater. Quantitative techniques may allow us to look at compelling aspects of feeding groups using a larger sample for the purposes of generalization. Quantitative or mixed methods approaches could be used to help researchers better measure caregiver stress and to determine if there is a change in stress levels following participation in a feeding group compared to before participation. Longitudinal research may help identify changes that occur during and following a caregivers and childs CAREGIVER EXPERIENCE OF FEEDING GROUP 34 engagement in a peer-based feeding group and if that change persists over time. This information may be especially beneficial for any therapist who supports families in long-term treatment, to understand the impact of group feeding sessions. Conclusion Nearly all caregivers had a deep desire to share their perspectives raising a child who is a picky eater. The interviews emphasized feelings of stress and isolation experienced during mealtime in particular. Caregivers were able to identify the benefits and impact of participation in peer-based feeding groups. The current study expands on the existing literature, and points to caregiver relief as previously unrecognized but important benefit that individual therapy does not offer. Further, group therapy is perceived as effective in reducing isolation for both the child during the structured group sessions and through informal caregiver interactions during but outside of the group sessions. The shift in accountability reduced caregiver stress during mealtime particularly as the children were more willing to try new foods as they were presented. Because of the plethora of benefits associated with group therapy identified for both the participating picky eaters and their caregivers, the option of group therapy for picky eating should continue to be utilized. Additional studies to identify who would most benefit compared to individual therapy should be also be considered. CAREGIVER EXPERIENCE OF FEEDING GROUP 35 References Alm, S., Olsen, S., & Honkanen, P. (2015). The role of family communication and parents' feeding practices in children's food preferences. Appetite, 89, 112-121. doi:10.1016/j.appet.2015.02.002 American Occupational Therapy Association. (2014). 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... Employers Perception of Occupational Therapists Entry-Level Competence for the Treatment of Upper Extremity Dysfunction Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Marie-Claude Touchette, MHS, OTR/L Copyright 10/05/2020 By: Marie-Claude Touchette, MHS, OTR/L All rights reserved Approved by: Laura Santurri, PhD, MPH, CPH Committee Chair ______________________________ Mary Ellen Stoykov, PhD, OTR/L Committee Member ______________________________ Corrin Pitluck, PhD Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ Running head: OCCUPATIONAL THERAPISTS ENTRY- LEVEL COMPETENCE 1 Employers Perception of Occupational Therapists Entry-Level Competence for the Treatment of Upper Extremity Dysfunction Marie-Claude Touchette University of Indianapolis Author Note Marie-Claude Touchette, Department of Occupational Therapy, University of Indianapolis Correspondence concerning this article should be addressed to Marie-Claude Touchette, Master of Occupational Therapy, Elmhurst University, Elmhurst, IL, 60126. E-mail: marieclaude.touchette@elmhurst.edu OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 2 Abstract Upper extremity dysfunctions can have devastating effects on an individuals functional status. Therefore, restoring upper extremity function is instrumental in increasing participation and performance in activities of daily living and leads to improved quality of life. Addressing upper extremity dysfunctions is a complex process that requires specific skill sets. Entry-level occupational therapists often treat patients with upper extremity dysfunctions. The purpose of this study was to explore the current perception of employers regarding entry-level occupational therapists expertise, or lack thereof, in the treatment of upper extremity dysfunction. A qualitative study using a basic interpretive approach was conducted using semi-structured interviews with seven direct supervisors of occupational therapy providers who had supervised entry-level occupational therapists within two years of the study. Three major themes were identified: overarching skills, evaluation skills, and intervention skills. These themes help to provide a greater understanding of the skills needed in the management of upper extremity dysfunctions, the skills expected for entry-level competence, and the perception of current entrylevel competence. Keywords: upper extremity dysfunction, hand therapy, occupational therapy, entry-level competence OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 3 Table of Content Chapter 1: Introduction ....................................................................................................................5 Problem Statement .................................................................................................................6 Purpose Statement and Research Questions ..........................................................................6 Significance of the Study .......................................................................................................7 Definition of Terms................................................................................................................7 Chapter 2: Literature Review ...........................................................................................................8 Scope of Practice....................................................................................................................8 Upper Extremity Dysfunction ................................................................................................9 Entry-Level Competence .....................................................................................................13 Employers Perspective .......................................................................................................17 Chapter 3: Method .........................................................................................................................18 Study Design ........................................................................................................................18 Participants ...........................................................................................................................18 Data Collection Procedures..................................................................................................19 Data Management and Analysis ..........................................................................................21 Chapter 4: Results ..........................................................................................................................22 Overarching Skills ...............................................................................................................23 Evaluation Skills ..................................................................................................................41 Intervention Skills ................................................................................................................41 Suggestions for Improved Entry-Level Competence ...........................................................45 Resources Available.............................................................................................................47 Chapter 5: Discussion and Conclusion ..........................................................................................48 OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 4 Limitations ...........................................................................................................................60 Implications for Practice and Future Research ....................................................................60 Conclusion ...........................................................................................................................62 References ......................................................................................................................................64 Tables .............................................................................................................................................71 Table 1 Participants Characteristics ...................................................................................71 Table 2 Overarching Skills ..................................................................................................72 Table 3 Evaluation Skills .....................................................................................................74 Table 4 Intervention Skills ...................................................................................................75 Figure 1 Suggestions for Improved Entry-Level Competence ......................................................76 Appendices .....................................................................................................................................77 Appendix A Recruitment Script...........................................................................................77 Appendix B Informed Consent Form ..................................................................................78 Appendix C Interview Guide ...............................................................................................81 OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 5 Employers Perception of Occupational Therapists Entry-Level Competence for the Treatment of Upper Extremity Dysfunction Upper extremity dysfunction (UED), due to neurological or orthopedic conditions, can have devastating effects on the individuals functional status. Sauers et al. (2011) found that pain resulting from upper extremity orthopedic injuries can lead to a decrease in quality of life. Upper extremity dysfunction after stroke can also lead to impaired functional use of the affected extremity (Raghavan, 2015). According to Gabr, Levine, and Page (2005), UED negatively affects performance in activities of daily living. As such, the use and training of the affected upper extremity after stroke is central to many stroke rehabilitation theories and considered essential to recovery (Urton, Kohia, Davis, & Neill, 2007). A significant implication to the restoration of upper extremity function is increased participation and performance in activities of daily living, leading to improved quality of life (Urton, Kohia, Davis, & Neil, 2007). Accurately assessing upper extremity dysfunction and developing an adequate treatment plan to remediate UED is a complicated process (Colclough, Copley, Turpin, Justins, & De Monte, 2015; Raghavan, 2015). Colclough et al. (2015) identified a dynamic relationship between knowledge and skills (p.1416) when treating UED, requiring a higher level of clinical reasoning skills. Similarly, Kuipers and Grice (2009) described the level of reasoning and decision-making needed to address UED after traumatic brain injury as challenging and complex. Occupational therapists are trained to be competent generalists upon graduation from accredited occupational therapy programs. According to the Accreditation Council for Occupational Therapy Education (ACOTE, 2012), occupational therapy students are educated as generalists with a broad exposure to the delivery models and systems used in settings where OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 6 occupational therapy is currently practiced and where it is emerging as a service (p. S6). According to Schofield (2012), entry-level competence includes problem-solving and clinical reasoning skills in order to determine the impact that UED has on clients occupational profile and thereafter, to develop an effective treatment plan to improve occupational performance. Entry-level competence of occupational and physical therapists for the treatment of UED has been compared to expert level in a few studies (Kuipers, & Grice, 2009; May, Withers, Reeve, & Greasley, 2010; Sizer Jr., 2007). They found that clinical reasoning of novice therapists was not as sophisticated as expert therapists and relied mostly on cognitive process, without the ability to fully integrate all components into efficient assessment and targeted interventions. Problem Statement Although occupational therapy entry-level competence has been explored from the perspective of occupational therapy students, clinical instructors, novice therapists, and clinicians (Dimick et al., 2009; Hodgetts et al., 2007; McCombie & Antanavageb, 2017; Wallingford & Knecht-Sabres, 2016), there has been no study exploring entry-level competence of occupational therapist from the employers perspective. Occupational therapists entering the job market are expected to meet the entry-level expectations (Avi-Itzhak, & Krauss, 2014); however, there are no specific guidelines regarding expected competencies required from an entry-level therapist treating UED. Purpose Statement The purpose of this study was to explore the current perception of employers regarding entry-level occupational therapists expertise, or lack thereof, in the treatment of UED. Research Questions This study sought to address the following primary research question and sub-questions: OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 7 How do direct supervisors of occupational therapy staff currently perceive entry-level competence of occupational therapists for the treatment of upper extremity dysfunction? o What suggestions would supervisors have to improve entry-level competency for the treatment of UED? o What resources do supervisors have available for the training of novice therapists in relation to the treatment of UED? Significance of the Study As the price of healthcare continues to rise (U.S. Centers for Medicare & Medicaid Services, 2018), it becomes even more imperative to provide skilled client-centered interventions while being mindful of resources. Therapists entering the field of rehabilitation need to have the knowledge and skills necessary to meet the needs of their clients while meeting the expectations of the job. A better understanding of the demands and expectations placed on entry-level occupational therapists will help better prepare them for their first job, as well as help employers identify targeted areas of growth for new employees. Definition of Terms Entry-level therapist. Entry-level generally refers to the skills that health professionals are expected to have acquired during their professional studies (Avi-Itzhak & Krauss, 2014; Baum et al., 2010; Jette et al., 2007). There is no agreement in the literature regarding the amount of time that a new graduates skills remain at entry-level (Crist, Brown, Fairman, Whelan, & McClure, 2007; Diede, McNish, & Coose, 2000; May et al., 2010; Mulholland & Derdall, 2004). For the purpose of this study, entry-level will be defined as the first year of employment after graduation. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 8 Upper extremity dysfunction. In the context of this study, upper extremity dysfunction will refer to impairments of the upper extremity from a neurological or orthopedic injury that is causing difficulties in functional use of the affected upper extremity and requiring interventions from an occupational or physical therapist (Hsu et al., 2011). Manual therapy. For this study, manual therapy refers to intervention strategies that utilize a manual, hands-on technique in order to facilitate physical changes. Review of Literature Scope of Practice Occupational therapists main concern is the ability of their clients to engage in and participate in occupations (American Occupational Therapy Association [AOTA], 2014). Occupational therapists use their unique knowledge of the interconnection between the components of the person, environment, and context to design and implement interventions that facilitate change or growth in client factors () and skills () needed for successful participation (AOTA, 2014, p. S1). Although the components of the person, or intrinsic factors, are not the main focus of occupational therapy, they are of great importance if they affect the clients ability to engage in meaningful occupations (AOTA, 2014). The Illinois occupational therapy scope of practice further defines what occupational therapy entails (AOTA, State Affairs group, 2014). According to the Illinois scope of practice, occupational therapy interventions may include (.) remediation or restoration of performance abilities that are limited due to impairment in biological, physiological, psychological, or neurological processes (p. 8). As such, occupational therapists are well suited to address intrinsic factors of the person, such as UED, for optimal remediation of deficits as related to increased occupational performance (AOTA, 2014; Baum et al., 2010; Carroll & Lawson, 2014). OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 9 Upper Extremity Dysfunction Complexity. Because addressing UED requires a complex set of skills, several authors have looked at the skill set needed to successfully address UED. According to Adam, Strong, and Chipchase (2013), occupational and physical therapists require an in-depth knowledge of anatomy and its implication related to human function. In their analysis of hand therapy practice, Keller et al. (2016) identified 25 fundamental knowledge and basic sciences and 26 common conditions in hand therapy. Kuipers and Grice (2009) reported that clinical reasoning and decision-making for the treatment of UED are complex and challenging. Colclough, Copley, Turpin, Justins, and De Monte (2015) described in more depth the skill set needed when addressing UED with hypertonicity. They described the knowledge base and skillsets necessary for addressing upper extremity hypertonicity as having a good understanding of neurological and biomechanical concepts, anatomy, and of the intervention process and implementation. They also describe the skill sets needed for the treatment of UED as demonstrating competence in task performance and in soft tissue interventions. In 2013, Proud, Miller, Martin, and Morriss study focused on the assessment of UED due to Parkinsons disease. They found that the method used most frequently by therapists to assess UED in patients with Parkinsons disease was observational analysis. Similarly, according to Bernhardt, Bate, & Matyas (2001), sound clinical judgment and decision-making depend in part on observational skills. Yet, according to Carroll and Lawson (2014), considerate anatomical instruction is necessary for an occupational therapist to effectively analyze functional performance and subsequently design a plan for rehabilitation (p. 495). Furthermore, detailed analysis of functional anatomy and the understanding of the impact that UED has on performance are essential skills for all occupational therapists (Schofield, 2017). OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 10 Manual therapy is a highly specific skill set used in the treatment of UED. It refers to skilled passive movement of soft tissues and joints used to improve range of motion and flexibility, and decrease pain and edema (APTA, 2014). Sizer Jr. (2007) describes a set of eight critical skillsets needed for competent manual therapy practice. These manual techniques include: joint assessment, proficiency in fine sensorimotor characteristics, patient management, bilateral hand-eye coordination, gross characteristics of the upper extremity, control of self and patient movement, and discriminate touch (Sizer Jr, 2007, p. 38). Finally, it is critical to address UED following a stroke. Upper limb impairments after stroke lead to functional limitations in using the affected upper extremity. This can lead to learned non-use, overuse of compensatory strategies, or inattention to the affected upper limb during occupational performance (Raghavan, 2015). It is therefore imperative to address the underlying upper extremity impairments to restore proper function. However, according to Raghavan (2015), developing a comprehensive understanding of UED is not an easy task and requires a solid knowledge of the disease process and the underlying deficits. The management of motor impairments after stroke is a complex process. It requires therapists to combine evidenced-based treatment strategies to address each clients individual needs and achieve maximal motor recovery for the upper extremity (Hatem et al., 2016). Furthermore, sensory deficits are common following strokes with an incidence of up to 85% (Hatem et al., 2016). Sensory impairments can negatively affect motor task performance and are associated with lower recovery prognosis (Hatem et al., 2016). Unfortunately, Doyle, Bennett, and Gustafsson (2013) identified lack of knowledge and skills as the main barrier to adequately treating sensory impairments post-stroke. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 11 Skill acquisition. According to Carroll and Lawson (2014), considerate anatomical instruction is necessary for an occupational therapist to effectively analyze functional performance and subsequently design a plan for rehabilitation (p. 145). Although occupational therapy students generally learn anatomy, physiology, and kinesiology during their educational program or as prerequisites the amount of time spent and modalities used for instructions vary greatly between educational programs (Carroll, & Lawson, 2014). Despite the amount of knowledge needed for UED management, Short et al. (2020) found that entry-level OT program faculty were satisfied with the inclusion of hand therapy content within their curriculum with the recommendation to increase the emphasis on occupation during didactic instruction (p. 112). Even though Bethea, Castillo, and Harvison (2014) found that the use of stimulation within OT educational programs improved clinical reasoning, problem-solving and decision making, and communication among students (p. S32), more advanced learning occur after graduation, during the first two years of practice (Dimick et al., 2009; Short et al., 2020). Many studies looked at the process of skill acquisition within clinical practice. Colclough et al. (2015) reported that exposure to clients over time in clinical setting is important to the development of skills for competent practice. Additional training after graduation helps in developing stronger clinical reasoning and decision-making skills for the treatment of UED (Bernhardt, Bate, & Matyas, 2001; Colclough et al., 2015; Kuipers, & Grice, 2009; May et al., 2010). Bernhardt, Bate, and Matyas (2001) found that training improved the accuracy of judgment in the observation of UED after stroke. Schneider, Lannin, and Ada (2019) found that a professional development program improved the use of evidence-based clinical practice guidelines by inpatient rehabilitation staff. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 12 Others found a significant difference when comparing the clinical expertise of entry-level therapists to more experienced therapists. According to Sizer Jr. et al. (2007) entry-level therapists used a cognitive-based learning technique and focused on the mechanical aspects of the task whereas experienced therapists were able to integrate their perception skills and increase their focus on implementation using a combination of psychomotor skills. As such, entry-level therapists used straight forward motor skills such as clinicians control of self and patient movements whereas experienced therapists used skills that required the integration of knowledge, the ability to combine previously developed skills, and a higher level of intuition and sensory-motor skills. May et al. (2010) found that entry-level therapists failed to associate many aspects of the history with significant findings or clinical implications. They found that over 50% of entry-level therapists failed to consider important aspects of decision-making and clinical reasoning for the treatment of shoulder problems. These included duration and status since onset; pain on resisted tests; capsular restriction; diagnostic implications of painful arc; differentiating muscle, capsule, and joint source of symptoms; and the use of markers to judge treatment effectiveness. With experience, therapists began to combine strategies and concepts into more advanced clinical reasoning skills (May et al., 2010). Overall, clinical reasoning, decision-making, and manual skills of entry-level therapists for the assessment and treatment of UED were weak and lacked sophistication (May et al., 2010). Of even greater concern, Kuipers and Grice (2009) found that before being exposed to clinical reasoning protocols, study participants either did not access or did not rely on prior knowledge of UED assessment and intervention. Therefore, experience appears to be a key component to the integration of advanced knowledge and skills (Dimick et al., 2009). As such, Colclough et al. (2015) recommended for future training to be focused on the development of OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 13 clinical reasoning. This would allow therapists to better integrate individualized circumstances into treatment planning, hence implementing a holistic approach to care and facilitating positive client outcomes. Entry-Level Competence Overall, the goal of educational programs is to produce entry-level generalists who are equipped with the skills and knowledge to deliver entry-level evidence-based occupational therapy services (Avi-Itzhak & Krauss, 2014). Entry-level occupational therapists should be able to meet the needs of clients, families, and communities in a variety of practice settings (Schofield, 2017, p. 1). The Fieldwork Performance Evaluation (FWPE/OTS) defines competency as adequate skills and abilities to practice as an entry-level occupational therapist (Wallingford & Knecht-Sabres, 2016). In the United States, it is the Accreditation Council for Occupational Therapy Education (ACOTE) that outlines the current standards for entry-level OT education (Wallingford & Knecht-Sabres, 2016). According to ACOTE (2012), entry-level occupational therapists should be educated as a generalist with a broad exposure to the delivery models and systems used in settings where occupational therapy is currently practiced and where it is emerging as a service (p. S6). Jette et al. (2007) describe entry-level as "the level of knowledge, skills, and professional behavior expected of a new graduate when entering the profession of physical therapy (p. 834). Despite having defined standards for entry-level educations, its clinical application remains somewhat suggestive. Wallingford and Knecht-Sabres (2016) found that the definition and perception of entry-level might be site-specific or influenced by the setting or employers where the occupational therapist practices. They also found that the level of supervision required for entry-level therapists may be situation or skill specific. In 2013, Adam, Strong, and OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 14 Chipchase found that educators perceived entry-level occupational and physical therapy students as being able to perform the majority of work-related tasks with only minimal supervision. According to Sass et al. (2006), the latest version of the Physical Therapy Clinical Performance Instrument described entry-level performance as the ability to treat complex patients and provide skilled assessment and interventions, whereas highly skilled intervention and assessment were reserved to beyond entry-level. In other words, entry-level clinicians are not expected to be entirely independent at all times (Sass et al., 2006). Several entities stand to benefit from more consistent and reliable entry-level expectations and performance. Occupational therapy clients expect occupational therapists to have adequate training and be well-prepared to address their needs in a competent manner (Sellar et al., 2017). Avi-Itzhak and Krauss (2014) reported that entry-level OT should be well prepared to join the job market with the expected competencies to meet their job demands. Entry-level skill demands. In 2007, Crist, Brown, Fairman, Whelan, and McClure analyzed the use of a variety of interventions by entry-level OT and occupational therapy assistant (OTA). They identified a list of ten most utilized interventions. It is noteworthy to mention that 50% of these interventions relate directly to the treatment of UED. Furthermore, four out of the five interventions related to the treatment of UED were amongst the five most commonly used interventions. They are, in order of importance: therapeutic exercise, fine motor training, strength and endurance training, therapeutic activities, and gross motor coordination training. In Britain, The College of Occupational Therapists (2016) included the knowledge and skills needed in the analysis of body functions and structures as part of the recommended core knowledge and skills. More specifically, they were described as: OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 15 [the] knowledge: of anatomy and physiology and how impairment impacts on activity and functioning [as well as the] skills in understanding the structures and functions of the body and the impact of a range of impairments on setting and achieving a range of occupational performance goals (The College of Occupational Therapists, 2016, p. 6). Erickson et al. (2017) found that anatomy and surface anatomy, kinesiology, physiology, pathology, and common UED diagnoses should be covered in detail within the curriculum. Thomas, Saroyan, and Snider (2012) addressed the expected level of evidence-based practice from entry-level therapists. They admitted that entry-level therapists could not provide evidencebased practice to the same level as experienced therapists. This is explained by the fact that expertise in evidence-based practice is highly dependent on extensive experience and practice (Thomas, Saroyan, & Snider, 2012) Challenges. There continue to be significant skill disparities across the schools of occupational therapy, leading to varying levels of entry-level competence amongst graduates from accredited programs (Crist et al., 2007). As such, Grace (2007) recommended the implementation of uniform entry-level educational competencies for the professional and technical levels of education (p. 281) to ensure equality of skills and outcomes amongst entrylevel therapists. In response to the increasing demands for efficient and accelerated interventions, and the requirements to better document the need for skilled therapy, Dimick et al. (2009) recommended that occupational therapy programs incorporate more practical skill training and education in foundational knowledge. They found that experienced therapists felt that there were several technical skills used for the treatment of UED that they would have benefited from learning within the first two years of practice. Accordingly, Hodgetts et al. (2007) found that occupational OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 16 therapy students and recent graduates felt that they were lacking general technical skills. As such, Rassafiani (2009) determined that clinical experience was an important component in the development of clinical expertise. The difference in clinical skills and expertise between entry-level therapists and experienced therapists has been documented in a variety of studies. Schofield (2017) found a significant difference in the perception of the knowledge of anatomy between entry-level therapists and experienced therapists. When experienced and entry-level therapists were asked to rate the knowledge of anatomy of therapists with up to two years of experience, entry-level therapists consistently rated their own knowledge higher as compared to the rating given by more experienced therapists. Failla, Maher, and Duffy (1999) also documented a heighten selfperception of skills and knowledge in entry-level professionals. New nursing graduates rated their own performance significantly higher as compared to their performance assessment completed by faculty and employers. McCombie and Antanavageb (2017) explored the transition of occupational therapy students over the first year of employment. They found that entry-level occupational therapists were more likely than experienced therapists to experience burnout and job stress and rated the transition from student to clinician in a less positive way. New graduates only felt marginally prepared for practice, especially when it comes to interacting with other healthcare professionals and applying evidence-based practice (McCombie & Antanavageb, 2017). The authors recommendation was for entry-level occupational therapists to assess the clinical demands and expectations of the job to ensure a proper fit between personal skills and expectations. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 17 Employers Perspective It is easy to see how a good education can benefit students and potential clients of occupational therapy. However, employers of occupational therapy staff also have high stakes in quality education. According to Mulholland and Derball (2004), educational programs must not only be accountable to students, providing them with a solid knowledge base and clinical skills, but also to employers. They recommended for the academic community to be aware of employers needs and balance those needs with the development of the profession and professional education. Knowledgeable students with strong clinical skills are more marketable to employers looking for individuals with a certain set of skills and attributes (Mulholland & Derball, 2004). The academic community needs to be aware of the needs of employers and attempt to balance their needs with the development of the profession and professional education (Mulholland & Derball, 2004). Unfortunately, employers expectations are not always in line with those of entry-level therapists and new employees. McCombie and Antanageb (2017) found that there was disagreement in performance rating between the employers rating and the entry-level therapists self-assessment. This may suggest a difference in expectations for occupational therapy entrylevel performance. As such, Grace (2007) highlighted the importance to engage in an open dialogue with external constituencies and educational programs to better assess the impact that changes or modifications in OT education could have on the constituents. To better align employers expectations to entry-level OT skills, it is important to understand what employers are looking for. According to Crist et al. (2007) recommendations, the OT profession needs to identify the interventions used in practice while considering professional expertise and the impacts of the demands and expectations on clinicians. They OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 18 recommended that the profession become more accountable regarding the specific skills and knowledge that are expected from entry-level occupational therapists. In 2004, Mulholland and Derball explored what Canadian employers were looking for when hiring OTs. They found that employers were looking for a certain combination of professional skills as well as personal attributes such as professional experience and interpersonal and communication skills. Desirable personal traits included the willingness to learn, independence, resourcefulness, flexibility, professionalism, creativity, enthusiasm, maturity, confidence, and overall personality (Mulholland & Derball, 2004). Method Study Design This study utilized a qualitative, basic interpretive approach. A basic interpretive approach is one that seeks to understand how people make sense of their lives and their experiences (Merriam & Associates, 2002, p. 38). The basic interpretive approach is used to explore and understand the lived experience from the participants point of view. Accordingly, this study used a basic interpretive approach to better understand the lived experience of occupational therapists direct supervisors, especially examining their experience supervising entry-level OT involved in the treatment of UED. Prior to data collection, the study was approved by the University of Indianapolis Institutional Review Board. Participants Inclusion and exclusion criteria. Inclusion criteria included participants who directly supervise occupational therapy staff and who have supervised at least one entry-level OT within the past 2 years. Given limited resources for the study, participants not fluent in the English language were excluded. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 19 Sample size. Seven participants were recruited for this study. Data thematic saturation was reached. Sample size was based on previous qualitative studies of similar constructs (Colclough, Copley, Turpin, Justins, & De Monte, 2015; May et al., 2010). Saturation of data was determined when the data collection reached a point of redundancy, where participants did not contribute new information to the study (Cottrell & McKenzie, 2011). Procedures Recruitment. Participants were recruited from rehabilitation clinics or departments in the Chicago land area using a purposive sampling and snowball recruitment strategy. A sample of convenience is used when researchers recruit participants that are available and accessible to the researcher (Hess-Biber & Leavy, 2011). The Chicago land area was selected as a matter of geographical convenience, while providing for a wide selection of occupational therapy worksites and educational programs. This allowed for a better representation of entry-level competence rather than site-specific or program-specific competence. When using purposive sampling, the researcher selects participants that can best contribute to the study (Carter, Lubinsky, & Domholdt, 2011). Qualitative researchers use purposive sampling not for representativeness, but for diversity of views (Carter, Lubinski, & Domholdt, 2011, p. 162). By using purposive sampling, the principal investigator was able to recruit therapy supervisors who have had experience working with entry-level OTs and who can best contribute to the study objectives. When using snowball sampling, the researcher asks participants to identify other potential participants (Carter, Lubinsky, & Domholdt, 2011). The principal investigator used this strategy in order to identify a greater number of potential participants. Recruitment strategies included contacting therapy supervisors from a variety of hospitals and clinics within the Chicago land OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 20 area via phone calls and emails (Appendix A) and selecting participants within the principal investigators professional network. Consent. Informed consent was obtained verbally prior to the start of the interview. Participants were provided with written information regarding the goal and purpose of the study, the structure of the interview, as well as the risks and potential benefits from the study (Appendix B). Informed consent was assumed when participants verbally agreed to participate in the interview after a review of the study information document. Potential risks to the participant include psychological distress. To minimize the risk, participants were given the choice not to answer any question and to terminate the interview at any time. Data collection. Data was collected using semi-structured, in-depth interviews conducted in person. The primary investigator conducted a 45 to 60 minutes interview with each study participant using a semi-structured, in-depth interview guide. The interviews were conducted at a time and place that was convenient for the participant and were audio-recorded. Each participant received a gift card as incentive for participating in the study. Interview guide. The interview guide (Appendix C) was reviewed by a qualitative researcher serving as the analysis expert for this study. In addition, the principal investigator piloted the interview guide through an interview with one direct OT supervisor to obtain her feedback concerning the interview process and the interview guide. The principal investigator made small revisions to the interview guide to reflect comments and suggestions obtained from pilot testing and the analysis expert. The interview guide included questions exploring the supervisors perception of the skills required for the treatment of UED, level of expertise in the treatment of UED, and resources needed and available for the mentorship or support of entrylevel OT. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 21 Data Management & Analysis The principal investigator transcribed the interviews verbatim after each interview using Temi transcription software. The transcriptions were identified using pseudonyms only and were stored electronically in a password-protected computer. The audio recordings were saved electronically in a password-protected computer. The electronic files and hard copy materials will be destroyed 36 months after the completion of the study. Since the aim of this study was to explore entry-level competency on the treatment of UED from the direct OT supervisors point of view, an inductive approach to data analysis was used. According to Thomas (2006), the inductive approach is a systematic procedure for analyzing qualitative data in which the analysis is likely to be guided by specific evaluation objectives (p. 238). When using an inductive approach, the researcher completes a comprehensive reading and interpretation of the raw data to form concepts, themes, or models (Thomas, 2006). As such, it is the raw data that guides the analysis through the emergence of frequent, dominant, or significant themes inherent in raw data, without the restraints imposed by structured methodologies (Thomas, 2006, p. 239). As suggested by Carter, Lubinsky, and Domholdt (2011), the principal investigator and the analysis expert completed independent parallel coding of the first two interviews. Following the inductive approach for analyzing qualitative evaluation data described by Thomas (2006), the initial codes were developed through careful examination of the interview transcript. The researchers identified and organized relevant information from the text into larger categories based on the research questions. The principal investigator and the analysis expert then worked in collaboration to reduce overlap and redundancy amongst categories until an agreement was reached. Finally, a model was created to include the five overarching themes that had emerged. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 22 The first three themes were developed based on the skills participants identified for competent UED management and were grouped into three sections: overarching skills, evaluation process, and intervention process. These themes were then applied to the expected skills needed for entrylevel competence and perceived entry-level competence. Themes regarding suggestions for improved competence and available resources were developed individually. The data analysis process was completed using Microsoft Word revision and comment functions. The principal investigator conducted periodic checks with the analysis expert throughout the analysis process. The principal investigator kept a detailed audit trail and memos with reflective notes during the transcription, coding, and theme development process. The principal investigator performed member checking to ensure proper interpretation of the narrative. Two participants from different work settings were sent a copy of the primary themes and sub-themes identified to verify that it reflected their perception of the topic. Both respondents provided written feedback and found that the themes and subthemes were reflective of their perception of entry-level OTs competence. Furthermore, an expert in the field reviewed a copy of the completed report. Finally, the principal investigator used triangulation to compare the study results with data from existing literature. Results Seven participants were interviewed for this study (Table 1). This group was comprised of three physical therapists and four occupational therapists. All participants were employed in managerial roles at the time of the interview. Participants had nine to 25 years of experience in their respective professions, with an average of 17.2 years of experience. Participants worked in various settings with four participants working primarily in an outpatient setting and three participants working primarily in an inpatient setting. Additionally, two of the participants had OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 23 dual roles in outpatient and inpatient settings, including one participant in a day rehabilitation outpatient setting. All participants were confident in their expertise for treating upper extremity dysfunction, with only one participant indicating a decreased level of confidence in addressing hand and finger injuries or conditions but feeling confident addressing elbow and shoulder dysfunction. Five themes were identified: overarching skills, evaluation skills, intervention skills, suggestions for improved entry-level competence, and resources available to managers in clinical settings. For the first three themes that are related to skills, results were organized in three subsections: Skills needed for UED management Skills expected for entry-level competence Employers perception of actual entry-level competence Overarching Skills Overarching skills (Table 2) includes all skills that are applicable through the entire occupational therapy process. Six sub-themes have been identified: safety, knowledge, communication skills, interpersonal skills, and holistic and client-centered care. Safety. Skills needed for UED management. Participants identified safety as being an important component of the occupational therapy process and as such, they expected entry-level OTs to maintain safety throughout the OT process. Participant 4 identified safety as one of three pillars of practice monitored and addressed within his institution: The big three pillars here are basically safety- patient safety, outcomes, and then customer and patient satisfaction- and they've got to be doing well in those areas. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 24 Certainly if there's () safety issues, we have safety reporting software here and people can go on that and do things anonymously. That would warrant conversations with the employee and we would have to do remediation of various kinds. Interventions targeting UED have the potential to cause harm. According to the participants, OT treating UED must know and understand the precautions associated with different conditions and to apply them within their intervention. Participants highlighted the importance of not harming patients by understanding the precautions associated with a specific diagnosis, understanding the physicians orders, and correctly identifying the cause of the dysfunction and ruling out other potentially harmful causes. According to Participant 5, if you're going to treat patients in that population, in that setting, you need to know how to rule out the cervical spine. Because again, you could be making things worse. Participants even expressed the willingness to prioritize safety over some of the quality of intervention. For example, Participant 2 felt that even if the mechanics arent the best, they have to be just safe. Perceived entry-level competence. Participants expressed concerns regarding the ability of entry-level OT to maintain safety throughout the intervention process. According to participant 7, entry-level OTs need some additional time to learn how to incorporate safety to patient care: Learning how to just work and be safe with patients, with different diagnoses or pathophysiology. What are the optimal treatments for certain presentations? They struggle. Knowledge. Skills needed for UED management. All participants agreed that having a foundational knowledge base was crucial when treating UED. The knowledge base needed to address UED was grouped into four categories: conditions, protocols or guidelines, sciences of the human body, and life-long learning. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 25 Conditions. Participants agreed that in order to address UED, therapists needed to have the knowledge and understanding of common conditions affecting the upper extremities: You need to know and understand the common diagnoses (P1). You also need to know some neurological diagnosis as well such as a wrist drop or hemiparesis of an extremity (P6). Protocols and guidelines. When discussing protocols and guidelines, participants referred to knowing the typical progression according to specific diagnoses. This also related to OTs knowing when to implement or not implement certain interventions, such as range of motion or strength training or as Participant 6 said: You need to know the protocols that are out there. So, if someone has a tendon injury, let's say a flexor zone 1 tendon injury, or zone 2, you have to know what the protocol is in order to treat the patients. Participants spoke of the ability to use protocols as guidelines for typical patient progression. As such, therapists should have the ability to modify the protocol based on the patients progress and circumstances: Good surgeons right now, hand surgeons, would say theyre guidelines. Protocols are kind of a thing of the past. Protocols are very strict and that's, most of the doctors I work with have guidelines. They have a general timeframe, but if you're not doing well, you have to either bump it up or move it so theyre not And I think that's where it is difficult. (P3) Sciences of the human body. Anatomy, functional anatomy, physiology, and pathophysiology were grouped within the sciences of the human body. All participants agreed that OTs treating UED should have a foundational knowledge of the sciences of the human body and apply this knowledge to the intervention process. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 26 Participants discussed the need to know anatomy in terms of knowing basic structures and the connection and interacting between these structures. According to participant 3, the knowledge of anatomy is the building block to competent UED practice: I think anatomy is the skeleton of it all, the base of everything. Participant 5 reported that the knowledge of biomechanics was also important to addressing UED: I think they need to have an understanding of the anatomy, both the musculature and the biomechanics of it. And again, how does it relate to the joints above and below. Participants also discussed the importance of pathophysiology or the understanding physiological processes associated with specific conditions and the typical response to injuries. Once again, participants discussed the need to integrate this knowledge during the intervention process: Have a deeper understanding of some of the pathophysiology going on or the decisionmaking process. You know, if this then do this, if this, then this. Like an algorithm type of decision making (P7). Life-long learning. Despite being experts in their field, all participants agreed with the need to continually seek additional knowledge to provide optimal interventions. They further expressed the importance to remain up to date with evidence as UED interventions continue to grow and surgical procedures continue to evolve. As such, participants believed that in order to be proficient in managing UED, therapists should commit to life-long learning: Because we live in a fast-paced medical world, you've got to do a lot of outside [work] until you know what you're doing. I'm still doing stuff outside. Looking stuff up. So it doesnt matter []. An OT you should always be willing to grow and develop. (P3) In order to seek knowledge and commit to learning, one must possess a certain level of selfawareness. According to Participant 1, I think more importantly, are skills of knowing your OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 27 strengths and your weaknesses [] and take feedback, and learning from it. Being open to feedback is an important skill to help develop self-awareness and it allows for further learning. Finally, life-long learning requires therapists to take the initiative for their own learning, actively seek out knowledge without depending on others, and know-how to utilize available resources: You have to go off on your own and, and do readings, and practice. You have to read up on the diagnosis that you're treating. So that that's important (P6). According to Participant 1, therapists should be skilled in utilizing your resources, communicating with other OTs, utilizing your resources as far as friends, colleagues who may have some experience in it. Utilizing the books and the foundations. Skills expected for entry-level competence. When it comes to knowledge, participants expressed having similar expectations for entry-level OTs than for experienced clinicians, especially in regards to the sciences of the human body. Entry-level OTs are expected to enter the field with the foundational knowledge of anatomy, functional anatomy or kinesiology, physiology, and pathophysiology. Additionally, they should have the ability to integrate their knowledge into the intervention plan and implementation. As such, they are expected to know conditions and diagnoses commonly seen in practice and to have a basic understanding of associated protocols or guidelines. However, they are not expected to know everything there is to know, but rather, they are expected to take the initiative for their own learning: Doing some research outside. You know, even though you're a new clinician, you're still a student (P3). Entry-level therapists are expected to take the initiative to research topics they are not familiar with and independently use available resources to improve their knowledge base continuously: Go read and practice the skill, research what you dont know (P6). OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 28 Perceived entry-level competence. Participants felt that entry-level OTs did not demonstrate the level of knowledge of common conditions they expected for entry-level competence. Conditions, protocols, and guidelines. Some participants felt that entry-level OTs did not have enough knowledge of common UE diagnoses and conditions seen in occupational therapy. Many participants expressed concerns regarding the lack of knowledge of the typical progression or outcomes of common diagnoses: Like expected recovery times for injuries, either postsurgery or post-trauma, or even non-surgical cases. I don't think there's a very good understanding of how those cases should progress (P4). Sciences of the human body. Participants felt that entry-level OTs did not display the level of knowledge Entry-level OTs knowledge of anatomy, kinesiology, physiology, and pathophysiology they expected for entry-level competence: A lot of the OTs first coming out of school don't have that knowledge of the biomechanics and the musculature. I think the ones that I have seen that had been very successful, are the ones that either have become certified hand therapists or have made it a point to gain additional knowledge. (P5) One participant was intrigued by the lack of knowledge of anatomy: I am so intrigued that the anatomy is not as strong as it should be. There are so many ways to get that knowledge (P3). Other participants contrasted the lack of knowledge of OTs to the foundational knowledge base displayed by entry-level physical therapists: I think that's where PT programs do a very good job of bringing it back to basic science. They are good at using a scientific approach to treating some of the injuries that we deal with on an outpatient basis, as opposed to the OT students. (P4) OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 29 Life-long learning. Participants felt that a strength of entry-level OTs resided within the commitment to life-long learning. The perceived entry-level OTs as willing and capable to learn: [They are] open to learning whatever they could about different ways of treating that patient. So I mean, they're kind of like a sponge. Whatever we teach them these, they soak it up (P6). Participants felt that even though entry-level OTs had the desire to learn, they did not always take ownership of their own learning. Despite entry-level OTs energy and willingness to learn, participants felt that they lacked the independence needed for life-long learning: Lately it's been more like just tell me what to do. I feel like as a new graduate you should be coming to me and present your thoughts of what you want to do (P3). Clinical reasoning. All participants expressed the importance of clinical reasoning skills for effective UED management. Skills needed for UED management. According to participants, OTs use clinical reasoning skills throughout the intervention process. These skills are used to apply their knowledge to clinical practice; triage and select important information; interpret evaluation results and apply the results to intervention planning; select and grade interventions in order to facilitate the best outcomes; and adjust clinical practice and protocols/guidelines based on each patients unique circumstances and clinical presentation. When working with patients, OTs receive information from several different channels such as subjective reports from patients, assessment or evaluation results, and clinical observations. According to Participant 4, OTs need to have enough clinical reasoning skills to be able to select the relevant information from all the different sources: It is like drilling down to and focusing on what is important for that particular case. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 30 Occupational therapists must also triage and apply relevant information from the evaluation and their base of knowledge to design and implement effective interventions. OTs should select interventions in a thoughtful and purposeful manner to address specific impairments and help the patient progress towards specific outcomes: Understanding why youre doing a certain intervention. Having that mindset of being able to answer the question: why am I doing this? (P1). OTs must also consider each clients individual circumstances: Not every patient is the same, and not every injury is the same, and not every surgical procedure is the same. So you have to be able to adapt to what the gains of the patients are at that time. (P6) Experienced OTs demonstrate the ability to use a scientific approach to problem solving by developing and using algorithms to guide their decision-making process. Skills expected for entry-level competence. Participants did not expect the same rigor and expertise from entry-level OTs as they did for experienced OTs. They identified the ability to justify interventions as being a more basic level of clinical reasoning. In comparison, experienced OTs would not only be able to justify his choice of intervention, but also utilize a deeper level of analysis and clinical reasoning while doing so: I think doing an assessment and then having good critical thinking skills, to then treat the dysfunction, are the things that I see as setting the entry-level clinician apart versus someone who has the experience (P2). Entry-level OTs are expected to interpret assessment results and apply their interpretation to selecting appropriate interventions to address patients individual dysfunctions. Participants did not expect entry-level OTs to select the optimal intervention. Instead, they expected entry-level OTs to demonstrate the ability to select and implement interventions that were appropriate to their clients case. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 31 Finally, participants expected entry-level OTs to use clinical reasoning skills to analyze functional performance and relate functional dysfunction to specific impairments: I think the thing that I always look at is, based on the functional performance, which systems are involved first (P2). Perceived entry-level competence. Participants identified several areas they felt entrylevel OTs could improve upon. They reported that entry-level OTs ability to integrate their knowledge base into the evaluation and intervention process was not at the level they expected for entry-level competence. More specifically, they reported that entry-level OTs had difficulty applying their knowledge of conditions to the development of intervention plans: We spend a lot of time on that with new graduates - processing all that information to arrive at an appropriate treatment plan (P4). As Participant 6 said: They would know the general upper extremity stuff as such as manual muscle testing, range of motion and stuff, but they didn't know what to do after that. Furthermore, participants felt that entry-level OTs had difficulty modifying their interventions based on the needs, circumstances, and responses of their patients: They come in thinking, well it's going to be this diagnosis so I will treat them this way. They're not doing the critical thinking to realize people are going to come in differently, If someone's not doing well and seems stiffer, youre always modifying your treatment. (P3) Communication skills. The primary communication skills participants identified as important for the treatment of UED included documentation and effective communication to all stakeholders, including the client, family members, physicians, and others. Skills needed for UED management. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 32 Documentation. When looking at the components needed for effective documentation, participants highlighted the importance of documenting outcomes to distill that information down into a coherent and succinct document without producing a six page initial evaluation (P3). Effective communication with all stakeholders. The importance of effective communication was described at different levels. First, therapists need to provide clear instruction and education to their clients: I think being able to instruct and guide a patient through the evaluation process. You need to learn to talk with people basically (P4). It is then important to be able to communicate with physicians and referral sources. It is important to maintain a communication channel between the therapist and physician to improve outcomes and maintain clients safety: And of course, you always have to check back with the physician because every physician is different in terms of what level of protocols they use. And then to crosscheck with the physician to make sure he agrees to the plan. (P4) Finally, participants reported that it was important to maintain open communication with peers and team members. Skills expected for entry-level competence. Effective communication with all stakeholders. Participants did not expect entry-level OTs to be excellent communicators at the beginning of their career, however, some communication skills were deemed important for entry-level competence. Participants identified the ability to reach out to physicians and clarify orders as needed and to build their comfort level when communicating with physicians: I think within the first year, having the ability to have that comfort level to have conversations with doctors, physicians, and referral sources (P1). OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 33 Finally, entry-level OTs were expected to provide patient instructions clearly throughout the occupational therapy process. Perceived entry-level competence. Effective communication with all stakeholders. Although participants felt that entry-level OTs generally possessed entry-level communication skills for some circumstances, their ability to communicate with physicians in a person-to-person manner did not meet their expectations: Learn how to talk more person-to-person. Theyre starting to learn. They want to do everything via email. I see the new graduates, they can't break barriers until they start seeing faces (P3). Participants felt that the main barrier to effective communication with physicians was related to the lack of confidence in their ability to communicate effectively with physicians. Interpersonal skills. Participants described several interpersonal skills needed for the management of UED. These included general interpersonal skills, teamwork, general attitude, and therapeutic use of self. Skills needed for UED management. Several participants spoke of the importance of interpersonal skills: A huge piece of what we do is just the interpersonal skill set and the people person skills. So if they're good with people, they will usually do pretty good (P7). Participants emphasized that having good technical skills was not enough, therapists needed to create a connection with their patients. Sometimes, its not the actual treatment and interventions that youre giving the patient. Sometimes, its the experience that they are having at your facility. () If the patient has a good experience as opposed to a bad experience youre probably going to have a better outcome. (P1) OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 34 An important part of building trust and rapport with clients resides in the ability to truly listen to patients, to be an active listener: And I think the difference was that I listened to her, talked to her, and acknowledged what she was feeling, and thats its ok that she was feeling that.() Sometimes, its not the actual treatment and interventions that youre giving the patient. The trust that they have with you. Feeling like, or having that sense or feeling like you care or that you are watching them. (P1) Teamwork. Participants discussed the importance of teamwork as a component of interpersonal skills. Several participants felt that the ability to work well within a team and to be a team player was one of the most important skills all therapists should have, regardless of the diagnoses or specialty area: But what makes a good clinician: () is a good team member, someone who gets along very well with the rest of the team, the rest of the department (P7). Another benefit of teamwork is that it offers continued opportunities for professional development. Team members become part of your resources to build knowledge and skills around specific topics (P3). Skills expected for entry-level competence. Although participants felt that entry-level OTs should have the skills needed to build a rapport or a therapeutic relationship with their clients, the expectations for entry-level OTs focused around the idea of teamwork. Teamwork. Entry-level OTs entering the job market will most likely have to integrate a team. As such, entry-level OTs are expected to work well within that team and contribute to the team process: It kind of goes down like what's her personality like? What's her interpersonal skills? My hiring process is quite robust. I do team interviews. I get staff feedback to get their ideas. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 35 Do you think this person would be a good fit for our team? () Learning really to be part of a team and a person who really gives for the betterment of the team and not so much self-focused. (P7) Perceived entry-level competence. Participants discussed entry-level OTs general attitude and therapeutic use of self. General attitude. General attitude was described as a strength of entry-level OTs. Participants felt that they were energetic, compassionate, creative, had great personalities, and were dedicated to their job: They have great personality and workability skills, you know patient rapport or things like that you can tell they get along (P3). However, participants felt that entry-level OTs needed to improve their level of self-confidence. According to several participants, entry-level OTs lacked the confidence to communicate effectively throughout the intervention process and with physician or referral sources: Yeah, I think that part of this comes with confidence in treating too. I didnt want to mess up and I wanted to do the things on the list of things I had to check off for my supervisor, the hospital, or wherever it was. (P2) Therapeutic use of self. Although entry-level OTs demonstrated good therapeutic use of self, or the ability to use their personality, insight, and perception as part of the therapy process, during basic day-to-day interaction with patients, they did not have the skill set needed to manage difficult situations. When working with patients, it is difficult to separate the deficits or impairments from the person. You are working with individuals with different personalities. Working with a patient who loves therapy, who is motivated to participate, and who listens to the therapist does not require the same level of interpersonal skills as working with a non-compliant patient or a patient with a more difficult personality: OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 36 You are not just dealing with orthopedic or biomechanical injuries. Youre now also dealing with personalities and people. So having patients who might have a little bit of a difficult personality to deal with and learning how to deal with that. As an entry-level, you dont have enough experience enough with it [dealing with difficult personalities] to figure out how to get through it in a positive way. As far as with my experience, seeing and dealing with different personalities, Ive learned how to: A) not take it too personal and B) how to find a different avenue to get a patient to buy into the therapy process. (P1) Holistic and client-centered care. Skills needed for UED management and skills expected for entry-level competence. Participants agreed that client-centered care and using a holistic approach throughout the occupational therapy process is important. As such, entry-level OTs were expected to effectively provide client-centered and holistic care to their patients. Therapists need to look at the whole person instead of compartmenting their care. As participant 3 said, OTs should be looking at the whole person. Its not always just a diagnosis. The hands-on touch-and-feel and looking at the whole person. Because you know what, you can look at this is the best evidence approach for a distal radius but yet, I haven't looked at the whole, the psychological part of it. Why is this person struggling so much? Like the fear why is that part of it? (P3) Entry-level competence. Entry-level OTs tend to focus on the diagnosis or the area directly affected by the injury or condition. It is difficult for them to use therapeutic activities or occupations that are meaningful to their patients during the occupational therapy process: How do you bring the patients goals into it. I hate looking at someone in the therapy space whos reaching for cones. When do we ever reach for cones in our life? Make it OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 37 into something functional. Make it into: were reaching to hang something up on the laundry line, make it something that somebody cares about. Thats what I see setting apart a lot of the experienced OTs compared to the entry-level. (P2) In summary, participants found that entry-level OTs strength centered on their willingness and desire to learn, their energetic personality, their compassion, and their dedication to work. According to participants, entry-level OTs were not at the level they had expected when it came to safety, clinical reasoning, knowledge, communication, holistic and client-centered care, and advanced interpersonal skills. Evaluation Skills Evaluation is an important part of the occupational therapy process as it is during an evaluation that OTs determine the impairments that are affecting occupational performance. Furthermore, it is the results of the evaluation that inform the development of an intervention plan. Three different sub-themes were identified within the evaluation process: completion of an occupational profile, skilled assessment, and goal writing and intervention planning (Table 3). Occupational profile. Skills needed for UED management. When looking at the evaluation process, it is important to gather information regarding the patients past medical history and the history and of the present condition and to understand the impact of the condition or injury on the patients daily life and goals. As Participant 1 said: Therapists must gain an understanding of the patient, understanding what they are going through. Knowing the basics and the foundations to listen and get a history of whats going on for the patient, being able to get their client or his patients profile. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 38 Participants emphasized the need to understand the impact UED has on function or occupation and not to focus mainly on the physical impairments. In order to do so, therapists should complete an activity or occupational analysis: And I think it goes back to the very first portion of the evaluation. So we know what occurred, what the injury is, what's causing the dysfunction, and then what function do you need to return to. Whether it's a work function, whether it's a home function, whether it's any of those things, sports or athletics as well. You focus your entire treatment program off of that: the initial identification of what function is required. (P4) Skills expected for entry-level competence. Participants believed that entry-level OTs should be able to obtain a comprehensive occupational profile. Perceived entry-level competence. The ability to obtain a good occupational profile as part of the evaluation process was identified as a strength of entry-level OTs: Coming back to an occupation-based or a functional-based approach [to the evaluation process], () is a very strong suit of entry-level therapists and I think that is probably the product of focusing a lot on occupation and function during the academic process. (P4) Skilled assessment. Skills needed for UED management. All participants agreed that OTs addressing UED should be proficient with the selection and administration of assessments commonly used to measure UE function. These include the ability to accurately measure range of motion, pinch and grip strength, upper extremity strength through manual muscle testing, and sensation. Furthermore, some participants discussed the importance of diagnostic skills. Although OTs working with UED work under a physicians order, oftentimes, it is up to the OT to accurately identify the source of the problem or the therapy diagnosis: OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 39 I think you need to be able to differentiate the diagnosis. I think you need to be able to explore what are potentially the other things that could be causing that pain and to rule them out and know how to rule them out, and then proceed from there. (P5) This requires a higher level of diagnostic skills, especially when working in an outpatient setting: In the outpatient arena you need a higher level of diagnostic skills. I think there are potentials for the diagnosis to not to be what it not seems. I think there's a big chance you need to rule out possible cervical involvement, especially with outpatient things () But when in the outpatient world I think there is a greater diagnostic skill level that's needed. (P5) Skill expected from entry-level competence. Participants expected entry-Level OTs to select and administer relevant assessment tools and outcomes measures: But what makes a good clinician is good outcomes as measured through objective outcome measures. That encompasses a good clinician (P7). I think basic goniometry skills, knowing how to look at a wrist, look at a finger, look at the form, and then know how to measure joint angles. That should be in the back pocket of any entry-level therapist. (P4) Perceived entry-level competence. Participants identified the selection and administration of common assessment tools as a strength of entry-level OTs: Theyve had good basic level skills they can look at whats the strength, whats the function, how are they using it. Assessments like doing a box and blocks or a grip strength test, and looking at outcomes measure that would relate to upper extremity. (P2) OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 40 Furthermore, entry-level OTs have the skillset needed to assess normal movement in relation to basic activities of daily living such as dressing and bathing: I think they are good at assessing normal movement and how it works in conjunction with ADLs (P5). According to participants, diagnostic skills are higher-level skills that entry-level OTs do not master. Several participants expressed typically having more experienced therapists work with patients with more complex UED: Anytime that we had a shoulder it went to a therapist that was more experienced with upper extremity. It wasn't an entry-level person. I think there was a gap between the skill levels of the person who was newer versus the person who had experience in hands and had focused on learning much more about upper extremity. (P5) Treatment planning. Skills needed for UED management. The process of treatment planning involves the ability to triage or select the relevant information obtained from the occupational profile and assessments and interpret this date to produce a client-centered plan of care. It also includes the ability to write function-based of occupation-based goals that are specific to each patient. Skills expected for entry-level competence. The expectation is for entry-level OTs to have the skillset needed to develop and document plans of care that are specific to each patient and that focusses on function and occupation. Perceived entry-level competence. According to participants, entry-level OTs were able to write occupation-focused goals. The challenge they encountered relates the lack of knowledge of the typical recovery process in relation to specific diagnoses. This rendered goal setting difficult since entry-level OTs did not have the knowledge base needed to determine reasonable OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 41 outcomes: [They dont have the] experience to know what the expectations are with the patients and their outcomes (P1). Overall, participants felt OTs met their expectations of entry-level level competence during the evaluation process. They found that entry-level OTs were able to gather a comprehensive occupational profile, administer common assessments used with UED, and write functional goals. However, entry-level OTs had difficulty setting reasonable expectations and integrating the results of their evaluation into the development of an intervention plan. Intervention Skills The intervention process refers to the ability to implement effective treatment strategies in order to meet specific outcomes. Three sub-themes have been identified: technical skills, intervention planning and implementation, and the ability to facilitate functional improvements (Table 4). Technical skills. Skills needed for UED management. Modalities. Electrical and thermal physical agent modalities are used frequently when addressing UED and as such, participants felt that it was important for OTs working with UED to have the knowledge and skills needed to select and use modalities. As Participant 6 stated: modalities is an important aspect of outpatient. Splinting. Splinting refers to the process of recommending, fabricating, and assessing orthosis while ensuring proper fit and function. Orthoses are commonly referred to as splints, hence the use of the term splinting. Orthoses are often utilized when addressing UED: Splinting is something that I think is very beneficial (P1). Therefore is it a skillset needed when working with that population. The level of skills required is dependent on the setting or population: So OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 42 on the outpatient side I'd expect them to be able to do splints and all these crazy splints with expertise, which definitely requires a higher-level skill set (P7). Furthermore, some participants considered splinting as a hallmark of the profession and as such, believed that all occupational therapists should have some level of splinting abilities: Granted, PTs have kind of made inroads at our territory because theyve become more functional. I mean hand therapy did start with OT. I know theres PTs there too, but in the end, thats our territory. Splinting is our big thing. Thats kind of been our specialty and why should we give it up? (P3) Manual therapy. Manual therapy, or the skills to use hands-on techniques to facilitate physical changes, is an important component to interventions when addressing UED: I think manual skills are necessary to effectively treat the patient if you want them to have optimal outcomes (P6). Some participants felt that manual therapy remained underutilized in practice: I think weve lost something though. I think theres a lot to be said for being able to put your hands on a patient and give a small cue and all of the sudden, theyre posture changes. And to put a little of a hand on somebody and shift their weight at the pelvis and see how that affects everything in their kinetic chain, from their feet all the way up to whatever their upper extremity is doing. (P2) Skills Expected for Entry-Level Competence. Modalities. Entry-level OTs working with patients with UED are expected to have basic knowledge of physical agent modalities. However, entry-level OTs are not expected to have the competency to administer physical agent modalities immediately after graduation. Instead, they are expected to achieve competency within the first year of practice: OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 43 Yeah, having a basic understanding of modalities. Understanding what the purpose of heat is, the purpose of ice is. They are not expected be competent in modalities [straight out of school]. (P1) Splinting. Although splinting is a technical skill that is required for entry-level OT practice, the expectation is not that of an experienced therapist. Entry-level OTs are expected to demonstrate basic splinting competency: You have to be able make splints, like the three basic types of splints: the resting hand splint, the wrist cock up splint, and thumb spika. That pretty much covers 80% of the splitting that they'll need to know whether they're in a rehab, acute care, or outpatient setting. The other 20%, they'll learn later on with experience. (P6) OTs are then expected to continue building their splinting proficiency through mentorship: I certainly benefited from the opportunity of having proper mentorship to be able to learn more splinting while I was working (P1) or continuing education courses: I think basic splinting courses are important (P4). Manual therapy. Since manual therapy is often considered an advanced skillset, participants expected entry-level OTs to have a basic understanding of manual therapy techniques. The expectation was for entry-level OTs to utilize proficiently a lower level of manual skills, such as range of motion, stretching, and soft tissue mobilization: I would not expect them to really have strong skills and be able to do joint mobilizations and manipulations. I think just the basics, passive range of motion, stretching, would be expected (P1). They would need to be proficient in ranging patients that are stiff (P6). Perceived entry-Level Competence. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 44 Splinting. Although the expectations for entry-level competence for splinting is for a basic level of mastery, participants were disappointed with splinting skills of entry level OTs. They expressed concerns with the relatively low exposure to splinting within educational settings: So splinting is also a big thing, which is amazing. Our last year student didn't, they maybe did one splint in school (P3). Manual therapy. Participants identified Manual therapy as an area for improvements. Entry-level OTs often do not demonstrate basic levels of manual skills: I do think that some of those hands-on skills dont seem to be coming out of occupational therapy programs (P2). From what I'm seeing coming out, they don't have a lot of real hands-on (P3). Other participants were disappointed that entry-level OTs do not have the knowledge of basic manual therapy skills to provide safe range of motion: They have not been taught in their program how to do an inferior glenohumeral glide for example to work on minimizing compression at the AC joint with shoulder elevation (P2). Facilitation of functional improvements and function-focused interventions. Skills needed for UED management. An important component of occupational therapy intervention is the ability to facilitate functional improvement through the use of functionfocused interventions: Going back to the true OT, going back to getting them back to whatever it is they want to do. How to correct their dysfunction to get them back functionally. As an OT, our whole goal is to think functional. (P3) Skills expected for entry-level competence. According to participants, entry-level OTs are expected to be proficient in the use of occupation during the intervention process and in the ability to facilitate functional improvement: Definitely be able to masterfully work through OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 45 ADL performance with patients who are really impaired in order to get them back into the community (P7). Perceived entry-level competence. Although entry-level OTs are generally competent in writing occupation-focused goals, they are not always able to integrate the use of functional or occupation-based activities within their intervention plan: Entry-level OTs may use therapies that are not meaningful to patients; it takes experience to think of activities that are real and relevant (P2). That is the challenge, trying to teach them how to relate to function. They are thinking about their patients limitations but are having a harder time connecting the dots. What are the impairments limiting them from doing? How do you get them to function? Yes, you have these limitations, but how has this affected function. (P3) Overall, participants felt that although entry-level OTs had the skills to provide intervention for less complex patients, they lacked the technical skills (splinting and manual therapy) to effectively manage UED, including shoulder dysfunctions. Furthermore, entry-level OTs had difficulty implementing function-based interventions. Suggestions for Improved Entry-Level Competence Suggestions provided by participants were grouped in four themes (Figure 1). Three of the themes addressed suggested changes at the occupational therapy education level: increasing the knowledge base of the sciences of the human body, providing more opportunities for handson experience, and providing exposure to the clinical setting of interest. One theme addressed suggestions at the clinical practice level: ensuring that entry-level OTs have access to mentorship when entering the profession. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 46 Sciences of the human body. Participants suggested that there should be more emphasis on the basic sciences of the human body and physical disabilities related content within the occupational therapy curriculum: I think traditionally some of the knowledge or content such as diagnostic skills and the science-related content hasn't been traditionally part of what OTs generally learn going in. That's your goal, to have that knowledge base. You get to build your knowledge base in school. Having that core knowledge puts you a step ahead and serves as a base when pursuing additional educational opportunities, such as continuing education, when you enter the field. (P5) There should be a greater balance between focusing on occupational-based and function related knowledge and obtaining the core knowledge needed to address physical disabilities, more specifically, upper extremity dysfunctions: OT education could be a little more focused on physical disabilities type stuff rather than such a focus on function and occupation-based interventions (P4). Finally, OT education should include content focused on UED, including common upper extremity injuries/diagnoses and basic interventions utilized when addressing UED: Having more classes related to upper extremity in OT school would help. Add content related to some of the basic protocols that you'll see, some basic fractures or diagnoses that you'll see. If you add maybe five, of the most common things that you see in outpatient, at least once they graduate and they enter the field, they will already be familiar with it. (P6) Hands-on experience. Participants recommended increasing the amount of hands-on experience and exposure to real patients within OT education: It's one thing to read a case study OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 47 but it's another thing to see a patient, work with a patient, and see the subtle difficulties because nothing is ever, or very rarely textbook presentation (P5). I think having hands-on exposure with actual patients and diagnoses in fieldwork would be beneficial (P1). Exposure to clinical setting. Although participants felt that it would ideal for all occupational therapy students to have direct exposure to real patients as part of occupational therapy education, they were mindful of the logistics associated with providing real-life clinical experience within the educational setting. As such, participants recommended that OT students with a known interest in UED be streamlined into completing a level 2 fieldwork experience within UED settings: I think one of the main things that academic programs could do to support entry-level competence is to allow those students that have an interest in a subspecialty like hand therapy, to track into a level 2 fieldwork in hand therapy. I think that's kind of a critical entry-level requirement for new grads interested in UED. (P4) Mentorship. Participants highly recommended a structured mentorship or orientation process for entry-level OTs working with UED: I would definitely say that mentorship is really important. If you have a mentorship in place then they can work through a lot of the details (P7). I think you need some mentoring, someone who's been in outpatient or who's worked with UED. That includes being able to shadow or work with an experienced therapist who specializes in UED (P6). Resources Available to Managers in Clinical Settings Participants agreed that entry-level OTs needed to continue improving their skills in order to become proficient in the management of UED. As such, there was generally resources set aside to help entry-level OTs continue to develop their skills. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 48 Clinical expertise. There is often some form of mentorship provided or available to entry-level OTs. This can be done in the form of a formal structured mentorship program or by setting up an informal mentorship where entry-level OTs are paired with more experienced OTs. The length of the mentorship program varies based on available experienced staff or productivity requirements: A lot of times, they'll learn hands-on with the experienced therapists. We have them shadow someone for a while before they go off on their own (P6). The first year we do set new graduates up with a mentor. So it's a one to one mentorship for the first 12 months because again, that first 12 month period is just so overwhelming (P7). Learning opportunities. Other resources available to entry-level OTs are continuing education courses. These courses are generally provided by outside companies and cover a wide variety of topics. In some settings, the cost of continuing education is either partially or fully covered as part of employees benefits: They can also take a continuing education course; there are always CE courses out there (P6). Barriers to onsite training. Participants described productivity as being a barrier to entry-level learning and support: Unfortunately, in the day and age of business, making sure that our volume is up, takes over the learning and mentoring opportunities (P1). Discussion Several skills were identified as important for the management of UED. Although participants identified some strengths in the area of evaluation, interpersonal skills, willingness to learn, and basic planning and implementation, they found that entry-level OTs did not possess most skillsets specific to UED management. As such, employers enrolled in this study reported that entry-level OTs meet their expectations entirely or partially for only five of the 17 general skill sets they considered as important to the management of UED. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 49 Knowledge and Clinical Reasoning Skills Participants in this study identified knowledge as an important aspect to the management of UED. This included the knowledge of common upper extremity diagnoses or conditions, anatomy, physiology, and kinesiology, as well as a commitment to life-long learning. Erikson et al. (2017), Keller et al. (2016), and Short, Sample, Murphy, Austin, and Glass (2018) agreed that OTs and physical therapists required knowledge of common upper extremity conditions or diagnoses in other to efficiently address UED. As such, Erickson et al. (2017) found that experts in the field of hand therapy recommended the inclusion of upper-extremity diagnosis-related content within entry-level physical therapy education. Several authors supported the need for the mastery of knowledge related to the sciences of the human body including anatomy and physiology (Adam et al., 2013; Carroll, & Lawson, 2014; Colclough et al., 2015; Erickson et al., 2017; Keller et al., 2016; Schofield, 2018; Short et al., 2018). Unfortunately, in this study, participants found that entry-level OTs did not possess the level of knowledge employers expected for entry-level competence. These findings are further corroborated within the existing literature. Schoffield (2018) found that OTs with over three years of experience felt that entry-level OTs did not have sufficient knowledge of anatomy to effectively address UED. In other studies, Doyle, Bennett, and Gustaffson (2013) and Jolliffe, Hoffman, Lannin (2019) found that even occupational therapists working within physical disability settings perceived their lack of knowledge as a barrier to providing effective intervention for upper extremity impairments. Therapists require high level of clinical reasoning to integrate the knowledge into the development of effective interventions (Colclough et al., 2015, Kuipers & Grice, 2009). Unfortunately, Kuipers and Grice (2009) found that, according to employers, entry-level OTs did OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 50 not possess the level clinical reasoning skills they expected for entry-level competence. Similarly, May et al. (2010) found clinical reasoning to be a major weakness in entry-level physical therapists when treating shoulder impairments. It is the clinical reasoning skills that allow for the integration of the theoretical knowledge and clinical presentation to the development and implementation of a safe and effective intervention plan (May et al., 2010). Similarly, participants in this study described the high level of clinical reasoning skills needed to integrate the theoretical knowledge to each clients clinical presentation in order to develop and implement an intervention plan targeting each clients unique needs. According to Schofield (2018), knowledge is also crucial to provide safe intervention. Safety is embedded within the profession of occupational therapy and as such, it is reflected within the principles and standards of the occupational therapy code of ethics. According to AOTA (2015), the first principle of conduct, beneficence, is defined as Occupational therapy personnel shall demonstrate a concern for the well-being and safety of the recipients of their services (p. 6913410030p2). Safety is also reflected within the second principle of conduct, nonmaleficence, which states that occupational therapy personnel shall refrain from actions that cause harm (AOTA, 2015, p. 6913410030p3). It is therefore not surprising that participants identified safety as an important overarching skill when treating UED. The importance of maintaining safety and preventing harm to patients was also reflected within the literature (Keller et al., 2016; Schofield, 2018). Furthermore, the Accreditation Council for Occupational Therapy Education (ACOTE) defined the need to demonstrate sound judgment in regard to safety of self and others and adhere to safety regulations throughout the occupational therapy process (p. 27). Although participants expected entry-level OTs to maintain safety during the occupational OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 51 process, some felt that entry-level OTs needed more training and time in order to maintain safety during the intervention process. Communication Skills According to Radomski and Trombly Latham (2014), communication is an important component to the occupational therapy process as it helps establish a therapeutic relationship with clients. Accordingly, participants in study identified effective communication as an important aspect of the therapeutic process. They felt that entry-level OTs were able to communicate effectively with their patients in their day-to-day interactions. However, communication skills are also required when interacting with members of the therapy teams, such as physicians, co-workers, and other allied health professionals. According to the participants of this study, entry-level OTs continued to need improvement in self-confidence when communicating with members of the interprofessional team, peers, and referral sources and therefore did not meet their expectations for entry-level performance. Interpersonal Skills In this study, participants found that some aspects of interpersonal skills, such as being energetic, compassionate, and dedicated, were a strength of entry-level OTs. Being able to interact with clients is crucial within the practice of occupational therapy as it helps establish a therapeutic relationship with the client (Radomski, & Trombly Latham, 2014). Client/therapist interaction relies heavily on interpersonal skills, including therapeutic use of self, or the ability to establish and maintain a therapeutic relationship with your client (Davidson, 2011). However, occupational therapists are sometimes placed in more complex situations where they have to diffuse heated situations, work across language barriers, use truthful but tactful communication about functional limitations, and be proficient in therapeutic use of self (Short et al., 2018, p. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 52 312). Participants of this study identified stress management, confidence during interpersonal interactions with peers and physicians, the ability to create a therapeutic relationship with their client, and being able to negotiate and manage difficult interaction as not meeting entry-level expectations. Interestingly, Davidson (2011) found that although faculty included therapeutic use of self within their curriculum, they tended to focus on positive aspects such as empathy, establishing rapport, self-awareness, active listening, and giving praise amongst others. However, skills associated with a more difficult or negative connotation such as setting limits, conflict negotiation, dealing with clients attempts to coerce or manipulate, dealing with potential aggression toward self or others, and sharing bad news (Davidson, 2011, p. 93) were taught with less frequency and, in some instances, omitted. Although interpersonal skills and therapeutic use of self can improve with experience, it is concerning that the areas that were identified as not meeting the expectations of employers were also the areas that were the least frequently addressed within occupational therapy educational programs. Holistic and Client-Centered Care According to the Occupational Therapy Practice Framework (AOTA, 2014), the occupational therapy process is the client-centered delivery of occupational therapy services (p. S10). Colclough et al. (2015) emphasized the importance of client-centered and holistic care when addressing UED. Furthermore, occupational therapists consider all aspects of the person, occupation, and environment, hence utilizing a holistic view of the person (AOTA, 2014). It is therefore not surprising that employers identified holistic and client-centered care as being essential to the delivery of occupational therapy for the management of UED. Unfortunately, entry-level OTs did not meet the expectations when it came to delivering holistic care when treating UED, focusing on the deficit area rather than looking at the whole picture. This might be OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 53 related to the lack of confidence, knowledge, and clinical reasoning skills previously mentioned. The level of complexity inherent to UED might increase the difficulty using clinical reasoning to integrate their theoretical knowledge and clinical presentation to form a holistic client-centered intervention plan. Evaluation Skills Skills identified related to the evaluation of UED included the ability to gather an indepth occupational profile, administer skilled assessment, and integrate the findings into the development of a comprehensive intervention plan. Colclough et al. (2015) described the importance to obtain a thorough occupational profile. They determined that in order to provide client-centered care, occupational therapists needed to gather information regarding each clients individuality, including their clients current life context. Employers in this study found that entry-level OTs met their expectations in terms of obtaining a comprehensive occupational profile, including completing the initial interview and relating UED to functional performance. The distinct value of occupational therapy is to promote occupational engagement through the use of occupation (AOTA, 2014). As such entry-level OTs were perceived as proficient in gathering data focused on occupation during the evaluation process and in considering the impact of UED on function. This may be a reflection of the focus on occupation as the unique contribution of the profession within the occupational therapy profession. Once the occupational profile is completed, occupational therapists must then select and administer assessments to gather information regarding the client factors, environment and contexts affecting occupational performance (AOTA, 2014). Assessments specific to UED might include but are not limited to range of motion, strength, sensation, edema, pain, biomechanics, and spasticity (Colclough et al., 2015; Erickson et al., 2017; Schofield, 2018). Employers within OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 54 this study reported that entry-level OTs were skilled in the administration of standardized assessments such as goniometry and manual muscle testing. Although the administration of such assessments requires hands-on practice, it does not require high level of clinical reasoning skills. The administration process is well-defined and can be mastered with repetitions and practice. It becomes a skill set that can easily be acquired early on. Therefore, despite the limited amount of clinical skills identified within this study, entry-level OTs were able to meet expectations for the administration of assessment tools commonly use when working with UED. Finally, occupational therapists triage and select relevant information/findings in order to write functional goals, set reasonable outcome expectations, and the integrate all information into to development of an intervention plan. In order to meet these expectations, entry-level OTs should be able to interpret the assessment data, develop and refine hypotheses about the clients strengths and limitations, establish client-centered occupation-focused goals, and delineate potential intervention approaches based on the best practice and available evidence (AOTA, 2014, p. s14). Employers enrolled in this study found that a strength entry-level OTs possessed was the ability to write functional or occupation-focused goals. This is not surprising considering the central part occupation holds within the profession. However, participants also identified some areas within the evaluation process where entry-level OTs did not meet their expectations: the ability to set reasonable expectations and to anticipate the progress or outcomes of the interventions, and the ability to integrate all information into developing an effective, evidence-based intervention plan. Several skills are needed in order to set reasonable expectations and develop an intervention plan. A deep understanding of anatomy and physiology, as well as the knowledge of a variety of conditions, are needed in order to understand the expected progression related to specific clinical OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 55 presentations (Carroll, & Lawson, 2014; Keller et al., 2016; May et al., 2010; Schofield, 2018.). Furthermore, occupational therapists must use clinical-reasoning reasoning skills in order to interpret and integrate all information relevant to intervention planning (Carroll, & Lawson, 2014; Colclough et al., 2015; May et al., 2010; Short et al., 2018). Therefore, it is probable that failure of entry-level OTs meet expectations in the area of intervention planning is associated and interconnected with the lack of knowledge and clinical reasoning skills previously identified by employers enrolled in this study. Intervention Skills. Employers within this study identified three different sets of skills needed for the management of UED: technical skills, intervention planning and implementation, and the ability to facilitate function. There is an agreement within the literature that proficient use of physical agent modalities is an important component to treating UED (Hodgetts et al., 2007; Short et al., 2018). Although employers within this study agreed that physical agent modalities should be part of interventions for UED, they did not expect OTs to possess the skill upon graduation. This could be in part due to the additional education required in Illinois for occupational therapists to use physical agent modalities. Although ACOTE standards mandate that students of accredited entry-level OT program demonstrate knowledge and use of the safe and effective application of superficial thermal agents, deep thermal agents, electrotherapeutic agents, and mechanical devices (ACOTE, 2018, p. 38), it does not specify how educational programs educational program should achieve this standard, leaving each program to set their own objective and instruction modalities. Therefore, not all programs can certify that OT graduates have met all the requirements for certification in the use of physical agent modalities. Employers within this OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 56 study were aware of the legal requirements and as such, expected students to meet these requirements within one year of practice. Employers also identified orthoses fabrication as a must when addressing UED. This is in agreement with the literature (Colclough et al., 2015; Hodgetts et al, 2007; Short et al., 2018). However, there was a consensus that most OTs entering the field were not competent in the design and fabrication of complicated orthosis. Rather, they expected entry-level OTs to demonstrate the skills and knowledge needed to fabricate common simple orthoses. Unfortunately, although employers expectations were reasonable for entry-level competence, they found that entry-level OTs often were not able to fabricate even the most common orthoses. Hodgetts et al. (2007) found that Canadian OT graduates would have preferred to learn orthoses fabrication skills within their educational program as they felt unprepared to meet the workplace expectations. According to Short et al. (2018), OT practitioners with the field of hand therapy expected OT students to have acquired some knowledge of manual therapy within their educational program. Since manual therapy skills develop over time with experience, employers within this study expected entry-level OTs to demonstrate basic manual skills such as range of motion, soft tissue mobilization, and joint mobilization. They then expected entry-level OTs to further their proficiency in the use of manual therapy during interventions for UED within their first year of practice. Unfortunately, employers reported that entry-level OTs did not meet their expectations or basic knowledge and skills in the use of manual therapy. Participants within this study proposed that it could be due to the lack of hands-on experience and educational content related to manual skills within OT entry-level educational programs. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 57 When it comes to intervention planning and implementation, employers within this study expected entry-level OTs to be independent thinkers and demonstrate some autonomy, to know how to use intervention to progress clients towards expected outcomes, and to have basic knowledge of interventions for common diagnosis. Entry-level OTs did not meet the expectations of this study participants because of: 1) a limited skill set to address shoulder dysfunction, 2) difficulty selecting and implementing optimal interventions, 3) difficulty using the scientific approach to care and integrate theoretical knowledge within clinical practice, and 4) entry-level OTs expectation to have direct guidance when selecting and implementing interventions. This finding could be in consequence to the previously identified lack of knowledge and clinical reasoning skills. According to this studys participants, entry-level OTs had sufficient skillset and knowledge to work with less complex diagnoses or clients. Furthermore, they felt that entry-level OTs brought new ideas and fresh way of thinking to the clinical site. Finally, employers within this study expected entry-level OTs to be able to relate UED to function, use equipment and interventions to support return to function, progress clients towards safe return to community, use occupation and meaningful activities as interventions, and be proficient when addressing occupational performance related to basic activities of daily living. There has been an emphasis within the profession on the use of occupation as a therapeutic modality and as outcome. The American Occupational Therapy Associations participation within the choose wisely campaign (Richardson, 2019) further illustrates that trend. As such, Short et al. (2020) found that faculty within entry-level OT educational programs strongly encouraged the use of an occupation-based model in hand therapy. Unfortunately, despite entry- OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 58 level OTs demonstrating the ability to write occupation-focused goals, employers within this study found that it did not translate to the ability to implement function-based interventions. Perceptions of Entry-Level Competence This study explored employers perception of OT entry-level competence when addressing UED dysfunctions. For the most part, employers felt that entry-level OTs did not meet their expectations. In their study, Hodgetts et al. (2007) examined the perception of OT students and graduates regarding their satisfaction with their professional education and preparedness for practice (p. 148). They found that students and OT graduates expressed varying degrees of frustration with initial work expectations, feeling that work demands were too high for their initial knowledge base (p. 154). Hodgetts et al.s study suggested that OT students and graduates did not feel they had the knowledge and skills to meet the expectations of clinical practice. The findings of this current study and those of Hodgetts et al. (2007) suggest a dissatisfaction with the preparedness to meet the expectations of clinical practice from two different perspectives. In contrast, Short et al. (2020) found that a majority of faculty from entry-level occupational therapy programs felt that students received sufficient hand therapy-related education within their program. In relation to their finding, Short et al. (2020) suggested that contradicting perceptions of adequate preparation for students may represent a disconnect between OT education and clinical expectations (p. 116). Further supporting these findings, Carroll and Lawson (2014) found that although the occupational therapy curriculum has progressed, improved, and expanded, the relative importance and prerequisite for anatomical training have not changed (p. 498). Although the standards for OT education set by ACOTE states that students graduating from an accredited OT program must demonstrate knowledge of OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 59 the structure and function of the human body to include the biological and physical sciences, neurosciences, kinesiology, and biomechanics (AOTA, 2018, p. 31), the responsibility to design learning objectives and activities rests with each program (Carroll, & Lawson, 2014). These conflicting findings may support Short et a. (2020) suggestion of a disconnect between entry-level OT education and the expectations of clinical practice and would warrant further exploration of the topic. Suggestions for Improved Entry-Level Competence Employers in this study provided a few suggestions they felt could improve OT entrylevel competence for effective management of UED. These included three suggestions at the OT entry-level educational level: increase the instruction related to UED, including anatomy, physiology, and kinesiology; provide more hands-on experience; and provide more exposure to clinical settings. The last suggestion at the clinical site level: provide structured mentorship for graduate students working with UED. Participants' suggestion to increase the amount of instruction provided UED management related content could improve the foundational cognitive understanding of entry-level OTs. According to Short et al. (2018) found that clinician working in hand therapy expected fieldwork students to have the foundational cognitive understanding without the full development of related skills (p. 312). Participants also suggested that entry-level OT educational programs provide students with added opportunities to practice hands-on skills and exposure to clinical settings. According to Colclough et al. (2015) and Short et al. (2018), hands-on or clinical experience can help better integrate skills such as splinting, manual therapy, conflict resolution, and setting reasonable goals/outcomes (Colclough et al., 2015; Short et al., 2018). Integrating clinical experience within OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 60 educational programs can be challenging. However, according to Bethea, Castillo, and Harvision (2014), simulated experiences can help develop safety with clients, practice clinical skills, use clinical reasoning and critical thinking, prepare for fieldwork, and facilitate concept integration (p. S35). Finally, participants suggested that clinical sites provide structured mentorship opportunities for entry-level OTs working with UED. According to McCombie and Antanavageb (2017), occupational therapists within their first year of practice were more likely to perceive their worksite as a good clinical fit, had higher job expectations and minimal job-related stress, and were better able to develop professional relationships as opposed to those without mentors. Limitations This study is not without limitations. As with any qualitative study, there is a risk of the researchers biases influencing the outcomes of the study. This is further emphasized in this study since the primary researcher is an occupational therapist with special interest and clinical expertise in the management of UED. Furthermore, the primary researcher also works in academia and is responsible for teaching content related to physical disabilities, including content related to UED. To decrease the risk of biases, content validity for the interview guide was obtained from occupational therapists working with UED. To ensure the validity of the results, two participants were sent the preliminary findings of the study for review. Both responded that it captured their experience related to entry-level competence for the management of UED. Furthermore, although data saturation was obtained, the sample size was relatively small and all participants worked within the Chicagoland area. Results are therefore not transferable to all employers supervising entry-level OTs. Implications for Practice and Future Research OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 61 Insufficient knowledge to address UED is concerning because of the potentials to cause harm and the inability to provide effective interventions. It would be beneficial to study entrylevel competence when treating UED, including the safety and effectiveness of interventions provided by entry-level OTs. Another area of study It would also be beneficial to further examine the way foundational knowledge, particularly knowledge of the sciences of the human body, are delivered within entry-level OT educational programs. According to ACOTE (2018) educational programs must include content related to anatomy, physiology, physical sciences, neurosciences, kinesiology, and biomechanics. However, there are no specific guidelines regarding the delivery of such content (Carroll, & Lawson, 2014). Further studies are needed to compare and contrast the perception of entry-level competence from different stakeholders. Faculty and educational programs might place more emphasis on the knowledge and skills needed as defined by the profession and the accreditation body; whereas, employers expectations might be influence by patient satisfaction and outcomes, as well as managerial aspects such as finance and productivity. On the other hand, payers or reimbursement sources may emphasize the need for efficient and economical interventions. The management of UED, and more specifically hand therapy, is considered a specialty area within the field of OT. Should entry-level OTs work in hand therapy or address UED? If so, it is imperative to address entry-level competence related specifically to UED. The possible disconnect between employers expectations and entry-level competence places OTs entering the profession at a disadvantage, increasing their risk for job dissatisfaction and work-related frustration (Hodgetts et al., 2007). It would be beneficial to implement strategies to ensure proper competence of entry-level OTs working with UED. At the OT education level, this could mean re-assessing the application OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 62 of foundational knowledge to clinical reasoning throughout the program, hence facilitating knowledge integration. Since hands-on experience and exposure to clinical settings were identified by employers as crucial to developing the skill set needed for the management of UED, educational programs could integrate authentic learning opportunities such as simulations, clinical setting observations, volunteering experience, or standardized patients. Educational program could consider the implementation of an additional clinical site experiences for students interested in UED management or target students with a known interest in UED management for fieldwork experiences in UED management. Finally, educational program could facilitate information sessions between colleges and area inpatient and outpatient centers to align understandings about the preparation programs and needs in the field, further emphasis on mentorship programs in workplaces for entry-level OTs. Conclusion Even with the stated limitations, this study helped in further defining the complexity and skills needed for the management of UED and the expectations of employers on entry-level competence for the management of UED. It is to the researchers knowledge the first study examining employers perception of entry-level competence in relation to UED. Occupational therapists are often responsible to address UED dysfunction in a variety of physical disability settings and is not exclusive to a hand therapy setting. As such, this study included participants from inpatient and outpatient settings working with orthopedic and neurological populations. Without the skillset and knowledge needed to treat UED, there is a potential to cause harm or provide ineffective care (Schofield, 2018). It is OTs ethical responsibility to ensure that no matter the level of expertise, therapists working with UED have OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 63 sufficient knowledge to not only avoid harm, but also to facilitate clients progress throughout their recovery (AOTA, 2015). This studys findings are concerning as employers reported that entry-level OTs only met expectations for five out of seventeen skills identified as important for the management of UED. This may be due to either inadequate preparation of occupational therapy students for the management of UED, or employers unrealistic expectations of entry-level competence. Both scenarios could lead to unsafe or ineffective practices, and increased job-related stress and dissatisfaction. As such, there is a need for further studies exploring entry-level expectations from different perspectives, entry-level competence for the treatment of UED, and entry-level OT program curriculum content related to the management of UED. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 64 References Accreditation Council for Occupational Therapy Education. (2018, November). 2018 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide (effective July 31, 2020). The American Journal of Occupational Therapy, 72(supplement 2), 7212410005p1-7212410005p83. Accreditation Council for Occupational Therapy Education. (2012). 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The Open Journal of Occupational Therapy, 4(4), 9-13. doi:10.15453/2168-6408.1243 OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 71 Table 1 Participants Characteristics ID Years of Professional experience Background Role Setting Expertise Advanced Certifications Manager in an OP clinic Therapy supervisor OP hand IP rehab Ortho UE CHT OP hand OP hand OP hand day rehab IP acute IP rehab IP acute OP hands IP acute IP rehab Ortho/neuro elbow/shoulder LE Ortho UE CHT Ortho UE CHT P1 9 OT P2 15 PT P3 25 OT Coordinator P4 18 OT Coordinator P5 20 PT Manager of rehab services P6 22 OT Senior OT P7 22 PT Manager Ortho UE/LE Ortho UE CHT Geriatric APTA geriatric certification Note. ID = participant identifier, OT = occupational therapist, PT = physical therapist, Ortho = orthopedic, Neuro = neurology, UE = upper extremity, LE = lower extremity, IP = inpatient, OP = outpatient, rehab = rehabilitation, CHT = certified hand therapist, APTA = American Physical Therapy Association OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 72 Table 2 Overarching Skills Skills for Entry-Level Competency Observed Entry-Level Competence Safety Needs to maintain safety for self and others Clinical reasoning Needs improvement Safely work with different clients and diagnosis Needs improvement: Adjust approach to clinical presentation and specific clients circumstances Integrate evaluation results into a treatment plan Select optimal interventions Justify interventions Skills Needed Knowledge: Conditions Sciences of the human body Synthesis of important information Interpretation of clinical findings Relation between impairments and function Integration of evaluation results into a treatment plan Justification for interventions Know and understand common diagnosis Know typical progression/outcomes Increase knowledge of shoulder within the first year Know protocols and guidelines associated with common conditions Need improvement: Understand common diagnosis Knowledge of typical progression Knowledge of the shoulder Strong knowledge of anatomy and functional anatomy/kinesiology Understanding pathophysiology in relation to the healing process Needs improvement Low knowledge of the sciences of the human body Difficulty applying knowledge to therapy process OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE Commitment to lifelong learning Communication Skills: Documentation Know how to find information needed Willingness to learn and grow Ownership of own learning Not mentioned Effective communication Interpersonal Skills: Team work Therapeutic use of self Customer service Attitude/personality Holistic and clientcentered care 73 Strength: Willingness and desire to learn Needs improvement: Confidence to ask questions Take ownership of own learning Not mentioned Education/instruction to patients Communication with physician/referral source Needs improvement: Building confidence to talk to peers, physicians, and referral source Work within a team and Contribute to the team Have confidence Have a positive attitude Create therapeutic relationship with clients Strength: Energetic Compassionate Dedicated Needs improvement: Stress management Creating therapeutic relationship Knowing how to react to difficult interactions Confidence Look at result in holistic manner Look at the whole person, not only at the deficit or injury Need to be client-centered and address what is meaningful to client Note. UED = upper extremity dysfunction Needs improvement: Difficulty seeing past the condition/deficit, Difficulty looking at the whole picture OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 74 Table 3 Evaluation Skills Skills Needed Skills for Entry-Level Competency Occupational profile: Previous level of function Past medical history History of present condition/injury Clients goals Skilled Assessment Treatment Planning Observed Entry-Level Competence Obtain a past medical history and of present condition Assess client specific impact on function Clients goals Strength: Complete initial interview Evaluate impact on function specific to client circumstances Relate UED to function Administration of common assessments Functional goal setting Reasonable expectations Triage of important information Develop intervention plan accordingly Strength: generally good at administration of assessment tools evaluation Strength: Writing functional goals Needs improvement: Reasonable expectation Anticipated outcome/progress Integrate all information into developing a POC Note. UED = upper extremity dysfunction OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 75 Table 4 Interventions Skills Skills Needed Technical Skills Modalities Splinting Manual skills Intervention planning and implementation Facilitate functional improvements Skills for Entry-Level Competency Observed Entry-Level Competence Not expected straight out of school however expected within first year of practice Basic splinting competency Fabrication or most common splints Obtain proficient splinting skills within first year of practice Basic manual skills: ROM, stretching, soft tissue mobilization Basic knowledge of joint mobilization Should increase proficiency within first year of practice Independent thinker Some autonomy needed Know how to progress patients towards expected outcomes Basic knowledge of interventions for common diagnosis Not mentioned Relate to function Use of equipment/intervention to support return to function Progress towards safe return to community Use of occupation/meaningful activities during intervention Strong ability to work through ADLs performance Need improvement General consensus with splint fabrication training within the orientation process Need improvement: Lack of hands on experience Limited knowledge on manual skills Positive: Skilled for less complicated patients Have news ideas and fresh way of thinking Needs improvement: Skill set for treating the shoulder Selection of optimal interventions Intervention implementation Expect to be told what to do Difficulty using scientific approach to care, bringing back knowledge of human sciences Needs improvement: Generally able to include function into goals however, difficulty implementing function-based interventions OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 76 Figure 1 Suggestions for Improved Entry-Level Competence C l i n i c a l S i t e s Knowledge O T Sciences of the human body Mentorship Entry-Level Competence Exposure to clinical setting Hands-on experience E d u c a t i o n OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 77 Appendix A RECRUITMENT SCRIPT We would like to invite you to participate in our research study to explore the current perception of employers regarding entry-level occupational therapists expertise, of lack thereof, in the treatment of upper extremity dysfunction. The researchers conducting the study are MarieClaude Touchette, MHS, OTR/,L and Dr. Laura Santurri from the Doctor of Health Science Program at the University of Indianapolis. If you agree to participate, you will complete a 45-60 minute, one-on-one interview with MarieClaude at a place of your choice. The interview will be comprised of questions regarding your perception of entry-level occupational therapists competence when treating clients with upper extremity dysfunctions. You may also be asked, at a later time, to review and provide feedback on the results of the study. Participation is voluntary and all answers will be kept anonymous. You may choose to not answer any questions, and you may discontinue participation at any time for any reason. You will receive a gift card at the completion of the interview as a thank you for your time and participation in our research study. Furthermore, participants may benefit from knowing that participation may be of assistance to future practice. The risks to participation are not more than those encountered in everyday life. If you have any questions or concerns, you may contact the principal investigator, Dr. Laura Santurri, from the Doctor of Health Science Program at the University of Indianapolis at (317)788-2409 or santurril@uindy.edu. If you have any questions regarding your rights as a research subject, you may contact the UIndy HRPP Office (hrpp@uindy.edu) or (317)781-5774 or (800)232-8634 x5774. This research study has been approved by the University of Indianapolis, Office of Human Research Protections Program (Exempt Study #0929). Marie-Claude Touchette, MHS, OTR/L University of Indianapolis Doctor of Health Science Program OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 78 Appendix B INFORMED CONSENT FORM Study Principal Investigator: Laura Eileen Santurri, PhD, MPH, CPH School/Department/Program: University of Indianapolis, Doctor of Health Sciences Department UIndy Email: santurril@uindy.edu UIndy Telephone: (317) 788-2409; Toll free: 800-232-8634 x2409 Co-Investigator: Marie-Claude Touchette, MHS, OTR/L UIndy Email: touchettem@uindy.edu INFORMED CONSENT TO PARTICIPATE IN HUMAN SUBJECTS RESEARCH Study Title: Employers Perception of Occupational Therapists Entry-Level Competence for the Treatment of Upper Extremity Dysfunction Introduction: The investigators invite you to participate in a research study. The purpose of this Informed Consent Form (ICF) is to provide information you should have in order to make a well-informed decision to consent to participate in the study. Please read the form carefully. You should ask questions about why the research is being done, what you will be asked to do, the possible risks and benefits, your rights as a volunteer, and anything else about the research or this form that is not clear. Your consent must be well informed and voluntary, without influence from the investigators or anyone else associated with this study. This process is called informed consent. Who is sponsoring/funding this study? This study is conducted as part of a doctoral project from the University of Indianapolis. Why are you invited to participate? You directly supervise occupational therapy staff, you have supervised at least one entry-level OT within the past 2 years. You will be excluded from this study if are not fluent in English. If you choose to participate, then you will be one of approximately 15 supervisors participating in this study. What is the purpose of this study? The purpose of this study is to explore the current perception of employers regarding entry-level occupational therapists expertise, or lack thereof, in the treatment of UED. What will you do while in this study? Complete a 45-60 minutes interview that will be audio-recorded. The purpose of the recording is for the interview to be transcribed word for word after the completion of the interview. You will be recorded using a hand-held recording device. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 79 The recording will be transcribed and analyzed using a Microsoft Word and a wed-based qualitative analysis software. We will assign a pseudonym to the transcript and will not include any personal identifiable information. Once the analysis is completed, you may receive an email asking you to review and provide feedback on the studys findings. The transcript and audio recording will be kept in a password secured computer. The material will be destroyed 36 months after the conclusion of the study. How long will your participation in this study last? The interview will last 45 to 60 minutes. If you are asked to review the findings and provide feedback, it should take you an additional 30 to 60 minutes. How will you benefit from participating in this study? The investigators do not intend or guarantee that you will receive any benefit as a direct result of participating in this study. Others may benefit from the results of this study because of your participation. What are the harms/discomforts that you can expect from participating in this study? Your participation in this study will expose you to little, if any, harm or discomfort. Unlikely harm(s) and/or discomfort(s) include emotional or psychological responses from answering questions, or loss of confidentiality. We will provide pauses as needed to limit emotional of psychological discomfort. You may choose not to answer any of the questions or terminate your participation in the interview at any time, without any repercussion. What will be done to keep your information confidential? Every effort will be made to keep your study-related information confidential (e.g., passwordprotected electronic devices, storing information in locked facilities, etc.). Personal information regarding your participation in this study may be disclosed if required by law (e.g., you are being threatened/harmed, you threaten to harm someone else, etc.). Also, your research records may be reviewed by regulatory authorities involved in the oversight of research in order to ensure that your rights as a research participant are being protected [i.e., Office for Human Research Protections or other federal, state, or international regulatory agencies, and members and/or representatives of the University of Indianapolis (UIndy) Human Research Protections Program (HRPP)]. The transcript and audio material will be saved on a password-protected computer, and destroyed 36 months from the completion of the study. When investigators present study results at professional conferences or publish results in professional journals the investigators will NOT use any individually identifiable information that may have been collected from/about you. What are your costs for participation in this study? There is no cost associated to participating in this study. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 80 What compensation/payment will you receive for participation in this study? To thank you for your participation in this study, you will receive a $20 gift card. The drawing will occur once all the interviews are completed. What are your rights as a participant in this study? To ask all questions/receive all information you need to make an informed, voluntary decision to consent; To choose to quit/withdraw from the study at any time. If you choose to quit/withdraw, then o You will NOT lose any benefits to which you are otherwise entitled, and o Your decision will not affect your present or future relationship with UIndy or other organizations associated with this study, including employment and/or academic status; and o You may ask investigators NOT to use any IDENTIFIABLE information collected from you. Investigators may retain and use ANONYMOUS information. o You should notify the investigator if you should to withdraw from this study To refuse to answer any questions/perform any tasks that may be asked/required during the study To request results of the study. If you want results of this study (NOT your individual results), then you should contact Marie-Claude Touchette at : touchettem@uindy.edu To have a copy of this informed consent form. You should either print this informed consent form, if online, or ensure you receive a hard copy from the investigators. What do you do if you have questions about this study? For questions about the study you may contact Marie-Claude Touchette at touchettem@uindy.edu, or Laura Santurri at santurril@uindy.edu The UIndy HRPP has reviewed and approved this study. The UIndy HRPP has the responsibility of protecting the rights and welfare of research participants. For questions regarding your rights and welfare as a participant in this study, you may contact the UIndy Human Research Protections Program (HRPP) Director, Dr. Greg E. Manship (manshipg@uindy.edu) or 317-7815774 or 800-232-8634 x5774. How do you indicate your informed consent to participate in this study? If you decide to participate, then your participation will indicate your voluntary, informed consent. You will NOT sign this or any other document to indicate your informed consent. If you consent to participate in this study, then you affirm that you satisfy inclusion criteria and your consent is voluntary. To indicate your voluntary consent and proceed with the questionnaire, select one of the following options: I voluntary consent to participate in this study. I do NOT consent to participate in this study. OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 81 Appendix C Interview Guide The aim of this study is to explore direct supervisors perception of occupational therapists entry-level competence for the treatment of upper extremity dysfunction. This will be achieved by completing an in-depth interview that should last between 45 to 60 minutes. If at any time you wish to skip a question or terminate this interview, you may do so at any time without any consequences. This interview will be audio-recorded. The transcription will not include personal information that could be linked to you. The electronic files of the recorded interviews will be password protected and destroyed 36 months after the conclusion of the study. Other hard copy materials will be destroyed with a shredder 36 months from the completion of the study. All information is strictly confidential unless disclosure is required by law. Do you have any questions regarding this interview process? If you are ready to begin, I will now start the audio recorder. 1. Can you please describe your role within this organization? 2. Can you please describe your level of expertise in the management of upper extremity dysfunction? a. In general, what skills do you think are needed to successfully treat upper extremity dysfunction? b. What specific skills do you think entry-level therapists should have already learned in their entry-level education in order to successfully address upper extremity dysfunction? OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 82 c. What skills or knowledge related to the treatment of upper extremity dysfunction do you think an entry-level occupational therapist should pursue or acquire within his/her first year as an occupational therapist? 3. In your department or setting, who do you think should be responsible to treat upper extremity dysfunction? a. What makes them best suited to treat upper extremity dysfunction? 4. Think about the last time you supervised an entry-level occupational therapist, what did you think of her/his skills while treating upper extremity dysfunction? a. What were her/his strengths? b. What were her/his areas for improvements? c. How do you think entry-level skills differ from experienced occupational therapists when treating upper extremity dysfunction? 5. What resources do you have available to assist entry-level therapists when treating upper extremity dysfunctions? a. How much time can you dedicate for the training of entry-level occupational therapists? b. Can you please describe the orientation process for a newly employed entry-level occupational therapist? 6. What suggestions do you have to improve occupational therapists entry-level competence for the treatment of upper extremity dysfunction? a. What do you see as a barrier to improved entry-level competence of occupational therapists when treating upper extremity dysfunction? OCCUPATIONAL THERAPISTS ENTRY-LEVEL COMPETENCE 83 b. In the best case scenario, what would you like your workplace to do to help improve the skill set of entry-level occupational therapist for the treatment of upper extremity dysfunction? c. In the best case scenario, what would you like OT educational programs to do to help improve the skill set of entry-level occupational therapist for the treatment of upper extremity dysfunction? Is there anything else that you would like to share on the topic? Can I leave you my email address if you think of anything else that you would like to add?  ...

... Physical Therapy Faculty Perceptions of High Fidelity Simulation Manikins Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Ren Thomas, PT, DPT, CLT-LANA Copyright October 5, 2020 By: Ren Thomas, PT, DPT, CLT-LANA All rights reserved Approved by: Steve Wiley, PT, PhD Committee Chair ______________________________ Lisa Borrero, PhD Committee Member ______________________________ Kristin Greenwood, PT, DPT, EdD, MS Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ Running head: FACULTY PERCEPTIONS OF HIGH FIDELITY SIMULATION Physical Therapist Faculty Perceptions of High Fidelity Simulation Manikins Ren Thomas University of Indianapolis 1 FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 2 Abstract This study examined physical therapist faculty members perceptions of the use of high fidelity simulation manikins in the doctor of physical therapy curriculum. A basic interpretative analysis was used to explore each individual faculty members perceptions through one-on-one semistructured interviews. This study answered the research question: How do physical therapy faculty members perceive high fidelity simulation as a teaching methodology within the physical therapy curriculum? The data obtained through qualitative analysis allowed the investigator to describe the perceptions of eight physical therapist faculty members who do not currently teach with high fidelity simulation mannikins. An examination of themes across participants identified three overarching themes. These themes included high fidelity simulation mannikins are unnecessary to achieve course objectives, high fidelity simulation manikins are not humans, and teaching with high fidelity simulation manikins may not be worth the effort. The findings of this study can assist DPT programs considering implementation of HFS manikins into the curriculum by increasing awareness of potential barriers and facilitators among PT faculty who have not taught with HFS manikins. Further research is warranted to continue to explore the evolving role this technology has in the DPT curriculum. Keywords: high fidelity simulation manikins, high fidelity simulation, physical therapy curriculum, physical therapy faculty, perceptions FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 3 Acknowledgements The journey to complete this Doctor of Health Science (DHSc) program has been an incredible experience. I am so thankful for the opportunity to grow both professionally and personally. However, I could not have completed this journey alone. I humbly thank my amazing husband, Matt Thomas, for his incredible support both physically, emotionally, and financially to allow me to achieve this goal for our family. We started on this journey with 2 awesome boys blessed to us through adoption and have had adopted 3 surprise boys along the way. There is no way I could have persevered on this path without my rock, Matt. I also want to thank my parents and Matts parents for their countless number of drives to our home to help with the children so I could work sort of undisturbed. I also could not have done this without the help of my committee: Drs. Steve Wiley, Lisa Borrero, and Kristin Greenwood. They have challenged me greatly along the journey, and this final product would not be where it is without their expertise, guidance, and patience. They were all so generous with their time and feedback, and I could not be more grateful. I also wish to thank the faculty and staff of the University of Indianapolis Interprofessional Health and Aging Studies. Their communication and caring have helped to make this rigorous program even more enjoyable. I am thankful for this journey, and excited to forge ahead on my next adventure. My genuine thanks to all of you! FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 4 Table of Contents Title Page.1 Abstract2 Acknowledgements..3 Table of Contents.4 Chapter 1: Introduction6 Background..6 Problem statement8 Purpose statement9 Research question9 Significance of the study..9 Chapter 2: Literature Review.10 Chapter 3: Method.17 Study Design..17 Participants.18 Procedures..18 Sampling and recruitment..18 Informed consent...18 Data collection...19 Data Management & Analysis...20 Rigor and trustworthiness..21 Chapter 4: Results..22 Chapter 5: Discussion29 FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 5 Chapter 6: Conclusion37 References..29 Tables.55 Appendix56 FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 6 Faculty Perceptions of High Fidelity Simulation Manikins Simulation-based learning experiences (SBLE) provide focused, deliberate practice in a safe and controlled learning environment for physical therapist (PT) students (Bishop, Sharp, & Ohtake, 2017). These experiences allow students to practice skills critical for physical therapists, including those in the psychomotor, clinical reasoning, communication, safety, and patient management domains (Greenwood et al., 2015). High fidelity simulation (HFS) is a specific type of SBLE that has been incorporated into the education of health professions students. High fidelity simulation is the use of a technologically advanced computerized manikin that mimics realistic patient situations (Mori, Carnahan, & Harold, 2015). High fidelity simulation allows PT students to transition from academic to clinical learning by fostering self-efficacy for clinical practice and the clinical decision-making skills expected of a doctoral-level professional (Silberman, Litwin, Panzarella, & Fernandez-Fernandez, 2016; Parker & Myrick, 2010). Although HFS has been documented as an effective teaching tool for medical, nursing and physical therapy students (Brenner, Aduddell, Bennet, & VanGeest, 2006; McGaghie, Issenberg, Petrusa, & Scales, 2010), only 40-50% of Commission on the Accreditation in Physical Therapy Education (CAPTE) accredited physical therapy programs incorporate immersive experiences such as SBLE into the curriculum (Stockert & Ohtake, 2017). Immersive experiences are not exclusively HFS activities, but can also include low fidelity, moderate fidelity experiences and teaching with standardized patients (SPs). Low fidelity simulation does not need to be controlled or programmed externally for learners to participate (Palaganas, Maxworthy, Epps, & Mancini, 2014). Low fidelity simulation lacks realism and has been considered more beneficial for novice learners (Munshi, Lababidi, & Alyousef, 2015). In physical therapy education, low fidelity simulation is commonly implemented and includes FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 7 activities such as role playing, and paper case studies (Roberts & Cooper, 2017). Moderate fidelity experiences include teaching with manikins or task trainers but also lack the authenticity of a realistic environment (Ntlokonkulu, Rala, & Goon, 2018). In physical therapy education, moderate fidelity simulation may include pulse palpation, blood pressure assessment, assessment of respiratory rate, auscultation of heart and breath sounds, ECG monitoring, and determining oxygen saturation levels (Sword, Thomas, Wise, & Brown, 2017). A standardized patient (SP) is a trained individual that portrays a real patient in order to simulate a set of symptoms or problems used for healthcare education, evaluation, and research (Lopreiato et al., 2016). In physical therapy education, SPs have been implemented for learning of professional behaviors in physical therapy, and basic interviewing skills (Blackstock et al., 2013; Murphy, Imam, & MacIntyre, 2015) that require faculty time to develop appropriate case scripts and adequately train SPs which can be costly (Aso, Inoue, Yoshimura, & Shimura, 2013; Bressmann & EriksBrophy, 2012). A recent systematic review indicated there is insufficient evidence to determine the overall effectiveness on learning outcomes of implementing a SP program into entry level physical therapy education (Pritchard, Blackstock, Nestel, & Keating, 2016). While the various types of SBLEs provide experiential learning opportunities for PT students to apply cognitive knowledge, practice psychomotor skills, and other clinical decisionmaking skills, HFS provides a safe learning environment that is both realistic and authentic (Bland, Topping, & Tobbell, 2014; Gaba, 2007). Low and moderate fidelity simulation experiences lack authenticity and realism, which can influence students ability to learn (Bland, Topping, & Tobbell, 2014; Ntlokonkulu, Rala, & Goon, 2018; Roberts & Cooper, 2017). A recent systematic review demonstrated that the impact of SPs in PT education is not clear due to several factors including SPs ability to realistically portray a given case, time required for FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 8 training, and other associated costs (Pritchard, Blackstock, Nestel, & Keating, 2016). Standardized patient interactions have not been as valuable when PT students are assessing specific cardiovascular skills whereas high fidelity manikins are able to demonstrate physiological changes that the use of SPs cannot replicate (Smith, Prybylo, & Conner-Kerr, 2012). SBLEs provide PT students practical learning experiences, but HFS allows for teaching of specific skills and competencies that low fidelity, moderate fidelity, and SPs cannot replicate, such as vital sign changes, ECG changes, and other physiological responses demonstrated through a high fidelity manikin in a safe, low-stakes learning environment (Mori, Carnahan, & Herold, 2015). Problem Statement Despite the positive findings in the literature surrounding SBLEs using high fidelity manikins (Stockert & Ohtake, 2017), very few PT programs have incorporated HFS into the PT curriculum, and there are no studies were identified specifically related to PT faculty perceptions about teaching with HFS manikins in the curriculum. Stockert & Ohtake further discovered that of the 114 CAPTE accredited respondent physical therapy programs, 39.5% reported using immersive simulation for uniprofessional (PT) and interprofessional simulation experiences, 30.7% reported only PT simulation experiences, and 29.8% reported no use of immersive simulation (2017). This study sought to understand PT faculty members perceptions of implementation of HFS manikins within the PT curriculum. Understanding faculty members thoughts on potential barriers and facilitators related to teaching with HFS manikins could provide opportunities for faculty discussion and decision making about utilization of this technology within physical therapy education. Increased teaching with HFS manikins could provide students with enhanced FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 9 experiential learning opportunities and improved preparation for clinical education and entrylevel practice. Purpose Statement & Research Questions The purpose of this basic interpretive qualitative study was to explore physical therapy faculty members perceptions of teaching with HFS manikins within the Doctor of Physical Therapy curriculum. Specifically, this study sought to answer the following research questions: How do physical therapy faculty members perceive HFS as a teaching methodology within the Doctor of Physical Therapy (DPT) curriculum? a. What is the current role of HFS in the DPT curriculum? b. What is the impact of perceived barriers and facilitators on the implementation of HFS within the DPT curriculum? Significance of the Study Faculty perceptions about teaching with HFS manikins within the PT curriculum could impact future curricular decisions, clinical education hour requirements, and the development of a framework for the implementation of HFS manikins within the PT curriculum. This study was timely as SBLE, including HFS has been suggested as a potential replacement for up to 25% of traditional clinical education hours in PT curriculums as the number of acute care clinical education experiences are decreasing (Blackstock, 2013; Mairella & Boissonnault, 2017; Mori, Carnahan, & Herold, 2015; Ohtake, Lazarus, Schillo, & Rosen, 2013; Pritchard, Blackstock, Nestel, & Keating, 2016). Literature Review Simulation FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 10 Simulation has been defined as a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions (Lopreiato et al., 2016, p. 33). Related to healthcare education, simulation has been defined as a set of conditions designed to present a clinical problem authentically that provides an opportunity for students to engage in realistic and contextually relevant clinical experiences prior to entering the clinical environment (Scalese, Obeso, & Issenberg, 2008). There are different types of SBLE including role playing, task trainers, teaching with SPs, and HFS (Lopreiato et al., 2016). Of these different types, high fidelity simulation provides a high level of interactivity and realism for the learner in a safe environment (INACSL, 2016). High fidelity simulation involves the use of a high fidelity simulator or full-body manikin that can mimic, at a realistic level, human body functions (Lopreiato et al, 2016). These manikins produce physical and verbal responses that are controlled by the instructor and adjusted based on the actions of the learner and the learning objectives of the scenario (Singh et al., 2013; Ward et al., 2014). High fidelity simulation has been widely used among health care professions to teach and simulate situations from basic vital sign pathologies to infrequent or complex medical scenarios (Bednarek, Downey, Williamson, & Ennulat, 2014; Cooper & Taqueti, 2004; Jones & Sheppard, 2011; Mori, Carnahan, & Herold, 2015; Murray, 2005; Shoemaker, Riemersma, & Perkins, 2011). High fidelity simulation in healthcare education also is growing in its use for development of complex clinical decision making and interprofessional collaboration, including using HFS in the health care providers practice environment (Sabus & Macauley, 2016). Due to these factors, HFS is being considered as a replacement for clinical education hours in some health professions including nursing and physical therapy pre-licensure curriculum (Hayden, Smiley, FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 11 Alexander, Kardong-Edgren, & Jeffries, 2014; Bennett, Rodger, Fitzgerald, & Gibson, 2017; Dudding & Nottingham, 2018; Blackstock et al., 2013; Watson et al., 2012). According to the National Simulation Study, up to 50% of traditional clinical practice can be substituted with HFS across the pre-licensure nursing curriculum (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Research supports that HFS has a significant impact on nursing students clinical performance and psychomotor skills demonstrating a carryover of learning from simulation to clinical practice (Shin, Park, & Kim, 2015). A recent study by Grillo & Thomas demonstrated that HFS is an effective clinical education tool to encourage application of knowledge, skills, and attitudes among speech-language pathology students (2016). Existing literature surrounding the use of HFS and Occupational Therapy (OT) students has demonstrated students interest and preference for HFS to develop clinical skills, and significant improvement in their knowledge, skills, and confidence in working with patients in an adult acute care setting (Shea, 2015). Physical therapy education has included SBLE including HFS , SPs, and role playing which facilitate deeper learning by presenting sequenced, realistic cases, which are contextualized to the level of the learner (Lopreiato et al., 2016; Mullen, Willis, & Prost, 2018; Riopel, Litwin, Silberman, & Fernandez-Fernandez, 2018; Smith, Prybylo, & Conner-Kerr, 2012). While teaching with SPs and role-playing have been beneficial in physical therapy education, HFS allows learners to practice various skills within a realistic and dynamic clinical environment and has been correlated with effective learning (Shoemaker, Riemersma, & Perkins, 2009). The body of literature is growing about the use HFS in PT education, and it has been identified that HFS positively influences self-efficacy in PT students, increases student confidence in acquired technical, behavioral, and cognitive skills, as well as increases high satisfaction with the learning experience, while potentially improving acute care clinical FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 12 performance (Ohtake, Lazarus, Schillo, & Rosen, 2013; Rosenthal et al., 2006; Silberman, Litwin, Panzarella, & Fernandez-Fernandez, 2016). Benefits of HFS and PT students High fidelity simulation provides a way to capture students experiences that can be vague, ambiguous, or harder to measure than didactic coursework (Semler et al., 2015). A recent systematic review by Mori, Carnahan, & Herold (2015) found that among studies that used HFS, PT students preferred HFS to see changes in patient signs or responses while interpreting ECG strips, and reported improved confidence in technical and behavioral performance measures (Ohtake, Lazarus, Schillo, & Rosen, 2013). Additionally, HFS has resulted in gains in clinical experience and the ability to modify patient examinations and interventions (Bednarek, Downey, Williamson, & Ennulat, 2014). As a learning tool, HFS also gives PT students the opportunity to practice cognitive, psychomotor, and communication skills, while providing a transition from the academic setting to clinical learning (Issenberg, 2006; Silberman, Panzarella, & Melzer, 2013). In particular, the opportunity for additional learning experiences can help to augment student learning experiences. This is important in that the Commission on Accreditation in Physical Therapy Education (CAPTE) requires that the PT curriculum include content and learning experiences that prepare students to achieve outcomes required for initial practice in physical therapy (2018). In addition, the Core Competencies for Entry-Level Practice in Acute Care Physical Therapy detail the required behaviors and knowledge for entry-level clinicians in acute care (Greenwood et al., 2015). As evidenced in the document, clinical decision making and communication are two priorities described (Greenwood et al., 2015). HFS scenarios allow students to practice clinical decision making and communication in a hands-on manner. FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 13 PT Student Perceptions of HFS Studies investigating PT student perceptions about HFS further explain the potential benefit of implementing HFS manikins into the PT curriculum. It has been noted that there is a shortage of physical therapists willing to work in intensive care settings including critical care, and a limited number of clinical placement spots for students (Silberman, Panzarella, & Melzer, 2013). Therefore, PT students perceptions of increased confidence, self-efficacy, and comfort while working in the critical care setting are valuable in the implementation of HFS in the PT curriculum (Silberman et al., 2016; Stockert et al, 2011). If PT students feel more comfortable and confident prior to an acute or critical care clinical experience, student performance on the Clinical Performance Instrument may be higher (PT CPI, 2018; Silberman, Litwin, Panzarella, & Fernandez-Fernandez, 2016). For example, a recent study by Nitham, Spiegel, & Lorello, found that PT students reported improvements in their perceived readiness for clinical education, as well as clinical decision-making skills contributing to positive patient and hospital outcomes (2016). A recent study expands upon PT student perceptions related to neurological patient simulation scenarios and describes how PT students perceive HFS to promote advanced clinical performance through reflection, promote authenticity without high risk, and highlights the value of teamwork when participating in neurological patient simulation scenarios (Donlan, Greenwood, & Kiami, 2020). High fidelity simulation also provides students the opportunity to participate in active learning that can facilitate the integration and application of information through problem solving, reflection of information, and feedback (Armbruster, Patel, Johnson, & Weiss, 2009). This active learning has been shown to result in perceived gains in confidence, decrease in anxiety, high satisfaction with the learning experience, and the ability to modify patient FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 14 examinations and interventions among PT students (Bednarek, Downey, Williamson, & Ennulat, 2014; Smith, Prybylo, & Conner-Kerr, 2012; Sword, Thomas, Wise, & Brown, 2017). Interprofessionalism and HFS High fidelity simulation provides PT students the opportunity to practice interprofessional collaboration in a realistic environment. This leads to stronger, patient-centered care given the sharing of knowledge across disciplines that is a requirement of CAPTE (CAPTE, 2017; Mai, Pilcher, Frommelt-Kuhle, 2018). High fidelity simulation provides a realistic learning environment that can facilitate a higher-level competency that includes interprofessionalism (Sabus et al., 2016). Gibbs, Dietrich, & Dagnan (2017) and Thomas, Rybski, Apke, Kegelmeyer, & Kloos (2017) included occupational therapy (OT) and physical therapy students in HFS experiences to incorporate interprofessional coordination and communication. Physical therapy and OT students reported an increase in knowledge, comfort, and confidence in handling an acutely ill patient with an IV, urinary catheter, and heart monitor (Gibbs, Dietrich, & Dagnan, 2017). Thomas et al. (2017) reported a significant increase in ratings of how prepared OT and PT students felt for acute care practice in the intensive care setting, and clinical instructors reported students were prepared to very prepared for and moderately confident to very confident in the acute care setting. Beyond PT and OT students, nursing and PT students also demonstrated an improvement in attitudes toward teamwork in an emergency hand off situation after participating in an HFS scenario together (Ronnebaum & Carlson, 2015). Faculty and HFS Despite the benefits of adding HFS into the PT curriculum, there have been few studies to demonstrate faculty perceptions and guidelines for implementation into the curriculum. However, nursing has provided an example of how HFS can be incorporated into healthcare FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 15 education which further helps to explain the importance of PT faculty perceptions into curricular implementation. In 2015, the National Council of State Boards of Nursing (NCSBN) released simulation guidelines for pre-licensure nursing programs (Alexander et al., 2015). These extensive guidelines include the need for commitment on the part of schools for simulation programs, the appropriate facilities for conducting simulation, education and technological resources with equipment to meet required objectives, qualified lead faculty and simulation lab personnel, faculty prepared to lead simulations, and policies and processes outlined by the program as part of the simulation experience (Alexander et al., 2015). Within each of these guidelines there are specific requirements for faculty such as knowledge of INASCL Standards of Best Practice, the ability to create a learning environment that encourages active learning and reflection through debriefing, knowledge of facilitation methods that meet the intended simulation objectives and expected outcomes, and the need for simulation-related professional development (Alexander et al., 2015). A recent study about nursing faculty perceptions of HFS found that nursing educators carry a heavy workload due to teaching more than one group of students at a time, and these educators had not explored the various ways in which SBLEs can be applied in the nursing curriculum (van Vurren, Seekoe, & Goon, 2018). While the majority of nursing faculty had no formal training or experience using HFS, they believed that HFS was an effective teaching strategy and reported positive intentions to use HFS, but had negative beliefs regarding the amount of time, preparation, and ease of using HFS (van Vurren, Seekoe, & Goon, 2018). While the NCBSN has released guidelines for simulation among nursing programs, PT programs do not have specific guidelines for the use of HFS within the curriculum. While student perceptions of HFS are generally positive, there are few studies investigating faculty FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 16 perceptions of HFS. However, literature does discuss the learning needs of faculty participating in simulation. In order to implement HFS, faculty members must understand the principles of simulation, from basic terminology to scenario creation to facilitated debriefing (INACSL, 2016). Additionally, it is important to note the frequency of HFS use is directly related to the complexity and provision of resources, such as faculty training, fear of technology, simulation support staff, administrative support, time constraints, designated laboratory space and equipment, and scheduling issues (Ray, 2017). Research has found that PT faculty are required to expend significantly more time and effort in order to implement HFS by expanding their teaching practice and course development (Cheng, Grant, Dieckman, Arora, Robinson, & Eppich, 2015). The expansion of faculty teaching practice and course development must include required competence in creating specific educational objectives related to the use of HFS and performing debriefing sessions for PT reflection and learning (INACSL, 2016; Thackray & Roberts, 2017). Despite the critical role of debriefing in experiential learning situations such as HFS (Dieckmann, 2009; Fanning & Gaba, 2007; Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007), faculty may struggle to learn and master this essential skill (Eppich & Chang, 2015). Due to the high cost of simulation equipment, as well as faculty time and training, further studies need to be done to justify to PT programs when, how, and why to use HFS in the curriculum (Baptista et al., 2016; Kardong-Edgren, Anderson, & Michaels, 2007). Overall perceptions of PT faculty of SBLE have been researched by Greenwood and Ewell, and found that SBLEs, including HFS, enhanced PT faculty members professional identity (2018). Additionally, PT faculty members professional identity was influenced by the introduction and training to HFS, was interconnected with interprofessional education, and led to FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 17 professional transformation among faculty members (Greenwood & Ewell, 2018). Given the results of this study, further exploration about PT faculty perceptions of the implementation of HFS in the curriculum is needed to augment the current literature. Method Study Design A basic interpretative qualitative design was employed to explore how physical therapy (PT) faculty members perceived HFS as a teaching methodology within the Doctor of Physical Therapy (DPT) curriculum by performing semi-structured one on one interviews to understand participants perceptions. This design was well suited as the investigator desired to understand how the participants made meaning of a situation, phenomenon, and/or process, allowing for a rich description of the findings (Merriam, 2002). Participants Eight physical therapy faculty members from CAPTE accredited physical therapy programs participated in the study. Inclusion criteria were as follows: Full-time DPT faculty members teaching acute care and/or cardiopulmonary content at U.S. institutions of higher education in physical therapy programs accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE) Full-time DPT faculty members as above who have not previously used HFS in their course work Setting FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 18 Interviews were conducted at a mid-sized DPT program in an urban Midwest city. For DPT faculty members not local, the on-line meeting app Zoom was used for the interview process. Procedures Recruitment. The primary investigator initially recruited participants by emailing PT faculty members known personally to the investigator. After contacting known faculty members, additional participants were needed. Therefore, snowball sampling was used in which existing study subjects recruited additional subjects among their acquaintances (Naderifar, Goli, & Ghaljaie, 2017). The primary investigator recruited eight participants via email. This email communication included a brief description of the study, inclusion criteria, estimated time commitment, a brief description of procedures, and information about the primary investigator and her contact information (see Appendix A). Individuals interested in participating in the study contacted the primary investigator via email and/or phone based upon the instructions provided in the recruiting email. The primary investigator confirmed eligibility for the study and answered any questions. When the PT faculty member agreed to participate, a time was established for the interview. Informed Consent. Institutional Review Board (IRB) approval was obtained prior to recruitment and data collection from the University of Indianapolis. Once a participant expressed interest in the study, the primary investigator emailed him or her an informed consent document. This document contained key information for potential research participants including the purpose of the study, procedures including the interview process, the use of audio recording including confidentiality of information, and any potential risks or benefits of participation. The FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 19 participant received the informed consent document at least one day prior to the scheduled interview allowing the participant to review the document prior to the interview. The informed consent document was reviewed verbally at the beginning of the appointed interview time by the primary investigator in which she read through the document with the participant and responded to any questions or concerns. The document was signed by the participant and emailed to the investigator prior to the start of the interview. Data Collection Process. Data was collected via one-on-one semi-structured interviews using a video-conferencing software. Semi-structured interviews allow researchers to understand and gain in-depth knowledge about complex phenomena (Mitchell, 2011), and, thus, was a fitting method to explore the meaning of DPT faculty members experiences with HFS. This aligned well with the inductive nature of basic interpretive research (Merriam, 2002), and the investigators aim of describing the perceptions of participants experiences. Interviews took place in the investigators office using video-conferencing software. The interviews were conducted using a semi-structured interview guide (see Appendix B) and began with a general, open-ended question with the purpose of establishing a comfortable interview rapport allowing for the participant to express his/her feelings, thoughts, and perceptions about the use of HFS within the DPT curriculum. Probing and follow-up questions were asked to further explore faculty perceptions, and potential facilitators and barriers surrounding the use of HFS in the DPT curriculum. The investigator utilized a reflexive journal after each interview to capture any initial bias that might have occurred secondary to her own investment of teaching with HFS manikins. This reflexive journal helped to ensure that any potential bias on the investigators behalf would not interfere with interpretation and analysis of FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 20 the interviews. Duration of interviews ranged from 30-60 minutes, and participants were audio recorded for transcription and analysis purposes. Data Management & Analysis The interview recordings were transcribed verbatim by the primary investigator. The primary investigator utilized Dedoose Version 7.0.23 for secure data management, analysis, and storage. Dedoose is a web-based application that allows for the organization, analysis, and storage of research data. Audio recordings were stored electronically and will be erased within three years of the studys completion. To protect confidentiality, the transcripts were deidentified prior to storage and a numeric coding system was applied to identify participants. In keeping with the tenets of a basic interpretive approach (Creswell & Poth, 2018), transcript data were analyzed using a systematic coding procedure that ultimately elucidated participants experiences and perceptions via the development of overarching themes. First, individual interview transcripts were read multiple times by the primary investigator. The initial coding process utilized an open coding approach in which key terms or phrases pertinent to the research questions were identified by the primary investigator and coded after reading and reviewing the transcripts. Specifically, the transcripts were read and re-read multiple times while highlighting and making hand-written notes of codes. Open coding was repeated after review and consultation with doctoral project committee members. Then, a codebook consisting of all open codes derived from analysis of interview transcripts was developed to organize the codes into potential patterns, which allowed for a visual way to further establish categories and themes. Using the codebook, patterns were noted and sorted into categories via axial coding (Merriam, 2002), and then organized into overarching themes (St Pierre & Jackson, 2014). FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 21 A second coder, and doctoral project committee members, were utilized in order to increase trustworthiness of the results. The second coder was a Doctor of Health Science student who is a physical therapist familiar with qualitative data analysis and coding. The second coder did not have any HFS experience in an effort to limit bias. The second coder reviewed two interview transcripts, and each doctoral project committee member reviewed two different interview transcripts for further discussion of potential open codes. Before moving to the development and analysis of themes across cases, the primary investigator, second coder, and committee met via phone, Zoom app, and email for comparisons. The committee members also performed check-ins at regular intervals to provide feedback and answer any questions or concerns. Member checking, a tool used to enhance trustworthiness of the results, took place next. In this process, the interview transcript or analyzed data are returned to the participants to ensure accuracy (Birt, Scott, Cavers, Campbell, & Walter, 2016). In this study, member checking took place after the initial data analysis via phone call and/or Zoom app during a time that was convenient for both the primary investigator and the participant. If the primary investigator and participants were unable to perform the member check via phone call or Zoom app, the themes identified were emailed to the participants. During the member check, the primary investigator described the themes identified for the individual participant, and how these themes were determined. None of the participants felt it was necessary to provide corrections or clarifications. Rigor & Trustworthiness Trustworthiness was enhanced via reflexivity, sampling strategies, member checking, and peer review. When practicing reflexivity, the primary investigator was transparent about her position and any potential bases and assumptions that may be present in judging the authenticity FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 22 of the findings (Reid, Brown, Smith, Cope, & Jamieson, 2018). According to Ary, Jacobs, and Sorensen (2006), reflexivity, demonstrated with a reflective journal, helped the researcher to recognize his or her biases. The purposive sampling strategy allowed for the identification and access to participants who can help to understand a specific experience (Daly, 2007). Member checking increased trustworthiness by validating, verifying, and assessing the results of qualitative research (Doyle, 2007). Utilizing a second coder as well as doctoral project committee members increased the credibility of the study because the data was analyzed by more than one researcher (Lincoln & Guba, 1985; Nowell, Norris, White, & Moules, 2017). Additionally, a committee of three educational scholars supervised the study from proposal to completion. Each of these strategies increased the trustworthiness and overall rigor of the results of this study (Henderson & Rheault, 2004). Results Eight physical therapist faculty members with 3 to 12 years of teaching experience participated in this study. None of the participants had experience using HFS manikins in his or her teaching responsibilities at the time of data collection. Table 1 provides an overall description of the individual participants and demographic information about the participants. Two of the eight faculty members were responsible for teaching acute care content only, three of the eight were responsible for teaching cardiopulmonary content only, and the remaining three were responsible for teaching both acute and cardiopulmonary content. All participants had varying-levels of experience with simulation-based education including low-fidelity, moderatefidelity, and the use of standardized patients in their courses. Overview of Findings FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 23 Three overarching themes arose through qualitative analysis of the transcripts which describe participants perceptions of the use of HFS manikins in the DPT curriculum. Major themes were (1) HFS manikins are unnecessary to achieve course objectives; (2) HFS manikins are not human; and (3) Teaching with HFS manikins may not be worth the effort. The theme, HFS manikins are unnecessary to achieve course objectives describes the perception of how the use of other types of simulation, such as low fidelity, moderate fidelity, or standardized patients achieve desired course outcomes without implementation of HFS manikins. The theme, HFS manikins are not human describes how characteristics including lack of mobility, inability to communicate, and absence of feedback contribute to the perception that HFS manikins are not realistic enough to substitute for human interaction. The last theme, Teaching with HFS manikins may not be worth the effort describes how participants are less likely to implement this technology into the DPT curriculum due to the perceptions of access issues such as, cost, time restraints, and limited availability. Theme 1: HFS manikins are unnecessary to achieve course objectives. Participants described how the use of other types of simulation, such as low fidelity, moderate fidelity, or standardized patients achieved desired course outcomes and provided real life clinically relevant scenarios without the need for implementation of HFS manikins. One participant who primarily used low fidelity, role play simulation explained the following as it related to achieving his course goals while providing real life clinical practice scenarios: Its a way for them to practice in not real-life situations but in safe situations that mimic real life. And so, theres a high level of stress, but low consequences and you know, thats kind of the way that they feel (Subject 107). FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 24 Another participant related to the importance of providing real life clinically based experiential learning opportunities using low fidelity simulation. Using the manikin couldnt, like I couldnt get it if it functioned the way I wanted to, you wouldnt meet my educational goals philosophically (Subject 121). Other participants used standardized patients as their primary type of SBLE in their courses. These faculty members reflected upon the ability of students to interact with real patients, and the ease of logistics allowing a greater number of students to have more purposeful interactions by using this type of HFS in their courses. Participants perceived the fidelity or realism of the scenario to be of great importance. One participant stated, I feel like if you did high fidelity simulation with standardized patients [versus HFS manikins], then that would be more realistic in my mind (Subject 102). To further support the idea of increased value and efficiency in using standardized patients to achieve course objectives, another participant reported: When we do the actor portrayal simulation, we usually have 10 actors that come in for a four to six hour block so that we can have the students each work with the actor for 30 minutesworking through the manikin would be a challenge (Subject 104). Participants valued the opportunity for students to have as realistic an experience as possible. By utilizing SPs there was a perception of ease of moving a large cohort of students through these experiences without having to put in additional valuable faculty and student efforts. One distinctive perspective among this group of participants was that they were able to reflect and verbalize potential uses of HFS manikins outside of their specific course objectives. Typical course objectives for acute and cardiopulmonary content focused on clinical decisionmaking, patient management, and discharge planning I think they have their place, FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 25 unfortunately, you know, I think they have their place for maybe examination and responding to emergency situations potentially (Subject 109). Another participant voiced a similar thought: I think they can be very helpful, in working through medical interventions, rightMy concern would be outside of managing of medical situations, I have trouble imagining how the clinic, like a high fidelity simulator is going to be an effective tool for therapists, for physical therapists because our primary goal is mobility (Subject 104). There seemed to be an unwillingness to use HFS manikins in their courses even if there were potential to meet specific course objectives. This could be due to reported unfamiliarity and lack of experience with the manikins. As one participant stated, But the, the biggest barrier is, and this could be a lack of experience with using the manikin to simulate what I see in the clinic is hard for me to do. So that is one barrier that I havent gotten over (Subject 121). This is distinctive in that all participants reported experiential and active learning was at the core of their teaching philosophies. Participants also acknowledged that SBLE was an important part of their pedagogies. However, for this group of participants, other types of experiential learning such as low fidelity simulation and the use of SPs met their teaching philosophy and course objectives. Participants wanted to provide students with as many real life clinically relevant learning scenarios as possible, and HFS manikins were not perceived to be useful or necessary over other types of SBLE already in place. Theme 2: HFS manikins are not humans. Participants described how characteristics including lack of mobility, inability to communicate, and absence of feedback contribute to the perception that HFS manikins are not realistic enough to substitute for human interaction. As physical therapists are considered movement experts, several participants felt HFS manikins were not FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 26 useful due to their lack of mobility. Lack of mobility specifically included the inability to transfer the manikin as well as the limited joint range of motion. One participant expressed, The biggest problem that I have, or the biggest challenge that I see is that the manikin, it doesnt, it doesnt move on its own (Subject 121). Other participants noted the desire for students to practice communication and relational skills with patients. HFS manikins were perceived to lack the ability for students to practice soft skills vital for the physical therapy profession. One participant commented, I think students, because were in a field where its such a hands-on profession, we are communicators, were hands on. We really need to have this relational experience with our patients (Subject 105). Another participant identified the additional barrier of lack of feedback related to limited communication and physical limitations of the manikin, They need hands on feedback. They need to hear it from a patient's perspective, and they will never get that with high fidelity [manikins] (Subject 106). An interesting point of discussion was provided when one participant noted the audio capabilities of HFS manikins. Students often practice auscultation with peers, and most peers would likely demonstrate normal heart and lung sounds. This participant noted the following during a lab session in which students were performing auscultation of both normal and abnormal heart and lung sounds. I guess they had a hard time differentiating what the sounds were supposed to simulate in all. Honestly, its a fake sound, so its not to them. They could definitely hear a stridor in the lungs or rhonchibut I think the heart sounds were more difficult (Subject 106). FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 27 This participant perceived the heart and lung sounds to be fake when students performed auscultation. This could be because students lack experience hearing abnormal sounds or could be due to the audio capabilities of the HFS manikin. This group of participants felt strongly that HFS manikins lacked the realism they desired for implementation in the DPT curriculum. Participants wanted students to be able to mobilize the manikin, communicate and interact with the manikin, and have as clinically realistic patient scenario as possible. One participant noted her ideal HFS manikin, What I think about is having a blend between a human body and a high fidelity manikin. And then we have the changes in the vital signs and whatever else you wanted, but have it on a, a human that can move like a human (Subject 107). Participants desired optimum experiential learning opportunities for their students. Having real human interaction and clinically relevant experiences were essential to this group of self-proclaimed experiential faculty. In addition to the perception that HFS manikins are not real enough to use in their courses, participants felt that other types of SBLE already in place were able to meet their course objectives. Besides these barriers, participants noted other barriers related to the current role of HFS manikins in the DPT curriculum. Theme 3: Teaching with HFS manikins may not be worth the effort. The last major theme identified described the perceived value of implementing HFS manikins into the DPT curriculum. Participants specifically discussed access issues including cost of the manikins, time restraints for both faculty and students, and the availability to use the manikins on site. The participants perceived that even if barriers such as the ability to meet course objectives, a more life-like manikin was available, and access issues were resolved, they would not be likely to implement HFS manikins in the DPT curriculum. One participant said: FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 28 Cost is the biggest barrier. I think sim labs are really expensive. I mean, we have a medical school on campus, but we cant use their sim lab for free and its way too expensive for my university to afford (Subject 102). Another participant added, I dont find them useful and theyre super expensive and I just dont think we get our moneys worth out of them (Subject 109). Another participant stated, I mean, we can have the students have a full day of actual [clinical] experiences for a far less cost (Subject 104) Concerns related to time were described by one participant, The simulation lab is 40-45 minutes away. You know, its just, even though its really not that far, its kind of hard to coordinate all the students to go there at one time (Subject 107). Another participant explained, I also think it is incredibly time intensive, high fidelity sim and faculty intensive. So you need a lot more people to run a high fidelity sim (Subject 102). Lastly, faculty members described their perceptions about the limited application of HFS manikins in the DPT curriculum. One faculty member stated, I think they have their place, unfortunately, you know, I think they have their place for maybe examination and uh, responding to emergency situations potentially (Subject 109). Another participant shared similar concerns: I think they can be very helpful, in working through medical interventions, rightMy concern would be outside of managing of medical situations, I have trouble imagining how the clinic, like a high fidelity simulator is going to be an effective tool for therapists, for physical therapists because our primary goal is mobility (Subject 104). One participant summarized her perception of the value of HFS manikins, To me, the, you know, the juice isnt worth the squeeze so to speak (Subject 102). FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 29 Other types of SBLE provided the participants desired course objectives and met their teaching philosophies. HFS manikins were also perceived to lack the real life clinical experiences these participants were seeking when performing SBLE. Simulation-based education was valuable to participants and perceived as essential in the curriculum. However, HFS manikins were not perceived as worth the trouble to implement. Participants were not interested in taking additional time out of already busy schedules to pursue a type of SBLE that they did not believe would add value to their courses. Participants felt confident and comfortable with using other types of SBLEs that fulfilled their course objectives, teaching philosophies, and desire for real life clinical experiences. Participants perceived that even if HFS manikins were available to them, the majority would not find them useful or valuable. The cost in money, faculty and student time, and access to manikins made it prohibitive for these participants to consider implementation of HFS manikins into the curriculum even if the technology was available on site. Discussion The findings of this study begin to explain physical therapy faculty members perceptions about the current role of HFS manikins in the DPT curriculum. While each participant brought a unique perspective to the discussion, three overarching themes arose describing the perceptions surrounding the use of HFS manikins. Participants in this study described the perception of how HFS manikins were unnecessary to achieve course objectives and preferred to teach with other forms of SBLE already in place such as low fidelity simulation and standardized patients. Some participants preferred to teach with low fidelity simulation rather than HFS manikins as it was perceived as a more valuable learning tool in their courses. Teaching with low fidelity simulation has been FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 30 shown to be effective as a learning tool in PT education. Evidence indicates that students reportedly have been overwhelmingly positive in their assessment of peer simulation (low fidelity simulation) as a learning tool. There were no negative comments about the use of low fidelity simulation as an educational method, and students reported that peer simulation enhanced their communication and clinical reasoning skills (Dalwood, Maloney, Cox & Morgan, 2018). In addition to low fidelity simulation, the participants in this study were more likely to teach with SPs than HFS manikins. Simulated patients are trained to depict a real patient, including both physical and emotional characteristics, and can be valuable in PT training, as they can portray active movements and functional mobility skills critical to physical therapy examination and interventions (Silberman et al., 2018). A recent study noted that PT students found a SBLE using SPs to be engaging, satisfying, and built confidence (Dennis, Parry, Miolin, Mercer, & Furness, 2019). A recent meta-analysis demonstrated that simulated patients appear to have an effect comparable to alternative educational strategies on development of PT clinical practice competencies and serve a valuable role in entry-level physical therapy education (Pritchard, Blackstock, Nestel, & Keating, 2016). Participants in this study also described the perception that HFS manikins were too costly, time intensive, and often have limited accessibility on site. Simulation can be a timeconsuming learning method as high fidelity simulation requires high staff-to-student ratios and well equipped simulated learning environments (Roberts & Cooper, 2017). Similar barriers have been reported in the literature that included time, resources, access to the lab (it is used by multiple departments), and the limited number of faculty who have been trained in running simulations and effectively guiding debriefing (Mai, Pilcher, & Frommlet-Kuhle, 2018). While PT literature has indicated there is insufficient evidence available at this time to unequivocally FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 31 determine the effect of SP interactions compared with no SP interaction or an alternative form of SBLE (Pritchard, Blackstock, Nestel, & Keating, 2016), participants in this study felt that the barriers related to implementation of HFS manikins was too great to add or replace current practices in place. An intriguing finding in this study was an apparent unwillingness of participants to teach with HFS manikins even if the technology was available on site. In part, this is due to reported implementation of other types of SBLE to achieve course objectives, such as low fidelity and standardized patients. This finding was unexpected as literature has demonstrated the value of HFS in PT education. High fidelity simulation has been implemented among health care professions to teach and simulate situations from basic vital sign pathologies to infrequent or complex medical scenarios (Bednarek, Downey, Williamson, & Ennulat, 2014; Cooper & Taqueti, 2004; Jones & Sheppard, 2011; Mori, Carnahan, & Herold, 2015; Murray, 2005; Shoemaker, Riemersma, & Perkins, 2011). Additionally, HFS provides a way to capture students experiences that can be vague, ambiguous, or harder to measure than didactic coursework (Semler et al., 2015). As a learning tool, HFS also gives PT students the opportunity to practice cognitive, psychomotor, and communication skills, while providing a transition from the academic setting to clinical learning (Issenberg, 2006; Silberman, Panzarella, & Melzer, 2013). Despite the findings in the literature in support of teaching with HFS manikins, this group of participants have established other types of SBLE to fulfill experiential learning activities. Participants also believed there was a lack of realism associated with HFS manikins. Specifically, they perceived that HFS manikins lacked mobility, produced fake sounds, and that students have limited ability to communicate and receive feedback from manikins. Therefore, HFS manikins were perceived as not realistic enough as compared to human interaction, and not suitable for implementation in their courses. This group of participants desired for students to FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 32 experience real life, clinically relevant learning scenarios. While participants perceived HFS manikins to be unrealistic as compared to humans, current literature supports that HFS manikins mimic, at a remarkably high level, human body functions (Lopreiato et al, 2016). High fidelity simulation provides a high level of interactivity and realism for the learner in a safe environment (INACSL, 2016). Additionally, HFS manikins produce physical and verbal responses that are controlled by the instructor and adjusted based on the actions of the learner and the learning objectives of the scenario (Singh et al., 2013; Ward et al., 2014). Evidence also demonstrates that PT students preferred HFS to see changes in patient signs or responses while interpreting ECG strips, reported improved confidence in technical and behavioral performance measures, reported a decrease in anxiety as well as high satisfaction with the learning experience while using HFS manikins (Ohtake, Lazarus, Schillo, & Rosen, 2013; Smith, Prybylo, & Conner-Kerr, 2012). Participants in this study did not have experience teaching with HFS manikins, which is likely why the manikins were perceived to be unrealistic, not human enough, and at odds with PT student perceptions about the value of learning with HFS manikins. Another surprising finding in this study was that all faculty members unanimously described experiential learning was their preferred teaching philosophy but were not willing to teach with HFS manikins. Experiential learning requires that students apply knowledge to new and different experiences. Students must engage in critical thinking and be active participants in their learning process (Smith & Crocker, 2017). Various types of SBLEs provide experiential learning opportunities for PT students to apply cognitive knowledge, practice psychomotor skills, and other clinical decision-making skills. HFS provides a safe learning environment that is both realistic and authentic (Bland, Topping, & Tobbell, 2014; Gaba, 2007). HFS also allows learners to practice various skills within a realistic and dynamic clinical environment and has FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 33 demonstrated correlation with effective learning (Issenberg et al., 2005; Shoemaker, Riemersma, & Perkins, 2009). Despite the support from literature that HFS is an effective experiential teaching tool, the faculty in this study did not identify the use of HFS manikins as valuable to incorporate in their courses as an experiential learning tool. Similarly, PT faculty members in this study did not perceive HFS manikins to be an asset in the PT curriculum. This finding was unanticipated as literature has demonstrated the value of HFS manikins in PT education. HFS has been found to increase PT students perceived confidence and competence in the clinical setting (Mori, Carnahan, & Herold, 2015; Silberman, Litwin, & Panzarella, 2016). Evidence has also described student perceptions of the value of HFS by endorsing the experience as it reinforced course content, was a useful teaching method, and should be added to additional courses in the PT curriculum (Ohtake, Lazarus, Schillo, & Rosen, 2013). The implementation of HFS manikins have recently been studied beyond use in acute and cardiopulmonary scenarios to include neurologic and pediatric populations demonstrating the value of HFS in PT curriculum (Donlan, Greenwood, & Kiami, 2020; Hough, Levan, Steele, Kelly, & Dalton, 2019). In this study, participants did not have experience teaching with HFS manikins, which might help to explain why there is an apparent disconnect between the well-established value of HFS and what the participants perceive. Participants described a greater number of barriers than facilitators for implementation of this technology into their courses, indicating a decreased likelihood for implementation of HFS manikins in their courses. This group of participants applied their experiential learning philosophy by teaching with other types of SBLE that provided the real-life, clinically relevant scenarios they were seeking. Fidelity seemed to be the deciding factor in what type of SBLE to implement. Specifically, participants in this study were FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 34 concerned with physical, functional, and psychological fidelity. Physical fidelity refers to the appearance of a manikin whereas functional fidelity would reflect physiological changes. Both pertain to the psychology of learning (Schoenherr & Hamstron, 2017). The participants in this study perceived they were able to achieve physical, functional, and psychological fidelity by teaching with other types of SBLE. Teaching with HFS manikins was not a consideration among this group of participants as they were satisfied with their students outcomes in their courses and received positive feedback from students about other SBLEs such as low fidelity simulation and SPs. Limitations There were several limitations in this study. Participants were interviewed only once, and as a novice qualitative investigator, there is potential that more follow up questions could have added increased depth to the perceptions and results. A second interview could have gleaned additional reasons why participants perceived HFS the way it was described. Participants were limited to a small number of accredited physical therapy programs within the United States. However, there are other physical therapy programs outside of the United States utilizing simulation that have been referenced within this study. Therefore, the results of this study may not be generalizable to all PT faculty members, however this is not the primary goal of qualitative research. The investigator has also taught with HFS manikins in her own courses and is supportive of the use of HFS manikins in the DPT curriculum. While this bias was known prior to the investigation and every effort was made to increase rigor and trustworthiness, her own experiences could have impacted the results. Specifically, this bias may have led the investigator FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 35 not to ask as many follow up questions due to her own assumptions of how the participants responded to interview questions. Implications for PT educators This study adds to the of literature surrounding PT faculty perceptions of teaching with HFS manikins in the DPT curriculum. This study was completed prior to the COVID-19 pandemic, however, due to changes in DPT curriculum requiring increased remote learning opportunities and limited in person clinical education experiences, these findings need to be further defined. According to CAPTE, during the COVID-19 pandemic, PT students may demonstrate competence by the implementation of telehealth, pro bono clinical experiences, simulation experiences, part-time clinical education, and in-class patient care, including paper or video case studies (2020). The results of this study are timely as teaching with HFS manikins may need to be incorporated more readily into the DPT curriculum to replace the face-to-face interactions on hold secondary to COVID-19. Openness to explore other types of simulation. Participants in this study were able to meet desired goals for their courses without implementation of HFS manikins. While teaching with low fidelity and standardized patients have benefits as reported in PT literature, HFS manikins can also provide benefits to PT students (Dalwood, Maloney, Cox & Morgan, 2018; Dennis, Parry, Miolin, Mercer, & Furness, 2019). This study has identified a potential dilemma that warrants further exploration. While this group of participants was able to achieve course objectives with other types of SBLEs, teaching with HFS manikins could become necessary due to the COVID-19 pandemic. PT educators in acute and cardiopulmonary content may be compelled to explore other types SBLEs to enhance clinical education hours and preparation for entry level practice given the significant challenge of finding acute care placements for students. FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 36 HFS manikins can be realistic. PT educators in this study were focused on the lack of realism associated with HFS manikins. Lack of mobility was perceived to be a major barrier for implementation in participants courses as well as lack of communication and feedback. Current literature supports that HFS manikins mimic, at a very high level, human body functions (Lopreiato et al, 2016). High fidelity simulation provides a high level of interactivity and realism for the learner in a safe environment (INACSL, 2016). PT educators should consider the importance of fidelity in their selected method of SBLE. Each educator should identify what features of SBLE are critical to their learning objectives (Schoenherr & Hamstra, 2017). With experience, PT educators can discover the technology that best fits the fidelity they are seeking for their students from low fidelity simulation to the implementation of HFS manikins. Accessibility to HFS manikins. The findings of this study indicate that participants could see potential value in the use of HFS manikins, but it was perceived as not worth their time or efforts to implement as other types of simulation reaped the results they were seeking for their courses. Participants in this study may have been willing to use HFS manikins in their courses if access was more feasible. The cost and accessibility barriers to HFS prompt the need to explore the educational benefits of more basic, accessible, and functionally realistic SBLEs (Issenberg & Scalese, 2008; Dalwood, Maloney, Cox & Morgan, 2018). Having a HFS manikin available for use on site was perceived as a facilitator in this study. Participants described how a sharing program or trade-off would promote interprofessionalism among departments at their universities. Time was also perceived to be a barrier to implementing HFS manikins. This included faculty training time, travel time for both faculty and students if no manikin was available on FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 37 site, and time to run a complete scenario. PT educators may choose to receive formal simulation training, or train by self-study or shadowing. Implications for Future Research Most of the research surrounding HFS and physical therapy is quantitative in nature. This study and few others have been qualitative in nature. Qualitative research allows for deeper meanings and increased depth of understanding participants feelings and perceptions about simulation. This study has the potential to be expanded to additional interviews to understand further the why participants perceive HFS simulation manikins in the way described. With the onset of the COVID-19 pandemic, there could be further need for implementation of more SBLEs in the DPT curriculum. Further qualitative studies from viewpoints of both physical therapy faculty and students will allow for a deeper understanding of potential barriers and facilitators. Quantitative research is also important to add to the body of growing literature in this area, specifically outcomes of HFS manikin experiences as it translates to clinical performance among physical therapy students. Conclusion This study sought to explore physical therapist faculty members perceptions of the implementation of HFS manikins in the DPT curriculum among eight participants. Three themes were identified that represented participants perceptions: HFS manikins are unnecessary to achieve course objectives, HFS manikins are not humans, and teaching with HFS manikins may not be worth the effort. The findings in this study provide insight to DPT programs and physical therapy faculty who are seeking to learn more about HFS manikins and how they may or may not be viewed as valuable within the DPT curriculum. DPT programs may also use these findings to help implement HFS manikins into the curriculum by awareness of potential barriers FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION and facilitators among those PT faculty who have not taught with HFS manikins. Ongoing research surrounding the implementation of HFS manikins in PT education should continue to explore the evolving role this technology has in the DPT curriculum. 38 FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 39 References Adamson, K. (2010). Integrating human patient simulation into associate degree nursing curricula faculty experiences, barriers, and facilitators. Clinical Simulation in Nursing, 6, 45-81. doi:10.1016/j.ecsns.2009.06.002 Akhtar-Danesh, N., Baxter, P., Valaitis, R. K., Stanyon, W., & Sproul, S. (2009). Nurse faculty perceptions of simulation use in nursing education. Western Journal of Nursing Research, 31(3), 312-329. doi:10.1177/0193945908328264 Al-Ghareeb, A. Z., & Cooper, S. J. (2016). 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Nurse Education Today, 35(1), 176-182. doi:10.1016/j.nedt.2014.09.009 Shoemaker, M. J., Riemersma, L., & Perkins, R. (2011). Use of high fidelity simulation to teach physical therapist decision making skills for the intensive care setting. Cardiopulmonary Physical Therapy Journal, 20, 13-18. Silberman, N. J., Litwin, B., Panzarella, K. J., & Fernandez-Fernandez, A. (2016). Student clinical performance in acute care enhanced through simulation training. Journal of Acute Care Physical Therapy, 7(1), 25-36. doi:10.1097/JAT.0000000000000021 Silberman, N., Panzarella, K., & Melzer, B. (2013). Using human simulation to prepare physical therapy students for acute care clinical practice. Journal of Allied Health, 42, 25-32. Singh, H., Kalani, M., Acosta-Torres, S., Ahmadieh, T., Loya, J., & Ganju, A. (2013). History of simulation in medicine: From Resusci Annie to Ann Myers Medical Center. Neurosurgery, 73, s9s14. Smith, S. N., & Crocker, A. F. (2017). Experiential learning in physical therapy education. Advances in Medical Education and Practice, 8, 427-433. doi:10.2147/AMEP.S140373 FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 53 Smith, N., Prybylo, S., & Conner-Kerr, T. (2012). Using simulation and patient role play to teach electrocardiograph rhythms to physical therapy students. Cardiopulmonary Physical Therapy Journal, 23(1), 36-42. Sole, M. L, Guimond, M. E. B., & Amidei, C. (2012). An analysis of simulation resources. Clinical Simulation in Nursing, 9(7), 265-271. Stockert, B., Brady, D. (2011). Programmable patient simulators as an educational technique in physical therapy. Journal of Acute Care Physical Therapy, 2, 111-116. Stockert, B., & Ohtake, P. J. (2017). A national survey on the use of immersive simulation for interprofessional education in physical therapist education programs. 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Journal of Interprofessional Care, 3, 317-324. doi:10.1080/13561820.2017.1280006 FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 54 Turner III, D. W. (2010). Qualitative interview design: A practical guide for novice investigators. The Qualitative Report, 15(3), 754-760. van Vuuren, V. J., Seekoe, E., & Goon, D. T. (2018). The perceptions of nurse educators regarding the use of high fidelity simulation in nursing education. Africa Journal of Nursing and Midwifery, 20(1), 1-20. doi:10.25159/2520-5293/1685 Ward, E. C., Baker, S. C., Wall, L. R., Duggan, B. L. J., Hancock, K. L., Bassett, L. V., & Hyde, T. J. (2014). Can human manikin-based simulation provide a feasible and clinically acceptable method for training tracheostomy management skills for speech-language pathologists? American Journal of Speech-Language Pathology, 23, 421436. Watson, K., Wright, A., Morris, N., McMeeken, J., Rivett, D., Blackstock, F. Jull, G. (2012). Can simulation replace part of clinical time? Two parallel randomised controlled trials. Medical Education, 46(7), 657-667. doi:10.1111/j.1365-2923.2012.04295. x. FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 55 Table 1 Participant Characteristics Subject Number 103 104 105 106 107 108 109 121 ________________________________________________________________ Gender F F F F F M F M # of years faculty 11 8 Course Instruction A/CP CP Cohort Size 30 Institution HFS manikin 12 5 3 5 4 7 A/CP CP A CP A A/CP 83 27 77 31 48 65 35 Pr Pr Pr Pr Pr Pu Pr Pu No No Yes Yes Yes No No Yes Yes No Yes Nursing program Yes Yes No Yes A-acute, CP-cardiopulmonary, Pr-private, Pu-public FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 56 Appendix A Dear Colleagues, My name is Ren Thomas. I am a Doctor of Health Science student at the University of Indianapolis. I am inviting you to participate in a study that I am conducting as part of my Doctoral degree. The title of my study is Physical Therapist Faculty Perceptions of High Fidelity Simulation. High fidelity simulation (HFS) and other simulation based learning experiences (SBLE) have been documented as an effective teaching tool for medical, nursing, and physical therapy students. Despite this, only 40-50% of Commission on the Accreditation in Physical Therapy Education (CAPTE) accredited physical therapy programs incorporate immersive experiences such as SBLE including HFS into the curriculum. Therefore, the purpose of this qualitative study is to explore physical therapy faculty members perceptions of high fidelity simulation within the Doctor of Physical Therapy curriculum. If you decide to participate, you will be asked to meet with me in person or virtually at a mutually agreed upon time and location for an interview lasting approximately 45-60 minutes. Participation is confidential and completely voluntary. Below are the inclusion criteria to participate in this study: Full-time DPT faculty members teaching acute care and/or cardiopulmonary content at U.S. institutions of higher education in physical therapy programs accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE) Full-time DPT faculty members as above who have not previously used HFS in their course work FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 57 If you are interested in participating in this study, please contact me at 317-698-8733 or by email at rlthomas@uindy.edu. I look forward to speaking with you and thank you in advance for your assistance in this project. Sincerely, Ren Thomas, PT, DPT, CLT-LANA FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 58 Appendix B My name is Ren Thomas. I am a student at University of Indianapolis. I will be conducting this interview for my Doctoral Project. The responses you provide for this interview will be used for the purposes of this doctoral project only; your responses are confidential. Your responses may be discussed with my Doctoral Project committee, but any identifying information will be removed. The purpose of this interview is to explore physical therapy faculty perceptions of using high fidelity simulation in the Doctor of Physical Therapy curriculum. You will provide the perspective of a physical therapy faculty member. The time frame for this interview will be 30 minutes to 45 minutes. Your participation is voluntary, and you may choose not to answer one or more questions. The interview can be terminated at any time upon your request. Do you have any questions about the interview or how the data will be used? To ensure I have all of your responses correct, I would like to audio record the interview. The recording will be deleted once it has been utilized for doctoral project purposes. Is it ok if I record the interview? RECORDINGI have started recording, is that ok? Questions: 1. Please tell me a little about your background. a. How long have you been a physical therapy faculty member? b. What courses are you primarily responsible for teaching? FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 2. 59 What experience(s) have you had with simulation as a student and/or faculty member? a. What type of simulation was used (high, moderate, low)? b. What was the purpose of the simulation? c. How did the simulation make you feel? How did it make the students feel? 3. What are your thoughts regarding the use of HFS in the PT curriculum? a. How do you think HFS impacts PT students educational experience? b.How do you feel about HFS potentially being a replacement for clinical experience hours? 4. What are some barriers that would lead you not to use high fidelity simulation in one of your courses? a. Why do you consider this to be a barrier? b. What could be done about this barrier so that you would use high fidelity simulation in your course if you desired? 5. What are some facilitators that would lead you to use high fidelity simulation in your courses? a. Why do you consider this to be a facilitator? b. What else could be done to help you implement high fidelity simulation into your courses if you had the desire? 6. How would you describe your identity/philosophy as an instructor? FACULTY PERCEPTIONS OF HIGH FIDELITY SIMUATION 60 a. What role do you take in preparing students to be effective clinicians? b. What are your thoughts on experiential learning? 7. To what extent has high fidelity simulation had an impact on you professionally as a faculty member? a. What impact has high fidelity simulation had on physical therapy students? 6. Thank you for your time; do you have anything else to share about high fidelity simulation in the physical therapy curriculum? This now concludes our interview. This interview will be downloaded and stored for further analysis. The data will be transcribed into Microsoft Word and stored on my personal computer with password-protection to determine possible themes and codes. The transcriptions will not contain any personal or confidential information. De-identified data including interview transcripts, spreadsheets, theme tables, and codebook will be stored on my computer passwordprotected for future research. Thanks again for your participation.  ...

... PERCEPTIONS OF THE CAREGIVER-PEDIATRIC PHYSICAL THERAPIST RELATIONSHIP Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Jodi Thomas PT, DPT, PCS Copyright February 20, 2019 By: Jodi Thomas PT, DPT, PCS All rights reserved Approved by: Laura Santurri, PhD, MPH, CPH Committee Chair Lisa Borrero, PhD Committee Member Donna Cech, PT, DHS, PCS Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: CAREGIVER-PEDIATRIC PT RELATIONSHIP Perceptions of the Caregiver-Pediatric Physical Therapist Relationship Jodi Thomas University of Indianapolis 1 CAREGIVER-PEDIATRIC PT RELATIONSHIP 2 Abstract The collaboration that occurs between physical therapists and caregivers of children who receive physical therapy is integral to both the functional outcomes of the child and the wellbeing of the caregiver. Successful collaboration is dependent upon a variety of factors, including the therapeutic relationship built within the caregiver-therapist dyad. However, the nature of these relationships is not well understood. The purpose of this study was to explore the caregivertherapist relationship from the viewpoints of both the caregiver and physical therapist. An enhanced understanding of these therapeutic relationships may be of benefit to healthcare providers. A qualitative case study methodology was used in which a caregiver and pediatric physical therapist represented a bounded case. Each caregiver and therapist within a dyad engaged in separate, semi-structured, in-depth interviews. Through within- and cross-case coding, three major themes were identified: physical therapist as a guide, social and emotional connection, and professional qualities and performance. These themes help to provide a rich understanding of the therapeutic relationships that can occur between therapists and caregivers. CAREGIVER-PEDIATRIC PT RELATIONSHIP 3 Table of Contents Title Page.1 Abstract2 Chapter 1: Introduction5 Background..5 Problem Statement...6 Purpose Statement6 Significance of the Study.7 Chapter 2: Literature Review...7 Family-Centered Care..7 Role of Collaboration...8 Collaboration in Various Settings9 Communication..11 Prior Studies...12 Chapter 3: Method.14 Study Design..14 Participants.15 Procedures..16 Data Analysis.18 Chapter 4: Results..20 Chapter 5: Discussion and Conclusion..30 References..36 Table 1 Participant Characteristics44 CAREGIVER-PEDIATRIC PT RELATIONSHIP 4 Table 2 Patient Characteristics...45 Appendices.46 Appendix A Recruitment Email.46 Appendix B Institutional Review Board Approval........47 Appendix C Semi-Structured Interview Guides....51 Appendix D Demographic and Background Questions.54 Appendix G Figure 1 Visual Representation.55 CAREGIVER-PEDIATRIC PT RELATIONSHIP 5 Perceptions of the Caregiver-Pediatric Physical Therapist Relationship The number of children affected by disabling conditions is on the rise. The prevalence of children between the ages of 3 and 17 years old with any developmental disability increased from 5.76% in 2014 to 6.99% in 2016 (Zablotsky, Black, & Blumberg, 2017). Cerebral palsy (CP) is the most common physical disability of childhood, affecting 2.6 to 2.9 out of 1000 live births in the United States (Maenner et al., 2016), and approximately 5,300 babies with Down Syndrome are born each year (Graff, Buckley, & Skotko, 2015). Autism currently is known to affect 1 in 68 children (Christensen et al., 2016). These are just a few examples of conditions for which families may seek the services of a pediatric physical therapist (PT). Pediatric PTs work with children and families to improve independence, participation, and function in all areas of life, such as home and school, as well as a variety of social settings (American Physical Therapy Association [APTA], 2009). There are no set guidelines for the duration, intensity, or frequency of pediatric physical therapy, though pediatric PTs often work with a child and the family for 30-60 minutes at a time, one to two times a week, and often for a year or more (APTA, 2012). This prolonged involvement with the child and family gives pediatric physical therapists a unique opportunity to build professional relationships and, at times, personal ones. The therapeutic process relies on a model of teamwork among therapy practitioners, but it also relies on the relationship among the caregiver-child-therapist triad, which should be viewed as a partnership. This partnership requires collaboration between families and therapists that is comprised of trust, honesty, support, and shared decision making (An et al., 2015; Broggi & Sabatelli, 2010; Peplow & Carpenter, 2013; Piggot, Paterson, & Hocking, 2002). Because this CAREGIVER-PEDIATRIC PT RELATIONSHIP 6 relationship is critical, a solid understanding of the caregiver-therapist relationship, from both the caregivers and PTs point of view, is necessary. Problem Statement Current literature reflects a lack of understanding regarding how caregivers and pediatric PTs perceive their relationship with one another. Additionally, little is known about the role of the caregiver-pediatric PT relationship in promoting effective teamwork. Lack of trust and poor communication have been identified as causes for concern and frustration for parents of children receiving therapy (Peplow & Carpenter, 2013), and parents have reported a desire to feel supported by their childs physical therapist (Chan, Lau, Fong, Poon, & Lam, 2005). Despite this reality, information is lacking on how best to develop a working relationship that more fully meets caregivers needs. Purpose Statement The purpose of this qualitative case study was to explore longer-term (six months or more) caregiver-pediatric PT relationships from both the caregivers and PTs points of view. The results from this study provide deeper insight into the caregiver-pediatric PT relationship. Research Question This study addressed the following primary research question and associated sub-question: How do caregivers of children with special needs and pediatric PTs, who have been in a therapeutic relationship for at least six months, perceive and experience their relationship with one another? o What role do the perceptions of the caregiver-pediatric PT relationship play in the decision-making process throughout the continuum of care? Significance of the Study CAREGIVER-PEDIATRIC PT RELATIONSHIP 7 Pediatric PTs, as well as other healthcare professionals, could benefit from an enhanced understanding of how to build a relationship with families that will best serve them and the child. Improved insights into the experiences of caregivers can help therapists enhance family-therapist collaboration to meet familys needs and improve long-term outcomes. Definition of Terms Pediatric physical therapist. Pediatric PTs work with children and their families to assist each child in reaching their maximum potential to function independently and to promote active participation in home, school, and community environments. Physical therapists use their expertise in movement and apply clinical reasoning through the process of examination, evaluation, diagnosis, and intervention (APTA, 2009). Caregiver. The individual who identifies themselves as the person who primarily provides care for the child, including involvement with physical therapy (Redquest, Reinders, Bryden, Schneider, & Fletcher, 2015). Special needs. A term applied to individuals with physical disabilities that may range from mild to severe who require more care than an individual without physical disabilities (Redquest et al., 2015). Literature Review Family-centered care should be considered best practice when providing healthcare services, including physical therapy, to children with special needs (Rosenbaum, 2011). The World Health Organizations International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY) provides a framework for understanding the various factors that contribute to a childs situation (World Health Organization, 2007). A childs primary context is within their family unit; therefore, to consider what is best for the child, what CAREGIVER-PEDIATRIC PT RELATIONSHIP 8 is best for the family needs to be addressed by partnering with the family to identify what is important to them (Rosenbaum, 2011). An important element of family-centered care is collaboration (An et al., 2015), which is dependent upon the relationship between the caregiver and the PT. When collaboration takes place between the family and the pediatric PT, parents confidence in parenting and caring for their child with special needs increases (An et al., 2015). The process of shared decision-making and open communication--hallmarks of collaboration--also decreases parent stress, improves functional outcomes, and improves family satisfaction with healthcare services (An et al., 2015; Broggi & Sabatelli, 2010; Hkstad, et al., 2016). A power imbalance naturally exists in a healthcare provider-patient/family relationship; one reason collaboration is effective may be due to its role in equalizing this imbalance and making the care more focused on the familys needs (O'Neil, Palisano, & Westcott, 2001; Peplow & Carpenter, 2013). Parents have also expressed that feeling a sense of connection with their childs therapist strongly influences the process of therapy itself (Piggot, Paterson, & Hocking, 2002). For example, a parent in one study reported that the relationship between the physio and the child and the parent is central to absolutely everything [in terms of managing cerebral palsy] (Peplow & Carpenter, 2013, p. 292). Another reason that a supportive, collaborative relationship may be effective is because it meets the familys need for social support. Parents of children with special needs often feel socially isolated (Caicedo, 2014; Redquest et al., 2015); they may not get out of the house as often as their peers and may not have someone readily available with whom they can discuss their child. Parents have expressed wanting support from their healthcare professionals (Chan et al., 2005); parents with a support system feel less stressed and burdened (Daudji et al., 2011). Pediatric PTs have identified that one role of a PT is to be a resource and provide support for CAREGIVER-PEDIATRIC PT RELATIONSHIP 9 families, ranking this higher than roles such as preventing deformity and promoting normal development (Dule, Korner, Williams, & Carter, 1999). More current research is needed to understand more about how PTs view their role as a support system for families. Collaboration has been identified as important to therapists, but implementing such collaboration can be challenging (LaForme Fiss, McCoy, Chiarello, & Move & Play Study Team, 2012; ONeil et al., 2001; Young, Moffett, Jackson, & McNulty, 2006). This is in part due to limited research on specific processes or strategies to promote collaboration (An et al., 2015; Darrah, Wiart, Magill-Evans, Ray, & Andersen, 2012). Pediatric PTs express a positive attitude regarding collaboration, but many do not understand how best to include it in their practice (An et al., 2015). Collaboration and how it manifests may differ among therapeutic approaches and models of care (Dirks & Hadders-Algra, 2011), which could explain why families and providers are uncertain how best to develop a working, collaborative relationship. For example, according to the Individuals with Disabilities Education Act (IDEA), Part C, which provides early interventions services, a coaching model is ideal. With this model, therapists assist caregivers in carrying out interventions and provide feedback as necessary (Friedman, Woods, & Salisbury, 2012). This model of therapy provision is wholly dependent upon a relationship between the caregiver and therapist that is supportive, collaborative, and built on trust and open communication (Rush, Shelden, & Hanft, 2003). Additionally, family-therapist relationships in the early intervention setting that are perceived as collaborative by the parents may positively influence outcomes (Broggi & Sabatelli, 2010). Another example of how the family-therapist relationship (including collaboration) may differ by setting is that of school-based therapy. IDEA mandates that children with disabilities be CAREGIVER-PEDIATRIC PT RELATIONSHIP 10 provided PT if such services assist the child in meeting their educational goals (IDEA, 2004). IDEA also requires that parents be involved in the process (IDEA, 2004), but it is often unclear how best to facilitate a parent-caregiver relationship in this setting, which can be complicated due to a variety of factors such as miscommunications and misconceptions about the nature of school-based therapy (Holt, Kuperstein, & Effgen, 2015). A model of collaboration, such as the coaching seen in early intervention is not applicable to school-based therapy because family members are not generally present during therapy sessions, since they take place at school. Hospital-based pediatric PTs may take yet a different approach, implementing more of a medical model of care that tends to be more focused on addressing immediate physical needs and limitations of the child (Ideishi, O'Neil, Chiarello, & Nixon-Cave, 2010). There may also be confusion about the role of the family in this setting (Tecklin, 2015). However, a family-centered approach highlighting good communication and consideration of the familys needs is considered best practice in a hospital setting as it is in other settings (APTA, 2013). The caregiver-PT relationship may need to differ depending upon the setting in which care is delivered. The variations inherent in different settings highlight the need for an enhanced understanding of the pediatric PT-caregiver relationship, so as to meet the unique needs not only of each family, but also of each setting. The process of collaboration may also be limited in effectiveness if parents do not adequately understand their role in it. They may instead defer to the PT as an expert and undervalue their role in decision making (Young et al., 2006). An important tenet of familycentered care is that families are the true experts when it comes to their child, family structure, and needs (Dirks & Hadders-Algra, 2011). Currently, collaboration is largely focused on goal planning and implementing treatment plans (An et al., 2015; ien, Fallang, & stensj, 2010). CAREGIVER-PEDIATRIC PT RELATIONSHIP 11 While this does improve therapists ability to tailor treatments to individual family/child needs, it may not provide the family with the support system they desire. Good communication is critical to the family-therapist relationship and to collaboration (An et al., 2015; Nolan, Orlando, & Liptak, 2007; ONeil, Ideishi, Nixon-Cave, & Kohrt, 2008). Providing reassurance, encouragement, and honesty can decrease tension in the provider-parent relationship (Parisien et al., 2016; Peplow & Carpenter, 2013) as can engaging the child and family in general discussions not necessarily related to the childs healthcare (Konstantynowicz, Marcinowicz, Abramowicz, & Abramowicz, 2016). Additionally, communication is the only way to get to know the family and their needs, which must be done to foster a concept of the family at the center of care. Each family is unique and that must be taken in to consideration for all aspects of a course of pediatric PT (Kruijsen-Terpstra et al., 2014). In contrast, poor communication can lead to feelings of parental stress and of feeling judged by the therapist as well as increased difficulty in carrying out home exercise programs (Parisien et al., 2016; Peplow & Carpenter, 2013). Despite the known importance of communication, deficits in this area for therapists and families are not uncommon (LaForme Fiss et al., 2012). Many healthcare providers, including pediatric PTs, cite the lack of time as a reason for the gap in communication (ONeil et al., 2008). Though this may be true, a focus on familycenter care may require reexamining how time and resources are spent (Rosenbaum, 2011). A clearer understanding of the caregiver-PT relationship, including communication styles and preferences, will be beneficial to that process of reexamination. Relationships marked by features identified as critical to family-centered care such as trust, honesty, communication, and collaboration take time to build (Kruijsen-Terpstra et al., 2014). Continuity of care, defined as having the same therapist versus more than one therapist CAREGIVER-PEDIATRIC PT RELATIONSHIP 12 through the course of care, has been linked to patient satisfaction and trust in adult patients (Beattie, Dowda, Turner, Michener, & Nelson, 2005). Caregivers of medically complex children have reported the feeling that a prolonged relationship with the same providers results in better outcomes, largely because it translates to a better understanding of the child (Chan et al., 2005; Miller et al., 2009), though this has not been studied specifically with regard to the caregiverpediatric PT relationship. The role the length of the caregiver-pediatric PT relationship plays is not well understood and further research is needed. The concept of the family-therapist relationship has been explored in various studies throughout the past 25 years, and its role in the provision of rehabilitation services has evolved (Dirks & Hadders-Algra, 2011). However, it is often a minor aspect of a study with a larger or different focus, such as the burden of care experienced by caregivers of medically complex children (Caicedo, 2014), therapists perspectives on care coordination (Ideishi et al., 2010), or caregiver views on their childs activity and participation levels (Chan et al., 2005). Current studies do not fully explore the therapist-caregiver relationship nor is any practical guidance offered. Some studies explore specific characteristics such as trust, confidence, and respect, but use of a survey format limits the researchers ability to gain deeper knowledge on the topic from the caregivers or PTs perspective (Broggi & Sabatelli, 2010; Chan, et al., 2005; LaForme Fiss et al., 2012; ONeil et al., 2001). Other studies have identified pertinent elements of the physical therapist-patient relationship, such as trust and feelings of bonding, but were conducted with adult physical therapy patients, not children and families (Ambady et al., 2002; Hall, Ferreira, Maher, Latimer & Ferreira, 2010). Qualitative studies that explore the family-therapist relationship have been conducted, revealing helpful information such as how caregivers seek emotional and social support from CAREGIVER-PEDIATRIC PT RELATIONSHIP 13 their childs therapist (Daudji et al., 2011; Hinojosa, 1990; Ideishi et al., 2010; ONeil et al., 2008). For some families, the childs therapist may be viewed as a friend, advocate, mentor, or part of the family (Hinojosa, 1990; Washington & Schwartz, 1996), but the characteristics of the relationship that were associated with these feelings have not been fully explored nor has more current research been conducted. Given this, important questions remain, such as whether or not caregivers want or need to have a personal relationship (i.e., social involvement, friendship) with their childs therapist and what features of the relationship make it more or less difficult to engage in sensitive or difficult conversations. There are aspects of pediatric physical therapy that lend themselves to building relationships with patients and families. As mentioned, continuity of care is a model common in pediatric rehabilitation; pediatric PTs often see their patients for years at a time, which can be a ready-made foundation for developing a relationship. Communication, in some form, has to take place between the caregiver and therapist as a part of pediatric physical therapy because the patient, a child, cannot be responsible for many components of care, including making decisions. It is clear from the literature that the PT-caregiver relationship is vital for a variety of reasons. What is less clear is how caregivers and pediatric PTs perceive their relationship, both as it is and how they might desire it to be. Therapists value family-centered care, but this does not always translate into practice (Dirks & Hadders-Algra, 2011). Perhaps a better understanding of the nature of the relationship between a caregiver and their childs PT can provide insight in to ways to make family-centered care common practice, not just an idea. Method Study Design CAREGIVER-PEDIATRIC PT RELATIONSHIP 14 A qualitative case study methodology was used, which primarily aligns with the concept that reality is constructed by individuals interacting with their social worlds (Merriam, 1998, p. 6). This study focused on the lived experience of caregivers and pediatric physical therapists (PT) who represented a bounded case. A bounded case has specific parameters such as place or time, but also can be broad enough to include any phenomenon that occurs within that bounded context (Merriam, 1998). The relationship between a caregiver of a child with special needs and the childs pediatric PT qualifies as both a phenomenon and a situation that has boundaries. Additionally, it is helpful for the case to be one that is in progress so that information can be gathered in real-time (Creswell, 2013). A holistic case study approach is ideal for this line of inquiry as it allows the exploration of a real, in-progress event (Yazan, 2015; Yin, 2014) which in this study, was the PT-caregiver relationship. Data collection took place from January 2018 to August 2018. Prior to participant recruitment, the study was approved by the Institutional Review Board at The University of Indianapolis. Participants Purposeful sampling was used throughout this study, which allowed the researcher to use best judgment to determine if the potential participants fit the criteria and needs of the study (Creswell, 2013; Portney & Watkins, 2009). All participants met the studys inclusion criteria and were willing to openly and honestly share their thoughts and feelings (Portney & Watkins, 2009; Seidman, 2013). Convenience sampling was also used; the researcher used known PT contacts to initiate recruitment. Participants were categorized as either a caregiver or a pediatric PT. A caregiver in this study was defined as someone who has primary decision making responsibilities for a child (ages CAREGIVER-PEDIATRIC PT RELATIONSHIP 15 birth to 21 years) currently receiving physical therapy services at the time of the study for any diagnosis and who had the most direct involvement in their childs physical therapy. Participants self-identified their role as the primary caregiver, which was confirmed in the interview. For this study, a pediatric PT could participate if they were a licensed, practicing physical therapist who has been engaged in a therapeutic relationship with the caregiver participant and their child for at least six months. Exclusion criteria included the presence of any cognitive deficits that would prevent a participant from being able to provide consent and answer a series of questions in an interview format and the inability to speak fluent English, since the interviews were conducted only in English. For this study, each case was comprised of one caregiver and one pediatric PT. A total of five cases equaling 10 participants were involved in this study. This met the targeted number of participants allowing themes to be developed within and across cases without having so many cases that the amount of detail has to be limited (Creswell, 2013). Procedures Each caregiver and pediatric PT within a dyad engaged in separate, semi-structured, indepth interviews. One-on-one interviews allowed for in-depth exploration of each participants experience; each person could tell their story, which resulted in a compelling way to gain insight into important issues that otherwise might go unnoted (Seidman, 2013). Interviews were conducted either in person or via phone call, selected at the participants convenience. Recruitment. To initiate recruitment, the primary researcher contacted local pediatric PTs from a variety of settings such as outpatient clinics, hospitals, and home health agencies by sending a recruitment email (Appendix A). After this initial stage of recruiting did not yield any CAREGIVER-PEDIATRIC PT RELATIONSHIP 16 interested participants, the email was sent to the listserv for the Academy of Pediatric Physical Therapy of the American Physical Therapy Association as well as distributed to an internet message board for parents of children with special needs. The addition of these recruitment methods resulted in eight individuals responding with interest. The primary researcher contacted all those who expressed interest to explain more about the study and to answer any questions. Ultimately, two caregivers and three pediatric PTs agreed to be in the study. The caregivers contacted their childs PT to discuss the study and ask them to participate. The PTs chose a caregiver of a current patient to participate. The primary researcher then followed up with all potential participants to answer any questions, confirm willingness to participate, obtain consent, and schedule interviews; this yielded a total of 10 participants in five dyads. The other three individuals who initially expressed interest did not respond after repeated attempts to engage them by the primary researcher. Informed consent. Prior to initiation of the interview, each participant signed a written informed consent document (see Appendix B). The written informed consent document fully explained the purpose of the study and the procedures that would take place (Portney & Watkins, 2009), including how long the interviews may last and the participants right to stop the interview at any time and/or request that parts of the transcript not be used. Risks and benefits of participation were clearly outlined. The consent form was emailed to each participant prior to scheduling an interview, to allow adequate time for the individual to consider consent and for any questions to be addressed prior to the initiation of an interview. Prior to the start of the interview, key components of the informed consent were discussed with each participant; questions and concerns were addressed as needed and then each participant signed the informed consent document. CAREGIVER-PEDIATRIC PT RELATIONSHIP 17 Data Collection Process. Interviews were conducted either face-to-face or via telephone with each participant and primary researcher. Face-to-face interviews provided the most interaction between interviewer and interviewee, including nonverbal communication (Creswell, 2013), but telephone interviews were conducted when participants could not engage in an inperson interview (e.g., lived in a different state than the primary researcher). Interviews were conducted at a time and in a place convenient to the participant and were audio recorded using a digital recorder. Ideally, the interview location should be quiet and where the interview process will not be disturbed, and the participant will not be distracted (Creswell, 2013). However, in reality, some interviews took place in areas with distractions (e.g., caregivers home with children, coffee shop) though all attempts were made to mitigate them. Interviews ended when no new information was revealed; the length of interviews ranged from 21 to 30 minutes. Interviews were conducted using a semi-structured interview guide (see Appendix C) comprised of general, open-ended questions designed to facilitate discussion (Creswell, 2013). The interview guide was constructed by the primary researcher and refined based on input from three additional experienced researchers. Participants were also asked general background and demographic information (see Appendix D). The primary researcher was a pediatric therapist with over 13 years of experience, which could introduce potential bias to the studys data collection and/or analysis process. Accordingly, efforts were made to limit any potential bias through the use of field notes before, during, and after the interviews. Through the use of the field notes, the researcher recorded any thoughts or feelings that arose during the process in order to maintain credibility and confirmability and thus enhance the studys overall trustworthiness (Henderson & Rheault, 2004). Data Management & Analysis CAREGIVER-PEDIATRIC PT RELATIONSHIP 18 Interviews were transcribed verbatim by the researcher by hand. Transcribing the recordings verbatim allowed the researcher to get the fullest picture of the interview and the context in which answers were given. This allowed for more accurate coding of the data (Seidman, 2013). The data analysis software Dedoose (version 8.1.8) was used to store the electronic files of the audio recordings as well as the typed transcripts, which were de-identified. Each participant received a copy of their interviews transcript, with instructions to review it and if needed, to correct any errors, add information, or remove information. One participant requested a specific comment she made not be used. Another inquired about some content that did not seem to make sense, so the researcher reviewed the recording and the transcript to confirm, after which the participant had no additional concerns. This process, referred to as member checking, enhances the studys credibility by ensuring the data is as accurate as possible (Henderson & Rheault, 2004; Seidman, 2013). The transcripts were thoroughly reviewed multiple times by the primary researcher. During the initial review, memoing was used to record the reviewers initial interpretations and perceptions about the data (Creswell, 2013); this was done through the Dedoose data management software. In the second review, key information related to the research question was identified and assigned individual codes, a process referred to as open coding. The number of codes varied among transcripts, depending upon the breadth of data provided. These codes were single words or phrases; some were exact words a participant used. At this stage, transcript excerpts for participants A1 and A2 were provided to a secondary researcher who has extensive experience in qualitative methodology. The secondary researcher reviewed and coded the excerpts independent from the primary researcher. Afterward, the primary and secondary researcher met via video conference to discuss codes. Though the two CAREGIVER-PEDIATRIC PT RELATIONSHIP 19 sets of codes were not identical, both agreed that the codes were very similar in nature and captured the essence of the transcript excerpts. Following open coding, a process known as axial coding was conducted to categorize the codes and establish relationships between them. Axial coding is a second-cycle coding method in which the researcher determines which codes are most relevant and eliminates any redundancies that may have come about from the first cycle of coding (Saldana, 2016). To manage the codes that accumulated, a codebook, within Dedoose, was used. The codebook contained a list of the codes, descriptions, and sample data for reference as recommended (Saldana, 2016). Throughout the coding process, the concepts developed were compared to one another to explore the similarities and differences. This constant comparative method allowed for better refinement of the codes and identification of patterns in the data (Boeije, 2002). After open and axial coding were completed, the codes were combined into categories representing themes that emerged (Creswell, 2013). For further assurance that results of the coding are trustworthy, a third researcher with extensive experience in qualitative study methodology, reviewed the codebook. Following the third researchers review, a discussion took place with the primary researcher regarding themes. The primary researcher developed themes and further refined them after this discussion. This process of triangulation helps verify the credibility of the results (Henderson & Rheault, 2004). During the processes described above, the researcher maintained an audit trail in the Dedoose data management software and in hardcopy form. An audit trail provides details of the entire research process, so the decision-making process and actions made throughout the study can be clearly followed. The audit trail outlined specifics steps of the study such as the initial CAREGIVER-PEDIATRIC PT RELATIONSHIP 20 proposal, participant selection, how data were analyzed, and previously-mentioned field notes that document the researchers thoughts and potential biases (Ryan-Nicholls & Will, 2009). An audit trail makes it more likely for another researcher to be able to determine how the codes and themes were generated, thus making the study more trustworthy (Henderson & Rheault, 2004). Results The five cases (10 total participants) in this study are described in Table 1. Characteristics of the patients (children receiving PT) are listed in Table 2. Where names are present in quotations, pseudonyms were used to protect privacy. Additionally, codes were used to protect privacy of participants. All caregivers who participated were mothers. All PT participants self-identified as pediatric therapists and had years of experience ranging from 15 to 30 (mean 24.8 years). The settings in which the child received PT were either in the home or in the clinic, with one participants child receiving PT both in the home and at an outpatient clinic. The length of the caregiver PT relationship ranged from 1 to 9 years (mean 3.3 years). Interviews ranged from lasting 21 to 30 minutes. Four interviews were conducted face-to-face, and six were conducted on the phone. Three major themes emerged: PT as a guide, social and emotional connection, and professional qualities and performance. These major themes combined with subthemes help create a picture of the PT-caregiver relationships in this series of case studies (Figure 1). Theme 1: PT as a Guide The role of the PT as a guide surfaced as an overarching theme, both within and across all cases. For these participants, a guide is someone who can help direct the way to a specific path or purpose by providing direction, assistance, advice, and leadership and does so on the basis of trust. Interviews with participants indicate PTs serve in this capacity in a variety of ways. One CAREGIVER-PEDIATRIC PT RELATIONSHIP 21 participant said, She [PT], you know, helps to make sure everything is going as we want, um, makes sure that we have everything we need and kind of guides us. For the PT to serve as a guide for a family, each must trust and rely on one another. Otherwise, the PTs thoughts and opinions would not be relevant to the family, and the PT could not rely on the family to provide an honest exchange of information. One PT participant said, I think that trust bond automatically kinda happens. It's something--they're putting their child in your care, so automatically I'm trusting you. And then, how you manage their child further builds that trust, or doesn't go anywhere. Another PT said: I think trust is hugeI think that she's [patients mother] done a great job of just letting me know how much she trusts me and also feels that my opinions and my perspective on things do somewhat drive some of his care. Families and therapists in this study reported seeking guidance from their PT about a variety of issues. Some of the matters discussed were directly related to physical therapy such as decisions about assistive devices, braces, and adjunct treatments such as Botox injections. Other topics discussed were related to health insurance, other medical appointments and decisions, other therapy disciplines, behavior management, and social situations for the child such as school, family, and community outings. One reason families may seek guidance from their PT on such a wide range of topics seems to be due to the relationship that is built, usually over time. Since PTs often work with children and families for extended periods of time, which ranged from 1 to 9 years in this study, the PT reaches a high level of familiarity with the child and the family. This familiarity is not just diagnosis or disability-related but also encompasses an understanding of the familys dynamics, their likes and dislikes, and their priorities. This close, CAREGIVER-PEDIATRIC PT RELATIONSHIP 22 intimate knowledge puts a PT in a unique position to guide a family through many processes and decisions. One participant stated: PT A2: Um, I think the fact that mom turns to me for a lot of advice on different things that ... I wouldn't say they're outside of the scope of PT practice, but kind of looking at how the gross motor and just his movement and his diagnosis in general affects his day to day living. And I feel like as the PT I definitely get to know him a little bit more than even some of his specialists that he would see. Additionally, one caregiver reported: Caregiver H1: And my husband says to me all the time youre the only other person in the world who understands how I feel about it and how much we love this child of ours and how much, how special he isand I have to tell you that I think our physical therapist is a close second in there, about understanding all of thatshe knows what a great kid he is, she knows what he came fromand sees how far hes come. Caregiver F1 indicated that: Every doctor has a piece of the puzzle and our pediatrician is great, but really Allie [PT] and I are the only ones that have the big picture and have the full picture, and she is my sounding board for almost everything and anything because she knows Beth as good as I do. Additionally, PT H2 stated: And, and that, I feel fortunate to be a pediatric PT cause I, you know, I think we have the capability of building relationships a lot more than a lot of other specialties or professions even, um, because we do really get to know the families. CAREGIVER-PEDIATRIC PT RELATIONSHIP 23 The ways in which a PT guides a family expands to many domains, and while each family has unique concerns and challenges, similarities could be seen across the cases in this study. Two additional themes emerged to help identify what factors drive the PT-caregiver relationship forward and support their role as a guide. Theme 2: Social and Emotional Connection There are elements of the social and emotional domain that become a part of the PTcaregiver relationship. Social. At times, a social or personal relationship forms between caregivers and PTs. PTs and caregivers often connect over their shared interest of and concern for the child receiving therapy. One PT stated: PT F2: I think it's a bond because you are connecting over this child and you, I think, that the parents especially appreciate you because you, you know, they appreciate your expertise, they know that you kind of get it, because they, um, because I've been doing this for a long time... They also sometimes connect over mutual interests such as hobbies, personal values, and mutual acquaintances, which helps forge a bond. As Caregiver A1 indicated: I like to have a personal relationship with them. You know, I share...a lot of our stuff with them, you know. I don't, for instance, share stuff like, okay my relationship with my husband or anything like that, but Charlie, being my child, is the biggest part of my life, so they know an intimate part of my life. Additionally, when a PT sees a child once a week for a course of physical therapy that often lasts years, a social connection can form as a natural byproduct. Caregivers and PTs often CAREGIVER-PEDIATRIC PT RELATIONSHIP 24 engage in social talk (conversation not directly related to PT) in the natural course of the PTchild-family relationship. One participant stated, But it has strengthened our bond in the fact that I knowI know more about her and she knows more about me, which just connects us on a morethat need for our relationship and a relational level (Caregiver F1). This seems to be somewhat magnified when the PT treats the child in the home, adding to the familiarity of the relationship. As one participant put it, So, you know, with Dana, it started off as professional and I think being in the home it kind of creates that atmosphere... Um it makes it a little bit easier to establish that friendship (Caregiver B1). PTs and families often engage in social talk out of politeness, exchanging pleasantries about their day or social activities. Um, yes, sometimes they're social [conversations], you know, just like how was your Mother's Day? or that kind of thing (Caregiver B1). At other times, conversations may turn social out of shared interests that were either present before the relationship began or have been built since it started. One PT expressed the following: I also had a son, um, our son, two and a half years ago suffered a severe traumatic brain injury, so I think she [mom] gets it from that point, that I, you know, I am a parent myself and I have experienced being on the patient side of thingsand I think it helps her to be able to talk about those kind of things because not only have I been a parent, I have worked with families that have children with disabilities for so long that I have a lot of perspective, so, I think it goes way beyond just what we do in the clinic Social talk also occurs because it may be indirectly related to PT. For example, a caregiver may talk to their PT about an upcoming vacation; this could be indirectly related to PT as the family may have questions or seek advice on how best to navigate a vacation with their child who may have different mobility or sensory needs. In turn, PTs may discuss social CAREGIVER-PEDIATRIC PT RELATIONSHIP 25 activities as a byproduct of keeping the family informed, such as needing to cancel or rearrange an appointment due to an illness or family event. Caregivers and PTs did sometimes refer to their relationship as a friendship, while also indicating this was secondary in priority to the childs PT. A friendship may form over the course of the PT-caregiver relationship, but PTs and caregivers can have a meaningful, successful relationship as part of the childs life without rising to the level of friendship. According to Caregiver B1: All that matters is that they're a good therapist. A lot of our therapists we've had for years and you do develop a friendship, but we don't initiate that from the beginning. I would much rather someone be our daughter's therapist than be our friend if there is an either or... Emotional. The PT-caregiver relationship often involves an element of emotional support at various times such as during stages that involve the diagnostic process, difficult treatment decisions, and celebrating the childs successes. And I got a very tearful conversation. What have we done? Is this going to last forever? Am I making the right choice (PT F2)? And, you know, I, it was so exciting cause he walked for the first time in our session and it was like we all cried (PT H2). One participant stated: Caregiver H1: So, um, for us, it was just a really emotional time, you know, we were dealing with this baby that we were in love with and um, we were concerned about what was to come for him she cares about the emotional side of it for us, too. Also, the PT can offer a safe, supportive space for the caregiver to express ideas and emotions, while also offering validation. I just listened and offered them a space for them to cryIt was okay to cry, and theres no judgement therereassuring, I know this hurts (PT F2). CAREGIVER-PEDIATRIC PT RELATIONSHIP 26 when she [mom] has questions and ideas, I feel like Im telling her oh yeah, those are great ideasyoure right on. I reiterate that shes doing all the right things for her daughter (PT B2). I might be the only person that's going to tell them, hey, you're doing a good job (PT F2). While not a primary focus of pediatric physical therapy, the role of social and emotional connections should not be ignored. For caregivers and PTs in this study, this type of support can serve to move the relationship forward in a positive way and set the stage for other important elements of the therapeutic process such as treatment planning and shared decision making. It would be harder for me to take advice from them if my personality didn't match as well (Caregiver F1). Additionally, one PT participant described the following: PT H2: And, um, she [patients mom] just said, I just needed to hear there was hope. But I was glad that she felt comfortable enough to say, you know, I just need to know that theres hope. Im glad she was able to express that. And you know, she says, looking back, she said she knew that day that we were a good match. Theme 3: Professional Qualities and Performance Within each case as well across all cases, a high priority for both the caregiver and the PT was how well the PT carried out the various professional aspects of the relationship. Skill as PT. For caregivers, having a skilled, knowledgeable therapist who engaged well with their child was of utmost importance. As one participant stated: Caregiver A1: My biggest priority is Charlie and so my biggest thing about the PT is thatso, my biggest thing is just that they're, um...skill and they're kind of like, uh, they're good at what they do, you know what I mean? It's not so much--my focus is not so much on my personal communication with her and everything, like building a personal relationship. Um, it's just, uh, I want him to have good therapists. CAREGIVER-PEDIATRIC PT RELATIONSHIP 27 While the lack of a personal relationship or friendship was not mentioned as a reason for selecting or keeping a PT, a lack of skill or knowledge as a PT was important enough to caregivers that it would cause them to pursue a new therapist. One caregiver conveyed the thought in this way: Caregiver F1: I think the other clicking that happened between Allie and I was because I could tell she had a deep, vast knowledge base and had experience that came through in a level of confidence and just in a level of ... I could tell outside of our one hour she had done research and she had a plan for what we were going to do the next time that I didn't necessarily feel like had been coming from the previous therapist. Collaboration. The caregiver-PT relationship was often described in terms such as a partnership, teamwork, and collaboration. Establishing open, honest lines of communication is an essential component to collaboration. Doing so will help the PT understand what is most important for the child and family. As one participant indicated: PT A2: allowing them to also have a role in guiding their child's care so that its--if it's not important for them to learn to do a balance beam, then that's not something we're necessarily gonna focus on, but when she tells me what's important I'll say, "Well here's what we're gonna do to try to get there." So, I think that's huge too, is giving them a voice. Often, this type of communication ventures into different aspects of the familys life that are not directly related to PT. However, participating in these types of conversations can help the PT gain a better understanding of the family and the childs role in it. One of the PT participants said: CAREGIVER-PEDIATRIC PT RELATIONSHIP 28 B2: Um...I think it's part of getting a whole picture of the family...um...I think it's important to engage, like, so that I can better support the family if I know-oh they go to grandparents, or swimming...so, it's part of getting a good picture of the whole family and supporting the whole family. Shared decision-making. Another component of collaboration that was important to both caregivers and PTs was that of a shared role in decision-making. When decisions needed to be made regarding the childs care, caregivers and PTs engaged in dialogue during which the caregiver could ask questions and the PT offered advice, based on experience and research. Conversations may be initiated by either the parent or the PT, depending on the situation and the topic of discussion. After an exchange of information and ideas, the caregivers and their family make the decisions. These are the options and this is what I would recommend, but you know, you have to figure out what works for you (PT H2). Caregiver F1: I think she's done a good job of empowering me to make sure-to remind me that I can say no, but she always will give me her opinion and will always remind me that I can-I can disagree with whatever she's saying, you know, she is very clear that it is her opinion, just like the doctors have an opinionEducation. Another relevant area of the PT as a professional that was important to both caregivers and PTs was that of education. Caregivers valued the education their PT provides them. This can take on many forms such as educating the caregiver about their childs condition or providing information based on past experiences and available research. As Caregiver B1 reported: CAREGIVER-PEDIATRIC PT RELATIONSHIP 29 We didn't understand body awareness and how that's not just a sensory processing disorder but you know how that goes in to her low muscle tone so her educating us has been really crucial for us understanding this side of our daughter that we didn't before. Additionally, one participant stated: PT H2: I think, um, you know I always think its a fine balance of educating and kind of havinghaving knowledge, um, and never coming across like Im the expert and you have to do what I say, you know Progress in physical therapy. In addition to the skill of providing physical therapy the therapist brings, the caregiver-PT relationship itself could have an influence on how the child progresses in therapy. Caregiver A1 said: But I think maybe if I didn't have a good relationship with her maybe that would inhibit his progressI think that maybe if it was a bad relationship then he wouldn't get as much out of it, you know, because maybe our own tension would hinder that. Therapists and caregivers recognize that therapy is limited to once or twice per week and progress is really made when activities are carried over in the times between therapy sessions. Having a relationship built on mutual goals, trust, and good communication can help a caregiver better understand how best to do this, therefore furthering the childs progress. I think though that, um, the relationship that we have with her has for sure, um, it has benefited my son tremendously (PT H1). There was a considerable amount of consistency within each case. The caregiver and therapist often shared the same story, though interviews were done separately. They each described their relationship in similar terms. The themes and sub-themes arrived at through the coding process are a good representation of both caregivers and PTs experiences. CAREGIVER-PEDIATRIC PT RELATIONSHIP 30 Discussion When a child begins receiving physical therapy, a relationship is established between the child and the PT as well as the PT and the caregiver(s) of the child. A child involved in physical therapy cannot access it on their own, nor can they make decisions on their own behalf. Therefore, a relationship with the caregiver and PT is inevitable. It is up to the PT and the childs family to determine aspects of their relationship that will best serve the family and child. There is no one right way for PTs and caregivers to interact with one another, though best practices, such as family-centered care, have been identified and recommended for practice. This exploration of five PT-caregiver dyads revealed themes of guidance, social and emotional connection, and professional PT qualities; these concepts may help all parties reflect on and build this critical relationship. Both caregivers and PTs in this study identified numerous ways in which the PT serves as a guide for the family as they navigate the process of caring for a child with special needs. A past study found that pediatric PTs highly ranked their role as a resource to the families they serve (Dule et al., 1999), but no specifics were provided as to what this entailed; participants simply ranked various items on a scale as part of a questionnaire. One qualitative study on mothers perceptions of their children with disabilities found that rehabilitation services helped to mitigate mothers perceived suffering and burden of care (Daudji et al., 2011, p. 517), though ways in which this occurred were not delineated. The findings of this current study indicate that supporting a family is done in many ways, including giving information and advice on a wide variety of topics, providing education on their child, and sharing in the decision-making process. The ability to do this is enhanced by the PTs familiarity and time spent with the child and family, characteristics that were identified as critical to the provider-caregiver relationship in a CAREGIVER-PEDIATRIC PT RELATIONSHIP 31 study on the perspectives of parents with chronically ill children (Miller et al., 2009). Other medical practitioners acknowledge they often lack the time to address the familys needs effectively (ONeil et al., 2008). The finding that an emotional and social connection between a caregiver and their childs PT is important to caregivers aligns with other studies whose results indicated social and emotional support can improve care (Ideishi et al., 2010), lead to deeper relationships (Hinojosa, 1990), and help validate the caregivers abilities (ONeil et al., 2008). However, this current study expanded on the idea more fully than in past studies. The caregiver-PT relationship has many qualities in common with those of a friendship such as trust, open and honest communication, and shared interests. Though a friendship may form between caregiver and PT, it is not a primary focus for either party. The role of discussions related to social topics is an important one revealed in this study. It can be a useful way for the caregiver and PT to get to know each other for the purpose of better serving the child receiving therapy. It also may help to mitigate the perception of a power differential in a healthcare provider-patient/family dynamic. This study confirmed that caregivers value being validated and also revealed that PTs actively work to provide such validation to caregivers, which may also serve to strengthen the relationship. This study highlighted the fact that for a caregiver whose child is involved in physical therapy, the most important role of the PT is to demonstrate skills, knowledge, and effectiveness throughout the course of their childs care. Parents in a study about their perception of physical therapy in a pediatric critical care unit indicated a similar feeling; the PTs role is to help their child improve (Parisien et al., 2016). To that end, this study brought to a light a concept not explored before in other studies, which is that the relationship between the caregiver and the PT CAREGIVER-PEDIATRIC PT RELATIONSHIP 32 could have a direct effect on the childs progress toward goals in therapy. If the groundwork of communication, trust, and partnership is not present, a caregiver may be less likely to take advice from their PT or carry over the PT plan of care in the home (Navarro et al., 2005). As a result, the child may not progress toward goals as quickly as if the caregiver and PT had a good working relationship. Family centered care is considered best practices for pediatric physical therapy (Rosenbaum, 2011) and is among the recommended core competencies in pediatric physical therapy education (Rapport et al., 2014). Past studies indicate that though therapists understand and value family-centered care, it is difficult to implement it in every day practice (Dirks & Hadders-Algra, 2011). However, both the caregivers and PTs in this study described the presence of many family-centered characteristics that were woven in to the course of physical therapy. This included being mindful of the childs role in the family unit, understanding what the family values when developing goals, and making decisions as partners. The themes identified in this study of guidance, emotional and social connection, and professional qualities and performance reveal how pediatric PTs are engaging in family-centered care and that caregivers recognize and value these attributes in the caregiver-PT relationship. Limitations This, like any study, has its limitations. There is a risk of researcher bias in this study since the primary researcher is a pediatric physical therapist. However, strategies were employed to mitigate bias during data collection and analysis through tools such as field journaling, an audit trail, and triangulation. Additionally, the primary researcher was not the therapist for any families included in this study. Using a case study methodology required a bounded unit--the caregiver and PT--to participate. Recruitment allowed for either the caregiver or PT to initiate CAREGIVER-PEDIATRIC PT RELATIONSHIP 33 contact and then recruit the other participant. It could be that this study only represents caregiverPT dyads who have close relationships since they both needed to feel comfortable participating in the study and discussing their shared relationship. Implications for Practice and Future Research Even with the stated limitations, this study serves to highlight salient aspects of the caregiver-pediatric physical therapist relationship. While the study is representative only of the bounded cases that were explored, the insight provided can be useful for caregivers and pediatric physical therapists as they navigate their relationship. The need for guidance, an emotional and social connection, and the importance of the PTs professional performance are all mirrors in which caregivers and pediatric PTs can look to for reflection of their own relationship. While not setting these conditions as the patterns by which all relationships should conform, these insights could be a helpful way to start the conversation between caregiver and PT to determine what characteristics of their relationship are most meaningful to them and in what areas they may want to see improvement. Future research into the caregiver-pediatric PT relationship could expand on these findings. A well-designed survey given to caregivers and pediatric PTs could provide more data on the relationship and could represent a larger sample of participants. For example, a survey could help objectively quantify if any particular factors seemed to influence the caregiver-PT relationship such as the race, gender, education level of any of involved parties or the age or diagnosis of the child involved in physical therapy. Additionally, a longitudinal study of the caregiver-PT relationship could help explore the factor of time and capture aspects of the relationship at more than just one point in time as this current study did. For example, participants could be given a survey at the beginning of their CAREGIVER-PEDIATRIC PT RELATIONSHIP 34 involvement with a pediatric PT and then again at other points in time. This would allow for direct comparison of the relationship over time. This study indicated that the length of the relationship was part of the reason PTs came to know the child and family well, but a quantitative examination of this could be helpful. One concept that emerged from this study was the idea that the caregiver-PT relationship could play a role in the childs outcomes with regard to improving function and independence. These outcomes are measured in a variety of ways such as through the PTs observation, progress toward specific goals, and performance on standardized tests. A future study that compared objective ratings of the caregiver-PT relationship (such as from a survey) with measured outcomes could help determine if the relationship does directly have an influence on the childs outcomes. Additionally, future qualitative studies of other types of caregivers (e.g., fathers or foster parents) could be helpful; this studys participants were all mothers, just by nature of who volunteered to be part of the study. Another qualitative study that could be beneficial is one in which caregiver are asked to share experiences specifically regarding any negative experiences they have had with their childs physical therapist. It could be helpful to find out any specific attributes that cause caregivers to feel the care being provided to them is not family-centered; this information could help create educational sessions or training modules for therapists. The therapists who participated in this study were experienced PTs; a potential qualitative study that might beneficial is one that explores the caregiver-pediatric PT relationship when the PT has five or fewer years of experience as it is possible the views of a novice PT may differ from those of with more experience. Conclusion CAREGIVER-PEDIATRIC PT RELATIONSHIP 35 A pediatric PT and caregiver of a child who receives PT must form a relationship so that the child can receive optimal care. The exact nature of this relationship is unique to each family, but guiding principles can be useful to both parties, as it can be difficult to know what to expect from such a relationship. This study provides the knowledge that for the participants interviewed, the caregiver-PT relationship is important; it involves the PT serving as a guide in many ways for a family and often, an emotional and social connection is formed. It is also critical that the PT displays professional characteristics, including being knowledgeable about a variety of topics and being skilled at carrying out physical therapy interventions. The ultimate goal is for the child receiving physical therapy and their family to have their goals and needs met. The relationship with the childs PT plays an important role in that goal. CAREGIVER-PEDIATRIC PT RELATIONSHIP 36 References Ambady, N., Koo, J., Rosenthal, R., & Winograd, C. H. (2002). Physical therapists' nonverbal communication predicts geriatric patients' health outcomes. Psychology and Aging, 17(3), 443-452. doi: 10.1037/0882-7974.17.3.443 American Physical Therapy Association: Section on Pediatrics. (2009). Fact sheet: ABCs of pediatric physical therapy. Retrieved from http://pediatricapta.org/includes/factsheets/pdfs/09%20ABCs%20of%20Ped%20PT.pdf American Physical Therapy Association: Section on Pediatrics. (2012). Fact sheet: Intensity in an outpatient setting for children with chronic conditions. Retrieved from http://pediatricapta.org/includes/fact-sheets/pdfs/12%20Intensity%20of%20Service.pdf American Physical Therapy Association: Section on Pediatrics. (2013). Frequency and duration of physical therapy services in the acute care pediatric setting. Retrieved from https://pediatricapta.org/includes/factsheets/pdfs/PEDS_Factsheet_FrequencyAndDuration.pdf An, M., Palisano, R., Dunst, C., Chiarello, L., Yi, C., & Gracely, E. (2015). Strategies to promote family-professional collaboration: Two case reports. Disability and Rehabilitation, 38(18), 1844-1858. doi: 10.3109/09638288.2015.1107763 Beattie, P., Dowda, M., Turner, C., Michener, L., & Nelson, R. (2005). Longitudinal continuity of care is associated with high patient satisfaction with physical therapy. Physical Therapy, 85(10), 1046-1052. Boeije, H. (2002). A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Quality and Quantity, 36(4), 391-409. doi: 10.1023/A:1020909529486 CAREGIVER-PEDIATRIC PT RELATIONSHIP 37 Broggi, M. B., & Sabatelli, R. (2010). Parental perceptions of the parent-therapist relationship: effects on outcomes of early intervention. Physical and Occupational Therapy in Pediatrics Journal, 30(3), 234-247. doi: 10.3109/01942631003757602 Caicedo, C. (2014). Families with special needs children: Family health, functioning, and care burden. Journal of American Psychiatric Nurses Association, 20(6), 398-407. doi: 10.1177/1078390314561326 Chan, H., Lau, P., Fong, K., Poon, D., & Lam, C. (2005). Neuroimpairment, activity limitation, and participation restriction among children with cerebral palsy in Hong Kong. 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Delivering therapy services for students with high support needs: Perceptions of roles, priorities and best practice. Journal of Intellectual & Developmental Disability, 24(3), 243-263. doi: 10.1080/13668259900034021 Friedman, M., Woods, J., & Salisbury, C. (2012). Caregiver coaching strategies for early intervention providers: Moving toward operational definitions. Infants & Young Children, 25(1), 62-82. doi:10.1097/IYC.0b013e31823d8f12 Graaf, G., Buckley, F., & Skotko, B. (2015). Estimates of the live births, natural losses, and elective terminations with Down Syndrome in the United States. American Journal of Medical Genetics, 167(4), 756-767. doi: 10.1002/ajmg.a.37001 Hkstad, R., Obstfelder, A., & berg, G. (2016). Parents perceptions of primary health care physiotherapy with preterm infants. Qualitative Health Research, 26(10), 1341-1350. doi:10.1177/1049732315608137 CAREGIVER-PEDIATRIC PT RELATIONSHIP 39 Hall, A., Ferreira, P., Maher, C., Latimer, J., & Ferreira, M. (2010). The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical Therapy, (90)8, 1-12. doi: 10.2522/ptj.20090245 Henderson, R., & Rheault, W. (2004). Appraising and incorporating qualitative research in evidence-based practice. Journal of Physical Therapy Education, 18(3), 35-40. Hinojosa, J. (1990). How mothers of preschool children with cerebral palsy perceive occupational and physical therapists and their influence on family life. OTJR: Occupation, Participation and Health, 10(3), 144-162. doi: 10.1177/153944929001000302 Holt, S. L., Kuperstein, J., & Effgen, S. K. (2015). Physical therapists' perceptions of schoolbased practices. Physical & Occupational Therapy in Pediatrics, 35(4), 381-395. doi:10.3109/01942638.2014.978931 Ideishi, R., O'Neil, M., Chiarello, L. & Nixon-Cave, K. (2010). Perspectives of therapist's role in care coordination between medical and early intervention services. 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Comparison of family and therapist perceptions of physical and occupational therapy services provided to young children with cerebral palsy. Physical and Occupational Therapy in Pediatrics Journal, 32(2), 210-226. doi: 10.3109/01942638.2011.619250 Maenner, M., Blumberg, S., Kogan, M., Christensen, D., Yeargin-Allsopp, M., & Schieve, L. (2016). Prevalence of cerebral palsy and intellectual disability among children identified in two U.S. National Surveys, 2011-2013. Annals of Epidemiology, 26(3), 222-226. doi: 10.1016/j.annepidem.2016.01.001 Merriam, S. (1998). Qualitative research and case study applications in education. San Francisco, CA: Jossey-Bass. Miller, A., Condin, C., McKellin, Shaw, N., Klassen, A., & Sheps, S. (2009). Continuity of care for children with complex chronic health conditions: Parents' perspectives. BMC Health Services Research, 9, 242. doi:10.1186/1472-6963-9-242 Navarro, C., Medina-Mirapeix, F., Escolar-Reina, P, Montilla-Herrador, J., Gomez-Arnaldos, F., and Oliveira-Sousa, S. (2015). Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists teaching styles influence adherence: a qualitative study. Journal of Physiotherapy, 61(2), 81-86. doi: 10.1016/j.phys.2015.02.014 Nolan, K. W., Orlando, M., & Liptak, G. S. (2007). Care coordination services for children with special health care needs: are we family-centered yet? Families, Systems, & Health, 25(3), 293-306. doi: 10.1037/1091-7527.25.3.293 CAREGIVER-PEDIATRIC PT RELATIONSHIP 41 ien, I., Fallang, B., & stensj, S. (2010). Goal-setting in paediatric rehabilitation: perceptions of parents and professional. Child: Care, Health & Development, 36(4), 558-565. doi: 10.1111/j.1365-2214.2009.01038.x O'Neil, M. E., Ideishi, R. I., Nixon-Cave, K., & Kohrt, A. (2008). Care coordination between medical and early intervention services: Family and provider perspectives. Families, Systems, & Health, 26(2), 119-134. doi: 10.1037/1091-7527.26.2.119 O'Neil, M., Palisano, R., & Westcott, S. (2001). Relationship of therapists' attitudes, children's motor ability, and parenting stress to mothers' perceptions of therapists' behaviors during early intervention. Physical Therapy, 81(8), 1412-1424. Parisien, R. B., Gillanders, K., Hennessy, E. K., Herterich, L., Saunders, K., Lati, J., . . . O'Brien, K. K. (2016). Experiences of four parents with physical therapy and early mobility of their children in a pediatric critical care unit: A case series. Journal of Pediatric Rehabilitation Medicine, 9(2), 159-168. doi: 10.3233/PRM-160374 Peplow, U. C., & Carpenter, C. (2013). Perceptions of parents of children with cerebral palsy about the relevance of, and adherence to, exercise programs: A qualitative study. Physical and Occupational Therapy in Pediatrics Journal, 33(3), 285-299. doi: 10.3109/01942638.2013.773954 Piggot, J., Paterson, J., & Hocking, C. (2002). Participation in home therapy programs for children with cerebral palsy: A compelling challenge. Qualitative Health Research, 12(8), 1112-1129. doi: 10.1177/104973202129120476 Portney, L. G., & Watkins, M. P. (2009). Foundations of clinical research: Applications to practice (3rd ed.). Upper Saddle River, N.J.: Pearson/Prentice Hall. CAREGIVER-PEDIATRIC PT RELATIONSHIP 42 Rapport, M., Furze, J., Martin, K., Schreiber, J., Dannemiller, L., DiBiasio, P., & Moerchen, V. (2014). Essential competencies in entry-level pediatric physical therapy education. Pediatric Physical Therapy, 26(1), 7-18. doi: 10.1079/PEP.0000000000000003 Redquest, B., Reinders, N., Bryden, P., Schneider, M., & Fletcher, P. (2015). Raising a child with special needs: the perspective of caregivers. Clinical Nurse Specialist CNS, 29(3), E8-E15. doi: 10.1097/NUR.0000000000000122 Rosenbaum, P. (2011). Family and quality of life: Key elements in intervention in children with cerebral palsy. Developmental Medicine & Child Neurology, 53(s4), 68-70. doi:10.1111/j.1469-8749.2011.04068.x Rush, D. D., Shelden, M. L., & Hanft, B. E. (2003). Coaching families and colleagues: A process for collaboration in natural settings. Infants & Young Children: An Interdisciplinary Journal of Early Childhood Intervention, 16(1), 33-47. doi: 10.1097/00001163200301000-00005 Ryan-Nicholls, K., & Will, C. (2009). Rigour in qualitative research: Mechanisms for control. Nurse Researcher, 16(3), 70-85. doi: 10.7748/nr2009.04.16.370.c6947 Saldana, J. (2016). The coding manual for qualitative researchers (3rd ed.). Los Angeles, CA: SAGE Publications. Seidman, I. (2013). Interviewing as qualitative research: A guide for researchers in education and the social sciences (4th ed.). New York, NY: Teachers College Press. Tecklin, J. (2015). Pediatric physical therapy (5th ed.). Baltimore, MD: Lippincott Williams & Wilkins. CAREGIVER-PEDIATRIC PT RELATIONSHIP 43 Washington, K., & Schwartz, I. S. (1996). Maternal perceptions of the effects of physical and occupational therapy services on caregiving competency. Physical and Occupational Therapy in Pediatrics Journal, 16(3), 33-54. World Health Organization. (2007). International classification system of functioning, disability and health: children and youth version. Geneva, Switzerland: WHO Press. Yazan, B. (2015). Three approaches to case study methods in education: Yin, Merriam, and Stake. The Qualitative Report, 20(2), 134-152. Yin, R. (2014). Case study research: Design and methods (5th ed.). Los Angeles, CA: SAGE Publications. Young, B., Moffett, J. K., Jackson, D., & McNulty, A. (2006). Decision-making in communitybased paediatric physiotherapy: A qualitative study of children, parents and practitioners. Health & Social Care in the Community, 14(2), 116-124. doi: 10.1111/j.13652524.2006.00599x Zablotsky, B., Black, L., & Blumberg, S. (2017). Estimated prevalence of children with diagnosed developmental disabilities in the United States, 2014-2016: National health statistics report, number 291. Centers for Disease Control and Prevention. Hyattsville, MD: National Center for Health Statistics. CAREGIVER-PEDIATRIC PT RELATIONSHIP 44 Participant Characteristics Table 1 Participant Characteristics Participant Role Length of Years of PT Relationship Experience Treatment Setting A1 Mother 2 years ----- Home A2 PT --------- 15 Home B1 Mother 3 years ----- Home B2 PT --------- 30 Home D1 Mother 1.5 years ----- D2 PT --------- 23 Clinic F1 Mother 1 year ----- Clinic F2 PT --------- 28 Clinic H1 Mother 9 years ----- Clinic H2 PT --------- 28 Clinic Home and Clinic CAREGIVER-PEDIATRIC PT RELATIONSHIP 45 Patient Characteristics Table 2 Patient Characteristics Caregiver of Patient A1 B1 D1 F1 H1 Current Age of Patient 2 years 7 years 2 years 3 years 9 years Patients Diagnosis Congenital Myasthenic Syndrome Cohen Syndrome Cerebral Palsy Cerebral Palsy Central Core Myopathy CAREGIVER-PEDIATRIC PT RELATIONSHIP 46 Appendix A Recruitment Email Subject Line: Research Regarding the Physical Therapist-Caregiver Relationship My name is Jodi Thomas, and I am a student in the Doctor of Health Science Program at the University of Indianapolis. I am also a pediatric therapist and have been practicing for over 12 years. In that time, I have become very interested in the unique features of the relationship between pediatric PTs and the caregivers of the children with whom they work. As a result, I decided to conduct research on this topic for my doctoral project. You are receiving this email because I thought you might be interested in participating. This study involves the participation of a pediatric PT along with a primary caregiver of a child who has been their patient for six months or longer. Both the pediatric PT and the primary caregiver would each participate in an interview with me (about 30-60 minutes long). Then, the pediatric PT and primary caregiver would participate in another interview together (also about 30-60 minutes long). Participants who complete both interviews will have their names entered in to a drawing to win a gift card. If you are interested and/or have questions, please contact me at jolthomas@uindy.edu or (325) 280-7878. Once you establish interest in participating, the next step is to find a caregiver of a child you treat who would be willing to participate. In order to maintain patient confidentiality, I will ask that you contact a caregiver and they can then contact me with any questions. Sincerely, Jodi Thomas CAREGIVER-PEDIATRIC PT RELATIONSHIP 47 Appendix B University of Indianapolis Institutional Review Board Principal Investigator: Laura Santurri Co-investigator: Jodi Thomas School/Department/Division: College of Health Sciences Telephone: 317-788-2409 Co-Investigator(s): Jodi Thomas INFORMED CONSENT FOR PARTICIPATION IN RESEARCH ACTIVITIES Perceptions of the Pediatric Physical Therapist-Caregiver Relationship 1. INTRODUCTION The investigators invite you to participate in a research study. The purpose of this Informed Consent Form (ICF) is to provide information you should have in order to make a wellinformed decision to consent to participate in the study. Please read the form carefully. You should ask questions about why the research is being done, what you will be asked to do, the possible risks and benefits, your rights as a volunteer, and anything else about the research or this form that is not clear. Your consent must be well informed and voluntary, without influence from the investigators or anyone else associated with this study. This process is called informed consent. 2. PURPOSE OF THIS RESEARCH STUDY The purpose of this research study is to explore longer-term (six months or more) caregiverpediatric PT relationships from both the caregivers and PTs points of view. You are invited to participate in this research study because you meet the criteria listed below. Inclusion criteria: Participants will be categorized as either a caregiver or a pediatric PT. o A caregiver in this study will be someone who has primary decision making responsibilities for a child (ages birth to 21 years) who is currently receiving physical therapy services for any diagnosis. This person will have direct involvement in their childs physical therapy. In the event that more than one person fits this definition (e.g., the childs father and mother), it will be up to the caregivers to self-select one person to participate in the interview. o For this study, a pediatric PT must be a licensed, practicing physical therapist who has been engaged in a therapeutic relationship with the caregiver participant and their child for at least six months. Exclusion criteria: CAREGIVER-PEDIATRIC PT RELATIONSHIP 48 Potential participants will be excluded if they have any cognitive deficits which would prevent them from being able to provide consent and answer a series of questions in an interview format. All interviews will be conducted in English, so individuals who do not speak English will be excluded. Your participation in this study will require two interviews, each of which may last 30-45 minutes. If you consent, then you will be one of approximately 10 persons participating in this study. 3. WHAT WILL BE DONE / PROCEDURES You will be asked about your experience with the pediatric physical therapist-caregiver relationship through two in-person, semi-structured interviews. A semi-structured interview is a type of interview that involves primary or required questions along with secondary or probing questions that are used depending on your responses to the primary questions. One interview will be between you and the researcher; the other interview will include you, a pediatric therapist, and the researcher. The interview will occur either locally or remotely depending on your convenience. A local interview will be performed privately in a place of your choosing. A remote interview will occur using telecommunication technology, such as the telephone or web-based program like Skype. Each interview will be audio-recorded and should last between 30 and 45 minutes. Breaks during the interview will be provided for you if requested. After the interview, the recording will be transcribed (i.e., typed out) and given to you for review to ensure that the investigator represents as accurately as possible what you said during the interview. Upon reviewing the transcript, you can request clarifications or corrections of errors as well as request that any part of the transcript not be used. 4. POSSIBLE BENEFITS The investigators do not intend and cannot guarantee that you will receive any benefit from participating in this study. Potential benefit to others may result from the knowledge gained from your participation in this research study. 5. POSSIBLE RISKS AND DISCOMFORTS The context and methods of this research study expose you to little, if any, risks. Possible, slight risks may include psychological or emotional distress such as embarrassment or nervousness associated with discussing perceptions and memories. The investigators will attempt to conduct your interview in a relaxed and supportive manner to ease possible discomfort. The interviewer will be trained to assess for participant discomfort. If at any time you do feel uncomfortable you may stop the interview. At that point, the information you have provided will be destroyed. CONFIDENTIALITY OF RECORDS Any information learned about you from this study will remain confidential. The investigators will NOT ask you for information, such as your name, email address, phone number, etc. that during the interview. You should try NOT to use names or other identifying CAREGIVER-PEDIATRIC PT RELATIONSHIP 49 information during the interview. If you disclose personally identifiable information, then the investigators will NOT transcribe the information from the recording. If your interview is remote using a web-based program such as Skype, then the investigators will use the confidentiality protections built into Skype or a similar program. The investigators will record ONLY the audio portion of the Skype interview. To better protect your privacy, you should conduct the interview in private setting using a secure internet connection. The investigators will ask for your contact information in order to send you a copy of your interview transcript. The investigators will establish and maintain confidentiality by: Storing identifiable information in a secure location with limited access Storing identifiable information in a locked container (e.g., file cabinet, desk drawer etc.) Storing identifiable information AWAY from your interview information All records will be stored in an online data management system called Dedoose. Only the investigator and members of the research team will have access to these records. If information learned from this study is published, you will not be identified by name. However, your consent to participate in this research study authorizes the investigators to make your research records available to the University of Indianapolis (UIndy) Human Research Protections Program (HRPP), law enforcement, and regulatory agencies as required by law. Although investigators will maintain the confidentiality of your information in order to protect your privacy, confidentiality may not be absolute or perfect. There are some circumstances where research staff might be required by law to share your information, such as, but not limited to: You provide information indicating that a child is being abused (or has been abused). The interviewer is required by Indiana state law to file a report with the appropriate agencies; You provide information indicating that you are being (have been) abused (in the past). The interviewer may have to file a report. You threaten serious harm to yourself or another person. The interviewer may have a duty to warn your intended victim, notify the police or take the steps to seek hospitalbased treatment. 6. OFFER TO ANSWER QUESTIONS AND RESEARCH INJURY NOTIFICATION Either Dr. Santurri (PI) or Dr. Thomas (co-investigator), responsible for this research study, must provide all information and answer any questions regarding your participation in this research study. If you have any further questions, then you can contact Dr. Santurri (PI) at 317-788-2409 or Dr. Thomas (co-investigator) at 325-280-7878. You MUST receive a copy of this informed consent document for your records. 7. COST TO THE SUBJECT / PAYMENT TO SUBJECT FOR PARTICIPATION CAREGIVER-PEDIATRIC PT RELATIONSHIP 50 Your participation in two interviews will result in your eligibility for a drawing to win one of two $75 Amazon gift cards. Participation is defined as being a part of the process from initiating contact with the researcher through completion of an interview with the researcher. An interview is considered completed if the participant answers at least one question. Completion is not based on any pre-set length of time spent in the interview. If you discontinue the interview before answering a question, which is your right to do, the interview will be considered incomplete and you will not be eligible for the drawing. If you enter the drawing, then you will be one of as many as ten other participants in the drawing. If you are a gift card winner, then you will electronically receive your gift card. 8. VOLUNTARY PARTICIPATION WITH RIGHT OF REFUSAL Your participation in this research study must be voluntary. Although you have been contacted by the investigators and/or a Physical Therapist, you are free NOT to consent. If you consent to begin the study and later change your mind, then you are free to withdraw from this study at any time without penalty. If you choose to withdraw after you complete an interview, then you should contact Dr. Santurri at 317-788-2409 or Dr. Jodi Thomas at 325280-7878. 9. IRB REVIEW AND IMPARTIAL THIRD PARTY The UIndy HRPP has reviewed and approved this research study as exempt, which means the study poses little to no risk to you. The HRPP is responsible for protecting the rights and welfare of all who conduct or participate in human subjects research. If you have questions or concerns about your rights or welfare as a participant in this research study, then you should contact the UIndy HRPP Team at hrpp@uindy.edu; (317) 781-5774; or (800)-232-8634 ext. 5774. 10. VOLUNTARY PARTICIPATION AS CONSENT Before you choose to participate, you must all information you require to make an informed choice to participate. If you choose to participate, then your participation is your implied, voluntary consent. Because the primary risk to you is loss of confidentiality and privacy as a result of disclosing your personally identifiable information, and because the investigators will NOT collect personally identifiable information as research data, the investigators will not require you to sign an Informed Consent Form (ICF). Participant name: Participant signature: Date: CAREGIVER-PEDIATRIC PT RELATIONSHIP 51 Appendix C Semi-structured Interview Guides For Caregiver Introduction. Thank you for agreeing to participate in this interview. My name is Jodi Thomas, and I will be conducting the interview; I am also the primary researcher for this project. We are here today because you responded to an inquiry I sent out asking for participants who are caregivers of children with special needs in physical therapy to speak about their relationship with their childs PT. This interview will last 30-60 minutes. I will guide the interview with questions, but please feel comfortable speaking freely; there are no right or wrong answers. Everything you say today will be confidential; portions of your interview may be used for the final research paper, but no identifying information will accompany it. To ensure I capture your perspective accurately, I would like your permission to record the interview. The recording will not be used for any other purposes and will be destroyed at the projects conclusion. Are you ready to begin? Once participant acknowledges readiness, the interviewer will begin recording and will state, We have now begun the recording. 1. Tell me about your relationship with your child's PT. 2. Describe a typical therapy session with your child 3. Describe conversations with your child's PT. a. Describe a time you had discussion with your childs PT about topics not related to your childs care (e.g., social activities, family, etc.)? b. Describe, if possible, a situation in which you and your childs PT had a conversation that was difficult or uncomfortable. CAREGIVER-PEDIATRIC PT RELATIONSHIP 52 4. Describe how you and your child's PT go about making decisions for your child's care. a. Describe your comfort level with approaching your childs PT to discuss treatment plan(s) for your child. 5. What aspects of your relationship with your childs PT are most important to you? 6. In what way, if any, does the relationship between caregiver and PT, play a role in the therapeutic process? 7. Is there anything else that you would like to share that we have not covered in our discussion? For PT 1. Tell me about your relationship with the caregiver in question. 2. Describe a typical therapy session. 3. Describe conversations with the childs caregiver a. Describe a time you had a discussion with the childs caregiver about topics not related to your childs care (e.g., social activities, family, etc.)? b. Describe, if possible, a situation in which you and your patients caregiver had a conversation that was difficult or uncomfortable. c. 4. Describe how you and your patients caregiver go about making decisions for the child's care. d. Describe your comfort level with approaching your patients caregiver to discuss treatment plan(s) for the child. 4. What aspects of your relationship with your patients caregiver are most important to you? CAREGIVER-PEDIATRIC PT RELATIONSHIP 53 5. 4. In what way, if any, does the relationship between caregiver and PT play a role in the therapeutic process? 6. Is there anything else that you would like to share that we have not covered in our discussion? CAREGIVER-PEDIATRIC PT RELATIONSHIP Appendix D Demographic and Background Information Caregiver 1. How long has your child been seeing their current PT? 2. How often does your child see his/her PT? 3. How old is your child? 4. What is your childs diagnosis? 5. What is the primary setting in which your child sees their PT? (e.g., at home, school, clinic, etc.) Age: Family role: (e.g. mom, dad, grandmother, etc.) PT 1. How long have you been a PT? 2. How many years of that have you been primarily working with pediatric patients? 3. What percentage of your caseload is pediatric patients? 54 CAREGIVER-PEDIATRIC PT RELATIONSHIP 55 Visual Representation Figure 1 Perceptions of the Caregiver-Pediatric Physical Therapist Relationship PT as a Guide Social and Emotional Connection Tim e PT Professional Qualities and Performance PT Caregiver Shared Decision-making Skill as a PT Education Collaboration Progress in Therapy  ...

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PATIENT PERCEPTIONS OF INITIAL PHASES OF REHABILITATION WITH SHOULDER ARTHROPLASTY Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Elizabeth Horrall Stith, OTR/L Copyright May 30, 2019 By: Elizabeth Horrall Stith, OTR/L All rights reserved Approved by: Lisa Borrero, PhD Committee Chair Laura Santurri, PhD, MPH, CPH Committee Member Lori Breeden, EdD, OTR Committee Member Sarah Shemanski, RN, BSN, RN-BC Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY Patient Perceptions of Initial Phases of Rehabilitation with Shoulder Arthroplasty Elizabeth Horrall Stith University of Indianapolis 1 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 2 Abstract Shoulder arthroplasty is a common intervention for patients with persistent pain and loss of function, but lack of research regarding recovery and rehabilitation limits practitioners from providing appropriate education and support following surgery. The purpose of this study was to explore and understand the patients experiences in the acute recovery phase of total shoulder arthroplasty as a result of osteoarthritis. A qualitative study utilizing a basic interpretive approach was conducted, which included three semi-structured interviews with 12 participants within the first six weeks following surgery. In the first two to four weeks following surgery, participants reported increased reliance on caregiver assistance and/or modifications to their daily routines such as dressing, bathing, self-feeding, and sleep. Interruption in sleep patterns was largely reported due to pain and/or positioning restrictions, and frustration due to both lack of sleep and need for assistance was a noteworthy theme in the first phase of recovery. As participants progressed beyond wearing their abductor sling continuously, they reported a gradual return to activities of daily living with a coinciding reduction in frustration. Finally, patients noted a progression not only in ADL recovery but also IADLs, reportedly returning to tasks such as driving, cooking and meal preparation, as well as being more active and returning to social engagements. Overarching themes throughout this study included pre-surgical expectations, advice for future patients, pain reduction, and general improvement in quality of life. These themes illuminate the recovery process and patient needs. Keywords: shoulder arthroplasty, occupational therapy, assistance, activities of daily living PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 3 Table of Contents Title Page.1 Abstract2 Chapter 1: Introduction6 Problem Statement...7 Purpose Statement and Research Questions.7 Significance of the Study..8 Definition of Terms .8 Chapter 2: Literature Review...9 Surgery Indications10 Surgery ......10 Neers Protocol...11 Patient Outcomes...13 Reverse Shoulder Arthroplasty vs. Anatomical Traditional Shoulder Arthroplasty...15 Factors Effecting Recovery....16 Joint Arthroplasty ..17 Chapter 3: Method..19 Study Design..19 Participants.19 Setting ...20 Procedures..20 Data Management and Analysis.23 Rigor/Trustworthiness ...25 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 4 Chapter 4: Results..25 Interview One.26 Interview Two ...34 Interview Three .....44 Overarching Themes..49 Chapter 5: Discussion and Conclusion...53 Limitations 60 Implications for Future Research ...60 Conclusion.64 References..66 Table 1 Participant Characteristics.77 Table 2 Theme Table: Interview 1..78 Table 3 Theme Table: Interview 2..81 Table 4 Theme Table: Interview 3..83 Table 5 Theme Table: Overarching Themes...84 Appendices.85 Appendix A Shoulder Replacement Protocol.....85 Appendix B University of Indianapolis IRB ......89 Appendix C Baptist Health Floyd Waiver .....92 Appendix D Study Details..........93 Appendix E Participant Form and Information Form.....95 Appendix F Consent Information..96 Appendix G Recruitment Script .....98 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 5 Appendix H Semi-Structured Interview Questions..100 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 6 Patient Perceptions of Early Phases of Rehabilitation with Shoulder Arthroplasty Over seventy thousand people in the United States underwent a total shoulder arthroplasty (TSA) in 2014 (Palsis et al., 2018). This commonly known shoulder replacement procedure is a surgical intervention for patients with persistent pain and loss of function as a result of osteoarthritis (OA), rheumatoid arthritis (RA), rotator cuff tear, osteonecrosis, and humeral head fractures, with primary and secondary OA being most prominent diagnoses for shoulder arthroplasty (SA) (Buck, Jost, & Holder, 2008; Craig, Goodier, Singh, Hopewell, & Rees, 2017; Wilcox, Arslainian, & Millett, 2005). This surgery, where a surgeon removes the humeral head and glenoid fossa to replace with artificial components, varies with the placement of the implants in either an anatomical placement (TSA) or reverse placement (RSA). There continue to be a variety of types of surgical procedures, but overall outcomes for SA are favorable to reduce pain and/or increase function (Triplet et al., 2015; Wand, Dear, Bigsby, & Wand, 2013). After surgery, many published protocols are used for recovery. Most of these protocols were developed from Dr. Charles Neers protocol guide, and progress healing and recovery (Denard & Ladermann, 2016; Mulieri et al., 2010; Wilcox et al., 2005). Patients are often limited by an abductor sling with instructions to complete no active range of motion (ROM) within the shoulder joint for 4-6 weeks (Groh & Groh, 2014; Hughes & Neer, 1975; Wilcox et al., 2005). Therapy often begins with a preoperative education class which may reduce anxiety regarding surgery (Flanigan, Everhart, & Glassman, 2015). The preoperative education focuses on donning and doffing the abductor sling, postsurgical precautions, and hemiplegic dressing techniques. After surgery, therapists often instruct patients to complete a home exercise program PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 7 (HEP) several times per day focusing on passive shoulder ROM as well as active elbow, wrist, and hand ROM to maintain distal mobility (Boudreau, Boudreau, Higgins, & Wilcox, 2007; Mulieri et al., 2010; Hughes & Neer, 1975). Problem Statement Due to TSA surgerys significant involvement with the soft tissue in the shoulder, the post-operative rehabilitation is large component of successful outcomes (Wilcox et al., 2005). Boardman et al. (2001, p. 484) states that there are very limited descriptions of postoperative rehabilitation programs for SA in the literature and even less literature addressing the patient perspective of SA rehabilitation. Lack of evidence limits therapists in providing appropriate prearthroplasty and postsurgical education to prepare patients for discharge to the home environment. Purpose Statement & Research Questions The purpose of this study is to explore the patients subjective perceptions of rehabilitation during the postsurgical and early strengthening phases of total shoulder arthroplasty following TSA or RSA as a result of osteoarthritis. Specifically, researchers sought to better understand patients views of recovery and their overall progression toward return to function. The primary researcher sought to answer the following research questions in this study: How do patients perceive and experience recovery during immediate postsurgical and early strengthening phases of shoulder arthroplasty? a) During this recovery period, how do patients perceive and experience engaging in Activities of Daily Living (ADL)? PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 8 b) During this recovery period, how do patients perceive and experience engaging in Instrumental Activities of Daily Living (IADL)? Significance of the Study This study will allow therapists to prepare patients for challenges they may encounter following discharge from the hospital. Based on patient assessments of information received, therapists will be able to adapt current strategies to provide better education regarding compensatory strategies for specific ADL impairments and assess what currently-provided information is useful to patients. Due to the depth provided by semi-structured interviews, the findings of this study may allow therapists to discover what surprises patients about the recovery process, how progression between the first few phases of rehab impacts patients daily lives, and how to better prepare patients for what to expect after surgery. Definition of Terms Activities of Daily Living (ADLs): activities oriented toward taking care of ones own body (American Occupational Therapy Association, 2014, p. S19). Instrumental Activities of Daily Living (IADLs): activities to support daily life within the home and community that often require more complex interactions than those used in ADLs (American Occupational Therapy Association, 2014, p. S19). Reverse Shoulder Arthroplasty (RSA): replacement of the humeral head and glenoid with components in a reversed configuration (Craig et al., 2017, p. 2). Shoulder Arthroplasty (SA): the removal of damaged bone and cartilage, with release of soft tissues that are causing contractures (Craig et al., 2017, p. 2) PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 9 Total Shoulder Arthroplasty (TSA): removal of the humeral head and glenoid process and subsequent replacement with metal and polyethylene component (Raiss, Aldinger, Kasten, Rickert, & Lowe, 2008). Literature Review Due to the variety of methods of both surgical approach and the rehabilitation protocols that follow, many authors have published on different aspects of shoulder arthroplasty. Many researchers have stressed the importance of recovery following shoulder arthroplasty, while others questioned the current methods utilized by physicians as well as therapists (Brems, 1994; Denard & Ladermann, 2016; Mulieri et al., 2010). Several researchers highlighted the need for preoperative education and managing postoperative expectations, and there are notable differences regarding rehabilitation with different protocols (Levy, Ashukem, & Formaini, 2016; Wilcox et al., 2005). To shape this study, the investigator focused primarily on the surgical indications, types of surgical approaches, subsequent rehab protocols, factors that may affect recovery, and literature available on other joint arthroplasty surgeries that may align well with patient experiences in shoulder arthroplasty recovery. Anatomically, the humerus, scapula (shoulder blade), clavicle (collarbone), and sternum (breastbone) are the bones that form the shoulder by forming four smaller joints: the glenohumeral joint (humeral head and glenoid cavity of scapula), the acromioclavicular or AC joint (meeting of clavicle and acromion of scapula), sternoclavicular or SC joint (meeting of clavicle and sternum) and scapulothoracic joint (scapula meeting ribs on back) (Wand et al., 2012). The muscles that stabilize these joints are most commonly known as the rotator cuff, which includes the supraspinatus, infraspinatus, teres minor, and subscapularis, and these provide a downward centering force on the humeral head (Rogers, Little, & Ricketts, 2012). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 10 Other muscles that aid shoulder movement include the deltoid, the pectoralis major, and the biceps, which act as superior forces to hold the humeral head in position (Pandya, Johnson, & Low, 2018). Surgery Indications There are many indications for shoulder replacement including arthritis, rotator cuff tears, fractures, and TSA revision (Garcia et al., 2015). The most common diagnosis for TSA is osteoarthritis, which results in cartilage thinning within the joint (Rasmussen, 2014). OA may wear the joint down to the point of the patient complaining of, diffuse, achy, and insidiously progressive pain, before eventually causing stiffness that progresses to permanent loss of motion (Fenlin & Frieman, 1998, p. 423). Eventually, OA will cause the humeral head to flatten, the neck to shorten, the glenoid to erode, and potential for large osteophytes (bony projections) to form (Rasmussen, 2014). Due to loss of motion, the rotator cuff may be contracted but typically intact with minimal lesions in patients with primary osteoarthritis (Edwards et al., 2002). In severe cases of OA, impaired quality of life was reported, and surgery is indicated when conservative methods such as therapy, lifestyle modification, and medications are no longer effective (Rasmussen, 2014). Surgery Total shoulder arthroplasty (TSA) originated in 1983, and surgical techniques and prosthesis have advanced since Neers humeral prostheses in 1955. Since the prosthesis was redesigned by Neer in the mid-1970s, surgical techniques and prosthesis have varied tremendously. (Ghazala & Candal-Couto, 2018; Kiet et al., 2015). There is considerable variability in surgical techniques, primarily in the type of prosthesis utilized and need for cement with prosthesis placement (Torchia, Cofield, & Settergren, 1997). TSA is typically completed under general PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 11 anesthesia with a ten cm. incision along the deltoid muscle (Wand et al., 2012). The surgeon works to remove part of the humeral head and replaces with metal component often called a humeral shaft, as well as utilizing a polyethylene artificial socket, or glenoid prosthesis, to facilitate movement with the prosthetic humeral head (Raiss et al., 2008). Potentially, a patient may need a Reverse TSA (RSA), where the ball and glenoid prosthesis are reversed (Kiet et al., 2015). Since the approval by the Food and Drug Administration in 2003, RSA has become the primary alternative surgical option for patients with rotator cuff disease and decreases risk of glenoid loosening (Palsis et al., 2018; Westermann et al., 2015). Most often, the degree of rotator cuff impairment determines how the surgeon may proceed (Kiet et al., 2015). One of the most common complications from a SA is loosening of the prosthetic (Daner & Boardman, 2016). Other significant complications include periprosthetic fracture, glenohumeral instability, rotator cuff tears, and nerve damage (Bohsali, Wirth, & Rockwood, 2006). Additionally, RSA patients were found to spend more days hospitalized after surgery, incur higher charges not related to the implant alone, and increased incidence of perioperative complications (Jiang, Toor, Shi, & Koh, 2014). While there have been similar patient outcomes and complication rates for both TSA and RSA (Kiet et al., 2015), patients requiring RSA are typically more impaired than those requiring TSA (Puskas et al., 2013). However, the recovery following TSA was typically quicker and more predictable in regard to reaching plateau in maximal improvement, whereas RSA demonstrated more variability in reaching (Levy, Everding, Gil, Stephens, & Giveans, 2014). Neers Protocol Following surgery, most surgeons use variations (Zec, Al-Qahtani, & Bicknell 2016) of Neers protocol, which identifies four phases of rehabilitation as Immediate Postsurgical, Early, PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 12 Moderate, and Advanced Strengthening (Appendix A) (Hughes & Neer, 1975). The focus of this study is primarily on patient recovery during Immediate Postsurgical and Early Strengthening phases. In the Immediate Postsurgical Phase (Phase one), goals include soft-tissue healing, maintaining joint integrity, reducing pain and inflammation, and limiting active range of motion (AROM) in the surgical shoulder. The patient typically wears an abduction sling continuously, is non-weight bearing throughout the surgical extremity, and PROM several times per day (Denard & Ladermann, 2016; Wilcox et al., 2005). Phase one lasts approximately 3-4 weeks, and by the end of this phase the patient is able to tolerate a minimum of 90o flexion and abduction passively (Wilcox et al., 2005). Phase two, or the Early Strengthening Phase, begins only when Phase one criteria has been met (Wilcox et al., 2005). The goals of this phase is to restore full passive range of motion (PROM), control pain and swelling, and slowly restore active motion of the shoulder joint (Wilcox et al., 2005). This phase most typically falls four to six weeks post-surgery. By the end of this phase, patients were able to actively complete shoulder flexion to 100o (Wilcox et al., 2005). Phases three and four work to further progress active range of motion, strengthen the shoulder capsule, and restore function without pain (Wilcox et al., 2005). Wilcox, Arslainian, & Millett (2005) also examined time frames on traditional and modified protocols to facilitate improvement and not the sole criteria of progressing ROM. These modified protocols may vary, but typically maintain that restoring passive ROM is the immediate goal of therapy, with strengthening to follow only after maximal ROM is achieved (Wilcox et al., 2005). Many authors have questioned the structure of current protocols, such as the need for immediate passive range of motion and the formal therapy program past eight weeks. Denard PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 13 and Ladermann (2016) found that there was no difference between immediate and delayed passive range of motion groups at one year. Immediate range of motion provided gains early in the rehabilitation process when compared to delayed range of motion, but there was not notable change between groups in range of motion or functional outcomes (Denard & Ladermann, 2016). Additionally, Mulieri et al., (2010) found significantly better forward flexion (154o vs. 119o) between patients who were released with ROM exercises to complete independently at eight weeks vs. patients following the standard protocol. Furthermore, the independent range of motion exercise group also demonstrated higher patient satisfaction (Mulieri et al., 2010). Despite limited research regarding postoperative rehabilitation protocols for total shoulder replacements, researchers identified, that the success of the procedure relies heavily on the soft tissue variables and the postoperative management (Wilcox, Arslainian, & Millett, 2005, p. 827). Neer himself stated, Shoulder replacement will fail without adequate rehabilitation (Brems, 1994). Furthermore, Wilcox, Arslainian, and Millett specifically stated that Nearly every article in literature about TSA states the success of TSA is dependent on rehabilitation (2005, p. 827). Patient Outcomes With appropriate rehabilitation, the results of shoulder arthroplasty are excellent. When asked to rate satisfaction as very good, good, satisfied, or dissatisfied, seventy percent of patients were very satisfied with their results following surgery (Sowa et al., 2017). In primarily osteoarthritis patients, nearly 90% rated their subjective satisfaction very good and good, with 95% of patients stating they were satisfied with their results (Raiss et al., 2008; Sowa et al., 2017). Patients reduction in pain is often closely associated with satisfaction, and multiple PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 14 studies have demonstrated notable changes in preoperative and postoperative pain levels (Fenlin & Frieman, 1998; Hurt et al., 2018; Wilcox et al., 2005). In addition to patient satisfaction, objective assessments of arm function were viewed as important outcome measures (Hurd et al., 2018). Using the Disabilities of Arm, Shoulder and Hand (DASH) as well as a physical-component summary known as the Short Form Health Survey (SF-36), Hurd et al. (2018) determined significant changes between patient pre-operative scores and scores at post-surgery. However, the SF-36 score changes were noted as early as two months post-surgery, while the DASH scores were not changed at two months (Hurd et al., 2018). This was likely due to the surgery restrictions limiting active range of motion for up to six weeks after surgery (Hurd et al., 2018). However, DASH scores between two months and the next reporting period in Hurd et al. (2018) study noted a 28% (45% impairment to 17% impairment) improvement in independence levels. Similarly, Fehringer et al. (2002) noted that patients will typically regain two-thirds of shoulder functions not present preoperatively, and potentially lose only 6% of functions (i.e., positioning of arm at side) present preoperatively. Unfortunately, research regarding shoulder functions and ADL is limited, and more current research does not appear to have been completed. A 2014 study researching return to sport and work following SA surgery found that most patients are retired before requiring surgery, but 20% of people in this study had to change occupations due the surgery (Bulhoff et al., 2014). The same study found that all patients who were active in a sport before surgery were able to return to the sport(s) after recovery (ranging from 2.5-12.6 years at time of study), but few patients began a new sport after undergoing SA (Bulhoff et al., 2014). Garcia et al. (2015) further investigated activity levels following RSA and found that the average time to return to sports was 5.3 months, though only 85% of patients in PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 15 this study returned to at least one sport at one-year follow-up. This study also found 70 years of age to be a predictor in returning to sports activities following RSA (Garcia et al., 2015). Iriberri et al. (2015) found that age was not a consideration in outcomes as patients greater than 80 years old had results like those over a decade younger. Younger patients have demonstrated higher rates of component loosening and risk of revision, likely due to increased wear and age of components (Petri et al., 2016). Furthermore, implant failures are found primarily on dominant arm SA, likely due to the increased usage and wear on the implant (Sowa et al., 2017). Regardless of patient descriptives, rehabilitation programs as a whole continue to be noted as determinate for successful outcomes (Wilcox et al., 2005). Reverse Shoulder Arthroplasty vs. Anatomical Traditional Shoulder Arthroplasty Several studies have focused on differences between RSA and TSA. Levy, Everding, Gil, Stephens, and Giveans (2014) compared recovery time of TSA and RSA and found that while both provide significant improvements in pain, TSA has a more consistent recovery trajectory than RSA. Patients recovering from TSA experienced a plateau in improvement in functional and subjective scores at six months, versus a widely-variable reported timeline for those recovering from RSA despite utilizing the same post-operative protocol (Levy et al., 2014). However, both surgeries provided 85-86% pain improvement by three months (Levy et al., 2014). Levy et al. (2014) state: Patients who are candidates for TSA can expect a consistent recovery with pain relief occurring early, functional gains by 6 months, and continued improvement in overhead motion until 1 year. Patients who are candidates for RSA can expect a majority of improvement within the first 3 months and continued improvement up to and possibly beyond 2 years. (p. 1880). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 16 Levy et al. (2014), also noted that candidates for TSA are often less medically complex than those requiring RSA. Multiple other researchers found RSA patients to be older with more comorbidities such as congestive heart failure, hypertension, diabetes, and anemia (Jiang et al., 2014; Ponce, Oladeji, Rogers, & Menendez, 2015; Villacis et al., 2016). This may explain RSA statistics for complications, extended hospitalizations, and higher costs (Jiang et al., 2014). Patients were more likely to return home following TSA (70%) than RSA (53%) (Ponce et al. 2015). Despite differences, complication and revision rates continue to be low for both groups, as Kiet et al. (2015) found TSA to have 13% complication rate and 11% revision rate while RSA had only 11% complication rate and 9% revision rate at two-year follow-up. Consistent with the similar and low revision and complication rates at two years, Villacis et al. (2016) found a complication rate at one year to be 8.4% for TSA and 9.9% for RSA. This study also highlighted a significant difference in complication rate between TSA and RSA at 30 days (1.7% and 3.0%, respectively) and 90 days (3.4% and 5.7%) (Villacis et al., 2016). Factors Effecting Recovery Several studies have addressed many factors and their effect on SA recovery. One study by Schwartz et al. (2014), found that intraoperative shoulder flexion, or ROM completed during the course of surgery, is the single best predictor of postoperative ROM as surgeons may use this as a tool to assess soft tissue during surgery. Another study by Levy, Ashukem, and Formaini (2016), analyzed comorbidities correlating with postoperative ROM in TSA. These researchers found body mass index (BMI) and diabetes to have negative correlations with postoperative ROM. Similarly, this study identified a negative correlation for preoperative ROM in patients with higher BMI, reinforcing the idea that preoperative and intraoperative ROM are good indicators for postoperative ROM (Levy et al., 2016). Levy et al. (2016) found no other PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 17 comorbidities, such as osteoporosis, age, inflammatory arthritis, or smoking, to correlate with postoperative motion. However, Bot, Menendez, Neuhaus, and Ring (2014) associated anxiety and depression with limited recovery following TSA. Other studies have focused on psychological factors affecting patient outcomes. Tokish et al., (2017) found a positive correlation between resilience, or the ability to recover from stress, and better postoperative outcomes after TSA. Styron, Higuera, Strand, and Iannotti (2015) revealed that patient confidence levels correlated with increased function and decreased pain postoperatively. These same researchers found that younger patients had higher expectations than older patients, though age was not associated with greater confidence (Styron et al., 2015). Not surprisingly, patient expectations were also linked to outcomes, pain perception, and patient satisfaction (Flanigan et al., 2015; Henn et al., 2011). Joint Arthroplasty Due to limited research on patient recovery and perceptions specific to shoulder arthroplasty, other articles focusing on knee and hip arthroplasty have offered insight. For example, Hall et al. (2008) identified patient perceptions of living with osteoarthritis and upcoming knee arthroplasty. In this study, researchers identified Breakpoints, or time when an individual... has come to realization that they will require arthroplasty (Hall et al., 2008, p. 172). These breakpoints were noted to represent increased difficulty with functional mobility, decrease in sleep quality as a result of pain, increased restriction in self-care tasks, and increased reliance on family for IADLs (Hall et al., 2008). Interestingly, patients in this study were less focused on the surgery or recovery period itself and more focused on the ultimate outcome (Hall et al., 2008). Not surprisingly, frustration and inadequacy were highlighted as common emotions, touching on psychological factors surrounding orthopedic surgeries (Hall et al., 2008). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 18 Harding, Holland, Hinman, and Delany (2015) conducted a qualitative study and identified perceptions of physical activity following a total hip and knee arthroplasty. The researchers found patients to have increased physical activity level as compared to before surgery, decreased pain with activities, and contentedness regarding their potential to be more active (Harding et al., 2015). A review of the literature by Flanigan, Everhart, and Glassman (2015) provided further insight into psychological factors in orthopedic surgeries, linking these factors to the effect of pain perceptions, compliance with rehabilitation, and patient outcomes. Several articles in this review associated self-efficacy and optimism of patients with successful outcomes following ACL repair and total knee arthroplasty (Flanigan et al., 2015). Similarly, stress and depression were found to have negative effects (Flanigan et al., 2015). Patients reported increased pain and stiffness at one-year post-knee surgery, with depression and stress hypothesized to affect the patients degree of social support (Flanigan et al., 2015). Despite vast amounts of research on the types of, results from, and factors affecting recovery from SA, little research has examined patient perspectives during rehabilitation. Multiple researchers have noted the need to educate patients preoperatively and define expectations of surgery outcomes (Levy et al., 2014; Wilcox et al., 2005), yet few have specifically sought to understand patient experiences throughout the rehabilitation process. The aim of this study is to utilize the findings to provide therapists increased insight into patient needs, expectations, and surprises during the first few phases of rehabilitation following SA. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 19 Method Study Design This study utilized a qualitative basic interpretive approach. This particular methodology, as stated by Merriam (2002), seek[s] to discover and understand a phenomenon, a process, the perspective and worldviews of the people involved, or a combination of these (p. 6). In this study, the researcher explored how patients experience their rehabilitation during the transition from hospital to home, throughout different limitations due to surgical precautions, and how this impacts their daily life. This study delved into patients' perceptions and experiences following total shoulder surgeries. Institutional Review Board (IRB) approval was sought and obtained from the University of Indianapolis (UIndy) prior to recruitment and data collection. In addition, Baptist Health Floyd Hospital entered into a reliance agreement with the UIndy IRB. Participants Purposive, convenience sampling was used to select participants who were preparing to undergo shoulder arthroplasty at Baptist Health Floyd Hospital, where the primary investigator is employed as an occupational therapist. Inclusion criteria for participants included a diagnosis of primary osteoarthritis, scoring within normal limits on the Short-Blessed testing for cognition, being independent ambulators prior to surgery, and discharge to home environment following hospitalization. Independence with ADLs prior to surgery was not utilized as inclusion criteria as it is anticipated that shoulder pain may significantly limit independence. Exclusion criteria included non-English speaking patients, patients who discharge to another healthcare facility following hospitalization, and those who have other comorbidities significantly limiting rehabilitation (i.e., amputations, other UE joint deformity). All patients utilized the same PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 20 rehabilitative protocol. A total of 12 participants were recruited in attempt to provide ample opportunity for researchers to understand common themes related to the SA recovery process, with only 11 participants completing all interviews. In keeping with the tenets of qualitative research, which prioritize understanding a phenomenon via the experience of a small number of individuals without generalizing to a broader population, a smaller sample size is appropriate (Creswell & Creswell, 2018; Creswell & Poth, 2018). Setting Patients pursuing SA for this study were recruited from Baptist Health Floyd Hospital in New Albany, Indiana. This county-owned hospital is part of the Baptist Health Network, with 236 beds (Baptist Health, 2017). Prior to surgery, patients at this hospital attend preoperative education at the hospital, led by a nurse and occupational therapist. Patients are seen within the first 24 hours following SA and typically discharge to their home environment one to two days after surgery with home healthcare or outpatient therapy services. Patients discharge from hospital with abductor sling to ensure proper positioning and a Polar Cube ice system to reduce pain and inflammation. Procedures Recruitment. Recruitment took place either during preoperative education at the hospital, as the occupational therapist in the class also serves as the primary investigator in this study, or in the patients hospital room a minimum of twenty-four hours prior to discharge. During the preoperative education class, the therapist introduced the study to patients after completing the educational portion of class and provided to patients the Study Details sheet (Appendix D), which included information such as purpose of the study, potential participants, PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 21 benefits and risks, and information storage. Each patient was given time to ask any questions before the therapist left class. To ensure patients were not pressured to participate, the therapist was not present during the time when patients expressed interest in this study. Specifically, after completing routine hospital-required paperwork with the nurse educator, patients were handed a study Information Form (Appendix E) and told, If you think that you would like to participate in this research study, please fill out this form and I will pass along to the therapist (primary researcher) . In the event that a patient did not attend preoperative education one week before surgery, or wished to have more time to review documents, recruitment took place in their hospital room a minimum of twenty-four hours prior to discharge. In this case, the nurse educator introduced the study to the patient utilizing the Study Details (Appendix D) form and recruitment script (Appendix G). The patient was provided time to ask questions before being provided the study Information Form while stating, If you think that you would like to participate in this research study, please fill out this Information Form and I will pass along to the therapist (primary researcher). The Information Form included the patients name, identification number, and phone number, as well as hand dominance and which shoulder was to be replaced. This identification number was recorded on a participant log along with the corresponding name. Information from the form was immediately uploaded to a password-protected spreadsheet, and hard copy of the forms were shredded. The participant log was kept in a locked file only accessible to the researcher in the therapy office at Baptist Health Floyd. The primary investigator contacted interested patients who met the study criteria by visiting them within their hospital room on the day of discharge from the hospital after all therapy had been completed. During this time, the investigator confirmed eligibility, answered PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 22 questions from the participant, reiterated that participation in the study is voluntary, verbally reaffirmed the patients wish to participate, and provided a consent handout for review (Appendix F). Finally, the primary investigator set up a time for the first interview and reviewed contact information with the participant. Informed Consent. Participants were provided a Consent Information form (Appendix F) prior to discharge from the hospital. At the beginning of the first interview session, which took place approximately two weeks following surgery, participants were provided with a review of the Study Details (Appendix D) document received during their preoperative education class which states there are no perceived risks of this study, that participation is voluntary, and that they may opt-out at any point in this process. Participants were informed that they would receive a $25 gift card upon completing all three interviews and will be given time to ask questions both during this encounter and during interviews. Verbal, audio-recorded consent was obtained during the first and each subsequent interview as the participant did not follow up with this researcher throughout the therapy process. Audio consent was obtained rather than written consent to decrease personally-identifying information held by therapist. During each interview, the researcher gained verbal consent to continue participation in the study. Data collection process. Data collection comprised of three distinct telephone interviews at approximately two, four, and six weeks following surgery. Each interview was completed by the primary investigator and was audio recorded. Each interview was expected to last approximately 15-20 minutes and followed a predetermined list of questions (Appendix H). Each interview began with a reminder that the conversations were being recorded, a brief introduction of the researcher, explanation of the study, and verbal consent to participate. Following the introduction, a brief summary of the previous interview themes (where applicable) PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 23 was relayed to the participant. Reviewing the previous interview not only provided baseline for where the last interview left off, but also served as a way of member checking, or allowing participants feedback regarding their previous responses and to verify that the researchers interpretations of their perceptions and experiences are accurate (Thomas, 2017). After member checking, the researcher followed up on concerns and difficulties brought up in the previous interview and pursued new topics related to progression of healing and therapy. Interview questions were open-ended and began with patient feelings regarding preparedness for discharge (Interview 1) or review of issues revealed in the previous interview and progression with therapy since last interview (Interviews 2 and 3). Each interview specifically asked what tasks were difficult for patients, the impact this surgery has had on the participants social life, sleep quality, and pain. Some interview questions were derived from a Total Shoulder Replacement Questionnaire utilized by the New Zealand Orthopaedic Association, with additions based on questions arising from the literature review (New Zealand Orthopaedic Association, 2018). Interviews followed a top-down approach, beginning with broad issues and progressing to more specific issues that the participant may be experiencing. Probing questions to elicit more information, examples, or clarification were used as follow-up questions to ensure researcher understanding of participant response. Upon completion of all three interviews, participants were provided a $25 gift card to their choice of selected merchants via email or postal mail. Data Management and Analysis After each interview, audio recordings were transcribed verbatim by a transcription service. Audio recordings were removed from the digital recorder, and transcriptions were stored in the data management and analysis application, Dedoose 8.1. Dedoose files were accessible only to the researchers involved in this study. Member checking, or the process of PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 24 participant validation (Birt, Scott, Cabers, Campbell, & Walter, 2016), took place approximately two weeks after each interview at the beginning of subsequent interviews as a validation technique. After the final interview, the researcher followed up with the participant in approximately 1-2 weeks to ensure the gift card was received and to complete member checking from the third interview. Once transcribed, each interview was analyzed line-by-line in a coding process. The coding process was carried out in keeping with Stuckeys (2015) characterization in which The process of coding breaks the data into parts so that the data are manageable, with the result of rebuilding the data to tell a storyline (p. 7). During the initial coding process, a second member of the research team, the analysis expert, assisted with codebook development. The primary investigator and analysis expert independently engaged in the coding process on the same transcript(s) and then came to consensus on codes that most accurately represent the data. First, each transcript was filtered through to find relevant text (Auerbach & Silverstein, 2003), before labeling codes. These codes, consisting of words or phrases that assign meaning to sections of text data (Saldana, 2009), were organized and defined within a codebook in Dedoose. These codes were then more specifically labeled into categories, and subcategories as needed, as a hierarchical coding scheme emerged (Lewins & Silver, 2007). From these categories, researchers searched for themes and patterns that emerged from both individual interviews and cross-theme comparisons. After an initial codebook was created, the primary investigator independently coded the remaining transcripts but sought guidance or feedback from the analysis expert if the codebook was modified or refined. After all transcripts were coded, and the codebook was finalized, the codes were categorized into larger units that share meaning (Saldana, 2009). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 25 Rigor/Trustworthiness To ensure quality results of this qualitative study, Gubas Model of Trustworthiness was used to assess the trustworthiness of the data collected. This model articulates four concepts (credibility, transferability, dependability, and confirmability) necessary to pre-emptively address any potential bias within qualitative research (Henderson & Renault, 2004). To ensure credibility and confirmability, member checking was used after interviews to ensure patients were able to correct errors in interpretation. To enhance dependability and confirmability, the use of triangulation (a variety of sources, methods, theories and/or investigators within the study), such as multiple investigators, was utilized to avoid bias and other preconceptions (Heale & Forbes, 2017). An additional, experienced qualitative researcher on the IRB protocol assisted with initial coding, which increases credibility (Amankwaa, 2016). Also, raw data, data reduction, analysis products, and process notes were all kept within the Dedoose software throughout the process of this study, thus creating an audit trail which further increases credibility within the data (Amankwaa, 2016). To ensure transferability, the open-ended questions were derived from another questionnaire (Amankwaa, 2016). Finally, to further promote dependability, the process of reflexivity, or continuous process of self-reflection that researchers engage in to generate awareness about their actions, feelings, and perceptions, was utilized (Darawsheh, 2014, p. 561). To this end, a reflexive journal was kept throughout the interview process to improve transparency during both interviews and the data analysis portions of research (Darawsheh, 2014). Results Twelve participants were interviewed for this project (Table 1). This group was comprised of five males and seven females, ranging in age from 59 to 89 years old, with a mean PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 26 age of 75.3 years. Nine participants had shoulder replacement on their dominant arms, and only three sought non-dominant shoulder replacements. All surgeries performed were RSA and followed the same protocol during recovery. Six participants discharged home with Home Healthcare services, five participants discharged directly to outpatient therapy services, and one patient, due to insurance limitations on home healthcare and outpatient therapy services, discharged home with significant education on progression of therapy services and caregiver education on how to complete passive ROM exercises at home with no therapy services. Interviews ranged from 9 to 31 minutes. Themes evolved and changed with each interview and are most easily understood by reviewing all first, second, and third interviews individually. Some themes were present throughout each interview, such as pain, pre-surgical expectations, and advice for future patients, which were interpreted as overarching themes. Interview One Interview one, completed approximately two-weeks after surgery, was typically completed after the first follow-up appointment with the surgeon. At this two-week mark, protocol dictates that patients are to wear an abductor sling at all times, with the exception of bathing, dressing, and completing HEP. The Polar Cube ice pack is encouraged to be worn frequently by the surgeon to reduce pain and swelling as well as to promote soft-tissue healing. During these interviews, it was apparent that participants required the most amount of assistance throughout the first stages of the protocol. Therefore, themes of assistance and modifications, frustration, and pain emerged during this time period. Most participants stated that they experienced a satisfactory hospital stay, though some reported feeling overwhelmed immediately after surgery, I was worried if I had done the right PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 27 thing (0003, Interview 1). Others reported a change in length of hospital stay, and one reported some apprehension regarding discharging home, I really thought Id go to rehab since I live alone. Im 81 years old I asked to have one more day at the hospital, which was granted (9866, Interview 1). Participants did report good understanding of the HEP exercises at discharge, and were pleased to be returning home. Assistance and modifications. Unsurprisingly, assistance and modified routines were overwhelming themes in the first two weeks of recovery. All participants returned home with either a spouse or plans for increased assistance in the first few weeks following surgery. While the majority of participants were fortunate to return home with a spouse, two participants discharged to a friend or family members home first before returning home alone, and others had the assistance of home health aides and multiple family members stopping in intermittently. Participants reported requiring assistance with ADLs such as dressing and showering, as well as IADLs and other challenging household tasks. One participant went as far as to describe the assistance of others as indispensable. (0003, Interview 1). Dressing. Participants often required assistance with dressing during the initial phases of recovery. In addition to requiring assistance with upper body dressing due to restricted use of the surgical arm, undergarments and lower body dressing were reported to be increasingly difficult. As one participant stated, Thank goodness, my old man took off work and he's been helping me get dressed. I can put on some stuff but some's impossible. Like tying your shoes. Underwear. I need some help with my underwear (0003, Interview 1). Due to inclusion criteria requiring a diagnosis of osteoarthritis, it was also common to hear of additional assistance being required to complete dressing tasks. Another participant (4648) stated: PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 28 I have terrible arthritis in my hands and it takes both hands for me to be able to put socks on. So, one hand being completely useless for right now, up 'til now, no, I couldn't put my socks on. I could put my pants on, and my underwear, but pulling them up is difficult. I can get one side good, but the other side, she grabs a hold and gives it a jerk. And she helps me with my shirts. I just lean over and let that arm hang and we put that in and then she just helps me with my shirts. (4648, Interview 1) However, many participants were able to complete dressing tasks without assistance, or with minimal assistance for some tasks such as buttoning jeans (3206, Interview 1). Many were able to complete dressing tasks without much assistance, but required significant modifications in both dressing techniques as well as the types of clothing they wore. One participant described dressing modifications in the following: Sometimes if the shirt's baggy enough and got a big neck it goes on a lot easier. And of course, you put on the bad side first. And really, really loose pants or leggings. I usually need help pulling them up, but if they're loose enough I can get them up most of the way on myself. But I usually keep on something baggy or just a baggy old nightgown so I can just lift it up and go to the bathroom. (9245, Interview 1).\ Several female participants reported wearing larger clothing such as gowns between showers (3126) to decrease difficulty with lower body dressing during toileting. Other participants stated requiring increased time to complete dressing tasks: So, it probably takes me 10 minutes just to tie my shoes, but I don't get out that much anyway, other than therapy. And as far as getting dressed, no I just take my time. I keep my right arm straight and pull the sleeve up over it and then over my head and into the left, as you taught me. So far, so good. (3126, Interview 1) PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 29 Bathing. Another area of assistance and modification frequently reported during the first few weeks after surgery was bathing. Often, assistance was required to wash head/hair (3206, Interview 1), and others reported assistance with washing the nonsurgical arm. Others reported some difficulty and frustration with modifications, such as adaptive equipment recommended by therapists. However, many reported that difficulty bathing was not acute, I had trouble even before I went in with washing my head. My right shoulder was the one that was damaged, and it was very hard. I couldnt hardly get my right hand up to work in the lather. I had to do it all with the left hand. (3206, Interview 1) Sleep. Sleep was both a frequent area of reported modification, as well as a frequently reported frustration for nearly all participants in the first two weeks following rehab. Due to positioning requirements set forth by the surgeon, participants were required to sleep with a pillow behind the surgical elbow to ensure proper joint alignment and were also instructed to sleep in the adductor sling until otherwise informed by physician. Difficulty sleeping was attributed to pain, discomfort, inability to sleep in preferred position due to positioning requirements, itching, and temperature changes, as reported by participant 1946, Sometimes in the night, it's like my elbow's asleep, and it's breaking out and starts itching, and then I wake up. This thing is really hot. Nearly all complaints were linked to one thing: the abductor sling. Its because of the sling. Its just kind of uncomfortable, the sling is, with that big padding (9245 Interview 1). Many participants sought solace in sleeping in a recliner for comfort rather than in bed. Last night I went to sleep in my bed. But, I got up about 4:00 and came out and got in the chair its better (1109, Interview 1). However, recliners were reported to be not without difficulty, as recliner handles are often located on the right-side. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 30 Not all participants reported difficulty sleeping, some reported fear of sleeping too much, potentially due to medication changes. Others reported inconsistency with sleeping, as conveyed by participant 3206: Some days, great. Some days, not so great. I can't put my finger on why, but there's days I'll get three or four hours in at a time and wake up and then, go back to sleep and then, there's other nights where I might be up six hours. (3206, Interview 1) Other ADLs and IADLs. While dressing and bathing were the two most common ADLs requiring assistance and modifications, multiple other ADLs were stated as difficult tasks early in the rehab process. In addition to difficulty with lower body dressing related to toileting, participants also reported difficulty with perineal hygiene after bowel movements, most reporting that they resulted to modifications to complete. Other ADLs that emerged during the first interview were brushing teeth, completing hair combing and styling, and positioning for ADLs. Many reported requiring assistance with ADLs early in this reporting period, but stated increased independence or total independence at the two-week mark, as conveyed by participant 3610, She helped me up until yesterday, and I think I did it today by myself, you know, so its just getting a lot better (3610, Interview 1). IADL assistance was reported by each participant, and with many having significant assistance from family to complete meal prep/cooking tasks, laundry, medication management, and housekeeping. Participants were not released to be driving during this reporting period, so assistance for transportation was also required. Grocery shopping was also consistently an area in which participants received assistance, likely due to driving restrictions during this time period. Modifications of IADLs appear more common nearing the two-week mark, with one participant outlining the modifications she required: PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 31 I have done very little housework. I can load the dishwasher. I can put clothes in the washer and take them out of the dryer with one hand. Instead of carrying four or five things, I may carry two or three, and put them away (9245, Interview 1). The other common modification of daily routines in regard to IADLs was to omit them. I probably just dont do them (1109, Interview 1). Frustration. Given that all participants were independent with ambulation prior to surgery and requiring assistance for ADLs and IALDs following surgery, frustration is a natural theme for this period of recovery. While many participants expressed frustration with tasks stated above, frustration also appeared to result from feelings of dependence rather than specific tasks. Participant 1155 noted difficulty requesting assistance, Well, I live by myself so my goal from the get-go has been to be able to do for myself (1155, Interview 1). Participant 4648 noted frustration with a specific situation, usually, Im over there with everybody else cleaning up and I couldnt do that. That was aggravating (4648, Interview 1). Others noted just sitting around the house (3206, Interview 1) to be increasingly frustrating. Participant 3126 stated, The hard part is actually not pushing yourself, but making sure you follow [the protocol] so that you will get better. In summary, Participant 9866 noted, everything you go to do is a real hassle. Other areas of frustration revolved around the abductor sling, both in its size and donning/doffing, as well as pain and pain interventions. Several participants were frustrated by continued pain following arthroplasty surgery, and more yet stated frustration with the Polar Cube ice pack. Participant 5262 (Interview 1) when asked about her most frustrating part of recovery, noted: PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 32 I would say the harness [abductor sling], taking it on and off, and hooking up the ice machine and that to get around. The first few days, I couldnt do that myself, and it was hard for me. Whenever I wanted to go to the bathroom, I had to wake somebody up in the middle of the night or during the day, holler and have help. Yet another participant noted frustrating with the Polar Cube system, noting that the cooler was knocked over spilling water all over the floor (1109, Interview 1). Others stated they did not feel that the ice packs delivered cryotherapy to the incision or appropriate location of pain. Many, like participant 9245, acknowledged impatience as well as frustration, citing, Im just an impatient person, and I expected to be better quicker. Therere only some things you can do, and some things you cant. And you just got to go with that. [Its] a lot of sitting (9245, Interview 1). Pain. Despite pain being a limiting factor while sleeping and an area of common frustration, several participants voiced surprise regarding pain following surgery. When asked the most surprising aspect of recovery during Early Stage 1, participant 0003 stated, That theres not more pain than there is now. Cause every time I've had a bone operated on, I've had a lot of pain. Another participant, 3206, also compared pain to previous surgeries, I guess I was expecting a lot more pain than I have now because I've had rotator surgery on both shoulders and that was brutal. Participant 4248 noted: All I heard everybody say was how painful it was and I have had no pain. And that surprised me. And I thought, well when that block wears off, yeah, we're going to have some fun, but no. I mean it has been pain free. (4248, Interview 1) Several participants noted only mild-to-moderate pain and frequently linked with activity or exercises on their surgical arm. Of those reporting pain, the highest pain reported was 5-6/10 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 33 after discharge to home environment. Participant 5262 stated, There was times though when I started exercising and doing different things, I did get more, but that's understandable I think because of the fact that I'm using things I've never used before (5262, Interview 1). Of those stating pain, most also cited utilizing the Polar Cube and pain medication as pain interventions during the first few weeks of recovery. Regarding the Polar Cube, Participant 3126 (Interview 1) reported wearing the sleeve anywhere from 12 to 16 hours a day, and Participant 5262 (Interview 1) stated, That ice pack really does help a lot. While many participants utilizing prescription pain medication stated the pain relief was adequate, many also questioned the need for stronger medication. They gave me Percocet and, to be honest, one of the reasons I took it, yeah, I had discomfort, not really a lot of pain, on the back of my arm, I could feel the bone pain, but it wasn't excruciating. But the nurses, and you as well, cautioned me to not let the pain get away. So, I went ahead and took a pill and I wound up taking, though, I think it was Sunday, I took no more than five pills. And that was just more because of what I told you, dont let the pain get away from you. (3126, Interview 1) Due to the underlying diagnoses of osteoarthritis, several patients unsurprisingly reported taking over-the-counter pain medication daily. Many reported returning to this routine only a few days after surgery, such as Participant 1109 (Interview 1), All Im taking for pain is ibuprofen and Tylenol. I havent taken any of the prescription pain [medication] since two days since surgery. Despite complaints of pain, most reported decreased pain from baseline or pre-surgical expectations. When asked about the most surprising aspect of recovery, Participant 1946 stated, not having the pain that I really thought I would be going through. It seems like every day it's getting a little bit better. Similarly, Participant 3206 stated, I feel so much better. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 34 Interview Two Interview two was completed approximately four-weeks after surgery. At the four-week mark, protocol dictates that patients should be only just beginning the Early Strengthening phase (not to begin before 4 weeks). Criteria for progression per the protocol is: tolerates PROM program, achieves at least 120 o PROM flexion, achieves at least 90 o PROM abduction, and achieves at least 70 o PROM IR in plane of scapula measured 30 o of abduction. During this phase, the surgeons protocol requires patient to be wearing the sling while sleeping, but allows for the patient to remove the sling gradually throughout the next two weeks. As with the first two weeks, no lifting or weight-bearing is allowed throughout the surgical arm. However, because this protocol requires patients to achieve all criteria from previous stage to progress to subsequent stages, some participants may have still been in Phase 1 (Immediate Postsurgical Phase) while others had progressed to Phase 2 (Early Strengthening Phase). Even with progression of therapy, movements with the surgical-arm continue to be passive or assisted in Phase 2. Therefore, continued themes of modified routines, with emphasis on IADLs, and pain emerged similarly to the first interview. Other themes that are notable fourweeks after shoulder replacement were pain and general progression, including both therapy progression as well as progression in recovery for patients to be able to return to most social situations. Modified routines and assistance. Similar to the first interview, assistance and modified routines were again a large theme emerging from the second set of interviews. Participant 4648 described this point of recovery: Well, it just seems that I want to do more with my arm than I'm really supposed to do. So, I have to be mindful, don't pick this up, don't ... I'm not supposed to put my arm PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 35 behind my back, and when you're pulling your pants up you wanna put your arm behind your back a little bit, so I gotta watch that. Let's see what else ... And at night, I sleep with a pillow under my arm and I've got to make sure I keep it on that pillow. Those are just problems that I'm having right now. Just trying not to use it but wanting to use it. (4648, Interview 2) At four-weeks following surgery, several participants were able to dress themselves while others continued to require assistance. Those that were occasionally requiring assistance found themselves modifying routines to complete while also complying with their postsurgical precautions: Yeah, because I tend to want to get dressed on my own, and so I have to be sure that I don't do that. Some shirts are really hard to put on, so my wife has to help me. My coat, it's really hard to put on, so she helps me with that. Yeah, I've modified in that area. Dress shirts are much harder to put on because I can't quite get the shoulders up where they go. Now my tee shirts, undershirts, they go on pretty easy. I can do them by myself. But a dress shirt I just can't manage. (4648, Interview 2) Similarly, nearly all patients were able to complete bathing tasks with little to no assistance, and those who did have some assistance with ADLs stated apprehension with utilizing their surgical arm, I'm sure that I could, but it's a mindset that I don't do any more than you have to with it. Stick with the exercises and the physical therapy rather than getting back to the actual normal stuff (3126, Interview 2). Several participants noted that they continued to utilize modifications learned prior to surgery, despite being released to use their surgical-arm within the home. No. I've had this problem for at least a year and a half. I think would be two years. I've been using my left hand a lot (1946, Interview 2). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 36 In contrast to the first interview, most participants were to a point of being independent enough to significantly decrease frustration. As previously stated, many participants were accustomed to modifying routines due to pain prior to surgery. Others were able to complete basic ADLs and required only assistance with IADLs. Of those receiving assistance, all participants stated appreciation for caregivers, You don't realize how nice people are until something happens (1946, Interview 2). Frequently, when discussing modifications and assistance, subthemes of sleep, selffeeding, and IADL assistance emerged. Sleep. Similar to the first two weeks, sleep continued to be an area of modification for many participants. Despite being given more freedom from the surgeon during the day, patients were instructed to continue wearing the abductor sling while sleeping to ensure proper joint alignment. Several participants reported sleeping without difficulty, but the vast majority found modifications to improve sleep. Most notably, the couch and the chair continued to be a method of modification due to the ease of repositioning, as reported by participant 9245: Well, I don't sleep very well at night. But I do sleep. I can get up and get on the couch and I've got pillows propped up there and then I can lay on my side and rest my back against the back of it, and it takes some of the weight off. (9245, Interview 2) After weeks of modifications, many were attempting to return to a more typical sleeping pattern, I'm sleeping on a couch right now. I tried a bed at night, the night before last, and I just couldn't get comfortable, so I'm not gonna do that for a while (3206, Interview 2). However, others were more successful, as reported by 3610: No, I slept in a bed. Sometimes it depends. I slept on a bed last night and I did pretty good. I think I don't sleep on the couch, I sleep in the recliner. It kind of boxes you up PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 37 where youre kind of in one position all night long, and you kind of get to hurtin' at night you know what I mean. (3610, Interview 2) Another participant reported returning to bed, with good results, I'm sleeping in my bed with the sling, so I'm sleeping on my back.Almost every night I've slept good, yes. I'm surprised (9866, Interview 2). Of those who were able to return to bed, difficulty finding a comfortable position or reposition in bed was a common nuisance. Participant 3126 reported such difficulty with position in bed: Even though I have things, pillows and so forth to pin me in, my favorite position is my right shoulder. Right side. I've been trying to sleep on my left side, which with my arm propped up, it feels pretty good, but I wind up waking up closer to my right side. That's what wakes me up. Well, the last few nights, the pain woke me up. Mostly my hand. Some in the back of my right arm in the area where the pin is. Last night for the first time, I thought, "Well, maybe a Tylenol PM is not absolutely necessary." I only had two pills left, so I thought, "Well, I'll see how it goes tonight." I got up at 3:30 and took the pills. (3126, Interview 2) Similarly, participant 5262 spoke to difficulties with getting comfortable in bed: When I try to do something like pull a cover over me or something like that, it's awkward for me to do it because my right arm just doesn't reach it. It doesn't have the strength in it yet that I need to pick up and move it. (5262, Interview 2) Self-feeding. As participants reporting having less assistance with other ADLs and were allowed more freedom to be without the sling while at home, self-feeding became a frequent area of improvement. Several participants stated no difficulty, with about a third stating they were PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 38 regaining independence with self-feeding. Oh well let's see. I am now. At first, I had somebody cut up like a pork chop for me. into pieces yeah. I can now (1109, Interview 2). The increased independence was not specific to utensil usage, as reported by participant 3126, I'm getting a lot of strength back in my arm now. Before, I couldn't even pull the top off of the little pudding cup. Now I can do that (3126, Interview 2). Participant 5262 continued to report requiring increased time and modification for self-feeding and meal prep tasks: Cutting I have done a little. I haven't done a lot. I don't know, it seems like its okay. I can handle it pretty much. I made hash the other day and I cubed up the potatoes for that. It's just, you have to learn how to do it as far as slicing them and quartering them and all that kind of stuff. (5262, Interview 2) Similar to requiring increased time, the same participant stated lack of strength and coordination as a limitation: Yes. I can eat with it but I have trouble because of the lack of strength, of putting the fork down through something to cut it. And to put it in my mouth I usually have to take my forefinger on the left hand and push down the side of the fork to get it through. Other than that, I guess I'm okay. (5262, Interview 2) IADLs. Unsurprisingly, as most participants were nearing a modified but generally independent approach to dressing and bathing at the two-week mark, most required no assistance with ADLs but significant assistance with IADLs. Most notably, and despite increased independence with self-feeding, many were still receiving assistance for meal preparation. Participant 5262 spoke of her daughter providing assistance, " She'll come in and bring supper to us or something like that when she comes so I don't have to really cook and so that's good (5262, Interview 2). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 39 Another area many participants stated receiving assistance with was housekeeping, most notably laundry. My daughter does my laundry, and she's been coming over, she'll change my bed. I have had a lady, she came in and cleaned (9866, Interview 2). Several participants found themselves returning to IADL activities throughout this reporting period, such as participant 9245 who stated, I can load and unload the dishwasher. I can load and unload the washer and dryer, and I can run the vacuum with my left hand in the kitchen and the living area. You can do most things that you want to.Most things that you really want to do you can figure out a way to get them done without getting yourself in trouble. (9245, Interview 2) Another large area of assistance reported was driving. Well, I've not been able to drive, so that's been one of the worst parts. But I've got this good friend that comes and gets me and takes me to church and different places. (1946, Interview 2). Many participants were able to drive by the four-week mark, despite difficulty with tasks such as turning the key in the ignition (primarily reported with right-sided surgery), or difficulty opening the door (more often with left-sided surgery). Other participants, such as Participant 4648, reported being released to drive but self-limiting for safety concerns: I'm not driving yet. Until I get good use of my right arm, I'm not going to, because I just, I don't want to endanger myself or anybody else. So, I just feel like it's better if I just be driven around, and let the wife do the driving. (4648, Interview 2) Despite limitations in driving, participants reported being much more active in weeks three and four post-surgery as compared to the first two weeks immediately following surgery. All participants reported they had returned to church, were able to complete errands, and returning to social activities. Some reported less desire to get out, Well yesterday I thought, oh PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 40 I really should go shopping, and look for a dress, but I decided not to. It wasn't worth the effort of getting in the car, driving, and being tired. (1109, Interview 2). Another reported decreased motivation to get out in public due to hassle: Just how immobile you feel sometimes, or little simple things you feel like, "Boy that took me twice as long to do that as it should have.. just dressing and undressing, and you can't tie your shoes so, you tie 'em first and then try to get 'em on, just little things like that.(9245, Interview 2) While many participants stated their thankfulness for those willing to help, others worried they were becoming an encumbrance for those providing assistance, such as participant 5262: She stops in about every other day for me. She's gone back to work and she's got a lot of meetings at night and things like this that she has to deal with and so I told her, There's no need to come every day. 5262, Interview 2). Likewise, another participant stated concern for caregiver, I don't want to wear everybody out so I switch around (1946, Interview 2). Despite concerns for those offering assistance, many recognized the need for assistance to ensure compliance with their surgical protocol, I want to do more with my arm than I'm really supposed to do (4648, Interview 2). Pain. Pain continued to be a limiting factor in many ADLs and IADLs, as previously stated, but most participants were generally very surprised regarding the level of pain they experienced at four weeks following surgery. I've really not had that much pain. I know that's crazy, but I haven't.It's just a little bit sore. But it really doesn't hurt (1946, Interview 2). When reporting pain, most reported early morning to be the most painful, with a few patients reporting pain waking them from their sleep. With the progression of therapy from Immediate PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 41 Postoperative Phase (I) to Early Strengthening Phase (II), it is unsurprising that many reported pain and soreness following exercise, such as reported by Participant 0555: Yeah, I mean I can move my arm around and stuff pretty decent, but I still have a lot of, not a whole bunch of pain but I still have pain in the back part of my ... as far as moving it around and stuff it seems like it's okay. (0555, Interview 2) Participants reporting pain stated utilizing primarily over-the-counter pain relievers for reprieve from pain. Many, such as participant 5262, reported not utilizing prescription pain relief in quite some time, I havent taken a pain pill probably in two or three weeks (5262, Interview 2). Several noted not having utilized their Polar Cube or other forms of cryotherapy, though a few mentioned utilizing a form of cryotherapy intermittently, I only do it usually after Ive done my therapy, just to take the soreness out (3206, Interview 2). All participants in this study have been diagnosed with osteoarthritis, and a number of participants stated utilizing pain relief options for other joints or questioned OA as a contributor to pain: Researcher: On a scale of one to ten, how is your greatest pain? 9866: Oh, well, you know, it's kind of hard to tell if it's the arthritis or it's my shoulder pain. I would say, oh, maybe a three. (9866, Interview 2) Therapy progression. Participants reported various progress in a multitude of areas, as previously illustrated by increased independence in ADLs and IADLs. Unlike the first interview, the second interview at four weeks following surgery found participants in various stages of their SA protocol due to the requirement that patients achieve all criteria from previous stage to progress to subsequent stages (in this case, Immediate Postsurgical Phase to Early Strengthening Phase). By this stage, most had phased out of Home Healthcare Services and had transitioned to Outpatient Therapy services. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 42 The most notable difference between participants in regard to their progression in therapy services is amount of shoulder flexion achieved at four weeks post-surgery. Participant 0555 noted he could raise his arm almost all the way straight up, while it seemed the majority were between 90 125 degrees shoulder flexion. Often, this flexion was completed in supine or with use of another device to support active-assisted range of motion, Well, I'm not really trying to do it myself, they told me not to. I can do it with pulleys, and I can get it almost all the way vertical (3206, Interview 2). At this point per protocol, most movement is passive or activeassisted range of motion: rehab has been going really well. Now today is four weeks since surgery, so now tomorrow they'll have me doing I guess some stuff on my own. Up till now everything's been passive. At least that's what they said was going to happen. I'm well ahead of when they take the angle measurements and all that stuff. I'm well ahead of where they think I oughta be. (4648, Interview 2) Similar to the variety of responses regarding shoulder flexion, each patient reported a variety of exercises to be completed with outpatient therapy. Participant 1109 described her exercises as: Well the pendulum, and the swinging back, and forth, and sideways. I do table top one forward, and then sweeping. I do a lay in the bed, and raise a cane up over my head, and then also just up in the air. And the hand exercise, and just dropping the hand down from the shoulder, and letting it hang.(1109, Interview 2) Similarly, Participant 3126 reported on his exercises: I've got I guess 11 different exercises that I do now. I do the pendulum yet, the ball. I'm using a five-pound weight for biceps and range of motion. Also, the five-pound weight PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 43 for the two wrist exercises. I'm using the dowel rod for the lateral motion of the shoulder to rotate. (3126, Interview 2) Regarding therapy progression, a few participants emphasized that stretching of the muscles as a large factor of recovery, as noted by Participant 5262: They gave a different one that you do that's supposed to stretch the same muscles. It's taking a yard stick and that and holding on to it on each end and bringing it up slow over my head and holding it there, and then bringing it back down slow. (5262, Interview 2) Participant 3126 reported similar therapy interventions at this time period, as well: [the therapist] makes sure that he stretches the muscles. He's even been putting my neck in traction physically with his hands to help hopefully reduce not only the swelling, but the pressure on the nerves from my neck down to my hand. He really has relieved in the pectoral muscles and the arm shoulder muscles ... He stretches those and massages them to relax them, so they're not pulling so tight. That's helped a lot. That's something that I really can't do here at home with the physical exercises that I do. So, the outpatient therapy on location is a huge help. (3126, Interview 2) It appeared that many participants were motivated by their therapy sessions and found improvement in daily tasks due to therapy. One participant specifically noted feeling motivated by his progress, and another stated confidence due to his therapy: Yeah, I'm gaining a lot more confidence in doing things. Since I've been doing the physical therapy and actually building strength, I'm getting the confidence to go ahead and do things. I can tell what my limitations are, so I know when to stop, so to speak. (3126, Interview 2). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 44 However, not all participants were being followed formally by a physical or occupational therapist, due to insurance constraints. This participant reported having family assistance once to twice daily to perform range of motion exercises, as well as completing the Home Exercise Program provided during her hospital stay. They gave me exercises from the hospital. He wanted me to do them all until the 8th of April. That's when I go back, and he said he would give me some more different ones to do then (1946, Interview 2). Interview Three For the final interview, most patients had progressed to the Early Strengthening Phase of rehabilitation, and some had continued to the Moderate Strengthening Phase. Criteria for progression to the next phase includes: tolerates PROM/AAROM isometric program, achieves at least 140 o PROM flexion, achieves at least 120 o PROM abduction, achieves at least 60 o PROM ER in plane of scapula, achieves at least 70 o PROM IR in place of scapula measured at 30 o of abduction, and be able to actively elevate shoulder against gravity with good mechanics to 100 o. Again, due to the progressive nature of this protocol, patients were progressing toward a variety of goals in this time period. However, overall themes were that of progression during this interview. One participant summed up his experiences at six-weeks post-surgery as: I have some good days, and I have some bad days. And I just got through with my exercises, and I'm getting ready to go to [outpatient therapy] and I've got an appointment with them today, twice a week down there. But it's doing all right, I can move it better. (3610, Interview 3) General progression. Most participants noted having recently returned from their sixweek postsurgical appointment with the surgeon during their third interview. I went to the doctor today and he said I wouldn't have to wear the sling anymore and I could start the normal PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 45 activities (9245, Interview 3). Nearly all participants reported discontinuing the sling, entirely or throughout most of the day, per MD recommendation at their six-week checkup, and none stated fear or anxiety regarding not wearing sling. I've abandoned the...sling. I don't wear it anymore because I'm confident enough that, it, everything seems to be okay (4648, Interview 3). All participants stated that the surgeon was pleased with their progress at their checkup, with 3126 reporting: I think Dr. Abeln was actually, in a way, stunned when I showed him my range of motion with my shoulder out in front and straight up and out to the side and up. He said, "My goodness, that's wonderful." I'm very pleased. It certainly was worthwhile having the surgery because before I couldn't lift up to 45 degrees, just my arm, much less try to raise something up or lift something on a top shelf or anything. I couldn't do it. (3126, Interview 3). Others reported some anxiety regarding seeing the surgeon, such as participant 3610 who returned to the doctor approximately one week before his scheduled checkup due to pain. I hurt my shoulder. That's why I had to go back, make an appointment to see him. And I thought he was going to get all over me for doing it. And I told him. I said, "I didn't mean to do this, And he said, "I'm here to help you." That's all he said. (3610, Interview 3) One of the most noteworthy areas of progression during weeks four through six following surgery was that of decreased pain. I call it soreness. When I'm not using it, it's just dull feeling. It's not pain at all. But when I use it there's some, two and a half, three (1109, Interview 3) reported one participant, while another stated Well, before I had the surgery, my shoulder and arm ached all the time, almost 24/7. It seems like I just couldn't get any relief from it. I had PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 46 the surgery and I haven't had that problem (5262, Interview 3). Participants noted pain generally resulting from therapy sessions or new activity/stretches, and about half the participants employed any type of intervention for pain, I take arthritis, Tylenol Arthritis, but I had been taking that prior (9866, Interview 3). Others stated the pain was fleeting, and not worth treating, I get a pain. It's just, it's here and gone, it's not a bad thing (5262, Interview 3) ADL and IADL progression. Unsurprisingly, sleep was a major area of improvement in this reporting period, likely due to the decrease in pain and, in some cases, total discontinuation of the abductor sling. One participant noted continuing difficulty with sleeping in the sling, while most reported significantly improved sleeping since discontinuing the sling. Participant 1946 reported being able to sleep uninterrupted by pain: This last seven or eight days, I've been able to sleep in the bed. I rolled the towel up to put under my arm. I went to bed at a quarter to 9:00 last night. Then, I didn't wake up until 6:00 this morning. (1946, Interview 3) Similarly, very few were reporting difficulty with dressing tasks. Few reported difficulty with upper body dressing, specifically with coats and jackets, I can put my shoes, socks on, put my...pants on. I can do all that, it's just my outer shirt and my coat that I have ...trouble with (4648, Interview 3). This was not a common theme during this interview, but it may have been more prevalent due to the time of year/season when most third interviews were completed. In regard to ADLs and IADLs, a few participants reported already being more independent than before surgery, Well before the surgery, and stuff it was really hard to move it around hardly at all, lift anything with it. But I still can't lift anything, but I know eventually I will. Before I couldnt reach up to get anything off the shelf or anything like that. (0555, Interview 3) PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 47 Mostly, participants required some modifications and assistance with IADLs, such as opening a jar and lifting heavy objects (1109 Interview 3, 9245, Interview 3). I can't pick up anything heavy but normal activities I'm okay. I can drive. I can load the dishwasher, the washing machine, run the vacuum. Normal activities like that I can do (9245, Interview 3). Those that required assistance from others were often tasks requiring driving or cleaning, and at times requiring assistance due to home set up, such as participant 9866: Researcher: Sure. Are you able to get your own groceries at this point? 9866: No, my daughter's still doing my shopping. Doing my laundry.I just don't feel like I can ... Because our laundry is ... We have one here in the complex, but it's like oh, a good block away. I would have to load the car and drive over and I can't lift that much yet, so yeah, she's okay with doing that.And still have a cleaning lady because ... And I may just keep her on because of the other arm not really good. It's really hard to vacuum. Researcher: Did you have that cleaning lady before surgery or is this9866: No.and like I said, I think I'll just keep her on. (9866, Interview 3) All participants had been released to driving at this time period, and the majority of participants were driving frequently. However, driving was not always without modification. I'm using both hands as much as I can but gripping the steering wheel with my right hand, it gets to a point where I have to let it off and let it rest a little bit. Just getting in and out of the car, closing the doors, lifting the tailgate on the wife's Toyota Prius, things like that [require modification]. (3126, Interview 3) Unsurprisingly, with the improvement in ADL and IADL status, and most participants returning to driving, there was also a large portion of participants who were returning to more social PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 48 activities. When asked about social life and relationship with others, participant 9866 reported little change at this time period than before surgery: 9866: I still do stuff with my daughter and she and my grandson and his fiance and my brother-in-law, we went out to dinner Saturday night. No, I don't think it's really ... It did in the first couple of weeks, but lately it's been no different. Researcher: Do you feel like you're much more active these last couple weeks than the first few? 9866: Well, definitely than the first couple, two or three anyway, because I didn't want to go anywhere, you know? (9866, Interview 3) Therapy progression. Despite being in different phases of their rehabilitation programs, all participants noted a steady progression in both types of exercise as well as shoulder flexion. Nearly all participants had begun outpatient therapy sessions, with two participants planning on beginning their outpatient therapy in the next week. Participant 9866 described her exercises in outpatient therapy as: the same ones that PT and OT had given me. The hand, the wrist, the elbow, the pendulum, and then lying on the bed, raising the arms up over your head, and then straight up like you were doing a pushup. .And snow angel.And then sitting in a chair raising the arms straight up. On the table, a forward and backward with the arm like you're cleaning, scrubbing, and then side to side. (9866, Interview 3) Participant 4648 described this change in therapy sessions as, Well, they give me a lot more to do. it seems to...work that shoulder awfully good. I've got to, where...they had me move it, somewhat on my own. Before the previous stages, I wasn't supposed to move it (4648, Interview 3). Another participant expressed that the progression was less painful than PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 49 anticipated, I'm doing strengthening exercises now, and I really expected to be kind of sore from that, but I'm not. So, it's really going well (3206, Interview 3). With this change in exercise, many noted an improvement with shoulder flexion I can get it way up. Not straight up but nearly (9245, Interview 3). Others noted a slower progression, but progression nonetheless, such as being unable to raise the arm above head unless being in gravity-eliminated position such as lying in supine. Overall, at six weeks following surgery participants reported satisfaction with progress to date, Yes, I'm pleased with my progress, a little impatient, but pleased anyway. (4648, Interview 3). Finally, participant 1956 stated, I can tell a difference in it practically every day (1946, Interview 3). Overarching Themes While some themes, such as assistance and modified routines as well as pain, were present in some capacity throughout all interviews, other themes were far more global in their application. These themes, categorized by Pre-Surgical pain and expectations, Satisfaction, and Advice, were noted throughout a variety of interviews in a variety of time periods. Pre-surgical pain and expectations. Expectedly, a large portion of participants in this study chose to pursue surgery due to pain. Most reported pain ranging from seven to ten on a ten-point scale, with a notable change following surgery. Its much better than what I expected (3206, Interview 1). One participant noted pre-surgical pain to be an 8-9/10 prior to surgery, and reported a 3/10 pain following exercise at six weeks following surgery (9866, Interview 3). Another participant stated the pain was constant and unrelenting, Well, before I had the surgery, my shoulder and arm ached all the time, almost 24/7. It seems like I just couldn't PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 50 get any relief from it. I had the surgery and I haven't had that problem. (5262, Interview 3). Not only was reported pain frustrating but also not predictable: I dont know what he did, but I know it's took away that pain that was in my shoulder. You never knew when that wasn't going to be there. It was like an electric shock is the only way I can describe it. Sometimes, it would hurt so bad that you'd almost feel like you was going to pass out.One day, I barely got in the door. I was trying to get in the door, and I don't know what. It was just like a real giant electric shock. I almost passed out. I managed to get in the house and sit down a little bit. (1946, Interview 3). Most importantly, participants stated their pain limited their daily activities, such as interacting with family: 5262: I had pain in it almost 24/7.Before I had the surgery. It was very depressing. I just, I felt horrible. Didn't want to do anything. Just wanted to sit and put ice packs on it. Then I'd rotate heat, whatever I thought ... would work. Researcher: Do you feel like it kept you from getting out and doing things socially or in public beforehand? 5262: Yeah, it did. It did. Things as little as, simple as playing with my great-grandkids. They wanted to climb up on my lap and things like that and it's hard. Or want me to pick them up and of course I can't do that. I sat down and they come and crawl on my lap and that. (5262, Interview 2) Many participants stated putting off surgery for a period of time before committing to the procedures, some for a few months while others stated several years. I just kept waiting for it to go away, but it never did (5262, Interview 3). Participant 3206 echoed this sentiment, I should have done it a long time ago, I know that (3206, Interview 1). Once committed to surgery, PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 51 many reported anxiety for the recovery process and fear of additional pain as reasons to prolong surgery. Participants reported talking to peers as well as other medical professionals regarding the surgery: Hell, to go through it, my [family doctor] told me that.He said, You've got a hard road to get through it, and everything. And he just let me know that it wasn't going to be easy. I went to see him right after I signed up to get the shoulder work done. I said, Well I want it done, I can't keep on. It's hurting me like it is, I can't use it much. I've got to do something." (3610, Interview 3) Similarly, participant 4648 reports, Well, everybody says, it was gonna hurt so bad, and it really hasn't hurt, and that was...kind of one of the things I was worried about, but...if I'd known before, I'd had this done a lot earlier (4648, Interview 3). However, when asked what the most surprising aspect of recovery was, Participant 1946 stated, how painless it was (1946, Interview 2). Another participant reflected that the process was, amazing, because I've suffered with it for years, really (3206, Interview 2). Satisfaction. Following surgery, nearly all participants were pleasantly surprised at the change in their shoulder, if not their lifestyle in general. If I had known it would've been this easy, I'd of had it done at least a year and five or six months ago (1946, Interview 3). Participants noted not only decreased pain, but relief to have the procedure completed and satisfaction with the surgeon, I'm just glad I decided to have it done, you know, and I'm glad that I picked a good doctor (3610, Interview 3). Likewise, participant 5262 noted his appreciation for medical support staff: PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 52 I just think it was wonderful to go through what I went through with such nice people.I mean, the doctor was very upfront with me with all this stuff. [Nurses and therapists] who helped me, really did a great job, I think (5262, Interview 3). A number of participants reported being so pleased with their surgery and recovery that they had already begun planning a subsequent shoulder arthroplasty. 4648: My left arm...my left shoulder, hurts much more than my right one does I plan on, next fall, getting it taken care of. Researcher: Okay, did you anticipate you'd be in there that soon? 4648: No this [has] gone that well. (4648, Interview 3) Participant 5262 summarized pre-surgical expectations by stating, Actually, overall though, it was a real good experience compared to what I'd been living with (5262, Interview 1). Advice for future. Though not every participant was eager to schedule another total joint arthroplasty at six weeks following surgery, every participant did have advice for future patients pursuing SA: Be prepared in the first few weeks that it will be a little difficult. But believe me... after another four to six weeks, you're going to change your tune and you're going to be glad that you did do it.(3126, Interview 3) Another participant identified therapy as a point of advice for future surgical candidates: If you don't intend to do the therapy, then don't do the surgery. Because it will not work. You won't have the mobility that you thought you'd have, and you know, you may not have the stamina that you thought you'd have. But that just is a progressing thing, as you recover. (1155, Interview 2) PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 53 Finally, participant 1109 spoke to the need for assistance following surgery: I think I would have been better off with somebody here at the house. They weren't here all the time. They were here at night and a couple times during the day but there were a few times when I needed them for the first five or six days. Researcher: Okay, if you had to put a time frame on it, how long do you think that people would need 24 hour care? 1109: Oh, four days, I guess.Maybe not even 24 hour care. Say 18 hour care. (1109, Interview 3) However, the majority of participants stated the benefit of the procedures as their main takeaway point. it's worth...the effort. You just gotta do your exercises and do your rehab (4648, Interview 3). Correspondingly, participant 5262 stated, Well, like I said earlier, if you're hurting, get it fixed. Don't wait around and suffer in pain (5262, Interview 3). Participant 3206 echoed this sentiment, stating, I wouldn't tell anybody to be afraid of it. At least two weeks in, I'm much better than I was for that three months that I put up with it, not doing anything about it (3126, Interview 1). Participant 9245, while reflecting on her thoughts regarding surgery as well as her advice for future candidates expressed her appreciation for the outcome of her surgery Its going to be a whole new world for me (9245, Interview 3). Discussion Regarding the participant demographics, there were very few surprises based on the previous research. Because RSA is the primary surgical option for patients with rotator cuff disease, and research that the rotator cuff may be contracted in those with OA, it is unsurprising that all participants in this study underwent an RSA surgery (Edwards et al., 2002; Palsis et al., PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 54 2018; Westermann et al., 2015). A few patients noted they requested or required additional time during their hospitalization, which is also consistent with previous literature stating RSA patients had higher rates of extended hospitalizations than those patients undergoing TSA (Jiang et al. 2014). However, no descriptive information was obtained regarding past medical history, and this study did not extend long enough to observe revision and complication rates that were linked to RSA in previous research. Furthermore, inclusion criteria for this study was for potential participants to discharge to home environment (not to an inpatient rehabilitation setting) following hospitalization, and thus the statistic of 53% of RSA patients returning home following surgery was not directly connected to this study (Ponce et al. 2015). It is worth noting that one participant in this study did discharge to a friends home, and the need for assistance was an overarching theme from this study. Finally, in regard to literature regarding age differences in RSA, no significant changes were noted between participants with differing ages in this study (Iriberri et al., 2015). In regard to recovery, the protocol utilized by the surgeon in this study mirrors Neers protocol with minimal deviation. Participants reported being immobilized with abductor sling and restricted to primarily PROM during the first few weeks of recovery, and progressed to nearly full ROM and strengthening by the last interview at six weeks following surgery (Denard & Ladermann, 2016; Wilcox et al., 2005). Unsurprisingly, patients reported assistance and modification required during the first two interviews due to protocol restrictions, and were nearly independent by the last interview when protocol allowed for AROM (Wilcox et al., 2005). Most participants were progressing well at six weeks, returning to normal life but continuing therapy for strengthening. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 55 However, one patient in this study did not follow up with home healthcare services or outpatient therapy at any point following hospitalization and instead had exercises prescribed by the surgeon to complete at home. While previous research may question the protocol necessity and/or therapeutic process, most researchers agree that the success of the procedure relies heavily on the soft tissue variables and the postoperative management (Denard & Ladermann, 2019; Mulieri et al., 2010; Wilcox et al., 2005, p. 827). This specific participant continued to progress well despite a prolonged immobilization period. However, her AROM was reported to be slightly behind those participants who pursued therapy services and she progressed through the phases of Neers protocol much slower than others, prolonging her rehabilitation period. No objective assessments of function were included in this study with exception of patient reported shoulder flexion, which in many cases were broad and more functionrelated. Similarly, no specific preoperative vs. postoperative functions were recorded in this study; therefore, no connection can be directly made to previous researchers statements regarding objective assessments as important outcome measures. However, the return to ADLs and IADLs coincided with decreased frustration among participants which is similar to the study completed Hall et al., (2008) which identified frustration and inadequacy as common emotions in orthopedic surgeries. This same study also indicated that requiring assistance from others for ADLs and IADLs was a breakpoint for patients realizing arthroplasty was required, and provides insight into the association with ADL/IADL dependence and frustration within this study (Hall et al., 2008, p. 172). One potential deviation from previous research noted in this study is the time in which patients returned to multiple functional activities. While no formal assessments, such as the DASH, were completed within this study, multiple participants were reported as returning to PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 56 preparing meals, making a bed, using utensils to cut food, sleeping, and placing an item on an overhead shelf within the six weeks of this study all tasks that are rated on the DASH assessment (Hudak, Amadio, & Bombardier, 1996). A study by Hurd et al. (2018) noted no changes in preoperative DASH scores and those collected at two months following surgery. However, Hurd et al. (2018) did note scores between two months and the next reporting period to have demonstrated a 28% (45% impairment to 17% impairment) improvement in independence levels Therefore, it is anticipated that participants in this study may have demonstrated a more rapid progression on the DASH measure. This example of progression of recovery and return to ADLs and IADLs aligns with a study by Lawrence, Ahmadi, Sanchez-Sotelo, Sperline, & Cofield (2012) which identified SA patients returning to low, medium, and high-demand activities. The researchers reported that the majority of patients were able to return to low demand activities, such as cooking and driving, and the greater part of most participants were able return to medium-demand activities such as gardening, lawn mowing, and aerobic activities (Lawrence et al., 2012). Though the questionnaire was sent an average of three and a half years following surgery, the majority of participants also returned to low-demand activities in the six-week duration of the study (Lawrence et al., 2012). Furthermore, some participants returned to medium- and high-demand activities in the six weeks following surgery. As previously stated, patients reduction in pain is often closely associated with satisfaction, and multiple studies have demonstrated notable changes in preoperative and postoperative pain levels (Fenlin & Frieman, 1998; Hurt et al., 2018; Wilcox et al., 2005). This study did not seek to specifically address patient satisfaction, but the participants responses suggest that most were satisfied with their surgery as evidenced by some participants choosing to PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 57 undergo surgery on the opposite arm, or statements regarding their feelings that surgery was a worthwhile endeavor, such as participant 5262 stating, It was a real good experience compared to what Id been living with (5262, Interview 1). Also congruent to previous research is the reduction in reported preoperative and postoperative pain, as reported by participant 1946 stating, it's took away that pain that was in my shoulder (1946, Interview 3). As indicated in the literature review, preoperative education is linked with decreased anxiety (Flanigan et al, 2015). The importance of preoperative education is further emphasized by researchers noting preoperative expectations as a contributor to overall satisfaction after surgery (Neuprez et al., 2016). Preoperative expectations specific to shoulder arthroplasty have been cited as relief of pain (both night-time and day-time), improvement in self-care tasks, and specific IADL tasks such as driving (Rauck et al., 2019). This study provides specific insight into recovery regarding when these improvements may occur, which may increase patient satisfaction and, in turn, contribute to greater satisfaction with arthroplasty and subsequent rehabilitation. Research has frequently shown the importance of sleep (Tester & Floss, 2017), as well as the relationship between sleep hygiene, mental health, and pain (Argoff, 2017; Bjornsdottir, Josson, & Valdimarsdottir, 2014). Impaired sleep is not a new concept for patients with OA or musculoskeletal chronic pain, as researchers have indicated sleep disorders as an important patient problem (Bjornsdottir et al., 2014; Pickering, Chapurlat, Kocher, & Peter-Derex, 2016). Nocturnal pain and decreased sleep quality, such as fragmented sleep and sleep disturbances, are commonly found in patients with shoulder dysfunction and have been associated with anxiety and depression (Hawker et al., 2011; Morris, Sciascia, Jacobs, & Edwards, 2017; Taylor-Gjevre, Gjevre, Nair, Skomro, & Lim, 2011). Poor quality of sleep has also been linked to poor mental health and health-related quality of life (Taylor-Gjevre, et al., 2011). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 58 A notable observation in the current study is that frustration and sleep appeared to have an inverse relationship. Especially within the first few weeks, frustration was a significant theme within this study, with participants stating frustration with functional limitations and lack of independence. The same participants reporting frustration also reported poor sleep habits and routines, reportedly due to pain and discomfort. Though few studies offer insight to the acuterecovery period, researchers have found depression, anxiety, and sleep disturbances to be common occurrences in populations having pain for greater than three months (Cho, Jung, Park, Song, & Yu, 2013). Participants of this study certainly made mention of depression and anxiety, most frequently related to loss of function/occupation. Participant 5262 noted both depression regarding health status, as well as decreased quality of life, Things as little as, simple as playing with my great-grandkids. They wanted to climb up on my lap and things like that and it's hard. Or want me to pick them up and of course I can't do that (5262, Interview 2). This same participant also noted sleep interruption post-operatively, I've been sleeping mainly in the chair, recliner and that I have slept in the recliner until about 3:00 in the morning. Then I get up and I go lay in bed (5262, Interview 2). While this study did not specifically address pre-operative sleep hygiene or disturbances, given the length of time that many participants in this study stated they had waited to schedule surgery it is likely that participants were experiencing sleep disturbances. However, nearly all participants noted preoperative pain. Several participants noted taking over-the-counter arthritis drugs or opioids for pain both before and after surgery. Opioid usage has been linked to sleep disturbances (Mahfoud, Talih, Steem, & Budur, 2009), and pre-operative and prolonged usage was found to increase sleep disturbances postoperatively (Austin et al, 2015). Additionally, and PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 59 most notably for this study, chronic shoulder pain has reportedly been the strongest predictor for sleep disturbance (Cho et al., 2013). While many factors, such as increased age and severity of surgical trauma, are associated with the progression of sleep disturbances, pain is possibly the most important one (Su and Wang, 2018, p. 85). Conversely, sleep problems have also been linked with reduced pain tolerance (Sivertsen et al., 2015). Noted in this research was a decrease in pain occurring at the same time as an increase in sleep for most participants at approximately four weeks following surgery. Similar to participants of other shoulder surgeries such as rotator cuff impairment, the SA participants in this study noted the worst sleep quality in the first two weeks after surgery (Austin et al., 2015). While this study examined only the first six weeks following surgery, a notable improvement in sleep was noted following surgery. Continued sleep improvement has been identified as progressing until approximately 6 months postoperatively (Austin et al., 2015). The literature on shoulder arthroplasty is plentiful in terms of surgical procedure, longterm outcomes, and appropriate protocols for recovery. However, very little research has been focused on the patient experience of recovery or needs during initial recovery periods. This studys purpose of understanding how patients experience ADLs and IADLs during the first few weeks following arthroplasty addresses one of numerous gaps in literature regarding patient experience. Halawi et al. (2015) identified patient expectations following hip and knee arthroplasties as the most important predictor of discharge destination. Though this study only followed those discharging to a home-setting, it is anticipated that managing expectations of patients prior to shoulder arthroplasty, as well as throughout the rehabilitative process, is also likely to improve the success of surgery and rehabilitative success. This study, by providing PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 60 insight into the recovery process, may allow healthcare professionals to guide patients focus during the first few phases of shoulder arthroplasty recovery. Limitations This study is not without limitations. First and foremost, as with any qualitative research, there is risk of researcher bias affecting the results. This risk may be exacerbated in this study as the primary researcher is an occupational therapist, as well as the therapist who provided initial education for discharge from the hospital with the majority of these patients. However, the primary researcher was not linked therapeutically with any participant after hospital discharge. Another limitation of this study is the inclusion of only one hospital with one version of the modified Neers protocol. Length of hospitalizations as well as modifications in other protocols, though likely similar, could result in changes in recovery for patients. Additionally, each participant discharged to different home healthcare and/or outpatient therapists who may have interpreted the protocol slightly differently. Finally, there is little known regarding participants compliance with the protocol at home, which may have influenced perceived independence levels at each interview/phase of recovery. Implications for Future Research Even with the stated limitations, this study serves to highlight the patients subjective perceptions of rehabilitation during the postsurgical and early strengthening phases of total shoulder arthroplasty following shoulder arthroplasty. While this study is representative only of the twelve participants that were interviewed, it could provide insight for a variety of practitioners, including therapists and physicians, to guide patients throughout the recovery following shoulder arthroplasty. Future research into recovery following shoulder arthroplasty PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 61 could include a variety of surgeons, protocols, and facilities to further expand understanding of patients in the first phases of rehabilitations. A significant theme in this study was frustration with assistance required, which begs the question of the psychological processes a person may experience following joint arthroplasty, shoulder or otherwise. Participants in this study reported decreased social interaction, decreased independence, and reduced sleep quality which could lend well to depression, increased anxiety, and other psychosocial changes. For many, this surgery was their first-time requiring assistance with ADLs. Driving cessation has been linked to increased depression, so it is possible that despite the short duration there could be a plethora of potential for psychological change (Chihuri et al., 2016). Additionally, qualitative research to specifically identify when patients typically regained ability to complete ADLs and IADLs independently following surgery may be helpful to encourage patients during rehabilitation by reducing frustration and anxiety by providing patients additional insight into typical progression of ADL recovery. Another area of research that is relatively unexamined is the role of mental health following total joint arthroplasty. As indicated in the literature review, preoperative education is linked with decreased anxiety (Flanigan et al., 2015). Other researchers note connections between driving cessation and depression (Chihuri et al., 2016), Additionally, depression and anxiety symptoms following a total joint replacement in older adults were significantly higher than the general population (Scott, Mathias, & Kneebone, 2016). Researchers have also stated that mental health conditions are not a barrier to clinical performance and outcomes in shoulder arthroplasty (Wong et al., 2018). However, no studies were found examining the mental health status of patients who have recently undergone surgery and find themselves limited with driving and often dependent on others for daily care tasks. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 62 In relationship to additional research on mental health issues following SA, additional research is needed on the impact of sleep during this acute recovery period. Little research regarding sleep following arthroplasty has been completed, though a substantial amount of research has been completed linking sleep, pain, and mental health conditions. Though sleep is often thought to be a secondary concern, lack of sleep plays a critical role in daily function (Tester & Foss, 2018). Additional research regarding improving postoperative sleep is essential, including medication roles/changes, and practitioners may play in improving sleep. Occupational therapists have long-since identified sleep as an essential component of health (Meyer, 1922), and recognize the relationship of sleep with occupational participation (Gentry& Loveland, 2013). Occupational therapists, in addition to providing a vital role in pre-operative and postoperative education, also possess the understanding of arthroplasty, environment, routines, and other factors that affect sleep (Tester & Foss, 2018). Additionally, with roots in psychiatry OTs have rigorous training and preparation in the treatment and support of people with mental health disorders and have a unique focus on building habits and routines that support mental health and positive outcomes (Mental Health Promotion, 2017, p. 14). This gives OT a unique understanding of interventions to address sleep, pain, and mental health. Therefore, there is a dire need for researchers to examine the potential role OTs may play in the relationship between sleep, pain, and mental health not only postoperatively but throughout the progression of OA and other chronic diseases. One consistently reported theme in this research is that of assistance and modification. Frequently, participants reported relying on assistance from friends and family and often noted appreciation for the reported assistance. Unsurprisingly, caregiver support at home has been identified as a significant predictor of discharge following hip and knee total joint PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 63 arthroplasty, as well as an important part of recovery and transition to home (Halawi et al., 2015; Churchhill et al., 2018). However, the level of support required after arthroplasty in general, let alone shoulder arthroplasty specifically, is a largely under-researched topic. In addition to research needed on levels of assistance required following surgery, the caregivers perspective following arthroplasty has remained relatively ignored. One study by Zadzika et al. (2018) noted that caregiver burden following knee arthroplasty was significantly improved at one month vs. one year following surgery. Other researchers identified the importance of caregivers having their own support network following surgery (Churchill et al., 2018). It is worth additional effort to examine the caregiver experience and perspective in the first few weeks following shoulder arthroplasty. Future qualitative studies, including studies interviewing the caregiver, may provide more accurate insight into the recovery process of those who are dependent on others for assistance in the first few stages of rehabilitation as well as an understanding of caregiver burden. A caregiver perspective, in addition to patients perspective, may provide some insight into patients true needs, as well as validate participants statements regarding assistance required. To further elaborate on the caregiver role in recovery, research regarding caregiver education prior to surgery may be noteworthy. Several researchers have identified the importance of preoperative education for patients, with both short-term and long-term positive results (Cook, Walker, Aitken, Freeman, & Cantrill, 2016; Neuprez et al., 2016; Rauck et al., 2019). However, little to no research has been published regarding importance of caregiver education prior to surgery, or the implications this may have on transition to the home environment following surgery. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 64 Again, there is ample research regarding quantitative outcomes following shoulder arthroplasty, with little regarding patient and caregiver experience throughout the rehabilitative process. This leaves many areas yet to be explored. Of the research noted, the majority reviews long-term results, following up at one year or greater time periods. More research regarding recovery and acute progress is important to provide appropriate education for practitioner, patient, and caregiver. Conclusion The purpose of this study was to explore the patients subjective perceptions of rehabilitation during the postsurgical and early strengthening phases of total shoulder arthroplasty. Specifically, researchers sought to better understand patients views of recovery and their overall progression toward return to function. Within the first two to four weeks following surgery, participants reported a heavy reliance on caregiver assistance and/or modifications to their daily routines such as dressing, bathing, self-feeding, and sleep. Interruption in sleep patterns was largely reported due to pain and/or positioning restrictions, and frustration due to both lack of sleep and need for assistance was a noteworthy theme in the first phase of recovery. As participants progressed beyond wearing their abductor sling at all times, they reported a gradual return to ADLs with a simultaneous reduction in frustration. At approximately four to six weeks following surgery, patients noted a progression not only in ADL recovery but also IADLs, reportedly returning to tasks such as driving, cooking and meal preparation, as well as being more active and returning to social engagements. Overarching themes including pre-surgical expectations and advice for future patients, pain reduction, and general improvement in quality of life were reported throughout this study. While these results work to narrow the gap in research regarding patient experiences during the PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 65 rehabilitative process, there continues to be a need for additional research regarding the recovery process for both patients and caregivers. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 66 References American Occupational Therapy Association. (2017). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 61: S1-S48. Argoff, C. E. (2007). The coexistence of neuropathic pain, sleep, and psychiatric disorders: A novel treatment approach. The Clinical Journal of Pain, 23(1): 15-22. Auerbach, C.F., & Silverstein, L.B. (2003). Qualitative data: An introduction to coding and analysis. 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Switzerland: Springer International Publishing. 76 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 77 Participant Characteristics Table 1 Participants Characteristics Participant ID Surgical Arm Dominant Arm Sex Age 1109 Left Right Female 77 1155 Right Right Female 75 5262 Right Right Female 73 4648 Right Right Male 70 3126 Right Right Male 68 9866 Right Left Female 81 3206 Right Right Male 65 1946 Right Right Female 73 0003 Right Right Female 79 3610 Right Right Male 89 9245 Right Right Female 83 0555 Left Right Male 58 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY Theme Table: Interview 1 Table 2 Interview 1 Theme 1: Assistance and Modifications Participant # 3126 1155 3 4648 3206 Page/Line Participant Quote Well, as I mentioned earlier, if it wasn't for my wife, poor thing getting up at 4:00 every morning and really 3126 I1, 21381 taking care of me, it would have been a lot tougher, a 21636 lot tougher. So it does pay to have somebody that cares and will do anything to help you. I don't know what I would have done without her because I had it in my mind couple of years ago, I had 1155 I1, 3591 - knee surgery and of course, I went straight home and 3881 managed. I had it in my mind that's what I was going to do with the shoulder, but I quickly found out that that was not the case. Sub-theme Assistance and Modifications: Dressing Thank goodness, my old man took off work and he's been helping me get dressed. I can put on some stuff but some's impossible. Like tying your shoes. Sometimes if the shirt's baggy enough and got a big 3 I1, 1992 neck it goes on a lot easier. And of course you put on 3167 the bad side first. And really, really loose pants or leggings. I usually need help pulling them up, but if they're loose enough I can get them up most of the way on myself.... Underwear. I need some help with my underwear. Well, if it were a permanent thing, yeah we would get 4648 I1, 6064 - this straightened out.but because it's just going to 6292 be for a couple of weeks or three weeks or whatever, she's been bathing me and helping me dress. Sub-theme Assistance and Modifications: Bathing I had trouble even before I went in with my washing my head. My right shoulder was the one that was 3206 I1, 6152 - damaged, and it was very hard. I couldn't hardly ... 6448 well, most of the time I couldn't get my right hand up to work in the lather. I had to do it all with the left hand, so that's a difference now. 78 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 3610 3610 I1, 2419 2589 She helped me bathe here, up till yesterday, and I think I did it today by myself, you know, so it's just getting a lot better for myself, you know, and everything. Sub-theme Assistance and Modifications: Sleeping It's because of the sling. I'm a side sleeper. It's just 4648 I1, 2917 4648 kind of uncomfortable, the sling is, with that big 3100 padding Still on the couch. In bed there's really no easy way to stay propped up and keep something under my right elbow for support. And with on the couch ... I can't 3126 I1, 4950 3126 sleep in my recliner because all recliners have the 5426 release on the right side....So our couch has ... It's motorized for foot rests on either end so I sleep on the left side so I can control that. Sub-theme Assistance and Modifications: Other ADLs and IADLs Any other tasks that are really up there, really 4648 I1, 7973 - challenging for you? 4648 8117 4648: Yes, cleaning myself after a bowel movement. That's difficult. They're helping with some of the cleaning and stuff 555 I1, 6493 - like that, things that I'm not able to do, take out 555 6813 garbage or something heavy, like garbage or something. 9245 9245 I1, 4395 4691 I have done very little housework. I can load the dishwasher. I can put clothes in the washer and take them out of the dryer with one hand. Instead of carrying four or five things, I may carry two or three, and put them away. Theme 2: Frustration 9245 5262 9245 I1, 6547 7025 I'm just an impatient person. And I expected to be better quicker.....There's only some things you can do, and some things you can't. And you just gotta go with that. A lot of sitting around. I try not to do too much of that. Try to be a little more active than ... 5262 I1, 4954 5284 Well, just being able to get around and do things. I'm a person that likes to try to do stuff for herself. It's hard for me to ask, so you know, it's been hard for me to say, "Can you do this for me? Can you go get me this?" Or something like that. I don't know. I've always been that way, so I guess it's I've been the caregiver. 79 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 4648 4648 I1, 8740 9001 3206 3206 I1, 7328 7455 Theme 3: Pain All I heard everybody say was how painful it was and I have had no pain. And that surprised me. And I thought, well when that block wears off, yeah, we're going to have some fun, but no. I mean it has been pain free I guess I was expecting a lot more pain than I have now because I've had rotator surgery on both shoulders and that was brutal. 80 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY Theme Table: Interview 2 Table 3 Participant # 1946 4648 1109 9245 5262 Interview 2 Theme 1: Assistance and Modifications Page/Line Participant Quote Well, I've not been able to drive, so that's been one of the worst parts. But I've got this good friend that 1946 Int 2, 5569 comes and gets me and takes me to church and - 6191 different places.You don't realize how nice people are until something happens. Well, it just seems that I want to do more with my arm than I'm really supposed to do. So I have to be mindful, don't pick this up, don't ... I'm not supposed to put my arm behind my back, and when you're 4648 Int 2, 3289 pulling your pants up you wanna put your arm behind - 3816 your back a little bit, so I gotta watch that. Let's see what else ... And at night, I sleep with a pillow under my arm and I've gotta make sure I keep it on that pillow. Those are just problems that I'm having right now. Just trying not to use it but wanting to use it. Sub-theme Assistance and Modifications: Sleeping And I'm sleeping in my bed. And last night I didn't 1109 Int 2, 1179 sleep with the brace on, but I think I'm going back to - 1341 it. Seemed like my shoulders hurt without it .. Well, I don't sleep very well at night.But I do sleep. I can get up and get on the couch and I've got pillows 9245 In 2, 1955propped up there and then I can lay on my side and 2295 rest my back against the back of it, and it takes some of the weight off. Sub-theme Assistance and Modifications: Eating Yes. I can eat with it but I have trouble because of the lack of strength, of putting the fork down through something to cut it. And to put it in my mouth I usually have to take my forefinger on the left hand and push down the side of the fork to get it through. Other than that I guess I'm okay. 5262 Int 2, Researcher: What about cutting things? 12438 - 13118 5262: Cutting I have done a little. I haven't done a lot. I don't know, it seems like it's okay. I can handle it pretty much. I made hash the other day and I cubed up the potatoes for that. It's just, you have to learn how to do it as far as slicing them and quartering them and all that kind of stuff. 81 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 1109 9866 5262 555 1946 3126 4648 Researcher: Okay. Are you able to cut your food with both hands, and? 1109 Int 2, 6514 1109: Oh well let's see. I am now. At first I had - 6928 somebody cut up like a pork chop for me. I can now. Sub-theme Assistance and Modifications: IADLs Well, my daughter does my laundry, and she's been 9866 Int 2, 1843 coming over, she'll change my bed. I have had a lady, - 2162 she came in and cleaned. Researcher: Is your daughter still coming by to help you with anything? 5262: She just left here actually. She stops in about every other day for me. She's gone back to work and 5262 Int 2, 6187 she's got a lot of meetings at night and things like this - 6628 that she has to deal with and so I told her, "There's no need to come everyday and that." She'll come in and bring supper to us or something like that when she comes so I don't have to really cook and so that's good. Theme 2: Pain Yeah, I mean I can move my arm around and stuff pretty decent, but I still have a lot of, not a whole 0555 Int 2, 2163 bunch of pain but I still have pain in the back part of - 2395 my ... as far as moving it around and stuff it seems like it's okay. No. I've really not had that much pain. I know that's 1946 Int 2, 3335 crazy, but I haven't.. It's just a little bit sore. But it - 3611 really doesn't hurt. Theme 3: Therapy Progression Yeah, I'm gaining a lot more confidence in doing things. Since I've been doing the physical therapy and 3126 Int 2, 9320 actually building strength, I'm getting the confidence - 9578 to go ahead and do things. I can tell what my limitations are, so I know when to stop, so to speak. rehab has been going really well. Now today is four weeks since surgery, so now tomorrow they'll have me doing I guess some stuff on my own. Up till now 4648, Int 2 1355 everything's been passive. At least that's what they - 1706 said was going to happen. I'm well ahead of when they take the angle measurements and all that stuff. I'm well ahead of where they think I oughta be. 82 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY Theme Table: Interview 3 Table 4 Interview 3 Theme 1: General Progression Participant # 9245 5262 Page/Line Participant Quote 9245 I3, 4061 4280 [The surgeon] thought I was doing very good and didn't have to wear the sling anymore and I could start my normal activities, you know, using that arm. But if it got to hurting, then just back off. 5262 I3, 5711 5964 Well, before I had the surgery, my shoulder and arm ached all the time, almost 24/7. It seems like I just couldn't get any relief from it. I had the surgery and I haven't had that problem Theme 2: ADL and IADL Progression 4648 4648 I3, 3350 3502 I can put my shoes, socks on, put my...pants on. I can do all that, it's just my outer shirt and my coat that I have...trouble with. 9245 9245 I3, 8838 1021 Well, I can't pick up anything heavy but normal activities I'm okay. I can drive. I can load the dishwasher, the washing machine, run the vacuum. Normal activities like that I can do. Theme 3: Therapy Progression 3206 3206 I3, 3 1005 - 1135 1946 1946 I3, 2107 2498 I'm doing strengthening exercises now, and I really expected to be kind of sore from that, but I'm not. So, it's really going well. He told me I could start lifting weights. By the sixth week, I should be lifting up to 10 pounds. He was really pleased with me. You could tell because he was just so happy. The first thing he said when I went in, "How's your pain?" I said, "What pain?" 83 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 84 Theme Table: Overarching Themes Table 5 Overarching Themes Theme 1: Presurgical pain and expectations. Participant # Page/Line Participant Quote 5262 5262 I2, 9744 10425 5262: I had pain in it almost 24/7.Before I had the surgery. It was very depressing. I just, I felt horrible. Didn't want to do anything. Just wanted to sit and put ice packs on it. Then I'd rotate heat, whatever thought I ... would work. Researcher: Do you feel like it kept you from getting out and doing things socially or in public beforehand? 5262: Yeah, it did. It did. Things as little as, simple as playing with my great-grandkids. They wanted to climb up on my lap and things like that and it's hard. Or want me to pick them up and of course I can't do that. I sat down and they come and crawl on my lap and that. 4648 4648 I3, 8084 8286 3206 3206, I3, 5294 5375 9245 3126 1155 Well, everybody says, it was gonna hurt so bad, and it really hasn't hurt, and that was...kind of one of the things I was worried about, but...if I'd known before, I'd had this done a lot earlier Theme 2: Satisfaction If I'd have known it was this easy I'd have done it a long time ago, I know that. 9245 I3, 2803 It's going to be a whole new world for me. 2851 Theme 3: Advice for future. I wouldn't tell anybody to be afraid of it. At least two 3126 I1, 19288 weeks in, I'm much better than I was for that three 19454 months that I put up with it, not doing anything about it. 1155 I2, 13529 13826 If you don't intend to do the therapy, then don't do the surgery. Because it will not work. You won't have the mobility that you thought you'd have, and you know, you may not have the stamina that you thought you'd have. But that just is a progressing thing, as you recover. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 85 Appendix A Shoulder Replacement Protocol Phase I: Immediate Postsurgical Phase Goals: Allow healing of soft tissue Maintain integrity of replaced joint Gradually increase passive range of motion (PROM) of shoulder, restore active range of motion (AROM) of elbow/wrist/hand Reduce pain and inflammation Reduce muscular inhibition Independence with activities of daily living (ADLs) with modifications, while maintaining the integrity of the replaced joint Precautions: Sling should be worn continuously for 4-6 weeks While lying supine, a small pillow or towel roll should be placed behind the elbow to avoid shoulder hyperextension/anterior capsule stretch/subscapularis stretch Avoid shoulder AROM No lifting of objects No excessive shoulder motion behind back, especially into internal rotation (IR) No excessive stretching or sudden movements (particularly external rotation (ER)) No supporting of body weight by hand on involved side. Use a platform walker as needed Keep incision clean and dry (no soaking for 2 weeks) No driving for 3 weeks Postoperative Day 1 (in Hospital) Passive forward flexion in supine to tolerance, no range of motion restriction Gentle ER in scapular plane to avoid PROM past neutral unless indicated. (attention: DO NOT produce undue stress on the anterior joint capsule, particularly with shoulder in extension). In general reverse total shoulders will not have external rotation restrictions. Standard arthroplasty will always have an external rotation limit. Limit will be in the therapy order Passive IR to chest Active distal extremity exercise (elbow, wrist, hand) Pendulum exercises Frequent cryotherapy for pain, swelling and inflammation management Patient education regarding proper positioning and joint protection technique Early Phase I (out of Hospital) PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY Late Phase I 86 Continue above exercises with passive forward flexion as tolerated Ok to begin pendulum and pulley forward flexion Begin scapula musculature isometrics/sets (primarily retraction) Continue active elbow ROM Continue cryotherapy as much as able for pain and inflammation management Continue previous exercises Continue to progress PROM as motion allows Begin assisted flexion, abduction, ER, IR in the scapular plane Progress active distal extremity exercise to strengthening as appropriate Criteria for progression to the next phase (II): Tolerates PROM program Achieves at least 120 PROM flexion Achieves at least 90 PROM abduction Achieves at least 70 PROM IR in plane of scapula measured 30 of abduction Phase II: Early Strengthening Phase (Not to begin before 4 to 6 weeks post-surgery to allow for appropriate soft tissue healing.) Goals: Restore full passive ROM Gradually restore active motion Control pain and inflammation Allow continue healing of soft tissue Do not overstress healing tissue Re-establish dynamic shoulder stability Precautions: Sling should only be used for sleeping and removed gradually over the course of the next 2 weeks, for periods throughout the day While lying supine, a small pillow or towel should be placed behind the elbow to avoid shoulder hyperextensions/anterior capsule stretch In the presence of poor shoulder mechanics avoid repetitive shoulder AROM exercises/active against gravity No heavy lifting of objects (no heavier than coffee cup) No supporting of body weight by hand on involved side No sudden jerking motions Early Phase II Continue with PROM, active assisted range of motion (AAROM) Begin active assist flexion, IR, ER, abduction pain-free ROM AAROM pulleys (flexion and abduction), as long as greater than 90 of PROM Begin shoulder submaximal pain-free shoulder isometrics in neutral Scapular strengthening exercises as appropriate PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 87 Begin assisted horizontal adduction Progress distal extremity exercises with light resistance as appropriate Gentle glenohumeral and scapulothoracic joint mobilizations as indicated Initiate glenohumeral and scapulothoracic rhythmic stabilization Continue use of cryotherapy for pain and inflammation Late Phase II Progress scapular strengthening exercises Criteria for progression to the next phase (III): Tolerates PROM/AAROM isometric program Achieves at least 140 PROM flexion Achieves as least 120 PROM abduction Achieves as least 60 PROM ER in plane of scapula Achieves as least 70 PROM IR in place of scapula measured at 30 of abduction Able to actively elevate shoulder against gravity with good mechanics to 100 Phase III: Moderate Strengthening (Not to begin before 6 weeks post surgery to allow for appropriate soft tissue healing and to ensure adequate ROM.) Goals: Gradual restoration of shoulder strength, power and endurance Optimize neuromuscular control Gradual return to functional activities with involved upper extremity Precautions: No heavy lifting of objects (no heavier than 3 kg) No sudden lifting or pushing activities No sudden jerking motions Early Phase III Progress AROM exercise/activity as appropriate Advance PROM to stretching as appropriate Continue PROM as needed to maintain ROM Initiate assisted shoulder IR behind back stretch Resisted shoulder IR, ER in scapular plane Begin light functional activities Wean from sling completely Begin progressive supine active elevation strengthening (anterior deltoid) with light weights (0.5-1.5kg) at variable degrees of elevation Late Phase III Resisted flexion, abduction, extension (TheraBands/sport cords) Continue progressing IR, ER strengthening Progress IR stretch behind back from AAROM to AROM, as ROM allows PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 88 (Pay particular attention as to avoid stress on the anterior capsule.) Criteria for progression to the next phase (IV): Tolerates AAROM/AROM/strengthening Achieves at least 140 AROM flexion supine Achieves at least 120 AROM abduction supine Achieves at least 60 AROM ER in plane of scapula supine Achieves at least 70 AROM IR in plane of scapula supine in 30 of abduction Able to actively elevate shoulder against gravity with good mechanics to at least 120 Note: If above ROM are not met, then patient is ready to progress when the patients ROM is consistent with outcomes for patients with the given underlying pathology. Phase IV: Advanced Strengthening Phase (Not to begin for 12 weeks to allow for appropriate soft tissue healing and to ensure adequate ROM.) Goals: Maintain nonpainful AROM Enhance functional use of upper extremity Improve muscular strength, power and endurance Gradual return to more advanced functional activities Progress weight-bearing exercises as appropriate Precautions: Avoid exercise and functional activities that put stress on the anterior capsule and surrounding structures (e.g., no combined ER and abduction above 80 of abduction) Enhance gradual progression of strengthening Early Phase IV Typically, patient is on a home exercise program by this point to be performed 3 to 4 times per week Gradually progress strengthening program Gradual return to moderately challenging functional activities Late Phase IV (Typically 4 to 6 months Postoperative) Return to recreational hobbies, gardening, sports, golf and doubles tennis Criteria for discharge from skilled therapy: Patient able to maintain nonpainful AROM Maximized functional use of upper extremity Maximized muscular strength, power and endurance Patient has returned to advanced functional activities PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY Appendix B University of Indianapolis Institutional Review Board 89 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 90 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 91 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY Appendix C Baptist Health Floyd Waiver Agreement 92 PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 93 Appendix D Study Details About this study. You are being asked to take part in a research study. Before you decide to participate in this study, it is important that you understand why the research is being done and what it will involve. Please read the following information carefully. Please ask the researcher if there is anything that is not clear or if you need more information. The study aims to investigate patient perception of daily activities and rehabilitation in the first six weeks following shoulder replacement surgery. This includes patients experiences regarding shoulder precautions, education received prior to and post-surgery, and experiences during progression in the first few phases of rehabilitation. What will I have to do? You will be interviewed by the researcher for approximately 15-20 minutes regarding your experiences at two, four, and six weeks following surgery. The interview will be audio-recorded. You will be asked basic questions relating to how you found various aspects of the process, including your challenges at home and information provided to you during your hospitalization. Who else is taking part? Patients at this hospital who are undergoing a total shoulder replacement in January to May of 2019. If you have a history of shoulder problems from birth, significant neurological impairments relating to your shoulders, or have other medical conditions that cause significant impairment to your ability to complete self-care, you are not eligible for this study. What if I do not wish to take part? Your participation in this study is voluntary. It is up to you to decide whether or not to take part in this study. If you decide to take part in this study, you will be asked to state your consent during each interview. You are still free to withdraw at any time and without giving a reason. Withdrawing from this study will not affect the relationship you have, if any, with the researcher. If you withdraw from the study before data collection is completed, your data will be destroyed. What happens if I change my mind during the study? You are free to withdraw at any time without explanation. What are the benefits and risks to you? Upon completion of all interviews, you will be offered your choice of a $25 gift card. Furthermore, you will be aiding the investigator in carrying out this research which will PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 94 potentially help inform clinical practice at this and other healthcare facilities. There are no anticipated risks to being interviewed. What happens at the end of this study? At the end of the study, all interviews will be transcribed and compiled to represent the results. A copy of this report will be made available to you and to the health professionals in the facility who are involved in treating shoulder-replacement patients. It is possible that the study may be published in a medical journal, in which case it would be available to many people. What happens to the information? All information gathered during this study will be confidential and only used for the purpose of this study. All subjects will remain unidentifiable due to coding of all subject data. Contact Information If you have questions at any time about this study, or you do not wish to participate, you may contact the researcher whose contact information is provided on the first page. If you have questions regarding your rights as a research participant, or if problems arise which you do not feel you can discuss with the Primary Investigator, please contact the Institutional Review Board at (317) 781-5774. Principal Investigator Elizabeth Stith Inpatient Rehabilitation 1850 State Street New Albany, Indiana 47150 Elizabeth.Stith@BHSI.com PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 95 Appendix E Participant Form and Information Form PATIENT PERCEPTIONS OF POSTSURGICAL AND EARLY STRENGTHENING PHASES OF REHABILITAITON WITH SHOUDLDER ARTHROPLASTY Name: ______________________________________________________________________ ID number: ___________ "----------------------------------------------------------------------------------------------------------------- ID number: ___________ Please circle to select: Hand Dominance: Left Right Gender: Male Shoulder replaced: Left Right Age:____________ Female Phone number to contact you: ___________________________________________________ Thank you for your interest in this study. The researcher will follow up with you following surgery, and before discharge from Baptist Health Floyd Hospital. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 96 Appendix F Consent Information PATIENT PERCEPTIONS OF POSTSURGICAL AND EARLY STRENGTHENING PHASES OF REHABILITAITONWITH SHOUDLDER ARTHROPLASTY PRINCIPAL INVESTIGATOR Elizabeth Stith Inpatient Rehabilitation 1850 State Street New Albany, Indiana 47150 Elizabeth.Stith@BHSI.com PURPOSE OF STUDY You are being asked to take part in a research study. Before you decide to participate in this study, it is important that you understand why the research is being done and what it will involve. Please read the following information carefully. Please ask the researcher if there is anything that is not clear or if you need more information. The purpose of this study is to understand patients experiences during the first few weeks following shoulder replacement surgery. Specifically, the investigators would like to understand what is most difficulty for the patient at home, what has surprised them about recovery, and how it has impacted different areas of daily life. This information will be used to better our current pre-surgical education, as well as understand how to better prepare patients for discharge home after surgery. STUDY PROCEDURES If you chose to participate, the Occupational Therapist will contact you at two, four, and six weeks after surgery to ask you a few questions regarding your recovery. All interviews will take place via telephone at the number provided to you and a time of your choosing and are expected to last approximately twenty minutes. These interviews will be recorded so investigators may later analyze responses from multiple interviews. BENEFITS Upon completion of all three interviews, you will be eligible for a $25 gift card. We hope that the information obtained from this study may aid us in better preparing other patients preparing for shoulder replacement surgeries. You may decline to answer any or all questions and you may terminate your involvement at any time if you choose. CONFIDENTIALITY For the purposes of this research study, your responses during interviews will be confidential. Interviews will be recorded and later transcribed for data analysis purposes. All interviews will be kept in password protected files and/or locked files within the therapy department. When the PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 97 research is complete, each patient will be referred to by assigning code names/numbers for research notes and documents. Patient descriptives, such as age and sex, may be referred to during this research project. CONTACT INFORMATION If you have questions at any time about this study, or you do not wish to participate, you may contact the researcher whose contact information is provided on the first page. If you have questions regarding your rights as a research participant, or if problems arise which you do not feel you can discuss with the Primary Investigator, please contact the Institutional Review Board at xxxxxxxx VOLUNTARY PARTICIPATION Your participation in this study is voluntary. It is up to you to decide whether or not to take part in this study. If you decide to take part in this study, you will be asked to sign a consent form. After you sign the consent form, you are still free to withdraw at any time and without giving a reason. Withdrawing from this study will not affect the relationship you have, if any, with the researcher. If you withdraw from the study before data collection is completed, your data will be returned to you or destroyed. If you are still interested in participating in this study, you will be contacted in approximately two weeks by: PRINCIPAL INVESIGATOR Elizabeth Stith Inpatient Rehabilitation 1850 State Street New Albany, Indiana 47150 Elizabeth.Stith@BHSI.com PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 98 Appendix G Recruitment Script (After completing preoperative education, so researcher will have already introduced self) In addition to being an Occupational Therapist at this hospital, Im also a student at the University of Indianapolis finishing my doctorate degree. Im completing a research study to better understand what patients experience in the weeks following shoulder replacement. For this study, Ill be contacting patients via telephone at two, four, and six weeks following surgery. Each interview would last about 25-30 minutes, discussing progression in rehab, what assistance you require at home, and how your daily habits have changed to meet your needs after surgery. Your responses will be kept in a locked file accessible only to the researchers on this study, and your name and telephone number will be stored separately to further de-identify responses. At the end of the study, Ill be looking for themes in responses to share with other practitioners and, hopefully, publish in a medical journal. Only participants from this hospital undergoing shoulder replacement will be invited to participate, and your participation is entirely voluntary. You will be asked at the beginning of each interview if you would like to participate, and you may withdraw from the study at any time. If you wish to participate, and complete all three surveys, you will be offered a $25 gift card to Kroger, Amazon, or Walmart. There is more information in this Study details form, so if youre interested please read through this and Im happy to answer any questions you may have. (Provide time for reading, questions/answers). If there are no more questions, Ill leave you with Sarah to complete more paperwork for surgery. PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 99 After all hospital-required paperwork is completed, Joint Coordinator to state: If you think that you would like to participate in this research study, please fill out this form and I will pass along to the therapist (provide Participant Information Form). PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 100 Appendix H Interview Questions Interview One: (~2 weeks s/p sx) Hi, _________. Its Elizabeth Stith, calling from Baptist Floyd. How are you? Im following up on your recent shoulder surgery and calling for our first interview for the research study Im completing. As a reminder this study is looking at patients experiences and feelings in the first few weeks of rehab after surgery. Participation is voluntary, and you may opt-out at any time. You may also skip any questions that you would prefer not to answer. This interview will be audio recorded for my data, but it all remains confidential, and your name will not be used with any answers you have given. Do you still wish to participate in this study? Great! Thank you for working with me. I have a few questions and expect this will take about 20 minutes of your time. If now is an okay time for you, Ill get started! Questions: Tell me how you felt after surgery. o How does this compare to your expectations? Tell me about your recovery so far. o What do you find the most frustrating part of recovery? Tell me about how the transition to home has been. o Who has been helping you? What tasks are most difficult for you? In what ways? How have you modified your daily routines? o How had you modified routines prior to surgery due to pain? In what ways did you feel prepared for discharge from the hospital? PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 101 o Unprepared? Which information sheet regarding surgery was most helpful? o What other handouts would have been helpful? Tell me about sleep. o Where are you sleeping? How are you sleeping? What has been the most surprising aspect of recovery for you? o How have you dealt with this aspect of recovery? How much assistance do you require from family and/or friends? o What other help are you receiving? Can you give me an example of how this surgery has impacted your social life and/or relationships with others? o Have you missed any social engagements due to surgery/recovery? Tell me about your two week follow-up appointment. o How did the doctor say your progress was going? When is your pain the greatest? o How are you managing your pain? Those are all of my questions today. Do you have anything else you would like to add? Any questions for me? I appreciate your time today. Ill be calling back in two weeks to complete our next series of questions. If you need me before then, please reach out to me at (812)664-0767. Is it okay to call you on ______ for the interview? Interview two: (~4 weeks s/p sx) PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 102 Hi, _________. Its Elizabeth Stith, calling from Baptist Floyd. How are you? Im following up on your shoulder surgery and calling for the second interview for the research study Im completing. As a reminder this study is looking at patients experiences and feelings in the first few weeks of rehab after surgery. Participation is voluntary, and you may opt-out at any time. You may also skip any questions that you would prefer not to answer. This interview will be audio recorded for my data, but it all remains confidential, and your name will not be used with any answers you have given. Do you still wish to participate in this study? Great! Thank you for working with me. I have a few questions and expect this will take about 20 minutes of your time. If now is an okay time for you, Ill get started! Questions: Last time we spoke, you mentioned (brief synopsis for member checking) Does that sound correct? Tell me about your recovery thus far. o Who has been helping you lately? o What have you required assistance with? o How high can you lift your arm? Last time we spoke you mentioned ______ as a challenging task for you. How is that going? o What other tasks have been a challenge for you in the last two Tell me about your progression to outpatient therapy. How have you modified your daily routines? weeks? o Have you found yourself changing routines due to decreased pain as compared to before surgery? PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 103 Can you give me an example of what continues to surprise you about this process? Can you give me an example of how this surgery has impacted your social life and/or relationships with others? o Have you been more active in these last two weeks as compared to the first two? Tell me about your sleep. o Where are you sleeping? Tell me about how this affects your eating habits. o Have you changed any eating habits as a result of this surgery? When is your pain the greatest? How are you managing your pain? Those are all my questions for today. Do you have anything else you would like to add? Any questions for me? I appreciate your time today. Ill be calling back in two weeks to complete our next series of questions. If you need me before then, please reach out to me at (812)664-0767. Is it okay to call you on ______ for the interview? Interview three: (~6 weeks s/p sx) Hi, _________. Its Elizabeth Stith, calling from Baptist Floyd. How are you? Im following up on your shoulder surgery and calling for our third and final interview for the research study Im completing. As a reminder this study is looking at patients experiences and feelings in the first few weeks of rehab after surgery. Participation is voluntary, and you may opt-out at any time. You may also skip any questions that you would prefer not to answer. This PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 104 interview will be audio recorded for my data, but it all remains confidential, and your name will not be used with any answers you have given. Do you still wish to participate in this study? Great! Thank you for working with me. I have a few questions and expect this will take about 20 minutes of your time. If now is an okay time for you, Ill get started! Questions: Last time we spoke, you mentioned (brief synopsis for member checking) Does that sound correct? Tell me about your progress in therapy since our last talk. o How high can you lift your arm? What tasks are most difficult for you? o What tasks have become easier for you? How have you modified your daily routines? o Do you find yourself able to do any tasks you were unable to complete before surgery? How is this stage of rehab different or similar than prior stages? Can you tell me about your experience wearing your sling? o How often do you wear it now? Tell me about your sleeping habits now. o How does your shoulder interrupt your sleeping habits? Can you give me an example of how this surgery has impacted your social life and/or relationships with others? Tell me about how this affects your eating habits. o Are you able to prepare your own meals at this stage of recovery? PERCEPTIONS OF REHAB IN SHOULDER ARTHROPLASTY 105 When is your pain the greatest? o How are you managing your pain? Tell me about your six-week follow-up appointment. o How did the doctor respond to your progress? At this point in rehab, do you feel that surgery was a worth-while endeavor? o Why or why not? What do you wish you had known before going into this procedure? o What could we have done better in the preoperative education class? What would you tell others looking to have this procedures? o What specific resources would you encourage them to utilize? Those are all my questions for today. Do you have anything else you would like to add? Any questions for me? I appreciate your time these last several weeks. This is our last interview. Since you have completed all three interviews you have your choice of a $25 gift card to Amazon, Kroger, or Walmart. Which do you prefer? And is email delivery okay or would you prefer USPS? I will be reaching back out in a few weeks to ensure you received your gift card. Thanks so much for participating in this research study.  ...

... ASSESSING RELIABILITY AND VALIDITY OF A FUNCTIONAL PAIN MEASURE FOR JOINT HYPERMOBILITY Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Carrie Shotwell, MEd, OTR/L Copyright April 15, 2019 By: Carrie Shotwell, MEd, OTR/L All rights reserved Approved by: Elizabeth Moore, PhD Assistant Professor College of Health Sciences University of Indianapolis Committee Chair Karen Harpster, PhD, OTR/L Cincinnati Children's Hospital Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: RELIABILITY AND VALIDITY OF A PAIN MEASURE 1 Assessing Reliability and Validity of a Functional Pain Measure for Joint Hypermobility Carrissa Shotwell University of Indianapolis RELIABILITY AND VALIDITY OF A PAIN MEASURE 2 Abstract The Pediatric Outcomes Data Collection Instrument (PODCI) is a self-reported outcome measure designed to assess upper extremity function and pain in adolescents. The purpose of this study was to determine the test-retest reliability and concurrent validity of the upper extremity function and pain portions of the PODCI (PODCI UEF and PODCI P) as an outcome measure in adolescents diagnosed with joint hypermobility (JH). The study also sought to establish the responsiveness of the PODCI subscales by calculating the standard error of measurement (SEM) and the minimal detectable change (MDC). One hundred and fifty adolescents (ages 11-18 years) with JH were recruited for the study. Test-retest reliability of both portions of the PODCI was examined with 83 participants using Lins concordance correlation coefficient (c) There was a very high test-retest reliability for the PODCI UEF, c = .81 (p < .001) and moderate test-retest reliability for the PODCI P, c = .68 (p < .001). To establish concurrent validity, the PODCI UEF was compared to the Patient Reported Outcomes Measurement Information System Pediatric Upper Extremity-Short Form (PROMIS PUE-SF) and the PODCI P was compared to Numeric Rating Scale (NRS) using Spearman rho correlations. There was a very high correlation between the PODCI UEF and the PROMIS PUE-SF, rs = .80 (p < .001) and a moderate inverse relationship rs = -.73 (p < .001) between PODCI P and NRS scores. These results, indicate concurrent validity between instruments. Occupational and physical therapists may consider using the PODCI clinically and in future research. Keywords: PODCI, joint hypermobility, pain, upper extremity function, PROMIS, NRS RELIABILITY AND VALIDITY OF A PAIN MEASURE 3 Assessing Reliability and Validity of a Functional Pain Measure for Joint Hypermobility Joint hypermobility (JH) is a chronic condition that is defined by excessive movement of the joints (Tinkle et al., 2009). Children and adolescents with JH often live with joint pain, fatigue, and poor tolerance to physical activity (Birt, Pfeil, MacGregor, Armon, & Poland, 2013). They are more likely to experience pain than their non-hypermobile peers, which can significantly impact their quality of life and participation in daily activities (Tobias, Deere, Palmer, Clark, & Clinch, 2013). Intervention provided by occupational and physical therapists is often recommended as part of a multidisciplinary approach to aid in the management of pain and improve functional limitations in this chronic condition (Cincinnati Childrens Hospital Medical Center [CCHMC] Joint Hypermobility Team, 2014). However, the reliability and validity has not been established for outcome measures used to measure pain and functional performance for children with JH, limiting the ability of researchers and clinicians to confidently interpret outcomes for this population. The use of valid and reliable outcome measures may assist in planning care and identifying best practice for the management of JH. Current literature recognizes the need for outcome measures that assess pain, function, and quality of life in adolescents within the therapy context to improve future research and clinical management of JH (Kemp et al., 2010). The Pediatric Outcomes Data Collection Instrument (PODCI) is a patient-reported outcome measure designed by the American Academy of Orthopedic Surgeons Outcomes Studies committee that is intended for use in the clinical setting (Daltroy et al., 1998). The upper extremity function subscale (PODCI UEF) measures upper extremity function and the pain/comfort subscale (PODCI P) measure the impact of pain on activity participation. The PODCI UEF and PODCI P are currently used in clinics to evaluate functional performance and pain in children diagnosed with JH; however, the validity and RELIABILITY AND VALIDITY OF A PAIN MEASURE 4 reliability of the subscales of the PODCI in this population has not been established. The purpose of this study is to determine the validity and reliability of the PODCI UEF and PODCI P subscales in measuring outcomes in adolescents diagnosed with JH. Specifically, this study aimed to address the following objectives: 1. To establish the stability of the PODCI UEF and PODCI P through the use of test-retest reliability. 2. To determine the concurrent validity of the PODCI UEF by comparing its results to the Patient Reported Outcomes Measurement Information Systems, Pediatric Upper Extremity Short Form (PROMIS PUE-SF). 3. To determine the concurrent validity of the PODCI P by correlating its results to the pain scores from the numeric rating scale (NRS). 4. To establish the responsiveness of the PODCI subscales, the minimal detectable change (MDC) and the standard error of measurement (SEM) will be calculated. Literature Review Background Joint hypermobility is a hereditary condition affecting the connective tissues of the body, multiple joints, and it is often characterized by pain (Schubert-Hjalmarsson, Ohman, Kyllerman, & Beckung, 2012). It is typically diagnosed using the Beighton scale criteria, in which excessive motion must be present in five or more of nine designated joints: elbows, finger metacarpals, thumbs, knees, and spine (Junge, Jespersen, Wedderkopp, & Juul-Kristensen, 2013). Joint hypermobility is a connective tissue disorder and the impact can be multidimensional, including increased pain and fatigue, muscle weakness, decreased proprioception, diminished activity tolerance, and anxiety. There is an increased incidence of depression, anxiety, and panic RELIABILITY AND VALIDITY OF A PAIN MEASURE 5 disorders among people with JH (Albayrak, Yilmaz, Akkurt, Salli, & Karaca, 2015). Pain is a common complaint among individuals with JH, influencing activity and disability (Bathen, Hngmann, Hoff, Andersen, & Rand-Hendriksen, 2013). The combination of physical and psychological factors is highly correlated with disability, which is significantly present in individuals with JH (Scheper et al., 2016). Joint hypermobility is present in genetic conditions such as Marfan syndrome and osteogenesis imperfecta; however, Ehlers-Danlos, type III (EDSIII, or benign hypermobile-type) is the most common genetic condition with JH as a primary characteristic. Throughout the literature the term EDS is often used interchangeably with JH and is now considered to be the same diagnosis among experts. Uniting the diagnoses of JH and EDS-III allows for clinicians and researchers to better serve the population (Tinkle et al., 2009). Impact of Joint Hypermobility It is becoming more recognized in the literature that there is a correlation between JH and musculoskeletal pain (Scheper et al., 2016). One theory is that the ligament laxity causes stress and strain to the joint, which can result in acute injury of ligaments and soft tissue (Albayrak et al., 2015). Albayrak et al. (2015) completed a cross-sectional study comparing pain, depression level, fatigue, sleep, and quality of life in 115 participants with JH with 114 age-matched and gender-matched healthy controls. The group with JH demonstrated higher scores than the healthy controls on the Beck Depression Inventory (14.57, 8.37, p < .001) indicting more depression, increased fatigue as measured on the Checklist Individual Strength (83.97, 71.02, p < .001) and impaired sleep quality per the Pittsburgh Sleep Quality Index (7.53, 6.14, p < .001). Regarding quality of life, the group with JH reported lower physical function (66.73, 77.01, p < .001), lower emotional role (41.15, 72.51, p < .001) and higher bodily pain (52.69, 25.52, p < .001) on the Short Form Health Survey (SF-36) (Albayrak et al., 2015). RELIABILITY AND VALIDITY OF A PAIN MEASURE 6 People with JH often demonstrate poor quality of life when compared to the general population (Bovet, Carlson, & Taylor, 2016). A cross-sectional study examined the quality of life, pain, and shoulder function among 110 participants with JH and 140 age-matched and gender-matched controls. The authors used the numeric rating scale (NRS) to assess pain, the Western Ontario Shoulder Instability Index to assess shoulder function, and Health Related Quality of Life (HRQoL) short-form to assess quality of life (Johannessen, Reiten, Lvaas, Maeland, & Juul-Kristensen, 2016). The group with JH reported higher mean pain intensity (6.4, 2.7, p < .001), lower mean shoulder function (49.9, 83.3, p < .001), and decreased mean HRQoL on the physical component scale (28.1, 49.9, p < .001) than the control group (Johannessen et al., 2016). Furthermore, there was higher incidences of pain reported in the shoulder in the JH group than in the control group, which the authors concluded may be a consequence of shoulder instability. The authors reported a correlation between pain, lower shoulder function, decreased physical function, as well as decreased leisure and work-related activity participation, when compared with the control group (Johannessen et al., 2016). Adults diagnosed with JH demonstrated higher incidences of disability in mobility and activities of daily living than in the general population (Engelbert et al., 2017). Chronic and recurrent pain is a common complaint among people with JH and can lead to disability (Castori et al., 2012). Adults with JH reported significantly higher pain, decreased physical function, and increased limitations due to physical problems than same age-matched peers, which often led to disability (Rombaut, Malfait, Cools, De Paepe, & Calders, 2010). A study by Rombaut et al. (2012), compared muscle strength and endurance using isokinetic dynamometry in 43 females with JH and 43 age-matched healthy control females. The JH group demonstrated significant muscle weakness, reduced static muscle endurance, and decreased functional performance when RELIABILITY AND VALIDITY OF A PAIN MEASURE 7 compared to the control group as measured by the Arthritis Impact Measurement Scales (Rombaut et al., 2012). Joint hypermobility has been identified in up to 34% of school-aged children (Birt et al., 2013). A prospective cohort study by Tobias et al. (2013) found that children diagnosed with JH have an approximately two-fold increased risk of having musculoskeletal pain later in adolescence, specifically in the shoulder, knee, and ankle/foot. Schubert-Hjalmarsson et al. (2012) found that 20 children with JH (ages 8-16 years) reported significantly more pain in a pain diary over a two week period when compared to a control group of non-hypermobile peers (p < .001). Additionally, the JH group demonstrated significantly less balance (p < .001) when measured by the Bruininks-Oseretsky test of motor proficiency and reported lower activity levels on the frequency of participation questionnaire (p < .001). The children in the JH group reported a significantly higher number of days in which activity participation was limited due to pain (p < .001). The authors concluded that pain appeared to influence activity and participation in children with JH (Schubert-Hjalmarsson et al., 2012). Children with JH may begin to avoid physical activities that they perceive may be painful, which consequently can lead to deconditioning (Rabin, Brown, & Alexander, 2017). Adult Intervention Physical and occupational therapy are recommended interventions for adults and children with JH; however, managing treatment for individuals with JH is challenging for therapists due to the complexity of their symptoms (Engelbert et al., 2017). There is a paucity in research regarding intervention for adults with JH. A systematic review by Corrado and Ciardi (2018) found no randomized control trials to support rehabilitation for individuals with JH. Most studies reported were primarily investigative in nature making it difficult to specify guidelines for RELIABILITY AND VALIDITY OF A PAIN MEASURE 8 therapeutic interventions (Corrado, & Ciardi, 2018). Additional research would be beneficial to guide therapy practice for individuals with JH. Focus groups from a study by Bovet, Carlson, and Taylor (2016) revealed themes of past negative therapy experiences including perceived injury and unmet therapy needs. Participants identified that caregivers frequently demonstrated lack of knowledge and that exercises were not appropriately tailored to their condition of hypermobility. Conversely, a positive therapy experience included therapists who were knowledgeable regarding JH, patient centered care, and multidisciplinary coordination across the healthcare system (Bovet et al., 2016). One pilot study found that a multidisciplinary rehabilitation program with physical and cognitive behavioral therapy was a possible intervention for women with JH (Bathen et al., 2013). Following a multidisciplinary inpatient rehabilitation with subsequent home program performance, a cohort of 12 women with JH found clinically significant improvement (2.95, 4.08, p < .008) in performance of activities of daily living as measured by the Canadian Occupational Performance Measure (Bathen et al., 2013). A systematic review by Smith et al. (2013) concluded that adults with JH demonstrate reduced joint proprioception compared to the general population, which may affect coordination and activity participation. A recent study by Scheper et al. (2017) found that proprioception is an influence on the relationship between activity limitations and muscle strength. The same study also found a correlation between low muscle strength and activity limitations in EDS-HT patients. These findings support evidence for the core assumption that treatment based on muscle strengthening and increasing proprioception acuity might be effective (Scheper et al., 2017). However, higher level evidence is needed to support which therapeutic interventions are most effective (Corrado & Ciardi, 2018) RELIABILITY AND VALIDITY OF A PAIN MEASURE 9 Pediatric Intervention Treatment to address pain and functional limitations in childhood may help to limit disability in adulthood (CCHMC Joint Hypermobility Team, 2014; Engelbert et al., 2017). However, there has been limited research that has been completed with children and adolescents with JH regarding therapy intervention and management of the chronic condition. Kemp et al. (2010) completed a randomized controlled trial comparing a targeted physiotherapy program with a generalized strengthening and fitness program in 57 children (ages 7-16 years) with JH. The targeted program focused on improving joint positioning, motor control, and stability while the fitness program focused on exercises aimed at strengthening. Pain was assessed using the Visual Analog Scale (VAS) for pain as perceived by the child and the parental-VAS for the childs pain as perceived by parents. Both groups demonstrated statistical improvement in child and parent pain scores following intervention (p < .05); however, there was not a statistical difference between the two groups (Kemp et al., 2010). A qualitative study found that children with JH and their parents saw improvement after completing a multidisciplinary treatment intervention that included physiotherapy. Despite recognizing the benefits of completing their prescribed home exercise program, children and parents reported difficulty with adhering to their exercises (Birt et al., 2013). Client-centered and family-centered care can help to improve outcomes and support adherence to home programs (Birt et al., 2013; CCHMC Joint Hypermobility Team, 2014). There is limited research supporting specific therapeutic interventions and protocols, despite therapy being a recommended intervention (Smith et al., 2013). There is a need for quality research to investigate the effects of therapeutic intervention including joint stabilization, strengthening, participation in physical activity, and pain management in adolescents with JH (Scheper et al., 2013) RELIABILITY AND VALIDITY OF A PAIN MEASURE 10 Outcome Measures Pain. There is not a consistent outcome measure reported in the literature that is used to assess pain in adolescents with JH. The current literature reflects the use of separate outcome measures to assess pain, function, quality of life, and strength. Pain is a primary concern for individuals with JH (Bathen et al, 2013). The Focus 17 Pain Questionnaire was used in a prospective cohort study by Tobias et al. (2013). The authors used logistic regression analysis to explore the relationship between JH and musculoskeletal pain in adolescents. Study participants with JH were more likely to have musculoskeletal pain in the shoulder (odds ratio [OR] = 1.68), knee (OR = 1.83), and ankle/foot (OR = 1.82) than their non-hypermobile peers (Tobias et al., 2013). However, the Focus 17 Pain Questionnaire has not been established as a reliable or validated assessment for the hypermobile population. The faces pain scale was used in a randomized control trial in children with JH for participants younger than 11 years and the VAS was used for participants older than 11 years as the primary outcome measure for the interventions. The study used the additional outcome measures of the Childhood Health Assessment Questionnaire (CHAQ), parents assessments of their childs pain, and the six-minute shuffle test to further assess quality of life, pain, and function. The authors recognized the need for more effective outcome measures within the therapy context to help improve research quality (Kemp et al., 2010). The NRS was used in conjunction with the Functional Disability Inventory (FDI) to examine change in pain related functional disability and pain intensity in children undergoing cognitive behavioral therapy (Lynch-Jordan et al., 2014). It is expected that there is a correlation between pain and function. However, the authors noted a statistically significant difference in function on the FDI, but not in pain on the NRS following the treatment (Lynch-Jordan et al., RELIABILITY AND VALIDITY OF A PAIN MEASURE 11 2014). The NRS is commonly used clinically and in research to measure pain intensity in children and adolescents with chronic pain including headaches, abdominal pain, complex regional pain syndrome, and musculoskeletal pain (Castarlenas et al., 2017; Ruskin et al., 2014; Sheehy et al., 2015). However, it does not measure how that pain may influence participation in daily activities or how it may contribute to disability. Accordingly, the current study seeks to establish the PODCI P as a reliable and valid outcome measure that assesses the interference of pain on function for adolescents with JH. Function. There is a lack of valid and reliable outcome measures to assess upper extremity function in adolescents with JH. The Pediatric Quality of Life Inventory 4.0 (PedsQL) is a pediatric and adolescent quality of life assessment that was found to have strong test-retest reliability, intraclass correlation coefficient (ICC) = .82, in a small sample of 10 children with JH. However, the sample size was not large enough to generalize the results to the larger population of children with JH (Fatoye et al., 2012). The PedsQL offers a score on global quality of life, but it does not specifically address pain and has limited questions on physical function. There is a need for patient reported outcome measures for adolescents with JH that can be completed quickly within the therapy visit and that can measure gains in function as well as reduction in pain and its interference with activity. Pediatric Outcomes Data Collection Instrument. Patient-reported outcome measures can be useful instruments to assess baseline function, improvement in function, and to guide clinical practice (Kempert, Benore, & Heines, 2017). The PODCI is a patient-reported outcome measure designed by the American Academy of Orthopedic Surgeons Outcomes Studies committee for use in children and adolescents, aged 2-18 years with a variety of musculoskeletal conditions including cerebral palsy, brachial plexus palsy, and congenital differences (Bae, RELIABILITY AND VALIDITY OF A PAIN MEASURE 12 Waters, & Zurakowski, 2008). It consists of three different forms: pediatric form (for ages 2-10 years) that is filled out by a parent/caregiver; adolescent parent report form that is filled out by parent/caregiver of adolescents ages 11-18 years; and the adolescent self-report form for ages 1118 years. The PODCI measures outcomes across eight domains: upper extremity and physical function, transfer and basic mobility, sports/physical function, pain/comfort, treatment expectations, happiness, satisfaction with symptoms, and global functioning. Each scale or domain yields a standardized score between 0-100. Test-retest reliability, sensitivity to change, and construct validity were established during development (Daltroy, Liang, Fossel, & Goldberg, 1998). Testing was completed in multiple institutions among a variety of musculoskeletal conditions including scoliosis, dysplasia, cerebral palsy, juvenile arthritis, leg-length discrepancies, developmental delays, and abnormal gait (Daltroy, et al., 1998). In the adolescent self-report questionnaire, the test-retest reliability was found to be high (ICC = .75 to .92). Construct reliability was established by comparing the PODCI to the CHAQ. A strong positive correlation was found indicating that the PODCI produces similar results when measuring comparable constructs (Daltroy et al., 1998). Hunsaker et al. (2002) found the PODCI demonstrated high internal consistency, as well as discriminant validity in the general population (ages 2-18 years). Multi-trait scaling techniques were used to examine reliability and item discriminant validity across all 11 scales (Hunsaker et al., 2002). The PODCI demonstrated high internal consistency (Cronbachs alpha exceeded .80). In multi-trait scaling, discriminant validity examines correlations of items of the scales of the assessment with items of other scales. Discriminant validity is reached when there is 80% of the item to scale correlations in the total data set and within each individual scale (Hunsaker et al., 2002). Cronbachs alpha range was .94 - .98 (p < .05) for the upper extremity RELIABILITY AND VALIDITY OF A PAIN MEASURE 13 portion of the PODCI, indicating that item discriminant validity was achieved (Hunsaker et al., 2002). The mean scores from the study were high across scales in the normative sample, however also demonstrated meaningful variability. Therefore, the authors concluded that the PODCI assessments will be utilized more effectively in populations with poor health. In an analysis among children with congenital limb differences, aged 2-18 years, the mean score for upper extremity function was significantly lower than in the normal population (76.6, p < .05; 98.7, respectively) (Wall, Shen, Roberts, & Goldfarb, 2016; Hunsaker et al., 2002). The utility and reliability of the PODCI was assessed in children between 2 and 18 years of age with acute hand and wrist injuries. The authors found that it demonstrated good internal consistency. The Cronbachs alpha for the PODCI UEF was .89 and .87. The study established that the PODCI UEF and PODCI P were responsive to change in function, with a standardized response mean of 0.42 (effect size 0.55) and 1.27 (effect size 1.37), respectively. The PODCI was also found to discriminate upper extremity function between children with acute hand and wrist injuries from children in the general population and between children with different injury locations. Furthermore, administering the PODCI did not impact treatment time in the clinic or patient satisfaction; therefore, it may be a useful outcome measure clinically and for research purposes (Kunkel, Eismann, & Cornwall, 2011). The clinical utility of the PODCI as an outcome measure, as well the established reliability and validity in multiple populations, make it a good option for the present study. In a study in adolescents with upper extremity conditions, the PODCI was found to demonstrate high correlation (r = .85) with the Pediatric QoL Inventory, indicating construct validity (Mahan et al., 2014). Similarly, a study by Pencharz, Young, Owen, and Wright (2001) reported good construct validity of PODCI by correlating it with the Child Health Questionnaire Parent Form and the RELIABILITY AND VALIDITY OF A PAIN MEASURE 14 Activities Scales for Kids (ASK). The study found that the PODCI was effective in measuring physical function and pain in children with disability, however the full PODCI questionnaire (108 questions) was not always feasible in the clinic setting. A recent retrospective study explored the relationships between functional disability and depression symptoms in children and adolescents with chronic pain. Bivariate correlations were separately performed between the subscales of the PODCI (global functioning, upper extremity and physical functioning, transfer and basic mobility, and sports and physical functioning) and the Childrens Depression Inventory (Broadbent, Bertino, Brooke, Fuller-Tyszkiewicz, & Chalkiadis, 2017). The authors found that depression and functional disability were not correlated among any of the four subscales, suggesting that the PODCI may be a useful measure of functional disability without the confounder of symptoms of depression in pediatric patients with pain (Broadbent et al., 2017). The PODCI has been established as a feasible, reliable, and valid clinical assessment in several orthopedic conditions including cerebral palsy, brachial plexus palsy, upper extremity acute conditions, and musculoskeletal conditions (Bae, Waters, & Zurakowski, 2008; Kunkel, Eismann, & Cornwall, 2011; Mahan et al., 2014; Pencharz et al., 2001). However, the utility of the PODCI has not been examined in adolescents with JH. Therefore, it is hypothesized that the adolescent self-report PODCI, specifically the upper extremity and pain/comfort scales, may be a reliable and valid outcome measure to use with adolescents with JH. The PODCI UEF and PODCI P are currently being used as an outcome measure by therapists at CCHMC. The PODCI UEF measures how easy or hard it is to complete daily tasks such as writing, combing hair, and opening containers. The PODCI P measures the impact of pain on function over the last week, as well as how pain may have interfered with participation in activities. The entire PODCI consists RELIABILITY AND VALIDITY OF A PAIN MEASURE 15 of a large number of items and may take away from treatment time in order to complete it (Mahan et al., 2014; Quatman-Yates et al., 2013). Accordingly, the aim of this study is to establish the PODCI UEF and PODCI P as reliable and valid outcome measurements in adolescents with joint hypermobility. Doing so may help to guide future research and clinical practice in the management of joint hypermobility. Method Study Design An observational study using a cross-section design was conducted to establish validity and reliability of the PODCI. The study took place from June 1, 2018 to January 31, 2019 at CCHMC. Prior to participant recruitment, the study was approved by the Institutional Review Board (IRB) at CCHMC and a reliance agreement was executed with the Human Research Protections Program at the University of Indianapolis. Participants A convenience sample of adolescents referred by a physician or nurse practitioner for occupational therapy and/or physical therapy at CCHMC to address pain or difficulties related to their JH were recruited for the study. The treating therapists and the primary researcher (C. S.) identified potential participants prior to their therapy visit through chart reviews completed as standard of care. To participate in the study, individuals must have met the following inclusion criteria: Age 11-18 years at the time of recruitment Diagnosed with joint hypermobility or Ehlers-Danlos, type III Referred by a physician to occupational and/or physical therapy due to functional limitations and/or pain that are associated with their JH RELIABILITY AND VALIDITY OF A PAIN MEASURE 16 Speak English as their first language Ability to read and comprehend English at the 5th grade level Must have a parent or legal guardian present during the treatment session if the adolescent is 17 years of age and under Individuals were excluded from the study if they had a formal diagnosis in their medical chart of another musculoskeletal disorder, intellectual disability, pregnancy, a co-existing disabling condition or joint diseases, including but not limited to arthritis or lupus. Sample size. A sample size calculation was conducted using the formula provided by Walter, Eliasziw, and Donner (1998) for reliability studies using the ICC. It is estimated that a minimum of 117 participants are required to established the test-retest reliability of the PODCI, with an alpha of .05, power of .80, acceptable reliability of .70 and expected reliability of .90 (Portney & Watkins, 2000). To account for possible attrition, the sample size was increased by 20% for a final sample size of 147 participants. Data Quantitative data were collected through Qualtrics (https://www.qualtrics.com/), a secure, online survey program. The initial PODCI, PROMIS, and NRS scores were collected during the participants therapy visits. The second PODCI assessments were completed between 5-14 days following the initial visit via a link that was sent to the participant through text message or email. In addition, participant age and gender were also collected at Time 2. Data from both time periods were downloaded from Qualtrics.com into a Microsoft Excel file by the primary researcher and collated using the unique ID entered by the participant. Once the scores for each of the instruments were calculated, the data were exported into a statistical software program for analysis. RELIABILITY AND VALIDITY OF A PAIN MEASURE 17 Instruments The Pediatric Outcomes Data Collection Instrument. The PODCI is a self-reported outcome measure designed by the American Academy of Orthopedic Surgeons Outcomes Studies committee that was intended for use in the clinical setting (Hunsaker et al., 2002). The PODCI measures outcomes across eight domains: upper extremity and physical function, transfer and basic mobility, sports/physical function, pain/comfort, treatment expectations, happiness, satisfaction with symptoms, and global functioning. Each scale or domain yields a standardized score between 0-100. In a population of typically developing children aged 2-18 years, the PODCI demonstrated high internal consistency as reported above and item discriminant validity when compared with the Disabilities of the Arm, Shoulder, and Hand (DASH) assessment (Hunsaker et al., 2002). In children and adolescents with acute wrist and hand conditions, the full version of the PODCI demonstrated internal consistency (Cronbachs alpha = .89) and responsiveness to change (Kunkel, Eismann, & Cornwall, 2011). This study used two subscales of the PODCI, the upper extremity function (UEF) and pain/comfort (P). This modified version of the PODCI consists of 11 questions designed to be used with children ages 11-18 years. Eight questions assess upper extremity function. The participant is asked to assess how easy or hard the following tasks are: writing with a pencil, pouring a half gallon jug, lifting heavy books, fastening buttons, using a fork or spoon, opening a jar that has already been opened, combing hair, and turning a doorknob. The activities are rated on a four-point Likert-like scale: 1 (easy), 2 (a little hard), 3 (very hard), and 4 (cant do at all). A score of 100 indicates no functional difficulties, while a score of 0 indicates that the user is unable to complete the tasks. The mean (with standard deviation in parentheses) in pediatric normative sample is 98.71 (4.93) (Hunsaker et al., 2002). A retrospective study by Gates and RELIABILITY AND VALIDITY OF A PAIN MEASURE 18 Campbell (2015) compared the norms established by Hunsaker, et al. (2002) to children and adolescents to evaluate the impact of a variety of comorbid conditions, age, and gender on the PODCI subscales using independent samples t tests. In that study, the mean for PODCI UEF in individuals with a comorbidity that was currently limiting was 93.1 (14.8). There was not a significant difference between the scores, F(1, 5047) = 0.003, p < .896. The comorbid conditions included arthritis, eating disorders, asthma, learning difficulties, heart conditions, vision and hearing impairment (Gates & Campbell, 2015). Three questions address how much pain interfered with the individuals activity over the last week. A score of 100 indicates no pain, while a score of 0 indicates that pain severely interfered with participation in activities. The mean in pediatric normative sample is 89.31 (14.79) (Hunsaker et al., 2002). In children and adolescents with a currently limiting comorbidity, the mean for the PODCI P was 77.0 (22.6). There was a significant difference between the normative sample and the sample with comorbidities, F(1, 5047) = 29.75, p < .001) (Gates & Campbell, 2015). The PODCI is calculated as follows: Upper extremity function score = [(4 - x)100]/3; x = mean of questions 1, 2, 3, 4, 5, 6, 7, 8 Pain score= [(4 - (x - 1))100]/4; x = the mean of y, z, and question #11; y = [(4 - the response to question #9)4]/3 +1; z = [(the response to question #10 -1)4]/5+1 Patient Reported Outcomes Measurement Information System, Pediatric Upper Extremity Short Form v2.0. The PROMIS is set of person-centered measures, initiated and supported by the National Institute of Health to aid in the evaluation of physical, mental, and social health across ages and health conditions (Irwin et al, 2012). The pediatric set is self- report RELIABILITY AND VALIDITY OF A PAIN MEASURE 19 for ages 8-17 years and measures across five health domains of physical function, pain, fatigue, emotional health, and social health. The five domains have been further defined into multiple forms for assessments to be used in the clinical and research environments. The PROMIS PUESF has demonstrated test-retest reliability among 54 participants with a correlation of .71 and good internal consistency with an alpha of .63 (Varni et al., 2014). It demonstrated good construct validity with the PODCI (r = .70, p < .001) and the DASH (r = .80, p < .001) in children with congenital hand differences (Waljee, Carlozzi, Franzblau, Zhong, & Chung, 2015). The PROMIS PUE-SF consists of eight questions to assess daily upper extremity function. Participants are asked to rate how much trouble it is to do the following items: button a shirt or pants, open a jar, open the rings in a school binder, pour a drink from a full pitcher, pull a shirt on over my head by myself, pull open a heavy door, put on shoes, use a key to unlock a door. The items are rated on a five point Likert scale 1 (not able to do), 2 (with a lot of trouble), 3 (with some trouble), 4 (with a little trouble), and 5 (with no trouble). There are two items that have collapsed scoring responses (button shirt or pants and pull shirt overhead). The PROMIS UEP and PROMIS P are scored using Tscores, mean of 50 and a standard deviation of 10; therefore, a score of 40 would indicate upper extremity function 1 standard deviation below the mean while a score of 60 would indicate upper extremity function 1 standard deviation above the mean (Thissen, et al., 2015). It is recommended to use the Health Measures Scoring Service to score the assessment, found at https://www.assessmentcenter.net/ac_scoringservice. However, it can also be calculated by hand, converting raw scores into standard scores using scoring tables in the PROMIS Physical Function Scoring Manual found at http://www.healthmeasures.net/administrator/components/com_instruments/uploads/PROMIS% 20Physical%20Function%20Scoring%20Manual.pdf. RELIABILITY AND VALIDITY OF A PAIN MEASURE 20 The Numerical Rating Scale. The NRS is commonly used by many disciplines across ages and diagnoses to measure an individuals pain (Brevik et al., 2008). A systematic review completed by Castarlenas, Jensen, von Baeyer, and Mir (2017) found the NRS to be a reliable and valid pain assessment tool for children over 8 years of age. However, it should be noted that only one of the sixteen articles reviewed established test-retest reliability in the measure. It was established using the Bland-Altman method and showed a high agreement, limits of agreement of 95% CI [0.90, 1.20] (Castarlenas et al., 2017). Convergent validity was established in children, ages 8-17 years, with chronic pain by comparing it to the Coloured Analog Scale (CAS). The authors found that the NRS met criteria for convergent face validity (r > .30 to .50) and correlated with the CAS on all four pain levels (r = .58 to .68, all p < .001). Discriminant validity was examined by comparing the magnitude of the correlations for NRS and CAS usual pain ratings with the correlation between NRS and Facial Affective Scale (FAS) using Fishers Z-transformation test (Ruskin et al., 2014). The magnitude of the correlation between NRS and FAS was found to be significantly lower than that between the NRS and CAS (Z = 2.84; p = .005) (Ruskin et al., 2014). Procedures Recruitment. Potential participants were identified after physician or nurse practitioner referral to occupational therapy and/or physical therapy. Treating therapists completed chart reviews to assess for inclusion and exclusion criteria at the time of their regularly scheduled therapy appointment. Potential participants must have met the inclusion criteria at that time to be invited to participate in the study. The treating therapist or the primary researcher verbally reviewed the consent document with the potential participants and their parent/legal guardian. They were also given a written description of the study to review. They were given time to ask RELIABILITY AND VALIDITY OF A PAIN MEASURE 21 questions and make a decision about being in the study. Formal consent was waived because data were de identified and the study posed minimal harm. Participants were considered to be in the study if they agreed to provide contact information for the study. Data collection. Participants who agreed to be in the study completed the following: Wrote down an email or phone number so that the survey could be sent to them through text or email. The parent/guardian was also able provide their own email address or phone number so that they could be copied on the email or text if they chose. Writing down their email and/or text and giving it to the treating therapist implied consent to participate in the study. The participant used a unique six character letter/number code when filling out the PODCI that was used to match their first and second assessments. The code consisted of the first two letters of their middle name, followed by the first two letters of their mothers first name and the first two numbers of their home address. Some children chose a different six character code when completing the PODCI. This code was used on all data collection documents in Qualtrics.com and was not linked to the participants name or contact information. Participants filled out the PODCI (both subscales), PROMIS, and NRS through Qualtrics.com at their initial therapy visit. A link to the online PODCI was emailed or texted to participants 5 days following their initial therapy visit. Their parent/legal guardian was copied on the email/text when requested; however, participants and their caregiver were instructed that only the adolescent should complete the assessments. A description of the study RELIABILITY AND VALIDITY OF A PAIN MEASURE 22 was included in the email or text and a copy of the informed consent form was included as the first page of the Qualtrics questionnaire. A reminder email or text was sent 10 days following their initial therapy visit. Participants were instructed to disregard the message if they had already completed the questionnaire through Qualtrics.com. If it was completed an additional time, the additional assessment was deleted and not collected as part of the data. Participants completed the PODCI within 14 days of their initial therapy visit through the secure website (Qualtrics.com) using their unique code to maintain their anonymity. Assessments completed after 14 days of the initial visit were deleted and not used in the study. The completed assessments were paired with each other using the six digit code provided by the participant and given a unique study number. Data were downloaded from Qualtrics.com. Only those approved to work on the research study had access to the data. Data Analysis Descriptive statistics were used to describe the baseline characteristics of participants. None of the Time 1 outcomes data were normally distributed; therefore, non-parametric tests were performed. In examining test-retest reliability, agreement between the PODCI UEF at two time points and the PODCI P assessments at two time points were assessed using Lins concordance correlation coefficient ([Lins C] Lin, 2000). A statistical calculator was used to calculate Lins C (www.niwa.co.nz/node/104318/concordance). Cronbachs alpha was calculated to assess for internal consistency. A Cronbachs alpha level 0 is the lowest score, while a score RELIABILITY AND VALIDITY OF A PAIN MEASURE 23 of 1 is the highest. An alpha of .70 is the minimal acceptable level for internal consistency for health professions research (Portney & Watkins, 2014). Concurrent validity for the PODCI upper extremity function subscale was explored by using the Spearman rho correlation test to determine if there was an association between the PODCI UEF and the PROMIS PUE-SF. The raw scores from the PROMIS PUE-SF were used rather than the normative scores as the PODCI UEF does not have normalized scores. The Spearman rho test was also used to determine if there was an association between the PODCI P subscale and the NRS. The following correlation scale for health professions was used for Lins C and Spearman rho: A score of 1.00 indicates perfect correlation, .80 - .99 = very high, .60 - .79 = moderate, .30 - .59 = fair, .29 - .10 = poor, while a score of 0 indicates no correlation (Altman, 1991). The study sought to establish test-retest reliability of at least .90 and validity of at least .70, consistent with instrumental reliability in health professions (Portney & Watkins, 2014). The minimal detectable change (MDC) was calculated using the standard error of measurement (SEM) (1.96*SEM*2). The SEM [SD * ((1 c)] was calculated using Lins C; however, it should be noted that the data were not normally distributed which may impact the results. The ShapiroWilk test was used to determine whether data were normally distributed. All data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY). All tests were two-tailed, and an alpha level of less than .05 was considered to be statistically significant. Results A total of 150 participants were recruited during regularly scheduled outpatient occupational and physical therapy visits from a pediatric hospital in the Midwest. The participants ranged in age from 11 through 18 years, with a median age of 15 years. The study recruited male and female participants, with 80% being female. This is consistent with JH being RELIABILITY AND VALIDITY OF A PAIN MEASURE 24 more prevalent in females (Smith et al., 2013). Of the 150 participants, 93 completed the PODCI a second time within the 14 day time frame. Ten PODCI surveys were excluded due to not having an ID code that matched the ID code of an initial assessment. Therefore, data on the 83 (55.3%) participants are reported for the test-retest results. For validity testing, all 150 participants completed the PODCI UEF, PODCI P, PROMIS PUE-SF, and NRS. Reliability. For the PODCI UEF portion, the Lins C correlation indicated very high relative test-retest reliability (c = .80). Absolute reliability was also established with no statistically significant difference found between Time 1 and Time 2 scores (Z = -1.15 p = .25). Cronbachs alpha was calculated using the Time 1 and Time 2 scores. The internal consistency among the 8 questions was assessed to be high with a Cronbachs alpha value of .81 for Time 1 and .76 for Time 2. The Lins C for the PODCI P indicated only moderate relative test-retest reliability (c = .68). However, there was not a statistically significant difference between Time 1 and Time 2 scores (Z = -1.78, p = .075), establishing absolute test-retest reliability of the subscale. Internal consistency among the three questions was assessed to be high with a Cronbachs alpha value of .88 for Time 1 and .83 for Time 2. Refer to Table 1 for the descriptive statistics for all Time 1 and Time 2 results for both time periods. Validity. The Spearman rho correlation between the PODCI UEF and the PROMIS PUESF was .79 (p < .001), indicating moderately high correlation between the two measures (Figure 1). There was also a moderate, negative correlation between the PODCI P assessment and the NRS, rs = -.73; p < .001 (Figure 2).A lower score on the PODCI P indicates greater pain, while a lower score on the NRS indicates less pain; therefore an inverse relationship was expected. Minimal detectable change. The study also sought to establish the responsiveness of the PODCI by calculating the minimal detectable change (MDC) using the SEM. The MDC is the RELIABILITY AND VALIDITY OF A PAIN MEASURE 25 smallest change that can be considered above the measurement error at a given level of confidence (Copay, Subach, Glassman, Polly, & Schuler, 2007). The confidence level was set at 95% and Time 1 data were used. For the PODCI UEF, the SEM was 6.99 with a MDC of 19.38. For the PODCI P, the SEM was 14.37 and the MDC was 39.83. This indicates that a change above these values would be 95% likely to be a true change verses a change that is caused by an error. Discussion This study sought to establish test-retest reliability of the UEF and pain interference portions of the PODCI in adolescents with JH. There is a lack of reliable assessments that measure upper extremity function and the impact of pain in this population. This study established an a priori correlation coefficient of .90, however this was not achieved. During its development, test-retest reliability was established for the PODCI UEF subscale (r = .96) and the PODCI P subscale (r = .89) in 30 adolescents with various chronic conditions. The test-retest assessments were taken 1-2 days apart (Daltroy et al., 1998). The smaller sample size, various diagnoses that did not include JH, and the differences in time frame may have impacted differences in the test-retest reliability between the original study and the current one. Using a convenience sample of participants currently undergoing treatment for function and pain may have also contributed to the non-normal distribution of the data which may have also biased the results. Some adolescents with JH may experience upper extremity dysfunction and pain, while others may not. This may depend largely on which joints are hypermobile, as well as the individuals unique daily activities. Some of the adolescents in the sample were undergoing occupational therapy to address upper extremity dysfunction and pain. However, some of the adolescents were not reporting upper extremity pain or dysfunction and therefore, were only RELIABILITY AND VALIDITY OF A PAIN MEASURE 26 receiving physical therapy and not occupational therapy. This difference in participants may have also contributed to the non-normal distribution of data. The PODCI UEF demonstrated better test-retest reliability than the PODCI P. It is worth noting that pain in a chronic condition such as JH can vary day-to-day which may affect the testretest reliability in an outcome measure. The participants took the PODCI retest between 5-14 days following therapeutic intervention. It is possible that the individuals experienced changes in pain related to their condition or to their therapy visit during this time frame. The PODCI P accounts for the impact of pain on participation in activities over the last week versus the NRS that measures only the intensity of pain. Using the PODCI P along with the NRS may help clinicians to assess the impact of interventions on meaningful activities that are not part of the PODCI UEF, such as extracurricular activities and social participation. Therefore, the PODCI P may be a useful tool in measuring the impact of pain on activities over time following therapeutic intervention. The PODCI was designed to be used as an outcome measure for chronic musculoskeletal conditions and has demonstrated test-retest reliability, validity, and responsiveness to change in other populations, making it a feasible option to use in the clinic and research settings (Kunkel, Eismann, & Cornwall, 2011). It is worth noting that reliability was established as well as a strong correlation between Time 1 and Time 2. This is clinically relevant because there is currently not an outcome measure for upper extremity function and pain that has established test-retest reliability among adolescents with JH. Concurrent validity. This study sought to establish concurrent validity between the PODCI UEF and PROMIS PUE-SF and between the PODCI P and the NRS with an r > .70. This was achieved in both measures. The findings have implications that the PODCI may be a RELIABILITY AND VALIDITY OF A PAIN MEASURE 27 useful tool in the clinic to assess upper extremity function and pain in adolescents with JH. There is currently not an outcome measure that has been established as valid in adolescents with JH. Minimal detectable change. The sample did not demonstrate a normal distribution, as determined by the Shapiro-Wilk test of normality. The SEM is meaningful when calculated from a normal distribution; therefore, the SEM and MDC for this study should be interpreted with caution. The lack of normally distribute data could account for the large values. In addition, there was variation in how long participants were in treatment when they completed the PODCI. Some were just beginning therapy while others had been in therapy for several months. It is possible that those in treatment longer were experiencing less functional limitation and pain than those just beginning treatment. This could account for the non-normal distribution and large SEM and MDC. To determine responsiveness of the instrument to detect change, it would have been better to collect the scores for all participants at the onset of treatment, then again after a specified number of visits or time frame. Not all individuals with a diagnosis of JH experience upper extremity dysfunction and/or pain. However, it is common for people with JH to have glenohumeral instability (Scheper, et al., 2013) and shoulder dysfunction (Johannessen et al., 2016). Using the PODCI UEF can help primary care providers, geneticists, and rheumatologists to identify potential areas of upper extremity dysfunction related to shoulder instability or hypermobility in the upper extremities and refer to occupational and/or physical therapy as indicated. A score of 100 on the PODCI is indicative of normal upper extremity function. Therefore a score below 90 would reveal decreased levels of function when compared to the normative sample (Haynes & Sullivan, 2001) and would suggest the need for therapeutic intervention. The PODCI UEF provides information on upper extremity function across different domains of participation, such as activities of daily RELIABILITY AND VALIDITY OF A PAIN MEASURE 28 living, instrumental activities of daily living, and school which may help guide clinicians when planning treatment. Clinicians can use the Likert-like scale responses to help adolescents identify the barriers to completing the tasks, such as decreased strength or pain. Using the PODCI UEF to identify and discuss areas of dysfunction can help to improve collaboration and client centered care. The PODCI P may help clinicians better understand how pain has impacted participation in meaningful occupations rather than the intensity of their pain at a particular moment. Children with JH report higher instances of pain that appears to limit activity and leisure participation (Schubert-Hjalmarsson et al., 2012). It is recommended clinicians treating pain to gather a comprehensive picture to help identify what is contributing to the pain (Rabin, Brown, & Alexander, 2017). The PODCI P can help clinicians gather more information about the impact of pain as well as what may be contributing to it. Additionally, the PODCI has previously been found to discriminate between the functional disability and depression that can be present in children with pain (Broadbent et al., 2017).Clinicians can use the PODCI P answers to guide questions on which areas of participation have been impacted, as well as guide subsequent treatment planning, activity modifications, and exercise program. The NRS has been established as a reliable and valid measure of pain; however, it measures the intensity of pain at one moment in time and does not capture the impact or interference of pain on activity. To effectively help adolescents manage pain, more clinical information is needed to understand the nature of the pain and its impact (Rabin et al., 2017). The NRS and the PODCI P demonstrated only a moderate correlation which is not surprising since they are measuring different aspects of pain. Pain is complex and variable in chronic conditions and may require an assessment in addition to the NRS to better understand the impact RELIABILITY AND VALIDITY OF A PAIN MEASURE 29 of pain on daily activities. Due to the inconsistent nature of chronic pain, it may be difficult to use the NRS alone as an outcome measure to assess the effectiveness of therapeutic interventions aimed at lessening pain during functional activities. The PODCI P allows clinicians to understand more about how the intensity of pain is impacting the adolescents participation in daily activities. For example, following an intervention, the NRS pain intensity may decrease, however pain may still impact or limit participation in meaningful activities. The NRS when used alone may capture pain that is happening during their clinic visit, however may not be reflective of pain that occurs during the school day or a leisure activity. Using the PODCI P in addition to the NRS can help clinicians better understand the pain the adolescent is having which may help them develop a more client-centered intervention. The NRS is routinely used across professions in many different settings and may be beneficial to use in conjunction with the PODCI P in assessing pain and changes in how pain impacts participation daily activities over time. The PODCI was primarily designed for children and adolescents with musculoskeletal conditions, such as JH (Quatman-Yates et al., 2013; Daltroy et al., 1998). Adolescents with scores below 80 - 90 on the PODCI indicated a difference from the normative population and therefore, may benefit from an intervention targeted at improving upper extremity function and pain. Conversely, adolescents with scores above 80 - 90 on the PODCI indicate upper extremity function and pain that is normal and may not benefit from therapeutic intervention (Haynes & Sullivan, 2001). The PODCI did appear to detect dysfunction and pain in adolescents with JH. The mean score for UEF in a normative sample was 98.71 (Hunsaker et al., 2002), while the median score for UEF in the current study was 87.50. The mean score of the PODCI P in a normative sample was 89.31. The median score in the current study was 49.44. It is important for RELIABILITY AND VALIDITY OF A PAIN MEASURE 30 clinicians to use outcomes to guide practice and intervention. The first step in client-centered care is identifying an area of concern and then determining which interventions may be appropriate for each adolescent. Using a self-report measure, such as the PODCI UEF and PODCI P may be a good first step in the process. The PODCI UEF and PODCI P instruments, when combined, are a total of 11 questions and are easy to administer in the clinic setting. Furthermore, both subscales have already been used in research with children with a variety of conditions, including brachial plexus injury, cerebral palsy, acute injuries, and limb differences. The PODCI UEF is comparable to the PROMIS PUE-SF in length, design, and content. The PROMIS PUE-SF did not demonstrate the ceiling effect that the PODCI UEF did with the same population. This could be because the PODCI was designed for adolescents with existing dysfunction and not for the general population. The PROMIS PUE-SF uses a T-score calculation with standard deviations that help to define difference from the mean, which may help it to be more sensitive to change. Many adolescents with JH report difficulty with writing and it is a question on the PODCI UEF. The PROMIS PUE-SF does not have a question regarding writing with a pencil. The PROMIS does have a pediatric pain/comfort scale short form in addition to the PUE-SF. However, it is eight questions and when combined with the eight questions from the PROMIS PUE-SF, it would take longer for an adolescent to complete. Additionally, more research is needed to determine the effectiveness of these scales as outcome measures. Neither the PROMIS PUE-SF nor the PROMIS pain interference scale has been established as valid in adolescents with JH. There is a need to establish the reliability and validity of the PROMIS scales in adolescents with JH to consider them as potential outcome measures to use clinically and in research. RELIABILITY AND VALIDITY OF A PAIN MEASURE 31 It has been established that adolescents with JH often live with joint pain that impacts their physical activity and quality of life (Birt et al., 2013; Tobias et al., 2013). Therapy is often recommended as part of the treatment process and the type of intervention may be left to the treating therapist to decide. It is agreed upon in the literature that more research is needed regarding which therapeutic interventions are the most effective for adolescents with JH. A valid and reliable outcome measure is necessary for this population to help guide clinical practice and research. Using a reliable outcome measure consistently in research is one step towards improving research and clinical practice in improving pain and function in adolescents with JH. This study established that the two PODCI subscales, PODCI UEF and PODCI P, demonstrate moderate to high test-retest reliability and concurrent validity. The combined subscales are a total of 11 questions and easy to use in the clinic setting. Furthermore, it has been previously established to be responsive to change, which adds value as an outcome measure both in research and clinically (Kunkel, Eismann, & Cornwall, 2011). Therefore, the PODCI may be useful as an assessment tool as well as an outcome measure for occupational and physical therapists when treating adolescents with JH. Limitations The study aimed to recruit 117 participants to establish test-retest reliability. A total of 150 participants were recruited; however, only 83 completed the test-retest portion of the study. All of the participants were receiving occupational and/or physical therapy, but the length of time receiving treatment varied. Some participants may have been receiving therapy for 6 months, while others may have just been referred to therapy. Some participants were receiving therapy for reasons other than upper extremity dysfunction, or were receiving only physical therapy. This may account for 40% of the participants having an UEF score greater than 90, RELIABILITY AND VALIDITY OF A PAIN MEASURE 32 while 10% of the participants had a P score greater than 90. Additionally, the PODCI was designed for children with orthopedic or musculoskeletal difficulties; therefore, there is a ceiling effect in the scores among children without orthopedic difficulties (Haynes & Sullivan, 2001). Future studies may consider excluding scores of 100, or only recruiting participants who are receiving occupational therapy. Some of the participants had been given the PODCI UEF and PODCI P prior to participating in the study as part of their regular therapy visit, which may have created a bias. The potential bias along with the variation in therapy visits may have also contributed to the non-normal distribution. Future studies may consider establishing responsiveness by administering the PODCI UEF and PODCI P prior to the onset of therapeutic intervention, then again after a controlled number of visits. Lastly, Daltroy et al. (1998) established test-retest reliability by administering Time 1 and Time 2 within 1-2 days, and it may have been better to follow a similar format in this study due to the chronic nature of the diagnosis and the variability of pain. Conclusion The UEF and pain interference subscales of the PODCI demonstrated moderate to high reliability and validity in adolescents with JH. Additionally, it has been previously established to be a feasible measure to use in the clinic setting (Hunsaker et al., 2002; Kunkel, Eismann, & Cornwall, 2011) and did not impact treatment time during this study. As the sample in this study did not have a normal distribution, more research is recommended to establish the responsiveness of these subscales in adolescents with JH. It is also recommended to continue to research the utility of the PODCI UEF and PODCI P as an outcome measure in adolescents with JH. While this study established concurrent validity between the PODCI UEF and the PROMIS PUE-SF, it would be helpful to determine if both are as responsive to change in function in RELIABILITY AND VALIDITY OF A PAIN MEASURE 33 adolescents with JH. Likewise, it is recommended that the validity of the PODCI P in this population be compared to another pain interference instrument like the PROMIS Pain Interference scale. Despite the need for further validation of the PODCI subscales, given the lack of available valid and reliable outcome measures for this population, occupational and physical therapists may consider using the PODCI UEF and PODCI P in conjunction with the NRS clinically and in research. Primary care physicians, rheumatologists, geneticists, psychologists, and nurse practitioners may also consider using the PODCI UEF and PODCI P to determine the need for referrals for therapy. It is also recommended that clinicians continue to assess reliability and validity in outcome measures for adolescents with JH to continue to advance clinical practice and research. RELIABILITY AND VALIDITY OF A PAIN MEASURE 34 References Altman, D. G. (1991). Practical statistics for medical research (1st ed.). New York, NY: Chapman and Hall. Arthur, K., Caldwell, K., Forehand, S., & Davis, K. (2016). 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(2016). Physiotherapy management of joint hypermobility syndromea focus group study of patient and health professional perspectives. Physiotherapy, 102(1), 93-102. http://doi.org/10.1016/j.physio.2015.05.001 Pencharz, J., Young, N. L., Owen, J. L., & Wright, J. G. (2001). Comparison of three outcomes instruments in children. Journal of Pediatric Orthopaedics, 21(4), 425432. Portney, L. G., & Watkins, M. P. (2014). Foundations of clinical research: Applications to practice. Harlow, UK: Pearson Education. Quatman-Yates, C. C., Gupta, R., Paterno, M. V., Schmitt, L. C., Quatman, C. E., & Ittenbach, R. F. (2013). Internal consistency and validity of the QuickDASH instrument for upper extremity injuries in older children. Journal of Pediatric Orthopaedics, 33(8), 838-842. RELIABILITY AND VALIDITY OF A PAIN MEASURE 39 Rabin, J., Brown, M., & Alexander, S. (2017). Update in the Treatment of Chronic Pain within Pediatric Patients. Current Problems in Pediatric and Adolescent Health Care, 47(7), 167-172. doi:10.1016/j.cppeds.2017.06.006 Rombaut, L., Malfait, F., Cools, A., De Paepe, A., & Calders, P. (2010). Musculoskeletal complaints, physical activity and health-related quality of life among patients with the EhlersDanlos syndrome hypermobility type. Disability and Rehabilitation, 32(16), 1339-1345. http://doi.org/10.3109/09638280903514739 Ruskin, D., Lalloo, C., Amaria, K., Stinson, J. N., Kewley, E., Campbell, F.,...McGrath, P. A. (2014). Assessing pain intensity in children with chronic pain: Convergent and discriminant validity of the 0 to 10 numerical rating scale in clinical practice. Pain Research and Management, 19(3), 141-148. http://doi.org/10.1155/2014/856513 Scheper, M. C., Juul-Kristensen, B., Rombaut, L., Rameckers, E. A., Verbunt, J., & Engelbert, R. H. (2016). Disability in adolescents and adults diagnosed with hypermobility-related disorders: A meta-analysis. 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BMC Pediatrics, 15(1), 1-8. doi:10.1186/s12887-0150515-4 Smith, T. O., Bacon, H., Jerman, E., Easton, V., Armon, K., Poland, F., & Macgregor, A. J. (2013). Physiotherapy and occupational therapy interventions for people with benign joint hypermobility syndrome: A systematic review of clinical trials. Disability and Rehabilitation, 36(10), 797-803. http://doi.org/10.3109/09638288.2013.819388 Thissen, D., Liu, Y., Magnus, B., Quinn, H., Gipson, D., Dampier, C., Huang, I., Hinds, P., Selewski, D., Reeve, B., Gross, H. and DeWalt, D. (2015). Estimating minimally important difference (MID) in PROMIS pediatric measures using the scale-judgment method. Quality of Life Research, 25(1), pp.13-23. Tinkle, B. T., Bird, H. A., Grahame, R., Lavallee, M., Levy, H. P., & Sillence, D. (2009). The lack of clinical distinction between the hypermobility type of Ehlers-Danlos syndrome and the joint hypermobility syndrome (aka hypermobility syndrome). American Journal of Medical Genetics Part A, 149(11), 2368-2370. doi:10.1002/ajmg.a.33070 Tobias, J. H., Deere, K., Palmer, S., Clark, E. M., & Clinch, J. (2013). Joint hypermobility is a risk factor for musculoskeletal pain during adolescence: Findings of a prospective cohort study. Arthritis & Rheumatism, 65(4), 1107-1115. doi:10.1002/art.37836 Varni, J. W., Magnus, B., Stucky, B. D., Liu, Y., Quinn, H., Thissen, D.,...DeWalt, D. A. (2014). Psychometric properties of the PROMIS pediatric scales: Precision, stability, and comparison of different scoring and administration options. Quality of Life Research, 23(4), 1233-1243. doi:10.1007/s11136-013-0544-0 RELIABILITY AND VALIDITY OF A PAIN MEASURE 41 von Baeyer, C. L., Spagrud, L. J., McCormick, J. C., Choo, E., Neville, K., & Connelly, M. A. (2009). Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for childrens self-reports of pain intensity. Pain, 143(3), 223-227. http://doi.org/10.1016/j.pain.2009.03.002 Wall, L. B., Shen, T., Roberts, S., & Goldfarb, C. A. (2016). Parental assessment of status of congenital upper limb differences: analysis of the pediatric outcomes data collection instrument. The Journal of hand surgery, 41(3), 381-386. http://dx.doi.org/10.1016/j.jhsa.201 Waljee, J. F., Carlozzi, N., Franzblau, L. E., Zhong, L., & Chung, K. C. (2015). Applying the Patient-Reported Outcomes Measurement Information System to assess upper extremity function among children with congenital hand differences. Plastic and Reconstructive surgery, 136(2), 200e-207e. doi:10.1097/PRS.0000000000001444 Weir, J. P. (2005). Quantifying test-retest reliability using the intraclass correlation coefficient and the SEM. The Journal of Strength & Conditioning Research, 19(1), 231-240. RELIABILITY AND VALIDITY OF A PAIN MEASURE 42 Table 1 Descriptive Statistics for Test Retest Reliability (N = 53) PODCI Time 1 Time 2 Mdn (IQR) Mdn (IQR) Upper Extremity Function 87.50 (25.00) 83.33 (25.00) Pain 49.44 (41.1) 58.89 (32.78) Note. IQR = interquartile range RELIABILITY AND VALIDITY OF A PAIN MEASURE 43 Figure 1. Scatterplot Showing the Correlation Between the PODCI Upper Extremity Function Scale and the PROMIS Pediatric Upper Extremity Short Form (raw scores) PROMIS Pediatric Upper Extremity Short Form Scores 40 35 30 25 20 15 10 0 20 40 60 80 PODCI Upper Extremity Function Scores rs = .79, p < .001 100 120 RELIABILITY AND VALIDITY OF A PAIN MEASURE 44 Figure 2. Scatterplot Showing the Correlation between PODCI Pain Scores and Numeric Rating Scale Scores NRS Numeric Rating Scale Scores 10 9 8 7 6 5 4 3 2 1 0 0 10 20 30 40 50 60 70 PODCI Pain Interference Scale Scores rs = -.73; p < .001 80 90 100 RELIABILITY AND VALIDITY OF A PAIN MEASURE 45 Appendix A PODCI Upper Extremity Function and Pain Interference Subscales Q1. During the last week, was it easy or hard for you to lift heavy books? Easy (1) A little hard (2) Very Hard (3) Can't do at all (4) Q2. During the last week, was it easy or hard for you to pour a half gallon of milk? Easy (1) A little hard (2) Very Hard (3) Can't do at all (4) Q3. During the last week, was it easy or hard for you to open a jar that has been opened before? Easy (1) A little hard (2) Very Hard (3) Can't do at all (4) Q4. During the last week, was it easy or hard for you to use a fork and spoon? Easy (1) A little hard (2) Very Hard (3) Can't do at all (4) Q5. During the last week, was it easy or hard for you to comb your hair? Easy (1) A little hard (2) Very Hard (3) Can't do at all (4) Q6. During the last week, was it easy or hard for you to button buttons? Easy (1) A little hard (2) Very Hard (3) Can't do at all (4) Q7. During the last week, was it easy or hard for you to write with a pencil? Easy (1) A little hard (2) Very Hard (3) Can't do at all (4) Q8. During the last week, was it easy or hard for you to turn door knobs? Easy (1) A little hard (2) Very Hard (3) Can't do at all (4) RELIABILITY AND VALIDITY OF A PAIN MEASURE 46 Q9. In regards to your upper extremity pain: During the last week, how much of the time did pain or discomfort interfere with your activities? Most of the time Some of the time A little of the time None of the time Q10. In regards to your upper extremity pain: How much pain have you had during the last week? None Very mild Mild Moderate Severe Very Severe Q11. In regards to your upper extremity pain: During the last week, how much did pain interfere with your normal activities (including at home, outside of the home, and at school)? Not at all A little bit Moderately Quite a bit Extremely RELIABILITY AND VALIDITY OF A PAIN MEASURE Appendix B 47 RELIABILITY AND VALIDITY OF A PAIN MEASURE 48 Appendix C Numeric Rating Scale (NRS) Please rate your average pain over the last week on the following scale. 0 means no pain at all and 10 means the worst pain you can imagine. 0 1 2 3 4 5 6 7 8 9 10  ...

... CERVICAL PROPRIOCEPTION IN FEMALE COLLEGIATE SOCCER PLAYERS COMPARED TO NON-CONTACT SPORT ATHLETES Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Michelle Ann Schneider PT, DPT, OCS Copyright June 21, 2019 By: Michelle Ann Schneider PT, DPT, OCS All rights reserved Approved by: Emily J. Slaven, PT, PhD Committee Chair Elizabeth S. Moore, PhD Committee Member Ed Jones, PT, DHSc, OCS Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS Cervical Proprioception in Female Collegiate Soccer Players Compared to Non-Contact Sport Athletes Michelle Schneider University of Indianapolis 1 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 2 Abstract A non-experimental study was conducted to explore whether cervical proprioception was compromised in female collegiate soccer players and to examine what factors may be related to impaired proprioception. Each study participant performed the Head Repositioning Accuracy (HRA) test using active relocation to the original self-selected neutral head position (NHP). Error, in degrees, for repositioning to the NHP was read from a cervical range of motion device. Phase one established cut-off values for classification of impaired cervical proprioception. Phase two compared cervical proprioception between a sample of soccer and non-contact sports athletes. Each phase two group consisted of 24 female participants who were 18-24 years of age. Comparisons between soccer players and non-contact athletes were conducted to determine if there were statistically significant differences in history of cervical injuries and history of concussions. Demographic data between groups lacked statistical significance. Absolute error (AE), constant error (CE), and variable error (VE) were calculated and compared between groups. A significant difference was found for AE left. Absolute error right, CE left and right, and VE left and right lacked statistically significant differences between groups. Within the soccer group a report of a previous concussion, a history of a cervical injury, and field position were compared for players with and without impaired cervical proprioception. Each lacked statistical significance. A higher percentage of soccer players with a history of a cervical injury had impaired cervical proprioception overall. The statistically significant difference in AE left may lead to consideration of proprioceptive preseason screening for injury prevention and postinjury rehabilitation. Keywords: cervical proprioception, head repositioning accuracy, soccer CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 3 Acknowledgements As I approach the end of this doctoral program, I feel grateful for the opportunity for professional advancement and personal challenge. I would like to take this opportunity to thank the people who have supported and encouraged me throughout the program. First, I would like to thank my husband, Curt, and my sons, Ben and Alex. Your love, support, and understanding throughout the process of earning the DHSc has meant more to me than words can express. You have been my central focus throughout this endeavor. To my mom and entire family, the interest and encouragement along the way contributed to my motivation to see the project through to completion. Next, I would like to thank my committee members, Dr. Emily Slaven, Dr. Elizabeth Moore, and Dr. Ed Jones. I have sincerely valued your expertise. Every piece of advice that was offered greatly improved this project, and it has been deeply appreciated. I would also like to expressly thank the entire faculty in the Interprofessional Health and Aging Studies at University of Indianapolis. I have truly enjoyed the journey over the past three years. I have great respect for everything that I have learned. Each faculty member has been a role model for adherence to high standards and academic excellence. I would like to acknowledge Michael Cibulka for providing the cervical range of motion device that was used for data collection. I would also like to thank the entire faculty of the Maryville University Physical Therapy Program, particularly Sandy Ross, Michael Cibulka, and Jack Bennett who teach alongside of me. Thank you for your encouragement, mentorship, and moral support. You have been excellent examples of professionalism and friendship. With gratitude, Michelle Schneider CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 4 Table of Contents Title Page.1 Abstract2 Acknowledgements..3 Table of Contents.4 Chapter 1: Introduction8 Problem Statement...8 Purpose Statement and Research Objectives...9 Significance of the Study.......10 Chapter 2: Literature Review.10 Proprioception13 Cervical Proprioception.14 Cervical Proprioception Assessment.................................................................................15 Cervical Proprioception Impairment..............................................................................16 Clinical Considerations......17 Chapter 3: Method.....18 Study Design..18 Participants.18 Data Collection..20 Operationalization of Variables and Definitions...20 Instruments.21 Procedures..23 Data Analysis.26 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 5 Chapter 4: Results..28 Phase One...28 Phase Two .....28 Chapter 5: Discussion and Conclusion......30 Limitations 37 Implications for Future Research ..39 Conclusion.39 References..41 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 6 List of Tables Table 1 Participant Characteristics by Sport Group..51 Table 2 Comparisons of Error Calculations and Impaired Proprioception between Soccer and Non-Contact Sport Athletes...52 Table 3 Soccer Athlete Impairments by Demographic Data53 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS List of Appendices Appendix A Inclusion and Exclusion Screening Form Phase One54 Appendix B Inclusion and Exclusion Screening Form Phase Two.......55 Appendix C Phase One Data Collection Form..56 Appendix D Phase Two Soccer Athletes Data Collection Form...57 Appendix E Phase Two Non-Contact Sport Athletes Data Collection Form....59 7 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 8 Cervical Proprioception in Female Collegiate Soccer Players Compared to Non-Contact Sport Athletes Soccer is the most popular sport in the world which accounts for the diversity of its participants not only in age, gender, and ethnicity but also in skill level ranging from amateur to professional (Hulteen, 2017). Concussions and cervical spine injuries are known to occur in recreational, collegiate, and professional soccer players (Rechel, Yard, & Comstock, 2008) and account for approximately 19.1% of injuries seen in emergency departments among high school and collegiate soccer players (Kerr, Pierpoint, Currie, Comstock, & Wasserman, 2017). High velocity collisions (Tsoumpos et al., 2013) and head balls, in which the player impacts the ball with the forehead to alter the trajectory or win possession of the ball (Janda, Bir, & Cheney, 2002), are two mechanisms of soccer-related head and neck injuries that create the potential for cervical injuries, such as whiplash associated disorders (WAD) (Tsoumpos et al., 2013). Cervical proprioception, position sense of the cervical spine, has been reported to be altered in individuals who experience concussion and cervical injuries such as WAD (Poorbaugh, Brisme, Phelps, & Sizer, 2008; Tsoumpos et al., 2013) and with cervical spine pain of traumatic or atraumatic onset (De Vries, et al., 2015; De Zoete, Osmotherly, Rivett, Farrell, & Snodgrass, 2017; Dugailly et al., 2015). A decrease in cervical proprioception presents an individual with an increased risk for an additional cervical spine injury and concussions by limiting the ability to accurately position the head to avoid injury or set the head in a specific position for anticipatory stabilization. (Armstrong, McNair, & Taylor, 2008; Hides et al., 2017). Therefore, the restoration of proprioception is integral in the rehabilitation after cervical injury (Zech et al., 2009). While it is known that concussions and cervical spine injuries occur among soccer players, it is unknown whether soccer players have an increased-risk of developing CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 9 cervical proprioception deficits. The purpose of this study was to explore whether cervical proprioception is compromised in female collegiate level soccer players and examine what factors might be related to impaired proprioception. To address this purpose, the study was organized into two phases. In phase one, the criterion for impaired cervical proprioception was established in healthy subjects using the cervical range of motion (CROM) device for the Head Repositioning Accuracy (HRA) test. In phase two, cervical proprioception and risk of cervical proprioception deficits in in female collegiate level soccer players were compared to that of female collegiate athletes who participated in non-contact sports. In phase one, the objective was to establish a cutoff value for identifying impaired cervical proprioception as assessed by the maximal error in HRA of healthy female collegiate non-athletes. In phase two, the following primary objectives were addressed: 1. To determine if there were significant differences in the proportions of female collegiate soccer players with (a) a history of a concussion and (b) a history of cervical injury compared to female collegiate athletes who participated in non-contact sports. 2. To determine if there was a significant difference in cervical proprioception assessed using absolute error (AE), constant error (CE), and variable error (VE) in degrees measured with a CROM device during the HRA test between female collegiate soccer players and female collegiate athletes who participated in non-contact sports. 3. To determine if there was a significant difference in impairment in cervical proprioception as assessed with maximal error between female collegiate soccer players and female collegiate athletes who participated in non-contact sports. CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 10 In addition, the following secondary objectives were addressed: 1. To determine if there were significant differences in player demographics including history of concussion, history of cervical injury, soccer field position, number of years of participation in competitive soccer, and the number of years with unrestricted head balls between female collegiate soccer players with and without impaired cervical proprioception. 2. To determine if a correlation existed between HRA absolute error measures and the number of years competing in soccer and the number of years of unrestricted head balls between female collegiate soccer players with and without impaired cervical proprioception. The significance of this study is that it attempts to determine whether female collegiate soccer players have impaired cervical proprioception and which factors that may be associated with impaired proprioception if it exists. This could provide evidence to clinicians regarding the appropriate utilization of proprioceptive tests for preseason screening, training and conditioning for injury prevention, and therapeutic intervention in the rehabilitation of acute and chronic cervical spine injuries in collegiate soccer players. Literature Review Head and neck injuries incurred through soccer participation, specifically concussions, neck contusions, and sprains, have been reported in the medical literature ranging from 2.6% 22.0% depending on the study sample under investigation (Armstrong et al., 2008; Mehnert, Agesen, & Malanga, 2005). While some injuries are reported to athletic trainers and/or are treated in emergency departments, some athletes may not seek treatment; therefore, the prevalence of these injuries may not be fully reported (Kerr et al., 2017). Authors of a 2005 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 11 injury surveillance study that included data from 100 high schools in the United States reported that head, face, and neck injuries accounted for 14.6% of total injuries and also indicated that a higher proportion of these of injuries occurred during competition rather than during practice sessions, 17.7% compared to 11.0% (Rechel et al., 2008). Concussions in competition were higher for females than males at 18.8% and 15.6% respectively (Rechel et al., 2008) with a higher percentage of females compared to males being seen in emergency departments for concussions incurred during soccer (Kerr et al., 2017). Most head injuries were due to contact of the head with another players head or body part, the ground, or the ball (Rodrigues, Lasmar, & Caramelli, 2016). In addition, a 2005 literature review by Mehnert et al. (2005) noted that several studies provided evidence of increased incidence and earlier onset of cervical degenerative changes in soccer players, which may be related to injuries incurred during soccer participation. Such injuries could be sub-traumatic in the form of head balls or traumatic in the form of high speed collisions (Janda et al., 2002; Tsoumpos et al., 2013). Collisions may be anticipated or unforeseen by an athlete and vary in magnitude based on the nature of the collision (Kerr et al., 2017; Rodrigues et al., 2016). Like collisions, there are several factors reported to influence the quantity and effects of head balls on the cervical spine. These factors include practice versus competition and frequency, technique, and types of head balls, which varied by field position (Erkmen, 2009; Mehnert et al., 2005). There may be various effects on the neck with different types of head balls. Head balls can be performed with the intentions of lightly redirecting a ball away from an opponent, maximally redirecting a ball to clear it away from the goal, or utilizing a lateral snap of the head and neck to alter the trajectory of the ball toward the goal (Mehnert et al., 2005). The various effects may be attributed to responses to ball impact during a head ball. It has been reported that the neck is CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 12 loaded in compression, posterior shear, and extension with 20% of the force being transmitted to the neck as shear and 80% being resisted by head inertia (Funk, Cormier, Bain, & Manoogian, 2011). Head balls result in a skull downward acceleration followed by a skull acceleration in the upward direction. The neck stiffness, which was conceptualized as the strength of the neck muscles (Taha, Hansun, Hassan, & Hasanuddin, 2015) and the resistance of the cervical joints and surrounding soft tissue to deformation (Needle et al., 2014), attenuates skull accelerations and, therefore, brain accelerations during head balls (Taha et al., 2015). Higher accelerations are noted in females soccer athletes compared to males (Needle et al., 2014; Taha et al., 2015, Tierney et al., 2008). This has been attributed, in part, to biomechanical differences in females, such as decreased neck muscle strength, decreased total head and neck mass, and a decreased ratio in size of the head to the size of ball in females as opposed to males (Kerr et al., 2017). This may be a factor in the significantly higher concussion rates from 2009 2010 to 2013-2014 reported in womens versus mens National Collegiate Athletic Association (NCAA) soccer at 136 and 55 respectively (Zuckerman et al., 2015). In addition, annual national estimates of reported sports-related concussions NCAA womens soccer during the same time frame were the second highest among NCAA sports at 1113, behind mens football at 3417 (Zuckerman et al., 2015). Concussion in soccer has been widely studied (Maher, Hutchison, Cusimano, Comper, & Schweizer, 2014; Taha et al., 2015; Zuckerman et al, 2015), but the effects on the cervical spine, particularly baseline and potential alterations of cervical proprioception of soccer players has not been studied. In rugby and Australian football players, Hides et al. (2017) presented impaired cervical proprioception as a risk factor for predicting in-season concussions due to the resulting deficiency in the ability to accurately position and set the head during sports participation to CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 13 avoid injury. Identifying impaired cervical proprioception in soccer players could inform intervention programs consisting of sensorimotor and stabilization exercises to improve proprioception and, thus, mitigate this injury risk factor (Stanton, Leake, Chalmers, & Moseley, 2016). Cervical stabilization and sensorimotor exercises have been effective for improving proprioception (Jull, Falla, Treleaven, Hodges, & Vicenzino, 2007; Lee, Kim, & Lee, 2016). Furthermore, a randomized controlled clinical trial has been proposed to examine the efficacy of specific sensorimotor and balance exercises used along with joint mobilization and therapeutic exercise to improve joint position sense and balance for participants with impaired cervical proprioception and neck pain (Sremakaew et al., 2018). Therefore, due to the evidence that cervical proprioceptive training reduces injury risk and that targeted intervention programs have been effective, cervical proprioception should be a consideration for injury prevention and rehabilitation after injury, and the potential benefits to soccer players should be examined. Proprioception Proprioception is the position sense which allows one to determine the position of a body part in space (Armstrong et al., 2008; Proske & Gandevia, 2012) as well as the sense of motion, tissue tension, muscular effort, and balance (Proske & Gandevia, 2012). Proprioception is achieved through the detection of mechanical change during movement, or changes of joint position, that occur due to the deformation of tissues that are innervated by receptors. The quantity of receptors varies throughout muscles and body regions. The primary receptor for proprioception is the muscle spindle, which detects changes in muscle length as well as changes of velocity. Secondary receptors are joint mechanoreceptors, Golgi tendon organs, and skin receptors (Armstrong et al., 2008; Proske & Gandevia, 2012). Proprioception is achieved through a feedback mechanism. The afferent fibers from the muscles, tendons, joints, joint capsules, and CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 14 skin detect changes in joint position and initiate reflexive muscle contractions for stability. Feedforward mechanisms also exist, which provide anticipatory stabilization of joints in preparation of motion or action (Armstrong et al., 2008; Artz, Adams & Dolan, 2015; Kristjansson & Treleaven, 2009; Strimpakos, 2011; Treleaven, 2008). Reflexive muscle contractions and anticipatory stabilization may be critical in the cervical spine for soccer players. The upper cervical spine, in particular, has a unique structure for which ligamentous stability is crucial, specifically at the atlanto-occipital and atlanto-axial joints. The left and right alar ligaments attach the superior lateral aspects of the dens to the occipital condyles and restrain excessive rotation, lateral flexion and flexion. This restraint of rotation protects the nerves and arteries in the upper cervical spine, particularly the vertebral artery. The transverse ligament and tectorial membrane provide restraint for anterior translation of the atlas on the axis, which would directly compress the spinal cord if unstable (Bodon et al., 2017; Levangie, & Norkin, 2011; Neumann et al., 2017; Poorbaugh et al., 2008; Siegmund et al., 2009). Cervical proprioception. In the cervical region, particularly high densities of muscle spindles are located in the suboccipital muscles, the longus colli and the cervical multifidi of the deep posterior middle layer. Mechanoreceptors exist in smaller quantities in the cervical facet joints, which may indicate that the joint receptors, along with skin receptors, might play a lesser role in proprioception compared with the muscle spindles in this region. (Armstrong et al., 2008; Kristjansson & Treleaven, 2009; Treleaven, 2008). In addition to the high quantity of muscle spindles present in the upper cervical spine, many connections exist among the cervical, vestibular, and visual afferents, which indicate a potentially greater contribution to cervical proprioception of the upper cervical spine verses the lower cervical spine (Kristjansson & CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 15 Treleaven, 2009). Cervical proprioception functions with the visual and vestibular system to allow an individual to accurately sense the head position and ultimately contribute to postural control, stabilization of joints, and control of head motion (Armstrong et al., 2008; Kristjansson & Treleaven, 2009; Proske & Gandevia, 2012; Treleaven, 2008). Cervical proprioception assessment. Clinically, one method of testing proprioception is to assess an individuals ability to perceive the position in which a limb was placed and accurately reposition a limb to this predetermined position. Proprioception measures and interventions are widely used for assessment after knee and ankle injuries and have been shown to be effective for injury prevention and rehabilitation for joint stability and function (Hbscher et al., 2010; Needle et al., 2014; Treleaven, 2008; Zech et al., 2009). Proprioceptive training aims to improve functional joint stability and postural control by means of improving receptor sensitivity, integrating sensory and motor systems, and enhancing neuromuscular control (Kristjansson, & Treleaven, 2009; Needle et al., 2014; Zech et al., 2009). Position sense in the cervical spine has been assessed with position matching tests that allow the assessment of absolute, constant and variable errors in cervical positioning. These methods have been shown to be reliable (Armstrong et al., 2008; Dugailly et al., 2015; Hill et al., 2009; Pinsault et al., 2008) with normal errors that are relatively low (two to five degrees) (Armstrong et al., 2008). One specific cervical proprioception test is the HRA test. It has been measured using a variety of measurement instruments, including a laser-tracking device, electromagnetic tracking devices, electronic systems that measure kinematics, ultrasound trackers, and a CROM device (Performance Attainment Associates, Lindstrom, MN). Specific benefits that have been cited regarding utilization of the CROM device include its convenience in clinical environments, affordability, ease of use, intra-rater reliability for cervical range of motion (Fletcher & Bandy, CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 16 2008), test-retest reliability, and validity for the HRA test (Audette, Dumas, Ct, & De Serres, 2010; Tousignant, Smeesters, Breton, Breton, & Corriveau, 2006; Wibault, Vaillant, Vuillerme, Dedering, & Peolsson, 2013). Cervical proprioception impairment. Any conflict among the afferent input from the proprioceptive, vestibular or visual systems has been associated with impaired cervical proprioception. It can be due to many factors including inflammation as well as changes in the sensitivity of the muscle spindles brought about by local muscle fatigue, trauma, or mechanical disruption of the spindles (Armstrong et al., 2008; Kristjansson & Treleaven, 2009; Pinsault, & Vuillerme, 2010; Treleaven, 2008). Impaired proprioception can also occur due to declines in peripheral muscle function as a result of aging (Artz et al., 2015). Impairment may also be associated with factors such as prolonged soft tissue elongation associated with poor posture while using mobile devices (Mousavi-Khatir, Talebian, Toosizadeh, Olyaei, & Maroufi, 2018; Reid & Portelli, 2016) and structural problems such as adolescent idiopathic scoliosis (Guyot et al., 2016). Impairments in position sense are observed in individuals who have experienced WAD as well as those with chronic neck pain of a non-traumatic origin, such as arthritis (Armstrong et al., 2008; Poorbaugh et al., 2008; Sjlander, Michaelson, Jaric, & Djupsjbacka, 2008; Treleaven, 2008). Individuals with idiopathic neck pain and traumatic onsets of neck pain demonstrate impaired cervical proprioception with head-to-neutral repositioning tests compared with asymptomatic controls (De Vries et al., 2015; Stanton, et al, 2016) with recommendations for further research to determine clinical relevance (De Zoete et al., 2017). In addition, greater impairments in cervical proprioception may exist with upper cervical spine pain conditions that are of traumatic origin as opposed to lower cervical spine conditions of traumatic or atraumatic CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 17 onset (Treleaven, Clamaron-Cheers, & Jull, 2011). In contrast, a lack of impairment with no significant differences in joint repositioning tests were found for a group of those with cervicogenic headache compared with a control group (De Hertogh, 2008). To classify proprioception as impaired, a cut-off value greater than the 90th percentile of the mean of the maximal error of three trials of the HRA test have been utilized (Wibault et al., 2013). The left and right proprioception impairments may be considered separately due to the nature of unilateral physical impairments in craniocervical dysfunctions and apophyseal joint -mediated pain that is atraumatic and associated with WAD (Dumas et al., 2001; Ita, Zhang, Holsgrove, Kartha, & Winkelstein, 2017; Rubio-Ochoa et al., 2016). Clinical Considerations If cervical proprioception is found to be impaired for soccer players, whether due to the effects of collisions or head balls, interventions may include musculoskeletal treatment to the cervical spine as well as individualized proprioceptive training as recommended for the management of neck pain (Treleaven, 2008; Treleaven, Peterson, Ludvigsson, Kammerlind, & Peolsson, 2016). Proprioceptive training is considered important for lower extremity rehabilitation after knee and ankle injuries (Hbscher et al., 2010; Needle et al., 2014; Treleaven, 2008; Zech et al., 2009), but it is not often included in rehabilitation programs or screening exams for the cervical spine (Armstrong et al., 2008; Treleaven, 2008). The benefits of assessment and intervention for impaired cervical proprioception include the prevention of injuries from becoming chronic conditions (Armstrong et al., 2008; Kristjansson & Treleaven, 2009) and a decrease in time for return to sports participation following head and associated neck injury (Treleaven, 2017). CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 18 Severe head and neck injuries have been reported, which include injuries reported by the athletes to athletic trainers and reports of emergency department visits (Kerr et al., 2017). Additionally, the potential exists that minor and asymptomatic injuries associated with collisions and head balls in soccer could contribute to the cervical proprioception impairments that increase the risk for future injury (Pinsault, Anxionnaz, & Vuillerme, 2010). Impaired cervical proprioception has been reported as a risk factor for head injury in rugby and Australian football (Hides et al., 2017). Although impaired cervical proprioception is a risk factor for rugby, it has not been studied in soccer players. This presents the need to determine impairments that might exist for cervical proprioception among soccer players. Preseason screening and preseason conditioning programs that include cervical proprioception could be used to identify these impairments and address this modifiable risk factor for sport-related concussion and cervical injury (Armstrong et al., 2008; Hides et al., 2017). This study will provide data that is currently lacking regarding the cervical proprioception in a sample of soccer players compared to noncontact sports athletes to determine the need for consideration for screening of cervical proprioception deficits with subsequent conditioning and intervention as indicated. Method Study Design A non-experimental study using a cross-sectional design was conducted. The study took place between January and June 2019. Prior to participant recruitment, the study was approved by the University of Indianapolis Human Research Protections Program with a reliance agreement with the Maryville University Institutional Review Board (IRB). Participants CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 19 Phase one. A convenience sample of 32 healthy non-athlete participants was recruited at a university setting for the establishment of left and right maximal error for the HRA test using the CROM device. The inclusion criteria were females between the ages of 18-24 years. The exclusion criteria were current cervical pain or diagnosis of cervical spine pathology at the time of recruitment, a history of neck or head surgery, a diagnosis of vestibular dysfunction, or a rheumatic condition, with each of the conditions having been diagnosed by a medical doctor. (See Appendix A for the inclusion/exclusion screening form). Phase two. A convenience sample of female athletes was recruited from two universities that were within a single athletic conference. Inclusion criteria for the soccer group were females who participate in the NCAA Division II soccer with an age range of 18-24 years. Inclusion criteria for the non-contact sports group were females who participate in the NCAA Division II non-contact sports, such as track, cross country, swimming, diving, and tennis, with an age range of 18-24 years. The exclusion criteria were current cervical pain or diagnosed cervical spine pathology, a history of neck or head surgery, a diagnosed vestibular dysfunction, or diagnosed rheumatic conditions, with each of the conditions having been diagnosed by a physician. (See Appendix B for the inclusion/exclusion screening form). A minimum sample size for phase two was calculated using G*Power 3.1 (Faul, Erdfelder, Lang, & Buchner, 2007). The calculation was based on comparing means between two independent groups and the following parameters: two-tailed tests, alpha of .05, power of .80, one-to-one allocation ratio for the two groups, and an effect size of 1.89. This effect size was based on a similar study that compared cervical proprioception of rugby players verses noncontact sport athletes (Pinsault et al., 2010). The calculation resulted in a minimum sample size of six participants per group. To account for a possible smaller effect due to the nature of the CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 20 contact and collisions involved in soccer being less intense than that in rugby, 24 participants per group were recruited. In addition, the increased sample size was useful in the event that any data needed to be excluded or if a non-parametric test needed to be utilized. Data Collection Demographic and outcome data were collected on all phase one and phase two participants by the primary researcher (M. S.) and occurred in lab space designated for physical therapist education and research data collection. All data were recorded on a data collection form (see Appendices C, D, and E for data collection forms). Demographic data collected for phase one were the ages of each participant. For phase two, the following demographic data were collected for the soccer group: age, field position, history of cervical injury, history of concussion, number of years spent playing competitive soccer, and number of years with unrestricted head balls. Demographic data collected for the non-contact athlete group were age, sport, history of cervical injury, history of concussion, and years spent participating in the sport. Outcome data for cervical proprioception consisted of repositioning errors read by the primary researcher directly from the CROM device and recorded in degrees. Operationalization of variables and definitions. For this study, non-contact sports were defined as competitive physical activities in which the participants either competed with a physical separation from the opponent or with the expectation that physical contact, such as collisions, was not normally experienced or allowed based on the rules of the sport. Examples of non-contact sports that were considered for recruitment were cross country, track, swimming, diving, and tennis. Cervical proprioception was defined as an individuals position sense (Armstrong et al., 2008; Proske & Gandevia, 2012) from the atlanto-occipital through the second thoracic vertebra (Levangie, & Norkin, 2011; Neumann et al., 2017). The HRA for the NHP test CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 21 assesses the participants ability to accurately replicate the self-selected neutral position after active movement in the transverse plane (Dugailly et al., 2015). The repositioning error is the difference between the neutral head position (NHP) and the retargeted positon, which was recorded for three trials to the left and three trials to the right for all phase one and two participants. Repositioning error was operationalized as the following error measures: AE, CE, and VE measured with the CROM device during the HRA test for phase two participants (Hill et al., 2009). Absolute error measured the overall accuracy of a participants repositioning without respect to whether the individual overshot or undershot the neutral position. Constant error measured the overall accuracy of a participants repositioning including consideration of whether the individual overshot or undershot the neutral position. Variable error measured the overall consistency of the attempts at repositioning to neutral for each participant (Hill et al., 2009). Impaired cervical proprioception was defined as a value at or greater than the 90th percentile of phase one participants left and right mean maximal errors (Wibault et al., 2013). Instruments Head Repositioning Accuracy test. Based on the reliability and validity values, the HRA test is an appropriate test to assess cervical proprioception. The HRA test has established test-retest reliability with intraclass correlation coefficients (ICC) that ranged from .39 to .78, which included vertical, horizontal, and global errors, for a mean of eight trials measured using a laser pointer device (Pinsault et al., 2008). The HRA test has good discriminant validity for patients with WAD and healthy control subjects (Michiels et al., 2013). Regarding the impact of the vestibular system, Pinsault, Vuillerme, and Pavan (2008) reported that while head repositioning errors were greater for patients with non-traumatic neck pain compared to healthy controls, there was no difference for patents with vestibular loss compared to healthy controls. CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 22 The authors suggested that the vestibular system was likely not involved in repositioning to the NHP when the HRA was used as a test of cervical proprioception; however, the repositioning was done without instructions regarding speed of motion. Cervical range of motion device. The CROM device uses inclinometers to measure motion in the sagittal, frontal, and transverse planes. It is a lightweight device that rests on an individuals nose and ears similar to eyeglasses and is fastened at the posterior aspect of the head with a Velcro closure. It includes a magnet that is worn at the upper trunk to function with the magnetic inclinometer that measures transverse plane cervical rotation (Tousignant et al., 2006). Separate gravity inclinometers measure flexion and extension in the sagittal plane and lateral flexion in the frontal plane. A magnetic compass meter measures rotation in the transverse plane (Tousignant et al., 2006), which is the plane tested in the HRA test proposed for this study. The CROM has established reliability and validity for measuring cervical range of motion (Williams, McCarthy, Chorti, Cooke, & Gates, 2010). The CROM device has excellent intra-rater reliability with ICCs from .87 to .94 for asymptomatic subjects and .88 to .96 for subject with neck pain (Fletcher & Bandy, 2008). The CROM has strong test-retest reliability for measuring cervical range of motion with ICC ranging from .89 and .98 for healthy subjects (Audette et al., 2010). Regarding validity, the CROM has good concurrent validity with the FASTRAK, an electromagnetic tracking device, with Pearson correlation coefficients ranging from r = .93 for flexion to r = .98 for cervical rotation to each direction and cervical extension (Audette et al., 2010). The CROM was found to have excellent criterion validity with the OptoTrak device, an electronic system for measurement of kinematics including spinal motions, with Pearson correlation coefficients of r = .89 to .94 (Tousignant et al., 2006). CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 23 Cervical range of motion device for Head Repositioning Accuracy. Specific to HRA testing, the CROM has been found to be a reliable and valid instrument. The CROM has testretest reliability established for three trials each to the left and right and a one-hour interval between trials with ICCs ranging from .79 to .85 for subjects with cervical disc disease (Wibault et al., 2013). The CROM for HRA has inter-rater reliability with ICCs ranging from .72 to .77 (Burke et al., 2016). Wibault et al. (2013) reported criterion validity of the CROM with the laser tracking device with ICCs ranging from .43 to .91 for the assessment of HRA of healthy participants. Procedures Recruitment. Phase one. The primary researcher presented the phase one study to a group of female college students. During the recruitment meeting, the primary researcher described the study, stated the inclusion and exclusion criteria, and answered questions about the study. All of the potential participants were informed of the voluntary nature of participation. Interested individuals were asked to meet briefly with the primary researcher. Phase two. The primary researcher initially contacted athletic directors, coaches, and athletic trainers at the various universities regarding this study, and letters of agreement for recruitment were signed by the athletic directors. Following letters of agreement and IRB approval, contact was made again with the athletic directors and coaches as appropriate, regarding setting a date and time to present the study to soccer and non-contact sports teams to recruit study participants. During the recruitment meeting, the primary researcher described the study, stated the inclusion and exclusion criteria, and answered questions about the study. All of CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 24 the potential participants were informed of the voluntary nature of participation. Interested individuals were asked to meet briefly with the primary researcher. Screening phase one and phase two. At the information session, the interested individuals were verbally screened for inclusion and exclusion criteria by the primary researcher. For eligible participants, a date and time was scheduled with the primary researcher for going through the informed consent process and formal review of the inclusion and exclusion criteria. There was a written script that was used for inclusion and exclusion screening (See Appendix A and B for the inclusion/exclusion screening form). Informed consent phase one and phase two. Before the scheduled data collection session began, informed consent was obtained by the primary researcher in the form of each participants verbal agreement to participate in the study after being fully informed of the risks and benefits of participation prior to testing. Participants were given the opportunity to read the informed consent document and indicated agreement by checking the box on the informed consent document pertaining to agreement to participate in the study. No signatures were collected on the informed consent document. Participants were given time to ask questions about the study, and formal screening, data collection, and testing did not begin until all of the participants questions were answered. Testing. Phase one and phase two. After familiarization of the test and instrumentation by explanation and demonstration, participants were seated upright in a standard height chair with a backrest. Each participants feet rested on the floor, their back rested on the backrest of the chair, and arms rested at the participants sides. Head repositioning errors were measured using a CROM device that was placed on the individuals head. Participants were permitted to wear any CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 25 type of shirt but removed any scarves, hoods, hats, eyewear, or facial and neck jewelry. During the HRA test, each participant was blindfolded to eliminate visual contribution and self-selected a NHP, at which point the CROM was set to zero degrees in the transverse plane. Each participant was instructed to actively move the head to the left and return to the self-selected NHP using his or her preferred speed of movement. The participant verbally indicated when he or she perceived that the position had been replicated, and that position was documented in degrees. The error was recorded as the difference in degrees between the NHP and the replicated position. Three trials to the left followed by three trials to the right were performed (Dugailly et al., 2015). The data collection process for each participant took 10 minutes to complete. All of the data collection was performed by the primary researcher, a physical therapist with experience and training in the performance of the test and the use of the CROM. Data management. Data were collected by the primary researcher using data collection forms (see Appendices C, D, and E). No individual identifiers were used on the data collection forms. Each participant was assigned a unique study identification number by the researcher after she met the inclusion/ exclusion criteria, which was used on the data collection form and in the electronic spreadsheets. Once data were input by the primary researcher into an Excel spreadsheet, the data collection forms were shredded. After all data were collected, they were exported into a statistical program for analysis. Both electronic data files were stored on a password-protected laptop. Absolute error was calculated as the mean of the three HRA values, referred to as raw errors, for each side without regard for the positive or negative values. Constant error was calculated as the mean of the three raw errors for each side utilizing the positive and negative values. Variable error was calculated as the square root of the mean of the squared differences CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 26 between each of the three raw errors and the CE (Hill et al., 2009). Maximal error for the left was the greatest absolute repositioning error of the three head repositioning trials on the left. Maximal error for the right was the greatest absolute repositioning error of the three head repositioning trials on the right. The mean of the maximal error for left and right was calculated for phase one participants. The cut-off value was the 90th percentile of the mean value (Wibault et al., 2013). The resulting cut-off values were used to classify phase two participants as having impaired cervical proprioception left and impaired cervical proprioception right. Participants were classified as having impaired cervical proprioception overall if they were impaired on one or both sides. Data Analysis All statistical data analyses were performed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY). Normality of the data was determined using the Shapiro-Wilk test and when appropriate, the Levenes test was used to determine if there was homogeneity of the variables. All comparisons were two-tailed and an alpha level less than .05 was considered statistically significant. Phase One. The left, right, and overall maximal error for each participant was determined as described above. The 90th percentile of the mean left and right maximal error served as the criterion for identification of impaired left, right, and overall cervical proprioception for phase two participants. Phase Two. Descriptive statistics were used to describe the sample. Nominal data are presented as frequencies and percentages. Normally distributed interval and ratio data are reported as means and standard deviations, and data that were not normally distributed are reported as medians and interquartile ranges. To determine if participants in the two groups CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 27 (soccer players and non-contact sports athletes) were similar in demographic characteristics, comparisons were conducted using Fishers exact test for nominal data and either an Independent t-test or non-parametric Mann-Whitney U test for interval and ratio data, dependent on whether the data were normally distributed. The Shapiro-Wilk test was used to assess the normality of data. For normally distributed interval or ratio data, equality of variance between groups was determined using Levenes test. Fishers exact tests were used to determine if statistically significant differences were present for the proportions of female collegiate soccer players (a) with a history of a concussion, (b) a history of cervical injury, and (c) with impaired cervical proprioception overall compared to female collegiate athletes who participated in non-contact sports. To determine if a statistically significant difference for HRA was present between groups, AE, CE, and VE values were compared between soccer players and non-soccer athletes using an Independent t-test or MannWhitney U test, as appropriate. Fishers exact tests were used to determine if statistically significant differences existed between soccer players with and without impaired cervical proprioception by (a) history of concussion, (b) history of a cervical injury, and (c) soccer field position. Independent t-tests were conducted to determine the difference in the number of years of participation in competitive soccer and the number of years with unrestricted head balls for soccer players with and without impaired proprioception. Correlation analyses were conducted to identify the relationship between AE and the number of years competing in soccer and the number of years of unrestricted head balls. The interpretation of correlation coefficients was r = 0 - .25 represented little or no relationship, r = 25 - .50 represented a fair degree of relationship, r = .50 - .75 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 28 represented a moderate to good relationship, and r > .75 represented a good to excellent relationship (Portney & Watkins, 2009). Results Phase One Thirty-two participants completed phase one of the study. Their median age (interquartile range) was 22.00 (0) years. As describe above, the mean (standard deviation) maximal error for the left side was 2.63 (2.37) and 2.19 (1.57) for the right side. The 90th percentile of the mean was used to determine the cut-off value for impaired cervical proprioception for both the left and right side which was > 5.66 for the left and > 4.21 for the right. Impaired cervical proprioception overall was determined for each participant if the maximal error was above the cut-off value for one or both sides. Phase Two Forty eight participants were enrolled in phase two of the study with 24 in the soccer group and 24 in the non-contact sports group. Their median (interquartile range) age was 19.98 (2.00). Participant characteristics by athletic group are represented in Table 1. As can be seen in the table, the only statistically significant difference (p < .001) in participant characteristics between the soccer group and the non-contact sports group was years of competition with the soccer group having more years of competitive play. Field positions represented by the soccer players were seven (29.17%) forwards, nine (37.50%) midfielders, and eight (33.33%) defenders. The non-contact sports group included 12 (50.00%) track & field athletes, five (20.83%) tennis players, six (25.00%) swimmers, and one (4.17%) diver. To address objective 1, the history of concussion and history of cervical spine injury were compared between the two athlete groups. Results are found in Table 1 which show that despite CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 29 the soccer player group having a higher incidence in both history of concussion and history of cervical injury, the difference was not statistically significant (p > .05). To address objective 2, repositioning errors, AE, CE, and VE, were compared for both the left side and right sides between the two athlete groups. Results are found in Table 2. Absolute error left had a statistically significant difference (p = .006) between the soccer and non-contact sports group. There was not a statistically significant difference (p > .05) in all the other repositioning errors between the groups. For objective 3, proportions of impaired cervical proprioception left, impaired cervical proprioception right, and impaired cervical proprioception overall were compared between female collegiate soccer players and female collegiate non-contact sports athletes. Results are found in Table 2. Each of these lacked a statistically significant difference (p > .05) between groups. To address the first secondary objective, player demographics including history of concussion, history of cervical injury, soccer field position, number of years of participation in competitive soccer, and the number of years with unrestricted head balls were compared between female collegiate soccer players with and without overall impaired cervical proprioception. Results are found in Table 3. There was not a statistically significant difference (p > .05) for any of the player demographics. The secondary objective, number two, was addressed through correlation analyses between absolute error measures and the number of years competing in soccer and the number of years of unrestricted head balls. All of the correlations had little to no relationship, r = .22 (p = .299) and r = .08 (p = .704) for years of competition with absolute error left and right CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 30 respectively and r = .18 (p = .395) and r = .04 (p = .858) for years of unrestricted head balls with absolute error left and right respectively. Discussion To explore whether cervical proprioception is compromised in female collegiate level soccer players and to examine what factors may be related to impaired proprioception, multiple objectives were utilized in this study. The objectives aimed to: (a) compare the frequencies of histories of a concussions and a histories of cervical injuries between female collegiate soccer athletes and non-contact sports athletes, (b) determine if a differences exist in cervical proprioception between female collegiate soccer payers compared to non-contact sports athletes using repositioning error values AE, CE, and VE, (c) examine the proportions of athletes classified as having impaired proprioception using maximal error established in phase one, (d) determine if there were differences in cervical spine injuries, concussions, field positions, number of years played, and number of years with unrestricted head balls between soccer players with and without impaired proprioception, and (e) determine if there were relationships between years of competition and years of performance of head balls with repositioning errors. Cervical Injury and Concussions between Groups Phase two participant characteristics between groups were not significantly different with the exception of the number of years of competition, with the soccer group having more years than the non-contact group. Concussions and cervical spine injuries were not reported at a rate that was statistically significant between groups. This is in contrast to Zuckerman et al. (2015) who reported that womens NCAA soccer had annual national estimates of reported sportsrelated concussions that were second behind football and greater than other contact and noncontact womens sports. The data for that study was collected from multiple divisions of the CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 31 NCAA as opposed to the small division II, single conference sample that was utilized for this study. The current study results also differ from that of Tsoumpos et al. (2013), who reported high rates of WAD in indoor soccer players, particularly among defenders. The increased rates were attributed to collisions and based on injuries reported in an orthopedic injury clinic that was not limited by gender, level of competition, or age. One possible explanation for the difference between in results between that study and the present study is that the wall that surrounds the indoor soccer field represents an additional structure into which players can collide. The present studys sample consisted of teams that compete outdoors with the potential for collisions to occur with other players, the ground, or goal posts (Rodrigues, 2016). While data regarding a history of cervical injury was collected for this study, a history of indoor soccer competition was not collected. Regarding the unexpected similarity in reported concussion and cervical injury rates between groups, it is possible that a larger sample size among different athletic conferences and divisions could be more representative of the populations of female collegiate soccer players and non-contact sport athletes. Error Calculations A statistically significant difference existed for the AE left between the soccer and noncontact sports group (p = .006). This result was consistent with a study conducted with a sample of male rugby athletes that compared rugby forward and backs to non-contact sports athletes, and a significant difference was found between the rugby and non-contact group using absolute error (Pinsault et al., 2010). That study was similar to the present study in the use of AE and VE to compare contact sport athletes to non-contact sport athletes, but it differed in the utilization of ten repositioning trials from each side, the sample of male athletes, and the specific sport (Pinsault et al., 2010). It was considered that the differences between the present study and that CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 32 of Pinsault et al. (2010) might be due to the nature of the collisions in rugby being more intense and more frequent that those incurred in female division II collegiate soccer. The significance found in AE left in spite of the small sample of athletes indicated that female collegiate soccer players might have impaired cervical proprioception compared to noncontact sport athletes as evidenced by greater repositioning errors following left rotation. This may provide justification for the consideration of head repositioning accuracy testing for female collegiate soccer players because impaired cervical proprioception has been identified as a risk factor for concussions (Hides et al., 2017), and soccer players may benefit from intact proprioception to accurately position the head for head balls and for feed-forward stabilization prior to anticipated collisions (Armstrong et al., 2008; Hides e al., 2017). Given the evidence that specific sensorimotor training improves repositioning errors and that intact proprioception decreases injury risk (Hbscher et al., 2010; Jull et al., 2007; Lee et al., 2016), an impairment in cervical proprioception can be considered a modifiable risk factor. This information may be useful for the consideration of HRA testing during preseason screening to guide intervention programs designed to mitigate injury risk and for rehabilitation after concussions and cervical spine injuries for a safe return to sport. In contrast to AE left, AE right lacked a statistically significant difference between the soccer and noncontact athlete groups. Evidence of asymmetrical results exist in previous studies (Hides et al., 2017; Jull et al., 2017; Rix & Bagust, 2001; Treleaven et al., 2011). For example, asymmetric repositioning errors have been reported for participants with non-traumatic neck pain and controls (Rix & Bagust, 2001). Treleaven et al. (2011) studied AE using three trials of joint reposition error testing using the Fastrack device along with the smooth pursuit neck torsion tests and standing balance tests for four subgroups of participants with neck pain: upper traumatic, CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 33 upper non-traumatic, lower traumatic, and lower non-traumatic. It was reported that participants with upper cervical pain of traumatic onset had greater errors with repositioning trials following right rotation, but not for left rotation or extension. Hides et al. (2017), in a study of rugby and Australian football players, reported that the athletes that sustained a head or neck injury during the season had higher repositioning errors in the preseason for repositioning from relative right cervical rotation. This was tested with the head stationary and with trunk active rotation to the left for the elimination vestibular input with six trials each from the left and right used for calculation of absolute error, and then a mean of the 12 trials was used to calculate an overall mean error. In an intervention study, Jull et al. (2017), reported improvement in right joint position error, but not the left, after a conventional proprioceptive training intervention. This was done using the AE of three trials to the left, right, and extension and compared AE pre- and postintervention. Based on the previously cited research, it may be suggested that asymmetry in repositioning for impaired individuals is not an uncommon finding, although the mechanism for the asymmetry has not been examined. In this study, it was noted that the outliers for AE right were participants that had a self-reported history of a cervical injury. Interpretation of this finding was limited by the lack of data collection regarding the specifics of the reported cervical injuries and the presence of impairments in posture, range of motion, muscle strength, flexibility, or handedness patterns. Regarding the potential relevance of posture, previous studies contained results of higher repositioning errors with forward head postures, flexed postures, and scoliosis (Guyot et al., 2016; Mousavi-Khatir et al., 2018; Reid & Portelli, 2016). Impaired Proprioception Based on Maximal Error CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 34 The phase one results for healthy non-athletes included the mean (standard deviation) maximal error, which was 2.63 (2.37) for the left side and 2.19 (1.57) for the right side. These results are consistent with previous studies in which normal AE and CE were less than 5 degrees for healthy subjects (Armstrong et al., 2008) with normal repositioning errors of 3.3 degrees for asymptomatic subjects and a clinical cut-off of 4.5 degrees for proprioception to be classified as impaired (Dugailly, e al,. 2017; Revel, Andre-Deshays, & Minguet, 1991). However, these are to be interpreted with caution due to a different methodology used in the present study. Dugailly, et al. (2017) set the threshold for impaired proprioception so that 100% of the healthy participants fell within the threshold, and 68% of the neck pain participants were outside of the clinical cutoff value. Revel et al. (1991) performed an analysis of sensitivity and specificity for 10 trials of repositioning from maximal left rotation, right rotation, flexion, and extension, and established a threshold of 4.5 degrees. Normative values have not been established specifically for this age group of 18-24 years of age. Controversy exists as studies have been conducted with results that lacked significant differences in repositioning based on age (Alahmari et al., 2017; Chen & Treleaven, 2013), while others have demonstrated significant effects of age on repositioning errors (Artz et al., 2015; Teng, Chai, Lai, & Wang, 2007; Vuillerme, Pinsault, & Bouvier, 2008). For this study that targeted females aged 18-24 years with a median age of 22 years, the cut-off for classification of impaired proprioception, 90th percentile of the mean maximal error, was > 5.66 for the left and > 4 .21 for the right. In comparison, Wibault et al. (2013) found a median maximal error of 2.7 with a standard deviation of 2.8 degrees for healthy participants with a cut-off value of 6.7 degrees for classification on impaired proprioception. The sample differed in demographics from the present study with 173 men and women with a mean age of 44 years and standard deviation CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 35 of 12 years. This result supports the above-cited findings that repositioning errors are greater with increased age (Teng et al., 2007; Vuillerme et al., 2008) and may support the need for the determination of age-specific norms. Phase two results lacked statistically significant differences in impaired cervical proprioception left, right, and overall between soccer and non-contact sports athletes. In this study 58% of the athletes in both the soccer group and the non-contact group were classified as having impaired cervical proprioception overall. One study was identified that used a similar methodology to classify participants with cervical radiculopathy due to disc disease as impaired verses unimpaired (Wibault et al., 2013), but no previous studies were identified that examined proportions of athletes with impaired proprioception comparing soccer and non-contact sports athletes. Demographic data and Correlation Analysis There were no statistically significant differences (p < .05) between soccer players with and without impairment for any of the demographic data. The lack of a statistically significant relationship between the field position and the impairment of proprioception was consistent with Pinsault et al. (2010) who reported no difference in repositioning errors between rugby forwards and backs. Although field position was not significant for proprioception in this study, it has been shown to be significant in studies of concussions with defenders and goalkeepers sustaining higher rates of concussion based on a systemic review (Maher et al, 2014). No goalkeepers volunteered for participation in this present study. While this small sample did not show statistical significance, it was noted that each of the three soccer players who reported a history of a cervical injury had impaired cervical proprioception overall. Of the three, two were forwards, and one was a defender. Although it was a small sample, this is consistent with higher CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 36 rates of head and neck injuries that were reported in central defenders and forwards compared to other field positions in a retrospective study (Onaka, et al., 2017). In this study, a history of a concussion was reported at similar frequencies for soccer players with and without impaired proprioception. Hides et al. (2017) reported that among rugby and Australian football players, a history of a sport-related concussion was not associated with preseason impairment in proprioception, but an impairment in proprioception in right cervical rotation at baseline increased the odds of sustaining a head or neck injury during the season. Furthermore, it was found that impaired proprioception was an independent predictor of a head or neck injury for athletes with or without a history of a concussion (Hides et al., 2017). The results from the present study, along with other published evidence, strengthens the recommendation that athletes not only be screened for impaired proprioception preseason but also after a concussion with appropriate intervention in an effort to prevent further injury (Jull et al., 2007; Lee et al., 2016). It was observed that each soccer player with a cervical injury was classified as having impaired cervical proprioception overall. Previous studies have been conducted with participants who are symptomatic, particularly with chronic neck pain, osteoarthritis, WAD, cervical radiculopathy caused by disc disease, and traumatic neck pain (Alahmari et al., 2017; De Vries et al., 2015; De Zoete et al., 2017; Stanton et al., 2016; Treleaven et al., 2017; Uremovic et al., 2007; Wibault et al., 2013). However, no studies have been published exploring cervical proprioception impairment for individuals with a history of a cervical injury. In contrast to the consideration of pain symptoms, Sjlander et al. (2008) recommended that an objective examination be conducted because impairments in motor control and accessory mobility as well as the presence of pathophysiology may be associated with the impaired proprioception. CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 37 In the present study, there were no statistically significant correlations between years of competition and years of unrestricted head balls with absolute error (p < .05). There are no published studies that have examined such relationships. The authors of previous studies have examined the long-term effects of heading and the effects of frequent heading on neurocognition (Maher et al., 2014), but none have examined the relationship of these factors to cervical proprioception. Limitations One of the study limitations is the non-random convenience sample consisting of a relatively homogeneous group of division II female collegiate athletes. Although it was a strategy to achieve internal validity, the relative homogeneity of the sample was a limitation for the generalizability of the results to a larger population. The small sample size was also considered a limitation of this study. The sample size estimate of six participants in each group was based on the results of a study of rugby players who most likely had higher rates of impairment. The sample of this study was increased to 24 per group in anticipation that the collisions incurred in female collegiate soccer were less intense and less frequent than those incurred in rugby. However, the sample of 24 per groups possibly left the study underpowered; therefore, that limited in the ability to have statistical significance. The HRA test was conducted as described in previously published studies, with the left side being tested first and the right side being tested second. While this contributed to the standardization of the data collection, the lack of randomization of the side that is initially tested during data collection could be considered a limitation due to the potential effects of learning the test, loss of attention span during the test loss of motivation, or fatigue (Chen & Treleaven, 2013; Dugailly et al, 2015). CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 38 A potential limitation was the lack of control for athlete fatigue. There were athletes in both groups that arrived at the data collection sessions immediately following practices or after general strengthening workouts that occurred the same day, and the details of that days workout was not part of the data collection. Armstrong et al., (2008) and Pinsault and Vuillerme (2010) reported that local fatigue specifically of cervical muscles resulted in higher repositioning errors foe AE and VE. However, regarding generalized fatigue, Pinsault et al. (2010) reported no difference in AE and VE for rugby forward and backs tested before and after a training session. The present study was conducted with three trials each to the left and right as conducted by Treleevan et al., (2016) and Wibault et al (2013). A potential weakness of the study could be a decreased sensitivity with three trials as opposed to six to 10 trials to each side (Pinsault et al., 2008). In a systemic review, Devries et al. (2015) noted that although only four out of 14 studies used more than six repositioning trials, those that used six or more had improved discrimination between participants with and without neck pan due to higher repositioning errors for subjects with neck pain. This may not pose a significant limitation to this study as soccer and non-contact sports athletes reported a history of cervical injury at similar frequencies, and none had current neck pathology per the exclusion criteria. However, De Vries et al. (2015) also suggested that higher repetitions could serve to lessen the influence of the outliers in the data set. Regarding demographic data, the histories of concussion and cervical injury were selfreported by the participants. The nature of self-reporting of data may lead to a limitation in the accuracy of the information. Additionally, information regarding whether or not there were interventions and what the interventions were for the past injuries was not collected. In spite of past injuries, no participants had a diagnosis of a current cervical pathology per the exclusion criteria. CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 39 Implications for Practice and Future Research Even with the stated limitations, this study serves as an initial step in the examination of cervical proprioception between soccer and non-contact sports athletes, and it provides a set of age-specific norms among the non-athlete healthy sample of females, from which a criterion for impaired proprioception was established. Future research into cervical proprioception among athletes could expand on the findings of this study. A cross-sectional design with a larger sample may be useful for generalizability, for statistical significance, and for the ability to overcome outliers in the data set (De Vries et al., 2015; De Zoette et al., 2017). Testing among a variety of athletic conferences and divisions would be the strategy to improve the generalizability of the study results. Randomization regarding initiating the data collection on the left or right would be beneficial to mitigate issues of learning the test, loss of attention span, and fatigue (Chen & Treleaven, 2013; Dugailly et al, 2015). Further research may be useful to determine what objective impairments, such as posture, range of motion, strength, and flexibility in addition to details regarding histories of cervical injuries, might be associated with impaired cervical proprioception. Future studies could be designed to further investigate the relationships between proprioception and injury to examine whether cervical injury results in impaired cervical proprioception and whether impaired proprioception increases the risk of concussion for female collegiate soccer players. The ultimate goal is to identify those who may benefit from cervical sensorimotor training for injury mitigation and as part of rehabilitation following head and neck injuries to facilitate a safe return to sport. Conclusion CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 40 This study provides clinical cut-off values that may be useful for the identification of impaired cervical proprioception for females aged 18-24 and utilized for preseason screening for injury prevention. Phase two results of this study indicate that there was a statistically significant difference in the repositioning errors of female collegiate soccer players verses non-contact sports athletes for AE left. The other error measures: AE right, CE left and right, and VE left and right lacked statistical significance. A history of cervical spine injury, history of concussion, field position, number of years in competitive soccer and number of years of unrestricted head balls lacked statistical significance between soccer players with and without impairment of cervical proprioception. There were no correlations between repositioning error values and the number of years of participation and the number of years of unrestricted head balls for soccer players. Further research with a larger and more heterogeneous sample may be beneficial to determine if differences between groups exist. Based on the statistical significance of AE left, routine screening for impaired cervical proprioception may be recommended for female soccer players. 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Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Manual Therapy, 13(1), 2-11. doi:10.1016/j.math.2007.06.003 Treleaven, J., Clamaron-Cheers, C., & Jull, G. (2011). Does the region of pain influence the presence of sensorimotor disturbances in neck pain disorders? Manual Therapy, 16(6), 636-640. doi:10.1016/j.math.2011.07.008 Treleaven, J., Peterson, G., Ludvigsson, M., Kammerlind, A., & Peolsson, A. (2016). Balance, dizziness and proprioception in patients with chronic whiplash associated disorders complaining of dizziness: A prospective randomized study comparing three exercise programs. Manual Therapy, 22, 122-130. doi:10.1016/j.math.2015.10.017 Treleaven, J. (2017). Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. Journal of Orthopaedic & Sports Physical Therapy, 47(7), 492-502. doi:10.2519/jospt.2017.7052 Tsoumpos, P., Kafchitsas, K., Wilke, H., Evagelou, K., Kallivokas, A., Habermann, B.,... Matzaroglou, C. (2013, April). Whiplash injuries in sports activities. Clinical outcomes and biomechanics. Paper presented at 3rd European College of Sports and Exercise Physicians conference, Frankfurt, Germany. Abstract retrieved from https://bjsm.bmj.com/content/47/10/e3.79 Uremovic, M., Cvijetic, S., Pasic, M., Seric, V., Vidrih, B., & Demarin, V. (2007). Impairment of proprioception after whiplash injury. Collegium Antropologicum, 31(3), 823-828. CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 50 Vuillerme, N., Pinsault, N., & Bouvier, B. (2008). Cervical joint position sense is impaired in older adults. Aging Clinical and Experimental Research, 20(4), 355-358. doi:10.1007/BF03324868 Wibault, J., Vaillant, J., Vuillerme, N., Dedering, A., & Peolsson, A. (2013). 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The American Journal of Sports Medicine, 43(11), 2654-2662. doi:10.1177/0363546515599634 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 51 Table 1 Participant Characteristics by Sports Group Soccer Non-Contact Sports N = 24 N = 24 N (%) N (%) History of Cervical Injury p 1.000 No 21 (87.50) 22 (91.67) Yes 3 (12.50) 2 (8.33) History of Concussion .125 No 13 (54.17) 19 (79.17) Yes 11 (45.83) 5 (20.83) M (SD) M (SD) Age* 20.00 (2.00) 19.00 (2.00) .437 Years of Competition 12.88 (2.38) 9.54 (3.51) < .001 Years of Unrestricted 12.83 (2.33) Head Balls Note. *Age is reported as a median (interquartile range). CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS Table 2 Comparisons of Error Calculations and Impaired Proprioception between Soccer and NonContact Sport Athletes Soccer Non-Contact N = 24 Sports N = 24 Mdn (IQR) Mdn (IQR) p AE left 4.00 (5.42) 1.33 (3.08) .006 AE right 2.33 (4.91) 3.00 (2.92) .788 CE left -3.17 (5.33) -1.00 (3.75) .334 CE right -0.17 (6.58) -2.83 (4.50) .363 VE left 1.41 (1.72) 0.94 (1.21) .068 VE right 0.94 (1.95) 1.41 (1.07) .090 N (%) N (%) 9 (37.50) 5 (20.83) .341 11 (45.83) 12 (50.00) 1.000 14 (58.33) 14 (58.33) 1.000 Impaired Cervical Proprioception Left Impaired Cervical Proprioception Right Impaired Cervical Proprioception Overall Note. IQR = interquartile range; AE = absolute error; CE = constant error; VE = variable error 52 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 53 Table 3 Comparison of Soccer Athlete Characteristics with Cervical Proprioception Status Impaired Not Impaired (N = 14) (N = 10) N (%) N (%) History of concussion p .697 No 7 (53.85) 6 (46.15) Yes 7 (63.64) 4 (36.36) History of cervical injury .239 No 11 (52.38) 10 (47.62) Yes 3 (100.00) 0 (0.00) Field position .591 Forward 5 (71.42) 2 (28.57) Midfield 4 (44.44) 5 (55.56) Defense 5 (62.50) 3 (37.50) Mdn (IQR) Mdn (IQR) p Participation years 13.00 (5.00) 13.00 (2.75) .900 Head ball years 13.00 (5.00) 13.00 (3.00) .954 Note. IQR = interquartile range CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 54 Appendix A Inclusion and Exclusion Screening Form Phase One Cervical Proprioception in Female Collegiate Soccer Players Compared to Non-Contact Sport Athletes Inclusion Criteria To be included in the study, the participant must: 1. Be female. Yes No 2. Be 18-24 years of age. Yes No Yes No Doctor (MD). Yes No 3. A history of head or neck surgery. Yes No 4. A vestibular dysfunction diagnosed by a MD Yes No 5. A rheumatic condition diagnosed by a MD. Yes No Yes No All Inclusion Criteria must be answered yes, to be included in study. Exclusion Criteria Based on the criteria for this study, the participant must not have: 1. Current cervical pain (occiput to second thoracic vertebra). 2. Current cervical pathology diagnosed by a medical All Exclusion Criteria must be answered no, to be included in study. Did the participant meet the eligibility requirements for this study? Investigator Signature: Date: CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 55 Appendix B Inclusion and Exclusion Screening Form Phase Two Cervical Proprioception in Female Collegiate Soccer Players Compared to Non-Contact Sport Athletes Inclusion Criteria To be included in the study, the participant must: 1. Be female. Yes No 2. Be 18-24 years of age. Yes No 4. Participate in NCAA Division II soccer or non-contact sport. Yes No Yes No Doctor (MD). Yes No 3. A history of head or neck surgery. Yes No 4. A vestibular dysfunction diagnosed by a MD Yes No 5. A rheumatic condition diagnosed by a MD. Yes No Yes No All Inclusion Criteria must be answered yes, to be included in study. Exclusion Criteria Based on the criteria for this study, the participant must not have: 3. Current cervical pain (occiput to second thoracic vertebra). 4. Current cervical pathology diagnosed by a medical All Exclusion Criteria must be answered no, to be included in study. Did the participant meet the eligibility requirements for this study? Investigator Signature: Date: CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 56 Appendix C Phase One Data Collection Form ID# Age HRA HRA #1/2/3 Left #1/2/3 Right (errors in degrees) (errors in degrees) CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 57 Appendix D Phase Two Soccer Athletes Data Collection Form ID # Age Soccer History History of Number of HRA Absolute HRA Absolute Field of Concussion years in #1/2/3 Error #1/2/3 Error Position Cervical competitive Left Left Right Right Injury participation/ (errors (in (errors (in Number of in degrees) in degrees) years with degrees) unrestricted head balls degrees) CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 58 CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 59 Appendix E Phase Two Non-Contact Sport Athletes Data Collection Form ID# Age Non- History History of Years HRA Absolute HRA Absolute Contact of Concussion spent #1/2/3 Error #1/2/3 Error Sport Cervical in Left Left Right Right Injury sport (errors in (in (errors in (in degrees) degrees) degrees) degrees) CERVICAL PROPRIOCEPTION IN FEMALE SOCCER PLAYERS 60  ...

... EFFECTS OF TRIGGER POINT DRY NEEDLING ON STRENGTH MEASUREMENTS OF THE GLUTEUS MEDIUS MUSCULATURE Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Eric Schneider, PT, MPT, OCS, CMTPT Copyright August 6, 2019 By: Eric Schneider, PT, MPT, OCS, CMTPT All rights reserved Approved by: Emily J. Slaven, PT, PhD Committee Chair Elizabeth S. Moore, PhD Analysis Expert Rob Stanborough, PT, DPT, MTC, CMTPT, FAAOMPT Content Expert Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH Effects of Trigger Point Dry Needling on Strength Measurements of the Gluteus Medius Musculature Eric Schneider University of Indianapolis 1 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 2 Abstract The purpose of this study was to investigate whether the application of deep trigger point dry needling (TDN) to latent trigger points within the gluteus medius musculature affected strength measurements of the gluteus medius immediately following intervention. A control and an intervention side were randomly assigned for each participant (N = 39). Hand held dynamometer (HHD) force measurements and surface electromyography (sEMG) amplitude readings were recorded during maximal volitional isometric contraction break tests of the gluteus medius in two separate positions (SL0 and SLIR) both before and after application of TDN. Comparison of within and between group data were conducted. A statistically significant interaction between time (pre-TDN to post-TDN) and groups (intervention side and control side), p < .001 was found for HHD measurements in both positions. Post hoc analysis revealed a statistically significant difference (p < .001) for all comparisons in the SL0 position, while, for the SLIR position, statistically significant differences (p < .001) were found for pre and post-TDN measurements within intervention side as well as between the intervention and control side for post-TDN measurements. For sEMG amplitude measurements, statistically significant differences were found only in the SL0 position for within group comparisons on the intervention side (p = .009) as well as for between group comparisons for post-TDN measurements (p = .002). Application of deep TDN to latent trigger points within the gluteus medius can significantly increase gluteus muscle force production immediately following intervention while reducing the level of muscle activation required during contraction. Keywords: latent trigger point, myofascial trigger point, trigger point dry needling, deep dry needling, muscle strength, muscle activation, gluteus medius TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 3 Table of Contents Title Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Problem Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Significance of Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Purpose of Study & Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Chapter 2: Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Myofascial Trigger Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Formation of Myofascial Trigger Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Effects of Latent Trigger Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Identifying Latent Trigger Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Dry Needling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Trigger Point Dry Needling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Trigger Point Dry Needling and Latent Trigger Points . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Study Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Chapter 3: Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Study Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Sample Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 4 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Statistical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Chapter 4: Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Phase One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Phase Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Chapter 5: Discussion and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Discussion of Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Study Limitations and Implications for Future Research . . . . . . . . . . . . . . . . . . . . . . . . 46 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Appendix A: Recruitment Email . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Appendix B: Recruitment Flyer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Appendix C: Participant Intake Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Appendix D: Data Collection Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Appendix E: Past Medical History Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 5 List of Tables Table 1: Reliability of HHD and sEMG Measurements Within Trials . . . . . . . . . . . . . . . . . . . . 65 Table 2: Test Retest Reliability of HHD and sEMG Measurements Prior to and Following 10 Minute Break . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Table 3: Descriptive Statistics for Demographic Information of Sample . . . . . . . . . . . . . . . . . . 67 Table 4: Descriptive Statistics for HHD Measurements Before (Pre) and After the Intervention (Post) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Table 5: Descriptive Statistics for sEMG Amplitudes Before (Pre) and After the Intervention (Post) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 6 List of Figures Figure 1: Comparisons of HHD Measurements in the SL0 Position . . . . . . . . . . . . . . . . . . . . . . 70 Figure 2: Comparisons of HHD Measurements in the SLIR Position . . . . . . . . . . . . . . . . . . . . . 71 Figure 3: Comparison of sEMG Measurements in the SL0 Position . . . . . . . . . . . . . . . . . . . . . . 72 Figure 4: Comparison of sEMG Measurements in the SLIR Position . . . . . . . . . . . . . . . . . . . . 73 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 7 Effects of Deep Trigger Point Dry Needling on Strength Measurements of the Gluteus Medius Musculature Multiple researchers have identified myofascial trigger points as a potential source of musculoskeletal dysfunction (Celik & Kaya Mutlu, 2013; Dommerholt, Bron, & Franssen, 2006; Ge & Arendt-Nielsen, 2011; K. R. Lucas, 2008; Shah et al., 2015). Trigger point dry needling (TDN) has become an increasingly popular intervention among physical therapists to reverse the effects of myofascial trigger points (Caramagno, Adrian, Mueller, & Purl, 2015; Dommerholt, 2011). However, there is still debate surrounding the effectiveness of TDN provided by physical therapists as a viable treatment option for musculoskeletal dysfunction as compared to other physical therapy interventions (Gattie, Cleland, & Snodgrass, 2017). Travell and Simons (1983) defined myofascial trigger points as hyperirritable and palpable nodules within a taut band of muscle. Myofascial trigger points are classified as either active trigger points or latent trigger points. An active trigger point can cause localized pain that is spontaneous in nature and can potentially refer pain to distal areas (Dommerholt et al., 2006; Shah et al., 2015). Conversely, latent trigger points are not spontaneously painful and will only elicit pain when palpated (Celik & Kaya Mutlu, 2013; Dommerholt et al., 2006; Shah et al., 2015). Most of the research conducted on myofascial trigger points has focused on active trigger points due to their ability to generate spontaneous pain without being palpated, even though latent trigger points are more commonly found in muscle tissue (Celik & Kaya Mutlu, 2012; K. R. Lucas, Rich, & Polus, 2009). Despite a lack of attention in the literature, latent trigger points are not without clinical significance. With regards to muscle function, latent trigger points have been found to increase muscle fatigability (Ge, Arendt-Nielsen, & Madeleine, 2012), decrease muscle strength (Celik & Yeldan, 2011), and alter muscle activation patterns (K. R. Lucas, 2008; TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 8 K. R. Lucas, Polus, & Rich, 2004). Furthermore, latent trigger points may have the potential to transition in to active trigger points if left untreated (Hong & Simons, 1998). It has been hypothesized that repetitive or unaccustomed eccentric loading of muscle tissue is a potential cause for the formation of myofascial trigger points (Dommerholt et al., 2006; Gerwin, Dommerholt, & Shah, 2004; Hong & Simons, 1998; Hoyle, Marras, Sheedy, & Hart, 2011; Shah et al., 2015; Simons, Travell, & Simmons, 1999). Musculature such as the gluteus medius must eccentrically control motion of the pelvis within the frontal plane during the gait cycle (Neumann, 2010). Subtle alterations in frontal plane gait kinematics may lead to excessive loading the gluteus medius musculature, thereby possibly causing the formation of myofascial trigger points. If latent trigger points are able to effect muscle function, then an asymptomatic individual may have altered stability of the pelvis and the hip during loading response of the gait cycle, which then has the potential to alter the alignment of the lower limb relative to the ground. Despite the increased demand for eccentric control during functional activities, such as ambulation, there are no studies that have investigated the effects of latent trigger points on the strength of musculature within the lower extremities. Furthermore, there are a limited amount of studies that have investigated whether deep TDN has any effect on the strength of the lower extremity musculature (Mansfield et al., 2019). The purpose of this study was to assess the effect of deep TDN to latent trigger points within the gluteus medius musculature. Specifically, the effect of deep TDN on the strength measurements of the gluteus medius musculature immediately following intervention was investigated. The author hypothesized that there would be a significant difference in strength measurements of the gluteus medius musculature between TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 9 the intervention and controls sides as well as within the intervention and control sides prior to and immediately following the application of deep TDN. Literature Review Myofascial Trigger Points Much of the research on myofascial trigger points has focused on the effects of active trigger points due to their ability to generate spontaneous pain (Boyles, Fowler, Ramsey, & Burrows, 2015; Gattie et al., 2017; Kietrys et al., 2013; Liu et al., 2015; Morihisa, Eskew, McNamara, & Young, 2016). However, some authors have argued that latent trigger points have the same pathophysiology as active trigger points, just to a lesser extent (Celik & Kaya Mutlu, 2013; Dommerholt et al., 2006; Hong & Simons, 1998; Shah et al., 2015). Both active and latent trigger points have been found to have decreased pH levels as well as elevated levels of bradykinin, substance P, serotonin, norepinephrine, calcitonin gene related peptide, tumor necrosis factor-, and interleukin-1. However, latent trigger points were found to have these chemical changes to a significantly lesser extent, which may explain a reduction in nociceptive input without mechanical stimulus (Shah et al., 2008; Shah & Gilliams, 2008; Shah, Phillips, Danoff, & Gerber, 2005). From a histological perspective, both active and latent trigger points may also have an effect on muscle function. The increase in calcitonin gene related peptide found in myofascial trigger points may block the production of acetylcholinesterase, thereby reducing the reuptake of acetylcholine in the synapses near the neuromuscular junction, potentially affecting alpha motor neuron activation (Gerwin et al., 2004; Mense, Simons, Hoheisel, & Quenzer, 2003). Furthermore, latent trigger points have been found to cause muscle cramps at a greater frequency than normal muscle tissue secondary to an increase an alpha motor neuron activity (Ge, Zhang, TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 10 Boudreau, Yue, & Arendt-Nielsen, 2008). Ge et al. (2008) proposed that the increase in alpha motor neuron activity is a result of the altered chemical state of latent trigger points as compared to normal muscle tissue. While the results of previous studies demonstrate the potential for motor dysfunction due to the histological differences between latent trigger points and normal muscle tissue, there are limited studies that correlate the pathophysiology of latent trigger points to the clinical manifestations of muscle dysfunction (Celik & Yeldan, 2011; Ge et al., 2012; Ge et al., 2008; Ibarra et al., 2011; K. R. Lucas et al., 2004). Formation of Myofascial Trigger Points There are several theories surrounding the formation of myofascial trigger points. An emerging theory is that myofascial trigger points are formed within muscle tissue as a result of repetitive and unaccustomed eccentric loading (Celik & Kaya Mutlu, 2013; Dommerholt et al., 2006; Gerwin et al., 2004; Hoyle et al., 2011; Shah et al., 2015; Simons et al., 1999). Hoyle et al. (2011) investigated the effects of postural and visual stressors on the formation of myofascial trigger points during computer work. Participants within the study developed myofascial trigger points after one hour of low-level static exertion of maintaining abnormal posturing while continuously typing on a computer. The amount of visual stressors applied throughout the study did not have an effect on the formation of the myofascial trigger points, suggesting that the low level, unaccustomed contractions of postural musculature was the cause for the formation of myofascial trigger points. Since latent trigger points do not generate spontaneous pain, it may be difficult for the individual to realize they have caused repetitive damage to the muscle tissue and as a result, stop the activity that is causing the damage. Furthermore, it has been suggested that latent trigger points have the potential to transition in to active trigger points if left untreated or if the repetitive and unaccustomed eccentric loading continues, which can lead to an increased TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 11 perception of pain at rest and with movement (Hong & Simons, 1998). Eccentric loading of muscle tissue in the lower extremities predominates functional activities that individuals must perform on a daily basis, such as gait (Neumann, 2010; Ward, Winters, & Blemker, 2010). During the gait cycle, ground reaction forces in the vertical, anterior-posterior, and medial-lateral directions force musculature of the pelvis and hip to eccentrically contract in order to control motion and absorb the forces acting on the body (Eng & Winter, 1995; Simoneau & Heiderscheit, 2017). Subtle alterations in gait mechanics may increase the frequency of unaccustomed eccentric loading to muscle tissue, which has been thought to cause the formation of subthreshold latent trigger points (Celik & Kaya Mutlu, 2013; Dommerholt et al., 2006; Gerwin et al., 2004; Hoyle et al., 2011; Shah et al., 2015; Simons et al., 1999). If left untreated, latent trigger points may alter the muscular function of the primary stabilizers during the gait cycle, such as the hip abductors. The most important functional role of the hip abductors is to provide stability of the pelvis and hip while the body is in single limb support during the gait cycle (Neumann, 2010) or during other functional activities where single limb support is required (Ward et al., 2010). The gluteus medius is considered to be the primary hip abductor as it accounts for 60% of the total cross sectional area of the hip abductor musculature (Dostal, Soderberg, & Andrews, 1986; Mastenbrook et al., 2017). If latent trigger points are able to cause impaired muscular function (Celik & Yeldan, 2011; Ge et al., 2012; Ge, Monterde, Graven-Nielsen, & Arendt-Nielsen, 2014; Ge et al., 2008; Ibarra et al., 2011; K. R. Lucas et al., 2004), an individual with latent trigger points in the gluteus medius muscular tissue may not be able to optimally control the forces acting on the pelvis and lower extremity during the gait cycle (Neumann, 2010). This lack of stability may have the potential to alter the alignment of the lower limb relative to the ground, TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 12 thereby placing the individual at a greater risk for injury (Chaudhari & Andriacchi, 2006; Cowan, Crossley, & Bennell, 2009; Prins & van der Wurff, 2009; Willson, Kernozek, Arndt, Reznichek, & Straker, 2011). Effects of Latent Trigger Points From a clinical standpoint, latent trigger points may have the ability limit motion of a joint as well as alter the function of surrounding musculature. Latent trigger points have been found to limit joint range of motion (ROM) of the ankle (Grieve et al., 2013), knee (Trampas, Kitsios, Sykaras, Symeonidis, & Lazarou, 2010), and cervical spine (Aguilera et al., 2009). In the upper quarter, latent trigger points have also been found to increase muscle fatigability of the upper trapezius (Ge et al., 2012), alter muscle activation patterns of the scapular positioning and stabilizing musculature (K. R. Lucas et al., 2004), increase antagonistic muscle contraction during movement of the glenohumeral joint (Ge et al., 2014; Ibarra et al., 2011), and decrease strength measurements of glenohumeral scaption (Celik & Yeldan, 2011). In the only study to investigate the effects of latent trigger points on muscle function in the lower extremities, Ge et al. (2008) found that latent trigger points have the ability to induce muscle cramping in the gastrocnemius muscle. Despite the identified clinical manifestations of latent trigger points, the exact mechanism for altered muscle function and limited ROM is not yet fully understood (K. R. Lucas, 2008). Furthermore, much of the research investigating the effects of latent trigger points on muscular function have focused on body regions within the upper quarter (Calvo-Lobo, Pacheco-da-Costa, & Hita-Herranz, 2017; Calvo-Lobo et al., 2018; Celik & Yeldan, 2011; Ge et al., 2012; Ge et al., 2014; Ibarra et al., 2011; K. R. Lucas et al., 2004; K. R. Lucas, Rich, & Polus, 2010). Little attention has been placed on the clinical manifestations of latent trigger points on muscle TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 13 function in the lower extremities (Mansfield et al., 2019), even though latent trigger points have been found to be more prevalent than active trigger points within muscle tissue (Celik & Kaya Mutlu, 2012; K. R. Lucas et al., 2009). K. R. Lucas et al. (2009) found that 89.8% of the 137 asymptomatic individuals assessed using manual palpation had at least one latent trigger point within their scapular positioning musculature, specifically the upper, middle, and lower trapezius, rhomboid major and minor, levator scapulae, serratus anterior, and pectoralis minor muscles. The mean number (standard deviation) of latent trigger points found in these muscles was 11.72 (+ 6.2). Celik and Kaya Mutlu (2012) found similar results when investigating the prevalence of latent trigger points in the upper and middle trapezius, rhomboid major and minor, supraspinatus, and serratus anterior musculature. They found that 60.57% of the 76 asymptomatic individuals assessed were found to have at least one latent trigger point. An important component of both studies by K. R. Lucas et al. (2009) and Celik and Kaya Mutlu (2012) was that participants were excluded if they were experiencing pain or had any musculoskeletal dysfunction of the glenohumeral complex or neck, shoulder, and upper thoracic region respectively. Therefore, latent trigger points had formed within the skeletal muscle analyzed without any identified musculoskeletal dysfunction or pain response. Furthermore, due to a latent trigger points ability to alter muscle function as well as limit ROM, participants may be at an increased risk for injury while completing their routine activities of daily living without actively being aware of it (Aguilera et al., 2009; Celik & Yeldan, 2011; Ge et al., 2012; Ge et al., 2014; Ge et al., 2008; Grieve et al., 2013; Ibarra et al., 2011; K. R. Lucas et al., 2004; Trampas et al., 2010) TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 14 Despite latent trigger points increased frequency within muscle tissue as well as the potential for a latent trigger point to cause impaired muscle function and limit joint ROM, they are often overlooked by clinicians as a potential source for non-articular musculoskeletal dysfunction. Shah et al. (2015) argued that the lack of a universally agreed upon method for identifying or quantifiably describing myofascial trigger points is the main reason why they are many times overlooked clinically. Specifically, it may be particularly difficult to identify latent trigger points due to their inability to generate spontaneous pain. Many times clinicians are forced to rely on the patients subjective interpretation of a pain response to identify myofascial trigger points and then classify them as either active or latent trigger points. Identifying Latent Trigger Points Within the literature, various methods for classifying myofascial trigger points have been identified (Ballyns et al., 2011; Sikdar et al., 2009; Turo et al., 2013). Using soneolastography, Ballyns et al. (2011) were able to distinguish between active and latent trigger points in the upper trapezius musculature with high specificity and sensitivity. Similarly, vibration elastography combined with ultrasound imaging has been found to be reliable in differentiating between active trigger points, latent trigger points, and normal tissue (Sikdar et al., 2009; Turo et al., 2013). While these methods for identifying and differentiating myofascial trigger points from normal muscle tissue may be useful in the research lab, their usefulness in the clinic has not yet been established. Clinically, manual palpation of a myofascial trigger point is considered the gold standard for the identification of either an active or latent trigger point (Shah et al., 2015). Criteria for identifying myofascial trigger points via manual palpation was first introduced by Simons et al. (1999). The criteria are as follows: presence of a locally tender spot or nodule within a taut band TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 15 of muscle, a subjective report of pain with palpation of the locally tender spot or nodule, a subjective report of referred pain with palpation of the locally tender spot or nodule, and the presence of a localized twitch response (LTR) or jump sign. A LTR is defined as a transient local contraction of skeletal muscle in response to palpation that is applied perpendicular to the muscle fibers (Shah et al., 2015; Simons et al., 1999). It is important to note that the standardization of the procedures for identifying myofascial trigger points, as well as the experience of the practitioner does have an effect the reliability and accuracy of palpation (N. Lucas, Macaskill, Irwig, Moran, & Bogduk, 2009; Myburgh, Larsen, & Hartvigsen, 2008). Two separate systematic reviews evaluating the research on reliability and validity of manual palpation of myofascial trigger points reported that there is significant variability in the criteria for trigger point identification within the literature (Myburgh et al., 2008; Tough, White, Richards, & Campbell, 2007). As a result, it has been difficult to come to a consensus on the usefulness of manual palpation to identify myofascial trigger points due to a lack of high quality research. In a systematic review of nine articles assessing the reliability of identifying myofascial trigger points, N. Lucas et al. (2009) found kappa scores ranging from -0.09 to 0.78. The inconsistency in scores was attributed to a lack of formal and standardized training of the practitioners performing the palpation. Myburgh et al. (2008) found moderate evidence (kappa range, 0.15 0.62) for the reproducibility of identifying myofascial trigger points in the upper trap for pain reproduction as well as the quadratus lumborum, and gluteus medius musculature for pain referral. Both N. Lucas et al. (2009) and Myburgh et al. (2008) stress the importance of specific training and standardization of palpation protocols in order to improve the reliability of myofascial trigger point palpation. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 16 Research utilizing the criteria proposed by Simons et al. (1999) showed that experienced clinicians were able to reliably identify myofascial trigger points in the upper trapezius musculature (Barbero et al., 2012), as well as the infraspinatus, anterior deltoid, and biceps brachii muscles (Bron, Franssen, Wensing, & Oostendorp, 2007). Rozenfeld, Finestone, Moran, Damri, and Kalichman (2017) found moderate to substantial interrater and intrarater reliability with manual palpation of myofascial trigger points within the hip and thigh musculature using the criteria defined by Simons (1999). Kappa exceeded 0.5 in 9 out of the 16 locations palpated for latent trigger points, while kappa exceeded 0.6 in 10 out of 16 locations palpated for active trigger points. Of specific interest to this study, the authors found moderate interrater and intrarater reliability between the identification of latent trigger points within the gluteus medius muscle with tenderness upon palpation being the indicator that had the highest kappa value at 0.75 for the posterior gluteus medius (Rozenfeld et al., 2017). Dry Needling The use of dry needling to treat painful musculoskeletal conditions has increased over the past 10 years (Caramagno et al., 2015; Dommerholt, 2011; Dommerholt, Grieve, Layton, & Hooks, 2015). In 2015, the Federation of State Boards of Physical Therapy published an analysis of the competencies required for physical therapists to possess in order to safely and effectively administer dry needling (Caramagno et al., 2015). In this analysis, dry needling was described as a skilled technique whereby filiform needles are used to penetrate skin and underlying tissues to affect change in body structures and functions. Dry needling can be used for the management of neuromuscular and musculoskeletal conditions, as well as pain and movement impairments (Caramagno et al., 2015). Dry needling can be classified as either superficial dry needling or deep dry needling (American Physical Therapy Association, 2013). The terms, dry needling and TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 17 deep dry needling or TDN have been used interchangeably throughout the literature (Dommerholt, 2011; Mansfield et al., 2019; Shah et al., 2015). However, there are very specific differences with each technique (American Physical Therapy Association, 2013; Dunning et al., 2014; Griswold, Wilhelm, Donaldson, Learman, & Cleland, 2019). Superficial dry needling utilizes a shallow insertion of a solid myofilament needle into the target tissue (Baldry, 2002). The needle is left in situ and may be manually manipulated or stimulated electronically in an attempt to achieve the desired response (Baldry, 2002; Langevin, Bouffard, Badger, Iatridis, & Howe, 2005). It has been hypothesized that superficial dry needling may stimulate mechanoreceptors in the surrounding tissue as well as A-delta fibers, thereby indirectly stimulating the anterior cingluar cortex and reducing the perception of localized or referred pain (Baldry, 2002; Olausson et al., 2002). Superficial dry needling may also affect connective tissue. Langevin et al. (2005) found that twisting a superficially inserted myofilament needle winds the collagen around the needle, thereby stretching the fibroblasts leading to cytoskeletal reorganization. As a result, superficial dry needling is traditionally utilized for managing dysfunction and pain arising from ligaments, tendons, fascia, and scar tissue (American Physical Therapy Association, 2013; Baldry, 2002; Dunning et al., 2014). Trigger Point Dry Needling For the purposes of this paper, the term TDN was used to describe deep dry needling of muscle tissue. The goal of TDN is to eliminate myofascial trigger points within muscle tissue, thereby reducing pain as well as improving motor control and function (Dommerholt et al., 2006; Shah et al., 2015). Like superficial dry needling, TDN also utilizes a solid filiform needle, but TDN focuses on the penetration of a palpable myofascial trigger point at various depths. The needle is then manipulated within the tissue in an attempt to elicit a LTR. Once the LTR has TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 18 ended, the needle is removed and another myofascial trigger point is located (Simons et al., 1999). The mechanism of the LTR and its role in the application of TDN is not yet fully understood (Boyles et al., 2015; Shah et al., 2015). However, Shah et al. (2008) found that substance P and calcitonin gene related peptide levels significantly reduced in myofascial trigger points, while blood flow to the tissue increased following the elicitation of a LTR. Furthermore, Cagnie et al. (2012) found an increase in blood flow and subsequent tissue oxygenation following the application of deep dry needling to the upper trap. These changes may correlate with a reduction in pain levels and local tenderness immediately following the application of TDN (Dommerholt, 2011). Additionally, Hong (1994b) found that elicitation of a LTR only occurs when a myofascial trigger point is manipulated. Therefore, the use of a LTR may be beneficial when using TDN to reduce the effects of myofascial trigger points in order to ensure that the needle has reached the necessary depth and the location of the myofascial trigger point. Trigger Point Dry Needling and Latent Trigger Points Much of the literature for treatment of myofascial trigger points has focused on the reduction of spontaneous pain caused by active trigger points and as a result, little attention has been placed on the effects that TDN has on latent trigger points, nor latent trigger points effect on muscle function (Boyles et al., 2015; Gattie et al., 2017; Kietrys et al., 2013; Liu et al., 2015; Mansfield et al., 2019; Morihisa et al., 2016). To date, there is no research that has specifically investigated the efficacy of TDN as a treatment for the clinical effects of latent trigger points in the lower extremity. There have been two studies that have analyzed the difference in strength measurements as measured by HHD force production prior to and following the application of TDN in the TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 19 lower extremities (Mayoral et al., 2013; Rossi et al., 2017). Of note, Mayoral et al. (2013) investigated the effects of TDN applied to musculature of the lower extremity prior to a total knee replacement and found a significant reduction in pain one month following surgery as compared to the control, but no differences in muscle strength were found. Muscle weakness following a total knee replacement is a commonly reported impairment that may be affected by variables other than the presence of myofascial trigger points such as the invasiveness of the surgical procedure, pain, swelling, and disuse atrophy (Bade, Kohrt, & Stevens-Lapsley, 2010). Rossi et al. (2017) compared the effects of segmental dry needling in combination with TDN to peripheral myofascial trigger points in the fibularis muscles as compared to peripheral TDN alone for individuals with a history of lateral ankle sprains. While there was a significant increase invertor and plantarflexion-evertor strength following the application of dry needling, there were no significant differences found between groups. Both Mayoral et al. (2013) and Rossi et al. (2017) did not differentiate between active or latent trigger points nor did they control for the different type of trigger points. A recent study by Haser et al. (2017) found improvements in the maximum force production of the knee extensors following the application of TDN to elite soccer players; however, there is no mention within the study if the intervention was applied to active or latent trigger points. Also of note in this study, TDN was not performed in isolation. Individuals within the study who received dry needling also received water pressure massage, so it cannot be said that TDN alone resulted in the improved force production of the knee extensors. The only study to date that has specifically investigated the effects that the application of TDN to latent trigger points has on muscle function was performed by K. R. Lucas et al. (2004). The authors found that the application of TDN to latent trigger points within the scapular TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 20 positioning musculature did normalize muscle activation patterns immediately following intervention (K. R. Lucas et al., 2004). No study has investigated the effect that the application of TDN in isolation and specifically to latent trigger points has on strength measurements of musculature within the lower extremities. Study Purpose Many clinicians focus solely on the identification and subsequent treatment of active trigger points as active trigger points have the ability to generate spontaneous and symptomatic pain. However, latent trigger points should not be ignored clinically as authors of previous studies have found that they do have an effect on motor function (Celik & Kaya Mutlu, 2013; Celik & Yeldan, 2011; Ge et al., 2012; Ge et al., 2014; Ge et al., 2008; Ibarra et al., 2011; K. R. Lucas, 2008; K. R. Lucas et al., 2004). Since latent trigger points do not generate spontaneous pain, it may be difficult for clinicians to identify them as a causative factor in neuromuscular or musculoskeletal dysfunction. As a result, clinicians may be missing a key component of their treatment plan. The purpose of this study was to assess the effect that the application of TDN to latent trigger points has on strength measurements. Specifically, the effect of TDN on the strength measurements of the gluteus medius musculature immediately following intervention was investigated. It is the authors intention that clinicians may be able to apply the results of this study to generate a safe and effective treatment plan that can reduce the risk for trunk and lower extremity injuries within their patient population by reducing the number of latent trigger points within muscle tissue. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 21 Method Study Design This quasi-experimental study used a single group, pretest-posttest, randomized control design that took place in the Department of Physical Therapys laboratory room at Mount St Joseph University in Cincinnati, Ohio. The study was approved by the Human Research Protections Program at the University of Indianapolis and a reliance agreement was enacted between the University of Indianapolis and Mount St Joseph University in May of 2018. Prior to participant recruitment, the study was registered on ClinicalTrials.gov, ID NCT03580200. Recruitment for the study began in August of 2018 and continued throughout the duration of the study until data were collected on 40 participants. Data collection took place from August of 2018 to April of 2019. Participants A convenience sample of asymptomatic males and females between the ages of 18 and 50 years from the Greater Cincinnati, Northern Kentucky, and Southeastern Indiana areas were recruited on a volunteer basis for participation in the study. Information regarding the study was disseminated through email (Appendix A) to Mount St Joseph University faculty and staff as well as through handouts (Appendix B) to local running and triathlon groups in the Greater Cincinnati, Northern Kentucky, and Southeastern Indiana areas. Males and females were included in the study if they were between the ages of 18 and 50 years and were asymptomatic at the time of screening and data collection. Asymptomatic individuals were defined as individuals who were experiencing no pain in their lumbar spine, sacroiliac region, pelvis, or bilateral lower extremities while at rest or with activity at the time of data collection. Participants were excluded from the study if they had one of the following: TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 22 Were pregnant or attempting to become pregnant at the time of data collection as selfreported by the participant Pain intensity greater than 0 out of 10 on the visual analogue scale (VAS) in the lumbar spine, sacroiliac region, pelvis, and bilateral lower extremities at rest or with activity Positive Flexion Adduction Internal Rotation test (FADIR) on either the left or right hip Present with signs and symptoms consistent with hip osteoarthritis during clinical screening using the criteria proposed Altman et al. (1991) on either the left or right hip Diagnosed with a progressive neurological disorder that may affect the strength of their lower extremities, a chronic pain condition such as fibromyalgia or myofascial pain syndrome, a connective tissue disorder, or osteoarthritis of the hip joint History of hip dysplasia or Legg Calve Perthes disease Sample size. An a priori sample size estimation was conducted using G*Power, version 3.1.9.2. (Faul, Erdfelder, Lang, & Buchner, 2009). The calculation was based on using a repeated measures ANOVA, analyzing the between-within interaction effect of four measurements between two groups and the following parameters, two-tailed test, alpha of .05, power of .80, a moderate effect size of 0.20. To date, there have been no studies investigating the effects of TDN on the strength measurements of the gluteus medius musculature. As a result, an effect size could not be calculated from previously completed studies. The use of a moderate effect size has been recommended if there is not an established effect size listed within the literature for a particular intervention (Hinkle, Wiersma, & Jurs, 1988). Cohen (1992) suggested an effect size of .25 be considered medium for an F test statistic. However, based on the clinical judgement of the primary investigator (E. S.) an effect size of 0.20 was utilized for the calculation of an appropriate sample size for this study. Based on the calculation, it is estimated that a minimum of TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 23 36 participants were needed for the study. To account for a potential participant dropout rate of 10% as well as individuals not presenting with latent trigger points in the gluteus medius when palpated, the total sample size for the study was set at 40 participants. Data Collection Data collection took place within the Department of Physical Therapys laboratory room at Mount St Joseph University. The room set-up was standardized prior to the start of data collection in an attempt to keep the conditions consistent for each participant. The primary investigator was responsible for data collection for all participants throughout the study. Demographic information of each of the participants, including gender, age, height, weight, and side dominance was collected prior to the start of the strength assessments via a participant intake questionnaire (Appendix C). Completed questionnaires were placed in a concealed folder in order to blind the primary investigator from this information during the data collection portion of the study. Once participants qualified for the study and agreed to participate by signing the informed consent form, they were unidentified by the random assignment of a unique study identification number. This unique study identification number was placed on the completed questionnaires as well as data collection forms. There were two independent variables for this study. The first independent variable was the status of the application of TDN at two levels, which were defined as either the control or the intervention side. The second independent variable was time at two levels and was defined as either measurement of strength prior to or following the application of TDN. There were also two dependent variables for this study. The first dependent variable was strength of the gluteus medius muscle as measured by a hand held dynamometer (HHD) on both the control and intervention sides. For the purpose of this study, strength of the gluteus medius TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 24 muscle was defined as the amount of force output measured by a HHD during a maximal volitional isometric contraction (MVIC) break test (Kendall, McCreary, Provance, Rodgers, & Romani, 2005; Mastenbrook et al., 2017; Otten, Tol, Holmich, & Whiteley, 2015). The measurement of force through the use of the HHD was recorded in kilograms (kg). The second dependent variable was the surface electromyography (sEMG) amplitude of the gluteus medius muscle contraction recorded during the MVIC break test on both the control and intervention sides. The sEMG amplitude was measured in millivolts (mV). Ratio data from both the HHD and the sEMG were collected utilizing a data collection form (Appendix D). The primary investigator recorded HHD measurements for each trial on the data collection form following each individual measurement. Surface electromyography measurements needed further processing to find the mean peak amplitude recorded during strength testing. Parameters for recording the raw sEMG data included a rejection ratio of > 110 dB at 60 Hz, a gain of 1000 Hz, band pass filtered at 20-450 Hz, and a sampling rate of 2000 Hz (Otten et al., 2015; Penney, Ploughman, Austin, Behm, & Byrne, 2014; Semciw, Neate, & Pizzari, 2014). Once the raw sEMG signals were analyzed by the primary investigator, the mean peak amplitude for each trial was recorded on the same data collection form as HHD measurements. The recordings listed on the data collection from as well as information listed on the participant intake questionnaire were entered into a Microsoft Excel spreadsheet at the end of each data collection day by the primary investigator. Completed data collection forms were kept under lock and key in the office of the primary investigator and were destroyed following the completion of the study. Once data collection was completed for all participants, data were exported from the spreadsheet into a statistical program for analysis. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 25 Instruments Hand held dynamometer. A microFET2 HHD (Hoggan Scientific, LLC, Salt Lake City, UT) was used during data collection. The HHD is commonly used to assess muscle strength within the field of physical therapy and has been shown to be a reliable and valid measurement tool for assessing strength of the lower extremities (Arnold, Warkentin, Chilibeck, & Magnus, 2010; Hbert et al., 2011; Ieiri et al., 2015; Mastenbrook et al., 2017). Hbert et al. (2011) measured the reliability and validity of the HHD on individuals aged 4 to 17 years, while Arnold et al. (2010) measured the reliability and validity of the HHD on individuals over the age of 65 years. Two studies reported the reliability of the HHD as a method to assess hip abduction strength in a patient population that is consistent with this study (Ieiri et al., 2015; Mastenbrook et al., 2017). Mastenbrook et al. (2017) reported strong intra-rater reliability with an intraclass correlation coefficient (ICC) = .94, while Ieiri et al. (2015) reported an ICC of .89 - .95 for intrarater reliability and an ICC = .76 - .79 for inter-rater reliability. Surface electromyography. Raw sEMG data were collected using a two-channel sEMG recording system (MP36R, Biopac, Goleta, CA). Recorded sEMG amplitude readings can be used as a direct measure of the activation level of a muscle during a contraction (Bamman, Ingram, Caruso, & Greenisen, 1997; Burden, 2010; Soderberg & Knutson, 2000). It has been suggested that intramuscular electromyography is superior to sEMG when it comes to analyzing low load or low level activation of the gluteus medius muscle (Semciw et al., 2014). However, sEMG is a common method of assessing the activation level of the gluteus medius muscle during MVIC as well as dynamic movements (Bolgla & Uhl, 2007; Boren et al., 2011; Claiborne, Timmons, & Pincivero, 2009; Otten et al., 2015; Penney et al., 2014; Semciw et al., 2014). In order to be compared between trials or between individuals, sEMG readings must be normalized TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 26 (Burden, 2010; Soderberg & Knutson, 2000). The method of normalization has been debated, but normalization using a MVIC is a widely used method of comparing sEMG readings (Burden, 2010). Bolgla and Uhl (2007) found that normalizing sEMG readings of gluteus medius activity utilizing a MVIC yielded the highest measurement reliability (ICC = .93 to .96) among methods of normalization. However, Claiborne et al. (2009) found sEMG to also be a reliable method of assessing gluteus medius activity during full range dynamic contractions, such as concentric contractions (ICC = .87 to .89) and eccentric contractions (ICC = .78 to .82). Establishing intra-rater reliability. Prior to the start of data collection, intra-rater reliability was established for the primary investigator using test-retest reliability and calculation of the ICC of the primary investigators sEMG and HHD measurements during strength testing of the gluteus medius. Measurement of gluteus medius strength and sEMG amplitude readings prior to and following the application of TDN was completed by the primary investigator and the primary investigator only. A total 10 participants with characteristics consistent with the studys sample population were recruited. The same procedures utilized in this study for strength testing of the gluteus medius (phase two of the study) was used for the intra-rater reliability study (phase one of the study). Initial force production readings were recorded for the right and left sides using the HHD and amplitude of each gluteus medius contraction was recorded by sEMG. A 10 minute break was given and then the same procedures for measuring force production and amplitude of the gluteus medius contraction were repeated. An ICC of greater than or equal to .75 was considered an acceptable level of intra-rater reliability (Portney & Watkins, 2000). Procedures Recruitment. A convenience sample of asymptomatic males and females between the ages of 18 and 50 years from the Greater Cincinnati, Northern Kentucky, and Southeastern TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 27 Indiana areas were recruited on a volunteer basis for participation in the study by the primary investigator. Information regarding the study was disseminated through email to Mount St Joseph University faculty and staff, as well as through handouts to local running and triathlon groups. A snowball method of recruiting was also utilized via word of mouth from the studys participants. Individuals who were interested in the study contacted the primary investigator by phone or email. Questions regarding the study were answered at that time. Once the individual had preliminarily agreed to participate in the study a date and time for them to come to Mount St Joseph University for eligibility screening, signing of the informed consent forms, and data collection was established. Eligibility screening. Individuals were screened for medical conditions that may have excluded them from participation in the study. Once an email was received from potential participants, they were instructed to call the primary investigator. Initial screening for participation within the study took place during this phone call. Individuals were asked if they were experiencing pain in their lumbar spine, sacroiliac region, pelvis, or bilateral lower extremities at rest or with activity. Furthermore, individuals were asked if they had been diagnosed with osteoarthritis of the hip, a progressive neurological disorder that may affect the strength of their lower extremities, a chronic pain condition, a connective tissue disorder, hip dysplasia, or Legg Calve Perthes disease. If individuals answered yes to any of the questions, they were excluded from the study. Individuals who met the inclusion criteria of the initial screening process were invited to come to the campus of Mount St Joseph University for more in-depth screening. Individuals were required to fill out a past medical history form (Appendix E) for the purposes of formally TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 28 screening for inclusion within the study. The individuals were also examined by the primary investigator to ensure there were no intra-articular conditions of the hip which would exclude them from the study. Screening for eligibility was completed in the same laboratory room at Mount St Joseph University where data collection took place. Participants were screened for osteoarthritis of the hip using the criteria purposed by Altman et al. (1991). If an individual presented with pain in the hip joint with hip internal rotation that is measured to be less than 15 degrees as well as hip flexion that is measured to be less than or equal to 115 degrees, he or she were excluded from participation in the study. Also, the anterior impingement test or FADIR test was used to screen individuals for painful conditions of the hip (Maslowski et al., 2010). If the individual experienced a reproduction of his or her pain response with overpressure into hip flexion, adduction, and internal rotation, he or she were excluded from participation in the study. Results of the screening process were recorded on the participants data collection form. Both the past medical history and data collection forms were kept in a locked filing cabinet in the locked office of the investigator. Informed consent process. Informed consent for participation in the study was obtained in person following eligibility screening but immediately prior to any demographic data collection or strength measurements. Once participants were screened and met the eligibility requirements for the study, documents describing the study, the procedures involved with the application of TDN, and the precautions and potential adverse effects of TDN were distributed to potential participants. The primary investigator reviewed the informed consent form with each participant and answered any question that came up regarding the study. Once all questions were answered, the individual signed the informed consent form, and the primary investigator served as the witness to the signing. At that time, the individual was considered to be a study TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 29 participant. The original copy of the informed consent form was kept under lock and key in the office of the primary investigator for the duration of the study. Each participant was given a duplicate copy of the form for his or her records. Once informed consent was obtained, each participant was randomly assigned a unique study identification number, and that number was used on all study documents, with the exception of the informed consent form, and in the electronic database. No participant identifiers were used on the data collection forms, past medical history forms, participant intake questionnaires, or in the electronic database. Demographic information. Following screening for eligibility within the study and the informed consent process, demographic information of each of the participants was obtained via the participant filling out a participant intake questionnaire. Each participant was required to fill out the questionnaire that asked him or her to record his or her gender, age, height, weight, and side dominance. The primary investigator left the room for this process. Participants were asked to place the completed questionnaire in a file folder located on a table in the room in order to blind the primary investigator from the demographic information during the data collection portion of the study. Once the questionnaire was placed in the folder, the primary investigator reentered the room. The primary investigator did not see information from the questionnaire until after data collection was completed. Each participants intake questionnaires were unidentified by recording the randomly assigned unique study identification number on the questionnaire just prior to the participant filling out the questionnaire. Completed questionnaires were kept under lock and key in the primary investigators office. Data from all participants questionnaires were recorded in a Microsoft Excel spreadsheet following the completion of data collection. Questionnaires were be destroyed following the completion of the study. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 30 Randomization. Participants served as their own control for this study. Each participant within the study was randomly assigned an intervention side, which for the purposes of this study, was defined as the side of the body that received TDN, as well as a control side, which was defined as the side of the body that did not receive TDN. A simple randomized method of flipping a coin was utilized to randomly assign the control and intervention side for each participant. Heads assigned the right gluteus medius muscle to receive TDN while the left gluteus medius muscle served as the control. Tails assigned the left gluteus medius muscle to receive TDN with the right gluteus medius muscle served as the control. The random assignment of both the intervention and control sides occurred prior to any pre-TDN strength measurements being taken or the identification of latent trigger points in the gluteus medius musculature. Strength testing pre-trigger point dry needling. Bipolar sEMG electrodes were placed on both the control and intervention sides. The electrodes were placed 2 cm apart from each other in a position distal to the iliac crest, midway between the anterior and posterior superior iliac spines and in line with the proximal tip of the greater trochanter (Penney et al., 2014; Semciw et al., 2014). A reference electrode was placed on the greater trochanter. Electrodes on the intervention side needed to be removed during the application of TDN. As a result, the electrode placement was marked by a sterile surgical pen in order to ensure that the electrodes were located as close to the exact location as possible. Once an intervention and control side were assigned and the sEMG electrodes were placed in the correct position, strength measurements of the gluteus medius musculature were obtained by the primary investigator, a licensed physical therapist with 13 years of clinical experience. Strength measurements were taken on both the control and intervention sides. In order to isolate the gluteus medius muscle, Kendall et al. (2005) suggested that the hip on the TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 31 side that is to be tested be positioned in 5 degrees of hip extension, 15 degrees of hip abduction, and slight hip external rotation in order to bias the gluteus medius muscle. However, recent research has found that positioning the hip in external rotation during strength testing of the gluteus medius actually places the muscle at a mechanical disadvantage, thereby decreasing its force production (Otten et al., 2015; Semciw et al., 2014). For this study, strength of the gluteus medius muscle was assessed with the hip in two separate positions. For the both strength assessments, participants were positioned in side lying with their bottom leg in a position of approximately 30 degrees of hip flexion and 90 degrees of knee flexion. The first testing position had the hip on the side that is to be tested in a neutral or zero starting position (SL0) at the hip with the knee fully extended. Neutral or zero starting position was defined as a position where the hip is in neutral position with respect to hip flexion and extension, abduction and adduction, as well as internal rotation and external rotation. Once strength measurements were recorded while the participant is in the SL0 position, the hip on the side that was being measured was then placed in the second testing position. This was a position of neutral hip flexion and extension as well as abduction and adduction, but the hip was maximally internally rotated (SLIR) with the knee fully extended. All subdivisions of the gluteus medius have been found to be the most active when the hip is in the SLIR and SL0 positions. As a result, it has been recommend that these two positions be used for assessing strength of the gluteus medius muscle (Otten et al., 2015). To ensure that the participant understood the position of testing, the leg that was to be tested was passively moved in to the testing positon with verbal cueing from the examiner. The pelvis was kept from rotating backwards by a manual stabilization force provided by the examiners hand, which was placed on the posterior and lateral iliac crest on the side that is to be TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 32 tested (Kendall et al., 2005; Mastenbrook et al., 2017). The amount of verbal cueing provided to each participant depended on the participants ability to achieve the testing position. However, standard cueing included the statement, Make sure to keep your pelvis still. While performing this test, the pelvis should not rock forward or backward, we only want your leg to move. The participant was then asked to move the leg that was to be tested in to the testing position without assistance, but with verbal cueing from the examiner. After the participant successfully achieved the proper position for testing without compensation on three consecutive attempts, he or she was asked to move their leg in to the testing position on their own and to maintain that position. Once the participant had demonstrated the ability move the leg that was to be tested in the testing position and maintained that position independently without compensation or the need for cueing, a trial MVIC break test was performed so that the participant was familiar with the amount of resistance that was to be provided by the examiner. For purposes of standardization, the strength of each participants gluteus medius on the control side was assessed first, followed by the strength of the gluteus medius on the intervention side for both the pre and post-TDN measurements. Measurements of gluteus medius force production were recorded using a HHD while readings of sEMG amplitude were simultaneously recorded during a MVIC break test (Kendall et al., 2005). Three maximal break tests were performed with one minute of rest in between each trial for both the SL0 and SLIR test positions in an attempt to reduce the effects of muscular fatigue (Bolgla & Uhl, 2007). Verbal cueing of, Hold your leg there and dont let me move you was provided to the participant prior to the application of resistance. The resistance applied during each break test was applied gradually until maximal resistance was provided. Maximal TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 33 resistance be held for a total of five seconds, or until the participant can no longer hold the testing position (Kendall et al., 2005). To standardize the resistance applied for each trial as well as each participant, the entire body weight of the examiner was placed 4 cm proximal to the lateral malleolus as the examiner attempted to adduct and slightly flex the hip to a neutral position (Kendall et al., 2005; Mastenbrook et al., 2017). The exact position of where the pressure should be placed was measured and marked on both the control and intervention sides to standardize the measurement of strength for each participant. Any compensatory movement of the trunk, pelvis, or lower extremity was noted. If compensatory movements were observed during the recording of a strength measurement, the measure obtained was not recorded and the primary investigator instructed the participant on the correct procedure and asked the individual performed the break test again. Once three valid tests were performed, the HHD values were averaged (Celik & Yeldan, 2011; Mastenbrook et al., 2017). An average force production was obtained for both the control and intervention sides. Identification of latent trigger points. Following the pre-TDN measurement of gluteus medius strength, latent trigger points were identified in the gluteus medius musculature on both the control and intervention sides by the primary investigator, who has been trained and certified in the identification of myofascial trigger points through Myopain Seminars, LLC and has 6 years of clinical experience with the application of TDN. Latent trigger points within the gluteus medius muscle on the intervention side were assessed first. The participant was positioned in side lying with the side that was palpated facing the ceiling. A pillow was placed in-between the participants knees to ensure that the hip on the side that was assessed was in a slightly adducted position to the point where normal muscle fibers were still on slack, while the taut bands of TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 34 muscle were placed under tension which made them more easily palpable (Celik & Kaya Mutlu, 2012; Celik & Yeldan, 2011; K. R. Lucas et al., 2004; K. R. Lucas et al., 2009). The method for identifying latent trigger points in the gluteus medius musculature was standardized using the methods proposed by Simons et al. (1999). The examiner first identified a taut band of muscle using a flat palpation, which is a technique for palpation where the pads of the second and third digits are pushed into muscular tissue. A taut band of muscle was identified by moving the pads of the second and third digits perpendicular to the muscle tissue. Once a taut band was identified, the examiner palpated parallel to the muscle fibers in an attempt to identify a slightly enlarged point or the focus of the contraction (Celik & Kaya Mutlu, 2012; K. R. Lucas et al., 2004; K. R. Lucas et al., 2009). Once a focal point was identified, the participant was asked if the spot being palpated was painful. If the answer was yes, they were then asked if the pain produced had recently been felt before without manual palpation. If the participant answered no, the trigger point was considered latent (Celik & Kaya Mutlu, 2012; Celik & Yeldan, 2011). The participant was also asked if the pain traveled in an area other than what was palpated while the examiner performed a snapping palpation of the latent trigger point in an attempt to elicit a LTR (K. R. Lucas et al., 2004; K. R. Lucas et al., 2009). The amount of latent trigger points identified on the control and intervention sides were recorded for comparison during the statistical analysis portion of the study. Application of trigger point dry needling. Participants must have had at least two latent trigger points in the gluteus medius muscle on the randomly assigned intervention side (Celik & Yeldan, 2011). Participants did not receive TDN until two latent trigger points within their gluteus medius were identified. Once a latent trigger point was identified, TDN was applied to that area by the same therapist who performed the palpation. Trigger point dry needling was TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 35 applied to each latent trigger point in an attempt to elicit a LTR. Once a LTR was elicited, the needle was manipulated either further into the muscle tissue or at a different angle in an attempt to elicit another LTR. The needle was manipulated in the muscle tissue until no more LTRs were elicited or if the participant verbally requested the intervention to stop. Once the needle was removed, pressure was held at the site of needle insertion via the pads of the second and third digits for a total of 30 seconds. The same process for TDN was repeated for all identified latent trigger points within the gluteus medius muscle. The application of TDN was stopped once there were no more LTR elicited and there were no more palpable latent trigger points within the gluteus medius muscle. The amount of needles used during the application of TDN was recorded for potential statistical analysis following the data collection portion of the study. Following the application of TDN, each participant was asked to stand up and walk around for a few minutes in an attempt to reduce any post needling soreness that may have occurred. They were then asked to rate their level of soreness on a 0 to 10 scale with a response of 0 representing, No soreness at all and a response of 10 representing, The worst soreness imaginable. The level of reported soreness for each participant was recorded for statistical analysis following the data collection portion of the study. Strength testing post-trigger point dry needling. The participant was then asked to lie back on the table and the same procedure measuring strength of the gluteus medius was repeated. Strength of the gluteus medius on the control side was assessed first followed by the intervention side. Once the participant demonstrated the ability to actively move the leg in to the test position and hold it there without compensation, a trial MVIC break test was performed so that the participant could once again become familiar with the amount of resistance that was to be TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 36 provided by the examiner. Three strength measurements were then taken with a minute rest break in between measurements for both the SL0 and SLIR positions in an attempt to reduce the effects of fatigue (Bolgla & Uhl, 2007). If the participant was unable to actively achieve the testing position without compensation, the same standardized procedure for teaching the participant the testing position that was used prior to the application of TDN was utilized. Data Management Biopac Student Lab software (Biopac, Goleta, CA) was used to analyze the recorded sEMG data. Raw sEMG readings were visually inspected by the primary investigator. The peak amplitude that occurred during the MVIC of each trial were identified. The raw sEMG readings were then transformed using a root mean square calculation. Data were smoothed over 1000 points which represented a 500 ms window around the identified peak amplitude, 250 ms prior to the peak and 250 ms following the peak (Bamman et al., 1997). If the 500 ms window included readings that were not part of the MVIC, the next closest peak within the MVIC were identified and used. The mean amplitude within the 500 ms window was recorded for each trial. Once a mean sEMG amplitude was found for each trial, the three trials in the SL0 and SLIR positions were averaged and recorded for both the intervention and control sides. The recorded HHD force measurements for all three trials in the SLO and SLIR positions were also averaged and recorded for both the intervention and control sides. This process was performed for all measurements recorded prior to and following the application of TDN. The averaged values for the sEMG and HHD measurements were used for statistical analysis. The resultant sEMG data were then normalized using the sEMG measurements recorded prior to the application of TDN as the 100% MVIC reference for both the intervention and TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 37 control sides. For comparison purposes, the sEMG measurements recorded following the application of TDN are expressed as a percentage of the 100% MVIC. Statistical Analysis All data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY). Normality of the data was determined using the Shapiro-Wilk test. All comparisons were two-tailed and an alpha level of less than .05 was considered statistically significant unless otherwise noted. Phase one. To assess the primary investigators intra-rater reliability, the mean HHD force and sEMG amplitude measurements for each trial in the SLO and SLIR positions were analyzed using ICC estimates and their 95% confidence intervals. The ICC calculations for all three trials in the SLO and SLIR positions on both the right and left side were based on consistency and a two-way-mixed-effects model ICC (3, 1). An ICC of > .75 was considered to be acceptable (Portney & Watkins, 2000). Phase two. Descriptive statistics were used to describe the baseline characteristics of the sample. Nominal data are reported as frequencies and percentages. Interval and ratio data are reported as means and standard deviations for data that were normally distributed or medians and interquartile ranges for data that were not normally distributed. A two-way repeated measures ANOVA was used to assess if there was a significant difference in HHD force measurements between the intervention and control sides as well as within the intervention and control sides prior to and immediately following the application of TDN. For results in which there was a significant interaction, post hoc tests were used to identify which pairs had a significant difference. Post hoc tests were conducted using paired t tests with a Bonferroni correction (alpha level of p < .013) to account for alpha inflation. Effect size of the TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 38 interaction between time (pre-TDN to post-TDN) and groups (intervention side and control side) were calculated using the partial eta squared results of the two-way repeated measures ANOVA. Interpretation of the partial eta squared was based off of the recommendations of Cohen (1988). To assess whether there was a significant difference in sEMG measurements within the intervention side and the control side over time as well as between sides prior to and following the application of TDN, pairwise tests were conducted for both the SLO and SLIR positions. Since sEMG data were not normally distributed, Wilcoxon signed-ranks tests with Bonferroni correction (alpha level of < .013) were conducted. The Bonferroni correction was used to account for alpha inflation that could result from conducting multiple comparisons. Effect sizes for the results of the Wilcoxon signed-ranks test were calculated using the recommendations of (Field, 2013) and the resultant effect sizes were expressed as Cohens d and interpreted using the recommendations of Cohen (1988). Results Phase One Ten individuals participated in phase one of the study. Results of the ICC analysis for measurements taken within trials for both the right and left sides and for both HHD force measurements and sEMG amplitudes can be found in Table 1. The ICC results for measurements taken between the two different time periods (prior to and after a 10-minute break) for both the right and left sides and for both the HHD force measurements and sEMG amplitudes are presented in Table 2. All ICCs were greater than .75 indicating acceptable intrarater and testretest reliability (Portney & Watkins, 2000). TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 39 Phase Two Description of sample. Forty participants were recruited for participation in phase two of the study. One participants results were excluded from the study due to the protocol for data collection not being followed. Therefore, the total sample size for this phase of the study was 39 participants. Descriptive statistics for the baseline characteristics of the sample can be found in Table 3. Hand held dynamometer. Descriptive statistics for HHD measurements of force for the intervention and control sides for both the SL0 and SLIR positions are presented in Table 4. There was a statistically significant interaction between the time (pre-TDN to post-TDN) and groups (intervention side and control side) for both positions, SL0 position, F(1,38) = 107.89, p < .001 and SLIR position, F(1,38) = 93.37, p < .001. This led to a rejection of the null hypothesis that there would not be an interaction at an alpha level of .05. The overall effect sizes were large for the interactions in the SL0 position (partial eta squared = .74) and the SLIR position (partial eta squared = .71). Because there was a significant interaction between timing of the intervention (pre-TDN and post-TDN) and TDN side (intervention and control) for both positions, pairwise post hoc analyses was completed using a paired t test with a Bonferroni correction. For the SL0 position, there was a statistically significant difference (p < .001) for all comparisons: pre-TDN to postTDN within the intervention side and within the control side and between the intervention side and control side for both time periods. For the SLIR position, there was a statistically significant difference (p < .001) for pre-TDN and post-TDN measurements within the intervention side as well as measurements between the intervention and control side for the post-TDN measurements. There was not a significant difference (p = .146) within the control side when comparing pre- TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 40 TDN and post TDN measurements, or when comparing pre-TDN measurements between the intervention and control sides (p = .074). Surface electromyography. Descriptive statistics for sEMG measurements of amplitude for the intervention and control sides for both the SL0 and SLIR positions are presented in Table 5. Because data were not normally distributed, a Wilcoxon signed-ranks test with a Bonferroni correction (p < .013) was utilized. Within group analysis revealed a statistically significant difference between pre-TDN and post-TDN sEMG amplitude measurements on the intervention side in the SL0 position Z(39) = - 2.60, p = .009 with a medium effect size (Cohens d = .62). There were no statistically significant differences between pre-TDN and post-TDN sEMG amplitude measurements in the SL0 position on the control side, Z(39) = - 1.46, p = .145. For the SLIR position, there was not a statistically significant difference within either the intervention side, Z(39) = - 2.09, p = .037 and the control side, Z(39) = - 1.00, p = .317. Between TDN group comparisons for the SL0 position revealed there was not a statistically significant difference in pre-TDN sEMG amplitude measurements between the intervention side and control side, Z(39) = -1.17, p = .241. However, there was a statistically significant difference in post-TDN sEMG amplitude measurements between the intervention side and control side in the SL0 position, Z(39) = -3.08, p = .002 with a medium effect size (Cohens d = .74). In the SLIR position, the difference between the intervention side and control side at pre-TDN and post-TDN was not statistically significant, Z(39) = -.27, p = .786 and Z(39) = -.20, p = .042, respectively. Discussion The authors of previous studies have identified latent trigger points as a source of impaired muscle function including a reduction in force production (Celik & Yeldan, 2011), TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 41 induction of muscle cramps (Ge et al., 2008), and fatigability (Ge et al., 2012), as well as alterations of muscle activation patterns and movement efficiency (K. R. Lucas et al., 2004). However, few authors have investigated the efficacy of a treatment in reducing these clinical manifestations of latent trigger points (Celik & Kaya Mutlu, 2013). The purpose of this study was to investigate whether the application of deep TDN to latent trigger points within the gluteus medius musculature affected strength measurements immediately following intervention. To assess if latent trigger points are a potential cause of muscle weakness, participants within this study had to be asymptomatic to ensure that the latent trigger points themselves were the sole reason for muscle weakness, not pain or articular dysfunction. Furthermore, to specifically assess the effect that TDN had on strength measurements, TDN had to be completed in isolation of any other therapeutic intervention. As such, this is the first study to investigate the effects of deep TDN in isolation on strength measurements of the gluteus medius in asymptomatic individuals. However, results of the study are consistent with previous studies that investigated immediate changes in force production as measured by a HHD following the application of dry needling to myofascial trigger points in the lower extremities for both symptomatic (Rossi et al., 2017) and asymptomatic individuals (Haser et al., 2017). Participants within this study demonstrated a statistically significant increase in HHD measurements of gluteus medius force production immediately following the application of TDN in both the SL0 and SLIR positions. While the minimal clinically important difference (MCID) for HHD measurements of the gluteus medius muscle has not been established (Bohannon, 2019; Romney, Weisbach, Anderson, & Yoshida, 2016), a large treatment effect size was found for interactions in the SL0 position (partial eta squared = .74) and the SLIR position (partial eta TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 42 squared = .71) following the application of TDN suggesting a strong relationship between intervention and the difference in HHD measurements over time as well as between groups. The authors of previous studies have shown increases in force production as measured by a HHD following the application of dry needling to myofascial trigger points in the lower extremities (Haser et al., 2017; Rossi et al., 2017). However, those authors either performed TDN on symptomatic individuals (Rossi et al., 2017) or applied dry needling to myofascial trigger points in combination with other interventions (Haser et al., 2017) while the authors of this study performed TDN in isolation on asymptomatic individuals. Furthermore, Rossi et al. (2017) did not control for the type of myofascial trigger point included within their study, while Haser et al. (2017) made no mention of the type of myofascial trigger point that received dry needling. Results of research performed on musculature within the upper quarter have also shown an increase in isometric strength measurements following the application of TDN to myofascial trigger points (Cerezo-Tllez, Lacomba, et al., 2016; Cerezo-Tllez, Torres-Lacomba, et al., 2016). Participants in two separate studies demonstrated an increase in isometric cervical force production in all directions as measured by a HHD following the application of TDN. However, in both studies, TDN was performed on individuals with neck pain and TDN was not performed in isolation (Cerezo-Tllez, Lacomba, et al., 2016; Cerezo-Tllez, Torres-Lacomba, et al., 2016). Calvo-Lobo et al. (2017) and Calvo-Lobo et al. (2018) compared the effects of applying TDN to an active trigger point versus an active trigger point and a latent trigger point in the infraspinatus musculature on isometric grip strength for older adults with non-operative shoulder pain. While both groups demonstrated an increase in isometric grip strength following the application of TDN, there was not a significant difference found between groups. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 43 Strength as measured by HHD force measurements was not the only outcome measure utilized in this study. The purpose of including sEMG as a primary outcome measure was to assess if there was a difference in sEMG amplitude readings recorded during strength testing following the application of TDN. Participants demonstrated a statistically significant decrease (78.17% of pre-TDN readings) in sEMG amplitude readings on the intervention side following the application of TDN even though HHD force measurements increased by 2.52 kg in the SL0 position. While not statistically significant, sEMG amplitude readings in the SLIR position also decreased (90.32% of pre-TDN readings) on the intervention side, while HHD force measurements increased by 3.38 kg. With regards to sEMG analysis, recorded sEMG amplitude readings can be used as a direct measure of the activation level of a muscle during a contraction (Bamman et al., 1997; Burden, 2010; Soderberg & Knutson, 2000). Both Dwyer, Stafford, Mattacola, Uhl, and Giordani (2013) and Penney et al. (2014) found an increase in sEMG amplitude readings recorded during functional activities for individuals who demonstrated weakness of the gluteus medius muscle during baseline testing. These results suggest individuals who present with weakness of a muscle will require an increased level of muscle activation during a contraction. This increased muscle activation may be a compensatory mechanism used to increase the amount of motor unit recruitment in order to achieve a given force output (Ling et al., 2007). As such, the inverse relationship of HHD force measurements and sEMG amplitude readings found in this study suggests a more efficient gluteus medius muscle contraction following the application of TDN, as participants required less motor unit recruitment to achieve greater levels of force production. Based on the results of this study, latent trigger points can be identified as a potential source for impaired muscle function of the gluteus medius muscle resulting in a weak and TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 44 inefficient muscle contraction. Latent trigger points have been found to be more prevalent in muscle tissue than active trigger points (Celik & Kaya Mutlu, 2012; K. R. Lucas et al., 2009) and should not be ignored by clinicians when working with patients who demonstrate weakness of the gluteus medius musculature. The application of TDN to these latent trigger points can improve the force production and efficiency of contraction immediately following intervention. The exact mechanism of how TDN can reverse the effects of myofascial trigger points is still unknown (Shah et al., 2015). Authors of previous research have stressed the importance of eliciting a LTR during TDN to ensure that the myofilament needle has come in contact with a myofascial trigger point (Hong, 1994a; Rha et al., 2011), while other authors have found a greater reduction in reported pain levels if a LTR is elicited (Chu & Schwartz, 2002; Hong, 1994a; Tekin et al., 2013). However, the effect of eliciting a LTR on muscle function has not been reported and is still theoretical in nature. Elicitation of a LTR during the application of TDN was monitored throughout the study. All 39 participants demonstrated a palpable LTR as well as a subjectively reported feeling a LTR during the application of TDN. Following the application of deep dry needling as well as the elicitation of a LTR, an increase blood flow and subsequent tissue oxygenation have been found, along with a reduction of the biochemicals associated with pain and a localized muscle contraction within the milieu of a myofascial trigger point (Cagnie et al., 2012; Shah et al., 2008). The increase in localized blood flow as well as biochemical changes within the tissue itself may explain the increase in force production following the application of TDN observed during this study. Specifically, a reduction of calcitonin gene related peptide may allow for improved overlap of actin and myosin proteins through elimination of the localized muscle contracture (Gerwin et al., 2004) which has the potential to improve cross bridge formation TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 45 within the sarcomere unit, thereby improving muscle force production. Furthermore, K. R. Lucas (2008) argued that a reduction of group III and IV afferent input to second order neurons could potentially reverse alpha motor neuron inhibition, thereby improving neuromuscular control which may further explain the inverse relationship between HHD force measurements and sEMG amplitude readings found in this study following the application of TDN. An unexpected outcome of the study was that there was also a statistically significant difference in HHD measurements for the control side in the SL0 position as force measurements decreased by 1.31 kg following the application of TDN. A possible explanation for this result could be found in the order in which the strength measurements were recorded and the level of soreness experienced following the application of TDN. Three trials of MVIC break tests were completed on the control side immediately following the application of TDN. During data collection, a common theme was noted among participants during their first post-TDN strength assessments while in the SL0 position. Participants reported an increased level of soreness in the gluteus medius muscle on the intervention side during the first MVIC break test trial on their control side. Even though strength was being assessed on the control side, participants reported an increased level of soreness on the side that they were lying on. Post needling soreness is commonly reported following the application of TDN (Perreault, Dunning, & Butts, 2017) and may have affected the participants ability to generate force during their first MVIC break test trial on the control side in the SL0 position. To support this explanation, post-TDN HHD force measurements of all three trials in the SL0 on the control side were analyzed for differences. Analyses using three separate paired t tests revealed statistically significant differences for the measurements recorded between trial 1 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 46 and trial 2 (mean difference = -0.71, t(38) = -2.42, p = .020) and trial 1 and trial 3 (mean difference = -0.97, t(38) = -3.60, p = .001). No significant difference was found between measurements recorded for trial 2 and trial 3 (mean difference = -0.26, t(38) = -1.08, p = .287). It is plausible that the level of soreness experienced in the gluteus medius musculature following the application of TDN reduced with each subsequent MVIC break test trial. This phenomenon may explain why there was no significant difference found between measurements recoded for trial 2 and trial 3 in the SL0 position as well as no significant difference between any of the measurements recorded in the SLIR position on the control side, which were collected following the measurements in the SL0 position. Clinically, TDN is rarely performed in isolation and as such, clinicians should be aware of the possibility for post needling soreness and its potential effect on force production. Results of this analysis suggest that it may be beneficial to perform isolated gluteus medius contractions in an open chain position prior to any functional strengthening activities. This may reduce the effects that post-needling soreness may have on force production immediately following the application of TDN thereby potentially reducing the risk for compensatory movement patterns during strengthening activities. Study Limitations There were several limitations noted within this study, namely the lack of investigator and participant blinding. The primary investigator was not blinded to which side received TDN and which side was the control. The primary investigator collected all of the data throughout the study as well as applied the intervention to each of the studys participants and as such, inadvertent bias cannot be completely ruled out. During a MVIC break test, the amount of muscle force generated has a direct relationship with the amount of resistance provided. Previous studies have utilized straps that the participants push into during a MVIC in an attempt to remove TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 47 investigator bias (Bolgla & Uhl, 2007; Boren et al., 2011; Otten et al., 2015); however, with this method the investigator cannot be sure that the participant gave maximal effort during testing. This is why some studies have preferred utilizing a MVIC break test where the investigator provides the resistance (Mastenbrook et al., 2017; Penney et al., 2014). Throughout this study, the primary investigator attempted to keep the amount of resistance provided during all MVIC trials consistent by using his entire body weight as resistance to each participants muscle contraction. However, since the primary investigator was not blinded to which side received the intervention and which side was the control, the possibility of the investigator inadvertently adjusting his resistance cannot be completely eliminated. Future research on this topic should include methodology where a one investigator is used to collect data, while another investigator is used to apply the intervention. The investigator collecting data would be blinded to the allocation of control and intervention sides, while the investigator applying the intervention would be blinded to the results of the force measurements. Participants within this study were aware of which side received TDN and which side was the control side and as such, performance bias cannot be completely ruled out. During the informed consent process, each participant was instructed that the purpose of the study was to assess the effects of TDN on strength measurements of the gluteus medius, whether that be an increase or decrease in strength. This was done in an attempt to reduce the risk of each participant giving more effort during strength measurements on the intervention side as compared to the control side following the application of TDN. It is difficult to account for the potential for a placebo effect in studies that investigate the effects of TDN. Sham needles have been utilized in studies that have investigated the effects of superficial dry needling (Mansfield et al., 2019), but when it comes to TDN studies, participants TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 48 are able to feel the difference in needle depth penetration between the sham and TDN needles, as well as the elicitation of a LTR on the intervention side. Furthermore, if study participants have previously received TDN, as was the case with this study, they may be able to realize the difference between the placebo and actual intervention. Mayoral et al. (2013) conducted the only TDN study to date that has been able to completely account for the placebo effect. The study investigators applied TDN to individuals who received anesthesia just prior to undergoing surgery for a total knee replacement. As such, the participants were unable to feel which side was receiving the TDN, nor were they able to see the procedure, as a sheet blocked their view of the application of intervention. Future research on this topic could include other types of dry needling including superficial dry needling techniques, which may make it easier to include sham needles as a true placebo. While results of this study demonstrated a significant change in force production of the gluteus medius immediately following the application of TDN to latent myofascial trigger points found within the gluteus medius musculature, the long lasting effects on force production were not analyzed. Further research is needed to assess the effects of TDN on muscle strength at different post-treatment time intervals. Furthermore, TDNs effect on muscle force production or activity during functional movements should also be investigated as this may have a more direct clinical application to improving performance during activities of daily living as compared to during strength testing. Conclusion Results of this study suggest that latent trigger points may have a negative impact on gluteus medius muscle strength as well as the efficiency of contraction. Application of TDN to these latent trigger points can significantly increase gluteus muscle force production immediately TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH following intervention while reducing the level of muscle activation required for force production. Clinically, latent trigger points should not be ignored as a potential source of impaired muscle function. 49 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 50 References Aguilera, F. J., Martn, D. P., Masanet, R. A., Botella, A. C., Soler, L. B., & Morell, F. B. (2009). 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Unmyelinated tactile afferents signal touch and project to insular cortex. Nature Neuroscience, 5(9), 900-904. Otten, R., Tol, J. L., Holmich, P., & Whiteley, R. (2015). Electromyography activation levels of the 3 gluteus medius subdivisions during manual strength testing. Journal of Sport Rehabilitation, 24(3), 244-251. doi:10.1123/jsr.2013-0149 Penney, T., Ploughman, M., Austin, M. W., Behm, D. G., & Byrne, J. M. (2014). Determining the activation of gluteus medius and the validity of the single leg stance test in chronic, nonspecific low back pain. Archives of Physical Medicine and Rehabilitation, 95(10), 1969-1976. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 61 Perreault, T., Dunning, J., & Butts, R. (2017). The local twitch response during trigger point dry needling: Is it necessary for successful outcomes? Journal of Bodywork and Movement Therapies, 21(4), 940-947. Portney, L. G., & Watkins, M. P. (2000). Foundations of clinical research: Applications to practice (2nd ed.). Upper Saddle River, NJ: Prentice Hall Health. Prins, M. R., & van der Wurff, P. (2009). Females with patellofemoral pain syndrome have weak hip muscles: A systematic review. Australian Journal Physiotherapy, 55(1), 9-15. Rha, D. W., Shin, J. C., Kim, Y. K., Jung, J. H., Kim, Y. U., & Lee, S. C. (2011). Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonography. Archives of Physical Medicine and Rehabilitation, 92(10), 15761580.e1571. doi:10.1016/j.apmr.2011.05.005 Romney, W., Weisbach, C., Anderson, H., & Yoshida, R. (2016). Hand held myometry/dynamometry. Retrieved from https://www.sralab.org/rehabilitationmeasures/hand-held-myometry-dynamometry Rossi, A., Blaustein, S., Brown, J., Dieffenderfer, K., Ervin, E., Griffin, S., . . . Johanson, M. (2017). Spinal and peripheral dry needling versus peripheral dry needling alone among individuals with a history of lateral ankle sprain: A randomized control trial. International Journal of Sports Physical Therapy, 12(7), 1034-1047. Rozenfeld, E., Finestone, A. S., Moran, U., Damri, E., & Kalichman, L. (2017). Test-retest reliability of myofascial trigger point detection in hip and thigh areas. Journal of Bodywork and Movement Therapies, 21(4), 914-919. doi:10.1016/j.jbmt.2017.03.023 Semciw, A. I., Neate, R., & Pizzari, T. (2014). A comparison of surface and fine wire EMG recordings of gluteus medius during selected maximum isometric voluntary contractions TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 62 of the hip. Journal of Electromyography and Kinesiology, 24(6), 835-840. doi:10.1016/J.JELEKIN.2014.08.015 Shah, J. P., Danoff, J. V., Desai, M. J., Parikh, S., Nakamura, L. Y., Phillips, T. M., & Gerber, L. H. (2008). Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Archives of Physical Medicine and Rehabilitation, 89(1), 16-23. doi:10.1016/j.apmr.2007.10.018 Shah, J. P., & Gilliams, E. A. (2008). Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of muscle pain concepts to myofascial pain syndrome. Journal of Bodywork and Movement Therapies, 12(4), 371-384. doi:10.1016/j.jbmt.2008.06.006 Shah, J. P., Phillips, T. M., Danoff, J. V., & Gerber, L. H. (2005). An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. Journal of Applied Physiology, 99(5), 1977-1984. doi:10.1152/japplphysiol.00419.2005 Shah, J. P., Thaker, N., Heimur, J., Aredo, J. V., Sikdar, S., & Gerber, L. (2015). Myofascial trigger points then and now: A historical and scientific perspective. American Academy of Physical Medicine and Rehabilitation, 7(7), 746-761. doi:10.1016/j.pmrj.2015.01.024 Sikdar, S., Shah, J. P., Gebreab, T., Yen, R.-H., Gilliams, E., Danoff, J., & Gerber, L. H. (2009). Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Archives of Physical Medicine and Rehabilitation, 90(11), 1829-1838. doi:10.1016/j.apmr.2009.04.015 Simoneau, G. G., & Heiderscheit, B. (2017). Kinesiology of walking. In D. A. Neumann (Ed.), Kinesiology of the musculoskeletal system: Foundations for rehabilitation (3rd ed., pp. 653-705). St. Louis, MO: Elsevier. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 63 Simons, D. G., Travell, J. G., & Simmons, L. (1999). The trigger point manual (2nd ed.). Baltimore, MD: Williams and Wilkins. Soderberg, G. L., & Knutson, L. M. (2000). A guide for use and interpretation of kinesiologic electromyographic data. Physical Therapy, 80(5), 485-498. Tekin, L., Akarsu, S., Durmu, O., Cakar, E., Diner, U., & Kralp, M. Z. (2013). The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clinical Rheumatology, 32(3), 309-315. doi:10.1007/s10067012-2112-3 Tough, E. A., White, A. R., Richards, S., & Campbell, J. (2007). Variability of criteria used to diagnose myofascial trigger point pain syndrome: Evidence from a review of the literature. Clinical Journal of Pain, 23(3), 278-286. Trampas, A., Kitsios, A., Sykaras, E., Symeonidis, S., & Lazarou, L. (2010). Clinical massage and modified Proprioceptive Neuromuscular Facilitation stretching in males with latent myofascial trigger points. Physical Therapy in Sport, 11(3), 91-98. doi:10.1016/j.ptsp.2010.02.003 Travell, J. G., & Simons, D. G. (1983). Myofascial pain and dysfunction: The trigger point manual (Vol. 1). Baltimore, MD: Williams & Wilkins. Turo, D., Otto, P., Shah, J. P., Heimur, J., Gebreab, T., Zaazhoa, M., . . . Sikdar, S. (2013). Ultrasonic characterization of the upper trapezius muscle in patients with chronic neck pain. Ultrasonic Imaging, 35(2), 173-187. doi:10.1177/0161734612472408 Ward, S. R., Winters, T. M., & Blemker, S. S. (2010). The architectural design of the gluteal muscle group: Implications for movement and rehabilitation. Journal of Orthopaedic and Sports Physical Therapy, 40(2), 95-102. doi:10.2519/jospt.2010.3302 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH Willson, J. D., Kernozek, T. W., Arndt, R. L., Reznichek, D. A., & Straker, J. (2011). Gluteal muscle activation during running in females with and without patellofemoral pain syndrome. Clinical Biomechanics, 26(7), 735-740. doi:10.1016/j.clinbiomech.2011.02.012 64 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 65 Table 1 Reliability of HHD and sEMG Measurements Within Trials Pre 10 Minute Break Post 10 Minute Break ICC (95% CI) ICC (95% CI) SL0 on R .96 (.89 - .99) .96 (.89 - .99) SLIR on R .92 (.79 - .98) .98 (.95 - .99) SL0 on L .94 (.84 - .98) .95 (.85 - .99) SLIR on L .95 (.87 - .99) .95 (.87 - .99) SL0 on R .83 (.60 - .95) .94 (.83 - .98) SLIR on R .92 (.78 - .98) .93 (.80 - .98) SL0 on L .96 (.88 - .99) .91 (.76 - .97) SLIR on L .93 (.81 - .98) .81 (.55 - .94) HHD Measurements sEMG Measurements Note: An ICC of > .75 was considered acceptable ICC = interclass correlation coefficient (ICC); HHD = hand held dynamometer; sEMG = Surface electromyography; SL0 = side lying neutral position; SLIR = side lying internal rotation position; R = right; L = left TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 66 Table 2. Test Retest Reliability of HHD and sEMG Measurements Prior to and Following 10 Minute Break HHD Measurements sEMG Measurements ICC (95% CI) ICC (95% CI) SL0 on R Pre to Post .91 (.80 - .97) .85 (.69 - .95) SLIR on R Pre to Post .91 (.80 - .97) .92 (.82 - .98) SL0 on L Pre to Post .94 (.87 - .98) .90 (.80 - .97) SLIR on L Pre to Post .93 (.85 - .98) .87 (.74 - .96) Note: An ICC of > .75 was considered acceptable ICC = interclass correlation coefficient (ICC); HHD = hand held dynamometer; sEMG = Surface electromyography; SL0 = side lying neutral position; SLIR = side lying internal rotation position; R = right; L = left TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 67 Table 3. Descriptive Statistics for Demographic Information of Sample (N = 39) M (SD) Minimum Maximum Age (years) 28.72 (5.47) 19.00 41.00 Height (inches) 67.18 (3.76) 58.00 74.00 167.67 (27.89) 107.00 232.00 7.00 (5.00)a 0.00 40.00 Intervention Side 4.00 (1.00)a 3.00 8.00 Control Side 4.97 (1.65) 2.00 9.00 Number of Needles Used 7.00 (2.00)a 5.00 10.00 Level of Soreness Post TDNb 3.00 (2.00)a 0.00 8.00 N % Male 16 41.03% Female 23 58.97% Right 33 84.62% Left 6 15.38% Weight (lbs) Hours of Weekly Activity Number of Trigger Points Gender Side of Lower Extremity Dominance TDN = trigger point dry needling a Data was not normally distributed. Results are reported as median and interquartile range b Soreness was measured on a scale of 0 to 10 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH Table 4. Descriptives for HHD Measurements Before (Pre) and After the Intervention (Post) (N = 39) SL0 Position (n = 39) SLIR position (n = 39) M (SD) M (SD) Pre-TDN 18.86 (4.20) 17.92 (4.56) Post-TDN 21.39 (4.77) 21.49 (4.71) Pre-TDN 20.56 (5.27) 18.49 (4.47) Post-TDN 19.25 (4.77) 18.77 (4.58) Interventiona Control Note: HHD measurements reported in kilograms HHD = hand held dynamometer; TDN = trigger point dry needling ; SLO = side lying neutral position; SLIR = side lying internal rotation position a Denotes the side that received trigger point dry needling 68 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 69 Table 5. Descriptives for sEMG Amplitudes Before (Pre) and After the Intervention (Post) (N = 39) SL0 Position SLIR position Mdn (IQR) % MVIC Mdn (IQR) % MVIC Pre .23 (.19) 100% .22 (.19) 100% Post .18 (.15) 78.17% .20 (.13) 90.32% Pre .24 (.14) 100% .20 (.15) 100% Post .23 (.12) 95.89% .21 (.14) 107.07% Interventiona Control Note: sEMG amplitudes reported in millivolts. sEMG = surface electromyography; TDN = trigger point dry needling; MVIC = maximal volitional isometric contraction; IQR = interquartile range; SLO = side lying neutral position; SLIR = side lying internal rotation position a Denotes the side that received TDN TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH HHD Force Measurements in kg 22 21 20 19 18 17 Pre-TDN Intervention side Post-TDN Control side Figure 1. Comparisons of HHD Measurements in the SL0 Position 70 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH HHD Force Measurements in kg 22 21 20 19 18 17 Pre-TDN Intervention side Post-TDN Control side Figure 2. Comparisons of HHD Measurements in the SLIR Position 71 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 105 100 % MVIC 95 90 85 80 75 Pre-TDN Intervention side Post-TDN Control side Figure 3. Comparison of sEMG Measurements in the SL0 Position 72 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 110 105 % MVIC 100 95 90 85 80 75 Pre-TDN Intervention side Post-TDN Control side Figure 4. Comparison of sEMG Measurements in the SLIR Position 73 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 74 Appendix A Recruitment Email Research Study: Volunteers Wanted for a Doctoral Project University of Indianapolis Doctor of Health Science Program Study Title: The Effects of Deep Trigger Point Dry Needling on Muscle Strength of the Gluteus Medius Musculature Study Purpose: The purpose of the research study is to investigate the effects that deep trigger point dry needling has on the strength of musculature located in the hip. What is trigger point dry needling? Trigger point dry needling utilizes a small, solid needle to penetrate and potentially eliminate trigger points within muscle tissue. Eligibility Criteria: You may qualify for participation in the study if you are between the ages of 18 and 50 years, are not currently pregnant, and are not experiencing pain in your low back, pelvis, or hip region at this present time. Participant Time Commitment: Your participation will be one day and will last 1-1.5 hours. What is required of participants? You will be screened for inclusion within the study. If you meet inclusion criteria, strength measurements of the gluteus medius musculature will be taken prior and following the application of trigger point dry needling. Where is the study being held? The study will take place in laboratory rooms of the Doctor of Physical Therapy Program at Mount St Joseph University Primary Investigator Dr. Emily Slaven, PT, PhD, MS, OCS Associate Professor Krannert School of Physical Therapy University of Indianapolis 317-788-3305 slavene@uindy.edu Student Investigator Eric Schneider, PT, MPT, OCS, CMTPT Assistant Professor Department of Physical Therapy Mount St Joseph University 513-244-4826 eric.schneider@msj.edu **Please contact Eric Schneider @ eric.schneider@msj.edu or 513-244-4826 if you are interested in participating in the study or if you have questions. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 75 Appendix B Recruitment Flyer Research Study: Volunteers Wanted for a Doctoral Project University of Indianapolis Doctor of Health Science Program Study Title: The Effects of Deep Trigger Point Dry Needling on Muscle Strength of the Gluteus Medius Musculature Study Purpose: The purpose of the research study is to investigate the effects that deep trigger point dry needling has on the strength of musculature located in the hip. What is trigger point dry needling? Trigger point dry needling utilizes a small, solid needle to penetrate and potentially eliminate trigger points within muscle tissue. Eligibility Criteria: You may qualify for participation in the study if you are between the ages of 18 and 50 years, are not currently pregnant, and are not experiencing pain in your low back, pelvis, or hip region at this present time. Participant Time Commitment: Your participation will be one day and will last 1-1.5 hours. What is required of participants? You will be screened for inclusion within the study. If you meet inclusion criteria, strength measurements of the gluteus medius musculature will be taken prior and following the application of trigger point dry needling. Where is the study being held? The study will take place in laboratory rooms of the Doctor of Physical Therapy Program at Mount St Joseph University Primary Investigator Dr. Emily Slaven, PT, PhD, MS, OCS Associate Professor Krannert School of Physical Therapy University of Indianapolis 317-788-3305 slavene@uindy.edu Student Investigator Eric Schneider, PT, MPT, OCS, CMTPT Assistant Professor Department of Physical Therapy Mount St Joseph University 513-244-4826 eric.schneider@msj.edu **Please contact Eric Schneider @ eric.schneider@msj.edu or 513-244-4826 if you are interested in participating in the study or if you have questions. TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 76 Appendix C Participant Intake Questionnaire Date of Data Collection: _________________ Study Identification Number: __________________________________ Participant Age: _________________ Participant Gender: Male Female Participant Height: _______________ Participant Weight: _______________ Participant Side Dominance: Right Left Number of Hours of Physical Activity or Exercise in an Average Week: _____________ TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH Appendix D Data Collection Form Study Identification Number: _________________________________________ Pre TDN Strength Measurements Intervention Side: Right HHD Left sEMG SL0 Trial 1 _________________ kg __________________ mV Trial 2 _________________ kg __________________ mV Trial 3 _________________ kg __________________ mV Average: _________________ kg __________________ mV Trial 1 _________________ kg __________________ mV Trial 2 _________________ kg __________________ mV Trial 3 _________________ kg __________________ mV Average: _________________ kg __________________ mV SLIR Pre TDN Strength Measurements Control Side: HHD Right Left sEMG SL0 Trial 1 _________________ kg __________________ mV Trial 2 _________________ kg __________________ mV Trial 3 _________________ kg __________________ mV Average: _________________ kg __________________ mV Trial 1 _________________ kg __________________ mV Trial 2 _________________ kg __________________ mV Trial 3 _________________ kg __________________ mV Average: _________________ kg __________________ mV SLIR 77 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH Post TDN Strength Measurements Intervention Side: Right HHD 78 Left sEMG SL0 Trial 1 _________________ kg __________________ mV Trial 2 _________________ kg __________________ mV Trial 3 _________________ kg __________________ mV Average: _________________ kg __________________ mV Trial 1 _________________ kg __________________ mV Trial 2 _________________ kg __________________ mV Trial 3 _________________ kg __________________ mV Average: _________________ kg __________________ mV SLIR Post TDN Strength Measurements Control Side: Right HHD Left sEMG SL0 Trial 1 _________________ kg __________________ mV Trial 2 _________________ kg __________________ mV Trial 3 _________________ kg __________________ mV Average: _________________ kg __________________ mV Trial 1 _________________ kg __________________ mV Trial 2 _________________ kg __________________ mV Trial 3 _________________ kg __________________ mV Average: _________________ kg __________________ mV SLIR Amount of Latent Trigger Points Identified: Control Side ________ Intervention Side ________ Number of Needles Used During Application of TDN: _________________________________ Was a LTR elicited during the application of TDN? Yes No TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH Level of Soreness Following the Application of TDN: _______/10 79 TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 80 Appendix E Past Medical History Form Are you currently experience pain: Yes No Please indicate below where your symptoms are located: KEY Numbness ====== Pins & Needles ******* Burning Pain BBBBBBB Stabbing Pain /////// Shooting Pain XXXXXXX Achy Pain AAAAAA If yes, please answer the following questions (Circle the best possible answer): Is your pain? Occasional Continuous Constant Intermittent Unrelenting Symptom trend: Condition improving Condition worsening Condition unchanging When is your pain the worst? Morning Afternoon Evening Nighttime When is your pain the best? Morning Afternoon Evening Nighttime Circle the number that rates your pain right now: None 1 2 3 4 5 6 7 8 9 10 Go to the hospital Circle the number that rates your pain at worst: None 1 2 3 4 5 6 7 8 9 10 Go to the hospital Circle the number that rates your pain at best: None 1 2 3 4 5 6 7 8 9 10 Go to the hospital TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 81 Have you ever had or been diagnosed with the following: Arthritis Back/Neck Pain Bleeding Tendency Ehlers Danlos Syndrome Fibromyalgia Guillian Barre Syndrome Hip Dysplasia Hypermobility Syndrome Labral Tear of the Hip Legg Calve Perthes Low Back Pain Multiple Sclerosis Myofascial Pain Syndrome Transverse Myelitis Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N If you answered yes to any of the items above, please briefly explain and give the date of your diagnosis: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you ever had surgery on your hip: Yes No If you answered yes, please describe the surgery below and provide the date of the surgery: ______________________________________________________________________________ ______________________________________________________________________________ PLEASE DO NOT FILL OUT INFORMATION BELOW THIS LINE FADIR Test: Right: Positive Left: Positive Negative Negative Hip ROM Hip Internal Rotation Right: ___________ Left: ___________ Hip Flexion Right: ___________ Left: ___________ Painful: Painful: Yes Yes No No Painful: Painful: Yes Yes No No TRIGGER POINT DRY NEEDLING AND GLUTEUS MEDIUS STRENGTH 82  ...

... AN ANALYSIS OF THE RELATIONSHIP BETWEEN PERFECTIONISM, STRESS PERCEPTION, AND STRESS MANAGEMENT AMONG DOCTOR OF PHYSICAL THERAPY STUDENTS Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Mike Richardson, PT, DPT Copyright December 11, 2019 By: Mike Richardson, PT, DPT All rights reserved Approved by: Laura Santurri, PhD, MPH, CPH Committee Chair Haylie Miller, PhD Committee Member Evan Papa, PT, DPT, PhD Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT An Analysis of the Relationship Between Perfectionism, Stress Perception, and Stress Management among Doctor of Physical Therapy Students Mike Richardson University of Indianapolis 1 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 2 Abstract Perfectionism consists of high standards and hyper-critical self-evaluation. Doctor of Physical Therapy (DPT) students are required to meet highly competitive admissions processes and rigorous academic expectations. Unsurprisingly, DPT students experience increased stress levels during their academic tenure. There is a limited understanding of how successful these students are at managing the increased stress, especially among perfectionists. In this non-experimental, cross-sectional study, participants completed perfectionism, stress perception, and stress management validated measures. Results demonstrated that this sample was composed of 41.10% Adaptive Perfectionists and 25.15% Maladaptive Perfectionists. There was a moderate, direct association of perceived stress and the perfectionism discrepancy measure (rs = .51, p < .01). The perceived stress and perfectionism subtype logistic regression model was statisticallysignificant, 2(1) = 18.73, p < .01. Additionally, there was a weak, indirect association between stress management and the perfectionism discrepancy measure (rs = -.38, p < .01). The stress management and perfectionism subtype logistic regression model was statistically-significant, 2(1) = 14.40, p < .01. DPT students who are Maladaptive Perfectionists may be at greater risk for stress-related concerns. Baseline measures of perfectionism, stress perception, and stress management may inform curricular decisions regarding placement and sequencing of stress management interventions. Additionally, these measures may assist educators with identifying at-risk students and monitoring student response to stress management interventions. DPT students who are able to effectively manage stress may ultimately have greater well-being and lower rates of burnout. Keywords: perfectionism, perceived stress, stress management, physical therapy student PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 3 Acknowledgements Completing this Doctor of Health Science (DHSc) program was not a solo endeavor. It definitely takes a team, and I owe much thanks to many people who supported me prior to, as well as during the pursuit of this terminal degree. I must start at the beginning and thank my parents Retta and Bill Richardson. They taught me so many invaluable lessons throughout my life. As elementary-school teachers, they taught me the importance of life-long learning and inspired me to become an educator. As good humans, they inspired me to protect those who need protecting. Also, I thank my sister Kristie Bernier. She has always shown me loving-kindness. I thank and immensely appreciate my girlfriend, Dr. Danielle Clement. She supported and encouraged me when I transitioned from clinician to educator as well as during obtaining my transitional DPT degree and now my DHSc. I owe a huge debt of gratitude to my wonderful committee, Drs. Laura Santurri, Haylie Miller, and Evan Papa. They gave me the gift of their expertise, knowledge, and time. Their guidance, editing, and patience made this final product what it is. I thank the Interprofessional Health and Aging Studies faculty at the University of Indianapolis. I could not imagine a better DHSc experience. This is a wonderful program, and I felt valued as a student and human throughout my degree pursuit. I am amazed and inspired by their willingness to solicit and listen to student feedback. My teaching has improved due to the content they taught me as well as observing their course design and course management strategies. I am appreciative of my mentor, Dr. Nicoleta Bugnariu. She has always supported me, challenged me, and advocated on my behalf. Finally, I thank my wonderful, dear friends who frequently checked on my progress and kept encouraging me, especially in these final stretches. My sincerest thanks to you all! PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 4 Table of Contents Abstract................................................................................................................................ 2 Acknowledgements ............................................................................................................. 3 Chapter 1: Introduction...................................................................................................... 10 Problem Statement......................................................................................................... 12 Purpose of the Study ...................................................................................................... 12 Research Questions ....................................................................................................... 12 Significance of the Study............................................................................................... 13 Definition of Terms ....................................................................................................... 14 Chapter 2: Literature Review ............................................................................................ 15 Physical Therapy Education .......................................................................................... 19 Perfectionism ................................................................................................................. 20 Frameworks ............................................................................................................... 21 Adaptive and Maladaptive Perfectionism ............................................................. 22 Self-Oriented, Other-Oriented, and Socially-Prescribed Perfectionism ................ 23 Perfectionistic Strivings and Concerns .................................................................. 23 Framework summary ............................................................................................. 24 Outcome measures..................................................................................................... 25 Multidimensional perfectionism approaches ......................................................... 26 Bidimensional perfectionism approaches .............................................................. 28 Outcome measure summary .................................................................................. 29 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 5 Theories and models ................................................................................................ 30 Perfectionism Acceptance Theory ......................................................................... 30 Perfectionism Diathesis-Stress Model ................................................................... 30 Perfectionism and higher education .......................................................................... 31 Perfectionism and health professions higher education ............................................ 34 Stress.............................................................................................................................. 35 Perceived stress ......................................................................................................... 35 Perceived stress and higher education ................................................................... 36 Perceived stress and health professions higher education ..................................... 38 Perceived stress and medical students ................................................................... 39 Perceived stress and nursing students.................................................................... 41 Perceived stress and dental students ...................................................................... 42 Perceived stress and physical therapy students ..................................................... 44 Perceived stress summary...................................................................................... 46 Stress management .................................................................................................... 47 Stress management and higher education.............................................................. 48 Stress management and health professions higher education................................ 49 Stress management and medical students.............................................................. 50 Stress management and nursing students .............................................................. 52 Stress management and dental students ................................................................ 53 Stress management and physical therapy students ................................................ 54 Stress management summary ................................................................................ 55 Summary........................................................................................................................ 56 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 6 Chapter 3: Method ........................................................................................................... 58 Study Design ................................................................................................................. 58 Participants .................................................................................................................... 59 Data................................................................................................................................ 59 Operationalization of variables.................................................................................. 59 Instruments .................................................................................................................... 60 Almost Perfect Scale-Revised ................................................................................... 61 Emotional Quotient Inventory 2.0 ............................................................................. 62 Perceived Stress Scale ............................................................................................... 64 Procedures ..................................................................................................................... 64 Recruitment ............................................................................................................... 65 Informed consent ....................................................................................................... 65 Testing procedures..................................................................................................... 65 Data Management .......................................................................................................... 66 Data Analysis................................................................................................................. 67 Chapter 4: Results.............................................................................................................. 72 General Participant Characteristics ............................................................................... 73 Gender description..................................................................................................... 73 Race/Ethnicity/Origin description ............................................................................. 74 Participant Outcome Measures ...................................................................................... 75 Perfectionist type ....................................................................................................... 75 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 7 Almost Perfect Scale Revised High Standards ........................................................ 75 Almost Perfect Scale Revised Discrepancy .............................................................. 76 Perceived Stress Scale ............................................................................................... 77 Emotional Quotient Inventory-Stress Management composite score ....................... 77 Effects of Student Characteristic on Perfectionism ....................................................... 78 Almost Perfect Scale Revised High Standards subscale score .................................. 78 Almost Perfect Scale Revised Discrepancy subscale score....................................... 80 Association in Perfectionism with Perceived Stress ..................................................... 81 Association in Perfectionism with Stress Management ................................................ 82 Results for Binomial Logistic Regression Analysis ...................................................... 83 Ability of student characteristic to predict perfectionism subtype ............................ 83 Ability of perceived stress score to predict perfectionism subtype ........................... 84 Ability of stress management composite score to predict perfectionism subtype..... 84 Chapter 5: Discussion and Conclusion .............................................................................. 85 Perfectionism ................................................................................................................. 86 Perfectionism and student characteristics .................................................................. 87 Perceived Stress ............................................................................................................. 88 Perceived stress and program year ............................................................................ 88 Perceived stress and perfectionism ............................................................................ 90 Stress Management ........................................................................................................ 90 Stress management and perfectionism ...................................................................... 91 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 8 Limitations ................................................................................................................... 91 Implications for DPT Education and Future Research .................................................. 92 Conclusion ..................................................................................................................... 94 References ......................................................................................................................... 95 Appendices ...................................................................................................................... 138 Appendix A: Conceptualization of Perfectionist Type Using the Almost Perfect ScaleRevised Subscales ....................................................................................................... 138 Appendix B: Permission of Use for Almost Perfect Scale-Revised (APSR) .............. 139 Appendix C: Permission of Use for Perceived Stress Scale (PSS-10) ........................ 140 Appendix D: Online Survey Consent Form ................................................................ 141 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 9 List of Tables Table 1: Perfectionism Frameworks, Dimensions, Terms, Types, and Tools ............................. 127 Table 2: Demographics by Gender and Year in Program ........................................................... 128 Table 3: Demographics by Race, Ethnicity, and Origin and Year in Program ........................... 129 Table 4: Perfectionism Classification by Year in Program ......................................................... 130 Table 5: Almost Perfect Scale-Revised Outcome Measure by Year in Program and Gender .... 131 Table 6: Perceived Stress Outcome Measure by Year in Program and Gender .......................... 133 Table 7: Emotional Quotient Intelligence 2.0 Stress Management Composite by Year in Program and Gender................................................................................................................................... 134 Table 8: Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Student Characteristic .................................................................................................................. 135 Table 9: Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Perceived Stress ........................................................................................................................... 136 Table 10: Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Emotional Quotient Inventory 2.0 - Stress Management Composite .......................................... 137 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 10 Analysis of the Relationship Between Perfectionism, Stress Perception, and Stress Management among Doctor of Physical Therapy Students Chapter 1: Introduction Graduate students matriculating in health professions programs experience elevated stress levels due to increased academic workload and performance expectations (Alzayyat & AlGamal, 2014; Dyrbye et al., 2006; Elani et al., 2014; Gibbons, Dempster, & Moutray, 2011; Hodselmans et al., 2018; Ruiz-Aranda, Extremera, & Pineda-Galn, 2014). There is a limited understanding of how successful these students are at coping with the increased stress burdens in general, and in particular, for those students who are Perfectionists. This is concerning since ineffective stress management may exacerbate depressive symptoms (Pauley & Hesse, 2009) and poor health behaviors, including problematic alcohol consumption and insufficient sleep (Amaral et al., 2018; Park & Iacocca, 2014). These symptoms and behaviors may ultimately adversely impact academic performance (Palmer et al., 2013; van der Heijden et al., 2018). Therefore, it is important to study the relationship between perfectionism and stress among Doctor of Physical Therapy (DPT) students. Perfectionism can be defined as a multifaceted personality characteristic comprised of extremely high internal expectations coupled with hyper-critical self-evaluations (Flett & Hewitt, 2002; Frost, Marten, Lahart, & Rosenblate, 1990; Stoeber, 2017c; Stoeber & Otto, 2006). Some groups have sub-divided perfectionism into Self-Oriented, Other-Oriented, and SociallyPrescribed Perfectionism (Hewitt & Flett, 1991; Stoeber & Childs, 2010). Others have viewed it in terms of being Adaptive or Maladaptive (M. Enns, Cox, Sareen, & Freeman, 2001; Rice & Slaney, 2002; Verner-Filion & Vallerand, 2016; Wagner & Causey-Upton, 2017). However, perfectionism also can be thought of bidimensionally as perfectionistic strivings and perfectionistic concerns (Stoeber & Gaudreau, 2017; Stoeber & Otto, 2006). Depending on the PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 11 interplay of these two dimensions, perfectionism may result in beneficial, benign, or unhealthy outcomes (Stoeber & Otto, 2006). As previously mentioned, stress can negatively impact academic performance. Clarifying the relationship between stress and perfectionism may allow educators to craft curricula in a way that allows for better stress management, and in turn, improve student outcomes. The goal of this research was to analyze the adaptive and maladaptive factors of perfectionism that correlate with stress management. Investigating this connection is important because of the deleterious impact of stress on academic performance (Palmer et al., 2013; van der Heijden et al., 2018) and overall health (Dimsdale, 2008; Nabi et al., 2013; Schneiderman, Ironson, & Siegel, 2008). Over 20 years ago, Hewitt and Flett (1993) found that the combination of perfectionism and stress was predictive of depression. In a recent longitudinal study, Bks and colleagues (2015) assessed the moderating effect of perfectionism on the relationship between stress and depression. Among undergraduate students, Maladaptive Perfectionists reported higher stress indicators (Ashby, Noble, & Gnilka, 2012) and a stronger association between perceived stress and drinking as a coping mechanism (Rice & Van Arsdale, 2010) compared to Adaptive Perfectionists. Ashby and Gnilka (2017) again examined stress management strategies and found that different types of strategies could mediate the perceived stress in both Adaptive and Maladaptive Perfectionists. Stress is one of the most common reasons to access counseling services by undergraduate students (Center for Collegiate Mental Health, 2017). Researchers reported higher rates of stress among health care professional students (Dutta, Pyles, & Meiderhoff, 2005), including medical students (Mosley et al., 1994), dental students (Alzahem, Van Der Molen, Alaujan, Schmidt, & Zamakhshary, 2011; Elani et al., 2014), nursing students (Alzayyat & Al-Gamal, 2014), graduate psychology students (El-Ghoroury, Galper, Sawaqdeh, & Bufka, 2012), occupational therapy students (Pfeifer, Kranz, & Scoggin, 2008), and physical therapy students (Frank & Cassady, PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 12 2005; Frazer & Echternach, 1991; Hodselmans et al., 2018; Jacob et al., 2012; OMeara, Kostas, Markland, & Previty, 1994). This is concerning because stress potentially has been associated with poorer coping mechanisms such as unhealthy eating, smoking, and drinking (Park & Iacocca, 2014). Additionally, perceived stress was associated with stress management strategies. Among health professions students, perceived stress was directly associated with maladaptive strategies and indirectly with adaptive strategies (A. Enns, Eldridge, Montgomery, & Gonzalez, 2018; Ruiz-Aranda, Extremera, & Pineda-Galn, 2014). When considered in its entirety, health professions students are particularly at risk for the negative impact of stress, which may increase their vulnerability to poorer academic performance and decreased overall health. Problem Statement Researchers have explored perfectionism in a variety of other health professions higher education programs (Comerchero & Fortugno, 2013; M. Enns et al., 2001; Henning, Ey, & Shaw, 1998; Wagner & Causey-Upton, 2017). This topic has yet to be explored among physical therapy students. Given the hyper-competitive admissions process and the rigor of DPT curriculum, it is anticipated that similar rates of perfectionism will be found among these students. Purpose of the Study The purpose of this study was to examine perfectionism among entry-level DPT students and assess its relationship to perceived stress and stress management. Research Questions The research questions addressed in this study were: 1. Was there a statistically significant difference in perfectionism level as measured on the subscale of High Standards score from the Almost Perfect Scale Revised PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 13 (APSR) by student characteristic (year in program, gender description, and race/ethnicity/origin description) among DPT students at a public university in Texas? a. Was student characteristic predictive of perfectionism subtype (Adaptive or Maladaptive) among DPT students at a public university in Texas? 2. Were there statistically significant associations between perfectionism level as measured on the subscale of High Standards score from the APSR and perceived stress as measured by the 10 question, Perceived Stress Scale (PSS-10) among students enrolled in a DPT program at a public university in Texas? a. Was perceived stress predictive of perfectionism subtype among DPT students at a public university in Texas? 3. Were there statistically significant associations between perfectionism level as measured on the subscale of High Standards score from the APSR and stress management as measured by the Stress Management Composite score from the Emotional Quotient Inventory 2.0 (EQi) among students enrolled in a DPT program at a public university in Texas? a. Was stress management predictive of perfectionism subtype among DPT students at a public university in Texas? Significance of the Study A better understanding of perfectionism and its association with stress perception and management in this population may assist educators with identifying at-risk students more efficiently. This may also improve stress management through innovative curricular design (e.g., mindfulness, self-care and resiliency techniques; Kreitzer & Klatt, 2017). This may produce improved academic performance since perceived stress negatively impacts academic PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 14 performance (Palmer et al., 2013; van der Heijden et al., 2018). Furthermore, a better understanding may help minimize maladaptive coping strategies since perceived stress is directly associated with problematic alcohol consumption in Maladaptive Perfectionists (Rice & Van Arsdale, 2010). Additionally, this may directly address the burnout issues among health care providers by increasing the resiliency of new graduates in managing stress (Bodenheimer & Sinsky, 2014; Bowles, Adams, Batcheller, Zimmermann, & Pappas, 2018; Morrow, Call, Marcus, & Locke, 2018). Definition of Terms The key terms used throughout this proposal were defined as follows: Perfectionism: Multifaceted personality characteristic that includes striving for flawlessness with an emphasis on excessively high standards as well as an element of hypercritical self-assessment (Flett & Hewitt, 2002; Stoeber, 2017c; Stoeber & Otto, 2006); Adaptive Perfectionism: A healthy and high functioning response to very high standards. Determined by scoring high on the APSR High Standards subscale (APSR-HS), but low on the APSR Discrepancy subscale (APSR-D; Rice & Ashby, 2007; Rice & Richardson, 2014). Appendix A conceptually describes this process; Maladaptive Perfectionism: Excessive, unhealthy response to self-imposed, excessively high standards. Determined by scoring high on the APSR-HS as well as the APSR-D (Rice & Ashby, 2007; Rice & Richardson, 2014). Appendix A conceptually describes this process; Stress perception: The relationship between appraised demands of a situation and the belief in ones capacity to cope with those demands. When the appraised PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 15 demands are viewed as being greater than capacity, then the situation may be viewed as a threat (Butler, 1993; Lazarus & Folkman, 1984; Phillips, 2013); Stress management: Strategies and other interventions aimed to enhance ones coping ability in order to decrease levels of distress (Esch & Stefano, 2010). Chapter 2: Literature Review Perfectionism can be defined as extremely high internal expectations coupled with hypercritical self-evaluations (Frost et al., 1990) or striving for flawlessness with unreasonably high standards (Flett & Hewitt, 2002; Stoeber & Otto, 2006). Many researchers consider perfectionism as comprised of different personality traits (Frost et al., 1990; Hewitt & Flett, 1991; Slaney, Rice, Mobley, Trippi, & Ashby, 2001; Stairs, G. Smith, Zapolski, Combs, & Settles, 2012). However, if traits are consistent patterns in behavior and thoughts are stable longitudinally and cross-situationally (Allport, 1966), and most Perfectionists are only Perfectionists in some, but not all domains, (Stoeber & Stoeber, 2009), then perfectionism may be better described as a personality disposition instead of a personality trait (Stoeber, 2017b). Currently, perfectionism is often articulated as multifaceted and multidimensional. However, there is not 100% consensus as to the most appropriate way to define and assess the different constructs of perfectionism. Although most researchers agree on the vast majority of perfectionism constructs, vigorous disagreement continues on a select few (Stoeber, 2017a). Lack of consistency in the use and definition of terminology presents an ongoing challenge in perfectionism research. Hewitt and Flett (1991) approached perfectionism multidimensionally, proposing three dimensions: Self-Oriented Perfectionism, Other-Oriented Perfectionism, and Socially-Prescribed Perfectionism. Frost et al. (1990) also viewed perfectionism multidimensionally, but as six dimensions, including High Personal Standards, Concerns Over Mistakes, Parental Expectations, PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 16 Parental Criticism, Doubts About Actions, and Organization. Conceptually, there is considerable overlap among these two most prominent perfectionism models (Frost, Heimberg, Holt, Mattia, & Neubauer, 1993). For example, High Personal Standards as characterized by Frosts model relates closely to the Self-Oriented Perfectionist dimension of Hewitt and Fletts model (Frost et al., 1993), and the Concerns Over Mistakes, Parental Expectations and Criticism dimensions of Frosts model are closely associated with Hewitt and Fletts Socially-Prescribed Perfectionist dimension (Frost et al., 1993). Slaney et al. (2001) developed a similar multidimensional model consisting of three constructs: High Standards, Order, and Discrepancy. This model overlaps conceptually with the models proposed by Frost et al. (1990) and Hewitt and Flett (1991). For example, Slaney et al.s (2001) Discrepancy dimension significantly associated with Hewitt and Fletts (1991) SociallyPrescribed Perfectionism, and with Frost et al.s (1990) Concerns Over Mistakes and Doubts About Actions. Additionally, Slaneys (2001) High Standards dimension strongly associated with Hewitt and Fletts (1991) Self-Oriented Perfectionism and Frost et al.s (1990) Personal Standards (Rice, Ashby, & Slaney, 2007). However, unlike previous models of perfectionism, Slaney and colleagues presented perfectionism as consisting of Adaptive or Maladaptive subtypes (Flett & Hewitt, 2015). In this model, an Adaptive Perfectionist has high standards but is able to tolerate mistakes; a Maladaptive Perfectionist has high standards accompanied by high levels of self-doubt, and in turn, low tolerance for mistakes (Rice, Ashby, & Slaney, 1998). Three years after positing a multidimensional approach to perfectionism consisting of six dimensions, Frost et al., (1993) narrowed their approach to a bidimensional view of perfectionism consisting of Positive Achievement Strivings (also called Perfectionist Strivings) and Maladaptive Evaluative Concerns (also called Perfectionistic Concerns). The Positive Achievement Strivings construct in this new model included the original dimensions of Personal PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 17 Standards and Organization, and the Maladaptive Evaluative Concerns included the original dimensions of Concerns Over Mistakes, Doubts About Actions, Parental Expectations and Parental Concerns (Frost et al., 1993). Cox, Enns, and Clara (2002) found evidence that supported this bidimensional model. Subsequent research from the Frost team continued to measure most, if not all of the original dimensions, but reported results in the framework of their revised bidimensional model (DiBartolo, Li, & Frost, 2008; Kawamura & Frost, 2004; Kawamura, Hunt, Frost, & DiBartolo, 2001). More recently, Stoeber and Otto (2006) also championed a bidimensional model similar to Frost et al. (1993). In this model, Perfectionistic Strivings would be analogous to High Personal Standards (Frost et al., 1990), Self-Oriented Perfectionist (Hewitt & Flett, 1991), Positive Achievement Strivings (Frost et al., 1993), and High Standards (Slaney et al., 2001). Perfectionism Concerns would be analogous to Concerns Over Mistakes (Frost et al., 1990), Socially-Prescribed Perfectionist (Hewitt & Flett, 1991), Maladaptive Evaluative Concerns (Frost et al., 1993), and Discrepancy (Slaney et al., 2001). Stoeber and Otto (2006) preferred this approach to studying perfectionism because the Perfectionistic Concerns dimension could potentially differentiate between the Adaptive and Maladaptive Perfectionism subtypes. Despite a historical narrowing of theoretical models of perfectionism from multidimensional to bidimensional, there has been a recent resurgence in attempts to measure perfectionism in a complex, multidimensional way. Stairs et al. (2012) revisited and analyzed 15 perfectionism models, including the three previously mentioned models. They identified nine perfectionistic trait dimensions from the 15 models and then performed exploratory as well as confirmatory factor analyses. The resulting model consisted of nine dimensional constructs: High Standards, Order, Perfectionism Toward Others, Reactivity Towards Mistakes, Perceived Pressure From Others, Dissatisfaction, Details and Checking, Satisfaction, and Black and White PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 18 Thinking (Stairs et al., 2012). However, a search in ERIC, MEDLINE, PsychINFO, SPORTDiscus, and Web of Science produced only three published studies measuring perfectionism in this way (Forney, Schwendler, & Ward, 2019; Kim et al., 2016; Lapoint & Soysa, 2014). Therefore, it does not appear that other researchers have widely embraced this broadened, multidimensional concept. Although there is overlap among the various theoretical approaches to perfectionism, both multidimensional and bidimensional, there is a striking lack of consensus on how best to define terms related to perfectionism. This inconsistency leads to difficulty evaluating the relative strengths and challenges of each model since they seem to measure different dimensions of perfectionism on face value, but inherently overlap in their underlying constructs. In summary, the conceptualization and assessment of perfectionism continues to evolve. As previously mentioned, most perfectionists are not perfectionists across all contexts (Stoeber & Stoeber, 2009). For example, collegiate student-athletes indicated significantly different levels of perfectionism when asked to consider the contexts of athletics and academics (Dunn, Gotwals, & Dunn, 2005). Given the apparent context-dependent nature of perfectionism, some theoretical models may be problematic if their underlying constructs are conflated with contexts. An interesting, emerging trend in perfectionism research is the use of context-specific approaches, for example, those that assess perfectionism in romantic relationships (Matte & Lafontaine, 2012) or athletics (Gotwals & Dunn, 2009). A multidimensional model consisting of nine constructs relating to perfectionism (Stairs et al., 2012) may be too broad to capture the potential context-dependent nature of perfectionism (Stoeber & Stoeber, 2009) in a health professions (e.g., medicine, nursing, dentistry, physical therapy) program setting. However, current, context-based approaches (Flett & Hewitt, 2015) may be too specific to capture perfectionism in a health professions program setting. Therefore, a PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 19 bidimensional model that accounts for interaction between the two dimensions may be the most appropriate (Gaudreau & Thompson, 2010; Rice & Ashby, 2007; Stoeber & Otto, 2006). Slaney et al.s (2001) bidimensional model, for example, accounts for interaction between the High Standards and Discrepancy dimensions in order to consider an Adaptive and Maladaptive type of Perfectionist (Rice & Ashby, 2007). Appendix A conceptually describes this process. This well-known model has been validated and extensively used in studies of undergraduate students, specifically psychology students. Furthermore, researchers have explored perfectionism in a variety of other health professions programs (Comerchero & Fortugno, 2013; M. Enns et al., 2001; Henning et al., 1998; Wagner & Causey-Upton, 2017). However, there is a paucity of research involving the specific context of assessing Adaptive and Maladaptive Perfectionism types (Rice & Ashby, 2007) among health professions students specific to physical therapy education. Because of the hyper-competitive admissions process and the rigor of DPT programs, it is anticipated that similar rates of perfectionism will be found among these students. Physical Therapy Education In response to a growing professional responsibility for patient management, physical therapy education has evolved into the DPT degree (Plack & Wong, 2002). This increasing responsibility of the physical therapist is associated with increased rigor post-graduation as well as the increased competitiveness of the admission process into DPT schools. For admission cycle 2017-2018, over 18,000 students submitted more than 112,000 applications for 10,400 possible seats (Physical Therapist Centralized Application Service [PTCAS], 2019). The mean GPA for successful applicants has increased from 3.45 to 3.57 over the past ten admissions cycles (20082018), with some programs approaching a perfect 4.0 standardized mean GPA (PTCAS, 2017). Inclusive of this same time period, a meta-analysis performed by Curran and Hill (2017) indicated an increase in perfectionism rates since 1989. As GPA trends higher towards a perfect PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 20 4.0 for successful DPT applicants, programs could begin to see an association with a level of perfectionism among physical therapy students. Perfectionism Researchers have reported on perfectionism in the literature since the mid-twentieth century (R. Cole, 1946; Hollender, 1965). Prior to the 1990s, researchers examined perfectionism unidimensionally using the Burns Perfectionism Scale (Burns, 1980) or the perfectionism subscale from the Eating Disorder Inventory (Gardner, Olmstead, & Polivy, 1983). However, in the early 1990s and independent of one another, Frost et al. (1990) and Hewitt and Flett (1991) created two multidimensional perfectionism scales that are commonly used today (Stoeber, 2017a). As previously described, perfectionism has been viewed by some as a multidimensional construct (Hewitt & Flett, 1991), consisting of extremely high internal expectations coupled with hyper-critical self-evaluations (Frost et al., 1990). The construct of perfectionism was initially viewed only as unhealthy and clinical in nature (Burns, 1980; Gardner et al., 1983; Hollender, 1965); more recently, researchers have conceptualized perfectionism as Adaptive or Maladaptive based on the interaction of the different perfectionistic constructs (Bieling, Israeli, & Antony, 2004; Rice & Ashby, 2007; Stairs et al., 2012; Stoeber & Otto, 2006). For example, two people could rate highly in the High Standards dimension from the model of Slaney et al. (2001). However, if one person also rates highly in the Discrepancy dimension, then this would be considered Maladaptive because the Discrepancy dimension indicates a perception of falling short of the high-performance expectations captured by the High Standards dimension. Rating low in the Discrepancy dimension along with rating highly in the High Standards dimension would indicate an Adaptive outcome because that person would not perceive themselves falling short of the high performance expectations (Rice & Ashby, 2007). Alternatively, other researchers view PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 21 perfectionism through the clinical, psychopathological lens and differentiate between striving for perfection and striving for excellence. Viewed through this lens, the Adaptive perfectionists are considered striving for excellence and not perfection. Therefore, by this definition, they are considered high-achievers rather than perfectionists (Flett & Hewitt, 2016; Gaudreau, 2019). Although most research on perfectionism has been cross-sectional, perfectionism appeared to be relatively stable over time when viewed longitudinally. In research ranging from two months to two years, perfectionism demonstrated stability in adolescents (Damian, Stoeber, Negru-Subtirica, & Bban, 2017) and in undergraduate students (Azevedo et al., 2010; Moore et al., 2018; Rice & Dellwo, 2001). Frameworks. Conceptually, a variety of different labels, sub-categories, and types have been used to further define the classification of perfectionism. Mentioned previously and demonstrated by the overlap among the multidimensional tools and conceptualization of perfectionism, there is a degree of similarities among these different frameworks. Because of the overlapping frameworks and diverse nomenclature research groups use to describe perfectionism, it can be confusing to compare the different approaches (Stoeber & Otto, 2006). However, in general terms, researchers tend to group Adaptive Perfectionism, Perfectionistic Strivings in the absence of Perfectionistic Concerns, and Self-Oriented Perfectionism in the absence of Socially-Prescribed Perfectionism. Additionally, and also in general terms, researchers tend to group Maladaptive Perfectionism, Perfectionistic Concerns, and SociallyPrescribed Perfectionism together (Stoeber & Otto, 2006). Refer to Table 1. Other researchers have argued that the classification of perfectionism is difficult because of a potential contextual component (Rice & Richardson, 2014). Although perfectionism can impact any facet of life, for most perfectionists, their perfectionism is not cross-contextual (Stoeber & Stoeber, 2009). For example, perfectionism tends to be more prevalent in the PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 22 domains in which one most closely self-identifies such as occupation (Stoeber & Stoeber, 2009), academics (Dunn et al., 2005; McArdle, 2010; Stoeber & Stoeber, 2009), and athletics (Dunn et al., 2005; McArdle, 2010). Therefore, perfectionism seems more domain-specific rather than a personality trait that influenced all of lifes domains. Adaptive and Maladaptive Perfectionism. Adaptive Perfectionism has been generally recognized as positive, healthy behaviors such as healthy eating and exercise habits as well as avoiding tobacco, illicit drugs, and problematic alcohol consumption. Maladaptive Perfectionism generally has been recognized as negative, unhealthy behaviors such as poor eating and exercise habits as well as tobacco, illicit drugs, and problematic alcohol consumption (Mackinnon, Ray, Firth, & OConnor, 2019; Molnar, Sadava, Flett, & Colautti, 2012; Williams & Cropley, 2014). In this framework, each subtype of perfectionismAdaptive or Maladaptiveis associated with certain manifestations. For example, Maladaptive Perfectionists tend to have higher rates of stress and anxiety when compared to those classified as Adaptive Perfectionists (Ashby & Gnilka, 2017; Bks et al., 2015; DiBartolo et al., 2008; Flett, Nepon, Hewitt, & Fitzgerald, 2016; Shafique, Gul, & Raseed, 2017; Zureck, Altsttter-Gleich, Wolf, & Brand, 2014). Building on the increased stress and anxiety in Maladaptive Perfectionists, when subjected to a shortterm, stressful situation, Maladaptive Perfectionists had higher levels of both systolic and diastolic blood pressure compared to Adaptive Perfectionists (Albert, Rice, & Caffee, 2016). Additionally, among undergraduate students, Maladaptive Perfectionism appeared to directly associate with decreased motivation, and this decreased motivation with academic burnout when compared to Adaptive Perfectionists (E. Chang, Lee, Byeon, Seong, & Lee, 2016). Furthermore, Maladaptive Perfectionists experienced chronic insomnia more frequently than Adaptive Perfectionists (Vincent & Walker, 2000). PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 23 Self-Oriented, Other-Oriented, and Socially-Prescribed Perfectionism. Flett, Hewitt, Blankstein, and OBrien (1991) hypothesized three different constructs of perfectionism: SelfOriented Perfectionist, self-imposed unrealistic expectations; Other-Oriented Perfectionist, imposing unrealistic expectations on others; and Socially-Prescribed Perfectionist, the perception of unrealistic expectations from others. Based on exploratory factor analysis, higher SelfOriented Perfectionist with lower Socially-Prescribed Perfectionist aligned with Adaptive Perfectionism, whereas higher Self-Oriented Perfectionist with higher Socially-Prescribed Perfectionist aligned with Maladaptive Perfectionism (Frost et al., 1993; Verner-Filion & Gaudreau, 2010). Although Other-Oriented Perfectionist was part of this multidimensional model, it is not directed internally towards self like Self-Oriented Perfectionist and SociallyPrescribed Perfectionist, but rather externally towards others. Therefore, Other-Oriented Perfectionist is considered outside the context of Adaptive and Maladaptive Perfectionism (Stoeber, 2014). Perfectionistic Strivings and Concerns. An exploratory factor analysis (Frost et al., 1993) of the previously mentioned multidimensional frameworks from Hewitt and Flett (1991) consisting of three constructs and Frost et al. (1990) consisting of six constructs, produced a close association among Personal Standards and Organization from Frosts team and SelfOriented Perfectionist as well as Other-Oriented Perfectionist from the Hewitt and Flett team. This was termed Perfectionistic Strivings (Frost et al., 1993). Additionally, the analysis (Frost et al., 1993) found a close association among Concern Over Mistakes, Doubts About Actions, as well as Parental Expectations and Concerns from Frost et al. (1990) with Socially-Prescribed Perfectionist from Hewitt and Flett (1991). This grouping was termed Perfectionistic Concerns (Frost et al., 1993). The concept of Perfectionistic Strivings, also called Personal Standards Perfectionism, is the self-direct pursuit of self-determined high standards, but often without high PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 24 self-criticism. The concept of Perfectionistic Concerns, also called Evaluative Concerns Perfectionism, is the drive to obtain unrealistically high standards based on the perception that these are valued by others resulting in harsh and excessive self-criticism that may lead to catastrophizing mistakes and doubting ones ability (Gaudreau, 2015; Stoeber & Otto, 2006). In this two-factor framework, Perfectionistic Strivings directly associated with positive affect and Perfectionistic Concerns directly associated with negative affect and depression (Frost et al., 1993). Additionally, Perfectionistic Strivings directly associated with positive school engagement (Damian et al., 2017). To place Perfectionistic Strivings and Perfectionistic Concerns in the context of Adaptive and Maladaptive Perfectionism, the interaction of Perfectionistic Strivings and Perfectionistic Concerns should be considered. An Adaptive Perfectionist would be high Perfectionistic Strivings and low Perfectionistic Concerns, whereas a Maladaptive Perfectionist would be high in both Perfectionistic Strivings and Perfectionistic Concerns (Gaudreau & Thompson, 2010; Stoeber & Otto, 2006). For some researchers, the neutrality of the Perfectionistic Strivings and Concerns labels is viewed as beneficial because the terms may accommodate for the complex, context-dependent nature of perfectionism whereas the labels of Adaptive and Maladaptive may not since they could be interpreted as good or healthy and bad or unhealthy (Gaudreau, 2013; Stoeber, 2017a). However, the neutrality of Perfectionistic Strivings and Concerns also has limitations by not considering the interaction between these two dimensions and, therefore, not indicating the perfectionistic behavior as Adaptive or Maladaptive (Rice, Suh, & Davis, 2017). Framework summary. Unfortunately, there is no perfect, universally agreed upon way to describe or measure perfectionism. As shown above, there is variance among the different terms describing perfectionists as well as perfectionism frameworks. There is also a significant overlap among some of the frameworks previously described. A unidimensional approach to measure PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 25 perfectionism, such as the Burns Perfectionism Scale (Burns, 1980), is insufficient to capture the complex, nuanced, and context-dependent nature of perfectionism (Flett & Hewitt, 2016). However, multidimensional approaches that try to capture up to nine dimensions (Stairs et al., 2012) may be measuring items beyond perfectionism constructs such as antecedents to perfectionism (Flett & Hewitt, 2015). Additionally, focusing on an internal, within-person approach may offer a clearer picture of perfectionism (Gaudreau, 2013). Finally, a multidimensional approach needs to account for interactions between the different constructs, such as seen with the APSR (Rice & Ashby, 2007). Current literature and perfectionism tool development is trending towards a bidimensional-interaction approach. The FMPS-Brief (Burgess, Frost, & DiBartolo, 2016) and Short Almost Perfect Scale (Rice, Richardson, & Tueller, 2014) are shorter versions of the FMPS and APSR, respectively. Validation of these tools is in the early stages, but they are not nearly as well validated as the FMPS and APSR. Therefore, a within-person, bidimensional approach using a more established tool that takes into account the interaction between two dimensions (Rice & Ashby, 2007; Stoeber & Otto, 2006) may be the strongest approach. The two-factor frameworks presented above include Perfectionistic Strivings and Perfectionistic Concerns approach (Stoeber & Otto, 2006) and the Adaptive and Maladaptive Perfectionistic approach (Rice & Ashby, 2007). Because the nomenclature of Perfectionistic Strivings and Perfectionistic Concerns tends to be more abstract than Adaptive and Maladaptive Perfectionistic nomenclature, it was more effective to follow the Adaptive and Maladaptive framework. This was accomplished using interaction between the High Standards and Discrepancy subscales of the APSR (Rice & Ashby, 2007; Slaney et al., 2001). Outcome measures. Although there are a variety of different bidimensional and multidimensional outcome measures available to assess perfectionism, the two oldest and most PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 26 common in the literature are the Frost Multidimensional Perfectionism Scale (FMPS; Frost et al., 1990) and the Hewitt-Flett Multidimensional Perfectionism Scale (HFMPS; Hewitt & Flett, 1991). The APSR (Slaney et al., 2001) is also commonly found in the literature but not as frequently as the other two measures (Stoeber, 2017b). Additionally, all three of these measures are well validated on populations similar to the population this research studied (Frost et al., 1990; Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991; Slaney et al., 2001). The following paragraphs will further describe these tools. Multidimensional perfectionism approaches. Concurrently and unbeknownst to each other, researchers Hewitt and Flett (1991) and Frost, Marten, Lahart, and Rosenblate (1990), created two widely known perfectionism measures. Using confirmatory factor analysis of the HFMPS, Hewitt and Flett supported the three dimensions from this outcome measure (Hewitt & Flett, 1991). Frost and colleagues supported six dimensions of perfectionism in the FMPS using exploratory and confirmatory factor analysis (Frost et al., 1990). However, using Horns parallel analysis and in an effort to decrease factorial instability, Stber (1998) recommended reducing the FMPS to four dimensions by combining Concerns Over Mistakes and Doubts About Actions as well as combining Parental Expectations and Parental Criticism. Researchers reported good psychometric properties for both tools (Frost et al., 1990; Hewitt & Flett, 1991), and both tools have been used to assess health professions students (M. Enns et al., 2001; Henning et al., 1998). However, both surveys require a fee to administer. A further limiting factor regarding the FMPS is a lack of published norms (Flett & Hewitt, 2015). A third tool frequently used to multidimensionally measure perfectionism is the APSR (Slaney et al., 2001). Slaney and colleagues supported three dimensions of perfectionism in the APSR using exploratory and confirmatory factor analysis (Slaney et al., 2001). The APSR consists of three subscales, High Standards, Order, and Discrepancy, and researchers have PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 27 reported sound psychometric properties for this tool (Rice et al., 2007; Slaney et al., 2001; Suddarth & Slaney, 2001). Although this tool has been used to assess students in higher education (Ashby et al., 2012; Rice et al., 2014; Rice & Slaney, 2002), it has been used less to measure samples of students in health professions programs (Wagner & Causey-Upton, 2017). However, unlike the FMPS and HFMPS, there is not a fee to administer the APSR when used for research purposes. More recently, Stairs and colleagues developed a comprehensive, multidimensional tool to measure perfectionistic constructs named the Measures of Constructs Underlying Perfectionism (M-CUP; Stairs et al., 2012). As mentioned previously, this research group analyzed 15 perfectionism tools. This included the aforementioned FMPS, HFMPS, APSR, the Eating Disorder Inventory-2 Perfectionism Scale, and the Burns Perfectionism Scale. Stairs and colleagues supported nine dimensions in the M-CUP using exploratory and confirmatory factor analysis (Stairs et al., 2012). The M-CUP consists of nine subscales, High Standards, Order, Perfectionism Toward Others, Reactivity Towards Mistakes, Perceived Pressure From Others, Dissatisfaction, Details and Checking, Satisfaction, and Black and White Thinking (Stairs et al., 2012). Although Stairs et al. (2012) validated this tool using an undergraduate student sample, unfortunately, it appears this tool is not commonly used among perfectionism researchers. As of November 2019, there were only three published studies using the M-CUP beyond the original work from Stairs et al. (2012). None involved students from health professions programs. Two studies involved undergraduate student samples (Forney et al., 2019; Lapoint & Soysa, 2014), and the other involved a clinical population (Kim et al., 2016). The M-CUP consists of 61 questions and nine subscales and is the longest among the four previously mentioned tools (Stairs et al., 2012). For comparison, the FMPS consists of 35 questions and six subscales (Frost PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 28 et al., 1990); the HFMPS consists of 45 questions and three subscales (Hewitt & Flett, 1991); and the APSR consists of 23 questions and three subscales (Slaney et al., 2001). Some authors argue that not all of the subscales on these multidimensional tools directly measure perfectionism (Stoeber, 2017b). For example, the subscales of Self-Oriented Perfectionism from the Hewitt-Flett MPS (HFMPS) and the Personal Standards from the Frost MPS (FMPS) may truly measure perfectionism. However, other dimensions such as OtherOriented Perfectionism and Socially-Prescribed Perfectionism from the HFMPS may not directly measure perfectionism, but instead constructs related to perfectionism (Shafran, Cooper, & Fairburn, 2002). Additionally, measures such as Parental Criticism from the FMPS did not directly represent an actual trait of perfectionism, but rather factors that may contribute to developing perfectionism (Stairs et al., 2012). Furthermore, to categorize perfectionists as Adaptive or Maladaptive, the creators of the APSR opted to exclude the tools subscale of Order and use only its two subscales of High Standards and Discrepancy (Rice & Ashby, 2007). By only including two of the three subscales, conceptually, this became a bidimensional view of perfectionism. Bidimensional perfectionism approaches. As previously explained, perfectionism research is moving from a multidimensional towards a bidimensional view of perfectionism. Further supportive of a bidimensional view was a comparison of the nine subscales from the closely related FMPS and the HFMPS measures conducted by Frost et al. (1993). This exploratory factor analysis of these two multidimensional tools consolidated the nine total subscales into two dimensions of perfectionism labeled Maladaptive Evaluation Concerns and Positive Strivings (Frost et al., 1993). Contemporary researchers also support and further refined this bidimensional model of perfectionism using the labels of Perfectionistic Strivings and Perfectionistic Concerns (Gaudreau & Thompson, 2010; Stoeber & Otto, 2006). PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 29 Additionally, the Rice research group explored a bidimensional approach to the multidimensional APSR by omitting the Order dimension and focusing only on the interaction of the High Standards and Discrepancy dimensions for classification of Adaptive and Maladaptive Perfectionism (Rice & Ashby, 2007; Rice et al., 2007). The APSR has evolved to a shorter version called the Short Almost Perfect Scale (SAPS) that omitted the order subscale questions in their entirety as well as other redundant items from the other subscales (Rice et al., 2014). Although researchers reported good psychometric properties among undergraduate students for the SAPS, they cautioned that these items were not administered in a stand-alone fashion. Rather, they were administered as part of the APSR. Additionally, they recommended administering the eight items from the SAPS with other items having a similar response set-up (Rice et al., 2014). Based on these recommendations, all of the APSR items were administered for this research project. Outcome measure summary. In summary, the above-mentioned perfectionism outcome measures FMPS (Frost et al., 1990), HFMPS (Hewitt & Flett, 1991; Hewitt et al., 1991), APSR (Ashby, Rice, & Martin, 2006; Rice & Aldea, 2006; Slaney et al., 2001), and M-CUP (Stairs et al., 2012) have all demonstrated good psychometric properties. As previously outlined, researchers have used the three dimension and 35-item FMPS and six dimension and 45-item HFMPS to measure perfectionism in higher education in general and in health professions programs (M. Enns et al., 2001; Henning et al., 1998). Researchers have also used the three dimension and 23-item APSR to measure perfectionism in higher education in general and in health professions programs (Ashby et al., 2012; Rice et al., 2014; Rice & Slaney, 2002; Wagner & Causey-Upton, 2017), just not as extensively as the FMPS and HFMPS (Stoeber, 2017a). Researchers seem to be reluctant to use the comprehensive M-CUP measure. This may be due to the nine dimensions and its 61-items. Since the APSR has good validity, a reasonable number of PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 30 items, and a bidimensional scoring approach allowing for the interaction of the two-dimension resulting in an Adaptive or Maladaptive classification, it was used in this research project. Theories and models. Although there are several different theories and models related to perfectionism, there are two that warrant further discussion in order to better understand perfectionism, stress, and the physical therapy student. The Perfectionism Acceptance Theory (PAT) from Lundh (2004) may better explain Adaptive and Maladaptive Perfectionism. Additionally, the Perfectionism Diathesis-Stress Model (PDSM) may further explain the result of the interaction between perfectionism and stress (Goforth, Pham, & Carlson, 2011). Perfectionism Acceptance Theory. The PAT differentiates Adaptive and Maladaptive Perfectionism based on the acceptance of non-perfectionism. The Adaptive and Maladaptive Perfectionist both pursue perfection. However, the Adaptive Perfectionist accepts non-perfection, whereas the Maladaptive Perfectionist does not accept non-perfection. Therefore, the pursuit of perfection only becomes maladaptive when this pursuit of perfection transitions into a demand for perfection (Lundh, 2004). This theory appears conceptually consistent with the bidimensional approach from Rice and Ashby (2007) that used the Discrepancy dimension to differentiate between Adaptive and Maladaptive Perfectionists. Perfectionism Diathesis-Stress Model. The PDSM frames perfectionism as a predispositional vulnerability. If the interaction between the Discrepancy dimension of perfectionism and perceived stress exceeds the perceived capacity to meet the resulting demand, then there is increased risk for the development of a negative outcome such as symptoms of distress (E. C. Chang & Rand, 2000; Flett, Hewitt, Blankstein, & Mosher, 1995). For example, regression analysis performed by Flett, Hewitt, and Dyck (1989) suggested an interaction between perfectionism and stress that was predictive of anxiety. The same research group further supported this model when they suggested a possible interaction between perfectionism and PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 31 stress to produce increasing levels of depressive symptoms (Flett et al., 1995). Additionally supporting this model, M. Smith, Saklofske, Yan, and Sherry (2017) showed a weak and direct association between stress, anxiety, and perfectionism. Interestingly, in a study involving participants diagnosed with depression, both dimensions of perfectionism (High Standards and Discrepancy) longitudinally moderated the association between chronic stress and depressive symptoms (Bks et al., 2015). Others have implicated the High Standards dimension as a vulnerability factor in the PDSM. Results from the work of Hewitt, Flett, and Ediger (1996) suggested High Standards as a vulnerability factor. Contrary to these findings and more consistent with the Adaptive and Maladaptive framework of perfectionism, first-year medical students who scored low on Adaptive dimensions and students who scored high on Maladaptive dimensions were vulnerable to negative effects of stress (M. Enns, Cox, & Clara, 2005). Although PDSM has been used to explain the interaction of perfectionism and stress, the role of the different dimensions of perfectionism in this model has been inconsistent in previous literature. The Adaptive and Maladaptive framework that accounts for the interaction between the two perfectionism dimensions (Rice & Ashby, 2007) may provide a better understanding of the relationship between perfectionism and stress in the PDSM. Furthermore, applying the Perfectionism Acceptance Theory and Perfectionism Diathesis-Stress Model may provide clarity of perfectionisms role in higher education. Perfectionism and higher education. Using undergraduate student samples, researchers have conducted numerous studies on the association between perfectionism and stress, as described in the following paragraphs. Among perfectionists, Adaptive Perfectionists reported lower levels of perceived stress than Maladaptive Perfectionists. Additionally, Adaptive Perfectionists more often employed task-oriented coping (e.g., taking action to address the PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 32 situation) and less likely employed emotion-oriented coping (e.g., altering ones response to the situation) compared to Maladaptive Perfectionists. In contrast, Maladaptive Perfectionists more often employed emotion-oriented coping and less likely employed task-oriented coping compared to Adaptive Perfectionists. Therefore, the coping strategy favored by Adaptive Perfectionists potentially served as a buffer to stressor, resulting in lower perceived stress in Adaptive Perfectionists (Ashby & Gnilka, 2017). Rice and Van Arsdale (2010) also examined perfectionism, stress, and coping in an undergraduate student sample. Supportive of the findings from Ashby and Gnilka (2017), Maladaptive Perfectionists had increased perceived stress, as well as the negative emotionoriented coping strategy of drinking-to-cope, than Adaptive Perfectionists (Rice & Van Arsdale, 2010). Additionally, other researchers have further supported that Maladaptive Perfectionists had higher levels of stress compared to Adaptive Perfectionists (Bieling et al., 2004; Rice & Richardson, 2014). Offering even further support of the association between stress and perfectionism, Maladaptive Perfectionists showed not only higher levels of stress, but also prolonged reactivity to stress indicating rumination among Maladaptive Perfectionists (Flett et al., 2016). Building on the work of Flett et al. (2016) and also potentially impacting academic performance, Maladaptive Perfectionists showed a relationship between perceived stress and fear of negative evaluation among both undergraduate and graduate students (Shafique et al., 2017). Also related to academic performance, coping strategies used by perfectionists may impact testing anxiety. Supportive of Ashby and Gnilka (2017) as well as Rice and Van Arsdale (2010), Maladaptive Perfectionists favored avoidant emotion-oriented coping strategies more than Adaptive Perfectionists and experienced more testing anxiety than Adaptive Perfectionists (Vanstone & Hicks, 2019). Interestingly, in a sample of Canadian and Chinese students, Canadian students showed significantly more Maladaptive Perfectionistic tendencies in one PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 33 aspect (Concerns over Mistakes), but not in another (Socially-Prescribed Perfectionism; M. Smith et al., 2017). Additionally, in a sample of Russian undergraduate students, there was no significant difference in stress levels between Adaptive and Maladaptive Perfectionists (Wang, Permyakova, & Sheveleva, 2016) indicating a potential cultural component to perfectionism that is beginning to be explored among researchers (DiBartolo & Rendn, 2012). Although the majority of adult, non-clinical perfectionism research has involved undergraduate students as described previously, pursuing perfectionism research among health professions programs should not be neglected. Researchers have already expressed concern that undergraduate student samples may have a higher proportion of perfectionists due to a selectionbias towards the individual with high standards (Rice & Richardson, 2014). For example, among a sample of undergraduate students, Grzegorek, Slaney, Franze, and Rice (2004) identified over 50% of this sample as perfectionists with 31% as Adaptive Perfectionists and 26% as Maladaptive Perfectionists. In comparison to a sample of pre-occupational therapy students, Wagner & Causey-Upton (2017) identified over 90% of this sample as perfectionists with 50% as Adaptive Perfectionists and 43% as Maladaptive Perfectionists. Unfortunately, non-clinical, general population sample norms were not found in the literature. If there is a concern of a higher proportion of perfectionists among undergraduate students due to high standards compared to the general population, then potentially a population of graduate students in health professions programs may have a more pronounced proportion of perfectionists than the undergraduate student population or a different distribution of Adaptive and Maladaptive Perfectionists. Although not reporting rates of perfectionism between undergraduate art students and medical students, there were higher rates of Adaptive Perfectionists among medical students and higher rates of Maladaptive Perfectionists among the undergraduate art students when comparing the two groups. (M. Enns et al., 2001). Seeliger and Harendza (2017) also reported lower rates of PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 34 Maladaptive Perfectionism among medical students compared to available normative data. Similar to the results involving medical students, there were lower rates of Maladaptive Perfectionists from a sample of students in health professions programs representing medical, nursing, dental, and pharmacy programs compared to a previous sample of undergraduate students (Henning et al., 1998). Therefore, perfectionism exploration among DPT students, as proposed in this research project, is prudent. Perfectionism and health professions higher education. As previously mentioned, despite a robust literature on the relationship between perfectionism and stress in undergraduate students, there is a dearth of research involving perfectionism and graduate students, and especially in health professions programs. In a longitudinal study involving medical students, Maladaptive Perfectionism strongly and directly associated with distress and predicted depressive symptoms (M. Enns et al., 2001). Supportive of these findings, one of the strongest predictors of distress in medical students was Maladaptive Perfectionism (Henning et al., 1998). This is concerning since Hu, Chibnall, and Slavin (2019) identified over 25% of first-year medical students as Maladaptive Perfectionists. Moving beyond perfectionism and stress, researchers have explored the association between perfectionism and academic performance in health professions programs. Witcher et al. (2007) found that, among psychology graduate students, Adaptive Perfectionism positively predicted academic performance, whereas Maladaptive Perfectionism negatively predicted performance. Although graduate health professions students were only a small subset of the sample of graduate student participants, Maladaptive Perfectionism predicted academic stress with women being more susceptible than their male counterparts (Cowie, Nealis, Sherry, Hewitt, & Flett, 2018). From a sample of pre-occupational therapy students, a sample that may closely match the student profile of DPT students, researchers identified a vast majority of the students PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 35 as perfectionists, with half of the sample identified as Adaptive Perfectionists. Using qualitative, survey data, the majority of students reported that their perfectionism caused increased stress levels (Wagner & Causey-Upton, 2017). In summary, a significant amount of perfectionism research has involved undergraduate students. There is a paucity of perfectionism research involving health professions programs, and none to date has involved DPT students. As outlined above, perfectionism, especially Maladaptive Perfectionism, is positively and strongly associated with stress in health professions students (Cowie et al., 2018; M. Enns et al., 2001; Henning et al., 1998; Wagner & CauseyUpton, 2017; Witcher et al., 2007). Therefore, research involving perfectionism, stress, and the DPT student addresses a significant gap in the literature. Stress Stress can be described as a dynamic and potentially cumulative process involving perceived demands and self-perceived capacity to meet them. It can impact all aspects of human function, including physiological, cognitive, emotional, and behavioral. Because stress is a dynamic relationship between perceived demands and self-perceived capacity to meet those demands, it may be beneficial when perceived capacity is greater than or at least meets the perceived demands. However, it may also be detrimental when perceived capacity is no longer able to meet the perceived demands (Butler, 1993). Therefore, Seyle (1975) separated stress into two different concepts, eustress and distress. He viewed eustress as positive stress, with perceived lower stress levels being healthy, and distress as negative stress, with perceived higher stress levels being unhealthy. Perceived stress. Perceived stress is the subjective appraisal of the relationship between environmental demands and available resources. Perceived stress can be an individual experience. Therefore, two individuals may experience similar events, but depending on other PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 36 variables such as support, personality, coping ability, they may appraise the situation differently based on these variables as well as the appraisal of their ability to meet the demand (Phillips, 2013). Perceived stress and higher education. Stress was one of the most common reasons for undergraduate students to access college counseling services, with just over 45% of clinicians citing stress as an area of concern among students (Center for Collegiate Mental Health, 2017). Perceived stress seems to be increasing among undergraduate students, Xiao et al. (2017) reported an increase in distress over multiple cohorts of students from 2010-2015. Supportive of this, Beiter et al. (2015) reported a greater than two-fold increase in yearly counseling center visits among undergraduate students over a four-year period with the top stressors being academic success, pressure to succeed, post-graduate plans, and financial concerns. Among undergraduate students, almost 60% reported high levels of stress (Makrides, Veinot, Richard, McKee, & Gallivan, 1998). In a predominately undergraduate student sample comprised of American and international students, American students indicated greater stress levels than their international counterparts indicating a potential cultural component to perceived stress (Misra & Castillo, 2004). Furthermore, from the same sample, gender may play a role in perceived stress among undergraduate students since women reported more perceived stress than men. However, this result is inconsistent in the literature, as Talib and Zia-ur-Rehman (2012) found no gender difference among undergraduate students and perceived stress. This increased, perceived stress, common in undergraduate students, also appears to negatively impact sleep quality (Amaral et al., 2018; Galambos, Vargas Lascano, Howard, & Maggs, 2013). In a sample of over 1,000 undergraduate students, perceived stress was the most significant risk factor for decreased sleep quality, with nearly two-thirds reporting stress had a negative impact on sleep (Lund, Reider, Whiting, & Prichard, 2010). Galambos et al. (2013) PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 37 longitudinally supported the cross-sectional findings of Lund and colleagues by reporting that perceived stress and sleep quality were weakly and indirectly associated with each other, meaning increased perceived stress resulted in decreased sleep quality in a sample of nearly 100 undergraduate students. Offering further support of the indirect association between perceived stress and sleep quality, Amaral et al. (2018) found a weak-to-moderate indirect association between stress and sleep quality in a sample greater than 500. The detrimental impact of perceived stress on sleep quality is concerning because, in a sample of nearly 1400, sleep quality was moderately, indirectly associated with academic performance. Additionally, in this same sample, perceived stress showed a weak, indirect association with academic performance (van der Heijden et al., 2018). This is not surprising because there is a robust body of work demonstrating that stress and fatigue negatively impact cognitive performance (Beilock & DeCaro, 2007; Lepine, Lepine, & Jackson, 2004; Palmer et al., 2013; Van Der Linden & Eling, 2006). For example, stress can negatively impact working memory (Beilock & DeCaro, 2007) and focus (Liston, McEwen, & Casey, 2009). Similar to stress, fatigue can also negatively impact focus in addition to local processing efficiency (Van Der Linden & Eling, 2006), However, consistent with the concept that perceived stress is a subjective appraisal of the relationship between environmental demands and available resources (Phillips, 2013), stress can positively or negatively impact learning performance based on if the stress is appraised as a positive and challenging experience or a negative and hindering experience (Lepine et al., 2004). Furthermore, stress may improve or inhibit the different types of memory as stress seemed to inhibit working memory, supporting the work of Beilock and DeCaro (2007), but improve spatial memory (Luethi, Meier, & Sandi, 2009). PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 38 Beyond the deleterious effect of stress on sleep and academic performance and perhaps more importantly, chronic stress has been associated with a variety of health-related issues such as a higher risk of cardiovascular disease (Chida & Steptoe, 2010; Dimsdale, 2008; Nabi et al., 2013; Sheps et al., 2002; H. Song et al., 2019; Spruill, 2010) and obesity (Brunner, Chandola, & Marmot, 2007; Sinha & Jastreboff, 2013). Furthermore, on a cellular level, increasing perceived stress levels have been associated with increased cell aging among first-year medical residents (Ridout et al., 2019). Additionally, chronic stress has been associated with poor health behaviors such as problematic alcohol consumption (Park & Iacocca, 2014) and stress-eating (Adam & Epel, 2007; Sinha & Jastreboff, 2013). Taken together, these findings are concerning as undergraduate students transition into more rigorous health professions programs with increasing academic load requirements and performance expectations, potentially resulting in elevated stress levels experienced by the health professions students (Dutta et al., 2005). A better understanding of the role stress plays in health professions programs may help minimize the negative impact stress has on students, as outlined above. Perceived stress and health professions higher education. Among a variety of different health professions programs, students experience significant levels of stress when compared to individuals of similar age (Henning et al., 1998). Further corroborating this in a 2005 review, Dutta, Pyles, and Meiderhoff (2005) reported high rates of stress among students in the health profession programs of medicine, dentistry, nursing, and allied health with medical students being the most stressed. Ruiz-Aranda, Extremera, and Pineda-Galn (2014) offered similar results in a sample of health professions programs, including physical therapy, occupational therapy, and nursing. Additionally supportive of the impact that stress has in health professions programs, researchers found in a study comprised of psychology, nursing, and social work students, perceived stress had a moderate, direct relationship with maladaptive coping and a PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 39 weak, indirect relationship with adaptive coping (A. Enns et al., 2018). Similarly, the RuizAranda group reported weak-to-moderate, indirect associations between perceived stress and life satisfaction as well as perceived happiness (Ruiz-Aranda et al., 2014). These stress-related issues among health professions students and health care providers have not gone unnoticed by professional organizations, health professions programs, and accrediting bodies (Anandarajah, Quill, & Privitera, 2018; Bodenheimer & Sinsky, 2014; Bowles et al., 2018; Kreitzer & Klatt, 2017; Morrow et al., 2018). There has been a call to mitigate stress and burnout issues among health care providers. Some health professions leaders have advocated to add care team well-being as a fourth aim to the Triple Aim health care approach which currently consists of patient experience, population health, and reducing costs (Bodenheimer & Sinsky, 2014; Bowles et al., 2018; Morrow et al., 2018). Additionally, there has been a call to assess and address health and wellness in first-year health professions students (Melnyk et al., 2016). Although in the early stages, a small number of universities have begun to heed these calls by offering programming to health professions students as well as practicing health care professionals. These different stress management curricular initiatives include resiliency (MejiaDowns, 2019), mindfulness, self-care, and work-life balance (Kreitzer & Klatt, 2017). Perceived stress and medical students. In multiple studies, researchers have identified stress-related issues among medical students (Dyrbye et al., 2006; Guthrie et al., 1998; Ishak et al., 2013; Stewart, Lam, Betson, Wong, & Wong, 1999). This is not a new concern in medical education, as evidenced by the Medical Education journal devoting an entire issue to the topic over 25 years ago (C. Cole, 1994). In the same year as the Medical Education issue on stress in medical education, Mosley et al. (1994) reported that among third-year medical students, greater than 50% reported high levels of stress. In a five-year longitudinal study, Guthrie et al. (1998) PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 40 further supported this concern by finding that the prevalence of students reporting high stress levels over the five years of attending medical school ranged from 50-60%. In another prospective, longitudinal analysis of medical students, Stewart, Lam, Betson, Wong, & Wong (1999) analyzed stress and academic performance during the first two years in medical school and found that academic performance, both prior to admission and during medical school, was weakly and indirectly associated with perceived stress levels at the start of medical training and eight months into the program. Confirming the prevalence of stress, Dyrbye, Thomas, & Huntington (2006) again identified a high prevalence of stress among medical students, with nearly 50% of medical students experiencing concerning levels of stress. They furthered the discussion of stress in medical education by identifying that personal life stressors such as a recent major illness or death of a close family member contributed just as much, if not more than academic-related (e.g., testing and evaluation, course and workload issues) stressors. More recently, the prevalence of stress among medical students has remained the same with Almojali, Almalki, Alothman, Masuadi, & Alaqeel (2017) reporting prevalence levels greater than 50%. Additionally, from logistic regression analysis, high stress levels were a strong predictor of and contributor to poor sleep (Almojali et al., 2017). Although identified as a concern over 25 years ago (C. Cole, 1994), the prevalence of stress among medical students has remained stubbornly constant around 50% (Almojali et al., 2017; Ishak et al., 2013; Mosley et al., 1994). Unfortunately, this issue does not appear to improve upon graduation and may increase post-graduation (Shanafelt et al., 2012; Shanafelt, Bradley, Wipf, & Back, 2002). Therefore, as previously mentioned, medical specialties, such as family and internal medicine, have championed initiatives that focus on the well-being of the health care professional (Anandarajah et al., 2018; Bodenheimer & Sinsky, 2014). One such initiative may be the incorporation of emotional intelligence training. Gupta, Singh, and Kumar PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 41 (2017) further supported the work of Birks et al. (2009) by observing a weak, indirect association between emotional intelligence and perceived stress. Perceived stress and nursing students. Similar to medical education, nursing educators and researchers have also identified stress-related issues among nursing students in multiple studies (Alzayyat & Al-Gamal, 2014; Gibbons et al., 2011; Pryjmachuk & Richards, 2007; Pulido-Martos, Augusto-Landa, & Lopez-Zafra, 2012). In addition to addressing personal stressors like Dyrbye, Thomas, & Huntington (2006) did with medical students, different groups of researchers have attempted to capture other causes of stress among nursing students (Alzayyat & Al-Gamal, 2014; Gibbons, Dempster, & Moutray, 2008; Pryjmachuk & Richards, 2007; Pulido-Martos et al., 2012). For example, results of a survey-based, self-report measure showed that academic sources (e.g., testing and evaluation, course and workload issues), clinic-related sources (e.g., fear of making mistakes, negative patient outcomes), and personal sources (e.g., money and budget issues, work-life balance) were common categories of stressors selected by nursing students (Pryjmachuk & Richards, 2007). The results of a systematic review of 23 articles by Pulido-Martos et al. (2012) also produced similar sources of stress as Pryjmachuk and Richards (2007). Offering an additional perspective of the sources of stress among nursing students, Gibbons et al. (2008) further supported the themes of academic and clinical sources of stress by using a qualitative method of focus-groups. In another systematic review of 13 articles that focused specifically on the clinic-related stressors of nursing students, Alzayyat and Al-Gamal (2014) further contributed to this discourse by identifying that the highest sources of stress while on clinical rotations were continued academic demands, interpersonal relations in the clinical setting, as well as patient and caregiver management. In order to determine possible moderators and mediators to perceived stress, Gibbons, Dempster, and Moutray (2011) investigated the PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 42 predictors of stress and found that self-efficacy buffered the effects of stress. Additionally, avoidance-coping was the strongest predictor of less healthy well-being. Meanwhile, approachcoping was not a predictor of more healthy well-being. Therefore, strategies that promote improving self-efficacy and promote effective coping may prove beneficial to address the prevalence of stress among nursing students (Gibbons et al., 2011). This is important because, although a 34% prevalence of stress in nursing students (Pryjmachuk & Richards, 2007) is not as high as the 50% prevalence of stress in medical students (Dyrbye et al., 2006), it is still a concern in the nursing profession (Lim, Bogossian, & Ahern, 2010). Similar to initiatives being championed among physician groups (Anandarajah et al., 2018; Bodenheimer & Sinsky, 2014), nursing leaders are championing initiatives that would focus on the well-being of the health care professional (Bowles et al., 2018). These initiatives may address some of the recommendations of self-efficacy and effective coping strategies promoted by Gibbons et al. (2011). One such initiative may be the incorporation of emotional intelligence training into nursing programs (Cleary, Visentin, West, Lopez, & Kornhaber, 2018; Judge, Opsahl, & Robinson, 2018). Through mapping of a nursing program curriculum, Por, Barriball, Fitzpatrick, and Roberts (2011) found evidence, albeit it limited, of emotional intelligence aspects. They also noted a weak-to-moderate indirect association between emotional intelligence and perceived stress among nursing students (Por et al., 2011). This was congruent with previous weak-to-moderate indirect associations between emotional intelligence and perceived stress in health professions programs in general (Birks et al., 2009; Faguy, 2012; RuizAranda et al., 2014) and among medical students (Gupta et al., 2017). Perceived stress and dental students. Very similar to the concerns of stress and the two previously mentioned health professions programs, various researchers have pursued this topic in studies involving dental students (Alzahem et al., 2011; Elani et al., 2014; Gorter et al., 2008; PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 43 Silverstein & Kritz-Silverstein, 2010). Dental students may experience more stress than medical students (Birks et al., 2009), however, this is inconsistent in the literature as other researchers found that stress among medical students was greater than dental students as well as nursing and allied health professions students (Dutta et al., 2005). Gorter et al. (2008) found the prevalence of stress among dental students greater than 30%. However, another research group reported prevalence levels of 70% in another sample of students (Abu-Ghazaleh, Rajab, & Sonbol, 2011). For comparison, reported stress prevalence among medical students is around 50% (Almojali et al., 2017; Guthrie et al., 1998; Mosley et al., 1994). Echoing the sources of stress among nursing students (Pryjmachuk & Richards, 2007; Pulido-Martos et al., 2012), themes associated with academic, personal, and clinical sources of stress for dental students emerged (Alzahem et al., 2011; Elani et al., 2014). For example, in a systematic review of 49 articles, Alzahem et al. (2011) identified common themes of stress sources experienced by dental students relating to academic (e.g., testing and evaluation, course and workload issues), clinic (e.g., fear of making mistakes, negative patient outcomes), and personal (e.g., money and budget issues, work-life balance) issues. In a larger, slightly more recent systematic review of 124 articles, Elani et al. (2014) confirmed the previously identified common sources of stress and further differentiated these sources based on the dental student being preclinical (didactic only) or clinical. Between these two groups, academic sources of stress were still the predominant concern for both groups, and, as to be expected, the preclinical group did not report clinical sources of stress. However, personal sources of stress were significantly higher in the preclinical group (50%) when compared to the clinical group (11%; Elani et al., 2014). This clinical source of stress may help explain the increase in stress among first-year dental students, when there is little, if any patient care, to the final year, when it is almost exclusively patient care (Gorter et al., 2008). In a multi-site, longitudinal study, dental PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 44 students reported higher levels of stress in their final year (44%) compared to their first year (36%) as well as higher rates of emotional exhaustion in their final year (22%) compared to their first year (39%; Gorter et al., 2008). Further supporting that dental school is a stressful time, another multi-site, albeit shorter, longitudinal study, Silverstein and Kritz-Silverstein (2010) found stress levels increased over the first year of dental school. This is concerning because students with higher levels of stress had poorer academic performance as there was a weak, indirect association between GPA and stress (Silverstein & Kritz-Silverstein, 2010). Additionally, these researchers continued to support the previously mentioned themes from Elani et al. (2014) of academic and personal sources of stress during the first year of dental school. As with leaders in medicine (Anandarajah et al., 2018; Bodenheimer & Sinsky, 2014) and nursing (Bowles et al., 2018) education, the levels of stress experienced by dental students is concerning in this field as well (Alzahem, Van der Molen, & De Boer, 2015; Silverstein & KritzSilverstein, 2010). However, similar to medicine (C. Cole, 1994), this is not a recent phenomenon as researchers such as Tisdelle, Hansen, St. Lawrence, and Brown (1984) as well as Howard, Graham, and Wycoff (1986) investigated stress management strategies. More recent suggestions to address this issue have included proactive symptom recognition by faculty and staff, effective coping strategy education including the role of physical activity, and educating faculty to their role as potential sources of stress (Silverstein & Kritz-Silverstein, 2010). Perceived stress and physical therapy students. Stress prevalence is also an issue among students from physical therapy programs (Frank & Cassady, 2005; Frazer & Echternach, 1991; Hodselmans et al., 2018; Jacob et al., 2012; OMeara et al., 1994). Moderate stress level prevalences of 57% (Hodselmans et al., 2018) and 82% (Frazer & Echternach, 1991) among physical therapy students are comparable to the 50-60% in medical students (Dyrbye et al., 2006; PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 45 Guthrie et al., 1998; Mosley et al., 1994), the 30-70% in dental students (Abu-Ghazaleh et al., 2011; Gorter et al., 2008), and the 30% in nursing students (Pryjmachuk & Richards, 2007). Currently, there is a paucity of research on effective stress management strategies among physical therapy students as well as identification of student characteristics, which may buffer the negative effects of stress. This is concerning since physical therapy students may be faced with a similar prevalence and source of stresses as medical (Dyrbye et al., 2006), nursing (Pryjmachuk & Richards, 2007; Pulido-Martos et al., 2012), and dental (Alzahem et al., 2011; Elani et al., 2014) students. These stressors include academic, personal, and clinical sources (Hodselmans et al., 2018; Tucker, Jones, Mandy, & Gupta, 2006) with academic sources ranked as the highest stressor (Jacob et al., 2012; Tucker et al., 2006). Consistent with students from health professions programs of medicine (Dyrbye et al., 2006), nursing (Alzayyat & Al-Gamal, 2014), and dentistry (Elani et al., 2014), physical therapy students also considered academic-related sources (e.g., testing and evaluation, course and workload issues) as one of their most significant stressors (Tucker et al., 2006). Similar to the other health professions programs (C. Cole, 1994; Tisdelle et al., 1984) previously mentioned, this is also not a new concern among physical therapy educators and researchers (Frazer & Echternach, 1991; OMeara et al., 1994). Over a quarter-century ago, in a multi-site study, Frazer and Echternach (1991) found academic stressors such as heavy workload as a frequent stressor among physical therapy students. When comparing perceived stress between first-year and second-year students, Frazer and Echternach (1991) found a decreased prevalence among the second-year students. However, this result may be inconsistent in the literature, as both OMeara et al. (1994) and Frank and Cassady (2005) reported that perceived stress appeared to remain unchanged between first-year and second-year students. These results are different from the results of increasing perceived stress from first-year to second-year among dental students from PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 46 Silverstein & Kritz-Silverstein (2010). However, these comparisons should be viewed cautiously as Silverstein and Kritz-Silverstein (2010) longitudinally compared the same group at two different times. In contrast, Frazer and Echternach (1991), OMeara et al. (1994), and Frank and Cassady (2005) compared two different groups cross-sectionally. OMeara et al. (1994) also observed higher stress levels in physical therapy students when compared to undergraduate students. Similarly, Frank and Cassady (2005) observed higher rates of stress in physical therapy students compared to individuals of similar age as well as finding that female physical therapy students reported higher stress levels than their male counterparts. Finally, similar to the work from Silverstein and Kritz-Silverstein (2010) in dental students, perceived stress levels also have a weak, indirect association between GPA and stress among physical therapy students (Frank & Cassady, 2005). Perceived stress summary. In summary, researchers and educators have been concerned about the perceived stress levels of health professions students and have called for stress management interventions for at least two decades (C. Cole, 1994; Frazer & Echternach, 1991; Tisdelle et al., 1984). In spite of this awareness, stress prevalence among these students has continued to remain high across all programs (Almojali et al., 2017; Alzayyat & Al-Gamal, 2014; Elani et al., 2014; Hodselmans et al., 2018). More recently, accrediting bodies at the professional level (Morrow et al., 2018) and health professions programs (M. Cox et al., 2017; Mejia-Downs, 2019; Melnyk et al., 2016) have recognized the importance of addressing this issue since these health professions programs are preparing these students for effective patient care. To accomplish this, a high level of academic rigor is to be expected (Dutta et al., 2005) and therefore, it was not surprising to find across all health professions programs that academicrelated sources (e.g., testing and evaluation, course and workload issues) was the most significant stressor (Alzayyat & Al-Gamal, 2014; Dyrbye et al., 2006; Elani et al., 2014; Jacob et PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 47 al., 2012; Tucker et al., 2006). Current trends in health professions programs (Alzahem et al., 2015; Chambers, Phillips, Burr, & Xiao, 2016; Willgens et al., 2016) and at the professional level (Kreitzer & Klatt, 2017) indicate that stress management strategies are being implemented. Therefore, the next logical step is establishing evidenced-based, stress management strategies. Stress management. Butler (1993) described stress as a dynamic and potentially cumulative process involving perceived demands and self-perceived capacity to meet those demands. If perceived capacity meets or exceeds perceived demands, then stress may be perceived as beneficial, or at least not detrimental. However, if perceived capacity fails to meet perceived demands, then stress may be perceived as detrimental (Butler, 1993). Because stress perception varies by individual, there may be significant variability between individuals in their response to the same, or a similar stressor (Leblanc, 2009). Stress can positively impact learning if the task is perceived as appropriately challenging or negatively impact learning if the task is perceived as overwhelmingly challenging (Lepine et al., 2004). Because stress may be a catalyst to learning, as well as a barrier to learning (Jols, Pu, Wiegert, Oitzl, & Krugers, 2006; Lepine et al., 2004; Schwabe, Wolf, & Oitzl, 2010), the goal of stress management is not to eliminate stress, but rather to improve ones perceived capacity to meet the perceived demands. Stress management interventions such as self-care (e.g., mindfulness-based interventions) (Kreitzer & Klatt, 2017; van der Riet, Levett-Jones, & AquinoRussell, 2018) and emotional intelligence development (Birks et al., 2009; Faguy, 2012; RuizAranda et al., 2014) are potential strategies to accomplish this goal. Mindfulness-based interventions (MBI) can include non-judgmentally and purposefully being in the moment that can be enhanced through different forms of meditation such as breathing, walking, and loving-kindness meditations as well as progressive relaxation techniques and different forms of movement-based meditations such as yoga, tai chi, and qi gong (Kabat- PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 48 Zinn, 2003). Varvogli and Darviri (2011) provided an evidence-based review for other stress management techniques such as progressive muscle relaxation, biofeedback, guided imagery, diaphragmatic breathing, transcendental meditation, cognitive behavioral therapy, and mindfulness-based stress reduction. They concluded that these evidenced-based techniques were safe, easy-to-learn, and effective in lowering stress. However, better-designed studies are needed to determine stronger efficacy of these techniques in disease management and prevention (Varvogli & Darviri, 2011). Stress management and higher education. In two relevant studies, 60% of undergraduate students reported high levels of stress (Makrides et al., 1998) and stress was one of the most common reasons for undergraduate students to access college counseling services, with just over 45% of clinicians citing stress as an area of concern among undergraduate students (Center for Collegiate Mental Health, 2017). Although not directly measuring stress, Mahmoud et al. (2015) found among undergraduate students using maladaptive coping (e.g., problematic drinking, avoidance, substance use) had a moderate-to-strong relationship with anxiety. MBIs may provide an alternative to maladaptive coping strategies. Kabat-Zinn and colleagues developed a mindfulness-based stress reduction program, which is comprised of different mindfulness techniques, breathing exercises, body scanning, meditation, and hatha yoga. The standard program is 2.5 hour weekly sessions over eight weeks and one all-day retreat (MBSR, n.d.). This mindfulness-based stress reduction program is one of the most commonly researched stress management strategies among undergraduate students (Bamber & Kraenzle Schneider, 2016) as well as among students in health professions programs (McConville, McAleer, & Hahne, 2017). Some universities are taking a more holistic approach to student stress management. For example, the SMART Lab at Ohio State University teaches stress management and resiliency PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 49 skills to undergraduate students (SMART Lab, n.d.). In addition to teaching these skills to students, their mission includes researching the efficacy of stress management and resiliency skills in students. Although the team has produced no journal publications as of yet, they do have a variety of active and pending research on this topic (SMART Lab, n.d.). Additionally, the Center for Spirituality and Healing (CSH) at the University of Minnesota offers undergraduate students and medical residents an eight-week online course focusing on resiliency and well-being (Center for Spirituality and Healing, n.d.; Kreitzer & Klatt, 2017). Similar to the SMART lab, CSH currently does not have any published research on this topic. However, they are collecting data as part of an NIH Y-U grant (Center for Spirituality and Healing, n.d.). Bamber and Kraenzle Schneider (2016) conducted a systematic review of 57 articles involving MBI and stress among undergraduate students and concluded that MBI supported stress reduction. Self-reported perceived stress decreased in over 75% of the studies specific to MBI (Bamber & Kraenzle Schneider, 2016). Even with a shorter duration of four weeks, Greeson, Juberg, Maytan, James, and Rogers (2014) supported MBI as beneficial with the MBI group demonstrating a 13.8% decrease in stress compared to the control group demonstrating only a 2.4% decrease. MBI durations ranging from 4-8 weeks offered 10-30% reductions in stress among undergraduate students, with longer durations producing greater stress reduction (Galante et al., 2018; Greeson et al., 2014; Newsome, Waldo, & Gruszka, 2012). Researchers have found similar evidence in health professions programs (Chambers et al., 2016; De Vibe et al., 2013; Jain et al., 2007; McConville et al., 2017; van der Riet et al., 2018). Stress management and health professions higher education. Similar to undergraduate students and previously noted, students from a variety of different health professions programs are experiencing significant levels of stress (Dutta et al., 2005; Henning et al., 1998; RuizAranda et al., 2014). Because of these higher stress levels, researchers and educators are PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 50 considering humanistic skills (e.g., emotional intelligence and self-care) as a way to decrease stress levels among health professions students (Birks et al., 2009; Faguy, 2012; RuizAranda et al., 2014). For example, in a multi-center, multi-health professional survey of firstyear dental, nursing, and medical students in the United Kingdom, there was a moderate, indirect association between emotional intelligence and perceived stress (Birks et al., 2009). RuizAranda, Extremera, and Pineda-Galn (2014) also found a weak, indirect association between perceived stress and emotional intelligence in a sample of female physical therapy, nursing, and occupational therapy students. Most recently, McConville, McAleer, and Hahne (2017) conducted a systematic review of 19 articles involving MBI and stress among health professions students. They concluded that MBI supported stress reduction at a small-to-moderate treatment effect favoring the MBI groups, similar to the results of this type of intervention in undergraduate students (McConville et al., 2017). The culture of health professions programs often consists of an unhealthy work-life balance and is carried out in highly stressful academic and clinical environments. However, it may be moving towards a healthier approach (Kreitzer & Klatt, 2017), as evidenced by university programs encouraging self-care and mindfulness. Dobkin and Hutchinson (2013) reviewed 14 medical and dental schools offering some type of MBI, including class lectures, one-day workshops, and 8-10 week modules. They recommended inclusion in health professions program curriculum because MBI seems to positively influence stress in students regardless of variance in the type and duration of the instructional design (Dobkin & Hutchinson, 2013). Stress management and medical students. High stress levels among medical students have been concerning to medical educators for over a quarter-century (C. Cole, 1994). Researchers have reported high stress prevalence levels in the 50-60% range at various points in the matriculation process (Guthrie et al., 1998; Mosley et al., 1994). Dr. Ronald Epstein, an early PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 51 proponent of using MBI to address stress among physicians and medical students, published a seminal article on mindful practice describing five levels of mindfulness: Denial, Imitation, Curiosity, Insight, and Incorporation (Epstein, 1999). In that same year, Epstein also advocated for promoting student well-being in medical school curricula (Novack, Epstein, & Paulsen, 1999). Proponents of a Quadruple Aim health care approach advocate for increased efforts to improve provider well-beingparticularly through efforts to mitigate stress and reduce burnout in addition to the current, widely-accepted Triple Aim health care approach consisting of enhancing patient experiences, improving population health, and reducing costs (Bodenheimer & Sinsky, 2014; Bowles et al., 2018; Morrow et al., 2018). Some medical schools have developed multi-intervention stress management programs to address stress among medical students (Center for Mindfulness, n.d.; Mindful Practice, n.d.; Vanderbilt Medical School Wellness Program, n.d.). For example, Mindful Practice at the University of Rochester Medical Center offers different workshops and courses that include different stress management elements (e.g., MBI, resiliency) (Mindful Practice, n.d.). In an eight-week intensive program for primary care physicians that included MBI, there was a weak, indirect association between mindfulness and burnout, suggesting that mindfulness may decrease perceived stress (Krasner et al., 2009). Another example is Mind-Body Medicine (MBM) at Georgetown University School of Medicine, which promotes self-care and stress management, among other things, into the medical school curriculum. In this eleven-week elective course, students learn different MBI, including relaxation and slow, deep breathing techniques, guided imagery, and different forms of meditation (Mind-Body Medicine, n.d.). Using qualitative content analysis of answers from 82 students from the MBM course, the themes of stress relief emerged (Saunders et al., 2007). De Vibe et al., (2013) added to the research on stress management by finding moderate effect size and a number needed to treat of four from a sample PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 52 of medical and psychology students completing a seven-week MBI. Other researchers have found similar results of moderate effect size for a seven-week MBI (Shapiro SL, Schwartz GE, & Bonner G., 1998) and large effect size for a four-week MBI (Jain et al., 2007). Further supportive of MBI as a stress management strategy, second-year medical students participated in a ten-week MBI and demonstrated a small effect size in reducing stress (Rosenzweig, Reibel, Greeson, Brainard, & Hojat, 2003). However, in a 12-article review, Daya and Hearn (2018) found mixed evidence, with only seven articles offering support of MBI in reducing stress among medical students. Given the variance in the MBI content and duration (4-11 weeks) (Jain et al., 2007; Krasner et al., 2009; Rosenzweig et al., 2003; Shapiro SL et al., 1998), it is not surprising that Daya and Hearn (2018) found mixed evidence regarding MBI as a stress management strategy. Stress management and nursing students. Similar to physician leaders (Anandarajah et al., 2018; Bodenheimer & Sinsky, 2014), there is a movement among nursing leaders to address the stress-related issues among students (Alzayyat & Al-Gamal, 2014; Gibbons et al., 2011; Pryjmachuk & Richards, 2007; Pulido-Martos et al., 2012) and improve self-care through strategies such as stress management (Bowles et al., 2018). MBI is a stress management strategy that has also garnered attention for reducing stress levels among nursing students (Jain et al., 2007; Y. Song & Lindquist, 2015; van der Riet et al., 2018). In a 16-article review, van der Riet et al. (2018) concluded that MBI positively impacted stress among nurses and nursing students. More specifically, nursing students participating in an eight-week MBI consisting of stress management techniques of progressive-relaxation, meditation, and self-reflection. Researchers reported a 27% decrease in perceived stress compared to no change in a control group (Kang, Choi, & Ryu, 2009). Song and Lindquist (2015) also observed greater decreased stress among nursing students compared to the control group in a similar eight-week MBI, though both groups PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 53 experienced large decreases in perceived stress levels of (79% and 54% respectively) independent of the intervention effect. In an eight-week online, asynchronous MBI, researchers observed moderate decreases in perceived stress for MBI consisting of online progressive relaxation and different meditations including breathing, walking, and yoga (Spadaro & Hunker, 2016). Although the data trended towards a direct association between MBI practice frequency and perceived stress reduction (Spadaro & Hunker, 2016), formal statistical analyses were not performed, highlighting the need for more robust studies on this topic. In research comparing two types of stress management interventions, MBI and biofeedback, Ratanasiripong, Park, Ratanasiripong, and Kathalae (2015) found that although both MBI and biofeedback decreased anxiety, only MBI significantly decreased perceived stress (13%). Similar to the research involving medical students, MBI appears to be a promising stress management strategy for nursing students. Stress management and dental students. Similar to other medical education programs (Novack et al., 1999; Saunders et al., 2007), dental school curriculum has incorporated stress management interventions (Brondani, Ramanula, & Pattanaporn, 2014) to address high levels of stress among dental students (Abu-Ghazaleh et al., 2011; Gorter et al., 2008). Although the research on stress management interventions in dental school environments is not as robust as it is in medical and nursing education, a few strategies have been studied (A. K. H. Pau & Croucher, 2003; A. Pau et al., 2007; Sugiura, Shinada, & Kawaguchi, 2005). In two separate studies, Pau and colleagues (2003) found a significant, weak, indirect association between emotional intelligence and perceived stress (A. K. H. Pau & Croucher, 2003; A. Pau et al., 2007). These results align with prior studies that found moderate (Birks et al., 2009) and weak (RuizAranda et al., 2014) indirect associations between emotional intelligence and perceived stress in other health professions students. Echoing the recommendation of incorporating MBI in medical PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 54 school curriculum (Dobkin & Hutchinson, 2013), Lovas, Lovas, and Lovas (2008) advocated for incorporating MBI into the dental school curriculum at Dalhousie University to address stress among students and potentially carry-over as a stress management strategy in future clinical practice. Stress management and physical therapy students. In response to high levels of stress among physical therapy students (Dutta et al., 2005; Frank & Cassady, 2005; Ruiz-Aranda et al., 2014; Tucker et al., 2006), physical therapy educators are taking an evidence-based approach to incorporating stress management strategies into the curriculum (Willgens et al., 2016). There is, however, a dearth of research regarding stress management among physical therapy students and clinicians. In a preliminary randomized-control trial, there was a trend, but not a significant difference towards improved perceived stress in the intervention compared to the control group following a four-week resiliency program (Mejia-Downs, 2019). Based on participant interviews following a ten-week MBI program that included guided meditation and mindfulness, Willgens et al. (2016) summarized that participants were open to learning the MBI and found this stress management strategy beneficial. Furthermore, they recommended that MBI stress management techniques should be included in the physical therapy curricula. Providing further support for the benefit of MBI in physical therapy programs, Chambers et al. (2016) found significant improvements in blood pressure and perceived stress among students. By the end of the eightweek intervention, four of the 24 participants blood pressure readings moved from prehypertensive into healthy normal range, and students reported 26% lower perceived stress (Chambers et al., 2016). Van Veld et al. (2018) used a mixed methods approach to champion the importance of coping skills development. Also using a mixed methods approach, but in nursing education, Reeve, Shumaker, Yearwood, Crowell, and Riley (2013) furthered the discussion of PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 55 coping methods as a viable stress methods strategy by concluding that active coping methods (e.g., social support) improved students ability to cope with stress. Researchers have considered the role that different coping strategies (e.g., task-oriented, emotion-oriented) may play in stress management (Mahmoud et al., 2015; Reeve et al., 2013; Sheilds, 2001; Van Veld et al., 2018; Willgens & Hummel, 2016). However, this line of research is not yet well-formed and is just beginning to coalesce. Future research recommendations include prospective, longitudinal studies testing the efficacy of curriculum focused on developing adaptive coping skills in improving the stress management of physical therapy students (Barbosa et al., 2013; Van Veld et al., 2018; Willgens & Hummel, 2016). Stress management summary. In summary, in response to high stress levels among health professions students (Almojali et al., 2017; Birks et al., 2009; C. Cole, 1994; Dutta et al., 2005; Elani et al., 2014; Frank & Cassady, 2005; Frazer & Echternach, 1991; Gibbons et al., 2008; Jacob et al., 2012; Ruiz-Aranda et al., 2014; Tisdelle et al., 1984), researchers are exploring the effectiveness of different stress management strategies such as holistic, multifaceted programs (Center for Mindfulness, n.d.; Mindful Practice, n.d.; SMART Lab, n.d.; Vanderbilt Medical School Wellness Program, n.d.; Drolet & Rodgers, 2010), mindfulness-based interventions (Bamber & Kraenzle Schneider, 2016; De Vibe et al., 2013; Galante et al., 2018; Greeson et al., 2014; McConville et al., 2017; Warnecke, Quinn, Ogden, Towle, & Nelson, 2011), emotional intelligence development (Birks et al., 2009; Faguy, 2012; Ruiz-Aranda et al., 2014), effective coping strategies (Mahmoud et al., 2015; Reeve et al., 2013; Van Veld et al., 2018) and resiliency training (Mejia-Downs, 2019). MBIs such as mindfulnessbased stress reduction (Bamber & Kraenzle Schneider, 2016; McConville et al., 2017; van der Riet et al., 2018), emotional intelligence development (Birks et al., 2009; Ruiz-Aranda et al., 2014), and effective coping strategies (Mahmoud et al., 2015; Reeve et al., 2013; Sheilds, 2001; PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 56 Van Veld et al., 2018) may be promising stress management strategies for both undergraduate and health professions students. To address the call for improved stress management among these current students and future health professionals (Anandarajah et al., 2018; M. Cox et al., 2017; Kreitzer & Klatt, 2017), health professions programs are adding elements of stress management into the curricula that range from lectures (Morrow et al., 2018) and modules of varying lengths (Krasner et al., 2009; MBSR, n.d.; Mindful Practice, n.d.) to full, elective courses (Mind-Body Medicine, n.d.; Saunders et al., 2007). More research is needed to fully understand the relative benefits of each of these different approaches as applied to health professions programs. Summary Most researchers conceptualize perfectionism as a bidimensional construct consisting either of Adaptive and Maladaptive Perfectionism (Ashby & Gnilka, 2017; Ashby et al., 2012; Rice & Ashby, 2007) or of strivings and concerns (Frost et al., 1993; Gaudreau & Thompson, 2010; Stoeber & Otto, 2006). Through the lens of the Perfectionism Acceptance Theory, Adaptive Perfectionism is striving for excellence and accepting non-perfection, whereas Maladaptive Perfectionism is demanding perfection coupled with not accepting imperfection (Lundh, 2004). Unsurprisingly, demanding perfection and not accepting imperfection (Lundh, 2004) may result in high levels of stress (Ashby & Gnilka, 2017; Bks et al., 2015; Bieling et al., 2004; E. C. Chang & Rand, 2000; Flett et al., 2016; Molnar et al., 2012; Rice & Van Arsdale, 2010). High stress levels are detrimental for a variety of reasons, and sequelae can include a higher risk of cardiovascular disease (Chida & Steptoe, 2010; Dimsdale, 2008; Nabi et al., 2013; Sheps et al., 2002; H. Song et al., 2019; Spruill, 2010), obesity (Brunner et al., 2007; Sinha & Jastreboff, 2013), poor sleep quality (Almojali et al., 2017; Amaral et al., 2018; Galambos et al., 2013; Vincent & Walker, 2000), and an increased cellular aging rate (Ridout et al., 2019). PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 57 This is concerning to health professions educators and researchers, since stress levels among health professions students have remained stubbornly high for more than a quarter of a century (Almojali et al., 2017; Alzayyat & Al-Gamal, 2014; Chambers et al., 2016; C. Cole, 1994; Elani et al., 2014; Frazer & Echternach, 1991; Henning et al., 1998; Tisdelle et al., 1984). Additionally, health professional organizations and academic accrediting bodies are calling for increased focus on provider self-care to mitigate burnout issues among health care professionals (Anandarajah et al., 2018; Bodenheimer & Sinsky, 2014; Bowles et al., 2018; M. Cox et al., 2017; Kreitzer & Klatt, 2017). To address this concern, innovative educational design targeting stress management strategies such as MBIs (Bamber & Kraenzle Schneider, 2016; De Vibe et al., 2013; Galante et al., 2018; Greeson et al., 2014; McConville et al., 2017; Warnecke et al., 2011), emotional intelligence development (Birks et al., 2009; Faguy, 2012; Ruiz-Aranda et al., 2014), effective coping strategies (Mahmoud et al., 2015; Reeve et al., 2013; Van Veld et al., 2018), and resiliency training (Mejia-Downs, 2019) are being incorporated into the curricula of health professions programs (Daya & Hearn, 2018; Dobkin & Hutchinson, 2013; Galante et al., 2018; Krasner et al., 2009; Kreitzer & Klatt, 2017; Saunders et al., 2007). Researchers have examined perfectionism (M. Enns et al., 2001; Henning et al., 1998; Hill & Curran, 2016; Lloyd, Schmidt, Khondoker, & Tchanturia, 2015; Seeliger & Harendza, 2017; M. Smith et al., 2016), stress (Beiter et al., 2015; A. Enns et al., 2018; Jacob et al., 2012; Robotham, 2008; Silverstein & Kritz-Silverstein, 2010), and stress management (Bamber & Kraenzle Schneider, 2016; Chambers et al., 2016; Daya & Hearn, 2018; De Vibe et al., 2013; Lovas et al., 2008; A. Pau et al., 2007; Shapiro SL et al., 1998; van der Riet et al., 2018; Van Veld et al., 2018) in different non-clinical adult populations including undergraduate students and, to some degree, in health professional programs. However, the body of available literature specific to graduate health professions programs remains limited. There are many remaining PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 58 gaps in the knowledge of how perfectionism, stress perception, and stress management interact in health professions students. Given that Maladaptive Perfectionism was one of the strongest predictors of distress among medical students (Henning et al., 1998), it is critical to examine the prevalence of perfectionism and its impact on other groups. As the entry-level degree for a physical therapist has become more rigorous over the past 30 years (Plack & Wong, 2002), so has the rigor of admittance to DPT programs (PTCAS, 2019). With an applicant pool approaching 20,000 and the number of seats in DPT programs just over 10,000 (PTCAS, 2019), some students may feel the need to strive for perfectionism in order to be considered for admittance. This may result in higher stress levels while matriculating through physical therapy school. This is concerning because if these students do not learn effective stress management strategies while in school, they may be more susceptible to burnout as practicing physical therapists. A better understanding of how perfectionism, stress perception, and stress management interact may assist educators with identifying students at risk for deleterious effects of stress. Additionally, this may support the development of curriculum to teach stress management skills. All of which may ultimately result in healthier, happier students. Chapter 3: Method Study Design Investigators conducted a non-experimental study using a single-site, cross-sectional design. Students currently enrolled at the University of North Texas Health Science Center (UNTHSC) in the DPT program in Fort Worth, TX, between the dates of January 1, 2019 and July 31, 2019 (Spring and/or Summer and/or Fall semester 2019 and Classes of 2019-2022) were eligible to be included in the study. The study consisted of an online survey and results from an emotional intelligence assessment administered as part of program requirements. The PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 59 Institutional Review Board at UNTHSC approved the study, and a reliance agreement from the University of Indianapolis was put in place prior to any data collection. Participants Investigators recruited a convenience sample from the first, second, and third-year DPT students enrolled at UNTHSC. Inclusion criteria for study participation included full-time enrollment as a first-, second-, or third-year student in the DPT program at UNTHSC. Students enrolled part-time in the UNTSHC Physical Therapy program were excluded. Investigators calculated an a priori sample size using a G*Power (Version 3.1.9.2; Faul, Erdfelder, Lang, & Buchner, 2007). The effect size was based on a previously reported effect size of .57 among undergraduate students (Rice & Ashby, 2007). Based on conducting an ANOVA test and the following input parameters: effect size of .50, an alpha of .05, and a power of .80, with two degrees of freedom, and three groups, a sample size of at least 42 was recruited. Data During the Spring, Summer and/or Fall 2019 semester, investigators collected participant name, demographics (year in program, gender description, age, and race/ethnicity/origin description), perfectionism score, and perceived stress scores. As part of a campus-wide emotional intelligence initiative, students completed the Emotional Quotient Inventory 2.0 (EQi) during Spring, Summer, and/or Fall 2019 semester. This tool has a Stress Management composite that was utilized for this project. Investigators collected all survey data via a secure online data collection platform. All data was downloaded, cleaned, and imported into IBM SPSS Statistics for Macintosh, Version 21.0 (IBM Corp., Armonk, NY) for analysis. Operationalization of variables. For this study, the Almost Perfect Scale-Revised (APSR) measured perfectionism; the 10-question Perceived Stress Scale (PSS-10) measured PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 60 perceived stress; and, the Stress Management composite score from the EQi measured stress management. These are all self-report tools. The APSR measured perfectionism (Slaney et al., 2001). Investigators classified participants who score less than 42 on the APSR High Standards (APSR-HS) subscale as NonPerfectionists. They also classified participants scoring at least 42 on the APSR-HS subscale and less than 42 on the APSR Discrepancy (APSR-D) subscale as Adaptive Perfectionists. Additionally, they classified participants scoring at least 42 on the APSR-HS subscale and at least 42 on the Discrepancy APSR-D subscale as Maladaptive Perfectionists (Rice & Ashby, 2007). The EQi Stress Management (EQi-SM) composite score measured stress management (MHS, 2011b). The EQi contains five composite scores, 15 constructs, and 133 items scored on a five-point Likert scale. It is one of the more widely used self-report measures of emotional intelligence (Faguy, 2012). Investigators used the EQi-SM composite consisting of the Flexibility, Stress Tolerance, and Optimism constructs. This composite is scaled, such that a score of 100 or greater indicates a higher-use skill, and scoring less than 100 indicates a loweruse skill (MHS, 2011c). The updated EQi and the original version have sound reliability and validity (Bar-On, 2004; MHS, 2011b). The PSS-10 measured perceived stress (Cohen & Williamson, 1988). The PSS-10 is used to measure the frequency of perceived stress over the past month. For the PSS-10, scores range 0 to 40 with higher scores indicating higher levels of perceived stress. Because the PSS-10 is not a diagnostic tool, there are no cut-off scores established (Cohen & Williamson, 1988). Instruments The APSR, the EQi-SM, and the PSS-10 measured perfectionism, stress management, and perceived stress, respectively. The APSR is available for research use only. UNTHSC is PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 61 using the EQi as part of an emotional intelligence educational initiative. Investigators documented permission of use for both instruments. The PSS-10 is available at no charge for non-commercial research purposes. The investigators completed a formal request and documented permission of use (See Appendices B and C). Although none of the tools below have been validated specifically for DPT students, they have been validated on undergraduate populations. Almost Perfect Scale-Revised. The APSR has 23 items, and this measure includes Discrepancy, High Standards, and Order subscales. The authors have granted permission of use for the APSR in research studies (See Appendix B). Psychometric properties have been established for the APSR among multiple undergraduate populations. Slaney et al. (2001) used samples from three different U.S. universities totaling over 800 students with the mean ages ranging from 19.23 and 21.00. In a different sample of nearly 200 U.S. students with a mean age of 20.30, Suddarth and Slaney (2001) also established psychometrics for the APSR. In a sample of almost 300 students with a mean age of 19.87, Grzegorek, Slaney, Franze, and Rice (2004) studied psychometric properties. Rice and Aldea (2006) used a sample of more than 100 students with a mean age of 19.42. Additionally, Ashby, Rice, and Martin (2006) established psychometric properties in a sample of over 200 U.S. undergraduate students with a mean age of 22.92. For comparison purposes for the outcome measures, the average age of the accepted DPT student was 22.96 (PTCAS, 2019). Although the APSR has not previously been validated using a sample of DPT students, the mean age of physical therapy students and the mean ages from the validation samples are comparable. In addition to comparable ages between the DPT students and the samples used in validation studies, this sample was also higher education students and, therefore, should have similar life demands and responsibilities as the samples used for tool validation. PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 62 Using Cronbachs alpha, multiple researchers have reported good to excellent internal consistency for the APSR subscales (Ashby & Rice, 2002; Grzegorek et al., 2004; Rice & Aldea, 2006; Slaney et al., 2001). For example, the subscales ranged from .85 to .92 (Slaney et al., 2001), .84 to .93 (Ashby & Rice, 2002), .82 to .92 (Grzegorek et al., 2004), and .89 to .96 (Rice & Aldea, 2006). Regarding concurrent validity, the APSR-HS subscale correlated with the SelfOriented Perfectionism subscale (HMPS) at .64 and .55 (Slaney et al., 2001) as well as .66 (Suddarth & Slaney, 2001). Additionally, the APSR-HS subscale correlated with the Personal Standards subscale (FMPS) at .64 (Slaney et al., 2001) and .61 (Suddarth & Slaney, 2001). The APSR-D subscale correlated with the Concerns Over Mistakes subscale (FMPS) at .55 (Slaney et al., 2001), .67 (Suddarth & Slaney, 2001), and .76 (Ashby et al., 2006) as well as with the Doubts About Actions subscale (FMPS) at .62 (Slaney et al., 2001), .66 (Suddarth & Slaney, 2001), and .91 (Ashby et al., 2006). Additionally, the APSR-D subscale correlated with the Socially-Prescribed Perfectionism subscale (HMPS) at .64 (Suddarth & Slaney, 2001). Test-retest reliability has been established for this measure among U.S. undergraduate students. Grzegorek, Slaney, Franze, and Rice (2004) found adequate subscale correlations over a three week period:.72 for APSR-HS, .92 for APSR-D, and .80 for Order. Additionally, Rice and Aldea (Rice & Aldea, 2006) produced test-retest reliability over an 8-10 week period in a sample of greater than 100 students of .76 to .87 for the APSR subscales. Emotional Quotient Inventory 2.0. The authors and distributors of the EQi reported data collection on over 10,000 participants in 2009-2010 in order to establish validity and reliability. The authors reported sound reliability with high internal consistency and test-retest reliability (MHS, 2011b). The internal consistency (Cronbach alpha) for the total score was .97, the range for the five composite scores was .88 to .93, and all subscales were at least .77 (MHS, 2011b). Specifically, the EQi-SM internal consistency for the 18-29 year-old normative group PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 63 was .90 (overall internal consistency was .92). Furthermore, internal consistency of the EQiSM subscales for the 18-29 year-old normative group was as follows: Flexibility .78 (overall internal consistency was .80), Stress Tolerance .86 (overall internal consistency was .87), and Optimism .88 (overall internal consistency was .89) (MHS, 2011a). Additionally, test-retest ranged .81 to .92 for the total score, composite test-retest scores ranged from .83 to .91, and subscale scores ranged from .70 to .89 (MHS, 2011b). Specifically, the EQi-SM test-retest was .90 for 2-4 weeks and .78 for 8 weeks. Furthermore, test-retest of the EQi-SM subscales was as follows: Flexibility .85 for 2-4 weeks and .70 for 8 weeks, Stress Tolerance .85 for 2-4 weeks and .75 for 8 weeks, and Optimism .88 for 2-4 weeks and .80 for 8 weeks (MHS, 2011a). Additionally, the creators reported appropriate content validity, correlations, and expected differences among different groups (MHS, 2011c). Confirmatory Factor Analysis results for the EQi-SM were as follows: Goodness of Fit Index .94, Adjust Goodness of Fit Index .91, Normed Fit Index .94, Non-Normed Fit Index .93, Comparative Fit Index .95, and Root Mean Square Error of Approximation .08 (MHS, 2011a). Correlations between the EQi composites were appropriately sized, indicating the assessment of a common characteristic, but not so high as to indicate measurement redundancy. The correlations between the EQi-SM and the other composites of the EQi were as follows: Self-Perception .78, Self-Expression .67, Interpersonal .63, and Decision Making .73. As for the correlations of the EQi-SM Subscales (Flexibility, Stress Tolerance, Optimism), these ranged from .48 - .58 (MHS, 2011a). For construct validity, specifically convergent validity, the EQi showed strong correlations with the original Emotional Quotient Inventory (Bar-On, 2004) total score (.90) and for the subscales of the EQi-SM (.67-.79; MHS, 2011a). In comparison with the Social Skills Inventory, which measures emotional and social communication skills (Riggio & Carney, 2003), the total score of the EQi showed a moderate correlation of .54 with the total score from the PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 64 Social Skills Inventory. Additionally, the EQi-SM showed a moderate correlation of .59 with the Total Control Scale and no correlation (-.03) with the Total Sensitivity Scale from the Social Skills Inventory (MHS, 2011a). In comparison with the Mayer-Salovey-Caruso Emotional Intelligence Test, which measures abilities relating to emotional intelligence (Mayer, Salovey, Caruso, & Sitarenios, 2003), the total score of the EQi showed only a weak correlation of .12 with the total score from the Mayer-Salovey-Caruso Emotional Intelligence Test. Additionally, the EQi-SM showed only a weak correlation of .14 with the Managing Emotions branch score from the Mayer-Salovey-Caruso Emotional Intelligence Test (MHS, 2011a). In summary, the EQi has proven to be a valid and reliable measure of emotional intelligence, including the EQi-SM score (MHS, 2011b, 2011c, 2011a). The EQi-SM score demonstrated appropriate internal consistency for the 18-29 year-old normative group as well as appropriate test-retest reliability at both 2-4 weeks and eight-week timeframes (MHS, 2011a). Additionally, the validity of the EQi-SM reflected appropriate convergence with similar measures (MHS, 2011b). Perceived Stress Scale. The PSS-10 was used for this study. The authors have granted permission of use for the PSS-10 in academic research studies (See Appendix C). Internal consistency reported using Cronbachs alpha was reported as good to excellent in three different samples from U.S. students with mean ages of 23.80, 20.23, and 22.44, respectively. The total scores were .89 (Roberti, Harrington, & Storch, 2006), .85 (Chao, 2012), and .92 (Deatherage, Servaty-Seib, & Aksoz, 2014). Roberti et al. (2006) also explored convergent validity between the PSS-10 and the State-Trait Anxiety Inventory-Trait Version (STAI-T) and reported that the PSS-10 correlated with STAI-T: Total score at .73, STAI-T: Anxiety subscale at .59, and STAIT: Depression subscale at .72. Procedures PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 65 Recruitment. Participants were recruited from UNTHSC DPT cohorts from the classes of 2019-2022. Participants completed the surveys at their convenience using an internetconnected device. Using the online learning management system and university-issued email addresses, potential participants were provided information regarding the overview and purpose of the research as well as links to access the survey. Recruitment was timed with the administration of the EQi, which is part of a university-wide initiative and occurred during the Spring, Summer, and Fall 2019 semesters. Informed consent. As part of the online platform housing the surveys, the potential participants were initially required to consent to participate via a consent form housed on a secure online data collection portal (e.g., Qualtrics, REDCap) (see Appendix D) prior to having access to the surveys. They had the option to agree to or decline participation in this study. Only after the potential participant indicated their consent/agreement by checking a box at the end of the survey, were they able to access the survey questions. Testing procedures. All outcomes data and demographics were collected using online surveys distributed through a secure online data collection portal (e.g., Qualtrics, REDCap). The APSR and the PSS-10 surveys were counterbalanced; however, the order of items on each tool was not counterbalanced. The EQi, including the EQi-SM, was completed previously as part of the unrelated emotional intelligence initiative. Participants accessed the online surveys through a web address or QR code and that was distributed to the participants via posting the link into an announcement on the online learning management system provided by UNTHSC. Participation was voluntary and could be discontinued at any time. Because the items of PSS-10 use a timeframe of the past month, the PSS-10 and APSR were available to participants for 30 days from the date of administration of the EQi. Any survey that was not completed was discarded and not included in the analysis. Any completed survey was considered for at least descriptive PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 66 statistical analysis; however, was not included in the correlational analysis if not all three surveys are completed. The EQi-SM was used for correlational analysis with perfectionism and perceived stress in this study. Students had the opportunity to complete the EQi in the Physical Therapy Department at UNTHSC. It takes 20-30 minutes to complete (MHS, 2011c). Both the APSR and PSS-10 are estimated to take 5-10 minutes each. Data Management Participant names and data were confidentially collected and managed using a secure online data collection portal (e.g., Qualtrics, REDCap). Since participants provided names and took the EQi at a different time than APSR and PSS-10, data were collected with an identifier (student name) so that survey results and EQi scores could be linked. An independent coder assigned unique identifiers to the data so that members of the research team conducting analyses were blinded to students EQi scores. Researchers conducting data collection involving the EQiSM provided participants these results per their protocol, including following up with a certified coach upon request. Researchers placed individual results from the APSR and PSS-10 in envelopes with the corresponding assigned unique identifier. Using the assigned unique identifier, participants can obtain APSR and PSS-10 results from administrative personnel upon request as well. The participant report included the raw scores for both surveys, description of the PSS-10 tool, and the APSR classification of Adaptive or Maladaptive Perfectionist, including the scoring cut-offs. See the operationalization of variables section for details. Additionally, the participant report included contact information for campus wellness services. Individuals who consented to participate in the study accessed the surveys via a URL. Data stored on a secure online data collection portal (e.g., Qualtrics, REDCap) was accessible only to the listed key personnel specifically designated and authorized by the Principal PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 67 Investigator. Data were downloaded from the secure online data collection portal (e.g., Qualtrics, REDCap) in password-protected files and stored on UNTHSC secure servers only accessible to authorized study personnel. All personnel were properly trained and supervised regarding the management and handling of confidential materials. Data collected from participants who withdrew, or were withdrawn, was destroyed. At the completion of this research, all data will be destroyed. The Principal Investigator assumes full responsibility for such training, supervision, and conduct. Data Analysis Descriptive statistics were used to describe the sample (e.g., age, year in program, gender identification, and race/ethnicity/origin description). In addition, student characteristics and outcomes (APSR, EQi, and PSS-10) were compared by student year to test for differences. If verified as similar, then their data was combined for analysis. Nominal data were reported as frequencies and percentages. Interval and ratio data were presented as means and standard deviations when they were normally distributed, or medians and interquartile ranges when they were non-normally distributed. All comparisons were two-tailed, and a significance level of less than .05 was considered statistically significant. The investigators used pairwise deletion to exclude participant data from research question one data analysis when any student characteristic data was missing. For the PSS-10, investigators used pairwise deletion for research question two unless at least 80% of the items were completed. When a participant completed at least 80%, but less than 100% of the PSS-10 items, then investigators used average imputation for the missing data and included the data in data analysis. The missing data plan for the APSR was similar; however, a participant must complete at least 80% of the items on both the APSR-HS and the APSR-D subscales to be included. When either subscale was less than 80% of the items completed, then the investigators PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 68 used casewise deletion to exclude participant data from all analyses because all research questions include perfectionism in the analysis. RQ1: Was there a statistically significant difference in perfectionism level as measured on the APSR-HS subscale by student characteristic (year in program, gender description, and race/ethnicity/origin description) among DPT students at a public university in Texas? For research question one, investigators used a three-way ANOVA test (e.g., factorial ANOVA) to compare student characteristics. Test assumptions for this test included only one continuous level dependent variable; three independent variables with each consisting of at least two categorical, independent groups; independence of observations; no significant outliers in any cell; approximately normal distribution for each cell of the dependent variable; and homogeneity of variances. Boxplots identified significant outliers, the Shapiro-Wilk test determined normality of data, and the Levenes test assessed equality of variance (Field, 2014a; Kellar & Kelvin, 2013a). When boxplots indicated significant outlier(s), the analysis continued with and without the outlier(s) to determine if the outlier(s) substantially affected the results. If significant outlier(s) did not significantly impact results, then results included the outlier(s). However, if the outlier(s) substantially affect the results, then a less extreme value (e.g., the next largest value) replaced the outlier(s), and data analysis continued. If, after modification of the significant outlier(s), the data remained non-normally distributed and/or lacked homogeneity of variance, then the investigators transformed all data for this variable and re-ran the tests of assumption. If the transformed outlier(s) still substantially affected the results, then the investigators did not include the outlier(s) in the analysis (Field, 2014e). RQ1a: Was student characteristic predictive of perfectionism subtype (Adaptive or Maladaptive) among DPT students at a public university in Texas? PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 69 For research question 1a, investigators used a binomial logistic regression to determine if student characteristic was predictive of perfectionism subtype. This binomial regression analysis was exploratory only and was secondary to answering the primary research question. Test assumptions for this test included only one, dichotomous dependent variable; at least one independent variable that was continuous or nominal; independence of observations and the dependent variable as well as all nominal independent variables were mutually exclusive; at least 15 cases per independent variable; linearity between any continuous independent variables and the logit transformation of the dependent variable; no multicollinearity present among independent variables; and no significant outliers. The Shapiro-Wilk test determined the normality of data and the Tolerance Collinearity Statistics table assessed for multicollinearity among independent variables. Additionally, Casewise Diagnostics tested for outliers (Field, 2014b; Kellar & Kelvin, 2013b). Researchers used tests of assumption to determine which independent variables to include in the regression analysis. Researchers applied a Bonferroni correction to all five independent variables resulting in a statistical significance being accepted when p < .01 (Tabachnick & Fidell, 2014). Any independent variable that failed to meet this threshold was not be included in the regression model. Researchers used a bivariate correlation to assess the assumption of multicollinearity. When Pearsons r was less than .85, investigators assumed no multicollinearity issues among independent variables. However, when Pearsons r was .85 or greater between two independent variables, the independent variable that had a weaker correlation with the dependent variable was excluded. RQ2: Were there statistically significant associations between perfectionism level as measured on the APSR-HS and perceived stress as measured by the PSS-10 among students enrolled in a DPT program at a public university in Texas? PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 70 For research question two, investigators completed a bivariate correlation to determine associations between perfectionism level and perceived stress. A Scatterplot determined the linearity of data and outliers. The Shapiro-Wilk test determined normality of data. When residuals were normally distributed, then investigators assumed homoscedasticity. The Pearsons correlation analyzed linear data that were normally distributed with homoscedasticity and no significant outliers. The Spearman Rho analyzed linear data with significant outliers. Finally, a Phi Correlation analyzed non-linear data. RQ2a: Was perceived stress predictive perfectionism subtype among students enrolled in a DPT program at a public university in Texas? For research question 2a, investigators used a binomial logistic regression to determine if perceived stress was predictive of the perfectionism subtype. This binomial regression analysis was exploratory only and was secondary to answering the primary research question. Test assumptions for this test included only one, dichotomous dependent variable; at least one independent variable that was continuous or nominal; independence of observations and the dependent variable as well as all nominal independent variables were mutually exclusive; at least 15 cases per independent variable; linearity between any continuous independent variables and the logit transformation of the dependent variable; no multicollinearity present among independent variables; and no significant outliers. The Shapiro-Wilk test determined normality of data and the Tolerance Collinearity Statistics table assessed for multicollinearity among independent variables. Additionally, Casewise Diagnostics tested for outliers (Field, 2014b; Kellar & Kelvin, 2013b). Researchers used tests of assumption to determine which independent variables to include in the regression analysis. Researchers applied a Bonferroni correction to all five independent variables resulting in a statistical significance being accepted when p < .01 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 71 (Tabachnick & Fidell, 2014). Any independent variable that failed to meet this threshold was not be included in the regression model. Researchers used a bivariate correlation to assess the assumption of multicollinearity. When Pearsons r was less than .85, investigators assumed no multicollinearity issues among independent variables. However, when Pearsons r was .85 or greater between two independent variables, the independent variable that had a weaker correlation with the dependent variable was excluded. RQ3: Were there statistically significant associations between perfectionism level as measured on APSR-HS and stress management as measured by the EQi-SM score among students enrolled in a DPT program at a public university in Texas? For research question three, investigators completed a bivariate correlation to determine associations between perfectionism level and stress management. A Scatterplot determined the linearity of data and outliers. The Shapiro-Wilk test determined the normality of data. When residuals were normally distributed, then investigators assumed homoscedasticity. The Pearsons correlation analyzed linear data that were normally distributed with homoscedasticity and no significant outliers. The Spearman Rho analyzed linear data with significant outliers. Finally, a Phi Correlation analyzed non-linear data. RQ3a: Was stress management predictive of perfectionism subtype among students enrolled in a DPT program at a public university in Texas? For research question 3a, investigators used a binomial logistic regression to determine if stress management was predictive of the perfectionism subtype. This binomial regression analysis was exploratory only and was secondary to answering the primary research question. Test assumptions for this test included only one, dichotomous dependent variable; at least one independent variable that was continuous or nominal; independence of observations and the dependent variable as well as all nominal independent variables were mutually exclusive; at least PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 72 15 cases per independent variable; linearity between any continuous independent variables and the logit transformation of the dependent variable; no multicollinearity present among independent variables; and no significant outliers. The Shapiro-Wilk test determined the normality of data and the Tolerance Collinearity Statistics table assessed for multicollinearity among independent variables. Additionally, Casewise Diagnostics tested for outliers (Field, 2014b; Kellar & Kelvin, 2013b). Researchers used tests of assumption to determine which independent variables to include in the regression analysis. Researchers applied a Bonferroni correction to all five independent variables resulting in a statistical significance being accepted if p < .01 (Tabachnick & Fidell, 2014). Any independent variable that failed to meet this threshold was not be included in the regression model. Researchers used a bivariate correlation to assess the assumption of multicollinearity. If Pearsons r was less than .85, investigators assumed no multicollinearity issues among independent variables. However, if Pearsons r was .85 or greater between two independent variables, the independent variable that had a weaker correlation with the dependent variable was excluded. Chapter 4: Results A total of 163 (91.56%) students enrolled in a DPT program at a public university in Texas consented to participate in this study. Only one participant did not select male or female for gender description and was excluded only during analyses involving gender categories. Additionally, three participants had decelerated in the program and had previously taken the EQi-SM composite. Since their experiences may have qualitatively differed from their current classmates, their data were excluded during analyses involving the EQi-SM composite. Two of the participants who decelerated did not complete the PSS-10 or the APSR. Therefore, their data were excluded from all analyses. The other student who decelerated completed the PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 73 PSS-10 and APSR. Since that participant had not previously taken those measures, those data were included in analysis involving PSS-10 and APSR. Table 2 lists each cohorts overall participation rates. For nominal data (e.g., gender description, race/ethnicity/origin description, and perfectionism category), investigators used chi-square tests of independence to determine if there were between group differences among the following cohorts of students enrolled in a DPT program: beginning first-year students (Y0), ending first-year students (Y1), ending second-year students (Y2), and ending third-year students (Y3). The investigators visually inspected the histograms to screen the data for outliers. The Shapiro-Wilk Test of normality revealed that the distribution of scores for neither the APSR-HS, APSR-D, PSS-10, nor EQi-SM composite were normally distributed at a p = .05 level among all student cohorts. Using APSR-D as an example, Y0 (p = .19), Y1 (p = .20), and Y2 (p = .20) were normally distributed; however, Y3 (p < .01) was not. Therefore, investigators used Kruskal-Wallis tests to determine if there were between group differences among the same cohorts of students. General Participant Characteristics The sample of 163 students reported being predominately female (66.26%), White (61.96%), from a suburban community (63.19%), with a mean age of 24.36 years. Tables 2 and 3 contain additional sample demographics. Gender description. Participants selected one of five options for gender description: male, female, transgender, not identified, and prefer no answer. All but one student selected male or female. At an alpha of .05, the Pearson chi-square test X2 (3, N = 162) = 3.02, p = .39 indicated that there was no statistical difference in self-reported gender categories between these four student cohorts. The overall effect size was small (d = .28). Since there were only two groups (male and female), a pair-wise post hoc analysis was not justified. For this sample overall, 66.26% identified as women, 33.13% as men, and 0.61% preferred not to PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 74 answer. For comparison, national averages for DPT students were 61.75% women, 38.21% men, and .05% other/no answer (Commission on Accreditation in Physical Therapy Education [CAPTE], 2019). Additional national averages for accepted DPT applicants were 61.36% women, 38.55% men, and .09% declined to answer (PTCAS, 2019). Race/Ethnicity/Origin description. The race/ethnicity/origin description category consisted of White, Hispanic, Latino, or Spanish Origin, Black or African American, Asian, American Indian or Alaska Native, Middle Eastern or North African, Native Hawaiian or Pacific Islander, and Some other race, ethnicity, or origin. However, no students selected Native Hawaiian or Pacific Islander. Additionally, the White and Hispanic, Latino, or Spanish Origin categories were the only cells that consistently reached the five-case threshold. Therefore, the self-reported race/ethnicity/origin description categories were collapsed into White and Other. Table 3 contains race/ethnicity/origin description details. At an alpha of .05 level, the Pearson chi-square test X2 (3, N = 163) = 1.09, p = .78 indicated that there was no statistical difference in self-reported ethnicity, race, and origin (White, Other) categories between these four student cohorts. The overall effect size was small (d = .16). Since there were only two groups (White, Other), a pair-wise post hoc analysis was not justified. An alpha of .05 revealed no significant between cohort differences among White and Other categories. For this sample overall, 61.96% self-reported as White or Caucasian, 15.34% as Hispanic, Latino, or Spanish, 9.20% as Asian, 4.91% as Black or African-American, and 6.75% selected more than one category. For comparison, national averages for DPT students were 74.57% self-reported as White or Caucasian, 6.53% as Hispanic, Latino, or Spanish, 8.91% as Asian, and 3.39% as Black or African-American. Data for Two or more races were not available (CAPTE, 2019). Additional national averages for accepted DPT applicants were 69.88% self-reported as White or Caucasian, 8.38% as Hispanic, Latino, or Spanish, 9.26% as PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 75 Asian, 3.56% as Black or African-American, and 3.13% as 2+Race/Ethnicity Designations (PTCAS, 2019). Participant Outcome Measures Perfectionist type. The APSR has 23 items and includes Discrepancy, High Standards, and Order subscales. The investigators used previous scoring cut-offs involving the interaction of the APSR-D and APSR-HS subscales to categorize participants as Adaptive or Maladaptive Perfectionist (Rice & Ashby, 2007). Appendix A conceptually describes the categorization of Adaptive, Maladaptive, or Non-Perfectionist (see the Operationalization of Variables section in Chapter III for details). Since these data (n = 163) are considered at a nominal level, a nonparametric chi-square test was used to determine if there was a between-groups difference in perfectionist type among student cohorts. At an alpha of .05 level, the Pearson chi-square test X2 (6, N = 163) = 10.07, p = .12 indicated that there was no statistical difference in perfectionist type between the four student cohorts. The overall effect size was medium (d = .51). Pair-wise post hoc analysis, with the Fishers exact test and Bonferroni correction at an adjusted alpha < .02, revealed no significant between cohort differences among perfectionist type categories. Table 4 contains perfectionist type details. Almost Perfect Scale Revised High Standards. The APSR-HS is a subscale of the APSR and has seven items ranging in score from 7-49. Scores less than 42 were categorized as Non-Perfectionists, and scores 42 and greater were categorized as Perfectionists (Rice & Ashby, 2007). Appendix A conceptually describes the role of APSR-HS in categorizing a participant as a Perfectionist or Non-perfectionist (see the Operationalization of Variables section in Chapter III for details). Since the data (n = 163) were not normally distributed, a non-parametric Kruskal Wallis test was used to determine if there was a between group difference in APSR-HS subscale scores. The APSR-HS subscale median score for Y0 was 46.0, for Y1 was 43.0, for Y2 was 42.0, PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 76 and for Y3 was 43.0. Table 5 contains APSR-HS details. The Kruskal Wallis test, X2 (3, N = 163) = 11.72, p =.01 indicated there was a significant difference in APSR-HS subscale scores between cohorts of students. The overall effect size was medium (d = .56). The pair-wise post hoc analysis, with the Mann-Whitney U test and the Bonferroni correction at an adjusted alpha < .01 revealed differences in APSR-HS subscale scores between Y0 and Y2 only. The median difference of 4.0 between starting Y0 and Y2 and the reported Mann-Whitney U test p value of < .01 indicated statistical difference. There were no differences in APSR-HS subscale scores between any other cohorts of students. Almost Perfect Scale Revised Discrepancy. The APSR-D is a subscale of the APSR and has 12 items ranging in score from 12-84. After the APSR-HS was used to categorize a participant as a Perfectionist, then the APSR-D can further categorize the Perfectionists as an Adaptive Perfectionist if the APSR-D score was less than 42 or Maladaptive Perfectionist if the APSR-D score was 42 and greater (Rice & Ashby, 2007). Appendix A conceptually describes the role of APSR-D in categorizing a participant as an Adaptive or Maladaptive Perfectionist (see the Operationalization of Variables section in Chapter III for details). Since the data (n = 163) were not normally distributed, a non-parametric Kruskal Wallis test was used to determine if there was a between group difference in APSR-D subscale scores. The APSR-D subscale median score for Y0 was 38.5, for Y1 was 31.0, for Y2 was 38.0, and for Y3 was 35.0. Table 5 contains APSR-D details. The Kruskal Wallis test, X2 (3, N = 163) = 9.51, p =.02 indicated there was a significant difference APSR-D subscale scores between cohorts of students. The overall effect size was medium (d = .50). The pair-wise post hoc analysis, with the Mann-Whitney U test and the Bonferroni correction at an adjusted alpha < .01, revealed differences in APSR-D subscale scores between Y0 and Y1 only. The median difference of 7.5 between starting Y0 and PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 77 Y1 and the reported Mann-Whitney U test p value of < .01 indicated statistical difference. There were no differences in APSR-D subscale scores between any other cohorts of students. Perceived Stress Scale. The PSS-10 ranges in score from 0-40 in which lower scores indicate lesser perceived stress (Cohen & Williamson, 1988). Since the data (n = 163) were not normally distributed, the non-parametric Kruskal Wallis test was used to determine if there was a between group difference in PSS-10 scores. The PSS-10 median score for Y0 was 13.5, for Y1 was 11.0, for Y2 was 16.0, and for Y3 was 16.0. Table 6 contains PSS-10 details. The Kruskal Wallis test, X2 (3, N = 163) = 30.29, p <.01 indicated there was a significant difference PSS-10 scores between these cohorts of students. The overall effect size was large (d = .96). The pairwise post hoc analyses, with the Mann-Whitney U test and the Bonferroni correction at an adjusted alpha of < .01 revealed differences in PSS-10 between cohorts Y0 and Y3, Y1 and Y2, as well as Y1 and Y3. The median difference of 2.5 between starting Y0 and Y3 and the reported Mann-Whitney U test p value of < .01 indicated statistical difference. The median difference of 5.0 between the ending Y1 and the Y2 groups and the reported Mann-Whitney U test p value of < .01 indicated statistical difference. The median difference of 5.0 between the ending Y1 and the Y3 groups and the reported Mann-Whitney U test p value of < .01 indicated statistical difference. There were no differences in PSS-10 scores between Y0 and Y1, Y0 and Y2, as well as Y2 and Y3. Emotional Quotient Inventory-Stress Management composite score. The EQi-SM composite is scaled, such that a score of 100 or greater indicates a higher-use skill, and scoring less than 100 indicates a lower-use skill (MHS, 2011c). Since the data (n = 160) were not normally-distributed, a non-parametric Kruskal Wallis test was used to determine if there was a between group difference in EQi-SM composite scores. The EQi-SM composite median score for Y0 was 107.0, for Y1 was 105.5, for Y2 was 105.5, and for Y3 was 105.0. Table 7 contains PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 78 EQi-SM details. The Kruskal Wallis test, X2 (3, N = 160) = .81, p =.85 indicated there was not a significant difference in EQi-SM composite scores between cohorts of students. Effects of Student Characteristic on Perfectionism The investigators chose a three-way ANOVA rather than a MANOVA because neither the APSR-HS nor APSR-D subscales data were normally distributed and therefore, violated the normal distribution MANOVA requirement (Field, 2014c; Kellar & Kelvin, 2013a). Furthermore, there was little, if any association for unaltered data (rs = .05, p = .50), modified data (rs = .05, p = .49), or transformed data (rs = .05, p = .50). Therefore, the APSR-HS and APSR-D violated the moderate correlation assumption required by MANOVA as well (Kellar & Kelvin, 2013a). Almost Perfect Scale Revised High Standards subscale score. Investigators used a three-way ANOVA to determine the effects of year in program, gender description, and race/ethnicity/origin description on perfectionism in a sample of 163 students. Initially, there were three outliers assessed as a value more than 1.5 box-lengths and no more than 3 box-lengths as well as two extreme outliers assessed as a value more than 3 box-lengths (Field, 2014e). Perfectionism APSR-HS subscale scores were not normally distributed (p > .05) for five groups (Y0 White males, p = .02; Y0 White females, p < .01; Y1 White males, p < .01; Y1 Other females, p < .05; Y3 White females, p = .01) as assessed by Shapiro-Wilks test for normality. Furthermore, there was homogeneity of variances, as assessed by Levenes test for equality of variances based on medians, p = .31, but not based on means, p = .01. There was a statisticallysignificant three-way interaction between student characteristics (F(3,146) = 2.69, p < .05), but there were no two-way interactions accepted at the p < .03 level (year in program, gender, F(3,146) = .09, p = .97; year in program, White/Other, F(3,146) = 1.11, p = .35; gender, White/Other, F(3,146) = .08, p = .78). However, because of the previously mentioned issues and PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 79 because the data were moderately, negatively skewed, the investigators applied a square-root reverse data transformation (Field, 2014e). This transformation improved homogeneity of variances, as assessed by Levenes test for equality of variances based on means, p = .12 and decreased the number of not normally distributed (p > .05) groups as measured by the APSR-HS subscale and as assessed by ShapiroWilks test for normality to three (Y0 White females, p = .02; Y1 White males, p < .01; Y1 Other females, p = .02). However, the transformed data increased the number of outliers assessed as a value more than 1.5 box-lengths and no more than 3 box-lengths to 12 and more importantly, there was no longer a statistically significant three-way interaction between student characteristics F(3,146) = 2.18, p = .09. Therefore, the investigators next modified the outliers to less extreme values. In order to maintain the value ranking, the investigators changed the outlier value to just larger or smaller than the nearest non-extreme value (Field, 2014e). After modifying the outliers, there was only one remaining outlier assessed as a value more than 1.5 box-lengths and no more than 3 box-lengths. Perfectionism APSR-HS subscale scores were normally distributed (p > .05) except for four groups (Y0 White males, p = .02; Y0 White females, p < .01; Y1 White males, p < .01; Y1 Other females, p < .05) as assessed by Shapiro-Wilks test for normality. There was homogeneity of variances, as assessed by Levenes test for equality of variances based on median, p = .09, but not based on means, p < .01. Similar to the original data, after modifying the outliers, there was a statistically significant three-way interaction between year in program, gender, and White/Other, F(3,146) = 3.73, p = .01. However, there were no two-way interactions accepted at the p < .03 level (year in program, gender, F(3,146) = .15, p = .93; year in program, White/Other, F(3,146) = 1.55, p = .20; gender, White/Other, F(3,146) = .35, p = .55). Therefore, even after modifying the outliers, no statistical difference in perfectionism level was found by student characteristic in this sample. PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 80 Almost Perfect Scale Revised Discrepancy subscale score. The investigators used a three-way ANOVA to determine the effects of year in program, gender description, and race/ethnicity/origin description on perfectionism using the APSR-D subscale. There was not a statistically significant three-way interaction between year in program, gender, and White/Other, F(3,146) = .30, p = .83. There were no two-way interactions accepted at the p < .03 level (year in program, gender, F(3,146) = .69, p = .56; year in program, White/Other, F(3,146) = .56, p = .64; gender, White/Other, F(3,146) = .04, p = .84). Additionally, there were seven outliers assessed as a value more than 1.5 box-lengths and no more than 3 box-lengths. Perfectionism APSR-D subscale scores were normally distributed (p > .05) except for three groups (Y3 White males, p = .01; Y3 Other males, p = .03; Y3 White females, p = .03) as assessed by Shapiro-Wilks test for normality. Furthermore, there was homogeneity of variances, as assessed by Levenes test for equality of variances based on medians, p = .79 and based on means, p = .29. Because of these issues and because the data were moderately, positively skewed, the investigators next applied a square-root data transformation (Field, 2014e). This transformation reduced the number of outliers from seven to five and reduced the number of groups that were not normally distributed (p > .05) from three to two groups (Y3 White males, p = .03 and Y3 Other males, p = .04). The homogeneity of variances, as assessed by Levenes test for equality of variances based on means, p = .38 and medians, p = .74 remained significant. Similar to the non-transformed data, there was not a statistically significant threeway interaction between year in program, gender, and White/Other, F(3,146) = .34, p = .80, nor were there any two-way interactions accepted at the p < .03 level (year in program, gender, F(3,146) = .93, p = .43; year in program, White/Other, F(3,146) = .47, p = .71; gender, White/Other, F(3,146) = .07, p = .80. Therefore, the investigators next modified the outliers to PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 81 less extreme values. In order to maintain the value ranking, the investigators changed the outlier value to just larger or smaller than the nearest non-extreme value (Field, 2014e). After modifying the outliers, there was only one remaining outlier assessed as a value more than 1.5 box-lengths and no more than 3 box-lengths. Perfectionism APSR-D subscale scores were normally-distributed (p > .05) for all groups except for the same three groups as the non-modified data (Y3 White males, p = .03; Y3 Other males, p = .03; Y3 White females, p = .03) as assessed by Shapiro-Wilks test for normality. Unlike the non-transformed data, after modifying the outliers, there was homogeneity of variances, as assessed by Levenes test for equality of variances based on medians, p = .33, but no longer based on means, p = .03. Similar to the original data, after modifying the outliers, there was not a statistically-significant threeway interaction between year in program, gender, and White/Other, F(3,146) = .21, p = .89. Additionally, there were no two-way interactions at the p < .03 level (year in program, gender, F(3,146) = .93, p = .43; year in program, White/Other, F(3,146) = .70, p = .55; gender, White/Other, F(3,146) = .01, p = .92). Therefore, even after modifying the outliers from the APSR-D data, no statistical difference in perfectionism level was found by student characteristic in this sample. Association in Perfectionism with Perceived Stress Investigators performed bivariate correlations to determine if there was an association between perfectionism and perceived stress in a sample of 163 students. The APSR-HS were not normally-distributed (p < .01) and did not meet the assumption of a linear relationship via visual examination of the scatterplot. The investigators modified the outliers to less-extreme values per individual class. In order to maintain the value ranking, the investigators changed the outlier value to just larger or smaller than the nearest non-extreme value (Field, 2014e). Again, the modified APSR-HS values were not normally-distributed (p < .01) and did not meet the PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 82 assumption of a linear relationship via visual examination of the scatterplot. Next, the investigators excluded the Non-Perfectionists and only included the Adaptive and Maladaptive Perfectionists (n = 108). Again, the APSR-HS values were not normally-distributed (p < .01); but the assumption of a linear relationship via visual examination of the scatterplot was met. However, there was no association between APSR-HS and PSS-10 (rs = .08, p = .40). Finally, the investigators evaluated the association of the APSR-D subscale and the PSS-10 using the full sample (n = 163). Similar to the results using the APSR-HS values, the APSR-D values were not normally-distributed (p < .01). However, the linearity assumption was met via visual examination of the scatterplot. Additionally, there was a moderate, direct association (rs = .51, p < .01) of PSS-10 and APSR-D among participants in this sample. Association in Perfectionism with Stress Management Investigators performed bivariate correlations to determine within a sample of 160 students if there was an association between perfectionism and stress management. Two students were excluded because they decelerated in the program and had previously taken the EQi-SM, and one case was missing data. As previously noted, the APSR-HS were not normallydistributed (p < .01) and did not meet the assumption of a linear relationship via visual examination of the scatterplot. The investigators modified the outliers to less-extreme values per individual class in order to maintain the value ranking (Field, 2014e). Again, the modified APSR-HS values were not normally-distributed (p < .01); however, there was a linear relationship via visual examination of the scatterplot. However, there was no association between APSR-HS and EQi-SM (rs = .15, p = .06). Next, the investigators excluded the NonPerfectionists and only included the Adaptive and Maladaptive Perfectionists (n = 107). Again, the APSR-HS values were not normally-distributed (p < .01) and did not meet the assumption of a linear relationship via visual examination of the scatterplot. PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 83 The investigators evaluated the association between the APSR-D subscale and the EQi-SM (n = 160). Similar to the results using the APSR-HS values, the APSR-D values were not normally-distributed (p < .01). However, the linearity assumption was met via visual examination of the scatterplot. There was a weak, indirect association between EQi-SM and APSR-D (rs = -.38, p < .01) in this sample. Finally, the investigators excluded the NonPerfectionists and only included the Adaptive and Maladaptive Perfectionists (n = 107). Similar to the results using the APSR-HS values, the APSR-D values excluding Non-Perfectionists were not normally-distributed (p < .01). However, the linearity assumption was met via visual examination of the scatterplot. There was a weak, indirect association of EQi-SM and APSR-D (rs = -.40, p < .01) among Adaptive Perfectionist and Maladaptive Perfectionist participants in this sample. Results for Binomial Logistic Regression Analysis The investigators categorized participants as Non-Perfectionists based on the APSR-HS subscale score and as Adaptive Perfectionists or Maladaptive Perfectionists based on the interaction of the APSR-HS and APSR-D subscale scores. Appendix A conceptually describes this process. The investigators excluded the Non-Perfectionist participants to determine the ability of student characteristic, perceived stress, and/or stress management to predict perfectionism subtypes of Adaptive or Maladaptive. Ability of student characteristic to predict perfectionism subtype. Investigators performed a binomial logistic regression to ascertain the effects of gender (male, female), current class, and race/ethnicity (White, Other) on perfectionism in this sample (n = 108). A Bonferroni correction was applied using all seven terms in the model, resulting in statistical significance when p < .01 (Tabachnick & Fidell, 2014). The logistic regression model was not statistically- PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 84 significant, 2(5) = 4.97, p = .42. Table 8 contains details from the binomial logistic regression. Therefore, these student characteristics were not predictive of perfectionism in this sample. Ability of perceived stress score to predict perfectionism subtype. Investigators performed a binomial logistic regression in this sample (n = 108) to ascertain the effects of perceived stress on perfectionism. A Bonferroni correction was applied using all three terms in the model resulting in statistical significance when p < .02 (Tabachnick & Fidell, 2014). Based on this assessment, the continuous independent variable was linearly related to the logit of the dependent variable. There was one standardized residual with a value of 2.79 standard deviations, which was kept in the analysis because it was relatively close to the 2.58 cut-off threshold and less than 3.29 (Field, 2014d). The logistic regression model was statisticallysignificant, 2(1) = 18.73, p < .01. The model explained 21.67% (Nagelkerke R2) of the variance in Maladaptive Perfectionism and correctly classified 66.67% of cases. Sensitivity was 69.62%, specificity was 58.62%, positive predictive value was 82.09%, and negative predictive value was 41.46%. The area under the curve (AUC) was .74, 95% CI [.65, .83] which is an acceptable level of discrimination according to Hosmer et al. (2013). The perceived stress predictor variable was statistically-significant (as shown in Table 9). Participants with increased perceived stress had 1.17 times higher odds of being categorized as a Maladaptive Perfectionist than those with lower perceived stress levels. Ability of stress management composite score to predict perfectionism subtype. Investigators performed a binomial logistic regression to ascertain the effects of the EQi-SM composite score on perfectionism in this sample (n = 107). A Bonferroni correction was applied using all three terms in the model resulting in statistical significance being accepted when p < .02 (Tabachnick & Fidell, 2014). Based on this assessment, all continuous independent variables PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 85 were found to be linearly related to the logit of the dependent variable. There were three standardized residuals with values of -2.91, 3.32, and 3.56 standard deviations which were all kept in the analysis because they were relatively close to the 2.5 cut-off threshold (Field, 2014d). The logistic regression model was statistically significant, 2(1) = 14.40, p < .01. The model explained 17.16% (Nagelkerke R2) of the variance in perfectionism and correctly classified 71.96% of cases. Sensitivity was 67.86%, specificity was 73.42%, positive predictive value was 47.50% and negative predictive value was 86.57%. The area under the curve (AUC) was .73, 95% CI [.63, .84] which is an acceptable level of discrimination according to Hosmer et al. (2013). The stress management predictor variable was statistically significant (as shown in Table 10). Participants with increased stress management composite scores had 0.93 times lower odds to be categorized as a Maladaptive Perfectionist than those with decreased stress management scores. Chapter 5: Discussion and Conclusion Previous researchers have addressed the prevalence of perfectionism in a variety of health professions programs (M. W. Enns et al., 2001; Henning et al., 1998; Hu et al., 2019; Wagner & Causey-Upton, 2017); however, it has yet to be addressed in DPT programs. Increased stress levels among students have been reported in multiple health professions programs (Alzahem et al., 2011; Alzayyat & Al-Gamal, 2014; Dutta et al., 2005; Elani et al., 2014; Mosley et al., 1994; Pfeifer et al., 2008) including physical therapy programs (Frank & Cassady, 2005; Frazer & Echternach, 1991; Hodselmans et al., 2018; Jacob et al., 2012; OMeara et al., 1994). Because of these higher stress levels among health professions students, some educators are considering humanistic skills (e.g., emotional intelligence and self-care) as the logical, next step to manage stress levels among health professions students (Birks et al., 2009; Faguy, 2012; Ruiz-Aranda et al., 2014). PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 86 Beyond health professions programs, various health care disciplines have advocated for transforming the widely accepted Triple Aim (improving the patient experience, improving population health, and reducing health care costs) into a Quadruple Aim by adding health care provider well-being (Bodenheimer & Sinsky, 2014; Bowles et al., 2018; Morrow et al., 2018). The purpose of this study was to examine perfectionism among entry-level DPT students and assess its relationship to stress perception and stress management. This is the first study to provide insight into the prevalence of perfectionism among DPT students and the relationship between perfectionism, stress perception, and stress management in this population. Perfectionism There was no significant difference among the subtypes of Adaptive, Maladaptive, and Non-Perfectionists by DPT class. This may offer support to previous work indicating perfectionism is stable over time (Azevedo et al., 2010; Moore et al., 2018; Rice & Dellwo, 2001). However, since this work was cross-sectional, one should be cautious in drawing this conclusion. Specific analysis of the APSR-HS subscale found statistical differences between beginning Y0 students with ending Y2 students. Additionally, a specific analysis of the APSR-D subscale found statistical differences between beginning Y0 students with ending Y1 students. Again, since this research is currently only cross-sectional, it is too early to offer anything beyond conjecture regarding perfectionism stability in this sample. Additionally, prevalence of Maladaptive Perfectionism in this sample was consistent with Maladaptive Perfectionism for both undergraduate students (Grzegorek et al., 2004; Rice & Ashby, 2007; Rice et al., 2014) and first-year medical students (Hu et al., 2019) but less than a sample of pre-occupational therapy students (Wagner & Causey-Upton, 2017). Adaptive Perfectionism prevalence in this sample was also less than that of the pre-occupational therapy students (Wagner & Causey-Upton, 2017) as well as in one undergraduate student sample (Rice et al., 2014), but not the other undergraduate PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 87 samples (Grzegorek et al., 2004; Rice & Ashby, 2007). Unfortunately, comparisons with firstyear medical students were not possible since those data were not reported (Hu et al., 2019). Perfectionism and student characteristics. There were no statistical differences in perfectionism level by the student-reported characteristics of gender description or race/ethnicity/origin description. Previous literature suggests similar levels of perfectionism across gender identities among graduate students (Cowie et al., 2018), though some early work noted gender differences among undergraduate students (Rice & Ashby, 2007). However, investigators often do not report differences in perfectionism level by gender description in research involving health professions students. This work begins to address this gap in the literature. There were no significant differences between students who identified as female or male for the APSR-HS or the APSR-D. These results were supportive of previous work involving a general graduate student sample that included a small percentage of health professions students (Cowie et al., 2018) as well as work from a community-based sample similar in age to this sample (Besser, Flett, & Hewitt, 2010). However, some of these current results contrasted results from a sample of undergraduate psychology students where women scored slightly higher on the APSR-HS and APSR-D than men (Rice & Ashby, 2007). Previous literature regarding race/ethnicity/origin description differences and perfectionism is even more sparse than the literature for gender differences. Previous researchers have called for a more diversified-sample approach that looks beyond predominately White American samples currently found in perfectionism research (Flett & Hewitt, 2015). Currently, there is a paucity of literature regarding race/ethnicity/origin description differences and perfectionism among health professions education students. Similar to the gender description and perfectionism literature, there were no reported consistent trends for race/ethnicity/origin PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 88 description and perfectionism (DiBartolo & Rendn, 2012). As previously mentioned, this sample did not have any significant differences in perfectionism level by race/ethnicity/origin description. It should be noted that this sample was predominately White, and for statistical purposes, the researchers collapsed race/ethnicity/origin description data into White and Other. Furthermore, there was only one demographic question related to race, ethnicity, and origin. Participants were instructed to select more than one if applicable; however, they may have selected only one group, not realizing they could select additional groups. Therefore, this item may not have fully captured race, ethnicity, and origin representation for all participants. This work highlights the need for better descriptive variables and data collection strategies for race, ethnicity, and origin representation in health professions education research. Perceived Stress Previous researchers found that physical therapy students reported perceived stress at higher levels than individuals of similar age (Frank & Cassady, 2005; OMeara et al., 1994; Walsh, Feeney, Hussey, & Donnellan, 2010). However, the results from the present study were not supportive of this. The perceived stress levels reported by students in this sample were lower than the reported stress levels from a sample of individuals younger than 25 years old and a sample 25-34 years old (Cohen & Janicki-Deverts, 2012). More specific to gender and stress, previous results are mixed. Some authors reported higher stress levels among women compared to men (Frank & Cassady, 2005; Jacob et al., 2012). However, supportive of other researchers (Tucker et al., 2006), these data do not indicate a perceived stress level difference between genders. Perceived stress and program year. There were statistical differences in stress perception by year in program in this sample. This included a trend towards the final two years PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 89 (Y2 and Y3) being more stressful with Y1 being less stressful. This result did not support the only other work involving a similar sample. Frank and Cassady (2005) found no differences in stress levels by year in program among students from an entry-level DPT program. Other researchers found significant differences in stress by year in program (Jacob, Itzchak, & Raz, 2013; Tucker et al., 2006). However, these other works included students from Masters and Bachelors of Science programs (OMeara et al., 1994), non-U.S., entry-level Masters and Bachelors of Science programs (Tucker et al., 2006), and non-U.S., entry-level Bachelors of Science programs (Jacob et al., 2012, 2013; Walsh et al., 2010). Because of the potential differences between DPT and non-DPT curricula and differences between U.S. and non-U.S. programs, it is not possible to compare the results with the results of these other studies. These results indicated there were significant differences in perceived stress by program year with Y2 and Y3 students reporting greater stress than the earlier cohorts. More specifically, Y0 students had less stress than Y3 students, and Y1 students had less stress than Y2 students as well as Y3 students. It is not surprising that Y2 and Y3 students reported higher stress levels than the other cohorts. The Y3 students are not only preparing for the licensure board examination, but they are also often engaged in a job search. The Y2 students are transitioning out of the classroom phase and into the clinical rotation phase, which requires a paradigm shift away from didactic application to psychomotor skill acquisition. Although not statistically significant, there was a trend towards incoming Y0 students experiencing more stress than Y1 students. Incoming Y0 students are starting a graduate program which in itself may cause greater stress levels in this cohort. Although anecdotally and not applicable to all incoming Y0 students, some are also relocating and moving away from established social support systems which may also result in greater stress levels. These results may be unique to the curricular design for this specific DPT program and may not be generalizable to other DPT programs. PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 90 Perceived stress and perfectionism. There was no association between perceived stress and perfectionism in general. However, there was an association between perceived stress and the discrepancy dimension of perfectionism. This moderate, direct association occurred between the PSS-10 and the APSR-D and not with the APSR-HS, where there was no association. Understandably, the direct association occurred between the PSS-10 and the APSRD, but not the APSR-HS, since the intent of the APSR-HS is only to differentiate Perfectionists from Non-Perfectionists. However, the purpose of the APSR-D is to differentiate Perfectionists as either Adaptive or Maladaptive Perfectionists. These results support previous findings of a direct association between stress and Maladaptive Perfectionism in medical students (M. W. Enns et al., 2005, 2001; Henning et al., 1998), pre-occupational therapy students (Wagner & Causey-Upton, 2017) graduate students (Cowie et al., 2018; Witcher et al., 2007), and undergraduate students (Bieling et al., 2004; Flett et al., 2016; Rice & Richardson, 2014). Applying the Perfectionism Acceptance Theory (PAT) may add clarity to this direct association between perceived stress and perfectionism. According to the PAT (Lundh, 2004), Adaptive Perfectionists may better accept non-perfectionism compared to Maladaptive Perfectionists. This reduced capacity for non-perfection acceptance among Maladaptive Perfectionists offers a potential explanation for the higher stress levels when compared to Adaptive Perfectionists. Stress Management Regarding stress management, there was not a significant difference in EQi-SM scores between cohorts of DPT students. This is the first study involving DPT students to report year in program comparisons as previous work has involved only one cohort (Van Veld et al., 2018) or did not differentiate students based on year in program (Chambers et al., 2016; Mejia-Downs, 2019). In this sample, the mean EQi-SM score was at least 100 both overall and at the cohort PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 91 level, suggesting that stress management is a higher-use skill among DPT students relative to higher-education norms (MHS, 2011c). Stress management and perfectionism. Similar to perceived stress, there was an association between stress management and the discrepancy dimension of perfectionism. However, the association was indirect rather than direct. This weak, indirect association occurred between the EQi-SM and the APSR-D. Also, similar to perceived stress, there was no association between the EQi-SM and the APSR-HS. A higher APSR-D score indicates an increased likelihood of being a Maladaptive Perfectionist and, therefore, an increase in the likelihood of stress management being a lower-use skill. Therefore, greater stress management ability was associated with a decreased likelihood of exhibiting Maladaptive Perfectionism. This supports previous research which found that Maladaptive Perfectionists have higher rates of perceived stress than Adaptive Perfectionists (Ashby & Gnilka, 2017; Bks et al., 2015; DiBartolo et al., 2008; Flett et al., 2016; Shafique et al., 2017; Zureck et al., 2014). Again, perhaps the reason for this may rest in the PAT. According to the PAT, Maladaptive Perfectionists demand perfection and only accept perfection, whereas Adaptive Perfectionists strive for excellence and accept non-perfection (Lundh, 2004). This demand for perfection, coupled with an inability to accept non-perfection, may explain the higher rates of perceived stress among Maladaptive Perfectionists compared to Adaptive Perfectionists. Limitations This study included a single-site sample of convenience at the primary investigators academic institution, which may not represent the general DPT student population. There may be factors that are unique to this institution, such as student support services or the supportiveness of faculty and staff, which could influence stress levels. The study was also cross-sectional, PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 92 comparing different student cohorts at a specific point during matriculation, rather than longitudinally comparing the same cohort through different points during the entire matriculation process. More specifically, the perceived stress experienced at the time of survey administration may be unique to that window of time rather than representative of students experiences across the entire program year. For example, most third-year DPT students were searching for jobs and preparing to take the licensure examination at the time of data collection. Also, second-year DPT students were transitioning from the classroom and into the clinic. Another limitation was the fact that the investigators provided only one demographic question related to race, ethnicity, and origin. Although participants were presented with the option to select more than one group, they may not have realized they could select more than one group. Thus, it is not possible to know if these results are generalizable to other entry-level programs because it is not possible to fully assess the potential effect of this student characteristic on the relationship between perfectionism, stress perception, and stress management. Adding a separate question for Hispanic/Latino data collection could address this issue and align with the data collection strategy of the two primary reporting agencies for DPT students (Commission on Accreditation in Physical Therapy Education, 2019; Physical Therapist Centralized Application Service, 2019). Finally, longitudinal, multi-site studies with a larger sample size could add to the robustness of the binomial logistic regression models. Implications for DPT Education and Future Research This research takes the initial step of identifying perfectionism prevalence among DPT students as well as establishing a relationship between perfectionism, stress perception, and stress management. Future multi-site, longitudinal research will provide a better understanding of these relationships in this population. A better understanding of these interactions may allow PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 93 earlier identification of those DPT students at risk for stress-related issues (Melnyk et al., 2016). This may allow for earlier stress management interventions. Additionally, future research involving perfectionism should not collapse race, ethnicity, and origin description into one question since these are different constructs. By doing this, future investigators may be better able to target under-represented groups and move beyond the current, predominately White, female samples (Flett & Hewitt, 2015). A better understanding of potential cultural components of perfectionism may allow for culturally sensitive stress management interventions. Future intervention studies should include emotional intelligence training. This may assist in the development of pedagogical and curricular approaches that enhance stress mitigation strategies among DPT students, which ultimately may improve provider well-being. Given the difference in perceived stress levels by year in program from this sample, DPT educators should consider embedding stress management interventions throughout DPT curriculum rather than a one-time intervention. Proactively embedding stress management interventions prior to peak stress times in the DPT curriculum may aid students in mitigating stress. Based on these results, DPT educators should consider an ongoing stress management curriculum with points of emphasis preceding the higher stress observed at program entry (Y0), during the transition from classroom to clinic (Y2), and prior to graduation (Y3). Since the stressors at each of those timepoints may be unique (e.g., licensure board examination preparation and job searching just prior to graduation), the DPT educators could specifically frame the stress management intervention to address the specific stressors occurring at those specific times. Additionally, since the investigators identified the end of the first year as a lower stress time, educators could consider a longer-duration intervention such as a 4 week resiliency training (Mejia-Downs, 2019) or even 8-10 week interventions (Chambers et al., 2016; Willgens et al., 2016). Students PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 94 may have an increased learning capacity at these lower stress times, which may positively impact information uptake and students willingness to engage in a longer intervention (Lepine et al., 2004). Finally, future research could add deeper context and understanding of the relationship between perfectionism, stress perception, and stress management. For example, the PSS-10 could quantitatively identify higher stress times, and anonymous student surveys could qualitatively provide a contextual understanding of the actual stressors causing the higher reports of stress. This could inform stress management intervention regarding topic sequencing and activity duration. Additionally, small focus groups of students could further inform stress management intervention curriculum by providing a richer understanding of stressors experienced by DPT students at unique time points in the program. Conclusion Health care provider burnout is a concern across multiple health care disciplines (Bodenheimer & Sinsky, 2014; Bowles et al., 2018; Morrow et al., 2018). New approaches are urgently needed to improve providers well-being. One such approach is including stress management interventions throughout the curricula of health professions programs. In this sample, there was a moderate, direct relationship between perceived stress and perfectionism subtype, suggesting that DPT students who are Maladaptive Perfectionists may be at greater risk for stress-related issues. Baseline measures of perfectionism, stress perception, and stress management may assist educators in identifying at-risk students and monitoring student response to stress management interventions. DPT students who can effectively manage stress may ultimately have greater well-being and lower rates of burnout. PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 95 References Abu-Ghazaleh, S. B., Rajab, L. D., & Sonbol, H. N. (2011). Psychological stress among dental students at the University of Jordan. Journal of Dental Education, 75(8), 11071114. Adam, T. C., & Epel, E. S. (2007). Stress, eating and the reward system. 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(2012) Ego-Dystonic Perfectionistic Concerns Discrepancy Maladaptive Evaluative Concerns Socially-Prescribed Perfectionist Concerns Over Mistakes Doubts About Actions Factor 2 (Concerns) HFMPS High Self-Oriented Perfectionism with High Socially-Prescribed Perfectionism (Frost et al. 1993) Black and White Thinking, Perceived Pressure From Others, Dissatisfaction, Reactivity To Mistakes (Stairs et al. 2012) High Perfectionistic Strivings with High Perfectionistic Concern (Gaudreau & Thompson, 2010; Stoeber & Otto, 2006 ) High Perfectionistic Strivings with Low Perfectionistic Concerns (Gaudreau & Thompson, 2010; Stoeber & Otto, 2006 ) Order, Satisfaction, Details and Checking, Perfectionism Towards Others, High Standards (Stairs et al. 2012) High Standards with High Discrepancy (Slaney et al. 2001) M-CUP varies APS-R FMPS FMPS Maladaptive Evaluative Concerns (Frost et al. 1993) Tool Maladaptive Concerns Over Mistakes, Parental Criticism, Parental Expectations, Doubts About Action (Frost et al. 1993) High Standards with Low Discrepancy (Slaney et al. 2001) Positive Achievement Strivings (Frost et al. 1993) High Self-Oriented Perfectionism with Low Socially-Prescribed Perfectionism (Frost et al. 1993) Personal Standards, Organization (Frost et al. 1993) Adaptive Dimension(s) representing perfectionism type: Note. This table presents the major perfectionism frameworks including how these frameworks can be used to map the two-factor model (Stoeber & Otto, 2006) and the Adaptive and Maladaptive Perfectionistic type model (Slaney et al. 2001). It also includes the tool associated with each framework. Frost Multidimensional Perfectionism Scale (FMPS), Hewitt-Flett Multidimensional Perfectionism Scale (HFMPS), Almost Perfect Scale-Revised (APS-R), Measures of Constructs Underlying Perfectionism (M-CUP) Dissatisfaction Details and Checking Satisfaction Black and White Thinking Positive Achievement Strivings Positive Achievement Strivings Maladaptive Evaluative Concerns Frost et al. (1993) Self-Oriented Perfectionist Self-Oriented Perfectionism Socially-Prescribed Perfectionism Other Oriented Perfectionism Personal Standards Hewitt and Flett (1991) Doubts About Action Parental Expectations Parental Criticism Factor 1 (Strivings) Personal Standards Organization Concerns Over Mistakes Dimensions/Subscales Frost et al. (1990) Framework Perfectionism Frameworks, Dimensions, Terms, Types, and Tools PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT Table 1: Perfectionism Frameworks, Dimensions, Terms, Types, and Tools Perfectionism Frameworks, Dimensions, Terms, Types, and Tools 127 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT Table 2: Demographics by Gender and Year in Program Demographics by Gender and Year in Program Year in Class Program n Participation Category n (%) Male 15 (35.71%) Y0 42 91.30% Female 27 (64.29%) No Answer 0 (0.00%) Male 8 (21.62%) Y1 37 90.24% Female 29 (78.38%) No Answer 0 (0.00%) Male 16 (37.21%) Gender Y2 43 95.56% Female 26 (60.47%) No Answer 1 (2.33%) Male 15 (36.59%) Y3 41 89.13% Female 26 (63.41%) No Answer 0 (0.00%) Male 54 (33.13%) Total 163 91.57% Female 108 (66.26%) No Answer 1 (0.61%) Note. Y0 = beginning year one; Y1 = ending year one; Y2 = ending year two; Y3 = ending year three. 128 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 129 Table 3: Demographics by Race, Ethnicity, and Origin and Year in Program Demographics by Race, Ethnicity, and Origin and Year in Program Year in Class Program n Participation Category n (%) White or Caucasian 26 (61.90%) Hispanic, Latino or Spanish 6 (14.29%) Black or African-American 1 (2.38%) Y0 42 91.30% Asian 4 (9.52%) American Indian or Alaska Native 0 (0.00%) Middle Eastern or North African 1 (2.38%) More than one selection 4 (9.52%) White or Caucasian 24 (64.86%) Hispanic, Latino or Spanish 4 (10.81%) Black or African-American 3 (8.12%) Y1 37 90.24% Asian 4 (10.81%) American Indian or Alaska Native 0 (0.00%) Middle Eastern or North African 0 (0.00%) More than one selection 2 (5.41%) White or Caucasian 24 (55.81%) Hispanic, Latino or Spanish 6 (13.95%) Race, Black or African-American 2 (4.65%) Ethnicity, Y2 43 95.56% Asian 4 (9.30%) and American Indian or Alaska Native 1 (2.33%) Origin Middle Eastern or North African 1 (2.33%) More than one selection 5 (11.63%) White or Caucasian 27 (65.85%) Hispanic, Latino or Spanish 9 (21.95%) Black or African-American 2 (4.88%) Y3 41 89.13% Asian 3 (7.32%) American Indian or Alaska Native 0 (0.00%) Middle Eastern or North African 0 (0.00%) More than one selection 0 (0.00%) White or Caucasian 101 (61.96%) Hispanic, Latino or Spanish 25 (15.34%) Black or African-American 8 (4.91%) Total 163 91.57% Asian 15 (9.20%) American Indian or Alaska Native 1 (0.61%) Middle Eastern or North African 2 (1.23%) More than one selection 11 (6.75%) Note. Y0 = beginning year one; Y1 = ending year one; Y2 = ending year two; Y3 = ending year three. PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT Table 4: Perfectionism Classification by Year in Program Perfectionism Classification by Year in Program Year in Perfectionist Program n Category n (%) Adaptive 19 (45.24%) Y0 42 Maladaptive 13 (30.95%) Non 10 (23.81%) Adaptive 21 (56.76%) Y1 37 Maladaptive 6 (16.22%) Non 10 (27.03%) Adaptive 13 (30.23%) Almost Perfect Scale Y2 43 Maladaptive 10 (23.26%) - Revised Non 20 (46.51%) Adaptive 14 (34.15%) Y3 41 Maladaptive 12 (29.27%) Non 15 (36.59%) Adaptive 67 (41.10%) Total 163 Maladaptive 41 (25.15%) Non 55 (33.74%) Note. Y0 = beginning year one; Y1 = ending year one; Y2 = ending year two; Y3 = ending year three. Participants were categorized as Non-Perfectionists when scoring less than 42 on the APSR-HS; as Adaptive Perfectionists when scoring at least 42 on the APSR-HS and less than 42 on the APSR-D; as Maladaptive Perfectionists when scoring at least 42 on the APSR-HS and at least 42 on the APSR-D (Rice & Ashby, 2007). 130 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 131 Table 5: Almost Perfect Scale-Revised Outcome Measure by Year in Program and Gender Almost Perfect Scale-Revised Outcome Measure by Year in Program and Gender Almost Perfect Scale-Revised Year in Program Gender n Mean Female 27 45.04 Male Y0 15 44.60 Total 42 44.88 High Standards Discrepancy SD Min Max 3.77 3.89 3.77 37 37 37 49 49 49 Y1 Female Male Total 29 8 37 43.14 43.88 43.30 3.11 5.19 3.59 36 36 36 49 49 49 Y2 Female Male No Answer Total 26 16 1 43 41.19 41.00 43.00 41.12 6.10 5.20 0.00 5.64 26 31 43 26 49 49 43 49 Y3 Female Male Total 26 15 41 42.65 42.87 42.73 5.31 3.98 4.81 28 37 28 49 49 49 Total Female Male No Answer Total 108 54 1 163 43.03 42.94 43.00 42.99 4.81 4.63 0.00 4.72 26 31 43 26 49 49 43 49 Y0 Female Male Total 27 15 42 39.85 40.80 40.19 12.63 10.14 11.68 16 21 16 79 57 79 Y1 Female Male Total 29 8 37 31.03 37.38 32.41 11.63 8.52 11.24 12 26 12 66 49 66 Y2 Female Male Total 26 16 43 39.96 36.63 38.79 13.02 14.90 13.54 18 15 15 65 68 68 Y3 Female Male Total 26 15 41 39.88 40.47 40.10 16.39 14.58 15.57 17 28 17 74 80 80 Total Female Male Total 108 54 163 37.52 38.96 38.03 13.86 12.63 13.40 12 15 12 79 80 80 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT Note. Y0 = beginning year one; Y1 = ending year one; Y2 = ending year two; Y3 = ending year three. 132 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 133 Table 6: Perceived Stress Outcome Measure by Year in Program and Gender Perceived Stress Outcome Measure by Year in Program and Gender Year in Measure Gender n Mean Program Female 27 13.19 Male Y0 15 13.93 Y1 Perceived Stress Scale-10 Y2 Y3 Total SD Min Max 4.39 5 27 6.05 3 29 Total 42 13.45 4.98 3 29 Female 29 10.76 4.68 2 20 Male 8 12.88 5.25 5 23 Total 37 11.22 4.81 2 23 Female 26 17.19 6.96 3 35 Male 16 14.07 5.95 2 24 No Answer 1 15.00 0.00 15 15 Total 43 16.02 6.62 2 35 Female 26 17.81 4.43 3 25 Male 15 15.13 3.54 7 24 Total 41 16.69 4.27 3 25 Female 108 14.61 5.91 2 35 Male 54 14.17 5.17 2 29 No Answer 1 15.00 0.00 15 15 Total 163 14.47 5.65 2 35 Note. Y0 = beginning year one; Y1 = ending year one; Y2 = ending year two; Y3 = ending year three. The PSS-10 is used to measure frequency of perceived stress over the past month. For the PSS-10, scores range 0 to 40 with higher scores indicating higher levels of perceived stress. Because the PSS-10 is not a diagnostic tool, there are no cut-off scores established (Cohen & Williamson, 1988). PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 134 Table 7: Emotional Quotient Intelligence 2.0 Stress Management Composite by Year in Program and Gender Emotional Quotient Intelligence 2.0 Stress Management Composite by Year in Program and Gender Year in Measure Gender n Mean SD Min Max Program Female 27 106.78 11.02 82 134 Male Y0 15 102.47 13.88 83 134 Total 42 105.24 12.13 82 134 Y1 EQi-SM Y2 Y3 Total Female 28 105.71 10.28 84 124 Male 8 100.13 16.23 66 118 Total 36 104.47 11.82 66 124 Female 26 106.69 15.83 67 132 Male 15 105.13 10.99 81 118 No Answer 1 97.00 0.00 97 97 Total 42 105.90 14.02 67 132 Female 25 101.44 12.24 79 127 Male 15 106.07 7.01 89 114 Total 40 103.18 10.73 79 127 Female 106 105.22 12.48 67 134 Male 53 103.89 11.73 66 134 No Answer 1 97.00 0.00 97 97 Total 160 104.73 12.19 66 134 Note. Y0 = beginning year one; Y1 = ending year one; Y2 = ending year two; Y3 = ending year three; EQi-SM = Emotional Quotient Inventory 2.0 Stress Management Composite. PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 135 Table 8: Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Student Characteristic Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Student Characteristic 95% CI for Odds Ratio B SE Wald df p Odds Ratio Lower Upper Current Class 3.46 3 .33 Current Class (1) -0.21 0.54 0.15 1 .70 0.81 0.28 2.33 Current Class (2) -1.05 0.61 2.92 1 .09 0.35 0.11 1.17 Current Class (3) -0.08 0.59 0.02 1 .89 0.92 0.29 2.91 Gender (1) 0.36 0.45 0.65 1 .42 1.44 0.60 3.46 White, Other (1) 0.22 0.44 0.25 1 .62 1.24 0.53 2.90 Constant -0.42 0.54 0.61 1 .43 0.66 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 136 Table 9: Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Perceived Stress Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Perceived Stress 95% CI for Odds Ratio B SE Wald df p Odds Lower Upper Ratio Perceived Stress 0.16 0.04 14.23 1 <.01 1.17 1.08 1.27 Constant -2.85 0.68 17.75 1 <.01 0.06 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 137 Table 10: Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Emotional Quotient Inventory 2.0 - Stress Management Composite Logistic Regression Predicting Likelihood of Maladaptive Perfectionism based on Emotional Quotient Inventory 2.0 - Stress Management Composite 95% CI for Odds Ratio B SE Wald df p Odds Ratio Lower Upper EQi Stress -0.07 0.02 11.62 1 < .01 0.93 0.90 0.97 Management Constant 6.67 2.11 10.02 1 < .01 789.73 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT 138 Appendices Appendix A: Conceptualization of Perfectionist Type Using the Almost Perfect Scale-Revised Subscales Conceptualization of Perfectionist Type Using the Almost Perfect Scale-Revised Subscales PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT Appendix B: Permission of Use for Almost Perfect Scale-Revised (APSR) Permission of Use for Almost Perfect Scale-Revised (APSR) The following is a screenshot stating that the APSR is available for use in research studies (Slaney & Wang, 2018). 139 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT Appendix C: Permission of Use for Perceived Stress Scale (PSS-10) Permission of Use for Perceived Stress Scale (PSS-10) The following is a screenshot stating that the PSS-10 is available for use in research studies (Cohen, n.d.). 140 PERFECTIONISM AND THE PHYSICAL THERAPIST STUDENT Appendix D: Online Survey Consent Form Online Survey Consent Form 141  ...