Busca

... Does Participation in an Occupational Justice Workshop change OT Practice in the Nursing Home? An Exploratory Pilot Study. Sarah Humbird, Kelsey Keefer, Emma Rodgers, Sharaya Sommers, Kelsy Tracy, Addie Williams December 15, 2017 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Julie Bednarski, OTD, MHS, OTR A Research Project Entitled Does Participation in an Occupational Justice Workshop change OT Practice in the Nursing Home? An Exploratory Pilot Study. Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Sarah Humbird, Kelsey Keefer, Emma Rodgers, Sharaya Sommers, Kelsy Tracy, Addie Williams Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Does Participation in an Occupational Justice Workshop Change OT Practice in the Nursing Home? An Exploratory Pilot Study. 2 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 3 Abstract The purpose of our study is to examine occupational therapy practitioners improved knowledge of issues of occupational justice and indication of intent to incorporate it into individual practice after completion of an educational workshop. Twelve occupational therapy practitioners participated in a pre-test post-test study that included a one-day 4-hour workshop. The workshop focused on the concept of occupational justice and how it can be facilitated into everyday practice. Prior to the workshop, participants were given the opportunity to complete a preworkshop survey inquiring about their knowledge of occupational justice. Two post-tests were sent out one week and four weeks after the workshop to observe a change in understanding and an intent to implement into practice. The results indicated that occupational therapy practitioners who participated in a one-day workshop focused on occupational justice were more likely to facilitate these concepts into practice. A one-day intensive workshop focusing on the concepts of occupational justice can potentially improve knowledge and facilitation of these concepts into practice. Keywords: Occupational Justice, Workshop, Skilled Nursing Facilities, Occupational Therapy PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 4 Does Participation in an Occupational Justice Workshop Change OT Practice in the Nursing Home? An Exploratory Pilot Study Literature Review Occupational justice is an important outcome measure of the occupational therapy process (American Occupational Therapy Association [AOTA], 2014). Occupational justice is defined as the ability to engage in the entire array of both meaningful and enriching occupations that are available to others, including social inclusion and those which satisfy personal, health, and societal desires (AOTA, 2014). Occupational injustice is described by Nilsson and Townsend (2010) as the deliberate or non-deliberate restriction of certain populations from engaging in occupational rights, responsibilities, or liberties that are typical of their community at any point in their lifespan. Three outcomes of occupational injustice include occupational marginalization, occupational deprivation, and occupational alienation (Townsend & Wilcock, 2014). The most recent definition of occupational marginalization is the restriction of a population from experiencing autonomy through lack of choice in occupations (Hammell & Beagan, 2016, p. 5). Occupational deprivation is defined as a form of social exclusion resulting from restrictions on populations in diverse contexts to participate in occupations that would promote their health and well-being (Hammell & Beagan, 2016, p. 3). Finally, occupational alienation is defined as a form of social exclusion through restricting a population from experiencing meaningful and enriching occupations (Hammell & Beagan, 2016, p. 4). The concept of occupational injustice can be seen in a multitude of contexts and environments, and therefore needs to be addressed (AOTA, 2014). Nilsson and Townsend (2010) also describe occupational injustice as the result of certain social policies or other governance exercising power in a way that therefore inhibits the participation in everyday occupations by individuals or PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 5 populations. Occupational rights, a concept inherently associated with occupational justice, describes humans as a species that innately need and want to participate in doing, being, becoming, and belonging, and thus have the right to do so (Nilsson & Townsend, 2010, p. 58). Older adults are one demographic experiencing occupational injustice, which can have negative effects on their well-being (AOTA, 2014). AOTA (2014) describes the need for therapists to ensure occupational justice is achieved with clients in order to promote therapy outcomes that address empowerment and self-advocacy (p. S9). The World Health Organizations 2001 perspective on health describes how ones health can be affected negatively by not being able to engage in meaningful activities and life situations (as cited in AOTA, 2014). Therefore, as an occupational therapy practitioner it is important to understand the concepts of occupational justice and the importance of assessing occupational justice with each client in order to improve health and well-being. Townsend (2012) states all humans need and want to be occupied for purposes of health, quality of life, and the sustenance of families and communities (p. 16). The purpose of our study was to examine occupational therapy practitioners improved knowledge of issues of occupational justice and indication of intent to incorporate it into individual practice after completion of an educational workshop. Through participation in a one-day workshop focusing on issues of occupational justice, we hypothesized occupational therapy practitioners will show improved knowledge and intent to incorporate it into their individual practices. Older Adults and Occupational Engagement The number of adults living in long-term care facilities, including nursing homes, is expected to reach 27 million by the year 2050 (Harris-Kojetin, Sengupta, Park-Lee, & Valverde, 2013, p. 3). Many individuals who may be experiencing injustices are those in nursing homes PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 6 and long-term care (LTC) facilities (Nilsson & Townsend, 2010). Commonly seen by occupational therapists is the lack of engagement in occupations among older adults (Clark et al., 2012; Hersch et al., 2012). Furthermore, Nilsson and Townsend (2010) state that many healthcare professionals who work with older adults witness the occurrence of occupational injustice daily without being aware of the concept. Many older adults living in the nursing home setting are unable to choose their occupations due to the lack of ability or opportunity to do so, and therefore do not have the chance to participate in meaningful occupations, which promotes health and well-being (Nilsson & Townsend, 2010). Additionally, some individuals in the nursing home setting may experience cognitive deficits, and thus consulting family members or those close to them may be necessary to determine meaningful occupations for the individual (Hersch et al., 2012). There is increased evidence showing that occupational engagement can promote the health of the very old, which are those 80 years of age and older, indicating the positive influence occupational engagement can have no matter ones situation (Nilsson & Townsend, 2010). Occupational Therapists Knowledge of Occupational Justice Nilsson and Townsend (2010) suggest the implementation of the theories of occupational justice into practice would have a positive result on targeted populations. According to CauseyUpton (2015), occupational therapists are qualified to ensure occupational justice, due to their knowledge of the importance of occupation. However, research has shown that occupational therapists have difficulty defining the concept of occupational justice, let alone determining how to translate it into practice (Hammell, 2008). Although there is an increasing amount of research on the topic of occupational justice available, there is a lack of conceptual clarity, which, combined with the novelty of this topic, results in the lack of application into practice (Durocher, PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 7 Rappolt, & Gibson, 2014, p. 435). Durocher et al. (2014) also argue that in order for an effective influence on overall client health to be implemented through an occupational justice perspective, more occupational therapists and health care providers need to adopt and translate the concept into practice. However, doing this successfully is often impeded due to various barriers. Barriers to Achieving Occupational Justice Barriers exist for both the therapists facilitation of occupational justice principles and the engagement in meaningful occupations by clients. Aside from lack of clarity about the topic, therapists barriers include political, institutional, and financial barriers (Durocher, 2014). Riegel and Eglseder (2009) described clients barriers having the most effect on well-being as societal, physical, and political. Societal barriers are those that prevent reintegration into society and can be addressed via occupational therapists observing clients interactions with friends, family members, and staff, as well as providing support groups and encouraging peer relationships (Riegel & Eglseder, 2009). Physical barriers include accessibility in public places when using a wheelchair or other mobility device and access to public transportation. Political barriers refer to subjects such as disability policy. Riegel and Eglseder (2009) also found that some occupational therapists reported absence of programs that would address political barriers; reasons for this include lack of awareness of pertinent political issues, limited awareness of advocacy groups aimed at these issues, and clients focus on their personal disabilities instead of political issues. Facilitating Occupational Justice in Practice With the increasing aging population, the facilitation of engagement in meaningful occupations is imperative in order to provide the best care for older adults. Nilsson and Townsend (2010) discussed increasing evidence supporting the promotion of health in very old adults due to occupational engagement. Furthermore, they described how health professionals, PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 8 such as occupational therapists, can unintentionally restrict client social inclusion and thereby prevent occupational justice by focusing on clients personal activities of daily living (PADL) and instrumental activities of daily living (IADL) instead of meaningful activities (Nilsson & Townsend, 2010). It is important for occupational therapists to consider the preferences of clients and implement the engagement of meaningful activities into practice in order to prevent occupational marginalization. Additionally, therapists need to remember that engagement in occupation is just as important as basic human necessities, such as water and food, in older adults, especially for the very old (Nilsson & Townsend, 2010). Those without the facilitation of occupational justice have been shown to endure emotional trauma, occupational identity problems, and feelings of decreased power because of the lack of opportunities available to perform meaningful occupations (Du Toit, Bning, & Van Der Merwe, 2014). It is a commonly held belief that occupational therapists should focus on self-care in the very old, but lack of leisure participation can negatively affect their health and well-being (Nilsson & Townsend, 2010). While it is true that adequate health is necessary to engage in meaningful occupations, the relationship between the two is actually seen as bidirectional, in that participation in occupations is associated with achieving health (Durocher et al., 2014). Durocher et al. (2014) stated that occupational participation promotes the fulfillment of personal aspirations, enables needs to be met, and aids in the ability to adjust to changes more seamlessly, all of which collaborate to improve health as well as preserve it. Researchers have found that by giving individuals independence, involvement, accessibility, and the freedom of choice, two key elements of facilitation of occupational justice, meaningful engagement and respect, can therefore be implemented (Du Toit, Bning, & Van Der Merwe, 2014, p. 134). It is also important to note PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 9 that occupational engagement is not limited to physical improvement, such as cardiovascular and physical fitness, but that social and productive occupations have been shown to have nearly equal benefits in decreasing mortality rates (Durocher et al., 2014). Moreover, studies have shown the relationship between occupations of a spiritual, cognitive, and emotional nature namely, creative arts occupations increased participants health in the areas of self-confidence, social interactions, and sense of hope (as cited in Durocher et al., 2014). Occupational therapists therapeutic use of self. AOTA (2014) emphasizes the need for therapists use of the therapeutic use of self, which is a defined as using narrative and clinical reasoning; empathy; and a client-centered, collaborative approach to service delivery (p. S12). Taylor, Lee, Kielhofner and Ketkar (2009) found that 80% of participantsall practicing occupational therapistsdescribed the therapeutic relationship with their client as the most important outcome determinant, although only 50% felt sufficiently trained in the topic upon graduation of occupational therapy school. Furthermore, only nine percent of participants said they had taken continuing education courses on this topic. A study focusing on occupational therapists education of interpersonal relationships with clients found that post-workshop, all participants reported increased content knowledge of the concept and a changed perception of clients who are particularly interpersonally challenging; most reported improved knowledge of skill (Gorenberg, 2013). One participant mentioned that the workshop helped her focus on the interpersonal side of the clinical reasoning process in order to help a client feel more successful (Gorenberg, 2013, p. 397). Another workshop was used as an educational tool to reflect on past experiences that correlated to client relationships, present a new framework that supports interpersonal reasoning, and show support to the therapists during implementation of their improved clinical reasoning PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 10 process with clients into their practice (Gorenberg, 2013). Through the use of transformative learning, which is the use of face-to-face activities, small focus groups, and online discussions, there was an outcome of increased knowledge of therapeutic use of self and a change in how the therapists perceived the quality of their client-therapist relationship. Because of the knowledge gained from the educational workshop, the participants of the workshop gained a different perspective and focused on the importance of the relationship between the therapist and client (Gorenberg, 2013). Lastly, educational workshops allow for more communication and reflection among occupational therapists (Gorenberg, 2013). Advocacy. The concepts of advocacy and client-centered practice are closely associated with a therapists therapeutic use of self. Although older adults express interest in meaningful occupations, advocating for clients is often overlooked by occupational therapists in the nursing home setting because the older adults often do not ask for additional help engaging in these activities (Borell, Lilja, Sviden, & Sadlo, 2001). Borell et al. (2001) also found that instead of therapists taking initiative in helping engage their clients in meaningful occupations, therapists tended to wait for the client to express his or her interest in an activity, thus producing a cycle of unfulfilled clients and unsatisfied therapists. Occupational therapists also need to advocate for clients to be able to participate in meaningful occupations to colleagues in order to best provide client-centered care and achieve occupational justice (Egan, Dubouloz, Leonard, Paquet, & Carter, 2014). As Hansen (2013) stated, with one united voice for justice, the lives of all may be transformed into a more just, fair and inclusive community (p. 57). Client-centered practice. Occupational therapy is a client-centered practice, wherein the therapist determines what is important and meaningful to a client by gathering information via the client identifying priorities and targeted outcomes, leading to participation in life and PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 11 occupational engagement (AOTA, 2014). Involving clients desires and opinions in intervention strategies is a key concept of both client-centered care and the facilitation of occupational justice, directly associating the two. Gagne and Hoppes (2003) found that clients are more likely to improve overall if their opinions and ideas are a key component of treatment. Furthermore, implementation of this type of practice is known to have positive outcomes, including increased satisfaction for the client, increased client participation in treatment, decreased time at rehabilitation facilities, and improvement of functional outcomes (Maitra & Erway, 2006). Researchers have observed positive outcomes in self-care skills and upper-body dressing to occur due to the occupational therapist asking for far more than the clients goals (Gagn & Hoppes, 2003). Overall, clients are more likely to improve if their opinions and ideas are a key component of treatment (Gagne & Hoppes, 2003). Assessments for client-centered practice. As occupational therapists, clientcenteredness is a major aspect of therapy. In order to maintain client-centeredness, it is imperative that the therapist discusses with the client his/her meaningful occupations. One way to assess a clients meaningful occupations is through the use of the Interest Checklist. This tool is used to determine the individuals interests which allows the therapist to create a personalized treatment plan (Klyczek, Bauer-Yox, & Fiedler, 1997). The Activity Card Sort (ACS) is an extensive tool to assess participation in various occupations. The ACS is considered a reliable and valid tool to assess occupational performance in regards to instrumental, social-cultural, and leisure activities (Katz, Karpin, Lak, Furman, Hartman-Maeir, 2003). Another common assessment tool is the Canadian Occupational Performance Measure (COPM). This tool focuses on what is important to the client through a series of questions. The client is asked about his/her perception of performance and the importance of occupations regarding self-care, productivity, PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 12 and leisure (Dedding et al., 2004). This tool allows therapist to focus on the clients perspective and personal goals throughout the therapy process (Law et al., 1990). Analysis of the COPM has shown that it has multiple benefits when implemented into practice. Some of these benefits include: enabling the therapist to create more realistic goals (Chen et al., 2002), enabling the therapist to keep therapy occupation-focused, and allowing the therapist to see from the clients viewpoint (Colquhoun, Letts, Law, MacDermid, & Edwards, 2010). These types of assessment tools are valid ways to ensure a clients rights to achieving occupational justice are implemented into therapy sessions. Client empowerment. In order for a therapist to participate in client-centered practice, the therapist must empower the client. According to Townsend (2003), some occupational therapists may be limited in regards to their ability to empower their client. Some occupational therapists feel that their profession does not have enough respect to empower them to make a difference in long-term care (Duggan, 2005). According to Morgan (1996), disempowerment of clients can be seen through the areas of others, attitudes, and inability. Clients identified that they can be empowered through ability, control, and feelings (Morgan, 1996). The clients also listed some criteria of an empowering individual and those included: being understanding, supportive, accepting, sharing, and having a positive attitude (Morgan 1996). Clients are to identify and choose personal goals, as well as eventually perform the goals after intervention (Townsend, 2003). Promoting empowerment for clients allows them to overcome difficult situations in life as well as increase their societal contributions (Cowger, 1994). Clark and colleagues (2012) found that therapists who encourage clients to engage in occupations that are specifically meaningful to each individual, have found that through their interventions the clients quality of life greatly improves. Clients mental and physical well-being also improved throughout the length of the PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 13 intervention by simply being encouraged to participate in occupations they felt were significant (Clark et al., 2012). Quality of life. Quality of life (QOL) refers to how satisfied an individual is in life in association with self- concept, health, and socioeconomic factors (AOTA, 2014, p. S45). It is one of the main outcomes that occupational therapists strive to accomplish through intervention (AOTA, 2014). Researchers found occupational therapists can be unaware that a client's perception of QOL is different than their own perception of the clients QOL (Leone, Moja, & Vegni, 2013). Often times this misconception can lead to a large turnover of employees, which could negatively influence the residents quality of life as well (Palacios-Cena et al., 2012). The more dependent an individual is in long-term care generally correlates with that person having a lower quality of life. This can be attributed to the fact more dependence leads to increased costs that decrease opportunities of leisure activities outside of the nursing home (Palacios-Cena et al., 2013). Having the ability to participate in leisure activities is integral to achieving occupational justice and has been known to decrease depression and increase quality of life by enhancing ones sense of identity as well as healthy interactions (Causey-Upton, 2015). Over 50% of the resident population are prescribed anti-depressant medication (Rosen, 2014). According to Causey-Upton (2015), only about 48.7% of residents participate in leisure interests, whereas 92% of adults in the community participate in leisure interests. Being able to choose meaningful activities would result in increased occupational participation, quality of life, and overall health and well-being, all of which are aspects of occupational justice (Causey-Upton, 2015). Socialization. The incorporation of meaningful activity allows older adults to participate in occupations they find enjoyable and to also make social connections with other residents living in the nursing home. Social groups may also be important for older adults who feel PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 14 depressed or alienated due to living in a setting they are not used to or do not feel they belong in (Hersch et al., 2012). Although the older adult population often goes unnoticed, social inclusion through occupation is important for a high quality of life (Riegel & Eglseder, 2009). Carrier et al. (2010) noted that social roles contributed more to older adults quality of life than ADL participation did. Furthermore, it was noted that being with a client proved more beneficial than doing to a client (Hammell, 2013, p. 144). Overall socialization, including listening to clients, can simultaneously improve the client-therapist relationship and promote a clients expression of interests, plans, hopes, and goals (Hammell, 2013). Continuing education on occupational justice. The need for education on the topic of occupational justice for practicing therapists is evident. Townsend and Wilcock (2004) describe advocacy for the concept, as well as its translation into practice, as a necessity and suggest that if therapists are not advocating for occupational justice, they are thereby participating in occupational injustice via inaction. It is described as an implicit issue, regardless of choice, due to the innate philosophy of occupational therapy, including client-centeredness, social inclusion, and professionalism as well as others (Townsend & Wilcock, 2004). Continuing education for occupational therapists is necessary in order to develop and maintain the knowledge, performance skills, interpersonal abilities, critical reasoning, and ethical reasoning skills that are needed to perform at current and future levels within the profession and sustain professional competence (AOTA, 2006, p. 1-2). Educational workshops have been proven as an effective form of educating and improving competencies in health care providers (Elminowski, 2015). While there have been previous workshops on the topic of occupational justice presented in Australia, Britain, Canada, Portugal, Sweden, and the United States, the need for advocacy and education is still present (Townsend & Wilcock, 2004). PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 15 Participants in these workshops have produced questions post-workshop about the difference between social and occupational justice, seeking to learn more about the concept, and commenting that they have already been practicing occupational justice without knowing the term existed (Townsend & Wilcock, 2004). A workshop targeting occupational therapists knowledge of occupational justice and ensuring translation of the concept into practice will have beneficial results for older adults. Translation of knowledge to practice cannot simply be done by reading about new methods of practice. For example, the Knowledge-To-Action Process may be utilized when attempting to implement learned knowledge (Metzler & Metz, 2010). There are also benefits observed from workshops using facilitated discussion between colleagues, which resulted in increased implementation of knowledge (Gorenberg, 2013). The implementation of new knowledge promotes utilizing a client-centered practice, which results in increased satisfaction to the client (Maitra & Erway, 2006). A pilot study was completed on students knowledge of occupational justice through a single case study (Aldrich, White, & Conners, 2016). This exploratory study focused on how one student used her passion about the topic of occupational justice to advocate for the rights of clients through protests. Researchers found the need for occupational therapy students and practitioners to learn how to promote the ideas of occupational justice throughout the community. Aldrich, White, and Connors, (2016), found that limited resources and lack of knowledge about occupational justice led to many clinicians being unaware of this issue and they simply accepted it. Aldrich, White and Conners, (2016), stated the importance of modeling how to engage with, reflect on, and apply the concept of occupational justice rather than unquestioningly accept it (p.231). It is the therapists responsibility to address injustices that their clients face (Townsend & PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 16 Wilcock, 2004). Townsend and Wilcock (2004) stated that therapists primary concern is the population vulnerable to injustices because of restricted access to occupational engagement. Furthermore, it is a common goal for the field of occupational therapy to exercise client-centered practice, enabling clients to be active in their own decision-making and promoting overall health and well-being (Townsend & Wilcock, 2004). Aldrich, Boston, & Daaleman (2017) explained the importance of integrating the values of occupational justice into education for occupational therapy students and practitioners. Researchers reiterated the original values of what occupational therapy practice was created on and how the lack of incorporation of occupational justice in practice inhibits practitioners from fully fulfilling these values created by AOTA (Aldrich, Boston, & Daaleman, 2017). Overall, occupational therapists have the power and responsibilities to promote occupational justice within their practice settings in order to increase health, well-being, social inclusion, and quality of life of clients. Berger (2012) conveyed an important message: knowledge of occupational justice can guide our ethical reasoning and actions on behalf of our clients (Berger, 2012, p. 3). Previous dialogue has suggested that gained knowledge about occupational justice may inspire and motivate health professionals to encourage and facilitate occupational justice into their practice (Nilsson & Townsend, 2010). Aldrich, Boston, & Daaleman (2017) pointed out that the mission of occupational therapists is to aid clients in living life to the fullest by being able to participate in occupations they need and want to do. A valuable part of being able to fulfill this mission to clients is by incorporating the ideas and the importance of occupational justice into professional practice. By integrating the concepts of occupational justice into everyday practice, this ensures occupational therapists are withholding the original intentions of occupational therapy practice (Aldrich, Boston, & Daaleman, 2017). The purpose of our study was to examine occupational PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 17 therapy practitioners improved knowledge of issues of occupational justice and indication of intent to incorporate it into individual practice after completion of an educational workshop. Through participation in a one-day workshop focusing on issues of occupational justice, we hypothesized occupational therapy practitioners would show improved knowledge and intent to incorporate it into their individual practices. Methods Research Design This study was an exploratory quantitative quasi-experimental pre-test post-test design. The study was given approval and classified as an exempt study by the Institutional Review Board (IRB) at the University of Indianapolis. Informed consent was obtained from participants at the beginning of the pre- and post-workshop surveys. Participants Researchers recruited 14 occupational therapy practitioners who, at the time of the workshop, worked in a nursing home in the Indianapolis area (Doyle & Bennett 2014; Elminowski, 2015). Occupational therapy practitioners are defined by AOTA as occupational therapists and occupational therapy assistants (2014). Previous research has shown that a minimum number of 13 participants yield statistically significant results (Steed, 2010). Participants were sent information via email, detailing the purpose of the free workshop, including information regarding continuing education units (CEUs) . Emails were sent to the University of Indianapoliss fieldwork contacts in the nursing home settings. The workshop took place in October 2016 before licensure requirements were due for the state of Indiana. Participants interested in the workshop registered online. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 18 Procedure A workshop to educate occupational therapy practitioners on the concepts of occupational justice and how to facilitate within the nursing home setting took place at the University of Indianapolis. An Associate Professor with an extensive background in occupational justice in the School of Occupational Therapy at the University of Indianapolis led the workshop and served as the primary investigator of the study. Once registered for the workshop, participants were offered the opportunity to participate in the research study through completion of a pre-workshop online survey. Occupational therapy practitioners who attended the workshop were not required to participate in the research study. Participants consented to the workshop via a link to an online Qualtrics survey (see Appendix A). If consent was given, participants then completed the pre-workshop survey regarding their current knowledge and opinions on the concept of occupational justice (see Appendix B). Twelve occupational therapy practitioners participated in the workshop, and eleven chose to consent to participate in the research and thus completed the pre-workshop survey. Participants then attended an on-site workshop at the University of Indianapolis campus. The workshop included lecture material, videos, interactive discussion, and reflection. Throughout the workshop, participants shared their input on the topics presented with the other occupational therapy practitioners at their tables. One week after the workshop, participants completed an initial post-workshop survey after a reminder email was sent by the primary investigator regarding their knowledge on occupational justice and their plan to implement the concept into practice (see Appendix C). The email also informed participants that a second and final post-workshop survey would be sent via email to them 4-6 weeks following the workshop for completion (see Appendix D). PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 19 Intervention Workshop design. A 4-hour workshop using lecture material, videos, interactive discussion, and reflection was designed by the primary investigator to improve occupational therapy practitioners knowledge and awareness of issues regarding occupational justice (see Appendix E). The goal of this workshop was to educate occupational therapy practitioners on the importance of occupational justice along with enabling them to find ways to incorporate this concept into their everyday practice. The workshop intervention was based on allowing occupational therapy practitioners to adapt an occupational justice frame of reference. Wolf, Ripat, Davis, Becker, and MacSwiggan (2010) analyzed the occupational justice frame of reference by stating the importance of teaching therapists to readjust their own viewpoint regarding a patients occupational engagement level. In order to do this, occupational therapy practitioners must be able to identify barriers that inhibit their clients from engaging in desired occupations (Wolf et al, 2010, p.15). This intervention plan was designed to teach occupational therapy practitioners the constructs of occupational justice and to educate occupational therapy practitioners on how to use those constructs to reduce barriers the client may have from engaging in meaningful activities. The first segment of the workshop involved defining occupational justice and how it pertains to practice in the nursing home setting based on the research by Townsend and Wilcock (2004). The primary investigator differentiated occupational justice from social justice and three subcategories of occupational justiceoccupational deprivation, occupational marginalization, and occupational alienationwere described as defined by Hammell (2008). Participants then broke into groups of 2-4 to discuss how these subcategories directly related to their clients, followed by a full group discussion. The primary investigator emphasized the importance of PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 20 occupation to ones health, supported by evidence from Wilcock (2004) and followed by further small-group discussions. The primary investigator refreshed participants on the importance of client-centeredness in the practice of occupational therapy. Three second-year Doctorate of Occupational Therapy students at the University of Indianapolis each discussed a client-centered assessment the practitioners could use in practice: the Canadian Occupational Performance Measure, Interest Checklist, and Activity Card Sort. The students educated participants on assessment content, administration of the tools, application to practice, and how to obtain them. Finally, the primary investigator educated participants on the importance of therapeutic use of self in practice, client empowerment, and advocacy, ending with participants creating and discussing action plans to utilize knowledge learned from the workshop in practice. Outcomes Survey. Pre- and post-workshop surveys containing Likert-scale questions and one-totwo open-ended questions were utilized to collect data. Survey questions were obtained and adapted from a previous study based on occupational justice through occupational storytelling and story making (Bednarski, 2016). Bednarski (2016) found that a similar workshop produced an improvement in the knowledge of occupational justice of students in an occupational therapy program. Using this study as a reference, similar questions were developed in order to detect change in knowledge of OT practitioners. The survey was designed to determine whether the objectives from the study had been met. Course evaluation. The primary investigator distributed a course evaluation to all twelve occupational therapy practitioners at the end of the workshop to assess whether the learning objectives were met. The occupational therapy practitioners rated their experiences from the workshop as not satisfied, somewhat satisfied, satisfied, or very satisfied based on the PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 21 objectives listed in Table F3. Data Analysis The University of Indianapolis Qualtrics program was utilized to collect and analyze data. Descriptive quantitative data was obtained from the Qualtrics Program and analyzed. Three sets of data were obtained from the pre-workshop survey and the two post-workshop surveys. Data was analyzed to identify the means for responses to questions within the survey. Further analysis utilized percentages derived from answers using the Likert-scale to identify changes in participant responses between survey periods. Results Eleven participants completed the pre-workshop survey; nine completed the first postworkshop survey, and five completed the second post-workshop survey. A scale of 1-5 was established correlating a number with corresponding answers with 1 indicating strongly agree and 5 indicating strongly disagree (see Table F1). Means were calculated in accordance with the scale for each individual question (see Table F2). Results of the data analysis indicated greatest differences in questions six and seven. Question six stated I feel I can clearly state the definition of occupational justice in which the pre-workshop mean was an average of 3.3 compared to a post-workshop mean of 1.44. Question seven stated I feel I can clearly state the definitions of occupational injustices (occupational marginalization, occupational deprivation, and occupational alienation) in which the pre-workshop mean was 3.2 compared to the postworkshop mean of 1.33. These means indicated a change from neither agree nor disagree towards agree or strongly agree. Quantitative data from the second post-workshop survey was not analyzed or used for this study due to limited participant responses showing no significance. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 22 Eleven out of the twelve occupational therapy practitioners who attended the workshop also completed course evaluations and 100% of the participants reported that they were very satisfied or satisfied that their learning objectives were met. The course evaluation aligned with the learning objectives of the workshop (see Table F3). Intent to Implement Qualitative data was analyzed by assessing an open-ended question included in the first post-workshop survey regarding the occupational therapy practitioners plan to implement gained knowledge after the workshop (see Table F4). All participant responses indicated intent to implement the concept of occupational justice into their practice. The second post-workshop survey data was used to assess participants implementation after the conclusion of the workshop. This data is shown in Table F5. The open-ended question for the second postworkshop survey produced a theme of advocating for clients amongst the four out of five participants who answered. Increased Knowledge Analyzed data assessed the workshop participants increased knowledge by comparing self-perceived knowledge on occupational justice before and after the workshop. When assessing the strongly agree responses from pre-workshop to the first post-workshop survey, questions eight, nine, and twelve each displayed at least a 70 percent increase (see Table F6). The differences in the percentage of respondents selecting strongly agree on various questions from the pre-workshop survey to the first post-workshop survey are shown in Figure F1. Questions 1 and 2 were omitted from Figure F1 because they inquire about demographics that remained unchanged. Additional analysis showed that when comparing the occupational therapy practitioners ages and years of practice, there was no significant impact on how they answered PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 23 the survey questions. Discussion The results indicated participation in an occupational justice workshop increased occupational therapy practitioners knowledge on occupational justice and the intent to implement into practice, and therefore supported our hypothesized outcome. By means of the educational intervention strategy, the workshop demonstrated effectiveness as evidenced by all participants indicating the intent to implement occupational justice practice in the nursing home setting. Elminowski (2015) acknowledged educational workshops as a proven way to inform others through an informative workshop held to improve competencies in health care providers. The workshop intervention had a positive impact on the participants as observed through improved knowledge and intent to incorporate occupational justice into their individual practices. Similar results of increased knowledge post-workshop were seen from a pilot study on individuals knowledge of occupational justice (Aldrich, White, & Conners, 2016). This indicates that older adults living in the nursing home setting will have better outcomes and a higher quality of life if occupational therapists are educated on ways to advocate for occupational justice in their practices. Egan, Dubouloz, Leonard, Paquet, & Carter (2014) similarly found that advocacy must occur for clients to have an increased quality of life through the engagement of meaningful activities. Overall, this study provides preliminary results supporting the use of an educational workshop to increase occupational therapy practitioners knowledge and intent to implement occupational justice into practice. Limitations The primary limitation of this study was the small sample size, in addition to decreased participation in each subsequent survey. If all participants would have completed the first and PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 24 second post-workshop surveys, then the outcomes would have been analyzed with greater significance. Another limitation was using a survey that was not standardized. Thus, the survey was not validated. A significant change with occupational therapy implementation of occupational justice within the nursing home setting could not be obtained due to the limitations previously stated. Conclusion Future replications of this study should include a larger sample size in order to produce significant results. The preliminary results indicate the usefulness for the field of occupational therapy to use this workshop, or one similar, as a foundation for future educational workshops on occupational justice or similar topics. To ensure follow-through, it is recommended that future studies consider implementing an initial educational workshop followed by a collaborative workshop on a different date detailing how to incorporate these ideas into everyday practice. A second workshop could yield more consistent results and increased participant participation. Further studies are crucial not only to raise awareness of occupational justice but to provide ideas and information on how to implement occupational justice into practice. There is limited research on the topic of occupational justice in the nursing home setting, resulting in uninformed OT practitioners. Occupational injustice is an ongoing issue amongst older adults that can be detrimental to their quality of life, and occupational therapists have a responsibility to advocate for and help improve the quality of life of this population through occupational justice. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 25 References Aldrich, R. M., Boston, T. L., & Daaleman, C. E. (2017). Centennial TopicsJustice and U.S. occupational therapy practice: A relationship 100 years in the making. American Journal of Occupational Therapy, 71, 7101100040. https://doi.org/10.5014/ajot.2017.023085 Aldrich, R. M., White, N. A., & Conners, B. L. (2016). Translating occupational justice education into action: Reflections from an exploratory single case study. OTJR: Occupation, Participation and Health, 36(4), 227-233. doi:10.1177/1539449216667278 American Occupational Therapy Association (AOTA). (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. doi:10.5014/ajot.2014.682006 AOTA fact sheet: Continuing competence in the occupational therapy profession [Website]. (2006). Retrieved from https://www.aota.org//media/Corporate/Files/Advocacy/State/Resources/ContComp/ccfact.pdf Bednarski, J. (2016). An elective course exploring occupational justice through occupational storytelling and story making. The Open Journal of Occupational Therapy, 4(1), 1-16. Berger, S., (2012). Infusing occupational justice into gerontology practice. American Occupational Therapy Association, 35(1), 1-4. Borell, L., Lilja, M., Sviden, G.A., & Sadlo, G. (2001). Occupations and signs of reduced hope: An explorative study of older adults with functional impairments. American Journal of Occupational Therapy, 55(3), 311-316. Carrier, A., Levasseur, M., & Mullins, G. (2010). Accessibility of occupational therapy community services: A legal, ethical, and clinical analysis. Informa Healthcare, 24(4), 360-376. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 26 Causey-Upton, R. (2015). A model for quality of life: Occupational justice and leisure continuity for nursing home residents. Informa Healthcare USA, Inc., 33(3), 175-188. doi: 10.3109/02703181.2015.1024301 Chen, Y., Rodger, S., & Polatajko, H. (2002). Experiences with the COPM and client-centred practice in adult neurorehabilitation in Taiwan. Occupational Therapy International, 9, 167-184. doi:10.1002/oti.163 Clark, F., Jackson, J., Carlson, M., Chou, C., Cherry, B. J., Jordan- Marsh, M., . . . Azen, S. P. (2012). Effectiveness of a lifestyle intervention in prompting the well-being of independently living older people: Results of the Well Elderly 2 Randomised Controlled Trial, Epidemiol Community Health, 66, 782-790. doi: 10.1136/jech.2009.099754 Colquhoun H., Letts, L., Law, M., MacDermid, J., & Edwards, M. (2010). Clinical utility of the Canadian Occupational Performance Measure for routine use. British Journal of Occupational Therapy, 73, 48-54. doi:10.4276/030802210X12658062793726 Cowger, C.D. (1994). Assessing client strengths: Clinical assessment for client empowerment. National Association of Social Workers, Inc., 39(3), 262-268. Dedding, C., Cardol, M., Eyssen, I., Dekker, J., & Beelen, A. (2004). Validity of the Canadian Occupational Performance Measure: A client-centered outcome measurement. Clinical Rehabilitation, 18, 660-667. doi: 10.1191/0269215504cr746oa Doyle, S. D., & Bennett, S. (2014). Feasibility and effect of a professional education workshop for occupational therapists management of upper-limb poststroke sensory impairment. American Journal of Occupational Therapy, 68, 74 83. doi: 10.5014/ajot.2014.009019 Duggan, R. (2005). Reflection as a means to foster client-centered practice. Canadian Journal of Occupational Therapy, 27(2), 103-112. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 27 Durocher, E., Rappolt, S., and Gibson, B. (2014). Occupational justice: Future directions. Journal of Occupational Science, 21(4), 431-442. doi:10.1080/14427591.2013.775693 Du Toit, S. J., Bning, W., & Van Der Merwe, T. R. (2014). Dignity and respect: Facilitating meaningful occupation for SeSotho elders. Scandinavian Journal of Occupational Therapy, 21(2), 125-135. doi:10.3109/11038128.2013.861015 Egan, M. Y., Dubouloz, C., Leonard, C., Paquet, N., & Carter, M. (2014). Engagement in personally valued occupations following stroke and a move to assisted living. Physical & Occupational Therapy in Geriatrics, 32(1), 25-41. doi:10.3109/02703181.2013.867559 Elminowski, N. S. (2015). Developing and implementing a cultural awareness workshop for nurse practitioners. Journal of Cultural Diversity, 22(3), 105-113. Gagne, D., & Hoppes, S. (2003). The effects of collaborative goal-focused occupational therapy on self-care skills: A pilot study. The American Journal of Occupational Therapy, 57(2), 215-219. Gorenberg, M. (2013). Instructional insights: Continuing professional education to enhance therapeutic relationships in occupational therapy. Occupational Therapy in Health Care, 27(4): 393-398. doi:10.3109/07380577.2013.834404 Hammell, K. W. (2008). Reflections on well-being and occupational rights. Canadian Journal of Occupational Therapy, 75(1): 61-64. doi:10.2182/cjot.07.007 Hammell, K. R. W. (2013). Client-centered occupational therapy in Canada: Refocusing on core values. Canadian Journal of Occupational Therapy, 80(3), 141-149. doi: 10.1177/0008417413497906 Hammell, K. W., & Beagan, B. (2016). Occupational injustice: A critique: L'injustice occupationnelle: une critique. Canadian Journal of Occupational Therapy. 84(1), 58-68. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 28 Hansen, A. W. (2013). Bridging theory and practice: Occupational justice and service learning. Work, 45(1), 41-58. doi:10.3233/WOR-131597 Harris-Kojetin L, Sengupta M, Park-Lee E, & Valverde R. (December 2013). Long-term care services in the United States: 2013 overview. National Center for Health Statistics [PDF file]. Vital Health Stat 3(37). Hersch, G., Hutchinson, S., Davidson, H., Wilson, C., Maharaj, T., & Watson, K. B. (2012). Effect of an occupation-based cultural heritage intervention in long-term geriatric care: A two-group control study. American Journal of Occupational Therapy, 66, 224232. http://dx.doi.org/10.5014/ajot.2012.002394 Katz, N., Karpin, H., Lak, A., Furman, T., Hartman-Maeir, A. (2003). Participation in occupational performance: reliability and validity of the Activity Card Sort. Occupational Therapy Journal of Research, 23(1), 11-17. Klyczek, J. P., Bauer-Yox, N., Fiedler, R. C. (1997). The Interest-Checklist: A factor analysis. American Journal of Occupational Therapy, 51(10), 815-823. Leone, D., Moja, E. A., & Vegni, E. (2013). Satisfaction for quality of life: a comparison of patient and occupational therapist perspectives. Scandinavian Journal of Occupational Therapy, 20(4), 315-320. doi:10.3109/11038128.2013.777939 Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H., & Pollock, N. (1990). The Canadian Occupational Performance Measure: An outcome measure for occupational therapy. Canadian Journal of Occupational Therapy, 57, 82-87. Maitra, K. K. & Erway, F. (2006). Perception of client-centered practice in occupational therapists and their clients. American Journal of Occupational Therapy, 60, 298310. Metzler, M. J., Metz, G. A. (2010). Translating knowledge to practice: An occupational therapy PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 29 perspective. Australian Occupational Therapy Journal, 57, 373-379. doi: 10.1111/j.14401630.2010.00873.x Morgan, L. (1998). Patient empowerment and chronic care: An exploration of the patient perspective (Masters theses). Retrieved from http://scholarworks.sjsu.edu/etd_theses/1708 Nilsson, I. and Townsend, E. (2010). Occupational justicebridging theory and practice. Scandinavian Journal of Occupational Therapy, 17, 57-63. doi:10.3109/11038120903287182 Palacios-Cena, D., Gomez-Calero, C., Cachon-Perez, J. M., Brea-Rivero, M., Gomez-Perez, D., & Fernandez-de-las-Penas, C. (2014). Non-capable residents: Is the experience of dependence understood in nursing homes? A qualitative study. Geriatrics Gerontology International, 14, 212-219. doi: 10.1111/ggi.12066 Riegel, S. K., and Eglseder, K. (2009). Occupational justice as a quality indicator for occupational therapy services. Occupational Therapy in Health Care, 23(4): 288-301. doi:10.3109/07380570903236500 Rosen, J. (2014). Depression in long-term care residents. Journal of the Catholic Health Association of the United States, 1, 43-47. Steed, R. (2010). Attitudes and beliefs of occupational therapists participating in a cultural competency workshop. Occupational Therapy International, 17, 142-151. Taylor, R. R., Lee, S., Kielhofner, G., & Ketkar, M. (2009). The therapeutic relationship: A nationwide survey of practitioners attitudes and experiences. American Journal of Occupational Therapy, 63(2): 198207. doi:10.5014/ajot.63.2.198 Townsend, E. (2003). Reflections on power and justice in enabling occupation. Canadian PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Journal of Occupational Therapy, 70(2), 74-87. Townsend, E. (2012). Boundaries and bridges to adult mental health: Critical occupation and capabilities perspectives of justice. Journal of Occupational Science, 19(1), 8-24. Townsend, E. & Wilcock, A. (2004). Occupational justice and client-centered practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 71(2), 75-87. Wolf, L., Ripat, J., Davis, E., Becker, P., & Macswiggan, J. (2010). Applying an occupational justice framework. Occupational Therapy Now, 12, 15-18. 30 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 31 Appendix A Occupational Justice in the Skilled Care Environment: Informed Consent EXEMPT UIndy Study# 0783 Study Version: 1.0 Study Version Date: August 9, 2016 ONLINE Informed Consent Document (ICD) Version: 1.0 ONLINE ICD Version Date: August 9, 2016 Principal Investigator: Julie Bednarski, OTD School of Occupational Therapy Email: jbednarski@uindy.edu Telephone: 317-788-3577 INFORMED CONSENT FOR PARTICIPATION IN RESEARCH ACTIVITIES Study Title: Does Participation in an Occupational Justice Workshop Change OT Practice in the Nursing Home Setting? WHAT IS THE PURPOSE OF THIS RESEARCH STUDY? Thank you for accessing the "Participation in an Occupational Justice Workshop: Does it Change OT Practice in the Nursing Home?" questionnaire. The purpose of this study is to investigate OTRs' knowledge of issues of occupational justice and indication of intent to incorporate it into individual practice after completion of an educational workshop. You have been asked to participate in this research project because you are a registered occupational therapist working in a nursing home setting in the Indianapolis area AND you have registered to participate in the Occupational Justice Workshop. The anticipated number of participants for this study is 20. WHAT WILL I DO IF I PARTICIPATE IN THIS RESEARCH STUDY? Participation in the workshop is NOT a research activity. If you choose to participate in the study, you will complete an online pre-workshop questionnaire, an initial online post-workshop questionnaire and an online post-workshop questionnaire approximately 4-6 weeks after the conclusion of the workshop. You will receive email notifications for both post-workshop questionnaires. The questionnaires are expected to take 5-10 minutes to complete. This preworkshop questionnaire will consist of three demographic multiple choice type question and 11 Likert-scale questions. The post-workshop questionnaires will consist of 12 Likert questions and 1 open-ended question. We are asking you to please be truthful when answering these questions so that the study yields optimal results. You may skip any question if you feel uncomfortable answering a question. If you feel uncomfortable at any time, you may stop at any point during the questionnaire and discontinue the questionnaire. You may still participate in the workshop PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 32 being offered if you choose not complete our online pre- and post-workshop questionnaires. WHAT ARE THE RISKS OF PARTICIPATING IN THIS RESEARCH STUDY? The risks of participating in this research study are few and minimal. You may experience some emotional discomfort when thinking about matters of occupational injustice. The most important risk is loss of confidentiality and privacy. HOW WILL MY PRIVACY BE PROTECTED? The questionnaires will NOT collect any individually identifiable information about you. You should not add any individually identifiable information about yourself when you answer the questions. The investigators will not collect the internet protocol (IP) address of the device you use to answer the questionnaires. To further protect your privacy, you should complete the questionnaires in a private location using a private device with a secure internet connection. The investigators will NOT connect your contact informationname and email addressto questionnaire results. Should the research from this study be published, no participant will be individually identified because the questionnaire results are anonymous. WHAT IF I HAVE QUESTIONS BEFORE PARTICIPATING IN THE RESEARCH STUDY? Questions regarding the survey can be answered by emailing Julie Bednarski at jbednarski@uindy.edu or calling (317)788-3577 or (800) 232-8634 x3577. The study was reviewed and approved by the University of Indianapolis Human Protections Administrator (HPA). The HPA has the responsibility of protecting the rights and welfare of people who participate in research that is exempt from Institutional Review Board (IRB) review because the research poses little to no risks to participants. If you have questions or concerns about your rights and welfare as a research participant, then you should contact the HPA, Dr. Greg E. Manship at (317) 781-5774 or (800) 232-8634 x5774. If you choose to participate in this research study, then you should print and/or save a copy of this informed consent page for your personal records. I have read and understand the above information and I consent to participate in this study. I do not consent to participate in this study. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Appendix B Occupational Justice in the Skilled Care Environment: Pre-Workshop Survey What is your current age? 21-30 31-40 41-50 51-60 61+ What is your primary work setting? Skilled Nursing Center/Nursing home Inpatient Acute Hospital Outpatient: Adults School System Rehabilitation Hospital Outpatient: Pediatrics Other How long have you worked in the nursing home setting? Less than 1 year 1-5 years 6-10 years 11+ years I feel I understand the concept of occupational justice. 33 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel I can clearly state the definition of occupational justice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel I can clearly state the definitions of occupational injustices (occupational marginalization, occupational deprivation, and occupational alienation). Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel occupational justice is an important outcome of occupational therapy. Strongly agree Agree Neither agree nor disagree Disagree 34 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 35 Strongly disagree I believe an OT has a role in the promotion of occupational justice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel occupational injustices may occur with clients in the setting in which I currently work. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel understanding the concepts of occupational justice assists me to create a more clientcentered practice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I believe an occupational therapist has a role in promotion of occupational justice in the nursing home environment. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I believe an occupational therapist has a role in advocating for their clients occupational needs. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I believe an occupational therapist has a role in assisting a person residing in the nursing home environment to advocate for their occupational needs. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel confident in my efforts to promote occupational justice in my current work setting. Strongly agree Agree Neither agree nor disagree 36 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Disagree Strongly disagree 37 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Appendix C Occupational Justice in the Skilled Care Environment: First Post-Workshop Survey What is your current age? 21-30 31-40 41-50 51-60 61+ What is your primary work setting? Skilled Nursing Center/Nursing home Inpatient Acute Hospital Outpatient: Adults School System Rehabilitation Hospital Outpatient: Pediatrics Other How long have you worked in the nursing home setting? Less than 1 year 1-5 years 6-10 years 11+ years 38 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP I feel I understand the concept of occupational justice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel I can clearly state the definition of occupational justice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel I can clearly state the definitions of occupational injustices (occupational marginalization, occupational deprivation, and occupational alienation). Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel occupational justice is an important outcome of occupational therapy. Strongly agree Agree Neither agree nor disagree 39 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Disagree Strongly disagree 40 I believe an OT has a role in the promotion of occupational justice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel occupational injustices may occur with clients in the setting in which I currently work. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel understanding the concepts of occupational justice assists me to create a more clientcentered practice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP I believe an occupational therapist has a role in promotion of occupational justice in the nursing home environment. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I believe an occupational therapist has a role in advocating for their clients occupational needs. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I believe an occupational therapist has a role in assisting a person residing in the nursing home environment to advocate for their occupational needs. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel confident in my efforts to promote occupational justice in my current work setting. Strongly agree 41 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Agree Neither agree nor disagree Disagree Strongly disagree I intend to implement the concept of occupational justice into my current practice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree How do you intend to implement the concept of occupational justice into your practice? (Please give specific examples.) ` 42 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Appendix D Occupational Justice in the Skilled Care Environment: Second Post-Workshop Survey What is your current age? 21-30 31-40 41-50 51-60 61+ What is your primary work setting? Skilled Nursing Center/Nursing home Inpatient Acute Hospital Outpatient: Adults School System Rehabilitation Hospital Outpatient: Pediatrics Other How long have you worked in the nursing home setting? Less than 1 year 1-5 years 6-10 years 11+ years 43 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP I feel I understand the concept of occupational justice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel I can clearly state the definition of occupational justice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel I can clearly state the definitions of occupational injustices (occupational marginalization, occupational deprivation, and occupational alienation). Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel occupational justice is an important outcome of occupational therapy. Strongly agree Agree Neither agree nor disagree 44 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Disagree Strongly disagree 45 I believe an OT has a role in the promotion of occupational justice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel occupational injustices may occur with clients in the setting in which I currently work. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel understanding the concepts of occupational justice assists me to create a more clientcentered practice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I believe an occupational therapist has a role in promotion of occupational justice in the PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP nursing home environment. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I believe an occupational therapist has a role in advocating for their clients occupational needs. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I believe an occupational therapist has a role in assisting a person residing in the nursing home environment to advocate for their occupational needs. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree I feel confident in my efforts to promote occupational justice in my current work setting. Strongly agree Agree 46 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Neither agree nor disagree Disagree Strongly disagree I have implemented the concept of occupational justice into my current practice. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree How have you implemented the concept of occupational justice into your practice? (Give specific examples.) 47 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Appendix E 48 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 49 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 50 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 51 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 52 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 53 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 54 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 55 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 56 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 57 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 58 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 59 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 60 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 61 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 62 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 63 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 64 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 65 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 66 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP Appendix F Table F1 Answers corresponding to a numerical value Answer Numerical Value Strongly agree 1 Agree 2 Neither agree nor disagree 3 Disagree 4 Strongly disagree 5 Table F2 Individual and Total Mean Values for the Pre and Post Workshop Surveys Question Pre-Workshop Mean Post-Workshop Mean 5 2.6 1.11 6 3.3 1.44 7 3.2 1.33 8 1.9 1 9 2.1 1 10 2.1 1.55 11 2.2 1.11 12 2.3 1 13 1.5 1.11 14 1.5 1.22 67 PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 15 2.6 1.44 Average 2.3 1.21 68 Table F3 Learning Objectives met after Occupational Justice Workshop 1. Define occupational justice and assess issues of occupational justice within his/her current setting. 2. Describe his/her perceived knowledge of occupational justice and ways to empower clients to improve quality of life and wellness. 3. Implement knowledge learned in order to improve occupational justice for those living in the nursing home setting. 4. Identify ways to improve client-centeredness in order to facilitate client participation in meaningful occupations. 5. Determine barriers to occupational justice in his/her setting and ways to remove barriers. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 69 Table F4 Participants Responses to Question 18 of the Post-Workshop Survey 1 How did you intend to implement the concept of occupational justice into your practice? (please give specific examples.) I have integrated the completion of the interest checklist in the treatment of many of my clients in order to understand their individual interests. Once I understand what their interests are, I am trying to find ways to get them involved in these activities in therapy and hopefully upon discharge. I have met with the activity coordinator to find ways to work together to help our residents. Use assessment tools to determine occupational injustice and develop a plan of care to promote occupational justice. As I evaluate each person to write their prior occupation and their hobbies. Implementing an interest checklist on all of my patients to establish goals that are centered on occupation as well as the patients specific daily routines. I plan to increase education to staff, specifically activities and nursing, to increase patient's opportunities to participate in meaningful occupations. Involved every discipline in the building to work as a team to promote and provide opportunity for participation in meaningful and individualized occupations. I have begun a program in which I correlate my assessments of patients with dementia with the activities department to better improve their department and improve our patients occupational justice. By improving their program with our assistance and expertise we can decrease the likelihood that our patients are marginalized, isolated and/or deprived of their occupational needs. Using more client centered assessment tools. Assess the patient's current roles/participation in desired occupations and client factors that affect participation. Provide OT services to facilitate appropriate skills required to participate, and advocate for the patient's needs if required. PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 70 Table F5 Participants responses to question 17 of the second post-workshop survey How have you implemented the concept of occupational justice into your practice? Advocating for pts. Determining occupational injustices and advocating for the client's highest level of participation in occupational needs. During routine screenings, I look to see if there is anything that OT can do to make their life more pleasurable or meaningful by better meeting their occupational needs Increased advocating efforts in combination with other departments within the setting I reside in. Table F6 Largest percentage increases of strongly agree responses from pre-workshop survey and first post-workshop survey Question Number 5 Question I feel I understand the concept of occupational justice Pre-Workshop Survey: 20% 6 Difference: 68.89% I feel I can clearly state the definition of occupational justice Pre-Workshop Survey: 0% 7 First PostWorkshop Survey: 88.89% First PostWorkshop Survey: 55.56% Difference: 55.56% I feel I can clearly state the definitions of occupational injustices (occupational marginalization, occupational deprivation, and occupational alienation) Pre-Workshop Survey: First PostWorkshop Survey: Difference: 66.67% PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 0% 8 Difference: 70% First PostWorkshop Survey: 100% Difference: 70% I feel understanding the concepts of occupational justice assists me to create a more client-centered practice. Pre-Workshop Survey: 20% 12 First PostWorkshop Survey: 100% I believe an OT has a role in the promotion of occupational justice Pre-Workshop Survey: 30% 11 66.67% I feel occupational justice is an important outcome of occupational therapy Pre-Workshop Survey: 30% 9 71 First PostWorkshop Survey: 88.89% Difference: 68.89% I believe an occupational therapist has a role in promotion of occupational justice in the nursing home environment Pre-Workshop Survey: 20% First PostWorkshop Survey: 100% Difference: 80% PARTICIPATION IN AN OCCUPATIONAL JUSTICE WORKSHOP 72 Figure F1. Comparison of pre- and post-workshop survey percentage of strongly agree answers. There is an increase in Strongly Agree answers with every question- except question 14 where there is only a slight increase. Questions 1-4 asked for consent, age, setting, and years in practice, which were not relevant for this graph since the answers remained the same. These results indicate that there was a change in the participants perception on occupational justice as a result of the workshop. Through participating in the workshop, the participants strongly agree that occupational justice is important, that occupational justice should be incorporated more into skilled nursing facilities, and that they have better knowledge about the concept of occupational justice.  ...

... DO PERSONAL HEALTH HABITS AND PERCEPTION OF ROLE MODELING OF PHYSICAL THERAPIST ASSISTANT STUDENTS' AFFECT EXPECTATIONS OF RECOMMENDING HEALTHY LIFESTYLE CHANGES TO PATIENTS? 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: Dawn Miller, PT, ATC, MHA Copyright 2018 By: Dawn Miller, PT, ATC, MHA All rights reserved Approved by: Dr. Heidi L. Hancher-Rauch, Ph.D., CHES Committee Chair Dr. Amie Wojtyna, PhD, MSBS, MPH Committee Member Dr. Ginger Snead, DPT 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 i TABLE OF CONTENTS Table of Contents ii Acknowledgements .iii Tables and Figures ...iv Abstract ...v Introduction .1 Purpose ....25 Methods ...27 Results .36 Discussion ...47 Conclusion ..60 References ......62 Appendices .70 Figures ....78 Tables .....79 ii ACKOWLEDGEMENTS I would like to thank my Committee of Heidi L. Hancher-Rauch, Ph.D., CHES, Dr. Amie Wojtyna, PhD, MSBS, MPH, and Dr. Ginger Snead, DPT for their insight and guidance. A special thanks for Dr. Wojtyna in her assistance with performing and interpreting the statistical analysis. I would also like to thank my husband for his support, his understanding, and assuming many responsibilities throughout the course of the doctoral program. iii TABLES AND FIGURES Appendices 1. 1-1 and 1-2: Health Promoting Lifestyle Profile II (HPLPII) questionnaire and Permission for Use of HPLPII 2. Role Model Questionnaire 3. Expectations for Working as a Physical Therapist Assistant Questionnaire 4. 4-1 and 4-2: Gamma Correlation Analysis Figures 1. Return Rate Tables 1. Demographic Characteristics 2. Perceived Expectations of Recommending Healthy Lifestyle Changes 3. Role Modeling Attitudes 4. Role Modeling Attitudes Compared to Black et al. 2012 5. Health Promoting Lifestyle Profile II 6. Physical Activity and Exercise Questions Correlations 7. Weight Questions Correlations 8. Diet and Nutrition Questions Correlations 9. Tobacco Questions Correlations 10. One-Sample Chi-Square Test 11. One-Sample Kolmogorov-Smirnov (K-S) Test iv ABSTRACT Background and Purpose: Several studies have looked at the personal health habits and role modeling attitudes of physical therapists (PTs), student physical therapists (SPTs), and physical therapist assistants (PTAs). No studies have examined the health habits and role-modeling attitudes in student physical therapist assistants (SPTAs). No studies were found that examined STPAs expectations for recommending healthy lifestyle changes to their future patients. Methods: A national sample of 335 SPTAs completed a questionnaire containing three surveys: a self developed survey on Expectations for recommending healthy lifestyle changes to patients (Expectations), the Role-Modeling Attitudes Questionnaire (RM), and the Health Promoting Lifestyle Profile II (HPLPII). The questions gathered data on the expectations of making healthy lifestyle changes to patients, personal health habits, and beliefs of the importance of role modeling healthy behaviors to patients. Results were analyzed using Chi-square test, Kolmogorov-Smirnov test, correlation analysis, multivariate logistic regression, and examination of co-linearity between variables. Results: After removing questionnaires with incomplete data, the response rate was 29.7% (n=335). Most SPTAs perceived they will often or routinely educate their patients on meeting physical activity guidelines (76.4%), maintaining healthy weight (78.6%), and decreasing or stopping the use of tobacco products (77.9%). The majority of SPTAs agreed role modeling is a powerful teaching tool (95.5%), that physical therapy professionals should practice what they preach (95.2%). SPTAs also perceived that it is important for physical therapy professionals to perform and role model performing: the CDC recommended amounts of physical activity (perform: 92.2%; role model: 91.9%), v maintain healthy weight (perform: 91.8%; role model: 91.9%), and abstain from smoking (perform: 94.3%; role model: 93.4%). Educating patients on the importance of exercise was correlated with perceived importance of performing regular physical exercise (=0.39), role modeling regular physical exercise (=0.46), and HPLPII physical activity subscore (=0.42). The expectation of educating patients on the importance of maintaining healthy weight was strongly correlated with the importance of physical therapy professionals role modeling maintaining a healthy weight (=0.37) and had a moderately strong correlation with maintaining healthy weight (=0.44). The importance of educating patients on a healthy diet was strongly correlated with eating and role modeling eating five servings of fruit and vegetables (respectively, =0.41, =0.49) and the HPLPII Nutrition sub-score (=0.46). Conclusion: Most SPTAs participate in healthy behaviors, feel that role modeling healthy behaviors is an important component of being a physical therapy provider, and that they should recommend healthy behavior changes to patients. However, the rate at which they perceive they will recommend healthy lifestyle changes to patients and their role modeling attitudes differ depending on the topic with stronger beliefs in the need to role model and educate patients on the topics of physical activity, weight, and diet. Current research is demonstrating that healthy behaviors are strongly associated with decreasing costly medical care, personal health habits of providers correlate to the health habit recommendations made to patients, and patients are more likely to follow the recommendations a provider makes when the provider role models healthy behaviors. Physical therapy providers are positioned to positively influence the health habits of their patients and potentially have a positive impact on overall public health. vi Introduction Poor health habits and poor physical fitness are directly correlated with many costly and preventable causes of morbidity and mortality.1-4 Unfortunately most patients receive only minimal and sporadic counseling on participating in preventive health measures and improving healthy behaviors during patient-provider interactions.5 Primary care providers most frequently cite a lack of time, poor reimbursement and lack of patient interest as significant barriers to providing more frequent and thorough health counseling.6-8 Prior research suggests that healthcare providers who maintain good personal health habits and physical fitness are more likely to recommend healthy lifestyle changes to their patients and to be more confident in their abilities to make these recommendations.2 Additionally, patients treated by healthcare providers who role model healthy behaviors may be more likely to implement the recommendations for healthy lifestyle changes and report that the provider is trustworthy and credible when providing any health care information.3 An essential component of physical therapy is to provide patients information regarding their health and to effect changes in patient behaviors and attitudes in order to promote neuromusculoskeletal recovery and improve overall health. This includes exercise prescription and patient education on performing regular physical activity and healthy lifestyle modifications to prevent or control neuromusculoskeletal conditions. These are the same skills needed to counsel patients on improving health habits and physical fitness to prevent chronic diseases that result from sedentary lifestyles and poor health habits.4,5 The frequency and length of physical therapy visits position physical therapists (PTs) and physical therapist assistants (PTAs) to have extended patient 1 interaction time.2,3,5 Physical therapy providers are therefore more readily able to identify sedentary and unhealthy behaviors, decreased physical activity due to illness or injury, and to provide education on healthy lifestyle modifications and the importance of increasing physical activity.4,5 There is a paucity of research on the frequency physical therapy providers recommend healthy lifestyle changes to their patients or the confidence these providers have in their ability to perform this type of patient education. The author was unable to find any research that included SPTAs, with PTAs being a growing number of physical therapy providers. Researchers have reported that 98 to 100 percent of PTAs believe that health promotion is fundamental to their occupation.5,10-12 This included providing advice on non-treatment related physical activity as well as the belief that physical therapy providers should promote healthy behavior changes such as increasing physical activity levels to prevent chronic diseases. 5,10-12 It remains unknown whether there is a correlation between PTAs and SPTAs personal health behaviors and the health recommendations made to their patients.5,10-12 The purpose of this study is to examine how SPTAs personal health habits and perception of role modeling influence the students expectations for recommending healthy lifestyle changes to patients. Literature Review Introduction There is ample evidence clearly demonstrating that a healthy lifestyle, including participation in regular physical activity, managing stress, eating a proper diet, having 2 proper sleep habits, and decreasing the use and abuse of nicotine and alcohol is essential to maintaining health and quality of life. 1-5,12-21 These personal health behaviors, particularly poor diet and lack of physical activity, clearly contribute to the increasing numbers of people who are overweight and obese, which in turn contributes to costly chronic health conditions and higher morbidity and mortality.20,22-26 The United States (US) Centers for Disease Control and Prevention (CDC) lists physical activity as the first indicator of health because physical activity provides the greatest improvement to an individuals health and wellness when compared to all other medical interventions.14,20 Researchers have found the performance of regular physical activity correlates with a reduction in all-cause mortality for both genders by as much as 20-45 percent.4,20,27,28 Due to this, physical activity is the single most significant modifiable risk factor for mortality and morbidity. 2,4,5,8,14,19,24,27,28 Participating in appropriate levels of physical activity can decrease the impact and risk of cardiovascular disease,4,5,12,14,19,21,24,27 cerebrovascular accident,12,14 diabetes mellitus,5,12,19,21,24,27,28 obesity,4,5,12,21,27 depression,4,5,27 vertebral and hip fractures, osteoporosis,14,19,21,27 some cancers such as colon and breast,4,5,12,27,28 as well as other cardiopulmonary, bone, and joint disorders.5,14,19,24 The US Surgeon General, the American College of Sport Medicine (ACSM), the American Heart Association (AHA), and the World Health Organization (WHO) all recommend at least 30 minutes of moderate intensity physical activity five times a week.4,14,19,21,27 The ACSM, AHA, and WHO alternately recommend between 60 to 75 minutes of weekly vigorous physical activity and acknowledge that as little as ten minutes of any level of physical activity can be beneficial.19,27 Proper diet, including daily consumption of five servings of fruits and vegetables, 3 and avoiding the use of tobacco products are also strongly correlated with maintaining physical health.16,21,22,28 A diet low in fat and high in whole grains, fruits and vegetables has been shown to reduce all-cause mortality by as much as 75 percent and cancer mortality by approximately 35 percent.16,22 Despite this evidence, it is estimated that at least 23 percent of US adults do not eat the recommended number of servings of fruits and vegetables and between 25 to 29 percent of the US population aged 2544 years old use tobacco products.21,22,29 Information regarding the need to implement healthy behaviors is readily available to the US population. However, despite the clear evidence that poor health habits negatively affect overall health, altering health behavior has proven difficult. The CDC estimates that in 2012, 35.7 percent of US adults and 17 percent of children were obese.30 These high percentages do not include the number of US citizens who are overweight. Other studies estimate at least 50 percent of US adults do not engage in recommended levels of physical activity.15,22 These statistics are even worse when considering males alone.22 The correlation of poor health habits with costly medical conditions is especially important in the US, which has the highest per capita spending on healthcare in the world but ranks only 31st in life expectancy.16,22 Healthcare Professionals and Counseling Patients on Healthy Behaviors Because healthy behaviors impact overall health and wellness, morbidity and mortality, healthcare providers generally agree that there is a professional responsibility to use the patient-provider relationship as a foundation to provide regular guidance on improving health behaviors.12-14,17,24,31 These behaviors include increasing physical 4 activity,5,12-14,17,24,28,31 improving diet,12,28,31 weight loss,14,24 reducing stress or improving emotional health,12,31 and decreasing or ceasing the use of tobacco 12,24,28,31 and alcohol.12,24,31 Some researchers have asserted the benefits of a healthy lifestyle are so substantial that an ethical obligation exists for all healthcare providers to provide patient education and guidance on healthy lifestyle modification.2,15,19,20,25,28 Positive lifestyle changes with reduction in costly and preventable morbidity and mortality have been associated with healthcare providers offering preventive counseling and patient education on implementing health behavior modification. Much of this research has focused on primary care, or general practice physicians.2,13,20,24,31-33 In one study, six months after receiving physician advice and written educational materials on proper diet and exercise, patients maintained increased levels of physical activity that caused a reduction in morbidity and mortality of approximately 25 percent.20 Other researchers have concluded that increasing patient education resulted in increased patient effort and likelihood of improvement in diet, smoking cessation, decreasing alcohol consumption, and increasing physical exercise.6,24,25,31,34 Even brief counseling has been shown to improve cessation of nicotine and decrease alcohol abuse.7,35 Patient compliance with health prevention and treatment programs has been shown to improve with healthcare provider counseling on health behavior modification.7,31,34,36, 37 Patient success with compliance was achieved in 64 percent of patients when knowledge was provided alone, 85 percent when behavioral strategies were employed, and 88 percent when a combination was used.31 The likelihood of health behavior change is further improved by utilizing a multidisciplinary approach with two or more healthcare providers offering advice on the benefits of a particular health behavior 5 change.5,7 Assisting patients in identifying health behaviors that can be changed, setting and modifying achievable goals, increasing patients self-efficacy and the ability to problem solve, and identifying positive social support are known to improve success with healthy behavior changes.31 Health Behavior Change Theories The Transtheoretical Model of Behavior Change Theory has been used to describe the reasons individuals change their health behaviors. The theory proposes that an individual passes through a series of stages of readiness in order to implement a change of personal health behavior. The five stages change identified in the model are: (1) Precontemplation when no change is considered, (2) Contemplation when change is considered, (3) Preparation when steps are taken in order to effect a change, (4) Action when a change is initially implemented, and (5) Maintenance when the change has been incorporated for more than six months. Patient education and counseling can be tailored during each stage in order to most effectively support the patient in implementing successful changes.8,36 This model has also been validated to identify the stage a healthcare provider is within in regards to providing health behavior counseling to patients. Studies have found that as practitioners advance to higher stages in the Transtheoretical Model of Behavior Change Theory for both providing patient health education and their own personal health behaviors, there is a decrease in perceived barriers to providing patients with health promotion education.8 Researchers have also used the Social Cognitive Theory (SCT), also known as the Stages of Change Model, to explain the process required to implement health behavior 6 changes. This theory incorporates a series of psychosocial factors, suggesting that a person, their behavior and their environment are influenced by the belief that a goal can be achieved, the amount of personal self-efficacy, and confidence that a specific task will result in the desired outcome. Behaviors performed more frequently result in higher selfefficacy and lead to increased performance of that behavior. Further, external reinforcement, particularly the observation of role-modeling, can either positively or negatively impact any of the psychosocial factors. The observation of another person successfully performing a health behavior or implementing a change can lead to higher self-efficacy in personally implementing that change. The higher a persons self-efficacy and outcome expectation, the more likely a change will occur and result in higher personal satisfaction. Researchers have supported the use of SCT, revealing that patients place more confidence in medical advice when it is given by a provider who role models healthy behaviors.15,16,32 Also, the more frequently a healthcare provider performs health behavior counseling, the higher the reported health behavior counseling selfefficacy.15,16,32 Social Learning Theory encompasses many of the concepts of SCT but focuses on how many behaviors are learned by observing the interaction of individuals within ones personal environment. This theory places great importance on healthcare provider role modeling positive health behaviors. Several studies have supported this theory, showing that when physicians, nurses, medical students, or medical clinical support staff receive education about improving their personal health habits, there are positive changes in the amount of health behavior counseling provided to patients, self-efficacy, and confidence that that patients benefit from the counseling. Healthcare educators may play an essential 7 role in role modeling healthy behaviors for their students, the next generation of healthcare providers, who in turn may influence their patient behaviors.30,34 Healthcare Provider Training and Ability to Provide Counseling on Health Behaviors Healthcare providers receive education regarding the benefits of healthy behaviors, which places these providers in a position to influence patients attitudes and behaviors.19,21,31 In a national survey of health education faculty, 93.5 percent of faculty agreed that health promotion and disease prevention were very important or somewhat important to their program goals.15 Despite faculty beliefs, many healthcare providers may require further training and expertise to develop the counseling skills. Effective counseling requires that healthcare providers have communication and relationship building training to deliver the counseling at the appropriate time and in the appropriate manner and language with empathy, respect, and unconditional positive support. Providers may also require training to be able to gather, review, and interpret the most current research and prevalent lay information so that advice on health behavior modification can be given to patients in lay terms.31 These skills can help patients identify health behaviors that could be improved and develop patient self-efficacy to act on the counseling in order to effect behavioral change. Researchers have also examined the effect of education provided to physicians and medical students in areas such as improving personal health behaviors for diet, exercise, and the use of alcohol and tobacco. After workshops and training on behavior change counseling, these providers reported improvement in personal health behaviors, 8 perception of the relevance of providing patient counseling, and self-efficacy with providing health behavior education to patients. The reported increase in patient counseling, empathy, and comfort with sharing their personal health information with patients was also correlated with an increase in the amount of health behavior education received.6,29,33,36,37 Interestingly, medical students have a greater belief that preventive counseling can positively affect patient behaviors as compared to practicing physicians. Unfortunately, this belief was shown to be less in fifth year medical students when compared to first year students.33 Receiving encouragement to perform more patient education has been identified as another factor directly associated with increased patient health promotion counseling. Nurses, nurse midwives, physician assistants, and other non-physician providers have been shown to have increased self-efficacy after receiving only encouragement to perform more health promotion patient education. 31 Multiple research studies have concluded that after physicians, dentists, dental hygienists, nurses, and pharmacists were encouraged to increase smoking cessation education with their patients, higher numbers of patients successfully decreased tobacco use.7,22 In one study, health promotion education was provided to both medical providers and support staff. After the training, the providers and staff were almost 40 percent more likely to be physically active, and 30 percent more likely to report being very comfortable counseling patients on increasing physical activity.34 These providers and staff were also 25 percent more likely to feel physical activity was an important part of their workplaces, 20 percent more likely to report their personal health habits were an example to their patients, and almost three times more likely to feel their workplace supported healthy food options.34 9 Multiple studies have shown that the more frequently healthcare providers perform health behavior counseling in clinical practice, the higher providers rate their self-efficacy in providing this education. Increased frequency of health behavior counseling is also associated with higher expectations of positive patient outcomes. This positive correlation between self-efficacy and promoting specific health behaviors has also been seen in studies involving PTs.12,15,31 The greatest predictor of a PT providing health counseling is the PTs educational background. On a daily basis during patient care, healthcare providers are regularly faced with the negative health effects of a sedentary lifestyle and the need for increased health promotion counseling during daily patient care.13,16,22,25,32 Primary care providers and other healthcare professionals who have regular contact with patients over an extended period of time are ideally positioned to affect health behavior changes. Because of the frequent interaction and ability to observe the patient over extended periods of time, these providers may help patients identify risk factors at an early stage before significant negative health effects occur. The regular contact these providers have with their patients also allows for follow-up on initial health behavior counseling and the opportunity to offer continued feedback and advice.2-5,20,24 28,39 PTs and PTAs have extended personalized interaction with patients during multiple, frequent visits.7,13,22,35 In addition, the universal goal of physical therapy is to identify movement deficits, assess potential, maximize function, and improve health related quality of life.10,13,14,17,19 To achieve this goal, providing patient education and health behavior counseling is a critical part of physical therapy intervention.10,13,14,17,19 This education helps patients to modify their behaviors to eliminate performance of 10 aggravating activities and to engage in prescribed exercises and physical activities that promote neuromusculoskeletal recovery.10,13,14,17,19 The skills PTs and PTAs need to improve neuromusculoskeletal related health behaviors are the same skills needed to improve overall health behaviors that can prevent disease and promote health.5,7,13,14,16,18 Some researchers have concluded that PTs and PTAs provide some form of healthy behavior education in 50 percent of physical therapy visits, with each visit containing an average of 2.44 health promotion statements.8,15,16 Topics include: improving physical and leisure-time activity for the patient and their family, smoking cessation, using or establishing personal support systems, reducing risk of secondary complications, accessing available resources, and reducing risk of recurrence of the condition for which the patient is receiving physical therapy. Several studies have found that the PTs statements focused primarily on a patients chief complaint.8,15,16 In the 2004 study by Rea, et al., 54 percent of health promotion statements provided by PTs and PTAs involved increasing physical activity and 41 percent involved improving psychological well-being.16 Statements regarding smoking cessation were addressed 17 percent of the time and statements regarding managing weight and nutrition were addressed in 19 percent of the statements.16 In the 2014 study by Fink et al., PTs reported confidence in their abilities to provide patient education with 85 percent reporting confidence on the topic of improving physical activity, 71.8 percent on nutrition and overweight issues, 69 percent on improving psychological well being, and 63.7 percent on smoking cessation.15 PTs and PTAs also have frequent contact with individuals with disabilities and patients who have sustained a recent illness or injury; populations known to have lower 11 physical activity and higher incidence of obesity compared to the general population.8,10,12,14,16,32 These individuals would particularly benefit from education and guidance on healthy lifestyle changes, including increased physical activity.8,10,12,14,16,32 PTs and PTAs are in an ideal position to promote healthy behaviors in a cost effective manner in order to prevent and treat chronic diseases in both those with and without health conditions. These rehabilitation providers regularly focus on altering patient behaviors, have the expertise in prescribing safe physical activity for ill, injured, and fragile populations, and maintain the belief that health promotion is integral to providing appropriate physical therapy patient care.10-14,16,17,19,32 Due to the increased need for health and wellness promotion for all US citizens, there may be an increased need to emphasize this topic during the education of SPTAs.20,33,37,38 Because provider personal health habits are associated with the amount patient healthy behavior education provided, this study attempts to fill the gap in literature as there is no current research on the personal health behaviors of SPTAs or their perception of role modeling to patients. Amount and Effectiveness of Health Behavior Counseling The majority of research on the amount of patient education and counseling on health behavior modification has been focused on primary care and general practice physicians. The counseling appears to be sporadic, minimal, and infrequent during normal physician visits.5,13,28,31 Most patients report receiving information on healthy lifestyle modification as a high priority during a visit with a healthcare provider. However, less than 25 percent of patients reported receiving smoking cessation advice, and only approximately 30 percent reported receiving advice on increasing physical 12 activity.28 In several studies, only 30 to 40 percent of obese individuals reported receiving counseling on weight loss, diet, and exercise from their physician.2,20,28,31 Patient surveys and the examination of patient encounter records revealed individuals with disabilities received less counseling on healthy lifestyle changes from providers and are recommended fewer preventive treatments.1 Numerous studies have established an association between healthcare providers personal health behaviors and an increased rate of patient counseling on the topics of improving physical activity, decreasing dietary fat intake, using sunscreen, obtaining mammography, smoking cessation, and decreasing the use of alcohol. 6,8,13,16,17,20,22,25,26,28,33-36,38,40 If a provider currently performs a specific health behavior, the provider reports higher self-efficacy, stronger belief of receiving proper training to counsel patients on the topic, and less difficulty providing healthy lifestyle modification counseling for that health behavior.6,22,28,34 Physicians who consume lower fat diets and higher amounts of fruits and vegetables educate their patients to improve their diets. Those with lower Body Mass Index (BMI) provide more patient counseling regarding weight loss and exercising. Those who do not smoke counsel more on smoking cessation. Those who consume little or no alcohol counsel more on reducing alcohol consumption.26,28,33,34,39 Patients of providers who personally participate in recommended preventive care measures such as vaccinations and screenings are significantly more likely to obtain these recommended measures. Female physicians who do not regularly perform self breast examinations, have mammograms, or receive Pap smears provide these services to their patients at the same rate as male physicians, much less frequently than female physicians who engage in these preventive services.26,28,40 13 Healthcare providers who perceive themselves as healthy also demonstrate increased likelihood of providing preventive screening and counseling, with the amount of counseling further increasing if the provider is attempting to improve that specific health behavior.6,28,34,36,38 It has been postulated that providers who have changed a personal health behavior may view the change as more achievable for their patients.24 Even when a provider is simply encouraged to improve their own personal health behaviors, the amount of health behavior patient education and counseling provided increases.6 Counseling to decrease the use of tobacco products can improve not only the health of the patient, but also individuals who are exposed to secondhand smoke, which is especially important for infants and children. Of note is that smoking rates are higher in individuals with disability, the very population that receives the least counseling.1 Some research has demonstrated smokers have a 44 percent reduction in years of healthy life compared to those who have never smoked.7 Known smokers do not receive smoking cessation counseling at almost 80 percent of their ambulatory care physician appointments despite evidence correlating cessation of smoking with even brief healthcare provider counseling.7 Frequently, PTs treat patients who transition from an acute care setting where patients have had a period of forced smoking cessation. This allows physical therapy providers an excellent opportunity to capitalize on extending the period of abstinence and progressing towards successful complete cessation. Evidence suggests that the effects of withdrawal from tobacco products including cravings, negative mood changes, weight gain, and insomnia can be lessened by exercise interventions provided by PTs.7 14 The relationship between PTs and PTAs health behaviors and patient counseling has had little research. Several studies suggest that PTs, in a manner similar to physicians, are more likely to discuss the benefits of increased physical activity and healthy behaviors with their patients when they participate in healthy behaviors. PTs who exercise are more likely to discuss exercise with their patients and believe that wellness counseling is important.8,16 Physical therapy providers were most likely to provide education on healthy behaviors when assisting patients with increasing physical activity (54%), improving psychological well being (41%), assisting with weight loss (19%), or counseling for smoking cessation (17%).15 The amount of health behavior education was not correlated with treatment location within the US, treatment session duration, physical therapy setting, how far along the patient was in the course of recovery, or the PTs degree level or years of experience.15 Healthcare Provider Personal Health Habits and Factors Affecting Counseling Practices Due to the strong tie between personal physician health habits and counseling practices, the health habits of other healthcare providers, including PTAs and SPTAs, need to be determined. In general, healthcare providers have been shown to maintain healthier lifestyles compared to the US population, living longer than sex and age matched groups, including when compared to other graduate educated professionals or groups with high socioeconomic status.19,23,26,28,33,41 Only a few studies have explored the personal health behaviors of physical therapy providers, particularly in the last ten years. The performance of physical activity, non-smoking, eating fruits and vegetables, and 15 maintaining healthy weight were studied either individually or in combination with one study focusing solely on PTs, one on PTs and PTAs, and two PTs, PTAs, and SPTs. All have concluded that physical therapy providers maintain better health habits when compared to the general population as well as other healthcare providers.8,16,17,22 A BMI between 18.5 and 24.9 is considered healthy weight.42 Several studies have found that approximately 80 percent PTs and SPTs maintain a healthy weight with 96 percent reporting the belief that PTs are responsible to promote this behavior.11,16,22 Male PTs, however, were less likely to maintain healthy weight and 44% less likely than female PTs to report it is important for PTs to role model healthy weight.22 In contrast, between 29 and 56 percent of health and fitness professionals are overweight.22 In a 2008 study by Groth, et al, the percent of female and male athletic trainers maintaining healthy weight was found to be 53 percent and 26 percent respectively with a mean BMI of 25.78 for the females and 27.97 for the males.21 In a 2012 study by Biernat, et al, normal BMI was maintained by only 39.8 percent of male physicians, 65.0 percent of female physicians, 53.3 percent of female nurses, 46.3 percent of other male medical personnel, and 61.5 percent of other female medical personnel.43 A few studies focusing on healthcare students have revealed a tendency for SPTs to be healthier than students entering other health professions, with lower likelihood of being overweight or obese and reporting that physical activity was an important part of their daily lives.19,23 One study showed that students in several different medical disciplines had healthy weight mean BMI. Medical students had the highest BMI (23.75), followed by SPTs (22.10), nursing students (21.26), pharmacy students (21.27), midwifery students (20.69), and cosmetology students (20.37).19 Another study found 16 that SPTs and sport education students had similar BMI.27 Despite these mean healthy weight BMI, approximately 20 percent of students enrolled in health-related majors were found to be overweight or obese compared to nearly 40 percent of students in non-health majors.23 Consuming proper diet is a struggle for much of the US population, including healthcare providers. More than 70 percent of PTs and SPTs report eating a balanced diet, more than 60 percent eating the recommended servings of fruits and vegetables, and only approximately 3 percent reporting eating fast food very often or often.16,22 Again, male PTs had lower health behaviors compared to female PTs and were 37 percent less likely to eat the recommended serving of fruits and vegetables, feel that it is important do so personally, and to recommend to this behavior to patients.22 In contrast, athletic trainers have been found to consume an average of only nine servings of fruits and vegetables weekly.21 Studies on students in health majors revealed an average of almost one more daily serving of fruits and vegetables compared to students in non-health majors. 23 However, only 35 percent of students in health majors were shown to eat five or more servings of fruits and vegetables daily compared to less than 15 percent of students in non-health majors.23 Many studies have revealed that healthcare providers use tobacco products and alcohol at much lower rates compared to the general population. In the few studies performed, well over 90 percent of PTs and more than 85 percent of SPTs were nonsmokers, lower than any other healthcare professional.10,16,22,38 Furthermore, between 65 to more than 80 percent of PTs and SPTs have never smoked.10,16,22,38 In contrast, many studies have shown that between 4 and 7.8 percent of physicians smoke which is lower 17 than the 14 and 27 percent of medical students who use tobacco products.26,29 Among athletic trainers, only one percent are smokers with 92 percent reporting that they have never smoked.21 A study by Kanwendo in 2000 revealed that 82 percent of student occupational therapists (SOTs) did not smoke with nearly 70 percent having never smoked and 74.2 percent nursing students did not smoke with 56.7 percent never having smoked.38 Approximately 90 percent of the general US population report consuming alcohol and 35 percent drink daily, the same rate of drinking reported by physicians.21 Similarly, 11 percent of athletic trainers reported being non-drinkers.21 In contrast, PTs have been shown to consume alcohol at a much lower rate with more than 55 percent being exdrinkers or non-drinkers.10,16 Additionally, only four percent of athletic trainers and one percent of PTs consumed more alcohol than the CDC recommended guidelines of one drink per day for women and two drinks per day for men, with more than 80 percent of PTs consuming less than three alcoholic beverages a week.16,21 Studies on the physical activity levels of physicians reveal between approximately 50 to 70 percent of physicians participate in regular physical exercise.2,43,44 Other studies have also revealed moderate to high levels of physical activity are performed by 60.6 percent of female nurses; 62.3 percent of male medical personnel, and 53.5 percent of female medical personnel.43 Several studies have concluded that approximately 80 percent of PTs are performing or increasing regular physical activity.8,22 In 2010, Chevan and Haskvitz found between 63.8 and 72.4 percent of PTs, PTAs, and SPTs performed physical activity at recommended levels.17 A 2014 study by Fink found that 90.2 percent of PTs and SPTs reported being somewhat or highly active but also 54.2 percent of SPTs 18 and 29.5 percent of PTs reported not meeting recommended exercise guidelines.16 In a study comparing female SOTs, SPTs, and student nurses, approximately 80 percent of SPTs performed regular physical exercise at least twice a week, followed by nearly 60 percent SOTs, and approximately 45 percent of nursing students.28 In a 2013 study of students at a medical university in Poland, all SPTs were moderate or highly active while students of other healthcare disciplines also performed moderate and high physical activity at rates higher than the general population (pharmacy students 96 percent, nursing students 94 percent, midwifery students 88 percent, cosmetology student 86 percent, medical students 74 percent).19 Interestingly, all disciplines had significantly lower perceptions of achieving recommended guidelines compared to the number who actually adhered to the guidelines. SPTs had the greatest discrepancy with only 62 percent perceiving themselves as meeting recommended guidelines despite doing so.19 This may indicate physical therapy providers have a tendency to underestimate their own activity levels.19 While these studies are promising, overall the research shows less than 20 percent of nursing students meet recommended physical activity guidelines.21 Excluding nursing students, only approximately 25 percent of other healthcare students meet the recommended guidelines.21 Higher educational attainment has been associated with higher levels of physical activity, but this does not explain why PTs and SPTs generally participate in physical activity at rates higher than other healthcare professionals.17 It is unclear whether individuals with better health behaviors self-select into the physical therapy profession or health behaviors improve during the course of education and training. 17,19,22,38 Regardless, the goal of education is to generate highly skilled healthcare professionals 19 prepared to competently provide patient care. Because provider personal health behaviors are so closely tied to their patient counseling purposes, the health behaviors of SPTs and SPTAs can be an indicator of the future patient care practices of the profession. Providing SPTs and SPTAs education on and encouraging personal adoption of proper health habits, including physical activity levels, may help promote best patient care outcomes.17,20,22,23,33,45,46 Researchers have also examined the relationship between the amount of health behavior counseling performed and a providers age and gender. Female physicians and nurse practitioners, especially those aged 45 to 64 years old, and PTs over the age of 40 years old were found to be more likely to provide patient education and counseling on the importance of health behavior modification.8,16,39 Female physicians were also more likely to provide physical activity counseling and to spend more time on health behavior counseling compared to male physicians. They were more likely to consume low fat diets, be attempting weight loss, consume little alcohol, use sunscreen, and not smoke.25,39 In one study, female PTs were more likely to provide health behavior counseling about the importance of maintaining healthy weight and proper diet when compared to their male counterparts. The percentage of male PTs maintaining a healthy weight and eating a well-balanced diet was lower than female PTs, with only 37% eating the recommended amount of fruits and vegetables.22 These male PTs were also more likely to state these behaviors were not important for them personally or to recommend to their patients.22 Healthcare Provider Role Modeling of Healthy Behaviors 20 Healthcare professionals have been shown to have increased patient credibility when they role model healthy personal behaviors, including physical exercise. Doing so avoids conflicting messages between the advice a provider gives to a patient and what the patient sees the provider doing.19,28,33,38,41 It is postulated that observing another person role modeling a behavior improves learning and may increase patient motivation to successfully adopt the behavior.16,38 Disclosure of a providers own personal health habits and risk factors affects patient counseling on healthy lifestyle modifications. The more information about personal health habits a provider discloses, the higher likelihood that a provider will counsel patients on behavior modification and patients will be willing to reveal more details of their own health habits.25,35,39 Many healthcare providers and fitness professionals report that they should role model proper weight and health behaviors for their patients, a belief correlated with increased patient counseling to improve health habits.21,25,30,39 This has been found to be particularly true for PTs and SPTs who consistently report a strong belief that physical therapy professionals have a responsibility to role model healthy behaviors in order to practice what they preach. 10,22,45 One study found that more than 90 percent of PTs and SPTs agreed that it is very important that physical therapy professionals role model healthy behaviors, including maintaining a healthy weight, following CDC guidelines for physical activity, and not smoking.22 Previous authors have demonstrated that patients view health care providers as a credible source of information regarding health and wellness.2- 5,20,24,28 It is of significant import that patients have been shown to view providers who maintain healthy weight and perform physical exercise as more trustworthy and more credible for health behavior 21 modification counseling.3,20-22 When being treated by physicians of normal body weight, patients were also more likely to have confidence in all medical advice received for any condition and to follow the physicians recommendations. 3,25 Patient compliance with physical activity recommendations has been shown to decrease when the recommendations are made by a healthcare provider who is overweight or has poor physical fitness.18,45 When a healthcare provider role modeled healthy behaviors, including physical exercise, patients reported being more open to health behavior counseling and having higher motivation to change their health behavior.6,16,17,22,26,28,31,33,35,41 Several studies have shown that when patients were told their physicians had healthy diets and exercised or the personal health behaviors of the physicians were disclosed, patients reported increased motivation to effect their own personal behavior changes. 6,16,22,26,28,34,35 Barriers to Providing Health Behavior Counseling Prior research has revealed several significant barriers to healthcare workers providing patients with health behavior modification education. The most frequently cited barriers are lack of time, reimbursement, and lack of awareness of supplemental materials that can be given to patients.6-8,20,24,31 Lower patient socioeconomic status has also been seen as decreasing compliance with behavior changes, as well as socioeconomic and ethnic disparities between the provider and patient.24,34 Several studies have found that many healthcare providers, including PTs, hold the belief that ultimately the patient is responsible for their lifestyle and health behavior choices. This can lower the amount of health behavior education provided because it reinforces the 22 perceived barrier that patients do not desire to receive such education.12,24 Past research has concluded that patient recall of specific medical advice on weight loss, diet, and exercise provided during an encounter with a healthcare provider can be as low as 30 percent and providing written information improves compliance.20,31 These barriers are serious concerns that will need to be addressed if the United States is to be successful in moving towards a more cost efficient preventive care model.20 Traditionally, healthcare education has focused on treatments provided to patients after an illness or injury occurs, not preventive health and wellness behavior modification, with most patient-provider interactions focused on an acute care diagnosis or a specific health problem. Some providers report the belief that health promotion is the responsibility of other professionals and patients themselves.24 Providers reported difficulty discussing preventive care measures and reluctance to discuss health behaviors with patients, particularly in regards to weight.20,34 Providers frequently cite a lack of confidence, self-efficacy, experience, and training on counseling strategies to influence behavior change as barriers to providing health behavior counseling.20,24,31,34 Providers also report lack of patient belief that a change needs to be made, poor patient motivation, and a limited patient support system as barriers to patient implementation of provider advice regarding modifying health behaviors.8,22,24,31 The belief that health behavior modification counseling will have poor outcomes because of patient resistance to or noncompliance with recommendations is another barrier to providing health education counseling, as reported by providers.7,8,20,31 Lower self-efficacy in counseling patients on health behaviors also has been found to be correlated with lower outcome expectations.31 Researchers have reported that providers stop performing preventive health behavior 23 counseling if they believe a patient does not want to implement change or discuss personal health behaviors.24 There is little research on barriers to health promotion within the profession of physical therapy. From the available data however, it appears PTs generally report having more time to counsel patients on health behavior changes. Interestingly, despite reporting more time with patients, some PTs identified a lack of time for discussing health behaviors. The primary limitation PTs reported was insurance limitations on the number of physical therapy visits, the length of each visit, and overall reimbursement. The outcomes of previous studies indicate the greatest limiting or facilitating factor in a patient adopting a health behavior is patient interest in changing the behavior.7,8,11,13,15 Traditionally physical therapy has been assigned a secondary or tertiary role in patient care because patients are generally referred after an illness or injury has created a loss of function, creating situations where incorporating preventive health promotion education may not be appropriate for the primary diagnosis. Reimbursement also frequently limits the amount of preventive care and treatment PTs are trained to provide, limiting the physical therapy scope of practice. Because patients are referred to physical therapy for specific neuromusculoskeletal disorders, PTs report patient expectations, motivation, and goals for physical therapy often do not include lifestyle modifications.8,11,13,32 Introduction Conclusion There is a clear relationship between a healthcare providers personal health behaviors and health education and counseling provided to patients.6,8,13,16,17,20,22,25,26,28,336,38-40 Maintaining healthy weight and physical fitness is also associated with increased 24 patient compliance with a providers recommendations, including implementing healthy lifestyle modifications.3,20,22 Personal health behaviors of physical therapy providers impact the expected amount of healthy lifestyle education provided to patients and offer insight into one facet that affects patient compliance. Furthermore, as education has been linked closely to patient counseling on improving healthy behaviors, it is in the best interest of the physical therapy profession to ensure educational curricula include the importance of providing patient health education and to encourage all physical therapy providers to maintain positive, healthy lifestyles and appropriate weight.18,45 However, the personal health behaviors of physical therapy providers remain largely unknown as there have been few studies performed in the last decade. The few that have been performed focused primarily on PTs or SPTs and reported health behaviors such as daily physical activity levels, diet, body weight, nicotine use, sleep habits, beliefs regarding role modeling, and amount of health behavior modification education provided to patients.8,16,17,19,22,23 No research on SPTAs health behaviors or their perceptions of role modeling were found in the current literature. Purpose The purpose of this study was to explore the relationship between SPTA: (1) personal health behaviors, (2) perceptions of role modeling to patients, and (3) expectations for recommending healthy lifestyle changes to future patients. The two null hypotheses investigated in this study were as follows: (1) there would be no relationship between SPTA personal health behaviors and expectations for recommending healthy lifestyle changes to future patients, and (2) there would be no correlation between SPTA 25 personal health behaviors and the perception of role modeling to patients. With increasing numbers of PTAs working as integral components of the physical therapy profession, PTAs have a greater opportunity to provide this education to physical therapy patients. Establishing SPTA health behavior practices and beliefs can offer insight into the probable personal behaviors and health counseling practices of these future physical therapy providers and may be useful in identifying areas of educational need and opportunities for improved patient care. 26 METHODS The Institutional Review Board of the University of Indianapolis approved both the trial and current study protocols. Each participant was provided informed consent to take part in this study. A literature review was conducted using internet databases: CINAHL Plus with Full Text, EBSCOhost, PubMed, MEDLINE (PubMed), SportDiscuss with Full Text, and GALE Nursing and Allied Health Collection. Keywords to obtain data in the search included physical therapy, physical therapist, health, health education, patient, provider, health behavior, health promotion, healthcare provider, self reported, and fitness. Study Design This study employed a cross-sectional survey study research design. Participation was voluntary with no incentive to participate and all responses were anonymous. Questionnaires with incomplete data were excluded from data analysis, as described by Fink et al. in 2014.16 Participants A convenience sample was obtained via a request for participation distributed to educators at PTA programs via the American Physical Therapy Association (APTA) Education Section listserv as well as posted on the PTA Educators Facebook page. The APTA listserv is open to APTA Education Section members. The PTA Educators Facebook page is available to all interested individuals. Neither of these sites maintains a list of the total number of schools that are represented by the members. 27 Those PTA educators willing to forward a recruitment email that included an internet hyperlink to their students were asked to contact the researcher, indicating the total number of students in their program who would be receiving the recruitment email. A list of all participating educators as well as the institutions and PTA programs they represented was compiled. In three cases, two educators from the same institution and PTA program responded to the request. Email correspondence was conducted with these educators, verifying they were from the same institution and PTA program for an accurate count of participants recruited to participate. In each case, both educators in question responded to the email and correspondence was conducted with both educators. During the correspondence, the educators determined which of them would be responsible for disseminating this studys email with the link to the online questionnaire to their students. Inclusion criterion was only that the SPTA be currently enrolled in an accredited PTA program with an educator who agreed to participate in this study. Procedure The internet hyperlink to the research questionnaire was provided to a total of 1,127 SPTAs electronically via an email from the educator. The email asked the students to complete the questionnaires within 6 weeks. At the start of the questionnaires, the study was explained and informed consent was obtained to protect the rights of the human subjects. To ensure anonymity, demographic information was only used in aggregate and no internet protocol (IP) addresses were collected. Participants were advised in the informed consent of these procedures. Two weeks after the initial email had been forwarded to the SPTAs, a follow-up email also including the internet hyperlink 28 was sent to the PTA educators to forward to their students one final time. SPTAs that had not completed the questionnaire were reminded to fill out the survey. Those SPTAs who had completed the questionnaire were thanked for their time. The research questionnaire included three separate questionnaires to measure the SPTAs (1) expectations for recommending healthy lifestyle changes to patients, (2) rolemodeling attitudes, and (3) personal health behaviors. The Expectation for Recommending Healthy Lifestyle Changes (Expectation) questionnaire was developed via pilot study and expert panel review. The Part III: Role-Modeling Attitudes Survey (RM) and Health Promoting Lifestyle Profile II (HPLPII) questionnaire were used in prior research and both have been shown to have good internal validity.22,47,48 Each of these questionnaires will be discussed in detail in the next section. To improve objectivity and trustworthiness of results, the order in which the three questionnaires would be organized in this research study was considered. Priming may occur when an individual is exposed to questions or concepts that may influence responses to subsequent questions.50 It was determined that if a participant were to answer questions relating to the perception of the importance of role-modeling healthy behaviors and personal health behaviors, a priming effect may occur causing that participants responses on the Expectation questionnaire to possibly become artificially inflated. Because of this, the Expectation questionnaire was placed first. Again considering possible priming effects, it was determined that placing the RM questionnaire second, after answering questions regarding expectations for recommending healthy lifestyle changes but not personal health behaviors, would minimize priming of respondents answers. Research on the construct validity of the HPLPII has demonstrated 29 lack of significant correlation with social desirability bias, thus having decreased possibility of participant responses being skewed by answering the other questionnaires first so it was determined that placing the HPLPII last should not significantly bias the participants responses.47 Data and Instruments Recommended ways to select and improve the development of questionnaires in research was reviewed and considered when selecting the three questionnaires to use in this study.51 These included determining if (1) existing instruments with established reliability and validity testing were appropriate to answer the questions posed and (2) the instruments would be acceptable to the respondents, particularly the combined length of the questionnaires. Two existing questionnaires were determined to be appropriate for this study, with one questionnaire needing to be developed. To begin, the two existing instruments will be discussed. Health promoting lifestyle profile II (HPLPII) The Health Promoting Lifestyle Profile II questionnaire was used to collect the quantitative personal health information data for this study (Appendix 1). This survey was selected as it directly assesses one of the constructs in this studys question, has been reviewed for validity and reliability in prior research, and has been used in a number of research studies to examine the personal health habits of adults in the general population,58, 59 adult patients, 60, 61, 62 and healthcare providers.63, 64 The HPLPII is composed of 52 statements that measure the frequency of the 30 personal performance of healthy behaviors and perceptions of healthy behaviors using a 4-point Likert rating scale (never, sometimes, often, routinely). Responses to these statements provide a multi-faceted view into the participants actions and perceptions related to maintaining or improving wellness, self-actualization, and overall fulfillment with ones life.47 The statements can be subdivided into six domains: health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations and stress management. Health responsibility includes statements regarding being accountable for ones own well-being including attention to personal health, self-education on health, and seeking professional healthcare. Physical activity includes statements regarding regular participation in physical exercise either as a regular fitness program or during daily activities. Nutrition includes statements regarding how well the participant searches out information on and is knowledgeable regarding the selection and consumption of healthy food in accordance with the United States Health and Human Services and United States Dietary Administration. Spiritual growth includes statements regarding practicing a balanced life leading to inner peace, having a sense of harmony and wholeness, and developing a meaning, purpose, and goals for life. Interpersonal relationships includes statements regarding the ability to develop close, intimate relationships by verbally and non-verbally sharing feelings. 31  Stress management includes statements regarding both identifying and incorporating psychological and physical strategies to cope with tension. 47 Prior research conducted used literature review and content experts to establish content validity of the HPLPII.47 The construct validity of the HPLPII was determined to be r = .678 in comparison to the Personal Lifestyle Questionnaire.47 Construct validity was strengthened by the lack of significant correlation with social desirability.47 HPLPII internal consistency alpha coefficient was calculated as .943 for the total score with subscale scores ranging from .793 to .872.47 A three week test-retest reliability coefficient for the HPLPII total score was calculated to be .982.47 Role-modeling questionnaire (RM) To determine the importance SPTAs place on role modeling healthy behaviors to their patients, the RM questionnaire was used (Appendix 2). This instrument was selected as it directly assesses one of the constructs in this studys research question, has been reviewed for validity and reliability in prior research, and has been previously used with PTs, PTAs, and SPTs.22,48 The RM questionnaire was originally developed by Cardinal, et al. for use with health, physical education, recreation, and dance (HPERD) professionals.48 Participants are asked to use a five point Likert scale to rate how strongly they agree with each statement [Strongly disagree, Disagree, Neutral, Agree, Strongly agree].22,48 The scale has been found to have a Cronbach coefficient of 0.95. 48 Black, et. al. 2012 modified the Attitudes Towards Role-Modeling Survey for use with PTs, PTAs, and SPTs.22 The modifications made include a terminology change from HPERD professionals to physical therapy providers, and specification of the 32 amount of physical activity necessary to meet CDC recommendations versus more general statements of performing physical activity at a sufficient level."22,48 In addition, the total number of questions were reduced from sixteen to ten. 22,48 Due to the modified questions specifying CDC recommendations, it was unnecessary to ask individual questions regarding resistance training, stretching, and aerobic fitness activities. Individual questions that discussed only future career opportunities, and fitness tests for graduation from HPERD programs and annually thereafter were also eliminated.22,48 This modified version was used as the RM questionnaire in this study. Expectation questionnaire (Expectation) PTA perceived expectations for recommending healthy lifestyle changes to patients was measured using a self-developed questionnaire: Expectations for Working as a Physical Therapist Assistant (Appendix 3). No existing instrument could be found that assessed this construct. This instrument employs a five point Likert scale: Never (0% of the time when I could), Rarely (1-25% of the time when I could), Sometimes (26-50% of the time when I could), Often (51-75% of the time when I could), Routinely (76-100% of the time when I could). Information gained from literature review helped guide the development of the questionnaire.51 The questionnaire was fully developed with assistance from a panel of experts to determine what question topics would best meet the goals of this study and to avoid duplication of constructs. In addition, question content, readability, and clarity 33 were assessed with the wording of several questions edited and refined. The questionnaire was then piloted with a convenience sample of ten SPTAs for construct and face validity and reliability. To minimize potential measurement error, questions were developed to be as specific as possible to decrease subjectivity with specific numbers being used whenever possible (i.e. specific ACSM and AHA recommendations for physical activity; CDC recommendations regarding diet, alcohol consumption, and sleep). In addition, expert review and pilot testing was performed. The results of a pilot study were examined to identify any problems with wording, reliability, or validity. The finalized questionnaire containing seven questions was established based on the expert panel reaching a consensus agreement regarding revision recommendations. The questions focused on the amount of education the PTAs felt they would provide their future patients on the topics of physical activity, healthy weight, diet, tobacco, alcohol, stress management, and sleep. Data Analysis All statistical analyses were performed using SPSS Statistics 24 (IBM Corp, 2016). Data was collected via the online questionnaire site, Qualtrics.com. Data was then checked for accuracy, coded and uploaded into SPSS. For each HPLPII domain, a subscore mean was calculated as instructed by the HPLPII scoring instructions then the subscores were entered into SPSS. The data in SPSS was then compared to the data both in the Qualtrics website and the calculated HPLPII sub-scores to ensure accurate data entry. Descriptive statistics were calculated for the demographic data and the RM, Expectation, 34 and HPLPII questionnaires individually. Cronbachs alpha () was performed on the Expectation questionnaire to establish internal consistency to determine the reliability of the questionnaire. Appropriate internal consistency was established with a Cronbach's of 0.798. To determine the normal distribution of the data, a one sample chi-square test was run for all questions on the Expectation and RM questionnaires and a one sample Kolmogorov-Smirnov test was run for the HPLPII and its 6 sub-scores. The results of these tests determined that all questions demonstrated statistically significant differences in the observed and expected responses (p<.001). Due to the danger of collinearity between variables, correlations between each of the dependent variables were performed. No collinearity was found using a tolerance of <0.2 and variance inflation factor >5. Correlation analysis and multivariate logistic regression was performed to examine relationships between the 3 questionnaires for potential correlations between personal health behaviors and self-efficacy for recommending health behavior changes to patients. These variables include SPTA personal performance of specific health behaviors such as participating in regular exercise, maintaining a healthy weight, and eating a healthy diet and expectations for recommending these behavior changes to patients. 35 RESULTS Return Rate PTA educators from a total of 35 PTA programs responded to the request. A total of 1,127 SPTAs received that recruitment email and hyperlink with 395 logging into the online questionnaire. Due to incomplete data, 60 participants were excluded from the data analysis resulting in a final response rate of 29.7% (n=335) (Figure 1). Prior research has Numberrate of Students shown that response improvesRecruited when the researcher follows up with a reminder email, N 1127 as performed in this study.10, 21 Figure 1 Response Rate Number (Percent) N 395 (35.05%) Excluded due to Missing Data N 60 (5.32%) Final Response Rate N 335 (29.72%) Respondent Demographics The demographic characteristics of the participants in the final sample are presented in Table 1. The majority of the final participants in this study were female (70.8%, n=238), between the ages of 18-35 years old (84.5%, n=282) and Caucasian (81.1%, n=273). Demographics for all enrolled SPTAs in 2013, the last year of available data, were reported by the Accreditation in Physical Therapy Education (CAPTE) as 36 66.7% female and 79.4% Caucasian, comparable to this studys participants who were 71.0% female and 81.6% Caucasian.49 Table 1: Demographic Characteristics Sex Total % (n) Male 28.9 (96) Female 70.8 (238) Prefer Not to Respond 0.4 (1) Age (years old) Total % (n) 18-25 47.3 (160) 26-35 37.0 (122) 36-45 8.9 (31) 46 and older 5.8 (19) Prefer Not to Respond 0.7 (2) Race Total % (n) Caucasian / White 80.8 (273) African American / Black 5.6 (18) Hispanic / Latino 5.4 (18) Asian / Pacific Islander 1.5 (5) Native American 1.4 (4) Other 0.7 (2) More Than One Race 2.7 (9) Prefer Not to Respond 1.5 (5) Central Tendencies Statistical analyses were performed for each questionnaire individually. Questions on the RM and Expectation questionnaires, as well as the overall HPLPII score and subscores for each domain, were calculated as mean scores. The percentage of SPTAs who perceive they will provide patient education on each healthy lifestyle topic was calculated (Table 2). Most SPTAs perceived they will often or routinely educate their patients on meeting physical activity guidelines (76.4%, n=256), maintaining healthy weight (78.6%, n=263), decreasing or stopping the use of tobacco products (77.9%, n=261), performing stress management techniques (61.8%, n=207), and getting the recommended amount of sleep (65.3%, n=219). The topics with 37 the lowest percentage of SPTAs perceiving they will often or routinely provide patient education were eating a healthy diet (55.2%, n=185) and consuming no more than recommended amounts of alcohol (59.1%, n=198). Table 2: Perceived Expectations of Recommending Healthy Lifestyle Changes % (n) of SPTAs Who Will Advise Provide Patient Education to: Often or Routinely Meet daily physical activity guidelines 76.4 (256) Maintain healthy weight 78.7 (263) Eat healthy diet 55.2 (185) Decrease or stop the use of tobacco products 77.9 (261) Consume no > recommended amount of alcohol 59.1 (198) Perform stress management techniques 61.8 (207) Get recommended amount of sleep 65.4 (219) The vast majority of SPTAs reported agreeing or strongly agreeing that it was important for physical therapy providers to perform and role model each healthy behavior except for the topic of eating five or more servings of fruit and vegetables a day (Table 3). Nearly all SPTAs agreed role modeling is a powerful teaching tool (95.5%, n=320) and that physical therapy professionals should practice what they preach (95.2%, n=319). More than 90% of SPTAs agreed or strongly agreed it is important for physical therapy professionals to perform and role model performing the CDC recommended amounts of physical activity (Perform: 92.2%, n=309; Role model: 91.9%, n=308), maintain healthy weight (Perform: 91.8%, n=308; Role model: 91.9%, n = 308), and abstain from smoking (Perform: 94.3%, n=314; Role model: 93.4%, n=312). The only topic with lower percentages of SPTAs agreeing or strongly agreeing was the importance of eating five or more servings of fruits and vegetables (74.6%, n=249) and role modeling this behavior (71.6%, n=240). This concurs with findings by Black et al 2012 who used the RM Questionnaire with PTs, PTAs, and SPTs (Table 4). 22 38 Table 3: Role Modeling Attitudes It is important for physical therapy professionals: Role modeling is a powerful teaching tool To "practice what they preach" To be involved in CDC* recommended levels of regular physical activity To eat 5 or more servings of fruits and vegetables a day To maintain healthy weight To abstain from smoking To role model CDC* recommended levels of regular physical activity To role model nonsmoking behavior To role model eating 5 or more servings of fruits and vegetables a day To role model maintaining a healthy weight *CDC Centers for Disease Control % (n) of SPTAs Who Agree or Strongly Agree 95.5 (320) 95.2 (319) 92.2 74.6 91.9 94.3 (309) (249) (308) (314) 91.9 (308) 93.4 (312) 71.6 (240) 92.2 (308) Table 4: Role Modeling Attitudes Compared to Black et al. 2012 % Who Agree or Strongly Agree It is important for physical therapy professionals: SPTA Results Black et al, 2012 Role modeling is a powerful teaching tool 95.5 91.2 To "practice what they preach" 95.2 90.3 To be involved in CDC* recommended levels of 92.2 91.3 regular physical activity To eat 5 or more servings of fruits and vegetables a day 74.6 77.9 To maintain healthy weight 91.9 91.6 To abstain from smoking 94.3 92.1 To role model CDC* recommended levels of regular 91.9 87.6 physical activity To role model nonsmoking behavior 93.4 88.6 To role model eating 5 or more servings of fruits and 71.6 73.2 vegetables a day To role model maintaining a healthy weight 92.2 89.6 *CDC Centers for Disease Control Finally, the central tendencies of the HPLPII survey are displayed in Table 5. The 4-point Likert scale was scored as follows: 1 = Never, 2 = Rarely, 3 = Often, and 4 = Routinely. The HPLPII total score had a mean (x ) of 2.90 (SD 0.42). The subsections 39 with the highest scores (those closest to 4) were Spiritual Growth (x 3.29, SD 0.48) and Interpersonal Relations (x 3.20, SD 0.49), followed by Physical Activity (x 2.86, SD 0.63) and Nutrition (x 2.81, SD 0.53). SPTAs reported the lowest healthy personal behaviors in the subscores of Health Responsibility (x 2.55, SD 0.55) and Stress Management (x 2.65, SD 0.56). Table 5: Health Promoting Lifestyle Profile II (HPLPII) Domain Mean* Variance SD HPLPII Total Score 2.90 0.18 0.42 Health Responsibility 2.55 0.31 0.55 Physical Activity 2.86 0.39 0.63 Nutrition 2.81 0.28 0.53 Spiritual Growth 3.29 0.23 0.48 Interpersonal Relations 3.20 0.24 0.49 Stress Management 2.65 0.31 0.56 *1 = Never, 2 = Rarely, 3 = Often, 4 = Routinely Correlation Analysis Correlation analysis was conducted to determine the strength and direction of associations that exist in the data. Goodman and Kruskal's gamma () was chosen over Spearmans rho for the correlation statistics due to the fact that the data contain many correlations. Gamma correlations were performed between the SPTAs responses on the Expectation questionnaire and their responses on the RM and HPLPII questionnaires (Appendix 4). All gamma correlations were positive with correlations noted for a variety of variables. Correlations above 0.4 were deemed strong and between 0.3-0.39 were deemed moderate. Results of the analysis for questions on the topics of: (1) physical activity and exercise, (2) weight, (3) diet and nutrition, and (4) tobacco use were reviewed in composite. 40 Physical activity and exercise question analysis Both the first and second null hypotheses were rejected for questions relating to physical activity and exercise. Statistically significant correlations were found between all questions relating to the topic of physical activity and exercise (p <.001) including SPTA personal performance of physical activity and exercise, expectations for recommending healthy physical activity and exercise changes to future patients and the perception of role modeling to patients (Table 6). Educating patients on the importance of exercise was moderately correlated with perceived importance of performing regular physical exercise (=0.39), role modeling regular physical exercise (=0.46), and HPLPII physical activity subscore (=0.42). Strong correlations also were noted with the beliefs of role modeling being a powerful teaching tool (=0.51) and the importance of physical therapy providers practicing what they preach (=0.45). The expectation of educating patients on the importance of physical activity was also correlated with other variables. A strong correlation was noted with role modeling abstaining from the use of using tobacco products (=0.43). Moderate correlations were noted with eating fruits and vegetables (=0.32), maintaining a healthy weight (=0.34), abstaining from the use of tobacco products (=0.35), role modeling eating fruits and vegetables (=0.38), role modeling maintaining healthy weight (=0.39), HPLPII total score (=0.39), HPLPII Nutrition sub-score (=0.34) and HPLPII Spiritual Growth subscore (=0.31). 41 Table 6: Physical Activity and Exercise Questions: Correlations Variables Expectation: RM Questionnaire Important to Perform Exercise Patient Role Model Exercise Education Teaching Tool Exercise Practice What They Preach Role Model Not Smoking Role Model Fruit and Vegetables Role Model Healthy Weight Important to Eat Fruit and Vegetables Important to Maintain Healthy Weight Important to Not Smoke HPLPII Total Score Physical Activity Nutrition Spiritual Growth (p<.001) 0.39 0.46 0.51 0.45 0.43 0.38 0.39 0.32 0.34 0.35 0.39 0.42 0.34 0.31 Weight question analysis Both the first and second null hypotheses were rejected for questions relating to physical activity and exercise. Statistically significant correlations were found between all questions relating to the topic of weight (p <.001) including SPTA personal weight maintenance, expectations for recommending healthy weight to future patients and the perception of role modeling to patients (Table 7). The expectation of educating patients on the importance of maintaining healthy weight was strongly correlated with the importance of physical therapy professionals role modeling maintaining a healthy weight (=0.37) and had a moderately strong correlation with maintaining healthy weight (=0.44). Strong correlations were also noted with the belief of role modeling being a powerful teaching tool (=0.54) and the importance of physical therapy professionals practicing what they preach (=0.45). Educating patients on maintaining healthy weight also was strongly correlated 42 with performing regular physical activity (=0.47) and role modeling regular physical activity (=0.41). Moderate correlations were found between eating and role modeling eating fruits and vegetables (respectively, =0.32, =0.37), role modeling abstaining from tobacco products (=0.0.35), HPLPII total score (=0.38), HPLPII Nutrition sub-score (=0.34) and HPLPII Spiritual Growth sub-score (=0.38). Table 7: Weight Questions: Correlations Variables Expectation: RM Questionnaire Important to Maintain Healthy Weight Patient Role Model Healthy Weight Education Practice What They Preach Weight Teaching Tool Important to Perform Exercise Role Model Exercise HPLPII (p<.001) 0.37 0.44 0.45 0.54 0.47 0.41 Important to Eat Fruit and Vegetables Role Model: Not Smoking Role Model: Fruit and Vegetables 0.32 0.35 0.37 Total Score Nutrition Spiritual Growth 0.38 0.34 0.38 Diet and nutrition question analysis Both the first and second null hypotheses were rejected for questions relating to diet and nutrition. Statistically significant correlations were found between all questions relating to the topic of diet and nutrition (p <.001) including SPTA personal diet and nutrition, expectations for recommending healthy diet changes to future patients and the perception of role modeling to patients (Table 8). All questions relating to the topic of diet and nutrition were strongly correlated. The importance of educating patients on a healthy diet was strongly correlated with eating and role modeling eating five servings of fruit and vegetables (respectively, =0.41, =0.49) and the HPLPII Nutrition sub-score (=0.46). 43 The importance of educating patients on eating a healthy diet also was strongly correlated with the belief of role modeling being a powerful teaching tool (=0.43), performing regular physical exercise (=0.46), and role modeling abstaining from the use of tobacco products (=0.42). Moderate correlations were noted for the importance of physical therapy providers practicing what they preach (=0.38), maintaining healthy weight (=0.345), abstaining from the use of tobacco products (=0.33), role modeling performing regular physical activity (=0.37), role modeling maintaining healthy weight (=0.39), HPLPII total score (=0.36), and HPLPII Spiritual Growth sub-score (=0.30). Table 8: Diet and Nutrition Questions: Correlations Variables Expectation: RM Questionnaire Important to Eat Fruit and Vegetables Patient Role Model Eating Fruit and Vegetables Education HPLPII Nutrition Diet Teaching Tool Practice What They Preach Important to Perform Exercise Role Model Exercise Important to Maintain Healthy Weight Role Model Healthy Weight Important to Not Smoke Role Model: Not Smoking HPLPII Total Score Nutrition Spiritual Growth (p<.001) 0.43 0.47 0.46 0.43 0.38 0.46 0.37 0.35 0.39 0.33 0.42 0.36 0.46 0.30 Tobacco question analysis Both the first and second null hypotheses were rejected for questions relating to tobacco use. Statistically significant correlations were found between all questions relating to the topic of tobacco use (p <.001) including SPTA personal tobacco use, expectations for recommending stopping tobacco use to future patients and the perception 44 of role modeling to patients (Table 9). Statistically significant correlations were discovered between all questions relating to the topic of tobacco use. Educating patients on decreasing or stopping the use of tobacco products was strongly correlated with perceptions about the importance of physical therapy providers abstaining from, and role modeling abstaining from, the use of tobacco products (respectively, =0.41, =0.49). The importance of educating patients on decreasing or stopping the use of tobacco products also was moderately correlated with the belief about role modeling being a powerful teaching tool (=0.39), the importance of physical therapy providers practicing what they preach (=0.36), performing regular physical exercise (=0.31), and role modeling performing regular physical activity (=0.36). Table 9: Tobacco Questions: Correlations Variables Expectation: RM Questionnaire Important not to Use Tobacco Patient Role Model Not Using Tobacco Education Teaching Tool Tobacco Practice What They Preach Important to Perform Exercise Role Model: Exercise (p<.001) 0.41 0.498 0.39 0.36 0.31 0.36 Multivariate Logistic Regression Multivariate logistic regression was conducted to determine the strength of associations that exist in the data. For each question on the Expectation questionnaire, all variables from the RM and HPLPII questionnaires were entered into the analysis. Next, backward elimination was performed, removing any variable with a p-value greater than 0.05 and the regression run again. Modeling the Expectation survey questions, the regression revealed that the r2 was very small. However small the r2, it can be determined that a variety of variables 45 contributed to the fit of the model. For the topic of educating patients on physical activity, 73.9% of the change in participant responses was predicted by four variables: the HPLPII Physical Activity subscore (34.3%), the HPLPII Interpersonal Relations subscore (15.1%), role modeling being a teaching tool (13.6%), and the importance of practicing that they preach (10.9%). For the topic of educating patients on maintaining healthy weight, 98.4% of the change in participant responses was predicted by four variables: the HPLPII Spiritual Growth subscore (37.2%), the HPLPII Nutrition subscore (21.6%), the importance of personally performing exercise (20.1%), and role modeling being a teaching tool (19.5%). For the topic of educating patients on eating a healthy diet, 93.5% of the change in participant responses was predicted by three variables: the HPLPII Nutrition subscore (59.9%), the importance of personally performing exercise (14.6%), and the HPLPII Spiritual Growth subscore (19.0%). 46 DISCUSSION A relationship has been established between a healthcare providers personal health behaviors and health education and counseling provided to patients.6,8,13,16,17,20,22,25,26,28,33-6,38-40 Role modeling healthy weight and physical fitness also have been associated with increased patient compliance with a providers recommendations, including implementing healthy lifestyle modifications.3,20,22 At this time, the personal health habits and role modeling attitudes of physical therapy providers are largely unknown. The few studies on these topics have been performed with PTs, PTAs, and SPTs with no studies including SPTAs. The purpose of this study was to attempt to fill the gap in literature by examining how SPTAs personal health habits and perceptions of role modeling influence the students expectations for recommending healthy lifestyle changes to patients. The first null hypothesis was that there would be no relationship between SPTA personal health behaviors and expectations for recommending healthy lifestyle changes to future patients. This null hypothesis was rejected. The results indicate that the SPTAs personal health behaviors for the topics of physical activity and exercise, weight, and diet and nutrition are correlated with expectations for recommending these health behaviors to patients. These findings concur with previous studies conducted with a variety of health care providers, including PTs, PTAs, and SPTs.6,8,13,16,17,20,22,25,26,28,33-36,38,40 The second null hypothesis was that there would be no correlation between SPTA personal health behaviors and the perception of role modeling to patients. This null hypothesis also was rejected. The results of this study indicate correlations exist between the SPTAs personal health behaviors for the topics of physical activity and exercise, 47 weight, and diet and nutrition. Further, the results indicate the belief of role modeling being a powerful teaching tool as well as the importance of physical therapy providers practicing what they preach. This concurs with a previous study performed with PTs and SPTs.22 Demographics The final response rate of 29.7% is comparable to other questionnaire based research, which was found to be approximately 20-40 percent.1,8,12,16,21 22,41,44 Studies with higher response rates typically were performed in countries other than the US or with students who completed questionnaires as a component of their coursework or at yearly orientation.2,4,10,17,29 While the participants in this study were a convenience sample, the sample appears to represent the SPTAs enrolled in PTA programs during the 2015-2016 academic year, including similar demographics. The 35 PTA programs in this study represent 10.3% of the 340 accredited PTA programs in 2015-2016, including public and private institutions.49 Participants represented 2.6% of the 12,726 SPTAs enrolled in all accredited PTA programs in 2015-2016.49 The programs participating in this study had a mean number of 29.7 SPTAs enrolled (n=7-76) which is comparable to the CAPTE reported average of 40 students in each PTA program in 2015-2016.49 Demographics for all enrolled SPTAs in 2013, the last year of available data, were reported by CAPTE as 66.76% female and 79.4% Caucasian, comparable to this studys participants who were 71.01% female and 81.60% Caucasian.49 Even so, generalization of these results to the entire SPTA population should be done with caution. 48 Throughout the analysis, no demographic was correlated to any question on the HPLPII, RM questionnaire, or Expectation questionnaire. Only one prior study noted a difference in the personal health behaviors between male and female physical therapy providers, which was not replicated in this study.22 It is possible that the high percentage of Caucasian females in this study, while comparable to all SPTAs, did not allow for demographic correlations to be revealed. Personal Health Behavior Performance A healthcare provider is more likely to counsel patients to make healthy lifestyle changes that the provider personally performs.6,8,13,16,17,20,22,25,26,28,33-36,38,40 When a provider role models healthy behaviors, including maintaining healthy weight, patients are more likely to report higher motivation to change their health behaviors 6,16,17,22,26,28,31,33,35,41 as well as follow all recommendations made by that provider.3,18,25,45 Examining the current health habits of healthcare students can be an indicator of future patient care practices. Further, when a patient is treated by a healthcare provider who role models healthy behaviors, the patient is more likely to attempt to make, and be successful at performing, healthy lifestyle changes.19,28,33,38,41 Prior studies also have concluded that PTs, SPTs, and PTAs are more likely to have better personal health habits when compared to other healthcare providers and the general population.8,16,17,22 The results of this study support previous findings, with the SPTAs in this study scoring highly on the total HPLPII and each subscore. 49 Role Modeling Attitudes Prior research has shown that providers who maintain healthy weight and perform regular physical exercise are viewed as more trustworthy and credible by their patients when providing health behavior counseling.3,20-22 Further, PTs and SPTs have reported that physical therapy providers are responsible for role modeling of healthy behaviors.10,22,45 The results this study indicate SPTAs role modeling attitudes are comparable to other studies performed on physical therapy providers. Role modeling attitudes can be directly compared to the 2012 study by Black et al. which used the same RM questionnaire and was performed with PTs and SPTs.22 The belief that role modeling the performance of physical activity was important for physical therapy providers also was reported by 91% of PTs and SPTs in the 2010 study by Shirley et al., which is comparable to the results of this study.4 Patient Education on Healthy Behaviors Prior research has concluded that patients are more likely to attempt to change, and be successful in changing, personal health behaviors when healthcare providers supply education on the topics of increasing physical exercise, diet, smoking cessation, and decreasing alcohol consumption.6,24,25,31,34 Because of this, establishing current SPTAs perceptions of providing patient education on the topics of healthy behaviors can assist in determining opportunities and weaknesses in the current educational structure in order to improve future patient care and physical therapy outcomes. In this study, age and gender did not contribute to any changes in HPLPII scores. 50 Most SPTAs in this study perceived they often or routinely will educate their patients on meeting physical activity guidelines (76.4%) which was lower than studies that included only PTs and SPTs (97%,4 99%5). Of note, in the 2004 study by Rea et al., the only study found asking PTs to report the amount of patient education they actually performed, PTs reported performing patient education on increasing physical activity 54% of the time.15 No other studies were found to compare how often PTs, PTAs, or SPTs perceived they would provide patient education on other healthy behavior topics. The 2004 study by Rea et al. where PTs reported the actual amount of patient education provided was the only comparison available. The discrepancy seen between the perceived and actual amounts of patient education provided on increasing physical activity was present for recommending other healthy behavior changes to patients. The percentage of time PTs reported providing patient education on the topics of nutrition and weight was 19.1% compared to the SPTAs in this study with 78.6% perceiving they would provide education on maintaining healthy weight and 55.2% on eating a healthy diet.15 In the 2004 study by Rea et al., PTs reported educating patients on decreasing the use of tobacco products 16.5% of the time compared SPTAs perception of 77.9%.15 In the same study, the percentage of time PTs reported performing patient education on stress management techniques was 41.4% compared to the SPTAs perception of 61.8%. 15 Multivariate Logistic Regression The multivariate logistic regression did not indicate a specific factor that most influenced SPTAs to recommend healthy lifestyle changes to their future patients. It is 51 possible that a specific factor responsible for the association was not included as a question in this study. However, based on the results of the multivariate logistic regression and the literature review, it appears SPTAs perceptions of recommending healthy lifestyle changes to patients are derived from a variety of multifaceted factors. Personal health behaviors and expectations for recommending healthy changes One of the factors contributing to recommending healthy lifestyle changes to patients is the personal performance of that healthy behavior. 6,8,13,16,17,20,22,25,26,28,33-36,38,40 The results of this study also demonstrated a relationship between SPTAs personal performance of healthy behaviors and their expectation for recommending healthy lifestyle changes to future patients. The HPLPII composite score and subscores were used to determine the SPTAs personal health behaviors for this study and was included in the multivariate logistic regression. The HPLPII physical activity subscore was used in this study to measure regular, personal participation in physical activity and accounted for 34.3% of the change in providing patient education on the topic of physical activity, the largest change for all variables on this topic. Further, the HPLPII Nutrition subscore which measured personally eating a healthy diet, accounted for the largest change in providing patient education on the topic of eating a healthy diet at 59.9%. Patient education on the topic of maintaining healthy weight was influenced by the personal health behaviors on three HPLPII subscores. The HPLPII Nutrition subscore accounted for 21.6% of the change and the belief in the importance of personally 52 performing exercise accounted for another 20.1% of the change. Interestingly, the HPLPII Spiritual Growth subscore accounted for 37.2% of the change in SPTA responses on the topic of maintaining healthy weight. This subscore did not include any questions regarding weight, diet or exercise. Instead it included questions such as feeling one is positively changing, believing ones life has purpose, looking forward to the future, being contented with oneself, working towards long-term life goals, and finding each day interesting, which may be related to self-esteem or some other psychological characteristics. Therefore, the results of this study concurred with the findings of prior studies. Furthermore, the first null hypothesis that there is no relationship between SPTA personal health behaviors and expectations for recommending healthy lifestyle changes to future patients should be rejected. For clinical practice, these results demonstrate SPTAs personal health behaviors do influence expectations for recommending healthy lifestyle changes to patients, an important step in improving patients health behaviors and overall health. Personal health behaviors and role modeling As in prior studies performed with PTs, PTAs and SPTs, there was a correlation between a providers personal health behaviors and their attitudes toward the importance of role modeling healthy behaviors for their patients.10,22,45 The multivariate logistic regression coefficients showed that the belief that role modeling is a teaching tool was responsible for 20.4% of the change in providing patient education to increase physical activity and 19.5% of the change in providing patient education to maintain healthy 53 weight. The belief that it is important for physical therapy providers to role model performing exercise was responsible for 13.3% of the change in the expectation regarding providing patient education to increase physical activity. The belief in the importance of personally performing exercise was responsible for 20.1% of the change in providing patient education to maintain healthy weight and 14.6% of the change in providing patient education to eat a healthy diet. The belief that it is important for physical therapy providers to role model eating five servings of fruit and vegetables was responsible for an additional 15.1% of the change in providing patient education to eat a healthy diet. Although there was not a strong goodness of fit with the multivariate logistic regression, it still supports the rejection of the second null hypothesis that there is no relationship between SPTA personal health behaviors and their attitudes toward the importance of role modeling healthy behaviors for their patients. For clinical practice, these results demonstrate SPTAs personal health behaviors do influence their attitudes towards the importance of role modeling. This is important for optimal patient care as prior research has concluded that patients are more likely to follow the advice of healthcare providers who role model healthy behaviors. Implications The results of this study reveal that the expectation of providing patient education is influenced by a variety of factors. Therefore, to positively affect the amount of patient education provided to future patients, a multifaceted approach will need to be incorporated in formal education. Because the amount of health behavior education healthcare providers receive and their personal health habits impact practice patterns, 54 these facets need to be addressed frequently during formal education.12,32 In a 2013 study by McMahon and Connolly, only 41.4% of PTs reported having sufficient knowledge of health behavior change theory with just over half reporting getting health promotion education training in school and only 29% reporting continuing education in health behavior counseling after graduation.12 No data exists for PTAs or SPTAs understanding of health behavior change theory, health promotion education, or self-efficacy for patient education on healthy behaviors. It should be noted that the length of formal education required to become a PT is much longer than for a PTA and CAPTE sets the guidelines for both educational processes. This makes it likely that clear gaps in knowledge seen in the formal educational process of PTs also will occur in PTAs. Multiple studies have shown that PTs and SPTs have better health behaviors compared to the general population as well as other healthcare providers.10,16,17,19,22,23,38 It is possible that healthier individuals self-select into the physical therapy profession or that health behaviors improve during the course of education and training. 17,19,22,38 Because of the generally high level of personal health behaviors, discussion and support of the importance of personal health behaviors may not be addressed fully during formal education. It is important to note that some students may have physical limitations or acquire musculoskeletal injuries as practicing physical therapy professionals, making role modeling all healthy behaviors difficult. By ensuring SPTAs receive strong foundational formal education on the importance of personal health behaviors and providing patient education, it is possible that PTAs can provide strong patient education and improve patient outcomes throughout their careers. 55 Future Research In order to determine what additional education, resources, and support may be most appropriate, future research may include studies to determine SPTAs and PTAs current levels of knowledge of health promotion education and health behavior counseling. The development of a controlled study to collect longitudinal data for SPTAs at the start and end of their educational experience as well as at various times after graduation could assist in determining knowledge gained during formal education and the increase or decrease in that knowledge over time. This should include the education physical therapy providers receive on the topics of personal healthy lifestyle habits and educating patients on these habits. The personal health habits of PTAs also should be determined to understand what pre- and post- graduation resources and education would most promote improved patient care. What educational components are most effective, as well as additional education most effective during school and after graduation, should be determined to encourage students to maintain or improve their personal health behaviors and improve patient care. Because the Expectation questionnaire was developed for this study, further development of this instrument to improve validity may lead to a stronger instrument with better data collected and more valid conclusions. The instrument could be refined to better determine the most influential factors in providing health behavior education and physical therapy providers perceived benefits of healthy behaviors. Future research should examine patients' attitudes toward physical therapists discussing health behaviors with them and the impact that role modeling may have on the success of these discussions. Studies to determine the amount and type of patient 56 education on healthy behaviors as well as patient compliance with recommendations to improve health behaviors also could be studied. A larger sample size including both APTA members and nonmembers would increase generalizability of the results. Assumptions The primary assumptions underlying this study are that the survey respondents were: the intended audience of SPTAs; that the questions were clearly understood; and the respondents were honest, accurate, objective, and reflective in their answers to the questions. Further, the pilot study and the use of experts was able to provide good internal consistency for validity of the Expectation questionnaire. Strengths There are several strengths to using a study with cross-sectional design. Questionnaire based research using a Likert scale is ethically safe, cost effective, provides efficient collection of a large amount of quantitative data in a short period of time on a variety of variables, allows for the ability to replicate the research, and has the potential for generalizability. In addition, while causality cannot be established, the presence or absence of relationships between study variables can be determined. A questionnaire based study also is useful to assist in the generation of hypotheses. Despite the participants being a convenience sample, they do appear to well represent the target population of all SPTAs. 57 Limitations The instructors invited to participate were all members of the APTA and active on APTA message boards and the participants in this study were chosen as a convenience sample. This may not accurately represent the target population of all SPTAs. While it appears the demographics of the participants were quite similar to those of all SPTAs, which suggests that the participants were representative of the SPTA population, generalization of the results should be done with caution. Cross-sectional study design also has several known limitations. First, only correlations can be established, not causality. This does not allow the establishment of temporality between personal health behavior variables and role modeling attitudes. There is potential for several biases within self-reported, questionnaire based research including recall bias, nonresponse bias, and social desirability bias. First, asking any participant to recall personal past behaviors can lead to some measurement error, as reported data may not be as accurate as intended. Further, some PTA instructors may have used class time for the participants to complete the questionnaire. Therefore, some participants may have felt pressure to participate and therefore not fully have read the questions or answered as truthfully as desired, also leading to response bias measurement error. Next, individuals who participate in, or have an interest in, healthy behaviors may be more likely to complete the questionnaire so those who did not participate may have had poorer personal health behaviors.22,51-57 Social desirability bias may occur when participants provide answers they perceive to be most acceptable, or how they should answer. Since SPTAs are training as healthcare providers, they know that healthy behaviors are more desirable and, 58 therefore, may provide responses they feel are correct instead of providing accurate responses based on self reflection. This could affect the validity and reliability of responses.4,17,22,51-57 Several studies have shown that social desirability bias is best minimized if results are taken from a large group, but there is no specific manner of data collection known to decrease social desirability bias.51,53,57 Given the potential for these biases, generalization of these results to the entire SPTA population should be done cautiously. 59 Conclusion To the authors knowledge, this is the first study to report on SPTA personal health behaviors, role modeling attitudes or expectations for recommending healthy lifestyle changes to patients. This research has shown that a significant portion of SPTAs participate in healthy behaviors, feel that role modeling healthy behaviors is a necessary component of being a physical therapy providers, and that they should recommend healthy behavior changes to patients. The literature review documented a clear relationship between a healthcare providers personal health behaviors and the amount and type of health education counseling provided to patients.6,8,13,16,17,20,22,25,26,28,33-6,38-40 In addition, patient compliance with recommendations has been shown to decrease when the recommendations are made by a healthcare provider who does not role model healthy behaviors.18,45 When healthy behaviors were role modeled, patients reported being more open to health behavior counseling and having greater motivation to change their health behavior.6,16,17,22,26,28,31,33,35,41 Because the universal goal of physical therapy is to identify movement deficits, maximize function, and improve health-related quality of life, providing patient education on healthy behaviors is a critical part of physical therapy intervention.10,13,14,17,19 Therefore, the health behaviors of SPTAs in this study can be an indicator of the future patient care practices of the profession. The literature also indicates that increasing patient education results in increased patient effort and likelihood of improvement in healthy behaviors.6,24,25,31,34 Further, the amount and type of health behavior education that healthcare providers receive impacts the health behavior education provided to patients.6,29,30,33,34,36,37 SPTAs favorable 60 attitudes towards recommending healthy behavior changes to their patients increase the likelihood of positively influencing patients attitudes, behaviors, and health in a cost effective manner. This would result in both treating and preventing chronic health conditions.19,21,31 Physical therapy providers regularly focus on altering patient behaviors, have expertise in prescribing safe physical activity for ill, injured and fragile populations, and maintain the belief that health promotion is integral to providing appropriate physical therapy patient care.10-14,16,17,19,32 With increasing numbers of patients receiving care from physical therapy providers for conditions caused or exacerbated by poor health habits, education for both providers and patients is vitally important. This study indicates areas of strengths and some for possible improvement in SPTA education in order to promote positive personal health habits that could affect future counseling practices, potentially leading to improved patient care and outcomes. 61 References 1. Downs A, Wile N, Krahn G, Turner A. Wellness promotion in persons with disabilities: physicians' personal behaviors, attitudes, and practices. Rehabil Psychol. 2004;49(4):303-308. 2. Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89-92. 3. Puhl R, Gold J, Luedicke J, DePierre J. The effect of physicians' body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice. Int J Obes. 2013;37(11):1415-1421. 4. Shirley D, van der Ploeg H, Bauman A. Physical activity promotion in the physical therapy setting: perspectives from practitioners and students. Phys Ther. 2010;90(9):1311-1322. 5. Mouton A, Mugnier B, Demoulin C, Cloes M. Physical Therapists Knowledge, Attitudes, and Beliefs About Physical Activity: A Prerequisite to Their Role in Physical Activity Promotion? J Phys Ther Educ. 2014;28(3):120-127. 6. Oberg E, Frank E. Physicians health practices strongly influence patient health practices. J R Coll Physicians Edinburgh. 2009;39(4):290-291. 7. Pignataro R, Ohtake P, Swisher A, Dino G. The role of physical therapists in smoking cessation: opportunities for improving treatment outcomes. Phys Ther. 2012;92(5):757-766. 8. Goodgold S. Wellness promotion beliefs and practices of pediatric physical therapists. Pediatr Phys Ther. 2005;17(2):148-157. 62 9. Commission on Accreditation in Physical Therapy Education. 2012-2013 Fact Sheet Physical Therapist Assistant Education [Web document]. Oct 24, 2013. http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources /Aggregate_Program_Data/AggregateProgramData_PTAPrograms.pdf#search=% 22aggregate program data%22. Accessed April 21, 2015. 10. Glazer-Waldman HR, Hart JP, LeVeau BF. Health beliefs and health behaviors of physical therapists. Phys Ther. 1989;69:204-210. 11. Ingman MS, Eckstrom A, Fisher A, Johnson M, Laska J, Weimass M. Physical therapists' knowledge, beliefs, barriers, and practices in the areas of health promotion and fitness testing. Cardiopulm Phys Ther J. 2011;22(4):38-39. 12. McMahon N, Connolly C. Health promotion knowledge, attitudes and practices of chartered physiotherapists in Ireland: A national survey. Physiother Pract Res. 2013;34(1):21-28. 13. Verhagen E, Engbers L. The physical therapist's role in physical activity promotion. Br J Sports Med. 2009;43(2):99-101. 14. Jewell D. The role of fitness in physical therapy patient management: applications across the continuum of care. Cardiopulm Phys Ther J. 2006;17(2):47-62. 15. Rea B, Marshak H, Neish C, Davis N. The role of health promotion in physical therapy in California, New York and Tennessee. Phys Ther. 2004;84(6):510-523. 16. Fink M, Black B, Butt S, Fenning S, Sharkey K. Health Behaviors of Physical Therapists and Physical Therapist Students in South-central Pennsylvania. HPA Resource. 2014;14(4):J1-j14. 17. Chevan J, Haskvitz E. Do as I do: exercise habits of physical therapists, physical 63 therapist assistants, and student physical therapists. Phys Ther. 2010;90(5):726734. 18. Sobush DC, Fehring RJ. Physical fitness of physical therapy students. Phys Ther. 1983;63:1266-1273.p 19. Dbrowska-Galas M, Plinta R, Dbrowska J, Skrzypulec-Plinta V. Physical activity in students of the Medical University of Silesia in Poland. Phys Ther. 2013;93(3):383-392. 20. Joy E, Blair S, McBride P, Sallis R. Physical activity counseling in sports medicine: a call to action. Br J Sports Med. 2013;47(1):49-53. 21. Groth J, Ayers S, Miller M, Arbogast W. Self-Reported Health and Fitness Habits of Certified Athletic Trainers. J Athl Train. 2008;43(6):617-623. 22. Black B, Marcoux B, Stiller C, Qu X, Gellish R. Personal health behaviors and role-modeling attitudes of physical therapists and physical therapist students: a cross-sectional study. Phys Ther. 2012;92(11):1419-1436. 23. Ferrara C, Nobrega C, Dulfan F. Obesity, diet, and physical activity behaviors of students in health-related profession. Coll Stud J. 2013;47(3):560-565. 24. Geense W, van de Glind I, Visscher T, van Achterberg T. Barriers, facilitators and attitudes influencing health promotion activities in general practice: an explorative pilot study. BMC Fam Pract. 2013;14(1):20-29. 25. Hash RB, Munna RK, Vogel RL, Bason JJ. Does physician weight affect perception of health advice? Prev Med. 2002;36:41-44. 26. Frank E. Physician health and patient care. JAMA. 2004;291(5):637. 27. Irna K, Anna M, Anda B. Physical activity and its relation to health-related 64 physical fitness in students. Ovidius University Annals, Series Physical Education Sport/Science, Movement Health. 2012;12(2):256-263. 28. Oberg E. Be a better doctor by practicing what you preach. Integr Med. 2010;9(3):22-25. 29. Frank E, Elon L, Spencer E. Personal and clinical tobacco-related practices and attitudes of U.S. medical students. Prev Med. 2009:49(23): 2339. 30. Wilkinson C, Pennington T, Barney D, Lockhart B, Hager R, Prusak K. PETE students' perceptions of a healthy and active lifestyle. Phys Educator. 2014;71(4):644-659. 31. Burke L, Fair J. Promoting prevention: skill sets and attributes of health care providers who deliver behavioral interventions. J Cardiovasc Nurs. 2003;18(4):256-266. 32. Boll M, Bostrm-Lindberg E. Physiotherapists' understanding and approach to health promotion work in compulsory school: perceiving and supporting coherence. Physiother Theory Pract. 2010;26(5):318-326. 33. Duperly J, Lobelo F, Frank E, et al. The association between Colombian medical students' healthy personal habits and a positive attitude toward preventive counseling: cross-sectional analyses. BMC Public Health. 2009;9:218. 34. Crawford P, Gosliner W, Yancey A, et al. Walking the talk: Fit WIC wellness programs improve self-efficacy in pediatric obesity prevention counseling. Am J Public Health. 2004;94(9):1480-1485. 35. Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med. 2000;9:287-290. 65 36. Cameron D, Katch E, Anderson P, Furlong M. Healthy doctors, healthy communities. J Ambul Care Manage. 2004;27(4):328-338. 37. Spollen J, Thrush C, Mui D, Woods M, Tariq S, Hicks E. A randomized controlled trial of behavior change counseling education for medical students. Med Teach. 2010;32(4):e170-7. 38. Kamwendo K. Adherence to healthy lifestyles: a comparison of occupational therapy students with nursing and physiotherapy students. Scand J Occup Ther. 2000;7(4):156-164. 39. Frank E, Segura C, Shen H, Oberg E. Predictors of Canadian physicians prevention counseling practices. Can J Public Health. 2000:101(5): 3905. 40. Frank E, Dresner Y, Shani M, Vinker S. The association between physicians and patients preventive health practices. Can Med Assoc J. 2013;185(8):649-653. 41. Van der Veer T, Frings-Dresen M, Sluiter J. Health behaviors, care needs and attitudes towards self-prescription: a cross-sectional survey among Dutch medical students. PLos One. 2011;6(11):e28038. 42. Centers for Disease Control and Prevention. Healthy Weight its not a diet, its a lifestyle! About BMI for adults [Web page]. http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/. Accessed April 19, 2015. 43. Biernat E, Poznaska A, Gajewski A. Is physical activity of medical personnel a role model for their patients. Ann Agric Environ Med. 2012;19(4):707-710. 44. Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and counseling practices of primary care physicians. Clin J Sport Med. 2000; 66 10:40-48. 45. Balogun JA. Assessment of physical fitness of female physical therapy students. J Orthop Sports Phys Ther. 1987;8(11):525-32. 46. Kotwica A, majcher P. Physical fitness level of 1st year medicine and physiotherapy students of Lublin medical university. Polish J Sport Tourism. 2012;19(2):107-112. 47. Walker SN, Sechrist KR, Pender NJ. Health promotion model instruments to measure health promoting lifestyle: Health-Promoting Lifestyle Profile [HPLP II] (Adult Version). Deep Blue University of Michigan Web site. 1995. http://deepblue.lib.umich.edu/handle/2027.42/85349. Accessed April 18, 2015. 48. Cardinal BJ, Cardinal MK, Drabbs MK, et al. Preliminary development of a scale to measure attitudes regarding the importance of role-modeling in physical activity and fitness behaviors among health, physical education, recreation, and dance professionals. Percept Mot Skills. 1998;86:627-630. 49. Commission on Accreditation in Physical Therapy Education. Home Page. Quick Facts. http://www.capteonline.org/home.aspx Accessed April 24,2016. 50. Rodriguez L, Neighbors C, Foster D. Priming effects of self-reported drinking and religiosity. Psychol Addict Behav. 2014;28(1):1-9. 51. Kimberlin C, Winterstein A. Validity and reliability of measurement instruments used in research. Am J Health Syst Pharm. 2008;65(23):2276-2284. 52. van de Mortel T. Faking it: social desirability response bias in self-report research. Aust J Adv Nurs. 2008;25(4):40-48. 53. Fastame M, Penna M. Does Social Desirability Confound the Assessment of Self67 Reported Measures of Well-Being and Metacognitive Efficiency in Young and Older Adults?. Clin Gerontol. 2012;35(3):239-256. 54. McMurray R, Ward D, Young D, et al. Do overweight girls overreport physical activity?. Am J Health Behav. 2008;32(5):538-546. 55. Adams S, Matthews C, Hebert J, et al. The effect of social desirability and social approval on self-reports of physical activity [corrected] [published erratum appears in Am J Epidemiol 2005 May 1;161(9):899]. Am J Epidemiol. 2005;161(4):389-398. 56. Ferrari P, Friedenreich C, Matthews C. The role of measurement error in estimating levels of physical activity. Am J Epidemiol. 2007;166(7):832-840. 57. Jones S, Knapik J, Sharp M, Darakjy S, Jones B. The validity of self-reported physical fitness test scores. Military Medicine. 2007;172(2):115-120. 58. Hulme P, Walker S, Effle K, Jorgensen L, McGowan M, Nelson J, Pratt E. Health-Promoting Lifestyle Behaviors of Spanish-Speaking Hispanic Adults. J Transcult Nurs, 2003:14(3), 244-254. 59. Padden D, Connors R, Posey S, Ricciardi R, Agazio J. Factors influencing a health promoting lifestyle in spouses of active duty military. Health Care Women Int, 2013;34(8), 674-93. 60. Berger A, Walker S. An explanatory model of fatigue in women receiving adjuvant breast cancer chemotherapy. Nurs Res, 2001;50(1), 42-52. 61. Grace S, Grewal K, Arthur H, Abramson B, Stewart D. A prospective, controlled multisite study of psychosocial and behavioral change following women's cardiac rehabilitation participation. J Women's Health, 2008;17(2), 241-8. 68 62. Hamilton J, Kives, Micevski V, Grace, S. Time Perspective and HealthPromoting Behavior in a Cardiac Rehabilitation Population. Behav Med, 2003;28(4), 132-139. 63. Stark M, Hoekstra T, Hazel D, Barton B. Caring for self and others: Increasing health care students' healthy behaviors. Work. 2012;42(3): 393-401. 64. Hensel, D. Relationships among nurses' professional self-concept, health, and lifestyles. West J Nurs Res. 2011;33(1), 45-62. 69 Appendix 1-1 Health Promoting Lifestyle Profile II Questionnaire (HPLPII) DIRECTIONS: This questionnaire contains statements about your present way of life or personal habits. Please respond to each item as accurately as possible, and try not to skip any item. Indicate the frequency with which you engage in each behavior by circling: N for never, S for sometimes, O for often, or R for routinely 1. Discuss my problems and concerns with people close to me. 2. Choose a diet low in fat, saturated fat, and cholesterol. 3. Report any unusual signs or symptoms to a physician or other health professional. 4. Follow a planned exercise program. 5. Get enough sleep. 6. Feel I am growing and changing in positive ways. 7. Praise other people easily for their achievements. 8. Limit use of sugars and food containing sugar (sweets). 9. Read or watch TV programs about improving health. 10. Exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber). 11. Take some time for relaxation each day. 12. Believe that my life has purpose. 13. Maintain meaningful and fulfilling relationships with others. 14. Eat 6-11 servings of bread, cereal, rice and pasta each day. 15. Question health professionals in order to understand their instructions. 16. Take part in light to moderate physical activity (such as sustained walking 30-40 minutes 5 or more times a week). 17. Accept those things in my life which I cannot change. 18. Look forward to the future. 19. Spend time with close friends. 20. Eat 2-4 servings of fruit each day. 21. Get a second opinion when I question my health care provider's advice. 22. Take part in leisure-time (recreational) physical activities (such as swimming, dancing, bicycling). 23. Concentrate on pleasant thoughts at bedtime. 24. Feel content and at peace with myself. 25. Find it easy to show concern, love and warmth to others. Never Sometimes Often Routinely N S O R N S O R N S O R N N N N N N N S S S S S S S O O O O O O O R R R R R R R N N N S S S O O O R R R N S O R N S O R N S O R N N N N N S S S S S O O O O O R R R R R N S O R N N N S S S O O O R R R 70 26. Eat 3-5 servings of vegetables each day. 27. Discuss my health concerns with health professionals. 28. Do stretching exercises at least 3 times per week. 29. Use specific methods to control my stress. 30. Work toward long-term goals in my life. 31. Touch and am touched by people I care about. 32. Eat 2-3 servings of milk, yogurt or cheese each day. 33. Inspect my body at least monthly for physical changes/danger signs. 34. Get exercise during usual daily activities (such as walking during lunch, using stairs instead of elevators, parking car away from destination and walking). 35. Balance time between work and play. 36. Find each day interesting and challenging. 37. Find ways to meet my needs for intimacy. 38. Eat only 2-3 servings from the meat, poultry, fish, dried beans, eggs, and nuts group each day. 39. Ask for information from health professionals about how to take good care of myself. 40. Check my pulse rate when exercising. 41. Practice relaxation or meditation for 15-20 minutes daily. 42. Am aware of what is important to me in life. 43. Get support from a network of caring people. 44. Read labels to identify nutrients, fats, and sodium content in packaged food. 45. Attend educational programs on personal health care. 46. Reach my target heart rate when exercising. 47. Pace myself to prevent tiredness. 48. Feel connected with some force greater than myself. 49. Settle conflicts with others through discussion and compromise. 50. Eat breakfast. 51. Seek guidance or counseling when necessary. 52. Expose myself to new experiences and challenges. N N S S O O R R N N N N N S S S S S O O O O O R R R R R N S O R N S O R N N N N S S S S O O O O R R R R N S O R N N S S O O R R N N N S S S O O O R R R N S O R N N N S S S O O O R R R N S O R N N N S S S O O O R R R S.N. Walker, K. Sechrist, N. Pender, 1995. Reproduction without the author's express written consent is not permitted. Permission to use this scale may be obtained from: Susan Noble Walker, College of Nursing, University of Nebraska Medical Center, Omaha, NE 68198-5330. 71 Appendix 1-2 Permission for Use: Health Promoting Lifestyle Profile II 72 Appendix 2 Role Modeling Attitudes Questionnaire Please indicate your level of agreement with each of the following statements using the following scale: 1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree 1 2 3 4 5 1. Role modeling is a powerful teaching tool for physical therapy professionals. 2. It is not enough to simply stay current in the field; physical therapy professionals must also practice what they preach. 3. Involvement in CDC-recommended levels of regular physical activity* is a desirable and recommended behavior for physical therapy professionals. 4. Eating 5 or more servings of fruit and vegetables a day is a desirable and recommended behavior for physical therapy professionals. 5. Maintaining a healthy weight is a desirable and recommended behavior for physical therapy professionals. 6. Abstaining from smoking is a desirable and recommended behavior for physical therapy professionals. 7. It is important for physical therapy professionals to role model CDC-recommended levels of regular physical activity. 8. It is important for physical therapy professionals to role model nonsmoking behavior. 9. It is important for physical therapy professionals to be role models for eating 5 or more servings of fruits and vegetables a day. 10. It is important for physical therapy professionals to role models maintaining a healthy weight. *The CDC defines regular cardiac/aerobic physical activity as: Moderate-intensity (such as brisk walking, bicycling, vacuuming, gardening or anything else that causes some increase in breathing or heart rate) for at least 30 minute on 5 or more days a week OR Vigourous-intensity (such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate) for at least 20 minutes on 3 or more days a week. 73 Appendix 3 Expectation for Working as a Physical Therapist Assistant Questionnaire Please answer the following questions based on what you expect to do when you are licensed and working as a Physical Therapist Assistant. Never (0% of the chances when I could) Rarely (1-25% of the chances when I could) Sometimes (26-50% of the chances when I could) Often (51-75% of the chances when I could) Routinely (76-100% of the chances when I could) Never Rarely Sometimes Often Routinely 1. I will provide specific education to my patients advising them to meet daily physical activity guidelines. (30 minutes, 5 times a week: American College of Sport Medicine, American Heart Association) 2. I will provide specific education to my patients advising them to maintain a healthy weight. 3. I will provide specific education to my patients advising them to eat a healthy diet. 5 daily servings of fruits and vegetables; low salt, fat and sugar; minimal intake of fast foods 4. I will provide specific education to my patients advising them to decrease or stop the use of tobacco products. 5. I will provide specific education to my patients advising them to consume no more than the recommended amount of alcohol. Women: 1 drink per day; Men: 2 drinks per day (US Centers for Disease Control and Prevention) 6. I will provide specific education to my patients advising them to perform stress management techniques. 7. I will provide specific education to my patients advising them to get the recommended amount of sleep. Adults: 7-9 hours per night (US Centers for Disease Control and Prevention) 74 Appendix 4-1 and 4-2 Gamma Correlation Analyses Appendix 4-1 Gamma Correlations: Perceived Expectations for Recommending Healthy Lifestyle Changes and HPLPII Questionnaires Variable * Variable * (p<.001) Patient Education: Alcohol (p<.001) Patient Education: Exercise HPLPII Total Score .39 HPLPII Total Score .19 HPLPII Health Responsibility .26 HPLPII Health Responsibility .17 HPLPII Physical Activity .42 HPLPII Physical Activity .15 HPLPII Nutrition .34 HPLPII Nutrition .16 HPLPII Spiritual Growth .31 HPLPII Spiritual Growth .20 HPLPII Interpersonal Relations .27 HPLPII Interpersonal Relations .18 HPLPII Stress Management .27 HPLPII Stress Management .10 Patient Education: Weight Patient Education: Stress Management HPLPII Total Score .38 HPLPII Total Score .24 HPLPII Health Responsibility .24 HPLPII Health Responsibility .21 HPLPII Physical Activity .30 HPLPII Physical Activity .14 HPLPII Nutrition .34 HPLPII Nutrition .17 HPLPII Spiritual Growth .38 HPLPII Spiritual Growth .21 HPLPII Interpersonal Relations .29 HPLPII Interpersonal Relations .24 HPLPII Stress Management .29 HPLPII Stress Management .27 Patient Education: Diet Patient Education: Sleep HPLPII Total Score .36 HPLPII Total Score .30 HPLPII Health Responsibility .24 HPLPII Health Responsibility .22 HPLPII Physical Activity .29 HPLPII Physical Activity .17 HPLPII Nutrition .46 HPLPII Nutrition .24 HPLPII Spiritual Growth .30 HPLPII Spiritual Growth .30 HPLPII Interpersonal Relations .26 HPLPII Interpersonal Relations .28 HPLPII Stress Management .24 HPLPII Stress Management .31 Patient Education: No Tobacco HPLPII Total Score .22 HPLPII Health Responsibility .13 HPLPII Physical Activity .15 HPLPII Nutrition .22 HPLPII Spiritual Growth .24 HPLPII Interpersonal Relations .22 HPLPII Stress Management .12 75 Appendix 4-2 Gamma Correlations: Perceived Expectations for Recommending Healthy Lifestyle Changes and Role Modeling Questionnaires * * Variable Variable (p<.001) (p<.001) Patient Education: Exercise Patient Education: Alcohol Role Model: Teaching Tool .51 Role Model: Teaching Tool .26 Important to Practice What They .45 Important to Practice What They .28 Preach Preach Important to Perform Exercise .39 Important to Perform Exercise .32 Important to Eat Fruit and .32 Important to Eat Fruit and .26 Vegetables Vegetables Important to Maintain Healthy .34 Important to Maintain Healthy .21 Weight Weight Important to Not Smoke .35 Important to Not Smoke .28 Role Model: Exercise .46 Role Model: Exercise .27 Role Model: Not Smoking .43 Role Model: Not Smoking .31 Role Model: Fruit and Vegetables .38 Role Model: Fruit and Vegetables .38 Role Model: Healthy Weight .39 Role Model: Healthy Weight .23 Patient Education: Weight Patient Education: Stress Management Role Model: Teaching Tool .54 Role Model: Teaching Tool .34 Important to Practice What They .45 Important to Practice What They .35 Preach Preach Important to Perform Exercise .47 Important to Perform Exercise .27 Important to Eat Fruit and .32 Important to Eat Fruit and .23 Vegetables Vegetables Important to Maintain Healthy .37 Important to Maintain Healthy .27 Weight Weight Important to Not Smoke .21 Important to Not Smoke .31 Role Model: Exercise .41 Role Model: Exercise .25 Role Model: Not Smoking .35 Role Model: Not Smoking .23 Role Model: Fruit and Vegetables .37 Role Model: Fruit and Vegetables .32 Role Model: Healthy Weight .44 Role Model: Healthy Weight .29 76 (continued) Appendix 4-2 Gamma Correlations: Perceived Expectations for Recommending Healthy Lifestyle Changes and Role Modeling Questionnaires Patient Education: Diet Patient Education: Sleep Role Model: Teaching Tool .43 Role Model: Teaching Tool .37 Important to Practice What They .38 Important to Practice What They .25 Preach Preach Important to Perform Exercise .46 Important to Perform Exercise .23 Important to Eat Fruit and .43 Important to Eat Fruit and .27 Vegetables Vegetables Important to Maintain Healthy .35 Important to Maintain Healthy .26 Weight Weight Important to Not Smoke .33 Important to Not Smoke .27 Role Model: Exercise .37 Role Model: Exercise .22 Role Model: Not Smoking .42 Role Model: Not Smoking .26 Role Model: Fruit and Vegetables .47 Role Model: Fruit and Vegetables .33 Role Model: Healthy Weight .39 Role Model: Healthy Weight .33 Patient Education: No Tobacco Role Model: Teaching Tool .39 Important to Practice What They .36 Preach Important to Perform Exercise .31 Important to Eat Fruit and .23 Vegetables Important to Maintain Healthy .23 Weight Important to Not Smoke .41 Role Model: Exercise .36 Role Model: Not Smoking .49 Role Model: Fruit and Vegetables .29 Role Model: Healthy Weight .26 77 Number of Students Recruited N 1127 Figures Figure 1 Response Rate Number (Percent) N 395 (35.05%) Excluded due to Missing Data N 60 (5.32%) Final Response Rate N 335 (29.72%) 78 Tables Table 1: Demographic Characteristics Sex Total % (n) Male 28.9 (96) Female 70.8 (238) Prefer Not to Respond 0.4 (1) Age (years old) Total % (n) 18-25 47.3 (160) 26-35 37.0 (122) 36-45 8.9 (31) 46 and older 5.8 (19) Prefer Not to Respond 0.7 (2) Race Total % (n) Caucasian / White 80.8 (273) African American / Black 5.6 (18) Hispanic / Latino 5.4 (18) Asian / Pacific Islander 1.5 (5) Native American 1.4 (4) Other 0.7 (2) More Than One Race 2.7 (9) Prefer Not to Respond 1.5 (5) Table 2: Perceived Expectations of Recommending Healthy Lifestyle Changes % (n) of SPTAs Who Will Provide Patient Education to: Advise Often or Routinely Meet daily physical activity guidelines 76.4 (256) Maintain healthy weight 78.7 (263) Eat healthy diet 55.2 (185) Decrease or stop the use of tobacco products 77.9 (261) Consume no > recommended amount of alcohol 59.1 (198) Perform stress management techniques 61.8 (207) Get recommended amount of sleep 65.4 (219) 79 Table 3: Role Modeling Attitudes It is important for physical therapy professionals: Role modeling is a powerful teaching tool To "practice what they preach" To be involved in CDC* recommended levels of regular physical activity To eat 5 or more servings of fruits and vegetables a day To maintain healthy weight To abstain from smoking To role model CDC* recommended levels of regular physical activity To role model nonsmoking behavior To role model eating 5 or more servings of fruits and vegetables a day To role model maintaining a healthy weight *CDC Centers for Disease Control % (n) of SPTAs Who Agree or Strongly Agree 95.5 (320) 95.2 (319) 92.2 74.6 91.9 94.3 (309) (249) (308) (314) 91.9 (308) 93.4 (312) 71.6 (240) 92.2 (308) Table 4: Role Modeling Attitudes Compared to Black et al. 2012 % Who Agree or Strongly Agree It is important for physical therapy professionals: SPTA Black et al, 2012 Results Role modeling is a powerful teaching tool 95.5 91.2 To "practice what they preach" 95.2 90.3 To be involved in CDC* recommended levels of 92.2 91.3 regular physical activity To eat 5 or more servings of fruits and vegetables a 74.6 77.9 day To maintain healthy weight 91.9 91.6 To abstain from smoking 94.3 92.1 To role model CDC* recommended levels of regular 91.9 87.6 physical activity To role model nonsmoking behavior 93.4 88.6 To role model eating 5 or more servings of fruits and 71.6 73.2 vegetables a day To role model maintaining a healthy weight 92.2 89.6 *CDC Centers for Disease Control 80 Table 5: Health Promoting Lifestyle Profile II (HPLPII) Domain Mean* Variance SD HPLPII Total Score 2.90 0.175 0.42 Health Responsibility 2.55 0.305 0.55 Physical Activity 2.86 0.390 0.63 Nutrition 2.81 0.282 0.53 Spiritual Growth 3.29 0.230 0.48 Interpersonal Relations 3.20 0.237 0.49 Stress Management 2.65 0.309 0.56 *1 = Never, 2 = Rarely, 3 = Often, 4 = Routinely Table 6: Physical Activity and Exercise Questions: Correlations Variables (p<.001) Expectation: RM Questionnaire Important to Perform Exercise 0.39 Patient Role Model Exercise 0.46 Education Teaching Tool 0.51 Exercise Practice What They Preach 0.45 Role Model Not Smoking 0.43 Role Model Fruit and Vegetables 0.38 Role Model Healthy Weight 0.39 Important to Eat Fruit and Vegetables 0.32 Important to Maintain Healthy Weight 0.34 Important to Not Smoke 0.35 HPLPII Total Score 0.39 Physical Activity 0.42 Nutrition 0.34 Spiritual Growth 0.31 81 Expectation: Patient Education Weight Table 7: Weight Questions: Correlations Variables RM Questionnaire Important to Maintain Healthy Weight Role Model Healthy Weight Practice What They Preach Teaching Tool Important to Perform Exercise Role Model Exercise HPLPII Expectation: Patient Education Diet (p<.001) 0.37 0.44 0.45 0.54 0.47 0.41 Important to Eat Fruit and Vegetables Role Model: Not Smoking Role Model: Fruit and Vegetables 0.32 0.35 0.37 Total Score Nutrition Spiritual Growth 0.38 0.34 0.38 Table 8: Diet and Nutrition Questions: Correlations Variables RM Questionnaire Important to Eat Fruit and Vegetables Role Model Eating Fruit and Vegetables HPLPII Nutrition Teaching Tool Practice What They Preach Important to Perform Exercise Role Model Exercise Important to Maintain Healthy Weight Role Model Healthy Weight Important to Not Smoke Role Model: Not Smoking HPLPII Total Score Nutrition Spiritual Growth Table 9: Tobacco Questions: Correlations Variables Expectation: RM Questionnaire Important not to Use Tobacco Patient Education Role Model Not Using Tobacco Tobacco Teaching Tool Practice What They Preach Important to Perform Exercise Role Model: Exercise (p<.001) 0.43 0.47 0.46 0.43 0.38 0.46 0.37 0.35 0.39 0.33 0.42 0.36 0.46 0.30 (p<.001) 0.41 0.49 0.39 0.36 0.31 0.36 82 Table 10: One-Sample Chi-Square Test Null Hypothesis* The categories of Patient Education: Exercise occur with equal probabilities. The categories of Patient Education: Weight occur with equal probabilities. The categories of Patient Education: Diet occur with equal probabilities. The categories of Patient Education: No Tobacco occur with equal probabilities. The categories of Patient Education: Alcohol occur with equal probabilities. The categories of Patient Education: Stress Management occur with equal probabilities. The categories of Patient Education: Sleep occur with equal probabilities. The categories of Role Model: Teaching Tool occur with equal probabilities. The categories of Role Model: Practice What They Preach occur with equal probabilities. The categories of Important to Perform Exercise occur with equal probabilities. The categories of Important to Eat Fruit and Vegetables occur with equal probabilities. The categories of Important to Maintain Healthy Weight occur with equal probabilities. The categories of Important to Not Smoke occur with equal probabilities. The categories of Role Model: Exercise occur with equal probabilities. The categories of Role Model: Not Smoking occur with equal probabilities. The categories of Role Model: Fruit and Vegetables occur with equal probabilities. The categories of Role Model: Healthy Weight occur with equal probabilities. The categories of Age occur with equal probabilities. The categories of Sex occur with equal probabilities. The categories of Race occur with equal probabilities. Asymptotic significances are displayed. *The significance level is .000 for decision to reject the null hypothesis Table 11: One-Sample Kolmogorov-Smirnov (K-S) Test Decision HLPII Sub-Score1 Mean SD HLPII Total Score 2.90 0.419 Reject the null hypothesis Health Responsibility 2.55 0.522 Reject the null hypothesis Physical Activity 2.86 0.625 Reject the null hypothesis Nutrition 2.81 0.531 Reject the null hypothesis Spiritual Growth 3.29 0.480 Reject the null hypothesis Interpersonal Relations 3.20 0.487 Reject the null hypothesis Stress Management 2.65 0.556 Reject the null hypothesis Asymptotic significances are displayed. 1The significance level is .000 for decision reject the null hypothesis, Lillifors Corrected 83  ...

... Differences in the Use and Perceptions of Evidence-Based Practice between Occupational Therapy Students and Practitioners Paige Creighton, Annie DeRolf, Shelby Hale, LeAnn VanDeman, Kersten Laughlin, and Kelsie Long December 15, 2017 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Alison Nichols, OTR, OTD A Research Project Entitled Differences in the Use and Perceptions of Evidence-Based Practice between Occupational Therapy Students and Practitioners Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Paige Creighton, Annie DeRolf, Shelby Hale, LeAnn VanDeman, Kersten Laughlin, and Kelsie Long Occupational Therapy Students Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date Running head: EBP PERCEPTIONS Differences in the Use and Perceptions of Evidence-Based Practice between Occupational Therapy Students and Practitioners Paige Creighton, Annie DeRolf, Shelby Hale, LeAnn VanDeman, Kersten Laughlin, and Kelsie Long University of Indianapolis EBP PERCEPTIONS 2 Abstract This study explored differences in perceptions of evidence-based practice (EBP) between occupational therapy (OT) students and practitioners. Researchers aimed to understand student and practitioner perceptions of barriers, knowledge, attitudes, and confidence in EBP. Eightythree OT students and practitioners completed an online survey, and seven individuals participated in a focus group. Results indicated practitioners were more confident in utilizing EBP, particularly when applying EBP to a client and assessing its efficacy on client outcomes. Students and practitioners identified time as the highest perceived barrier to EBP implementation. Three themes emerged from the focus group responses: supports and barriers to EBP, client-centered EBP, and perceptions of EBP by role. These results support a gap between student and practitioner perceptions as related to EBP implementation. It is critical for practitioners to demonstrate EBP implementation in order to bridge the disconnect between student and practitioner utilization of EBP. EBP PERCEPTIONS 3 Literature Review In 2006, the American Occupational Therapy Association (AOTA) devised a strategic plan, known as the Centennial Vision, aimed to direct occupational therapy (OT) to an evidencebased, science-driven, and widely recognized profession with a common future. In 2016, AOTA shifted to Vision 2025, which states, "Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living (Stoffel, 2016, p. 4). The Vision 2025 expanded on effective solutions, including evidence-based practice, client-centered care, and cost-effective strategies. Therefore, as the profession continues to apply evidence to practice, it aims to effectively solve issues that inhibit occupational performance in everyday living, as well as make strides towards Vision 2025 (AOTA, 2016). Graham, Robertson, and Anderson (2013) defined evidence-based practice (EBP) as the integration of the best available research evidence with clinical expertise and patients values and circumstances to make the best decision regarding patient care (p. 120). According to Thomas, Saroyan, & Snider (2012), there are five steps to EBP implementation. These steps include: (a) posing a PICO (Population, Intervention, Comparison, Outcome) question regarding treatment considerations or potential outcomes, (b) searching for literature that best supports the question, (c) evaluating the evidence in order to determine relevant and valuable information, (d) using the evidence to make both clinical decisions and client-centered applications, and (e) evaluating the interventions ability to meet the clients needs (2012). A gap in EBP implementation between OT students and practitioners was found in the literature. Thomas et al. (2012) explored the implementation of EBP and found that experienced OT practitioners excelled at clinical decision-making and evaluating intervention techniques, EBP PERCEPTIONS while occupational therapy students were more proficient at posing a clinical question, searching literature, and appraising the evidence. With the exception of Thomas et al. (2012), there was a lack of literature that further investigated this relationship between student and practitioner attitudes, knowledge, confidence, and barriers to utilization of EBP. The Contemporary Paradigm and EBP Occupational therapy as a profession experienced a number of changes throughout the twentieth century (Gustafsson, Molineux, & Bennett, 2014). The essence of the term occupation changed simultaneously with the way of the world, specifically the medical profession. The once reductionist approach transformed in order to fit within the Contemporary Paradigm. The basis of this paradigm was formed by three concepts: the importance of occupation to health and wellbeing, recognition of occupational problems and challenges as the focus of OT, and the recognition of the use of occupation to improve health as the defining feature of OT practice (Joosten, 2015). Gustafsson et al. (2014) argued that the philosophical underpinnings of the Contemporary Paradigm needed to be congruent with evidence-based interventions in order to retain a professional identity. Because the Contemporary Paradigm was described as the most stable factor regarding OTs conceptual foundations, it was suggested that evidence-based knowledge and techniques outside of the occupational therapy profession were implemented under two conditions: (a) the knowledge needed to be in accordance with the Contemporary Paradigm and all conceptual foundations, and (b) the evidence could not dictate the intervention or the measure of the clients intervention outcomes (Joosten, 2015). The shift toward EBP demanded that occupational therapy practitioners consistently reflect on their practice to be sure that it was congruent with the paradigm, with occupation at the center. 4 EBP PERCEPTIONS Attitudes Toward EBP Perceived congruence between the philosophical underpinnings of OT practice and the shift toward being a more evidence-based profession impacted EBP attitudes among OT students and practitioners. A study conducted in New Zealand found that the surveyed occupational therapists had positive feelings towards EBP, with 84 percent of the OT practitioners surveyed reporting that EBP had daily benefits when using it throughout their practice (Graham, et al., 2013). The majority of the practitioners also reported that they believed the use of EBP was important to the practice of occupational therapy, and it increased the ability to make care more client-centered. These findings were congruent with a prior study where researchers found that 96% of the OT practitioners stated that EBP was an important part of their daily practice, and 87% of the participants stated that they found literature and research to be a crucial part of their practice (Salls, Dolhi, Silverman, & Hansen, 2009). OT practitioners were not the only population found to have positive attitudes about EBP. In an Irish study, Stronge and Cahill (2012) found that OT students had optimistic feelings about EBP and believed that it is a critical component to the OT curriculum. These researchers determined that all 86 of the final-year students reported a willingness to engage in EBP in academic work, on clinical placements, and in the future as therapist" (Stronge & Cahill, 2012, p. 12). Furthermore, Stube and Jedlicka (2007) found that OT students at the University of North Dakota had positive perceptions of EBP and were enthusiastic about the professions use of EBP. One third-year OT student stated, Its the future of the OT profession. It provides a basis and rationale for treatment, and it offers avenues of continued research to expand the profession, when sharing her excitement (Stube and Jedlicka, 2007, p. 56). However, attitudes were not inherently enough to solidify the certainty of EBP implementation. 5 EBP PERCEPTIONS Knowledge and Confidence in EBP Use Despite general positive attitudes regarding EBP, actual implementation necessitated a certain comfort level that was preceded by knowledge and confidence regarding the use of EBP. Egan, Cahill, Huber-Lee, and Wallingford (2016) utilized an online training module aimed to increase 29 OT practitioners skills and knowledge. Using the Adapted Fresno Test (AFT), clinicians who completed a training module demonstrated a higher average change in EBP knowledge and skills than a control group (2016). Similarly, Nichols (2017) used the AFT and found an increase in knowledge and skills and a statistically significant change in confidence among fieldwork educators after the completion of an introductory short course in EBP. The findings of Egan et al. (2016) and Nichols (2017) were congruent with the research of Graham et al. (2013) in which Australian occupational therapists who received training for EBP techniques from their university had more confidence than occupational therapists who had not received training . However, clinical and academic experience created a gap in knowledge and confidence in comparison to more novice groups. Atler and Gavin (2012) highlighted this gap in knowledge between recent graduates and current, experienced occupational therapy practitioners. The researchers found that recent graduates had higher levels of confidence in their abilities to perform EBP-related activities, such as database searches and Internet usage, versus occupational therapists who graduated five or more years ago. When examining differences in confidence among OT students, DeCleene Huber et al. (2015) found that third year OT students report more confidence than first- and second-year students when evaluating a course of action and selecting a decision based on evidence. These findings indicate that further education in EBP increases the 6 EBP PERCEPTIONS confidence and ability for students to implement EBP principles. However, research suggested that the fieldwork experience needed to be congruent with this formal instruction. Crabtree, Justiss, and Swinehart (2012) used pre-test/post-test methods and discovered that an EBP-directed course facilitated an increase in MOT students scores for comprehension and use of EBP after the completion of the course. However, scores for the same students declined between postcourse and postfieldwork measurements (Crabtree, Justiss, & Swinehart, 2012, pg. 146). This decrease in scores post-fieldwork could be due to a lack of EBP implementation by fieldwork coordinators or a lack of opportunity for students to apply skills learned in the EBP course. Despite the veracity of findings regarding low self-reported levels of knowledge, confidence, and skills among both OT practitioners and students, there were still other barriers that were pervasive in the literature. Barriers to EBP Implementation Reasons for a lack of EBP implementation in the clinical and academic settings was evident among OT students and practitioners due to multiple barriers. In 2012, Hu reported lack of time, skills, expertise, and support from management as barriers to EBP implementation among practitioners. In a more recent study, Harding, Porter, Horne-Thompson, Donley, and Taylor (2014) explained that without an understanding of underlying factors that contribute to barriers, it was difficult to design and implement supportive techniques to allow for the utilization of EBP in practice. Therefore, Harding et al. (2014) aimed to use qualitative and quantitative methods to better understand barriers to the implementation of EBP among allied health clinicians. Researchers found a common barrier, lack of time, was broken down into three sub-themes with the use of the qualitative results. These sub-themes were, attitudes and expectations of clinicians and managers, lack of resources resulting in too many tasks to 7 EBP PERCEPTIONS 8 complete in the time available, and lack of skills leading to inefficiencies in the implementation of EBP (Harding et al., 2014, p. 227). Clinicians felt they had a lack of time due to their caseloads, as well as diminished access to physical and electronic resources due to cost or availability. Lastly, some clinicians felt that a portion of the staff lacked understanding of EBP, or the search for literature was overwhelming, leading to time inefficiency. These mental representations had negative limitations on the advancement of EBP within the profession. In summary, literature surrounding EBP was abundant in regards to the analysis of attitudes, knowledge, confidence, and barriers affecting EBP implementation. There were consistent discoveries highlighting, in general, positive attitudes toward EBP in conjunction with low self-reported levels of knowledge and confidence. Common barriers, such as lack of time and lack of skills, were also pervasive in the literature. With the exception of the study by Thomas et al. (2012), there is minimal literature comparing the population of OT students and OT practitioners. These findings reflected the inconsistent nature of competencies between education and practice. The recognition of this inconsistency supported the existence of a gap in the EBP decision-making processes between OT clinicians and students. There is a need for research that highlights the differences in the factors influencing EBP implementation among OT students and OT practitioners alike. The current study aimed to explore this gap and provide insight into the relationships among knowledge, attitudes, confidence, and barriers of EBP implementation. Methods Participants Criteria to participate in the study required all participants to be either students in or alumni from the School of Occupational Therapy or alumni from the Doctorate of Health EBP PERCEPTIONS Sciences program at the University of Indianapolis. After receiving approval from the universitys Institutional Review Board, a purposive sample of 188 students was selected to complete a survey regarding evidence-based practice in the fall of 2016. The student cohorts were differentiated by degree and year of expected graduation, including Master of Occupational Therapy (MOT) and Doctor of Occupational Therapy (OTD). Fifty-four students were invited to complete the survey from MOT 2016, as well as 21 from MOT 2018, 18 from MOT 2019, 46 from OTD 2018, and 49 from OTD 2019. A random sample of two-hundred alumni were invited to complete this survey, however, due to invalid e-mail addresses, only 169 of the original 200 alumni were successfully sent. Study Design and Procedure The current study was a mixed methods design using qualitative and quantitative data. Qualitative data were retrieved from a focus group and quantitative data were derived from an online survey. The online survey was created with Qualtrics software. Recruitment letters, which contained a link to the survey, were sent via email from the University of Indianapolis School of Occupational Therapy Chair. Participants completed informed consent before beginning the survey. If participants did not agree to the informed consent, then they were redirected out of the survey. The participants were allowed five weeks to complete the survey. Reminder emails were sent two weeks after the initial email. At the end of the survey, participants were asked to provide their email if they were interested in participating in a focus group. The primary investigator contacted participants who indicated interest in participating, and a focus group that consisted of occupational therapy students and one OT clinician was created and held one month after survey completion. The focus group took place in the Health Pavilion located at the University of Indianapolis. The session lasted for approximately 90 9 EBP PERCEPTIONS minutes, and it was facilitated by two of the student investigators. A third student investigator took down field notes, including a record of times in which important statements were made. Focus group questions concentrated on participants definitions of EBP, perceptions of how EBP was used in the classroom and clinically, and barriers and supports for utilization of EBP. Instruments The survey created for this study was reviewed by professors in the occupational therapy department at the University of Indianapolis. These professors were experts in survey design and EBP. Reviewers provided feedback regarding survey content, which was considered and implemented. The student survey included 15 questions, and the practitioner survey included 17 questions. Participants were not required to provide identifying information in order to ensure anonymity. The survey content between practitioners and students was similar; however, practitioner questions were focused on clinical experience, while the student questions were related to current academic and fieldwork experiences. Basic demographic information, as well as attitudes and barriers in relation to EBP, were included in the surveys content. Participants were also asked questions regarding access to research, knowledge of research, and implementation of research. Also included in the survey were 11 questions using the EvidenceBased Practice Confidence (EPIC) scale, which rated participants confidence in implementation of EBP and their ability to appraise evidence-based research and interpret findings from the articles (Salbach & Jaglal, 2011). Each participant was asked to rate their confidence in completing EBP skills using an 11-point scale that ranged from 0-100 percent at ten percent intervals. The EPIC scale can be found in Appendix A. Empirical support for the construct validity of the EPIC scale was noted in a study with 125 occupational therapists conducted by 10 EBP PERCEPTIONS Clyde, Brooks, Cameron, and Salbach (2016); results indicated excellent test-retest reliability (ICC 0.92, 95% CI). Data Analysis Quantitative data from the survey was analyzed using Qualtrics and Microsoft Excel. The responses to the perceived barriers and EPIC scale (Salbach & Jaglal, 2011) were entered into Microsoft Excel, and manual member-checking was performed for accuracy. Modes regarding barriers were calculated in the following categories: (i) time, (ii) expertise, (iii) managerial support, (iv) research skills, and (v) access to literature. Two-tailed t-tests were performed in Microsoft Excel to determine statistical significance of survey data. The two independent variables were the OT students and OT practitioners, while the dependent variables were their responses to both the EPIC scale (Salbach & Jaglal, 2011) and email survey questions. Statistical significance was assumed at p < .05. Qualtrics was utilized to compare relationships of survey data based upon participant responses regarding themes generated by the research team. Crosstabs within Qualtrics allowed researchers to compare results among the data within the survey. While participating in the focus group, participants used pseudonyms to preserve anonymity. The focus group was audio recorded and later transcribed verbatim. The transcript was reviewed by student researchers as a form of member-checking for accuracy. The primary investigator and six student investigators read the transcript independently to gain a holistic perspective of the collected data, then individually identified common key pieces of data throughout the transcript. After, the student researchers grouped the data into themes. Utilizing Dedoose software, the student researchers reviewed the transcript again, locating participant statements that best illustrated these themes. 11 EBP PERCEPTIONS 12 Results Quantitative Data Eighty-three of the original 357 participants (23.25%) completed parts of the survey. There was a higher response rate for OT students at 32.98% (n=62), although only 12.43% (n=21) of practitioners responded to the survey. The sample size fluctuated per survey question for both practitioners and students, as 8.43% of respondents did not complete the barriers section. While 100% of practitioners completed the demographic and knowledge section, the sample size ranged from 19 to 21 respondents for the remainder of the survey. In total, student sample size varied from 57 to 62 respondents per question. Furthermore, 30.12% of the participants did not complete the EPIC scale. Participant demographic information was collected and presented in Appendix B. Participant characteristics. The majority of respondents were predominantly female (97.54%, n=80) and reported their highest level of degree achieved as Masters degree (90.48%, n=19), and the majority of OT students were enrolled in OTD class of 2018 and 2019 (79.41%, n=46) at the time of the study. There were five student cohorts invited to participate, including: MOT 2016, MOT 2018, MOT 2019, OTD 2018, and OTD 2019. At the time of this survey, each cohort had completed varying levels of fieldwork. MOT 2016 (n=13) completed all level I rotations and the first level II 12-week rotation. MOT 2018 (n=2) had completed a 1-week level IA fieldwork. MOT 2019 (n=1) had not completed any fieldwork experience. OTD 2018 (n=26) had completed a 1-week level IA rotation and 2-week level IB rotation. OTD 2019 (n=20) had not completed any fieldwork experience. The majority of OT practitioner respondents were graduates of the University of Indianapolis Master of Occupational Therapy program (76.19%, n=16). The programs EBP PERCEPTIONS curriculum related to EBP in research has been consistent over the last 10 years. The remainder of alumni were graduates from the University of Indianapolis Doctorate of Health Sciences program. In regards to area of practice, 33.33% of OT practitioners worked in inpatient acute or an inpatient rehabilitation setting, while the largest percentage of OT students expressed interest in working in inpatient acute care or rehabilitation (47.54%, n=29). In terms of experience, 60% of practitioners had ten years of experience or less in clinical practice. All demographic data is presented in Appendix B. Knowledge of EBP use. In response to EBP knowledge, there was no statistically significant difference between student and practitioner perceptions (See Appendix C). The majority of students agreed (45.76%, n=27) or strongly agreed (22.03%, n=19) that they knew the components of a PICO question; however, half of practitioners disagreed (33.33%, n=7) or strongly disagreed (14.29%, n=3) to knowing the components. The majority of practitioners and students agreed with having the ability to appraise, search, and interpret EBP literature. The majority of practitioners either agreed or strongly agreed (42.86%, n=9) to having the skills to identify clinical relevance to research findings. Similarly, 59.32% (n=35) of OT students agreed and 27.12% (n=16) strongly agreed to having these skills. Confidence to EBP implementation. The EPIC scale (Salbach & Jaglal, 2011) was utilized to gain perceptual knowledge regarding OT practitioner and student confidence in components of EBP implementation. With a 69.88% (n=58) response rate, participants rated confidence of EBP implementation on a scale from 0-100 percent. Results indicated a statistically significant difference between student and practitioner perceived confidence for the following: identifying a gap in knowledge (p= <0.001), asking about values, needs, and treatment preferences with clients (p= 0.002), deciding on a course of action (p= <0.001), and 13 EBP PERCEPTIONS continually evaluating actions (p= < 0.01), as practitioners rated higher confidence in these areas. These differences are presented in Appendix D. The majority of practitioners reported a higher level of confidence in identifying a gap in knowledge and asking about values, needs, and treatment preferences, as compared to students (Figure 1). Students felt most confident conducting an online literature search, and they reported lower levels of confidence when deciding on a course of action and continually evaluating actions compared to practitioners (Figure 1). Both students and practitioners reported the lowest levels of confidence for interpreting statistical t-tests and procedures. They findings from the EPIC scale can be found in Figure 1. Figure 1. Comparison of practitioner and student scores on EPIC scale items. Attitudes to EBP use. There was a statistically significant difference between practitioner and student reports of feeling qualified to implement EBP (p= 0.001), as the majority of OT practitioners strongly agreed at a higher rate than OT students (Appendix B). Additionally, OT students reported EBP is strongly focused on meeting client needs (p= 0.004) at a higher percentage than OT practitioners. OT students reported being expected to be an evidence-based 14 EBP PERCEPTIONS professional at a higher rate than practitioners did. Half of the practitioners strongly agreed that EBP is essential to clinical practice, and 57.89% of students expressed the same level of agreement. Though most participants identified EBP as being an important component to clinical practice, 24.56% of students and 15.00% of practitioners felt clinical experience was more important than EBP. See Appendix C for further information about the attitudes of participants towards EBP use. Barriers to implementation of EBP. Practitioners ranked perceived barriers on a scale of 1-5, with 1 being the highest perceived barrier and 5 being the lowest perceived barrier. Practitioners perceived time as their largest barrier to EBP implementation, followed by access to literature, management support, expertise, and research skills. Students equally ranked time and expertise as their highest perceived barriers, followed by management support, research skills, and access to literature. Though practitioners reported limited access to literature as the second highest perceived barrier, 52.63% (n=10) agreed to having access to EBP articles. The third highest identified barrier to EBP implementation for OT practitioners was managerial support. In relation to workplace expectations, 45.00% of practitioners agreed evidence-based practice was expected at work and 50.00% agreed to being an evidence-based practitioner. The majority of practitioners agreed EBP was allowed by administration (57.89%, n=11); however, 31.58% (n=6) reported their workplace was not equipped to allow EBP implementation. OT students identified time and expertise as the highest perceived barriers to EBP implementation, while OT practitioners reported expertise as the second lowest perceived barrier. Students agreed to searching EBP once a month or more for fieldwork, with 46% selfidentified as an evidence-based fieldwork student. The majority of practitioners utilized EBP to 15 EBP PERCEPTIONS implement interventions, with 57.89% (n=11) performing interventions based on EBP once a week or more. However, 42.11% (n=8) of practitioners disagree or strongly disagree to having ample time during the workday to incorporate EBP and only 50.00% identified self as an evidence-based practitioner. Qualitative Data Seventeen individuals indicated interest in participating in the focus group after completion of the online survey. When these individuals were contacted, seven agreed to participate in the focus group. The final group participants included one OT practitioner, two students from each of the MOT 2016 and OTD 2018 cohorts, and one student from each of the MOT 2018 and OTD 2019 cohorts. The focus group was led by two student researchers. After the focus group discussion, three main themes emerged related to evidence-based practice, including: (1) supports and barriers of evidence-based practice, (2) client-centered evidence based-practice, and (3) perception of evidence-based practice by role (i.e. student vs OT practitioner). Work environment (having a supportive team), practice setting, academic research experience, access to university research, sharing resources with peers, the use of the American Journal of Occupational Therapy through AOTA, reimbursement for continuing education, accountability, and journal review programs were the supports identified. An MOT 2016 student who had completed all Level I fieldwork and one 12-week Level II fieldwork rotation explained, Ive had some settings where they actively encouraged you to look up a new article every week and to talk about them and other settings where it was never mentioned. Barriers identified by focus group participants included: productivity requirements, time, gap between newer practitioners and senior practitioners, and the lack of research available. An MOT 2016 student explained her negative experience with productivity, describing it as the 16 EBP PERCEPTIONS biggest factor about being able to use evidence-based practice, and the barrier of time as not being able to have the time to look up things. The utilization of evidence as client-centered practice was the second theme that emerged from the focus group. When reflecting on implementing client-centered practice, an OTD 2018 student stated: I desire to be in a setting where the setting views that as important, and that its ethical; ...therefore, its already built in to that decision where Im going to have to be accountable and following up with that. And I know that Im being respected for that time, and then its more of a cohesive thought of providing the best care...for the client, because were all looking together collaboratively to figure out what that best evidence is. The OT practitioner indicated that the client can also implement and guide client-centered use of EBP: I had a kid, hes 20 with muscular dystrophy, and he came with this great idea on his own. Sometimes its not even the research; its just the interview process and seeing what they have done... An OTD 2019 student indicated her understanding of client-centered EBP from her didactic experiences, stating, Having that holistic view, you want to give the best care to your patient and thats kind of built within for each of us. Evidence based practice perceptions by role varied from individual to individual during the focus group. An MOT 2016 student had different experiences from fieldwork educators during her level II rotations: I found across the board some fieldwork educators come in and theyre like, What did you learn in school? This is so great we get to talk about this . . . and the other fieldwork educators had a little bit more of like, Im here to teach you. And it was very...much...expected that you would ...simply do things the way you had been taught. 17 EBP PERCEPTIONS 18 Overall, the students and practitioner found EBP to be an important aspect of fieldwork, classroom work, and general practice. An OTD 2018 student discussed the importance of utilizing research for justifying treatment interventions by saying, I think that we just have to be providing more research to really show that strong evidence for what were doing, so then we can be respected by other disciplines. The OT practitioner emphasized the importance of students and fieldwork educators collaborating, sharing resources, and discussing research: I love to take students because they bring...much more of that [research] into my practice and that keeps me fresh on using it. Discussion Barriers Practitioners and students, as indicated by the survey and focus group, found lack of time to be the largest barrier to EBP implementation, which was consistent with the literature (Graham et al., 2013). Students in this study rated access to literature as the lowest perceived barrier, while practitioners ranked access to literature as the second highest perceived barrier, indicating that students likely have more access to EBP literature than practitioners do. Students rated expertise as one of the highest perceived barriers to EBP implementation and OT practitioners reported it as the second lowest perceived barrier. This finding reflects the clinical experience of practitioners and supports the statistically significant EPIC scale finding, in which practitioners reported higher levels of confidence in identifying a gap in knowledge and asking about values, needs, and treatment preferences, and deciding on a course of action as compared to students. Correspondingly, Thomas et al. (2012) found practitioners demonstrated the ability to apply decision-making and re-evaluation skills at a higher rate as compared to students. Though practitioners reported higher confidence in clinical application skills, students demonstrated the ability to form a PICO question and search literature at a higher rate (Thomas EBP PERCEPTIONS et al., 2012). This challenges the findings of the current study, in which practitioners reported a higher rate of confidence (70.28%) for the ability to form a PICO question and search the literature as compared to students (59.56%). Attitudes In regards to attitudes of EBP implementation, our study found that 50.00% of practitioners (n=10) strongly agreed there was great benefit to EBP research and identified EBP as essential to clinical practice. OT practitioners reported utilizing EBP to implement interventions (57.89%, n=11); however, the majority reported searching articles once or twice a year during the workday (31.56%, n=6). This finding shows that though practitioners utilized EBP for implementation of interventions, article searches are not performed frequently. However, OT students searched for literature at a statistically significant higher rate than OT practitioners. This significance is likely due to a strong focus on EBP implementation throughout their OT program. The student and clinician motivations for completing EBP varied. For example, students may be required to perform EBP as a part of an assignment, whereas clinicians may perform EBP to provide the best possible care for the patient. Graham et al. (2013) found that 84% of the OT practitioners surveyed believed in the benefits of EBP implementation when used in daily practice. Though EBP implementation was positively viewed as beneficial to daily practice, OT practitioners identified rate of implementation would be higher if there was an emphasis on clinical research in practice (Graham et al., 2013). Knowledge OT students viewed EBP as essential to clinical practice at a higher rate than OT practitioners. This is similar to our finding that a greater percentage of students than clinicians agreed that they are expected to be evidence-based. Students views of EBP being essential to 19 EBP PERCEPTIONS 20 clinical practice may correlate with their belief that they are expected to be evidence-based practitioners upon graduation. A study by Stronge and Cahill (2012) also found that Irish OT students had optimistic feelings about EBP and believed that it is a critical component of the OT school curriculum. Students from the University of North Dakota had positive perceptions of EBP and were enthusiastic about its use clinically (Stube, & Jedlicka, 2007). Our results indicated that seventy percent of OT practitioners strongly agreed that their academic backgrounds emphasized the importance of EBP implementation, as compared to 56.14% of students. Confidence Atler and Gavin (2012) found recent graduates had higher levels of confidence in the ability to use database searches and Internet usage for EBP. These conclusions correspond to our study findings, as students reported that they were most confident when conducting an online literature search. This may be related to the alumnis presumed lack of online database availability during their education. Our studys results also indicated that OT students reported lower levels of confidence when deciding on a course of action and continually evaluating actions as compared to practitioners. The statistically significant finding in student and practitioner perceived confidence from the EPIC scale further support the findings of Thomas et al. (2012), in which experienced OT practitioners excelled at clinical decision-making and evaluating intervention techniques. Limitations One limitation of the current study was the use of a small convenience sample with different levels of OT student and practitioner education and limited practitioner involvement. This study used convenience sampling in which all potential participants were either current or EBP PERCEPTIONS 21 former students of the University of Indianapolis. Therefore, generalizing the result to individuals from other universities may not be appropriate. Additionally, due to changes in the occupational therapy curriculum, students who graduated 20 years ago may have had different education related to EBP and research than more recent alumni, which may have impacted practitioner responses. A relatively low sample size of 83 participants (students [n=62], practitioners [n=21]) further limits generalizability of the research findings. Limited practitioner involvement in the focus group (n=1) may also influence the qualitative data results, creating a personal bias in reference to practitioner perceptions towards EBP. Additional limitations, including cohort year of current students, were also present. For example, individuals from the OTD 2019 cohort (first year of OT school) reported lower levels of confidence in implementing EBP, and this may be due to the fact that no fieldwork had been completed at the time of our survey. Contrastingly, students from MOT 2018 and OTD 2018 (second year of OT school) may report higher levels of confidence due to additional education and practice through advanced fieldwork experience. Biases regarding EBP may also affect the results of this study, as individuals with strong feeling towards EBP may have been more likely to complete the survey and participate in the focus group. Conclusion Our study aimed to explore the perceptual differences in knowledge, attitudes, confidence, and barriers of EBP implementation between OT students and practitioners. Though students and practitioners are expected to utilize EBP in both the classroom and clinic, there is an existing gap between confidence in EBP utilization and decision-making processes. Our study explored this gap and found practitioners felt more qualified to implement EBP clinically, while students felt more strongly that EBP is focused on meeting clients needs. As measured by the EBP PERCEPTIONS EPIC scale, practitioners were more confident in all areas related to utilizing EBP compared to students. This finding was inconsistent with previous research. Both practitioners and students rated time as the largest barrier to EBP implementation, which was consistent with previous study findings. By demonstrating EBP implementation in a clinical setting, practitioners are able to increase students confidence in incorporating EBP into practice. This is a vital component to bridging the disconnect between practitioner and student confidence when using EBP. As part of this reciprocal learning process, students are able to share evidence learned in the classroom with fieldwork educators to allow for a collaborative approach to treatment. This collaborative approach is critical to increasing student confidence in EBP implementation, as well as EBP literature searching skills in practitioners. 22 EBP PERCEPTIONS 23 References American Occupational Therapy Association. (2006). AOTAs centennial vision. Retrieved From: https://www.aota.org//media/corporate/files/aboutaota/centennial/background/vision1.pf American Occupational Therapy Association. (2016). AOTA unveils Vision 2025. Retrieved from http://www.aota.org/aboutaota/vision-2025.aspx Atler, K., & Gavin, W. J. (2012). Service-learning-based instruction enhances student's perceptions of their abilities to engage in evidence-based practice. Occupational Therapy in Health Care, 24(1), 23-38. doi: 10.3109/07380570903410860 Clyde, J. H., Brooks, D., Cameron, J. I., & Salbach, N. M. (2016). Validation of the EvidenceBased Practice Confidence (EPIC) Scale with occupational therapists. The American Journal of Occupational Therapy 70(2), 7002280010. doi:10.5014/ajot.2016.017061 Crabtree, J. L., Justiss, M., & Swinehart, S. (2012). Occupational therapy Master-level students evidence-based practice knowledge and skills before and after fieldwork. Occupational Therapy in Health Care, 26(2-3), 138-149. doi: 10.3109/07380577.2012.694584 DeCleene Huber, K. E., Nichols, A. Bowman, K., Hershberger, J., Marquis, J., Murphy, T., . . . and Sanders, C. (2015). The correlation between confidence and knowledge of evidencebased practice among occupational therapy students. The Open Journal of Occupational Therapy, 3(1), Article 5. doi:10.15453/2168-6408.1142 Egan, B. E., Cahill, S. M., Huber-Lee, C., & Wallingford, M. (2016). The use of an online module to increase occupational therapy practitioners evidence-based practice knowledge and skills. Internet Journal of Allied Health Sciences and Practice, 14(2), 1-5. Graham, F., Robertson, L., & Anderson, J. (2013). New Zealand occupational therapists' views EBP PERCEPTIONS on evidence-based practice: A replicated survey of attitudes, confidence and behaviors. Australian Occupational Therapy Journal, 60(2), 120-128. Gustafsson, L., Molineux, M., & Bennett, S. (2014). Contemporary occupational therapy service: The challenges of being evidence based and philosophically congruent. Australian Occupational Therapy Journal, 61, 121-123. doi: 10.1111/1440-1630.12110 Harding, K. E., Porter, J., Horne-Thompson, A., Donley, E., & Taylor, N. F. (2014). Not enough time or a low priority? Barriers to evidence-based practice for allied health clinicians. Journal of Continuing Education in the Health Professions, 34(4), 224-231. Hu, D. (2012). Occupational therapists' involvement views, and training needs of evidencebased practice: A rural perspective. International Journal of Therapy and Rehabilitation, 19(11), 618-628. Joosten, A. V. (2015) Contemporary occupational therapy: Our occupational therapy models are essential to occupation centred practice. Australian Occupational Therapy Journal, 62, 219-222. doi: 10.1111/1440-1630.12186 Nichols, A. (2017). Changes in knowledge, skills, and confidence in fieldwork educators after an evidence-based practice short course. The Open Journal of Occupational Therapy, 5(1), Article 13. doi:10.15453/2168-6408.1204 Salbach, N. M., & Jaglal, S. B. (2011). Creation and validation of the Evidence-Based Practice Confidence Scale for health care professionals. Journal of Evaluation in Clinical Practice, 17, 794-800. http://dx.doi.org/10.1111/j.1365-2753.2010.01478.x Salls, J., Dolhi, C., Silverman, L., & Hansen, M. (2009). The use of evidence-based practice by occupational therapists. Occupational Therapy in Health Care, 23(2), 134-145. doi:10.1080/07380570902773305 24 EBP PERCEPTIONS Stoffel, V. G. (2016). Coming home to family: Now is the time! The American Journal of Occupational Therapy, 70(6), 7006120010. doi:10.5014/ajot.2016.706003 Stronge, M., & Cahill, M. (2012). Self-reported knowledge, attitudes, and behaviour towards evidence-based practice of occupational therapy students in Ireland. Occupational Therapy International, 19, 7-16. Stube, J. E., & Jedlicka, J. S. (2007). The acquisition and integration of evidence-based practice concepts by occupational therapy students. American Journal of Occupational Therapy, 61, 53-61. Thomas, A., Saroyan, A., & Snider, L. M. (2012). Evidence-based practice behaviours: A comparison amongst occupational therapy students and clinicians. Canadian Journal of Occupational Therapy, 79, 96-107. doi:10.2182/cjot.2012.79.2.5 25 EBP PERCEPTIONS 26 Appendix A EBP PERCEPTIONS 27 Appendix B Table 1. Demographic Data of OT Practitioners and OT Students Characteristic Practitioner: n = 21 (25.30%) Student: n = 62 (74.70%) Male 0 (0.00) 2 (3.82) Female 21 (100) 59 (96.72) 20-29= 7 (33.33) 20-23= 45 (73.77) 30-39= 6 (28.57) 24-27= 11 (18.03) 40-49= 4 (19.05) 28-30= 2 (3.28) 50-59= 2 (9.52) 31-34= 0 (0.00) 60-69= 2 (9.52) >35= 3 (4.92) Gender Age >70= 0 (0.00) Highest Degree Completed Bachelors Degree= 0 (0.00) Bachelors Degree in Progress= 11 (18.03) Masters Degree= 19 (90.48) Bachelors Degree= 49 (89.03) Entry-level Doctorate= 0 (0.00) Masters Degree= 1 (1.64) Post-professional Doctorate= 2 (9.52) Doctorate= 0 (0.00) 0-5= 7 (33.33) N/A Years in Practice 5-10= 6 (28.57) 11-20= 2 (9.52) 21-30= 3 (14.29) >30= 3 (14.29) Cohort N/A MOT 2016= 13 (21.31) MOT 2018= 2 (3.28) MOT 2019= 0 (0.00) OTD 2018= 26 (42.62) OTD 2019= 20 (32.79) EBP PERCEPTIONS 28 None= 20 (32.79) Fieldwork completed N/A Level I= 28 (45.90) Level II (first 12 week)= 13 (21.31) None= 20 (32.79) Hours Practiced Weekly 0-9= 2 (9.52) N/A 10-19= 1 (4.76) 20-29= 3 (14.29) 30-39= 3 (14.29) 40-49= 12 (57.14) Note: Bachelors in progress students have less exposure to EBP training and instruction, as they are in their first year of the OT program. Year of cohort reflects exposure to FW experience. EBP PERCEPTIONS 29 Appendix C Table 2. Statistical significance of OT Practitioners (Pr) vs. OT Students (S) Perceived Knowledge, Attitudes, and Utilization of EBP. Survey Question Pr. Average S. Average p-Value Know components of a Pico question 3.14 3.644 .18 Appraise strength of research articles 4.05 3.98 .79 Adequate literature searching skills 3.95 4.37 .11 Interpret findings of research articles 3.90 4.12 .35 Identify clinical relevance to findings 4.19 4.08 .66 Feel qualified to implement EBP clinically 4.25 3.10 <0.001 Feels EBP is essential to clinical practice 4.40 4.53 .46 Feels EBP focuses on meeting client needs 3.35 4.11 .004 Feel clinical experience is more important than EBP 3.00 3.30 .26 Feel there is great benefit for EB research 4.45 4.35 .52 Fell willing to change/try new ideas 4.55 4.58 .83 Education emphasized clinical importance of EBP 4.55 4.38 .52 I am an EB practitioner/student 3.89 4.19 .15 I search for research articles during the work/school day 3.06 4.25 .005 I search for appropriate articles during my free time 3.11 2.52 .070 I use clinical interventions based on EBP 4.22 4.06 <0.001 I attend educational sessions on EBP 2.24 1.85 .043 Note. All Pr. and S. averages are of a possible 5 points; with 5 being equal to Strongly Agree, and 1 being equal to Strongly Disagree. EBP PERCEPTIONS 30 Appendix D Table 3. Statistical Significance in Difference of EPIC Scores between Clinicians and Students EPIC Scale Questions p-Value 1. Identify a gap in knowledge related to a patient or client situation >0.001 2. Formulate a question to guide literature search .25 3. Effectively conduct an online literature search .70 4. Critically appraise strengths and weaknesses of a study .80 5. Critically appraise measurement properties of tests .46 6. Interpret statistical t-test .60 7. Interpret statistical procedures .75 8. Determine if evidence applies .13 9. Ask about values, needs, and treatment preference .002 10. Decide on course of action >0.001 11. Continually evaluate actions >0.001  ...

... Development of an Animal Assisted Therapy Program for an Outpatient Pediatric Setting Alexandria Kessens August, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jennifer Fogo, PhD, OTR A Capstone Project Entitled Development of an Animal Assisted Therapy Program for an Outpatient Pediatric Setting Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. Alexandria Kessens, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Running head: ANIMAL ASSISTED THERAPY PROGRAM Development of an Animal Assisted Therapy Program for an Outpatient Pediatric Setting Alexandria A. Kessens, OTS University of Indianapolis 1 ANIMAL ASSISTED THERAPY PROGRAM 2 Abstract Stones Crossing Physical Therapy and Rehab offers clients a variety of treatments and therapists have multiple advanced training and certifications in different skills. Staff wanted an animal assisted therapy (AAT) program to give clients an alternative therapy method but had limited time and resources. Therefore, a doctorate capstone experience (DCE) student was brought in at the site to develop the AAT program. The purpose of this DCE is to create an AAT program to support and/or enhance therapy interventions which will ultimately increase the QOL in an outpatient pediatric population. A needs assessment survey was created by the DCE student in order to determine if staff thought there was a need for an AAT program and what they thought potential benefits and barriers of the program would be. Based on research findings and findings from the needs assessment survey, the student developed a program proposal, policies and procedures, and found an AAT organization that best fit the site. Additionally, the student created a resource packet that included textbooks, links to the Animal Assisted Therapy International Standards of Practice and glossary terms for AAT, and citations/abstracts for intervention research articles. An inservice was presented to staff and staff completed a pre and post survey to measure their understanding of AAT after attending the presentation and reviewing the resources. Average scores on the post survey for each question increased from the pre survey. It is recommended that staff use these resources when the AAT program is implemented to ensure best practice. ANIMAL ASSISTED THERAPY PROGRAM 3 Development of an Animal Assisted Therapy Program for an Outpatient Pediatric Setting The Stones Crossing Health Pavilion is a joint venture of Community Health and Johnson Memorial Hospital to provide multiple services to meet the needs of families. The goal of Stones Crossing is to keep your best health possible (Community Health Network, 2017). Stones Crossing Physical Therapy and Rehab offers occupational therapy, physical therapy, and speech therapy for all ages. However, for the purposes of this paper pediatric services will be highlighted. There are unique services offered, such as aquatic therapy and a sensory integration gym for infants and children to use for play based therapy. Other services are used to assist children with diagnoses of speech-language developmental delays, autism spectrum disorder, and gait disorders, (Community Health Network, 2017). Therapists who are employed at Stones Crossing have advanced training in the following: feeding difficulties, neurodevelopment treatment, neurogenic communication disorders, voice disorders, outpatient dysphagia therapy, gait abnormalities and spasticity, and Handwriting Without Tears. Several therapists also have multiple certificates including sensory integration, pool operators, aquatic therapy, LOUD, and Beckman oral motor treatment (Community Health Network, 2017). This advanced certification allows therapists to provide specialized OT services, occupation-based practice and optimal client-centered care. Occupational therapists work with children to address difficulties of ADLs, IADLs, and social participation such as toileting, dressing, feeding, personal hygiene and grooming, communication management, meal preparation and cleanup, play, and social participation. Occupational therapist also addresses client factors such as sensory function, neuromuscular function, mental functions which include attention, executive functions, perception, and emotional regulation during treatments (American Occupational Therapy Association, 2014). ANIMAL ASSISTED THERAPY PROGRAM 4 Even though therapists currently offer extensive, comprehensive services, therapists and staff believed that overall services could be enhanced with the addition of animal assisted therapy. However, they lacked the time and resources to fully investigate the possibility of attaining and sustaining such services. Therefore, a DCE student was brought in to develop the program. The purpose of this DCE was to create an animal assisted therapy program to support and/or enhance therapy interventions which will ultimately increase the QOL in an outpatient pediatric population. Literature Review The DCE student investigated the literature before developing an AAT program. The DCE student also researched the need for AAT for a pediatric population and investigated the number of individuals who have a developmental disability in the United States. Since neither the DCE student nor the site had any prior knowledge about AAT, the student explored the terminology of AAT and how it might be incorporated into therapy at Stones Crossing. The DCE student found evidence to support the use of AAT in a pediatric population. There are multiple areas that children with developmental disabilities have difficulty with. These areas will be outlined in the paper as well as the evidence that supports the use of AAT to support and/or enhance therapy interventions for those difficulties. Developmental Disability Statistics Centers for Disease Control and Prevention (CDC) completed a study that evaluated the prevalence of developmental disabilities in the United States from 1997-2008. The prevalence of developmental disabilities over 12 years of the study increased by 17.1 percent. This equates to 1.8 million more children with a developmental disability compared to a decade before (Centers for Disease Control and Prevention, 2015, p. 1). In 2006-2008, one in six children had a ANIMAL ASSISTED THERAPY PROGRAM 5 developmental disability. The prevalence of autism increased by 289.5 percent and ADHD increased by 30.9 percent (Centers for Disease Control and Prevention, 2015, p. 1). More recently Zablotsky, Black, and Blumberg (2017) estimated that the prevalence of children diagnosed with a developmental disability has continued to rise from 5.76 percent in 2014 to 6.99 percent in 2016. Children with developmental disabilities have difficulty with learning, regulating behavior, and self-care (Zablotsky et al., 2017, p. 2). Other difficulties include language, mobility, self-help, and independent living. Developmental disabilities can be diagnosed anytime from birth up to age 22 and impact the persons entire life (Centers for Disease Control and Prevention, 2015). The results indicate the rising need for interventions to assist these individuals to live a more independent life and be able to participate in meaningful occupations. Brief Overview of Animal Assisted Therapy Animal assisted intervention (AAI) is a term that encompasses both AAT and animal assisted activity (AAA) (Calcaterra et al., 2015; Goddard & Glimer, 2015; Morrison, 2007; Urbanski & Lazenby, 2012). AAT and AAI are a goal-directed part of the therapy process in which therapists work specifically with an animal to achieve therapeutic goals and outcomes. The progress on goals is documented and measured. Whereas, an AAA is not goal directed and is more of a causal interaction between an animal and a group or an individual (Calcaterra et al., 2015; Dietz, Davis, & Pennings, 2012; Goddard & Glimer, 2015; Morrison, 2007; Urbanski & Lazenby, 2012, Yap, Schienberg, & Williams, 2017). A variety of animals can be used for AAT, but the most common animal is a dog (Goddard & Glimer, 2015; Morrison, 2007). A trained health professional guides the intervention session (Calcaterra et al., 2015; Morrison, 2007). These health professionals include but are not limited to, registered nurses, nurse practitioners, ANIMAL ASSISTED THERAPY PROGRAM 6 physicians, occupational therapists, physical therapists, social workers, psychologists, and licensed counselors (Morrison, 2007). Professionals are licensed in their discipline and then trained to become animal specialists. These specialists use the dog in therapy as a modality during treatment (Morrison, 2007; Velde, Cipriani, & Fisher, 2005). Occupational therapists use modalities to create/promote, establish/restore, maintain, modify, and prevent (Velde et al., 2005). AAT can be used in multiple settings such as hospitals, residential care facilities, and hospices (Martin & Farnum, 2002). AAI can be used across the lifespan for individuals who need improvement in mood, motivation, self-esteem, and physical and psychological well-being (Morrison, 2007). One might use AAI to address issues related to medical conditions such as autism, dementia, chronic diseases, mental health, and neurological disorders such as aphasia and epilepsy (Morrison, 2007). AAT goals focus on improvements in ones physical, social, emotional, and/or cognitive functioning (Goddard & Gilmer, 2015; Morrison, 2007; Urabanski & Lazenby, 2012). There are several therapeutic benefits that AAT can offer to children with disabilities which will be discussed next in the paper. Stress/Anxiety There is a growing concern that children with physical or mental disabilities like cerebral palsy (CP) may also develop psychotic disorders such as aggression, agitation, social withdrawal, and depression (Elmaci & Cevizci, 2015). Dogs can offer benefits in emotional, social, and psychological well-being of children (Wohlfarth, Mutschler, Beetz, & Schleider, 2014). This is facilitated through the human-animal interaction. The human-animal interaction is composed of psychological, emotional, playful, and physical simulation elements which guide treatment (Elmaci & Cevizci, 2015). The human-animal interaction can influence neurochemicals such as dopamine which decreases blood pressure and provides relaxation which ANIMAL ASSISTED THERAPY PROGRAM 7 can improve an individuals quality of life (QOL) and coping (Elmaci & Cevizci, 2015; Urbanski & Lazenby, 2015). Martin and Farman (2002) discussed how interaction with animals can lower heart rate and blood pressure and reduce anxiety and depression. Velde et al., (2005) and Schuck, Emmerson, Fine, and Lakes (2015) also stated that AAT can alleviate stress. One of the reasons animals reduce stress is because they can provide comfort, which promotes a sense of safety and can improve self-esteem (Velde, et al., 2015). AAT can reduce stress and increase QOL in pediatric oncology patients (Calcaterra et al., 2015; Urbanski and Lazenby, 2015). A randomized controlled pilot study performed by Calcaterra et al. (2015) evaluated the neurological, cardiovascular, and endocrinological impacts that AAT had on 40 children post-surgery compared to standard postoperative care. There were 20 children assigned to the standard care and 20 children were given AAT for 20 minutes. Neurological measurements were conducted by comparing the difference in beta electroencephalogram (EEG) activity pre and post intervention. Cardiovascular input was measured using cerebral prefrontal oxygenation (HbO 2), heart rate (HR), blood pressure (BP), and oxygen saturation (SpO2). Salivary cortisol levels were used to measure endocrinological impact (Calcaterra et al., 2015). Results of this study found that the group with AAT had lower brain wave activity and oxygen levels, heart rate, and blood pressure levels post-op. The group of children receiving AAT after surgery also experienced more rapid recovery and vigilance after anesthesia, modified pain signals, and children were able to regulate emotions better after surgery (Calcaterra et al., 2015). Children who survive sexual abuse can also have high anxiety, depression, and stress disorders such as post traumatic stress disorder (PTSD) (Dietz et al., 2012). Therapeutic stories is a common treatment used to treat the psychological needs of child abuse survivors (Dietz et al., ANIMAL ASSISTED THERAPY PROGRAM 8 2012). Dietz et al. (2012) compared three treatment groups: therapeutic stories with no dog, dog with stories, and dog with no stories. There were a total of 153 children between the ages of 7-17 who had all experienced sexual abuse. The group with therapeutic stories and no dogs had 12 sessions over topics including trust, self-esteem, secrets, triggers, boundaries, feelings, and welcome and unwelcome touch (Dietz et al., 2012). The group with dogs and no stories and the group with stories and no dogs also participated in the same 12 sessions covering similar topics. However, in the group with a dog and stories the dogs came in for 10-15 minutes at the beginning of the group. This group also included specific stories related to the dog to give the dog visits more structure. The results of the study found that the children who participated in the groups with the dogs had decreased scores on the Trauma Symptom Checklist for Children (TSCC) in anxiety, depression, PTSD and dissociation with the group including the therapeutic stories and dog demonstrating the most improvement when compared to the children who engaged in stories with no dog. (Dietz et al., 2015). Children can also have anxiety from new or difficult tasks such as reading (Wohlfarth et al., 2014). In a cross over design, 24 children were assigned to either a human interaction for reading or reading with an animal and human. The children were assessed on literal reading, content comprehension, reading time, and text comprehension (Wohlfarth et al., 2014). The group that included the dog and human had higher scores in three out of four of the reading parameters. Childrens reading performance improved because the child was not as stressed about the task in the presence of a dog. The dog also provided a warm, friendly, compassionate atmosphere which decreased stress and motivated the child to read (Wohlfarth et al., 2014). Elmaci and Cevizci (2015) explored the use of a dog as part of an occupational therapy intervention to reduce childrens fear of medical interventions and decrease stress and anxiety ANIMAL ASSISTED THERAPY PROGRAM 9 when going to a hospital environment. The occupational therapist had two children pretend that the dog was going to the vet and that he was scared to go (Elmaci & Cevizci, 2015). The intervention consisted of the children giving the dog a physical exam and providing encouragement/empathy. By using the dog as part of the intervention, the children were able to demonstrate decreased anxiety of medical procedures and showed empathy to another living object. This assisted them in achieving their goals in occupational therapy (Elmaci & Cevizci, 2015). Physical Physically, individuals range of motion (ROM), balance, and strength can improve with AAT (Velde et al., 2005). AAT can also be used to improve motor skills in children (Winkle & Jackson, 2012). Children with CP have difficulty performing motor tasks which can limit their daily function (Elmaci & Cevizci, 2015). A study by Elmaci and Cevizci (2015) used three different therapy dogs to achieve occupational therapy goals. The children were put in five different groups based on their therapy goals. One child had CP and hemiparesis and the goal was to increase muscle tonus regulation by using different sensory stimulation to increase mobility on the right side. The dog was used to provide sensory stimulation to the extremity by licking yogurt off the childs extremity and the childs tonus was decreased. However, the results were only temporary (Elmaci & Cevizci, 2015). The goals for another boy with bilateral CP were to increase muscle activities, which included handwriting and standing balance. The dog was used to assist the boy with standing and using fine motor movements such as writing a letter to the dog and painting. The boy achieved his therapy goals and his motivation for treatment was increased with the use of the dog during therapy (Elmaci & Cevizci, 2015). Another child had spastic CP, which limited his lower and upper extremity movement. After using a therapy dog, ANIMAL ASSISTED THERAPY PROGRAM 10 his movements and bowel movement increased. Even though the sample size was small each child had a positive experience using a therapy dog and the therapy dog assisted in achieving goals for the children. (Elmaci & Cevizci, 2015). Executive Functions AAT can provide more meaningful clinical interactions and positively impact human emotion and cognition in children with disabilities (Yap et al., 2017). Interactions between animals and children with developmental and emotional disorders and Down syndrome can improve childrens emotional stability, decrease negative behaviors and aggression, and increase their attention and cooperation (Urbanski & Lazenby, 2015). Growing evidence suggests that utilizing AAT can make treatment motivating for participants (Schuck et al., 2015). Sams, Fortney, and Willenbring (2006) concluded that using AAT was an intrinsic motivator for children with autism. Therefore, external rewards were not necessary to coax the children to participate in treatment. The children wanted to complete the treatment because the use of an animal was intrinsically motivating. Also, Velde et al. (2005) stated that participants were more motivated to come to treatment when an animal was present. Participants were more motivated which increased the duration of occupational therapy activities and improved the outcomes of occupational therapy intervention since the participants stayed longer. Children with attention deficit hyperactivity disorder (ADHD) have impairments in executive functioning, attention, emotional regulation, arousal, self-regulation, and motivation. This can lead to poor frustration tolerance, and difficulty accepting consequences. A traditional treatment approach to ADHD is cognitive behavioral therapy (Schuck et al., 2015). Schuck et al. (2015) randomly assigned 24 children to a 12 week group with either cognitive behavioral therapy or a group with cognitive behavioral therapy and canine-assisted intervention (CAI). ANIMAL ASSISTED THERAPY PROGRAM 11 Data were collected per parent report and from the ADHD Rating Scale Fourth Edition, Home and School Version (ADHD-RS-IV), Social Skills Improvement System Rating Scales (SSISRS), and the Social Competence Inventory (SCI). The ADHD-RS-IV uses a four point scale from never = 0 to very often = 3 to measure 3 subscales: inattention, hyperactivity/impulse, and total symptoms. SSIS-RS measures two domains: social skills and competing problematic behaviors. The SCI uses a 25 item measure of behavioral aspects of social competence (Schuck et al., 2015). Both groups demonstrated improvements in scores of social skills, pre-social behaviors, and competing problematic behaviors (Schuck et al., 2015). However, children who received CAI in addition to cognitive behavioral therapy showed a significant improvement of ADHD symptoms such as attention and inhibitory control, which are important executive functions. The benefits of CAI added with cognitive behavioral therapy were observed at week four and continued to improve throughout the 12 weeks. This indicates that CAI may enhance traditional evidenced based interventions (Schuck et al., 2015). Examining the effects on emotional regulation, Anderson and Olson (2006) evaluated the impact of having a dog in a self-contained classroom with children diagnosed with severe emotional disorders. The goal of the project was to determine if having a dog present improved the childrens emotional stability. Baseline data were collected eight weeks prior to the study (Anderson & Olson, 2006). Parent interviews were conducted and behavior change was examined from from the Problem Solving Sheet and the Antecedents Behaviors and Consequences (ABC) analysis form. The Problem Solving Sheet was used to record a problem a student was having, how the problem was resolved, and what could be done different to address the problem and the ABC analysis form was used when there was severe verbal and physical aggression displayed. The dog was present eight weeks in the classroom. Qualitative data were ANIMAL ASSISTED THERAPY PROGRAM 12 also gathered by teacher/researcher five days for eight weeks and notes were made about the students comments and interactions during students one-on-one session with the dog.Conclusions indicated that the children had overall improved emotional stability, which was evidenced by de-escalation and emotional crises. The children also had improved attitudes towards school and were more responsible, respectful, and empathic throughout the learning process (Anderson & Olson, 2006). Social Skills Animals can assist in the social and cognitive development of a child (Velde et al., 2005). Interactions with animals increase childrens social behavior and responsiveness, and increase play (Urbanski & Lazenby, 2015). Social interactions of smiling, laughing, looking, touching, and verbalizing improved when AAT was used in treatment (Elmaci & Cevizci, 2015). Sams et al. (2006) evaluated whether AAT, when added to traditional occupational therapy treatment for individuals with autism, improved social interaction and language use compared to children who participated in a typical intervention session. Each child participated in a typical occupational therapy intervention session and a session incorporating AAT. This study was conducted over 15 weeks (Elmaci & Cevizci, 2015). The results of this study revealed that the children used a considerable amount of language and their social interaction increased significantly when AAT was used. The authors concluded that this could be due to interactions with animals being less complex than with a person (Elmaci & Cevizci, 2015). Even though the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) does not recognize pervasive developmental disorders (PDD) as a diagnosis, in 2002 PDD was recognized as a category of disorders that included autistic disorder, Retts, syndrome, childhood disintegrative disorder, pervasive developmental disorder not otherwise specified, and ANIMAL ASSISTED THERAPY PROGRAM 13 Aspergers. Children with PDD had difficulty with social interaction and communication skills. For example, they were socially withdrawn, did not have appropriate social skills, and were disinterested in their social environment. At that time, traditional therapy approaches did not treat all of the symptoms of PDD (Martin & Farnum, 2002). Martin and Farnum (2002) investigated the use of AAT for improving social skills in individuals with PDD. Three treatment tools were used 15 out of 45 minutes of treatment. The conditions included a ball, a stuffed dog, and a live dog. The study encompassed 15 weeks (Martin & Farnum, 2002). The results of this study demonstrated that the children laughed more and gave treats to the live dog, which indicated the children were happier, more playful, and had increased energy when the dog was present. The children were also less distracted and paid more attention when a live dog was present compared to the dogs absence in the other conditions. In addition, the children showed an increase in socialization by exchanging numerous conversations with the dog and with the therapist about the dog. While talking, children stayed more on topic when a live dog was present. Conversations about themselves or the therapist were minimal with the live dog condition. Also, children participated in more hand flapping in the dog condition, which is usually associated with negative behavior but the study indicated hand flapping as excitement and exhilaration (Martin & Farnum, 2002). Elmaci and Cevizci (2015), used AAT in a group of four children ranging in ages from 8 to 22 years old with severe mental and physical impairments. The goal of the session was to improve communication, planning, and empathy skills. The children planned and organized a birthday party for the canine therapy dog (Elmaci & Cevizci, 2015). Communication skills and planning were improved as observed when the group members communicated how they were going to plan the party. At the party, group members sang happy birthday and invited others to ANIMAL ASSISTED THERAPY PROGRAM 14 participate in the birthday party which demonstrated improved communication skills and allowed them to feel like they belonged with a group. The group members achieved their session goals with AAT by demonstrating improved communication, planning, and empathy skills (Elmaci & Cevizci, 2015). Theory Combining the QOL theory and the person-occupation-environment theory will guide this doctorate capstone experience. Increasing QOL was the first goal of Healthy People 2020 (USDHHS, 2000). QOL reflects a general sense of happiness and satisfaction with our lives and environment (U.S. Department of Health and Human Services, 2000, p.10). There are three major aspects of QOL with subdimensions (Scaffa, Reitz, & Pizzi, 2010). Being is the first major aspect of QOL, which is who the individual is. The subdimensions of being are physical, psychological, and spiritual. Belonging is the next aspect of QOL, which is how the individual fits within their environment. The subdimensions of belonging are physical, social, and community. Lastly, becoming is an aspect of QOL that focuses on the persons goals and dreams. The subdimensions of becoming are regular activities and leisure (Scaffa et al., 2010). The American Occupational Therapy Association (AOTA) describes QoL in (Occupational Therapy Domain and Process), QOL is discussed as an outcome, which is the end result of the therapy process (AOTA, 2014). The person-environment-occupation (PEO) model relates the fit of the person, environment, and occupation. The greater overlap of the person, environment, and occupation, the better performance one has. If there is a gap or one of the components is not fitting well with the other components, this can lead to greater dysfunction with an individual (Scaffa et al., 2010). The person consists of physical, cognitive, and affective characteristics. The environment ANIMAL ASSISTED THERAPY PROGRAM 15 is physical, social, and cultural components of the individual. Occupation includes self-task, leisure, and productive pursuits (Scaffa et al., 2010). The fit between the PEO can decrease or increase throughout the developmental stages. The PEO can be used by occupational therapists in many different settings and with different age groups and populations and the PEO has been used in rehabilitation of individuals with CP due to having a family-centered approach (Strong et al., 1999). The aspects of the QOL correlate well with the PEO. For example, being, the first aspect of QOL, fits within the person category in the PEO since it includes different aspects of the individual. Belonging and the environment portion of the PEO both describe*e how an individual interacts with different aspects of the environment. Becoming discusses leisure and regular activities of the person. This would fit under the occupation portion of the PEO because they both describe what an individual enjoys doing. Level of satisfaction and functioning equals the level of quality in someones life. This is the outcome of the fit between the person-environmentoccupation (Strong et al., 1999). For the purposes of this DCE, AAT fits well with the QOL and PEO theory since AAT can be added to therapy treatment. As stated in the research above, AAT assists with the person and being of the individual because it assists with decreasing stress and anxiety, increasing social skills, and improving mental functions and ROM, strength, and endurance. The belonging and environment will be Stones Crossing Physical Therapy and Rehab which includes the childs social environment. Using AAT, can potentially improve the environment of Stones Crossing Physical Therapy and Rehab by making it feel more friendly and nonjudgmental. By increasing social skills, the child will be able to participate in the social environment. AAT will promote becoming and occupation by supporting treatment goals that address activities of daily living ANIMAL ASSISTED THERAPY PROGRAM 16 (ADLs) such as grooming and bathing/showering and play. As an occupational therapist, interventions should focus on what is meaningful to someone to promote the QOL of that individual. Using canine assisted therapy as an addition to therapy treatment, can improve QOL, therefore, increasing the fit between the PEO. Eventually, this will lead to better function in ones life. Screening and evaluation There is limited research about staff perspectives of AAT and how they would use animal assisted therapy. Further research about how occupational therapists would use AAT and how frequently it is used needs to be addressed, so that staff understands the intervention outcomes of AAT (Velde et al., 2005). Survey questions were developed using Survey Monkey. There were multiple types of quantitative and qualitative questions. Quantitative questions included yes/no responses, drop down responses, a likert scale, and multiple choice responses. Qualitative questions were free text responses in which staff could type perceived barriers and benefits to an AAT program. There was also a section where therapists could add any additional comments or questions. Several interventions were listed, in question 7 from which therapists could select interventions they believed could benefit from having a dog present. Interventions included were social interaction (Elmaci & Cevizci, 2015; Martin & Farnum, 2002; Sam et al., 2006; Velde et al., 2005), calming strategies (Calcaterra et al., 2015; Dietz et al., 2012; Elmaci & Cerizci, 2015; Martin & Farman, 2002; Schuck et al., 2015; Velde et al., 2005; Wohlfarth et al., 2014), executive functions (Andrew & Olson, 2006; Sams et al., 2006; Schuck et al., 2015; Urbanski & Lazenby, 2015; Velde et al., 2005; Yap et al., 2017), communication and language (Elmaci & Cevizci, 2015; Martin & Farnum, 2002), balance and/or gait training (Elmaci & Cevizci, 2015), emotional regulation (Anderson & Olson, 2006), ADLs (Elmaci & Cevizci, ANIMAL ASSISTED THERAPY PROGRAM 17 2015), fine/gross motor (Elmaci & Cerizci 2015; Winkle & Jackson, 2012; Velde et al., 2005), neurological (Elmaci & Cevizci, 2015), sensory integration (Velde et al., 2005). The survey was developed based on findings from Yap et al. (2017) study. A total of 128 staff members from different disciplines, including nurses, medical staff, administrative staff, and researchers, who worked at a childrens hospital, were given a survey to determine the attitudes and beliefs about AAT. As a result of this survey, the staff members indicated AAT would be helpful in treating conditions of CP, autism spectrum disorder (ASD), and acquired brain injury (ABI). Frequent themes for treatment of CP were to assist with movement, function, and emotional support. Themes for both ASD and ABI included emotional support, calming agent, and assistance with behavioral management. Themes that were global across all diagnoses were companionship, improve mood, motivation, and facilitate social interaction and communication. (Yap et al., 2017). Of the staff members, 92 percent stated that AAT would be beneficial when combined with physical therapy or other rehabilitation activities and 76 percent believed AAT would be beneficial when combined with speech language pathology. Barriers of implementing an AAT program that staff identified were limited resources, fear of animals, infection, and high cost. Of the staff members that completed the survey, 98 percent were supportive of an AAT program in the hospital (Yap et al., 2017). Therefore, a ten question online survey was sent via an email with a link to survey monkey to 20 therapists including occupational therapists (OT), physical therapists (PT) and speech language pathologist (SLP), employed at Stones Crossing Physical Therapy and Rehab . The survey included questions allowing the therapists to indicate how AAT would be utilized by therapists and to determine if therapists thought there was a need for AAT to support performance and participation in therapy sessions. Research supports utilizing a survey to collect ANIMAL ASSISTED THERAPY PROGRAM 18 information about individuals understanding of the role of AAT at a site and staff perspectives (Yap et al., 2017). Out of the 20 therapists who received the survey, 12 therapists, including 3 occupational therapists, 4 physical therapists and 5 SLPs responded to the survey. Eight therapists worked with children. One therapist worked with adults, and three therapists worked with both children and adults. Based on a Likert scale of 1-5, with 1 being strongly disagree to 5 being strongly agree, 83 percent of the respondents either agreed or strongly agreed that there was a need for AAT and that AAT would be beneficial to therapy sessions. The top three interventions based on the greatest percentage of responses were social interaction, calming strategies, and executive functions (motivation, cognition, attention, memory). Refer to Figure 1A for the rest of the interventions and responses. Therapists gave feedback on potential barriers and benefits of AAT at Stones Crossing Physical Therapy and Rehab. The responses were divided into categories. The top categories listed for barriers were AAT therapy concerns, health and safety, and patients fear of dogs. The top categories for benefits were motivation and alternative therapy. The number of responses are listed below in parentheses next to each category (see Appendix A: Needs assessment survey questions and responses on p. 20). A hundred percent of the staff that completed the survey stated that they would support AAT at Stones Crossing Physical Therapy and Rehab (see Appendix A: Needs assessment survey questions and responses on p. 20). The results from this survey will be used to structure the AAT program development. Implementation During the implementation stage, the DCE student researched different AAT organizations, established policies and procedures, and developed a program proposal for Stones Crossing Physical Therapy and Rehab facility. The first step of implementation was to research ANIMAL ASSISTED THERAPY PROGRAM 19 various organizations that trained facility dogs. The staff at the site preferred to obtain a facility dog that had received strict training and management feeling more comfortable with a trained facility service dog versus having one of the therapists dog trained and certified. A facility service dog works alongside different professionals at the facility to increase the quality of life of individuals, assisting professionals with improving motivation, social interaction, comfort, and feelings of safety and wellbeing. (Therapy Dogs United, 2016). The DCE student compared and contrasted organizations placement rate, graduation rate, training requirements of both the handler and dog, cost, application process, and wait list. The site wanted to partner with an AAT organization located close to the site, so the handler did not have to travel far for training. Cost was one of the barriers staff at the site identified when completing the survey. Therefore, it was important to find an organization that met the requirements but kept cost low. With these guidelines in mind, the DCE student found three organizations that fit the sites needs the best. These organizations included Canine Companions for Independence, Indiana Canine Assistance Network, and Medical Mutts. The DCE student also developed policies and procedures and a program proposal. Since the site had no prior research or understanding about the topic, it was the DCE students responsibility to find evidence to support the program. Research included findings about the description of AAT, how AAT can support or enhance therapy sessions, and identification of barriers and precautions that need to be addressed when implementing an AAT program. Staff had a huge role in assisting with the development of policies and procedures and the AAT program proposal. One of the staff members agreed to be the handler of the dog. Her specific responsibilities were listed in the policies and procedures to provide staff and the handler with more clarity about her role in the program. The site mentor has experience with program ANIMAL ASSISTED THERAPY PROGRAM 20 development, so she assisted with the implementation stage based on her professional competencies and job responsibilities. Other staff members assisted with the development of the program proposal and policies and procedures through completion of the needs assessment survey. Staff members completed a Benefits and Barriers section of the survey which was used to individualize the policies and procedures and program proposal specific to the sites needs. The policies and procedures and program proposal will be given to staff members to further their understanding about AAT program. It is recommended to establish clear policies and procedures when implementing an AAT program at a facility (Goddard & Gilmer, 2015; Velde et al., 2002). There were multiple considerations that needed to be analyzed while creating the policies and procedures. First, the safety of patients, staff, and the dog needed to be considered. Second, guidelines for scheduling procedures and billing structures needed to be developed. Third, the handlers specific role and responsibilities needed to be outlined. Lastly, the freedoms of the dog needed to be defined. (Fine, Tedeschi, and Elvove, 2015). For the complete policies and procedures (see Appendix B: Policies and procedures on p. 30) Staff at the capstone site identified health and safety such as allergies and fear as top barriers to implementing an AAT program in the needs assessment. A primary concern listed in research was the possibility of a childrens family and/or the child fearing animals such as dogs (Goddard & Gilmer, 2015; Winkle & Jackson, 2012; Yap et al., 2017). Allergies are another primary concern that needed to be addressed in the policy and procedures (Goddard & Gilmer, 2015; Urbanski & Lazenby, 2012; Velde et al., 2002; Winkle & Jackson, 2012). Other medical conditions that need to be considered before engaging in AAT are open wounds, infectious disease, and asthma (Urbanski & Lazenby, 2012; Winkle & Jackson, 2012). The DCE student ANIMAL ASSISTED THERAPY PROGRAM 21 recommended in the policy and procedures that signs be posted outside of rooms that the dog is being used in so patients who have a fear of dogs can avoid the dog. Hand washing before and after treatment is crucial to decrease the risk of an allergic reaction (Goddard & Gilmer, 2015; Velde et al., 2002). Staff at the site also recommend sanitizing any equipment that was used by the dog after the session was over. Sanitizing equipment is already a procedure in place that staff engage in daily as well as hand washing or using sanitizer before and after patients. Hand washing and wiping equipment polices were therefore included in the policies and procedures created by the DCE student for Stones Crossing. The policies and procedures also provide therapists with a guideline on medical conditions that need to be considered before a patient can engage in AAT. The policy also requires that therapists ask the family or client if they are allergic to dogs and if they fear dogs. When interviewing with a handler at a site that already has AAT implemented, the handler at Community Health Physical Therapy and Rehab Fort Benjamin Harrison stated that hand washing and wiping down equipment has been a successful way of decreasing allergic reaction (K. A. Reuter, personal communication, April 27, 2018). The DCE student also created policies and procedures to address safety concerns such as fall hazards, how to document injuries resulting from working with a dog, and specific questions to ask to determine a childs/ familys history or cultural beliefs about dogs. Velde et al. (2002) suggested that dog equipment such as food, water, and the dogs resting area were kept away from high traffic areas to reduce fall hazards. Therapists also need to be cautious of a clients background such as religious/cultural views (Winkle & Jackson, 2012) and previous relationships with animals (Urbanski & Lazenby 2012; Winkle & Jackson, 2012). Some religions and cultures may identify dogs as dirty or unclean or believe dogs should be outside (Winkle & Jackson, 2012) or a child may be aggressive towards animals or have abused animals in the past ANIMAL ASSISTED THERAPY PROGRAM 22 (Urbanski & Lazenby, 2012; Winkle & Jackson, 2012). To address these concerns, it was recommended to have a screening or assessment for therapists to use (Goddard & Gilmer, 2015; Winkle & Jackson, 2012). The questions on the policies and procedures are similar to a site that already has an AAT program. The site asks clients if they are allergic or fear dogs before they can participate in AAT (K. A. Reuter, personal communication, April 27, 2018). Clients at Stones Crossing who might benefit from working with AAT will need to be asked if they are allergic, if they are afraid of dogs, what are their views of animals, what is their history with animals, and if the client has any medical conditions that may impact therapy such as open wounds, weak skin integrity, asthma, or an infectious disease. If the patient responds positively, then it is recommended that the client does not engage in AAT. The AAT policies and procedures also require that therapists follow the incident report that is already in place at the site if an injury were to occur when using AAT. This is similar to the procedure used at Community Health Physical Therapy and Rehab Fort Benjamin Harrison whose handler reported that her site uses the same incident report if there was an injury from AAT (K. A. Reuter, personal communication, April 27, 2018). The roles and responsibilities of the handler and the rights of the animal also were addressed in the policies and procedures. AAT and therapy concerns such as training, responsibility of taking care of the dog, approval of services and insurance coverage were barriers listed in the needs assessment. The handler is the responsible for the wellbeing of the animal (Ng, Albright, Fine, and Peralta, 2015; Winkle & Jackson, 2012). This includes food, water, shelter, and veterinary care (Ng et al., 2015). Copies of vaccinations, parasitic prevention, registration, and ongoing training will be at the site. The handler will be responsible for keeping these documents up to date. Staff members must be trained before they incorporate the animal ANIMAL ASSISTED THERAPY PROGRAM 23 into therapy sessions (Winkle & Jackson, 2012). The handler is responsible for training staff members about commands and triggers of the dog (Ng et al., 2015; Winkle & Jackson, 2012). Winkle and Jackson (2012) suggested that inservice training for staff occurs annually and that the handler does a minimum of six hours of continuing education to ensure best practice of AAT (see Appendix B: Policies and Procedures on p. 37). Staff also listed insurance coverage for AAT services as a barrier to implementing an AAT program. Services completed with an animal can be billed as therapeutic equipment or activity or whatever services are normally covered under insurance (K. A. Reuter, personal communication, April 27, 2018). For example, if an occupational therapist is working on fine motor coordination, instead of having a child place coins inside a slot, the child could open a container of treats and get a few from the container to give to the dog. Both activities are working on the same goal, so they can be billed as therapeutic activity. The staff also identified difficultly with scheduling as a potential barrier to establishing an AAT program at Stones Crossing. Procedure was developed such that a schedule will be posted in the office where staff can block out 15-30 minute time frames of using the dog. This allows staff to use the dog with different children even if they are scheduled at the same time. The procedure established that the handler will be responsible for the schedule and for giving the dog breaks throughout the day. The dog also has rights and freedoms at the site. Ng et al. (2015) listed five freedoms, freedom from thirst, hunger, and malnutrition; freedom from discomfort; freedom from pain, injury, and disease; freedom from fear and distress; and freedom to express most normal dog behavior. All of these were included in the policies and procedures. A program proposal was also developed during the implementation stage. The program proposal gives an introduction into the program and includes statement of need for the program. ANIMAL ASSISTED THERAPY PROGRAM 24 Details of the program are outlined in the program proposal. Lastly, a strengths, weakness, opportunities, and threats (SWOT) analysis as a way to analyze outcomes of program. The DCE student especially evaluated the weakness and threats of the program and attempted to find solutions for all of the weakness and threats to ensure the success of the program (see Appendix C: Program Proposal on p. 31). The DCE student used research findings of potential barriers, staff identified barriers and the DCE student identified weaknesses or threats to the program to develop appropriate policies and procedures to address as many weaknesses and threats as possible. Some of the identified threats were out of the DCE students control such as a long wait list to receive a facility service dog. Leadership skills Leadership skills were demonstrated throughout the process of the DCE. The DCE student made a schedule to be organized and keep track of progress, which made the student accountable for the DCE. The DCE student met with her site mentor daily to give updated progress to ensure that the site mentor and the DCE student were on the same page. The DCE student had to find research and be knowledgeable on the topic since the site had no exposure to AAT and limited understanding. The DCE student wanted to keep the project client centered. A survey was developed to gather information for the needs assessment. The findings from the survey were used to structure the program. The policies and procedures and program proposal were evidenced based and client-centered for the site. An inservice presentation and a resource packet was completed in addition to the policies and procedures and program proposal. The DCE student wanted to be part of the team at the site so she participated in other activities outside the DCE project such as a six week handwriting camp and staff events that students were not required to go too. The DCE student also demonstrated leadership by scheduling interviews, ANIMAL ASSISTED THERAPY PROGRAM 25 contacting different AAT organizations and sites that have AAT, and communicating with staff, site mentor, and facility mentor. Outcomes An inservice was completed for staff members at the site. The presentation was over background information and research about AAT and the process of the DCE project. A resource packet, the policies and procedures and program proposal were passed out during the presentation. The resource packet contained information about the Animal Assisted Therapy International Standards of Practice and glossary terms for AAT that therapists can refer too. There are also three activity books listed in the resource packet. The books have different AAT activities and provide step by step instructions for implementing the activities. The resource list also includes a book about AAT which includes standards of AAT practice and information about how to implement AAT in a variety of settings and with a variety of populations. Citations and the abstracts of the intervention research articles are included in the resource packet. The articles were divided into sections according to interventions addressing specific deficits typically seen with pediatric clients (social interaction, executive function, ROM/strength, and stress/anxiety). An outcome measure for the behavior of the dog is included in the resource packet. The behavioral assessment is broken down into nine categories (aggression, fear/anxiety/stress, excitability, interaction with people, interaction with dogs, obedience, tiredness, reactivity, and anticipation). The therapist using the assessment can score it before, during, and/or after a session to evaluate if the dog is too tired or too stressed to participate in the session. The scores are 0-3 for each category. The higher the score the higher stress or discomfort the dog is experiencing which indicates the dog needs a break (Fine & Eisen, 2008). ANIMAL ASSISTED THERAPY PROGRAM 26 A survey was used to ensure quality improvement resulting from this project. The DCE student wanted to ensure that the presentation and materials given to staff answered their questions about the AAT program and that staff had no additional concerns about the AAT program. In the initial needs assessment survey, staff members identified potential barriers to the program and gave feedback about potential threats and weaknesses to the program. The DCE student specifically developed the resources and the presentation to address these potential barriers and threats/weaknesses to the AAT program. The survey was given before and after the presentation. The survey was a hard copy made in Microsoft Word by the DCE student. The pre survey composed of six questions to explore the therapists understanding of using AAT in therapy and to identify the therapists comfort level of having AAT at the site. The post survey composed of 8 questions. The first six questions were same as the pre survey and the other two questions asked therapists to indicate if the presentation and resources answered their questions. The survey was all quantitative except the last question on the post survey. All other questions on the pre and post survey used a likert scale from 1-5, with 1 being strongly disagree to 5 being strongly agree. The last question was an open ended question allowing staff to write any questions they still have about the program or write any comments about the presentation and resource packet (see Appendix D: Pre/post Survey on p. 45). Discontinuation There was a total of 11 individuals who came to the presentation and completed the pre and post survey. Ten of those individuals were staff (therapists and manager) and one was a student. One of the staff members was the manager, five were pediatric staff members, one staff member does both pediatrics and adults, and three adult therapists. The DCE student handed ANIMAL ASSISTED THERAPY PROGRAM 27 surveys to the individuals before the presentation and collected the surveys at the end of the presentation. Data were analyzed by comparing the average scores of the pre-presentation responses to the post presentation responses. Question 8 on the post survey asked if the staff had any feedback or additional questions that staff had about the program. Staff gave positive feedback such as great work, very informative, and thanks for setting the foundation. Overall averages increased on the post survey compared to the pre survey. Refer to Table 1, to see pre versus post averages. Table 1 Pre and Post Survey Averages of Responses to DCE Presentation and Resources Question Number Pre survey averages Post survey averages Question 1 3 4 Question 2 2 4 Question 3 2 4 Question 4 2 4 Question 5 2 4 Question 6 4 5 Question 7 5 There will be a folder created on Sharepoint, which is a cloud service that therapists at this site use, to keep all of the documents about the AAT program. The DCE student made multiple resources for staff to ensure that they can respond to societys changing needs. Staff agreed to continue the program and make any additional changes to the resources if a new situation arises after the student leaves. The DCE student also created a policy to insure that ANIMAL ASSISTED THERAPY PROGRAM 28 therapists who use AAT engage in continuing education. Completing continuing education, ensures that the program remains evidenced based and up to date with the current standards. Some suggested websites for continuing education courses were included in the resource list. Staff can also modify the list of activities that they do with children and/or add new activities to ensure best practice. Overall Learning Communication was a crucial component of this DCE. I was in contact with multiple individuals and I used a variety of communication styles throughout the DCE. In the beginning of the DCE, I had to write my own online survey and send it to staff members via email. I had to be clear with what the survey was asking so that therapists understood how to complete the survey so I had good data. Written communication was used in the implementation stage when I composed policies and procedures and a program proposal. It was critical that these documents were written in a professional manner because they will be official documents at the site. I also created a chart that compared different AAT organizations that had to be organized and clear so that staff can easily compare and contrast the different organizations. Non-verbal communication and verbal communication with different professionals and organizations were used in the implementation stage. I had to contact a handler at a site that already has an AAT program to discuss the structure of their AAT program. I communicated with different AAT organizations over the phone and/or email to gain more information about the organization. Some of the organizations I had to be professional and wait for responses or send follow up emails or phone calls. After I had the information from the AAT organizations, I met with a staff member who agreed to be the handler and discussed different AAT organizations with her so she could make a decision about what organization she wanted to ANIMAL ASSISTED THERAPY PROGRAM 29 partner with. A follow up email summarizing information about all of the organizations was sent so she could have that information and think about her decision. During the discontinuation stage, I provided a final inservice presentation at the site to discuss the program and the process of the DCE project. A resource packet was composed and given to staff and a pre-post survey was also given to staff at the inservice. Throughout the capstone, I constantly communicated with my site mentor and faculty mentor so that they knew how I was progressing. The DCE has provided me with multiple learning experiences and has prepared me for future practice. I learned how to be more independent. I couldnt rely on anyone for knowledge or guidance about AAT because most of the staff members have never had exposure to AAT or they had limited knowledge. It was my responsibility to find information and develop the documents needed for the DCE. The DCE has made me feel more confident in my abilities. I feel more confident to communicate with others, find information and research, and complete program development. One of my professional development goals has been to improve my confidence and this capstone has assisted me in achieving that goal. I learned how important leadership and advocacy skills are in practice. I had to be a leader in this DCE so the program succeeded. I believe that an important quality of a leader is listening to others and being respectful of their opinions. I demonstrated this when I developed the resources for the AAT program based on the staffs concerns and desires for the program. I advocated for the benefit of AAT and advocated for the development of an AAT program working with a pediatric population. The staff at the site was supportive of the DCE project and was willing to take time to meet with me and complete surveys that I sent out. Their feedback was a valuable piece of this project in insure that the program was client centered. They demonstrated effective communication ANIMAL ASSISTED THERAPY PROGRAM 30 skills with me and were timely with their responses. I truly felt like I was part of the team at the site and not just a student. There was mutual respect between the staff and myself while completing the project. I respected the staff members knowledge of the structure of the site and their feedback about what they thought would be feasible for an AAT program. The staff respected my suggestions for the program and the education that I provided for them. Overall, this DCE has provided skills for me to be an educator, advocate, developer, and leader in the profession of occupational therapy. I will use these skills to make myself a better practitioner and better team member in whatever setting I am in. I am truly grateful for the opportunity to assist in pushing the profession of occupational therapy forward by completing this DCE project. ANIMAL ASSISTED THERAPY PROGRAM 31 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Anderson, K. L., & Olson, M. R. (2006). The value of a dog in a classroom of children with severe emotional disorders. Anthrozoos a Multidisciplinary Journal of the Interactions of People and Animals, 19(1), 35-49. doi: 10.2752/089279306785593919 Calcaterra, V., Veggiotti, P., Palestrini, C., De Giorgis, V., Raschetti, R., Tumminell, M., Mencherini, S., Papotti, F., Klersy, C., Albertini, R., Ostuni, S., & Pelizzo, G. (2015). Post-operative benefits of animal-assisted therapy in pediatric surgery: A randomized study. Plos one, 10(6), 1-13. doi: 10.1371/journal.pone.0125813 Centers for Disease Control and Prevention. (2015, February 12). Key Findings: Trends in the Prevalence of Developmental Disabilities in U.S Children. 1997-2008. Retrieved April 16, 2018 from https://www.cdc.gov/ncbddd/developmentaldisabilities/features/birthdefects-ddkeyfindings.html# Community Health Network. (2017). Stones Crossing Health Pavilion. Retrieved on 13 April 2018 from https://www.ecommunity.com/locations/stones-crossing-health-pavilion Dietz, T. J., Davis, D., Pennings, J. (2012). Evaluating animal-assisted therapy in group treatment for child sexual abuse. Journal of Child Sexual Abuse, 21, 665-683. doi: 10.1080/10538712.2012.726700 Elmaci, D, T., and Cevizci, S. (2015). Dog-assisted therapies and activities in rehabilitation of children with cerebral palsy and physical and mental disabilities. International Journal of ANIMAL ASSISTED THERAPY PROGRAM 32 Environmental Research and Public Health, 12, 5046-5060. doi:10.3390/ijerph120505046 Fine, A. H., & Eisen, C. (2008). The development of the pet assisted therapy welfare assessment tool. In Paper presented at the 2013 IAHAIO conference, Chicago, Illinois, July 20-22. Fine, A. H., Tedeschi, P., Elvove, E. (2015). Forward thinking: The evolving field of humananimal interactions. In A. H. Fine (Eds), Handbook on Animal Assisted Therapy (pp. 2135). San Diego, CA: Elsevier Goddard, A. T., Gilmer. M. J. (2015). The role and impact of animals with pediatric patients. Pediatric Nursing, 41(2), 65-71. Healthy People 2010: Understanding and Improving Health (U.S. Department of Health and Human Services [USDHHS], 2000 Martin, F., Farnum, J. (2002). Animal-assisted therapy for children with Pervasive Developmental Disorder. Western Journal of Nursing Research, 24(6), 657-670. Morrison, M. L. (2007). Health benefits of animal-assisted therapy. Complementary Health Practice Review, 12(1), 51-62. doi: 10.1177/1533210107302397 Ng, Z., Albright, J., Fine, A. H., Peralta, J. (2015). Forward thinking: The evolving field of human-animal interactions. In A. H. Fine (Eds), Handbook on Animal Assisted Therapy (pp. 357-376). San Diego, CA: Elsevier Sams, M. J., Fortney, E. V., & Willenbring, S. (2006). Occupational therapy incorporating animals for children with autism: A pilot investigation. American Occupational Therapy Association, 60, 268274. doi:10.5014/ajot.60.3.268 Scaffa, M., Reitz, S.M., & Pizzi, M.A. (2010). Occupational therapy in the promotion of health and wellness. Philadelphia: F.A.Davis Company. ANIMAL ASSISTED THERAPY PROGRAM 33 Schuck, S. E. B., Emmerson, N. A., Fine, A. H., & Lakes, K. D. (2015). Canine-assisted therapy for children with ADHD: Preliminary findings from the positive assertive cooperative kids study. Journal of Attention Disorders, 19(2), 125137. doi.org/10.1177/1087054713502080 Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the person-environment-occupation model: A practical tool. Canadian Journal of Occupational Therapy, 66(3), 122-133. doi: 10.1177/00841749906600304 Therapy Dogs United. (2016). What is a Facility Service Dog? Retrieved May 27, 2018 from http://www.therapydogsunited.org/programs/facility_therapy_dog/ Urbanski, B. L., & Lazenby, M. (2015). Distress among hospitalized pediatric cancer patients modified by pet-therapy intervention to improve quality of life. Journal of Pediatric Oncology, 29(5), 272-282. doi: 10.1177/104345424555697 Velde, B. P., Cipriani, J., Fisher, G. (2005). Resident and therapist view of animal-assisted therapy: Implications for occupational therapy practice. Australian Occupational Therapy Journal, 52, 43-50. Winkle, M. Y., & Jackson, L. Z. (2012). Animal kindness: Best practices for the animal-assisted therapy practitioner. OT Practice, 17(6), 10-14. Wohlfarth, R., Mutschler, B., Beetz, A., & Schleider, K. (2014). An investigation into the efficacy of therapy dogs on reading performance in 6-7 year old children. Human-Animal Interaction Bulletin, 2, 60-73. Yap, E., Scheiberg, A., Williams, K. (2017). Attitudes to and beliefs about animal assisted therapy for children with disabilities. Complementary to Clinical Practice, 26, 47-52. http://dx.doi.org/10.1016/j.ctcp.2016.11.009 ANIMAL ASSISTED THERAPY PROGRAM 34 Zablotsky, B., Black, L. I., & Blumberg, S. J. (2017). Established Prevalence of Children with Diagnosed Developmental Disabilities in the United States, 2014-2016 (Report No. 291). Hyattsville, MD: National Center for Health Statistics. ANIMAL ASSISTED THERAPY PROGRAM 35 Appendix A Needs assessment survey questions and responses: Survey used to analyze staff perspectives of the use and need of AAT at Stones Crossing Physical Therapy and Rehab Question 1: Are you afraid of dogs? Yes No 1 respondent (8%) 11 respondents (92%) Question 2: Are you allergic to dogs? Yes No 0 respondents (0%) 12 respondents (100%) Question 3: What therapy profession are you? Occupational therapy Physical therapy Speech therapy 3 respondents (25%) 4 respondents (33%) 5 respondents (41%) Questions 4: What population do you work with? Pediatrics Adults Both 8 respondents (66%) 1 respondent (8%) 3 respondents (3%) Question 5: There is a need for AAT in my population Strongly Disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly agree (5) 0 respondents (0%) 0 respondents (0%) 2 respondents (16%) 7 respondents (58%) 3 respondents (25%) Question 6: AAT would be beneficial for me to use in therapy sessions Strongly Disagree (1) 0 respondents (0%) Disagree (2) 0 respondents (0%) Neutral (3) 2 respondents (16%) Agree (4) 8 respondents (66%) Strongly agree (5) 2 respondents (16%) Question 7: What interventions would you use AAT? Social interaction Communication and language skills Calming strategies Executive functions (motivation, cognition, attention, memory) Sensory integration Emotional regulation ADLs Neurological Fine and gross motor ROM and Strength Balance and gait training Other (please specify) Question 8: Would you support AAT at this site? Yes No 8 respondents (66%) 5 respondents (41%) 8 respondents (66%) 8 respondents (66%) 2 respondents (16%) 4 respondents (33%) 4 respondents (33%) 3 respondents (25%) 4 respondents (33%) 5 respondents (41%) 0 respondents (0%) 12 respondents (100%) 0 respondents (0%) Question 9: What are the potential barriers for implementing AAT at Stones Crossing? What are the benefits? Barriers: Scheduling (3), AAT and therapy concerns such as training, responsibility of taking care of the dog, and approval of services (4), health and safety (4), patients fear of dogs (4), other responses were cost and patients being distracted. Benefits: motivation (8), reduce anxiety and provide support (3), Social interaction/communication (3), alternative therapy for therapists (5), other responses include improving compliance with therapy and set clinic apart from competitors Questions 10: Any questions or comments for me? I will use your feedback to help me research and add information to my project. Feedback given: In-service training would be helpful, use of dog has been very beneficial for me when I have had access to a dog in the past, providing another home for the dog when the handler is on vacation ANIMAL ASSISTED THERAPY PROGRAM Figure 1A. Intervention responses. This figure illustrates the percentage of responses for each intervention listed. 36 ANIMAL ASSISTED THERAPY PROGRAM 37 Appendix B Policies and procedures: Complete policies and procedures for the AAT program Purpose: Therapists will use a trained facility dog to enhance and/or support goal-directed treatment sessions to address physical, emotional, social, psychological needs to increase quality of life in individuals. Policy: A trained facility dog will be used in therapy as a form of alternative treatment to achieve individuals goals. Procedure 1. Handler responsibilities/role: a. The handler determines the schedule of the dog. If the dog needs breaks the handler has a right to deny the use of the dog for treatment sessions. b. The handler will be in charge of ensuring the dog is up to date with veterinary check-ups and vaccinations. c. Copies of vaccinations, parasitic prevention, registration, and ongoing training will be on record at the site. d. The handler will train therapists about commands and triggers of the dog e. The handler will keep up to date with all certifications and training requirements. 2. The dog has five freedoms: a. Freedom from hunger and thirst b. Freedom from discomfort c. Freedom from pain, injury, or disease d. Freedom to express most normal behavior e. Freedom from fear and distress 3. Therapists must be trained by the handler before using the dog in therapy sessions. 4. Therapists who use the dog for therapy purposes should have annual education to review animal assisted therapy to ensure the best practice is used. It is recommended the trainer completes in a minimum of six hours of continuing education per year from Winkle and Jacksons article Animal Kindness published in OT practice. 5. A schedule will be posted in the office where therapists will sign up for 15-30 minute time frames. The handler will be in charge of the schedule 6. Practicing patient safety is key during sessions a. Both patients and therapists must wash hands before and after the treatment session b. Equipment needs to be wiped down after the use of the dog c. If there is an incident with the dog, follow the normal protocol for an incident report d. Signs will be posted outside of rooms where the dog is located so that staff and patients are aware a dog is being used e. To decrease fall hazards, place food, toys, and dog resting area away from high traffic patient areas f. Dog will not be left alone with patients. 7. At evaluation, the patient will be determined if he or she is appropriate for animal assisted therapy. A patient is not appropriate if they answer yes to any of the questions listed: a. Is the child allergic to dogs? If so, how severe? Can the child interact with a dog? b. Is the child/family afraid of dogs? c. How does the child/family view dogs? d. What is the childs/family past relationships with animals? Any aggressive behavior towards animals in the past? e. Does the child have any medical conditions such as serve asthma, open wounds, skin integrity, infectious diseases? 8. Treatment sessions with the dog will be goal-orientated and progress will be evaluated per standard documentation guidelines. The services will be billed like other therapy interventions based on activities completed. ANIMAL ASSISTED THERAPY PROGRAM 38 Appendix C Program proposal: Written program proposal for an AAT program at this site. Introduction The program being requested is an animal assisted therapy (AAT) program for Stones Crossing Physical Therapy and Rehab. The purpose of this program is to use a trained facility dog to enhance or support goal-directed treatment sessions to address physical, emotional, social, and psychological needs to increase quality of life in individuals. Animal assisted therapy is used in a session to support therapy goals. The dog can be used with multiple therapy disciplines and will have a handler who is responsible for the wellbeing of the dog (Morrison, 2007). Research has reported that dogs assist with the treatment of social interaction (Elmaci & Cevizci, 2015; Martin & Farnum, 2002; Sams, Fortney, & Willenbring, 2006; Velde, Cipriani, & Fisher, 2005) executive functions (attention, motivation, and emotional regulation) (Anderson & Olson, 2006; Sams et al., 2006; Schuck, Emmerson, Fine, & Lakes, 2015; Urbanski & Lazenby, 2015; Velde et al., 2005; Yap, Scheiberg, & Williams, 2017) ROM/strength (Elmaci & Cerizci 2015; Winkle & Jackson, 2012; Velde et al., 2005), stress/anxiety (Calcaterra et al., 2015; Dietz, Davis, Pennings, 2012; Elmaci & Cerizci, 2015; Martin & Farman, 2002; Schuck et al., 2015; Velde et al., 2005; Wohlfarth, Mutschler, Beetz, & Schleider, 2014), and overall wellbeing (Elmaci & Cerizci, 2015; Urbanki & Lazenby, 2015). Statement of need There a need for therapy services to address the increase of developmental disabilities across the United States. Centers for Disease Control and Prevention (CDC) completed a study that evaluated the prevalence of developmental disabilities in the United States from 1997-2008. The prevalence of developmental disabilities over 12 years of the study increased by 17.1 percent, which equates to1.8 million more children had a developmental disability compared to the decade before (Centers for Disease Control and Prevention, 2015, p. 1). In 2006-2008, one in six children had a developmental disability. More recently, Zablotsky, Black, and Blumberg (2017) estimated that the prevalence of children diagnosed with a developmental disability had continued to rise from 5.76 percent in 2014 to 6.99 percent in 2016. The results indicate the rising need for interventions to assist these individuals to live a more independent lives and be able to participate in meaningful activities. Program ANIMAL ASSISTED THERAPY PROGRAM 39 At evaluation, the patient will be determined if he or she is appropriate for AAT. If a patient is severely allergic (Goddard & Gilmer, 2015; Urbanski & Lazenby, 2012; Velde et al., 2002; Winkle & Jackson, 2012), is afraid of dogs (Goddard & Gilmer, 2015; Winkle & Jackson, 2012; Yap et al., 2017), has cultural or religious views that impact the relationship with the dog (Winkle & Jackson, 2012), has past history of abusing animals or aggressive behavior (Urbanski & Lazenby, 2012; Winkle & Jackson, 2012), and/or has medical conditions such as severe asthma, open wounds, weak skin integrity, or infectious disease (Goddard & Jackson, 2015; Urbanski & Lazenby, 2012) he or she would be deemed not appropriate to engage in AAT. A staff member is going to be the handler of the dog. The handler is responsible for the wellbeing of the dog. This includes water, food, veterinary care, and giving the dog breaks during the day (Ng, Albright, Fine, and Peralta, J. 2015; Winkle & Jackson, 2012). The handler is responsible for the schedule to use the dog (Ng et al., 12015; Winkle & Jackson, 2012). The schedule will be assigned a location in the office and therapists will sign up to use the dog for 15-30 minute increments. The handler will train staff on the commands and stresses of the dog. All staff members who plan on using the dog in therapy must be trained by the handler before they can use the dog. At a minimum, the handler should complete six hours of continuing education regarding AAT to ensure best practice. In-services should be provided annually for staff who use the dog in therapy (Winkle & Jackson, 2012). To ensure patient safety, hand washing procedures and wiping down equipment must be followed. Signs will be posted outside of therapy rooms where the dog is being used so the staff and patients are aware. Food, toys, and the dogs resting area need to be placed away from high traffic patient areas to decrease fall hazards (Velde et al., 2002). Patients will not be left unattended with the dog. If an incident occurs, follow the normal incident report protocol (K. A. Reuter, personal communication, April 27, 2018). The dog also has freedoms and should be treated with respect. The five freedoms are freedom from hunger and thirst, freedom from discomfort, freedom from pain, injury, or disease, freedom to express most normal behavior, and freedom from fear and distress (Ng, Albright, Fine, and Peralta, J. 2015). Treatment sessions with the dog are goal-oriented and will be billed as services that are already covered under insurance (K. A. Reuter, personal communication, April 27, 2018). SWOT analysis A strengths, weaknesses, opportunities, and threats (SWOT) analysis was used to assist with structuring the program. A SWOT analysis is a strategic tool that is used in marketing and business (Gregory, 2018). A SWOT analysis is helpful because it outlines the strengths, weaknesses, opportunities, and threats of a program. The ANIMAL ASSISTED THERAPY PROGRAM 40 developer can evaluate the weaknesses and threats and try to come up with strategies to overcome those obstacles. Also, the developer can highlight the strengths and opportunities that a program can provide for a company (Gregory, 2018). The writer chose to use the SWOT analysis matrix to structure the program and provide organization. The SWOT analysis matrix is listed below. Strengths - Flexibility to be used across the lifespan - Multiple therapeutic benefits - Dog can be used in combination with treatment - Motivation - Decrease anxiety - Social interaction and communication - Improve therapy compliance Weaknesses - Learning curve on how to document and incorporate dog into therapy - Cost - Scheduling of dog and patient care - Safety - Allergies/fear of dog - Patients getting distracted Opportunities - Alternative form of therapy - Set apart from nearby competitors Threats - Company policy Not having a dog in the past Long wait list Travel and time for handler training For weaknesses, the student is going to give an inservice about using the dog in therapy and how the program will be structured. Guidelines will be listed in the policies and procedures. Therapists can use these guidelines to address allergies, fear, safety, and scheduling guidelines. Not every child will be appropriate for AAT due to medical conditions, getting too distracted, or background with an animal. There are guidelines listed in the policies and procedures to address what child may be appropriate for AAT. The handler will receive training on how to incorporate the dog into therapy and will train other therapists. AAT organizations were considered based on a variety of factors including cost. The student found an organization that provides a dog for no charge and an organization that provides a dog at low cost. Therapists at Physical Therapy and Rehab Fort Ben already utilize AAT. An interview was conducted with the handler who provided information on how the site documents with the dog in therapy. The therapists at Physical Therapy and Rehab Fort Ben can also provide some guidance for ANIMAL ASSISTED THERAPY PROGRAM navigating company policy. Unfortunately, there is a long wait list to receive an animal but the strengths and opportunities for the program outweigh the threats of having a long wait list, travel time, and handler training. 41 ANIMAL ASSISTED THERAPY PROGRAM 42 Appendix D Pre/post Survey: Survey given to staff members before and after presentation and after resource materials. Survey Please circle or write your response Pre 1. 2. 3. 4. 5. 6. I understand the purpose of AAT in therapy Strongly disagree Disagree Neutral 1 2 3 Agree 4 Strongly agree 5 I understand how to utilize AAT into therapy sessions Strongly disagree Disagree Neutral 1 2 3 Agree 4 Strongly agree 5 I understand my responsibilities when using a dog in therapy sessions Strongly disagree Disagree Neutral Agree 1 2 3 4 Strongly agree 5 I understand what individuals are able to participate in AAT Strongly disagree Disagree Neutral Agree 1 2 3 4 Strongly agree 5 I understand how to document and bill AAT Strongly disagree Disagree Neutral 1 2 3 Agree 4 Strongly agree 5 I feel comfortable with AAT being offered at this site Strongly disagree Disagree Neutral 1 2 3 Agree 4 Strongly agree 5 I understand the purpose of AAT Strongly disagree Disagree 1 2 Agree 4 Strongly agree 5 Agree 4 Strongly agree 5 Post 1. 2. 3. 4. 5. Neutral 3 I understand how to utilize AAT into therapy sessions Strongly disagree Disagree Neutral 1 2 3 I understand the my responsibilities when using a dog in therapy sessions Strongly disagree Disagree Neutral Agree 1 2 3 4 Strongly agree 5 I understand what individuals are able to participate in AAT Strongly disagree Disagree Neutral Agree 1 2 3 4 Strongly agree 5 I understand how to document and bill AAT Strongly disagree Disagree Neutral 1 2 3 Strongly agree 5 Agree 4 ANIMAL ASSISTED THERAPY PROGRAM 6. 7. 8. 43 I feel comfortable with having AAT offered at this site Strongly disagree Disagree Neutral 1 2 3 Agree 4 Strongly agree 5 The presentation answered my questions about AAT Strongly disagree Disagree Neutral 1 2 3 Agree 4 Strongly agree 5 Feedback to improve presentation and/or materials?  ...

... Running head: DOCTORAL CAPSTONE LEVEL OF CARE 1 Development of a Level of Care Assessment for the PACE Program Brown, K. OTD 2018 May 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Rebecca A. Barton, DHS, OTR, FAOTA DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT A Capstone Project Entitled Development of a Level of Care Assessment Using the Person-Occupation-EnvironmentPerformance Model for PACE Program Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Kelsey Brown Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT Abstract Background/Purpose: At Franciscan Senior Health and Wellness PACE Program, the individuals served are 55 years or older and require skilled nursing level care. A programmatic need identified for the site included the creation and implementation of a tool to determine appropriate living environments for participants. Falls prevention was also identified as an area needing development. Falls commonly occur among the frail elderly and decreasing falls is a reoccurring challenge the PACE team faces with their participants. Essential Features: A Level of Care Assessment was developed for the team to use when a participant asks about moving assisted living, or the team feels a participant may need to consider other living options. Once the tool was implemented, the student created and administered a survey to assess staff perception and acceptance of the level of care tool. The student also started the Center for Disease Control and Prevention (CDC) fall prevention Stopping Elderly Accidents, Deaths & Injuries (STEADI) program at PACE. The student gave presentations on implementing STEADI and use of the tool to increase staff understanding and acceptance. Outcomes: The student effectively implemented the CDCs STEADI program at the PACE center to decrease falls by providing resources and consistent interventions for practitioners to follow. The student was also able to address the need for a level of care tool by creating the Level of Care Assessment. The student provided corresponding intervention charts, and protocols for use of the tool depending on the context. Acceptance of using the tool was high as determined by the survey. The survey results were presented to staff at an all staff meeting. A follow-up study is recommended to determine whether the changes at PACE decreased falls and increased participants quality of life over time. 3 DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 4 Development of a Level of Care Assessment for the PACE Program Literature Review The Franciscan Senior Health and Wellness PACE Program is a member of the Program of All-Inclusive Care (PACE). PACE is a unique model of managed care available to individuals who meet the following requirements: 55 years of age or older, residing in one of the zip codes included in the PACE service area, require skilled nursing level care, defined as clinically eligible by the Indiana Area Agencies for Aging, and have the desire and ability to live safely in the community (Franciscan Health, 2018). Managed care in this setting is defined as an agreement between the service provider (PACE) and service recipient (PACE participant) agreeing to only receive health care services through Franciscan Senior Health and Wellness in place of Medicare and Medicaid benefits (Franciscan Senior Health & Wellness, 2014). The Franciscan PACE Program is one of 233 PACE centers located across 31 states. PACE provides all-inclusive healthcare to the participants of the program. PACE offers services including therapy (at home or in the clinic), attendance to the PACE adult day center, provides medications, medically necessary transportation, hospitalization or nursing care, durable medical equipment, doctors and nurses visits and more (National PACE Association, 2018). The focus of the program is community-based treatment, so maintaining a participants ability to live at home is very important. It is appropriate to address factors that promote independent living as well as factors that hinder it. While the PACE program strives to keep participants in their homes, some participants reside in assisted living and long-term care facilities depending on their needs. Safety is the main concern when working with participants and is the determining factor for staying in their homes. For this reason, home evaluations, home modifications, and falls prevention have been identified as areas influencing a participants ability to live safely at home. DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 5 The Person Environment Occupation Performance theory (PEOP) was used to guide this research. The PEOP can be used to help understand how the person, occupation, and environment work together to produce the participants occupational outcome or performance (Cole & Tufano, 2008). The participants roles, tasks, and activities are important to consider when looking at performance and their ability to complete tasks is almost always influenced by the environment in which the activities are taking place (Cole & Tufano, 2008). With safety in the home being so important, the PEOP model can be used to assess and conceptualize occupational performance as the participants environments are modified to be safer. With a safer functioning environment participants occupational performance will improve as their daily tasks will be easier to complete. According to this model, dysfunction is viewed as a person experiencing limited occupational performance due to a restrictive environment, deficit in ability or health condition, or limiting barriers (Cole & Tufano, 2008). At PACE, therapists are working toward improving participants overall function in the least restrictive and safest environment. Falls are a common and reoccurring incident within the PACE population as well as the older adult population. According to the Centers for Disease Control (CDC), every second of every day an older adult falls and every 20 minutes an older adult dies because of a fall (CDC, 2017a). Falls result in a variety of injuries ranging from minor soft tissue damage to severe brain injuries and in some cases even death (Oliver, Healey, & Haines, 2010). Soft tissue damage, minor fractures, and even falls that do not result in injury have a negative impact on participants emotional and physical wellbeing. Falls have been shown to lead to increased anxiety, limited engagement within ones environment, and distress (Oliver, Healey, & Haines, 2010). Of the 104 participants who were enrolled in the PACE program for the entire 2017 year and did not disenroll or pass away, there were a total of 126 falls. Two participants fell seven times in 2017 and DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 6 three participants fell six times in 2017. PACE data revealed most falls occurred in August, with a record of 17 falls. The falls data was recorded by the sites quality coordinator. There are many factors that influence falls, including both intrinsic and extrinsic factors. Intrinsic factors are defined as factors deriving from the individual, including age, diagnosis, cognition, other personal impairments, and previous falls (Grundstrom, Guse, & Layde, 2012). Extrinsic factors are outside of the participants control and may include: time of day, polypharmacy, or environmental factors such as home set up, or poor lighting (Grundstrom, Guse, & Layde, 2012). Furthermore, the CDC recognizes home hazards as one of the seven main risk factors linked to older adults falls (CDC, 2017b). Stevens, Baldwin, Ballesteros, Noonan, & Sleet (2012), state that risk factors for falls should be approached with great detail by addressing environmental factors, behavioral factors, biologic factors, and socioeconomic status. The PACE program does assess all aspects of the participants personal factors, home-set up, and medical history, striving to address all factors using an interdisciplinary team. With falls being such a prominent issue within the older adult population, interventions need to be implemented, especially considering that 78% of older adults fall related injuries take place at or near their home (Pynoos, Steinman, & Nguyen, 2010). Research shows that the bulk of older adults in the United States want to remain in their homes and age in place (Fausset, Kelly, Rogers, & Fisk, 2011). Aging in place refers to a persons ability to remain in their own home safely as they age (Fausset, Kelly, Rogers, & Fisk, 2011). Home evaluations by skilled professionals are necessary for older adults with health conditions that may affect their safety and desire to reside in their homes (Stark et al., 2018). Home evaluations are completed to identify barriers in the home and influence recommended modifications to decrease environmental hazards (Pynoos, Steinman, & Nguyen, 2010). Home modifications may be DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 7 completed by occupational therapists as they have training and knowledge regarding home modifications, adaptive equipment, and the ability to assess the person, occupations, and the environment. When hazards are identified and removed by occupational therapists, falls are significantly reduced (Stark et al., 2018). A multifactorial assessment should be completed to determine safety in the home, not only a home evaluation, but also an occupational history, including falls, gait, balance, and cognition (Bradley, 2011). The PACE center does follow these common guidelines, completing initial evaluations that address falls, balance, home set-up, safety, and other related factors. Home modifications are most beneficial to their intended audience when they consider the individuals current level of function, health status, and the way they interact with their environment (Pynoos, Steinman, & Nguyen, 2010). When modifications are suggested to be made to the home that are not client centered, the adherence rate can be as low as 33-40% (Stark, Landsbaum, Palmer, Somerville, & Morris, 2009). Individuals with home modifications have increased perceptions of daily task completion, increased activity performance, as well as demonstrate increased overall independence (Stark, Landsbaum, Palmer, Somerville, & Morris, 2009). Common home modifications may include inexpensive measures such as removing throw rugs, removing clutter, adding additional lighting, grab bars, incorporating memory reminders, and addressing safety hazards. More expensive modifications may include equipment for bathroom safety, building a ramp, or extending doorways to accommodate a wheelchair. It is a common occurrence for older adults to be unable to identify all of the risk factors in their homes as identified by Horowitz, Nochajski, & Schweitzer (2013), finding that older adults looking for risk factors did not initially consider something in their home a safety concern, until it was put DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 8 into context by an occupational therapist. This provides further evidence for the importance of occupational therapists identifying hazards in the home and also providing recommendations for devices that may help keep participants safer. Screening/Evaluation Screening was completed over the course of two weeks. This was completed by observing treatment sessions with every discipline, attending meetings and gathering information on commonly mentioned concerns. Evaluating the site occurred through a needs assessment. A needs assessment is a combination of collecting, analyzing, and distributing information about an organization to understand and identify its needs (Scaffa & Reitz, 2014). The student completed a thorough needs assessment with the (IDT) to determine the needs of the site. The IDT includes an occupational therapist, physical therapist, physical therapy assistant, social workers, quality coordinator, nurse, nurse practitioner, recreational therapist, and home care coordinator. To complete the needs assessment, the student discussed the needs of the center in a group setting and one on one interviews, asking facilitating questions to determine concerns related to participant care. The student also aimed to identify the effects of the concerns on the participants. During a team meeting, it was brought up that multiple participants or their families had recently inquired about moving to an assisted living facility. A common concern among the interdisciplinary team was that there was not a standardized assessment to determine if a participant should move into an assisted living facility. With PACE, all participants require nursing level care to qualify for the program, so every participant qualifies for assisted living (Franciscan Health, 2018). While this is true, the vision of PACE is to help participants remain in the community with the highest level of independence possible (National Pace Association, 2018). This means helping participants live DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 9 in their home for as long as possible and as safe as possible. Many PACE participants requiring a high level of care are successful at home when provided with home care hours and other recommended services. Providing the right supports in the home are crucial to maintain a participants safety and ability to live at home (Fange & Ivanhoff, 2009). The PACE program nationally keeps about ninety percent of their participants living in the community, and this is the goal of all PACE programs (National PACE Association, 2018). Living at home is often considered safer for individuals with physical and cognitive impairments due to their familiarity with the environment (Fange & Ivanhoff, 2009). However, many studies also support modifying and changing home environments to increase safety and occupational performance. If a participant is determined unsafe at home after all interventions have been implemented, then other options are discussed. Typically, the next step is to move into an assisted living facility. But, assisted living facilities are often costly, with research showing that many Americans cannot afford to move themselves or a family member into the types of assisted living facilities they prefer (Ball, Perkins, Hollingsworth, Whittington, & King, 2009). PACE provides subsidized housing rates for their participants residing in assisted living, and the participant pays a fixed amount out of pocket each month. This is a major benefit for individuals who need assisted living services to remain safe. Unfortunately, some PACE participants inquire about moving to assisted living only because of the cost, as the rent for assisted living may be less expensive with the subsided rate than what they are currently paying for their home. Without the subsidized rent, it is more cost effective for an individual to remain at home with both formal and informal caregivers than it is to move to an assisted living facility (Chappell, Dlitt, Hollander, Miller, & McWilliam, 2004). Participants are not able to move into an assisted living only for the cost break, they must also require the services provided. With PACE paying the DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 10 majority of the assisted living costs, it is imperative that the individuals moving to assisted living really require the services offered to be successful and safe. After further research and an in-depth discussion with the quality coordinator and occupational therapist, the decision was made to begin working on a tool to assess appropriate living situations. The needs assessment also revealed a need for corresponding interventions including a program to address falls. The tool to determine living environments includes interventions to increase safety at home based on how participants score. This will improve quality of care, participant outcomes, and increase occupational performance. The tool provides clear guidelines to assist practitioners in determining the least restrictive environment for PACE participants and what interventions should be taken. The student analyzed current falls statistics, observed the current decision-making process, and collected information on the requirements for assisted living. The student also reviewed current policies and procedures regarding home safety, qualifications for home care hours, falls prevention, and transition services offered. The tool addresses the need for standardized procedures when determining if assisted living or other home environments are the least restrictive environments for the participants. The corresponding interventions ensure that there is consistency with implementation and the falls prevention program will keep people safer in their homes longer. Determining whether someone is safe to live at home is a common service that occupational therapists and other health care providers provide. PACE, however, has a unique amount of stake in the decision. PACE is not only the service provider but also the insurance provider. Providing managed care gives PACE the ability to have skilled professionals determine what is necessary for their participants. Safety and quality care is always the goal during the decision-making process. The PACE team and the participant make the ultimate decision when DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 11 determining where a participant will live. In a traditional setting, a therapy team may make a recommendation for assisted living, but that does not mean that the individual will be able to afford it or will qualify. This form of service delivery varies from other models of care in terms of services and items covered. In most settings, a therapist may make a recommendation for a modification or device but that does not mean that the request will be fulfilled. PACE completes requests after they have been agreed upon by the interdisciplinary team as necessary to improve quality of life or provide greater care. PACE also offers many types of equipment and services that a standard insurance would not approve. For example, PACE will order lift chairs, pay for caregiver respite days, order blenders, pay for someone to help a participant pack their items in preparation to move, and cover types of adaptive equipment not covered by a standard insurance. The PACE occupational therapy program runs similarly to a variety of other settings offering occupational therapy services. The occupational therapist (OT) working at PACE has outpatient therapy sessions with PACE participants who attend the adult day center. The OT also completes home visits for those who do not come to the adult day center or the clinic for treatment. This is a different service model than most, as the OT completes home visits, hospital visits, monitors participants overall health status, and completes administrative insurance related tasks. To ensure quality of care is provided, treatments outside of the OTs comfort level or expertise, are referred to an in-network professional that can provide the appropriate care. Another difference between PACE and other centers, PACE therapists do not bill insurance for their time, as they are the insurance company and all services are covered. Instead therapists only document the time spent with the participant and the treatment details. PACE is a unique setting where the participants can receive therapy as needed, regardless of the progress they are or are not making. Occupational and physical therapy also hold a restorative daily exercise group for DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 12 those who attend the adult day center. For those who do not attend, they are provided with a custom home exercise program and frequently visited and re-assessed by members of the interdisciplinary team. This ensures quality care by skilled professionals even if they are not currently on caseload for skilled services. Implementation Phase Program Planning After the student completed the needs assessment and identified the need for a tool to help determine the most appropriate living environments for PACE participants, program planning began. Program planning included first evaluating the current outline of information suggested by the quality coordinator. The student obtained a level of service form used by the assisted living facility that houses most of the PACE participants. This tool is used to determine how much care the assisted living facility must provide to PACE participants (Altenheim Health and Living Community, 2013). The quality coordinator reported that a portion of her original outline was adapted from this form. The student reviewed forms the team were already required to complete during IDT meetings. This was done to ensure the team would have time to complete an additional form and to better understand the standard scoring systems. Then the student discussed implementation with the staff to develop a timeline and completion date. Meetings were set for the interdisciplinary team (IDT) to examine the tool and make suggestions for edits as necessary. A projected completion date was set for three weeks from the date the student began working on the project. Meetings were held each Friday to determine the status of the tool until the tool was completed. Development DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 13 The development process included first reviewing what the quality coordinator wanted in the tool and speaking with OT, PT, nursing, and social work to determine what factors they assess when evaluating safety at home. All of the suggestions were researched and added to the tool as they pertained to home safety and function. Items added to the original document included locomotion, transfers/bed mobility, stairs, and conditions or services that warrant an increase in level of care. Each item was divided into four scoring levels with corresponding percentages in the scoring definition to ensure valid scoring. The scoring of each item was rated based on the participants functional ability. A score of independent was worth zero points and was given when a participant could complete the task independently or modified independent. A score of minimal assistance was worth one point and was given when the participant requires supervision or set up to complete the task and performs 75% or more of the task. A score of moderate assistance was worth two points and given when the participant completed 50%-74% of the grooming task. A score of maximum assistance is worth three points and given when the participants completes less than 50% of the task. The student and the quality coordinator wanted a low score to indicate a lesser level of care for easy interpretation. The scoring and wording went through many stages of change throughout the creation process. The sections of the new tool were established after speaking with the team and reviewing multiple different types of assessments and documents. Documents reviewed include: Medicaid Level of Service Assessment/Evaluation, The Occupational Therapy Practice Frameworks definitions of Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs), PACE Home Care Assessment Tool, Altenheim Functional Assessment, review of the FIM, and the AM-PAC 6-Clicks (CMS, 2017; AOTA, 2014; VanderVeen, n.d.; Altenheim Health and Living Community, 2013; UBFA, 2001; Jette, et al., 2014). Once the tool was DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 14 completed, maximum points were totaled, and five levels of care were determined. The Level of Care Assessment was created and reviewed by multiple parties, including the student, PTA, quality coordinator, and OT to ensure all relevant areas of evaluation were included in the new tool. Wording and formatting errors were addressed by the student prior to presenting the tool to the entire team. Levels were determined to give a clearer understanding in which environments the participants might be the most successful. The student established the total score for the tool, not including additional points given for falls and hospitalizations. The total was established by adding the total points. After determining the highest score, the student and the quality coordinator determined a need for levels including: home, assisted living, and long-term care. After assessing a total of 20 participants at various levels using the tool, the need for 5 levels were established. The total points were distributed between five levels with the first two levels consisting of one more point each. Levels 1 and 2 participants will be most successful at home, levels 3 and 4 most appropriate for assisted living, and level 5 most appropriate for long term care. Consistent with the PACE mission, everyone who can live at home will have the opportunity to try with the correct supports (National Pace Association, 2018). Therefore, interventions for each level were created with recommendations or requirements to keep a participant in their home. The team determined that if all interventions were implemented and the participant was still not successful at home, then the IDT would reassess and consider assisted living (See Appendix B and C). Inter-rater reliability is established when multiple raters use the same tool and then compare their results to ensure scoring is synonymous across all raters (Sullivan, 2011). Determining inter-rater reliability differs in this setting as the tool is meant to be completed as a DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 15 team. The tool would not produce accurate results if each team member completed the assessment individually, as every team member brings different information about the participant to the discussion. There were no duplicate positions, so the student was unable to have different teams complete the tool and compare results to determine reliability. Test-retest reliability is present when an assessment tool produces the same results each time it is completed without change in the participants status (Sullivan, 2011). Test-retest reliability was established by completing the tool, measuring the same participants functional abilities at different times and producing reliable and consistent results. Test-retest reliability was also established after comparing the initial participants assessments that the student and the quality coordinator completed to the official participants assessments completed as a team. While the scores varied slightly, the level the participant was placed in remained consistent. Content validity is achieved when a test measures what it is was designed to measure (Sullivan, 2011). Content validity was agreed upon as established by the team after completing the tool and assessing ADLs and IADLs consistent with the OT evaluation, mobility consistent with how the PT evaluated the participant, and the cognition questions consistent with what social work assessed. The scoring was valid because the student completed training with the staff to ensure they were competent and comfortable using the tool and understood how to complete the scoring. Validity was also addressed through the feedback survey given by the student. One question of the survey addressed how accurately the Level of Care Assessment determined the correct level of care. Sixty-seven percent of staff strongly agreed the tool accurately determined appropriate levels of care and thirty three percent agreed. Full results of the survey are disclosed later in the paper. DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 16 The tool was utilized with PACE participants to determine the validity of the results. The IDT used the tool, assessing many participants of the PACE program. Participants were chosen to be scored based on their known need of assistance level and ranged from needing low levels of care to high levels of care. The assessments were completed multiple times over multiple days, showing the tool to be reliable and valid. (See Appendix A). The student also addressed the concern of needing a falls prevention program and began researching the Center for Disease Control and Prevention (CDC)s program Stopping Elderly Accidents, Deaths and Injuries (STEADI) (CDC, 2017b). The student took the online STEADI certification course and received a certificate of completion. The student then compiled the STEADI resources and created a short presentation to present to the therapy team and gain interest in incorporating the program. The student created a flowsheet formula that will auto populate into participant flowsheets in the sites documentation system. The flowsheet will list the screening questions that STEADI suggests practitioners first ask. The flowsheet then provides a number based on how the participant answers the screening questions to determine if the participant is a fall risk. The student also created a smartnote in the facilities documentation system outlining what steps need to be taken per STEADI protocol after a fall. The smartnote has an outline of which assessments need to be completed with the participant. A second smartnote was created to outline what preventative fall interventions should be implemented after screening. The interventions provided by STEADI vary based on how at risk the participant is for falling. These interventions were woven into the Level of Care Assessment mentioned above. This was done because the CDC STEADI program is highly regarded in terms of falls prevention, provides standardized DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 17 gait and balance assessments, effective screening tools, and includes methods to incorporate STEADI into practice (CDC, 2017b). Implementation Implementation of a program is the progression of beginning a new process or use of a new tool. Starting a new program functions best when the current staff is interested in a change, leaders are intent on improvement, a need has been identified, and there is a means for action (Hebert, Thibeault, Landry, Boisvenu, & Laporte, 2000). At PACE, implementation of the new Level of Care Assessment was simple to incorporate into current practice. The staff was receptive to the use of the tool and had previously expressed a desire for a tool of this type. The tool was ready for use with the IDT after educating the IDT on how it worked and what each category encompassed. The form will be completed once a year by the IDT using their collective knowledge of the participant; meaning that the tool will be completed without the participant present. The tool was also completed within the first month of a new participant joining PACE to establish a baseline. The tool may be completed more frequently if participants are eligible for a level of care re-assessment, if the participant or their family has inquired about moving to assisted living, or if the participant has experienced a significant change. In this setting a significant change is classified as two or more disciplines in the IDT identifying a significant change relevant to their discipline. IDT meetings occurred once a week and the quality coordinator sent out a list of participants that were due for review. The IDT completed the tool collaboratively determining the appropriate score for each item listed. The tool included information ranging from number of falls and hospitalizations to the amount of assistance a participant needed with ADLs, IADLs, and mobility. The team used their clinical judgement to select the appropriate interventions from DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 18 the interventions lists based on the participants score and corresponding level. These interventions are recorded at the bottom of the tool and the tool is uploaded to the participants chart. Once the tool has been completed, the results of the tool will be conveyed to the participant and their family both in person and in writing. Implementation of the STEADI protocol was not near as seamless as implementation of the Level of Care Assessment. The PT and OT on site were very excited and receptive to introducing a falls prevention program. The program was implemented once the therapists completed the online training course, the smartnotes were ready for use, and the student had provided therapists with all relevant handouts. The student and dietician created a Vitamin D and Calcium protocol for the nurses to implement with new participants and participants at risk for falls. The protocol includes dosages and frequencies of labs and recommendations based on falls status. However, the student continued to receive slight push back from nursing staff despite education and the rest of the team being on board. to The OT and PT began implementing the STEADI protocol by completing the algorithm and screening questions provided by STEADI to determine how at risk a participant was for falling. The current goal is to begin using the algorithm on those who have just fallen and new participants. Eventually the site hopes the screening will have been completed with every participant. Once screened, the PT then completes a gait and balance test with the participant, and OT completes a vision screen as part of their initial assessment. If a fall has occurred, therapists review the interventions and complete as appropriate. STEADI classifies older adults into categories of low risk, moderate risk, and high risk with individualized interventions for each and these responsibilities were divided between disciplines for even implementation (CDC, 2017b). Leadership DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 19 The student demonstrated leadership skills by developing a detailed plan for completion and review of the Level of Care Assessment tool. The student was also responsible for establishing and facilitating discussions to decide upon completion and implementation dates for the tool. The student further demonstrated leadership skills by requesting meetings with involved parties to review the use of tool and when it should be completed in the care plan process. As an independent student, it was imperative to schedule meetings with other disciplines to ensure collaborative and interdisciplinary input. As a student, it was important to ensure that the meetings were on track, purposeful, and always occurred on time. This type of project is very independent and self-initiated therefore, it is important to remain focused and on top of the project at hand. The student maximized time by delving into the literature to provide practitioners with relevant information and to better understand effective interventions for participants. Having effective leadership skills improved not only the quality of the tool produced but also made the implementation phase seamless. Building rapport with other professionals at the site during the doctoral capstone experience also assisted in the implementation of the tool. To market the tool, the student requested time to speak to the team during an IDT meeting. The student emphasized that the new tool may take time to complete but it has many of the same components as the forms required for the Levels of Service Assessments and the Functional Assessments to be completed for an assisted living community. Having this information in one central location makes it easier for the social work team to complete these forms. The social work team will no longer have to take time out of their days to speak with each discipline separately. The student explained that the tool with corresponding interventions will also simplify the Home Care Coordinators evaluation of needed home care hours. The home care DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 20 coordinator reported she did not prefer using the current home care assessment tool and was excited to have the levels of care tool help determine hours. With the help of the PTA and the home care coordinator, suggested home care hours were built into the intervention section of the new Level of Care Assessment based on the participants level. A benefit of the tool is that it provides a score and concrete reasons as to why a certain participant may or may not be appropriate for assisted living. It also provides a simple way to indicate to a participant or their families why assisted living is the recommendation of the team. The last piece of information the student presented during the IDT meeting was the benefit of having an electronic template that can be easily saved into the participant folder and updated as needed. This allows for a simple update to be made to the form when the participant is re-evaluated. To market the STEADI program, the student gave a short presentation during an IDT meeting. The student worked through the algorithm and explained the benefits of starting a specific falls prevention program. The student also showed the team how to access the online training and how to submit their post test results to earn continuing education credits (CEUs). Most staff members were intrigued by the free online course and CEUs. The quality coordinator was receptive to beginning the program as she will now have specific interventions to include with her falls tracking. The quality coordinator is responsible for tracking and enforcing the STEADI portion of the falls interventions. Staff Development Staff development was addressed by explaining the Level of Care Assessment in great detail. The student and the quality coordinator explained how to complete the tool, how to work the auto-totaling features, determine suggested level of care, and read the intervention charts. This form was completed during IDT meetings, with one person controlling the computer and DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 21 inputting the data while it was projected on the screen. This was done to ensure that every discipline was involved and understood how each section was being rated. Staff development was promoted by requiring the forms to be completed as a group. This was also achieved through the continuous knowledge gained by reviewing participants needs and other disciplines treatment approaches. The team was asked to review participants before they attended the IDT meetings. This has always been a requirement and the staff did a good job of knowing their participants and arriving prepared. Staff members were competent in their job descriptions and capable of completing the tool accurately and efficiently. The quality coordinator was required to come with data on the participants being reviewed, including number of falls, hospital admissions, and number of medications. The quality coordinator was also in charge of tracking intervention implementation and sending out reminder emails to review certain participants before the meetings. She was responsible for continued staff education and management tasks related to completing the tool once the student left. Further staff development was incorporated by educating the staff on the number of falls occurring each month and per participant on average at PACE. This was followed up by giving brief information about the implementation of the STEADI protocol. The student strongly suggested all participants of the IDT completed the online certification training for STEADI falls prevention. The course not only offered CEUs but valuable information that was very relevant to everyday practice at PACE. Outcome/Discontinuation Phase Outcome During the outcome phase, the student established how the changes to the PACE Program had been received by the staff. The Level of Care Assessment will be an ongoing tool that will DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 22 continue to be used after the student has completed the capstone experience. The goals behind creating the Level of Care Assessment include creating a standardized tool that will be completed once yearly to help determine appropriate living situations, decrease falls, increase quality of care, and establish a way to provide consistent and effective interventions. It is not possible to effectively determine participant outcomes after use of the tool and interventions now. These outcomes will need to be determined longitudinally. During the students time at the site, five participants were transitioning from their homes into an assisted living facility per the results of the tool. However, the student was unable to determine if the interventions have decreased falls or resulted in increased quality of life for these participants due to the recency of implementation. The student did, however, administer a survey to the members of the IDT requesting information about the new tool (See Appendix D). The survey was brief, containing five questions. Four questions required members of the IDT to rate each question using a Likert scale, rating each item on a scale from one to five. A score of one indicates the IDT member strongly disagrees with the statement, while five indicated they strongly agree. The questions on the survey covered ease of use of the tool, accuracy, relevance, and whether utilization would improve quality of care. The fifth question asked for a narrative response, asking the members of the IDT for suggestions and comments regarding the implementation or use of the tool. The paper survey was dispersed to the ten members of the IDT. The student and the quality coordinator did not take the survey to avoid bias. The results of the survey are as follows: out of the ten surveys, nine were returned. Staff members were asked to complete and return the survey within five business days. Overall, there was good acceptance of the Level of Care Assessment. Questions three, and four had the same results, 55.6% of staff members reported DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 23 these items as a 5, strongly agree. For questions three and four, 44.4% rated these three items as 4s, meaning they agree. The lowest rated item was the first question regarding the language used on the tool, with 55.6% of respondents reporting they strongly agreed that the tool was easy to use, 33.3% agreed it was easy to use, and one respondent, accounting for 11.1% reported a 3, neutral. The highest rated question was question two, with 66.7% of staff members reporting they strongly agreed the tool accurately determined levels of care, and 33.3% stating they agreed. The qualitative data obtained from the last question had a common theme with two members of the IDT leaving comments related to determining the consistency and goals of the tool and the interventions. One IDT member wrote, So far it [the tool] is very useful and helpful. After the results of the survey were analyzed, the student took the results to the IDT meeting and asked for more feedback from the IDT to assure that the tool was something they felt comfortable using and to address common themes identified by the survey. The team came up with the idea to also use the tool to establish a baseline at initial evaluation, as this was not an initial consideration of the student and the quality coordinator. Using the tool at evaluation and throughout the year will help track changes in participant independence levels over time. The team also requested specific protocols be developed for each situation that they tool may be used in, so they would know exactly how to proceed. The student created protocols for each of the four situation the tool would be used. The protocols were approved by the quality coordinator and agreed upon by the team. The protocols were sent via email to the team containing specific protocols. The team reported the protocols made using the tool much simpler, as they now know in what order to complete the preliminary work. The student also tracked the use of the Level of Care Assessment and recorded who the tool was used with by documenting the participants private PACE ID number. The student kept DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 24 a password secure excel document and recorded the level each participant was placed in, their current living situation, number of falls in the past year, interventions chosen by the team, and the participant outcome. Integrating the STEADI program was an ongoing component of the students project. Therapy staff was been receptive to using the smartnotes and smartphrases designed for following STEADI protocols in EPIC. The PT reported, I really appreciate having the STEADI smartnotes, it helps me know exactly what to assess (Major. J, personal communication, February 26, 2018). The long-term goal of implementing the STEADI protocol was to decrease falls. This cannot be determined at this time due to the how recently the STEADI protocols have been accepted into practice. The student met goals established in the memorandum of understanding (MOU). The MOU went through several revisions as the student identified needs of the site. The student developed a level of care assessment tool utilizing aspects of home evaluation tools, literature, assisted living facility requirements, and effective interventions. The student also met the goal of becoming certified in the CDC STEADI Falls Prevention Program and implementing STEADI protocols. During the project, the student assisted with the development of a database, compiled evidence related to falls prevention and created a binder of literature for the site. The student was also able to research alternative living models including the Emerson House, Green House Cottages of Carmel, and review literature regarding alternate and successful living models globally. Discontinuation The ongoing process for quality improvement once the student has left the facility will be completed by the quality coordinator. As mentioned above, the student is currently tracking DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 25 when the Level of Care Assessment was completed, and other important information. The excel document will be given to the quality coordinator for her to continue the tracking once the student has completed the project. The program changes that were implemented to ensure quality of services included starting to use the new tool and implementing more interventions after falls. The student worked closely with the quality coordinator to modify the previous administrative process for determining appropriate living environments. The previous process included filling out a Resource Allocation Decision Form (RAD) and bringing it to the IDT meeting. The team would then discuss the request to move to an assisted living facility. The team would collaboratively determine whether the participant was appropriate and would relay the information to the participant. The IDT recognized that this was not the most effective way to determine such an impactful decision. With the tool, the team has a concrete number to give to participants when delivering the news of if they should move or stay home and directly correlated interventions to promote community living. The changes to the process were discussed with the IDT during a level of care meeting to promote a team approach to completing the tool and selecting the interventions. The student consulted with the PT and the OT and they agreed to continue incorporating the STEADI protocols into their evaluations and treatments after the project is done. With the treatment and assessment smartnotes already in EPIC, and staff proficient in following all STEADI protocols, it will be easy to continue use. The quality coordinator is tracking the STEADI interventions implemented after a participant falls. She will continue to track implementation of STEADI interventions and determine whether or not using STEADI has helped PACE reach the goals set prior to beginning the program. The main goal attached to DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 26 implementing the STEADI program was to decrease falls. Falls are tracked by the quality coordinator and the student and PACE hope to see a decrease over time. Societal Needs It was important to the student that the tool was both occupation and performance based. The student used the PEOP model to guide understanding of how client factors, occupations, and the environment, influence overall performance. It was imperative that participant function was captured through the tool, as the participants functional abilities are the greatest influencer of their success and safety at home. This project greatly impacted the needs of society by assisting the PACE program in completing their mission of keeping their participants safe at home. Creation of the tool responded to the needs of the IDT and to the needs of the participants. Intervention charts provided are aiding the staff in developing consistent and effective interventions for participants and is also improving quality of services provided. Starting the STEADI program is also responding to societys need of decreasing fall in older adults. The STEADI program presents as a simple tool to help ensure that the staff is consistent across the board when completing fall risk assessments and treating at high fall risk participants. The student used this opportunity to further advocate for occupational therapy and occupational therapys role as a consultant. Identifying as a consultant was a strategy the student used to build trust and positive relationships. Other disciplines and staff members appreciated being consulted on current practice and new policies. Overall Learning/Communication Overall Learning This DCE focused on program development, policy development, and education. The student worked with multiple disciplines to develop a level of care tool and corresponding DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 27 interventions to be used with participants to determine their most successful living environment. The student established protocols for use of the Level of Care Assessment to decrease confusion on how/when to use the form. The protocols were developed after analyzing the feedback from the survey distributed to the staff. The student also completed implementing the STEADI protocol for Falls prevention. She created notes in EPIC, held a short in-service on the benefits of the fall prevention program for both PACE staff and management, and started a balance group with the PT. The student also created a body of knowledge for the site. She included information on falls prevention, home modification, cognitive interventions, and the STEADI program. All literature included in the binder is peer reviewed and provides evidence to support the interventions the student implemented. The student gained knowledge throughout the doctoral capstone experience that will be utilized in future practice. The student developed her critical thinking skills while problem solving through the sites needs assessment and daily problems. Critical thinking skills were also developed during extensive exploration into building the Level of Care Assessment and interventions. Critical thinking skills will be essential to practice when evaluating patients, treating, and producing new interventions. The student also increased her research skills. The student spent weeks researching articles on topics related to the project. The time and effort spent on research gave the student insight into how to determine key words, identify relevant articles, and request articles from external sources. Effective research habits will be extremely helpful in practice. The student will be able to use her knowledge to further her practice skills and successfully implement evidence-based interventions into practice. This will also assist the student in maintaining her professional licensure as she has the skills to search and identify relevant information. DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 28 The Doctoral Capstone Experience was unique in the fact that the student had to be very self-directed in her leaning and self-sufficient in identifying resources. The ability to work independently and remain focused is a great skill to have in any practice setting the student may work in. Time management skills were also essential to complete all projects at the site, assignments for the school, and attend all required meetings. The ability to manage time efficiently is a skill that is consistently utilized during treatment sessions and documentation. The student also had the opportunity to plan, develop, organize, and market her tool. This is something that not everyone has an opportunity to do and will be beneficial in the future if the student sees a need for a problem in her future employment. The student demonstrated leadership and advocacy when explaining the project that she would like to complete at the PACE center. She advocated for the participants by choosing to implement a falls prevention program, STEADI to improve quality of life. Creating a level of care tool to help accurately determine living situations based on participants occupational performance in their current environment was also a way for the student to advocate for the best outcome for PACE participants. The student participated in weekly forum posts with her classmates. These forum posts helped the student become a more reflective practitioner by prompting her to think about where she was at, what still needed to be done, and why the project was important. To help establish competency in implementation of a program and gain a better understanding of the practice area, the student completed other assignments including a scholarly report for presentation and her doctoral capstone paper. Overall, the student had exposure to working with many disciplines in an emerging area of practice, experienced a variety of treatment styles, and met many passionate individuals. Communication DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 29 The student interacted professionally and effectively when communicating with individuals at the PACE Program. The student had the opportunity to interact with clients during treatment sessions and home evaluations. The student offered her expertise in fabricating custom orthoses, ordering pre-fabricated orthoses, and making adjustments as needed. The student also interacted verbally with the participants when leading balance group, stretching group, and exercise group. The student had the opportunity to interact with the participants families and significant others during care plan meetings and home evaluations. This was an important piece of the students project, as the aim was to implement long lasting interventions. Oral and written communication was utilized with colleagues as the student collaborated with various disciplines on the project. The student delivered presentations on the STEADI program, use of the Level of Care Assessment, and implementation of additional fall prevention interventions. The student utilized written communication when discussing the Level of Care Assessment with another PACE program in Indiana. The student provided a detailed email of how to use the Level of Care Assessment and the corresponding interventions. Non-verbal communication was essential when interacting with both participants and colleagues. Many PACE participants do not speak English or have progressed dementia and no longer understand verbal communication. Remaining sincere and kind was necessary when communicating with these individuals. The student was also aware of nonverbal communication when discussing implementation of the STEADI program with colleagues. The student did not always get the responses or the results she was aiming for. Maintaining a professional stance and awareness of nonverbal communication helped preserve rapport and respect. DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 30 References Altenheim Health and Living Community. (2013). Functional assessment. [Facility assessment tool]. 1-3. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3 rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Ball, M. M., Perkins, M. M., Hollingsworth, C., Whittington, F. J., & King, S. V. (2009). Pathways to assisted living: The influence of race and class. Journal of Applied Gerontology, 28(1), 81-108. doi: 10.1177/0733464808323451 Bradley, S. M. (2011). Falls in older adults. Mount Sinai Journal of Medicine, 78, 590-595. doi: 10.1002/MSJ Chappell, N. L., Dlitt, B. H., Hollander, M. J., Miller, J. A., & McWilliam, C. (2004). Comparative costs of home care and residential care. Gerontologist, 44(3), 389-400. doi: doi.org/10.1093/geront/44.3.389 Centers for Disease Control and Prevention (2017a). Important facts about falls. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Centers for Disease Control and Prevention (2017b). STEADI materials for healthcare providers. Retrieved from https://www.cdc.gov/steadi/materials.html Centers for Medicare and Medicaid Services Aged and Disabled Medicaid Wavier (2017). Level of service assessment/evaluation: Assisted living. Waiver: IN.0210.R05.03 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 31 Edwards, M. (2014). Family caregivers for people with dementia and the role of occupational therapy. Physical and Occupational Therapy in Geriatrics, 33(3), 220-232. doi: 10.3109/02703181.2015.1031926 Fausset, C. B, Kelly, A. J., Rogers, W. A., & Fisk, A. D. (2011). Challenges to aging in place: understanding home maintenance difficulties. Journal of Housing for the Elderly, 25(2), 125-141. doi: 10.1080/02763893.2011.571105 Fange, A. & Ivanhoff, S. D. (2009) The home is the hub of health in very old age: findings from the ENABLE-AGE project. Archives of Gerontology and Geriatrics, 48, 340-345. doi: doi:10.1016/j.archger.2008.02.015 Franciscan Health (2018). Franciscan Senior Health & Wellness (PACE Program). Retrieved from https://www.franciscanhealth.org/healthcare-facilities/franciscan-senior-healthwellness-pace-program-1907 Franciscan Senior Health & Wellness (2014). Enrollment Agreement. 1-29. Grundstrom, A. C., Guse, C. E., & Layde, P. M. (2012). Risk factors for falls and fall-related injuries in adults 85 years of age and older. Archives of Gerontology and Geriatrics, 54, 421-428. doi:10.1016/j.archger.2011/ 06.008 Heber, M., Thibeault, R., Landry, A., Boisvenu, M., & Laporte, D. (2000). Introducing an evaluation of community based occupational therapy services: A client-centred practice. The Canadian Journal of Occupational Therapy, 67(3), 146-154. doi: 10.1177/000841740006700309 Horowitz, B. P., Nochajski, S. M., & Schweitzer, J. A. (2013). Occupational therapy community practice and home assessments: Use of the home safety self-assessment tool (HSSAT) to DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 32 support aging in place. Occupational therapy in health care, 27(3), 216-227. doi: 10.3109/07380577.2013.807450 Jette, D. U., Stilphen, M., Ranganathan, V. K., Passek, S. D., Frost, F. S., & Jette, A. M. (2014). Validity of the AM-PAC 6-Clicks inpatient daily activity and basic mobility short forms. American Physical Therapy Association, 94(3), 379-391. doi: 10.2522/ptj.20130199 National Pace Association (2018). Is PACE for you? Retrieved from http://www.npaonline.org/pace-you National Pace Association (2018). Eligibility Requirements for Programs of All-Inclusive Care for the Elderly. Retrieved from http://www.npaonline.org/pace-you/eligibilityrequirements-programs-all-inclusive-care-elderly Oliver, D., Healey, F., Haines, T. P. (2010). Preventing falls and fall-related injuries in hospitals. Clinical Geriatric Medicine, 26(4), 645-692. doi: 10.1o16/j.cger.2010.06.005 Pynoos, J., Steinman, B. A., & Nguyen, A. Q. D. (2010). Environmental assessment and modification as fall-prevention strategies for older adults. Clinical Geriatric Medicine, 26, 633-644. doi: 10.1016/j.cger.2010.07.001 Scaffa, M. E., & Reitz, S. M. (2014). Occupational therapy in community-based practice settings (2nd ed.). Philadelphia, PA: F. A. Davis Company. Stark, S., Landsbaum, A., Palmer, J., Somverville, E. K., & Morris, J. C. (2009). Client-centered home modifications improve daily activity performance of older adults. Canadian Journal of Occupational Therapy, 76, 235-245. Stark, S., Somerville, E., Conte, J., Keglovits, M., Hu, Y.-L., Carpenter, C., Hollingsworth, H., & Yan, Y. (2018). Feasibility trial of tailored home modifications: Process outcomes. DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 33 American Journal of Occupational Therapy, 72, 7201205020p1-7201205020p10. https://doi.org/10.5014/ajot.2018.021774 Stevens, J. A., Baldwin, G. T., Ballesteros, M. F., Noonan, R. K., & Sleet, D. A. (2010). An older adult falls research agenda from a public health perspective. Clinical Geriatric Medicine, 26(4), 767-769. doi: 10.1016/j.cger.2010.06.006 Sullivan, G. M. (2011). A primer on the validity of assessment instruments. [Editorial]. Journal of Graduate Medical Education, 119-120. Retrieved April 1, 2018, from doi:10.4300/JGM-D-11-00075.1 UB Foundation Activities, Inc. (2002). IRF-PAI training manual: Section 3: The FIM instrument. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-forService.../irfpai-manualint.pdf VanderVeen, D. J. (n.d.) Home care assessment tool: In-home needs worksheet. Adapted from Blue Ridge PACE. DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT Appendix A. 34 DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 35 DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 36 DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 37 38 DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT Appendix B. Intervention Guidelines for Level of Care For Home Level Home Care Hours 1 1-5 Hours / wk -IADL support -Informal supplement care recommended 1-3 Days / wk -Socialization -Restorative program -Nursing / MD appts 2 6-12 Hours / wk -IADL support -Basic ADL support -Fall supervision -Informal supplement care recommended 2-3 Days / wk -Socialization -Restorative program -Nursing / MD appts 3 13-20 Hours / wk -IADL support - ADL support -Fall supervision -Informal supplement care recommended 2-5 Days / wk -Socialization -Restorative program -Nursing / MD appts -Showering at center -Regular vital sign checks -Skincare checks 4 21-26 Hours / wk -IADL support -ADL support -Fall supervision -Informal supplement care required 3-5 Days / wk -Socialization -Restorative program -Nursing / MD appts -Showering at center -Regular vital sign checks -Skincare checks 5 >27 Hours / wk -IADL support -ADL support -Fall supervision -Informal supplement care required 3-5 Days / wk -Socialization -Restorative program -Nursing / MD appts -Showering at center -Regular vital sign checks -Skincare checks Attendance Assessment Multidisciplinary Home Safety Evaluation Nursing Medication Management -Assess home equipment needs for ADLs, IADLs &O2 -Assess home equipment needs for mobility -Assess bathroom safety -Assess kitchen safety -Personal emergency pendant -Fall Sensor -Assess home equipment needs for ADLs, IADLs &O2 -Assess home equipment needs for mobility -Assess bathroom safety -Assess kitchen safety -Personal emergency pendant -Fall Sensor -Assess home equipment needs for ADLs, IADLs &O2 -Assess home equipment needs for mobility -Assess bathroom safety -Assess kitchen safety -Personal emergency pendant -Fall Sensor -Assess home equipment needs for ADLs, IADLs &O2 -Assess home equipment needs for mobility -Assess bathroom safety -Assess kitchen safety -Personal emergency pendant -Fall Sensor -Assess home equipment needs for ADLs, IADLs &O2 -Assess home equipment needs for mobility -Assess bathroom safety -Assess kitchen safety -Personal emergency pendant -Fall Sensor -MacPack deliveries -Medication check-ins biweekly or monthly -Medication management plan established with participant, family and home caregiver. -Low to Moderate fall risk -Home exercise program -Home safety modifications -MacPack deliveries -Medication review -Medication check-ins biweekly -Medication management plan established with participant, family and home caregiver. -Moderate to High fall risk -Home exercise program to do with informal/formal care -Home safety modifications -Outpatient PT/OT -Foot care/Footwear check -Visual testing and clearance -MacPack deliveries -Medication review -Medication check-ins 3-4x / month -Medication management plan established with participant, family and home caregiver. -Moderate to High fall risk -Home exercise program to do with informal/formal care -Home safety modifications -Outpatient PT/OT -Foot care/Footwear check -Visual testing and clearance -MacPack deliveries -Medication review -Medication check-ins weekly -Medication management plan established with participant, family and home caregiver. -High fall risk -Home exercise program to do with informal/formal care -Home mobility modifications -Home safety modifications -Outpatient PT/OT -Foot care/Footwear check -Visual testing and clearance -High fall risk -Home exercise program to do with informal/formal care -Home mobility modifications -Home safety modifications -Outpatient PT/OT -Foot care/Footwear check -Visual testing and clearance -MacPack deliveries -Medication review -Medication check-ins weekly -Medication management plan established with participant, family and home caregiver. Fall Risk Evaluation STEADI 39 DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT Appendix C. Intervention Guidelines for Level of Care For Assisted Living and Long Term Care *** LEVELS 1-3 Attempt to provide services for home per PACE Mission and Goals (See home guidelines sheet) *** Level 1 Assisted Living 2 Assisted Living 3 Assisted Living 4 Assisted Living or Long Term Care 5 Long Term Care Assisted Living Interventions **NO INFORMAL SUPPLEMENT CARE AVAILABLE** Attendance Assessment -IADL support -ADL Support Independent to setup for ADLs -Fall supervision -Nursing care / assistance available 24/7 -Socialization and group activities 1-2 Days / wk -Socialization -Restorative program -Nursing / MD appts -IADL support -Basic ADL support Standby to minimal assist with ADLs -Fall supervision -Nursing care / assistance available 24/7 -Socialization and group activities -IADL support -ADL support Minimal to moderate assist with ADLs -Intermittent mobility assistance for safety -Fall supervision -Nursing care / assistance available 24/7 -Socialization and group activities -IADL support -ADL support Moderate to Maximal assist with all ADLs -Moderate to maximal assist with mobility safety -Fall supervision -Nursing care / assistance available 24/7 -Socialization and group activities -IADL support -ADL support Total assist with all ADLs -Maximal to total assist with mobility safety -Fall supervision -Nursing care / assistance available 24/7 -Socialization and group activities 1-2 Days / wk -Socialization -Restorative program -Nursing / MD appts Multidisciplinary Safety Evaluation Nursing Medication Management Fall Risk Evaluation STEADI -MacPack deliveries -Medication management plan established with AL nursing. -Low to Moderate fall risk -Home exercise program -Home safety modifications -MacPack deliveries -Medication management plan established with AL nursing. -Moderate to High fall risk -Home exercise program -Home safety modifications -Outpatient PT/OT -Foot care/Footwear check -Visual testing and clearance 1-3 Days / wk -Socialization -Restorative program -Nursing / MD appts -Showering at center -Regular vital sign checks -Skincare checks -Assess equipment needs for ADLs, IADLs &O2 -Assess equipment needs for mobility -Assess bathroom safety -Personal emergency pendant -Fall Sensor -Assess equipment needs for ADLs, IADLs &O2 -Assess equipment needs for mobility -Assess bathroom safety -Personal emergency pendant -Fall Sensor -Assess equipment needs for ADLs, IADLs &O2 -Assess equipment needs for mobility -Assess bathroom safety -Personal emergency pendant -Fall Sensor -MacPack deliveries -Medication management plan established with AL nursing. -Moderate to High fall risk -Home exercise program -Home safety modifications -Outpatient PT/OT -Foot care/Footwear check -Visual testing and clearance 1-3 Days / wk -Socialization -Restorative program -Nursing / MD appts -Showering at center -Regular vital sign checks -Skincare checks -Assess equipment needs for ADLs, IADLs &O2 -Assess equipment needs for mobility -Assess bathroom safety -Personal emergency pendant -Fall Sensor -MacPack deliveries -Medication management plan established with AL nursing. -High fall risk -Home exercise program -Home mobility modifications -Home safety modifications -Outpatient PT/OT -Foot care/Footwear check -Visual testing and clearance 1-3 Days / wk -Socialization -Restorative program -Nursing / MD appts -Regular vital sign checks -Skincare checks -Assess equipment needs for ADLs, IADLs &O2 -Assess equipment needs for mobility -MacPack deliveries -Medication management plan established with LTC nursing. -High fall risk -Home exercise program -Home mobility modifications -Home safety modifications -Outpatient PT/OT -Foot care/Footwear check -Visual testing and clearance DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT Appendix D. 40 DOCTORAL CAPSTONE LEVEL OF CARE ASSESSMENT 41  ...

... Developing a Juvenile Arthritis Transition Program for Teens Nicole M. Meert May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Rebecca Barton, DHS, OTR, FAOTA A Capstone Project Entitled Developing a Juvenile Arthritis Transition Program for Teens Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Nicole M. Meert OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Running head: DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 1 Abstract Over 300,000 children in the United States have been diagnosed with some form of juvenile arthritis. However, there are fewer than 350 board-certified practicing pediatric rheumatologists in the United States, with only 25 percent of children living with juvenile arthritis seeing a pediatric rheumatologist to manage their treatment. The purpose of this project was to develop transition program recommendations for teens with juvenile arthritis transitioning to adult care in the United States. The main models used in this project were the Precaution Adoption Process Model and the Person-Environment-Occupation-Performance Model. An outcome tool was developed to gather information on several topics important to the transition process such as disease management self-efficacy, health distress, current behaviors when visiting a doctor, and depression. There were a total of 4 respondents to the survey with an average Function score of 54 and an average Dysfunction Score of 35.5. Through a literature review, it was determined that it is important to acknowledge that the teens with arthritis have autonomy in the decision-making process when it comes to their health care. Therapists need to allow the client to decide when it is time to progress through each stage in the transition process, as well as provide the tools necessary to become independent with their new role, including providing the opportunity for trial and error, exploring various coping strategies, instilling the skills of time and medication management, and teaching them how to seek out reliable resources as they continue throughout their life span with their chronic condition. DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 2 Developing a Juvenile Arthritis Transition Program for Teens Over 300,000 children in the United States have been diagnosed with some form of juvenile arthritis (Arthritis National Research Foundation, n.d.). With fewer than 350 boardcertified practicing pediatric rheumatologists in the United States, only 25 percent of children living with juvenile arthritis are seen by pediatric rheumatologists (Arthritis Foundation, n.d.). The remaining 75 percent are seen by adult rheumatologists or pediatric rheumatologists that lack adequate training to treat children with juvenile arthritis along with their additional comorbidities that they may have (Arthritis Foundation n.d.). Due to recent medical advances and the development of new medications, the predicted 10-year survival rates of chronic pediatric rheumatological diseases is now over 95 percent (Anelli et al., 2017). This has led to a recent push internationally for a transition program for children with juvenile arthritis. There is currently a large body of research on transitioning children, their parents, and the expectations surrounding the transition, however, there is limited research investigating transition programs themselves. There are several established transition programs in Canada and Europe, however, there is very little research for the United States. Rettig and Athreya (1991) determined that a structured transition program is needed to ensure that children who transitioned were not lost due to lack of follow-up with their adult rheumatologist. A study performed by Staa, Jedeloo, Meeteren, & Latour (2011) confirmed that transitioning is a logical step, but parents are concerned due to the culture gap between pediatric and adult care. The researchers stated that more preparation is needed for children and their parents before the transition occurs (Staa, Jedeloo, Meeteren, & Latour, 2011). Although there is a worldwide shortage of qualified pediatric rheumatologists there is not a difference in outcomes based on whether children were treated by a pediatric rheumatologist or a general pediatrician, DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 3 however, it is still imperative to that education is provided to the children and their families regarding their transition to adult care (Miyamae et al., 2014). This is due to the multitude of studies that indicate the transition process is flawed due to inadequate staff training; lack of resources; financial difficulties; anxiety of the doctors, patients, and parents; and patients often feeling abandoned or rejection, also, experiencing a difficult transition may lead to high drop-out rates and poor medical outcomes (Anelli et al., 2017). In 2007, the American Academy of Pediatrics listed transitioning youth with special healthcare needs to adult care as one of their top 10 priorities (Anelli et al., 2017). Rettig & Athreya (1991) completed a study and determined that the primary obstacle with developing a comprehensive transition program is the lack of funding for services of the transition team. Insurance companies are less likely to reimburse for services provided by a transition nurse or transition social worker (Rettig & Athreya, 1991). However, due to the clientcentered model of practice and collaborative team approach that occupational therapy utilizes, occupational therapists are qualified to assist with transitions due to our scope of practice (Orentlicher et al., 2017). The Occupational Therapy Practice Framework: Domain and Process (3rd ed) guides therapists to examine client factors, performance patterns, roles, and contexts when discussing transitions (American Occupational Therapy Association [AOTA], 2014). Due to occupational therapists extensive knowledge of task analysis and environmental adaptations they can apply their knowledge to assist with transitioning into secondary education and assuming adult roles either through the public education system or a community-based setting (Orentlicher et al., 2017). The purpose of this project was to develop transition program recommendations for teens with juvenile arthritis transitioning to adult care. The main models used are the Precaution DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 4 Adoption Process Model (PAPM) and the Person-Environment-Occupation-Performance Model (PEOP). These two models were selected based on how each model views the decision-making process of a person and what factors the person desires to modify or change to promote optimal occupational participation and performance. The PAPM has its roots in the public health field and was originally designed to demonstrate how people respond to provided information based on a newly discovered "threat to their health" (Weinstein, Sandman, & Blalock, 2008). The idea of this model is that a new "threat" (in this case the young adults being made aware that they must eventually transition to an adult rheumatologist), would not be known unless the person is consciously aware of the harm (rushed into a transition, not ready for a transition, feelings of abandonment, or lack of follow up with their new doctor) (Weinstein, Sandman, & Blalock, 2008). The seven stages of this model include Stage 1: Unaware of the issue, Stage 2: Unengaged by the issue, Stage 3: Deciding about acting, Stage 4: Deciding not to act, Stage 5: Deciding to act, Stage 6: Acting, and Stage 7: Maintenance (Weinstein, Sandman, & Blalock, 2008). In stage 4, if the person decides not to act, then the process is complete (Weinstein, Sandman, & Blalock, 2008). If the person decides to act, the process continues to stage 5 and ultimately culminating in stage 7 (Weinstein, Sandman, & Blalock, 2008). This model is laid out in a linear fashion, but the process is not necessarily linear in nature. A person may be in stage 6 and then experience a setback and move to stage 4 for a period (Weinstein, Sandman, & Blalock, 2008). The PAPM model is the best fit for introducing the topic of transition to young adults, because it recognizes that everyone is at their own unique spot in the process and their priorities or stage may change as their life/symptoms change. This model also recognizes the autonomy of the person deciding not to act. The PEOP model has its roots in occupational therapy (Cole & Tufano, 2008). This model focuses on the client, relevant intrinsic and extrinsic factors, DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 5 environment, occupations, and the performance of occupations (Cole & Tufano, 2008). The PEOP model states that a positive change happens when a positive cycle of motivation is created due to intrinsic and extrinsic rewards (Cole & Tufano, 2008). The PEOP will be used to help guide the decision-making process for recommendations made for the transition program. The topics that will be discussed, in the transition program, will focus on adaptations/modifications that can occur now as well as adaptations and modifications that may need to occur in the future. This model is the best fit, because it does not stress one specific area where improvements must be made to improve the person's overall occupation performance. Juvenile Arthritis is a chronic health condition that changes throughout a person's life and a model to address adaptations/modifications must be able to change as well. Since Juvenile Arthritis changes throughout the young adults' life it was important to select models that are not strict in their order or process. By giving the participants the option to not act, their autonomy is being respected. The PEOP model provides the flexibility to discuss different adaptations/ modifications, for example, ADL equipment, energy conservation, ergonomics, adaptive school/work equipment, and leisure pursuits. By not limiting the topics of discussion to just occupations or just the environment the transition program can cover more topics and additional resources for when the young adults are ready to consider other options such as a shower chair or modified desk/car. Screening and Evaluation A needs assessment and literature review were conducted to determine the needs of the Indiana Arthritis Foundation in assisting young adults and teenagers diagnosed with juvenile arthritis transitioning to adult care. A literature review revealed that there are several successful transition programs throughout the world including the ONTRAC and Good2Go programs in DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 6 Canada, however, there is a significant lack of research being conducted in the United States (Grants & Pan, 2011). Therefore, it was determined that there is a need for a transition program specific for teens and young adults in the United States diagnosed with juvenile arthritis that are transitioning to adult care. According to the Arthritis Foundation, the transition process should ideally begin at 1214 years of age and culminate at ages 23-26 (Arthritis Foundation, 2018f & 2018a). The screening process will include those that have been diagnosed with juvenile arthritis, are between the ages of 13 and 21, and reside in Indiana. The participants were recruited from using the Arthritis Foundation database of past and current event participants. This Doctoral Capstone project is unique in the sense that Occupational Therapy is currently not involved in the transition process (Arthritis Foundation, 2018a). Currently the only medical professionals involved are the pediatric and adult rheumatologists. This is in direct contrast to the role that occupational therapists have in transition planning for those in the school system with an Individualized Education Plan or IEP (Orentlicher et al. 2017). Occupational therapists assist clients with career exploration and assuming independent roles in their healthcare and social interactions (Orentlicher et al. 2017). However, many teenagers with juvenile arthritis do not have IEPs through school and do not receive this guidance as they transition. Implementation Phase Due to the lack of literature and knowledge concerning the topic of what to include in a juvenile arthritis transition program in the United States, it was determined that data needed to be collected concerning this topic. An online survey was selected as the best format to collect data, due to several factors including the quantity of surveys to be sent out, it was not feasible to send DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 7 out paper surveys with the risk of zero follow up. An additional factor was the ease to complete the survey, it is easier for those with fine motor and dexterity issues to complete a survey online than to fill it out with a paper and pencil. Therefore the best option for data collection was the electronic survey. Online Survey It was determined that no comprehensive survey existed that measures more than one component of patients current self-efficacy for managing their disease and investigating their current mental health. Therefore, a comprehensive survey was created by adapting questions from multiple surveys from the Self-Management Resource Center tools, see Appendices A-E. These scales were noted to be used freely without permission. Section A, the scoring sheet, and function/dysfunction scales were added to the preexisting scales to make a comprehensive screening tool for the Juvenile Arthritis population. The completed screening is titled the Juvenile Arthritis Medical management, Self-efficacy, Symptom limitations, and Mental health Screen (JAMS-M Screen), a copy of the screen used can be found in Appendix F. The survey collected data on the subjects actions when attending doctors appointments, self-efficacy of the management of their arthritis, the impact of their arthritis on their social roles and activities, their current level of distress due to their health status, and their current level of depression due to their diagnosis. The demographics section was added to collect relevant information including current age, gender, age of diagnosis, type of arthritis and type of doctor they are seeing for treatment to better categorize results. The current actions they complete while visiting their doctors was measured by using a 3 item 6-point Likert scale, see Appendix A (Self-Management Resource Center [SMRC], n.d.b). This scale was tested on 1130 subjects with chronic disease and 51 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 8 subjects were used for test-retest reliability, with an internal consistency reliability of .73 and a test-retest reliability of .89. (Lorig et al., 1996). The self-efficacy section of the survey consists of 8 items on a 10-point Likert scale adapted from the Arthritis Self-efficacy scale, see Appendix B (SMRC, n.d.a). This scale was tested on 175 subjects with arthritis and has an internal consistency reliability of .92 (Stanford Arthritis Self-Management Study). Their level of distress was measured by 4 items on a 6-point scale adapted from the Health Distress scale, see Appendix C (SMRC, n.d.c). This scale was tested on 1130 subjects with chronic diseases and 51 subjects for test-retest reliability with an internal consistency of .87 and test-retest reliability of .87 (Lorig et al., 1996). The impact of their arthritis on their social roles and activities was measured using 4 items on a 5-point Likert scale, see Appendix D (SMRC, n.d.e). This scale was tested on 1130 subjects with chronic disease and 51 for test-retest reliability with an internal consistency reliability of .91 and test-retest reliability of .68 (Lorig et al., 1996). Their current level of depression was measured on an 8 item 4-point Likert scale, see Appendix E (SMRC, n.d.d). This scale was tested on 1165 subjects with chronic conditions with an internal consistency reliability of .86 (Ory et al., 2013). These scales were selected due to their strong psychometrics and specificity for people with arthritis and chronic diseases. The scores from each section of the JAMS-M screen were combined in to a function score and a dysfunction score. The function score is calculated using the scores from the communication with physicians and arthritis self-efficacy sections, see Appendix F. Function scores can range from 8-95 points, with 8 indicating low function and 95 indicating high function. The dysfunction score is calculated using the scores from the social/role activity limitations, health distress, and depression sections. Dysfunction scores can range from 0-60, with 0 being no dysfunction and 60 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 9 being high dysfunction. With the two score, the scorer can determine which areas the client is having difficulty in and provide interventions accordingly. The JAMS-M Screen was sent via email to 178 registered Indiana Arthritis Foundation past and present event participants between the ages of 13 and 21 years old. This age range was selected due to previous research that determined the transition process takes place during the ages of 13 to 21 (Arthritis Foundation, 2018e). The JAMS-M screen was also posted on an Indiana and Central Illinois Families Juvenile Arthritis Facebook page run by the Indiana Arthritis Foundation. The collected data was used to prioritize the topics of mental health and coping skills, self-efficacy, life skills needed for managing a chronic disease, and health literacy. Staff Training and Education Due to the Arthritis Foundation being an emerging setting for occupational therapy, the staff had limited knowledge on the role and benefits of occupational therapy for people with arthritis and how occupational therapy could specifically help with the transition process. While preparing for the annual walk the foundation holds, the staff made the decision to have an Ask a Doc area that included a chiropractor, massage therapist, physical therapist, and an occupational therapist. When it came time to create materials for this area describing what each professional could offer to the participants, the staff had limited knowledge of what occupational therapy could do to help those with arthritis throughout the lifespan. They knew that OTs can help with energy conservation and activity modifications as well as after joint replacement surgeries, but that is where their knowledge ended. Through the needs assessment process, it was determined that the staff would benefit from a presentation to address these gaps in knowledge. The presentation developed for the staff, covered topics including the role and benefits of occupational therapy in the treatment for people with arthritis, the differences between DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 10 occupational therapy and physical therapy, and common occupational therapy treatments for people with arthritis. The goal of this presentation was to increase the staffs knowledge and ability to advocate for occupational therapy services for those with arthritis, a copy of the presentation can be found in Appendix G. Leadership I had taken on several roles during this project including serving as a resource for the staff of the foundation, assisting with material development for their national Juvenile Arthritis Conference, and serving as an expert on transitioning. I had anticipated serving as a resource for the staff in several ways, including educating them and the people they serve on the benefits of occupational therapy and assisting with program development for transition program recommendations. I however, did not anticipate assisting with the National Juvenile Arthritis Conference. I had this amazing opportunity as a result discussing my journey with two people in charge of juvenile arthritis at the national office. I provided suggestions for social media activity designed to help those not attending the conference feel included. Using my skills from my undergraduate degree, I recommended a photo voice campaign to shed the light on what it is like to live with JA behind the scenes. The teens would post pictures and caption them to show what it is like, including showing how they cope with having JA or manage their many invisible symptoms. Another role that I had not planned for, was becoming an expert on transitioning with juvenile arthritis. This idea happen by accident when I was looking for resources online for those with autoimmune diseases. I found several blogs about living with arthritis, but none of these were for children or teens transitioning to adult care, and many were written by people with many different life roles. However, none of them wrote about their transition to adjusting to their DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 11 diagnosis and none of them were written by a medical professional. Therefore, I took it upon myself to use my personal experiences and occupational therapy knowledge to write a monthly blog about various topics including energy conservation, vacationing, how to prepare for transiting to college, and mental health (Meert, 2018). My blog includes information from my perspective, helpful suggestions, and online resources to help the readers learn more, a copy of selected blog posts can be found in Appendix H. Outcomes As stated previously, a comprehensive survey was created by adapting questions from multiple surveys from the Self-Management Resource Center tools, see Appendices A-E. These scales were noted to be used freely without permission. Section A, the scoring sheet, and function/dysfunction scales were added to the preexisting scales to make a comprehensive screening tool for the Juvenile Arthritis population. The JAMS-M Screen was sent via email to 178 registered Indiana Arthritis Foundation past and present event participants between the ages of 13 and 21 years old and posted on the Indiana and Central Illinois Families Juvenile Arthritis Facebook page run by the Indiana Arthritis Foundation. The JAMS-M Screen was completed by 4 female participants, with ages ranging from 13-21. Three out of the four participants have Juvenile Idiopathic Arthritis (JIA) Polyarticular, meaning that 5 or more joints are involved. One participant has Non-Ankylosing Spondylitis. A summary of the demographic data can be found in Table 1. Table 1 Participant 1 2 3 4 Age 19-21 13-15 16-18 16-18 Type of Juvenile Arthritis Non-Ankylosing Spondylitis JIA-Polyarticular (5+ joints) JIA-Polyarticular (5+ joints) JIA-Polyarticular (5+ joints) Age of diagnosis 12 2 15 2 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 12 The participants scores from each section and the means scores were calculated. A summary of the scores can be found in Table 2. The mean score for communication with physicians was 7.75. The participants score demonstrates that they all demonstrate positive communicate with their physicians at appointments. The mean score for arthritis self-efficacy was 46.25. Participants scores for arthritis self-efficacy demonstrate moderate self-efficacy with managing their arthritis symptoms. The function scale scores were 52, 45, 62, and 57 respectively. These scores demonstrate that the participants are functioning well despite their diagnoses. The mean score for social/role activities limitations was 9. Participants scores for social/role activity limitations fell into the moderate limitations range due to disease activity. This demonstrates a need for activity/environmental modifications education, as well as medication management and coping strategies education, to decrease the participants social/role activity limitations impacting their occupations and occupational performance. The mean score for health distress was 13.75. Participants scores ranged from minimally to highly impacted due to health distress. This demonstrates the need for health literacy and coping skills education, to decrease the amount of health distress the participants are experiencing. The mean score for depression was 12.75. The participants scores ranged from minimal to moderate depression symptoms. This demonstrates a need for coping skills education to decrease the participants depression symptoms. The dysfunction scale scores were 28, 36, 27, and 51 respectively. These scores demonstrate that the participants are experiencing some limitations in managing their symptoms either due to disease activity or depression/ health distress, as well as that they would benefit from the interventions and education that occupational therapy services could provide as listed previously in this section. DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 13 Table 2 Communication with Physicians Arthritis Self-efficacy Function Scale Participant 1 2 3 4 Participant 1 2 3 4 Participant 1 2 3 4 Score 7 5 11 8 Score 45 40 51 49 Score 52 45 62 57 Mean 7.75 Social/Role Activity Limitations Mean 46.25 Health Distress Mean 54 Depression Dysfunction Scale Participant 1 2 3 4 Participant 1 2 3 4 Participant 1 2 3 4 Participant 1 2 3 4 Score 8 7 9 12 Score 9 17 9 12 Score 11 12 9 19 Score 28 36 27 51 Mean 9 Mean 13.75 Mean 12.75 Mean 35.5 My online blog has received positive feedback so far, there are several families that follow my posts and the Arthritis Foundation has received positive feedback from several nurses at Riley Childrens Hospital. Discontinuation The staff education was a onetime presentation that I left with the staff for them to use when needed and when new staff members are hired. I plan to submit my recommendations for a transition program to the Indiana Arthritis Foundation to take into consideration. My hope is that either another occupational therapy student will continue the process by developing the program, or that I will develop it after I have been practicing for at least a year. As for the blog, I plan to continue posting at least once a month. The blog has proven to be beneficial based on the feedback I have received and I want it to be out there and ready for the teens to use when they begin their own transitions. I also plan to continue to be a resource for the foundation after graduation because of the experiences that I have had as a direct result of this doctoral DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 14 experience. Also, the teens will continue to transition in various aspects of their lives and will need continual support. Overall Learning I have had the opportunity to interact with the clients, in this case children with arthritis, through various mediums including verbally at meet and greets and written through blog/social media posts. The meet and greets were designed to meet others with arthritis for networking and social support through shared experiences and sharing their personal stories. I have written several blog posts sharing my personal experiences to provide motivation for others transitioning to adult care, and to provide insight for health professionals working with teens and young adults to manage their chronic conditions. I have also had the opportunity to interact with several colleagues at the local office and national office during conference calls and weekly video meetings. During my time I was able to attend several public events for the Arthritis Foundation including health fairs, fundraisers, charity walks/runs, and presentations. Completing this project in an emerging practice area has allowed me to use my occupational therapy knowledge to advocate for the populations served by the Arthritis Foundations as well as investigate the needs of the teens and young adults with juvenile arthritis transitioning to adult care. Through this learning experience, I have been able to conduct preliminary research into the topic of developing a program for teens with juvenile arthritis transitioning to adult care in the United States. I have been able to perform a brief survey that confirms my personal experiences that during the transition process there needs to be an emphasis and education provided on communicating with physicians, self-efficacy for managing arthritis, activity/environmental modifications, medication management, coping skills, and health literacy. I have also learned several things throughout this process that will aid occupational therapists that are helping DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 15 teenagers transition to adult care. It is important to acknowledge that they have autonomy in the decision-making process when it comes to their health care, therapists need to allow the client to decide when it is time to progress through each stage in the transition process. It is also imperative that therapists provide the tools necessary to become independent with their new role, including providing the opportunity for trial and error, exploring various coping strategies, instilling the skills of time and medication management, and teaching them how to seek out reliable resources as the teens continue throughout their life span with their chronic condition. DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 16 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1 S48. http://dx.doi.org/10.5014/ajot.2014.682006 Anelli, C., Amorim, A., Osaku, F., Terreri, M., Len, C., & Reiff, A. (2017). Challenges in transitioning adolescents and young adults with rheumatologic diseases to adult care in a developing country- the Brazilian experience. Pediatric Rheumatology, 15(47). Doi: 10.1186/s129-017-0176-y Arthritis Foundation. (n.d.). Address shortage of pediatric rheumatologists. Retrieved April 10, 2017, from http://www.arthritis.org/advocate/our-policy-priorities/access-tocare/increase-access-to-pediatric-rheumatologists/ Arthritis Foundation. (2018a). Improving the transition to adult rheumatology: Six core elements of health care transition. Retrieved May 11, 2018, from http://www.jatransition.org/pages/provider_portal Arthritis Foundation. (2018b). Tracking & monitoring. Retrieved May 11, 2018, from http://www.jatransition.org/pages/elements/tracking Arthritis Foundation. (2018c). Transfer completion. Retrieved May 11, 2018, from http://www.jatransition.org/pages/elements/completion Arthritis Foundation. (2018d). Transfer of care. Retrieved May 11, 2018, from http://www.jatransition.org/pages/elements/transfer Arthritis Foundation. (2018e). Transition planning. Retrieved May 11, 2018, from http://www.jatransition.org/pages/elements/planning DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 17 Arthritis Foundation. (2018f). Transition policy. Retrieved May 11, 2018, from http://www.jatransition.org/pages/elements/policy Arthritis Foundation. (2018g). Transition readiness. Retrieved May 11, 2018, from http://www.jatransition.org/pages/elements/readiness Arthritis National Research Foundation. (n.d.). What is Juvenile Arthritis? Retrieved April 10, 2017, from http://www.curearthritis.org/juvenile-arthritis/ Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Grant, C., & Pan, J. (2011). A comparison of five transition programmes for youth with chronic illness in Canada. Child: Care, Health and Development, 37(6), 815-820. doi:10.1111/j.1365-2214.2011.01322.x Krokenke, K., Strine, TW., Spritzer, OL., Williams, JB., Berry, JT., & Mikdad, AH. (2009). The PQH-8 as a measure of current depression in the general population. J Affect Disord. 2009; 114(1-3):163-73. Lorig, K., Chastain, RL., Ung, E., Shoor, S., & Holman, HR. (1989). Development and evaluation of a scale to measure self-efficacy in people with arthritis. Arthritis and Rheumatism, 32 (1), pp. 37-44 Lorig, K., Stewart, A., Ritter, P., Gonzalez, V., & Lynch, J., Outcome Measures for Health Education and other Health Care Interventions. Thousand Oaks CA: Sage Publications, 1996, pp. 24, 25, 40, 52-53 Meert, N. (2018, May 7). The JA World According to Nicole. Retrieved July 29, 2018, from https://thejaworldaccordingtonicole.wordpress.com/ DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 18 Miyamae, T., Tanaka, E., Kishi, T., Matsuyama, T., Igarashi, T., Fujikawa, S., . . . Yamanaka, H. (2014). Long-term outcome of 114 adult JIA patients in a non-pediatric rheumatology institute in Japan. Modern Rheumatology, 25(1), 62-66. doi:10.3109/14397595.2014.929558 Orentlicher, M., Case, D., Podvey, M., Myers, C., Rudd, L., & Schoonover, J. (2017). Frequently asked questions (FAQ); What is occupational therapys role in transition services and planning? [Handout]. Retrieved from https://www.aota.org/~/media/Corporate/Files/Secure/Practice/Children/FAQ-What-isOTs-Role-in-Transition-Services-and-Planning-20170530.pdf Ory, MG., Ahn, S., Jiang, L., et al. National study of chronic disease self-management: Six month outcome findings. Journal of Aging and Health. 2013 [in press]. Rettig, P., & Athreya, B. (1991). Adolescents with chronic disease. Transition to adult health care. Arthritis Care & Research, 4(4), 174-180. doi:10.1002/art.1790040407 Self-Management Resource Center (n.d.a). Arthritis Self-Efficacy [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English_-_selfefficacy_arthritis.pdf Self-Management Resource Center (n.d.b). Communication with Physicians [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English__communication_w_physicians.pdf Self-Management Resource Center (n.d.c). Health Distress [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English_-_healthdistress.pdf DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 19 Self-Management Resource Center (n.d.d). Personal Health Questionnaire Depression Scale (PHQ-8) [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English_-_phq.pdf Self-Management Resource Center (n.d.e). Social/Role Activities Limitations [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English__social-role_activities_limitations.pdf Staa, A. L., Jedeloo, S., Meeteren, J. V., & Latour, J. M. (2011). Crossing the transition chasm: Experiences and recommendations for improving transitional care of young adults, parents and providers. Child: Care, Health and Development, 37(6), 821-832. doi:10.1111/j.1365-2214.2011.01261.x Stanford Arthritis Self-Management Study participants. Unpublished. Stewart AL., Hays, RD., & Ware, JE., Health Perceptions, energy/fatigue, and health distress measures, in Stewart AL., & Ware, JE. Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham NC: Duke University Press, 1992, pp. 143172. Weinstein, N., Sandman, P., & Blalock, S. (2008). The Precaution Adoption Process Model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health Behavior and Health Education (4th. ed.). Retrieved February 20, 2017, from http://www.psandman.com/articles/PAPM.pdf DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM APPENDIX A 20 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 21 APPENDIX B (continued) Appendix B (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 22 (continued) Appendix B (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 23 (continued) Appendix B (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 24 (continued) Appendix B (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 25 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 26 APPENDIX C (continued) Appendix C (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 27 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM APPENDIX D 28 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM APPENDIX E 29 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 30 APPENDIX F Juvenile Arthritis Medical management, Self-efficacy, Symptoms limitations, and Mental health Screen (JAMS-M Screen) Section A: Demographic information (please select one answer for each question) 1. How older are you? a. b. c. d. e. 12 and younger 13-15 16-18 19-21 22 and older 2. Are you a. b. c. Female Male Prefer not to answer 3. What type of arthritis do you have? a. JIA-Oligoarthritis (1-4 joints) b. c. d. e. f. g. JIA-Polyarthritis (5+ joints) JIA-Systemic Juvenile Arthritis, Unspecified Juvenile Rheumatoid Arthritis Unknown Type Other:__________________ 4. At what age were your diagnosed? ______ 5. What type of doctor are you currently seeing for treatment of your arthritis? a. b. c. d. e. f. Pediatric Rheumatologist Rheumatologist Pediatrician Internal or family medicine Dont Know Other:______________ Section B: Communication with Physicians (please circle one number for each question) When you visit your doctor, how often do you do the following? 1. Prepare a list of questions for your doctor Never 0 Almost never 1 Sometimes 2 Fairly often 3 Very Often 4 Always 5 2. Ask questions about the things you want to know and things you dont understand about your treatment Never 0 Almost never 1 Sometimes 2 Fairly often 3 Very Often 4 Always 5 Very Often 4 Always 5 3. Discuss any personal problems that may be related to your illness Never 0 Almost never 1 Sometimes 2 Fairly often 3 (continued) Appendix F (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 31 Section C: Arthritis Self-efficacy (please circle one number for each question) How certain you are that you can do the following tasks regularly at the present time? 1. Decrease your pain quite a bit? very uncertain 1 2 3 4 5 6 7 8 9 10 very certain 6 7 8 9 10 very certain 9 10 very certain 2. Keep your arthritis from interfering with your sleep? very uncertain 1 2 3 4 5 3. Keep your arthritis pain from interfering with the things you want to do? very uncertain 1 2 3 4 5 6 7 8 4. Regulate your activity so as to be active without aggravating your arthritis? very uncertain 1 2 3 4 5 6 7 8 9 10 very certain 5. Keep the fatigue caused by your arthritis from interfering with the things you want to do? very uncertain 1 2 3 4 5 6 7 8 9 10 very certain 6. Do something to help yourself feel better if you are feeling blue? very uncertain 1 2 3 4 5 6 7 8 9 10 very certain 5 6 7 8 9 10 very certain 7. Deal with the frustration of arthritis? very uncertain 1 2 3 4 8. As compared with other people with arthritis like yours, how certain are you that you can manage pain during your daily activities? very uncertain 1 2 3 4 5 6 7 8 9 10 very certain Section D: Social/Role Activity Limitations (please circle one number for each question) During the past 4 weeks, how much has your health interfered with 1. Your normal social activities with family, friends, neighbors or groups? Not at all 0 Slightly 1 Moderately 2 Quite a bit 3 Almost totally 4 Moderately 2 Quite a bit 3 Almost totally 4 Moderately 2 Quite a bit 3 Almost totally 4 Moderately 2 Quite a bit 3 Almost totally 4 2. Your hobbies or recreational activities? Not at all 0 Slightly 1 3. Your household chores? Not at all 0 Slightly 1 4. Your errands and shopping? Not at all 0 Slightly 1 (continued) Appendix F (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 32 Section E: Health Distress (please circle one number for each question) How much time during the past 4 weeks, were you... 1. Discouraged by your health problems? None 0 A little 1 Some 2 A good bit 3 Most 4 All 5 Some 2 A good bit 3 Most 4 All 5 A good bit 3 Most 4 All 5 A good bit 3 Most 4 All 5 2. Fearful about your future health? None 0 A little 1 3. Frustrated by your health problems? None 0 A little 1 Some 2 4. Was your health a worry in your life? None 0 A little 1 Some 2 Section F: Personal Health Questionnaire (please circle one number for each question) Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things Not at all 0 Several days 1 More than half the days 2 Nearly every day 3 More than half the days 2 Nearly every day 3 2. Feeling down, depressed, or hopeless Not at all 0 Several days 1 3. Trouble falling or staying asleep, or sleeping too much Not at all 0 Several days 1 More than half the days 2 Nearly every day 3 Several days 1 More than half the days 2 Nearly every day 3 Several days 1 More than half the days 2 Nearly every day 3 4. Feeling tired or having little energy Not at all 0 5. Poor appetite or overeating Not at all 0 6. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down Not at all 0 Several days 1 More than half the days 2 Nearly every day 3 7. Trouble concentrating on things, such as reading the newspaper or watching television Not at all 0 Several days 1 More than half the days 2 Nearly every day 3 (continued) Appendix F (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 33 8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Not at all 0 Several days 1 More than half the days 2 Nearly every day 3 References Self-Management Resource Center (n.d.a). Arthritis Self-Efficacy [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English_-_selfefficacy_arthritis.pdf (continued) Appendix F (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM Self-Management Resource Center (n.d.b). Communication with Physicians [Measurement 34 Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English__communication_w_physicians.pdf Self-Management Resource Center (n.d.c). Health Distress [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English_-_healthdistress.pdf Self-Management Resource Center (n.d.d). Personal Health Questionnaire Depression Scale (PHQ-8) [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English_-_phq.pdf Self-Management Resource Center (n.d.e). Social/Role Activities Limitations [Measurement Tool]. Retrieved from https://www.selfmanagementresource.com/docs/pdfs/English__social-role_activities_limitations.pdf DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 35 APPENDIX G Staff Training Presentation (continued) Appendix G (continued)DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 36 (continued) Appendix G (continued)DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 37 DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 38 APPENDIX H Selected blog posts (continued) Appendix H (continued) DEVELOPING A JUVENILE ARTHRITIS TRANSITION PROGRAM 39  ...

... CONTENT-ORIENTED VALIDATION CONTENT-ORIENTED VALIDATION OF THE FUNCTIONAL COGNITIVE ASSESSMENT 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: Alyssa A. Ford, MOT, OTR Copyright September 5, 2017 By: Alyssa A. Ford, MOT, OTR All rights reserved Approved by: Candace Beitman, EdD, OTR Committee Chair Beth Ann Walker, PhD, OTR Committee Member Kim Warchol, BS, 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 CONTENT-ORIENTED VALIDATION ii Abstract The Functional Cognitive Assessment is a standardized cognitive performance assessment that is criterion referenced and administered during everyday tasks (Ebell, Ford, & Warchol, 2016). Psychometric testing is needed in order to establish content-oriented validity evidence and utility of the Functional Cognitive Assessment; thus, the purpose of the study was to establish the content-oriented validity evidence of the Functional Cognitive Assessment. Ten subject matter experts anonymously responded to a survey comparing the test items to the construct of functional cognition. Interrater agreement was 0.90 for representativeness and 0.70 for clarity. Item level content validity indices ranged from 0.70-0.90 for representativeness. The scale level content validity index was 0.81 for representativeness. Factor validity index ranged from 0.90-1.0 for each subtask. The overall factor validity index was 0.98. Item content validity indices for representativeness were assessed using a multi-rater kappa statistic, which ranged from 0.66-0.90 for each subtask, indicating that the subtasks ranged from excellent to good. Results support initial content-oriented validation of the Functional Cognitive Assessment. Keywords: cognitive disabilities model, Alzheimers disease and related dementias, performance assessment, content-oriented validity evidence, content validity, functional cognition CONTENT-ORIENTED VALIDATION iii Acknowledgements I would like to acknowledge the guidance, support, and encouragement that my parents, John Hawkins and Marianne Hawkins provided throughout my entire academic career. They ensured that I had access to the resources and education that I needed throughout every stage of my education. They instilled a value of work-ethic, love for learning, and lifted me up when I was down. Thank you to my siblings for encouraging me every step of the way. Jonathan Hawkins, is my closest sibling in age and always set the bar high. Leah Scott was my sounding board during the past year while we simultaneously engaged in coursework for separate academic endeavors. I thank Mary Comparato for reviewing my application for the Early Investigator Scholarship for Dementia Research and Study. I thank Stephen Hawkins for his support during the data analysis stage of this doctoral project. I would also like to acknowledge my mother-in-law, Joyce Ford for her support throughout the Doctor of Health Science Program and during completion of this doctoral project. My sons, Anderson and Aaron Ford, inspire me to be an ethical and efficient role model and to always complete the best work that I am possible of accomplishing. Thank you to my husband, Andrew Ford, for being by my side through every stage of the Doctor of Health Science program and this doctoral project. I would not have been able to complete the course work or this doctoral project without his instrumental support on a daily basis. Andrew Ford is a loving and engaged husband and father who patiently performed more than his fair share of the family responsibilities while I pursued my academic goals. For this, I will forever be grateful. I would also like to acknowledge several colleagues who have been pivotal in my career. Thank you to Kim Catlett, Lora Alonzo, and Ryan Palombit for modeling true interprofessionalism in the care of clients who have Alzheimers disease or related dementias. CONTENT-ORIENTED VALIDATION iv Not only are they colleagues, they were role models during my early years as an occupational therapist. It was with this team that I began to understand how to incorporate the cognitive disabilities model into occupational therapy practice. I must also acknowledge Kathryn McCormick for her support during the early stage of this doctoral project. A fellow occupational therapist that Id like to recognize is Sarah King, who has been a close colleague as I have solidified my understanding of the cognitive disabilities model and completed my coursework and doctoral project. Sarah was always willing to hear about my educational pursuits. Thank you to C. Ann Irwin for her support, which has enabled me to have access to exceptional continuing education and opportunities to disseminate my knowledge. Finally, thank you to the pilot reviewers and all of the respondents who completed the survey for this doctoral project. Id like to express my deep gratitude to my doctoral project committee at the University of Indianapolis. Dr. Candace Beitman was my graduate school advisor and later agreed to be the committee chair for my doctoral project. Dr. Beitman provided guidance during the doctoral project proposal process, and patiently provided support throughout the doctoral project. Her kind words of encouragement seemed to come at the right moments. Thank you to Dr. Beth Ann Walker for being the analysis expert on my committee. I was grateful for her critical eye and analytical skills. She went above and beyond as an analysis expert for my doctoral project and made herself available whenever I needed to discuss small and large details. Thank you to Kim Warchol for providing crucial continuing education to healthcare professionals who treat clients who have Alzheimers disease or related dementias. Her continuing education courses formalized my understanding of the cognitive disabilities model and its application to occupational therapy. I am grateful that our professional paths crossed and that we have had opportunities to collaborate on projects. I will always be grateful that Kim involved me in the CONTENT-ORIENTED VALIDATION creation of the Functional Cognitive Assessment and agreed to be the content expert for my Doctoral Project. Finally, thank you to the Alzheimers Association Greater Indiana Chapter for awarding me the 2015 Early Investigator Scholarship for Dementia Research and Study. People with Alzheimers disease and related dementias deserve to live the highest possible quality of life. Thank you for the financial support and believing in the merits of this doctoral project. v CONTENT-ORIENTED VALIDATION vi Table of Contents Abstract ......................................................................................................................................... ii Acknowledgements ....................................................................................................................... iii List of Tablesviii INTRODUCTION ........................................................................................................................ 1 LITERATURE REVIEW ............................................................................................................. 5 Cognitive Disabilities Model ........................................................................................................ 5 Allen Cognitive Levels ................................................................................................................. 6 International Classification of Functioning, Disability and Health Model ................................... 14 Similarities between the CDM and ICF-M ................................................................................... 17 Theory of Retrogenesis ................................................................................................................. 18 The Allen Battery of Assessments ................................................................................................ 18 The Functional Cognitive Assessment.......................................................................................... 21 Content-Oriented Validity Evidence............................................................................................. 23 METHODS ................................................................................................................................... 24 Research Design............................................................................................................................ 24 Sampling ....................................................................................................................................... 24 Instrumentation ............................................................................................................................. 26 Pilot Study..................................................................................................................................... 27 The Survey .................................................................................................................................... 27 Plan for Data Analysis .................................................................................................................. 29 RESULTS ..................................................................................................................................... 32 Interrater Agreement ..................................................................................................................... 32 CONTENT-ORIENTED VALIDATION vii Content Validity Index (representativeness) ................................................................................ 33 Factor Validity Index .................................................................................................................... 33 I-CVI using a Modified Kappa Statistic ....................................................................................... 34 Respondent Feedback ................................................................................................................... 35 DISCUSSION ............................................................................................................................... 36 Potential Use of the FCA .............................................................................................................. 38 Limitations .................................................................................................................................... 39 Conclusion .................................................................................................................................... 40 REFERENCES ............................................................................................................................. 41 Appendix A ................................................................................................................................... 55 Appendix B ................................................................................................................................... 56 Appendix C ................................................................................................................................... 57 CONTENT-ORIENTED VALIDATION viii List of Tables Table 1...34 CONTENT-ORIENTED VALIDATION 1 Content-Oriented Validity Evidence of the Functional Cognitive Assessment It has been estimated that 5.2 million Americans aged 65 years or older have Alzheimers disease (AD) (Herbert et al., 2013). The incidence of AD amongst this population is projected to nearly triple by 2050, which could yield up to 13.8 million cases unless a cure or prevention is found (Herbert et al., 2013). As cited in the 2012 Alzheimers Disease Facts and Figures (Alzheimers Association, 2012), adults with Alzheimers disease or related dementias (ADRD) have more than triple the amount of hospital stays as compared to other older adults (Bynum, 2011). Risks encountered by people with ADRD who live alone or in the community may include: malnourishment (Nourhashemi, Amouyal-Barkate, Gillette-Guyonnett, Cantet, & Vellas, 2005); nursing home placement (Yaffe et al., 2002); unmet social, environmental, psychological, and medical needs (Miranda-Castillo, Woods, & Orrell, 2010); disorientation or self-neglect resulting in harmful incidents or emergencies (Tierney et al., 2007; Tierney et al., 2004); falls (Rubenstein & Josephson, 2006); injuries and wandering away from home while unattended (Rowe et al., 2010), fatal injuries (Kibayashi, Sumida, Shojo, & Hanada, 2007); and psychiatric symptoms such as depression, agitation, and psychosis (Apostolova & Cummings, 2008; Lehmann, Black, Shore, Kasper, & Rabins, 2010). In a population-based sample, Steinberg et al. (2003) noted mental and behavioral symptoms such as delusions, apathy, and aberrant motor behavior. Lehmann et al. (2010) noted that a lack of awareness about cognitive dysfunction, functional deficits, and psychiatric symptoms increase the risk of adverse outcomes in people who have dementia and live alone. It is clear that inadequate support of the person with ADRD can lead to unfortunate and disastrous consequences. The risks associated with CONTENT-ORIENTED VALIDATION 2 inadequate support are further complicated when people who have ADRD and their caregivers are unaware of the condition (Alzheimers Association, 2015). A lack of understanding about ones medical condition and the risks of inadequate supervision during day to day tasks may lead to expensive, preventable hospitalizations. Preventable hospitalizations are those which could have been avoided with better access or higher quality of preventive or primary care. The Office of Disease Prevention and Health Promotion set a goal of reducing preventable hospital admissions for people with ADRD by 10% by 2020 (Office of Disease Prevention and Health Promotion, 2014). Community-dwelling individuals with dementia are more likely than those individuals without dementia to have a potentially preventable hospitalization or an emergency department visit that resulted in a hospitalization (Feng, Coots, Kaganova, & Wiener, 2014). In addition, a substantial number of hospitalizations and emergency department visits prior to and during the last year of life were shown to be potentially avoidable (Feng et al., 2014). Individuals with dementia, as well as comorbid dementia and depression are a particularly at risk population of individuals who may benefit from interventions to reduce preventable hospitalizations (Davydow et al., 2014). Occupational therapists and other professionals are positioned to provide support to people with ADRD and their caregivers. In fact, occupational therapy (OT) has been found to be an essential and effective element in discharge planning (Renda, Lee, Keglovits, & Somerville, 2016). The Alzheimers Disease 2016 Facts and Figures (Alzheimers Association, 2016) lists a variety of interventions that can be offered to caregivers, such as case management, psychoeducational, counseling, support groups, respite, psychotherapeutic approaches, and CONTENT-ORIENTED VALIDATION 3 multicomponent approaches (Pinquart & Srensen, 2003; Srenson, Duberstein, Gill, & Pinquart, 2006). However, none of these approaches explicitly describes the provision of oneon-one intervention with the client who has ADRD during activities of daily living, instrumental activities of daily living, leisure tasks, etc., nor education to the caregiver about the clients task performance and how to provide verbal, visual, and tactile cues to the client in order to facilitate the best possible performance during these tasks. Based on the Occupational Therapy Practice Framework: Domain and Process, 3 rd edition (OTPF-III), (American Occupational Therapy Association, 2014) client factors are capacities, characteristics, or beliefs that influence performance in occupations. Body functions is a category of client factors, and cognition falls within the mental functions (American Occupational Therapy Association, 2014). OT practitioners are particularly concerned with how cognition affects performance skills in occupations such as activities of daily living (ADLs), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation. OT practitioners using the Cognitive Disabilities Model (CDM) (Allen et al., 1995; Allen et al., 1992) assess functional cognition in the context of the above stated areas. Functional cognition is how an individual utilizes and integrates his or her thinking and processing skills to accomplish everyday activities in clinical and community living environments (American Occupational Therapy Association, 2016, para. 3). Additionally, occupational therapists have described that functional cognition . . . encompasses both functional performance and the global cognitive processing capacities of the brain. Functional performance arises from the interaction between global cognitive processing capacities reflected in what a person pays attention to and the activity demands of specific functional tasks, e.g. the motor and verbal skills, social behaviors, self-awareness, and awareness of contexts required for CONTENT-ORIENTED VALIDATION 4 performing various tasks (Allen, Austin, David, Earhart, McCraith, & Riska-Williams, 2007, p. 7-8). An Allen Cognitive Level (ACL) is a descriptor of a clients cognitive abilities (Allen, 1982, Allen et al., 1995; Allen et al., 1992). OT practitioners using the cognitive disabilities model may initially administer the Allen Cognitive Level Screen-5 (ACLS-5) or Large Allen Cognitive Level Screen-5 (LACLS-5) (Allen et al., 2007). The authors clearly describe that the ACLS-5 and LACLS-5 were designed to be a quick estimate of undetected problems related to functional cognition or for providing an estimate of the severity of the functional cognition deficits. The score should be used by the OT practitioner or other skilled clinician in order to effectively select additional assessments and in the overall interpretation of the clients cognitive status (Allen et al., 2007). Therapists who use the CDM also use non-standardized skilled observation to identify and describe specific patterns of behavior associated with each cognitive level during any functional task (Allen et al., 1992; McCraith, et al., 2011). Ebell, Ford, and Warchol (2016) developed a tool titled The Functional Cognitive Assessment (FCA) to guide therapists skilled observations and the determination of a clients ACL through functional task analysis. The FCA is a standardized, criterion-referenced test in which the client performs a variety of functional tasks (Ebell et al., 2016). The FCA consists of 10 functional tasks, including three ADLs, four IADLs, and three leisure activities. Test administrators use scoring rubrics to identify observable behaviors during completion of the functional tasks that are consistent with ACLs. See Appendix A for a copy of the FCA at the time of this study. CONTENT-ORIENTED VALIDATION 5 In order to achieve the American Occupational Therapy Associations 2017 Centennial Vision, Doucet, Woodson, & Watford (2014) recommended that OT practitioners focus on quantifying and centering on occupational-based practice. In a systematic review of studies on measurement properties of evaluation instruments for adults, Yuen and Austin (2014) stated that methodologically strong content validity articles explored content validity by assessing relevance and representativeness of potential test items. Furthermore, they discussed that studies related to assessment development could be strengthened by including theoretical underpinnings of the assessments construct. Yuen and Austin (2014) concluded by stating that the implementation of psychometric research will support the goal to be recognized as a scientific and evidence-based profession. The next step is to determine if the FCA demonstrates evidence of content-oriented validity. Therefore, the purpose of this study was to establish content-oriented validity of the FCA. Literature Review Cognitive Disabilities Model The American Occupational Therapy Association (AOTA) (2013) identified the CDM as a model that addresses cognition and occupational performance in an evidence-based manner in Cognition, cognitive rehabilitation, and occupational performance. Allen et al. (1992, p. 102) stated that by understanding a clients cognitive abilities, a therapist can adapt activities so that the clients cognitive abilities are continuously maximized. According to the OTPF-III (2014), activity analysis is important because the process helps OT practitioners understand the demands of an activity. Therefore, the aforementioned concept of establishing task equivalence and providing caregiver training about task equivalence is consistent with the OTPF-IIIs (2014) CONTENT-ORIENTED VALIDATION 6 description of OT interventions such as education and training, as well as approaches to intervention, such as maintenance, modification (compensation and adaptation), and prevention. As cited in the OTPF-III (2014), the intervention of modification/compensation/adaptation has been described as finding ways to revise the current context or activity demands to support performance in the natural setting, [including] compensatory techniques, [such as] . . . enhancing some features to provide cues or reducing other features to reduce distractibility (Dunn, McClain, Brown, & Youngstrom, 1998, p. 533). By understanding the clients difficulties with learning and problem solving, therapists may be able to anticipate hazards in the environment and prevent unsafe or undesirable situations (Allen et al., 1995; Allen et al., 1992; Allen, 1999). Allen et al. (1992) postulated that the therapist is responsible for discharge recommendations, which may include training caregivers to provide opportunities for the client to use their cognitive abilities and warning the client and caregivers about potentially harmful situations if safeguards are not put into place. Allen Cognitive Levels Allen (1982) initially developed six cognitive levels which represent a hierarchy of abilities. The determination of a clients Allen Cognitive Level (ACL) is based on clinically observable and qualitative differences in his or her abilities during screening, testing, and functional activities (Allen et al., 1995; Allen et al., 1992; Allen, 1999; McCraith et al., 2011). Allen Cognitive Levels 1-5 are further defined into performance modes (Allen et al., 1995; Allen, et al., 1992; Allen, 1999; McCraith et al., 2011). Because Level Six is the highest level, representing normal cognition, there was no need to refine it into performance modes CONTENT-ORIENTED VALIDATION 7 (Allen et al., 1992). The performance modes were developed to be more specific measures of cognitive abilities and are formally described as .0, .2, .4, .6, and .8 within the Allen Cognitive Levels (Allen et al., 1992). There are functional descriptors associated with the ACLs and performance modes. Clients who function in .8 modes begin to demonstrate abilities in the next level. However, these higher abilities at .8 are inconsistent and clients can easily become frustrated if they are expected to perform at the next higher performance mode. Clients who function in .0 modes demonstrate a shift from the previous level. (Allen et al, 1992; McCraith et al., 2011). When therapists have an understanding of a clients ACL, they can develop appropriate goals, treatment plans, and discharge recommendations (Allen et al., 1995; Allen et al., 1992; McCraith et. al., 2011). Allen Cognitive Level One comprises the lowest level of cognitive abilities, while Allen Cognitive Level Six (ACL 6) describes normal cognitive function. Allen Cognitive Level One is titled Automatic Actions (Allen et al., 1992; McCraith et. al., 2011). Clients functioning in this level present with reflexive abilities and can be positioned to sit with support (Allen et al., 1995; Allen et al., 1992; McCraith, et al., 2011). They require total cognitive assistance and 24-hour supervision via nursing care for all aspects of self-care (Allen et al., 1995; Allen et al., 1992). Communication may range from moans and grimaces to smiles and increased responses to loved ones. The client may initiate communication in response to pain or external stimuli (Allen et al., 1995; Allen et al., 1992; McCraith et al., 2011). Allen Cognitive Level Two is titled Postural Actions (Allen et al, 1995; Allen et al., 1992; McCraith et al., 2011). Clients functioning in this level may present with gross motor abilities, such as the ability to sit, stand, and walk (Allen et al., 1995; Allen et al., 1992; McCraith et al., 2011). Within this level, there is also an emerging use of the hands, such as the CONTENT-ORIENTED VALIDATION 8 ability to grab onto a bar to prevent falling (McCraith et al., 2011). Clients may wander aimlessly; thus, caregivers may engage in environmental modifications to prevent falls and unsafe wandering (McCraith et al., 2011). Individuals may require maximum cognitive assistance for 24 hour supervision via nursing care to prevent falls during gross motor activities (Allen et al., 1995; Allen et al., 1992). Clients in this level may recognize and state their names, use perseverative words, and use short phrases and gestures (Allen et al., 1995; Allen et al., 1992; McCraith et al., 2011). Allen Cognitive Level Three is titled Manual Actions (Allen et al, 1995; Allen et al., 1992; McCraith et al., 2011). People functioning in Allen Cognitive Level Three have the use of their hands, which may be demonstrated in the ability to grasp, manipulate, and attempt to use objects for their intended purpose. Clients may also exhibit an understanding of task completion upon the utilization of all available objects, and may be able to communicate their needs and name familiar objects and actions (Allen et al., 1995; Allen et al., 1992; McCraith et. al., 2011). Individuals may not differentiate between day, date, or time; however, they may be able to acknowledge the difference between their home and the hospital. People functioning in Allen Cognitive Level Three require moderate cognitive assistance and 24 hour supervision for cues through the steps of an activity to avoid potentially dangerous situations (Allen et al., 1995; Allen et al., 1992). Allen Cognitive Level Four is titled Goal-Directed Actions (McCraith et al., 2011). Individuals functioning in Allen Cognitive Level Four have the ability to sequence themselves through the steps of a simple, routine task. Based on their performance mode, task quality may be degraded. However, they may also complete a goal with good quality. There is a continuum of problem-solving abilities within this level (Allen et al., 1995; Allen et al., 1992; CONTENT-ORIENTED VALIDATION 9 McCraith, et. al., 2011). During communication, individuals may interrupt others, speech may be egocentric and concrete, and they may not be able to understand the viewpoint of others (McCraith et al., 2011). New learning can occur through repetitive training, however, individuals often require minimum cognitive assistance on a daily basis to remove dangerous objects and solve any problems that occur due to changes in the environment (Allen et al., 1995; Allen et al., 1992). If clients are found to be functioning at the lower performance modes in this level, they will most likely require 24 hour assistance due to immediate problem-solving needs (Allen et al., 1995; Allen et al., 1992). Individuals functioning in the higher performance modes of this level may be able to live alone with daily checks of the environment for safety and health reasons (Allen et al., 1995; Allen et al., 1992). Allen Cognitive Level Five is titled Exploratory Actions (Allen et al., 1995; Allen et al., 1992; McCraith, et. al., 2011). Individuals functioning in Allen Cognitive Level Five understand that changes in neuromuscular control can cause different effects on objects. Allen (1999) coined the phrase neuromuscular adjustments and described this occurrence as the process that uses overt trial and error to improve the effect of actions (p. 111). Allen further elaborated that a classic example of the use of neuromuscular control is demonstrated while opening a can of paint with a screwdriver. The screwdriver acts as a primary lever and the client has to manually apply the necessary amount of pressure to gently pry open the lid. If too much force is used, the lid may fly off the container (Allen, 1999). In the lower performance modes, individuals may only consider the primary effects of their actions. In the higher performance modes, an individual considers the secondary effects of their actions and identifies the need to consult with others (Allen, 1995; Allen, 1992). At this level, individuals have a better ability to understand written and auditory information. They are able to hear and understand differences in CONTENT-ORIENTED VALIDATION 10 intonation. However, their language may appear impulsive and accusatory during difficult conversations (Allen et al., 1999). Persons functioning at this level often require supervision while learning new tasks, in order to avoid potentially hazardous situations (Allen et al., 1995; Allen et al., 1992). They may live alone with weekly checks to monitor safety and finances (Allen et al., 1995; Allen et al., 1992). In the mid-range of Level Five, individuals may also work in a job that allows for a wide margin of error or in consistent and predictable settings (Allen et al., 1995; Allen et al., 1992). In the high-range of the level, individuals may live and work independently (Allen et al., 1995; Allen et al., 1992). Allen Cognitive Level Six is titled Planned Actions (Allen et al., 1995; Allen et al., 1992; McCraith et al., 2011). Clients functioning in Allen Cognitive Level Six have the ability to plan ahead and think abstractly. They are independent and do not need cognitive assistance to anticipate hazardous situations (Allen et al., 1995; Allen et al., 1992; McCraith et al., 2011). Importance of identifying and understanding the Allen Cognitive Level. Allen et al. (1995; 1992) argued that it is important to determine an individuals ACL in order to recommend an environment that will maximize safety and the individuals best ability to function. Therapists should consider the client's cognitive status when developing a plan of care and making decisions with the client and caregiver about goals, treatments, and discharge planning. Effective discharge planning could include caregiver training. Caregiver training may include topics such as successful ADL and IADL completion, as well as recommendations to decrease the risk of falls, elopement, occupational deprivation, aggressive behaviors, and the proper use of verbal cues, visual cues, tactile cues, and environmental modifications during any functional task. CONTENT-ORIENTED VALIDATION 11 Cognitive programming. Several authors have developed programming based on the cognitive status of the client. Gitlin et al. (2009) designed a non-pharmacological, home-based program in which caregivers were trained to implement purposeful, prescribed activities as a means to manage behaviors during daily care. The Tailored Activities Program (TAP) is an intervention composed of four phases. In Phase I, the occupational therapist evaluated caregiver communication and management techniques and assessed the client with dementia in order to identify remaining abilities. The occupational therapist also completed an environmental assessment. In Phase II the occupational therapist educated the caregiver on the role of the environment, utilization of activities, and demonstration and practice. Phase III involved continued caregiver training in the utilization of activities. Caregivers who participated in the program noted high confidence in using the activities, decreased frustration with behavioral symptoms, and enhanced skills and personal control. The OT interventionists noted engagement and pleasure by those with dementia who received the intervention (Gitlin et al., 2009). Warchol (2004, 2006) described an interdisciplinary program for persons with dementia in long-term care. The program was based on the CDM (Allen, 1982; Allen 1985; Allen et al., 1995; Allen et al., 1992) and the theory of retrogenesis (Reisberg et al., 2002). Warchol (2004, 2006) described the need for geriatric rehabilitation specialists to utilize a comprehensive battery of performance-based cognitive assessments to identify the stage of dementia, as well as remaining functional abilities. In order to prepare healthcare professionals and caregivers to effectively interact with and care for residents with ADRD, Warchol (2004) recommended that front-line staff receive intensive training, as well as ongoing inservices. Warchol (2004, 2006) also advocated that geriatric rehabilitation professionals should consider a rehabilitative and/or CONTENT-ORIENTED VALIDATION 12 habilitative approach when providing therapy services to clients with ADRD. In addition, (Warchol, 2004, 2006) recommended that communities that serve people with ADRD (such as skilled nursing facilities, assisted living communities, and memory care communities) incorporate specialized programming for ADLs, mobility, and activities with this population. Warchol (2004, 2006) discussed the need to assess the clients ACL and incorporate a treatment approach of modification/compensation to maximize a clients remaining abilities. Geriatric rehabilitation specialists should also consider the clients internal factors, such as interests, values, and cultural considerations, as well as contextual factors, such as the environment and caregiver support when planning interventions (Warchol, 2006; Warchol, Copeland, & Ebell, 2006; Crisis Prevention Institute, 2010). In addition, Warchol (2004, 2006) argued that the clients values and support systems may directly impact treatment outcomes and maximization of the clients abilities. This is consistent with the CAN DO, WILL DO, and MAY DO, biopsychosocial perspective on function (McCraith, Austin, & Earhart, 2011, pp. 384385). As cited in McCraith et al. (2011), individuals with ADRD may experience ones best ability to function when there is a match between functional activities, activity demands, and when there is a supportive context. The CAN DO are realistic abilities, the WILL DO are relevant activities, and the MAY DO represents possible abilities based on social context and the environment (Allen & Blue, 1998). For example, a client with cognitive dysfunction may have memory impairments and experience problem-solving difficulties. When problems occur in the environment and a client lacks problem-solving skills, external sources, such as a geriatric rehabilitation specialist or caregivers can provide a spectrum of cues (Crisis Prevention Institute, 2010). These cues may range from nonspecific cues, to more specific cues, and finally to a demonstration of the solution CONTENT-ORIENTED VALIDATION 13 (Crisis Prevention Institute, 2010). The geriatric rehabilitations specialist or caregiver should observe the clients response to these cues and consider the effectiveness of the cues in terms of the clients change in task performance (Crisis Prevention Institute, 2010). If the client lacks problem solving skills, problem-solving expectations by the staff should be minimized in order to decrease the risk of frustration by the client (Crisis Prevention Institute, 2010). Cognitive functioning and learning is impacted by the individuals ability to process information (Warchol et al., 2006; Crisis Prevention Institute, 2010). When processing information, the individual must first attend to cues in the environment. If the individuals attention is not gained and maintained, information coming in through the senses will not be processed (Warchol et al., 2006; Crisis Prevention Institute, 2010). Once the individuals attention is gained, new information can be processed by working memory (Warchol et al., 2006; Crisis Prevention Institute, 2010). This new information is temporarily housed in short-term memory, may then be stored as a long-term memory, and retrieved later as a procedural memory (Warchol et al., 2006; Crisis Prevention Institute, 2010). This is similar to the informationprocessing model of memory functioning (Braungart, Braungart, & Gramet, 2011, Chapter 3). Once functional abilities and the stage of dementia are identified, interdisciplinary team members should train caregivers in order to maximize the clients functional skills and prevent unnecessary or excess disability (Warchol, 2004, 2006). The interdisciplinary team member can design a restorative or maintenance program with reasonable goals and specific approaches that caregivers can use to achieve the clients maximum functional potential on a consistent basis (Warchol, 2004, 2006). The Centers for Medicare and Medicaid Services described maintenance programs in the Medicare Benefit Policy Manual (Centers for Medicare and Medicaid Services, CONTENT-ORIENTED VALIDATION 14 2016, Ch. 15, Section 220.2, D) as an opportunity to provide patient or caregiver training in order to maintain the patients current condition or prevent the risk of functional deterioration. The use of a maintenance program can decrease the risk that a client with ADRD will experience excess disability. Excess disability is a term that describes a discrepancy between an individuals level of functioning and their actual abilities. As cited by Brody, Kleban, Lawton, and Silverman (1971), the excess disability may be greater than the medical condition warrants (Kahn, 1965). Rogers et al. (2000) identified excess disability in nursing home residents and reported that the excess disability could be alleviated if the caregivers increased opportunities for independent activity and substituted verbal assistance for physical assistance. Researchers have studied the negative effects of excess disability when a person has dementia. Excess disability has been associated with decreased walking abilities (Slaughter, Eliasziw, Morgan, & Drummond, 2011) and depression (Espiritu et al., 2001). More recently, Slaughter and Hayduck (2012) determined that the quality of the living environment is at least as important as the progression of dementia in delaying the onset of walking and eating disabilities. International Classification of Functioning, Disability and Health Model The FCA is supportive of the concepts within the International Classification of Functioning, Disability, and Health (ICF) (World Health Organization, 2002) and the CDM. The ICF (2002) is a cross-cultural, standard language and framework for health and the World Health Organizations (WHO) universal framework for health and disability. The WHO (2002) described health-related domains, such as descriptions of body function and structure, level of capacity in a standard environment, and level of performance in a usual environment. The WHO (2002) described health and functioning, rather than disability, and the model has been used as a CONTENT-ORIENTED VALIDATION 15 universal tool to measure function in society, regardless of the reason behind the impairment or disability. The WHO (2002) acknowledged that every human being can experience a certain degree of disability, which in effect, mainstreams the concept of disability. By focusing on the impact on function, users of the ICF can address the functional capacity of the person by modifying the social and physical environment (World Health Organization, 2002). The WHO developed the ICF (2002) to address equity, inclusion, and to promote the maximization of functioning in the environment. In the ICF-Model (ICF-M) (2002), the WHO emphasized a biopsychosocial approach by integrating both the medical and social models. In the medical model, disease causes a disability, which then requires a subsequent intervention to correct the disability (World Health Organization, 2002). In the social model, disability is considered to be a socially-created problem, not a problem of the person (World Health Organization, 2002). According to the WHO, neither the medical nor the social model completely explain disability nor its management (World Health Organization, 2002). According to the WHO (2002), disability and functioning are viewed as outcomes of interactions between health conditions and contextual factors, including external environmental factors, such as social attitudes, architectural characteristics, legal and social issues, and climate and terrain. Other contextual factors included internal personal factors, such as age, gender, coping styles, social background, education, profession, past and current experiences, overall behavior patterns, character, and other factors that influence the individuals disability (World Health Organization, 2002). CONTENT-ORIENTED VALIDATION 16 In the ICF-M, the WHO described performance qualifiers and capacity qualifiers (World Health Organization, 2002). Performance qualifiers are a term for what an individual does in his or her current environment. Performance was described as the lived experience (which may or may not include assistance) in the environment (World Health Organization, 2002). The capacity qualifier was a term for an individuals ability to execute a task. The capacity qualifier was the persons highest probable level of functioning at a given moment (World Health Organization, 2002). The WHO (2002) postulated that when a person has a capacity problem that is related to a health condition, that capacity problem is a component of their state of health. The WHO described that users of the ICF-M should consider both performance and capacity as they relate to participation in functional tasks (World Health Organization, 2002). Analyzing performance and capacity can help to identify the gap between actual abilities and the persons potential (World Health Organization, 2002). A gap in performance could indicate the possibility that some aspect of the environment prohibited the individual from fully utilizing his or her capabilities (World Health Organization, 2002). Assistive devices or personal assistance are one additional qualifier that can be used in this model. Assistive devices or personal assistance can not alter impairments. However, the use of assistive devices or personal assistance can minimize or remove limitations in the environment (World Health Organization, 2002). There are three underlying principles of the ICF-M: universality, parity, and neutrality (World Health Organization, 2002). The ICF-M can be universally applied to all people and their ability to function (World Health Organization, 2002). Parity refers to the notion that disability should not be referred to by etiology. Therefore, the WHO recommended that users of the ICF do not distinguish between physical and mental disabilities (World Health Organization, CONTENT-ORIENTED VALIDATION 17 2992). The language of the ICF-M has neither a positive nor a negative connotation, and is therefore considered to be neutral (World Health Organization, 2002). Similarities between the CDM and ICF-M There are significant parallels between the CDM and ICF-M. The first similarity is the emphasis on function. Claudia Allen simply stated that function is what people do! (Allen, 1999, p. 4) and that cognition impacts function. Body functions, activities, and participation are addressed in the ICF (World Health Organization, 2002). Users of both the CDM and ICF-M focus on health and functioning, as opposed to ones disability. It is important to understand an individuals cognitive abilities and maximize the individuals abilities in any given living environment with the support of care partners as needed. The demands of the environment should fit the clients cognitive abilities in order to ensure safety (Allen et al., 1995; Allen et al., 1992; McCraith et al., 2011). The notion that function can be maximized by addressing environmental or contextual barriers is explicitly addressed in the ICF-M. In the ICF-M, (World Health Organization, 2002) and CDM (Allen et al., 1995; Allen et al, 1992), it was identified that there can be a discrepancy between the individuals capacity and actual functioning due to the physical and social environment; in other words, excess disability. Allen (1999) referred to the individuals greatest ability as best ability to function (BATF), whereas, the World Health Organization (2002) referred to the individuals maximum abilities as capacity. The authors of both models identify that there may be environmental barriers and facilitators that impact an individuals ability to function (Allen, 1999; World Health Organization, 2002). CONTENT-ORIENTED VALIDATION 18 Theory of Retrogenesis The theory of retrogenesis is a reverse developmental theory in which the author concluded that the functional deficits associated with Alzheimers disease or related dementias correlate with developmental stages of humans (Reisberg et al., 2002). Reisberg et al. (2002) identified that the Functional Assessment Staging Tool cross-references stages of dementia with developmental ages, acquired abilities, lost abilities, and Alzheimers stage. Reisberg et al. (2002) recommended that caregivers should consider the stage of dementia and corresponding developmental age when providing care to the person who has ADRD. The Allen Battery of Assessments Routine Task Inventory-Expanded. In the ICF-M, standardized tools facilitate enhanced functional performance in activities through the use of universal design. There are multiple assessment tools based on the CDM that incorporate functional tasks. The Routine Task Inventory-Expanded (RTI-E) is a functional analysis of behaviors that a client exhibits during tasks such as ADLs, IADLs, communication, and work readiness (Katz, 2006). It can be completed via self-report, caregiver report, or by therapist observation and a subsequent report (Katz, 2006). The RTI-E does not provide guidelines for the use of verbal, visual, or tactile cues during task observation. Therefore, users of the RTI-E do not standardize the environment in which the functional tasks are performed. Allen Cognitive Level Screen-5 and Large Allen Cognitive Level Screen-5. Researchers have not specifically tested the psychometric properties of the Allen Cognitive Level Screen-5 (ACLS-5) or the Large Allen Cognitive Level Screen-5 (LACLS-5) CONTENT-ORIENTED VALIDATION 19 (Allen et al., 2007). However, researchers have studied the psychometric properties of earlier versions and found moderate-high levels of inter-rater reliability (Henry, Moore, Quinlivan, & Triggs, 1998; Keller & Hayes, 1998; Lee et al., 2003; Penny, Mueser, & North, 1995; Raweh & Katz, 1999; Velligan, Bow-Thomas, Mahurin, Miller, Dassori, & Erdely, 1998; Velligan, True, Lefton, Moore, & Flores, 1995). Researchers have reported significant test-retest reliability of the ACLS (McAnama, Rogosin-Rose, Scott, Joffe, & Kelner, 1999). Researchers have also reported positive correlations between ACLS and LACLS scores and scores from measures of ADLs and IADLs (Keller & Hayes, 1998; Mcanama et al., 1999; Velligan et al., 1998; Velligan et al., 1995; Ziv, Roitman, & Katz, 1999); living situation (Henry et al., 1999; McAnanama et al., 1999), and social competence (Penny et al., 1995). Allen Diagnostic Module-2 Edition. nd If a potential cognitive impairment is identified on the ACLS-5 or LACLS-5, the therapist can choose an assessment from the Allen Diagnostic Module-2 Edition (ADM-2) nd (Earhart, 2006) to verify a cognitive impairment or measure changes in functional cognition. Over 25 novel, craft-based performance assessments from the ADM-2 are intended to be used to assess functional cognition within the context of the cognitive disabilities model. The ADM was designed for standardized administration and has accompanying scoring rubrics (Earhart, 2006). However, critics of the ADM-2 argue that it is difficult to accurately ascertain ones ability to function in his or her environment from performance on a standardized craft project. CONTENT-ORIENTED VALIDATION 20 Other assessments that are functional in nature. Other standardized assessments are described in the literature. The Cognitive Performance Tool (CPT) is a standardized, performance-based test of ADLs and IADLs (Burns, 2006). The CPT was grounded in the cognitive disabilities model and designed to assess a functional level in clients who have Alzheimers disease (Burns, 1992). However, the current version of the CPT corresponds with the cognitive disabilities reconsidered model (Levy & Burns, 2011, Chapter 18). Users of the CPT assess functional cognition during the seven subtasks, which include: (a) Medbox, (b) Shop, (c) Phone, (d) Travel, (e) Toast, (f) Wash, and (g) Dress. The scores on the CPT are associated with six profiles that correspond to levels in the cognitive disabilities reconsidered model (Levy & Burns, 2011). In a recent inter-rater reliability study, it was found that the results of the CPT provide users with accurate and consistent information (Schaber, Stallings, Brogan, & Ali, 2016). Test users should be cautioned, however, that the cognitive disabilities model reconsidered is not interchangeable with the original CDM. Therefore, occupational therapists using the CPT should not use the CDMs scoring and interpretation (McCraith et al., 2011). The Executive Function Performance Test (EFPT) is standardized, performance-based test of IADLs (Baum, Morrison, Hahn, & Edwards, 2007). The EFPT was developed using the person-environment-occupational performance model (Baum, et al., 2008). The purpose of using the EFPT is to identify impairments in executive function, determine capacity for executive function, and determine the amount of assistance required during the executive function tasks (Baum et al., 2007). The subtests of the EFPT include (a) preparing or heating up a light meal, (b) managing medications, (c) using the telephone, and (d) paying bills. Researchers have demonstrated that the EFPT is a valid and reliable tool and there is CONTENT-ORIENTED VALIDATION 21 support for the inter-rater reliability and construct, criterion, and discriminant validity with clients who have experienced a mild or moderate stroke (Baum, et al., 2008). People with multiple sclerosis performed significantly worse on the EFPT than healthy people (Goverover et al., 2005). In a study involving people with schizophrenia and use of the EFPT, internal consistency reliability was high, construct validity was significant, and there was moderate to high criterion validity (Katz, Tadmor, Felzen, & Hartman-Maeir, 2007). The Alternate EFPT (aEFPT) was developed to provide occupational therapists with additional testing tasks. No statistically significant differences were found between the EFPT and the aEFPT. Therefore, the aEFPT was found to be comparable to the EFPT to identify performance deficits in clients who have experienced a stroke (Hahn et al., 2014). Traditionally, OT practitioners have been asked to determine a persons capacity to live at home safely, work, and engage in valued occupations (Baum et al., 2008). While the CPT, and EFPT are functional in nature, they are not theoretically based on the cognitive disabilities model. The RTI-E was not designed to incorporate specific cueing protocols for optimal administration to clients with ADRD. As a result, there is a substantial need for a standardized, performance-based assessment grounded within the cognitive disabilities model to guide cueing and scoring of skilled observations during ADLs, IADLs, and leisure tasks with clients who have ADRD. The Functional Cognitive Assessment The FCA was developed to measure the construct of functional cognition in adults with ADRD through assessing how the client performs everyday tasks (Ebell et al., 2016). The FCA was developed using the CDM, however, it inherently was also influenced by the theory of CONTENT-ORIENTED VALIDATION 22 retrogenesis (Reisberg et al., 2002) and has parallels with the ICF-M (World Health Organization, 2002). The FCA has standardized administration and scoring guidelines. First, test administrators determine if the associated tasks are familiar or unfamiliar to the client (Ebell et al., 2016). A client may demonstrate optimal abilities during tasks that are familiar, meaningful, relevant, or which engage procedural memories. Alternately, a client may have the opportunity to demonstrate new learning skills and other executive function skills while completing unfamiliar tasks or the client may not perform optimally if a task is considered to be irrelevant or unfamiliar (Ebell et al., 2016). During the test, the therapists standardized use of cues to prompt performance corresponds with a standardized environment in the ICF-M. Because sensory cues are gradually added as needed during each task, the results of the test are representative of the clients best ability to function, which is described as the capacity qualifier in the ICF-M. Allen et al. (2007) emphasized the importance of assessing the clients use of sensory cues to complete motor actions during a cognitive assessment. Users of the FCA identify the type and amount of verbal, visual, and tactile cues that the client requires during a variety of functional tasks (four ADLs, three IADLs, and three leisure tasks) (Ebell et al., 2016). The graded cues that may be provided by the therapist are for the purpose of gaining and maintaining the clients attention to the given tasks and for identifying and solving problems, in order to elicit a positive response or change in behavior during task completion (Ebell et al., 2016). (See Appendix A) Analysis is needed to establish evidence of content-oriented validity and determine if the FCA can be used to identify patterns of behaviors that are associated with ACLs. CONTENT-ORIENTED VALIDATION 23 Content-Oriented Validity Evidence As cited in the APA Handbook of Testing and Assessment in Psychology (2013, vol. 1, p.12), involving subject matter experts is one way to evaluate if a tests content is indicative of the construct that is being measured and if the test items are relevant and representative of the construct (Haynes, Richard, & Kubany, 1995). According to the Standards for Educational and Psychological Testing (American Educational Research Association, American Psychological Association, and National Council on Measurement in Education, 2014), Test content refers to the themes, wording, and format of the items, tasks, or questions on a test (p.14). In addition, inter-rater agreement amongst the subject matter experts should be explicitly stated (American Educational Research Association, American Psychological Association, and National Council on Measurement in Education, 2014, p. 25). The peer-reviewed literature describes both quantitative and qualitative methods for establishing content-oriented validity evidence. Several methods for analyzing content-oriented validity evidence from a quantitative perspective can be located in the literature. Quantitative methods include calculation of the interrater agreement (IRA), content validity index (CVI), and factorial validity index (FVI) (Rubio, Berg-Weber, Tebb, Lee, & Rauch, 2003). A variety of other researchers have also discussed the use of the CVI in instrument development (Claeys, Neve, Tulkens, & Spinewine, 2012; Delgado-Rico, Carretero-Dios, & Ruch, 2012; DeVon et al, 2007; Lynn, 1986; Malmgreen, Graham, Shortridge-Baggett, L. M., Courtney, M., & Walsh, 2009; Polit & Beck, 2006; Polit, Beck, & Owen, 2007). Researchers have acknowledged that one weakness of the CVI is the failure to adjust for chance agreement amongst the reviewers. Therefore, Wynd, Schmidt, and Schaefer (2003) and Polit, Beck, and Owen (2007) recommended translating itemlevel CVIs (I-CVIs) into values of a modified kappa statistic. CONTENT-ORIENTED VALIDATION 24 Methods Research Design This study used a cross-sectional design using a web-based survey to establish contentoriented validation of the FCA. A cross-sectional design was selected in order to receive feedback about the representativeness and clarity of the items during the evaluation phase of the FCA. According to Rubio et al. (2003), if researchers do not complete a content validity study, they would risk disseminating an untested measure to clinicians for a pilot study. If recommendations were provided after the pilot study and test revisions occurred as a result of the pilot study, the researchers would need to again pilot the test with another subject pool (Rubio et al., 2003). Therefore, a content validity study can save valuable resources by analyzing the measure prior to the pilot phase (Rubio et al., 2003). Sampling The Human Protections Administrator for the University of Indianapolis determined that the proposal was not eligible for Institutional Review Board (IRB) review because the study was not within the purview of human research protections. The Human Protections Administrator determined that the proposal did not meet the definition of human subjects research as set forth in the federal regulations at 45 CFR 46.102 (U.S. Department of Health and Human Services, 2009) because the information being elicited concerned the FCA, and not about the respondent. Please see Appendix B for the letter of formal certification of institutional review and determination. The Standards for Educational and Psychological Testing (American Educational Research Association, American Psychological Association, and National Council on CONTENT-ORIENTED VALIDATION 25 Measurement in Education, 2014) described that content-related evidence can come from expert judges and recommended that test developers fully describe the procedures used to select the experts and that the qualifications and experience of the judges should be presented. For the purposes of this research study, professional experts were defined as individuals with at least an associates degree who have published papers or presented at state, regional, or national meeting on the topic of implementation of the cognitive disabilities model with clients who have ADRD or have experience in psychometric testing. Recruits with experience in psychometric testing were included in the inclusion criteria because they would possibly be able to provide additional information regarding test construction (Davis, 1997). Rehabilitation professionals who did not meet the above criteria were considered for inclusion as lay experts if they had at least five years of work experience using the cognitive disabilities model with older adults who have ADRD. The respondents were asked to provide their professional opinion regarding relevance and clarity of the tests content as compared to the construct of functional cognition. The criteria for professional and lay experts was described in a survey question. Research participants had the option to identify as either a professional or lay expert on the survey. Rubio et al. (2003) recommended using three to 10 professional experts and three to 10 lay experts yielding a possible sample size of six to 20 experts. Polit, Beck, and Owen (2007) recommended that the first round of expert content validation would ideally have a large panel, such as eight to 12 experts. Polit, et al. (2007) developed a table for three to nine content experts that adjusted for the possibility of chance agreement amongst experts, in order to determine fair, good, or excellent Item Level-Content Validity Index (I-CVI). Therefore, this researcher attempted to recruit nine professional experts and nine lay experts to participate in this content CONTENT-ORIENTED VALIDATION 26 validity study. The survey was sent to 33 individuals who potentially met the qualifications for a professional or lay expert. The participant recruitment email was comprised of the informed consent for online data, which included contact information for the researchers, the purpose of the study, inclusion criteria for the participants, a description of The FCA, an explanation of the survey, and an active hyperlink for the survey. Proceeding with the survey indicated consent. Participation in the study was completed anonymously; however, some recruits and respondents personally contacted this author to discuss this research study. Follow up reminder emails were sent weekly. The informed consent for online data collection and the active hyperlink were sent to participants four times in order to give the respondents adequate time to complete the survey. Rubio et al., (2003) recommended offering the content experts a final version of the scale as an incentive to participate in the content validity study. Upon conclusion of this survey, the respondents had the option to click on an active hyperlink, which routed them to another survey. If they so desired, respondents entered their contact information in order to receive a free copy of the FCA after the conclusion of the study and after the test developers revised the FCA. Instrumentation Data were collected via a Qualtrics survey delivered to respondents via electronic mail. Within the Qualtrics survey (Appendix C), the respondents evaluated four topics for each task of The Functional Cognitive Assessment: (a) representativeness of the content domain, (b) clarity of the item, (c) factor structure, and (d) comprehensiveness. Representativeness described an items ability to represent the content domain of functional cognition. The clarity of an item CONTENT-ORIENTED VALIDATION 27 was evaluated on how clearly the item was worded. Respondents were also asked to assign each task to a factor (area of occupation). Pilot Study Prior to submitting the proposal to the IRB, the survey was piloted with five individuals. All five individuals worked in the rehabilitative field of occupational therapy, physical therapy, or speech-language pathology. Two individuals offered specific suggestions to enhance the usability of the survey. Based on feedback from the pilot study, changes were made to enhance the clarity of the introduction and to include additional context on test administration. In addition, the font size of the Qualtrics survey questions was increased and minor revisions related to punctuation and formatting were made to the survey. One respondent in the pilot study noted that it might take the actual study participants approximately 30 minutes to complete the survey. The Survey The survey included a definition of the construct of functional cognition, an opportunity for the expert to identify as a professional or lay expert, initial survey instructions, and the standardized test instructions that test users are recommended to state prior to administering a task to a client. Throughout the survey, respondents were asked to rate the representativeness of the content domain (ability of the test item to represent the content domain as established in the theoretical definition of functional cognition), rate the clarity of each test item (how clearly an item is worded), to select the factor (area of occupation) associated with each test item, and to rate the comprehensiveness of the FCA. CONTENT-ORIENTED VALIDATION 28 The respondents evaluated the description of each task and scoring rubric on representativeness and clarity using a scale of one through four. Anchors were provided for the scale points. For example, a value of one indicated that the item was not representative of the domain or was not clear. A value of four indicated that the item was representative of the domain or clear. As cited by Rubio et al. (2003) it is recommended to use a four-point scale, in order to prevent content experts from choosing the middle score if they are unsure of a response (Lynn, 1986). For representativeness, the scoring criteria were as follows: (a) 1=Item is not representative of functional cognition; (b) 2=Item needs major revisions to be representative of functional cognition; (c) 3=Item needs minor revisions to be representative of functional cognition; (d) 4=Item is representative of functional cognition; and (e) I prefer not to answer. Respondents were next asked to make any comments about the representativeness of the task. For clarity, the scoring criteria were as follows: (a) 1=Item is not clear; (b) 2=Item needs major revisions to be clear; (c) 3=Item needs minor revisions to be clear; (d) 4=Item is clear, and (e) I prefer not to answer. Respondents were then asked to indicate any comments regarding the clarity of the task instructions and scoring rubric. The respondents were asked to assign each test item to a factor. Several factors were listed for the construct of functional cognition. These factors were selected from OTPF-III. (American Occupational Therapy Association, 2014). The factors were: (a) ADLs, (b) IADLs, (c) leisure tasks, or (d) other. Respondents had the opportunity to make comments regarding the factor that was selected for the task in terms of its fit. The comments section enabled the respondents to identify a different occupation that was not listed or whether the task encompassed multiple occupations. Finally, the respondents were asked to address the comprehensiveness and CONTENT-ORIENTED VALIDATION 29 thoroughness of the entire assessment by recommending which items should be deleted or added to the assessment. The format of the survey was modeled after Grant and Daviss (1997) and Rubio et al.s (2003) recommendations for structural elements that should be included within content reviews. Throughout the survey, items were designed as forced-response questions. However, respondents had the option of selecting I prefer not to answer in order to provide the opportunity to avoid a question and still proceed through the survey. Plan for Data Analysis Data were exported and analyzed using Microsoft Excel. As recommended by Rubio et al. (2003), four types of analyses were performed: (a) IRA for representativeness and clarity, (b) CVI for representativeness, (c) FVI, and (d) I-CVI using values of a modified kappa statistic. Polit, Beck, and Owen (2007) reported that a weakness of the CVI is the failure to adjust for chance agreement. Therefore, Polit et al. (2007) recommended translating I-CVIs into values of a modified kappa statistic. The probability of chance and modified kappa statistic were calculated for representativeness and clarity of each test item. This approach is recommended for studies that have more than five experts because as the number of experts increases, the chances of all of them agreeing decreases (Lynn, 1986). Interrater agreement. Rubio et al. (2003) described a method to quantify content validity, which included the use of the interrater agreement (IRA), content validity index (CVI), and the factorial validity index (FVI). The IRA determines the extent to which the experts agree that the item is representative of the construct and is clearly written. Rubio et al. recommended (2003) calculating the IRA for representativeness and clarity for each test item and the overall test in CONTENT-ORIENTED VALIDATION 30 order to assess the extent to which the experts are reliable in their ratings. Rubio et al. (2003) advocated that the researcher can count the number of test items rated as one or two on the scale and the items rated three or four on the scale. The IRA for each item can be calculated by determining the agreement between experts. The IRA for the entire scale can also be calculated by counting the number of items that have an IRA of at least 0.80 and dividing that number by the total number of items. Rubio et al. (2006) did not offer a recommendation regarding an acceptable IRA. Rubio et al. (2003) recommended that the IRA be calculated for representativeness and clarity in order to assess the extent to which the experts are reliable in their ratings. The scale is dichotomized, with values of one and two combined and values of three and four combined. The researcher counts the items that the experts rated as one or two and three or four. As the number of experts increases above five, a conservative approach is recommended due to the decreased likelihood that the experts will all agree. A conservative approach for IRA can be calculated by counting the number of items that have an IRA of at least .80 and dividing that number by the total number of items (Lynn, 1986; Rubio et al., 2003). Lynn (1986) created a table to show the proportion of experts whose endorsement of an item or instrument is required to establish content validity beyond the .05 level of significance. With the use of 10 experts, the recommendation is .78 or greater. Content validity index. The CVI of a tool can be calculated based on the representativeness of the measure to the construct or items being measured. Rubio et al. (2003) recommended that the CVI be calculated for the representativeness of each item by counting the number of experts who rated the item as CONTENT-ORIENTED VALIDATION 31 three or four and dividing that number by the total number of experts. This yields the proportion of experts who deemed the item as content valid. For a study with six to 10 experts, Lynn (1986) recommended a minimum item CVI of .78. Polit and Beck (2006) referred to this as item-level CVI (I-CVI). As referenced by Polit and Beck (2006) I-CVI should be no lower than .78 when there are six or more judges (Lynn, 1986). Researchers can also investigate the CVI for the entire measure. Rubio et al., (2003) recommended that the CVI for the measure be estimated by calculating the average CVI across the items. It has been recommended that new measures have an overall CVI of at least .80 (Davis, 1992). Polit and Beck (2006) referred to this as Scale-CVI Average (S-CVI/Ave). The S-CVI/Ave can be estimated by calculating the average CVI across the items. Polit, Beck, and Owen (2007) recommend that a scale should have S-CVI/Ave of .90 or higher to indicate excellent content validity. Polit et al. (2007) argued that this stringent S-CVI/Ave adjusts for chance agreement amongst the experts and that there is strong conceptual work, good items, outstanding subject matter experts, and that there were clear instructions to the experts. Factor validity index. Rubio et al. (2003) created the FVI to determine the degree to which the experts appropriately assigned the items to their respective factors. The factors of the FCA included categories for (a) ADLs, (b) IADLs, (c) leisure, and (d) other. The number of experts who correctly assigned the item with the factor was divided by the total number of experts. The average was calculated across items to compute the FVI for the measure. Rubio et al. (2003) recommended an FVI of at least .80. CONTENT-ORIENTED VALIDATION 32 Item-content validity index using a modified kappa statistic. Wynd, Schmidt, and Schaefer (2003) and Polit et al. (2007) recommended translating item-level CVIs (I-CVIs) into values of a modified kappa statistic (k*). This technique was recommended to adjust for the possibility of chance agreement amongst expert raters. First, the probability of chance (Pc) agreement was computed using the formula for a binomial random variable. Next, the modified kappa (k*) statistic was calculated for the representativeness of each item. Cicchetti and Sparrow (1981) and Fleiss (1981) described evaluation criteria as follows for kappa: Fair=k of .40 to .59; Good=k of .60-.74; and Excellent = k>.74. Results Fifteen respondents participated in the survey, which yielded a 45% response rate. Due to an unclear submit icon on the survey, data were not saved for multiple participants. One respondent only answered one question, in which the respondent free-typed a response. Therefore, data from 10 participants were considered in the data analysis, which yielded a final response rate of 30%. Based on the date of when it was identified that data were not being saved and which respondents had entered their contact information to obtain a final version of the FCA, this author contacted those experts and notified them that it was possible that their research data were not saved. Several respondents sent their impressions of the survey and subjective feedback to this researcher. Their comments were considered during the revision stage of the test development. However, the raw data was not included in this data analysis. Interrater agreement The interrater agreement (IRA) was calculated for representativeness and clarity of each task (see Table 1). The IRA for representativeness of each item ranged from 0.70-0.90. The CONTENT-ORIENTED VALIDATION 33 Medication Management task did not meet the 0.80 criteria for acceptability. This yielded a scale IRA of 0.90 for representativeness, which is acceptable for a scale IRA and exceeds the recommendation by Lynn (1986) and Polit et al. (2007) of 0.78. The IRA for clarity of each item ranged from 0.60-0.90. Making seasoned rice, washing dishes, and medication management were below the 0.80 recommendation. Therefore, the scale IRA for clarity was of 0.70, which is below the recommended level of 0.78 by Lynn (1986) and Polit et al. (2007). Content Validity Index (representativeness) The CVI of the FCA was calculated for representativeness of each task, as well as the entire measure (see Table 1). The CVI for representativeness ranged from 0.9 for the bathing task, to 0.8 (dressing, oral care, making seasoned rice, making coffee, washing dishes, playing cards, gardening, and using a remote control), to 0.7 for the task of medication management. Since the task of medication management task was below the 0.78 cutoff criteria, the medication management task was removed from the calculation. Therefore, the S-CVI Average was 0.81 for representativeness. This is above the recommended S-CVI Average of at least 0.8 for new measures (Davis, 1992; Polit et al., 2007). Factor Validity Index The FVI was 1.0 for the tasks of bathing, dressing, making seasoned rice, making coffee, washing dishes, medication management, playing cards, and gardening (see Table 1). The FVI was .9 for oral care and using a remote control. The average FVI for the FCA was 0.98. The FVI for the FCA exceeded the recommended FVI of 0.8 (Rubio et al. 2003). CONTENT-ORIENTED VALIDATION 34 I-CVI Using a Modified Kappa Statistic The modified kappa statistics for representativeness (see Table 1) ranged from 0.90 (Bathing), 0.79 (Dressing, Oral Care, Making Seasoned Rice, Making Coffee, Washing Dishes, Playing Cards, Gardening, and Using a Remote Control), to 0.66 (Medication Management). All of the tasks for representativeness were evaluated as being excellent, with the exception of Medication Management, which was rated as good. Table 1 Data Analysis for Content-Oriented Validation of the Functional Cognitive Assessment IRA CVI Rep. Clarity Rep. Bathing 0.90 0.90 0.90 Dressing 0.80 0.80 Oral Care 0.80 Making Seasoned Rice FVI I-CVI Rep. Rating Pc k* 1 0.01 0.90 Excellent 0.80 1 0.05 0.80 Excellent 0.80 0.80 0.90 0.05 0.80 Excellent 0.80 0.60 0.80 1 0.05 0.80 Excellent Making Coffee 0.80 0.90 0.80 1 0.05 0.80 Excellent Washing Dishes 0.8 0.70 0.80 1 0.05 0.80 Excellent Medication Management 0.70 0.60 0.70 1 0.12 0.66 Good CONTENT-ORIENTED VALIDATION 35 Playing Cards 0.80 0.80 0.80 1 0.05 0.80 Excellent Gardening 0.80 0.80 0.80 1 0.05 0.80 Excellent Using a Remote Control 0.80 0.80 0.80 0.9 0.05 0.80 Excellent Scale Scale Scale Scale 0.90 0.70 0.81 0.98 Respondent Feedback The respondents provided some useful comments for revisions of the FCA. Particularly helpful recommendations included the need to clarify the initial standardized instructions in the introduction of the test. In addition, the respondents requested further clarification of the task segmentation when verbal, visual, or tactile cues are introduced during the standardized administration procedures of each task. The respondents provided very specific feedback about the scoring rubrics. For example, one respondent identified the need to switch the scoring rubrics from an active voice to a passive voice. The need to enhance the descriptions of observed abilities in the scoring rubrics for Allen Cognitive Levels one and two was identified. Regarding the medication management task, it was noted that there was a need to expand upon the scoring rubric in order to include a more comprehensive task analysis of medication management. It was also indicated that a revision of the title of the medication management task might better reflect the observations noted in the scoring rubric. CONTENT-ORIENTED VALIDATION 36 Specific feedback regarding the medication management task. The respondents had useful comments about the medication management task, such as, This assessment is looking at one aspect of medication management. It does not appear to assess the client's awareness of how to order medications, when the medications are scheduled, why the medications are prescribed, or what conditions the medications are treating. . . The task being assessed here is "taking medications." Similarly, another respondent wrote, The domain being assessed, the directions and the rubric do not align . . . medication management involves more than the act of taking pills. The assessment does not appear to assess medication management in its entirety. The rubric indicates behaviors that a client may demonstrate at a particular cognitive level, however the assessment does not explore these potential behaviors. Another respondent wrote, Would suggest revising Level 1-2 since clearly medication would be administered to a person functioning at this level, and the observation of responses to being provided...medication is the behavior to be observed. . . this isn't clear since the instructions prompt the rater to have the person take the medication themselves. In terms of the clarity of the medication management task, one respondent noted that for Low Level 3, the last bullet point in the scoring rubric could be misinterpreted that the caregiver should consume the medication. Discussion The purpose of this study was to establish content-oriented validity evidence of the FCA, which is a necessary step during test development. Based on the results of the data, there is content-oriented validity evidence for the FCA. A group of professional experts objectively evaluated the tool to determine the representativeness, clarity of the items, the area of occupation CONTENT-ORIENTED VALIDATION 37 with which the items is associated, and if any test items should be added or deleted. The tasks of bathing, dressing, oral care, making seasoned rice, making coffee, washing dishes, playing cards, gardening, and using a remote control were rated as having excellent representativeness of the construct of functional cognition. The task of medication management was rated as having good representativeness of the construct of functional cognition. FVI was well above the recommended threshold of 0.8. Based on the results of the survey, it was determined that a variety of occupations identified on OTPF-III (2014) are included in the FCA. Tasks of the FCA, encompass occupations such as ADLs, IADLs, and leisure tasks. Recommendations gathered from this study were utilized to clarify the assessment and minor revisions were made to the administration and scoring manual. Based on feedback from a respondent, it is now permissible to consider asking the client to select which testing tasks are preferred in order to capitalize on the clients motivation during the test. The test administrators instructions for all 10 tasks were revised in order to clarify the general instructions, include the clients preferences during task completion, answer any questions that the client might have during task completion, and further describe the use of verbal cues by the test administrator. The IRA for clarity was below Polit and Becks (2006) recommendation of 0.78 for the tasks of making seasoned rice, washing dishes, and medication management. Therefore, it is recommended that those items be revised in order to enhance the clarity of each task. The CVI for representativeness of the medication management task was 0.70. Based on the recommendation by Polit and Beck (2006), items with CVI <.78 are candidates for revision. Therefore, it is recommended that the task of medication management be revised. It is also recommended that the medication task is renamed for clarity. Perhaps by changing the title from Medication Management to Taking Medications. This title change would better reflect the CONTENT-ORIENTED VALIDATION 38 observations that were noted in the scoring rubric. It is further recommended specific pill boxes are included in the task of Taking Medications. Finally, it is recommended that aspects of overall medication management such as renewing prescriptions, taking the medications at the prescribed time of day, and consuming the medications be removed from the scoring rubric. The CVI-Scale and FVI for the FCA were considered to be strong. Test items within the FCA are categorized in the following areas of occupation (a) Activities of Daily Living, (b) Instrumental Activities of Daily Living, and (c) Leisure. The excellent FVI and identification of additional areas of occupation further supports the notion that the FCA is a comprehensive tool which can be used to assess functional cognition in clients who have ADRD. There are no occupations related to work or social participation in the FCA. Clients with ADRD may participate in these occupations. In order to address additional, relevant occupations, it is recommended that work and social participation tasks be included in the FCA. Potential Use of the FCA The FCA could be used to confirm core clinical criteria associated with the diagnosis of dementia. For example, cognitive symptoms must be severe enough that they interfere with work or usual activities (McKhann et al., 2011). The client must also have an impaired ability to acquire and remember new information, impaired reasoning and judgement, impaired visuospatial abilities, and impaired language (McKhann et al., 2011). To diagnose a client with probable Alzheimers Disease dementia, the client must meet the criteria for dementia, demonstrate an insidious onset, and worsening of cognitive symptoms by report or observation McKhann et al., 2011). Improper diagnosis of a disorder may lead to inappropriate or harmful treatments (Sireci & Sukin, 2014). If a healthcare provider has concerns that a client is CONTENT-ORIENTED VALIDATION 39 exhibiting the core clinical criteria associated with the diagnosis of dementia, the client could be referred to an OT practitioner who is trained to administer and interpret the FCA within the context of the CDM. The OT practitioner could confirm or deny the presence of the core clinical criteria associated with dementia. Once evidence of reliability is established for the FCA, the FCA would be useful to identify and describe the impact of dementia on functional cognition as well as track changes over time. Limitations All of the respondents identified themselves as professional experts. Therefore, there were no lay experts in the study. However, it should be noted that the professional experts worked in both academic and clinical settings. In addition, not all of the respondents responses were saved on the survey due to the unclear submit icon at the end of the survey. Because the responses were not submitted, they were not able to be recovered. It is also important to caution readers that this study was only designed to establish content-oriented validity evidence. Other aspects of validity evidence, such as construct validity, criterion validity, concurrent validity, and predictive validity have not been investigated, nor has reliability. Pending revisions following this initial content validity study, it is recommended that another content validity study occur in order to assess the revised test (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education, 2014). Future research should also investigate other aspects of validity, reliability, and pilot testing of the FCA. Studies should include culturally diverse populations in order to determine if the FCA can be effectively used with a variety of clients with different backgrounds. CONTENT-ORIENTED VALIDATION 40 Conclusion Administration of the FCA could be used to identify the impact of ADRD during the completion of ADL, IADL, and leisure tasks. When OT practitioners utilize the FCA with clients who have ADRD, they can share the results and subsequent recommendations with caregivers about safety and the clients best ability to function. Occupational therapy practitioners can specifically inform caregivers about the verbal, visual and/or tactile cues that are useful to maximize the clients performance; thereby, decreasing the risk of excess disability, decreasing the risk of potential safety hazards, and reducing the risk of hospital readmissions. CONTENT-ORIENTED VALIDATION 41 References Allen, C. K. (1982). Independence through activity: The practice of occupational therapy (psychiatry). American Journal of Occupational Therapy, 36, 731-739. Allen, C. K. (1999). Structures of the Cognitive Performance Modes. Ormond Beach, FL: Allen Conferences. Allen, C. K., Austin, S. L., David, S. K., Earhart, C. A., McCraith, D. B., & Riska-Williams, L. (2007). Manual for the Allen Cognitive Level Screen-5 (ACLS-5) and Large Allen Cognitive Level Screen-5 (LACLS-5). Camarillo, CA: ACLS and LACLS Committee. Allen, C. & Blue, T. (1998). Cognitive disabilities model: How to make clinical judgments. In N. Katz (Ed.), Cognition and occupation in rehabilitation: Cognitive models for intervention in occupational therapy (pp. 225-279). Rockville, MD: American Occupational Therapy Association. Allen, C. K., Blue, T., & Earhart, C. A. (1995). Understanding cognitive performance modes. Ormond Beach, FL: Allen Conferences. Allen, C. K., Earhart, C. A., & Blue, T. (1992). Occupational therapy treatment goals for the physically and cognitively disabled. Bethesda, MD: The American Occupational Therapy Association, Inc. Alzheimers Association. (2012). 2012 Alzheimers disease facts and figures: Includes a special report on people with Alzheimers disease and other dementias who live CONTENT-ORIENTED VALIDATION 42 alone. Alzheimers disease, 8(2). Retrieved from https://www.alz.org/downloads/facts_figures_2012.pdf Alzheimers Association. (2015). 2015 Alzheimers disease facts and figures: Includes a special report on disclosing a diagnosis of Alzheimers disease. Alzheimers & Dementia, 11(3), 332+. Retrieved from https://www.alz.org/facts/downloads/facts_figures_2015.pdf Alzheimers Association. (2016). 2016 Alzheimers disease facts and figures: Includes a special report on the personal financial impact of Alzheimers on families. Alzheimers and Dementia, 12(4), 1-84. Retrieved from https://www.alz.org/documents_custom/2016facts-and-figures.pdf American Educational Research Education, American Psychological Association, & National Council on Measurement in Education. (2014). Standards for Educational and Psychological Testing. Washington, DC: American Educational Research Education. American Occupational Therapy Association. (2013). Cognition, Cognitive Rehabilitation, and Occupational Performance. American Journal of Occupational Therapy, 67, S9S31. doi: 10.5014/ajot.2013.67S9 American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl.1), S1-S48. http://doi.org/10.5014/ajot.2014.682006 CONTENT-ORIENTED VALIDATION 43 American Occupational Therapy Association. (2016). Role of occupational therapy in assessing functional cognition. Retrieved from http://www.aota.org/advocacy-policy/federal-regaffairs/resources/role-ot-assessing-functional-cognition.aspx Apostolova, L. G. & Cummings, J. L. (2008). Neuropsychiatric manifestations in mild cognitive impairment: A systematic review of the literature. Dementia and Geriatric Cognitive Disorder, 25(2), 115126. doi: 10.1159/000112509 Baum, C. M., Morrison, T., Hahn, M., & Edwards, D. F. (2007). Test protocol booklet: Executive Functional Performance Test. Retrieved from http://www.ot.wustl.edu/about/resources/executive-function-performance-test-efpt308 Baum, C. M., Connor, L.T., Morrison, T. Hahn, M., Dromerick, A. W., Edwards, D. F. (2008). Reliability, validity, and clinical utility, of the Executive Function Performance Test: A measure of executive function in a sample of people with stroke. American Journal of Occupational Therapy, 62, 446-455. Braungart, M. M., Braungart, R. G., & Gramet, P. R. (2011). Applying learning theories to healthcare practice. In Bastable, S.B., Gramet, P., Jacobs, K., & Sopczyk, D.L., Health Professional as Educator (pp. 63-110). Sudbury, MA: Jones & Bartlett Learning. Brody, E. M., Kleban, M. H., Lawton, M. P., & Silverman, H. A. (1971). Excess disabilities of the mentally impaired aged: Impact of individualized treatment. Gerontologist, 11, 124-133. Burns, T. (2006). Cognitive Performance Test (CPT). Pequannock, NJ: Maddak. CONTENT-ORIENTED VALIDATION 44 Bynum, J. (2011). Unpublished tabulations based on data from the Medicare current beneficiary survey for 2008. Prepared under contract by Julie Bynum, MD, MPH, Dartmouth Institute for Health Policy and Clinical Care, Dartmouth Medical School. Centers for Medicare and Medicaid Services. (2016). Medicare Benefit Policy Manual. Retrieved from https://www.cms.gov/Regulationsand- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf Claeys, C., Neve, J., Tulkens, P. M., & Spinewine, A. (2012). Content validity and interrater reliability of an instrument to characterize unintentional medication discrepancies. Drugs Aging, 29(7), 577-591. Crisis Prevention Institute. (2010). Dementia Capable Care: Dementia Therapy Intermediate. Dementia Care Specialists: a CPI specialized offering. Milwaukee, WI: Crisis Prevention Institute. Davis, L. (1992). Instrument review: Getting the most from your panel of experts. Applied Nursing Research, 5, 194-197. Davydow, D. S., Zibin, K., Katon, W. J., Pontone, G. M., Chwastiak, L., Langa, K. M., & Iwashyna, T. J. (2014). Neuropshychiatric disorders and potentially preventable hospitalizations in a prospective cohort study of older Americans. Journal of General Internal Medicine, 29(10), 1362-1371. Delgado-Rico, E., Carretero-Dios, H., & Ruch, W. (2012). Content validity evidences in test development: An applied perspective in test development. Journal of Clinical and Health Psychology, 12(3), 449-460. CONTENT-ORIENTED VALIDATION 45 DeVon, H. A., Block, M. E., Moyle-Wright, P., Ernst, D. M., Hayden, S. J., Lazzara, D. J., Savoy, S. M., & Kostas-Polston, E. (2007). A Psychometric Toolbox for Testing Validity and Reliability. Journal of Nursing Scholarship, 39(2), 155-164. Doucet, B. M., Woodson, A., & Watford, M. (2014). Centennial VisionMoving toward 2017: Progress in rehabilitation intervention effectiveness research. American Journal of Occupational Therapy, 68, e124-e148. http://dx.doi.org/10.5014/ajot.2014.011874 Dunn, W., McClain, L. H., Brown, C., & Youngstrom, M. J. (1998). The ecology of human performance. In M. E. Neistadt and E. B. Crepeau (Eds.), Willard and Spackmans Occupational Therapy (9 ed., pp. 525-535). Philadelphia: Lippincott th Williams and Wilkins. Earhart, C. A. (2006). Allen Diagnostic Module-2 Ed. Colchester, CN: S & S Worldwide. nd Ebell, C., Ford, A. A. & Warchol, K. (2016). Standardized Administration and Scoring Manual for the Functional Cognitive Assessment. Milwaukee, WI: Crisis Prevention Institute. Elliot, A. F., Burgio, L. D., & DeCoster, J. (2010). Enhancing caregiver health: Findings from the Resources for Enhancing Alzheimers caregiver Health II Intervention. Journal of the American Geriatrics Society, 58(1), 30-37. doi: 10.1111/j.15325415.2009.02631.x Espiritu, D. A. V., Rashid, H., Mast, B. T., Fitzgerald, J., Steinberg, J., & Lichtneberg, P. A. (2001). Depression, cognitive impairment and function in Alzheimers disease. International Journal of Geriatric Psychiatry, 16, 1098-1103. CONTENT-ORIENTED VALIDATION 46 Feng, Z., Coots, L. A., Kaganova, Y., & Wioner, J. M. (2014). Hospital and ED use among Medicare beneficiaries with dementia varies by setting and proximity to death. Health Affairs, 33(4): 683-690. doi: 10.1377/hlthaff.2013.1179 Gitlin, L. N., Winter, L., Earland, T. V., Herge, E. A., Chernett, N. L., Piersol, C. V., & Burke, J.P. (2009). The Tailored Activity Program to reduce behavioral symptoms in individuals with dementia: Feasibility, acceptability, and replication potential. The Gerontologist, 49(3), 428-439. doi:10.1093/geront/gnp087 Grant, J. S., & Davis, L. T. (1997). Selection and use of content experts in instrument development. Research in Nursing & Health, 20, 269-274. Goverover, Y., Kalmar, J., Gaudino-Goering, E., Shawaryn, M., Moore, N. B., Halper, J., & DeLuca, J. (2005). The relation between subjective and objective measures of everyday life activities in persons with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 86, 2303-2308. Hahn, B., Baum, C., Moore, J., Ehrlich-Jones, Spoeri, S., Doherty, M., & Wolf, T. (2014). Brief Report-Development of additional tasks for the Executive Function Performance Test. American Journal of Occupational Therapy, 68, e241-e246. http://dx.doi.org/10.5014/ajot.2014.008565 Haynes, S. N., Richard, D. C. S., & Kubany, E. S. (1995). Content Validity in Psychological Assessment: A Functional Approach to Concepts and Methods. Psychological Assessment, 7(3), 238-247. CONTENT-ORIENTED VALIDATION Office of Disease Prevention and Health Promotion. (2014). Dementias, including Alzheimers Disease. Retrieved from https://www.healthypeople.gov/2020/topicsobjectives/topic/dementias-including-alzheimers-disease/objectives Herbert, L. E., Weuve, J., Scherr, P. A., & Evans, D. A. (2013). Alzheimer disease in the United States (2010-2050) estimated using the 2010 census. Neurology. Advance online publication. doi: 10.1212/WNL.0b013e31828726f5Neurology10.1212/WNL.0b013e31828726f5 Henry, A. D., Moore, K., Wuinlivan, M., & Triggs, M. (1998). The relationship of the Allen Cognitive Level Test to demographics, diagnosis, and disposition among psychiatric inpatients. American Journal of Occupational Therapy, 52(8), 638-643. Katz, N. (2006). Routine Task Inventory-Expanded. Retrieved from http://www.allencognitive-network.org/images/stories/pdf_files/rtimanual2006.pdf Katz, N., Tadmore, I., Felzen, B., & Hartman-Maeir, A. (2007). Validity of the Executive Function Performance Test in individuals with schizophrenia. Occupational Therapy Journal of Research, 27, 1-8. Keller, S. & Hayes, R. (1998). The relationship between the Allen Cognitive Level Test and the Life Skills Profile. American Journal of Occupational Therapy, 52(10), 851-856. doi: 10.5014/ajot.52.10.851 Kibayashi, K., Sumida, T., Shojo, H., & Hanada, M. (2007). Dementing diseases among elderly persons who suffered fatal accidents: A forensic autopsy study. American Journal of Forensic Medicine and Pathology, 28(1), 7379. 47 CONTENT-ORIENTED VALIDATION 48 Lehmann, S. W., Black, B. S., Shore, A., Kasper, J., & Rabins, P. V. (2010). Living alone with dementia: Lack of awareness adds to functional and cognitive vulnerabilities. International Psychogeriatrics, 22(5), 778784. doi: 10.1017/S1041610209991529 Lee, C. C., Czaja, S. J., & Schulz, R. (2010). The moderating influence of demographic characteristics, social support, and religious coping on the effectiveness of a multicomponent psychosocial caregiver education in three radical ethnic groups. Journal of Gerontology: Psychological Sciences, 65B(2),185-192. doi: 10.1093/geronb/ghp131 Lee, S. N., Gargiullo, A., Brayman, S., Kinsey, J. C., Jones, H. C., & Shotwell, M. (2003). Adolescent performance on the Allen Cognitive Levels Screen. American Journal of Occupational Therapy, 57(3), 342-346. doi: 10.5014/ajot.57.3.342 Levy, L. L. & Burns, T. (2011). The cognitive disabilities model in 2011. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy 3 ed. (pp. 407rd 441). Bethesda, MD: AOTA Press. Lynn, M. (1986). Determination and quantifications of content validity. Nursing Research, 35(6), 382-385. doi:10.1097/00006199-1986-11000-00017 Malmgreen, C., Graham, P. L., Shortridge-Baggett, L. M., Courtney, M., & Walsh, A. (2009). Establishing content validity of a survey research instrument. Journal of nurses in staff development, 25(6), E14-E18. CONTENT-ORIENTED VALIDATION 49 McAnanama, E. P., Rosgosin-Rose, M. L., Scott, E. A., Joffe, R. T., & Kelner, M. (1999). Discharge planning in mental health: The relevance of cognition to community living. American Journal of Occupational Therapy, 53(2), 129-137. McCraith, D. B, Austin, S. L. & Earhart, C. A. (2011). The cognitive disabilities model in 2011. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy 3 ed. (pp. 383-406). Bethesda, MD: AOTA Press. rd McKhann, G. M., Knopman, D. S., Chertkow, H., Hyman, B. T., Jack, C. R., Kawas, C. H., . . . Phelos, C. H. (2011). The diagnosis of dementia due to Alzheimers disease: Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic guidelines for Alzheimers disease. The Journal of the Alzheimers Association, 7(3), 263-269. Retrieved from https://doi.org/10.1016/j.jalz.2011.03.005 Miranda-Castillo, C., Woods, B., & Orrell, M. (2010). People with dementia living alone: What are their needs and what kind of support are they receiving? International Psychogeriatrics, 22(4), 60717. doi: 10.1017/S104161021000013X Abstract retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20214844 Nourhashemi, F., Amouyal-Barkate, K., Gillette-Guyonnnet, S., Cantet, C., & Vellas, B. (2005). Living alone with Alzheimers disease: Cross-sectional and longitudinal analysis in the Real.FR study. The Journal of Nutrition, Health & Aging, 9, 117120. CONTENT-ORIENTED VALIDATION 50 Penny, N. H, Mueser, K. T., & North, T. C. (1995). The Allen Cognitive Level Test and social competence in adult psychiatric patients. American Journal of Occupational Therapy, 49(5), 420-427. doi:10.5014/ajot.49.5.420 Pinquart, M. & Srensen, S. (2003). Association of stressors and uplifts of caregiving with caregiver burden and depressive mood: A meta-analysis. The Journals of Gerontology: Series B, 58(2), 112-128. Polit, D. F. & Beck, C. T. (2006). The Content validity index: Are you sure you know whats being reported? Critique and recommendations. Research in Nursing and Health, 29, 489-497. doi:10.1002/nur.20147 Polit, D. F., Beck, C. T., & Owen, S. V. (2007). Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in Nursing and Health, 30, 459- 467. doi:10.1002/nur.20199 Raweh, D. V. & Katz, N. (1999). Treatment effectiveness of Allens cognitive disabilities model with adult schizophrenic outpatients: A pilot study. Occupational Therapy in Mental Health, 14(4), 65-77. Reisberg, B., Franssen, E. H., Souren, Liduin. E. M., Auer, S. R., Akram, I., & Kenowsky, S. (2002). Evidence and mechanisms of retrogenesis in Alzheimers and other dementias: Management and treatment import. American Journal of Azheimers Disease & Other Dementias, 17(4), 202-212. Renda, M., Lee, S., Keglovits, M., & Somerville, E. (2016). The role of occupational therapy in reducing hospital readmissions. OT Practice, 21(5). CE-1-CE-8. CONTENT-ORIENTED VALIDATION Rogers, J. C., Holm, M. B., Burgio, L. D., Hsu, C., Hardin, J. M., & McDowell, B. J. (2000). Excess disability during morning care in nursing home residents with dementia. International Psychogeriatrics, 12(2), 267-282 Rowe, M. A., Ahn, H., Benito, A. P., Stone, H., Wilson, A., & Kairalla, J. (2010). Injuries and unattended home exits in persons with dementia: a 12-month prospective study. American Journal of Alzheimers Disease and Other Dementias, 25(1), 27-31. doi: doi:10.1177/1533317508323138 Rubenstein, L. Z. & Josephson, K. R. (2006). Falls and their prevention in elderly people: What does the evidence show? Medical Clinics of North America, 90(5), 80724. Rubio, D. M., Berg-Weger, M., Tebb, S. S. Lee, E. S., & Rauch, S. (2003). Objectifying content validity: Conducting a content validity study in social work research. Social Work Research, 27(2), 94-104. Schaber, P., Stallings, E., Brogan, C., & Ali, F. (2016). Interrater reliability of the Revised Cognitive Performance Test (CPT): Assessing cognition in people with neurocognitive disorders. American Journal of Occupational Therapy, 70, 7005290010p1. doi: 10.5014/ajot.2016.019166 Sireci, S. G. & Sukin, T. (2014). Test Validity. In K. F. Geisinger (Editor-in-Chief). APA Handbook of Testing and Assessment in Psychology: Volume 1 Test Theory and Testing and Assessment in Industrial and Organizational Psychology. (p. 79). Washington, DC: American Psychological Association. Slaughter, S. E., Eliasziw, M., Morgan, D., & Drummond, N. (2011). Incidence and predictors of excess disability in walking among nursing home residents with middle-stage 51 CONTENT-ORIENTED VALIDATION 52 dementia: a prospective cohort study, International Psychogeriatrics. 23(1), 54-64. doi:10.1017/S1355617711001238 Slaughter, S. E. & Hayduck, L. A. (2012). Contributions of environment, comorbidity, and stage of dementia, to the onset of walking and eating disability in long-term care residents, Journal of the American Geriatric Society, 60, 1624-1631. doi: 10.1111/j.1532-5415.2012.04116.x Srensen, S., Duberstein, P., Gill, D., & Pinquart, M. (2006). Dementia care: Mental health effects, intervention strategies, and clinical implications. The Lancet Neurology, 5(11), 961-973. Steinberg, M., Sheppard, J. M., Tschanz, J. T., Norton, M. C., Steffens, D. C., Breitner, J. C., & Lyketsos, C. G. (2003). The incidence of mental and behavioral disturbances in dementia: The Cache County Study. Journal of Neuropsychiatry and Clinical Neurosciences, 15(3), 340345. Tierney, M. C., Charles, J., Naglie, G., Jaglal, S., Kiss, A., & Fisher, R. H. (2004). Risk factors for harm in cognitively impaired seniors who live alone: A prospective study. Journal of the American Geriatrics Society, 52(9), 14351441. Tierney, M. C., Snow, W. G., Charles, J., Moineddin, R., & Kiss, A. (2007). Neuropsychological predictors of self-neglect in cognitively impaired older people who live alone. American Journal of Geriatric Psychiatry, 15(2), 1408. United States Department of Health & Human Services. (2009). Code of Federal Regulations. Retrieved from https://www.hhs.gov/ohrp/regulations-andpolicy/regulations/45-cfr-46/#46.102 CONTENT-ORIENTED VALIDATION 53 Velligan, D.I., Bow-Thomas, C.C., Mahurin, R., Miller, A., Dassori, A., and Erdely, F. (1998). Concurrent and predictive validity of the Allen Cognitive Levels Assessment. Psychiatry Research, 80(3), 287-298. Velligan, D. I., True, J. E., Lefton, R. S., Moore, T. C., & Flores, C. V. (1995). Validity of the Allen Cognitive Levels Assessment: A tri-ethnic comparison. Psychiatry Research, 56(2), 101-109. Walstra, G. J., Teunisse, S., van Gool, W. A., & van Crevel, H. (1997). Symptomatic treatment of elderly patients with early Alzheimers disease at a memory clinic. Journal of Geriatric Psychiatry and Neurology, 10(1), 33-38. Warchol, K. (2004). An interdisciplinary dementia program model for long-term care. Topics in geriatric rehabilitation, 20(1), 59-71. Warchol, K. (2006). Facilitating functional and quality-of-life potential: Strengthbased assessment and treatment for all stages of dementia. Topics in Geriatric Rehabilitation, 22(3), 213-227. Warchol, K., Copeland, C., & Ebell, C. (2006). Dementia Therapy: Achieving Positive Outcomes for the Personwith Dementia Self-Study Manual. Chesterfield, MO: Dementia Care Specialists, Inc. World Health Organization. (2002). Towards a Common Language for Functioning, Disability and Health ICF. Geneva, Switzerland. Retrieved from http://www.who.int/classifications/icf/icfbeginnersguide.pdf?ua=1 Yaffe, K., Fox, P, Newcomer, R. Sands, L., Lindquist, K., Dane, K., & Covinsky, K. E. (2002). Patient and caregiver characteristics and nursing home placements in patients CONTENT-ORIENTED VALIDATION 54 with dementia. Journal of the American Medical Association, 287(16), 2090-2097. doi:10.1001/jama.287.16.2090 Yuen, H. K., & Austin, S. L. (2014). Centennial VisionSystematic review of studies on measurement properties of instruments for adults published in the American Journal of Occupational Therapy, 2009-2013. American Journal of Occupational Therapy, 68, e97-e106. http://dx.doi.org/10.5014/ajot.2014.011171 Ziv, N., Roitman, D. M., & Katz, N. (1999). Problem solving, sense of coherence and instrumental ADL of elderly people with depression and normal control group. Occupational Therapy International, 6(4), 243-250. CONTENT-ORIENTED VALIDATION 55 Appendix A CONTENT-ORIENTED VALIDATION 56 Appendix B CONTENT-ORIENTED VALIDATION 57 Appendix C  ...

... COMPARISON BETWEEN STANDARD PHYSICAL THERAPY AND NEUROMUSCULAR RE-EDUCATION FOLLOWING ROTATOR CUFF REPAIR 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: Nathan Ryndak, PT, CSCS Copyright December 15, 2017 By: Nathan Ryndak, PT, CSCS All rights reserved Approved by: Emily J Slaven, PT, PhD, MS Committee Chair ______________________________________________ Elizabeth S. Moore, PhD Committee Member ______________________________________________ Frank Bates, PT, DPT, MBA 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 Physical Therapy Following Rotator Cuff Surgery 2 Abstract Rotator cuff repair (RCR) is the most common shoulder procedure for which patients are referred for post-operative physical therapy (PT). Standard PT after RCR frequently consists of modalities, range of motion (ROM), and strength exercises. However, the optimal treatment approach has not been established. Neuromuscular re-education (NMR) is an alternative treatment to standard PT, but it has not been studied after RCR. The purpose of this study was to compare standard PT to standard PT and NMR to determine if NMR impacted selected clinical outcomes post-RCR. A non-experimental retrospective case-control study was conducted to achieve this purpose. A convenience sample of patients who underwent PT following RCR was identified from electronic medical records. Active ROM (AROM), numeric pain rating scale (NPRS), and the Disability of the Arm Shoulder and Hand questionnaire (DASH) data were collected to determine if there were significant differences in these outcomes between the treatment groups and over time. Additionally, a change score was calculated and compared between treatment groups. The change in AROM was significantly greater in the NMR group than the standard PT group (p = .024). The NMR group reached a greater level of clinically important change than the standard PT group (p = .006). There were no differences between the two groups for NPRS and DASH scores. Results of this study suggest that NMR may help optimize AROM after RCR. Further research incorporating evidence-based treatment guidelines for NMR is needed to determine if NMR adds benefit to standard PT after RCR. Physical Therapy Following Rotator Cuff Surgery Keywords: rotator cuff repair, physical therapy, neuromuscular re-education, range of motion, proprioception, neuromuscular control 3 Physical Therapy Following Rotator Cuff Surgery 4 Acknowledgements Completing this degree was the most challenging accomplishment of my life and tested every portion of my emotional, mental, and physical capacity. With regard to my juried project, I am indebted to the accomplished members of my committee of whom I would not have been able to complete this project without. I am very grateful to Dr. Slaven for accepting to be my chair when this project was in proposal form and for sticking with me until the entire project was completed. She worked tirelessly to ensure that I stayed on track and worked with me through the challenges faced while working on the manuscript. I also thank Dr. Moore for her stern, but steady hand in fielding my many statistical questions and for objectively assisting me through the process of the statistical analysis portion of the project. I thank Dr. Bates for reviewing the literature review to make sure my research was current and relevant. I thank all of the faculty and staff in the College of Health Sciences at the University of Indianapolis who contributed to my completion of this degree throughout my time there. I want to acknowledge the team members at ATI physical therapys department of research and data analytics who were responsible for assisting me with this project: Dr. Stout, Sucharitha Galvatoria, Hanying Wang, and data managers responsible for pulling and organizing data. Finally, I want to extend a thank you to my family for not giving up on me as I pursued this despite the many challenges I faced and for the support and prayers they extended to me during this time. I thank my wife Kirsten and kids for supporting me while I worked on the juried project, for being patient with me and for the sacrifices they made while I was away from them, especially at the end. Physical Therapy Following Rotator Cuff Surgery 5 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgements ......................................................................................................................... 4 Introduction 7 Literature Review.......................................................................................................................... 10 Post-Operative Standard Physical Therapy ............................................................................... 12 Neuromuscular Re-education .................................................................................................... 15 Anatomy of the Neuromuscular System ................................................................................... 16 Neuromuscular Control ............................................................................................................. 17 Preparatory muscle contraction and muscle stiffness ............................................................ 18 Factors that Adversely Affect Proprioception ........................................................................... 19 The Role of the Rotator Cuff and Force Couples in Joint Stability .......................................... 21 Neuromuscular Re-education Exercise ..................................................................................... 22 Neuromuscular Re-education after Rotator Cuff Repair........................................................... 28 Clinical Outcomes ..................................................................................................................... 31 Method .......................................................................................................................................... 35 Study Design ............................................................................................................................. 35 Sample ....................................................................................................................................... 35 Data Collection.......................................................................................................................... 37 Instruments ................................................................................................................................ 38 Procedures ................................................................................................................................. 41 Data Analyses............................................................................................................................ 42 Results ........................................................................................................................................... 46 Clinical Outcomes ..................................................................................................................... 46 Active range of motion flexion .............................................................................................. 47 Numeric Pain Rating Scale. ................................................................................................... 48 Disabilities of the Arm, Shoulder, and Hand......................................................................... 49 Discussion ..................................................................................................................................... 51 Conclusion .................................................................................................................................... 60 References ..................................................................................................................................... 61 Table 1. ......................................................................................................................................... 71 Table 2 .......................................................................................................................................... 73 Table 3 .......................................................................................................................................... 74 Physical Therapy Following Rotator Cuff Surgery 6 Table 4 .......................................................................................................................................... 75 Appendix A ................................................................................................................................... 76 Appendix B ................................................................................................................................... 77 Appendix C ................................................................................................................................... 78 Physical Therapy Following Rotator Cuff Surgery 7 A Comparison between Standard Physical Therapy and Neuromuscular Re-education Following Arthroscopic Rotator Cuff Repair Rotator cuff repair (RCR) surgery is a frequently performed orthopedic procedure intended to restore the integrity of torn rotator cuff tendons, decrease pain, and restore functional shoulder mobility in individuals suffering from rotator cuff pathology.1 This surgery continues to gain popularity where the number of RCR surgeries in the United States increased 141% in the decade from 1996 to 2006.2 Despite the increased number of RCR surgeries performed and subsequent understanding of the timeline for healing, recovery after this surgery can be fraught with challenges.3 Post-surgical challenges that may affect patient satisfaction with functional outcomes include post-surgical pain, loss of strength and mechanical stability at the glenohumeral and scapulothoracic joints, and loss of range of motion (ROM).1,4 Following RCR surgery, physical therapists provide interventions to help patients manage their pain, prevent reinjury, and restore pain-free functional mobility. During post-surgical care, physical therapists advise and assist patients in self-care, precautions to protect and promote healing at the repair site, pain management, and exercises to improve ROM and strength.4-6 Physical therapy (PT) involves decreasing muscle inhibition and achieving voluntary control of the rotator cuff to achieve normal glenohumeral arthrokinematics during shoulder motion.4,7 To accomplish this, PT may include cryotherapy, interferential electrical stimulation, passive range of motion (PROM), active assisted range of motion (AAROM), active range of motion (AROM) exercises, soft tissue and joint mobilization, and strength training.1,5,6,8 These are all elements of what might be considered a standard PT approach for treating a patient following RCR surgery. Post-surgical guidelines for exercise Physical Therapy Following Rotator Cuff Surgery 8 progression, various exercises, and adjunctive interventions that help progress patients through recovery following RCR surgery can be found in published research studies.1,6,7,9,10 For example, Pabian et al1 and McCormick et al10 suggested dividing the post-surgical program in four phases to assist therapists in deciding when to begin PROM, AROM, and strength training in a manner that protects the tendon graft. Several researchers recommended therapists communicate with the surgeon about the surgical procedure used prior to initiating treatment and use that information to individualize that patients treatment plan based on additional factors including the patients age, size of the rotator cuff tear, and comorbidities that affect recovery. 1,6,3 Injury to or pathology of the shoulder joint and supporting structures may cause a deficit in proprioception and neuromuscular control of the shoulder.11 Neuromuscular re-education (NMR) is an intervention used by physical therapists to improve proprioceptive characteristics, independent control of AROM, and joint stability.12 This occurs through retraining motor output by stimulating motor input at the mechanoreceptors.12,13 Neuromuscular re-education has been more commonly studied in the ankle and knee joints than in the shoulder joint.14-18 Numerous clinical trials of the ankle and knee provide support for the efficacy of NMR to significantly affect clinical and functional outcomes.14-18 Borsa et al12 recommended evidence-based evaluation methods and constructs for utilizing NMR for glenohumeral instability in 1994. However, since then there have been few studies evaluating proprioceptive impairment or the efficacy of using NMR exercises in the shoulder.19-22 In particular, there has been a lack of research on proprioceptive deficits and the efficacy of using NMR to help restore ROM and dynamic stability following RCR surgery. Therefore, the purpose of this study was to compare a standard PT treatment approach to an approach using NMR to determine if PT treatment with NMR had an impact on clinical outcomes post-RCR surgery. Physical Therapy Following Rotator Cuff Surgery 9 To address the study purpose, clinical outcome data from a multi-site national orthopedic organization were evaluated to determine if adding NMR to standard PT after RCR surgery, compared to standard PT alone, affected clinical outcomes. The following null hypothesis was tested: there will not be a statistically significant difference in clinical outcomes between patients who received NMR and standard PT compared to those who received only standard PT following RCR surgery. The specific outcomes tested were AROM shoulder flexion, pain measured with the numeric pain rating scale (NPRS), and shoulder function measured with the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire. This study is important because it provides preliminary data for future studies to examine for neuromuscular deficits following RCR surgery and to further explore the efficacy of using NMR exercises after RCR surgery. This is relevant to evidence-based practice to help the profession of PT stay current with the advancements and growing prevalence of rotator cuff surgery in orthopedic practice and for justifying NMR for third party billing. Physical Therapy Following Rotator Cuff Surgery 10 Literature Review There has been a considerable increase in the incidence of RCR surgeries over the past few decades.2,23 Colvin et al2 reported an increase in outpatient RCR surgeries from 58,846 in 1996 to 272,148 in 2006. This increase coincided with significant advancements in arthroscopic surgical techniques, and currently 95% of rotator cuff repairs are performed arthroscopically.9 Along with this trend, several age-related and gender-related demographic characteristics of the RCR population have been reported in the general population.2,24,25 There is a wide range in age of those individuals who undergo RCR surgery with this spanning from 12 years of age to 92 years of age in the general public.23 Huberty et al24 reported a median age of 55 years for a cohort of 489 Americans from the general population who underwent RCR surgery. The authors of several studies reported that there is a disproportionate number of men compared to women in the general population who undergo RCR surgery.2,24,25 Huberty et al24 described 489 individuals who underwent this surgery where 67% were men and 32.9% were women. Colvin et al2 and Brennen et al25 reported similar proportions of men and women undergoing RCR as 56% and 44% respectively. In addition to age and gender-related demographics, duration of medical care data should also be considered when understanding the population who undergoes this surgery. Brennan et al25 reported for 282 individuals who had RCR surgery, 24.5 days was the mean number of days between the day of surgery and the PT evaluation. For this same group of patients, the mean number of days between the date of surgery and PT discharge was 102.8 days. Additionally, these authors identified that the mean number of days between PT initial evaluation and discharge was 80.2 days, and the number of sessions of therapy was 14.8.25 Boissonnault et al26 reported a mean of 25 sessions over a 13-week time frame to complete a RCR rehabilitation protocol. There are several factors that may affect Physical Therapy Following Rotator Cuff Surgery 11 duration of care and account for the variability in duration of the rehabilitation protocol in particular. The course of rehabilitation and outcomes may be affected by several risk factors. Of particular interest in the course of rehabilitation and outcomes is tendon healing. Successful tendon healing varies from 40% to 95% depending on the presence of risk factors.3 Mulligan et al3 reported the following risk factors predict poorer outcomes after RCR: age, smoking status, and the presence of comorbidities. Increased age was the most influential biological limitation to tendon healing, with the greatest risk of tendon failure in those over 65 years of age.27 Other risk factors such as osteoporosis, hypertension, and obesity also significantly affect tendon healing.3 The chronicity of the tear prior to surgery affects healing because morphological changes in the damaged tissue that effect the integrity of the tendon. However, the risk factor that has the greatest influence on the structural success or failure of a repair is the size of the tear prior to surgery, with larger tears presenting with a higher failure rate.3 The mean number of comorbidities was 2.01 in a population of 118 patients after rotator cuff repair with the most reported comorbidities being obesity 84% and hypertension 43%.26 Comorbidities may contribute to post-surgical complications and delayed recovery or failure of the repairs. The most common complication after RCR is post-operative stiffness.3 Risk factors that can lead to stiffness include age under 50 years, workers compensation payer class, adhesive capsulitis or calcific tendonitis, and concurrent capsule-labral repairs.24 Although, stiffness can be complicated to treat and painful for the patient, it can at least be managed with post-surgical rehabilitation such as PT and if necessary manipulation under anaesthesia.3 Physical Therapy Following Rotator Cuff Surgery 12 Post-Operative Standard Physical Therapy Physical therapists have examined the post-operative management of patients after RCR and developed interventions to improve function in this population.1 Currently available commentaries and research provide some information to guide care regarding use of modalities, immobilization, ROM, and strength exercise.28-32 However, there is a lack of substantive clinical research to support the efficacy of an optimal treatment approach to standard PT interventions and post-surgical protocols after RCR.28,32 In a systematic review of 11 randomized clinical trials of various post-surgical rehabilitation interventions, Thomson et al32 reported there were a variety of PT rehabilitation programs aimed at restoring ROM, strength, and function. However, the heterogeneity of studies, variability in timing of measures, and variability in interventions made it difficult to compare the studies to determine an optimal approach to care. These authors concluded that while patients may expect a reduction in pain, increase in motion, and improved function after rotator cuff repair, there was no benefit found in favor of any one rehabilitation method. Additionally, higher quality randomized controlled trials with standardized treatment protocols and measures, longer follow up, and larger patient samples were recommended.32 Several treatments and management strategies such as continuous passive motion (CPM), splinting, and modalities have been evaluated and were found to provide no benefit to postoperative rehabilitation outcomes. Hayes et al8 compared an individualized PT program to a home exercise program given by a surgeon. In this study, the control group was given a threephase standardized home exercise program. Phase one consisted of elbow motion, grip exercise, scapular retraction, and pendulum shoulder movements. Phase two consisted of AAROM and isometrics. Phase three consisted of AROM, AAROM, and resisted-band strength exercises. The experimental group was given individualized PT treatment in addition to the home exercise Physical Therapy Following Rotator Cuff Surgery 13 program. The individualized treatment consisted of manual therapy techniques, any combination of exercise, ice, heat, and further advice on the home exercise program. Physical therapists determined the treatment content, rate of progression, and number of sessions. These authors found that a standard PT program provided no advantage to individuals than providing a home exercise program. In a study examining the use of CPM, there was no significant difference in outcomes between use of CPM on a CPM machine and a program consisting of manual PROM exercises.29 Additionally, when CPM was combined with PT, there was no significant difference in time to achieve ROM goals compared to standard PT.30 For this reason, the use of CPM is not recommended after RCR. With regard to the use of splinting after RCR, there was no difference when comparing a five-week post-surgical splinting protocol in abduction versus resting the arm in neutral for five weeks.31 Some PT modalities have been supported in the literature while others have been found to have mixed results.4,6,33 For example, in individuals with impaired muscle activation after surgery, electromyogram (EMG) analysis demonstrated that neuromuscular electrical stimulation (NMES) applied to the posterior cuff helped regain muscular control.4 Also, cryotherapy was shown to result in less post-operative pain and need for narcotics.33 However, the efficacy of transcutaneous electrical nerve stimulation (TENS), iontophoresis, and ultrasound remains controversial due to lack of well controlled clinical trials evaluating their role in the rehabilitation of those patients recovering following RCR.6 Clinical guidelines have been developed for post-surgical RCR care.1 In these guidelines, phases of rehabilitation were identified to assist clinicians in their decision-making during the post-operative time period. Pabian et al1 described several phases of rehabilitation: the maximum protection/passive phase, the moderate protection/active phase, and the minimum protection/resistive phase.1 McCormick et al10 described a slightly different protocol with a Physical Therapy Following Rotator Cuff Surgery 14 protected phase, ROM restoration phase, early strength phase, functional recovery phase, and a progressive return to sport phase. The pace of patient progression through the phases of recovery will vary between patients. Factors that affect this pace include the size, shape, and location of the tear, surgical procedure, tissue quality, and other patient characteristics such as age, comorbidities such as diabetes, and whether the patient smokes or not.1,10 Pabian et al1 evaluated EMG analyses and were able to identify various exercises and daily activities appropriate to improving ROM and strength in each phase of recovery. Guidelines for how much muscle activity was appropriate for each phase were given. Muscle activity was identified as a percentage of maximum voluntary isometric contraction (MVIC). According to Pabian et al,1 exercises in phase one should demonstrate minimal activity (MVIC less than 20%), exercises in phase two should demonstrate moderate activity (20-40% MVIC), and exercises in phase three should demonstrate high activity (41-60% MVIC). Electromyogram analyses of activation patterns for shoulder muscles during shoulder exercises has been reported in other studies as well.34-36 For instance, Wells et al36 highlighted exercises and daily activities appropriate for the early phase of recovery. Reinold et al34, reported optimal exercises for stimulating specific shoulder musculature. Side-lying external rotation (ER) produced the greatest amount of EMG activity for the infraspinatus and teres minor, and prone horizontal abduction at 100 with full ER produced the greatest amount of activity in the supraspinatus, middle deltoid, and posterior deltoid.34 However, clinical trials in the patient population who have undergone RCR have not been conducted to test the efficacy of utilizing these exercises during the different phases of recovery to optimize ROM, strength, and function. There has been focus in the literature on whether ROM exercises should be introduced in the first one to two weeks after surgery or be delayed to a safer period of four to six weeks in Physical Therapy Following Rotator Cuff Surgery 15 order to allow time for the graft to heal.1,6,9,37 While there was some disagreement as to whether to start exercising in early phase to prevent shoulder stiffness or to wait until a safer period to prevent a breakdown in repair, there does not appear to be a greater benefit to either strategy according to Cuff et al.9 Clinicians should recognize that patient specific factors such as the presence of pre-surgical adhesive capsulitis or the size of the rotator cuff tear may influence outcomes, and a decision about when to introduce ROM should take these factors into account.3,9,10 There is a need for more randomized clinical trials addressing standard PT interventions.32 Additionally, standard PT interventions may only progress patients to a certain point in clinical and functional outcomes post-operatively. Alternative interventions such as NMR, which takes more of a neurological approach to care as opposed to a mechanical approach, should also be explored to determine if better outcomes may be achieved. Neuromuscular Re-education The objective of the NMR treatment approach is to enhance the function of the nervous systems interaction with the muscles and joints in the body.12,13,20,38 Afferent neural function is the intake of neural information through the nervous system, and proprioception is the term commonly used to describe afferent neural information communicated from the peripheral nervous system to the central nervous system (CNS).12,13 Proprioception includes three functional components each with distinct characteristics.13 The first functional component is joint position sense; this is the ability to distinguish where a joint is oriented in space. The second is the sensation of resistance which is the ability to recognize the force generated within a joint. The third and last functional component is kinesthesia or kinesthetic sense which is the ability to recognize joint motion including when motion begins and when it ends, sudden motion, acceleration, and deceleration. All three sub-modalities are thought to be realized both Physical Therapy Following Rotator Cuff Surgery 16 consciously and sub-consciously and are components of the proprioceptive domain of neural information that is communicated to the CNS.12,13 Anatomy of the Neuromuscular System The anatomy of the neuromuscular system is the basis for understanding proprioception and how NMR affects motion via the nervous system. The neuromuscular system encompasses the sensory, motor, and central integration and processing components at higher levels of the CNS.13 Mechanoreceptors are the primary organ of proprioception at the joint level. There are intra and extra-articular mechanoreceptors located in joint capsules, ligaments, labrums, tendons, muscle bodies, encapsulating fascia, and skin. Mechanoreceptors convert mechanical tissue deformation in the form of a stretch, strain, or compression into neural signals which communicate with the CNS via afferent neural pathways. Intra-articular mechanoreceptors are located in non-contractile tissue such as the labrum, ligaments, or joint capsule and contribute proprioceptive information primarily at the end ranges of motion.12,39 Examples of intra-articular mechanoreceptors are Pacinian corpuscles, Ruffini endings, and Golgi-tendon organ-like endings. Ruffini endings and Golgi-tendon organ-like endings signal information important for distinguishing joint position sense whereas Pacinian corpuscles signal information important for distinguishing kinesthetic sense. Extra-articular mechanoreceptors include muscle spindles and Golgi tendon organs (GTOs) which relay information about muscle length and tension as muscles contract and stretch. Muscle mechanoreceptors are stimulated at mid-ranges of motion, so they relay proprioceptive information important for joint position sense at mid as well as end ranges of motion.12,13,39 Procedures used to examine sub-modalities of proprioception may help with understanding the afferent function of the neuromuscular system as it applies to the shoulder. Physical Therapy Following Rotator Cuff Surgery 17 The test most often administered to determine kinesthetic sense is the threshold to detection of passive motion (TTDPM), which quantifies the ability of the CNS to consciously detect when motion begins. When there is a delay in the ability to detect when motion begins, this is called latency; it indicates that there is a deficit in kinesthetic sense.12,13 Joint position sense is most commonly tested by measuring reproduction of active positioning (RAP) or reproduction of passive repositioning (RPP), which is the ability to actively or passively reproduce upper extremity angular motion. Reproduction of active positioning theoretically assesses the function of GTOs and muscle spindles since muscle contraction occurs. Reproduction of passive positioning theoretically assesses the function of Pacinian corpuscles, Ruffini endings, and Golgi tendon organ like endings, since the contractile tissues are at rest.12 Afferent information communicated from mechanoreceptors in the shoulder to the CNS may be combined either at higher brain centers or in the spinal cord. When this occurs at the level of the spinal cord, this allows complex and isolated movements that are repeatedly practiced to eventually be performed without reference to consciousness.12,13,40-42 Organs at the higher brain centers that communicate with the neuromuscular system in the shoulder include the motor cortex, basal ganglia, and cerebellum. Cognitive awareness of limb and body movement and position mediate higher brain centers, which then initiate, program, and store voluntary movements as central commands. Neuromuscular Control Neuromuscular control is the unconscious activation of the muscles, which occurs in preparation for joint stabilization or movement, and is in response to the afferent input from joint motion and loading.13 Where proprioception describes the afferent function of the neuromuscular system, neuromuscular control describes the efferent function, or motor output of the Physical Therapy Following Rotator Cuff Surgery 18 neuromuscular system needed for joint stability. Several mechanisms of the neuromuscular system are influenced by neuromuscular control. Co-activation is the simultaneous contraction of antagonistic muscles. When the rotator cuff and the antagonistic deltoid or the pectoralis and the antagonistic trapezius are synergistically activated at the glenohumeral or scapulothoracic joint, co-activation enhances glenohumeral and scapular stability, thereby improving reaction to external load or control of shoulder motion.13 Control of shoulder motion may also be enhanced by performing exercises that activate the spinal reflex arc. The spinal reflex arc results from afferent neural signals originating at the mechanoreceptors in the joint capsule, tendon, and ligament that rapidly travel to the spinal cord and back resulting in a muscle contraction around that joint.12 Jerosch et al43 arthroscopically demonstrated a spinal reflex arc between the shoulder musculature. However, the spinal reflex arc may not be fast enough to produce immediate joint stability when the joint is compromised. Instead, pre-programmed motor patterns that are received from higher levels of the CNS effective in altering joint motions are thought to be adjusted by the spinal reflex arc. In doing so, it is believed to assist programmed motor patterns through a diminishing function, which helps prevent harmful movements by improving preparatory and reactive abilities of muscles.12 Preparatory muscle contraction and muscle stiffness. Preparatory muscle contraction or pre-activation and muscle stiffness results when proprioceptive feedback from previous experiences is learned and stored at the higher brain centers and is then used for planning and executing motions.13 Imagery exercise is a form of exercise which demonstrates a link between stored motor commands in the motor cortex and preparatory muscle contraction. During imagery exercise, a person mentally imagines a motion rather than physically performing the motion. Khademi-Kalantari et al44 used EMG to demonstrate that imagery exercises activate shoulder Physical Therapy Following Rotator Cuff Surgery 19 muscles, which illustrates the connection between the motor cortex and muscle pre-activation. Planning and execution of motions help enhance muscle stiffness which assists joint stability, heightens muscle spindle sensitivity, and enhances reflexive joint stability.44 Components of neuromuscular control may be understood by discussing procedures used to test them. To assess the functionality of the spinal reflex arc, one method uses EMG to measure muscle activation patterns in response to joint perturbation to determine if muscle response latency exists after an injury or during rehabilitation.13 Active ROM also assesses neuromuscular control; it may be examined with motion analysis software, goniometry, or an inclinometer. Active ROM may be an indicator of the effectiveness of co-activation of muscles at the glenohumeral and scapulothoracic joint. Muscle performance tests such as strength, torque, work, or power measure the force generating capacity of the muscle and the velocity of contraction. Muscle performance tests may be associated with pre-activation ability in muscles and may be measured in the laboratory with isokinetic dynamometry.13 Functional measures such as the functional throwing performance index (FTPI) and the single arm dynamic stability (SADS) test are used to assess dynamic shoulder stabilization. 13,20,21,45 Better throwing accuracy with the FTPI is correlated with superior neuromuscular control, where less corrections and falls during the SADS test is correlated with superior neuromuscular control.13,20 Factors that Adversely Affect Proprioception Historically, authors of NMR research suggest that several factors affect proprioceptive feedback to the CNS, and proprioceptive deficits may occur when there is an alteration to the mechanoreceptors in and around a joint.13,20,21,41 Based on what is known about proprioception, deficits are thought to occur after injury or pathology around the shoulder due to impairment of Physical Therapy Following Rotator Cuff Surgery 20 the mechanoreceptors. Exercise-induced fatigue was reported to alter proprioceptive feedback and neuromuscular control of the shoulder.19,22,46 For example, Carpenter et al19 used TTDPM to examine proprioceptive feedback at the shoulder after exercise induced muscle fatigue to the shoulder. They found TTDPM latency increased 171% for internal rotation and 179% for ER after fatigue, which supported the theory that fatigue effects sensation of joint movement (kinesthetic sense).19 Meyers et al20 theorized fatigue may also adversely affect neuromuscular control as measured with the SADS test. They reasoned that because fatigue hinders proprioceptive feedback from the shoulder to the CNS, the neuromuscular response and joint stability may be adversely affected.20 Wickiewicz et al22 performed kinematic analysis of glenohumeral motion after the shoulder muscles were fatigued and noted an increase in superior humeral head migration in the glenoid fossa at 45, 90, and 125 of shoulder scaption in standing. These authors considered from their results that fatigue may alter co-activation of opposing muscles at the glenohumeral joint resulting in a loss of dynamic stability.22 These studies collectively illustrated how multiple factors may alter proprioceptive feedback and cause deficit in neuromuscular control. The authors of several studies have examined the effect glenohumeral instability has on proprioceptive feedback.22,47-50 Lephart et al47 compared patients with chronic shoulder instability to individuals with healthy shoulders and patients with arthroscopically repaired shoulders after rehabilitation. The authors theorized proprioceptive feedback could be impaired in individuals with glenohumeral instability. Threshold to detection of passive motion and RPP were used to examine kinesthetic sense and joint position sense in each of these groups. They found that TTDPM was impaired in patients with chronic shoulder instability but not in healthy people or surgically repaired shoulder instabilities after rehabilitation (p < .05). They rationalized that Physical Therapy Following Rotator Cuff Surgery 21 damage to mechanoreceptors in the articular structure and soft tissues, believed to be common in shoulder instability, impaired proprioceptive feedback to the CNS. Mechanical instability as it relates to proprioceptive feedback has also been studied in the lower extremity of patients with anterior cruciate ligament (ACL) deficiencies in the knee.51,52 Several authors have reported a deficit in proprioceptive feedback in patients with ACL deficiencies, and the anatomical evidence of nerve endings in the ACL suggests that it provides proprioceptive feedback to the CNS.51,52 Researchers suggested that the symptom of giving way seen in the ACL deficient knee may at least partially result from the loss of this proprioceptive feedback and subsequent alteration of the spinal reflex arc.51,52 Lower extremity studies further support the rational that if injury or pathology occurs to joints and the soft tissues that stabilize them that proprioceptive feedback is altered.51,52 The Role of the Rotator Cuff and Force Couples in Joint Stability Proprioceptive feedback and resultant neuromuscular control is important to address during PT of the shoulder because the shoulder is inherently mobile and relies heavily on muscles and ligaments for stability and control of motion.13 Rotator cuff muscles provide dynamic stability at the glenohumeral joint by producing forces that compress and centralize the humeral head within the glenoid fossa during shoulder motion. Specifically, these forces balance the pull the deltoid has on the humerus, which helps decrease upward migration of the humeral head during arm elevation.12,13 The role the rotator cuff plays in stabilizing the humeral head during shoulder motion suggests it serves an important role in achieving neuromuscular control of the glenohumeral joint, preventing deleterious functional movement. The shoulders reliance on the rotator cuff for stability was examined in laboratory studies with digital fluoroscopic video (DFV).53,54 Thompson et al54 used DFV to examine if Physical Therapy Following Rotator Cuff Surgery 22 upward migration of the humeral head occurred during normal shoulder motion by measuring the distance between the acromion and the humeral head during shoulder scaption in healthy baseball players.54 In particular, they measured the distance between the acromion and the humeral head which is called the acromiohumeral interval (AHI). These authors showed a progressive decrease in the AHI during scaption. However, when a load was added to the motion, the AHI did not change.54 The authors rationalized that the rotator cuff helped to preserve the AHI when the extremity was loaded, which provided evidence to support the role of the rotator cuff to stabilize the humeral head while elevating the arm. An EMG study supports the role of the rotator cuff for glenohumeral stability by examining activation of the rotator cuff to determine firing patterns during various arm motions. Reinold et al34 used EMG in the laboratory to show peak percentages of MVIC of the rotator cuff muscles during seven shoulder exercises. All seven exercises resulted in EMG activation of the rotator cuff to varying degrees. The rotator cuffs role in stabilizing the humeral head during shoulder motion suggests an important role in achieving adequate, timely neuromuscular control of the glenohumeral joint during functional motion. While standard PT uses strength training to improve the function of the rotator cuff, neuromuscular exercises may optimize this stabilizing function of the rotator cuff. Neuromuscular Re-education Exercise Neuromuscular exercises may be used to improve proprioceptive feedback and restore adequate neuromuscular control at the shoulder. These exercises include rhythmic stabilization, active repositioning, resistive repositioning, and plyometric exercises. However, in the literature, there is confusion regarding the description of some of these exercises and conflicting descriptions of rhythmic stabilization versus dynamic stabilization exercises.12,13,41,55 Rhythmic Physical Therapy Following Rotator Cuff Surgery 23 stabilization exercises may be defined as a group of exercises where a person tries to maintain joint position while outside forces or perturbations are applied to the extremity in order to stimulate joint and or muscle mechanoreceptors.12 There are multiple purposes of rhythmic stabilization exercises. These include restoring co-contraction of the rotator cuff and scapulothoracic musculature, facilitating preparatory muscle activation, stimulating muscle reactive abilities via the spinal reflex arc, and promoting muscle stiffness in order to improve joint stability.12,13 Rhythmic stabilization exercises are performed in both open and closed chain positions. Rhythmic stabilization exercise may be performed open chain with manual perturbations, closed chain on unsteady surfaces and different positions, closed chain with manual perturbations, or with shoulder movements on a variety of surfaces.12,13,41,45,55 Open chain exercises can be performed in a variety of lying positions, in sitting, and in standing. Examples of closed chain body positions are the pushup position, plank positions, or tripod position. In addition to this, various surfaces such as the floor, wall, wobble board, sliding board, or therapy ball are appropriate to use. Externally applied perturbations or self-controlled movement may be performed at varying speeds during these exercises. Movements and perturbations may be performed in a safer more functional range or in positions of vulnerability in order to allow individuals to advance through a progressive rhythmic stabilization program.12,13 Using a broad description of rhythmic stabilization helps avoid confusion when various positions and surfaces are evaluated for their effectiveness in shoulder conditions. Rhythmic stabilization exercises stimulate the spinal reflex arc, which provides an elementary form of motor control for shoulder stability.12,13 Naughton et al41 evaluated the effects of stimulating the spinal reflex arc with rhythmic stabilization exercises performed in closed chain on a wobble board by individuals who had suffered shoulder dislocation. Before Physical Therapy Following Rotator Cuff Surgery 24 and after four weeks of an intensive rhythmic stabilization exercise program, researchers tested what they called active movement discrimination using active shoulder ER with the shoulder abducted 90 and in ER. Active movement discrimination assessed joint position sense, similar to RAP and RPP. After the training program, a statistically significant improvement in active movement discrimination was demonstrated in the experimental group (p < .001) but not in the control group (p = .55). The authors suggested from their findings that rhythmic stabilization in closed chain enhanced proprioception in a shoulder with instability and provided support that closed chain exercises stimulate both articular and muscle mechanoreceptors to increase reflex stabilization. Limitations of this study were that a control group was not used, and clinical or functional outcomes were not evaluated. Dilek et al56 used closed chain rhythmic stabilization exercises to evaluate the efficacy of proprioceptive exercises on the symptoms of sub-acromial impingement syndrome (SIS). The authors reported that the intervention group performed proprioception exercises, with all these exercises being in the form of closed chain rhythmic stabilization done on different surfaces. Individuals who performed rhythmic stabilization exercises along with a standard PT regimen were compared to individuals who received standard PT. Standard PT included electrical stimulation, heat, ROM exercises, posterior capsule stretching, and strength training. Authors evaluated RAP and RPP, AROM, strength, function, and pain pre and post exercise intervention. Both treatment groups showed significant improvement in clinical and self-reported functional measures after intervention. The group treated with rhythmic stabilization exercises had superior results to the control group in RAP and RPP but did not show significantly greater results than the control group in clinical or functional measures. The authors concluded that there may not be benefit to adding proprioception training to traditional PT in patients with SIS. However, the Physical Therapy Following Rotator Cuff Surgery 25 authors reported that specific exercise programs for proprioception may be included with SIS since individuals in the rhythmic stabilization group experienced better improvements in kinesthesia, RAP and RPP than the control group. The authors were not able to compute a sample size prior to initiating the study which may account for why they were not able to find a difference between groups for clinical and self-reported outcomes. While closed chain rhythmic stabilization exercises benefit the unstable shoulder, efficacy for use of this type of exercise in SIS is not fully supported here.56 Bae et al57 evaluated an exercise protocol based on motor control theory to determine if adding this protocol to a strength program provided additional benefit to clinical measures and a self-reported functional outcome in individuals suffering from SIS. According to motor control theory, abnormal movement caused by damage or disease re-organizes the cerebral cortex leading to changes in the brain and uncoordinated movement. Therefore, exercise aimed at achieving normal motion control (motor control exercises) can help restore normal movement in patients with SIS. Bae et al57 and Roy et al58 suggested that when an exercise protocol based on motor control theory was performed, normal pain free movement could be achieved in this population. Bae et al57 compared AROM, pain, strength, and functional outcomes pre and post intervention to test this hypothesis. They found a significantly greater effect on strength, AROM, pain, and self-reported functional outcomes after completing four weeks of strength training along with a protocol based on motor control theory compared to strength training alone. However, there were limitations to this study. For example, the description of the motor control theory protocol presented by authors in this study was not complete. Similar to exercises based on motor control theory, joint repositioning exercise is another form of neuromuscular exercise Physical Therapy Following Rotator Cuff Surgery 26 which may be used to enhance kinesthetic sense and joint position sense during shoulder motion.13 Joint repositioning exercises may include active or resisted joint repositioning. Joint repositioning exercise is where the extremity is brought through angular motion to a certain point in the persons available ROM to allow the person to familiarize with that point. Then the person is asked to reproduce that motion to the best of his or her ability with or without resistance.13 Wilke et al45 suggested using manually resisted concentric and eccentric internal and ER ROM exercises (resistive joint repositioning) at the glenohumeral joint. Although an increase in strength may result from performing these exercises, the emphasis of these exercises is not to increase strength since the exercises may be performed with a consistently low to moderate load to patient tolerance. The emphasis is on retraining joint position sense and kinesthetic sense by stimulating mechanoreceptors in the rotator cuff and articular structures. Borsa et al12 suggested that resistive joint repositioning helps with learning motion and trains cognitive appreciation of joint position. Joint repositioning activities are initiated at the cognitive level and are thought to assist programming motor commands to voluntary movements. With consistent practice, joint repositioning activities may stimulate conscious to unconscious motor programming in the higher brain centers resulting in better quality of motion.12 Besides the research done by Bae et al,57 there is lack of research to support the efficacy of joint repositioning exercise or to suggest when it is appropriate to initiate the use of these exercises in PT after RCR. While active and resistive joint repositioning exercise and exercises based on motor control theory are important to improve kinesthetic and joint position sense, plyometric exercises are intended to improve all aspects of the neuromuscular system. Physical Therapy Following Rotator Cuff Surgery 27 Specifically, plyometric exercise is a dynamic form of neuromuscular exercise that enhances kinesthetic sense, increases dynamic muscle restraint around the joint, and enhances muscle pre-activation and stiffness.40,42 The neuromuscular effect of plyometric exercise is potentiation of the concentric muscle action by use of the spinal reflex arc. Potentiation is the change in the force-velocity characteristics of the contractile components of muscles caused by a stretch of the muscles.59 Additionally, plyometric exercises are thought to improve sub-conscious use of the central commands from higher brain centers.40-42 Plyometric exercises are composed of three components: eccentric loading, amortization time, and concentric contraction. An example would be throwing a weighted ball against a trampoline, starting at shoulder height and progressing gradually to overhead throwing.5 During eccentric loading, tension placed on the muscle spindles stimulates the spinal reflex arc, which is thought to enhance the neuromuscular response of the muscles in the shoulder. Stimulation of the spinal reflex arc during eccentric loading allegedly increases muscle force production by 10-15%.5 Davies et al46 reinforced the idea that the adaptation of the muscle spindles with the practice of plyometric exercise results in refined subsequent ballistic concentric muscle contraction during plyometric exercise. This results in reduced amortization time and improved motion velocity during both concentric and eccentric phases of muscle contraction. Swanik et al42 tested RAP and TTDPM to evaluate the effect plyometric exercises had on kinesthetic and joint position sense. After six weeks of training, they found significant differences between the control and experimental groups for both RAP and TTDPM at a reference position of 75 of ER and moving into ER (p = .013 and p < .001 respectively). Similar to what Vo et al6 and Davies et al46 had previously put forward, Swanik and colleagues42 speculated that desensitization of GTOs in the joint capsule heightened stretch sensitivity of the Physical Therapy Following Rotator Cuff Surgery 28 muscle spindles which enhanced afferent communication to the CNS. They added that during plyometric exercise it was important to move the extremity through the entire range of motion in order to maximize proprioceptive feedback from muscle spindles and GTOs. This increase in afferent communication to the CNS formed peripheral adaptations at the spinal reflex arc and central adaptations at the cerebellum and basal cortex. Repetitive preparatory muscle activation in anticipation of catching the ball and involuntary muscle activity while throwing the ball contributed to central adaptations at the cerebellum.42 These studies support the current rational for using plyometric exercise as a form of neuromuscular exercise once adequate strength is achieved. Neuromuscular Re-education after Rotator Cuff Repair There is evidence to support an association between rotator cuff tear and impaired proprioception at the shoulder.60 However, there is currently a lack of research evaluating deficits in structure and function of proprioception in patients following RCR. Bachasson et al60 evaluated several animal studies where tenotomy was performed on rabbit rotator cuff tendon, and based on their findings, they reported that rotator cuff tear was associated with structural and functional alterations of proprioceptors. Authors attributed impaired proprioception, kinematics, and muscle recruitment strategy at the shoulder complex to either reduced or inconsistent proprioceptive information from the injured tendon and altered muscle reflex activity.60 Ghodadra et al5 advocated the use of NMR during certain phases of RCR rehabilitation to address these proprioceptive and neuromuscular deficits. Controlled activities that could safely activate the rotator cuff muscles, including submaximal and pain-free rhythmic stabilization exercises in the supine position were recommended. For rhythmic stabilization, the arm was placed in the balanced position, defined as 100 of shoulder elevation and slight horizontal Physical Therapy Following Rotator Cuff Surgery 29 abduction. The authors suggested that this position may have promoted the co-activation of surrounding shoulder muscles. In this position, the physical therapist applied perturbation in an alternating manner with an extremely low force of about 0.5 kg to 1.5 kg. Rhythmic stabilization for the shoulder internal and external rotators in the supine scapular plane position were also described to isolate co-activation of the rotator cuff muscles.5 Wilke et al45 and Borsa et al12 recommended that rhythmic stabilization drills be performed in open and closed kinetic chain positions to optimize stimulation of muscle and articular receptors. Rhythmic stabilization may improve kinesthetic sense, pre-activation, and muscle stiffness of the rotator cuff, and surrounding shoulder muscles after surgery. The temporal adaptation may be improved dynamic glenohumeral and scapulothoracic joint stability.12,45 Currently, there is no consensus as to when it is appropriate to introduce NMR into a post-surgical RCR program. The decision relating to the timing of start of NMR may be based more on the type of NMR intervention being used and the individual circumstances of the patient. Zamani et al44 suggested imagery exercise may be performed in the early protective phases of rehabilitation. The role of these exercises at this time may be helpful in preventing neural inhibition and disruption of motor control which are considered to be a common challenge for patients after RCR surgery. Vo et al6 recommended gradually introducing most NMR exercises during the early strengthening phase of rehabilitation which is considered to occur 12 to16 weeks post-operatively. Vo et al6 advocated the use of plyometric exercise at the end of the advanced strength training phase of RCR rehabilitation, 16 to 22 weeks post-operatively to allow adequate development of strength because of the ballistic stress placed on the tendon. The lack of consensus as to when to introduce NMR into a post-surgical program reflects the lack of clinical trials evaluating efficacy of NMR in those with shoulder pathology and after RCR surgery. Physical Therapy Following Rotator Cuff Surgery 30 While the efficacy for the use of NMR in the RCR post-surgical population continues to be an area requiring research, the efficacy of NMR has been more thoroughly studied in the knee and ankle joints.14,28,61-63 Zeck et al14 reported in their literature review on NMR in the knee and ankle that various forms of NMR exercises effectively improved function as well as decreased the incidence of recurrent injury and episodes of giving way after recurrent ankle sprains and after ACL injuries. However, they also surmised that there were mixed results or no efficacy of training on joint position sense, neuromuscular control, joint laxity, and strength.14 Risberg et al64 examined if there was a difference between NMR and strength training after ACL repair. These researchers analyzed Cincinnati Knee Scores, the visual analogue scale (VAS) for pain, global knee function (VAF), strength, balance, and TTDPM. The NMR group demonstrated significantly improved Cincinnati Knee Scores and VAF scores after training. However, there was no difference in strength, balance, and TTDPM between groups after training.64 Beard et al51 examined the effect of NMR and strength training after ACL repair using a test that measured reflex hamstring contraction latency (a test of the efficiency of the spinal reflex arc), and the Lysholm and Gillquist Functional Scoring Scale for the knee. The authors discovered that there was a significant hamstring reflex latency in the acutely injured ACL. They attributed this latency to the deficit in proprioceptive input from the ACL or other proprioceptors within the joint. Both forms of exercise showed improvements in outcomes but a significantly greater improvement occurred in the NMR trained group. A limitation of this study was that it was difficult to identify what functional component of proprioception was trained based on the exercise description provided.51 Ageburg et al63 researched the effect of a NMR program on patients awaiting total knee or hip replacement with severe osteoarthritis. They assessed selfreported-outcomes and measures of physical function, and they compared the results to a control Physical Therapy Following Rotator Cuff Surgery 31 group who did not receive the intervention. The NMR trained group showed significant improvement in self-reported outcomes and measures of physical function compared to the control group.63 These studies provide support that NMR may enhance muscle reflex, joint stability, and over-all function at the knee, hip and ankle after injury.14,51,63,64 However, there were mixed results with respect to the effect of NMR exercises on proprioceptive components and the ability of NMR to improve results of tests of neuromuscular control at the knee and ankle. Some of the challenges in interpreting findings in NMR research include lack of clarity of theoretical framework for how exercises uniquely train components of the neuromuscular system and the lack of adequate exercise description.14-18 Clinical Outcomes Clinical outcome measures and self-reported outcomes are used to assess change in patient physical impairment, perceived function, and disability during orthopedic care. Clinical outcome measures are used to assess change in a patients physical function, while self-reported outcome measures indicate change in the patients perceived of level disability and function.65,66 In the shoulder, a clinical outcome measure may include AROM. Active ROM measurements indicate progress with healing, change in soft tissue flexibility, joint mobility, and neuromuscular control. Self-reported outcome measures include the DASH questionnaire and the NPRS. The DASH questionnaire and NPRS help determine how patients perceive their pain and functional ability.67,68 In the orthopedic literature, clinical outcome measures and self-reported outcomes have been used in NMR and RCR research to evaluate change pre to post intervention and to establish if significant differences are present between treatment groups.37,38,57 Several authors have used ROM, self-reported pain scales, and functional outcomes in clinical trials to evaluate NMR for the shoulder similar to the methods used in the lower Physical Therapy Following Rotator Cuff Surgery 32 extremity NMR literature.14,28,61-63 Bae et al57 analyzed clinical and functional measures to assess efficacy of adding a NMR protocol to strength training in SIS. They evaluated the efficacy of this protocol by assessing changes in ROM, strength, self-reported pain, and the Shoulder Pain and Disability Index. Ginn et al38 used a nine-question individually-standardized self-reported functional score in a group of patients with unilateral shoulder pain of local mechanical origin in addition to the clinical outcomes that Bae et al57 used. Patients who completed NMR exercises were compared to the standard of care at the hospital where the study was conducted. The standard of care in this study was corticosteroid injection and a combination of electrophysical modalities, joint mobilization, and ROM exercises.38 In these studies, both groups showed significant improvements in all of the measures after the intervention period.38,57 Clinical measures and self-reported outcome measures successfully captured measurable change from pre to post NMR intervention in individuals with shoulder dysfunction. Additionally, in the study by Bae et al57 authors discovered a statistically significant difference between treatment groups at post assessment periods for clinical and self-reported functional outcomes. Keener et al37 evaluated AROM shoulder flexion with standard goniometry in a group of 124 patients in several follow-up assessments after RCR. Patients were randomized to either a traditional PT protocol involving early PROM or to an immobilization group in which ROM was delayed for six weeks. At the three-month follow-up, the mean AROM flexion for the traditional PT group was 136 and 123 in the immobilization group (p = .02). At six months the traditional PT group had a mean AROM of 155 and the immobilization group mean was 159 (p = .61).37 The authors of this study were able to detect clinical change in AROM flexion at follow-up time periods after RCR establishing validity of AROM measurement. Physical Therapy Following Rotator Cuff Surgery 33 Brennan et al25 evaluated changes in NPRS scores pre and post RCR rehabilitation in 341 patients to identify the clinical outcomes following standard outpatient PT and to examine the differences in outcomes between men and women. The authors reported that for males the mean NPRS score at evaluation was 4.9 and at discharge was 2.5 with a mean change of 2.5 points. For females, the mean NPRS at evaluation was 4.1 and at discharge was 2.0 with a mean change of 2.1 points. Statistically significant differences pre to post rehabilitation were found in both genders (p < .05) even though change score values were not statistically significantly different between genders (p > .05).25 Boissonnault et al26 evaluated DASH scores pre and post a RCR rehabilitation protocol to assess the effect of comorbidities on functional outcomes. Patients received a protocol including therapeutic exercise, manual therapy, electrotherapeutic modalities, and physical agents. The authors reported that the mean DASH scores decreased significantly pre to post rehabilitation (p < .001) and that the number of comorbidities did not affect DASH scores.26 No control group was used in this study. In the Brennon et al25 study, there was a statistically significant decrease in mean DASH scores pre to post rehabilitation in males from 56.1 to 21.9 and in females from 63.9 to 28.9. These studies support that functional outcomes can detect changes pre to post intervention in patients who have undergone RCR. In summary, it may be considered that adding NMR to standard PT care after RCR may positively influence clinical measures and self-reported outcomes. A significant gap in the broader post-operative RCR rehabilitation literature exists for randomized controlled clinical trials to support the optimal treatment approach for postoperative rehabilitation. The NMR approach may help optimize outcomes after RCR. Working to improve neuromuscular components of the system associated with control of the rotator and surrounding scapular Physical Therapy Following Rotator Cuff Surgery 34 musculature after surgery reduces deleterious humeral head migration during active shoulder motion and enhances joint stability, which can significantly affect post-surgical recovery. However, the optimal way to achieve this objective is less clear throughout the literature since there are few randomized controlled clinical trials to support NMR interventions, specifically in the post-operative RCR population. Therefore, these concepts need further research following RCR. Clinically, NMR may help improve the quality of motion during other PT exercise, reduce pain, mitigate the effects fatigue, and reduce chances of developing stiffness or graft failure. Retraining the cerebral cortex and motor commands, as was suggested by Bae et al,57 may also help improve the quality and velocity of functional movements such as reaching behind the back or head and across the body. Physical Therapy Following Rotator Cuff Surgery 35 Method Study Design A non-experimental retrospective case control study was conducted to determine if adding NMR to standard PT after rotator cuff surgery affected selected clinical outcomes when compared to patients who only received standard PT after their surgery. The study was approved by the University of Indianapolis Human Research Protection Program in December 2014. The electronic medical records (EMR) located at the central office of ATI Physical Therapy, a national private PT organization, was queried to identify potential participants. Data were collected from a five-year time frame (January 1, 2012 December 31, 2016) The EMR system used by this private practice was developed by the information technology (IT) department of the practice and is proprietary to the practice organization. Sample A sample of convenience of patients between the ages of 25 to 75 years who received PT at an ATI facility following arthroscopic rotator cuff surgery between January 1, 2012 and December 31, 2016 was identified from the EMR. Based on an a priori sample size calculation (see section below), a minimum sample size of 122 (61 in each group) was required. Once a list of potential patients was derived from the query of the EMR, patients were screened for eligibility based on the following inclusion and exclusion criteria. Inclusion criteria. The following inclusion criteria were used: Patients age is between 25 and 75 years Patient received treatment and was discharged with the data collection dates The PT start date was with-in the first 10 weeks of the documented surgery date Physical Therapy Following Rotator Cuff Surgery 36 A PT start date with-in the first 10 weeks after surgery was chosen because research supports long-term outcomes are similar whether someone starts immediately or delays the beginning of therapy1,6 A minimum of five visits of NMR and standard PT or standard PT only sessions were completed Based on studies investigating the use of NMR in the shoulder population, the aim was to include a minimum mean of 12 sessions of NMR in the experimental cohort57,69 Exclusion criteria. The following exclusion criteria were used: Previous history of ipsilateral rotator cuff surgery Infection in the ipsilateral shoulder present at the time of the PT evaluation Neoplasm in the ipsilateral shoulder Irreparable rotator cuff tear Incomplete repair of a rotator cuff tear Clavicular or scapular fracture present at the time of the PT evaluation8 Current adhesive capsulitis Calcific tendonitis24 Pain and/or paresthesia referred from inflamed structures in the cervical spine38 Missing AROM flexion data at discharge Patients were screened sequentially until 61 patients in both treatment groups were identified. Sample size. An a priori sample size calculation was conducted using G*Power sample size calculator.70 The calculation was based on shoulder AROM flexion using a two tailed independent t test, alpha of .05, power of .80 and a moderate effect size of .51. The effect size for Physical Therapy Following Rotator Cuff Surgery 37 the sample size calculation was based on data provided in a study by Bae et al57 which looked at similar AROM flexion in individuals with sub-acromial impingement syndrome. From the calculation, it was estimated that a minimum of 122 participants (61 in each treatment group) was required for the study to achieve adequate power. Data Collection Both demographic and clinical outcomes data were extracted from the EMR for each participant selected. The demographic data were collected by physical therapists pre-treatment and included age, gender, body mass index (BMI), comorbidities, payer type, diagnosis description, surgical side, comorbidities yes/no, comorbidity number, the Functional Comorbidity Index (FCI) score, days from surgery to initial evaluation, days from surgery to discharge, days from initial evaluation to discharge, number of visits total/case, and number of visits standard PT/case. The clinical outcomes and self-reported outcomes were collected from both pre-treatment and post-treatment and included shoulder AROM flexion, NPRS scores, and DASH scores. These outcomes were collected by both physical therapists and physical therapist assistants responsible for treating the patients as part of their standard care. Active ROM data were used for analyses with the assumption that this would more accurately represent an improvement in neuromuscular control than PROM. The FCI was calculated using comorbidity data recorded by physical therapists as part of the patients usual care. Data were collected from the index assessment and the discharge assessment. The index assessment was defined as the second post-surgical PT assessment within the study period. The second assessment period was chosen as the index assessment because frequently many surgeons and post-surgical protocol guidelines do not allow AROM measurement on the surgical side at the initial evaluation. The discharge assessment was defined as the last assessment in which the patient was discharged by Physical Therapy Following Rotator Cuff Surgery 38 the treating physical therapist. The data were originally recorded in Microsoft Excel and later exported to a statistical software program for analysis. Operationalization of variables. For payer type, individuals were categorized as having either private, public, or other insurance. Individuals were categorized as other if the payer was part of personal injury, workers compensation, or auto litigation. Individuals were categorized into one of three categories by their diagnosis description. The first category was Repair: RTC. The second category was Repair: RTC type II or III. The third category was Repair: complete rupture. Co-morbidity were recorded as present (yes/no) and was considered present if it was reported in the patients EMR. For this study, 17 conditions identified in the FCI were considered to be a comorbidity. A list of these co-morbidities can found in appendix A. In addition, the number of different co-morbidities were also collected. These comorbidities were used to calculate the FCI score. The number of days from surgery to initial evaluation, days from surgery to discharge, and days from initial evaluation to discharge were calculated from surgical dates, evaluation dates, and discharge dates for each case. Instruments The following instruments were used to collect outcome measures: goniometer, selfreported NPRS, and the self-reported DASH. These outcome measures used for analyses in this study are clinical PT measures and self-reported outcome measures commonly used by clinicians. The organizations EMR prompts clinicians to take clinical measures every fourth visit and to enter the measurements into the EMR immediately after the measurement is taken. Goniometer. Therapists employed by ATI are advised to use industry standard goniometric measurement techniques to take AROM measures.71 To improve the reliability of clinical measures, ATI advises clinicians to take AROM measures at the beginning of the Physical Therapy Following Rotator Cuff Surgery 39 session. Goniometric AROM measurements in the shoulder, including flexion, have strong intrarater reliability values (ICC = .89 - .97).66,72 Muir et al66 reported good interrater reliability for AROM flexion measured in supine on individuals with shoulder pathology (ICC = .89). Mullaney et al73 reported good interrater reliability of AROM shoulder flexion measured in the supine position (ICC = .93). In a study by Muir et al66, the established minimal detectible change (MDC) for AROM shoulder flexion measured in supine on individuals with shoulder pathology was 12,66 and the standard error of measure (SEM) was four degrees. In this same study, the minimally clinically important difference (MCID) was found to be eight degrees.66 Numeric Pain Rating Scale. The NPRS quantifies patient-reported pain on an 11-point scale with scores that range from zero to ten. The scale is anchored on the left with the phrase no pain and on the right with the phrase worst pain imaginable.68 A negative change in the NPRS is considered an improvement in pain with less pain reported. At ATI facilities, the NPRS was verbally delivered to patients at each office visit. Clinicians were advised to explain the setup and direction of the NPRS to patients when they introduce it to them. The intrarater reliability of the NPRS for patients with a primary complaint of shoulder pain was strong (ICC = .74, 95% CI [.08, .92]).65 Mean weighted kappa for interrater reliability was k = .48.74 Kappa values between .41-.60 indicate the test provides moderate strength of agreement between observers.75 Mintken et al65 reported an MDC of 2.5 for the NPRS in patients with reported shoulder pain. In a study by Michener et al,68 the MCID for the NPRS was 2.17 for patients with post-surgical shoulder pain.68 Disability of the Arm, Shoulder, and Hand. The DASH is a self-reported questionnaire used to measure upper extremity disability and symptoms. It consists of 38 items total with the main part consisting of a 30-item disability/symptom sub-scale.67,76 Responses for each item are Physical Therapy Following Rotator Cuff Surgery 40 totaled, and the final score ranges from 0 (no disability) to 100 (severe disability).67 Negative change in DASH is considered improvement in function. Clinicians working at ATI facilities are advised to deliver the DASH at the initial evaluation, at re-evaluations, and at discharge. Responses to the DASH are entered into the EMR which automatically calculates the DASH score. The DASH has been shown to be a highly responsive, valid, and a reliable measure of disability in patients with shoulder disability.77 The authors of several studies evaluated the intrarater and interrater reliability of the DASH.77,78 Intrarater reliability was determined to be strong in individuals with an upper humerus fracture (ICC = .92, 95% CI [.86, .96]).77 Interrater reliability was established by Dixon et al.78 In their study, 24 academic judges were asked to match the 38 items on the DASH to the definitions of the constructs of impairment, activity limitation, and participation restriction from the international classification of functioning disability and health (ICF). Authors reported interrater reliability for all judgements across all 38 items was at ICC = .96; 95% CI (.94 - .97).78 In a study by Franchignoni et al76 the MCID and MDC for the DASH was 10.83 points and 10.81 points respectively.76 Functional Comorbidity Index. The FCI consists of 17 comorbid diseases and is used in the general population to predict physical function as the primary outcome of interest. The premise behind the FCI is that comorbidities such as arthritis associated with physical function have more of an effect on physical function.79 The 17 comorbid diseases reported on the FCI were able to predict the physical function subscale of the 36-item Short Form Survey (SF-36) which established the validity of this index to predict physical funcion.79 Therefore, the index may be used in research to adjust for the effect of comorbidity on physical function similar to how other comorbidity indices are used to adjust for the effect of comorbidity on mortality.79 The FCI was shown to be associated with self-reported functional outcome measures at baseline and Physical Therapy Following Rotator Cuff Surgery 41 at a 64-week follow-up in a group of 222 patients who sustained rotator cuff tears. Patients with higher FCI scores were associated with lower functional outcomes (p = .025) which showed it to be a reliable predictor of outcome in the rotator cuff tear population. Procedures All data were originally accessed from a database at ATIs central office where data from over 700 separate clinics were collected via the EMR network. After agreement from ATIs chief compliance officer, patient filed data were downloaded from the IT system by data developers of the Department of Research and Data Analytics of the organization. Patients who had rotator cuff surgery were identified in the EMR by common diagnosis description, international Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes, and International Classification of Disease, Tenth Revision. For those patients who received PT after the Fall of 2015, the Clinical Modification (ICD-10-CM) was used. The list of ICD-9 and ICD-10 codes used for query can be found in Appendix B. Patient files were pulled from the EMR based on common diagnosis descriptions and ICD-9-CM codes or ICD-10-CM codes that the evaluating physical therapist entered into the EMR at the same time of the patients initial visit. Results of the query were sent to the author of this study in an encrypted Excel file from the research department. All the data had private health information (PHI) redacted per Health Insurance Portability and Accountability Act (HIPAA) standards to maintain patient confidentiality prior to the data being sent to the author of this study. The author checked files for inclusion and exclusion criteria and excluded patients who did not meet the specified criteria. Study participants were classified into one of two separate groups: (1) participants who received standard PT care and (2) participants who received standard PT care with NMR. With a large number of clinics spread out nationally, the author believed patient demographics, interventions, Physical Therapy Following Rotator Cuff Surgery 42 and clinical outcome data represented the larger population of patients who had RCR during the same time period. Group assignment was based on current procedural technology (CPT) codes entered by physical therapists and physical therapist assistants at office visits for interventions given. The list of CPT codes used for query can be found in Appendix C. Using the data sample query from the EMR, the author formed two groups via the matching process. The standard PT group consisted of participants billed with one or more of the following CPT codes but never the code for NMR: cold therapy, electrical stimulation, manual therapy, therapeutic exercise, and therapeutic activities. The NMR group consisted of patients billed with CPT codes for NMR interventions in addition to one or more of the codes from the standard PT cohort. The intent was that this group reflected current literature for use of various exercises presented in NMR shoulder literature such as: rhythmic stabilization, plyometric, resisted, active, and passive joint repositioning exercise.1,5,6,38-42,45,57,69,80 Data Analyses Descriptive statistics were conducted on the entire sample and then on both treatment groups. Nominal data are presented as frequencies and percentages and ordinal data as medians and interquartile ranges (IQR). Interval and ratio data are reported as means and standard deviations or medians and IQRs, dependent on whether or not the data were normally distributed. To determine if participants in both groups were similar in demographic characteristics, comparisons were conducted using a Pearson chi-square test for nominal data, and nonparametric tests for ordinal data (Mann-Whitney U test or Kruskal-Wallis test, as appropriate). Either an independent t-test or non-parametric Mann-Whitney U test were used for interval and ratio data, dependent on whether or not the data were normally distributed. If significant Physical Therapy Following Rotator Cuff Surgery 43 differences were found between groups using Pearson chi-square test, post hoc tests using the Bonferroni correction were conducted. All three outcomes were compared between groups at both time periods and within groups. Because AROM values, NPRS scores, and DASH scores were not normally distributed at the index assessment or discharge assessment period, they were compared at both time periods using a Mann-Whitney U test. The Wilcoxon signed-ranks test was used to determine if there was a significant change in AROM values, NPRS scores, and DASH scores between the index assessment and discharge assessment period for both treatment groups. To determine if there was significant difference in the amount of change that occurred from the index assessment to the discharge assessment among the three groups, a change score (post-intervention score minus preintervention score) was calculated for each outcome. Change scores between the groups for AROM and NPRS were compared using the Mann-Whitney U test while change scores for the DASH were compared using independent t test. Clinical relevance of the results was determined using established MDC and MCID values for each of the outcomes. In addition, effect sizes were calculated and reported for all clinical outcomes as a measure of experimental effect. Calculations were conducted using formulas provided by Cohen.81 Interpretation of the effect size is as follows: .20 = small effect, .50 = medium effect, and .80 = large effect.81 Because significant differences in several demographics were found between the treatment groups, multiple linear regression was undertaken to determine if demographic variables had a significant impact on the clinical outcomes along with the treatment group. Explanatory variables that demonstrated a statistically significant difference or correlation with the clinical outcome variable were introduced into the regression model simultaneously using the Physical Therapy Following Rotator Cuff Surgery 44 Enter method. Data screening and preliminary analyses were performed to confirm assumptions of normality, linearity, multicollinearity, and homoscedasticity. Multicollinearity was determined to be present if a correlation coefficient was greater than .80 and tolerance values were less than 0.10, and the assumption of independence of observations was met if the Durbin-Watson value was between 0.80 and 3.20.82 Outcome data were transformed if they were not normally distributed. If there was multicollinearity between covariates, then based on bivariate correlation results, the variable with a higher correlation with the outcome was entered into the model and the other variable removed. Dummy variables were created for multinomial demographic variables for regression analysis. Minimal detectable change scores for outcome variables reported in the literature for individuals with shoulder dysfunction were used to make cut off scores for outcomes. Dichotomous variables separating individuals who demonstrated clinically meaningful change from those who did not were created for each outcome measure based on these cut off scores.65,66,76 A Pearson chi-square test was used to see if a statistically significant difference existed between treatment groups for these dichotomous variables. Individuals with change scores greater than the cut off score were determined to have demonstrated clinically meaningful change. Individuals with change scores greater than the cut off score, but where change was actually negative as determined by individual measure, were considered to have clinically worsened. Individuals with change scores that were less than the cut off score were determined to have clinically stayed the same regardless of the direction of change recorded. The frequency and percentage of individuals in each group who clinically improved, clinically stayed the same, and clinically worsened are reported. Physical Therapy Following Rotator Cuff Surgery 45 Data were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY). Normality of data was determined using the Shapiro-Wilk test for all outcome data. All comparisons were two-tailed, and a significance level of less than .05 was considered to be statistically significant. Physical Therapy Following Rotator Cuff Surgery 46 Results The query of the EMR resulted in the identification of 7,385 potential participants, with 736 having NMR and PT and the other 1,006 having PT only. From this query 122, 61 in both treatment groups, participants were selected. Demographic descriptive data for the entire sample and by group can be found in Table 1. The median age of participants in this study was 58. (IQR = 14.0) years with the majority of the participants being male (80, 65.6%). All participants in the study had at least one comorbidity. The median number of days from PT evaluation to discharge was 98.5 (IQR = 61.0). The median number of visits which included NMR per case was 16.0 (IQR = 12.5). For standard PT, the median number of visits was 21.0 (IQR = 14.0). Seventyeight (63.9%) participants were in the private payer category, 17 (13.9%) were in public payer category, and 27 (22.1%) were in the other payer category. There was a statistically significant difference between treatment groups for seven of fourteen demographic variables (See Table 1). The treatment groups were found to be significantly different for payer type, age, number of comorbidities, number of total visits, number of PT visits, number of days between surgery and discharge, and number of days between evaluation and discharge. Post hoc analysis revealed that participants in the NMR treatment group had a significantly higher percentage of participants in the other category than those in the standard PT treatment compared to both private insurers (p = .001) and public insurers (p = .008). Clinical Outcomes Descriptive statistics and p values for analysis of differences between groups at the index assessment and the discharge assessment are given for all three clinical outcomes in Table 2. P Physical Therapy Following Rotator Cuff Surgery 47 values for differences between time periods within groups are given in Table 3. Change score results for all three clinical outcomes are presented in Table 4. Active range of motion flexion. The difference between treatment groups at the index assessment and discharge assessment period were not significantly different for AROM flexion (See Table 2). However, both treatment groups improved significantly from the index assessment to the discharge assessment period (p < .001 for both groups). Analysis of change scores for each group indicates that the NMR group had significantly more change in AROM flexion than the standard PT group (p = .024). Both treatment groups demonstrated clinical improvement in AROM flexion based on the established greater than or equal to 12 degree MDC value. However, significantly more participants in the NMR group had improvement in their AROM score greater than the established MDC compared to the standard PT group, X2(1, N = 122) = 7.65, p = .006. Fiftythree (86.6%) participants in the NMR group demonstrated clinically meaningful change compared to 40 (65.6%) participants in the standard PT group. One participant (1.6%) in the standard PT group with clinically meaningful change actually worsened, and 21 participants (34%) stayed the same. Of the 86.6% of participants with clinically meaningful change in the NMR group, none worsened. Only eight participants (13%) in the NMR group clinically stayed the same. For both treatment groups, the improvement from the index assessment to the discharge assessment had a large effect size, d = 1.34 and d = 1.56 respectively. However, the difference in change scores had a relatively small effect size, d = .42. Multiple regression analysis. Based on bivariate analysis, gender was found to be significantly different with AROM and was entered into the regression model along with treatment group. The regression model accounted for 5.4% of the variance of AROM flexion at Physical Therapy Following Rotator Cuff Surgery 48 the second time period. However, in the final model, gender was the only variable that significantly predicted AROM, F(2,119) = 4.48, p = .013, R2 = .054, indicating that treatment group is not significantly associated with AROM. Numeric Pain Rating Scale. The difference between treatment groups at the index assessment and discharge assessment period was not significantly different for pain (See Table 1). There was a statistically significant decrease in pain scores for both treatment groups from the index assessment to the discharge assessment period (See Table 3). However, the change scores for the treatment groups were not significantly different from each other (See Table 4). Neither treatment group reached a level of clinical improvement in pain based on the established greater than or equal to 2.5 point MDC value. The two treatment groups were not statistically different for the greater than or equal to 2.5 point MDC value for NPRS change scores, X2(1, N = 118) = .32, p = .572. In the standard PT group, three participants (4.9%) had at least a 2.5-point change; however, it was an increase in pain score. Twenty-three (40%) improved, and 31 (54.4%) stayed the same. In the NMR group, one participant (1.6%) clinically worsened, 30 (49.2%) improved, and 30 (49.2%) stayed the same. Even though it was not statistically significant, 9.2% more participants in the NMR group experienced clinically meaningful improvement in pain than in the standard PT group. Both treatment groups had large effect sizes for the analysis of differences between assessment periods for the NPRS, d = .89 and d = 1.20 respectively. The difference in change scores had a small effect size, d = .29. Multiple regression analysis. Based on bivariate analysis, BMI was found to be significantly correlated with NPRS pain scores and was entered into the regression model along with treatment group. The regression model accounted for 9.3% of variance of pain scores at the second time period. However, only BMI significantly predicted pain at the discharge assessment, Physical Therapy Following Rotator Cuff Surgery 49 F(2,105) = 5.37, p = .006, R2 = .09, indicating that treatment group was not associated with pain scores. Disabilities of the Arm, Shoulder, and Hand. The difference between treatment groups at the index assessment and discharge assessment period were not significantly different for DASH (See Table 1). There was a statistically significant decrease in the DASH scores for both treatment groups from the index assessment to the discharge assessment period (See Table 3). The change in DASH scores from the index visit to the second time period for the standard PT group was slightly higher than the change for the NMR group, but the difference was not statistically significant. Mean, standard deviation (SD), and p-value for the DASH change scores are reported in Table 4. Both treatment groups demonstrated clinical improvement in the DASH based on the established greater than or equal to 10.81 MDC value. However, there was no association between treatment groups and the greater than or equal to10.81 MDC cut off point for DASH change scores, X2(1, N = 50) = .00, p = .64. None of the participants in either group clinically worsened, three (13%) in both groups stayed the same, and 20 (86.9%) in both groups improved. Both treatment groups had large effect sizes for analysis of differences between assessment periods, d = 1.58 and d = 1.48 respectively. However, the effect size for the difference between groups change scores was small, d = .03. Multiple linear regression analysis. Based on bivariate analysis, the following variables were found to be significantly different or correlated with DASH: comorbidity number, BMI, FCI scores, comorbidity Y/N, and payer. Treatment group was entered into the regression model along with these variables to determine if they predicted DASH. The regression model accounted for 41% of the variance for DASH scores at the second time period. In the final model, the other Physical Therapy Following Rotator Cuff Surgery payer category and comorbidity Y/N significantly predicted DASH at the second time period, F(5, 39) = 5.35, p = .001, R2 = .41, indicating that there was no association between treatment group and the DASH. 50 Physical Therapy Following Rotator Cuff Surgery 51 Discussion The purpose of this study was to determine if adding NMR to standard PT after rotator cuff repair, compared to standard PT alone, influenced clinical outcomes. The null hypothesis was that there would not be a statistically significant improvement in clinical outcomes when NMR was used in addition to standard PT compared to standard PT alone. The findings of this study were that both treatment groups significantly improved from index assessment to the discharge assessment period and the NMR group experienced a significantly greater statistical and clinical change in AROM flexion. However, the change in NPRS scores and the DASH as well as the difference between treatment groups at the second time period for all three clinical outcomes were not significantly different. Active Range of Motion Flexion The primary outcome of interest for this analysis was AROM shoulder flexion. There is extensive evidence in the literature that working to improve neuromuscular control of the rotator cuff and surrounding scapular musculature will reduce deleterious humeral head migration during active shoulder motion and enhance joint stability.12,13,20-22,34,45,53,54 Authors have demonstrated that NMR exercises improve neuromuscular control.13,20,21,45 Further, it has been reported that adding NMR to standard PT increases AROM shoulder flexion significantly more than standard PT alone in patients with impingement syndrome.57 Our analysis discovered both treatment groups significantly improved from the index visit to the second time period. While the NMR group was not statistically significantly better than the standard PT group at the second time period, the NMR group demonstrated a statistically significantly greater change in flexion from the index visit to the second time period than the standard PT group (P=.024). While the effect size for this difference was small (d =.43),81 this finding is still clinically relevant as can be Physical Therapy Following Rotator Cuff Surgery 52 explained by the following assessment of the data. When comparing the two groups for MDC cut-off scores, 86.6% individuals in the NMR group demonstrated clinically meaningful change compared to only 63.9% in the standard PT group. This indicated a greater number of individuals demonstrating clinically meaningful improvement in the NMR group than the standard PT group for shoulder AROM flexion. This finding refutes the primary hypothesis of this study that individuals who receive NMR will not demonstrate significant improvement in clinical outcomes compared to standard PT. Active ROM flexion for both groups was comparable to the 165 average post-surgical follow up measure reported by Romeo et al83 in a group sample of 72 patients who had full thickness rotator cuff tears. However, the length of time between surgery and post-surgical measurements in their study was 54 months,83 comparing to the median length of time between surgery and the second time period in the present study is 98.5 days (3.5 months). Keener et al37 reported a mean AROM flexion of 136 at three-month follow-up RCR surgery and 155 at sixmonth follow up. These values are significantly less than median values of 160 in the NMR group and 157 in the standard PT group for a similar follow up time period in this study. Both groups improved significantly greater in AROM in the first three months post operatively than was reported in the study by Keener et al.37 The statistically insignificant difference between treatment groups for AROM flexion at the second time period (p =.174) is similar to what Dilek at al56 reported after NMR intervention in individuals with SIS. In that study, the authors reported a median of 170 in the NMR group and a median of 177 in the standard PT group after six weeks of intervention, summarizing that the groups were not significantly different (p = .72). Authors of that study reported a statistically significant change in flexion from baseline to six weeks in both treatment groups (p < .016) in Physical Therapy Following Rotator Cuff Surgery 53 both the NMR and standard PT group, similar to what was found in this current study after RCR (p = .001). While it may appear that adding NMR does not significantly improve AROM flexion greater than standard PT alone, Dilek et al56 did not test for a difference in change scores between groups. They also reported that they did not conduct a sample size calculation prior to their study, which brought into question if their sample size of 61 participants could have contributed to a type II error in their results. Those authors reported the power of the study was 50% for proprioceptive changes at 12 months. The difference in median change scores between the NMR group and standard PT group in this study was both statistically significant and clinically significant, which means the magnitude of change in the NMR group was significantly greater than the standard PT group. Post hoc power analysis for AROM flexion revealed 73% power for analysis of AROM flexion in the current study.70 While it is relevant that there was a statistical and clinical difference between groups in AROM flexion, there was a confounding variable in the analysis that threatened the validity of results for this clinical measure. There was a statistically significant difference between genders for AROM flexion at discharge. Multiple linear regression revealed that gender significantly predicted AROM flexion, where the treatment group did not. However, demographic analysis looking for difference between treatment groups revealed the number of males and females were evenly distributed between treatment groups thereby reducing the overall effect gender might have had on statistical results. Additionally, the over-all sample was 65.6% males and 34.4% female, which is representative of the target population of individuals receiving RCR in the general population and therefore supports the external validity of results.2,24,25 Physical Therapy Following Rotator Cuff Surgery 54 Numeric Pain Rating Scale Both treatment groups had a statistically significant improvement in pain from the index assessment to the discharge assessment (p < .001). However, pain levels were statistically similar between treatment groups at the discharge assessment, and there was no difference between groups in change scores (p > .05). Multiple regression analysis indicated that treatment group was not associated with pain scores. The NPRS results of this study are similar to what was reported after RCR for NPRS scores by Brennan et al.25 Those authors reported a similar reduction in pain from pre to post rotator cuff repair rehabilitation on the NPRS from 4.1 to 2.0 in males and 4.9 to 2.5 in females (p <. 05). However, the finding of the current study that there was no difference between groups in pain scores or association between treatment group and pain scores at discharge, somewhat conflicts with what has been reported in the NMR literature for pain. Bae et al57 reported a statistically significantly greater reduction in self-reported pain and function in the NMR group compared to the standard PT group (p < .001) for patients with SIS. Authors in that study were able to control better for the kind of exercises administered and progression for each treatment group. In this study, the assumption was made that NMR and standard PT interventions were representative of the current orthopedic literature and subject to the discretion of each physical therapist due to the retrospective nature of the analysis. The MDC cut off point for the NPRS revealed that in the standard PT group 63.9% of individuals clinically did not change and only 40% clinically improved. Where in the NMR group only 49.2% clinically stayed the same and 49.2% clinically improved. While this difference was not statistically significant, 9.2% more individuals in the NMR group were found to demonstrate clinically meaningful improvement in pain than in the standard PT group. This difference, as well as the over-all statistically insignificant difference between groups, may have Physical Therapy Following Rotator Cuff Surgery 55 reached a level of statistical and clinical significance had it not been for missing data and an underpowered sample size. The post-hoc power analysis for the NPRS revealed the sample was only powered at 40%, which may have contributed to a type II error for these statistical test results. Disability of the Arm Shoulder and Hand Despite having such a large number of missing cases for DASH, it was decided to report results for the DASH after completing sub-analysis to determine if results from this sample population could be relevant to the broader RCR population. Published literature supports that including self-reported outcome measure results are significant to the overall validity of research.25,56,57 The sub-analysis compared all the demographic variables between participants who had DASH data at the index assessment and discharge assessment and those who did not. The results of this analysis revealed that the two groups were not different for most of the variables. Therefore, participants with DASH data were determined to be demographically representative of the entire sample and were included in results. The DASH scores for both treatment groups improved significantly from pre to post intervention (p < .001), which is consistent with the DASH results in RCR rehabilitation literature.25,26 However, no difference was found between groups at the second time period or between groups for change scores. Post hoc power analysis for DASH revealed the sample was only powered at 6%, which could have definitely contributed to a type II error. Concurrently, results may have been effected by whether individuals did or did not have comorbidities. There was a statistically significant difference in DASH scores between individuals that did have comorbidities and those that did not. Further, regression analysis revealed there was a significant association between the DASH scores at discharge and whether or not someone had comorbidities. However, the percentage of Physical Therapy Following Rotator Cuff Surgery 56 individuals who did and did not have comorbidities was not statistically different between treatment groups (p = .174). Finally, the median number of comorbidities and FCI score in the sample were each only one. However, the median of two comorbidities in the standard PT group was statistically significantly greater than the median of one in the NMR group (p = .047). Since these findings were somewhat conflicted as to extent comorbidities actually confounded the results of the analysis between treatment groups, a look at the literature on DASH scores in the RCR population and the effect of comorbidities on functional outcomes was conducted. Boissonnault et al26 studied the impact of comorbidities on DASH outcomes in a sample of 118 individuals in the RCR population. They reported that DASH scores significantly improved pre rehabilitation to post rehabilitation, but having a greater number of comorbidities was not associated with poorer DASH scores post rehabilitation (p = .21). However, in another study, it was reported that a higher FCI score is statistically significantly associated with poorer functional outcome measures at the index visit and at 64 weeks in individuals with rotator cuff tear.84 When those authors separated individuals that had RCR from individuals who managed the rotator cuff tear conservatively, they found that FCI scores were not statistically significantly associated with functional outcome change scores or functional outcomes at 64 weeks. Authors attributed this lack in association to an under-powered sample size. But they also reported that in their sample, for every 1-point change in FCI there was only a 3-point change in the functional outcome. Where they cited previous studies reported an MCID of 12-17 for that functional outcome which would have required an FCI of 3-5 comorbidities to reach a clinically relevant effect.84 They concluded the lower mean FCI score of 1 might not be clinically relevant in predicting outcomes, where a much higher FCI score may result clinically meaningful change.84 Physical Therapy Following Rotator Cuff Surgery 57 Their results suggest that a lower FCI score (Mdn = 1.0) found in the current study was not likely to have effected change in DASH scores. Conversely, the other payer category may have had a significant effect on DASH results at the second time period. As stated previously, payer type was associated with treatment groups. Post hoc chi square analysis revealed that the other category was the category most responsible for this association. There was a three to one ratio of other insurance in the NMR group compared to the standard PT group. Further, multiple regression revealed that predicted DASH scores were 14.2 points higher for those in the other category of payer than those that were not. Therefore, the other category of payer may have had an adverse effect on the NMR group DASH outcomes because the other category consisted of patients with workers compensation and litigation cases which may have contributed to an underreporting of improvement in function with the DASH. Limitations There are multiple limitations of this study which must be considered when assessing the value of the findings of this study. Some of the limitations inherent to the retrospective nature of this analysis included inadequate control of exercise interventions given to each group and in particular the NMR group, standardization of data entry procedures for each participant, standardization of clinical measurements and self-reported outcomes, and missing participant outcome data. One of the biggest limitations of this study was the assumption that the intervention exercises administered in the NMR treatment group were representative of the current best available evidence. Given the problems in the NMR literature with regard to exercise description and confusion with regard to definition of exercises, there was a possibility that the exercise Physical Therapy Following Rotator Cuff Surgery 58 interventions chosen by physical therapists and physical therapist assistants at ATI may have been an inconsistent representation of NMR exercises. This limitation may have also been influenced by possible discrepancies in CPT codes entered into the EMR by physical therapists and physical therapist assistants. Due to the retrospective nature of this study, standardization of how CPT codes were entered was limited. There are no standard procedures for entering CPT codes within ATI Physical Therapy. The entry of CPT codes was dependent upon the therapists working knowledge of neuromuscular re-education vs other therapeutic exercises presented in current orthopedic literature. The therapists understanding of proprioceptive and neuromuscular control deficits and which NMR exercises best train these deficits could have affected the effectiveness and timing of implementing these exercises thereby affecting the internal validity of the results. Other factors that may have affected validity could have been related to ways that data were entered into the EMR. All initial data entry for the analysis, including comorbidities and outcome measures, was predicated on the completeness of the participants reporting and the therapists recording of the data. Therefore, it could not be guaranteed that the comorbidities reported were the complete comorbidities for each participant. Additionally, consistency and reliability of clinical measurement technique was dependent on the measurement of multiple clinicians. While AROM flexion was done according to the industrywide standards for goniometric measurement, and ATI has some guidelines to improve reliability of clinical and self-reported outcome measures, there was still no way to adequately control proper patient positioning, mechanics, and alignment of the goniometer for measurement while assessments were taken. There were multiple measurers for clinical outcomes and self-reported outcome measures, which Physical Therapy Following Rotator Cuff Surgery 59 could have threatened the interrater reliability of results. However, interrater reliability was good to excellent for AROM, adequate for NPRS and, excellent for DASH, which would have mitigated the effect multiple measurers could have had on results. Further, due to the retrospective nature of this study, the therapists and patients could not have known about the significance of their results which helped control for rater bias or inflated measures. Also, because measurements were taken nationally, they are representative of the broader population of individuals having RCR increasing their external validity. Finally, missing DASH and NPRS data caused decrease in the sample size that decreased the statistical power for these measures, which may have statistically affected the results and caused a Type II error for these outcome measures. Clinical Significance Currently there does not appear to be a post-operative RCR rehabilitation approach superior to others.32 This study explored if NMR exercises improved outcomes in the postoperative RCR population. In this study, both treatment groups demonstrated clinically meaningful change in all outcome measures. However, the magnitude of change in AROM was statistically and clinically better than the change experienced by the standard PT approach. This sample was demographically representative of the broader RCR population, so results may be generalized to this population. The NMR approach may provide the basis necessary to maximize improvement in shoulder motion after surgery. Further, there was a trend toward clinically improving results for pain as well. Future Research Authors may continue to improve defining NMR as a therapeutic exercise and how it may be effectively used in the post-operative RCR population and efficacy of NMR exercises. Physical Therapy Following Rotator Cuff Surgery 60 Laboratory research is needed using RAP, RPP, and TTDPM to determine the extent of proprioceptive deficit after RCR. This would support the relevance of NMR in this population. Further, the current study would have been ideally conducted as a prospective study. A prospective study would better control for reliability of clinically measured and self-reported outcome measures. Precision and consistency of measurement could be better controlled for in a prospective study. Further, therapists should be given standard procedures and description of exercises for interventions chosen for NMR based on the current best available evidence. Ideally, such studies would use performance based tests of neuromuscular control, such the dynamic throwing performance index or the SADS test, and proprioceptive tests such a RAP, RPP, and TTDPM, along with clinical and self-reported outcome measures. Future studies would also need to control better for payer type. Conclusion This study explored if NMR improved outcomes after RCR surgery. Results showed that the null hypothesis, which stated NMR would not affect outcomes greater than standard PT, could not be entirely rejected. While significant differences in AROM flexion change scores were discovered between treatment groups and results were clinically significantly different, there was no difference between groups at the second time period. NPRS scores showed a trend toward being clinically significantly different with superior findings for the NMR group. However, both NPRS and DASH results may have been effected by confounding variables and an underpowered sample. Randomized controlled clinical research trials with standardized measurements and control for what is used for the NMR treatment approach is needed to further explore if NMR may be used to optimize outcomes in the post-RCR population. Physical Therapy Following Rotator Cuff Surgery 61 References 1. Pabian P, Rothschild C, Schwartzberg R. Rotator cuff repair: considerations of surgical characteristics and evidence based interventions for improving muscle performance. Phys Ther Rev. 2011;16:374-387. 2. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227-233. 3. Mulligan EP, Devanna RR, Huang M, Khazzam M. Factors that impact rehabilitation strategies after rotator cuff repair. Phys Sports Med. 2012;40:102-114. 4. Reinold MM, Macrina LC, Wilk KE, Dugas JR, Cain EL, Andrews JR. The effect of neuromuscular electrical stimulation of the infraspinatus on shoulder external rotation force production after rotator cuff repair surgery. Am J Sports Med. 2008;36(12):23172321. 5. Ghodadra NS, Provencher MT, Verma NN, Wilk KE, Romeo AA. Open, mini-open, and all-arthroscopic rotator cuff repair surgery: Indications and implications for rehabilitation. J Orthop Sports Phys Ther. 2009;39(2):81-89. 6. Vo A, Zhou H, Dumont G, Fogerty S, Rosso C, Li X. Physical Therapy and Rehabilitation after Rotator Cuff Repair: A Review of Current Concepts. Int J Phys Med Rehabil. 2013;01(05):1-11. 7. Holzer N, Cunningham G, Duthon V, Graf V, Ziltener JL, Hoffmeyer P. Rehabilitation after rotator cuff repair: development and recommendations. Review Medicale Suisse. 2013;18(411):2376-2379. Physical Therapy Following Rotator Cuff Surgery 8. 62 Hayes K, Ginn KA, Walton JR, Szomor ZL, Murrell GC. A randomised clinical trial evaluating the efficacy of physiotherapy after rotator cuff repair. Aust J Physiother. 2004;50(2):77-83. 9. Cuff DJ, Santoi BG. Rehabilitation strategies after rotator cuff repair: How to optimize outcomes. Tech Should Elb Surg. 2016;17:149-152. 10. McCormick F, Wilcox RB, Alqueza A. Postoperative Rotator Cuff Repair Rehabilitation and Complication Management. Oper Tech Orthop. 2015;25(1):76-82. 11. Marzetti E, Rabini A, Piccinini G, et al. Neurocognitive therapeutic exercise improves pain and function in patients with shoulder impingement syndrome: a single blind randomized controlled clinical trial. Eur J Phys Rehabil Med 2014;50:255-264. 12. Borsa PA, Lephart SM, Kocher MS, Lephart SP. Functional assessment and rehabilitation of proprioception for glenohumeral instability. J Sport Rehabil. 1994;3:84104. 13. Meyers JB, Lephart SM. The role of the sensorimotor system in the athletic shoulder. J Athl Train. 2000;35:351-363. 14. Zech A, Hubscher M, Vogt L, Banzer W, Hansel F, Pfeifer K. Neuromuscular training for rehabilitation of sports injuries: A systematic review. Med Sci Sports Exercise. 2009;41:1831-1841. 15. Bernier JN, Perrin DH. Effect of coordination training on proprioception of the functionally unstable ankle. J Orthop Sport Phys Ther. 1998;7:264-275. 16. Cooper RL, Taylor NF, Feller JA. A randomised controlled trial of proprioceptive and balance training after surgical reconstruction of the anterior cruciate ligament. Res Sports Med. 2005;13(3):217-230. Physical Therapy Following Rotator Cuff Surgery 17. 63 Beard DJ, Dodd CF, Trundle HR, Simpson HW. Proprioception enhancement for anterior cruciate ligament deficiency. J Bone Joint Surg Br. 1994;76:654-659. 18. Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physically active individuals. Phys Ther. 200;80:128-140. 19. Carpenter JE, Blasier RB, Pellizon GG. The effects of muscle fatigue on shoulder joint position sense. Am J Sports Med. 1998;26:262-265. 20. Meyers JB, Guskiewicz KM, Schneider RA, Prentice WE. Proprioception and neuromuscular control of the shoulder after muscle fatigue. J Athl Train. 1999;34:362367. 21. Wassinger CA, Meyers JB, Gatti JM, Conley KM, Lephart SM. Proprioception and throwing accuracy in the dominant shoulder after cryotherapy. J Athl Train. 2007;42:8489. 22. Wickiewicz TL, Chen SK, Otis JC, Warren RF. Glenohumeral kinematics in a muscle fatigue model Paper presented at: Specialty Day Meeting, American Orthopaedic Society for Spors Medicine1994; New Orleans. 23. Ensor KL, Kwon YW, Dibeneditto MR, Zuckerman JD, Rokito AS. The rising incidence of rotator cuff repairs. J Shoulder Elbow Surg. 2013;22(12):1628-1632. 24. Huberty DP, Schoolfield JD, Brady PC, Vadala AP, Arrigoni P, Burkhart SS. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy. 2009;25(8):880-890. Physical Therapy Following Rotator Cuff Surgery 25. 64 Brennan GP, Parent EC, Cleland JA. Description of clinical outcomes and postoperative utilization of physical therapy services within 4 categories of shoulder surgery. J Orthop Sports Phys Ther. 2010;40(1):20-29. 26. Boissonnault WG, Badke MB, Wooden MJ, Ekedahl S, Fly K. Patient outcome following rehabilitation for rotator cuff repair surgery: the impact of selected medical comorbidities. J Orthop Sports Phys Ther. 2007;37(6):312-319. 27. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full thickness tears of the supraspinatus: does the tendon heal. J Bone Joint Surg Am. 2005;87-A:1229-1240. 28. Huisstede BM, Koes BW, Gebremariam L, Keijsers E, Verhaar JA. Current evidence for effectiveness of interventions to treat rotator cuff tears. Man Ther. 2011;16:217-230. 29. Raab MG, Rzeszutko D, O'Connor W, Greatting MD. Early results of continuous passive motion after rotator cuff repair: a prospective, randomized, blinded, controlled study. Am J Orthop. 1996;25(3):214-220. 30. Michael J, Knig D, Imhoff A, et al. Efficiancy of a postoperative treatment after rotator cuff repair with a continuous passive moion device (CPM). Z Orthop Ihre Grenzeb. 2005;2005:438-445. 31. Watson M. Major rupture of the rotator cuff. The results of surgical repair in 89 patients. J Bone Joint Surg Br. 1985;67:618-624. 32. Thomson S, Jukes C, Lewis J. Rehabilitation following surgical repair of the rotator cuff: a systematic review. Physiotherapy. 2016;102(1):20-28. 33. Speer KP, Warren RF, Horowitz L. The efficacy of cryotherapy in the post-operative shoulder. J Shoulder Elbow Surg. 1996;5:62-68. Physical Therapy Following Rotator Cuff Surgery 34. 65 Reinold M, Wilke KE, Fleisig GS, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common external rotation exercises. J Orthop Sports Phys Ther. 2004;34:385-394. 35. Townsend H, Jobe FW, Pink M, Perry J. Electromyographic analysis of glenohumeral muscles during a baseball rehabilitation program. Am J Sports Med. 1991;19:264-272. 36. Wells SN, Schilz JR, Uhl TL, Gurney AB. A literature review of the studies evaluating rotator cuff activation during early rehabilitation exercises for post-op rotator cuff repair. J Exerc Physiol. 2016;19:70-79. 37. Keener JD, Galatz LM, Stobbs-Cucchi G, Patton R, Yamaguchi K. Rehabilitation following arthroscopic rotator cuff repair: a prospective randomized trial of immobilization compared with early motion. J Bone Joint Surg Am. 2014;96(1):11-19. 38. Ginn K, Cohen M. Exercise therapy for shoulder pain aimed at restoring neuromuscular control: A randomized comparitive clinical trial. J Rehabil Med. 2005;37(4):115-122. 39. Zimny M. Mechanoreceptors in articular tissues. Am J Anat. 1988;182:16-32. 40. Wilke KE, Voight ML, Keirns MA, Gambetta V, Andrews JR, Dillman CJ. Stretch shortening drills for the upper extremities: Theory and clinical application. J Orthop Sports Phys Ther 1993;17:225-239. 41. Naughton J, Adams R, Maher C. Upper-body wobble-board training effects on the postdislocation shoulder. Phys Ther Sport. 2003;6:31-37. 42. Swanik KA, Lephart SM, Swanik CB, Lephart SP, Stone DA, Fu FH. The effects of shoulder plyometric training on proprioception and selected muscle performance characteristics. J Shoulder Elbow Surg. 2002;11(6):579-586. Physical Therapy Following Rotator Cuff Surgery 43. 66 Jerosch J, Steinbeck J, Schrder M, Westhues M. Intraoperative EMG recording in stimulation of the glenohumeral joint capsule. Unfallchir. 1995;98:580-585. 44. Zamani S, Okhovation F, Naimi S. Narrative Review. The effect of imagery exercises on activation of shoulder muscles. J Clin Physio Res. 2016;1:32-38. 45. Wilke KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J Sports Phys ther. 2006;1:16-31. 46. Davies GJ, Dickoff H. Neuromuscular testing and rehabilitation of the shoulder complex. J Orthop Sport Phys Ther. 1993;18:449-458. 47. Lephart SM, Warner JP, Borsa PA, Fu FH. Proprioception of the shoulder joint in healthy, unstable, and surgically repaired shoulders. J Shoulder Elbow Surg. 1994;3:371380. 48. Hung Y, Darling WG. Shoulder position sense during passive matching and active positioning tasks in individuals with anterior shoulder instability Phys Ther. 2012;92:563-575. 49. Smith RL, Brunolli J. Shoulder kinesthesia after anterior glenohumeral joint dislocation Phys Ther. 1989;69:106-112. 50. Zuckerman JD, Gallagher MA, Cuomo F, Rokito A. The effect of instability and subsequent anterior shoulder repair on proprioceptive ability. J Shoulder Elbow Surg. 2003;12(2):105-109. 51. Beard DJ, Kyberd PJ, Fergusson CM, Dodd CA. Proprioception after rupture of the anterior cruciate ligament: and objective indication of the need for surgery. J Bone Joint Surg Br. 1993;75-B:311-315. Physical Therapy Following Rotator Cuff Surgery 52. 67 Skinner HB, Barrack RL. Joint position sense in the normal and pathologic knee joint. J Electromyogr kinesiol. 1991;1:180-190. 53. Teyhen DS, Miller JM, Midday TR, Kane EJ. Rotator cuff fatigue and glenohumeral kinematics in participants without shoulder dysfunction. J Athl Train. 2008;43. 54. Thompson MD, Landin D, Page PA. Dynamic acromial humeral interval changes in baseball players during scaption exercises. J Shoulder Elbow Surg. 2001;20:251-258. 55. Wilke KE, Macrina LC. Rehabilitation for patients with posterior instability and multidirectional instability. Oper Tech Sports Med. 2014;22(1):108-123. 56. Dilek B, Gulbahar S, Gundogdu M, et al. Efficacy of proprioceptive exercises in patients with subacromial impingement syndrome: A single-blinded randomized controlled study. Am J Phys Med Rehabil. 2016;95(3):169-182. 57. Bae YH, Lee GC, Shin WS, Kim TH, Lee SM. Effect of motor control and strengthening exercises on pain, function, strength, and range of moion of patients with impingement syndrome. J Phys Sci. 2011;23:687-692. 58. Roy JS, Moffet H, Hebert LJ, Lirette R. Effect of motor control and strengthening exercises on shoulder function in persons with impingement syndrome: A single-subject study design. Man Ther. 2009;14(2):180-188. 59. Potach DH, Chu DA. Plyometric training. In: Essentials of Strength Training and Conditioning. 3rd ed. Champaign IL: Human Kinetics; 2008:413-427. 60. Bachasson D, Singh A, Shah SB, Lane JG, Ward SR. The role of the peripheral and central nervous systems in rotator cuff disease. J Shoulder Elbow Surg. 2015;24(8):13221335. Physical Therapy Following Rotator Cuff Surgery 61. 68 Lin CW, Delahunt E, King E. Neuromuscular training for chronic ankle instability. Phys Ther. 2012;92(8):987-991. 62. Swanik B, Lephart SM, Giannantonio FP, Fu FH. Re-establishing proprioception and neuromuscular control in teh ACL injured athlete. J Sport Rehabil. 1997;6:182-206. 63. Ageberg E, Nilsdotter A, Kosek E, Roos EM. Effects of neuromuscular training (NEMEX-TJR) on patient-reported outcomes and physical function in severe primary hip or knee osteoarthritis: a controlled before-and-after study. Bmc Musculoskel Dis. 2013;14:1-14. 64. Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: A randomized clinical trial. Phys Ther. 2007;87:737-750. 65. Mintken PE, Glynn P, Cleland JA. Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain. J Shoulder Elbow Surg. 2009;18(6):920-926. 66. Muir SW, Corea CL, Beaupre L. Evaluating change in clinical status: Reliability and measures of agreement for assessment of glenohumeral range of motion N Am J Sports Phys Ther. 2010;5:98-110. 67. Gummesson C, Atroshi I, Ekdahl C. The Disability of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:1-6. 68. Michener LA, Snyder AR, Leggin BG. Responsiveness of the numeric pain rating scale in patients with shoulder pain and the effect of surgical status J Sport Rehabil. 2011;20:115-128. Physical Therapy Following Rotator Cuff Surgery 69. 69 Rogol IM, Ernst G, Perrin DH. Open and closed kinetic chain exercises improve shoulder joint position sense equally in healthy adults. J Athl Train. 1998;33:315-318. 70. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175-191. 71. Norkin CC, White DJ. Measurement of Joint Motion: A guide to Goniometry. 2nd ed. Philadelphia, PA: F.A Davis Company; 1995. 72. Kolber MJ, Hanney WJ. The reliability and concurrent validity of shoulder mobility measurements using a digital inclinometer and goniometer: A technical report. Int J Sports Phys Ther. 2012;7:306-313. 73. Mullaney MJ, McHugh MP, Johnson CP, Tyler TF. Reliability of shoulder range of motion comparing a goniometer to a digital level. Physiother Theory Pract. 2010;26(5):327-333. 74. Lara-Munoz C, De Leon SP, Feinstein AR, Puente A, Wells CK. Comparison of three rating scales for measuring subjective phenomena in clinical research. I. Use of experimentally controlled auditory stimuli. Arch Med Res. 2004;35(1):43-48. 75. Jim J, Wright CC. The Kappa statistic in reliability studies: Use, interpretation and sample size requirements Phys Ther. 2005;85:257-268. 76. Franchignoni F, Vercelli S, Giordano A, Sartorio F, Bravini E, Ferriero G. Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH). J Orthop Sports Phys Ther. 2014;44(1):30-39. Physical Therapy Following Rotator Cuff Surgery 77. 70 Slobogean GP, Noonan VK, O'Brien PJ. The reliability and validity of the Disabilities of Arm, Shoulder, and Hand, EuroQol-5D, Health Utilities Index, and Short Form-6D outcome instruments in patients with proximal humeral fractures. J Shoulder Elbow Surg. 2010;19(3):342-348. 78. Dixon D, Johnston M, McQueen M, Court-Brown C. The Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) can measure the impairment, activity limitations and participation restriction constructs from the International Classification of Functioning, Disability and Health (ICF). BMC Musculoskelet Disord. 2008;9:1-6. 79. Groll DL, To T, Bombardier C, Wright JG. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol. 2005;58(6):595-602. 80. Hayes K, Callanan M, Walton j, Paxinos A, Murrell GA. Should instability: Management and rehabilitation. J Orthop Sports Phys Ther. 2002;32:497-509. 81. Cohen J. Quantitative methods in psychology, a power primer. Psychol Bull. 1992;112:155-159. 82. Field A. Discovering statistics using IBM SPSS statistics. 4th ed. Los Angeles, CA: SAGE Publications Ltd; 2013. 83. Romeo AA, Dang DW, Bach BR, Shott S. Repair of full thickness rotator cuff tears. Clin Orthop Relat Res. 1999;367:243-255. 84. Gagnier JJ, Allen B, Watson S, et al. Do medical comorbidities affect outcomes in patients with rotator cuff tears. Orthop J Sports Med. 2017;5(8):1-5. Physical Therapy Following Rotator Cuff Surgery 71 Table 1. Demographic descriptive data Total NMR PT PT (N = 122) (N = 61) (N = 61) N (%) N (%) N (%) 80 (65.6) 37 (60.6) 43 (70.5) 42 (34.4) 24 (39.3) 18 (29.5) Private 78 (63.9) 33 (54.0) 45 (73.7) Public 17 (13.9) 7 (11.5) 10 (16.4) Other 27 (22.1) 21 (17.2) 6 (9.8) 83 (68) 38 (62.3) 45 (73.8) 39 (32) 23 (37.8) 16 (26.2) Gender: Male Female p* .253 Payor Co-morbidity: Yes No .005 .174 Common Diagnosis Repair: RTC 75 (61.5) 41 (67.2) 34 (55.7) Repair: RTC, Type II or III 20 (16.9) 10 (16.4) 10 (16.4) .291 Physical Therapy Following Rotator Cuff Surgery Repair: Complete Rupture 72 27 (22.1) 10 (16.4) 17 (27.9) Right 76 (62.3) 37 (60.6) 45 (73.8) Left 46 (37.7) 24 (39.3) 16 (26.2) Mdn (IQR) Mdn (IQR) Surgical Side Mdn (IQR) .709 Age 58.5 (14) 55 (15) BMI 27.95 (5.8) 27.5 (6.6) 28.65 (5.7) .206 FCI 1 (1) 1 (2) 1(1) .189 Commorbidity Number 1 (3) 1 (1) 1 (1) .047 Number of visits PT/case 21 (14) 18 (14.5) 25 (12.5) .001 Number of visits total 20 (15) 16 (12.5) 25 (12.5) .001 Surgery_Evaluation 25 (30.3) 24 (31.5) 26 (29) .776 Surgery_Discharge 128 (58.5) 144 (58.5) 107 (42) < .001 98 (61) 121 (55) 86 (44) < .001 Evaluation_Discharge 60 (10.5) .035 Note. NMR = neuromuscular re-education, PT = physical therapy, IQR = interquartile range, BMI = body mass index, * p < .05. Physical Therapy Following Rotator Cuff Surgery 73 Table 2. Comparison of Outcomes Between Groups. Index Assessment NMR PT PT Mdn (IQR) Mdn (IQR) AROM 125 (50.5) NPRS DASH Discharge Assessment NMR PT PT p* Mdn (IQR) Mdn (IQR) p 130 (57) .540 160 (19) 157 (36) .177 5 (3) 4 (2) .051 3 (3) 2 (3) .861 64 (25) 64 (34) .490 21 (23.5) 22 (20.5) .478 Notes. NMR = neuromuscular re-education. IQR = interquartile range. AROM = active range of motion for flexion. DASH = Disabilities of the Arm Shoulder and Hand questionnaire. NPRS = Numerical Pain Rating Scale. *p < .05 Physical Therapy Following Rotator Cuff Surgery 74 Table 3. Comparison of Outcomes Within Groups NMR PT Index Discharge Mdn (IQR) Mdn (IQR) AROM 125 (50.5) NPRS DASH Standard PT Index Discharge p* Mdn (IQR) Mdn (IQR) p 160 (19) < .001 130 (57) 157 (36) < .001 5.0 (3.0) 3.0 (3.0) < .001 4.0 (2.0) 2.0 (3.0) < .001 64 (25) 21 (23.5) < .001 64 (34) 22 (20.5) < .001 Notes. NMR = neuromuscular re-education. IQR = interquartile range. AROM = active range of motion for flexion. DASH = Disabilities of the Arm Shoulder and Hand questionnaire. NPRS = Numerical Pain Rating Scale. *p < .05. Physical Therapy Following Rotator Cuff Surgery 75 Table 4. Comparison of Change Scores for Outcomes Between Groups. NMR PT Standard PT Mdn (IQR) Mdn (IQR) p AROM 30 (43.5) 23 (41.5) .024* NPRS 2.0 (3.0) 2.0 (3.0) .123 DASH -34.88 (22.6) -35.64 (23.6) .908 Notes. NMR = neuromuscular re-education. AROM = active range of motion. NPRS = Numeric Pain Rating Scale. DASH = Disabilities of the Arm Shoulder and Hand questionnaire. Mean and standard deviation values given. Independent t-test results. *p < .05 Physical Therapy Following Rotator Cuff Surgery Appendix A Arthritis (rheumatoid and osteoarthritis) Osteoporosis Asthma COPD, ARDS, or emphysema Angina Congestive heart failure (or heart disease) Heart attack (myocardial infarct) Neurological disease (such as multiple sclerosis or Parkinsons) Stroke or TIA Peripheral vascular disease Diabetes (types I and 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) Obesity and/or BMI >30 76 Physical Therapy Following Rotator Cuff Surgery Appendix B ICD-9-CM code: 727.61 ICD-10-CM codes: M25.511, M25.512, M75.41, M75.42, S46.011D, S46.012D, Z47.89 77 Physical Therapy Following Rotator Cuff Surgery Appendix C Current Procedural Technology (CPT) codes: 97001, 97010, 97014, 97016, 97035, 97110, 97140, 97530, 97530.59 78  ...

... Coal Railway Heavy Metal Contamination By Lauren Joyal An Honors Project submitted to the University of Indianapolis Strain Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Dr. Levi Mielke. 12th, February 2016 Approved by: __________________________________________________________________ Dr. Levi Mielke, Faculty Advisor ______________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College ______________________________________________________________________ First Reader ______________________________________________________________________ Second Reader L. Joyal ii Abstract The Harding Street Generation Station near downtown Indianapolis is a coalpowered energy plant that could have adverse effects on the surrounding air and soil resulting from coal dust and ash. In particular, properties adjacent to the plant, such as the sampling site, could be at high risk for contamination. Dr. Mielke and I had concerns about possibly dangerous levels of heavy metals such as chromium, lead, or arsenic in soil, root, and plants. To determine the levels of heavy metals, soil, root, and plant body samples were taken in transects to quantify heavy metals and determine if these could be considered toxic. Soils were expected to have higher levels of heavy metals, while the roots of the plants, as well as the bodies, were expected to absorb a portion of the heavy metals from the soil and contain them for evaluation. Transects were predicted to contain higher concentrations of metals closest to the railroad carrying coal into the power plant, decreasing in concentration with distance. Heavy metals were examined by measuring their fluorescence using microwave-plasma atomic emission spectrometry after their digestion in strong acids as per the EPA Method 3050B. The analysis demonstrated no metals exceeding regulatory limits set by the EPA. In addition, samples did not have decreasing quantities moving away from the railroad track. Although, soil presented with the largest concentration of metals, followed by roots, and lastly, plant bodies. L. Joyal iii Acknowledgment Dedicated to the University of Indianapolis and Dr. Mielke for making this project possible. In addition, thank you to Dr. Katherine Stickney for providing a sampling site, The Department of Chemistry at UIndy, as well as the Shaheen College of Arts and Sciences for use of instrumentation. Lastly, I would like to dedicate this research to the Strain Honors College for funding and support. L. Joyal iv List of Tables Table 1: Heavy Metal Regulations .........................................................................6 Table 2: MP-AES Detection Limits ......................................................................14 Table 3: Study Calculated Detection Limits .........................................................15 Table 4: Final Sample Dry Weights ......................................................................17 Table 5: Final Coal Sample Dry Weights ..............................................................17 Table 6: Acid Elemental Quantities and Averages ................................................23 Table 7: Coal and Coal Dilution Elemental Quantities and Averages ..................24 Table 8: Element Averages with Regulations ........................................................30 Table 9: Element Percentages of Samples .............................................................32 L. Joyal v List of Figures Figure 1: Linear and Nonlinear Calibration Curves ..............................................13 Figure 2: Map of Sample Site ................................................................................21 Figure 3: Ground View of Sample Site .................................................................22 Figure 4: Ground View of Power Plant ................................................................22 Figure 5: Barium Increasing Trend Graph .............................................................25 Figure 6: Zinc Decreasing Trend Graph ................................................................26 Figure 7: Aluminum No Trend Graph ...................................................................26 Figure 8: Average Manganese Quantity ................................................................27 Figure 9: Average Copper by Row and Sample ....................................................28 L. Joyal vi Table of Contents Cover Page ............................................................................................................... i Abstract .................................................................................................................. ii Acknowledgement ................................................................................................. iii List of Tables ......................................................................................................... iv List of Figures ..........................................................................................................v Statement of Purpose ...............................................................................................1 Introduction ..............................................................................................................3 Method/Procedure ..................................................................................................15 Results.. ..........................................................................................22 Analysis/Conclusion ..............................................................................................24 Reflection ...............................................................................................................33 References ..............................................................................................................35 Appendices .............................................................................................................38 Appendix A: MLA Style Guidelines .........................................................38 Appendix B: Raw Data ..............................................................................38 Appendix C: Budget ..................................................................................46 Appendix D: CITI Training .......................................................................47 L. Joyal 1 Statement of Purpose Indiana is among the top 10 coal production states in the US, making it susceptible to large amounts of pollution (Nunez). As a state invested in the burning of coal, many local railroads, such as at the railroad leading into the coal-powered Harding Street Generation Station owned by the Indianapolis Power & Light company, transport large amounts of coal in order to generate power. The power plant itself releases large amounts of chemical wastes, which in 2010 totaled 1,499,059 pounds of on-site releases (Facility Report). The majority of these releases were via the air, followed by water, and lastly by land (Detail Facility Report).The railcars that transport the coal are often uncovered and leave behind coal dust along their routes as well as whole pieces of bituminous coal. The United States Department of Labor defines coal dust as dust from the extraction or mining of coal (United States Department). Coal dust and droppings from railcars can pollute local soils and waterway systems through leaching of heavy metals. According to the EPA (Environmental Protection Agency), heavy metals are metallic elements with high atomic weights such as, mercury, chromium, cadmium, arsenic, and lead that do not decompose or bioaccumulate, which even at low levels can damage living things, causing health concerns (Glossary). Soil health is an essential component of an ecosystem. It provides nutrients for plants, which then can provide shelter for other organisms in the ecosystem. It is also a natural filter that cleans water before it enters local waterways and aquifers. If soil is contaminated with heavy metals it can inhibit plant growth within the soil, which will lead to a reduction in natural wildlife in the area. L. Joyal 2 Heavy metals present in soil can also be a risk to human health. Because of this, the EPA has set standards for heavy metal soil contaminants such as lead, mercury, and arsenic, which are common products of coal combustion. These standards pinpoint the limit of acceptable amounts of heavy metals in soil, which if exceeded, begin to cause symptoms of heavy metal exposure. The purpose of this study was to determine the amount of contamination taking place along the small section of railroad to the east of the Harding Street Generation Station in order to assess the extent of environmental damage. Figure 2 provides a photo of the section of railroad examined in this study. This study contributes to the current knowledge base on pre-combusted coal and how, or if, it leaches heavy metals into the surrounding environment. It adds to the limited amount of current research on coal dust that is emitted from railcars as they travel. Many studies investigating the contaminants produced from the combustion of coal are available; however, there is little research on the effects of coal dust originating from transportation. Also, the given effects of bituminous coal left on top of soil for an extended period have not been studied thoroughly. Coal dust and bituminous coal components were evaluated in order to assess their potential or possible current damage to the soil and plant life adjacent to the railroad tracks. My research was one of the first studies to assess the danger of transporting freshly mined coal by rail. The research conducted contributed significantly to my skillset as an environmental science major. Previously acquired skills from my chemistry and biology background were tapped so that I could gain in-field experience with experimentation. L. Joyal 3 The study facilitated my independent research, with the aid of my research advisor, Dr. Levi Mielke. It improved my research abilities and prepared me for future studies that I hope to conduct. Introduction Components of Coal Coal is a fossil fuel commonly used for energy production because of its low cost and availability. Overconsumption of coal leads to environmental damage from the mining site to the coal plant. At coal power plants, toxins, particularly heavy metals are leached into surrounding areas, polluting local air, waterways, and soil. The type of chemicals that are left behind through coal transportation and combustion are solely dependent upon the type of coal and the minerals within it. However, all coals have the same basic mineral compositions with a slight variation. Coals are mainly composed of carbon (60-95%), followed by hydrogen, oxygen, sulfur, nitrogen, organic minerals, and water (Coal). In a study by primary researcher, Liu Guijan in the Yanzhou mining district of China, samples were taken from a local mine as well as fly ash (ash less than 100 micrometers), bottom ash (ash greater than 100 micrometers from the scrubber), and raw coal from the power plant. The chemical analysis of the sources concluded that coal ash from this region is primarily composed of SiO2 and AlO2 with minor amounts of FeO2, MgO, and MnO, along with other compounds. However, it is shown that when fly ash and bottom ash are compared to raw coal, there are elevated levels of heavy metals and L. Joyal 4 harmful elements present in fly ash and bottom ash. This hints towards the redistribution of these elements during coal combustion that may cause them to concentrate in ash (Liu 363). The study shows that raw coal has trace amounts of thorium, vanadium, chlorine, arsenic, fluorine, lead, copper, and zinc (Liu 359-366). This indicates that coal has varying amounts of heavy metals along with other elements that are potentially harmful to ecosystems. It also confirms that raw coal does not have as many damaging chemicals and compounds as fly ash or bottom ash when burned as a result of the chemical structure of coal metamorphosing into a more toxic form during combustion. A similar study in which samples were taken from coal ash ponds at a coal power plant was conducted in Delhi, India. The samples were collected from fly ash produced at the plant and from groundwater near the power plant and tested for chromium, nickel, and zinc (Singh 685). The instrument used to analyze the samples, the ultraviolet visible spectrophotometer Hach Model DR 4000, was approved by the EPA for reporting purposes for chromium and zinc, but not nickel, deeming the nickel measurements not EPA approved (Hach Company). This flaw can be improved upon by utilizing different analytical methods such as my intended use of the 4200 MP-AES (created by Agilent Technologies), which is approved by the EPA for nickel analysis. However, the study indicates that there is leaching of nickel, chromium, and zinc that takes place near coal power plants. This is shown by the presence of these three elements in unusually high quantities in the groundwater adjacent to the coal plant. Elements found in coal ash can have a leaching rate of approximately 8% to 17%, leaving up to 92% of the metals remaining in the soil (Singh 687). This suggests the elements found in raw coal and coal L. Joyal 5 dust deposited by rail transportation have the potential to leach and pollute the soil near the railways on which they are transported. Although pollution rates from coal are difficult to identify, as the study mostly considered coal ash, it did find a negative correlation between particle size and elemental concentration. However, this trend is only attributed to coal remnants, not raw coal itself. The research does indicate the harmful potential of coal, but raw coal is further explored in my study Coal dust and coal ash are two very disparate entities. When coal is burned, the elements within it are chemically altered into different, more toxic chemicals that compose coal ash. This ash is seen in much higher quantities than coal dust because it is a product of coal combustion, also contributing to its harmful effects. Coal dust is simply dust that is emitted from raw coal as it is being transported. This dust has the same components as raw coal and is found in smaller quantities than coal ash. Therefore, it has not been chemically altered by the process of combustion and has a lower toxicity level than coal ash. In order to determine the harmfulness of coal, there must a safe standard put forth to compare against results. When examining metals amounts that are safe to be present in soil, there are many specific sets of regulations, considering the many uses of soil. Soil can be used industrially, meaning that its toxin levels are able to be slightly higher. It can be used for residential purposes, in which case the quantity of allowable toxins is much smaller. Or perhaps it can be used for agricultural purposes, making it report to the most restrictive regulations. Residential soil was sampled for this research, causing it be accountable to the EPAs soil regulations for residential soils. These L. Joyal 6 regulations take into consideration the possibility of the soil being ingested by a child 6 years-old or younger. In other words, the regulations are set so that the standards allow for children to ingest the soil without any health risks. There are different regulations according to state and federal law. The Indiana Department of Environmental Management (IDEM) has less severe regulations than the EPA. Table 1. EPA and IDEM regulations for metals (ppm) in residential soils Element EPA Residential Soil IDEM Residential Soil Fe 77,000 Zn 23,000 32,000 Cd 70 98 Ca 100,000 Ag 390 550 Cu 3,100 4,300 Mg Al 78,000 100,000 Mn 1,900 2,500 Pb 400 Cr 230 V 390 550 Ba 15,000 21,000 K 100,000 *Units are in ppm or mg/kg *Ca is in the form of Calcium Pyrophosphate *Potassium is in the form of Potassium Tripolyphosphate As the Table 1 demonstrates, the EPA and IDEM deem different amounts of the same metals to be dangerous and therefore do not monitor metals at the same rates. The quantity at which metals become toxic is determined by humans and therefore not concrete, causing IDEM and the EPA to state different quantities of the same metal as harmful to human health. Some particularly harmful heavy metals, such as lead, silver, and cadmium are regulated by a distinctive set of standards known as Human Health L. Joyal 7 Screening Levels (HHSL). These standards are referenced when the EPA Regional Screening Level results in a risk of cancer 4 times larger than HHSL (Gorospe). They are applicable to any type of soil, although the typical amount of each element naturally occurring in the soil is dependent upon the type of soil, regardless of its use. Impacts of Heavy Metals on Plant Growth Heavy metals that are leached from coal and its byproducts have a significantly negative impact on plant growth. When heavy metals are present in soil, plant roots have been shown to grow shorter in length. A study using the Azolla filiculoides water fern was conducted to determine the effects of heavy metals on plant growth. The ferns were dried and then stirred in a solution of 5-20 parts per million (ppm) of 5 heavy metals salts. After they absorbed the heavy metals, they were dried and placed in nitric acid in order to prepare the samples for analysis by a spectrophotometer. This experiment also investigated the heavy metal content in the plants with a spectrophotometer, specifically with the Perkin-Elmer model 2380 atomic absorption spectrophotometer. The results show that the amount of nitrogenase enzyme (crucial to nitrogen fixation) activity was drastically reduced by nickel, cadmium, and zinc. Nitrogen fixation decreased with a corresponding increase of copper. A. filiculoides ultimately was affected by heavy metals in several ways which included: loss of water, stunted growth rate, changes in color and texture, and loss of cations. These symptoms of heavy metal exposure reveal that even in heavy metal-tolerant plants (such as the water fern) biological activity suffers (Sela 7-11). The findings indicate soluble metal salts are disruptive to plant growth in a variety of L. Joyal 8 ways. However, my study analyzed only compounds found in coal, many of which are not metal salts and therefore are not as soluble. The manner in which heavy metals affect plant growth varies depending on the plant as well as the metal quantity. For example, Researcher Symenodois demonstrated that heavy metals actually affect the amount of chlorophyll in a plant. Chlorophyll is the unit in plants that captures sunlight in order to carry out photosynthesis, without which a plant cannot execute photosynthesis and will perish. The chlorophyll content in the leaves of Holcus latanus L. was observed with increasing amounts of lead and zinc. Individual plants were grown in nutrient solutions with 0.0, 3.0, 8.0, and 12.5 ppm of lead. Other plants were grown in nutrient solutions of 0.0, 9.0, 13.0, and 25.5 ppm of zinc. Conclusions established that chlorophyll decreased while lead and zinc increased. The most critical decrease of chlorophyll occurred with the first addition of lead and zinc, indicating that the initial exposure to heavy metal contaminants is the most influential to chlorophyll production. The study suggests that heavy metals may interfere with the synthesis of chlorophyll or may reduce, indirectly the chlorophyll content by inhibition of other essential micronutrients (Symeonidis 108-111). Once again, heavy metals clearly have a negative effect on the biological functions of plants. Railway Transportation Rail is often thought be a harmless means of transportation due to a focus on automobiles and their contribution to global warming through greenhouse gas emissions. L. Joyal 9 This shifts the focus away from railcars, despite their possible contribution to environmental contamination. Trains are convenient, moving massive amounts of materials across the country in a relatively short timeframe. But unfortunately, the cargo they carry causes pollution, the two most important types of which are polycyclic aromatic hydrocarbons (PAHs) and heavy metals. A study in Ilawa Glowna, Poland found increased amounts of heavy metals at sample sites near railroad tracks when soil samples were taken from four different areas. Sampling was conducted so that several samples were taken from areas between two rail ties and several were taken from areas outside of the rail ties in order to compare the two. Samples from between two tracks (the rail gauge) were expected to have higher pollution than samples from outside the tracks, and in fact, did. Inductively coupled plasma spectroscopy (ICP), the method most similar to MP-AES, was used in order to determine the amount of heavy metals in plants in the two zones mentioned above. Inductively coupled plasma spectrometer-optical emission, a form of ICP, was used for soil samples. Iron was present in the most substantial concentration, reaching up to 59,700 milligrams per kilogram (mg/kg) in one area. Overall, the lowest level of a single heavy metal deposited was molybdenum (2.00 mg/kg) and mercury (0.046 mg/kg) (Wilkomirski 333-342). Samples were also taken from different areas of the tracks which were: the loading dock, the platform, the rolling dock cleaning bay, and the siding. This enabled the researchers to study which metals occur more often in various functioning areas of the track. All four areas displayed elevated levels of heavy metals. Zinc for example, measured 60 times the control level, testifying to the tracks pollution. Knowing that railroad tracks have previously been L. Joyal 10 found to have elevated levels of heavy metals in surrounding soil, my study examined the metals analyzed in this study closely to find similar results. 4200 MP-AES Analysis My analytical methods for the coal research project included the use of the 4200 MP-AES. This instrument is new in its field and is comparable to the slightly older inductively coupled plasma atomic emission spectrometer (ICP-AES) (Vlasov 444-445). Microwave plasma spectrometers work by first introducing an aqueous sample into the instrument in an aerosol form. This requires liquids to be nebulized by nitrogen gas, which is magnetically ionized by the microwave. This is a key difference between ICP and microwave plasma atomic emissions spectrometry (MP-AES). ICP uses argon gas rather than nitrogen. Once the sample is in aerosol form, it travels to the high-temperature plasma flame where it is dried to decompose into its atomic form in a process called atomization. The atoms travel through the plasma until they absorb enough energy to create an ion (ionization) or one of their valence electrons is excited to a higher energy level. The sample then enters the interface, in which it is depressurized and the temperature is regulated to a lower temperature. These ions and excited atoms emit measurable light waves as they return to lower energy states. Here the wavelength of light is a fingerprint for the identity of the atom and the amount of light emitted is related to the concentration of the metal. The light passes through a monochromator (device that mechanically selects certain wavelengths to transmit), then is reflected onto the charge coupled device (measures electrical charges induced by light), which measures spectra L. Joyal 11 and background light simultaneously (Bazilio 2-8). In comparison with the MP-AES, ICPs are more expensive because of their high cost of plasma sources and complexity of operation (Vlasov 449). Also, ICP plasma images spread samples across a larger volume, resulting in a sensitivity decline. Lastly, the ICP plasma density is magnitudes lower than that of the microwave-plasma discharge (Vlasov 449). The innovative new technology of microwave plasma spectrometry improved my research greatly with more accurate readings of the amounts of heavy metals present in the soil, although the results of the MP-AES are still comparable with the older ICP methods. 4200 MP-AES Reliability Methods for soil analysis vary; however, with the 4200 MP-AES there are several key features that provide excellent and precise analysis of soils, one of which is its analytical calibration. Calibration of the instrument is carried out using multielement standards from Agilent Technologies. These standards are diluted to known concentrations, the results of which are used to produce calibration curves that mathematically relate the intensity of light at a given wavelength to the concentration of the metal. These readings are able to be carried out using one wavelength for a sample, without any dilutions. Calibration curve correlation coefficients for the instrument are automatically set to a tolerance of 0.999 (Lowenstern 2). With such little room for error, the instrument is extremely precise. There are two calibration curves in the software, the first of which is a rational calibration fit. This is a non-linear curve fit that allows for the extended range of one-wavelength analysis. The other option for analysis is a linear L. Joyal 12 calibration fit, which does not allow for an extended concentration range. There are two examples of these calibration fits from an experiment done by Agilent to determine the amount of metals in wastewater in Figure 1 (Hettipathirana). The fitted calibration curve shows a curved line, displaying the instruments ability to calculate for a more expansive range of data. At high concentrations fluorescence becomes nonlinear, making it very difficult to achieve a linear calibration, and proving nonlinear calibrations to be vital to data examination. L. Joyal 13 Figure 1. Agilent Technologies example of a linear curve fit versus a nonlinear curve fit of copper adapted from the Terrance source Another advantageous aspect of the 4200 MP-AES is its range of detection, yielding accurate results in samples with miniscule elemental presence. The 4200 MPAES measures elements down to parts per billion (ppb) limits of detection (LOD) with examples given in Table 2. The table is adapted from Agilents brochure for the 4200 L. Joyal 14 MP-AES that was created in order to display the improved accuracy of the 4200 MP-AES (Lower). Table 2. Agilent 4200 MP-AES LODs of elements in ppb Ca Ag Mg Mn Pb Cr K 0.50 0.50 0.12 0.25 4.40 0.50 0.65 Agilent LODs were calculated as the concentration equal to 3 times the standard deviations of blanks. The LODs shown in Table 3 were calculated in the same manner from data in the heavy metals experiment. Three times the standard deviation of a blanks intensity was divided by the slope of a linear calibration curve. When compared to Agilents LODs, our calculated LODs were lower and therefore more accurate in several cases. For example, the instrument used in my research can measure silver down to 0.04 ppb, while Agilents records show they can only detect 0.50 ppb or above. The results from my experiments calculations show a lower detection limit for lead, dropping as low as 0.05 ppb while Agilents only reach 4.40 ppb. L. Joyal 15 Table 3. Calculated LODs of analyzed elements Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba 0.0010 0.0030 0.1000 0.0100 0.0004 0.0800 0.0100 0.0070 0.0001 0.0050 0.0010 0.0010 0.0001 Table 3 showcases the instruments precision by showing its detection of elements in ppb. The ppb LODs, as well as advanced calibration of the instrument has proven the 4200 MP-AES to be an integral part of the analysis of many samples for a variety of metals. Method/Procedure I performed my project beginning in the summer of 2015 through February of 2016. To initiate the project, I surveyed the area of sampling, searching for any significant features. The area of interest is directly east of the Harding Street Generation Station, therefore implicating it had elevated amounts of metals in the soil and plants due to coal combustion. Dr. Mielke and I decided four transects would be taken along the fenced side of the yard facing the railroad. Each transect then had corresponding transects north, with each additional transect 25 feet further north than the previous. Each row was also 25 feet from the previous. The first two rows only contained three additional L. Joyal 16 transects heading north, while the third and fourth rows included a fourth additional transect heading north. We provided an extra transect to explore if heavy metal accumulation towards the far north end of the propertys fence was present. Once the distance from one transect to another was decided, the sample sites were selected by hand measurements with a tape measure. The transect numbering system is used in the demonstrative figures and tables. The first transect was closest to Division St. and labeled T1-1. The transect 25 feet north of that, forming the first column was labeled T1-2, this continues until the last transect in the column. The second column, heading east 25 feet, or right when referencing Figure 2, is T2-1, and the pattern continues. In tables, each transect is assigned a P, R, or S to identify whether it is a plant, root, or soil sample. Samples were then collected from each transects position. Samples were taken with a prewashed plastic shovel to avoid any possible metal contamination. Each soil sample was approximately 3 inches in depth, with any plants other than grass on the top portion of the soil being bagged and labeled as well as all roots deeper than two inches being kept intact and bagged. Any excessive soil from the plant roots was shaken off and left at the sample site. The plant and root samples were separated from one another in the lab rather than in the field. Along with plant and soil samples, pieces of bituminous coal were collected from the property from atop the soil. Once collection was completed, the samples were moved to the lab where the plant and root samples were separated with a plastic knife. Each sample was then placed in its own weigh boat and given a wet weight using an analytical balance. To dry the samples, they were placed in a dry oven at approximately 25C for two days. Once dry, L. Joyal 17 each sample was reweighed and its mass recorded. It should be noted that root samples had an extensive variation of dry weight, as some sample sites did not have a notable presence of plants other than grass. However, in the data analysis, heavy metal concentrations were converted to milligrams of metal per dry weight gram of sample for consistency. All soil samples had a much larger dry weight than the one gram recommended by EPA Method 3050B for acid digestion of sediments, sludges, and soils. In reaction to this, any samples that were significantly higher than the one recommended gram dry weight were proportioned to approximately one gram, ready for digestion. All dry sample weights can be found in Table 4 below. Table 4. Final dry weight of samples before digestion (grams) Table 5. Final dry weight of coal samples before digestion (grams). Coal dilution dry weights are calculated from original coal dry weight Dry, appropriately weighed samples were then digested according to EPA Method 3050B. This method begins with placing the sample in 10 ml of 1:1 nitric acid and heating for 10 to 15 minutes, then placing 5 ml of pure nitric acid in the container and heating again. Brown fumes are typically generated, requiring an additional 5 ml to be continuously added and refluxed for 30 minutes until brown fumes cease. Using a ribbed watch glass, the solution was then heated until it was approximately 5 ml, or until 2 hours had passed. The sample was allowed to cool, then 2 ml of water and 3 ml of 30% L. Joyal 18 hydrogen peroxide were added. The solution was reheated, without boiling. If the sample effervesced, 1 ml aliquots of hydrogen peroxide were added until the effervescence ceased, or until 10 ml of hydrogen peroxide had been added. Afterwards, 10 ml of hydrochloric acid was added and refluxed for 15 minutes. The sample cooled and was filtered with filter paper into the desired container for analysis. Lastly, the sample was diluted to 50 ml with nano pure water. All glassware used in the research was first acid washed with a 1:10 solution of aqua regia to eliminate any trace metals remaining from previous use. When digestion was complete, the samples were allowed to cool and then diluted to 50 ml with nano pure filtered water. All samples were stored in a refrigerator until their analysis. Prior to any sample analysis, standards for the elements in question had to be created. The elements that were examined were selenium, mercury, arsenic, iron, zinc, cadmium, uranium, calcium, silver, copper, cobalt, magnesium, aluminum, manganese, lead, chromium, vanadium, barium, sodium, and potassium. To make standards to run with these samples, standards were purchased from Agilent Technologies. The elements to be studied were determined by running a coal sample as well as a 1:10 dilution of a coal sample. Whichever elements were deemed to be present and of interest were put on a list of elements to be examined with all other samples. Standards for each element were made of 5, 10, and 15 ppm by taking 3, 2, and 1 ml increments of the Calibration Mix Majors standard solution containing iron, calcium, magnesium, sodium, and potassium and diluting them to 100 ml with nano pure water. The Calibrations Mix Majors 2 standard solution contained the rest of the elements tested and had 10, 5, and 2 ml L. Joyal 19 increments diluted to 100 ml with nano pure water. Standards were run at the beginning of every sample sequence. We attempt to run all sample types together to ensure that all plant, root, and soil samples were tested with the same instrument conditions. Unfortunately, this was not entirely possible due to the instruments use of compressed nitrogen and air tanks that did extinguish during several test sequences. Before every sample run the instruments housing torch was examined for cloudy spots, and in the one instance it did present with a cloudy spot (indicating residual metals) the torch was placed into an aqua regia bath for 24 hours before use. After the torch was checked, the air tank pressure lines were adjusted to approximately 80 psi, if not already there. When the instrument was initially turned on, the gas lines were typically purged 4 times before operation could proceed. For each sample run, the instrument was properly prepared for samples by first running nano pure water (<18 Mega Ohms resistivity) through the tubing while the torch activated for 10 minutes. The instrument was then calibrated using a test solution as well as tested for LODs. After all operational tests were passed, each sample sequence began with all of the standards, followed by samples and periodic blanks of nano pure water. Blanks were run after about every 5 samples to check for residual elements from samples presenting themselves in the water as well as to purge the torch of residual elements, specifically those found in extremely high concentrations such as iron and calcium. Every sequence run terminated with a blank as well. All plant, root, and soil samples were run and analyzed as well as coal samples and acid solutions samples. Acid solutions samples were evaluated to determine which elements were present in the digestion solutions of the EPA L. Joyal 20 3050B Method alone, so that they may be negated in the final analysis. These solutions were simply the nitric and hydrochloric acids as well as hydrogen peroxide used to digest samples. During sample runs, each sample was shaken several times before being introduced to the instrument to create an even distribution of elements in the solution. In addition to this, each sample was run through the instrument for approximately 2 minutes before being quantified to enable the liquid from the current solution to displace the liquid of the previous solution in the torch chamber before assessment. This process provides accurate results with little to no carryover of samples. Once all samples were tested, the results were adjusted, requiring error coefficients to be adjusted from 5% to 25% which typically occurred for selenium, calcium, and potassium. Upon completion of the sample sequence, the data was converted into excel worksheets for further exploration. The data in the excel worksheets was originally in ppm and needed to be converted to mass of element per mass of sample. This was achieved through the formula 1000 50 .The results were used to subtract any elements found in the acid digestion. The two acid digestion blank results were averaged for each element and the average subtracted from every sample. This negates any elements added to the samples through the acids used to digest them. In total, the data was converted to milligrams of element/ kilogram of sample. The average concentration of each element present in the acid digestion was subtracted for every sample involving that element. In order to analyze data, the transects were approached in rows and columns. The same elements from different transects were always grouped together throughout this process. L. Joyal 21 The columns were the same transect, the 3 or 4 different sample sites of each. This explanation is better seen in Figure 2 below in which all transects, rows, and columns are labeled. The columns run along Division Street, while the rows are the first samples of all four transects, paralleling Hanna Street and the railroad line just outside of the sample site. In addition, Figures 3 and 4 show the ground view of the property and Harding St. Generation Station. Figure 2. Google earth map of sample site with transects, rows, and columns labeled. Division St. runs north-south on the west edge of the property and the railroad runs eastwest on south end of the property L. Joyal 22 Figure 3. Google earth ground view, looking northeast from Division St at railroad and sampling site property Figure 4. Google earth view of Harding St. Generation Station from Division St. Results Tables of the results are given below. Each tables data has already been converted to mg of element per kg of sample to allow for accurate analysis. No two samples had the same dry weight and therefore mg of element per gram of sample L. Joyal 23 provides a standard analysis in which all data is consistent. All values that are shown as #### indicate that the concentration of the element was too large for the 4200 MP-AES to quantify. In addition, some elements had to be removed from the results. The removed elements were not able to be analyzed due to wavelength interference, causing inaccurate results, or the instruments inability to calibrate for the element. Iron was present in enormous quantities and caused wavelength interferences in several elements, particularly mercury and arsenic. Selenium, however, was removed due to the lack of a standard and low raw intensity. Without a standard the results were not reliable. The standard for sodium would not calibrate, likely due to instrument error, as all the other elements from the same standard solution calibrated very well. Table 6. Acid samples and acid averages in ppm Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K Acid 1 BLOD 0.14 0.04 0.17 0.01 BLOD 0.00 0.01 0.08 0.17 0.06 0.02 BLOD 0.01 Acid 2 1.44 0.19 0.17 0.2 0.00 BLOD 0.02 0.01 0.07 0.14 0.05 0.02 BLOD 0.01 Acid Avg 1.44 0.165 0.105 0.185 0.005 N/A 0.01 0.01 0.075 0.155 0.055 0.02 N/A 0.01 *Uncal indicates instrument did not find calibration curve for element and cannot quantify it *BLOD signifies below detection limit of instrument *N/A indicates average not found L. Joyal 24 Data from Table 6 was subtracted from every sample in order to assure the results only displayed what was present in the samples and not what was present in the acid digestion mix. The data in Table 7 confirms that the coal being mined and transported to the Harding St. Generation Station contains all of the elements selected for analysis and all elements in Table 7 were therefore analyzed in the conclusion. All results from the 4200 MP-AES can be found in Appendix B. Table 7. Coal and coal dilution mg of element/gram of coal with averages of coal and coal dilution samples. Elements not analyzed were removed Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K Coal 1 Coal 2 Coal 3 Avg Coal Coal Dil 1 Coal Dil 2 Coal dil 3 Avg Dil 4.301 3.433 4.623 4.119 0.456 0.371 0.582 0.470 0.010 0.007 0.003 0.007 BDL BDL BDL N/A 0.036 0.010 0.035 0.027 0.001 BDL BDL 0.001 0.464 0.619 0.285 0.456 0.011 0.019 0.001 0.010 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.015 0.033 0.008 0.019 0.002 0.003 0.001 0.002 BDL 0.578 BDL 0.578 BDL 0.046 BDL 0.046 0.352 1.956 0.243 0.850 0.034 0.205 0.041 0.093 0.003 0.020 0.001 0.008 BDL 0.001 0.000 0.000 0.077 0.017 0.004 0.032 0.010 0.004 0.003 0.006 0.001 0.003 BDL 0.002 BDL BDL BDL N/A 0.005 0.013 0.003 0.007 0.001 0.001 0.001 0.001 0.005 0.027 0.002 0.011 0.000 0.002 0.000 0.001 0.282 0.924 0.015 0.407 0.016 0.102 0.001 0.040 *Coal 1, 2, and 3 are all separate coal samples. Coal dilutions 1, 2, and 3 are all 1:10 dilutions of the corresponding coal samples. Analysis/Conclusion To begin, samples were examined in transects in order to determine if heavy metals decreased as they moved further away from the railroad track. This was an expected result, as the samples move further away from the tracks, there should be a L. Joyal 25 lower quantity of heavy metals from coal dust. Due to its proximity, heavy metals are less likely to reach the more distal sample sites. In a general consensus, the opposite appeared to be true. When examining the transects, there are 32 separate column transects to analyze due to each column having 3 types of samples. Each row sample type also has 13 elements that were tested. However, silver, for the roots and calcium, for the plants were not examined due to lack of calibration. This leaves 148 separate transects that could possibly decrease as they go north, away from the railroad. Of the 148 possible transects, 34 increased as they progressed north. Eleven of the transects decreased, leaving 103 with no particular pattern. There are examples of each trend given below in Figures 5, 6, and 7. Barium g/g Barium in Column 1 Soil 0.105 0.100 0.095 0.090 0.085 0.080 0.075 T1-1S T1-2S T1-3S Sample Site Figure 5. Barium in soil column 1 in mg/g showing general increasing trend L. Joyal 26 Zinc in Root Column 2 0.200 Zinc g/g 0.150 0.100 0.050 0.000 T2-1R T2-2R T2-3R Sample Site Figure 6. Zinc in root column 2 in m/g, showing general decreasing trend Aluminum in Plant Column 1 Aluminum g/g 0.850 0.800 0.750 0.700 0.650 0.600 T1-1P T1-2P T1-3P Sample Site Figure 7. Aluminum in plant column 1 (mg/g) displaying no general trend Overall, only 7.4% progressively decreased leaving the railroad and 23.0% increased. The large majority, 69.6%, had no pattern. The bulk of the samples that escalated with distance from the railroad were soil samples, with 16 examples, followed by roots with 12, and plants with 10. This could be due to the plants abilities to absorb nutrients. Or. the density and type of plants at the sample site could attribute to this. Not all nutrients present in the soil are absorbed in the roots and plant body at the same rate, which would cause an uneven distribution pattern. L. Joyal 27 This phenomenon could be incited by the closeness of the sample sites to the actual power plant. The proximity could allow for contaminants from the scrubber to be released and settle into the soil in the yard, causing a random interference in the transects. Both forces, the railroad and the power plant, working in collaboration would produce a random pattern of metals in the samples. Further investigation of the samples demonstrated there was a trend in the elements with the three sample types. When the average quantity of each element was established, it was apparent that typically the largest quantity of an element was present in the soil, then the root, and lastly, the plant body. An example of this is given below with manganese in Figure 8. Only 11 elements were eligible for this analysis, and out of these seven showed a clear trend of increasing quantities from plant to root to soil. Figure 8. Average of manganese for plant, root, and soil samples This trend continued when samples were broken down into rows. Although, sample TR1-1 appeared to have unusually inflated measures of metals, causing the overall trend to be broken by row 1. A visual of this is shown below, in Table 9, as the L. Joyal 28 root of row 1 spikes, destroying the overall trend. This graph is representative of all graphs when comparing the abundance of metals in each sample type. There is no correlation between the trends of the transects and the other sample types of that transect. Figure 9. Average copper in mg/g of each row The final work conducted was a health hazard check utilizing EPA regulations for residential soils. However, the EPA has different regulations than the state of Indiana. In the case that both have standards for the same element, the EPA standard was applied. However, if there was an HHSL quantity given, this regulation was abided by in spite of other regulations. In regards to the EPA regulations for all metals, none were broken. In order to reveal this, the average for each element was calculated for the three different sample types. This chart can be found in Appendix B, Table B16. An overall average for every element was also calculated and none were noted to be hazardous to human health. In L. Joyal 29 fact, no regulations were surpassed for any elements. This was an unexpected result, as sitting within a mile of the Harding St. Generation Station, the soil, at minimum, was thought to be contaminated. Not only were the regulations not exceeded, but the samples had drastically lower concentrations than the regulations allowed. For example, zinc, which can be present up to 23,000 ppm without posing a threat to a child 6 or under ingesting it, averaged 10.7 ppm. This is several orders of magnitude lower than the health risk for children. Other elements were closer to the health hazard amount, for instance lead. Lead was averaged at 36.89 ppm overall, while the HHSL is 400 ppm. While this is only 9.22% of the 400 ppm, it has a much higher percentage in comparison to aluminum which only consist of 0.047% of the health hazard quantity. Table 8 displays the final averages of all transects for each element, converted into ppm so that they can be compared to governmental regulations. Manganese is the closest to threatening regulation standards composing 20.34% of the regulation, although this is a typical element of soil in this region and therefore may be attributed to this. L. Joyal 30 Table 8. Overall average of each element in ppm, compared to governmental regulations Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K Overall Average 5098 106.9 -39.87 5176 0.2990 23.53 1671 3206 386.4 36.88 -2.087 11.21 54.51 6099 Percent of EPA Residential Soil IDEM Residential Soil HHSL Regulation 77,000 6.62 23,000 32,000 0.33 70 98 1.7 N/A 100,000 5.18 390 550 380 0.08 3,100 4,300 0.76 N/A 78,000 100,000 4.11 1,900 2,500 20.34 400 9.22 230 N/A 390 550 2.87 15,000 21,000 0.36 100,000 6.10 *The symbol indicates no regulations are provided *N/A indicates no calculations could be made Although large infractions upon the regulations were not anticipated, some elements were expected to approach or perhaps surpass regulatory standards. The soil may not have been as contaminated as predicted due in part to the site it occupies. The field in which samples were taken has residential horses, eating some of the vegetation, perhaps ingesting some of the metals into their bodies. Another explanation could be possible wind patterns. The wind may not carry any coal ash or coal dust to the property where the samples were collected, but blow them in other directions. Pollution can also be evaluated by inspecting the components of coal and their corresponding presence in the samples. Table 9 exhibits the calculated percentages of available elements. The averages of all plant, soil, and root samples for each element were used to gauge what percentage each element comprises of the sample total. It should L. Joyal 31 be noted that potassium is as high as 66.85% in the root samples. Although it is helpful to analyze the components of each sample type to determine if they correspond with raw coal samples, it should be noted that potassium is a natural element in soil. It usually is found in high quantities due to plants nutritional needs. Other elements, specifically calcium, magnesium, and iron are fairly abundant naturally and cannot easily be contributed to coal dust pollution. However, upon examination many of the elements are in similar proportions to those in coal. Iron, the largest concentrated element in coal, is 42.92% of the soil samples and 23.29% overall. Some elements, considerably lead, which is an element of high concern given its potential for adverse human health impacts, could possibly be attributed to the coal dust blown in from the plant. At 0.53% of coal composition, it is not a sizable percentage. However, there is about 1/3rd as much lead present in the overall samples as there is in coal. Further inquiry would be needed to prove a correlation, but there is a possible connection. The same could said for copper, as this is not a commonly occurring element such as calcium or potassium, and can be sourced more easily. L. Joyal 32 Table 9. Calculated percentages of each analyzed element in coal, plant, root, soil, and overall average Element % of Coal % of Plant % of Root % of Soil % Overall Fe 67.27 9.77 15.62 42.92 23.29 Zn 0.11 0.59 0.54 0.49 0.49 Cd 0.44 Ca 7.45 23.70 16.23 23.65 Ag 0.00 0.00 0.00 Cu 0.30 0.11 0.10 0.13 0.11 Mg 2.92 13.68 7.59 6.97 7.63 Al 13.89 7.77 11.59 24.26 14.65 Mn 0.13 0.90 1.33 3.02 1.77 Pb 0.53 0.10 0.15 0.26 0.17 Cr 0.01 0.07 0.08 V 0.11 0.02 0.03 0.10 0.05 Ba 0.19 0.21 0.21 0.36 0.25 K 6.65 66.85 39.14 5.19 27.86 The research produced an unforeseen result, exhibiting no contamination levels above regulatory limits for any of the governmental agencies. This is a positive finding for the neighborhood the samples were taken from as well as the owner of the sample site. However, this study does not confirm there is not contamination surrounding the Harding St. Generation Station. Further studies, spanning more acreage and perhaps larger sample ranges, such as volatile organic compounds, may give more concrete evidence of pollution. A future study would need several control soils to examine the typical amounts of heavy metals in the Indianapolis area that are comparable to the findings from the samples near the plant. Although the samples were not found to be toxic, there was a correlation between the quantities of metals in the plant, root, and soil samples. It was hypothesized that soil samples would have the highest concentrations of metals, as soils are the first subject to L. Joyal 33 anything in the environment. Plants then absorb many elements, particularly potassium, magnesium, and calcium into their roots, causing the roots to have the second highest concentration of metals. Lastly, the plant bodies contained the lowest concentration of elements, as was anticipated. Roots absorb the first of the metals out of the soil and then distribute them to the plant body. This was likely to dilute the metals concentrations. However, in the future it would favorable to gather identical kinds of plant to examine for plant testing. Options for this study were limited to whichever plants were on the sample site, which did vary slightly. Similar studies need to be conducted in order to confirm results from this research. Perhaps groundwater could be inspected as well. There are many different outlets for pollution, making it difficult to pinpoint sources and concentrations. Reflection Through my research, I have come to understand a great deal more about the 4200 MP-AES instrument. I feel my abilities in running the instrument have improved significantly. I now understand how the instrument works and also how incredibly sensitive it can be. The 4200 MP-AES has taught me patience as well as given me a thirst to learn more about such a precise measurement technique. Although, the scientific process has always seemed somewhat vague and not particularly important to me, I now understand the importance of creating a hypothesis and researching the idea. Without my research, I never would have fully understood the 4200 MP-AES or how coal combustion affects the surrounding environment. The L. Joyal 34 scientific process also seems vital when looking back at the original question and hypothesis. My project had a massive amount of data that could be presented in many different ways. I now understand how to hone in on my exact question and analyze my data accordingly. Through the process of research, I realized there are hundreds of ways to do any experiment and the way you choose to do your experiment should be directly dependent on what it is you are trying to understand. There are also hundreds of sources you can utilize for a project. I learned to focus on research relevant to my own and even improve upon the previous research. This is particularly true when I was reading the Liu Guijan research on coal ash. The experiment used an instrument that was not approved by the EPA to measure nickel concentrations. In reading this, I was sure to use elements that had approved testing standards. From beginning to end, my honors project has given me a greater sense of confidence. Although my results did not turn out as I expected, I already know what I would do differently in the future to improve upon the project. I now have ingrained in me a sense of accomplishment and eagerness for more research to come. L. Joyal 35 References Brazilio, A., & Weinrich, J. (2012). Easy Guide to: Inductively Coupled Plasma Mass Spectrometry (ICP-MS). Retrieved March 3, 2011 from http://www.ecs.umass.edu/eve/facilities/equipment/ICPMS/ICPMS%20quick%20 guide.pdf Coal. (n.d.). Retrieved March 10, 2015, from http://www.ems.psu.edu/~radovic/Chapter7.pdf Environmental Protection Agency. (2014). Coal Ash, Bottom Ash, and Boiler Slag. Retrieved March, 10 2015 from, http://www.epa.gov/radiation/tenorm/coalandcoalash.html Environmental Protection Agency. (2014). Detailed Facility Report (FRS identification No. 110000396991). Retrieved from http://echo.epa.gov/detailed-facilityreport?redirect=page&fid=110000396991 Environmental Protection Agency. (2014). Facility Profile Report. Retrieved from http://iaspub.epa.gov/triexplorer/release_fac_profile?TRI=46217NDNPL3700S& year=2010&trilib=TRIQ1&FLD=&FLD=RELLBY&FLD=TSFDSP&OFFDISP D=&OTHDISPD=&ONDISPD=&OTHOFFD= Environmental Protection Agency. (1996). Microwave Assisted Acid Digestion of Siliceous and Organically Based Matrices. Retrieved from http://www.epa.gov/osw/hazard/testmethods/sw846/pdfs/3052.pdf Gorospe, Jennifer. "Heavy Metals and Gardens." Heavy Metals and Gardens. San Jos State University, n.d. Web. Gremion, F., Chatzinotas, A., Kaufmann, K., von Sigler, W., & Harms, H. (2004), Impacts of heavy metal contamination and phytoremediation on a microbial community during a twelve-month microcosm experiment. FEMS Microbiology Ecology, 48: 273283. doi: 10.1016/j.femsec.2004.02.004 Hach Company. DR/4000 UV-VIS Spectrophotometer. Retrieved from www.hach.com/asset-get.download.jsa?id=7639984462 IPL-Harding Street Station Map. Google Maps. Google, 2016. Web. 29 January 2016. "Land Quality in Indiana." : IDEM Screening and Closure Level Tables. IDEM, 2015. Web. 07 Feb. 2016. Liu, G., Peng, Z., Yang, P., Gui, H., & Wang, G. (2001). Characteristics of Coal Ashes in Yanzhou Mining District and Distribution of Trace Elements in Them. Chinese L. Joyal 36 Journal of Geochemistry, 20(4), 357. Retrieved From Academic Search Complete Premier,EBSCO. Retrieved from http://search.ebscohost.com Lowenstern, Phil, and Elizabeth Resiman. PDF. N.p.: Agilent Technologies, 2011. Lower Operating Costs, Safer Operation, More Productive. Agilent 4200 MP-AES. N.p.: n.p., n.d. Agilent.com. Agilent Technologies. Web."OEHHA Risk Assessment Soil-Screening Numbers." OEHHA Risk Assessment - Soil-Screening Numbers. OEHHA, n.d. Web. 07 Feb. 2016. Nunez, Christina. "See Which States Use Coal the Most as New Climate Rule Is Finalized." National Geographic 11 Aug. 2015. Print. Preface: The Importance Soil Organic Matter (n.d.). Retrieved from http://www.fao.org/docrep/009/a0100e/a0100e02.htm "Risk-Based Screening Table - Generic Tables." EPA. Environmental Protection Agency, n.d. Web. 07 Feb. 2016. "Safe Levels - Heavy Metals and Gardens." Safe Levels - Heavy Metals and Gardens. EPA, 2009. Web. 07 Feb. 2016. Sela, M., Garty, J. & Tel-or, E. (1989). The accumulation and the effect of heavy metals on the water fern Azolla filiculoides. New Phytologist, 112: 712. doi: 10.1111/j.1469-8137.1989.tb00302.x Singh, R., Singh, R.K., Gupta, R.C. & Guha, B.K. (2010). Assessment of Heavy Metals in Fly Ash and Groundwater-A Case Study of NTPC Badarpur Thermal Power Plant, Delhi, India. EM International, 29(4): 685-689. Retrieved from Research Gate. Retrieved from http://www.researchgate.net/publication Symeonidis, L., & Karataglis, S. (1992), The Effect of Lead and Zinc on Plant Growth and Chlorophyll Content of Holcus lanatus L. Journal of Agronomy and Crop Science, 168: 108112. doi: 10.1111/j.1439-037X.1992.tb00986. Terrance Hettipathirana, Terrance. "Determination of Metals in Industrial Wastewaters by Microwave ..." Envirotech Online. Agilent Technologies, n.d. Web. 04 Feb. 2016. United States Department of Labor. Part I Definition. Washington, D.C.: United Sates Department of Labor. Retrieved from http://www.dol.gov/brb/References/reference_works/bla/bldesk/BD02-A2.pdf United States Environmental Protection Agency. Glossary. (2012). Retrieved from http://water.epa.gov/drink/info/well/glossary.cfm Vlasov, D. V., Sergechev, K. F., & Sychev, I. A. (2002). Microwave Plasma Torch for Analytical Spectrometry. Plasma Physics Reports, 28(5), 444 Retrieved from Academic Search Premier. Retrieved from http://www.search.ebscohost.com L. Joyal 37 Wikomirski, B., Sudnik-Wjcikowska, B., Galera, H., Wierzbicka, M., & Malawska, M. (2011). Railway transportation as a serious source of organic and inorganic pollution. Water, Air, and Soil Pollution, 218(1-4), 333345. doi:10.1007/s11270010-0645-0 3535 Division St Indianapolis, IN 46227 Map. Google Maps. Google, 2016. Web. 29 January 2016. 3535 Division St Indianapolis, IN 46227 Map. Google Earth. Google, September 2011. Web. 29 January 2016. L. Joyal 38 Appendices Appendix A: Style Guidelines MLA format was used in the creation of this research. To access MLA style guidelines go to the website providedhttps://owl.english.purdue.edu/owl/resource/747/01/. Purdue Owl is a widely known and accepted style guideline for all styles of writing and was referenced frequently throughout this project. Appendix B: Raw Data in mg/g from 4200 MP-AES Analysis All data was provided by the MP-AES software. Every element that was not suitable for analysis were removed from the tables. Raw data was in ppm, however, to be consistent, all numbers were converted to mg/g due to the different original dry weights of samples. After this, the quantities of elements were calculated by subtracting the average of the two acid samples from each and every sample. The following tables are in the resulting form. Tables often present with ####, signifying the quantity of the element was too large to be quantified with the given calibrations. BLOD signifies below detection limit, meaning the element was in such small quantities the instrument could not measure it. N/A indicates the quantity could not be calculated due to a lack of data. In addition, samples T3-3P and T4-1R were not run due to human error and after discovery were not able to be run because of instrument dysfunction. L. Joyal 39 Table B1. Plant samples mg/g with averages for column 1 and 2 Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K T1-1P T1-2P T1-3P Average T2-1P T2-2P T2-3P Average 0.906 1.132 0.881 0.973 0.454 0.485 1.893 0.944 0.103 0.036 0.052 0.064 0.057 0.025 0.036 0.039 0.005 0.004 0.001 0.003 BDL BDL BDL N/A #### #### #### #### #### #### #### #### 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.013 0.014 0.017 0.015 0.011 0.008 0.015 0.011 1.259 1.338 1.468 1.355 0.811 0.904 1.667 1.128 0.737 0.803 0.682 0.741 0.287 0.345 1.334 0.655 0.092 0.096 0.079 0.089 0.055 0.053 0.158 0.089 0.010 0.013 0.009 0.011 0.007 0.007 0.018 0.011 BDL BDL BDL N/A BDL BDL 0.001 0.001 0.002 0.002 0.002 0.002 0.001 0.001 0.004 0.002 0.026 0.018 0.037 0.027 0.020 0.014 0.021 0.018 #### #### #### N/A 10.164 8.812 6.917 8.631 Table B2. Plant samples mg/g and averages of column 1 and 2 Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K T3-1P T3-2P T3-3P 0.342 0.104 0.096 0.004 BDL BDL #### #### 0.000 0.000 0.005 0.002 0.720 0.333 0.263 0.232 0.046 0.009 0.005 0.002 BDL BDL 0.001 0.000 0.019 0.004 7.309 2.538 T3-4P Average T4-1P T4-2P T4-3P T4-4P Average 0.261 0.236 2.758 1.493 1.579 0.213 1.511 0.023 0.041 0.195 0.056 0.047 0.012 0.077 BDL N/A 0.002 BDL BDL BDL 0.002 3.915 N/A 1.821 3.766 9.870 1.406 4.216 0.000 0.000 0.001 0.000 0.000 0.000 0.000 0.007 0.005 0.012 0.013 0.014 0.005 0.011 1.380 0.811 0.835 3.157 2.493 0.862 1.837 0.204 0.233 2.366 1.268 1.322 0.176 1.283 0.032 0.029 0.229 0.131 0.139 0.029 0.132 0.005 0.004 0.013 0.010 0.017 0.003 0.011 BDL N/A BDL BDL 0.000 BDL 0.000 0.001 0.000 0.006 0.004 0.004 0.000 0.004 0.005 0.009 0.030 0.027 0.030 0.010 0.024 #### 4.923 2.802 18.247 16.005 9.049 11.526 L. Joyal 40 Table B3. Root samples mg/g and averages of column 1 and 2 Element T1-1R T1-2R T1-3R Average T2-1R T2-2R T2-3R Average Fe 24.504 1.015 1.202 8.907 3.683 4.575 2.572 3.610 Zn 1.185 0.038 0.028 0.417 0.159 0.132 0.062 0.118 Cd 0.057 BDL 0.000 0.029 BDL BDL BDL N/A Ca 29.071 4.615 7.565 13.750 2.374 5.141 6.776 4.764 Ag BDL uncal uncal N/A uncal uncal uncal N/A Cu 0.125 0.017 0.010 0.051 0.029 0.030 0.023 0.027 Mg 9.348 1.328 1.421 4.032 1.346 1.636 2.634 1.872 Al 15.966 0.890 0.857 5.904 2.873 3.534 2.179 2.862 Mn 2.140 0.089 0.086 0.772 0.286 0.372 0.225 0.294 Pb 0.172 0.015 0.011 0.066 0.025 0.038 0.027 0.030 Cr BDL BDL BDL N/A BDL 0.008 0.001 0.005 V 0.042 0.001 0.002 0.015 0.005 0.010 0.006 0.007 Ba 0.324 0.022 0.027 0.124 0.045 0.059 0.037 0.047 K 52.662 12.210 7.715 24.195 14.984 7.151 8.270 10.135 Table B4. Root samples mg/g and averages of column 3 and 4 Element T3-1R T3-2R T3-3R T3-4R Average T4-1R T4-2R T4-3R T4-4R Average Fe 12.834 0.368 1.102 2.009 4.078 BDL 0.430 2.228 1.588 1.415 Zn 0.373 0.012 0.066 0.157 0.152 BDL 0.018 0.088 0.060 0.055 Cd BDL BDL 0.000 BDL 0.000 BDL BDL BDL BDL N/A Ca 15.041 3.381 1.154 4.469 6.011 BDL 2.400 5.270 1.819 3.163 Ag uncal uncal uncal uncal N/A BDL uncal uncal uncal N/A Cu 0.089 0.007 0.013 0.021 0.033 BDL 0.009 0.025 0.010 0.015 Mg 4.660 0.902 0.478 1.450 1.872 BDL 0.596 1.416 0.852 0.955 Al 10.328 0.298 0.657 1.773 3.264 BDL 0.292 1.944 1.038 1.091 Mn 1.044 0.037 0.094 0.151 0.331 BDL 0.040 0.187 0.114 0.114 Pb 0.107 0.005 0.013 0.012 0.034 BDL 0.005 0.026 0.008 0.013 Cr 0.020 0.000 0.001 BDL 0.007 BDL 0.000 BDL BDL 0.000 V 0.030 0.001 0.002 0.006 0.010 0.000 0.001 0.005 0.003 0.002 Ba 0.174 0.014 0.015 0.020 0.056 BDL 0.015 0.037 0.016 0.022 K 10.203 2.916 2.141 6.712 5.493 BDL 2.348 8.022 4.523 4.965 L. Joyal 41 Table B5. Soil samples mg/g and averages of column 1 and 2 Element T1-1S T1-2S T1-3S Average T2-1S T2-2S T2-3S Average Fe 11.232 11.284 10.927 11.148 9.663 11.526 9.867 10.352 Zn 0.099 0.142 0.145 0.129 0.083 0.169 0.131 0.128 Cd BDL BDL BDL N/A BDL BDL BDL N/A Ca 2.911 3.198 6.166 4.092 1.941 3.546 6.566 4.018 Ag 0.000 0.001 0.001 0.001 0.000 0.002 0.001 0.001 Cu 0.025 0.043 0.040 0.036 0.022 0.048 0.040 0.037 Mg 1.412 1.535 2.110 1.686 1.255 1.684 1.953 1.631 Al BDL 7.336 7.678 7.507 7.043 BDL 7.084 7.063 Mn 0.860 0.759 0.721 0.780 0.788 0.798 0.755 0.780 Pb 0.046 0.081 0.074 0.067 0.049 0.092 0.081 0.074 Cr 0.014 0.024 0.020 0.019 0.013 0.030 0.021 0.021 V 0.027 0.023 0.025 0.025 0.021 0.029 0.022 0.024 Ba 0.086 0.097 0.100 0.094 0.072 0.122 0.096 0.096 K 1.629 1.295 1.508 1.477 1.178 1.344 0.977 1.166 Table B6. Soil samples mg/g and averages of column 3 and 4 Element T3-1S T3-2S T3-3S T3-4S Average T4-1S T4-2S T4-3S T4-4S Average Fe 9.525 10.129 10.875 8.181 9.677 6.953 9.889 10.007 9.500 9.087 Zn 0.113 0.122 0.155 0.063 0.113 0.055 0.132 0.125 0.055 0.092 Cd BDL BDL BDL BDL N/A BDL BDL BDL BDL N/A Ca 1.765 2.945 7.433 3.430 3.894 1.942 3.798 4.878 2.259 3.219 Ag 0.000 0.001 0.002 0.000 0.000 0.000 0.001 0.001 0.000 0.000 Cu 0.018 0.034 0.045 0.014 0.028 0.015 0.035 0.037 0.014 0.025 Mg 1.302 1.434 2.813 1.204 1.688 0.951 1.591 2.220 1.364 1.531 Al 6.836 7.024 7.546 5.097 6.626 5.037 6.799 7.020 6.825 6.420 Mn 0.705 0.689 0.745 0.443 0.646 0.528 0.691 0.713 0.561 0.623 Pb 0.032 0.070 0.086 0.024 0.053 0.025 0.068 0.073 0.024 0.047 Cr 0.011 0.021 0.024 0.005 0.015 0.005 0.019 0.019 0.008 0.013 V 0.022 0.024 0.025 0.017 0.022 0.015 0.022 0.022 0.024 0.021 Ba 0.065 0.093 0.105 0.041 0.076 0.049 0.093 0.092 0.051 0.071 K 1.063 1.066 1.527 0.948 1.151 0.848 1.328 1.039 1.098 1.078 L. Joyal 42 Table B7. Averages of plant elements per column in mg/g Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K P1 P2 0.973 0.064 0.003 N/A #### #### 0.000 0.015 1.355 0.741 0.089 0.011 N/A 0.002 0.027 N/A P3 0.944 0.039 P4 0.236 0.041 1.511 0.077 0.002 4.216 0.000 0.011 1.837 1.283 0.132 0.011 0.000 0.004 0.024 11.526 N/A N/A 0.000 0.011 1.128 0.655 0.089 0.011 0.001 N/A 0.002 0.018 8.631 0.000 0.005 0.811 0.233 0.029 0.004 0.000 0.009 4.923 Table B8. Averages of root elements in columns in mg/g Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K R1 R2 8.907 0.417 0.029 N/A 13.750 N/A N/A 0.051 4.032 5.904 0.772 0.066 N/A 0.015 0.124 24.195 R3 3.610 0.118 R4 4.078 0.152 0.000 N/A 4.764 6.011 N/A N/A 0.027 0.033 1.872 1.872 2.862 3.264 0.294 0.331 0.030 0.034 0.005 0.007 0.007 0.010 0.047 0.056 10.135 5.493 1.415 0.055 3.163 0.015 0.955 1.091 0.114 0.013 0.000 0.002 0.022 4.965 L. Joyal 43 Table B9. Averages of soil elements per column in mg/g Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K S1 S2 11.148 0.129 N/A S3 10.352 0.128 N/A 4.092 0.001 0.036 1.686 7.507 0.780 0.067 0.019 0.025 0.094 1.477 S4 9.677 0.113 N/A 4.018 0.001 0.037 1.631 7.063 0.780 0.074 0.021 0.024 0.096 1.166 9.087 0.092 N/A 3.894 0.000 0.028 1.688 6.626 0.646 0.053 0.015 0.022 0.076 1.151 3.219 0.000 0.025 1.531 6.420 0.623 0.047 0.013 0.021 0.071 1.078 Table B10. Averages of elements in mg/g across rows with averages of rows Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K T1-1P T2-1P T3-1P 0.906 0.454 0.103 0.057 0.005 BDL BDL #### #### #### 0.000 BDL BDL 0.013 0.011 1.259 0.811 0.737 0.287 0.092 0.055 0.010 0.007 BDL BDL BDL 0.002 0.001 0.026 0.020 #### 10.164 T4-1P 0.342 0.096 0.005 0.720 0.263 0.046 0.005 BDL 0.001 0.019 7.309 Avg Row 1 P T1-1R T2-1R 2.758 1.115 24.504 0.195 0.113 1.185 0.002 0.003 0.057 BDL 1.821 N/A 29.071 0.001 0.001 BDL uncal 0.012 0.010 0.125 0.835 0.906 9.348 2.366 0.913 15.966 0.229 0.105 2.140 0.013 0.009 0.172 N/A BDL BDL 0.006 0.002 0.042 0.030 0.024 0.324 2.802 6.758 52.662 T3-1R 3.683 0.159 BDL 2.374 uncal 0.029 1.346 2.873 0.286 0.025 0.005 0.045 14.984 T4-1R Avg Row 1 R 12.834 BDL 13.674 0.373 BDL 0.572 BDL 0.057 15.041 BDL 15.495 BDL N/A 0.089 BDL 0.081 4.660 BDL 5.118 10.328 BDL 9.722 1.044 BDL 1.157 0.107 0.097 0.100 0.020 BDL 0.020 0.030 0.000 0.019 0.174 BDL 0.181 10.203 BDL 25.950 L. Joyal 44 Table B11. Averages of elements in mg/g across rows with averages Element T1-1S T2-1S T3-1S T4-1S Avg Row 1 S T1-2P Fe 11.232 9.663 9.525 6.953 9.343 Zn 0.099 0.083 0.113 0.055 0.087 Cd BDL BDL BDL BDL N/A Ca 2.911 1.941 1.765 1.942 2.140 #### Ag 0.000 0.000 BDL 0.000 0.000 Cu 0.025 0.022 0.018 0.015 0.020 Mg 1.412 1.255 1.302 0.951 1.230 Al #### 7.043 6.836 5.037 6.305 Mn 0.860 0.788 0.705 0.528 0.720 Pb 0.046 0.049 0.032 0.025 0.038 Cr 0.014 0.013 0.011 0.005 0.011 V 0.027 0.021 0.022 0.015 0.021 Ba 0.086 0.072 0.065 0.049 0.068 K 1.629 1.178 1.063 0.848 1.180 #### T2-2P 1.132 0.036 0.004 BDL #### 0.000 BDL 0.014 1.338 0.803 0.096 0.013 0.000 BDL 0.002 0.018 T3-2P T4-2P Avg Row 2P 0.803 0.030 BDL BDL 0.004 #### 3.766 N/A BDL BDL 0.000 0.008 0.002 0.013 0.009 0.904 0.333 3.157 1.433 0.345 0.232 1.268 0.662 0.053 0.009 0.131 0.072 0.007 0.002 0.010 0.008 BDL BDL 0.000 0.001 0.000 0.004 0.002 0.014 0.004 0.027 0.016 8.812 2.538 18.247 9.866 0.485 0.025 0.104 0.004 1.493 0.056 Table B12. Averages of elements in mg/g across rows with averages Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K T1-2R T2-2R T3-2R T4-2R Avg Row 2 R T1-2S T2-2S T3-2S T4-2S Avg Row 2 S 1.015 4.575 0.368 0.430 1.597 11.284 11.526 10.129 9.889 10.707 0.038 0.132 0.012 0.018 0.050 0.142 0.169 0.122 0.132 0.141 BDL BDL BDL BDL N/A BDL BDL BDL BDL N/A 4.615 5.141 3.381 2.400 3.884 3.198 3.546 2.945 3.798 3.372 uncal uncal uncal uncal N/A 0.001 0.002 0.001 0.001 0.001 0.017 0.030 0.007 0.009 0.016 0.043 0.048 0.034 0.035 0.040 1.328 1.636 0.902 0.596 1.116 1.535 1.684 1.434 1.591 1.561 0.890 3.534 0.298 0.292 1.254 7.336 #### 7.024 6.799 7.053 0.089 0.372 0.037 0.040 0.134 0.759 0.798 0.689 0.691 0.734 0.015 0.038 0.005 0.005 0.016 0.081 0.092 0.070 0.068 0.078 BDL 0.008 BDL 0.000 0.004 0.024 0.030 0.021 0.019 0.024 0.001 0.010 0.001 0.001 0.003 0.023 0.029 0.024 0.022 0.025 0.022 0.059 0.014 0.015 0.028 0.097 0.122 0.093 0.093 0.101 12.210 7.151 2.916 2.348 6.156 1.295 1.344 1.066 1.328 1.258 Element Fe Zn Cd Ca Ag Cu Mg Al Mn Pb Cr V Ba K T1-3P T2-3P T3-3P 0.881 1.893 0.052 0.036 0.001 BDL #### #### 0.000 0.000 0.017 0.015 1.468 1.667 0.682 1.334 0.079 0.158 0.009 0.018 BDL 0.001 0.002 0.004 0.037 0.021 #### 6.917 Table B13. Averages of elements in mg/g across rows with averages T4-3P Avg Row 3 P T1-3R 1.451 0.045 BDL 0.001 BDL 9.870 N/A BDL 0.000 uncal 0.014 0.015 2.493 1.876 1.322 1.112 0.139 0.125 0.017 0.015 BDL 0.001 BDL 0.004 0.003 0.030 0.029 16.005 11.461 1.579 0.047 T2-3R T3-3R T4-3R Avg Row 3 R 1.102 2.228 1.776 0.066 0.088 0.061 BDL 0.000 BDL 0.000 7.565 6.776 1.154 5.270 5.191 uncal uncal uncal N/A 0.010 0.023 0.013 0.025 0.018 1.421 2.634 0.478 1.416 1.487 0.857 2.179 0.657 1.944 1.409 0.086 0.225 0.094 0.187 0.148 0.011 0.027 0.013 0.026 0.019 0.001 0.001 BDL 0.001 0.002 0.006 0.002 0.005 0.004 0.027 0.037 0.015 0.037 0.029 7.715 8.270 2.141 8.022 6.537 1.202 0.028 2.572 0.062 L. Joyal 45 Table B14. Averages of elements in mg/g across row 3 of soil with average Element T1-3S T2-3S T3-3S T4-3S Avg Row 2 S Fe 10.927 9.867 10.875 10.007 10.419 Zn 0.145 0.131 0.155 0.125 0.139 Cd BDL BDL BDL BDL N/A Ca 6.166 6.566 7.433 4.878 6.261 Ag 0.001 0.001 0.002 0.001 0.001 Cu 0.040 0.040 0.045 0.037 0.040 Mg 2.110 1.953 2.813 2.220 2.274 Al 7.678 7.084 7.546 7.020 7.332 Mn 0.721 0.755 0.745 0.713 0.734 Pb 0.074 0.081 0.086 0.073 0.078 Cr 0.020 0.021 0.024 0.019 0.021 V 0.025 0.022 0.025 0.022 0.024 Ba 0.100 0.096 0.105 0.092 0.098 K 1.508 0.977 1.527 1.039 1.263 Table B15. Averages in mg/g of each row broken into sample types Element Avg Row 1 P Avg Row 1 R Avg Row 1 S Avg Row 2 P Avg Row 2 R Avg Row 2 S Avg Row 3 P Avg Row 3 R Avg Row 3 S Fe 1.115 13.674 9.343 0.803 1.597 10.707 1.451 1.776 10.419 Zn 0.113 0.572 0.087 0.030 0.050 0.141 0.045 0.061 0.139 Cd 0.003 0.057 N/A 0.004 N/A N/A 0.001 0.000 N/A Ca N/A 15.495 2.140 N/A 3.884 3.372 N/A 5.191 6.261 Ag 0.001 N/A 0.000 0.000 N/A 0.001 0.000 N/A 0.001 Copper 0.010 0.081 0.020 0.009 0.016 0.040 0.015 0.018 0.040 Mg 0.906 5.118 1.230 1.433 1.116 1.561 1.876 1.487 2.274 Al 0.913 9.722 6.305 0.662 1.254 7.053 1.112 1.409 7.332 Mn 0.105 1.157 0.720 0.072 0.134 0.734 0.125 0.148 0.734 Pb 0.009 0.100 0.038 0.008 0.016 0.078 0.015 0.019 0.078 Cr N/A 0.020 0.011 0.000 0.004 0.024 0.001 0.001 0.021 V 0.002 0.019 0.021 0.002 0.003 0.025 0.003 0.004 0.024 Ba 0.024 0.181 0.068 0.016 0.028 0.101 0.029 0.029 0.098 K 6.758 25.950 1.180 9.866 6.156 1.258 11.461 6.537 1.263 L. Joyal 46 Table B16. Overall averages in mg/g of each sample type and total overall average of each analyzed element Element Plant Root Soil Fe 0.916 4.503 Zn 0.055 0.185 Cd 0.003 0.014 N/A Ca N/A 6.922 Ag 0.000 N/A Cu 0.010 0.031 Mg 1.283 2.183 Al 0.728 3.280 Mn 0.085 0.378 Pb 0.009 0.036 Cr 0.000 0.004 V 0.002 0.009 Ba 0.020 0.062 K 8.360 11.197 Overall Avg 10.066 5.161 0.115 0.119 0.008 3.805 5.364 0.001 0.000 0.031 0.024 1.634 1.700 6.904 3.637 0.707 0.390 0.060 0.035 0.017 0.007 0.023 0.011 0.085 0.056 1.218 6.925 Appendix C: Budget Heavy Metals Soil Analysis Budget Soil Sampling ($25 EST) Small plastic shovel 10 ziploc bags 3 meter tape measure Black sharpie Cooler or refrigerator for samples Soil Digestion ($221 EST) 500 mL Hydrochloric acid ($62 sigma-aldrich) 500mL Nitric Acid ( $68 sigma-aldrich) 500mL 30% Hydrogen Peroxide ($91 sigma-aldrich) Analysis with MP-AES ($460) L. Joyal 47 99.5% Size T Nitrogen Cylinders ($60 per cylinder - Airgas) Zero Air Size T Cylinders ($40 per cylinder - Airgas) Actual Cost of Project Soil Sampling ($5.37) 28 ziploc bags ($5.37) Soil Digestion ($91) 500mL 30% Hydrogen Peroxide ($91 sigma-aldrich) Analysis with MP-AES ($460) 99.5% Size T Nitrogen Cylinders ($60 per cylinder - Airgas) Zero Air Size T Cylinders ($40 per cylinder Airgas) Appendix D: CITI Training Group 2 COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM) COURSEWORK REQUIREMENTS REPORT* * NOTE: Scores on this Requirements Report reflect quiz completions at the time all requirements for the course were met. See list below for details. See separate Transcript Report for more recent quiz scores, including those on optional (supplemental) course elements. Name: Lauren Joyal (ID: 4458701) Email: joyall@uindy.edu Institution Affiliation: University of Indianapolis (ID: 473) Institution Unit: College of Arts and Sciences Phone: 8128782281 Curriculum Group: Human Research Course Learner Group: Group 2.Social / Behavioral Research Investigators and Key Personnel. Stage: Stage 1 - Basic Course Description: The social behavioral track is applicable when you conduct epidemiologic, genetic, prevention/ screening, psychosocial and/or quality of life studies. Report ID: 14288921 Completion Date: 10/13/2014 Expiration Date: 10/12/2016 Minimum Passing: 75 Reported Score*: 92 REQUIRED AND ELECTIVE MODULES ONLY DATE COMPLETED Introduction 10/11/14 Students in Research 10/13/14 L. Joyal 48 History and Ethical Principles - SBE 10/13/14 Defining Research with Human Subjects - SBE 10/13/14 The Federal Regulations - SBE 10/13/14 Assessing Risk - SBE 10/13/14 Informed Consent - SBE 10/13/14 Privacy and Confidentiality - SBE 10/13/14 Research and HIPAA Privacy Protections 10/13/14 Conflicts of Interest in Research Involving Human Subjects 10/13/14 For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution identified above or have been a paid Independent Learner. CITI Program Email: citisupport@miami.edu Phone: 305-243-7970 Web: https://www.citiprogram.org Group 3 COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI) HUMAN RESEARCH CURRICULUM COMPLETION REPORT Printed on 10/13/2014 LEARNER Lauren Joyal (ID: 4458701) 3285 Glenwillow Ct. Bargersville Indiana 46106 United States DEPARTMENT College of Arts and Sciences PHONE 8128782281 EMAIL joyall@uindy.edu INSTITUTION University of Indianapolis EXPIRATION DATE 10/10/2016 GROUP 3 HEALTH INFORMATION PRIVACY AND SECURITY COURSE/STAGE: Basic Course/1 PASSED ON: 10/11/2014 REFERENCE ID: 14288889 REQUIRED MODULES DATE COMPLETED Belmont Report and CITI Course Introduction 10/11/14 For this Completion Report to be valid, the learner listed above must be affiliated with a CITI Program participating institution or be a paid Independent Learner. Falsified information and unauthorized use of the CITI Program course site is unethical, and may be considered research misconduct by your institution. Paul Braunschweiger Ph.D. Professor, University of Miami Director Office of Research Education CITI Program Course Coordinator  ...

... Canine-Assisted Therapy in the Pediatric Outpatient Setting Kelsey Keefer May 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jennifer Fogo, PhD, OTR A Capstone Project Entitled Canine-Assisted Therapy in the Pediatric Outpatient Setting Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Kelsey Keefer Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Canine Assisted Therapy in the Pediatric Outpatient Setting Kelsey Keefer University of Indianapolis; Hopebridge, LLC CANINE ASSISTED THERAPY IN PEDIATRICS 2 Abstract The human-animal bond has existed and been documented on for centuries, and the use of animals in the healthcare setting has steadily increased since the 1980s. Animal-assisted therapy has been shown to improve aspects of occupational functioning and performance skills in children with ASD, ADHD, CP, Down syndrome, and other varying diagnoses, although little research is available for canine-assisted therapy (CAT) in the outpatient pediatric setting. The purpose of this project was to assess the effects on occupational performance of children engaging in a CAT program. Ten clients regularly engaged in CAT at a rate of once per week during occupational therapy sessions. Surveys were completed for each of the ten clients, as well as 11 other clients who interacted with the therapy dog during various therapy sessions. Of all the surveys completed, 75% of respondents reported that the presence of the therapy dog positively impacted the clients session. A qualitative question on the survey resulted in five major themes relating to the therapy dog: the therapy dog (a) improved client motivation or participation; (b) calmed or provided emotional regulation; (c) improved attention and/or social skills; (d) positively impacted sensory skills; or (e) positively impacted motor skills. Overall, the results from this project indicate that a CAT program can positively impact a clients occupational functioning, potentially allowing children to meet goals and develop skills at a faster rate. CANINE ASSISTED THERAPY IN PEDIATRICS 3 Canine Assisted Therapy in the Pediatric Outpatient Setting The bond between humans and animals has existed and been documented on since the earliest domestication of animals (Fine, 2010). Some of the earliest accounts of human interaction with animals yielding an intentionally positive effect are in the late 17th century, when John Locke wrote about providing children with animals in order to encourage caring for others and to promote a sense of responsibility (Fine, 2010; Locke, 1699). In the 19 th century, animals as pets became increasingly common in mental institutions in England as well as other countries (Fine, 2010). In 1880, Florence Nightingale (1946) wrote in Notes on Nursing that small animals often make great companions for chronically ill patients. Psychiatrist Boris Levinson was one of the first to document the positive effects of the human-animal bond of dogs and children with autism (Levinson, 1997). In 1961 at a meeting for the American Psychological Association, Levinson theorized that children with autism engaging in playful interactions with dogs could improve social and communication skills, coining it petoriented child psychotherapy (Levinson, 1997, p. xii). Despite the healthcare system mostly eschewing animals in the hospital system in the early part of the 20 th century, the topic of animals in the healthcare setting made a resurgence in the 1980s after a groundbreaking study that found patients in a cardiac care unit tended to live longer if they were pet owners (Fine, 2010; Friedmann et al., 1980). The human-animal bond, defined as a mentally beneficial and dynamic relationship between people and animals that is influenced by behaviors that are essential to the health and well-being of both (American Veterinary Medical Association [AVMA], 2018b). Interactions may be, but are not limited to, emotional, psychological, or physical in nature. CANINE ASSISTED THERAPY IN PEDIATRICS 4 Societys shift towards using the human-animal bond within the contemporary health care setting has resulted in its own terminology. The use of animals in a beneficial manner for humans, termed animal-assisted intervention (AAI), is an umbrella term with four distinct subgroups: animal-assisted therapy (AAT), animal-assisted education (AAE), animal-assisted activity (AAA), and AAI resident animalsanimals who are owned by and live at a facility full time and are cared for by staff, volunteers, or residents (AVMA, 2018a). AAT is goal-directed and delivered or directed by a health or human services professional working within the scope of their practice (AVMA, 2018a). AAT has goals that may target aspects of ones physical, social, emotional, or cognitive functioning health, may be implemented in group or individual settings, and must be documented and evaluated (AVMA, 2018a). Literature Review While there is extensive research supporting the use of animal-assisted therapy, much of the literature is limited to case studies or small sample studies (Andreasen et al., 2017). Furthermore, there is a lack of longitudinal research examining the effects of animal-assisted intervention over long periods of time. Compiled research for the purpose of this project focus on common diagnoses seen in children and adolescents by outpatient occupational therapists. Benefits of Animal-Assisted Therapy Many positive outcomes have been documented as a result of engaging in AAT. Research supports the use of AAT for multiple populations, including adults and older adults with varying diagnoses as described by Cherniack and Cherniack (2014), but as previously stated, the following compiled research is limited to children and adolescents due to the scope of this project. As the human-animal bond can assist in improving emotional, psychological, or physical CANINE ASSISTED THERAPY IN PEDIATRICS 5 functioning, children with various diagnoses and functional impairments can improve occupational functioning with implementation of AAT. Autism spectrum disorder (ASD). ASD is defined as a spectrum of symptoms, abilities, and impairments (National Institute of Mental Health [NIMH], 2016b). Common characteristics include deficits in social skills or the ability to interact with others, frequent engagement in repetitive behaviors, and limited interests or activities, all of which impact ones daily functioning (NIMH, 2016b). According to the Centers for Disease Control and Prevention (CDC) (2017), an estimated 1 in 68 children have been identified with ASD. A meta-analysis completed by Berry et al. (2013) found that multiple studies showed interactions with therapy dogs significantly improved social interaction and reduced negative behaviors, including aggression and obsession, in children with ASD. Siewertsen, French, and Teramoto (2015) found that pet therapy can improve one or more functions affected by ASD and can positively impact a clients life outside of the therapy process. Furthermore, improved motor function and reduced physiological responses to stress have been shown (Siewertsen et al., 2015). OHaire, McKenzie, McCune, and Slaughter (2014) found that after an 8-week AAA intervention in the classroom setting, children with ASD demonstrated significantly improved social functioning. Hallyburton and Hinton (2017) analyzed studies relevant to recreational therapy that examined the effect of canine-assisted therapy (CAT) on children with ASD, and found interaction with therapy dogs resulted in significant improvements in verbal social interactions. Attention-deficit/hyperactivity disorder (ADHD). ADHD is characterized by inattention and/or hyperactivity or impulsivity that impacts development or functioning (NIMH, 2016a). Schuck, Emmerson, Fine, and Lakes (2015) found that after a 12-week canine-assisted intervention treatment combined with cognitive-behavioral therapy (CBT), children with ADHD CANINE ASSISTED THERAPY IN PEDIATRICS 6 demonstrated greater reductions in the severity of ADHD symptoms compared to the control group, who received only CBT. Cerebral palsy (CP). Defined as a disorder affecting movement, muscle tone, or posture as a result of damage to the developing brain, CP may present in myriad ways, affecting multiple areas of functioning, (Mayo Clinic, 2018). Elmaci and Cevizci (2015) found that two children with CP demonstrated improved symptoms including increased active muscle movements, bowel motility and regulation, instilled feelings of comfort, and reduced tonus by utilizing the body temperature and oscillations of a therapy dog, all of which helped facilitate motor learning. Rodrigues Porto and Bertoldo Quatrin (2014) found that a teenager with CP improved both gross motor skills and socioaffective skills after engagement in AAT in a single case study design. Down syndrome. People with Down syndrome, a genetic condition resulting from an extra copy of chromosome 21, may demonstrate low muscle tone, cognitive impairments, delayed developmental milestones, impulsivity, poor attention, poor judgment, and delayed speech and language development (National Institute of Child Health and Human Development [NICHD], 2017). Satiansukpong, Pongsaksri, and Sasat (2016) found that after eight weeks of participation in an elephant-assisted therapy program in Thailand, children with Down syndrome demonstrated improved visual-motor integration skills. Furthermore, Griffioen and EndersSlegers (2014) discovered significant improvements in verbalization and recognition of others and a decreased in impulsiveness in children with Down syndrome after a six-week dolphinassisted therapy intervention. Other benefits. AAT may also improve attention, cognitive functioning, confidence, motivation for self-improvement, feelings of responsibility, feelings of acceptance, and reduce maladaptive behaviors in children and adolescents with fetal alcohol spectrum disorder (FASD), CANINE ASSISTED THERAPY IN PEDIATRICS 7 pervasive developmental disorder (PDD), intellectual disabilities (ID), conduct disorder, epilepsy, or victims of neglect and/or abuse (Martin & Farnum, 2002; Silva, Lima, Magalhes, & de Sousa, 2011; Maber-Aleksandrowicz, Avent, & Hassitosis, 2016; Williams & Metz, 2014; Vincent, Kropp, & Byrne, 2014; Parish-Plass, 2008). Additional potential benefits of AAT include positive behavior patterns and improved levels of trust, caring for others, empathy, cooperation and responsibility (Firmin, Brink, Firmin, Grigsby, & Trudel, 2016). The Role of AAT in Occupational Therapy The field of occupational therapys scope of practice includes facilitating participation in everyday life activities (occupations) that people find meaningful and purposeful, and thus, any occupation-based goal aligns with AATs inherent definition (American Occupational Therapy Association [AOTA], 2004). Skilled occupational therapists can use AAT as a tool for enhancing childrens daily functioning and development in the occupations of activities of daily living (ADL), instrumental activities of daily living (IADL), education, work, play, leisure, and social participation (Andreasen et al., 2017). Because the presence of an animal tends to increase childrens motivation to participate in purposeful activity, occupational therapists can use this to further facilitate development of various performance skills, including motor skills, process skills, and social interaction skills (Andreasen et al., 2017). Additionally, AOTA has defined pet care as an Instrumental Activity of Daily Living (IADL), further emphasizing the importance of the human-animal relationship as a daily occupation. The Person-Environment-Occupation (PEO) Model. The Person-Environment-Occupation (PEO) Model served as a framework during this project for engaging in the occupational therapy process with a client. The Model focuses on the person, environment, and the occupations in which one engages (Law et al., 1996). The Model is CANINE ASSISTED THERAPY IN PEDIATRICS 8 conceptualized as three overlapping circles, each one representing either the person, environment, or occupations, and all of which overlap (Strong et al., 1999). A person theoretically achieves harmony when the circles overlap as much as possible (Strong et al., 1999). The area in the center of all three circles overlapping represents occupational performance; the greater the overlap, the greater the occupational performance (Strong et al., 1999). A persons satisfaction and occupational functioning is a direct result of the level of interaction between the three components of the PEO Model. Both internal and external changes may impact the PEO fitthe interaction between the person, environment, and occupation potentially requiring modifications or adaptations in order to continue achieving functional outcomes (Strong et al., 1999). The focus of the PEO Model is to enable occupation via improvement of the PEO fit (Strong et al., 1999). When considering a clients occupational performance, an occupational therapist may look at specific environments in which occupational engagement occurs to make changes. Altering the environment by implementing AAT to promote occupational participation allows for increased interventional opportunity, thus theoretically increasing successful outcomes for clients (AOTA, 2014). However, there is limited research on the effect AAT has in the occupational therapy setting and on the occupational functioning of children. The purpose of this project was to quantitatively and qualitatively assess the effects on occupational functioning of children engaging in a canine-assisted therapy program in the outpatient pediatric setting. CANINE ASSISTED THERAPY IN PEDIATRICS 9 Screening and Evaluation Setting The project took place at Hopebridge Pediatrics, LLC in Kokomo, Indiana. Hopebridge Pediatrics, LLC is an organization committed to providing personalized therapy for children and their families touched by behavioral, physical, social, communication and sensory challenges, helping them live their best life possible (Hopebridge, n.d.). The organization provides outpatient services including Applied Behavioral Analysis (ABA) for children on the autism spectrum, as well as occupational, speech, and physical therapies (Hopebridge, n.d.). Participants Ten clients regularly engaged in CAT during occupational therapy sessions for a duration of approximately 15 weeks at the site. Clients who received outpatient OT by a specific certified occupational therapy assistant (COTA) on Tuesdays or Thursdays received traditional OT services in conjunction with CAT. Exclusion criteria for participation in the project included a history of aggression towards animals or inappropriate/maladaptive behavior towards the therapy dog during a session. One participant who participated in one session with the therapy dog was subsequently excluded from the project after demonstrating unfavorable behavior towards the dog. The primary diagnoses and number of clients for each for the clients who regularly engaged in CAT as part of their OT sessions is shown in Appendix A. The average age of the 10 clients engaging in OT in conjunction with CAT was 9 years and 2 months at the beginning of the project. The youngest client was 4 years old and the oldest was 16 years old; there were eight males and two females. Nine clients identified as white (nonHispanic or Latino) and one client identified as Hispanic/Latino. Occupational therapy sessions CANINE ASSISTED THERAPY IN PEDIATRICS 10 lasted for one hour each week, with the exception of one client who received two 30-minute sessions per week, one on Tuesday and one on Thursday. Occupational therapy sessions were scheduled for the same time and day each week, although changes were made depending on need. The following sections describe each of the nine clients who primarily engaged in CAT in conjunction with traditional OT services over the 15-week project, as well as their primary deficits in occupational performance. Client A. Client A was a 9-year-old male with a primary diagnosis of Down syndrome. As of his most recent plan of care, Client A demonstrated continued deficits with core strength, gross motor skills, self-care skills, attention, cognition, and visual-motor skills. Client B. Client B was a 6-year-old male with a primary diagnosis of ASD. Client Bs goals for his most recent plan of care included sensory modulation skills, toleration of sensory input, and participation in a directed activity for greater than 20 seconds. Client C. Client C was a 16-year-old female with a primary diagnosis of CP. Client Cs goals for her most recent plan of care targeted improved strength and endurance, bilateral upper extremity (BUE) strength/endurance, unsupported static sitting balance, BUE active range of motion (AROM), dressing, fine motor skills, and motor control via weight bearing. Client D. Client D, a 10-year-old male with ASD as a primary diagnosis, had goals on his plan of care targeting strength and endurance, feeding, dressing, self-care, toleration of sensory input, visual motor skills, and fine motor strength. Client E. Client E was a 6-year-old male with a primary diagnosis of Down syndrome. Client Es plan of care goals included upper extremity and core strength and endurance, fine motor skills, dressing, sensory input, attention, and oral motor control. CANINE ASSISTED THERAPY IN PEDIATRICS 11 Client F. Client F, a 12-year-old male, had diagnoses including unspecified disorder of psychological development and unspecified lack of expected normal physiological development in childhood. Client Fs goals targeted BUE strength and endurance, dynamic standing balance, cognition, dressing, bilateral coordination, and attention. Client G. Client G was an 8-year-old male with a diagnosis of ASD. Client Gs goals included improving social skills, safety awareness, cognition, and IADL, including meal preparation. Client H. Client H, a 7-year-old female, had diagnoses including: attention and concentration deficit, delayed milestone in childhood, and unspecified lack of coordination. In her most recent plan of care, Client Hs goals included visual motor skills, handwriting, cognition, fine motor skills, and social skills. Client I. Client I was an 8-year-old male with a primary diagnosis of ASD. Client Is goals as of his most recent plan of care targeted sensory modulation, transitioning skills, purposeful play, termination of activities, dressing, and implementation of a sensory diet. Client J. Client J was a 4-year-old male with a diagnosis of ASD. Client Js goals were to improve fine and visual motor skills, self-care including feeding, tolerating brushing teeth, sitting tolerance at a tabletop, sensory modulation, and self-regulation. Potential impact of CAT on these clients. As stated in the literature review, CAT has been shown to improve several components of occupational functioning in children. Engagement in CAT in conjunction with traditional OT services has been shown to improve social skills and verbal interactions for children with ASD diagnoses (Berry et al., 2013; Hallyburton & Hinton, 2017). Clients G and H had goals on their respective plans of care addressing social skills. While Client CANINE ASSISTED THERAPY IN PEDIATRICS 12 H did not have an ASD diagnosis, interaction with the therapy dog may improve social skills for both of these specific clients for improved interaction in everyday activities. Reduced severity of symptoms were found with children who had ADHD diagnoses after engaging in CAT during CBT compared to the control group who received only CBT (Schuck et al., 2015). While none of the participants regularly engaging in CAT at this site had an ADHD diagnosis, several participants had goals targeting attention, a component of functional cognition necessary for success in everyday occupations. Clients A, E, and F demonstrated deficits in attention to task and had specific goals targeting this performance skill. Engagement in CAT was hypothesized to improve these deficits throughout OT sessions. Motor function was also found to improve for children with ASD diagnoses (Siewertsen et al., 2015). Motor skills are an important component of performance skills, necessary for engagement in everyday tasks, including ADLs (AOTA, 2014). Nearly all clients had goals related to motor skills, including gross motor skills, fine motor skills, and core strength: clients A, C, D, E, F, H, and J. While not all of these clients had ASD diagnoses, the benefits from CAT on motor function may still be observed. Furthermore, motor learning was significantly impacted for children with CP as noted by two case studies completed by Elmaci and Cevizci (2015). Improved symptoms included increased active muscle movements, bowel motility and regulation, feelings of comfort, and reduced tonus by utilizing the body temperature and oscillations of a therapy dog (Elmaci and Cevizci). Two clients with diagnoses of CP participated in sessions with the therapy dog during this project in order to catalyze improvements in these specific areas of motor functioning. As stated previously, visual-motor integration was improved for children with Down syndrome after an eight-week AAT intervention with elephants as evidenced by Satiansukpong et CANINE ASSISTED THERAPY IN PEDIATRICS 13 al. (2016). Client A, who had a diagnosis of Down syndrome, had a specific goal targeting visualmotor integration. Clients D and H also had goals for visual-motor integration, but did not have a diagnosis of Down syndrome. As the facility also provides outpatient ABA services to clients on the autism spectrum, many other children interacted with the therapy dog throughout the 15-week duration. Furthermore, the occupational therapist, other COTA, and therapists from other disciplines at the site (physical therapy and speech language therapy) had clients engage with the therapy dog during sessions. Data were collected from these clients, therapists, and caregivers to further qualitatively support the hypothesis. Comparison to the Traditional Outpatient Setting There is not evident data on the prevalence of AAT in any setting, indicating it is likely not very common, especially in the outpatient pediatric setting. The organization in which the therapy dog was certified, Paws & Think, LLC (detailed further later), had only one other contract with a pediatric outpatient facility out of 25 healthcare venues. However, as stated above in the literature review, the benefits of AAT for children are extensive. While all pediatric outpatient facilities likely provide traditional therapy services, including occupational, speech, and physical therapies, there is an opportunity to deliver improved benefits for clients as a result of AAT. Altering the environment by implementing a therapy dog, as described above in relation to the PEO model, may encourage a calming environment, provide a specific motivation for participation or accomplishments, and allows for a greater number of interventional opportunities compared to traditional treatment. CANINE ASSISTED THERAPY IN PEDIATRICS 14 Implementation The 15-week project began in January of 2018 and continued until April of 2018. As described previously, the therapy dog came to the site on Tuesdays and Thursdays each week. The following sections describe how the project was implemented over the 15 weeks at the site. Therapy Dog The therapy dog that participated in this project was a two-year-old male Labradoodle, Oliver, the personal pet of the primary author of this article, an occupational therapy student at the University of Indianapolis. Oliver and the occupational therapy student became a certified therapy team through the organization Paws & Think, Inc. in preparation for this project. Paws & Think, Inc. is an organization based out of Indianapolis, IN, that trains and provides therapy animals for both animal-assisted activities and animal-assisted therapies to youth, seniors and special needs individuals of all ages (Paws & Think, Inc., n.d.). The organization partners with schools, detention centers, healthcare facilities, youth agencies, and more to serve at-risk populations (Paws & Think, Ind., n.d.). The therapy team attended four skills classes once a week for an hour and 45 minutes each to prepare for the Paws & Think therapy team evaluation. Once the evaluation was complete and the therapy team became certified, the occupational therapy student attended a four-hour handlers class to gain further knowledge about being a certified therapy team. Paws & Think produced a memorandum of understanding with the clinical site in order to establish and recognize each partys responsibility, as is customary with each of Paws & Thinks partnerships. The therapy dog visited the clinic two days a week, on Tuesdays and Thursdays, from January to April 2018, for a total of 29 visits. Interventions CANINE ASSISTED THERAPY IN PEDIATRICS 15 Several interventional methods were used by means of the therapy dog throughout this process. The primary and most frequently used intervention was the alteration of the environment by implementation of the therapy dog into the normal therapeutic process. Human-animal interaction (HAI) is defined as any manner or interaction between a person and a non-human animal (Purdue University College of Veterinary Medicine, 2017). While a few children did not acknowledge the therapy dog during sessions, the majority of children interacted with the therapy dog at least once throughout a session, at the very minimum by simply looking at and acknowledging him, thus qualifying as a HAI. Beetz, Uvns-Moberg, Julius, and Kotrschal (2012) completed a review of 69 studies researching human-animal interactions and the role of oxytocin, concluding that the interaction with animals correlates with an increase in oxytocin levels in humans, thus promoting social interaction, reduce stress and anxiety, and improve human health. Further methods for intervention are detailed below. Petting. Most children interacted with the therapy dog via petting. Repetitive petting is a form of tactile sensory input, addresses AROM of an upper extremity, and can impact passive range of motion (PROM). Furthermore, petting can reduce blood pressure and the heart rate of those petting the animal (Grossberg & Alf, 1985; Handlin et al., 2011). Brushing. Brushing the therapy dog as an intervention targeted AROM, PROM, and specific grasp patterns. The main brush used throughout this project had a cylindrical handle, therefore addressing the clients cylindrical grasp. While seated and brushing the therapy dog, many clients crossed midline, using their right upper extremity (RUE) to brush the dog on the left side of them, and vice versa. CANINE ASSISTED THERAPY IN PEDIATRICS 16 Giving treats. Giving treats to the therapy dog promoted fine motor skills, specifically a clients pincer grasp and in-hand manipulation. The clients often had to reach into a bag and retrieve only one treat, relying on inherent stereognosis skills. Obstacle courses. Several children engaged in obstacle courses with the therapy dog involved. Obstacle courses address gross motor skills, overall strength, activity tolerance, and cognitive skillsspecifically, the ability to follow multi-step directions, attend to a task for a certain amount of time, and recall steps in a specific order. The implementation of a favored activity, such as giving treats to the therapy dog, during obstacle courses increased client motivation and therefore success in these activities. Walks. Walks outside were frequently used to target community integration skills, activity tolerance, safety awareness, and gross motor strength. Integrating the therapy dog into these walks similarly increased client motivation and allowed for improved outcomes. Motivation. Overall, the therapy dog served as a motivator throughout sessions. If a client requested play time with the therapy dog, it was used as motivation for completing an unfavorable or particularly difficult task. Other therapists also occasionally used the therapy dog as a motivator or comfort for their clients. Leadership Self-directed leadership was an integral component of this project, called a Doctoral Capstone Experience (DCE), which was the final step for the occupational therapy student in achieving a Doctorate in Occupational Therapy. Planning for this project began in the fall of 2016, with more serious and concrete plans beginning to form in the spring of 2017, in accordance with appropriate coursework at the University of Indianapolis. The occupational therapy student relied on connections from previous fieldwork experiences to initiate planning of this project; however, CANINE ASSISTED THERAPY IN PEDIATRICS 17 this experience was different than that of the past, as the student was responsible for reaching out to potential sites independently from the schools fieldwork coordinators. Furthermore, the student had to conduct an informal needs assessment at the proposed location in order to determine if the project was even plausible. Factors that were considered throughout this process include the target population, the caseload quantity of the COTA, and the relationship between the facility and the CAT organization, Paws & Think. Organizing this project took many months of planning and training. The student had to foremost advocate for the profession of occupational therapy to Paws & Think and explain how this project would be beneficial for both parties. Once an agreement was made between both, the student was responsible for becoming an official Paws & Think volunteer and subsequently a certified therapy team with the therapy dog, which took multiple weeks and many hours. Upon initiation of the project, the student demonstrated leadership skills in many ways. Primarily, the student was responsible for juggling the therapy dog and the client simultaneously. The student had to make often quick decisions based upon the environment, the client, and inherent knowledge. Occasionally, the therapy dog was omitted from sessions due to various circumstances based on the students professional judgement. The student was responsible for advocating for the therapy dog, making sure to not cause undue or excessive stress. Because of that, it was agreed upon that the therapy dog visit the clinic only two days per week, with necessary changes being need based upon the therapy dogs observed stress levels. Attending the handlers course put on by Paws & Think gave the student the necessary resources to observe clear and unclear signs of stress emanating from the therapy dog. During sessions, balancing the therapy dog and the client could be very challenging. Some children had a tendency to run out of a designated treatment area due to impulsivity or deficits in CANINE ASSISTED THERAPY IN PEDIATRICS 18 functional communication. The student had to advocate for herself and the therapy dog, as a team, and made sure that the site mentor, a COTA, was present during those treatment sessions so as to not over-stress or excite the therapy dog by chasing after a child. On the days that the therapy dog was not there, the student was responsible for the COTAs caseload as customary with a typical fieldwork placement. Service provision was provided in a direct method, in accordance with traditional outpatient pediatric occupational therapy services. Staff Development While the student had direct responsibility for the therapy dog, including being the only person allowed to handle him, the other staff members at the site had a unique role in this project, as well. Most of the staff members were aware of the role of occupational therapy in the lives of children with varying diagnoses or developmental delays. However, the staff had to be educated on how a therapy dog could positively impact these children within the scope of occupational therapy practice. By educating other staff members, including Registered Behavioral Technicians (RBTs) those who deliver ABA therapy to children daily with an autism diagnosis children engaged in more interactions with the therapy dog. RBTs were able to use the therapy dog as a reward for children completing required tasks. Discontinuation and Outcomes The primary method for measuring the impact of CAT on certain clients was through a short survey, completed by either a client or a therapist (see Appendix B). The survey was created by the occupational therapy student. While the survey was written in a staff members point of view (using the terminology your client), certain clients who demonstrated the ability to read, understand, and answer the questions on the survey were encouraged to fill one out themselves, as well. The survey consisted of three questions: a simple yes/no question asking whether the therapy CANINE ASSISTED THERAPY IN PEDIATRICS 19 dog made a positive impact on the client, a mark-all-that-apply question asking which specific performance skills and/or client factors were noticeably improved during or after interaction with the therapy dog, and an open-ended question for further details or necessary information on the client-animal interaction. Quality Improvement Quality improvement (QI) is defined by the American Academy of Family Physicians (AAFP) (2018) as a systematic, formal approach to the analysis of practice performance and efforts to improve performance. Solid quality improvement practices can improve efficiency, safety, and clinical outcomes (AAFP, 2018). The surveys were used for data as well as a method for quality improvement. Any pertinent suggestions from the surveys for alteration of the program were considered and, if appropriate and potentially beneficial, implemented. If a respondent selected No on question oneasking whether the therapy dog made a positive impact on the clients day or sessionthe respondent then elaborated on that in question three. If the reason why the therapy dog did not positively impact the client was because of approach, then the approach was changed. For example, one client was particularly timid, nervous, and avoidant of the therapy dog during his first visit. This was noted, and during subsequent visits, the occupational therapy student adjusted the approach with the therapy dog in a gentler way in order for the client to feel more comfortable. Eventually, the child began smiling, petting, and laughing at the therapy dog, showing social skills which had rarely been seen before, and therefore demonstrating positive results for this project. Results A total of 21 surveys were completed by therapists, RBTs, and clients. The occupational therapist, COTA, physical therapy assistant (PTA), and speech therapist all completed at least one CANINE ASSISTED THERAPY IN PEDIATRICS 20 survey after a client engaged with the therapy dog during a session in order to provide multifaceted data. The assigned COTA completed one survey per participant for each of the 10 participants regularly engaging in CAT weekly. The remaining 11 surveys were distributed and completed by the following: one by the speech therapist, two by the PTA, two by the registered occupational therapist, three by clients themselves, and three by RBTs. Quantitative data. The first question, a yes/no question, asked: Did interacting with Oliver positively impact you/your clients session/day? Sixteen out of 21 respondents selected Yes, indicating a positive impact for 75% of those who interacted with the therapy dog. The five responses were from the COTA in which the therapy dog was reported not to have positively impacted the clients session, and were for Clients B, E, G, I, and J. Therefore, in the treatment group, five out of 10 participants regularly receiving canine assisted therapy were reported to have positively benefited from the experience. The second question, a mark-all-that-apply question, asked respondents to mark which performance skills were noticeably improved during/after interaction with Oliver. The results are shown in Table 2 in Appendix A. Selections in this area were only made on 13 out of all 21 surveys; they were not filled out on the surveys in which No was selected on the first question or the surveys completed by RBTs. For the three surveys completed by clients themselves, the respective therapist for that session filled out the performance skill section. Seven respondents selected social skills, three selected gross motor skills, one selected fine motor skills, three selected sensory processing skills, three selected attention, eight selected motivation, six selected emotional regulation, zero selected cognition, and eight selected participation. Respondents selected motivation and participation improved the most out of the skills listed. Respondents also indicated CANINE ASSISTED THERAPY IN PEDIATRICS 21 that social skills and emotional regulation were also noticeably improved with the presence of the therapy dog in a treatment session. Qualitative data. The third and final component of the survey was open-ended and asked the respondent to elaborate on any previous answer or to provide any further details on the impact the therapy dog had on the respondent or their client. Themes were categorized from the openended responses by identifying commonly-used key words in each response. Five major themes emerged during classification of the open-ended responses. These five themes describe conditions in which the therapy dog: (a) provided motivation and/or increased participation, (b) provided a calming effect or assisted in the clients emotional regulation, (c) positively impacted a clients attention or social skills, (d) positively impacted a clients sensory skills, and (e) positively impacted a clients motor skills. Commonly written words or phrases on the surveys that assisted in identifying the first theme, providing motivation and/or increasing participation, included: working harder, motivation, reinforcement (ABA terminology), an increase in productivity, and participation. Respondents frequently included words in their responses relating to a clients emotional regulation, such as calming, toleration, and handling of different environments, resulting in the second theme: providing a calming effect or assisting in the clients emotional regulation. Respondents wrote words relating to attention or social skills, such as any social skill (for example, smiling), improved focus, stating wants/needs more frequently, and improved attention to the task or surroundings/peers, and therefore the theme of a positive impact on a clients attention or social skills emerged. A responded reported on a survey that the therapy dog positively impacted a clients sensory diet, and therefore the fourth theme, a positive impact on a clients sensory skills, was identified. Lastly, respondents commonly wrote that the therapy dog assisted in motor skill CANINE ASSISTED THERAPY IN PEDIATRICS 22 development with phrases such as holding items, grasp patterns, range of motion (ROM), and gross motor skills, resulting in the theme of the therapy dog positively impacting a clients motor skills. Motivation and participation. Several respondents described how the therapy dog provided motivation to complete activities in order to engage or play with the dog. For example, one RBT reported that the therapy dog increased [my clients] productivity and motivated her to work hard in order to spend time with him. Client H reported, He makes me happy and I like to play with him. I work harder so that I can play with him. Another RBT reported that she used the therapy dog as a reinforcement when her client was in a noncompliant behavior. The COTA described how the therapy dog provided motivation for Clients A and F: Motivation/participation completing activity for access to canine, and will complete activity for Oliver reinforcement, respectively. The speech therapist reported that although it was difficult to notice a difference during a short 30-minute speech therapy session, his client participated enthusiastically and appeared to enjoy Olivers presence. Calming and emotional regulation. The occupational therapist used the therapy dog to help calm a client during an activity the client perceived as fearful: [She] was easily calmed while we addressed her gravitational insecurities. Today was the longest shes ever tolerated our sensory activity. The PTA used the therapy dog as motivation as well as emotional regulation, stating the therapy dog was a reminder to finish all tasks during session that helped [my client] stay calm and focused. Furthermore, with a different client, the PTA used the therapy dog to handle a busy gym. An RBT noted that a calmer nature is noted for her client during days that the therapy dog is present. CANINE ASSISTED THERAPY IN PEDIATRICS 23 Attention and social skills. Client D demonstrated improved social verbalizations when in the presence of the therapy dog, with the COTA reporting that he states wants/needs, requesting pet dog. Furthermore, a newer client who was initially apprehensive became interested in Oliver and sought out his attention, per the COTAs response. The COTA also reported that the client, who was often reserved, shy, and quiet, smiled [this date] as well. An RBT also reported that her client is better attentive to surroundings/peers and has better social skills. The COTA reported that Client A demonstrated improved social skills interacting with canine. Sensory skills. As stated above, the occupational therapist reported that during one of her sessions with a client, Oliver was a great addition to our sensory tactile play. My client was more apt to tolerate petting, touching, and wetness on her hands without a negative reaction. Motor skills. Client A also demonstrated improved gross motor skills during interactions with the therapy dog. The COTA reported that Client A was riding bike with canine following. Client C held brush to brush Oliver improving active ROM grasp pattern and gross motor movement patterns. Summary Overall, the results indicate that the implementation of a therapy dog positively impacts most children who participate in canine assisted therapy. Surveys completed by various clients and staff members at the site produced results that showed 75% of respondents felt that the therapy dog had a positive impact on their clients day or session. The COTA responded that of clients receiving CAT weekly, half demonstrated positive results after engagement with the therapy dog. Although the quantitative results for the clients who regularly engaged in CAT week after week provided varied results, the qualitative results received from clients and their therapists were noteworthy. Five major themes emerged for the impact the therapy dog had on a clients day or CANINE ASSISTED THERAPY IN PEDIATRICS 24 sessionthose in which the implementation of the therapy dog: improved motivation or participation, calmed or provided emotional regulation, improved attention and/or social skills, positively impacted sensory skills, and positively impacted motor skills. Societal Needs The immense growth in the field of occupational therapy throughout the past decade is indicative of the importance the discipline has in the evolving healthcare needs of society. Regarding the pediatric population, the Bureau of Labor Statistics (2018) reported that 24% of occupational therapists worked in outpatient therapy offices in 2016, although this statistic includes pediatric and adult practices. However, an additional 10% worked in elementary and secondary schools, which are exclusively pediatric settings by nature (Bureau of Labor Statistics, 2018). The ever-increasing need for occupational therapy services in society, as well as the consistently large percentage of practitioners working in a pediatric setting of some form, substantiates the need for innovative and evolving intervention strategies that result in improved client outcomes. The positive impact CAT can have on children with varying developmental delays or deficits in occupational functioning is evident through the results from this project as well as the numerous studies cited throughout this paper. The use of a therapy dog via CAT supported improvements in occupational functioning in many children who interacted with the animal during sessions, including occupational performance, performance skills, performance patterns, and the clients context and environment. The fostering of these interactions allowed for children to meet goals earlier and develop skills faster. Overall, this may allow these children to progress through the therapy process quicker, thus allowing for time and space for treatment of other children in society with similar needs. Moreover, earlier achievement of age-appropriate functional CANINE ASSISTED THERAPY IN PEDIATRICS 25 performance may have additional advantages in the long run that are not only personally valuable but also greatly impact society. Overall Learning A significantly integral component throughout this entire process focused on professional and open communication with various staff members at the site, affiliates of the University of Indianapolis, clients, and their parents or guardians. The first, and arguably the most important, interaction was the initial communication between the occupational therapy student, the contact at Hopebridge (the COTA), and contacts at Paws & Think. The student was responsible for reaching out to said contacts professionally, proposing the project in a way that demonstrated potential benefits for both parties, and explaining the logistics for the entire project without appearing to cause too much extraneous stress. Once in the clinic, the student was responsible for explaining the purpose of and advocating for the use of CAT in the outpatient pediatric setting. Many employees and parents were unaware of either the purpose of CAT or how CAT could be implemented into sessions. The communication between different people associated with the clinic allowed for improved understanding of the purpose of the therapy dog, as well as a platform for introducing nontraditional intervention techniques in the world of occupational therapy. The occupational therapy student learned an unquantifiable amount throughout this entire process in preparation for future practice. Largely, the student learned how to independently form contacts, reach out to, and professionally communicate with various parties and organizations in preparation for future needs. The student also learned about and was able to actively practice networking, which allowed for improved inter- and intraprofessional relationships impacting both present and future connections. CANINE ASSISTED THERAPY IN PEDIATRICS 26 On another note, the student learned the importance of applying current supported research into practice and the trials and tribulations that go along with implementing said novel research and techniques. Most research articles are not perfectly replicable, and even if they are, most therapy sessions do not go as planned in the pediatric population. The occupational therapy student learned throughout this project how to adjust the session to incorporate the therapy dog as much as possible for improved outcomes, but also, as stated previously, how to read the needs of both the therapy dog and the child and adjust the session as needed. This four-month project provided relevant experience needed for the student to use the therapy dog in future practice and continue on improving outcomes for children engaging in CAT. The outpatient pediatric setting is fast-paced and often unpredictable. The occupational therapy student learned and honed throughout this process several professional development skills necessary for this setting, as well as others, including leadership, teamwork, responsibility, communication, and adaptability. The student, the first to complete a DCE at this clinical site, demonstrated leadership by being the primary planner and implementer of the project. As described above, the student was responsible for reaching out to various contacts, arranging plans for the project, participating in training to become a certified therapy team, and making adjustments throughout the project as needed. However, the student also relied heavily on teamwork and collaboration throughout the process, communicating frequently with the assigned site mentor (daily) and the faculty mentor (weekly) to make appropriate modifications, ensure the best methods for efficacious data collection, and implement the project in the most effective way. The student grew immensely in the development of professional responsibility, juggling the role of a student implementing a new project and a student occupational therapist, gaining CANINE ASSISTED THERAPY IN PEDIATRICS 27 advanced clinical skills on the days the therapy dog was not present. Three days a week, the student treated the entire caseload with intermittent (minimal) supervision from the COTA/occupational therapist and completed all respective documentation. The student also completed occupational therapy evaluations and updated clients plans of care (POCs) as needed, all while also maintaining up to date on academic requirements. The student demonstrated leadership and advocacy skills throughout the entire process by planning, executing, and adjusting the project as needed. The student was the sole party responsible for the success of this project, and therefore had to demonstrate leadership by proactively solving problems and identifying and implementing solutions. Advocacy was demonstrated by the student in multiple ways: first, the student advocated for the nontraditional practice of CAT in the pediatric setting to the clinical site as a potential DCE project, with evidence-based support; furthermore, the student advocated for the nontraditional area of practice to the various staff members, parents, and clients at the clinical site in order to promote the projects reach and, hopefully, improve results. In summary, this project has taught the occupational therapy student many things about the importance of professionalism, leadership, advocacy, independence, and evidence-based practice as it relates to the world of occupational therapy. The impact this project has made will influence the occupational therapy students practice greatly in the years to come, and has strategically guided the student into a better future practitioner. CANINE ASSISTED THERAPY IN PEDIATRICS 28 References American Academy of Family Physicians (AAFP). (2018). Basics of quality improvement [Website]. Retrieved from https://www.aafp.org/practicemanagement/improvement/basics.html American Occupational Therapy Association (AOTA). (2004). Scope of practice. American Journal of Occupational Therapy, 58(6), 673-677. http://doi.org/10.5014/ajot.58.6.673 American Occupational Therapy Association (AOTA). (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1S48. doi:10.5014/ajot.2014.682006 American Veterinary Medical Association (AVMA). (2018a). Animal assisted interventions: Definitions [Website]. Retrieved from https://www.avma.org/KB/Policies/Pages/AnimalAssisted-Interventions-Definitions.aspx American Veterinary Medical Association (AVMA). (2018b). Human-animal bond [Website]. Retrieved from https://www.avma.org/KB/Resources/Reference/human-animalbond/Pages/Human-Animal-Bond-AVMA.aspx Andreasen, G., Stella, T., Wilkison, M., Szczech Moser, C., Hoelzel, A., & Hendricks, L. (2017). Animal-assisted therapy and occupational therapy. Journal of Occupational Therapy, Schools & Early Intervention, 10(1), 1-17. Beetz, A., Uvns-Moberg, K., Julius, H., & Kotrschal, K. (2012). Psychosocial and psychophysiological effects of human-animal interactions: The possible role of oxytocin. Frontiers in Psychology, 3(234). http://doi.org/10.3389/fpsyg.2012.00234 Berry, A., Borgi, M., Francia, N., Alleva, E., & Cirulli, F. (2013). Use of assistance and therapy dogs for children with autism spectrum disorders: A critical review of the current CANINE ASSISTED THERAPY IN PEDIATRICS 29 evidence. Journal of Alternative and Complementary Medicine, 19(2), 7380. doi:10.1089/acm.2011.0835 Bureau of Labor Statistics. (2018). Occupational outlook handbook, occupational therapists [Website]. Retrieved from https://www.bls.gov/ooh/healthcare/occupationaltherapists.htm Centers for Disease Control and Prevention (CDC). (2017). Autism spectrum disorder (ASD) [Website]. Retrieved from https://www.cdc.gov/ncbddd/autism/data.html Cherniack, E. P., & Cherniack, A. R. (2014). The benefit of pets and animal-assisted therapy to the health of older individuals. Current Gerontology and Geriatrics Research, 2014(623203). http://doi.org/10.1155/2014/623203 Elmac, D. T., & Cevizci, S. (2015). Dog-assisted therapies and activities in rehabilitation of children with cerebral palsy and physical and mental disabilities. International Journal of Environmental Research and Public Health, 12(5), 5046-5060. doi:10.3390/ijerph120505046 Fine, A. H. (Ed.). (2010). Handbook on animal-assisted therapy (3rd ed.). London, UK: Elsevier Inc. Firmin, M. W., Brink, J. E., Firmin, R. L., Grigsby, M. E., & Trudel, J. F. (2016). Qualitative perspectives of an animal-assisted therapy program. Alternative & Complementary Therapies, 22(5), 204-213. doi:10.1089/act.2016.29073.mwf Friedmann, E., Katcher, A. H., Lynch, J. J., & Thomas, S. A. (1980). Animal companions and one-year survival of patients after discharge from a coronary care unit. Public Health Reports, 95(4), 307312. CANINE ASSISTED THERAPY IN PEDIATRICS 30 Griffioen, R. E., & Enders-Slegers, M. (2014). The effect of dolphin-assisted therapy on the cognitive and social development of children with down syndrome. Anthrozos, 27(4), 569-580. doi:10.2752/089279314X14072268687961580 Grossberg J. M., Alf E. F. (1985). Interaction with pet dogs: Effects on human cardiovascular response. Journal of the Delta Society, 2(1), 20-27. Hallyburton, A., & Hinton, J. (2017). Canine-assisted therapies in autism: A systematic review of published studies relevant to recreational therapy. Therapeutic Recreation Journal, 51(2), 127-142. Handlin, L., Hydbring-Sandberg, E., Nilsson, A., Ejdebck, M., Jansson, A., & Uvns-Moberg, K. (2011). Short-term interaction between dogs and their owners: Effects on oxytocin, cortisol, insulin and heart rateAn exploratory study. Anthrozos, 24(3), 301-315. Hopebridge, LLC. (n.d.). About Hopebridge [Website]. Retrieved from http://www.hopebridge.com/about/ Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The PersonEnvironment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9-23. Levinson, B. M. (1997). Pet-oriented child psychotherapy (2nd ed.). G. P. Mallon (Ed.). Springfield, IL: Charles C Thomas Publisher, Ltd. Locke, J. (1699). Some thoughts concerning education (Vol. XXXVII, Part 1). New York, NY: P.F. Collier & Son. Maber-Aleksandrowicz, S., Avent, C., & Hassiotis, A. (2016). A systematic review of animalassisted therapy on psychosocial outcomes in people with intellectual disability. Research in Developmental Disabilities, 49-50322-338. doi:10.1016/j.ridd.2015.12.005 CANINE ASSISTED THERAPY IN PEDIATRICS 31 Martin, F., and Farnum, J. (2002). Animal-assisted therapy for children with pervasive developmental disorders. Western Journal of Nursing Research, 24(6), 657-670. Mayo Clinic. (2018). Cerebral palsy [Website]. Retrieved from https://www.mayoclinic.org/diseases-conditions/cerebral-palsy/symptoms-causes/syc20353999 National Institute of Child Health and Human Development (NICHD). (2017). Down syndrome [Website]. Retrieved from https://www.nichd.nih.gov/health/topics/downsyndrome National Institute for Mental Health (NIMH). (2016a). Autism spectrum disorder [Website]. Retrieved from https://www.nimh.nih.gov/health/topics/autism-spectrum-disordersasd/index.shtml National Institute for Mental Health (NIMH). (2016b). Attention-deficit/hyperactivity disorder [Website]. Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficithyperactivity-disorder-adhd/index.shtml Nightingale, F. (1946). Notes on nursing: What it is, and what it is not (Ed.). New York, NY: Appleton-Century. (Original work published 1859) O'Haire, M. E., McKenzie, S. J., McCune, S., & Slaughter, V. (2014). Effects of classroom animal-assisted activities on social functioning in children with autism spectrum disorder. Journal of Alternative and Complementary Medicine (New York, N.Y.), 20(3), 162-168. doi:10.1089/acm.2013.0165 Parish-Plass, N. (2008). Animal-assisted therapy with children suffering from insecure attachment due to abuse and neglect: A method to lower the risk of intergenerational transmission of abuse? Clinical Child Psychology and Psychiatry, 13(1), 730. doi:10.1177/ 1359104507086338 CANINE ASSISTED THERAPY IN PEDIATRICS 32 Paws & Think, Inc. (n.d.). About Paws & Think [Website]. Retrieved from http://pawsandthink.org/about/ Poleshuck, L. R. (1997). Animal-assisted therapy for children and adolescents with disabilities. Work, 9(3), 285293. Purdue University College of Veterinary Medicine. (2017). What is human-animal interaction? [Website]. Retrieved from https://vet.purdue.edu/chab/ohaire/HAI.php Rodrigues Porto, J., & Bertoldo Quatrin, L. (2014). Effect of animal-assisted therapy on issues related to motor performance and socioaffective interaction of a teen with cerebral palsy: A case study. Conscientiae Saude, 13(4), 625-631. doi:10.5585/ConsSaude.v13n4.5093 Satiansukpong, N., Pongsaksri, M., & Sasat, D. (2016). Thai elephant-assisted therapy programme in children with Down Syndrome. Occupational Therapy International, 23(2), 121-131. doi:10.1002/oti.1417 Schuck, S. B., Emmerson, N. A., Fine, A. H., & Lakes, K. D. (2015). Canine-assisted therapy for children with ADHD: Preliminary findings from the Positive Assertive Cooperative Kids study. Journal of Attention Disorders, 19(2), 125-137. doi:10.1177/1087054713502080 Siewertsen, C. M., French, E. D., & Teramoto, M. (2015). Autism spectrum disorder and pet therapy. Advances in Mind-Body Medicine, 29(2), 2225. Silva, K., Correia, R., Lima, M., Magalhes, A., & de Sousa, L. (2011). Can dogs prime autistic children for therapy? Evidence from a single case study. Journal of Alternative & Complementary Medicine, 17(7), 655-659. doi:10.1089/acm.2010.0436 Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the Person-Environment-Occupation Model: A practical Tool. Canadian Journal of Occupational Therapy, 66(3), 122-33. 10.1177/000841749906600304. CANINE ASSISTED THERAPY IN PEDIATRICS 33 Vincent, B., Kropp, C., & Byrne, A. M. (2014). Animal-assisted therapy for fetal alcohol spectrum disorder. Journal of Applied Rehabilitation Counseling, 45(3), 39. doi:10.1002/syn.21827 Williams, R. L., and Metz, A. E. (2014). Examining the meaning of training animals: A photovoice study with at-risk youth. Occupational Therapy in Mental Health, 30(4): 337357. CANINE ASSISTED THERAPY IN PEDIATRICS 34 Appendix A Table 1 Participants and Diagnoses Number of clients 5 2 1 1 1 Diagnosis/Diagnoses Autism spectrum disorder Down syndrome Cerebral palsy Unspecified disorder of psychological development; unspecified lack of expected normal physiological development in childhood Attention and concentration deficit; delayed milestone in childhood; unspecified lack of coordination Table 2 Quantitative Survey Responses Performance Skill Social skills Gross motor skills Fine motor skills Sensory processing skills Attention Motivation Emotional regulation Cognition Participation Number of Responses Marked as Noticeably Improved After Interaction with Therapy Dog 6 3 1 3 3 7 6 0 7 CANINE ASSISTED THERAPY IN PEDIATRICS Appendix B Outcome Survey for CATs Impact 35  ...