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... The Role of Education on Occupational Therapy Concepts within Child Care Services Calliope Gray 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: Dr. James McPherson, PhD, OTR A Capstone Project Entitled The Role of Occupational Therapy Concepts within Child Care Services 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 Calliope Gray The Role of Occupational Therapy Concepts within Child Care Services 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 THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 3 Abstract This doctoral capstone project will focus on the education of staff, by a doctoral capstone student, within a daycare setting in order to improve their current knowledge and ability to implement concepts of occupational therapy into the daily routines of their classes. The purpose of this project is to educate the staff of a childcare facility on the topics of sensory awareness, behavior modification, health and wellness, and left brain/right brain, while working within the classrooms to identify areas of need and apply the topics in order to improve the knowledge and abilities of the staff. Education occurred through presentations regarding each topic, and classroom collaboration with the staff. Data was gathered through pre- and post- surveys in order to determine changes in staff level of competence, ability to relate the topic to the class, and resources available. Overall, improvements were seen in nearly all topics covered at the site, demonstrating that the staffs knowledge and implementation abilities increased due to the education they received on concepts involved within occupational therapy. Introduction Childcare facilities in the state of Ohio do not have the services of occupational therapy included in their businesses. While some children are able to receive services prior to entrance to Kindergarten, this only occurs when identifiable problems are noted in the child and are addressed by parents, doctors, or teachers. In 2010, it was recorded that 12.1 million children under the age of 5 attended care outside of their home, and 24% of these children were in a daycare setting (United Census Bureau, 2011). According to the United Census Bureau, children spend an average of twenty-five to thirty-three hours per week in a daycare setting (2011). This means, that children spend the majority of their week with their teacher in their classroom. If teachers have knowledge of occupational therapy and the topics involved within the practice, THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 4 then they may be able to better identify difficulties in the children that they are interacting with each day and address these difficulties as needed. By educating the teachers, this may help to ensure that all childrens needs are appropriately met, and that teachers may understand the appropriate challenges that children need to grow and succeed. Given this information, it is relevant for teachers to understand the concepts of occupational therapy, since it is not directly provided at the daycare site. Staffs should be educated on current information and research to ensure they are utilizing up-to-date practices when leading their students. If teachers have current foundational concepts and are able to properly communicate with parents, the children in their classes may be better served, and the staff may have more foundational concepts to rely upon. If childrens needs are not met within their daily classrooms, they may develop problems as they continue to age, such as difficulty with motor control, social participation, and behavior regulation (Cosbey, Johnston, & Dunn, 2010; May-Benson & Koomar, 2010). This doctoral capstone project will focus on the education of staff within a daycare setting in order to improve their current knowledge and ability to implement practices into the daily routines of their classes. The Adult Learning Theory The Adult Learning Theory, which is also known as andragogy, was created by Malcolm Shepherd Knowles (Learning Theories, 2017). This theory will apply to the staff at Evergreen Childrens Center Inc., as it will aid in creating a better understanding of how the adults may learn (Merriam, 2008). Having knowledge of this will allow the DCE student to apply this information to presentations and classroom collaborations with the staff. Knowles theory contains five assumptions of adult learners, each of which will be used to ensure teachers at the site are able to learn effectively. These assumptions include self-concept, past learning experience, readiness to learn, orientation to learning, and motivation to learn (Pappas, 2013). THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 5 The aspect of self-concept will be used to ensure that teachers feel they obtain enough knowledge on each topic so that they may be able to self-direct and be independent on classroom implementation (Pappas, 2013). When presentations to the staff and collaborating within the classroom, past learning experience will be used in order for the staff to share experiences with their peers. The DCE student will also use these experiences to as further opportunities for learning when completing education (Pappas, 2013). Readiness to learn occurs from the site expressing their needs and asking their own questions in order to achieve the answers they need (Pappas, 2013). Orientation to learning till be affected by staff learning to apply the topics discussed with ease, rather than having to delay action due to lack of knowledge. By learning from the DCE student, staff will be able to effectively apply concepts efficiently and without delay in order to achieve better outcomes within the classroom (Pappas, 2013). The last assumption of Knowles to be used will be motivation to learn, which will occur internally within the staff and drive them to have a desire to obtain more knowledge on the topics to use in their future (Pappas, 2013). In addition to the five assumptions playing a role in the education of staff at the site, the four principles of Knowles theory will also be used to ensure optimal learning (Learning Theories, 2017). Since self-direction is to occur through the assumptions, adults will be given the opportunity to provide input into their learning through asking questions in their surveys (Learning Theories, 2017). This will help to ensure that staff are active in finding answers to questions they may have. Since adults have past experience, they will use this information to add to their previous knowledge, which will be done through reflecting on past experiences and relating this to the current learning (Merriam, 2008; Learning Theories, 2017). Next, due to adults wanting practical learning, the content will remain focused on the staff members work and THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 6 difficulties which may arise within their classrooms in order to ensure information is relatable to their situations (Learning Theories, 2017). Finally, learning will focus on problem solving by having constructive conversation with teachers to ensure that they are not memorizing the information presented, but are applying it within the classroom setting (Learning Theories, 2017). The Person-Environment-Occupation-Performance Model The model that will be used while at this site is the Person-Environment-OccupationPerformance (PEOP) model (Cole & Tufano, 2008). By using this model, the teachers will be able to gather more understanding of how children within their classrooms may be having difficulty, and how they may work to make changes within the environment. The person discussed will be the children, and the environment will vary depending on where the class is interacting (Cole & Tufano, 2008). The environment at Evergreen Childrens Center Inc. may vary between the Art room, S.T.E.M. room, Evergreen room, Library, playground, woods, and lunchroom. These environments may affect the children in various ways, so it is important to consider each one in order to best understand the children. Next, the childrens occupations will be taken into consideration, which may include writing, completing projects, playing and more. Lastly, the childs ability to perform a task will be noted, and then this information will be relayed to the teacher. By displaying the information through concepts of this model, the teachers will be better able to understand what children in their classes most need to succeed and where changes are needed to create the most optimal environment for students (Cole & Tufano, 2008). This doctoral capstone project examines four areas in which need is identified within the site, and addresses these topics with the staff and teachers. Each topic is discussed below with information pertaining to a review of the literature regarding each topic. THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 7 Sensory Awareness Sensory processing includes an individuals ability to process their senses so that they may properly participate in their daily activities (Case-Smith & OBrien, 2015). Sensory functions are a vital part of each individual and are an important body function which help to structure a person and their ability to perform daily activities (American Occupational Therapy Association, 2014). Research has found that 95% of children with a diagnosed developmental disability have diagnosed sensory processing difficulties. In addition to this, at least 14% of Kindergarteners and 16% of elementary-aged children have diagnosed sensory difficulties without developmental disabilities (Watling & Mori, 2017). Sensory difficulties may include children having low registration, being sensation seeking, being sensory sensitive, or having sensory avoidance, and vary between individuals (Dunn, 2007). Although these percentages are known, this only includes those children with severe sensory difficulties which have been properly diagnosed, and is unknown at this time the percentage of children with sensory difficulties which have not been diagnosed (Watling & Mori, 2017). When working with children, it is important to review the seven senses which are important components to a childs development (Watling & Mori, 2017). The seven senses include vision, auditory, gustatory, olfactory, tactile, vestibular, and proprioceptive (Watling & Mori, 2017). During childhood, it has been found that years three through seven are the most foundation for the future of an individuals sensory abilities (Case-Smith & OBrien, 2015). This relates to the DCE site as the children in attendance range from the ages of eighteen months through eleven years. Although not all children in attendance fall within the age range of three to seven, it is still important for children to experience the seven senses prior to the age of three, to ensure they are properly prepared to lay a foundation, and after the age of seven to ensure that THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 8 continued growth and development may occur (Case-Smith & OBrien, 2015). If children are able to take part in sensory exploration, which comes naturally to most children, then they will learn to appropriately respond to situations within their environment and learn to form typical behaviors (Case-Smith & OBrien, 2015). It is important for teachers to understand that although they may not have severe difficulties, the children in their class may benefit from changes to their environment. Children who have unmet sensory needs have been shown to have difficulty with social participation, which affects their ability to properly participate in their daily occupations (Cosbey, Johnston, & Dunn, 2010). Also, fine motor difficulties and gross motor planning can become affected if a child has continued sensory difficulties that are not addressed properly (May-Benson & Koomar, 2010). Behavior Modification Behavior difficulties can arise at any age, and in a variety of ways such as temper tantrums, lack of participation, defiance, and more (Osterman & Bjorkqvist, 2010). This topic is important for teachers and staff to have an understanding of, as behaviors occur in all children. About eighty-seven percent of parents report that their children have behavioral regulation difficulties (Osterman & Bjorkqvist, 2010). About sixty-four percent of children ages two to three years old have behavior difficulties, which then lessens to about fifty-one percent of children older than five, and then only about four percent of children over age eight have the same difficulties (Osterman & Bjorkqvist, 2010). Hence, as children get older, they are less likely to experience behavioral difficulties; however, when situations occur, they last typically between five and ten minutes (Osterman & Bjorkqvist, 2010). Teachers should have a more complete understanding of this so they are aware what are behavior is typical, what they may do for certain behaviors, and how they can best address those in need within their classrooms. THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 9 Having increased exposure to the topic at this time of the DCE can educate staff on new topics in research as well as provide insight into behavior management techniques which have not yet been attempted at the site. Behavior modification is the process of changing a behavioral pattern through an individuals learning (Morin, 2017). When working with children with behavioral difficulties, it is important to ensure that teachers are recognizing the individual and have the means to address situations as needed (Eyberg, Nelson, & Boggs, 2008). Without having resources available, staff may not be able to sufficiently manage a situation within their classroom, and may need additional help in a situation. By ensuring staff have a meaningful understanding of behavior modification, they may feel more competent in their ability to handle situations, and use the resources they have to properly execute a plan within the classroom (Hayes, Gardere, Abowd, & Truong, 2008). Health and Wellness When educating the staff on health and wellness in children it is important to educate on the seven dimensions of wellness, to ensure that staff is considering all components of an individual in their classroom (University of California Riverside, 2014). The seven dimensions which will be included are social, emotional, spiritual, environmental, occupational, intellectual, and physical (University of California Riverside, 2014). When educating the staff, some dimensions may be more relevant to the staff needs, these include physical, emotional, social, and intellectual (University of California Riverside, 2014). The Centers for Disease Control (CDC) released data regarding physical wellness which showed that from 2015 to 2016 one in every five school aged children has obesity (2018). Healthy eating habits are also important to childrens physical wellness, as forty percent of childrens daily intake is from sugars and solid THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 10 fats, and sugar-sweetened beverages are ten percent of childrens daily intake (CDC, 2017). Due to the obesity rates among children, it is recommended that children should get at least sixty minutes of physical activity per day, while also be educated on healthy eating habits in order to promote better physical wellness (CDC, 2018). Although individuals should be educated on physical health for promotion of healthy eating habits, it has also been shown that emotional and mental health may relate to individual eating habits and obesity (Russell-Mayhew, McVey, Bardick, & Ireland, 2012). Mental health diagnosis in children is becoming more prevalent and more of a concern as the ability to diagnose children earlier arises (NAMI, 2018). More than fifty percent of children between ages eight and fifteen receive services for mental health, and children with unmet mental health needs have the highest dropout rate of any group with disabilities (NAMI, 2018). By educating staff and health and wellness, they will have the opportunity for expanded knowledge on the topic and concepts involved in order to allow for proper classroom implementation. Left Brain and Right Brain When discussing left brain and right brain, it is important to consider how each hemisphere affects the body, and ensure integration occurs for proper development (Olgakabel, 2014). The left hemisphere is to be more involved with language and motor control, while the right brain is known more for spatial representation and attention (Serrien, Ivry, & Swinnen, 2006). However, it has been shown that although these areas are more focused within each hemisphere of the brain, they cannot fully develop without communication between the two hemispheres (Serrien, Ivry, & Swinnen, 2006). Since each hemisphere has control over the opposing side of the body, proper integration will allow for bilateral coordination, crossing the midline, and proper developmental stages to THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 11 occur (Olgakabel, 2014). Both hemispheres of the brain are used depending on which task is being attempted by an individual, which allows individuals to complete tasks to the best of their abilities (BrainoBrain, 2016). Brain integration can occur through numerous forms, such as completing movements and exercise that involves usage of both hemispheres (Olgakabel, 2014). If an individual does not have proper integration between the hemispheres, they may not have the necessary skills to complete tasks and address challenges of daily living (Field, 2017). Individuals with decreased left brain and right brain integration also may lack flexibility, spontaneity, and problem solving skills (Field, 2017). Hence, it is important to ensure individuals are given a variety of activities to address each hemisphere and allow for growth in the brain. After reviewing each of the topics chosen for this doctoral capstone experience, it can be seen that all topics are relevant to the staff at the daycare center, and the concepts apply to children of all ages in attendance. The purpose of this project is to educate the staff of Evergreen Childrens Center Inc. on the topics of sensory awareness, behavior modification, health and wellness, and left brain/right brain, while working within the classrooms to identify areas of need and apply the topics in order to improve the knowledge and abilities of the staff. Screening and Evaluation When reviewing the literature it can be seen that teachers and staff being properly educated is important to the development of the child. If teachers do not understand the different aspects of their students, then they may not be able to help them to the best of their abilities. It has been shown that less than one-third of teachers feel they are able to properly incorporate different individual needs into their daily classroom (AOTA, 2017a). Before arriving at the site, it was determined that there was no occupational therapist working at or with the site. Children served by the daycare site are determined to be between the ages of eighteen months and eleven THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 12 years. When reviewing available occupational therapy services, early childhood services occur birth through the age of three, school-based therapy occurs beginning in Kindergarten and then throughout the childs education, and outpatient services cover through the age of eighteen for pediatrics (Opp, A, 2018; AOTA, 2016). Hence, all children attending this site are age appropriate for occupational therapy services, meaning that all topics which staff are being educated on are appropriate for the students in attendance. After determining this information prior to arriving at the site, the student then met with the director of Evergreen Childrens Center in order to discuss areas which were to be addressed with teachers for further development of skills, and hence conduct an assessment of their needs. The areas of need were determined to be sensory awareness, behavior modification, health and wellness, and left brain/right brain, as were previously discussed within the literature review. These areas of need were identified collaboratively between the DCE student and the site mentor. The DCE student had previous opportunities to interact with the daycare staff and classes in order to determine that the areas of need described were relevant to the DCE. Sensory awareness arose as a need due to staff questioning how they could improve sensory experiences, and acknowledge sensory difficulties within the children (Case-Smith & OBrien, 2015). Behavior modification is a topic necessary for education so that staff feel competent in their ability to address varying behavior situations (Osterman & Bjorkqvist, 2010). Also, staff would have the knowledge base of various approaches to behaviors which are seen among children at the site (Morin, 2017). Health and wellness is needed to educate the staff on various aspects of health and wellness, including the seven dimensions of wellness, in order to ensure the staff has a holistic understanding of the topic (University of California Riverside, 2014). Lastly, left brain and right brain is a need for staff to ensure they are addressing both hemispheres of the THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 13 developing brain in the children, and providing opportunities for integration throughout daily activities. (Olgakabel, 2014). Through collaborative discussions with the site mentor, it was determined that the student would be educating staff on the four concepts identified, and that the DCE student would be working with the classrooms as a supplement to the education they are receiving. To begin the screening process, the occupational therapy student began by observing within each classroom. This allowed for an understanding by the DCE student of daily schedules, activities, and expectations which the teachers had for their classes. In order to further evaluate understanding of the topics to be addressed, all staff member were provided with a survey. These surveys contained three Likert scale statements and an opportunity for teachers to ask their own questions as well. The Likert statements were self-scoring and on a range of one to five, where one is strongly disagree, two is disagree, three is neutral, four is agree, and five is strongly agree. The three statements included in the survey were as follows: I feel that I am competent about this topic, I feel that this topic relates to the class I am teaching, and I have resources available to me about this topic. By having the teachers answer the question What would you like to learn about this topic? Are there any questions you have? at the end of the survey, there was an opportunity to further evaluate areas of concern and ensure these were addressed later. Pre-test survey information was analyzed to assess the amount of education needed, the resources presently available, and to ensure questions were answered within presentations. These surveys are to be used for each topic, as a measure of pre and post intervention, see Appendix A. Relation to Other Settings Due to their relation to the DCE site, it is important to consider how occupational therapy plays a role within other practice settings which treat similar ages. School based occupational THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 14 therapy is a well-known setting in the field of occupational therapy. When a child receives school-based occupational therapy services, these typically occur beginning in Kindergarten, and continuing throughout a childs education. Twenty-five percent of occupational therapists work in a school based or early intervention setting (AJOT, 2017b), demonstrating the prevalence of this practice area. Within this setting children work with an occupational therapist to improve areas such as sensory processing (Watling & Mori, 2017), behavior modification (Osterman & Bjorkqvist, 2010), health and wellness (University of California Riverside, 2014), and left brain/right brain (Olgakabel, 2014) by completing assessments, evaluations, and collaborating with a multidisciplinary team. By working with a multidisciplinary team, occupational therapists in the school setting are able to create an Individualized Education Plan (IEP) (AJOT, 2017a). An IEP helps all staff who interact with a child in the school system to have knowledge on their needs for success in the classroom (AOTA, 2017a). Hence, it is important for staff within a daycare setting to also have knowledge on these topics so that they may understand the relation to their own classrooms, and work to ensure all children have the highest levels of success that they can. At this point teachers at the DCE site are not receiving education that is current on these topics, and are then not able to implement the best practices into their daily work. By educating the teachers on the importance of engagement for their students in these topics, they will have more opportunity to improve the quality of life in the children attending their classes, as well as increase the childrens performance in necessary areas. It is important for the doctoral capstone student to educate staff at the site on the topics identified in order to ensure the teachers are providing the best quality of care and improving the functional abilities of their students (AOTA, 2014). Having occupational therapy within a daycare setting is similar to the school setting THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 15 because the children at the daycare in the morning are attending pre-school. Also, even though pre-school ends prior to the afternoon, it is still filled with structured and educational time. However, one difference between daycare and school settings is that those children attending school have the opportunity to receive occupational therapy, but those only attending pre-school at the doctoral capstone site do not have occupational therapy services at this time. This also relates to the teachers, as those teachers in the school setting have the opportunity to interact with an occupational therapist and understand how they may best serve children in their classes. Teachers at the doctoral capstone site on the other hand do not have the resource of a knowledgeable occupational therapist to provide information on the best practice for their classroom. Another setting where children can receive occupational therapy is the outpatient setting. If a child is attending outpatient therapy, their teacher may be unaware of difficulties they are having, and may have no communication with the therapist. The staff at the DCE site has communication with families and has knowledge on outside services some children are receiving, but staff still does not have the opportunity to interact with the therapists. Outpatient therapy services are also different than having occupational therapy within a pre-school setting, as these children would already be attending the pre-school where the service is offered. With outpatient therapy, parents have to arrange for separate times to pick up their children and take them to therapy; however, is a child is arranged to have therapy at pre-school, this could be incorporated into their schedule and not take additional time out of the familys day. The Implementation Phase After completing the needs assessment with the director and receiving feedback from surveys filled out by the staff, the implementation phase may begin. For each of the four topics THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 16 discussed, the same implementation plan was put into place, as each topic was focused on for four weeks. The student began by reviewing surveys and questions which staff had, and began to compile power points with relevant information. Also, the student completed observations within the classrooms to determine themes that may be relevant to educate teachers on for classroom modification. Presentations were given twice over each topic, so that staff had an opportunity to choose which session they would attend. This worked to ensure that all staff members were able to attend each topic, while also confirming that classes were able to be covered and staff did not become short-handed due to the presentations. All presentations took between forty-five and sixty minutes including staff questions. Each presentation contained information relevant to the topic, and examples which may be included within the classroom environment. The information included on the individual topics comprised of themes that were addressed through staff questions, and student observations. Themes included within the sensory awareness power point presentation were sensory strategies, definitions of sensory processing, and information on the seven senses (Watling & Mori, 2017). The next topic of behavior modification included information on making behavior modification plans, potential causes of behaviors, and approaches to behaviors (Osterman & Bjorkqvist, 2010). Health and wellness included themes of mental health, and physical health (UCR, 2014). Left brain/right brain included themes of crossing midline, bilateral coordination, and occupations involved within the hemispheres of the brain (Olgakabel, 2014). All presentations were provided to the site in digital format for future use and reference after the students departure. After presentations were given, the doctoral capstone student returned to the classrooms to further educate teachers on how they may use the topics discussed to better their classrooms and the childrens education. While in the classroom the student had conversations with each THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 17 teacher in order to ensure individual understanding. When a teacher had questions, the student was also able to demonstrate solutions through the one on one interactions to provide the best quality of care. Throughout the time at the site the student also compiled resources for the teachers to have after the doctoral capstone experience is completed. The resources included: a list of sensory objects at the site, lists of recommended activity videos for physical activity indoors, outlines for age appropriate guidelines, a behavior modification plan outline, and other resources as requested by the site, which were all kept within a binder to be left at the site, as well as digital copies of presentations were stored as well. Once this implementation was complete, surveys were re-administered to staff to track improvements, and final outcomes. Staff Development While working with the staff, development occurs throughout the implementation phase. Staff can develop their own skills through one on one interaction with the student, having questions answered, and working within their own classrooms. There is also an opportunity for staff to develop group skills at presentations. These presentations allow for staff members to ask questions to not only the student, but to their fellow staff members. This may provide alternative perspective to a situation. By creating these opportunities for further interaction, the staff also may learn to continue to use this questioning after the student leaves in order to receive differing perspectives on a situation and alternative solutions. Leadership The doctoral capstone student demonstrated leadership at the site in numerous ways. Presentations were all given by the student, which allowed the student to lead the staff group attending for forty-five to sixty minutes. This allowed the student to practice commanding a group to ensure all topics were covered, while also working collaboratively with a group to THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 18 ensure the presentation was inclusive, interactive, and answered all remaining questions. This was a valuable opportunity for the student to learn the components of presenting to a small group. Leadership also occurred through the student taking initiative within the classrooms to demonstrate strategies to staff, answer various questions that arose, and individual interactions with staff and students. This allowed the student to have the opportunity to learn leadership in individual situations and through taking more initiative. Also, the student was able to learn to be proactive through observations to determine what areas may become questions for staff in the future. Outcomes Pre and post survey information was compiled into figures to assess improvement after the implementation phase of the DCE. Ten staff members filled out the surveys for sensory awareness, while eleven staff members filled out the survey for behavior modification, health and wellness, and left brain/right brain due to addition staff attending the latter three sections. Sensory processing, covered weeks one through four, discussed the senses and they may be Sensory Integration incorporated into the classroom to 5 benefit childrens development 4 (Watling & Mori, 2017). For sensory 3 Pre 2 post 1 0 awareness, it can be seen in Figure 1 that after implementation occurred the Competence Relation to class Resources available Figure 1. Sensory awareness results of pre and post surveys provided to ten staff members, showing increases in all areas. teachers level of competence, the teachers ability to relate the topic to their class, and the amount of resources the teacher obtained all increased. This demonstrates that teachers did feel that they were able to THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 19 have a greater understand and more ability to properly implement the concepts of sensory processing into their daily classrooms in order to meet the needs of their class. Staff was also able to see that this topic related to their class more than they originally believed. Additional resources were provided to the site through online resources, and handouts included within the resource binder regarding sensory clothing, sensory items available throughout the site, and suggested sensory activities. Throughout classroom time, the DCE student was able to demonstrate sensory table ideas, adaptive materials for sensory needs children may face, concepts for sensory inclusive art projects, and other various ways of activating all of a childs senses throughout their daily routine. Behavior modification was the second topic discussed during weeks five through eight. This topic covered what it means for a child to have behaviors requiring modification, and how teachers can manage through with challenging behaviors (Osterman & Bjorkqvist, 2010). Results of the behavior modification topic can be seen in Figure 2. The surveys for this topic were completed by eleven staff members. This shows that staff felt more knowledge and competence on the topic after implementation of Behavior Modification 5 the presentation and the DCE students 4 working within the classrooms. Staff 3 Pre 2 post 1 also felt that they had greater resources available, likely due to the inclusion of 0 Competence Relation to class Resources available Figure 2. Behavior modification results of pre and post surveys provided to eleven staff members. Showing increases in competence and resources. a behavior modification plan template, and online resources. When looking at relation to class it can be seen that less teachers felt this topic related to their classroom. From discussion with teachers while working in THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 20 the classrooms, it was determined that numerous staff members believed children in their classes had behaviors which required modification; however, after implementation he teachers expressed that they no longer felt their children had behaviors requiring modification, but instead that these behaviors were typical of the age and could be handled in other ways. While working in the classrooms, the DCE student was able to demonstrate techniques for coping with children having behavior difficulties, and preventing behaviors from occurring by removing triggers within the childs environment. The health and wellness topic at this site, covered weeks nine through twelve, discussed the importance of health components within a childs life (University of California Riverside, 2014). It can be seen in Figure 3 that staff improved in all areas after the implementation phase Health and Wellness was completed. This demonstrates 5 that the staff felt more competence, 4 relation to class and resources 3 Pre 2 post 1 availability after the presentation and classroom interactions. Staff were 0 Competence Relation to class Resources available Figure 3. Health and wellness results of pre and post surveys given to eleven staff members, showing increases in all areas. provided with resources of recommended books for children on various aspects of health, as well as recommended songs that include encouragement of healthy habits. A compiled list of indoor activities allowing for physical activity to occur was also provided to be used for days when the classes are unable to go outside. Throughout classroom time the DCE student was able to demonstrate hope to talk to children about their feelings, such as using social stories, and provide the staff present with feedback on classroom implementation. THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 21 The left brain/right brain portion of the DCE is in the implementation phase, as it is being completed weeks thirteen through sixteen (Olgakabel, 2014). Figure 4 demonstrates the increases seen in all areas of survey completion. This demonstrates that again staff felt more competence, relation to class and resource availability after implementation. Staff were provided with resources of recommended exercises, Left Brain/Right Brain information on the hemispheres of the 5 brain, and recommended activity to 4 3 Pre 2 post 1 encourage brain integration. Throughout classroom time the DCE 0 Competence Relation to class Resources available student was able to demonstrate proper implementation of exercises. In Figure 4. Left brain/right brain results of pre and post surveys given to eleven staff members, showing increases in all areas. addition staff then had the opportunity to understand what challenges with crossing the midline may be, and how exercises may come to help those in their classrooms. Overall it can be seen that the staff experienced increases in their competence, relation to class, and resource availability after implementation. This demonstrates that the staff did benefit from receiving education on occupational therapy concepts. Quality Improvement & Impact on Society Throughout the doctoral capstone experience the DCE student discussed with the staff at the site their expectations and the areas of their classrooms which may need addressed. This allowed for continued conversation throughout the experience to ensure the site was provided with what was needed to meet their ongoing needs. The student also had conversation with the site mentor throughout the DCE to ensure their needs and expectations were also met. A resource THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 22 binder being left at the site includes up-to-date information which the site may use in order to continue implementation within the classroom. After the DCE student leaves the site, it will be the responsibility of the director, or individually assigned teachers to continue implementation of the concepts within the classrooms. Conclusion Overall, it can be seen that when working with teachers and staff in a daycare setting, there is an overall improvement on teacher knowledge and concept implementation within the classroom. Staff are now more able to provide a variety of solutions for situations which may arise within their classroom. Throughout the experience staff had the opportunity to learn more about the situations they face daily, and the action they may take to face challenges their students obtain. Although it cannot be measured within the time allotted at this site, this will likely have a positive impact on the children in attendance at the site, as they may receive more educated care. Overall Learning By completing the DCE, the student was provided with the opportunity for interaction with a variety of individuals, and a chance to learn valuable experiences for future practice. The student had the opportunity to work with all staff members at the site, while also having the chance to work with children. Communication was a key component in these interactions, and was vital to the execution of the DCE. Oral communication was the main method of communication at the DCE site. Presentations were provided on each topic orally, and discussions throughout presentations also occurred to ensure proper understanding while information was being provided. While working in the classrooms, oral communication was vital to ensuring that the DCE student had a proper understanding of classroom functions. In addition, this form of communication was important to ensure that staff understood what the student was THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 23 observing within the classroom, which children may be having difficulties, and how the staff may come to address the childrens various needs. This allowed for a dialogue to occur between the staff and the DCE student to ensure proper understanding of implementation and modifications necessary within each classroom. Nonverbal communication occurred mostly through the DCE students interaction with children in the classrooms. By having these interactions, the DCE student was able to demonstrate to the staff, in a nonverbal manner, actions to take in a given situation to help a child best succeed. Written communication was completed first by the staff filling out surveys, and then by the student providing the site with handouts and resources for future use. These handouts were also provided to parents, by the staff, which created a greater outreach to the childrens families and the public. Notes also provided a way for written communication to occur. If staff members had questions before or after the student was on site, they would leave notes in the main office for the student to address when they returned. Dissemination of this paper also provided written communication for those involved within the profession, or those of the public wanting to learn more about the topics included. From this experience, the student learn the aspects of the Adult Learning Theory, and how to best use these principles to educate adults on various topics (Learning Theories, 2017). This will be beneficial to future practice as the student as more experience educating adults, and can apply the newly practiced principles of the Adult Learning Theory to individuals who may be seen in the future. The student also had the opportunity to apply the PEOP model to the DCE, which provided a chance for the student to apply these concepts and examine the individual roles of each person, their environment, their occupation, and their performance in the topic areas discussed (Cole & Tufano, 2008). This was applied to the staff, to ensure their knowledge and THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 24 understanding of each topic, but also to the children in attendance to ensure that their needs were being identified and addressed as necessary. While the experience of using theories and models will be beneficial to the students future practice, the chance to work with individuals on education was extremely beneficial. Opportunities for interaction with various ages was valuable to the DCE student as experience was gained working with different populations. Through working with the teachers, the student had the opportunity for further interaction with adults; however, there also was opportunity to work with and interact with the children at the site. By interacting with all ages throughout the time at the site, the student gained a valuable understanding of the role occupational therapy may play despite the age of an individual. Completing the doctoral capstone experience provided the student with insight into how to educate adults, and work to develop programs in order to educate a population on the importance of occupational therapy concepts. THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 25 Appendix A Pre-test Survey Topic: -I feel that I am competent about this topic. Strongly Disagree Disagree Neutral Agree 1 2 3 4 Strongly Agree 5 -I feel that this topic relates to the class I am teaching. Strongly Disagree Disagree Neutral Agree 1 2 3 4 Strongly Agree 5 -I have resources available to me about this topic. Strongly Disagree Disagree Neutral Agree 1 2 3 4 Strongly Agree 5 What would you like to learn about this topic? Are there any questions you have? Post-test Survey Topic: -I feel that I am competent about this topic. Strongly Disagree Disagree Neutral Agree 1 2 3 4 Strongly Agree 5 -I feel that this topic relates to the class I am teaching. Strongly Disagree Disagree Neutral Agree 1 2 3 4 Strongly Agree 5 -I have resources available to me about this topic. Strongly Disagree Disagree Neutral Agree 1 2 3 4 Strongly Agree 5 THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 26 Resources American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1). doi: http://dx.doi.org/10.5014/ajot.2014.682006 American Occupational Therapy Association (AOTA) (2016). Fact sheet: Occupational therapy in school settings. American Occupational Therapy Association. Retrieved from: https://www.aota.org/~/media/Corporate/Files/ AboutOT/Professionals/WhatIsOT/CY/ Fact-Sheets/School%20Settings%20fact%20 sheet.pdf American Journal of Occupational Therapy (AJOT) (2017a). Guidelines for occupational therapy services in early intervention and schools. American Journal of Occupational Therapy, 71 (2). Retrieved from: http://ajot.aota.org/terms American Journal of Occupational Therapy (AJOT) (2017b). Occupational therapys role in inclusion and school routines. American Journal of Occupational Therapy. Retrieved from: https://www.aota.org/~/media/Corporate/Files/Secure/Practice/Children/OTs-Rolein-Inclusion-Infographic.pdf BrainoBrain (2016). Integrating the two hemispheres of the brain. BrainoBrain. Retrieved from: http://www.brainobrain.cz/en/2016/06/26/integrating-the-two-hemispheres-of-the-brain/ Case-Smith, J., & OBrien, J.C. (2015). Occupational therapy for children and adolescents. (7th ed.). St. Louis, MO: Elsevier Mosby. Centers for Disease Control (CDC) (2017). Childhood nutrition facts. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/healthyschools/nutrition/facts.htm THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 27 Centers for Disease Control (CDC) (2018). Childhood obesity facts. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/healthyschools/obesity/facts.htm Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Cosbey, J., Johnston, S. S., & Dunn, M. L. (2010). Sensory processing disorders and social participation. American Journal of Occupational Therapy, 64, 462473. doi: 10.5014/ajot.2010.09076 Dunn, W. (2007). Supporting children to participate successfully in everyday life by using sensory processing knowledge. Infants & Young Children, 20(2). 84-101. Field, T. A. (2017). Integrating left-brain and right-brain: The neuroscience of effective counseling. The Professional Counselor. Retrieved from: http://tpcjournal.nbcc.org/integrating-left-brain-and-right-brain-the-neuroscience-ofeffective-counseling/ Eyberg, S. M., Nelson, M. M., Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37(1), 215-237. doi: 10.1080/15374410701820117 Hayes, G. R., Gardere, L. M., Abowd, G. D., & Truong, K. N. (2008). Carelog: A selective archiving tool for behavior management in schools. Tools for Education. Retrieved from: https://people.eng.unimelb.edu.au/vkostakos/courses/ubicomp10S/papers/healthcare/haye s-08.pdf Learning Theories (2017). Andragogy-Adult learning theory (Knowles). Learning Theories. Retrieved from: https://www.learning-theories.com/andragogy-adult-learning-theoryknowles.html THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 28 May-Benson, T. A., & Koomar, J. A. (2010). Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. American Journal of Occupational Therapy, 64, 403 414. doi: 10.5014/ajot.2010.09071 Merriam, S. B. (2008). Adult learning theory for the twenty-first century. Wiley InterScience: New Directions for Adult and Continuing Education, 119. 93-98. doi: 10.1002/ace Morin, A. (2017). What is behavior modification? VeryWell. Retrieved from: https://www.verywell.com/what-is-behavior-modification-1094788 National Alliance on Mental Illness (NAMI). (2018). Mental health by the numbers. National Alliance on Mental Illness. Retrieved from: https://www.nami.org/learn-more/mentalhealth-by-the-numbers Olgakabel. (2014). How to integrate your right and left brain through movement. Sequence Wiz. Retrieved from: http://sequencewiz.org/2014/08/13/integrating-right-and-left-brain/ Opp, A. (2018). Occupational therapy in early intervention: Helping children succeed. American Occupational Therapy Association. Retrieved from: https://www.aota.org/AboutOccupational-Therapy/Professionals/CY/Articles/Early-Intervention.aspx Osterman, K., & Bjorkqvist, K. (2010). A cross-sectional of onset, cessation, frequency, and duration of childrens temper tantrums in a nonclinical sample. Psychological Reports, 106(2), 448-454. doi: 10.2466/PRO.106.2.448-454 Pappas, C. (2013). The adult learning theory-Andragogy-of Malcolm Knowles. eLearning Industry. Retrieved from: https://elearningindustry.com/the-adult-learning-theoryandragogy-of-malcolm-knowles THE ROLE OF EDUCATION WITHIN CHILD CARE SERVICES Gray 29 Russel-Mayhew, S., McVey, G., Bardick, A., & Ireland, A. (2012). Mental health, wellness, and childhood overweight/obesity. Journal of Obesity, 1-9. doi: 10.1155/2012/281801 Serrien, D. J., Ivry, R. B., & Swinnen, S. P. (2006). Dynamics of hemispheric specialization and integration in the context of motor control. Nature Reviews: Neuroscience, 7. 160-167. Retrieved from: http://sequencewiz.org/wp-content/uploads/2014/08/Dynamics-ofhemispheric-specialization.pdf United Census Bureau. (2011). Child care in the 21st century. Retrieved from: https://www.census.gov/newsroom/pdf/cspan_childcare_slides.pdf University of California Riverside (2014). Seven Dimensions of Wellness. UC Riverside. Retrieved from: https://wellness.ucr.edu/seven_dimensions.html Watling, R., Mori, A. B. (2017). Frequently asked questions (FAQ) about: Ayres sensory integration. American Occupational Therapy Association, 1-5.  ...

... THE METAL ANALYSIS OF DOG FOOD By Hannah Clinton 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. Brad Neal. April 15, 2016. Approved by: __________________________________________________________________ Dr. Brad Neal, Faculty Advisor ______________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College ______________________________________________________________________ First Reader ______________________________________________________________________ Second Reader Abstract Packaged dry kibble is the main source of nutrients for most household dogs. As such, it is important that kibble contains proper amounts of various metals necessary for biological functions including ATP production, maintaining the proper biochemical gradient across cell membranes, and respiration. Therefore, the concentrations of specific metals in various brands of dog food were analyzed using the microwave plasma atomic emission spectrometer (MP-AES) via an adapted methodology that can now be applied to future, similar undergraduate research projects. Because of their critical roles in maintaining the functionality of the body, sodium, potassium, magnesium, iron, and calcium were chosen to be the focus of this study. The elemental concentrations determined by the methodology using the MP-AES were compared to the accepted concentration guidelines put forth by the American Association of Feed Control Officials (AAFCO). Based on the importance of each metal and how closely each foods concentration of metals compared to the AAFCO recommended values, the dog foods were assessed. H. Clinton iii Acknowledgment I would like to provide a big thank you to my project advisor, Dr. Brad Neal. His instruction and dedication has been instrumental both in completing this project and in my personal growth throughout my years at the University of Indianapolis. I would also like to thank Dr. Levi Mielke and the rest of the Chemistry Department for their support and guidance throughout this process. My gratitude is also extended to Dr. John Langdon and the Undergraduate Research Fund for their financial support during the course of this project. Lastly, I would like to thank my family and friends for their prayers and support, not only while I was completing this project, but throughout my entire life. H. Clinton iv List of Tables Table 1: Elemental Wavelengths Analyzed from the MP-AES.............................19 Table 2: Dog Food Brands and Sources ................................................................20 Table 3: Standard Solutions for MP-AES Calibration ...........................................21 Table 4: Data Obtained from the MP-AES ............................................................22 Table 5: Metal Concentrations Without Matrix .....................................................23 Table 6: Data to be Compared to AAFCO Guidelines ..........................................25 Table 7: AAFCO Values ........................................................................................25 Table 8: Percent Difference ...................................................................................27 Table 9: Weights Developed Based on Importance of Metal ................................28 Table 10: Dog Food Scores....................................................................................29 Table 9: Prices of Dog Food ..................................................................................30 H. Clinton v List of Figures Figure 1: Electron Excitation .................................................................................14 Figure 2: MP-AES Schematic ................................................................................15 Figure 3: Percent Composition of Metals ..............................................................26 Figure 4: Dog Food Scores ....................................................................................29 Figure 5: Price Vs. Score .......................................................................................31 H. Clinton vi Table of Contents Cover Page ............................................................................................................... i Abstract .................................................................................................................. ii Acknowledgement ................................................................................................. iii List of Tables ......................................................................................................... iv List of Figures ..........................................................................................................v Statement of Purpose ...............................................................................................7 Introduction ..............................................................................................................8 Methods..................................................................................................................17 Results and Analysis ..............................................................................................21 Conclusion .............................................................................................................33 Reflection ...............................................................................................................34 References ..............................................................................................................35 Appendices ................................................................................................................. Appendix A: Grant Proposal ......................................................................38 Appendix B: CITI Training .......................................................................40 Appendix C: Material Safety Data Sheets .................................................42 H. Clinton 7 Statement of Purpose Several different minerals are necessary in trace amounts for vital canine bodily functions. However, if those minerals are too abundant in a dogs diet, the minerals can start causing more harm than good. Some minerals, such as copper, iron, and manganese, are labeled on the majority of dog food bags, but other minerals, such as chromium, nickel, and cadmium, are commonly left off of the labels and still found in the dog food.1 That said, not all dog foods are created using the same ingredients or in the same ways. Different dog food companies use varying techniques and ingredients to create a product that is unique and marketable. Examining just how unique each of these dog food brands are was the main focus of this project. While examining the health benefits was out of the scope of this project, the chemical makeups of the different types of dog food were evaluated. An additional product of this project was the creation of a method to analyze future food samples by undergraduate students conducting similar research. H. Clinton 8 Introduction Just like humans, animals have specific nutritional requirements that must be met for them to live long, healthy lives. The Association of American Feed Control Officials (AAFCO) is an organization that determines nutritional standards for animal feeds across the United States. AAFCO produces literature on the nutritional standards that should be upheld in pet foods.2 It is the responsibility of the companies that produce dog food to uphold the standards produced by AAFCO. Because of this, commercial pet food companies take great care in producing safe and nutritionally well balanced foods to their customers. These companies use ingredients that provide the protein, fat, minerals, carbohydrates, fiber, and vitamins that an animal needs for normal bodily functions.3 In all types of food, canned, dry, or semimoist, commercially produced dog food undergoes rigorous sterilization techniques. Dr. S. Zicker, a veterinarian with a PhD in nutrition, explained that the dog food companies spend much effort toward producing products that not only meet nutrient targets but that are also safe for their intended purposes.4 However, because large companies have limited amounts of time and resources, sometimes contaminated dog food will unknowingly make it to the market. This can cause many adverse and even lifethreatening effects on the pets that consume them. One such incident occurred in 2007 and resulted in many pets developing renal toxicity.3 R. L. Dobson, et al. were assigned to discover the contaminant that caused many brands of pet foods to be recalled. High-performance liquid chromatography and mass spectrometry were used to analyze the components of the dog foods. Melamine and H. Clinton 9 cyanuric acid were both identified as contaminants in the recalled pet foods and the researchers identified that an interaction between those two components as the most likely cause of the renal failure in the affected animals.5 In 2014, Pedigree recalled several bags of dog food due to a possible contamination of an unspecified metal. The bags of Adult Complete Nutrition dog food were sold in multiple states, which complicated the recall. Mistakes like this one cost Pedigree thousands of dollars and endangered the lives of hundreds of pets.6 Common Minerals Found in Dog Foods The concentrations of metals in dog foods must remain within a tight range in order to keep the pet as healthy as possible. The minimum amount required of a certain mineral can also change over time based on the age and activity level of the pet according to AAFCO.7 Having a dietary deficit of a crucial metal can cause a multitude of health effects on an animal. For example, the cause of canine epilepsy, a disease characterized by uncontrollable seizures, has been partially attributed to deficiencies in zinc, calcium, and magnesium.8 A deficiency of iron can lead to anemia and possibly even cognitive defects in canines.9 While certain breeds may have genes that cause their mineral tolerance levels to be lower than average, such as certain Bedlington Terriers who often develop liver cirrhosis or die prematurely due to their livers removing copper at a slower than average rate,10 most need concentrations within the same range. AAFCO provides general guidelines for dog food companies to follow in order for them to provide the best nutrition for the majority of dogs.11 Too much of a particular metal can also cause adverse health effects. For example, an excess of lead in a dogs diet can lead to lead H. Clinton 10 poisoning and can cause severe symptoms including, but not limited to, convulsions, vomiting, and hysteria.12 Because lead is not listed on pet food labels, there is no way for pet owners to know how much their animal is getting from the food and this can cause serious issues. Copper, iron, and manganese are all minerals that should be present in dog food in trace amounts. In a study of the concentrations of trace elements produced by A. Duran, M. Tuzen, and M. Soylak, dog foods commercially available in Turkey had a mean concentration of 6.22 g/g of copper, concentrations between 23.9 and 71.1 g/g of iron, and a mean concentration of 8.64 g/g of manganese. All of these values fell within the AAFCO guidelines and were listed on the food label, but other trace metals were also found in these samples. Lead, nickel, and chromium are just a few metals that are not required to be listed on pet food labels and were found in varying amounts in this study.1 Iron, calcium, magnesium, sodium, and potassium are all metals that play important roles in a canines body. Calcium is critical for bone development and plays a large role in muscle and nerve function.13 The actin and myosin in muscles would be unable to interact correctly without the proper flow of calcium through the cell.14 Several types of epithelial cells are also dependent on calcium ions to allow cadherins to form the dimers that are critical in cell to cell adhesion.15 While it is rare that a dog would ingest an overabundance of calcium just from its dog food, an excess of this micronutrient can cause polydipsia (excessive thirst), lethargy, depression and, in severe cases, bladder stones or hypertension.16 H. Clinton 11 While calcium allows muscles to contract and nerve impulses to be propagated throughout the body, magnesium plays a critical role in dampening the muscle and nerve impulses. Magnesium also functions in reactions involving the formation of adenine triphosphate (ATP) which is the bodys main source of energy.13 Dogs lacking in magnesium tend to have excessive calcification of the heart and arteries found throughout the body, which can negatively affect blood flow. The heart can also be affected by an excess of magnesium. Too much magnesium shrinks the lipid deposits protecting the heart and can lead to other severe heart problems.17 Sodium is arguably the most important extracellular ion with its function in maintaining the proper water balance of the body. Its role in maintaining the electrical potential across cell membranes is especially important in the flow of nerve and muscle cell impulses throughout the body.13 There are also many ion pumps throughout the body that rely on sodium for proper functionality. Salt poisoning has little to no effect on the body as long as the animal has constant access to fresh water. However, without enough water, excessive salt intake has been known to cause severe vomiting, muscle tremors, and seizures.18 Potassium assists sodium in the maintenance of cell electrical potential. For this reason, fairly constant levels of potassium are needed in the body at all times to maintain the functionality of the various sodium/potassium pumps throughout the body. Paralysis of muscles and disruption of proper cardiac function are both side effects of having too little potassium in the body.13 Dogs suffering from hyperkalemia, or excessive potassium, can have minor symptoms such as depression or weakness throughout the H. Clinton 12 body. However, in severe cases of hyperkalemia, dogs can suffer from cardiac arythmias.19 A micronutrient that is essential for almost all living organisms is iron. Iron acts as a co-factor for many proteins that have crucial life sustaining roles. In dogs, as well as other vertebrates, iron plays a critical role in cell division as well. Without iron, it would be very difficult for the body to maintain functionality.13 An overdose of iron has severe effects on the body, by first causing gastrointestinal trauma, then shock and tachycardia, and, in severe cases, death.20 Because of the severity of iron toxicity and the important roles that iron plays in day to day functionality, it can be argued that iron is the most important micronutrient. Various Instruments and Digestion Techniques Many different instruments have been used to analyze the different components of dog food. The most common method of determining the concentrations of trace elements involves flame atomic absorption spectroscopy, which is directly related to microwave plasma atomic emission spectroscopy. However, most of these instruments require samples to be in an aqueous in order to be analyzed. Therefore, digestion of solid compounds is necessary for analysis. Several different digestion methods are proposed and tested by different studies. S. Dimerel, M. Tuzen, S. Saracoglu, and M. Soylak published an article in the Journal of Hazardous Materials in 2008 that investigated the reliability of various digestion methods. Dry ashing, wet ashing, and microwave digestion were compared and used to analyze known concentrations of substances. The researchers concluded that the microwave digestion method had a higher recovery in a H. Clinton 13 shorter amount of time and, therefore, deemed it the best of the three different techniques.21 Hydrochloric acid, hydrofluoric acid, nitric acid and hydrogen peroxide are all different chemicals often used to digest materials in flame atomic absorption spectroscopy. A. Bazzi, B. Kreuz, and J. Fischer used 6 M hydrochloric acid to treat cereal samples,22 while N. Cha, et al. used a 7:3:2 ratio of nitric acid, hydrofluoric acid, and hydrochloric acid, respectively.23 Nitric acid and hydrogen peroxide was used in 2008 in an analysis of dried fruit24 and that same method was used in 2010 on a study of dog foods.1 It is apparent from these studies that at least one strong acid is needed to dissolve samples when using this method of spectroscopy. In a study by D. Alomar, et al. near infrared reflectance spectroscopy was investigated as an alternative method of determining the nutrient content of dog foods. While this method successfully identified the concentration of crude fiber and gross energy, it was not accurate in determining the amount of trace minerals found in the dog food.25 S. Simcock, S. Rutherfurd, T. Wester, and W. Hendriks also used an alternative method for analyzing pet foods in New Zealand. These researchers used a fluorometric method to analyze the selenium content in both wet and dry pet foods. Although the range of selenium concentrations in each type of food was very different, this method worked well and produced usable results.26 However, these methods were limited to measuring only selenium concentrations and not that of other metal compounds. H. Clinton 14 hv A B C Figure 1: Electron Excitation To better understand how atomic absorption works, the basics of atomic theory must be discussed. The electrons in atoms exist at all times at certain energy levels, which are denoted generically by the label n. As the atoms increase in size, they increase in the number of electrons around the atoms. These atoms fill energy levels with pairs of electrons and as the number of electrons is increased, the distance between the energy levels decreases as shown in Figure 1. To better understand the physical changes that occur in atomic spectroscopy, it is simpler to consider a system in which only one electron exists. Energy absorbed by an electron can promote it from a lower energy level to a higher energy level. This is reflected in Figure 1A as the electron is promoted from n = 1 to n = 3. However, this promotion is not limited to just these two energy levels. For example, an electron could be promoted from n = 2 to n = 3 or n = 1 to n = 5, depending on the amount of energy absorbed by the electron. Having an electron at a higher energy level is energetically unfavorable and, therefore, the electron will eventually fall back down to its original energy level, or its ground state. When the electron returns to its H. Clinton 15 ground state, it can release energy in the form of a discrete wavelength of light (Figure 1B).27 While many of these wavelengths are unique for a given element, each element may have multiple wavelengths of light emitted due to its unique combination of electrons around the nucleus and their changing energy levels. For example, lithium has two electrons at n=1 and one electron in its valence shell at n=2 as shown in Figure 1C. These electrons have the opportunity of being promoted to n=3, n=4, n=5, etc. Each transition will provide a different wavelength of light when the electron returns to its ground state. Figure 2: MP-AES Schematic28 H. Clinton 16 Atomic emission spectroscopy (AES) relies on the light emitted when an electron returns to its ground state to identify each type of metal. A microwave plasma atomic emission spectrometer (MP-AES) specifically uses a plasma torch to initially excite electrons as shown in Figure 2 near the point labelled a.28 After excitation, the electrons return to their ground state and emit light that is reflected through the instrument towards a detector which is shown at point j in Figure 2. The detector is programmed to detect one wavelength which corresponds to one type of metal at a time. The intensity of the light correlates to the concentration of the metal in the sample. While each wavelength is indicative of a certain element, some elements release light at wavelengths that are close to that of other elements. In these cases, it is important to program the instrument to identify wavelengths that do not interfere with any other elements that are being studied. H. Clinton 17 Methods Overview of Approach Using a modified method from previously described work,1 several different kinds of dog foods were analyzed for their trace metallic content. Table 2 lists the sources of each of the different dog foods. Before digestion, all dog foods were stored either in their original containers or in plastic bags in a cool, dry area. This storage method was critical as it allowed the food to be free of metal contamination and prevented them from losing very much, if any, of their metal content. Because the MPAES only analyzes dissolved, aqueous samples, an acid digestion technique involving hydrogen peroxide and nitric acid was used. This digestion technique was also necessary to release the metals from their matrix. Aqueous samples were stored in plastic chemical bottles and diluted to known concentrations. All samples were diluted to a volume of 100 milliliters with the exception of sample 8, which was diluted to 200 milliliters. MP Expert software provided by Agilent was used to operate the instrument as well as collect data from the experiments and quantitatively identify the concentrations of metal compounds in the digested solutions. Glassware Cleaning Techniques All glassware used in this investigation was cleaned at the beginning of each semester using an acid solution of aqua regia. Extreme caution must be used when preparing and using aqua regia, especially near any organic matter. The method for creating aqua regia used in this experiment is thoroughly outlined in a paper published in the Applied Physics Letters by S. Han, J. Kim, J. Lee, and Y. Baik.29 Aqua regia was H. Clinton 18 produced by carefully combining 6 Molar hydrochloric acid with 69.5 % (15.7 Molar) nitric acid in a 3:1 ratio. The solution was then diluted by 50% using nanopure water. After the aqua regia was generated, glassware that was to be used in the digestion of samples or other parts of the experimental procedure was allowed to soak in the aqua regia solution for thirty seconds to five minutes depending on the relative dirtiness of the glassware. A solution of 50% aqua regia was also used to clean the MP-AES plasma torch periodically when carbon buildup became visible on the outside of the torch. In between acid cleanings, glassware was cleaned by thoroughly rinsing with distilled water and then with nanopure water. If more thorough cleaning was necessary, soap or acetone was used before thorough rinsing with distilled and nanopure water. Preparation of Dog Food Samples The dog food was retrieved from storage and 5-20 pieces of kibble were placed in a clean, dry mortar. If the kibble appeared to have a significant amount of water content, they were first dried in a 40C oven on watch glasses for at least 24 hours. A pestle was used to grind samples to a fine powder after the drying process. Approximately one gram of crushed kibble was weighed into a plastic weigh boat. Twelve milliliters of 69.5% nitric acid was added to four milliliters of 30% hydrogen peroxide in a fifty milliliter beaker. The crushed sample was then added to the digestion solution and placed onto a hot plate. An alundum boiling chip was also placed in the solution to prevent excessive boiling. The temperature was monitored and kept around 100C. When orange fumes stopped escaping as frequently from the solution, the beakers were removed from heat and allowed to cool. The samples were then filtered and diluted to a known H. Clinton 19 concentration using a 100 milliliter volumetric flask. A volumetric pipette was used to transfer ten milliliters of each solution to a new volumetric flask to obtain a 1:10 dilution. These solutions were then ready to be analyzed by the instrument. A matrix was digested with each set of samples. A matrix involves using the same procedure outlined for digestion without adding the kibble and is used to identify how much metal is in the digestion mixture. Preparation of the MP-AES The instrument used to analyze the samples was an Agilent Technologies 4100 Microwave Plasma- Atomic Emission Spectrometer with a 4200 adaption. MP Expert software was used to obtain data from the instrument. A manual sample introduction was used as well as a linear fit on the calibration curves. The sample uptake time was increased to 80 seconds to account for errors encountered in early trials. In order to obtain results, the correlation coefficient was reduced to 0.9000 and the calibration error was increased to 50%. The wavelengths shown in Table 1 were chosen for each of the metals studied in this experiment. These particular wavelengths were chosen to minimize the amount of interference and error in the data. Standard solutions were prepared by serial dilution from Agilent stock solutions. Element Wavelength (nm) Iron 371.993 Calcium 616.217 Magnesium 766.491 Sodium 518.360 Potassium 588.995 Table 1: Elemental Wavelengths Analyzed from the MP-AES H. Clinton 20 Sample Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Brand Name Purina One Smart Blend - Healthy Puppy Formula Purina Dog Chow Purina Puppy Chow Purina Moist and Meaty, Hamburger Flavor Greenbrier Kennel Club Premium Dog Food Iams Sensitive Naturals - Ocean Fish and Rice Purina Dog Chow* Orijen Six Fish Kibbles 'n Bits Bistro Whole Earth Farms Grain Free - Pork, Beef, and Lamb Diamond Naturals - Chicken and Sweet Potato Iams So Good with Chicken Pedigree Small Dog - Chicken Eukanuba Excel Adult Formula Hills Ideal Balance - Beef, Peas, and Buckwheat Newman's Own Adult Recipe Table 2: Dog Food Brands and Sources * Refers to the blind sample that will be explained vide infra Source Individual Individual Individual Individual Dollar Tree Individual Individual Amazon Amazon Amazon Amazon Amazon Amazon Amazon Amazon Amazon H. Clinton 21 Results and Analysis Before the samples were analyzed by the instrument, standard solutions of known concentrations were used to calibrate the MP-AES. The concentrations of the standard solutions are shown below in Table 3. The standard solutions are used to produce calibration curves that the instruments program can use to determine metal concentrations in unknown samples. It is important to note that parts per million and milligrams per liter are equivalent units and were, therefore, used interchangeably. Standard Number 1 2 Fe (mg/L) Ca (mg/L) Mg (mg/L) Na (mg/L) K (mg/L) 5.00 5.00 5.00 5.00 15.00 15.00 15.00 15.00 Table 3: Standard Solutions for MP-AES Calibration 5.00 15.00 Table 4 represents values obtained through the MP Expert software without any further manipulation. Although the nanopure water should have had no metal during the analysis, metal concentrations were sporadically found in concentrations of 0.01 milligrams per liter or less. Because these concentrations were miniscule, they should have very little effect, if any, on the results. Table 5 represents the actual concentrations of metals found in the samples after accounting for the matrix values (Sample Calculation 1). These values are more useful for further calculations because they represent the metal concentrations from the dog food alone and excludes the metals that are found in the digestion mixture. Table 5 also contains the mass of each sample digested which was used to further manipulate the data into percent composition for calcium, magnesium, sodium, and potassium (Sample Calculation 2, 3A), while iron was manipulated into milligrams of iron per kilogram of dog food (Sample Calculation 2, 3B). These values H. Clinton 22 are represented in Table 6. The units for the metal concentrations were chosen to allow for easy comparison to the AAFCO recommended guidelines in Table 7.25 Nanopure Matrix 1 Sample 1 Sample 2 Sample 3 Nanopure Matrix 2 Sample 5 Sample 6 Sample 7 NanoPure Matrix 3 Sample 8 Sample 9 Sample 10 NanoPure Matrix 4 Sample 11 Sample 12 Sample 13 NanoPure Matrix 5 Sample 14 Sample 16 Fe Ca Mg Na (mg/L) (mg/L) (mg/L) (mg/L) 0.00 0.01 0.00 0.00 0.05 0.03 0.01 0.16 0.08 7.46 0.17 2.07 0.10 12.81 1.06 4.53 0.14 18.58 1.19 4.42 0.01 0.01 0.00 0.00 0.02 0.06 0.02 0.13 0.08 10.78 1.94 3.21 0.12 8.03 0.90 3.83 0.08 13.56 1.06 4.53 0.01 0.00 0.00 0.00 0.03 0.14 0.04 0.11 0.07 8.70 0.80 3.41 0.14 10.46 1.78 11.04 0.13 21.01 1.35 4.02 0.01 0.00 0.00 0.00 0.04 0.12 0.04 0.07 0.13 7.35 1.04 3.93 0.12 6.13 1.03 2.96 0.10 10.24 1.04 5.15 0.01 0.00 0.00 0.00 0.04 0.13 0.03 0.14 0.23 10.82 1.04 4.19 0.16 10.61 1.20 2.53 Table 4: Data Obtained From the MP-AES Sample Calculation 1 = Sample 1, Iron Concentration = 0.08 0.05 = 0.03 K (mg/L) 0.00 0.02 4.50 6.83 7.75 0.00 0.03 7.57 7.26 6.91 0.00 0.05 5.84 12.41 12.26 0.00 0.02 7.49 8.38 7.03 0.00 0.14 4.19 2.53 H. Clinton 23 Sample Number 1 2 3 5 6 7 8 9 10 11 12 13 14 16 Fe Ca Mg Na K (mg/L) (mg/L) (mg/L) (mg/L) (mg/L) 0.03 7.43 0.16 1.91 4.48 0.05 12.78 1.05 4.37 6.81 0.09 18.55 1.18 4.26 7.73 0.06 10.72 1.92 3.08 7.54 0.10 7.97 0.88 3.70 7.23 0.06 13.50 1.04 4.40 6.88 0.04 8.56 0.76 3.30 5.79 0.11 10.32 1.74 10.93 12.36 0.10 20.87 1.31 3.91 12.21 0.09 7.23 1.00 3.86 7.47 0.08 6.01 0.99 2.89 8.36 0.06 10.12 1.00 5.08 7.01 0.19 10.69 1.01 4.05 4.05 0.12 10.48 1.17 2.39 2.39 Table 5: Metal Concentrations Without Matrix Sample (g) 1.0160 1.0135 1.0132 0.9991 1.0090 1.0092 1.0550 1.1265 2.0461 0.9918 1.0378 1.0636 1.0270 1.0296 Sample Calculation 2 Determining the Metal Composition = Sample 1, Calcium 0.1 7.43 = 10 = 7.312 1.0160 Sample 1, Iron 0.1 0.03 = 10 = 0.02952 1.0160 H. Clinton 24 Sample Calculation 3A Percent Compositions = 1 100 1000 Sample 1, Calcium = 7.312 1 100 = 0.7312 % 1000 Sample Calculation 3B Calculating Iron Concentration = 1000 1 Sample 1 = 0.02952 1000 = 29.52 1 1 H. Clinton 25 Sample Fe (mg/kg) Ca (%) Mg (%) Na (%) K (%) Number 1 29.527559 0.731299 0.015748 0.187992 0.440945 2 49.333991 1.260977 0.103601 0.431179 0.671929 3 88.827477 1.830833 0.116463 0.42045 0.762929 5 60.054049 1.072966 0.192173 0.308277 0.754679 6 99.108028 0.789891 0.087215 0.3667 0.716551 7 59.453032 1.337693 0.103052 0.435989 0.681728 8 75.829384 1.622749 0.122075 0.625592 1.097630 9 97.647581 0.916112 0.154461 0.970262 1.097204 10 48.873467 1.019989 0.064024 0.191095 0.596745 11 90.744102 0.728978 0.100827 0.389191 0.753176 12 77.086144 0.57911 0.095394 0.278474 0.80555 13 56.412185 0.951486 0.09402 0.477623 0.659082 14 185.00487 1.040896 0.098345 0.394352 0.394352 16 116.55012 1.017871 0.113636 0.232129 0.232129 Table 6: Data to be Compared to AAFCO Guidelines Minimum Maximum Fe Ca (%) Mg Na (%) (mg/kg) (%) 80 0.6 0.04 0.06 3000 2.5 0.3 N/A 25 Table 7: AAFCO Values K (%) 0.6 N/A Figure 3 graphically shows the percent composition of each metal in the dog foods. H. Clinton 26 Metal Concentrations 2 1.8 1.6 Percent Composition 1.4 1.2 Fe Ca 1 Na 0.8 K 0.6 Mg 0.4 0.2 0 1 2 3 5 6 7 8 9 10 11 12 13 14 16 Sample Number Figure 3: Percent Composition of Metals The sample values were compared to the AAFCO guidelines through percent difference calculations (Sample Calculation 4) and the results are shown in Table 8. If the values fell between the AAFCO recommended minimum and maximum values, no percent difference was calculated. This comparison is important in determining whether or not an animal is receiving proper nutrition from its food. H. Clinton 27 Sample Calculation 4 = | | 100 + 2 Sample 1, Iron = Sample Number 1 2 3 5 6 7 8 9 10 11 12 13 14 16 |80 29.53| 100 = 92.16 % 80 + 29.53 2 Fe Ca Mg 92.16391 0 87.00565 47.42142 0 0 0 0 0 28.48322 0 0 0 0 0 29.46794 0 0 5.352798 0 0 0 0 0 48.30557 0 0 0 0 0 3.709883 3.54341 0 34.58315 0 0 0 0 0 0 0 0 Table 8: Percent Difference Na K 0 0 0 0 0 0 0 0 0 0 0 0 0 0 30.55976 0 0 0 0 0 0 0 0.543971 0 0 0 41.3631 88.41683 In order to further evaluate and differentiate the different dog foods, a grading rubric was developed (Table 9). Each metal studied was assigned a weight based on its relative importance in the body as explained in the introduction. The percent difference was used in conjunction with the developed rubric to assign a score (Sample Calculation 5) to each type of dog food for each metal as shown in Table 10. The scores for all of the metals H. Clinton 28 were added together to create the total score for every sample. A score of 1 was given to dog foods that had metal concentrations that all fell within the AAFCO recommended guidelines. The scores are compared in Figure 4. Weight Fe 0.25 Ca 0.2 Mg 0.15 Na 0.25 K 0.15 Table 9: Weights Developed Based on Importance of Metal Sample Calculation 5 = (100 ) 100 Sample 1 (100 92.16) (100 0) (100 87.00) = [ 0.25] + [ 0.2] + [ 0.15] 100 100 100 (100 0) (100 30.56) +[ 0.25] + [ 0.15] = 0.593 100 100 H. Clinton 29 Sample 1 2 3 5 6 7 8 9 10 11 12 13 14 16 Fe Ca Mg Na K 0.01959 0.2 0.01949 0.25 0.10416 0.131446 0.2 0.15 0.25 0.15 0.25 0.2 0.15 0.25 0.15 0.178792 0.2 0.15 0.25 0.15 0.25 0.2 0.15 0.25 0.15 0.17633 0.2 0.15 0.25 0.15 0.236618 0.2 0.15 0.25 0.15 0.25 0.2 0.15 0.25 0.15 0.129236 0.2 0.15 0.25 0.149184 0.25 0.2 0.15 0.25 0.15 0.240725 0.192913 0.15 0.25 0.15 0.163542 0.2 0.15 0.25 0.15 0.25 0.2 0.15 0.25 0.087955 0.25 0.2 0.15 0.25 0.017375 Table 10: Dog Food Scores Total Score 0.593 0.881 1.000 0.929 1.000 0.926 0.987 1.000 0.878 1.000 0.984 0.914 0.938 0.867 Comparison of Dog Food Scores 1 0.9 0.8 Score 0.7 0.6 K 0.5 Na 0.4 Mg 0.3 Ca 0.2 Fe 0.1 0 1 2 3 5 6 7 8 9 10 11 Sample Number Figure 4: Dog Food Scores 12 13 14 16 H. Clinton 30 The cost of each type of dog food is represented in Table 11. All prices, except for that of sample 5, were obtained from Amazon. The price of sample 5 was found by its selling price at Dollar Tree. Figure 5 compares the price of the dog food and its score from Table 10 to graphically determine if there is a correlation between price and score. Sample Price Weight Price per Number Pound 1 11.99 8 1.49875 2 8.75 4.4 1.988636364 3 14.52 4.4 3.3 5 1.00 1.03 0.970873786 6 27.54 17.2 1.601162791 7 8.75 4.4 1.988636364 8 6.24 0.75 8.32 9 5.87 3.5 1.677142857 10 7.99 4 1.9975 11 11.03 5 2.206 12 5.49 3.2 1.715625 13 5.22 3.5 1.491428571 14 4.07 4 1.0175 16 4.39 1.5 2.926666667 Table 11: Prices of Dog Food H. Clinton 31 Cost of Food Vs. Score 9 Price (dollars/pound) 8 7 6 5 4 3 2 1 0 0.55 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 1.05 Score Figure 5: Price Vs. Score It should be noted that sample 7 was a blind sample throughout this study. At the conclusion, it was revealed that sample 7 was the exact same dog food as sample 2, but they were from two different sources. Although the two did not receive the same score, there was only a 4.98% difference between the two scores (Sample Calculation 6). This difference could be caused by several possible errors including differences in storage, normal variations in dog food companies products, or slight differences in the digestion procedure. H. Clinton 32 Sample Calculation 6 = | 2 7| 100 2 + 7 2 Sample 2 and Sample 7 = |0.881 0.926| 100 = 4.98 % 0.881 + 0.926 2 H. Clinton 33 Conclusion Concentrations of iron, calcium, potassium, magnesium, and sodium were quantified using a microwave plasma atomic emission spectrometer and compared through a self-developed scale. Due to time constraints and unforeseen instrument malfunctions, only one trial was able to be completed. However, a known sample and a blind of the known sample were compared and found to have a low percent difference which indicates that the results are reproducible. From the results represented in Figure 5, there seems to be no direct correlation from the price of a dog food to the score of the kibble. Duplicating this methodology and completing more trials could provide more definitive results. The grading rubric used to score the dog food was developed through research, but could be reassessed in a future study. H. Clinton 34 Reflection From the completion of this project, I have learned how to connect the tools and techniques acquired in previous chemistry classes to my interests in veterinary medicine while applying all of these skills to a real world, tangible research project. The process of completing this Honors Project has stretched me both academically and personally as I developed the project, determined instrument malfunctions, overcame unprecedented setbacks, and completed this manuscript. I have increased my ability to decipher primary literature and apply previous research to a new area. While I developed concrete skills such as learning how to operate the microwave plasma atomic emission spectrometer, I also learned problem solving techniques that will be applicable in my future studies and occupation. If I had the opportunity to complete this project again, more time would be provided to account for inevitable and unforeseen issues. H. Clinton 35 References 1. Duran, A.; Tuzen, M.; Soylak, M. Trace element concentrations of some pet foods commercially available in Turkey. Food and Chemical Toxicology [online] 2010, 48(10), 2833-2837. 2. AAFCO Dog Nutrient Profiles, Frequently Asked Questions. http://www.dogfoodadvisor.com/frequently-askedquestions/aafco-nutrient-profiles/ (accessed November 4, 2014). 3. Thompson, A. Ingredients: where pet food starts. Topics in companion animal medicine [online] 2008, 23(3), 127-132. 4. Zicker, S. C. Evaluating pet foods: how confident are you when you recommend a commercial pet food?. Topics in companion animal medicine [online] 2008, 23(3), 121-126. 5. Dobson, R. L.; Motlagh, S.; Quijano, M.; Cambron, R. T.; Baker, T. R.; Pullen, A. M.; Regg, B. T.; Bigalow-Kern, A. S.; Vennard, T.; Fix, A.; Reimschussel, R.; Overmann, G.; Shan, Y.; Daston, G. P. Identification and characterization of toxicity of contaminants in pet food leading to an outbreak of renal toxicity in cats and dogs. Toxicological Sciences [online] 2008, 106(1), 251-262. 6. Maddison, J. E. Lead poisoned pets and your family. http://www.lead.org.au/fs/fst9.html (accessed November 4, 2014). Lead Toxicity in Dogs and Cats. 7. Demirel, S.; Tuzen, M.; Saracoglu, S.; Soylak, M. Evaluation of various digestion procedures for trace element contents of some food materials. Journal of hazardous materials [online] 2008, 152(3), 1020-1026. 8. Bazzi, A.; Kreuz, B.; Fischer, J. Determination of Calcium in Cereal with Flame Atomic Absorption Spectroscopy. An Experiment for a Quantitative Methods of Analysis Course. Journal of chemical education [online] 2004, 81(7) 1042-1044. 9. Cha, N. R.; Lee, J. K.; Lee, Y. R.; Jeong, H. J.; Kim, H. K.; Lee, S. Y. Determination of Iron, Copper, Zinc, Lead, Nickel and Cadmium in Cosmetic Matrices by Flame Atomic Absorption Spectroscopy. Analytical Letters [online] 2010, 43(2), 259-268. 10. Forman, O.; Boursnell, M.; Dunmore, B.; Stendall, N.; Sluis, B.; Fretwell, N.; Jones, C.; Wijmenga, C.; Rothuizen, J.; Oost, B.; Holmes, N.; Binns, M.; H. Clinton 36 Jones, P. Characterization of the COMMD1 (MURR1) mutation causing copper toxicosis in Bedlington terriers. Animal genetics [online] 2005, 36(6), 497-501. 11. Duran, A.; Tuzen, M.; Soylak, M. Trace element levels in some dried fruit samples from Turkey. International journal of food sciences and nutrition [online] 2008, 59(7-8), 581-589. 12. Alomar, D.; Hodgkinson, S.; Abarzua, D.; Fuchslocher, R.; Alvarado, C.; Rosales, E. Nutritional evaluation of commercial dry dog foods by near infrared reflectance spectroscopy. Journal of animal physiology and animal nutrition [online] 2006, 90(56), 223-229. 13. Simcock, S. E.; Rutherfurd, S. M.; Wester, T. J.; Hendriks, W. H. Total selenium concentrations in canine and feline foods commercially available in New Zealand. New Zealand veterinary journal [online] 2005, 53(1), 15. 14. May, L. Canine Epilepsy can be caused by nutritional deficiencies. Natural News [online] 2010 http://www.naturalnews.com/030511_canine_epilepsy_nutritional_deficie ncies.html (accessed April 5, 2016) 15. Fry, M.; Kirk, C. Reticulocyte indices in a canine model of nutritional iron deficiency. Veterinary Clinical Pathology [online] 2006, 35(2), 172-181. 16. Fieten, H.; Penning, L.; Leegwater, P.; Rothuizen, J. New canine models of copper toxicosis: diagnosis, treatment, and genetics. Annals Of The New York Academy Of Sciences [online] 2014, 1314(1), 42-48. 17. Fuller, M. Encyclopedia of Farm Animal Nutrition; CAB International: Wallingford, 2004. 18. Lodish, H.; Berk, A.; Zipursky, S.; et al. Molecular Cell Biology, 4th ed. W. H. Freeman: New York, 2000. 19. Peterson, M. Hypercalcemia in Dogs and Cats. Merck Veterinary Manual [online] 2013. http://www.merckvetmanual.com/mvm/endocrine_system/the_parathyroid _glands_and_disorders_of_calcium_metabolism/hypercalcemia_in_dogs_ and_cats.html (accessed April 4, 2016) H. Clinton 37 20. Vitale, J.; Hellerstein, E.; Nakamura, M.; Lown, B. Effects of magnesiumdeficient diet upon puppies. Circulation research [online] 1961, 9(2), 387-394. 21. Thompson, L. Overview of Salt Toxicity. Merck Veterinary Manual [online] 2014. http://www.merckvetmanual.com/mvm/toxicology/salt_toxicity/overview _of_salt_toxicity.html (accessed April 5, 2016) 22. Constable, P. Hyperkalemia. Merck Veterinary Manual [online] 2014. http://www.merckvetmanual.com/mvm/metabolic_disorders/disorders_of_ potassium_metabolism/hyperkalemia.html (accessed April 5, 2016) 23. Albretson, J. Toxicology Brief: The toxicity of iron, an essential element. [online] 2006. http://veterinarymedicine.dvm360.com/toxicology-brieftoxicity-iron-essentialelement?id=&sk=&date=&%0A%09%09%09&pageID=2 (accessed April 4, 2016) 24. PEDIGREE Adult Complete Nutrition Limited Recall Due to Metal Fragments. [online] 2014. http://www.fda.gov/Safety/Recalls/ucm412314.htm (accessed April 1, 2016) 25. Dzanis, D. AAFCO Dog and Cat Food Nutrient Profiles. Kirks Current Veterinary Therapy [online] 2000, 13, 1228-1235. 26. Szent-Gyrgyi, A. G. Calcium regulation of muscle contraction. Biophysical Journal [online] 1975, 15(7), 707723. 27. Scheeline, A.; Spudich, T. Atomic Emission Spectroscopy. [online] 2013. http://www.asdlib.org/learningModules/AtomicEmission/index.html (accessed April 9, 2016) 28. Hettipathirana, T. D. Determination of boron in high-temperature alloy steel using non-linear inter-element correction and microwave plasma-atomic emission spectrometry. Journal of Analytical Atomic Spectrometry [online] 2013 28(8), 1242-1246. 29. Han, S.; Kim, J.; Lee, J.; Baik, Y. Pretreatment effects by aqua-regia solution on field emission of diamond film. Applied Physics Letters [online] 2000, 76(25), 3694-3696. H. Clinton 38 Appendices Appendix A: Grant Proposal Dear Grant Committee, Animals are a huge part of the lives of most Americans. If you ask any pet owner, they would tell you that they want to provide the best care for their animals possible. One way to ensure a proper health for pets is to provide a diet that contains the proper nutrients in the proper quantities. Currently, I am conducting primary research analyzing the metal components of different types of gourmet dog foods using atomic absorption spectroscopy via the Chemistry Departments microwave plasma atomic emission spectrometer (MP-AES). In order to enhance our abilities to successfully analyze these dog food samples, we respectfully request $400 to purchase a plasma torch for the MP-AES. Currently, the Chemistry Department only owns one torch, which is a crucial part of the MP-AES instrumentation. If this torch were to break or be damaged, my research, as well as other research and lab experiments, would no longer be able to be completed. There is a large likelihood that our torch will become damaged by the sheer volume of use that the instrument receives. The instrument would essentially become useless without a working torch and would sit idly until a new torch was procured, which will greatly stymie my research progress. To ensure that my research project will be conducted in a timely and uninterrupted manner, another torch is needed. In addition to seeking funding here, I am also pursing funding of an additional $150 through the Ron and Laura Strain Honors College to help cover the costs of this item. This project is beneficial to both me and the university in several ways. These funds would allow me to successfully complete my study of the content of dog food. This is of great interest to me because, in the future, I plan to pursue a career in the field of veterinary medicine. Additionally, the completion of this project will bring me one step closer to graduating with distinction through the Ron and Laura Strain Honors College. This project will teach me how to work independently and efficiently. As I move on to professional school, the skills that I am developing through this project, such as efficient use of time and resources, will ensure my success. H. Clinton 39 In addition, these funds will provide the opportunity for other students to successfully use the MP-AES for projects of their own. This instrument is currently being used in another student-led research project analyzing the heavy metal contamination of soil collected from the Harding Power Plant. This instrument is also used in the instruction of several labs in the chemistry curriculum, including Advanced Lab Techniques and Environmental Chemistry. With so much use, having this extra torch will provide insurance that I will be able to conduct my studies. If you have any further questions regarding my request or research, please feel free to contact me at clintonh@uindy.edu. Sincerely, Hannah Clinton Advisor: Brad Neal H. Clinton 40 Appendix B: CITI Training COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI) HUMAN RESEARCH CURRICULUM COMPLETION REPORT Printed on 10/28/2014 LEARNER Hannah Clinton (ID: 4307835) 2948 N 225 W Washington IN 47501 DEPARTMENT Math PHONE 812 698 1888 EMAIL clintonh@uindy.edu INSTITUTION University of Indianapolis EXPIRATION DATE 08/23/2016 GROUP 2.SOCIAL / BEHAVIORAL RESEARCH INVESTIGATORS AND KEY PERSONNEL. : The social behavioral track is applicable when you conduct epidemiologic, genetic, prevention/ screening, psychosocial and/or quality of life studies. COURSE/STAGE: Basic Course/1 PASSED ON: 08/24/2014 REFERENCE ID: 13772853 REQUIRED MODULES DATE COMPLETED H. Clinton 41 Introduction 08/23/14 Students in Research 08/23/14 History and Ethical Principles - SBE 08/23/14 Defining Research with Human Subjects - SBE 08/23/14 The Federal Regulations - SBE 08/23/14 Assessing Risk - SBE 08/23/14 Informed Consent - SBE 08/23/14 Privacy and Confidentiality - SBE 08/24/14 Research and HIPAA Privacy Protections 08/24/14 Conflicts of Interest in Research Involving Human Subjects 08/24/14 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 H. Clinton 42 Appendix C: Material Safety Data Sheets Sigma-Aldrich - 84378 Page 1 of 8 SIGMA-ALDRICH sigma-aldrich.com SAFETY DATA SHEET Version 5.5 Revision Date 08/23/2014 Print Date 11/03/2014 1. PRODUCT AND COMPANY IDENTIFICATION 1.1 Product identifiers Product name : Nitric acid Product Number : 84378 Brand : Sigma-Aldrich Index-No. : 007-004-00-1 CAS-No. : 7697-37-2 1.2 Relevant identified uses of the substance or mixture and uses advised against Identified uses : Laboratory chemicals, Manufacture of substances 1.3 Details of the supplier of the safety data sheet Company : Sigma-Aldrich 3050 Spruce Street SAINT LOUIS MO 63103 USA Telephone : +1 800-325-5832 Fax : +1 800-325-5052 1.4 Emergency telephone number Emergency Phone # : (314) 776-6555 2. HAZARDS IDENTIFICATION 2.1 Classification of the substance or mixture GHS Classification in accordance with 29 CFR 1910 (OSHA HCS) Oxidizing liquids (Category 3), H272 Skin corrosion (Category 1A), H314 Serious eye damage (Category 1), H318 For the full text of the H-Statements mentioned in this Section, see Section 16. 2.2 GHS Label elements, including precautionary statements Pictogram Signal word Danger Hazard statement(s) H272 May intensify fire; oxidiser. H314 Causes severe skin burns and eye damage. Precautionary statement(s) P210 Keep away from heat. P220 Keep/Store away from clothing/ combustible materials. P221 Take any precaution to avoid mixing with combustibles. P264 Wash skin thoroughly after handling. P280 Wear protective gloves/ protective clothing/ eye protection/ face protection. P301 + P330 + P331 IF SWALLOWED: Rinse mouth. Do NOT induce vomiting. P303 + P361 + P353 IF ON SKIN (or hair): Remove/ Take off immediately all contaminated H. Clinton 43 Sigma-Aldrich - 84378 Page 2 of 8 clothing. Rinse skin with water/ shower. P304 + P340 IF INHALED: Remove victim to fresh air and keep at rest in a position comfortable for breathing. P305 + P351 + P338 IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. P310 Immediately call a POISON CENTER or doctor/ physician. P321 Specific treatment (see supplemental first aid instructions on this label). P363 Wash contaminated clothing before reuse. P370 + P378 In case of fire: Use dry sand, dry chemical or alcohol-resistant foam for extinction. P405 Store locked up. P501 Dispose of contents/ container to an approved waste disposal plant. 2.3 Hazards not otherwise classified (HNOC) or not covered by GHS - none 3. COMPOSITION/INFORMATION ON INGREDIENTS 3.2 Mixtures Formula : HNO3 Molecular weight : 63.01 g/mol Component Classification Concentration Nitric acid CAS-No. EC-No. Index-No. 7697-37-2 231-714-2 007-004-00-1 Ox. Liq. 3; Skin Corr. 1A; Eye Dam. 1; H272, H314 90 - 100 % For the full text of the H-Statements mentioned in this Section, see Section 16. 4. FIRST AID MEASURES 4.1 Description of first aid measures General advice Consult a physician. Show this safety data sheet to the doctor in attendance.Move out of dangerous area. If inhaled If breathed in, move person into fresh air. If not breathing, give artificial respiration. Consult a physician. In case of skin contact Take off contaminated clothing and shoes immediately. Wash off with soap and plenty of water. Consult a physician. In case of eye contact Rinse thoroughly with plenty of water for at least 15 minutes and consult a physician.Continue rinsing eyes during transport to hospital. If swallowed Do NOT induce vomiting. Never give anything by mouth to an unconscious person. Rinse mouth with water. Consult a H. Clinton 44 physician. 4.2 Most important symptoms and effects, both acute and delayed The most important known symptoms and effects are described in the labelling (see section 2.2) and/or in section 11 4.3 Indication of any immediate medical attention and special treatment needed No data available 5. FIREFIGHTING MEASURES 5.1 Extinguishing media Suitable extinguishing media Use water spray, alcohol-resistant foam, dry chemical or carbon dioxide. Sigma-Aldrich - 84378 Page 3 of 8 5.2 Special hazards arising from the substance or mixture Nitrogen oxides (NOx) 5.3 Advice for firefighters Wear self-contained breathing apparatus for firefighting if necessary. 5.4 Further information Use water spray to cool unopened containers. 6. ACCIDENTAL RELEASE MEASURES 6.1 Personal precautions, protective equipment and emergency procedures Use personal protective equipment. Avoid breathing vapours, mist or gas. Ensure adequate ventilation. Evacuate personnel to safe areas. For personal protection see section 8. 6.2 Environmental precautions Do not let product enter drains. 6.3 Methods and materials for containment and cleaning up Contain spillage, and then collect with an electrically protected vacuum cleaner or by wetbrushing and place in container for disposal according to local regulations (see section 13). 6.4 Reference to other sections For disposal see section 13. 7. HANDLING AND STORAGE 7.1 Precautions for safe handling Avoid inhalation of vapour or mist. Keep away from sources of ignition - No smoking.Keep away from heat and sources of ignition.Normal measures for preventive fire protection. For precautions see section 2.2. 7.2 Conditions for safe storage, including any incompatibilities Keep container tightly closed in a dry and well-ventilated place. Containers which are opened must be carefully resealed and kept upright to prevent leakage. 7.3 Specific end use(s) Apart from the uses mentioned in section 1.2 no other specific uses are stipulated 8. EXPOSURE CONTROLS/PERSONAL PROTECTION 8.1 Control parameters Components with workplace control parameters Component CAS-No. Value Control H. Clinton 45 parameters Basis Nitric acid 7697-37-2 TWA 2 ppm USA. ACGIH Threshold Limit Values (TLV) Remarks Eye & Upper Respiratory Tract irritation Dental erosion STEL 4 ppm USA. ACGIH Threshold Limit Values (TLV) Eye & Upper Respiratory Tract irritation Dental erosion ST 4 ppm 10 mg/m3 USA. NIOSH Recommended Exposure Limits TWA 2 ppm 5 mg/m3 USA. NIOSH Recommended Exposure Limits TWA 2 ppm 5 mg/m3 USA. Occupational Exposure Limits (OSHA) - Table Z-1 Limits for Air Contaminants The value in mg/m3 is approximate. Sigma-Aldrich - 84378 Page 4 of 8 TWA 2 ppm 5 mg/m3 USA. OSHA - TABLE Z-1 Limits for Air Contaminants - 1910.1000 STEL 4 ppm 10 mg/m3 USA. OSHA - TABLE Z-1 Limits for Air Contaminants - 1910.1000 8.2 Exposure controls Appropriate engineering controls Handle in accordance with good industrial hygiene and safety practice. Wash hands before breaks and at the end of workday. Personal protective equipment Eye/face protection Tightly fitting safety goggles. Faceshield (8-inch minimum). Use equipment for eye protection tested and approved under appropriate government standards such as NIOSH (US) or EN 166(EU). Skin protection Handle with gloves. Gloves must be inspected prior to use. Use proper glove removal technique (without H. Clinton 46 touching glove's outer surface) to avoid skin contact with this product. Dispose of contaminated gloves after use in accordance with applicable laws and good laboratory practices. Wash and dry hands. Full contact Material: Fluorinated rubber Minimum layer thickness: 0.7 mm Break through time: 480 min Material tested:Vitoject (KCL 890 / Aldrich Z677698, Size M) Splash contact Material: Nitrile rubber Minimum layer thickness: 0.11 mm Break through time: 30 min Material tested:Dermatril (KCL 740 / Aldrich Z677272, Size M) data source: KCL GmbH, D-36124 Eichenzell, phone +49 (0)6659 87300, e-mail sales@kcl.de, test method: EN374 If used in solution, or mixed with other substances, and under conditions which differ from EN 374, contact the supplier of the CE approved gloves. This recommendation is advisory only and must be evaluated by an industrial hygienist and safety officer familiar with the specific situation of anticipated use by our customers. It should not be construed as offering an approval for any specific use scenario. Body Protection Complete suit protecting against chemicals, The type of protective equipment must be selected according to the concentration and amount of the dangerous substance at the specific workplace. Respiratory protection Where risk assessment shows air-purifying respirators are appropriate use a full-face respirator with multipurpose combination (US) or type ABEK (EN 14387) respirator cartridges as a backup to engineering controls. If the respirator is the sole means of protection, use a full-face supplied air respirator. Use respirators and components tested and approved under appropriate government standards such as NIOSH (US) or CEN (EU). Control of environmental exposure Do not let product enter drains. 9. PHYSICAL AND CHEMICAL PROPERTIES 9.1 Information on basic physical and chemical properties a) Appearance Form: liquid Colour: colourless b) Odour No data available c) Odour Threshold No data available d) pH < 1.0 e) Melting point/freezing point No data available H. Clinton 47 Sigma-Aldrich - 84378 Page 5 of 8 f) Initial boiling point and boiling range 120.5 C (248.9 F) - lit. g) Flash point No data available h) Evaporation rate No data available i) Flammability (solid, gas) No data available j) Upper/lower flammability or explosive limits No data available k) Vapour pressure 49 hPa (37 mmHg) at 50 C (122 F) l) Vapour density No data available m) Relative density 1.37 - 1.41 g/cm3 at 20 C (68 F) n) Water solubility No data available o) Partition coefficient: noctanol/ water No data available p) Auto-ignition temperature No data available q) Decomposition temperature No data available r) Viscosity No data available s) Explosive properties No data available t) Oxidizing properties No data available 9.2 Other safety information No data available 10. STABILITY AND REACTIVITY 10.1 Reactivity No data available 10.2 Chemical stability Stable under recommended storage conditions. 10.3 Possibility of hazardous reactions No data available 10.4 Conditions to avoid No data available 10.5 Incompatible materials Alkali metals, Acetic anhydride, Organic materials, Alcohols, Acetonitrile, Acrylonitrile 10.6 Hazardous decomposition products Other decomposition products - No data available In the event of fire: see section 5 11. TOXICOLOGICAL INFORMATION 11.1 Information on toxicological effects Acute toxicity No data available Inhalation: No data available H. Clinton 48 Dermal: No data available No data available Sigma-Aldrich - 84378 Page 6 of 8 Skin corrosion/irritation No data available Serious eye damage/eye irritation No data available Respiratory or skin sensitisation No data available Germ cell mutagenicity No data available Carcinogenicity IARC: No component of this product present at levels greater than or equal to 0.1% is identified as probable, possible or confirmed human carcinogen by IARC. ACGIH: No component of this product present at levels greater than or equal to 0.1% is identified as a carcinogen or potential carcinogen by ACGIH. NTP: No component of this product present at levels greater than or equal to 0.1% is identified as a known or anticipated carcinogen by NTP. OSHA: No component of this product present at levels greater than or equal to 0.1% is identified as a carcinogen or potential carcinogen by OSHA. Reproductive toxicity No data available No data available Specific target organ toxicity - single exposure No data available Specific target organ toxicity - repeated exposure No data available Aspiration hazard No data available Additional Information RTECS: Not available Material is extremely destructive to tissue of the mucous membranes and upper respiratory tract, eyes, and skin., Inhalation may provoke the following symptoms:, spasm, inflammation and edema of the bronchi, spasm, inflammation and edema of the larynx, pneumonitis, Symptoms and signs of poisoning are:, burning sensation, Cough, wheezing, laryngitis, Shortness of breath, Headache, Nausea, Vomiting, Pulmonary edema. Effects may be delayed., Large doses may cause: conversion of hemoglobin to methemoglobin, producing cyanosis; marked fall in blood pressure, leading to collapse, coma, and possibly death. Liver - Irregularities - Based on Human Evidence Liver - Irregularities - Based on Human Evidence H. Clinton 49 12. ECOLOGICAL INFORMATION 12.1 Toxicity No data available 12.2 Persistence and degradability No data available 12.3 Bioaccumulative potential No data available 12.4 Mobility in soil No data available 12.5 Results of PBT and vPvB assessment PBT/vPvB assessment not available as chemical safety assessment not required/not conducted Sigma-Aldrich - 84378 Page 7 of 8 12.6 Other adverse effects No data available 13. DISPOSAL CONSIDERATIONS 13.1 Waste treatment methods Product Burn in a chemical incinerator equipped with an afterburner and scrubber but exert extra care in igniting as this material is highly flammable. Offer surplus and non-recyclable solutions to a licensed disposal company. Contact a licensed professional waste disposal service to dispose of this material. Dissolve or mix the material with a combustible solvent and burn in a chemical incinerator equipped with an afterburner and scrubber. Contaminated packaging Dispose of as unused product. 14. TRANSPORT INFORMATION DOT (US) UN number: 2031 Class: 8 (5.1) Packing group: II Proper shipping name: Nitric acid Reportable Quantity (RQ): 1000 lbs Marine pollutant: No Poison Inhalation Hazard: No IMDG UN number: 2031 Class: 8 (5.1) Packing group: II EMS-No: F-A, S-Q Proper shipping name: NITRIC ACID Marine pollutant: No IATA UN number: 2031 Class: 8 (5.1) Packing group: II Proper shipping name: Nitric acid IATA Passenger: Not permitted for transport 15. REGULATORY INFORMATION SARA 302 Components Nitric acid CAS-No. 7697-37-2 Revision Date H. Clinton 50 2007-07-01 SARA 313 Components Nitric acid CAS-No. 7697-37-2 Revision Date 2007-07-01 SARA 311/312 Hazards Acute Health Hazard, Chronic Health Hazard Massachusetts Right To Know Components Nitric acid CAS-No. 7697-37-2 Revision Date 2007-07-01 Pennsylvania Right To Know Components Water CAS-No. 7732-18-5 Revision Date Nitric acid 7697-37-2 2007-07-01 New Jersey Right To Know Components Water CAS-No. 7732-18-5 Revision Date Nitric acid 7697-37-2 2007-07-01 California Prop. 65 Components This product does not contain any chemicals known to State of California to cause cancer, birth defects, or any other reproductive harm. Sigma-Aldrich - 84378 Page 8 of 8 16. OTHER INFORMATION Full text of H-Statements referred to under sections 2 and 3. Eye Dam. Serious eye damage H272 May intensify fire; oxidiser. H314 Causes severe skin burns and eye damage. H318 Causes serious eye damage. Ox. Liq. Oxidizing liquids Skin Corr. Skin corrosion HMIS Rating Health hazard: 3 Chronic Health Hazard: * Flammability: 0 Physical Hazard 3 NFPA Rating Health hazard: 3 Fire Hazard: 0 H. Clinton 51 Reactivity Hazard: 0 Further information Copyright 2014 Sigma-Aldrich Co. LLC. License granted to make unlimited paper copies for internal use only. The above information is believed to be correct but does not purport to be all inclusive and shall be used only as a guide. The information in this document is based on the present state of our knowledge and is applicable to the product with regard to appropriate safety precautions. It does not represent any guarantee of the properties of the product. Sigma-Aldrich Corporation and its Affiliates shall not be held liable for any damage resulting from handling or from contact with the above product. See www.sigma-aldrich.com and/or the reverse side of invoice or packing slip for additional terms and conditions of sale. Preparation Information Sigma-Aldrich Corporation Product Safety Americas Region 1-800-521-8956 Version: 5.5 Revision Date: 08/23/2014 Print Date: 11/03/2014 H. Clinton 52 Sigma-Aldrich - 339253 Page 1 of 8 SIGMA-ALDRICH sigma-aldrich.com SAFETY DATA SHEET Version 5.5 Revision Date 03/07/2014 Print Date 04/02/2016 1. PRODUCT AND COMPANY IDENTIFICATION 1.1 Product identifiers Product name : Hydrochloric acid Product Number : 339253 Brand : Sigma-Aldrich Index-No. : 017-002-01-X REACH No. : 01-2119484862-27-XXXX CAS-No. : 7647-01-0 1.2 Relevant identified uses of the substance or mixture and uses advised against Identified uses : Laboratory chemicals, Manufacture of substances 1.3 Details of the supplier of the safety data sheet Company : Sigma-Aldrich 3050 Spruce Street SAINT LOUIS MO 63103 USA Telephone : +1 800-325-5832 Fax : +1 800-325-5052 1.4 Emergency telephone number Emergency Phone # : (314) 776-6555 2. HAZARDS IDENTIFICATION 2.1 Classification of the substance or mixture GHS Classification in accordance with 29 CFR 1910 (OSHA HCS) Corrosive to metals (Category 1), H290 Skin corrosion (Category 1B), H314 Serious eye damage (Category 1), H318 Specific target organ toxicity - single exposure (Category 3), Respiratory system, H335 For the full text of the H-Statements mentioned in this Section, see Section 16. 2.2 GHS Label elements, including precautionary statements Pictogram Signal word Danger Hazard statement(s) H290 May be corrosive to metals. H314 Causes severe skin burns and eye damage. H335 May cause respiratory irritation. Precautionary statement(s) P234 Keep only in original container. P261 Avoid breathing dust/ fume/ gas/ mist/ vapours/ spray. P264 Wash skin thoroughly after handling. P271 Use only outdoors or in a well-ventilated area. P280 Wear protective gloves/ protective clothing/ eye protection/ face protection. Sigma-Aldrich - 339253 Page 2 of 8 H. Clinton 53 P301 + P330 + P331 IF SWALLOWED: rinse mouth. Do NOT induce vomiting. P303 + P361 + P353 IF ON SKIN (or hair): Remove/ Take off immediately all contaminated clothing. Rinse skin with water/ shower. P304 + P340 IF INHALED: Remove victim to fresh air and keep at rest in a position comfortable for breathing. P305 + P351 + P338 IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. P310 Immediately call a POISON CENTER or doctor/ physician. P321 Specific treatment (see supplemental first aid instructions on this label). P363 Wash contaminated clothing before reuse. P390 Absorb spillage to prevent material damage. P403 + P233 Store in a well-ventilated place. Keep container tightly closed. P405 Store locked up. P406 Store in corrosive resistant stainless steel container with a resistant inner liner. P501 Dispose of contents/ container to an approved waste disposal plant. 2.3 Hazards not otherwise classified (HNOC) or not covered by GHS - none 3. COMPOSITION/INFORMATION ON INGREDIENTS 3.2 Mixtures Formula : HCl Molecular Weight : 36.46 g/mol Hazardous components Component Classification Concentration Hydrochloric acid CAS-No. EC-No. Index-No. Registration number 7647-01-0 231-595-7 017-002-01-X 01-2119484862-27-XXXX Met. Corr. 1; Skin Corr. 1B; Eye Dam. 1; STOT SE 3; H290, H314, H335 30 - 50 % For the full text of the H-Statements mentioned in this Section, see Section 16. 4. FIRST AID MEASURES 4.1 Description of first aid measures General advice Consult a physician. Show this safety data sheet to the doctor in attendance.Move out of dangerous area. If inhaled If breathed in, move person into fresh air. If not breathing, give artificial respiration. Consult a physician. In case of skin contact Take off contaminated clothing and shoes immediately. Wash off with soap and plenty of water. Consult a physician. H. Clinton 54 In case of eye contact Rinse thoroughly with plenty of water for at least 15 minutes and consult a physician.Continue rinsing eyes during transport to hospital. If swallowed Do NOT induce vomiting. Never give anything by mouth to an unconscious person. Rinse mouth with water. Consult a physician. 4.2 Most important symptoms and effects, both acute and delayed The most important known symptoms and effects are described in the labelling (see section 2.2) and/or in section 11 4.3 Indication of any immediate medical attention and special treatment needed no data available Sigma-Aldrich - 339253 Page 3 of 8 5. FIREFIGHTING MEASURES 5.1 Extinguishing media Suitable extinguishing media Use water spray, alcohol-resistant foam, dry chemical or carbon dioxide. 5.2 Special hazards arising from the substance or mixture Hydrogen chloride gas Hydrogen chloride gas 5.3 Advice for firefighters Wear self contained breathing apparatus for fire fighting if necessary. 5.4 Further information no data available 6. ACCIDENTAL RELEASE MEASURES 6.1 Personal precautions, protective equipment and emergency procedures Wear respiratory protection. Avoid breathing vapours, mist or gas. Ensure adequate ventilation. Evacuate personnel to safe areas. For personal protection see section 8. 6.2 Environmental precautions Do not let product enter drains. 6.3 Methods and materials for containment and cleaning up Soak up with inert absorbent material and dispose of as hazardous waste. Keep in suitable, closed containers for disposal. 6.4 Reference to other sections For disposal see section 13. 7. HANDLING AND STORAGE 7.1 Precautions for safe handling Avoid contact with skin and eyes. Avoid inhalation of vapour or mist. For precautions see section 2.2. 7.2 Conditions for safe storage, including any incompatibilities Keep container tightly closed in a dry and well-ventilated place. Containers which are opened must be carefully resealed and kept upright to prevent leakage. 7.3 Specific end use(s) H. Clinton 55 Apart from the uses mentioned in section 1.2 no other specific uses are stipulated 8. EXPOSURE CONTROLS/PERSONAL PROTECTION 8.1 Control parameters Components with workplace control parameters Component CAS-No. Value Control parameters Basis Hydrochloric acid 7647-01-0 C 2 ppm USA. ACGIH Threshold Limit Values (TLV) Remarks Upper Respiratory Tract irritation Not classifiable as a human carcinogen C 5 ppm 7 mg/m3 USA. Occupational Exposure Limits (OSHA) - Table Z-1 Limits for Air Contaminants The value in mg/m3 is approximate. Ceiling limit is to be determined from breathing-zone air samples. Sigma-Aldrich - 339253 Page 4 of 8 C 5 ppm 7 mg/m3 USA. OSHA - TABLE Z-1 Limits for Air Contaminants - 1910.1000 C 5 ppm 7 mg/m3 USA. NIOSH Recommended Exposure Limits Often used in an aqueous solution. 8.2 Exposure controls Appropriate engineering controls Handle in accordance with good industrial hygiene and safety practice. Wash hands before breaks and at the end of workday. Personal protective equipment Eye/face protection Tightly fitting safety goggles. Faceshield (8-inch minimum). Use equipment for eye protection tested and approved under appropriate government standards such as NIOSH (US) or EN 166(EU). Skin protection Handle with gloves. Gloves must be inspected prior to use. Use proper glove removal technique (without touching glove's outer surface) to avoid skin contact with this product. Dispose of contaminated gloves after use in accordance with applicable laws and good laboratory practices. Wash and dry hands. Full contact Material: Nitrile rubber Minimum layer thickness: 0.4 mm H. Clinton 56 Break through time: 480 min Material tested:Camatril (KCL 730 / Aldrich Z677442, Size M) Splash contact Material: Nitrile rubber Minimum layer thickness: 0.11 mm Break through time: 120 min Material tested:Dermatril (KCL 740 / Aldrich Z677272, Size M) data source: KCL GmbH, D-36124 Eichenzell, phone +49 (0)6659 87300, e-mail sales@kcl.de, test method: EN374 If used in solution, or mixed with other substances, and under conditions which differ from EN 374, contact the supplier of the CE approved gloves. This recommendation is advisory only and must be evaluated by an industrial hygienist and safety officer familiar with the specific situation of anticipated use by our customers. It should not be construed as offering an approval for any specific use scenario. Body Protection Complete suit protecting against chemicals, The type of protective equipment must be selected according to the concentration and amount of the dangerous substance at the specific workplace. Respiratory protection Where risk assessment shows air-purifying respirators are appropriate use a full-face respirator with multipurpose combination (US) or type ABEK (EN 14387) respirator cartridges as a backup to engineering controls. If the respirator is the sole means of protection, use a full-face supplied air respirator. Use respirators and components tested and approved under appropriate government standards such as NIOSH (US) or CEN (EU). Control of environmental exposure Do not let product enter drains. 9. PHYSICAL AND CHEMICAL PROPERTIES 9.1 Information on basic physical and chemical properties a) Appearance Form: liquid Colour: light yellow b) Odour pungent c) Odour Threshold no data available d) pH no data available e) Melting point/freezing -30 C (-22 F) Sigma-Aldrich - 339253 Page 5 of 8 point f) Initial boiling point and boiling range > 100 C (> 212 F) - lit. g) Flash point not applicable h) Evapouration rate no data available i) Flammability (solid, gas) no data available H. Clinton 57 j) Upper/lower flammability or explosive limits no data available k) Vapour pressure 227 hPa (170 mmHg) at 21.1 C (70.0 F) 547 hPa (410 mmHg) at 37.7 C (99.9 F) l) Vapour density no data available m) Relative density 1.2 g/cm3 at 25 C (77 F) n) Water solubility soluble o) Partition coefficient: noctanol/ water no data available p) Auto-ignition temperature no data available q) Decomposition temperature no data available r) Viscosity no data available s) Explosive properties no data available t) Oxidizing properties no data available 9.2 Other safety information no data available 10. STABILITY AND REACTIVITY 10.1 Reactivity no data available 10.2 Chemical stability Stable under recommended storage conditions. 10.3 Possibility of hazardous reactions no data available 10.4 Conditions to avoid no data available 10.5 Incompatible materials Bases, Amines, Alkali metals, Metals, permanganates, e.g. potassium permanganate, Fluorine, metal acetylides, hexalithium disilicide 10.6 Hazardous decomposition products Other decomposition products - no data available In the event of fire: see section 5 11. TOXICOLOGICAL INFORMATION 11.1 Information on toxicological effects Acute toxicity no data available (Hydrochloric acid) Inhalation: no data available (Hydrochloric acid) Sigma-Aldrich - 339253 Page 6 of 8 Dermal: no data available (Hydrochloric acid) no data available (Hydrochloric acid) Skin corrosion/irritation H. Clinton 58 Skin - rabbit Result: Causes burns. Serious eye damage/eye irritation Eyes - rabbit (Hydrochloric acid) Result: Corrosive to eyes Respiratory or skin sensitisation no data available (Hydrochloric acid) Germ cell mutagenicity no data available (Hydrochloric acid) Carcinogenicity This product is or contains a component that is not classifiable as to its carcinogenicity based on its IARC, ACGIH, NTP, or EPA classification. (Hydrochloric acid) (Hydrochloric acid) (Hydrochloric acid) IARC: 3 - Group 3: Not classifiable as to its carcinogenicity to humans (Hydrochloric acid) NTP: No component of this product present at levels greater than or equal to 0.1% is identified as a known or anticipated carcinogen by NTP. OSHA: No component of this product present at levels greater than or equal to 0.1% is identified as a carcinogen or potential carcinogen by OSHA. Reproductive toxicity no data available (Hydrochloric acid) no data available (Hydrochloric acid) Specific target organ toxicity - single exposure The substance or mixture is classified as specific target organ toxicant, single exposure, category 3 with respiratory tract irritation. (Hydrochloric acid) Specific target organ toxicity - repeated exposure no data available Aspiration hazard no data available (Hydrochloric acid) Additional Information RTECS: MW4025000 burning sensation, Cough, wheezing, laryngitis, Shortness of breath, spasm, inflammation and edema of the larynx, spasm, inflammation and edema of the bronchi, pneumonitis, pulmonary edema, Material is extremely destructive to tissue of the mucous membranes and upper respiratory tract, eyes, and skin. (Hydrochloric acid) 12. ECOLOGICAL INFORMATION 12.1 Toxicity Toxicity to fish LC50 - Gambusia affinis (Mosquito fish) - 282 mg/l - 96 h (Hydrochloric acid) 12.2 Persistence and degradability no data available 12.3 Bioaccumulative potential no data available 12.4 Mobility in soil H. Clinton 59 no data available (Hydrochloric acid) Sigma-Aldrich - 339253 Page 7 of 8 12.5 Results of PBT and vPvB assessment PBT/vPvB assessment not available as chemical safety assessment not required/not conducted 12.6 Other adverse effects no data available 13. DISPOSAL CONSIDERATIONS 13.1 Waste treatment methods Product Offer surplus and non-recyclable solutions to a licensed disposal company. Contact a licensed professional waste disposal service to dispose of this material. Dissolve or mix the material with a combustible solvent and burn in a chemical incinerator equipped with an afterburner and scrubber. Contaminated packaging Dispose of as unused product. 14. TRANSPORT INFORMATION DOT (US) UN number: 1789 Class: 8 Packing group: II Proper shipping name: Hydrochloric acid Reportable Quantity (RQ): 13514 lbs Marine pollutant: No Poison Inhalation Hazard: No IMDG UN number: 1789 Class: 8 Packing group: II EMS-No: F-A, S-B Proper shipping name: HYDROCHLORIC ACID Marine pollutant: No IATA UN number: 1789 Class: 8 Packing group: II Proper shipping name: Hydrochloric acid 15. REGULATORY INFORMATION REACH No. : 01-2119484862-27-XXXX SARA 302 Components SARA 302: No chemicals in this material are subject to the reporting requirements of SARA Title III, Section 302. SARA 313 Components The following components are subject to reporting levels established by SARA Title III, Section 313: Hydrochloric acid CAS-No. 7647-01-0 Revision Date 1993-04-24 SARA 311/312 Hazards Acute Health Hazard Massachusetts Right To Know Components Hydrochloric acid CAS-No. H. Clinton 60 7647-01-0 Revision Date 1993-04-24 Pennsylvania Right To Know Components Water CAS-No. 7732-18-5 Revision Date Hydrochloric acid 7647-01-0 1993-04-24 New Jersey Right To Know Components Water CAS-No. 7732-18-5 Revision Date Hydrochloric acid 7647-01-0 1993-04-24 California Prop. 65 Components Sigma-Aldrich - 339253 Page 8 of 8 This product does not contain any chemicals known to State of California to cause cancer, birth defects, or any other reproductive harm. 16. OTHER INFORMATION Full text of H-Statements referred to under sections 2 and 3. Eye Dam. Serious eye damage H290 May be corrosive to metals. H314 Causes severe skin burns and eye damage. H318 Causes serious eye damage. H335 May cause respiratory irritation. Met. Corr. Corrosive to metals Skin Corr. Skin corrosion STOT SE Specific target organ toxicity - single exposure HMIS Rating Health hazard: 3 Chronic Health Hazard: Flammability: 0 Physical Hazard 0 NFPA Rating Health hazard: 3 Fire Hazard: 0 Reactivity Hazard: 0 Further information Copyright 2014 Sigma-Aldrich Co. LLC. License granted to make unlimited paper copies for internal use only. The above information is believed to be correct but does not purport to be all inclusive and shall be used only as a guide. The information in this document is based on the present state of our knowledge and is applicable to the product with regard to appropriate safety precautions. It does not represent any guarantee of the properties of the H. Clinton 61 product. Sigma-Aldrich Corporation and its Affiliates shall not be held liable for any damage resulting from handling or from contact with the above product. See www.sigma-aldrich.com and/or the reverse side of invoice or packing slip for additional terms and conditions of sale. Preparation Information Sigma-Aldrich Corporation Product Safety Americas Region 1-800-521-8956 Version: 5.5 Revision Date: 03/07/2014 Print Date: 04/02/2016 H. Clinton 62 Sigma - H1009 Page 1 of 8 SIGMA-ALDRICH sigma-aldrich.com SAFETY DATA SHEET Version 3.13 Revision Date 10/07/2015 Print Date 04/02/2016 1. PRODUCT AND COMPANY IDENTIFICATION 1.1 Product identifiers Product name : Hydrogen peroxide solution Product Number : H1009 Brand : Sigma CAS-No. : 7722-84-1 1.2 Relevant identified uses of the substance or mixture and uses advised against Identified uses : Laboratory chemicals, Synthesis of substances 1.3 Details of the supplier of the safety data sheet Company : Sigma-Aldrich 3050 Spruce Street SAINT LOUIS MO 63103 USA Telephone : +1 800-325-5832 Fax : +1 800-325-5052 1.4 Emergency telephone number Emergency Phone # : (314) 776-6555 2. HAZARDS IDENTIFICATION 2.1 Classification of the substance or mixture GHS Classification in accordance with 29 CFR 1910 (OSHA HCS) Oxidizing liquids (Category 1), H271 Acute toxicity, Oral (Category 4), H302 Skin corrosion (Category 1A), H314 Serious eye damage (Category 1), H318 Acute aquatic toxicity (Category 3), H402 For the full text of the H-Statements mentioned in this Section, see Section 16. 2.2 GHS Label elements, including precautionary statements Pictogram Signal word Danger Hazard statement(s) H271 May cause fire or explosion; strong oxidizer. H302 Harmful if swallowed. H314 Causes severe skin burns and eye damage. H318 Causes serious eye damage. H402 Harmful to aquatic life. Precautionary statement(s) P210 Keep away from heat. P220 Keep/Store away from clothing/ combustible materials. P221 Take any precaution to avoid mixing with combustibles. Sigma - H1009 Page 2 of 8 P264 Wash skin thoroughly after handling. P270 Do not eat, drink or smoke when using this product. H. Clinton 63 P273 Avoid release to the environment. P280 Wear protective gloves/ protective clothing/ eye protection/ face protection. P283 Wear fire/ flame resistant/ retardant clothing. P301 + P312 + P330 IF SWALLOWED: Call a POISON CENTER or doctor/ physician if you feel unwell. Rinse mouth. P301 + P330 + P331 IF SWALLOWED: Rinse mouth. Do NOT induce vomiting. P303 + P361 + P353 IF ON SKIN (or hair): Take off immediately all contaminated clothing. Rinse skin with water/shower. P304 + P340 + P310 IF INHALED: Remove person to fresh air and keep comfortable for breathing. Immediately call a POISON CENTER or doctor/ physician. P305 + P351 + P338 + P310 IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Immediately call a POISON CENTER or doctor/ physician. P306 + P360 IF ON CLOTHING: rinse immediately contaminated clothing and skin with plenty of water before removing clothes. P363 Wash contaminated clothing before reuse. P370 + P378 In case of fire: Use dry sand, dry chemical or alcohol-resistant foam to extinguish. P371 + P380 + P375 In case of major fire and large quantities: Evacuate area. Fight fire remotely due to the risk of explosion. P405 Store locked up. P501 Dispose of contents/ container to an approved waste disposal plant. 2.3 Hazards not otherwise classified (HNOC) or not covered by GHS - none 3. COMPOSITION/INFORMATION ON INGREDIENTS 3.2 Mixtures Formula : H2O2 Molecular weight : 34.01 g/mol Hazardous components Component Classification Concentration Hydrogen peroxide CAS-No. EC-No. Index-No. 7722-84-1 231-765-0 008-003-00-9 Ox. Liq. 1; Acute Tox. 4; Skin Corr. 1A; Eye Dam. 1; Aquatic Acute 3; H271, H302 + H332, H314, H318, H402 >= 30 - < 50 % For the full text of the H-Statements mentioned in this Section, see Section 16. 4. FIRST AID MEASURES 4.1 Description of first aid measures General advice H. Clinton 64 Consult a physician. Show this safety data sheet to the doctor in attendance.Move out of dangerous area. If inhaled If breathed in, move person into fresh air. If not breathing, give artificial respiration. Consult a physician. In case of skin contact Take off contaminated clothing and shoes immediately. Wash off with soap and plenty of water. Consult a physician. In case of eye contact Rinse thoroughly with plenty of water for at least 15 minutes and consult a physician.Continue rinsing eyes during transport to hospital. If swallowed Do NOT induce vomiting. Never give anything by mouth to an unconscious person. Rinse mouth with water. Consult a physician. Sigma - H1009 Page 3 of 8 4.2 Most important symptoms and effects, both acute and delayed The most important known symptoms and effects are described in the labelling (see section 2.2) and/or in section 11 4.3 Indication of any immediate medical attention and special treatment needed No data available 5. FIREFIGHTING MEASURES 5.1 Extinguishing media Suitable extinguishing media Use water spray, alcohol-resistant foam, dry chemical or carbon dioxide. 5.2 Special hazards arising from the substance or mixture Nature of decomposition products not known. 5.3 Advice for firefighters Wear self-contained breathing apparatus for firefighting if necessary. 5.4 Further information Use water spray to cool unopened containers. 6. ACCIDENTAL RELEASE MEASURES 6.1 Personal precautions, protective equipment and emergency procedures Use personal protective equipment. Avoid breathing vapours, mist or gas. Ensure adequate ventilation. Evacuate personnel to safe areas. For personal protection see section 8. 6.2 Environmental precautions Prevent further leakage or spillage if safe to do so. Do not let product enter drains. Discharge into the environment must be avoided. 6.3 Methods and materials for containment and cleaning up Contain spillage, and then collect with an electrically protected vacuum cleaner or by wetbrushing and place in container for disposal according to local regulations (see section 13). 6.4 Reference to other sections For disposal see section 13. H. Clinton 65 7. HANDLING AND STORAGE 7.1 Precautions for safe handling Avoid contact with skin and eyes. Avoid inhalation of vapour or mist. Keep away from sources of ignition - No smoking. For precautions see section 2.2. 7.2 Conditions for safe storage, including any incompatibilities Keep container tightly closed in a dry and well-ventilated place. Containers which are opened must be carefully resealed and kept upright to prevent leakage. Recommended storage temperature 2 - 8 C 7.3 Specific end use(s) Apart from the uses mentioned in section 1.2 no other specific uses are stipulated 8. EXPOSURE CONTROLS/PERSONAL PROTECTION 8.1 Control parameters Components with workplace control parameters Component CAS-No. Value Control parameters Basis Hydrogen peroxide 7722-84-1 TWA 1.000000 ppm USA. ACGIH Threshold Limit Values (TLV) Remarks Upper Respiratory Tract irritation Eye irritation Skin irritation Sigma - H1009 Page 4 of 8 Confirmed animal carcinogen with unknown relevance to humans TWA 1.000000 ppm 1.400000 mg/m3 USA. NIOSH Recommended Exposure Limits TWA 1.000000 ppm 1.400000 mg/m3 USA. Occupational Exposure Limits (OSHA) - Table Z-1 Limits for Air Contaminants The value in mg/m3 is approximate. TWA 1 ppm USA. ACGIH Threshold Limit Values (TLV) Upper Respiratory Tract irritation Eye irritation Skin irritation Confirmed animal carcinogen with unknown relevance to humans TWA 1 ppm 1.4 mg/m3 USA. NIOSH Recommended H. Clinton 66 Exposure Limits TWA 1 ppm 1.4 mg/m3 USA. Occupational Exposure Limits (OSHA) - Table Z-1 Limits for Air Contaminants The value in mg/m3 is approximate. TWA 1 ppm 1.4 mg/m3 USA. OSHA - TABLE Z-1 Limits for Air Contaminants - 1910.1000 8.2 Exposure controls Appropriate engineering controls Handle in accordance with good industrial hygiene and safety practice. Wash hands before breaks and at the end of workday. Personal protective equipment Eye/face protection Tightly fitting safety goggles. Faceshield (8-inch minimum). Use equipment for eye protection tested and approved under appropriate government standards such as NIOSH (US) or EN 166(EU). Skin protection Handle with gloves. Gloves must be inspected prior to use. Use proper glove removal technique (without touching glove's outer surface) to avoid skin contact with this product. Dispose of contaminated gloves after use in accordance with applicable laws and good laboratory practices. Wash and dry hands. Full contact Material: Nitrile rubber Minimum layer thickness: 0.11 mm Break through time: 480 min Material tested:Dermatril (KCL 740 / Aldrich Z677272, Size M) Splash contact Material: Nitrile rubber Minimum layer thickness: 0.11 mm Break through time: 480 min Material tested:Dermatril (KCL 740 / Aldrich Z677272, Size M) data source: KCL GmbH, D-36124 Eichenzell, phone +49 (0)6659 87300, e-mail sales@kcl.de, test method: EN374 If used in solution, or mixed with other substances, and under conditions which differ from EN 374, contact the supplier of the CE approved gloves. This recommendation is advisory only and must be evaluated by an industrial hygienist and safety officer familiar with the specific situation of anticipated use by our customers. It should not be construed as offering an approval for any specific use scenario. Body Protection H. Clinton 67 Complete suit protecting against chemicals, The type of protective equipment must be selected according to the concentration and amount of the dangerous substance at the specific workplace. Sigma - H1009 Page 5 of 8 Respiratory protection Where risk assessment shows air-purifying respirators are appropriate use a full-face respirator with multipurpose combination (US) or type ABEK (EN 14387) respirator cartridges as a backup to engineering controls. If the respirator is the sole means of protection, use a full-face supplied air respirator. Use respirators and components tested and approved under appropriate government standards such as NIOSH (US) or CEN (EU). Control of environmental exposure Prevent further leakage or spillage if safe to do so. Do not let product enter drains. Discharge into the environment must be avoided. 9. PHYSICAL AND CHEMICAL PROPERTIES 9.1 Information on basic physical and chemical properties a) Appearance Form: clear, liquid Colour: colourless b) Odour No data available c) Odour Threshold No data available d) pH No data available e) Melting point/freezing point No data available f) Initial boiling point and boiling range No data available g) Flash point No data available h) Evaporation rate No data available i) Flammability (solid, gas) No data available j) Upper/lower flammability or explosive limits No data available k) Vapour pressure No data available l) Vapour density No data available m) Relative density 1.110 g/cm3 n) Water solubility No data available o) Partition coefficient: noctanol/ water No data available p) Auto-ignition temperature No data available q) Decomposition H. Clinton 68 temperature No data available r) Viscosity No data available s) Explosive properties No data available t) Oxidizing properties No data available 9.2 Other safety information No data available 10. STABILITY AND REACTIVITY 10.1 Reactivity No data available 10.2 Chemical stability Stable under recommended storage conditions. Sigma - H1009 Page 6 of 8 10.3 Possibility of hazardous reactions No data available 10.4 Conditions to avoid No data available 10.5 Incompatible materials Zinc, Powdered metals, Iron, Copper, Nickel, Brass, Iron and iron salts. 10.6 Hazardous decomposition products In the event of fire: see section 5 11. TOXICOLOGICAL INFORMATION 11.1 Information on toxicological effects Acute toxicity LD50 Oral - Acute toxicity estimate - 1,253 mg/kg (Calculation method) Inhalation: No data available Dermal: No data available No data available Skin corrosion/irritation No data available Serious eye damage/eye irritation No data available Respiratory or skin sensitisation No data available Germ cell mutagenicity No data available Carcinogenicity IARC: 3 - Group 3: Not classifiable as to its carcinogenicity to humans (Hydrogen peroxide) NTP: No component of this product present at levels greater than or equal to 0.1% is identified as a known or anticipated carcinogen by NTP. OSHA: No component of this product present at levels greater than or equal to 0.1% is identified as a carcinogen or potential carcinogen by OSHA. Reproductive toxicity No data available No data available H. Clinton 69 Specific target organ toxicity - single exposure No data available Specific target organ toxicity - repeated exposure No data available Aspiration hazard No data available Additional Information RTECS: Not available To the best of our knowledge, the chemical, physical, and toxicological properties have not been thoroughly investigated. Stomach - Irregularities - Based on Human Evidence Stomach - Irregularities - Based on Human Evidence (Hydrogen peroxide) Sigma - H1009 Page 7 of 8 12. ECOLOGICAL INFORMATION 12.1 Toxicity No data available 12.2 Persistence and degradability No data available 12.3 Bioaccumulative potential No data available 12.4 Mobility in soil No data available 12.5 Results of PBT and vPvB assessment PBT/vPvB assessment not available as chemical safety assessment not required/not conducted 12.6 Other adverse effects An environmental hazard cannot be excluded in the event of unprofessional handling or disposal. Harmful to aquatic life. 13. DISPOSAL CONSIDERATIONS 13.1 Waste treatment methods Product Burn in a chemical incinerator equipped with an afterburner and scrubber but exert extra care in igniting as this material is highly flammable. Offer surplus and non-recyclable solutions to a licensed disposal company. Contact a licensed professional waste disposal service to dispose of this material. Dissolve or mix the material with a combustible solvent and burn in a chemical incinerator equipped with an afterburner and scrubber. Contaminated packaging Dispose of as unused product. 14. TRANSPORT INFORMATION DOT (US) UN number: 2014 Class: 5.1 (8) Packing group: II Proper shipping name: Hydrogen peroxide, aqueous solutions Reportable Quantity (RQ): Poison Inhalation Hazard: No IMDG H. Clinton 70 UN number: 2014 Class: 5.1 (8) Packing group: II EMS-No: F-H, S-Q Proper shipping name: HYDROGEN PEROXIDE, AQUEOUS SOLUTION IATA UN number: 2014 Class: 5.1 (8) Packing group: II Proper shipping name: Hydrogen peroxide, aqueous solution 15. REGULATORY INFORMATION SARA 302 Components The following components are subject to reporting levels established by SARA Title III, Section 302: Hydrogen peroxide CAS-No. 7722-84-1 Revision Date 1993-04-24 SARA 313 Components This material does not contain any chemical components with known CAS numbers that exceed the threshold (De Minimis) reporting levels established by SARA Title III, Section 313. SARA 311/312 Hazards Reactivity Hazard, Acute Health Hazard, Chronic Health Hazard Massachusetts Right To Know Components Sigma - H1009 Page 8 of 8 Hydrogen peroxide CAS-No. 7722-84-1 Revision Date 1993-04-24 Pennsylvania Right To Know Components Water CAS-No. 7732-18-5 Revision Date Hydrogen peroxide 7722-84-1 1993-04-24 New Jersey Right To Know Components Water CAS-No. 7732-18-5 Revision Date Hydrogen peroxide 7722-84-1 1993-04-24 California Prop. 65 Components This product does not contain any chemicals known to State of California to cause cancer, birth defects, or any other reproductive harm. 16. OTHER INFORMATION Full text of H-Statements referred to under sections 2 and 3. Acute Tox. Acute toxicity Aquatic Acute Acute aquatic toxicity Eye Dam. Serious eye damage H. Clinton 71 H271 May cause fire or explosion; strong oxidizer. H302 Harmful if swallowed. H302 + H332 Harmful if swallowed or if inhaled H314 Causes severe skin burns and eye damage. H318 Causes serious eye damage. H402 Harmful to aquatic life. Ox. Liq. Oxidizing liquids Skin Corr. Skin corrosion HMIS Rating Health hazard: 3 Chronic Health Hazard: * Flammability: 0 Physical Hazard 2 NFPA Rating Health hazard: 3 Fire Hazard: 0 Reactivity Hazard: 2 Special hazard.I: OX Further information Copyright 2015 Sigma-Aldrich Co. LLC. License granted to make unlimited paper copies for internal use only. The above information is believed to be correct but does not purport to be all inclusive and shall be used only as a guide. The information in this document is based on the present state of our knowledge and is applicable to the product with regard to appropriate safety precautions. It does not represent any guarantee of the properties of the product. Sigma-Aldrich Corporation and its Affiliates shall not be held liable for any damage resulting from handling or from contact with the above product. See www.sigma-aldrich.com and/or the reverse side of invoice or packing slip for additional terms and conditions of sale. Preparation Information Sigma-Aldrich Corporation Product Safety Americas Region 1-800-521-8956 Version: 3.13 Revision Date: 10/07/2015 Print Date: 04/02/2016  ...

... The Influence of Bridge Employment on Roles and Routines in Older Adults Amanda Abbott, Kelsey Robertson, Ashley Barber, Calliope Gray, Jamie Guangco, and Samantha Rush December, 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: Lori Breeden, EdD, OTR A Research Project Entitled The Influence of Bridge Employment on Roles and Routines in Older Adults 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 Amanda Abbott, Kelsey Robertson, Ashley Barber, Calliope Gray, Jamie Guangco, and Samantha Rush 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 INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS Abstract 3 This qualitative study examined the influence of bridge employment on roles and routines in older adults. The participants included seven older adults, age 55 and above, who had retired from their primary employment and were working in a post-retirement bridge occupation. Participants completed the Occupational Questionnaire which contributed to the development of focus group questions to further discover the experiences of older adult retirees. Participants discussed topics related to their roles and routines as impacted by engagement in bridge employment. Thematic analysis was completed revealing three themes of managing time, exploring options, and planning finances. Member checking and the use of an outside coding expert ensured trustworthiness. Researchers found that the schedules of these older adults were influenced by individual personality and a desire to have less responsibility. Participants expressed interest in making a difference in the world, giving back to the community, remaining active, and using finances for memorable time with family. A limitation of the study was lack of racial and socioeconomic diversity. Findings are relevant for occupational therapy practitioners working with older adults who are transitioning to full retirement. INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS The Influence of Bridge Employment on Roles and Routines in Older Adults 4 Older adults are continuing to work past the age of retirement. The changing demographics within the United States and the developed world offer a choice between full retirement and the possibility of bridge employment. Bridge employment is a term for part-time or casual work after retirement (Griffin & Hesketh, 2008). Retiring older adults have the option of full retirement, bridge employment in their own career field or in a different field of work, or beginning volunteer work (Ulrich & Brott, 2005). The retirement transition can be complex, but people who avail themselves of bridge employment have improved health, sense of self, participation in social activity, and marital satisfaction (Wells, de Vaus, Kendig, & Quine, 2009). The following research question guided the exploration of bridge employment in this study: how does bridge employment influence the roles and routines in older adults? This qualitative study examined how bridge employment influenced the roles and routines of older adults. An examination of the literature included a variety of topics related to the retirement transition and bridge employment, such as choices, concerns, and effects on roles and routines. Pinquart and Schindler (2007) recommend determining which roles were active before and after the retirement transition in order to identify what roles continue to be important in daily life. By integrating bridge employment into their lives, retirees may be able to maintain their role identity as they transition from a previous job (Zhan, Wang, Liu, & Schultz, 2009). The amount of satisfaction an individual has with work before retirement can have an effect on their desire to participate in bridge employment, and whether or not their bridge job is similar to their pre-retirement career (Gobeski & Beehr, 2009). Although the number of older adults participating in bridge employment is increasing as Baby Boomers are approaching retirement age, there is limited research on the effects of bridge employment on roles and routines. The INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 5 purpose of this study was to examine how the retirement transition and bridge employment influenced the roles and routines of older adults. Literature Review Bridge employment can be categorized into two primary types: career bridge employment and bridge employment in a different field (non-career bridge employment) (Gobeski & Beehr, 2009) and can also include volunteer work. There are a variety of reasons why a person would choose to stay in their career field versus the alternative. Career attachment is the desire to remain active in the same career and have a positive effect related to employment in that specific career (Gobeski & Beehr, 2009). Those who have experienced career attachment or who have enjoyed considerable job satisfaction in their career field tend to stay in the same type of work, but those who did not enjoy their pre-retirement work will likely choose another form of employment (Gobeski & Beehr, 2009). Individuals with a higher income prior to retirement are less likely to fill their time with paid work (Griffin & Hesketh, 2008), choosing to work in volunteer positions. Dendinger, Adams, and Jacobson (2016) further explored Mor-Baraks (1995) four reasons for participation in bridge employmentjob satisfaction, retirement attitude, and occupational self-efficacy. Mor-Baraks research led to a theory of four main factors that give meaning to work for older adults, which included social, personal, financial, and generative subjects (Dendinger, Adams & Jacobson, 2016). Generativity, a concern and commitment towards future generations by passing on skills and abilities, was identified as a reason behind bridge employment (Dendinger, Adams & Jacobson, 2016). Dendinger, Adams and Jacobson (2016) concluded that the generative reason for work served as a reliable predictor of job satisfaction and attitudes toward retirement. In a study by Loi and Schultz (2007), similar results on generativity were confirmed. Older adult workers were categorized into four subgroups: INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 6 midlifers, displaced workers, retirees, and older retirees. Of these groups, they found that retirees and older retirees were guided by generativity, and were not compelled to choose bridge employment because of benefits or financial needs (Loi & Schultz, 2007). Pinquart & Schindler (2007) examined the satisfaction of the retirement transition through a comparison approach of various sub-groups within a population. These researchers concluded, that retirement is not a uniform transition. Different trajectories of life satisfaction can be observed depending on external circumstances of retirement (e.g., transition from unemployment or from employment) and on available individual resources (e.g. SES, being married, physical health) (Pinquart & Schindler, 2007, p. 453). Ulrich and Brott (2005) explored transition issues, experiences, and decision-making processes of older workers who selected bridge employment. Researchers found that three factors led to participants feeling successful in their jobs: to keep learning, to make a difference with others around them, and to prove that they are competent (Ulrich & Brott, 2005). For the purposes of this study, roles were defined using the Occupational Therapy Practice Framework as sets of behaviors expected by society and shaped by culture and shaped by culture and context (AOTA, 2014, S8). Retirement Retirement allows for more free time for retirees to participate in roles of their choosing (Wang, 2007). Yet, as adults approach retirement, they are likely to experience role loss (Cozijnsen, Steven, & van Tilburg, 2010). Those who are retired will have less diversity within their roles, as the roles that they are able to participate in become more limited (Cozijnsen, Steven & van Tilburg, 2010). Individuals can prepare for this change by gradually developing new roles or strengthening their existing roles (Noone, Stephens & Alpass, 2010). Due to the trend of older adults desiring a more active life after retirement, there is a greater focus on role change (Schnittker, 2007). Olesen and Berry (2011) found that one way an individual could begin to increase their roles is by participating in INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 7 their community. The found that the desire for increased community participation was a strong influencing factor for numerous retirees (Olesen & Berry, 2011). When roles change, the relationships with family, friends, and colleagues may change as well (Cozijnsen, Steven, & van Tilburg, 2010). Social roles are likely to change during the time of retirement, along with work roles (Schnittker, 2007). However, social relationships formed within the work role need to be maintained outside of the workplace prior to retirement (Cozijnsen, Steven & van Tilburg, 2010). Developing relationships outside of work gives those who retire the ability to maintain stronger social connections throughout their retirement transition (Cozijnsen, Steven & van Tilburg, 2010). Gender also can have an effect on role change in the retirement transition. Women are more likely to have roles that involve caring for and nurturing others, which creates an easier role transition as they rely on existing roles (Diekman & Goodfriend, 2006). Family obligations and commitment to familial roles stereotypically fall to women and they are able to maintain these roles throughout the course of their life (Byles, et al., 2013). Consistency of familial roles throughout the lifespan for women creates a more stable and positively viewed role and retirement transition (Diekman & Goodfriend, 2006). Since women have more lifestyle stability in this time, they are also thought to have better role transformation, as they are better able to embrace and fully commit to roles that previously played a smaller part in their lives, versus males who have to typically discover new roles (Byles, et al., 2013). For the purposes of this study, routines were defined as established sequences of occupations or activities that provide structure for daily life; routines also can promote or damage health (AOTA, 2014, p. S8). Segal (2004) performed a qualitative study on routines or rituals in families. He theorized that by adding occupations or activities into a routine, or INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS adapting the way routines are performed, significant adaptations in life can be easier to 8 implement. Methods The research question was: how does bridge employment influence the roles and routines in older adults? To address this question, qualitative design was used to examine the narratives of older adults who engage in bridge employment to determine the roles and routines that were important to their individual lifestyles. This study used the Occupational Questionnaire (Smith, Kielhofner & Watts, 1986) and a focus group to discover the experiences of older adults who have engaged in bridge employment. All portions of the project were approved by the Institutional Review Board and were conducted at the University of Indianapolis. Participants This research study included seven participants from the Indianapolis area. Shtivelband (2013) determined that the age to be considered an older adult began at 55 years old. Therefore, the inclusion criteria were adults, aged 55 and older, who had retired from career employment and now participated in bridge employment or volunteer work on a regular basis. Family members of researchers were excluded from participation this study. Procedures and Materials The participants, aged 55 and above, were recruited through the use of personal contacts and a recruitment flyer, which was posted at community centers and other organizations where older adults may engage in vocational, leisure, or social activities. Following initial phone or email contact, prospective participants offered their availability. Once seven participants were identified, researchers scheduled a date for the focus group that was convenient to all participants. Upon arrival to the University of Indianapolis, participants completed the informed consent process, and selected pseudonyms for use throughout the session. Researchers then INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 9 individually administered the Occupational Questionnaire with each participant. This tool was used to learn about the unique variations in routines with comparison of a typical bridge employment workday to a typical non-work day, and the value that participants placed on these daily activities. Each participant ranked time spent by labeling activities into the following categories: work, daily living tasks, recreation, or rest, with ratings in performance, importance, and enjoyment (Smith, Kielhofner & Watts, 1986). The Occupational Questionnaire was selected for its reliability and validity (Smith, Kielhofner, & Watts, 1986) and for its focus in occupation-based language as a Model of Human Occupation (MOHO) tool (Keilhofner, 2008). The time required to administer the Occupational Questionnaire was approximately twenty minutes, which was consistent with previous use of this tool (Kielhofner, 2008). After doing so, the Occupational Questionnaires were reviewed and used to generate additional topics for conversation during the focus group. Following the Occupational Questionnaire, the participants gathered for a focus group. Utilizing the guidelines identified by Kruger and Casey (2015), the focus group included seven participants and lasted approximately one hour. The leaders of the focus group prompted participants using semi-structured questions, which were tied to participant value statements regarding their bridge employment and daily routine (see Appendix). Following the focus group, participants were individually debriefed, allowing the opportunity to address any remaining topics that might have contained sensitive information or were not addressed directly during the session. Their participation in the data collection lasted approximately two hours. Member checking (Creswell, 2013) occurred after initial data analysis, two weeks following the focus group, via telephone. INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS Data Collection 10 The focus group discussion was audio recorded and two researchers were assigned to record field notes. Audio recordings were transferred to a password-protected computer and stored behind a locked office door at the University of Indianapolis. Transcription of the focus group discussion occurred within 72 hours of the event using Microsoft Word. Field notes provided context and were incorporated into the transcription documents using the comments feature within Microsoft Word. Data Analysis Thematic analysis (Braun & Clark, 2006) occurred after transcription was completed. Memos provided context to the initial codes to further develop meaning. Codes were compared across research team pairings and verified by an outside content expert. A matrix was used to categorize frequently occurring codes from participant statements and helped organize these narratives into themes. An audit trail was maintained to enhance trustworthiness. To further insure trustworthiness, each member of the research team completed a reflexivity journal (Creswell, 2013) immediately following the focus group. Data analysis included an examination of reflexivity journal entries to expose researcher bias. Findings Researchers identified three themes regarding the effect of bridge employment on roles and routines of participants: managing time, exploring options, and planning finances. Managing Time There were two sub-themes discussed throughout the focus group for older adult retirees participating in bridge employment including evening consistency and daytime freedom. A contrast to the pre-retirement routine of daytime consistency and evening freedom. The participants indicated consistent evening routines for both workdays and non-workdays. INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 11 Participant A. (retired Air Force officer and special education teacher) offered, Even when I was working and now that Im retired, theres a certain hour of the day that everything kind of falls back where it always was. Participant K. (retired law enforcement officer) also supported this theme when stating, But my evening routine is very, very standard. Participants, noting that bedtime routines were consistent for workday versus non-workday, also supported this theme of a consistent evening routine during administration of the Occupational Questionnaire. Participant B. (retired from a telephone company and national sorority) also commented, I was very schedule oriented and I think in retirement Im very schedule oriented. Although their daily routine varied greatly, their evening routine did not seem to change, and each individual expressed that they enjoyed new control over daily schedules. Participant A. gave an example of this, saying, The days when I dont have that early class, I get up and I might get dressed. Although their schedules varied from day to day, the participants were often engaged in meaningful activities that brought fulfillment. I wanted to be in control and do things that I wanted to do and things for me in a selfish way (Participant G., retired elementary teacher). Participant L. (registered nurse) gave an example by stating, We want to be involved with something where we are making a difference, where we are making some kind of impact on whatever that may be. On the other hand, Participant K. (police officer) disagreed by saying, I dont want to make an impact, Ive done that all my life. Not with my career. I want to do something that is a little bit more fun and relaxed and not so stressful. Participants reported satisfaction in controlling of their work and activity routine. A consistent theme of the discussion was the ability to independently manage their schedule. As Participant G. said, I told myself when I retired that I was not going to not do things, cause that was not my, thats not my make-up. And I am so excited to be able to now drive my own INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 12 calendar. Participant L. also supported the notion of managing time, when he asked another participant, Having control of your own schedule is just so huge for you isnt it? Participants agreed that they preferred staying busy with family and friends rather than relaxing all day. Many expressed their thoughts and feelings on keeping busy because they wanted to make a difference in the world, give back to their community, and continue to be active. We want to feel like we are engaged in making a difference with something (Participant L). The desire to stay busy as influenced by personal interests, without having many real-time commitments, allowed participants to fill their days with new activities. Exploring Options Throughout the retirement transition, older adults who participated in bridge employment often explored their options in reflection of the desire to have both responsibility and the ability to try new things. Personality impacted individual preferences toward retirement options. In this study, older adults had personal motivation to participate in bridge employment, which included various occupational desires such as volunteer work, part-time work, family time, or other hobbies. This motivation was reflective of the volition described in the Model of Human Occupation that helps to secure ones occupational identity (Keilhofner, 2008). There was a notable difference between the individuals who feared commitment and those who desired to explore new options. One way of identifying these differences was via the results of the Occupational Questionnaire, which revealed the differences in scheduling for a workday versus non-work day. Those who expressed they enjoyed exploration had more free time on their nonwork days for new activities, such as different exercise classes, social groups and more. Participant K. stated, I have the option of not working quite so hard or stressfully. Individuals who showed more tendencies to avoid commitment had less free time within their schedules and did not allow much time to explore options. These aspects also related to the level of INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 13 responsibility individuals wished to maintain through their retirement. Those who have more responsibility in their life did not have as much time to explore options. They felt a commitment to the things they were already doing in their life and had no desire to change them. Participants frequently expressed a preference to do only the things that they chose, and not necessarily the things that were required of them. This gave them less responsibility, and more flexibility when pursuing their options. Participant L. said, I have the option to say yes or no to it. This flexibility can again be seen through the responses on the Occupational Questionnaire, as those who wanted more flexibility had more open time in their schedule, where others had more predetermined schedules with less flexibility. The participants were able to define themselves in new ways by exploring their options. Participant L. stated, We have just a bazillion options of what we want to do with our time now. Participants used these options to develop themselves as individuals during their retirement. The definition of their new self had a tendency to also have meaning or be impactful in reflection of their increasing desire give back as they experienced retirement. This gave them the ability to focus on their new areas of interests throughout their retirement with intentional use of their time. Participant A. described this by saying, You go where your passion leads you, but if you dont like it, it isnt a 30-year commitment. Although passions were a driving focus, individuals were also able to explore opportunities that were not previously possible due to finances. Planning Finances Finances were a recurring topic of focus group discussion. Participant K., while referencing his financial planning both before and after retirement, stated, Everybodys situations a little different. Participants nodded in agreement with this statement; however, they also recognized similarities in financial planning amongst group members. The group discussed that, unlike previous generations that saved their money for their family to inherit, they INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 14 preferred to use their money while they were still alive and enjoy it with their family. Participant A. referenced a conversation she had with one of her daughters about leaving money to her. She offered her daughters comments stating, We want to enjoy this with you. So get your butt out and go. And so we do, we make trips together. Participants also explained that they pay more attention to the stock market now that they have retired. Participant B. supported this when stating, I worry about the stock market more, with many of the members nodding in agreement. Participant A. stated, I kind of plan things out knowing my set income. During a discussion of financial planning before retirement, Participant K. offered, I stressed throughout the years to get that stuff. Group members agreed that planning prior to retirement relieved stress post-retirement. Discussion Participants in this focus group revealed how individuals who retire, then return to bridge employment or participate in a volunteer opportunity are active in managing their schedules, exploring new opportunities, and anticipating how to spend their earnings. Findings in this study mirrored a research article that used the Model of Human Occupation (MOHO) to assess elderly retirees. Tincher (1992) found that older adults choices for occupations after retirement are of their own volition, and this choice influenced their performance and designated roles that came to structure their routine. Each participant in this study expressed their volition through their exploration of a variety of different types of bridge employment. Volition was seen in this study through the participants emphasis on controlling their own schedule. Several participants reflected on their motivation for retirement, such as participant G. who said the following: INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 15 I mean for once you sort of feel like hey Im in control. I mean which is what I wanted to be. I wanted to be in control and do things that I wanted to do and things for me in a selfish way. Although some aspects of participants daily lives varied, evening routines remained consistent. Participants suggested that they valued their evening routine. Participant A. said, You just dont think about it, its such a habit. Youre right. Even when I was working and now that Im retired theres a certain hour of the day that everything kinda falls back where it always was. Consistent routines enhance occupational participation by offering a daily time of relaxation for participants in this study. This was supported by a study completed by Jonsson, Borell & Sadlo, who also found that older adult retirees spent their weekday evenings in rest, described as reading and watching television (2000, p. 31). This study also indicated that routines in older adult retirees evolved into a slower rhythm (2000, p. 31) after retirement. Participants demonstrated performance capacity through the use of bridge employment as a tool to enhance opportunities. For these participants, a pre-planned retirement income allowed the financial freedom to control their schedules and broaden their interests. Engagement in bridge employment provided fulfillment through expansion of ones social circle, increased community involvement, and improved sense of self-worth. We want to feel like we are engaged in making a difference with something (Participant L). This sense of importance drove many participants to maximal performance capacity within their bridge employment or volunteer work. Sewdas et al., (2017) confirmed these findings in a study where post-retirement work was identified as giving a practical meaning to life to older adult retirees. Managing Time When examining the management of time, there was consistency in participants preferring to have control of their own schedule. One participant indicated that gaining control INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 16 of time and schedule was the primary benefit of retirement. Participant L. stated We get to choose how we spend our time now. One participant noted that she enjoyed being able to build her own schedule by choosing what she participates in on a daily basis. Other participants agreed on the value of having the ability to plan days around personal schedules and make modifications as necessary. Many participants emphasized the importance of evening consistency and daytime freedom. Participant K. said the following: My evening routine is similar every day. Whether Im working its a workday or recreation day or whatever. Thats you know the eight-ish, eight or nine oclock in the evening, you know done with dinner, wind down, relax, ten oclock news then off to bed. That, you could almost set a clock by that I guess. Many participants agreed that they had the same evening routine, which included winding down around the same time every night. This is supported by previous research, which found that individuals prefer to have control of their own schedules in order to give themselves more feelings of confidence, and cultivate more purposeful time spent (Lim & Feldman, 2003). Dingemans (2014) also found that individuals choose to partake in bridge employment based upon the schedule flexibility of the employer, furthermore, suggesting that these individuals value the self-determination of their own schedule. In addition to determining their own schedule, spending time with family and friends as desired was important to participants in this study. Participants discussed their new freedom of using weekdays for socialization. One participant stated, Generally, a lot of my friends say lets not do it on the weekend when everybody else is at the show or at the restaurant, lets just, you, you can go during the week, the prime time (Participant A.). Kojola & Moen (2015) found similar results indicating individuals in retirement still have a tendency to plan based on their personal wants and needs, or the wants and needs of their family. Participants in this study INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 17 placed high value on the control of time in retirement, and this included the daily freedom to participate in hobbies or other activities of their own choice. Exploring Options Retirement can offer an opportunity for older adults to participate in roles they did not previously have time for by allowing them to do more of what they choose (Wang, 2007). Participants in this study expressed that they enjoyed having the chance to explore new activities Participant K. offered, I want to do something that is a little bit more fun and relaxed. Previous researchers confirm these experiences, reporting that retirees who carry more positive attitudes or express that they enjoy retirement are more motivated and interested in making plans during their retirement (Lim & Feldman, 2003). Participant A stated I just think that retirement is great, reflecting her positive attitude, and verifying Lim and Feldmans results as she went on to express her desire to make new plans in her retirement. Participant A. continued on and stated, when I retired I thought, there is a lot of things out there and Im not done learning yet. Retirees may be involved in many other roles through bridge employment, volunteer work, or even caregiving within their family. Olsen and Berry (2011) found that participating in community activities is a way for individuals to expand their roles. The findings of this study support Olsen and Berrys work shown by participants suggestions that bridge employment allows them to give back to the community. This community participation was revealed in previous research as supportive of a higher quality of life in older adults (Merrian & Kee, 2014). Planning Finances Participants in this study indicated that earnings were often valued as a provision for their families, for both the present and the future. Participants expressed they would rather spend money on experiences with family now, rather than save to pass on to their family. In reference to using money for family memories, Participant A. offered the phrase shared with her children, INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 18 I want to see the expression on your face when you use my money. This is supported by a previous research study by Kojola and Moen, (2015) who also discovered that individuals who have entered retirement are more likely to plan and consider their families when preparing for the future. Participants also reported that they spent more time attending to the stock market. This was supported by another study by Lusardi and Mitchell (2006) who found that current older adult generations are more exposed to the stock market than cohorts younger than them. Participants reported that they were active in financial planning for retirement. Results of a study by Schooley & Worden (2013) support this idea of planning prior to retirement in order to have reliable savings during retirement. The researchers explained how individuals become savers during later stages of life and then convert these savings to use during retirement (Schooley & Worden, 2013). Limitations A limitation of the study was that participants had been retired from their career job for a varying number of years. Time retired, along with the age of the participant, may have affected the results in that more life experiences had occurred with increased time since retirement. Making some participants more savvy retirees. Another limitation was that the limited diversity in the focus group might prevent the results from being applicable to individuals who have different financial resources or live in different areas. This was evident in the discussion regarding preparation for retirement. Individuals from a variety of socioeconomic backgrounds may be more or less likely to connect their enjoyment of retirement to financial planning. Recommendations Future studies may consider what led individuals to pursue bridge employment or how demographic characteristics influence selecting bridge employment in retirement. Another area that may benefit from further study is how relationships change between spouses, families, and INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS friends during bridge employment or retirement alone, and how these relationships are 19 influencing the transition. These findings are relevant for occupational therapy practitioners who work with older adults during the retirement transition. The occupational therapy scope of practice includes identifying and assisting individuals with their daily roles and routines (AOTA, 2014, p. S35). Older adults who are engaged in bridge employment have evolving roles and routines. Occupational therapy practitioners can use the findings in this study to support the occupational performance of their clients and assist them with the challenges of the retirement transition. Conclusion This study examined how bridge employment during the retirement transition influenced the roles and routines of older adults. Consistent themes from focus group participants were managing time, exploring options and planning finances. Findings included that schedules of older adult retirees were often influenced by individual personality and the desire to have less responsibility. Regardless of personalities, older adult retirees who participated in bridge employment valued evening consistency and daytime freedom. Participants expressed continued interests in making a difference in the world, giving back to the community, remaining active, and using finances for memorable time with family during retirement. Occupational therapists are uniquely positioned to help older adults develop roles and routines to improve the transition process of older adult retirees as they engage in bridge employment. INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS References 20 American Occupational Therapy Association (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. American Occupational Therapy Association (2014). Scope of practice. American Journal of Occupational Therapy, 68(Suppl. 3), S34-S40. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. doi:10.1191/1478088706qp063oa Byles, J., Tavener, M., Robinson, I., Parkinson, L., Smith, P. W., Stevenson, D., & ... Curryer, C. (2013). Transforming retirement: New definitions of life after work. Journal of Women & Aging, 25(1), 24-44. doi:10.1080/08952841.2012.717855 Cozijnsen, R., Stevens, N. L., & van Tilburg, T. G. (2010). Maintaining work-related personalities following retirement. Personal Relationships, 17(3), 345-356. doi:10.111/j.14756811.201201283 Creswell, J. W. (2013). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). Thousand Oaks, CA: Sage Publications. Dendinger, V., Adams, G., & Jacobson, J. (2016). Reasons for working and their relationship to retirement attitudes, job satisfaction and occupational self-efficacy of bridge employees. The International Journal of Aging and Human Development,61(1), 21-35. doi:10.2190/K8KU-46LH-DTW5-44TU Diekman, A. B., & Goodfriend, W. (2006). Rolling with the changes: A role congruity perspective on gender norms. Psychology of Women Quarterly, 30(4), 369-383. INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 21 Dingemans, E. (2014). Involuntary retirement, bridge employment, and satisfaction with life: A longitudinal investigation. Journal of Organizational Behavior, 35(4). 575-591. doi:10.1002/job.1914 Gobeski, K. T., & Beehr, T. A. (2009). How retirees work: predictors of different types of bridge employment. Journal of Organizational Behavior, 30(3), 401-425. doi:10.1002/job.547 Griffin, B. & Hesketh, B. (2008). Post-retirement work: The individual determinants of paid and volunteer work. The Journal of Occupational and Organizational Psychology, 81, 101121. Jonsson, H., Borell, L. & Sadlo, G. (2000). Retirement: An occupational transition with consequences for temporality, balance and meaning of occupations. Journal of Occupational Science, 7:1, 29-37 Kielhofner, G. (2008). Model of Human Occupation: Theory and application. Baltimore, MD: Lippincott Williams & Wilkins. Kojola, E., & Moen, P. (2015). No more lock-step retirement: Boomers shifting meanings of work and retirement. Journal of Aging Studies, 36. 59-70. doi:10.1016/j.jaging.2015.12.003 Krueger, R. & Casey, M. (2015). Focus groups: A practical guide for applied research. New Delhi, India: SAGE Publications Asia-Pacific Pte. Ltd. Lim, V. K. G., & Feldman, D. (2003). The impact of time structure and time usage on willingness to retire and accept bridge employment. International Journal of Human Resource Management, 14(7). 1178-1191. doi:10.1080/09585190320000114255 Loi, J., & Shultz, K. (2007). Why older adults seek employment: Differing motivations among subgroups. Journal of Applied Gerontology, 26(3), 274-289. doi:10.1177/0733464807301087 INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 22 Lusardi, A., & Mitchell, O. S. (2007). Baby Boomer retirement security: The roles of planning, financial literacy, and housing wealth. Journal Of Monetary Economics, 54(1), 205-224 doi:10.1016/j.jmoneco.2006.12.001 Merriam, S. B., & Kee, Y. (2014). Promoting community wellbeing: The case for lifelong learning for older adults. Adult Education Quarterly, 64(2). 128-144. doi:10.1177/0741713613513633 Noone, J. H., Stephens, C., & Alpass, F. (2010). The process of retirement planning scale (PRePS): Development and validation. Psychological Assessment, 22(3), 520-31. doi:10.1037/a0019512 Olesen, S. C., & Berry, H. L. (2011). Community participation and mental health during retirement in community sample of Australians. Aging & Mental Health, 15(2), 186-197. Pinquart, M., & Schindler, I. (2007). Changes of life satisfaction in the transition to retirement: A latent-class approach. Psychology and Aging, 22(3), 442-455. doi:10.1037/08827974.2.3.442 Schnittker, J. (2007). Look (closely) at all the lonely people: Age and the social psychology of social support. Journal of Aging and Health, 19(4), 659-682. doi:10.1177/0898264307301178 Schooley, D. K., & Worden, D. D. (2013). Accumulating and spending retirement assets: A behavioral finance explanation. Financial Services Review, 22(2), 173-186. Segal, R. (2004). Family routines and rituals: A context for occupational therapy interventions. American Journal of Occupational Therapy, 58, 499-508. INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS 23 Sewdas, R., de Wind, A., van der Zwaan, L. L., van der Borg, W. E., Steenbeek, R., van der Beek, A. J., & Boot, C. L. (2017). Why older workers work beyond the retirement age: a qualitative study. BMC Public Health, 171-9. doi:10.1186/s12889-017- 4675-z Shtivelband, A. (2013). Bridge employment among the aging workforce: Recommendations for future research. The 10th International Conference on Occupational Stress and Health, May 16-19, 2013, Los Angeles, California: Protecting And Promoting Total Worker Health [Abstracts], doi:10.1037/e577572014-292 Smith, N. R., Kielhofner, G., & Watts, J. H. (1986). The Relationships Between Volition, Activity Pattern, and Life Satisfaction in the Elderly. American Journal of Occupational Therapy, 40, 278-283 doi:10.5014/ajot.40.4.278. Spradley, J. (1979). The ethnographic interview. Belmont, Canada: Wadsworth Group. Tincher, B. (1993). Retirement: Perspectives and theory. Physical & Occupational Therapy in Geriatrics, 11(1). 55-62. Ulrich, L., & Brott, P. (2005). Older workers and bridge employment: Redefining retirement. Journal of Employment Counseling, 42, 159-170. Wang, M. (2007). Profiling retirees in the retirement transition and adjustment process: Examining the longitudinal change patterns of retirees psychological well-being. Journal of Applied Science. 92(2), 455-474. doi:10.1037/0021-9010.92.2.455 Wells, Y., de Vaus, D., Kendig, H., & Quine, S. (2009). Health and wellbeing through work and retirement transitions in mature age: Understanding pre-post and retrospective measures of change. International Journal of Aging and Human Development, 69(4), 287-310. INFLUENCE OF BRIDGE EMPLOYMENT IN OLDER ADULTS Appendix 24 1. Please state your career job, retirement date, and current bridge employment or volunteer position. 2. What things in your routine on a workday carry over on a non-work day? What are the main differences in your routine on workdays versus non-work days? 3. Tell us how your roles have changed since retiring and beginning bridge employment. 4. Tell us about any hobbies that you have picked up since you have entered your bridge job. How have your responsibilities in the home changed? 5. How does your hygiene/self-preparation routine change on the days that you work? 6. Since you began bridge employment, has your diet changed? Would you say it is consistent throughout the week or does it change based on the day you work? 7. How has your health been affected since beginning bridge employment? Do you think your health is better than your parents at the same age? Did your parents participate in bridge employment? 8. How do you find yourself socializing or participating in community outings differently compared to your lifestyle prior to retirement? Is there opportunity to socialize with friends or family during the day, that you used to only do in the evenings or on the weekends? 9. How is your concern for finances different from when you were employed in your career job? Do you find yourself less worried or more? How have you had to manage finances differently? 10. Do you find your sleep is more consistent/less consistent? Do you find you need more or less sleep, why?  ...

... Running Head: SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 1 The Impact of Combining Sensory Based Activities into Physical Education Classes with Adolescents Diagnosed with Autism Spectrum Disorder Shelby Hale 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: Taylor McGann, OTD SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES A Capstone Project Entitled The Impact of Combining Sensory Based Activities into Physical Education Classes with Adolescents Diagnosed with Autism Spectrum Disorder 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 Shelby Hale 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 2 SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 3 Abstract This Doctoral Capstone Project explored the benefit of adding sensory based activities to physical education (PE) classes at DAMAR with students diagnosed with Autism Spectrum Disorder (ASD). This project aimed to increase the participation of the students during PE classes, as well as educate the staff on the importance of physical activity participation for the students. All six ASD classes from DAMAR participated in this project with a total of 93 students. Outcomes of this project were an increase in participation in students during sensory based gym activities. Post-satisfaction surveys indicated teacher satisfaction with the PE activities, improvements in sensory behaviors in the classroom after PE, and satisfaction with the increase of student participation. Staff education and resources were provided to DAMAR staff to further educate on the importance of continuation of sensory based gym activities during PE time, as well as importance of encouraging student participation during PE. Outcomes of this project were affected by the number of student absences week by week and limited staff participation. SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 4 Literature Review Autism Spectrum Disorder (ASD) is defined as persons having significant difficulties in social communication and reciprocity, developing and maintaining relationships, restricted and repetitive patterns or behavior, and deficits in non-verbal communication (Guest, Balogh, Dogra, & Lloyd, 2017). Occupational Therapys (OT) role with treating children with ASD, based on the PEOP theory, is enhancing participation in performance of activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, leisure, play, and social participation (American Occupational Therapy Association, 2010). For an individual with ASD, occupational therapy services are defined according to the persons needs and priorities for participation. Throughout the OT process, collaboration with the child with ASD, caregivers, teachers, and other supporters are essential to understanding the daily life experiences of the individual. OT services can focus on personal development, quality of life, and needs of the family (American Occupational Therapy Association, 2010). OTs can also help children with ASD adjust to tasks and conditions to match their needs and abilities by adapting the environment to minimize external distraction or identifying skills that are needed to accomplish ADL and or IADL tasks (American Occupational Therapy Association, 2010). Mische and Foster (2018) concluded that occupational therapy practitioners can partner with recreation and exercise professionals to increase physical activity among children with ASD by developing programs that meet the needs of the clients, matching clients with existing programs, and teaching clients underlying skills to succeed in preferred activities. Based on the ideas of Mische and Foster (2018) the purpose of this doctoral capstone project examined the impact of combining sensory based activities into physical education classes with adolescents diagnosed with ASD. SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 5 Sensory Benefits OT practitioners have been using the sensory integration theory since it was introduced in 1963 by Jean Ayers. This theory postulates that learning occurs when the child has the ability to receive accurate sensory information, process it, use it to organize behaviors, and adapt responses (Matsushima & Kato, 2013). Sensory processing disorders are sensory processing challenges and deficiencies that continually interfere with higher levels of function and social participation. Matsushima and Kato (2013) reported that the symptoms of SPDs are common with children with ASD with incidence rates up to 95%. Children with ASD that exhibit SPD symptoms have trouble modulating their responses to various types of sensory input such as vestibular, tactile, and proprioceptive. Matsushima and Kato (2013) examined the association between SPD and social interaction deficits in Japanese students with ASD. Their study consisted of 84 children ranging from 4-6 years old with and without ASD. A likert scale questionnaire and standardized test was filled out by the caregivers to compare behavioral responses of the children to different sensory stimuli.. Their results concluded that there is a patterns of sensory processing deficits in children with ASD that are impacting their social interaction (Matsushuma & Kato, 2013). Mische and Foster (2018) recruited participants from a sensory enhanced aquatics program for children with ASD 4-17 years of age seeking to find a relationship between sensory processing patterns, obesity, engagement in physical activity, and body mass index. The researchers collected data from caregivers through a demographic form, recreation participation log, and the Sensory Profile-2. After analysis of the data, researchers found that low sensory profile scores show that children with greater sensory seeking behaviors participate in more physical activities and children with avoiding sensory patterns have a higher BMI (Mische SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 6 &Foster, 2018). These results suggested that sensory patterns may be related to increased obesity rates in children with ASD and that sensory avoiding negativity affects daily living skills (Mische & Foster, 2018). With the knowledge that sensory processing patterns influence participation in physical activity, OTs are able to understand the influence of sensory processing patterns on physical activity. This allows OTs to design and structure environments with various levels of sensory stimuli to provide a better fit for children who display SPD behaviors with ASD (Mische &Foster, 2018). Benefits of Participation Participation in physical activity is crucial to ones physical, emotional, and cognitive health, and is associated with greater health for all population (Lawson & Little, 2017). Participation in physical activity for children with ASD has been shown to improve maladaptive and repetitive behaviors (Lawson and Little, 2017; Taliaferro, Rienzo, & Donovan, 2010), but there is an observed lack of participation in physical activity in children with ASD (Ninot, Bilard, & Delignieres, 2005). Participation in physical activity can also provide numerous benefits including increased physical conditioning, decline in isolation, improved psychosocial health, enhanced independence and self-efficacy, autonomy, and overall enjoyment (Guest, Balogh, Dogra, & Lloyyd, 2017). Fundamental motor skills (FMS) are essential skills that develop throughout childhood and can enable participation in sport, recreation, and leisure activities (Guest et al., 2017). These skills include locomotor and object control skills and they contribute to physical, cognitive, and social development. Delays in FMS have been strongly correlated with children with ASD and become more prominent with age (Guest et al., 2017). Children with ASD are seen to have significant motor delays compared to their peers which can influence their participation in SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 7 physical activities. Guest et al. (2017) designed a five-day multi-sport camp for 13 girls ages 811 with ASD. The skills that were taught at the camp were locomotor and object control that progressed in difficulty throughout the camp. At the beginning of the research, participants were measured to have very poor or below average gross motor skills. At the end of the five-day camp there was significant improvements in all motor skills (Guest et al, 2017). The authors concluded that the improvements made will lead to functional gains, improved self-confidence, and increased physical abilities that encourage further participation (Guest et al, 2017). Participation in physical activities has been shown to improve self-efficacy and selfperceptions among children with ASD and other developmental coordination disorders (Guest et al., 2017). Oladunni, Lyoka, and Goon (2015) found that students were more motivated to participate in sports because of several factors: enjoyment, competency, need to socialize, and health and psychological benefits. The researchers looked at 120 different schools and questionnaires that were completed by the students or their caregivers about the students motivational factors influencing students with disabilities to participate in physical activities. The researchers also conducted interviews with teachers of the students interviewed and were asked about the benefits they see in participation in physical activities. The teachers reported that they noticed greater development of social skills, better attention span, and more productivity in the classroom when the students participated in physical activity (Oladunni et al., 2015). Benefits to Socialization Hand in hand with participation, greater motor skills and physical function have been linked with greater social skills and behavioral outcomes that are all beneficial for learning daily living skills (Guest et al., 2017). The ability to move with competence is required in structured SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 8 and unstructured recreational activities. For children of all ages, these skills are important for social scenarios that children with ASD may miss out on due to lack of skill (Guest et al., 2017). Research has shown that children with ASD that have made improvements in motor skills have also had a positive effect on social skills including a reduction in maladaptive behaviors and improvements with peer engagement (Guest et al., 2017). In the study by Guest et al. (2017), the researchers also found that with the use of the sport camp the participants showed significant improvements among the social skills domains including interpersonal adaptive levels of coping. Guest et al. (2017) also concluded that there was a small increase in social skills, cooperation, empathy, and self-control. Greater perceptions of having the skills to participate is also a contributing factor in order to engage in physical activities in a social setting and this may translate into more engagement with peers, providing more opportunities for these kids to interact socially (Guest et al., 2017). Screening and Evaluation Problems in Occupational Performance DAMAR is a non-for-profit organization with a mission to integrate academic instructional techniques with life skills education, to ensure a better future for children facing lifes greatest developmental and behavioral challenges. DAMAR Services has put together a wellness program that has a mission to encourage and enhance a healthy lifestyle by creating opportunities to educate and support each individuals lifelong wellness practices (DAMAR employee, personal communication, February 2018). The fitness goal for this wellness program is to provide opportunities for every client to develop the knowledge and skills for specific physical activities, maintain physical fitness, and regularly participate in physical activity (DAMAR employee, personal communication, February 2018). With this goal, the wellness SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 9 program has objectives that incorporate development of motor skills and social skills through each students participation in physical activity offered during PE/recreation times (DAMAR employee, personal communication, February 2018). After completion of a four week needs assessment and observation in the recreational department, it was observed that the goals and objectives made through DAMAR Services were not being addressed. There was limited participation by the students in PE and there were limited opportunities for the students to develop knowledge and skills. With the limited participation and limited creativity in PE activities, motor and social skills were not being developed during PE times. Aligned with meeting the goals and objectives that was set by the DAMAR Services wellness program as well as evidence based ideas, this capstone project was created. The findings of Mische and Foster (2018) supported the problems that were found at DAMAR by concluding that OTs can partner with recreational staff to increase the physical activity participation among children with ASD by developing supporting sensory based program during physical education/recreation times. Process As stated above, the screening and evaluation processes for this Doctoral Capstone project started with a needs assessment done at DAMAR during physical education (PE) classes offered during the school day on the DAMAR campus. Classes from both the public off campus DAMAR Charter Academy (DCA) and private on campus DAMAR Freeway Academy (DFA) both take part in PE 1-3 times per week. Three DCA and three DFA classes were chose to be the focus for this project with a total of 93 students. The students in the 6 classes that were chosen, have a diagnosis of ASD. Students are enrolled in an Autism class at DCA and or are residents SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 10 on either the Autism Transition Residential Unit (ATU) or the Autism Service Residential Unit (ASU) on the DAMAR campus. Students ages ranged from 7 to 21 years of age. The information gained from the four week needs assessment and observation period was used to guide planning of best fit activities to create and increase student participation in PE. The Pittsburg Rehabilitation Participation Scale (PRPS) was used to track the participation of the students in gym class each week for seven weeks after the needs observation was completed. According to Lenze et al. (2004) the PRPS can be easily and reliably measured and the scores can predict functional outcomes. The PRPS also was found to have clinical and research outcome measurements (Lenze et al., 2004). Each participant was gave a rating from 1-6 based on their performance in the activities. With 1 being no participation and 6 being full participation of the student with maximal effort. Refer to Table 1 for detailed PRPS and scoring information. Anonymity of the students were preserved during collection of PRS scores by assigning initials to each student. Teachers gave approval for the doctoral capstone student to participate in activity planning and implementation of activities during gym times once per week. Staff was informed their help would be needed to aid the students in participation in the structured gym activities. Comparison to Practice Areas The American Occupational Therapy Association (AOTA) identified Health and Wellness as a practice area of importance in the 21st century (American Occupational Therapy Association, 2018). According to AOTA, the factors that drive an increase need for wellnessrelated services are the ideas that an individuals health is directly related to physical as well as emotional well-being. AOTA states that factors that increase the need for health and wellness services are: a growing aging population, increased focus on health care disparities, rising rates SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 11 of obesity, and technology and imbalances in life roles (American Occupational Therapy Association, 2018). Some of the strategies that AOTA suggests for OTs to promote wellness and prevention are bullying education, obesity prevention, afterschool groups, and support of education programs (American Occupational Therapy Association, 2017). With this information stated this project can be considered a support of education programs, due to the support gave to the recreational staff at DAMAR when planning activities, as well as an obesity prevention due to its focus on increasing participation in physical activity among the children with ASD. Combing the ideas of AOTAs health and wellness strategies with the ideas from Mische and Foster (2018) this project is supporting the idea that occupational therapists should partner with recreational staff to be an additional resource to the staff, increase physical activity participation, and decrease obesity rates in children with ASD. Implementation Phase After completion of a four-week needs assessment, a seven-week intervention was designed to address the needs in the PE classes. The biggest need to address was the unstructured atmosphere of the autism PE classes. One teachers assistant said it best when she asked, Why cant our class do structured activities like the other classes (DAMAR employee, personal communication, January 2018)? The next need that arose during the needs assessment phase was the unwillingness of staff to encourage the kids to participate. How can we get the kids to participate when the staff just sits on the bleachers and refuse to get up (DAMAR employee, personal communication January 2018), commented one DAMAR employee. After observing the staff, this second problem arose for lack of staff education and lack of staff expectations. Some of the staff comments were the kids cant do that (DAMAR employee, personal communication, January 2018), you wont be able to get them to do that(DAMAR employee, SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 12 personal communication, January 2018), or the gym time isnt for the kids it is for us[staff] (DAMAR employee, personal communication, Feburary2018). The seven-week interventions were designed to increase the structured atmosphere in the gym classes while increasing student participation. As a doctoral student, I worked closely with the recreation manager to design activities that would increase participation as well as add sensory components. Activities were combined into two different units to cover 7 weeks: The DAMAR Winter Olympics and DAMAR Ninja Warrior. To increase student and staff participation, awards were presented to winning classes/individuals after completion of both units. The first unit that was implemented was the DAMAR Winter Olympics. This unit was completed by each class over the course of four weeks. Activities that were completed were similar to the Olympic games: hockey, biathlon, bobsled, figure skating, skiing, and snowboarding. All activities were completed in the gym during PE class times. Gym equipment such as scooters, mats, trikes, and bean bags were used to adapt each activity. I assigned rules to each game and decided the scoring qualification per day. Each class participated and a running total of class points were posted in the gym each day. The second unit that was implemented was DAMAR Ninja Warrior. This unit was completed by each class over the course of three weeks. The obstacle course was broken up into three sections, with a new section added every week. Gym equipment such as mats, hula-hoops, climbing ropes, scooters, mini hurdles, and cones. During PE, the classes took turns practicing the different obstacles and completing the course for time. SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 13 Leadership As a Doctoral student and a soon to be graduate, I understand the importance of continuous improvements in leadership skills. I have found that through this project, I was given a task that challenged both my advocacy and leadership skills. Through this project, I was able to collaborate with multiple disciplines and the many kids that are served at DAMAR that were not aware of the OTs role or job responsibilities. I created this project because of its relevance to the emerging health and wellness area of OT practice (American Occupational Therapy Association, 2018). I had to start my project by describing what role an OT can play in this setting and what I could bring being an OT Doctoral student. For the first few weeks I assumed the role of advocate and educator to the recreation and school staff along with the students on what my role was as a doctoral capstone student. Also the first few weeks of my project, I was using the time to observe and get to know clinical operations at DAMAR to get an idea of what was needed using a consultative model. The consultative model focuses on meeting all individuals needs that are involved, and with consulting with staff members I was able to pinpoint problem areas that I would later address as my project (Dreiling & Brudy, 2003). I brought these problem areas to my supervisor and the rest of the recreation team and advocated on why there was a need for OT intervention. This brought me out of my comfort zone, because I was not used to providing constructive criticism on how an individual can enhance their job performance. This made me grow in my leadership and advocacy skills to create the best atmosphere for the DAMAR clients during their PE times. Staff Development Based on the observations that were found, staff education was provided during the fourweek needs assessment to educate on the role of OT, during the seven-week intervention phase SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 14 to educate on the importance of participation, and after completion of the project to educate staff on data that was collected and importance of continuation of similar interventions to promote health benefits for the kids with ASD. Information on ASD interventions were provided to the recreational staff that were involved in this project. I used evidence-based literature to create a handout of what ASD is, the importance of recreation participation for this participation, and tips to increase participation with activities and interventions that they will enjoy (Tomchek, Koenig, Arbesman, & Lieberman, 2017). This handout also addressed tips on how to properly handle sensory seeking and sensory avoidant children (Kuhaneck & Watling, 2018) . Discontinuation Phase Quality Improvement Quality improvement is best defined as using current professional knowledge to address a clinical problem by increasing the likelihood of the desired outcome to improve quality of care (Mainz, 2003). Having noticed the need to structure the PE classes for the students with ASD, I made the intent of my capstone project creating activities that are both achievable for the students and simple for the recreational staff to implement. After determining the need, I used evidence-based techniques and ideas to structure and plan the activities. The activities I implemented brought more structure to the DAMAR PE classes and an increase in student participation. While using a structured sensory-based approach to the DAMAR PE classes, the students participation increased, their negative behavior tendencies decreased, and staff reported satisfaction in the project. SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 15 Data Collection The outcome measures that were used to assess the effectiveness of my project was a post intervention satisfaction survey and the average change in PRPS scores. Each of the six classes had an increase in PRPS scores when comparing pre-intervention PRPS scores to week seven PRPS scores. (Figure 1). Limitations caused by holidays, school functions, and classroom activities affected PE attendance week by week. Even with changes in attendance, there was still an overall increase in PRPS scores from pre-intervention to week seven (Figure 2 and Figure 3). Classes 6 and 4 had the greatest improvements in participation during this doctoral capstone project, with PRPS improvements of 4.250 and 4.000. The post survey was completed by the teachers. Results of the survey showed satisfaction with the doctoral capstone project. The teachers reported that the gym activities were fun, high quality, useful, and unique. Eighty percent of the teachers reported that the sensory based gym activities met the sensory needs of the students as well as increased student participation. One hundred percent of the teachers noted that they did see benefits in the classroom after the students participated in the sensory based gym activities. The above data was collected and presented to the recreation staff as well as were used to create staff resources. The information and resources provided to that staff was used to increase advocacy for occupational therapy services in recreation (Mische & Foster, 2018) as well as to increase staff education on the importance of participation in gym and sensory activities for the students with autism (Kuhaneck & Watling, 2018). Discontinuation Lovarini, Clemson and Dean (2013) identified factors that can better sustain a program: financial support, participation, planning, training, and collaboration. This programs financial SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 16 support is strong since DAMAR receives funding for its recreation equipment through generous grants and donations from various organizations. These funds allow for equipment to be purchased for the gym and/or other activities when it is needed. These funds supplied the equipment needed for the Olympic unit as well as the ninja warrior unit that I implemented for this capstone project. To support planning, training, collaboration and staff participation the recreational staff were provided resources for future use. These resources consisted of planned activities that they can do with the students. Staff received an informative handout regarding sensory needs in children that includes tips on how to appropriately address these needs. Lastly, for discontinuation of this project, I began a collaboration process for the OT and the recreation staff at DAMAR to continue sensory based PE activities. This collaboration opportunity provided the recreation staff with a resource for answering questions and generating ideas. Creating an atmosphere of collaboration and educating the staff, will hopefully sustain the use of sensory-based PE activities for the students with ASD in the future. Professional Development My project strived to improve the professional development of the staff at DAMAR. I worked regularly with the recreation staff, the teaching staff, and other support staff to educate them on the role of OT and the importance of student participation in PE. Daily, I explained to all staff the reason for each activity and how to appropriately encourage student participation. For the activities I implemented, I led by example through modeling to teach staff how to continue similar activities after the completion of my project. SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 17 Outcome The goal of this doctoral capstone project aimed to increase staff education on the importance of student participation in PE activities as well as planning structured, sensory-based activities for the ASD classes. This project promoted both staff and student productivity in the school setting while hoping to influence other societal roles. 1.5 million Americans with ASD are learning how and adapting to functioning in society as they are growing older every day. With the help of projects in the school system like this one, students will learn ways of coping with sensory needs as well as participating in group activities. These learned skills as well as peer interaction will benefit the individuals with ASD as they become functional members of society. Regarding the students, this project facilitated participation in sensory-based PE activities that also promoted refining gross motor movements. These activities aided in social engagement with peers, following simple and complex directions, and decreasing the tendency of maladaptive behaviors. Before my interventions, ASD classes came to the gym, and there were no activities planned. If the students did not want to or know how to shoot basketballs or ride a tricycle, they sat in the bleachers. After my interventions, ASD classes came to class with an expectation of and a desire to participate in the various structured, sensory-based activities. This project outcome is consistent with current ASD research findings that participation in physical activity has shown an improvement in behavior outcomes (Lawson and Little, 2017; Taliaferro et al., 2010; Guest et al., 2017; Oladunni et al., 2015). Regarding the staff, this project encouraged staff participation in helping the students complete the activities. Before my intervention, staff used the PE classes as their own recreation time and would not encourage student participation. This led to students sitting in the bleachers SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 18 and staff participating in recreational activities of their choosing. After my intervention, the majority of the staff are now encouraging student participation and helping guide them in the activities. This project has taught the staff the importance of PE participation for the ASD classes as well as the role of OT. In addition to the staff encouraging the students in the PE atmosphere, staff are now educated on activities that they can implement now and in the future. Overall Learning Communication Skills During this doctoral capstone review I increased my OT knowledge and my interpersonal and professional skills. Partnering with the recreation department at DAMAR presented many challenges that I had to overcome. I was working with a population that was unfamiliar with both the role of OT and the role that I was playing. During my project, I had to explain the reasoning underlining my presence at DAMAR, what OT is, and the importance of my role in the recreation department. I was asked questions such as, Why are you doing this? or Why are you in the gym? frequently, so I learned to clarify my reasoning so that staff would easily understand. To increase staff support, I had to justify the importance of student participation in gym and describe the benefits they would see from it. Due to the nature of the recreation department, I worked daily with a majority of the staff at DAMAR using verbal interactions as the primary method of communication. As a result of this project, my confidence in defending myself and my profession grew. This project also required me to demonstrate suitable written communication skills. These skills were necessary when writing emails and creating staff resources. I had to ensure these were written in a professional manner and could be easily understood by the staff. The resources created were instructions and tips that the staff could use to maintain my project. These SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 19 instructions had to be articulated in a way that was simple for the staff to interpret in order to increase the chances that they would put into practice my advice and activities. This project developed my written communication skills by requiring my writing to be both professional and easily understood by the staff at DAMAR. Future Practice I have learned many skills that will benefit my future career as an OT during this doctoral capstone project. I practiced my clinical knowledge by creating and implementing sensory-based activities during gym time for the DAMAR students. This will apply to my future in pediatrics during which I will use sensory-integration techniques with clients. Another skill that I gained was how to better lead a group session. Kessler, Momich and Perel (1990) stated that occupational therapists have used groups as their preferred modality in psychosocial settings since the beginning of the profession. I gained experience with this since all classes were conducted in a group setting. This increased my knowledge about conducting group therapy that I will be able to implement in the future. Lastly, during my time at DAMAR, my professional skills developed. These skills included communicating, advocating, and educating. While I took on many roles during my time at DAMAR, the role I played the most was as an educator to the staff and an advocate for the students. I learned how to effectively articulate the importance of physical activity for the students with ASD and disruptive behaviors to the staff. In the future, this project will aid in my ability to connect with my clients families and educate them on the importance of home programs and of interventions that I implement. Through educating the staff, I learned how best to advocate for the students in order to secure the services that they needed and better treatment from the staff. This built my confidence in defending the students and upholding what I believed SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES was right; this increased confidence will be used to pursue the best treatment for all my future clients. In closing, my time at DAMAR has helped me grow as an occupational therapist, and I will implement the knowledge and skills I have learned in my future career. 20 SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 21 References American Occupational Therapy Association. (2010). The scope of occupational therapy services for individuals with an autism spectrum disorder across the life course. American Journal of Occupational Therapy, 64(Suppl.), S125S136. American Occupational Therapy Association. (2017). Occupational therapys role in health promotion [Fact sheet]. Bethesda, MD: Author. American Occupational Therapy Association. (2018). Health and wellness [ Fact sheet]. American Journal of Occupational Therapy. Dreiling, D. S., & Bundy, A. C. (2003). Brief reportA comparison of consultative model and directindirect intervention with preschoolers. American Journal of Occupational Therapy, 57, 566569. Guest, L., Balogh, R., Dogra, S., & Lloyyd, M., (2017). Examining the impact of a multi-sport camp for girls ages 8-11 with autism spectrum disorders. Therapeutic Recreation Journal, 2, p. 109-126. Kessler, J., Momich, C., & Perel, S. (1990). Therapeutic Factors in Occupational Therapy Groups. American Journal of Occupational Therapy. 45(1):59-66. doi: 10.5014/ajot.45.1.59. Kuhaneck-Miller, H., and Watling, R. (2018). Parental or teacher education on coaching support function and participation of children and youth with sensory processing and sensory SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 22 integration challenge: a systematic review. American Journal of Occupational Therapy, 72, 7201190030 Lawson, L., and Little, L., (2017). Feasibility of a swimming intervention to improve sleep behaviors of children with autism spectrum disorder. Therapeutic Recreation Journal; 2. P. 97-108. Lenze, E., Munin, M., Quear, T., Dew, M., Rogers, J., Begley, A., & Reynolds, C. (2004). The Pittsburg Rehabilitation Participation Scale: reliability and validity of a clinician-rated measure of participation in acute rehabilitation. Physical Medical Rehabilitation, 84(3), 380-384. Lovarini, M., Clemson, L., & Dean, C. (2013). Sustainability of community-based fall prevention programs: A systematic review. Journal of Safety Research, 47, 9-17. Mainz, J. (2003). Defining and classifying clinical indicators for quality improvements. International Journal for Quality in Health Care, 15, 523-530. Matsushima, K & Kato, T., (2013). Social interaction and atypical sensory processing in children with autism spectrum disorder. Hong Kong Journal of Occupational Therapy; 23. P. 8996. Mische, L., & Foster, L., (2018). Sensory patterns, obesity and physical activity participation of children with autism spectrum disorder. American Journal of Occupational Therapy, 7005180070 SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 23 Ninot, G., Bilard, J., & Delignires, D. (2005). Effects of integrated or segregated sport participation on the physical self for adolescents with intellectual disabilities. Journal of Intellectual Disability Research: JIDR, 49(Pt 9), 682-689. Olandunni, B., Lyoka, P.A., & Goon, D.T. (2015). Perceived motivational factors influencing students with disabilities towards sports participation in Amathole district, Eastern Cape Province, South Africa. African Journal for Physical, Health Education, Recreation & Dance, 21(4:2), 1389-1401. Scaffa, M. E. & Reitz, S.M. (2014). Occupational therapy in community based practice settings (2nd ed.). Philadelphia: F.A.Davis. Taliaferro, L., Rienzo, B., & Donovan, K. (2010). Relationships between youth sport participation and selected health risk behaviors from 1999 to 2007. Journal of School Health, 80(8), 399-410. doi:10.1111/j.1746-1561.2010.00520.x Tomchek, S., Koenig, K., Arbesman, M., & Lieberman, D., (2017). Evidence connectionoccupational therapy interventions for adolescents with Autism Spectrum Disorder. American Journal of Occupational Therapy, 71,7101395010. SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 24 Table 1: Pittsburg Rehabilitation Participation Scale Score Justification 1 None: Student refused entire session or did not participate in exercise session 2 Poor: Student refused or did not participate in at least half of session 3 Fair: Student participated in most of all exercise with less than maximum effort 4 Good: Student participated in all exercises with good effort and passively followed directions 5 Very Good: Student participated in all exercise with maximal effort and finished all tasks 6 Excellent: Student participated in all exercises with maximal effort, finishes all tasks, and actively took interest in session. Note: Adapted from sralab.org for use with student population. SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES Figure 1. PRPS scores recorded for pre-intervention week and week 7 showing an increase in participation after completion of this doctoral capstone project in all six classes. 25 SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 26 Weekly Change in PRPS scores 6 PRPS Scores 5 Class 1 4 Class 2 3 2 Class 3 1 0 Pre-intervention Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Figure 2. PRPS score fluctuation for classes 1-3 over the 7 week project intervention showing overall increase in scores. Dips in scores to 1 for class 2 and 3 show no participation from class due to classroom/holiday activities that did not allow time for PE that week. SENSORY BASED ACTIVITIES IN PHYSICAL EDUCATION CLASSES 27 Weekly Change in PRPS scores 6 PRPS Scores 5 Class 4 4 Class 5 3 2 Class 6 1 0 Pre-intervention Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Figure 3. PRPS score fluctuation for classes 4-6 over the 7 week project intervention showing overall increase in scores. Dips in scores to 1 for class 4 and 6 show no participation from class due to classroom/holiday activities that did not allow time for PE that week.  ...

... The Effects of Hair Color and Gender on Judgments of Warmth and Competence By Taylor Welch 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. Kathryn Boucher. 4/24/2017 Approved by: ______________________________________________________________________ Dr. Kathryn Boucher, Faculty Advisor ______________________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College ______________________________________________________________________ First Reader ______________________________________________________________________ Second Reader T. Welch 2 Abstract Hair color and gender are two factors that are seldom studied together in snap judgment research of impressions of others. However, past research suggests that women are more frequently stereotyped in regards to their hair color. Some of these stereotypes include the dumb blonde and fiery redhead stereotypes. In a mixed model design study, I expected there to be a difference between judgments of warmth and competence based on these gender stereotypes. While I expected warmth and competence differences between hair colors across genders, I expected these warmth and competence differences to be greater for pictured women than pictured men. I also predicted that judgments would be influenced by participants own gender such that males would be more likely to judge according to stereotypes than females. To test these hypotheses, I presented participants with pictures of novel people of varying hair colors and different genders, and these individuals are people that the participants have never seen before and would likely never interact with. Participants gave their judgments of them. The results of this study show that gender and hair color do have an effect on peoples judgments of warmth and competence, as well as intended behaviors toward individuals. Red-haired females were judged as warmer and more competent than the other hair colors. Males were overall judged significantly lower than females in terms of warmth, competence, and intended behaviors. All significant interactions between target hair color and target gender were driven by the red-haired group. Future research should look more closely at the differences between males and female participants judgments. T. Welch 3 Acknowledgment Dr. Kathryn Boucher Dr. Boucher guided and advised me throughout the entire process of this project. She has been a great mentor and provided the support and encouragement needed to be successful. She made this project possible for me, and I cannot thank her enough for all she has done. Dr. James Williams Dr. Williams provided support throughout my time as an honors student. He encouraged me when I needed it and was an invaluable resource throughout all stages of the project. Special thanks to Paige Stratton Paige taught me how to use Photoshop to change the hair color of some of the photos I used in my study. T. Welch 4 List of Figures Figure 1: Warmth Score Means for the Interaction 36 Figure 2: Competence Score Means for the Interaction 37 Figure 3: Intended Behavior Score Means for the Interaction 38 T. Welch 5 Table of Contents Cover Page 1 Abstract 2 Acknowledgement 3 List of Figures 4 Statement of Purpose 6 Introduction 7 Method/Procedure 20 Results 24 Discussion 28 Reflection 31 References 33 Appendices 39 Appendix A: Materials 39 Appendix B: CITI Training 40 Appendix C: IRB Documents 42 T. Welch 6 Statement of Purpose The purpose of my project was to understand the different views that people hold about others based solely on their hair color and how gender of the people we are judging can affect that view. Through original research, I attempted to determine if others hair color and gender affected peoples judgments of them. This project included a survey where participants answered questions about warmth and competence based on photos of individuals that the participants have never seen before and would likely never interact with. I found that the results showed partial support for my hypotheses, such that there were interactions, but not always in the directions that I had predicted. The knowledge gained from this research contributes to a broader understanding of hair color and the effect it has on our judgments of others, which can impact relationships in social, personal, and professional settings. Knowing these stereotypes can lead to better relationships and a more open mindset when first meeting others, as individuals who know their pre-existing biases can work to avoid the thoughts and behaviors involved in forming judgments based on these biases. These findings can be applied to contexts where impressions are incredibly important, like in relationships, jobs, and everyday interactions, by sharing the results with other scientists. T. Welch 7 Introduction A large business owner is hiring for a secretary position at his office. The two final applicants he is contemplating for the job have similar applications in terms of experience and qualifications. Both are female and the same age. However, one has blonde hair, while the other applicant has brown hair. At the end of both of the interviews, the business owner wrote down his first impressions of the two women. He judged the blonde applicant as friendlier and more attractive. On the other hand, he saw the brunette applicant as more intelligent and capable of doing the job. This process that the business owner went through is similar to what we all do, all of the time. This process is what psychologists refer to as a snap judgment. Snap judgments A snap judgment is a determination formed in an instant, with very little conscious deliberation. It is the first thing you think when you see something or someone. Snap judgments affect how we view others and how we interact with them. In a major review of studies on snap judgments, Ambady and Rosenthal (1992) show the range of ways we can have snap judgments, the consequences of these snap judgments, how they are made, and their accuracy. This review shows that we can make snap judgments on many dimensions, including behavior, competence, attractiveness, and personality. These judgments can change peoples behavior and are usually rather accurate at predicting important outcomes like someones behavior or success. Specifically, the results from this meta-analysis found that judgments made on behavior viewed for less than five minutes are generally accurate, and our judgments do not become more accurate when given more time to form a judgment or when we have a different way of getting the information. T. Welch 8 Snap judgments can also be predictive and can have an impact on people in important daily life matters. As an example, a study by Babad and Rosenthal (2004) on predicting teaching evaluations based on snap judgments of nonverbal communication demonstrated how snap judgments can effectively predict students end of year teacher evaluations. Students who never had the professors watched video clips of their teaching and then made judgments of them in terms of the quality of their teaching. Their judgments were significant in predicting actual semester course evaluation ratings by actual students. Furthermore, the study by Simpson and Ostrom (1975) on snap judgments versus thoughtful judgments demonstrates the prominence or staying power of snap judgments. Participants were asked to make either snap or thoughtful judgments of pictured individuals. The results indicated that there was not a significant difference between snap or thoughtful judgments, despite the significant time difference it takes to make them. This shows that snap judgments are rather accurate and stable pictures of an individual's perception of others even when more time and information becomes available. The review by Ambady and Rosenthal (1992) also showcased the various ways that snap judgments are studied. Some studies show their participants images and ask them to make judgments from them, and others provide audio, video, or written vignettes. The predominant approach to studying snap judgments is seen in studies like Rule et al. (2010) where they have participants view a certain number of faces in a random order and rate them on scales of personality attributes like dominance and likeability. Participants are usually given no other information about the person other than their face on the screen. In this particular example study, Rule et al. (2010) asked participants to rate political candidates faces, in order to determine if it T. Welch 9 had a predictive relationship with the outcome of the election. Their results show that perceivers judgments based on just the candidates faces were indeed predictive of the percentage of votes that each candidate received in the actual election. Another study further showing the power of snap judgments with a similar procedure, Rule, Ambady, and Adams (2009) studied peoples judgments of faces on personality traits, including warmth and competence. As additional variables, this particular study was interested in the differences in rankings based on the angle at which the face was presented as well as time. Participants in this study viewed images in random order and made judgments of each target on five aspects of personality (i.e., aggressiveness, competence, dominance, likeability, and trustworthiness). There were three angle conditions (i.e., 0 degrees, 45 degrees, and 90 degrees). The findings showed that perceptions of full faces led to relatively similar inferences across both viewing angle and time. They also found that judgments of personality were not affected when given less time to make a judgment, meaning that the judgments did not change between snap judgments and self-paced ones. This information supports the notion that snap judgments are made quickly and are relatively stable despite how the information is presented. Snap judgments can occur in many important contexts such as the workplace and with important people such as CEOs. A study by Rule and Ambady (2009) involved examining whether male and female CEOs were perceived differently. They used the same traits as before (i.e., aggressiveness, competence, dominance, likeability, and trustworthiness). The participants were shown faces of male and female CEOs on a screen and asked to rate them on a series of these personality traits. Ratings of competence and leadership predicted the amount of profits that the CEOs companies made, and ratings of dominance predicted the individual T. Welch 10 compensation amounts that the CEOs received. Higher ratings of competence and dominance based on facial appearance correlated to the companies that acquired more profit. Interestingly, no significant gender differences were found for the CEOs and for the participants making the snap judgments. A limitation of the reviewed snap judgment work is that when researchers select the stimuli for these studies, they try to control for many differences among individuals such as age, gender, attractiveness, and race. Much of the work on snap judgments has not varied hair color or has chosen to eliminate it as a potential variable. It is sometimes held constant or is cropped out. This leads me to believe that researchers expect there to be variation in how people judge others by their hair color. Because different aspects like hair color are controlled in these experiments, it is possible that the researchers believe that variation would impact peoples judgments of the pictured individuals. My study extended the work on snap judgments by being one of the first to explore hair color and how it interacts with our judgments of people of different genders. This focus allowed me to more directly test hair color stereotypes and how they relate to gender in a way that previous work has not. Judgments of people based on their hair color It is important to note first what the range of natural hair color is in the world. Approximately 75-80% of the worlds population has black hair, while the remaining people have brown (15%), blonde (9%), and red (only 1%) hair, according to the 2016 American Board of Certified Hair Colorists. Given that this is an estimation worldwide, the hair color distribution for North America is expected to be different from that of the global population, with fewer people with black hair and more people with other hair colors given the demographic breakdown T. Welch 11 for North American countries. Despite the differences in frequencies, people are likely aware of different hair colors and may judge people differently based upon them. There have been very few studies on snap judgments of hair color. One of these studies is by Takeda, Helms, and Romanova (2006), where they focused on hair color stereotypes in a job context. The methods that they used were gathering statistics about the percentage of different hair colors of CEOs. The researchers found the frequency of different hair colors in the workplace and the positions that they held. Their findings supported the hair color distribution previously mentioned, as most of the CEOs had brown hair (68.2%) and the least amount had red hair (4%). These results suggest, somewhat indirectly, that who becomes a leader in the workplace could be tied to different hair colors, such that we have different ideas of what someone who leads companies should look like. There were no gender differences found. When hair color differences are explored in snap judgment research, it is often paired with other cues of an individual, including body size. In Clayson and Klassen (1989), White male and female college students were asked to rate men and women on their attractiveness after the pictured individuals hair color and weight had been manipulated. The results showed that blondes were judged as most attractive, followed by brunettes and then people with black hair; redheads were rated as being the least attractive. Obese individuals were judged as less attractive than non-obese individuals. Hair color and obesity did not significantly interact with one another in this study. There were no significant gender differences in the judgments of the pictured individuals or by the participants who judged them. The raters characteristics can also make a difference in their judgments of others. A study by Lawson (1971) about hair color and personality had male and female participants rate T. Welch 12 others based on their hair color. The main results indicated that individuals rated their own hair color higher on personality traits. Also, both men and women rated darker hair as being more dominant, and red hair as the least dominant. Several studies have explicitly assessed the content of hair color stereotypes. In a study by Heckert (1997), he looked at the stigmatization of redheads. In this article, he presented a few stereotypes associated with redheads. These stereotypes include the weird redhead, the flaring temper, the clown, and the wild redhead. These stereotypes came from past research and also interviews with redheads. Another related study found that men and women viewed brunettes as more capable than red-haired individuals or blondes (Kyle & Mahler, 1996). Also, in the same study, the authors found that there was not much difference between opinions of redheads and blondes in terms of capability. No gender differences were noted. This research shows that hair color stereotypes do in fact exist and that there is somewhat of a consensus of what those stereotypes are. However, some hair color stereotypes likely differ based on context. White/grey hair stereotypes are one example of this. When we think about someone who we know, perhaps our grandparents, we think of them as warmer and possibly less capable. A study by de Paula Couto and Koller (2012) asked participants to rate elderly individuals on their warmth and competence. The participants were instructed to answer a questionnaire at home about their views of elderly people. The results showed that the participants judged the elderly as more warm than competent. It is probable that the participants all thought of someone who they knew while answering the questions. They were not shown pictures, leaving them nothing on which to base their answers other than their own experience and knowledge. This result supports the idea that T. Welch 13 when asked to think about someone with grey/white hair (i.e., the elderly), you will more likely see him or her as more warm than competent. However, when thinking about professionals, especially pictures of them, it is possible that we may judge them as having more competence and less warmth. Hair color stereotypes can impact important outcomes such as performance. Bry et al. (2008) presented male and female participants with several tasks to complete, one of those being an encyclopedic knowledge test. The participants hair colors were black, blonde, red, or brown. The first group had been primed prior to completing the tasks with the dumb blonde stereotype. The results showed that the individuals who had been primed with the dumb blonde stereotype performed worse than the participants who had not. This finding did not depend on the participants own hair color, and no gender differences were noted. This indicates that stereotypes can affect individuals, even if the stereotype does not apply to them. As the research reviewed above about snap judgments of hair color suggests, we do use this aspect as an important cue in our judgments of many characteristics like attractiveness, competence, and intelligence. Several of these studies show that these snap judgments are similar when the people being rated are male and female or the people providing the ratings are male and female, while other studies just focus on judgments of one gender. This is problematic because this past work may be obscuring the role of gender in our judgments of hair color. We can hold stereotypes of different hair colors, and these stereotypes may be gendered. Gender stereotypes as they relate to hair color A stereotype is a thought or belief about a group, where that thought or belief is applied to everyone belonging to that group. Although stereotyping makes it easier on our brains to T. Welch 14 process information faster (Macrae, Milne, & Bodenhausen, 1994), it can be harmful to others, and it need not be true to be impactful. Our stereotypes can take many forms including stereotyping people based on their social class, race, gender, and sexual orientation. What many of these stereotypes involve are two key dimensions of human judgment: warmth and competence. Warmth is the degree of someones likeability or kindness, and competence is the degree that someone is intelligent or capable. In a seminal paper, Fiske, Cuddy, Glick, and Xu (2002) demonstrated how many of our stereotypes relate to warmth and competence. Stereotype content is considered in terms of ingroups and out-groups. An in-group is the group making the judgment, and the out-group is the group being judged in their studies. In their work, they found that competence and warmth are differently related to different out-groups, many particular out-groups were rated highly on one dimension but low on the other, and out-groups are perceived as either competent or warm depending on their status. This stereotype content model provides a framework for what the content of stereotypes are, especially for women. They found that participants, irrespective of their own gender, rated women as high in warmth, but low in competence. The importance of warmth and competence in judgments of people can be extended to hair color and its interaction with gendered views. This study did not look at gender interactions between participants and the target. Beddow, Hymes, and McAuslan (2011) had participants rate individuals on a projector screen. The goal of this study was to determine the effects of stereotypes with respect to hair color and setting. Participants were asked to pretend that they had visited a social networking page to find out some information about a male or female target model. On the site, the participant saw a short profile about the model as well as a photo. The T. Welch 15 profile was gender neutral, meaning that they did not lean toward one gender or the other in appearance, and described the model, including favorite activities and that the model was single and recently unemployed. Participants viewed the profile twice: once in a work-related setting in which the participant was to review job candidates, and a second in a dating setting in which the participant was asked to review prospective dates for a friend. Participants then rated these individuals with blonde, red, and brown hair on characteristics such as attractiveness, intelligence, work ethic, maturity, emotional level, success level, aggressiveness, and femininity/masculinity. The results showed that hair color stereotypes are affected by the setting. Brunettes were judged as having a higher work ethic and more maturity in a work setting, pointing to them as being higher in competence. Blondes were judged as more emotional and the least mature, suggesting that they are often seen as warmer rather than more competent. This shows how the judgment context and gender can affect how people interact with one another. Other aspects of hair, in addition to color, can also affect judgments. In a study by Roll and Verinis (1971), the researchers looked at hair color, hair length, and quantity, quality, and amount of facial hair in males. Male and female students were shown slides of male faces. The slides were designed to test the variables of hair color (i.e., blonde, black, red), hair length (i.e., crew cut, regular, and Beatle cut), amount of scalp hair (i.e., regular, balding, bald), hair quality (i.e., straight, wavy, curly), and facial hair (i.e., clean, mustachioed, bearded). The same face was used for each and was modified accordingly. Participants judged the pictures on dimensions of warmth, attractiveness, femininity, and dominance. Regular amount of hair was judged as valued and high on strength and being active. Bald-headed people were judged as the opposite. No facial hair was also rated the highest on the same scales, and bearded individuals were rated as T. Welch 16 lowest on dimensions of attractiveness and warmth. Blonde hair was rated as most valued, and red hair was least valued. These results show that men, too, can be judged negatively or positively based on their hair. These judgments also relate to age and possibly grey hair because of the inclusion of balding and bald-headed individuals. Men and women of the same hair color are often judged very differently. Clayson and Maughan (1986) studied stereotypes of both redheads and blondes and for both genders. Male and female individuals were instructed to move hair colors toward adjectives and nouns such as feminine and doctor. It was found that the concept of blonde female was placed 5.3 times closer to the concept of feminine as the concept of redhead female. However, the concept of blonde male was placed 1.23 times farther from feminine than a redheaded male. Both male and female redheads were closer to neutral than male and female blondes. These results show the differences between stereotypes of blonde and redheaded individuals and how they are gendered. Gendered hair color stereotypes and gender differences in perceptions While some research includes both genders and shows that hair color stereotypes are applied to both groups, much of the research on hair color stereotypes seems to demonstrate the impact of the content of hair color stereotypes and how they are applied to judgments of women only. In particular, outside of the work and leadership context, we see that peoples hair color preferences impact their judgments and behaviors. An example of this is a study by Swami and Barrett (2011), who studied British mens hair color preferences. They studied courtship solicitations of men in a nightclub setting of three women with different hair colors (i.e., brown, blonde, and brunette). They found that out of the three hair colors, the woman with blonde hair was approached the most and the redhead the least. The second method they used was a paper T. Welch 17 and pencil questionnaire to rate individuals of different hair colors on ten different characteristics. The notable results found that brunettes were rated the most competent and intelligent, with blondes being last in competency and second in intelligence compared to redheads. This study more clearly demonstrates the role that hair color and particularly hair color stereotypes play in our views of others, especially for women. Hair color plays a strong role in snap judgments, even when studied along with other variables. Kyle and Mahler (1996) studied hair color in a similar way as Swami and Barrett (2011), but this experiment examined whether a female applicants hair color and use of cosmetics affected perceptions of her ability for a professional position. Male and female participants were asked to complete a questionnaire, look at a picture, and examine a resume. They then were asked to rate the applicant's capability and assign them a beginning salary. Both male and female participants rated the female applicant both more capable and assigned her a higher beginning salary when she was not wearing cosmetics and even more so when she had brown hair rather than with blonde or red hair. As further evidence of the gendered nature of hair color stereotypes, a study by Gueguen (2012) looked at womens hair color and others spontaneous helping behavior toward them. In the study, women wore three different colors of wigs (i.e., blonde, brown, and dark). They then walked ahead of someone and dropped a glove, pretending not to have noticed. Observers recorded whether the participant warned the woman within seconds of the loss of the glove. They found that men helped the blonde women 75.5% of the time, the most of all hair colors. They only helped the brunettes 59% of the time, and those with dark hair 56.5% of the time. These results perhaps show that men perceived blondes as warmer. On the other hand, women more T. Welch 18 frequently helped brunettes (53.5%) compared to those with dark hair (48.55%) and blondes (47.5%). As the results show, there was an opposite effect for women and their behaviors, suggesting that there are differences in how men and women perceive hair colors and act based on them. Another study by Gueguen (2012), using the same method, studied the amount of tips female waitresses received in relation to their hair color. Results found that blondes received the most tips, but only with male patrons. Hair color had no effect on females tipping behavior. Also, in a similar fashion, Gueguen (2009) studied hitchhiking women's hair color and others helping behavior toward them. Trained actors or research confederates (five women aged 19-22), who were rated as possessing average physical appearance, wore a wig of different colors (i.e., blonde, brown, and black) and were staged on the side of the road to pose as a hitchhiker. Only one research confederate was used at a time. The goal of the study was to determine if the hair color of the hitchhiker affected whether motorists stopped. The results showed that blonde confederates were helped the most at 18.9% compared to those with the brown hair wig (14.3%) and those with the black wig (13.1%). More male motorists stopped than female motorists. Taken together, these results suggest that women are more likely the target of hair color stereotypes and also the consequences of them. The judgments of women differ importantly based on the gender of who is making the snap judgment. A limitation of these studies is that there is no comparison group, specifically no comparison to male targets. Rationale for my study Extending on this past work, I explored hair color stereotypes in my research paper. In contrast to past work, my study looks at judgments of different hair colors for men and women, T. Welch 19 and both men and women made the judgments. It also includes hair color along with gender. There are few past studies that have included these variables as a focus in their full design. Additionally, I am connecting these judgments to warmth and competence, which is a common theme in past snap judgment research. This study is a necessary addition to the existing literature on the subject of gender and hair color and snap judgments. The three research questions that I am exploring are if there are any significant differences in perception between hair colors on warmth and competence, if there is an interaction between hair color and gender of photos on warmth and competence, and if there is a three-way interaction between hair color, photo gender, and participant gender on warmth and competence. I predicted that people with white/grey hair would be viewed as most competent, followed by brunettes and then blondes and redheads. For warmth, I predicted that blondes are seen as warmer than brunettes, who are warmer than redheads and those with white/grey hair. I also expected there to be a significant interaction between the hair color and the gender of the individuals in the photos because men and womens characteristics are sometimes judged very differently. Specifically, I expected there to be a difference between judgments of warmth and competence based on gender stereotypes. While I expected brunettes and blondes to be judged as warmer than the other hair colors across genders, I expected this pattern to be more obvious or accentuated for pictured women than pictured men. I also predicted that there would be gender differences for competence such that white-grey hair pictured men would be judged as more competent than women with the same hair color, and for blonde hair, pictured women would be judged as less competent than men with the same hair color. For the interaction with participant gender, I predicted that males would be more likely to judge according to stereotypes compared T. Welch 20 to females. I thought this because females are more often the subjects of stereotypes, and knowing this could lead them to avoid doing the same. I included behavioral intentions to determine how judgments could affect a potential interaction between individuals. I predicted that women would have more positive behavioral intentions. I also predicted that blondes would have more positive intended behaviors, and redheads would be more negative. Method Participants Undergraduate students (N=120) participated in this study. Female (n=111) and male (n=9) students received research credit for their participation. They were recruited through the psychology research pool, SONA. This gender distribution was not what I intended; I discuss this further below. They received 0.5 research credits for their participation. For the participants included in the sample, 69 indicated that they had brown hair, 35 blonde, 12 black, and 4 red. Not what I was expecting with gender dis. I discuss below Procedure At the beginning of the study, participants completed an informed consent form where they were told the purpose of the study as well as what the study would include, possible risks and benefits, and confidentiality. The purpose of this study was to determine how people form impressions of novel people. These are people that the participant had not seen before and would likely never interact with. The participants were shown pictures of individuals, followed by questions about each person in terms of their impressions of that person. They were then asked demographic questions, were thanked, and were debriefed. T. Welch 21 Materials I obtained the faces shown to participants from the Chicago Face Database that I had been given permission to access and utilize (see Appendix A for example images used in this study). All of the faces on the database were normed for attractiveness, meaning that they were all considered to be an average attractiveness level. I chose faces with neutral expressions so that their expressions could not distract from the variables I was focusing on. There were no redheaded males and also no grey haired males or females in this database. To fix this, I chose faces who would look the most natural with those hair colors and used Photoshop to change their hair colors. In this study, there were equal numbers of pictures of the different hair colors and genders shown to the participants, 16 in total. The pictures were a headshot and were shown one by one in random order on the screen. The participant was shown one picture at a time, with questions under each picture. Because participants saw every combination of gender and hair color, these two independent variables were within subjects factors. This study utilized a mixed model design with these two within subjects factors and the between subjects factors of participant gender and participants own hair color. Participant gender and participant hair color are between subject factors because people are categorized as belonging to only one of the potential categories. The hair colors that I chose are brown, blonde, red, and white/grey. I chose to use these hair colors because I focused on gender in this study, and all of these hair colors have gender stereotypes based on the previous research I reviewed. To ensure that potential participants knew these gender stereotypes noted in past work, I pretested a separate group of students at the T. Welch 22 University of Indianapolis before the study began. I asked a small group of students who did not participate in the full study about their awareness level and their perceptions of other peoples awareness of hair color stereotypes tied to gender. Some examples of these stereotypes are that women with blonde hair are scatter-brained, women with red hair are fiery, and people with grey hair are less likeable, but have more wisdom. For the pre-test, I distributed short surveys via email to 15 students at the University of Indianapolis. The purpose of this was to confirm that the population being tested was aware of the hair color stereotypes assumed in the study. The survey consisted of two short answer questions and three yes or no questions. The first question, which was short answer, asked, What hair color stereotypes have you heard of? The next three questions were yes or no response questions where the respondent was asked if they had heard of the following hair color stereotypes referring to hair color: they were: Blonde women are unintelligent, Redheads have a bad temper, and People with grey hair have wisdom. The last question was a free response item that asked if the respondent thought that hair color stereotypes were gendered. Some common responses for the first short answer were that blondes are not very smart, and redheads have a bad temper. All 15 participants said that they have heard the stereotype that blonde women are unintelligent, 14 out of 15 said that they had heard of redheads having a bad temper, and all 15 said that they were familiar with the stereotype surrounding individuals with grey hair. Also, 14 out of 15 agreed that hair color stereotypes were gendered. These results showed that the stereotypes were present in the population I am testing. In the study, I excluded black hair because it generally is found with those from certain racial minority groups (e.g., African Americans, Asians). I am not focusing on race because I did T. Welch 23 not have the statistical power to look for additional group differences. It would also have been difficult to recruit equal numbers of participants from different races. Measures For my main dependent variables, I used a warmth and competence scale modified from past research on snap judgments (Fiske et al., 2002), and I also created some of my own questions for the survey. I used these two dimensions because Fiske et al. (2002) suggest that these two dimensions drive much of our judgments of others, and there are strong gender differences in them such that women are typically seen as warmer and less competent than men. While there has not been a previous direct link to these dimensions and gender differences in hair color stereotype endorsement, past snap judgment research suggests that this link possibly exists. Warmth ( = .91) and competence ( =.85) of each individual. Asked below each presented picture were two questions about warmth and competence from the warmth and competence scale (i.e., How warm does this person seem?, How intelligent does this person seem?). There were questions not related to warmth and competence added so that participants were less aware of my key variables; these were five items assessing personality traits such as being outgoing, respectful, and trustworthy on a similar scale as the warmth and competence. These filler items were not analyzed. The response scale for all these items was from 1 (not at all) to 7 (extremely). Behavioral intentions toward the pictured individual ( = .95). After the warmth and competence and other personality questions, there were three questions about behaviors toward each person. Participants were asked how likely they would be to: want to work in a group with this person, hire this person, and befriend this person. These items were included because they T. Welch 24 helped understand the impact that the manipulations of hair color and target gender had on intended behaviors toward the pictured person. Participants answered each question on a scale from 1 (not at all) to 7 (extremely). Demographic questions. At the end of the whole survey, I included demographic questions like the participants age, gender, and hair color, and also included an attention check (i.e., What did I say the purpose of this study was?). An attention check was needed in order to spot participants who were not taking the survey seriously. This gave me the ability to exclude individuals who had not been paying attention during the course of the study. Only one person indicated that they were not paying much attention, and since it was only one, I decided to still include them in the data analyses. In total, this study took on average about 13 minutes to complete, and participants received their research credit for participating. It is important to note that I collected contact information about participants in order to give them their research credit (i.e., name and UIndy email) via a second Qualtrics survey that is separate from the main survey that contains participants responses to the pictures and my questions about them and the demographic questions. Therefore, the responses for my study were not identifiable, meaning that individuals responses cannot be linked to them personally. Results Overview of the data analysis plan After all of the data were gathered, I analyzed the responses and determined whether there was any statistical difference in the way in which participants viewed people with certain hair colors. I specifically determined if there were any trends in the way a certain hair color is T. Welch 25 perceived based upon the pictured persons gender. Below, I analyzed my results in withinsubjects factorial ANOVAs with target hair and target gender as my independent variables. An ANOVA is the appropriate test to use because I have three or more groups or conditions. Specifically, a within-subjects factorial ANOVA is the most appropriate test because there is more than one independent variable, and the independent variables are within-subjects variables. A separate within-subjects factorial ANOVA was run for each of my three dependent variables: warmth, competence, and intended behaviors. If an effect was statistically significant, I then tested to see where there were any significant differences between hair colors on warmth, competence, and intended behaviors via post hoc tests. I also tested if there was an interaction between hair color and gender of photos on warmth, competence, and intended behaviors. If the interaction was significant, I decomposed the interaction. I planned to test if there was a threeway interaction between hair color, photo gender, and participant gender on warmth, competence, and intended behaviors in mixed model ANOVAs, but I had a major disparity between the number of male and female participants in my sample, making it inappropriate to run these analyses; therefore, these tests were not run. I had 111 female participants, and only 9 male participants. Lastly, I ran exploratory analyses, including participants own hair color in similar mixed model ANOVA tests. Target hair color and gender on judgments of warmth First, I ran a within subjects factorial ANOVA with target hair color and target gender on judgments of their warmth. There were significant differences in warmth between hair colors, F(3,357) = 4.391, p = .005. In planned comparisons, the redheaded pictures (M = 3.799, SD=0.991) were judged higher in warmth than the brunette (M = 3.517, SD=1.043), blonde T. Welch 26 (M=3.643, SD=1.066), and grey haired (M= 3.649, SD=1.149) pictures, ps < .07. Judgments of warmth for the brunette, blonde, and grey-haired individuals did not significantly differ from each other, ps>.09. There were also significant differences on judgments of warmth based on the gender of the pictured person, F(1,119) = 35.724, p < .001. Female (M = 3.798, SD=1.060) pictures were judged as warmer than male (M=3.506, SD=1.064) pictures. There was also a significant interaction between target hair color and target gender, F(3,357) = 90.519, p < .001 (see Figure 1). For brunettes, men (M = 3.717, SD=1.086) were rated as significantly warmer than women (M = 3.317, SD=0.999), p < .001. For grey-haired individuals, men (M = 3.735, SD=1.102) were rated as marginally warmer than women (M = 3.563, SD=1.195), p = .082. For blondes, men (M = 3.635, SD=1.072) and women (M = 3.650, SD= 1.059) were not judged differently for warmth, p=.885. For redheads, women (M = 4.663, SD= 0.987) were rated as significantly warmer than men (M = 2.935, SD= 0.996), p < .001. Target hair color and gender on judgments of competence First, I ran a within subjects factorial ANOVA with target hair color and target gender on judgments of their competence. There were significant differences in competence between hair colors, F(3,357) = 3.741, p = .011. In planned comparisons, the redheaded pictures (M = 4.090, SD=1.003) were judged lower in competence than the brunette (M = 4.265, SD=1.017), blonde (M =4.229, SD=1.068), and grey haired (M= 4.346, SD=1.127) pictures, ps < .07. Judgments of competence for the brunette, blonde, and grey- haired individuals did not significantly differ from each other, ps>.159. There were also significant differences on judgments of competence based on the gender of the picture, F(1,119) = 8.117, p = .005. Female (M = 4.307, SD=1.041) pictures were judged as more competent than male (M=4.157, SD=1.067) pictures. T. Welch 27 There was also a significant interaction between target hair color and target gender, F(3,357) = 24.216, p < .001 (see Figure 2). For brunettes, men (M = 3.717, SD=1.047) and women (M = 3.317, SD=0.987) were not significantly different in judgments of competence, p = .710. For grey haired individuals, men (M = 4.392, SD=1.145) and women (M = 4.300, SD=1.108) were not significantly different in judgments of competence, p = .378. For blondes, men (M = 4.308, SD=1.089) and women (M = 4.150, SD=1.046) were not significantly different in judgments of competence, p = .137. For redheads, women (M = 4.533, SD=1.020) were rated as significantly more competent than men (M = 3.646, SD=0.986), p < .001. Target hair color and gender on intended behaviors First, I ran a within subjects factorial ANOVA with target hair color and target gender on their intended behaviors toward the pictured people. There were no significant differences in intended behaviors between hair colors, F(3,357) = 1.630, p = .182. The redheaded (M = 3.784, SD=1.033), brunettes (M = 3.766, SD=1.082), blondes (M =3.888, SD=1.158), and grey-haired (M= 3.735, SD=1.135) pictures were rated similarly in intended behaviors toward them. There were significant differences on judgments of intended behaviors based on the gender of the picture, F(1,119) = 41.766, p< .001. Participants rated more positive behavioral intentions for female (M = 3.996, SD=1.122) pictures than male (M=3.591, SD=1.082) pictures. There was also a significant interaction between target hair color and target gender, F(3,357) = 57.494, p < .001 (see Figure 3). For brunettes, men (M = 3.836, SD=1.107) and women (M = 3.696, SD=1.058) were not significantly different in intended behaviors, p = .150. For grey-haired individuals, men (M = 3.651, SD=1.087) and women (M = 3.819, SD=1.182) were not significantly different in intended behaviors, p = .119. For blondes, men (M = 3.828, T. Welch 28 SD=1.151) and women (M = 3.949, SD=1.165) were not significantly different in intended behaviors, p = .278. For redheads, women (M = 4.519, SD=0.982) were rated more positively in terms of future interactions with them than men (M = 3.049, SD=1.085), p < .001. Influence of participants hair color Mixed model ANOVAs were run including participants own hair color with the target gender and target hair color manipulations, and no significant interactions were found with participants hair color and these two factors, ps > .10. Discussion General trends in the results indicated that overall, women had the most positive intended behaviors toward them and were seen as warmer and more competent than males. This could be due to the participant pool being largely female. Females, often being the subject of gender stereotypes, may have sought to mitigate this by judging fellow females more positively in the study. Brown and grey hair trended in the opposite direction for warmth, in that the men were seen as warmer than the women. Redheaded females were seen as warmer and also more competent than redheaded males. Overall, redheads were warmer and also less competent than the other hair colors. There was not a difference in warmth between blonde males and females, but blonde males were seen as more competent that the blonde females. These findings differ from my predictions because I expected blondes to be judged as warmest and least competent, while redheads would be lower on warmth and high on competence. The findings for red hair might be due to the hair color being a warm color, resulting in higher judgments of warmth. Also, the participant pool was largely female, causing more positive judgments for females. T. Welch 29 Limitations A limitation to this study is that the number of male participants was very low. Despite aiming for 60 male participants, I only got 9. This happened due to there being more female students at UIndy in general, especially in psychology, and a competing study on SONA that was recruiting only men. Despite wanting more males, this aspect of the study was out of my control. Changing my recruiting method halfway through the study would mean that my sample would have selection issues based on differences in recruitment methods. This is a limitation because it makes it difficult to compare differences between genders and does not provide enough data to make conclusions about males. However, when I ran these analyses without men, I still found all of the same effects reported above. This clearly shows how women make judgments of others. Women rate other women higher in both warmth and competence. Past research reviewed above shows mostly how men make judgments of women, where men especially judge women as high in warmth, but low in competence. This is why I wanted to look at how both men and women make judgments of others, but I was not able to get the participants for that comparison. Future work should look at how both men and women make judgments of others. Another limitation is that all of the participants were recruited from the same place. Although any major was welcome to take the survey, the majority of students who access SONA are psychology students. Having a larger variety of participants could provide more accurate data that could be better generalized to a broader population. Thirdly, a possible limitation is that some of the images used as stimuli in the study were edited. Despite making the edits look as natural as possible, some of the individuals in the photos could have looked like their hair had T. Welch 30 been edited or dyed. This is potentially problematic because these individuals could have been judged differently based on how natural their hair looked. Future directions Some ways that this study could be expanded in future research would be to recruit participants in a different manner in order to obtain more males and a wider variety of majors. It would be interesting to know how individuals of different majors perceived hair colors. This would address the issue that I had with few male participants as well. This variable could better portray how the general population viewed hair color and gender, rather than the homogenous participant group that I had. In addition, future research could examine differences in actual behaviors toward each hair color to see if they would remain the same or differ from behavioral intentions. A few behaviors that I would like to observe would be job hiring, making friends, or choosing members for a group project. This would be good to study because it would be important to know if hair color stereotypes affect individuals daily lives and potential life and career opportunities. Exploring differences for the blonde and grey hair individuals would be a direction future research could take. This would be interesting to know, especially considering the stereotypes surrounding these hair colors. Lastly, including more hair colors is also one future direction that this research could take. Adding in dyed, or unnatural hair colors, as well as black hair, could provide more data to determine if the interactions would still be driven by red hair and would also make this research more applicable to an even broader population. Judgments of others can affect them in real world scenarios. The interaction between hair color and intended behaviors could mean that being a redheaded male could put individuals at a T. Welch 31 disadvantage when looking for jobs or when working in a group setting. This could have real effects for them in their personal and social well-being, as they could be potentially looked over for jobs or other opportunities. On the other hand, redheaded females may be at an advantage in the same scenarios. These results show how a snap judgment made about a person, given just a picture, can have such strong implications for that individual. Understanding if the intended behaviors judgment were acted upon could determine if snap judgments are predictive of actual behavior. These results also indicate that hair color stereotypes are still gendered toward women. Making others aware of this could reduce gender stereotyping. Applying the results of this study could change how individuals act on their judgments of others. Reflection Above, I discussed how this work adds to existing research, but I also learned a lot personally. Completing this project was a journey filled with many ups and downs. I am grateful for the opportunity to be able to do research at the undergraduate level at the capacity to which I was able. Through this project, I learned how to better set and meet goals, and I learned the importance of having a plan. This project required small goals along the way to complete, rather than tackling the whole thing at once. A detailed plan was necessary in order to meet deadlines and get things done in a timely manner. I gained skills that I otherwise would have never learned, including the proper process of data collection, how to create a proposal for the IRB, how to set up a study on Qualtrics, and then how to give credit to participants via SONA. It was amazing to see this project go from a simple idea into an actual study with participants and data. I grew tremendously as an individual as a result of doing this project. The amount of dedication and time that I put into this project is unmatched by any other scholastic work I have T. Welch 32 ever done. I also grew to appreciate and accept criticism. A few times, I felt discouraged but came to realize that the small setbacks that I had along the way were improving my final product. My love for research and psychology has grown throughout this process, and I hope to continue to do research as a part of my future career as an Occupational Therapist. I could not be more grateful for the opportunity to be an honors student at UIndy. T. Welch 33 References Ambady, N., & Rosenthal, R. (1992). Thin slices of expressive behavior as predictors of interpersonal consequences: A meta-analysis. Psychological Bulletin, 111(2), 256-274. doi:10.1037/0033-2909.111.2.256 American Board of Certified Hair Colorists. (2017). Unpublished manuscript, Exam Study Portfolio, San Pedro. Ames, D. R., Kammrath, L. K., Suppes, A., & Bolger, N. (2010). Not so fast: The (not-quite-complete) dissociation between accuracy and confidence in thin-slice impressions. Personality and Social Psychology Bulletin, 36(2), 264-277. doi:10.1177/0146167209354519 Bry, C., Follenfant, A., & Meyer, T. (2008). Blonde like me: When selfconstruals moderate stereotype priming effects on intellectual performance. Journal of Experimental Social Psychology, 44(3), 751-757. doi:10.1016/j.jesp.2007.06.005 de Paula Couto, M. P., & Koller, S. H. (2012). Warmth and competence: Stereotypes of the elderly among young adults and older persons in Brazil. International Perspectives in Psychology: Research, Practice, and Consultation, 1(1), 52-62. doi:10.1037/a0027118 Fiske, S. T., Cuddy, A. C., Glick, P., & Xu, J. (2002). A model of (often mixed) stereotype content: Competence and warmth respectively follow from perceived status and competition. Journal of Personality and Social Psychology, 82(6), 878-902. doi:10.1037/0022-3514.82.6.878 T. Welch 34 Gueguen, N. (2012). The sweet color of an implicit request: Women's hair color and Spontaneous helping behavior. Social Behavior and Personality, 40(7), 1099 1102.doi:10.2224/sbp.2012.40.7.1099 Gueguen, N., & Lamy, L. (2009). Hitchhiking women's hair color. Perceptual and Motor Skills, 109(3), 941-948. doi:10.2466/pms.109.3.941-948 Hall, J. A., Braunwald, K. G., & Mroz, B. J. (1982). Gender, affect, and influence in a teaching situation. Journal of Personality and Social Psychology, 43(2), 270280. doi:10.1037/0022-3514.43.2.270 Heckert, D. M. (1997). Ugly duckling to swan: Labeling theory and the stigmatization of red Hair. Symbolic Interaction, 20(4), 365-384. Kyle, D. J., & Mahler, H, I.M. (1996). The Effects of Hair Color and Cosmetic Use on Perceptions of a Female's Ability. Psychology of Women Quarterly, 20, 447-455 Lawson, E. D. (1971). Hair color, personality, and the observer. Psychological Reports, 28(1), 311-312. doi:10.2466/pr0.1971.28.1.311 Macrae, C. N., Milne, A. B., & Bodenhausen, G. V. (1994). Stereotypes as energy-saving devices: A peek inside the cognitive toolbox. Journal Of Personality And Social Psychology, 66(1), 37-47. doi:10.1037/0022-3514.66.1.37 Roll, S., & Verinis, J. S. (1971). Stereotypes of scalp and facial hair as measured by the semantic differential. Psychological Reports, 28(3), 975-980. doi:10.2466/pr0.1971.28.3.975 Rule, N. O., Ambady, N., Adams, R. J., Ozono, H., Nakashima, S., Yoshikawa, S., & Watabe, M. (2010). Polling the face: Prediction and consensus across cultures. Journal of T. Welch 35 Personality and Social Psychology, 98(1), 115. doi:10.1037/a0017673 Rule, N. O., Ambady, N., & Adams, R. J. (2009). Personality in perspective: Judgmental consistency across orientations of the face. Perception, 38(11), 16881699. doi:10.1068/p6384 Rule, N. O., & Ambady, N. (2009). Shes got the look: Inferences from female chief executive officers faces predict their success. Sex Roles, 61(9-10),644- 652. doi:10.1007/s11199-0099658-9 Simpson, D. D., & Ostrom, T. M. (1975). Effect of snap and thoughtful judgments on person impressions. European Journal of Social Psychology, 5(2), 197-208. doi:10.1002/ejsp.2420050205 Steckler, N. A., & Rosenthal, R. (1985). Sex differences in nonverbal and verbal communication with bosses, peers, and subordinates. Journal of Applied Psychology, 70(1), 157-163. doi:10.1037/0021-9010.70.1.15 Takeda, M. B., Helms, M. M., & Romanova, N. (2006). Hair color stereotyping and CEO selection in the United Kingdom. Journal of Human Behavior in the Social Environment, 13(3), 85-99. doi:10.1300/J137v13n03_06 T. Welch 36 Figure 1. Warmth score means for each hair color and gender combination T. Welch 37 Figure 2. Competence score means for each hair color and gender combination T. Welch 38 Figure 3. Intended behavior score means for each hair color and gender combination T. Welch 39 Appendices Appendix A: Materials T. Welch 40 Appendix B: CITI Training T. Welch 41 T. Welch 42 Appendix C: IRB Documents T. Welch 43 T. Welch 44 T. Welch 45  ...

... Running Head: Sensory Integration Intervention and Parent Education 1 The Effectiveness of Sensory Integration Education for Parents of Children with Sensory Needs Allison Fritz 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: Dr. Taylor McGann, MS, OTR, OTD Sensory Integration Intervention and Parent Education 2 Abstract When working with children who have sensory processing disorders (SPD), occupational therapists (OTR) will utilize a wholesome approach by providing sensory-based treatments, relationship-based interventions, developmental skill-based programs, and parent education (Case-Smith & Arbesman, 2008). A current challenge in the field of occupational therapy is many therapists may not have ample time to engage in their therapy sessions as well as allow time for parent education on SPD. The purpose of this Doctoral Capstone project is to work oneon-one with parents to educate and empower them to implement sensory strategies to their children. The student utilized interviews and observations to create a sensory diet for the parents. Sensory diets were reviewed by the childs OTR before being given to the parents. The diets were discussed and modified with the help of the parents each week until an effective and appropriate schedule was complete. Each family that participated in the program reported it to be effective for their family as a whole. Literature Review Defining the Aspects of Sensory Processing Disorder Sensory Integration (SI) refers to an individuals ability to feel, understand, and organize the sensory input they are receiving from their environment and body, to respond in an appropriate manner (Emmons & McKendry, 2005). SI is an occupational frame of reference theorized by the occupational therapist (OTR) and psychologist, Dr. A. Jean Ayres (Cole & Tufano, 2008). SI is not something an individual has or does not have; it is a spectrum in which one has his or her own unique response to sensory input (Ayres, 1982, p. 7). In many people, SI is something that comes naturally; SI does not have to be sought after, and it is something that is often taken advantage of (Ayres, 1982, p. 3). Sensory processing disorders can be broken down Sensory Integration Intervention and Parent Education 3 into three different components: sensory discrimination disorder, sensory modulation disorder, and sensory-based motor disorder (Miller, 2014). When a child has sensory modulation disorder, they may be over or under reactive to touch, appear high energy or lethargic, be sensory seeking, or may have a delayed or heightened response to sensory input (Miller, 2014). A child who has a sensory-motor disorder will have inappropriate motor responses to sensory input (Miller, 2014, p. 41). These disorders can be categorized into dyspraxia and postural disorder (Miller, 2014, p. 41). Finally, sensory discrimination disorder presents as the inability to interpret and distinguish between similar sensations (Miller, 2014, p. 37). These children will have difficulty distinguishing between objects in a bag without looking, using appropriate pressure with writing utensils, and recognizing the differences between the tastes of different foods (Miller, 2014, p. 37). Sensory challenges are different than SPD in that they may not affect every area of a childs life (Emmons & McKendry, 2005). An example of a sensory processing challenge is a preschooler having an adverse reaction to the feeling of sand and avoids playing in it during recess, however, engages in all other school activities without trouble (Emmons & McKendry, 2005). A child who has SPD may be overly sensitive to all tactile stimuli, therefore they cannot engage in feeding, eating, dressing, and playing without experiencing some amount of distress or anxiety (Emmons & McKendry, 2005). Since SPD is so broad it can be difficult to diagnose. Signs and symptoms of SPD are typically reported by parents, teachers, or caregivers (Schoen & Miller, 2018). Whether a child has few sensory challenges or is diagnosed with SPD, an occupational therapist can provide intervention through sensory and play-based activities to improve their participation in everyday tasks (Kashefimehr et al., 2017). SPD and Occupational Therapy Sensory Integration Intervention and Parent Education 4 Past studies have demonstrated a correlation between sensory integration and engagement in functional tasks such as selfcare, play, and school activities (Bar-Shalita, Vatine, & Parush, 2008). When working with children who have SPD, occupational therapists will utilize a wholesome approach by providing sensory-based treatments, relationship-based interventions, developmental skill-based programs, and parent education (Case-Smith & Arbesman, 2008). Sensory integration therapy (SIT), based on Dr. Jean Ayres frame of reference, is a common method many OTs implement to improve a childs ability to process and organize sensory input (Case-Smith & Arbesman, 2008). Sensory integration therapy incorporates play and sensorybased interactions to elicit the childs adaptive response (Kashefimehr et al., 2017). The therapist encourages the child to engage in activities that challenge their sensory processing and motor planning skills through activities that incorporate play, school, and self care (Kashefimehr et al., 2017). The therapist will continue adjusting and adapting the treatment plan to a just-right level in order to increase therapeutic results (Kashefimehr et al., 2017). Sensory integration education is an important component in OT intervention to allow parents to fully understand and successfully interact with their child, as well as maximize the childs strengths (Miller-Kuhaneck & Watling, 2018). Kashefimehr et al. (2017) utilized SIT techniques on a sample of children who have ASD and SPD. One aspect of SIT the researchers utilized was parent education and training (Kashefimehr et al., 2017). Through proper training and education, the parents were able to modify their home environment and routines to provide ample opportunities for their child to self-regulate and engage in their meaningful occupations (Kashefimehr et al., 2017). The results of this study support the effectiveness of SIT on improving occupational performance in the home of children diagnosed with ASD and SPD (Kashefimehr et al., 2017). Sensory Integration Intervention and Parent Education 5 Benefits of Sensory Education for Parents SPD may present as the child being uncooperative, having poor frustration tolerance, and frequent temper tantrums (Freese, Porter, & Pelham-Foster, 2016). Parents experience decreased confidence in their role as a parent when their child engages in a behavior that is commonly seen as socially unacceptable (Freese, Porter, & Pelham-Foster, 2016). The care that children with SPD require include accommodations for elevated irritability levels, emotional challenges, and behavioral challenges (Freese, Porter, & Pelham-Foster, 2016). As a result, parents of children with SPD have a higher stress level and greater difficulties in their family life than parents of typically developing children (Freese, Porter, & Pelham-Foster, 2016). Family-centered practice (FCP) is an intervention technique focused on parent education and can be used to work with parents of children with SPD (Freese, Porter, & Pelham-Foster, 2016). It has been found to decrease stress and increase parent self-efficacy, ultimately leading to improved engagement in family-centered activities (Freese, Porter, & Pelham-Foster, 2016). Education and training is a large factor in parents ability to understand their child and his or her improvements, to interact with their child and relate to them, and overall improved family quality of life (QOL) (Freese, Porter, & Pelham-Foster, 2016). Parent Reports on Sensory Education In 2008, Elizabeth Dunstand and Sian Griffiths sought to identify the thoughts and attitudes toward sensory integration in the home by interviewing parents of children with SPD. Their findings suggest that the most important role of an OT in the home environment is to train, reassure, educate, and empower parents to become the main provider of sensory strategies used with their children (Dunstand & Griffiths, 2008). Researchers conclude that when a child has SPD, their needs and limitations affect the entire family dynamic (Dunstand & Griffiths, 2008). Sensory Integration Intervention and Parent Education 6 The participants reported that every day activities such as bathing, dressing, eating, and sleeping could be the most challenging parts of the day (Dunstand & Griffiths, 2008). One participant, Lucy, reported that all members of her family had to accommodate to meet the needs of James, her child with SPD (Dunstand & Griffiths, 2008). Participants felt an ongoing uncertainty on whether or not they were doing the best they could for their children (Dunstand & Griffiths, 2008). Lucy reinforced the importance of the OT providing reassurance: it is really important to validate that whole attitude of yes, you are a good parent, yes, this is an issue that youre dealing with, and yes, you havent made this up (Dunstand & Griffiths, 2008). One participant from the same study highlighted the importance of SI parent education (Dunstand & Griffiths, 2008). She felt that by understanding her sons feelings she was better able to sympathize and communicate with him (Dunstand & Griffiths, 2008). Lucy discussed the positive results from the sensory strategies training she received regarding self-care (Dunstand & Griffiths, 2008). Her son finally began to tolerate bathing and tooth brushing, something that was a large struggle for both of them (Dunstand & Griffiths, 2008). I cannot tell you how huge it is to be able to do that, she stated (Dunstand & Griffiths, 2008). Despite Lucys gratitude for the sensory training and education she received, she found the delivery of information to be overwhelming and too much at once (Dunstand & Griffiths, 2008). The findings from this study suggest that parent training should focus on increased support from the therapist in the early stages (Dunstand & Griffiths, 2008). Hands on assistance and support should then reduce over time as the child makes improvements and the parents feel more confident implementing strategies (Dunstand & Griffiths, 2008). When working with a child the occupational therapist needs to allow time to sit down with the parents to discuss and identify the treatment option that best fits the family as a whole (Dunstand & Griffiths, 2008). Sensory Integration Intervention and Parent Education 7 In 2009, a study was implemented to identify parents thoughts regarding their childs sensory experiences during preschool (Dickie, Baranek, Schultz, Watson, & McComish, 2009). The researchers unexpectedly found that parents were confused by the concept of sensory and could not define or identify it in their childs daily experiences (Dickie et al., 2009). Researchers concluded that parents do not typically deconstruct their childs experiences and categorize them into different components, such as sensory aspects (Dickie et al., 2009). This leads to the idea that sensory aspects of a childs behavior are not noted unless they are unusual (Dickie et al., 2009). These results support the need for parent SI education when working with a child with SPD to ensure understanding and competence when providing sensory strategies at home. Methods The placement for this Doctoral Capstone project was an outpatient pediatric clinic in Indianapolis. The clinic provides occupational, physical, speech, and developmental therapy to children and a small percentage of adults. The clinic is also a First Steps provider. A thorough needs assessment was conducted at the site to identify areas of concern, aspiration, and intention for the staff members and clients. A semi-structured interview was completed with the owner and director of the site, who is also an OTR. Several other short interviews were held with two onsite practicing OTRs and one First Steps OTR. These interviews transitioned into constructive discussions that determined an area in which the students services would be most beneficial. It was identified that an SI training program providing parents with the tools needed to implement sensory strategies in the home would be most beneficial to the site. The clinic director was adamant about the need for this program, as it would relieve the OTRs of some parent education responsibilities, therefore allowing them to spend more time with the child one-onone. She also stated that a program of this nature would likely provide families with a greater Sensory Integration Intervention and Parent Education 8 quality of life by reducing stress in the home. Research supports parent education as an advantageous tool to increase QOL when working with children who have SPD (Freese, Porter, & Pelham-Foster, 2016). The director also stressed the importance of building rapport with the parents. Rapport will allow the student to understand the participants perceptions of daily life with their child, therefore resulting in a trusting and strong relationship (B. Blain, personal communication, 2018). Recruitment of participants occurred after the needs assessment and systematic review of the literature was completed. The onsite OTRs assessed their caseloads and identified several clients whose parents would benefit from this program. The student then completed thorough chart reviews to ensure the clients fit the studys criteria and fit into a large spectrum of sensory processing difficulties. All clients are children who receive occupational therapy in the clinic. Children were not required to have a formal diagnosis; however, they must have sensory processing difficulties as identified by the parents and OTRs. The parents of these children were then asked if they would like to join the program. They were given a permission form and detailed program outline to ensure understanding of what was expected for the program. Five parents of six children agreed to be participants in the program. One of the parents had two children who received OT at the clinic. To measure results of the program, a pre-test and post-test survey were created for the parents. The tests used a 5-point Likert scale, which assumes that the strength of an experience is linear; the scale ranges from strongly disagree to strongly agree (McLeod, 2008). The six statements are qualitative and address the parents understanding of their childs sensory difficulties, perception of quality of life within the home, and their ability to seek out resources and services to assist their child and family. These statements were created under the supervision Sensory Integration Intervention and Parent Education of the clinic director. Statements were carefully chosen to ensure parents would not feel criticized. Pre-tests were distributed during the first parent session to establish a baseline. Posttests were completed on the last day of the program to determine outcomes. This program can be compared to a study conducted in 2017 exploring the effectiveness of an education program for the caregivers of stroke patients (Anand, Sumeet, & George, 2017). The researchers found that after a 60-minute course the participants had a significantly greater knowledge regarding strokes and how to care for a person who has had a stroke (Anand et al., 2017). The SI parent education program was held weekly for 30-60 minutes each, and spanned over two and a half months. With more frequent parent meetings, the parents gained an even greater amount of knowledge than with a singular session. Implementation Implementation of the program began week seven of the students doctoral capstone placement. Participants attended a one-on-one session with the OTS in a private room for confidentiality. The first session was an interview consisting of eleven questions addressing family dynamics, areas of daily living, sensory barriers for the child, current parent sensory strategies, and any areas of concern. To build rapport, the OTS first explained her role and personal reason for wanting to create the program. Program goals were explained to ensure the parents understood the OTSs intent. At the end of the session parents were given a folder of informative handouts regarding SPD. The OTS found it important for the parents to understand the basics of SPD before implementing sensory strategies. The parents were encouraged to review the information at their convenience so that during the next session these topics could be broken down into greater detail. 9 Sensory Integration Intervention and Parent Education 10 The week in between interviews and creating the sensory diet was spent gathering research related to each childs individual sensory difficulties. The OTS observed multiple weeks of OT sessions to ensure a comprehensive understanding of the childs sensory needs. She then created a sensory diet based on the information found during interviews and OT observations. Sensory diets are a schedule of sensory activities chosen specifically for a child to assist with attention, motor organization, arousal, and adaptive response (Kelly, n.d.). Each sensory diet was uniquely modified to fit the child and family. The OTS then discussed the diet with the childs OTR to ensure it would be appropriate for the childs specific needs. The OTS then presented the sensory diets to the families and discussed why certain activities were chosen. The OTS ensured the sensory diet would be plausible to implement based on the parents schedules. The parents were then trained on how to facilitate these strategies in a safe and inviting manner. Parents were encouraged to try the strategies and record outcomes of each one to discuss with the OTS the following week. Once parents implemented the sensory strategies for a week or two (dependent upon parents schedule) there was a follow-up session to discuss outcomes. The focus of this session was to identify strengths and weaknesses of the strategies. The OTS spent the next week modifying the strategies and schedule to better fit the family. Some sensory strategies were discontinued if they were too difficult to implement or did not yield positive results. The program ended at week fifteen of the OTS doctoral capstone rotation, allowing for 4-8 training sessions with parents. Leadership Skills and Staff Development The setting of this doctoral capstone traditionally offers occupational therapy. My site supervisor has offered guidance throughout my program. However, as she is the director and Sensory Integration Intervention and Parent Education 11 owner her time is limited. I had to independently create my pre/post tests, parent interviews, permission forms, and sensory strategies. I had assistance when necessary from my supervisor and the onsite OTRs. It has been a huge learning experience thus far as I have had to navigate this program on my own terms and find a way to fit into the model of the site. Connecting with staff has been an enjoyable experience as they have all been so kind and inviting. The on-site OTRs have taken time out of their schedules to assist me with recruiting my participants and creating my sensory diets. As they have helped me I have also returned the favor. When the therapists need assistance with a treatment activity or preparation for one, I have come forward to offer help. In this way, we have learned to trust and respect one another, and I believe this to be an important aspect of the OTR and student relationship. I have learned a lot about sensory integration, child development, and school development from these OTRs and appreciate the knowledge I have gained. Discontinuation During OT sessions and my program sessions I have observed a trend in the children with SPD. When a child becomes overstimulated, they begin displaying signs of stress, frustration, and discomfort (Kostelyk, 2018). These signs vary from child to child, but once they have a sensory meltdown, it is hard to calm them down. A sensory meltdown can include anything from shutting down to a panic attack (Kostelyk, 2018). During my sessions, I have observed several sensory meltdowns. The children experiencing these do not explain to the OTR what they are feeling, therefore, without prior sensory intervention it becomes difficult to prevent a meltdown. I have found that it is crucial for the OTR to observe and study a childs body language, facial expressions, and behaviors in any situation to gain an understanding of their sensory Sensory Integration Intervention and Parent Education 12 difficulties. When a child is not able to explain how they feel, they are subject to occupational injustice, as they cannot independently engage in their occupations. I often see children becoming discouraged and frustrated by small tasks because they seem scary to them. Through sensory play and exploration, the OTR is able to pinpoint areas of stress and find a way to address them in an occupation-based intervention. This is often difficult and frustrating to the child, but as they learn that they can succeed, it yields greater confidence and quality of life for the child. Through the parent education program, the parents learned how to successfully implement sensory strategies through the use of handouts and individualized sensory diets. Parents reported having a greater understanding of their childs needs as well as understanding what they can do to help their children (Dunstand and Griffiths, 2008). To allow for continuation of this program, I compiled evidence, program instructions, program responsibilities, sensory handouts, and examples of sensory diets and how to create them into a binder for the clinic. The clinic will now be able to utilize this binder as a tool in parent SI education. Outcomes To find outcomes, the OTS utilized the same pre/post test likert scale utilized during the first session. The post test was completed by participants on the last session of the program. On average, parents reported a higher level of understanding of their childs sensory needs, responses to sensory stimuli, improvement in ADL participation, improvement of stress in the family, and ability to find resources (see Appendix). In addition to the pre/post test, the student gave each parent an End of Program Questionnaire to identify areas of strength and weakness in the program. Each parent reported the program to be beneficial in understanding and implementing of sensory strategies. On average, the parents reported the educational sensory Sensory Integration Intervention and Parent Education 13 handouts to be the most helpful for them. One parent reported a weakness of the program to be insufficient time during each session. The same parent stated, it was sometimes hard to communicate in waiting area with my other child present. No other parent reported an area of weakness of the program. A limitation of this program is there were five parents who participated in the program. One of the parents was absent during the last program session, therefore she did not complete the post test or End of Program Questionnaire. This group would have been more reliable if more families had participated. Another limitation is one of the parents started the program later, so she did not receive as much feedback on her sensory diets as some other parents did. Despite these limitations, the program was seen as efficient and beneficial at this pediatric clinic, and the parents reported positive feelings towards it. More programs similar to this should be conducted in other settings and clinics to ensure reliability. Overall Learning This DCE has been wonderful in many ways. I have met many amazing people at this site and have learned so much from each of them. The OTs at the site have truly immersed me in the subject of sensory integration and have passed on much knowledge, from how to observe a child with SPD to how to create a sensory diet specific for their needs. The other disciplines at the site have taught me a lot about interdisciplinary teamwork and how I can be of help to them regarding sensory issues. I have also been working closely with six other OT students of various schools and it has been a huge learning experience to collaborate with them in treatment and during the camp we held one week during my DCE. Although I have learned a lot from the individuals I work with, I have learned the most from the parents of my clients. Through working closely with parents, I have grown immensely Sensory Integration Intervention and Parent Education 14 in professionalism. In the past it has been difficult for me to speak with the families of my clients, but through this DCE I finally feel confident and comfortable giving recommendations and advocating for these families. It has been a heartwarming and gratifying experience to provide assistance to these families and hear about their successes throughout this program. I think a program similar to this could be effective in many other settings, not just exclusive to pediatric outpatient. Conclusion Children who have SPD often have a difficult time with self-regulation, selfcare tasks, play activities, and school engagement, leading to poor social skills, stressful family relationships, and low self-esteem (Dunstand & Griffiths, 2008) Studies show that SPD also affects the childs parents, causing increased stress and family issues, as well decreased confidence when interacting with their child (Freese, Porter, & Pelham-Foster, 2016). SPD is most commonly diagnosed in children, however sometimes it is not caught nor treated (About SPD, n.d.). Adults with SPD may have a difficult time engaging in work, relationships, and leisure and often experience depression, under achievement, and social isolation (About SPD, n.d.). For these reasons, parent SPD and SI education is necessary to ensure individuals are getting the treatment they need starting in childhood to improve overall QOL for families (About SPD, n.d.). Through this DCE, I have advocated for individuals living with SPD and the daily challenges they face, raised awareness of signs and symptoms of SPD, and provided an educational program for parents at this outpatient pediatric outpatient clinic. Parents reported this program to have several strengths, and to be an aid in improving overall quality of life of their children and themselves. Sensory Integration Intervention and Parent Education 15 Resources About SPD. (n.d.). Retrieved April 17, 2018, from https://www.spdstar.org/basic/about-spd Ayres, J. A. (1982). Sensory integration and the child. Los Angela, CA: Western Psychological Services. Bar-Shalita, T., Vatine, J. J., & Parush, S. (2008). Sensory modulation disorder: A risk factor for participation in daily life activities. Developmental Medicine & Child Neurology, 50 (12), 932-937. Bunim, J. (2013). Breakthrough study reveals biological basis for sensory processing disorders in kids. University of California San Francisco. Retrieved from https://www.ucsf.edu/news/2013/07/107316/breakthrough-study-reveals-biological-basissensory-processing-disorders-kidsi Case-Smith, J., & Arbesman, M. (2008). Evidence-based review of interventions for autism used in or of relevance to occupational therapy. American Journal of Occupational Therapy. 62(4), 416- 429. https://doi/10.5014/ajot.62.4.416 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Conducting a Needs Assessment. (n.d.). Retrieved from https://cyfar.org/ilm_1_9 Dickie, V. A., Baranek, G. T., Schultz, B., Watson, L. R., McComish, C. S. (2009). Parent reports of sensory experiences of preschool children with and without autism: A qualitative study. American Journal of Occupational Therapy, 63(2), 172-181. Sensory Integration Intervention and Parent Education 16 Dunstand, E. & Griffiths, S. (2008). Sensory strategies: Practical support to empower families. New Zealand Journal of Occupational Therapy. 55(1), 5-13. Effects, Signs & Symptoms of Sensory Processing Disorder. (n.d.). Retrieved April 18, 2018, from http://www.ascentchs.com/developmental/sensory-processing/symptoms-signseffects/ Emmons, P. & Anderson, L. (2005). Understanding sensory dysfunction: Learning, development, and sensory dysfunction in autism spectrum disorders, ADHD, learning disabilities and bipolar disorder. London, UK and Philadelphia, PA: Jessica Kingsley Publishers. Ermer, J., & Dunn, W. (in press). Considerations in finding ways to score the Sensory Profile. American Journal of Occupational Therapy. Freese, D., Porter, L., & Pelham-Foster, S. (2016). Providing parent education for children with sensory processing disorder. The American Occupational Therapy Association, 21(12), 18-20. Kashefimehr, B., Kayihan, H., & Huri, M. (2017). The effect of sensory integration therapy on occupational performance in children with autism. OTJR: Occupation, Participation and Health, 38(2), 75-83. Kelly, K. (n.d.) Sensory Diet Treatment: What You Need to Know. Retrieved from https://www.understood.org/en/learning-attention-issues/treatmentsapproaches/therapies/sensory-diet-treatment-what-you-need-to-know Sensory Integration Intervention and Parent Education 17 Kostelyk, S. (2018). Is my child having a sensory meltdown? Retrieved from https://www.thechaosandtheclutter.com/archives/child-sensory-meltdown McLeod, S. (2008). Likert scale. Retrieved from https://www.simplypsychology.org/likertscale.html Miller, L. J. (2014). Sensational Kids: Hope and help for children with sensory processing disorder (SPD). New York, NY: Penguin Group. Miller-Kuhaneck, H. & Watling, R. (2018). Parental or teacher education and coaching to support function and participation of children and youth with sensory processing and sensory integration challenges: A systematic review. The American Journal of Occupational Therapy, 72(1), 1-11. Overstimulated and Overwhelmed: Sensory Overload, Anxiety, and Depression. (2017). Retrieved from http://www.yoursunshine.org/overstimulated-and-overwhelmed-sensoryoverload-anxiety-and-depression/ Wilkes-Gillan, S., Bundy, A., Cordier, R., & Lincoln, M. (2014). Evaluation of a pilot parentdelivered play-based intervention for children with attention deficit hyperactivity disorder. American Journal of Occupational , 68 (6), 700-709. https://doi.org/10.5014/ajot.2014.012450 Sensory Integration Intervention and Parent Education 18 Appendix: Pre/Post Test Results of Parent SI Education Program Below are the results of the Parent SI education program, displaying an average increase in score. The pre/post test was a likert scale ranging from 1 Strongly Disagree to 5 Strongly Agree. The statements are as follows: Statement 1: I know what my childs sensory needs are. Statement 2: I understand my childs reactions to sensory stimuli. Statement 3: My childs sensory processing difficulties do not cause stress in my family. Statement 4: Everyday activities, such as mealtime, dressing, bathing, etc., are easy to maneuver. Statement 5: I feel confident implementing sensory strategies to my child when necessary. Statement 6: I know where to find resources regarding sensory processing difficulties. Pre/Post Test Results of Parent SI Education Program 5 4.5 4 3.5 3 Pre-Test 2.5 Post-Test 2 1.5 1 0.5 0 Statement 1 Statement 2 Statement 3 Statement 4 Statement 5 Statement 6  ...

... Running head: THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC The Development of a NICU Follow-Up Clinic Kelsey Robertson 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: Alison Nichols, OTR, OTD THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC A Capstone Project Entitled The Development of a NICU Follow-Up Clinic 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 Robertson 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 THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC Abstract Infants who are discharged from the neonatal intensive care unit (NICU) at Indiana University Health North Hospital are not typically followed by the hospital to ensure they are developing appropriately with their peers. A follow-up clinic would regularly follow these discharged infants to ensure they do not fall behind developmentally and to provide resources and support services for families. A needs analysis was conducted with hospital staff to identify the need for a follow-up clinic and the individual concerns of various disciplines. Data were collected from thirty existing follow-up clinics around the country through site visits, email contact, and individual websites. The information was analyzed and contributed to the program development plan, then presented to the hospital staff to gain support for the follow-up clinic to open. The program development plan was created to meet the needs of the infants and their families after discharge from the NICU through the provision of quality services. The components of the program development plan were realistic, specific to the facility and considered all of the factors that would facilitate success and sustainability. At the end of this project, the recommendation is to schedule the follow-up clinic as soon as the resources are received. 3 THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 4 The Development of a NICU Follow-up Clinic The NICU at Indiana University Health North Hospital (IU Health North) provides interdisciplinary services to infants and their families who require specialized care after birth. One long-term goal of this team was to create a follow-up clinic for infants and their families after they are discharged to make sure that no infant falls through the gaps of the healthcare system. When the infants from the NICU are discharged, they typically are not seen again or followed by the hospital to ensure they are receiving the services they need to thrive. The purpose of this Doctoral Capstone Experience (DCE) is to research and identify the need for a follow-up clinic at IU Health North and to create a program development plan to initiate the creation of a clinic. Literature Review Ecology of Human Performance The theory guiding this DCE is the Ecology of Human Performance (EHP). The focus of EHP is the transaction that occurs between the person, the task, and their context to develop the performance range (Cole & Tufano, 2008). The person is unique and they have the skills that will develop their occupational performance within their environment (Cole & Tufano, 2008). The tasks are the behaviors and activities that will be completed in order to reach the persons goals and develop their occupational performance (Cole & Tufano, 2008). The context in this theory has both environmental and temporal aspects that make up the persons surroundings that can also impact performance (Cole & Tufano, 2008). When these three variables interact together and begin to affect one another interdependently, occupational performance occurs (Cole & Tufano, 2008). THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 5 The infants discharged from the NICU are a unique population who develop skills as they grow, and their experiences make them different from typical infants. They have developmental milestones and behaviors that they are completing for their occupational performance. The infants can have both a temporal and environmental context throughout their development. Examples of the temporal context could be their stage of development, their age both chronologically and gestational, and their level of disability. Their environmental context could be where they are living and performing their occupations, how they are socially engaged in their daily lives, or how their family raises them culturally. The NICU follow-up clinic will focus on preventative care and will provide rehabilitative evaluations that will identify gaps in the occupational performance of infants strongly connecting from the focus of EHP (Cole & Tufano, 2008). The clinic will look at the infants task performance at various stages of their life to evaluate if occupational performance is ageappropriate or if additional services are needed. The clinic can evaluate the infants context they are being raised in to determine if that is impacting their development as well. Through the process of following up, an interdisciplinary staff can take a preventative approach to analyze the skills, environmental factors, and tasks that are delaying the developmental growth of infants who were discharged from the NICU and refer them to the services they need so they can have optimal occupational performance. The Development of NICU Infants Infants can be born at risk for further complications and the risks can be both biologic in nature and/or environmental (Cronin & Mandich, 2016). Biologic risks can be something genetic within the infant or contributed to by factors with the mother, such as maternal age, smoking or drug use, HIV exposure, Intrauterine Growth Restriction (IUGR), and prematurity (Cronin & THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 6 Mandich, 2016). The environmental risks that can impact the development of the infant could be their nutrition, socioeconomic level, and the level of care they receive from their caregiver (Cronin & Mandich, 2016). The NICU provides specialized care for these high-risk infants after birth (Case-Smith & OBrien, 2015). Many studies have looked into the developmental and behavioral patterns that occur in common diagnoses seen in the NICU. Infants who are considered preterm or very low birth weight (<1000 g) are at a higher risk for motor, cognitive and behavioral problems (American Academy of Pediatrics, 2004). Preterm infants are born prior to 37 weeks gestational age, and they are at a greater risk for immediate and distant delays and complications with their development (Cronin & Mandich, 2016). Many of these complications are due to their physiologic immaturity and can impact many of the infants body systems. Examples of complications could include respiratory distress syndrome, bronchopulmonary dysplasia, gastroesophageal reflux, change in muscle tone and reflexes, encephalopathy, periventricular leukomalacia, retinopathy and intraventricular hemorrhage (Cronin & Mandich, 2016). As the infants gestational age decreases, their risk for developmental delay increases (American Academy of Pediatrics, 2004). Risk factors for neurodevelopmental deficits were identified as severe preterm delivery, lung disease, those with severe growth restrictions, meningitis, sepsis, hydrocephalus, multiple births, males, complications and abnormalities, and the environmental stress from the NICU stay itself (American Academy of Pediatrics, 2004). Infants who had a stay in the NICU may have difficulty with feedings and require alternative feeding strategies that are challenging to manage at home. They may require early intervention services to follow them to improve their skills (Cronin & Mandich, 2016). Infants born in both extremely (<1000 g) and THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 7 very low (<1500) birth weight categories later demonstrated deficits with executive function, visual motor integration and fine motor delays (American Academy of Pediatrics, 2004). Preterm infants are commonly treated in the NICU where the lighting, noise, and somatosensory conditions are unlike what they would be in the womb, causing an abnormal sensory experience (Cronin & Mandich, 2016). In the womb, their environment would be dark and they would be flexed in their aquatic surroundings (Cronin & Mandich, 2016). The NICU typically will have high lighting, increased noise, and physical contact is often a negative medical procedure or experience for the infant. These conditions can have negative effects on their physiology and behavior (Cronin & Mandich, 2016). When looking at children aged four years and six months who were born very preterm (<32 weeks gestational age), Crozier et al. (2016) found that almost half of the 160 children in the sample were atypical for sensory processing. They also found significantly lower birth weight, lower APGAR (appearance, pulse, grimace, activity, and respiration) scores, more days of ventilation, and a longer stay in the NICU correlated with atypical sensory processing in the very preterm population (Crozier et al., 2016). The authors determined that over 40% of those children that were atypical had sensory seeking behavior and over one-third demonstrated sensory sensitivity. As these children begin to enter school, they may have increased difficulties with social adaptive behaviors and academic participation due to their sensory processing differences (Crozier et al., 2016). This high prevalence of atypical sensory processing and the impact it had on these children at a later age may indicate a need for early referral to be evaluated for therapy (Crozier et al., 2016). In addition to sensory processing difficulties, a different study determined that of the 85 infants who were preterm, 31% had mild delays in the area of expressive language and 47% in their gross motor skills in their first year of life (Greene, Patra, Nelson, & Silvestri, 2012). THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 8 Another population commonly seen in the NICU are those with Neonatal Abstinence Syndrome (NAS); these infants commonly demonstrated poor sleeping, feeding, increased tone and tremors and a high-pitched cry (Logan, Brown, & Hayes, 2013). These symptoms began to appear around 24 to 72 hours after birth and sometimes required pharmacological intervention to wean the infant in order to be fully withdrawn from the addictive substance (Logan et al., 2013). Infants who were exposed to methadone had motor deficits, poor social participation and attention span; these difficulties continued into toddler years (Logan et al., 2013). Illicit drugs and licit drugs affected motor and cognitive performance long-term in infants (Logan et al., 2013). Those exposed to alcohol had poor coordination, delayed gross and fine motor skills and poor cognition (Logan et al., 2013). Early Intervention As some children begin to miss their developmental milestones and families notice their lack of age-appropriate behaviors, developmental screens may occur to identify areas of delay (Cronin & Mandich, 2016). If the developmental screen identifies an area of delay, the children are referred to specialists to assist the child in catching up to their peers. Those specialists involved in early intervention could include occupational therapy, physical therapy, speech therapy, neurology, developmental pediatrics, and geneticists (Cronin & Mandich, 2016). Because children have great neuroplasticity in their brain, the earlier they can receive interventions, the better the outcomes (Cronin & Mandich, 2016). When the infant has positive early experiences, their brain is strengthened and they have better development of their physical, cognitive and social health (Case-Smith & OBrien, 2015). Neuroplasticity is greatest in the first three years of life and supports the need for early intervention to improve the childs development and health early (Case-Smith & OBrien, 2015). THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 9 Nwabara, Rogers, Inder, and Pineda (2016) studied early therapy services in preterm infants and the accessibility of those services. Thirteen out of the 57 participants did not receive therapy after they were discharged from the NICU despite that 85% of these infants had received a referral at discharge (Nwabara et al., 2016). Over half of those that did not receive therapy demonstrated developmental delay at two years when assessed (Nwabara et al., 2016). The infants that participated in therapy services within the first two years of life were more likely to have been ventilated longer, had a single mother, or had abnormal behavior when leaving the NICU (Nwabara et al., 2016). There was found to be a delay in time between discharge and early intervention beginning. Physical therapy was started at a mean age of 4.3 months with occupational therapy following at 5.1 months of age (Nwabara et al., 2016). Speech therapy was typically initiated much later at the mean age of 14.0 months. This was believed to occur due to the more apparent nature of gross motor delays seen by parents (Nwabara et al., 2016). A major concern identified with provision of early intervention to this population was the gap that occurs after discharge during an important period of development (Nwabara et al., 2016). The NICU follow-up clinic at Rush University Medical Center completed a retrospective study to better understand the early intervention referral and use with infants that were preterm (Greene & Patra, 2016). The amount of preterm infants that were enrolled in early intervention services increased from 56% at four months corrected age to 66% at twenty months (Greene & Patra, 2016). The need for early intervention referral was twice as likely for babies who were less than 1000 grams at birth than those above 1000 grams (Greene & Patra, 2016). Preterm infants were more likely to receive early intervention by the age of two if they had abnormal head ultrasounds, were older at NICU discharge or had a language index score on the Bayley Scales of THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 10 Infant and Toddler Development-III (Bayley-III) that was identified as delayed at one year of life (Greene & Patra, 2016). Current Follow-up Programs NICU follow-up programs can provide infants with specialized and coordinated care that can identify delays in development, growth, and behavior (Bockli, Andrews, Pellerite, & Meadow, 2014). Services that have been identified as beneficial are nutrition services, occupational therapy, physical therapy, speech therapy, feeding assessment, social worker assistance, education on managing medical devices and behavioral assessments (Kuppala, Tabangin, Haberman, Steichen, & Yolton, 2012). Of 143 NICU programs that responded to a survey, 93% of the NICUs stated that they had a follow-up clinic and 37% completed research in addition to their clinical care (Kuppala et al., 2012). A neonatologist was most likely to be the primary care provider of the clinics, and other common staff included a developmental pediatrician, physical and occupational therapists, and a developmental psychologist (Bockli et al., 2014). Roles of the follow-up clinic staff were addressed by Lipner & Huron (2018), which included physical therapists, occupational therapists, developmental pediatricians, audiologists, speech therapists, and a social worker. Physical and occupational therapy services were recommended to assess the infant between one and two months of age for surveillance of motor skills, visual-motor skills, and functional performance (Lipner & Huron, 2018). The developmental pediatrician identified referrals that were necessary based on comorbidities seen, developmental performance, and their social behavior (Lipner & Huron, 2018). The speech therapist provided education and services to the infants who had swallowing or oral feeding issues (Lipner & Huron, 2018). Financial and informative resources were provided through consultation with the social worker to improve the support provided (Lipner & Huron, 2018). THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 11 The majority of the funding that supported the clinics were from the NICU department itself and the hospital with some assistance from the state (Bockli et al., 2014). Kuppala et al. (2012) found the majority of the respondents identified multiple funding sources for the programs that included department, hospital, state, and research funds, but the most common sources was patient insurance. Funding was identified as a primary struggle faced by follow-up clinics (Bockli et al., 2014). In a survey of high-risk infant follow-up programs, lack of qualified personnel and financial resources were identified as additional barriers to follow-up clinics (Kuppala et al., 2012). Another common struggle identified was the high no-show rate and the need to improve the coordination of care after discharge (Bockli et al., 2014). Harmon, Conaway, Sinkin, and Blackman (2013) sought to determine what factors could cause poor follow-up compliance, as they found 42 of their 133 participants (31.6%) were noncompliant. Appointment noncompliance was more likely caused by the cost of travel and the distance from the hospital for the families; however, individual factors that were common included maternal drug use and multiple gestation pregnancies (Harmon et al., 2013). Similar information was found in follow-up programs in Canada where they identified younger mothers, single parents, greater distance to the clinic, and concern about alcohol and drug use as having poor attendance (Ballantyne, Stevens, Guttmann, Willan, & Rosenbaum, 2012). Of the 42 families that were noncompliant, 43.4% identified that appointments during times when parents were busy/working was a minor reason for noncompliance (Harmon et al., 2013, p.392). To improve compliance, researchers suggest that providing an appointment for follow-up is provided at the time of discharge in addition to physician education and that they have set standards for who receives the referral (Harmon et al., 2013). Another suggestion for improved compliance THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 12 included strong relationships with pediatricians who can encourage follow-up rather than waiting for parents to notice missed developmental milestones (Lipner & Huron, 2018). Criteria used for determining who attends follow-up clinics included the infants birth weight, gestational age, diagnosis when in the NICU, and a referral from a provider (Kuppala et al., 2012). The majority of the participating clinics had clinic appointments 2-5 times a month and the first clinic visit occurred between 3-4 months of age up to approximately 36 months of age (Kuppala et al., 2012). The American Academy of Pediatrics (2004) identified that follow-up clinics should have the minimum referral qualifications of extremely low birth weight, less than 28 weeks gestation, and those born with hypoxic ischemic encephalopathy or hyperbilirubinemia that requires a transfusion. They generally stated that any child that had a stay in the NICU should participate in a follow-up clinic for the preventative assessment that is performed (American Academy of Pediatrics, 2004). It was found that most follow-up occurs under the age of two but can go up to the age of five with referrals made at the time of discharge (American Academy of Pediatrics, 2004). Additional guidelines for those who can attend clinic are typically set by their gestational age and birth weight, and it is suggested that those who are high-risk could be those who were premature, had single mothers, were admitted to NICU, and/or had a birth defect (Bockli, Andrews, Pellerite, & Meadow, 2014). A study completed by Lipner & Huron (2018) identified that preterm infants who were born under 34 weeks or had a genetic or pre-existing medical condition when they were discharged should be referred to follow-up clinic. Benefits of a follow-up clinic include a reduction of re-admission rates after discharge through preventative care and solving medical issues (Bockli et al., 2014). Through the reduction of inpatient visits, some of the financial cost that occurs within the hospital could be decreased THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 13 (Bockli et al., 2014). The hospital may not profit from these clinics, but infants that are high risk often have a high cost related to their healthcare that may be lowered with the preventative services provided (Kuppala et al., 2012). Summary The current processes at IU Health North in the NICU involve a discharge where the infants are rarely followed by an interdisciplinary team unless they are directly referred to early intervention. The literature has identified common diagnoses and conditions that are seen in the NICU and the developmental delays that may follow their stay within their first few years of life (American Academy of Pediatrics, 2004; Cronin & Mandich, 2016; Crozier et al., 2016; Logan et al., 2013). Early intervention services can be provided to children in their first few years of life to decrease the gap in these developmental delays and grow age appropriate behaviors. For many of the infants seen at IU Health North, they do not always qualify for early intervention services. This leads to poor occupational performance and an environment that does not enhance their skill development in order to perform their daily tasks appropriately. Using a developmental followup clinic, the infants and their families can be followed in the first few years of life by a team of specialists who can identify any services they may need before they reach school-age. NICU follow-up clinics that are currently documented can provide a framework and evidence-based support for the development of a clinic at IU Health North. Screening and Evaluation The screening and evaluation process that was performed to develop the plan for this project involved the input of those who work with the NICU population and the evidence that supports the development of a NICU follow-up clinic. The evaluation process included a needs assessment through an interview with varying staff members of the NICU and a review of the THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 14 literature to develop a questionnaire for other follow-up clinics. This questionnaire was created to collect data on the currently existing NICUs, both in the state of Indiana as well as out-ofstate. Using the outline of a business plan developed by Jacobs & McCormack (2011), all of the factors were identified that would need to be addressed in the implementation phase when creating the proposal for the clinic. The literature identified the Bayley-III as a developmental evaluation tool for use in the NICU follow-up clinic, which will be further discussed in this section (Kuppala et al., 2012). Needs Assessment A needs assessment was completed to identify the factors that needed to be addressed in this program proposal. Scaffa & Reitz (2014) noted that the purpose of the needs assessment was to recognize the priorities of the program and services that would benefit the people being served. These authors stated the needs assessment can locate the factors that are a part of the overarching issue and use the priorities identified to make the interventions address the populations needs (Scaffa & Reitz, 2014). The population addressed in this project included infants in the NICU who may not have age-appropriate occupational performance. This project used two forms of the data collection that are typically used in a needs assessment: the written questionnaire and a face-to-face interview (Scaffa & Reitz, 2014). Multiple disciplines were interviewed to determine the information that would need to be obtained in order to develop a follow-up clinic at IU Health North. The program developer met with members of the NICU interdisciplinary team to determine the questions that would need to be answered in order for this clinic to be started. Interviewed individuals included the occupational therapist, physical therapist, neonatologist, social worker, two nurse practitioners and the NICU manager. The THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 15 evidence found in the literature was also requested by staff members to provide support for the development of the follow-up clinic. There was significant overlap in the discussions that occurred during the meetings with staff members. This brought about areas of concern that would play a significant role in the adoption of a follow-up program, along with less significant areas of concern that would increase the quality of the program development plan. Important areas of concern included the location of the clinic, funding and reimbursement, staffing, consumers, and services that would be provided. These concerns were used to help develop the questionnaire given to facilities with pre-existing clinics. The questions that were included in the questionnaire were transferred to Microsoft Excel so the data could be collected and organized. The list of questions can be found in Appendix A. After obtaining the data from various clinics using the questionnaire, they were combined with the information from interviews to develop the program proposal. Ten areas that need to be addressed in the program were identified, which correlated with the areas identified in the initial needs assessment. These areas include the background and trends of the service sector, services, market analysis, marketing, management and ownership, staffing, finances, facilities, program evaluation and risks (Jacobs & McCormack, 2011). These are all factors that needed to be researched and identified in the implementation phase in order to create the proposal. This outline for a business plan guided the proposal and ensured that all necessary information was provided in order to decide whether or not to move forward with this program (Jacobs & McCormack, 2011). Comparison with Other Areas of Practice in Occupational Therapy The needs assessment process used in this project was consistent with developing a program in the field of occupational therapy. However, the purpose is different than the typical THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 16 existing areas of occupational therapy. The majority of the existing areas of practice will use the needs assessment to find diagnostic information about the individual who is being treated, whereas this needs assessment looked at how the services provided by the new plan would affect a group of people (Scaffa & Reitz, 2014). The written questionnaire was used within a community to collect data (Scaffa & Reitz, 2014). This strategy was used in this project in order to obtain information from clinics both in-state and out-of-state. This would not be typical of an occupational therapist who is working with an individual. If an occupational therapist is looking specifically at the occupational performance of an individual, they may choose to perform a more standardized assessment tool in order to measure outcomes. The needs assessment is still collecting valuable and measureable information; however, its goal is to improve the occupational performance of the population of NICU infants. This evaluation process is most consistent with that of a community or program development setting in the field of occupational therapy (Scaffa & Reitz, 2014). In a typical setting of occupational therapy, there would most likely be a face-to-face interview with the individual to identify his or her needs. This project also incorporated a faceto-face interview in the needs assessment with various individuals who work with the population that is of interest and to voice their disciplines needs in this program. Similar to traditional occupational therapy practice of working with an individual, by performing the needs assessment in this project, the population will receive client-centered and interdisciplinary care through the development of this program. The Bayley-III is the assessment tool that was recommended for use in the follow-up clinic, and it is more comparable to a traditional evaluation in a pediatric setting. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 17 Bayley Scales of Infant and Toddler Development III (Bayley-III) Developmental assessments can identify an infants abilities and needs across all areas of development in order to recommend the appropriate services and interventions that the child needs (Cronin & Mandich, 2016). The NICU follow-up clinic at IU Health North needed a developmental assessment tool to identify any developmental concerns and the need for further services. The Bayley Scales have been used consistently to refer children to early intervention services and to identify improvement and performance for infants who are labeled high-risk; however, there is limited research on the third version (Greene et al., 2012). The Bayley-III is a developmental assessment tool that assesses the function of children between the ages of one and 42 months (Bayley, 2006). If the children are identified to have developmental delay using the assessment tool, it can provide assistance with intervention planning to improve function for the children (Bayley, 2006). The five subscales that are assessed include: cognitive, language, motor, social-emotional and adaptive (Bayley, 2006). The language scale can be divided into receptive and expressive subtests while the motor scale can be divided into fine and gross motor subtests (Bayley, 2006). The caregiver of the child completes a questionnaire for the social-emotional and adaptive scales whereas the other sections are completed on the record form by the individual administering the assessment (Bayley, 2006). Test scores of the Bayley-III are norm-referenced and they include scaled scores, composite scores, percentile ranks, and growth scores. Additionally, they can provide confidence intervals and developmental age equivalents for the various subtests (Bayley, 2006). All of the scores that are collected can be used to compare the child at their adjusted age with their peers and can be performed as a diagnostic test by an interdisciplinary team (Bayley, 2006). It is recommended that the members of the interdisciplinary team that administer the test be THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 18 experienced and trained or have completed some formal graduate or professional training (Bayley, 2006). The Bayley-III Administration Manual provides the instructions to score and administer the assessment tool and the standard procedures of the test to ensure standardization (Bayley, 2006). The test can be administered in approximately 50 minutes for infants under the age of 12 months and approximately 90 minutes if they are older (Bayley, 2006). The Technical Manual of the Bayley-III includes information on the history, revisions of the scales, research procedures, evidence of reliability and validity, and interpretive considerations that can be used to support the use of this developmental assessment tools with various populations of children (Bayley, 2006). The previous version of the Bayley only divided the scores into psychomotor and mental sections, compared to the five subscales that are in the new version (Greene et al., 2012). The use of the specific subscales was suggested to be more effective to refer to various disciplines for services (Green et al., 2012). Bos (2013) provided commentary on the comparison of the second and third versions and suggested that the second version may underestimate development and the third version may overestimate development. These differences could impact the severity of disability found and the referrals that could follow (Bos, 2013). Pearson Education, Inc. (2008) attributed the differences of the scores to the normative representative populations at the time the assessments were created. Parent education levels, ethnic and racial backgrounds, cultural, and socioeconomic characteristics changed from 1988 to 2000 and could have changed the normative scores from one test to another (Pearson Education, Inc., 2008). Another change was that 9.8% of the normative sample in the third version were clinical cases, which would have provided the population a full range of abilities whereas the second version had no clinical cases and the norms were higher (Pearson Education, Inc., 2008). The Bayley-III demonstrated good THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 19 sensitivity, specificity and discrimination to recognize the clinical cases, and the scores correlate with the expected performance of a certain diagnosis (Pearson Education, Inc., 2008). The Bayley-III was a common assessment tool used in follow-up clinics and ninety-nine percent of the follow-up clinics make early intervention referrals if they determine a need in their visit (Kuppala et al., 2012). The Bayley-III was used at Rush University Medical Center NICU Follow-Up Clinic as their primary neurodevelopmental testing to determine qualification for early intervention services (Greene & Patra, 2016). If the child had above a thirty-percent delay in any of the index scores, he or she qualified for services in Illinois (Greene & Patra, 2016). Identifying the Program Needs The evaluation process conducted for this project is comparable to that of the emerging practice areas of program development or community practice. The needs assessment of IU Health North was completed with the interdisciplinary team members that best know the NICU population. Following the face-to-face interviews conducted on-site and in addition to the literature review, the questionnaire for existing follow-up clinics was developed in preparation for the implementation phase of this project. The steps involved in a business plan were also included in the questionnaire to ensure that all information was provided to the decision makers and to provide a format for the proposal itself. Implementation Phase The implementation phase of this project was completed at IU Health North and three off-site visits were conducted to collect data. During the first portion of the implementation phase, data were collected from various follow-up clinics nationally and locally through the use of a questionnaire, one-on-one interviews, onsite visits, and information from hospital websites. The data collected were combined and analyzed to provide a summary of the important factors THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 20 involved in the follow-up clinics that were researched. This comprehensive analysis was used to develop the recommendations and program development plan for the creation of a follow-up clinic at IU Health North. Data Collection and Organization The implementation phase of this project consisted of two parts. The first part included the data collection and organization of information on follow-up clinics. Thirty follow-up clinics that existed were found through an internet search. The clinics found were located throughout the country and had a website that provided varying amounts of basic information on their follow-up clinic. Contacts were found either on websites or through peers that had relationships with individuals who were involved with follow-up clinics at their site. A draft email was developed to send to the varying follow-up clinics to obtain support, information, or an opportunity to observe for this project. This email was sent to individuals from the various follow-up clinics as their contact information became available. For seven of the clinics, phone calls were made to locate individuals who may be able to provide information. Of those seven clinics, one clinic responded and provided an email contact. Four of the individuals contacted were not involved in their follow-up clinics and provided contacts who were. All of the follow-up clinics were contacted a minimum of two times to collect information. For those that did not respond, the information on their websites was used for data collection. Following the initial email contact of the follow-up clinics, three site visits were scheduled in the city of Indianapolis. The follow-up clinics visited were Community Hospital North, Franciscan Health and Eskenazi Health. During each of the visits, I observed a typical day of follow-up clinic at that location and shadowed each of the disciplines involved to better understand their role in the process. Notes were completed based on the observation and the THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 21 questionnaire was completed through one-on-one interviews with the individuals at the followup clinic. Once the available data was collected from all sites, the information was organized into an Excel spreadsheet to identify the similarities and differences of the follow-up clinics. All of the data collected provided valuable information for the program development plan and was used in the recommendations for the creation of a follow-up clinic at IU Health North. Program Development Plan The program development plan for the NICU follow-up clinic at IU Health North was created based on existing literature, data collection, and the input and resources of the hospital. The program development plan can be found in Appendix B. This part of the implementation phase used the ten areas of program development identified by Jacobs and McCormack (2011) to outline the format of the program development plan and presentation to the hospital. This outline ensured that the program development plan was comprehensive and contained the quality information that was required to make the decision for the creation of the follow-up clinic. The program development plan addressed all ten areas, as well as answered staff questions, which were identified at the beginning of the project. These areas include the background and trends of the service sector, services, market analysis, marketing, management and ownership, staffing, finances, facilities, program evaluation and risks (Jacobs & McCormack, 2011). All sections of the proposal outline were completed based on current follow-up clinics and the literature in conjunction with the resources and needs assessment of IU Health North to create a plan that was realistic and specific to the hospital. Leadership and Staff Development Through the completion of a survey from Rath (2007), I received my top five themes of leadership strengths and in order they were: Woo, Empathy, Positivity, Futuristic, and Belief. An THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 22 individual who is talented in the Woo theme is described as someone who finds satisfaction in making connections with others and meeting new people, often used to develop networks of people around them (Rath, 2007). This strength was used throughout this project to make connections with members of the team to ensure their best interests and concerns were met by the services provided. It was also used when reaching out to the various follow-up clinics to obtain information and the opportunity to visit to collect data. The second strength that was identified was Empathy. The description of this strength included imagining yourself in others situations and understanding feelings of other individuals (Rath, 2007). This includes engaging others in conversation about their feelings or key ideas (Rath, 2007). I utilized this strength in the beginning of this project when meeting with the individuals who played a role in the development of the follow-up clinic and obtaining the key ideas they had. I also used it when relating it to the populations who would benefit from this new program and developing the plan to best fit their needs and concerns. Positivity was an additional strength that was identified, which is the ability to spark enthusiasm in others about what they are going to do and are optimistic about your results regardless of the value others put on them (Rath, 2007). This was an effort I made throughout the entire process of my project with all of the individuals that I interacted with. When I first met with the individuals at IU Health North, their expectations were not that a clinic would be developed, but that they would obtain as much information on what it would take to develop a follow-up clinic. I put a lot of effort in to build excitement for this program development plan with members of all disciplines to gain their support and also to educate them on the ability for this dream to become a reality. The strength that was the most predominant in this project was the futuristic theme. Individuals with this strength have the ability to be inspired and inspire THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 23 others with a vision for the future (Rath, 2007). These individuals put tireless efforts towards goals and have the ability to envision the future based on big dreams of themselves and others (Rath, 2007). From the start of this process, I was motivated to make the dreams of the staff at IU Health North a reality and to meet the needs of the NICU population through the development of a follow-up clinic. I developed the program plan with the vision that the follow-up clinic would be a reality, and all of my best efforts were given with the hope that a good quality program would be started. The final strength that was identified was Belief. This theme is described as motivation to make the world a better place than you found it and using talents to benefit individuals (Rath, 2007). A follow-up clinic could make a big impact in the lives of infants and their families that discharge from the NICU. My motivation throughout this whole project has been the quality of life that can be improved for these individuals and the quality of services that can be provided at IU Health North through follow-up services. In addition to leadership, staff development was promoted during the implementation phase to strengthen the development and support of the program proposal. I met with various disciplines that have a role on the NICU treatment team to understand the needs of the program from their perspective. This allowed for me to better understand their current participation in the NICU along with the discharge process and how they could be involved in a follow-up clinic. Additionally, the first meetings with these individuals included education from the literature review and the goals of the project that were created. As the project evolved, I met with individuals and the team as a whole to provide updates on the data collection from other clinics and the various factors that were addressed in the program development plan outline. This provided the team with the opportunity to raise questions and anticipate challenges they may face to strengthen the quality of the program proposal. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 24 Outcome Phase The implementation phase of the project resulted in the completion of a program development plan that was proposed to IU Health North. This plan included the individuals who will staff the follow-up clinic and their role as a member of the interdisciplinary team. Following the data collection and literature review, I was able to advocate for positions of the various disciplines and the services they would provide in the development plan. The staff was educated on the follow-up clinic and the purpose of the individuals who will be staffing the clinic during the proposal presentation. The outcomes that will be addressed for this project include the data from existing follow-up clinics, the additional documents created based on feedback from staff to strengthen the program plan and the program evaluation recommendations for the future if the follow-up clinic is started. Data Collection Results Data was collected from thirty existing follow-up clinics around the country. The majority of the information was collected from the facilities websites. A list of those sites can be found in Appendix C. Additionally, three site visits were conducted locally to collect information and observe the follow-up clinics while they were occurring to better understand the process. Individual interviews were conducted with the individuals who were followed at these sites. Lurie Childrens Hospital sent their handbook for the follow-up clinic for review to collect data. All of the collected data was documented and organized into an Excel spreadsheet. The data was then distributed into six separate spreadsheets of categories that would provide quality information to guide the program development plan. The first category was the staffing of the follow-up clinics. The identified disciplines ranked from most commonly used in a follow-up clinic to least commonly used were physical therapy, occupational therapy, social work, dietitian, THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 25 speech therapy, neonatologist, developmental pediatrician, nurse practitioner, psychologist, nursing, therapies, physiatrist, and neurology. In the category that identified the ages the infants were seen in clinic, the responses were more sporadic in nature. Two age sets were more commonly seen that included either a start date at six months and follow-up every six months or start at two months and follow-up every six months. The next category that was measured reviewed the qualifications for referral to the follow-up clinic. From the most common to least common responses it included: NICU graduate, detailed specifications for that facility, received therapy in the NICU, or were labeled high risk. Out of the 30 clinics that were reviewed, 22 indicated that they provided services for the parents of the infants. Twenty-three of the follow-up clinics discussed the assessment tools they administered. The most commonly used assessment tool was the Bayley-III, a developmental assessment tool, psychology evaluation, feeding evaluation and neurological exam. The scheduling process of follow-up clinics for this population revealed that 90% of the infants were discharged from the NICU with an appointment and referral made. All of the data that was collected for this project assisted in the development of a realistic program development plan for IU Health North. Areas that were addressed in the program development plan were focused on the needs of the infant and family population identified in the literature review. The data collected in this project supported the services and standards developed for the follow-up clinic. Continuous Quality Improvement Continuous Quality Improvement (CQI) was the management process used to evaluate the current procedures at IU Health North and what needs to be addressed to enhance the quality of the follow-up clinic (Jacobs & McCormack, 2011). There is a nine-step process that has been shown to produce higher quality performance in a program. The first step is finding what needs THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 26 to be improved in the process (Jacobs & McCormack, 2011). For IU Health North, the process of follow-up after discharge for the infants and families needed to be improved to prevent the infants from falling behind developmentally. This was identified by both staff and the literature in the beginning stages of this project. The next three steps are creating a group that recognizes the issues, clarifying the problems with the current performance and understanding why, and how they can be improved (Jacobs & McCormack, 2011). This was completed in the evaluation and implementation process with the various members of the staff that are employed in both the NICU and rehabilitation. The needs assessment identified the group of individuals who understand and are impacted by the current discharge process. Throughout the implementation process and as the program recommendations were presented to various members of the team at IU Health North, feedback was received to strengthen the development plan. The following resources were developed to meet the needs of the staff and population being served to enhance the services provided. The first request was that a schedule example would be provided based on the recommendations and services to better understand how to conduct the appointment. The example created can be seen in Appendix D. In addition to the appointment example, a sample of a note template was requested in order to guide the development of a formal template for documentation in the follow-up clinic. The template can be found in Appendix E. Both of these requests were added to the program development presentation to strengthen the quality and to increase the support for the follow-up clinic to occur. The next component is identifying what will improve the performance (Jacobs & McCormack, 2011). In this project, this step was seen with the recommendation to start a followup clinic for NICU graduates. The final step that occurred in this project was the development of THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 27 a plan for change (Jacobs & McCormack, 2011). The program development plan created for the follow-up clinic provides details for the whole process for it to be successful. The implementation, evaluation, and maintenance stages are not seen during this process but the plans and recommendations for these portions can be found in the program development plan. Program Evaluation The follow-up clinic at IU Health North was not adopted during the time of this project and could not formally be evaluated. I have identified future recommendations for a program evaluation for once this program has been functioning for a year. The first component would be data collection that could evaluate appointment compliance, results of the Bayley-III and referrals, diagnosis from NICU, documentation, and other continuous quality improvement items. The second component could be related to reviewing billing and reimbursement to examine the financial aspects of the follow-up clinic. This portion would look at the cost of the program for the first year and compare it to the reimbursement received for therapy services in the follow-up clinic. Both of these program evaluations could improve the quality of the program, increase longevity, and can validate the need for a follow-up clinic at IU Health North. The program development plan that was created during this project was intended to meet the needs of the infants and families who leave the NICU. The future program evaluations will continue to ensure quality services and that those needs continue to be met as the program grows. This will allow for any changes that occur within this infant population to be addressed regularly through program evaluation standards set in the future. Meeting the Needs of Society Existing evidence states that infants who are very low birth weight or preterm are at greater risk for developmental delays and complications (American Academy of Pediatrics, THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 28 2004). Over half of the infants that received referrals for early intervention after discharging from the NICU did not receive services and demonstrated developmental delay (Nwabara et al., 2016). The infants that did receive services for the various disciplines waited for months at a time to be seen (Nwabara et al., 2016). The NICU at IU Health North typically does not followup with infants who are discharged after a length of stay. Three of the infants in one month who were seen and were referred to early intervention never received a phone call for evaluation. The number of infants who are discharged are increasing as outcomes are improving with technology and care, and they will need to be followed during their early development. The NICU follow-up clinic would follow the infants who discharge from IU Health North to ensure that they are not missed by early intervention or do not fall behind if they are not seen immediately by early intervention services. The follow-up clinic would provide developmental evaluations to identify the common delays that occur with this population, provide the resources, and make referrals to various services that will improve quality of life and function for these infants. This would promote preventative care for this population and meet their need to fill the developmental gap that is often seen. Overall Learning Throughout the DCE at IU Health North, learning and growth occurred daily. This occurred through observational experiences, the completion of the project, development of the paper, and communications with individuals of varying disciplines. I observed the NICU from admission to discharge through the lens of multiple disciplines to better understand the experience of the infants and their families. I documented the discharge process to understand all of the aspects that occur currently and how it would be affected if a follow-up clinic was opened. Additionally, I observed the evaluations and treatments of infants who were discharged from the THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 29 NICU but were not seen for therapies or followed after discharge in an outpatient setting. These observations allowed me to look at the current process and determine if it was meeting the needs of the population being served at IU Health North. Interviews and meetings occurred frequently throughout this project to communicate with the various members of the team at IU Health North to meet the needs of the various disciplines and ensure the program proposal addressed those needs. The project was completed in written format with multiple resources attached to provide a comprehensive report that was presented to the staff at IU Health North. I was able to learn and grow from this experience both as a practitioner and a professional. I learned about a specialty area that we typically do not go into a lot of depth about in the classroom and the roles of various healthcare professions, not just the occupational therapist. I was able to conduct a formal needs assessment and collected data to develop a program development plan that would benefit many families that are served at IU Health North. I learned how to write a paper independently that was evidence-based and created something that would be valuable. I learned how to write a comprehensive program development plan that was required for a follow-up clinic to start. I learned more about the billing and reimbursement process and the information required for a new program to begin at a hospital. For my future practice, this experience has given me the tools and experience to develop a sustainable and realistic program that promotes occupational therapy interventions. This experience has also allowed me to understand non-traditional areas of practice and the specialty skills involved with providing services. I now have a greater understanding of the roles of other disciplines through experiences working with them and advocating for their services. The interdisciplinary members of IU Health North taught me a lot about teamwork and leadership. I was able to participate in rounds where members of the team discussed patient care THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 30 and programming weekly. I interviewed various individuals throughout this process to make sure that the program development plan advocated for the needs of all of the disciplines involved with this population. I had the opportunity to observe the other disciplines practice with the infant population that was targeted to obtain a holistic picture of the development. I learned a lot about leadership as I was offered opportunities with other team members to participate in projects and advocacy for the NICU. My interactions with the team members developed initiative, interpersonal communication and self-drive throughout the entire process. I demonstrated the five leadership qualities described in the implementation phase of this project for the entire duration that I was at IU Health North. Additionally, I demonstrated leadership as the individual who researched and developed the follow-up program to create the comprehensive plan that was proposed to IU Health North. I completed this project with passion and energy to better serve and improve the quality of life in the families that leave the NICU. Advocacy was required throughout the project. To gain the support for the development of a follow-up clinic, I found evidence and data that supported the plan. I proposed this plan to various members of the team to advocate for the needs of the infants and their families who discharge from the NICU. Additionally, I advocated for all of the disciplines that would participate in the follow-up clinic. As an occupational therapy student, it was clear the role that occupational therapy could play, therefore making advocacy an easy component to implement. I was able to research, observe and discuss with physical therapy, speech therapy and social work to create a role for them in the clinic and advocate for their place as well. Growth occurred every day throughout this experience both for myself as an individual and for the IU Health North team. For myself, I was able to use leadership opportunities and experiences that will make me a better occupational therapy practitioner and team member. I was THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 31 able to create a comprehensive program that will increase the opportunities offered to the families that leave the NICU. The services that are offered to these families will expand as will the roles of the interdisciplinary team. This experience makes me feel like I contributed something meaningful and important to a large population of people and as an individual, I will take away more than I could have ever anticipated. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 32 References American Academy of Pediatrics. (2004). Follow-up care of high-risk infants. Pediatrics, 114(5), 1377-1397. Ballantyne, M., Stevens, B., Guttmann, A., Willan, A.R., & Rosenbaum, P. (2012). Maternal and infant predictors of attendance at neonatal follow-up programmes. Child: Care Health and Development, 40(2), 250-258. Bayley, N. (2006). Bayley scales of infant and toddler development: Administration manual (3rd ed.). San Antonio, TX: Harcourt Assessment, Inc. Bayley, N. (2006). Bayley scales of infant and toddler development: Technical manual (3rd ed.). San Antonio, TX: Harcourt Assessment, Inc. Bockli, K., Andrews, B., Pellerite, M., & Meadow, W. (2014). Trends and challenges in United States neonatal intensive care units follow-up clinics. Journal of Perinatology, 34, 71-74. Bos, A.F. (2013). Bayley-II or Bayley-III: What do the scores tell us? Developmental Medicine & Child Neurology, 55(11), 978-979. Case-Smith, J., & OBrien, J.C. (2015). Occupational therapy for children and adolescents (7th ed.). St. Louis, MO: Elsevier Inc. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Cronin, A., & Mandich, M. (2016). Human development and performance: Throughout the life span (2nd ed.). Boston, MA: Cengage Learning. Crozier, S. C., Goodson, J. Z., Mackay, M. L., Synnes, A. R., Grunau, R. E., Miller, S. P., & Zwicker, J. G. (2016). Sensory processing patterns in children born very preterm. American Journal of Occupational Therapy, 70(1), 1-7. Greene, M. & Patra, K. (2016). Part C early intervention utilization in preterm infants: THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 33 Opportunity for referral from a NICU follow-up clinic. Research in Developmental Disabilities, 53-54, 287-295. Greene, M.M., Patra, K., Nelson, M.N., & Silvestri, J.M. (2012). Evaluating preterm infants with the Bayley-III: Patterns and correlates of development. Developmental Disabilities, 33,1948-1956. Harmon, S.L. Conaway, M., Sinkin, R.A., & Blackman, J.A. (2013). Factors associated with neonatal intensive care follow-up appointment compliance. Clinical Pediatrics, 52(5), 389-396. Jacobs, K. & McCormack, G.L. (2011). The occupational therapy manager (5th ed.). Bethesda, MD: American Occupational Therapy Association, Inc. Kuppala, V.S., Tabangin, M., Haberman, B., Steichen, J., & Yolton, K. (2012). Current state of high-risk infant follow-up care in the United States: Results of a national survey of academic follow-up programs. Journal of Perinatology, 32, 293-298. Lipner, H.S., & Huron, R.F. (2018). Developmental and interprofessional care of the preterm infant: Neonatal intensive care unit through high-risk infant follow-up. Pediatric Clinics Of North America, 65, 135-141. Logan, B.A., Brown, M.S., & Hayes, M.J. (2013). Neonatal abstinence syndrome: Treatment and pediatric outcomes. Clinical Obstetrics and Gynecology, 56(1), 186-192. Nwabara, O., Rogers, C., Inder, T., & Pineda, R. (2016). Early therapy services following neonatal intensive care unit discharge. Physical & Occupational Therapy in Pediatrics, 1-11. Pearson Education, Inc. (2008). Bayley-III technical report 2: Factors contributing to differences between Bayley-III and BSID-II scores. Retrieved from: THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 34 https://images.pearsonclinical.com/images/Assets/Bayley-III/BayleyIII_TechReport2.pdf Rath, T. (2007). StrengthsFinder 2.0. New York, NY: Gallup Press. Scaffa, M.E. & Reitz, S.M. (2014). Occupational therapy in community-based practice settings (2nd ed.). Philadelphia, PA: F.A. Davis Company. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC Appendix A 1. What is the basic process of your follow-up clinic? 2. What services are provided through the follow-up clinic? 3. How was this program started and when did it start? 4. Who is on your follow-up team and what are the roles of these people involved? 5. How does reimbursement work for services? 6. What is the frequency of your clinic and what ages do you see the infants? 7. Who attends follow-up clinic? 8. Does a physician need to staff the clinic? If so, what does their participation need to be? 9. What are the strengths of your program? What would you change about the program if you could? 10. How many a month from your NICU do you discharge and how many follow-up at clinic? 11. How many do you see during a clinic session? 12. Do you provide services for the parents? 13. How did you sell this program to the decision makers? 14. How long did it take for the program to start? 15. How is the program funded? 16. How does documentation occur? 17. What assessment do you use and why? Who administers it? 18. How do you evaluate your program? 19. What are the days and times your clinic is open and where is it located? 20. How does the discharge process work from the NICU and from clinic? 35 THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 36 Appendix B Program Development Plan-NICU Follow-Up Clinic 1. Background and Trends of the Service Sector a. Nature of the Service Sector i. The current process of NICU discharge from IU Health North includes the required parent education by nursing with the provision of resources and appointments at that time. If therapies were involved, they also provide parent education and may make referrals for First Steps (early intervention) or outpatient therapies. If child was determined high risk during their stay and met the requirements, they may receive referral to Developmental Pediatric Clinic at Riley. After discharge, they are not followed. ii. Social Work recently noted multiple infants who received referrals for First Steps but were never contacted. First Steps has been overwhelmed and it is taking an extended amount of time before the infant is even evaluated. The infant may not be picked up for services initially, but they may need services later in their development. iii. The literature review went over the development of NICU infants, early intervention, and current follow-up programs to identify the evidence that supports the need and value of a follow-up clinic. iv. Data were collected from follow-up clinics from all over the country and were used to make recommendations for the program proposal. The data THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 37 collection provided information on existing programs that serve the population that would be targeted. b. Problem Statement i. The neonatal intensive care unit (NICU) at Indiana University North Hospital (IU Health North) provides interdisciplinary services to infants and their families who require specialized care after birth. One long-term goal of this team was to create a follow-up clinic for infants and their families after they are discharged to make sure that no infant falls through the gaps of the healthcare system. When the infants from the NICU are discharged, they typically are not seen again or followed by the hospital to ensure they are receiving the services they need to thrive and develop along with their peers. ii. The mission of IU Health is, We are guided by the vision that we will lead the transformation of healthcare through quality, innovation and education, and make Indiana one of the nations healthiest states. This mission is not fully meeting its potential for this population. Infants who discharge from the NICU in other facilities locally are being followed and are receiving services to ensure they are healthy and developmentally appropriate. If IU Health North started the follow-up clinic, they would be able to take that leadership role providing quality services for these infants and their families through a unique and innovative program that improves their quality of life. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 38 iii. A needs assessment was conducted with the various disciplines (occupational therapy, physical therapy, speech therapy, neonatology, nursing, social work, and management) of the staff at IU Health North to identify specific needs that need to be addressed through this program and the roles they believe individuals could play to improve the quality of life in infants who are discharged from the NICU. iv. Topics and questions that were identified by NICU and rehabilitation staff that would need to be answered included; services provided by follow-up clinic, staffing and roles, space in facility, reimbursement, cost and equipment, evaluation tools used, documentation, frequency of clinic, and requirements for referral to clinic. c. Market Factors and Future Trends i. The number of infants who are discharged from the NICU are increasing as outcomes are improving with technology and care. This will increase the amount of infants who survive and will need to be followed during their early development. This could also increase the number of infants who will be referred for outpatient services in the hospital. 2. Services a. Description of Services i. The follow-up clinic will provide developmental evaluations, parent education and resources, feeding assessments, and appropriate referrals for specialty services to the infants seen after discharge. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 39 ii. Infants who received therapy services in the NICU or those that were identified to be followed, will receive a referral from the neonatologist at discharge along with a scheduled appointment for their two months corrected age. iii. Infants will be seen at 2 months, 14 months and 20 months corrected age and clinic will occur one time a month. Each appointment will last approximately one hour. A breakdown of the recommended schedule is included as an attachment to the proposal. There will be approximately 7-8 appointments a clinic day. iv. At two months, the appointment will include the social worker, dietitian, occupational therapy, physical therapy, and speech therapy. All other appointments will include occupational, physical and speech therapy. The roles of the staff will be further addressed later in this proposal plan. v. The standardized developmental tool that is recommended to administer is the Bayley Scales of infant and Toddler Development-III and information regarding cost and training are discussed later. Evidence that supports the use of this tool is in the literature review and evaluation portions of the student report. vi. Documentation will be completed on a template used by all disciplines and the report will be given to the parents and primary care provider. An example of the template is attached to the proposal. vii. The recommendation for start date is to start scheduling appointments when the Bayley-III is purchased and received at IU Health North. This THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 40 will give therapists two months to train on it prior to the first scheduled appointment. b. Unique Program Services or Features i. The infants will be seen in the same hospital they were discharged from. ii. The infants will receive comprehensive evaluations by an interdisciplinary team all in one appointment. iii. They could be seen by the same therapists who treated them in the NICU or if they are referred to outpatient services, they could be seen by the therapist who will follow them. iv. If they were not picked up by First Steps, they can be followed regularly to make sure they do not fall behind their peers developmentally. They can be seen and evaluated prior to First Steps evaluation if the process is delayed. v. Parents can receive resources and education that will assist them between appointments. 3. Market Analysis a. Target Market and Analysis i. The initial goal of the follow-up clinic is to see between 7-8 infants a month. With the inclusion of all infants that were followed by therapy services in the NICU, assuming approximately 12-15 infants a month, that will ensure the schedule is full for follow-up clinic each month. This has the potential to grow to more than once a month as the appointments evolve later in the first year. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 41 ii. The follow-up clinic will be at IU Health North and it is assumed that it is closer to the families residences and other doctors offices that may be following the infants. b. Competitors: Comparing Strengths and Weaknesses i. Locally, other hospitals have follow-up programs and if IU Health North develops this program, they will not be a threat due to referrals occurring at discharge within the hospital network. ii. Data were collected from hospitals locally and outside of the state to provide a framework for the development of this follow-up clinic considering both the strengths and weaknesses they have. iii. Strengths that local programs demonstrated were the limited amount of space that they needed to have clinic at their site and that feeding assessments and interventions were provided. iv. Weaknesses of the local programs were the need to improve times of administration of the standardized assessment, two of the clinics only had two therapy disciplines, and one clinic did not follow the infants regularly after their first appointment. 4. Marketing a. Promotion i. Promotion will occur starting during the discharge process in the NICU. Parents will be educated on the purpose of the follow-up clinic, the benefits of attending, and the roles of the team members that provide services to promote compliance and attendance. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 42 b. Marketing Strategy i. The follow-up clinic can serve as a marketing strategy for the outpatient therapy clinic at IU Health North if the infant is appropriate. It can be marketed to the family as they are discharged from the NICU. There also is the potential to market to primary care physicians if they believe a child is appropriate. 5. Management and Ownership a. Key Players Qualifications and Experience i. Neonatal and Nursing staff will provide the referral, education and appointment information during the discharge process prior to leaving the NICU. ii. Outpatient office coordinators will assist with pre-authorization for insurance and appointment reminders to help with compliance and reimbursement. 6. Staffing a. Staffing Patterns i. Social Work: The role of this individual will be to participate in the twomonth appointment and provide resources to the parents based on their needs. This will allow for the parents to get home and settled to identify needs they may have. ii. Dietary: The role of this individual will be to participate in the two-month appointment and discuss feeding with the parents and provide consultative services. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 43 iii. Speech Therapy: The role of this individual will be different based on the age of the infant. At the two-month appointment they will participate with dietary in the feeding assessment. They will also complete the receptive and expressive language sections of the Bayley-III during all three appointments. iv. Occupational Therapy: The role of this individual will be to complete the fine motor and cognitive portions of the Bayley-III with the infant at all ages. The two-month appointment will be done with physical therapy and the 8- and 14-month appointments will be in conjunction with speech therapy. v. Physical Therapy: The role of this individual will be to complete the gross motor portion of the Bayley-III with the infant at all ages. At the twomonth appointment, it will be in conjunction with occupational therapy, in and the remainder of appointments will be completed independently. vi. All of the staff members will complete documentation on the template with the results of the Bayley sections and their assessment and plan for their discipline. b. Staff Training i. Staff training will be minimal for social work and dietary as they will be in more of a consultative role for the two-month appointment. ii. Therapies will have to be trained in the administration of the Bayley-III and documentation. They will otherwise have little training. 7. Finances THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 44 a. Funding Requests/Investments i. Funding that would be required would be for the Bayley-III and all of the record forms to replace. The comprehensive kit is $1248.00 and includes 25 forms to start. Packages of 25 for the forms are $134.70. All other equipment needs are already available in the outpatient clinic. A more detailed reference sheet will be provided with the proposal. b. Assumptions i. Reimbursement will occur with evaluation codes for all therapy disciplines. 8. Facilities a. Location i. IU Health North Outpatient Rehabilitation in a therapy room. b. Building and Space Requirements i. It would only need to be a small room for the majority of the appointment and an area with a mat for the gross motor portions at the 8- and 14-month appointments. c. Equipment and Supplies i. The Bayley-III kit will have all of the equipment required to perform the assessment. ii. An open crib or mat table could be used for the two-month appointment and a table will be needed for the 8- and 14-month appointment. iii. A mat will be needed for the gross motor portion of the assessment. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 45 iv. Social Work and Dietary may require handouts for their portion of the appointment. 9. Program Evaluation a. A doctoral candidate in the occupational therapy program could complete the program evaluation in the future. b. The first component could include data collection that could look over appointment compliance, results and referrals, documentation, and other continuous quality improvement items. c. The second component could be related to billing and reimbursement, examining the financial side of the follow-up clinic. 10. Risks a. Having available space for the follow-up clinic long term. b. Assuming services will be reimbursed for the evaluations of therapy services. c. Completing a three-discipline evaluation in an hour with ease and documentation. THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 46 Appendix C Childrens Hospital and Medical Center Omaha: https://www.childrensomaha.org/nicu-followup-clinic2 Childrens Hospital at Vanderbilt: http://www.childrenshospital.vanderbilt.org/services.php?mid=2085 Childrens Hospital of Philadelphia: http://www.chop.edu/centers-programs/neonatal-followprogram Childrens Hospital of Pittsburgh: http://www.chp.edu/our-services/newborn-medicine/neonatalfollow-up-clinics Childrens Hospital of Richmond at VCU: https://www.chrichmond.org/Services/Cardiology.htm Cincinnati Childrens Hospital: https://www.cincinnatichildrens.org/service/n/nicu-follow-up Cleveland Clinic: https://my.clevelandclinic.org/pediatrics/departments/nicu-follow-up Cone Health: https://www.conehealth.com/services/pregnancy-and-childbirth/nicu/follow-upclinics/ Connecticut Childrens Medical Center: https://www.connecticutchildrens.org/searchspecialties/neonatology/neonatology-programs-services/neonatal-neurodevelopmental-followup-program/ Golisano Childrens Hospital: https://www.urmc.rochester.edu/childrenshospital/neonatology/follow-up.aspx Gundersen Health System: http://www.gundersenhealth.org/services/pediatric-care/neonatalfollow-up/ Eastern Carolina University: http://intranet.ecu.edu/cs-dhs/neonatology/followup.cfm THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 47 Kalispell Regional Healthcare: https://www.krh.org/krhc/services/neonatal-intensive-careunit/follow-up-clinic Lurie Childrens Hospital: https://www.luriechildrens.org/en-us/care-services/specialtiesservices/neonatology/programs/Pages/neonatal-and-cardiac-intensive-care-follow-up-clinic.aspx Lutheran Health Network: http://www.lutheranchildrenshosp.com/interior.php?t=93 Mayo Clinic: https://www.mayoclinic.org/departments-centers/childrenscenter/overview/specialty-groups/newborn-intensive-care-unit-follow-up-clinic Mercy Health: https://mercyhealthsystem.org/parents-guide-nicu/nicu-follow-clinic/ Nationwide Childrens: https://www.nationwidechildrens.org/nicu-followup-clinic-visits Peyton Manning Childrens Hospital: http://www.peytonmanningch.org/medical-genetics-neurodevelopment/ Riley Childrens Hospital: https://www.rileychildrens.org/departments/developmental-pediatrics Rush University Childrens Hospital: https://www.rush.edu/kids/services-conditions/neonatalintensive-care-unit/follow-care-nicu Wake Forest School of Medicine: http://www.wakehealth.edu/School/Neonatal-and-PerinatalMedicine/Neo-Assets/NICU-Follow-Up-Clinic---Amos.htm Sacred Heart Childrens Hospital: https://washington.providence.org/hospitals/sacred-heartchildrens-hospital/services/neonatal-intensive-care/neonatal-developmental-follow-up-clinic/ San Antonio Regional Hospital: https://www.sarh.org/our_services/healthy_beginnings/maternity_services/nicu_followup_clinic/ Saint Joseph Health System: http://www.sjmed.com/nicu-follow-up-clinic THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC St. Louis Childrens Hospital: http://www.stlouischildrens.org/women-and-infants/newbornmedicine University of Kentucky HealthCare: https://ukhealthcare.uky.edu/kentucky-childrenshospital/services/neonatal-intensive-care-unit 48 THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 49 Appendix D Two Month Appointment Example: 8:00-8:15: Dietary & Speech Therapy perform feeding evaluation and consultation (OT & PT frontload templates for the documentation with history and the Bayley-III). 8:15-8:50: Occupational Therapy and Physical Therapy perform the fine motor, cognitive and gross motor portions of the Bayley-III (Speech Therapy observes for language and documents during this time). 8:50-9:00: Score the Bayley-III and provide parents with results and recommendations. 9:00-9:15: Dietary & Speech Therapy perform feeding evaluation and consultation (OT & PT document from previous appointment). Cycle through 8 & 14 Month Appointment Example 8:00-8:30: Occupational Therapy administers the fine motor and cognitive portions of the Bayley-III while the Speech Therapist completes the language portions. 8:30-8:50: Physical Therapy administers the gross motor portion of the Bayley-III. (OT and ST score their sections and complete documentation.) 8:50-9:00: Finish scoring the Bayley-III and provide parents with results and recommendations. 9:00-9:30: OT and SLP administer Bayley-III. (PT completes documentation). THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 50 Appendix E NICU FOLLOW-UP EVALUATION FORM Name: Onset Rehab Dx: Parents: PATIENT STICKER Click here to enter a date. Date of Total Click here to enter a date. Evaluation: Time: The following evaluation was completed with parent/patient interview, interaction, and observation. Standardized testing: Bayley-III (see attachment summary) Contraindications/Precautions: Patient Information and History: Gestational Age: Medical Hx. Social Hx. Prior Therapies: Chronological Age: Adjusted Age: Parent/Caregiver Goals and Concerns: Subjective Information: Social Work: Dietary: Results of the Bayley-III: Subscale: Gross Motor Fine Motor Cognitive Expressive Language Receptive Language Adjusted Age: Speech Therapy Assessment: Score: Developmental Age: THE DEVELOPMENT OF A NICU FOLLOW-UP CLINIC 51 Occupational Therapy Assessment: PATIENT STICKER Physical Therapy Assessment: Education/Resources for Parents: RECOMMENDATIONS: PLAN: Social work signature: _________________________________ Dietitian signature: _________________________________ Therapist signature: _________________________________ Therapist signature: _________________________________ Therapist signature: _________________________________ PHYSICIAN CERTIFICATION: From:Click Click here to enter a date. here to enter a date. To:Click here to enter a date. __________________________________________ Physician Signature (stamped signature not acceptable) Please sign and fax back to 317-688-2670 Date: Date: Date: Date: Date: ___________ Date Phone: 317-688-2021  ...

... Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study The Application of Shaping Techniques with Lower Extremity Exercises for Community Dwelling Adults with Chronic Stroke: A Feasibility Study Beth Gustafson, PT, MSEd gustafso006@gannon.edu University of Indianapolis Word count: 16,999 1 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 2 TABLE OF CONTENTS Purpose.......................................................................................................................................................... 7 Hypotheses .................................................................................................................................................... 8 Literature Review.......................................................................................................................................... 9 Impairments, Limitations, and Restrictions Following Stroke ................................................................. 9 Common Lower Extremity Impairments ................................................................................................ 11 Gait Remediation Following Stroke ....................................................................................................... 13 Constraint-Induced Movement Therapy ................................................................................................. 16 Constraint-Induced Movement Therapy: The Upper Extremity Protocol .............................................. 18 Constraint-Induced Movement Therapy Upper Extremity: The Evidence ............................................. 22 Constraint-Induced Movement Therapy Applied to the Lower Extremity ............................................. 27 Method ........................................................................................................................................................ 30 Study Design ........................................................................................................................................... 30 Participants.............................................................................................................................................. 31 Inclusion Criteria ................................................................................................................................ 31 Exclusion criteria ................................................................................................................................ 32 Instruments.............................................................................................................................................. 32 Primary hypothesis: feasibility............................................................................................................ 33 Secondary hypotheses: treatment effect .............................................................................................. 35 Procedures ............................................................................................................................................... 38 Recruitment. ........................................................................................................................................ 38 Eligibility determination. .................................................................................................................... 38 Orientation and informed consent. ...................................................................................................... 38 Testing................................................................................................................................................. 39 Intervention. ........................................................................................................................................ 41 Data Storage ............................................................................................................................................ 47 Data Analysis .......................................................................................................................................... 47 Results ......................................................................................................................................................... 48 Primary Hypothesis: Feasibility .............................................................................................................. 49 Secondary Hypothesis: Treatment Effect ............................................................................................... 52 Discussion ................................................................................................................................................... 53 Primary Hypothesis................................................................................................................................. 53 Secondary Hypothesis ............................................................................................................................. 57 Shaping ................................................................................................................................................... 59 Clinical Relevance .................................................................................................................................. 62 Limitations .............................................................................................................................................. 62 Conclusion .............................................................................................................................................. 64 References ................................................................................................................................................... 65 Table 1. Participant General Characteristics ............................................................................................... 74 Table 2. Primary Hypothesis: Feasibility Benchmarks and Outcomes ....................................................... 75 Table 3. Continuous Variables: Measures of Central Tendency................................................................. 76 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 3 Appendix A: Fugl-Meyer Motor Function Lower Extremity .................................................................. 78 Appendix B: Five Times Sit to Stand ......................................................................................................... 79 Appendix C: Functional Gait Assessment .................................................................................................. 80 Appendix D: Activities Specific Balance Confidence Scale ...................................................................... 82 Appendix E: Participant: Eligibility and General Information Form.......................................................... 83 Appendix F: Demographics ........................................................................................................................ 84 Appendix G: Test Tracking ........................................................................................................................ 87 Appendix H: Intervention Log Sheet .......................................................................................................... 88 Appendix I: Trial Tracking ......................................................................................................................... 89 Appendix J: Study Flyer ............................................................................................................................. 90 Appendix K: Initial Contact Script ............................................................................................................. 91 Appendix L: Informed Consent .................................................................................................................. 92 Appendix M: Medical Release Form .......................................................................................................... 94 Appendix N: Table of Contents for Bank of Exercises............................................................................... 95 Appendix O: Study Personnel Training ...................................................................................................... 96 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 4 Dedication To individuals and their loved ones everywhere who are living with the effects of stroke. Acknowledgements My Committee My heartfelt thank you to my committee chair, Dr. Stephanie Combs-Miller. Thank you for your patience, encouragement and guidance. Dr. Elizabeth Moore, your keen eye, attention to detail, and thoughtful questions were always appreciated. Dr. Stephanie Kelly, thank you for adding in your expertise and helpful suggestions. Gannon University Doctor of Physical Therapy Students The original team Thank you to Christina Estes, Brenna Feeney and Heather Roberts for being a sounding board for the original design, process, and implementation. You helped set the tone for all the good that followed! The subsequent teams Thank you to Michael Groesch for your interest in data analysis and initial thoughts on interpretation. Thank you to each of the following and all Gannon students named above for their interest, dedication and support during implementation of this project: Joseph McNally, Meghan Mieczkowski, Mark Tattersall, Janelle Therasse, and James Zorich. Gannon University Colleagues Thank you for your support and encouragement through this process. My Family Thank you for your patience with and support of me during completion of this huge endeavor. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 5 Abstract Introduction: The purpose of this study was to investigate the feasibility and effects of applying the principles of shaping to part-task, pre-gait activities in persons with chronic stroke. It was hypothesized that this would be feasible and would result in positive treatment effects. Method: Eleven participants completed this prospective, repeated measures study (6 male; mean age 61.18 10.41years; median months post stroke18.00 IQR 10.00; 7 left hemiparesis). The intervention was administered five times a week for two consecutive weeks for 60-minute sessions; each exercise performed for ten 30-second trials. Exercises addressed common gait impairments for individuals with chronic stroke. Verbal praise and informing participants of repetitions contributed to shaping. Outcomes assessed at baseline, post and retention were Five Times Sit to Stand (5xSTS), Functional Gait Assessment (FGA), Activities Specific Balance Confidence Scale, and gait symmetry for step length, swing time, stance time and velocity measured on an electronic walkway. Results: The group of participants met pre-determined benchmarks for feasibility: intervention completion rate (100%), safety (0 falls, 0 emergency calls), tolerance (90% tolerated 30 second trials), 15% increase in repetitions (100%) and personnel (100% required two or less helpers). There was an increase in mean repetitions per session from 594 during days 1-3 to 1026 on the final day of intervention (P=.003). Only the 5xSTS and the FGA showed statistically significant improvements over time (P<.01). Discussion: The study protocol was feasible and safe to implement for this sample. The protocol yields a high number of repetitions in a short, intense time with a positive treatment effect for functional measures of lower extremity strength and gait activity. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 6 The Application of Shaping Techniques with Lower Extremity Exercises for Community Dwelling Adults with Chronic Stroke: A Feasibility Study Cerebral vascular accident or stroke is a leading cause of serious long-term disability affecting an estimated 6.6 million adults in the United States aged 20 years and older.1 Stroke takes a toll on the individual, on the family, and on society. The acute onset of stroke is followed by varying degrees of recovery; however, despite this recovery many individuals are left with impairments in cognition, speech, memory, higher order thinking skills, and limb use. Impairments contribute to activity limitations, such as inability to mobilize and/or perform activities of daily living (ADLs). Loss of autonomy effects ones role in life.2,3 The dynamic relationship between spouses, between parents and children, and between employer and employee4 may be impacted, contributing to participation restrictions. Rising healthcare costs, loss of productivity, and limited engagement in vocational and avocational endeavors impact the individual, the family and society at the local, state and national levels.5 Therapist-directed and insurance-financed rehabilitation is traditionally more comprehensive and frequent in the first few months following stroke.5As improvements slow down, rehabilitation often concludes, leaving individuals living with chronic effects of stroke (six months and longer post-stroke) and believing that most gains have been experienced. Individuals learn to compensate for deficits with increased use of the less-affected limb which reinforces limited use or learned non-use of the limbs affected by stroke. Evidence supports that gains can be made post stroke, even when an individual is living with the chronic sequelae.5-12 It is increasingly clear that intensity in practice is important for driving change.5,13,14 Systematic reviews6-8 and published guidelines for management following stroke5 do not yield conclusive evidence regarding the specific dosing needed to bring lasting change, especially in lower Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 7 extremity (LE) function, gait and gait-related activity.5,14 Lack of any commonly used protocol contributes to the challenge of identifying dosing parameters for LE and gait intervention.15 Constraint-induced movement therapy (CIMT) utilizes a protocol for dosing and type of practice, developed through bench and clinical research to address learned non-use of the upper extremity (UE) following stroke. The protocol has been found to yield improvements, even when initiated years post stroke.9,15-19 Repetitive, task-oriented training is one component of the protocol and includes two sub-components, shaping and task practice. Shaping is specifically applied to part-task exercises or activities, while task practice is applied to whole-task activities. The UE CIMT protocol has been applied in various modified versions, including protocols that address the LE and gait activity.10-11 In LE studies reviewed, there was more emphasis on task practice, even when part-task exercise was employed. There is evidence that shaping component, applied to part-task UE exercise, is the most effective means to maximize motor capacity15 but shaping has not been adequately studied in LE studies. Purpose The primary purpose of this study was to investigate the feasibility of applying the principles of shaping to LE part-task, pre-gait activities, for individuals with chronic stroke who lived in the community and continued to experience mobility limitations. The secondary purpose was to investigate the treatment effect across all levels of the International Classification of Functioning, Disability and Health (ICF). Results from this study may help establish the feasibility of conducting a larger scale study and would add to the body of knowledge examining application of the principles of CIMT to the LE. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 8 Hypotheses Primary hypothesis. It will be feasible to apply principles of shaping to part-task pregait exercises. To test this hypothesis, the following objectives were addressed. a. To establish the feasibility of the study process as measured through intervention completion and intervention attendance rates. b. To determine safety of the study protocol as measured by falls and emergency medical calls. The study protocol will be considered safe if zero fall and medical calls are identified. c. To assess the tolerability of the dosing used in the study protocol will be tolerable for planned dosing (ten 30-second trials for each exercise) d. To establish if participants in the study yield an increase in repetitions performed over the course of the 10 treatment sessions. e. To determine if management of the intervention protocol is feasible as measured through number of study personnel required per participant during intervention periods (maximum two) and ease of consistently applying positive reinforcement (observation/field notes) during the exercise bouts. f. To determine if the allocated resources of physical space and exercise equipment are sufficient to carry out the study plan. Secondary hypotheses. There will be positive treatment effect across all levels described in the ICF. To test this hypothesis, the following objectives were addressed. a. To determine if LE motor function as measured on Five Times Sit to Stand test improves after intervention; Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 9 b. To determine if gait activity as measured on the Functional Gait Assessment and electronic walkway (gait velocity; step length symmetry, stance time symmetry, swing time symmetry) improves over time from pre-intervention to post-intervention; c. To determine if participation as measured on the Activity Specific Balance Confidence Scale total score improves over time from pre-intervention to post-intervention. Literature Review Cerebral vascular accident or stroke occurs when there is a sudden interruption in blood supply to brain tissue from an ischemic or hemorrhagic event that results in neuronal cell death.20 Stroke is a leading cause of serious long-term disability of adults in the United States. The American Heart Association1 reported an estimated 6.6 million Americans aged 20 years and older have had a stroke with an estimated prevalence of 2.6% (2009 to 2012) and incidence of approximately 795,000 (610,000 new onset and 185,000 recurrent). The 2011 direct and indirect cost of stroke was $33.6 billion. The mean individual expense per patient for direct care in 2011 was estimated at $4692. The cost of direct care is projected to triple between 2012 and 2030 with an associated projected cost of $71.6 billion to $184.1 billion. Between 2001 and 2005, the average cost for outpatient rehabilitation services the first year after discharge from inpatient services was $11,145 (medication: $3376; rehabilitation $7418).1 Identifying the most efficacious interventions is imperative to managing the burden of stroke on the individual, the family and society. Impairments, Limitations, and Restrictions Following Stroke The World Health Organization, (WHO) using the ICF, categorizes sequalea from illness and injury into three primary domains: impairments in body functions and structure (i.e. limited tissue flexibility), limitations in activity performance (i.e. standing, walking, driving) and Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 10 restriction in participation of life roles (i.e. family leadership and work). Stroke leads to longterm constraints in all domains.2,4,21 Individuals post stroke experience challenges in moving the limbs (impaired body functions and structure), walking, completing household chores, using public transportation, driving, working, shopping, and socializing (activity limitations and participation restrictions).4,6-8,21 Recovery from stroke occurs most rapidly in the initial weeks post onset with the most measurable recovery occurring within the first three months, generally considered the acute phase.2,5,20 As the individual improves during the early phases post stroke, he or she often learns to compensate for deficits in limb function by relying heavily on the less affected limb/limbs. Neglect of the affected limbs and compensation with the less affected limbs may further retard recovery of function.15 During the sub-acute phase three to six months post stroke the individual continues to experience improvement in function but at a declining pace and with a declining impact. At six months post stroke, the condition is considered chronic.2,6-7 In the chronic phase of stroke, continued mobility impairment and inactivity further limit return to maximal function and full participation in life roles.6,22 Individuals with continued impairments and inactivity are dissatisfied with performance related to cognition, outdoor activities, work/housekeeping, mobility, indoor leisure activities, and self-care.4 Impaired ability to move the limbs in a smooth, coordinated fashion contributes to depression, decreased life satisfaction, and difficulty mobilizing in the home and community.2,8,21 Post stroke, individuals can experience limitations with prolonged standing, stepping, turning, walking, lifting, and/or carrying items while walking, leading to restricted participation in life roles.4,21,23-27 Life satisfaction post stroke is related to physical and cognitive independence, fatigue and mood.2,4,21 Depressive status is more likely to increase with chronic stroke.2 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 11 Common Lower Extremity Impairments A closer look at common gait abnormalities may help define intervention goals to remediate gait and mobility disability. If LE impairments and gait can be improved, activity, participation, and life satisfaction may improve as well. To move freely within the environment, the ambulatory person needs to respond to anticipated and unanticipated demands by altering limb movement, the direction of propulsion, and speed while maintaining a stable trunk and upright posture against gravity.8,23,28 Efficient speed and tolerance for various distances are also needed.27 Gait abnormalities from stroke impair the individuals ability to respond quickly and efficiently to environmental challenges, decrease speed and distance tolerance, therefore, impacting ambulation in the community.4,8,21,23 Gait can be objectively evaluated by examining temporal, spatial and kinematic parameters.23,25-26,29 Temporal measures of gait quantify time to complete components of the gait cycle such as swing and stance time, single and double support time and gait velocity. Spatial measures of gait reflect distance associated with components of the gait cycle such as step and stride length and step width. Kinematic measures of gait quantify joint position during movement. The ambulatory individual must be able to effectively manipulate variables within these parameters in order to adapt to changing environmental and task demands encountered during mobility in the community.8,23,25-27,30 Gait impairments are often evident post stroke in the form of asymmetry in spatial and temporal parameters.23,25-26,29 Individuals with stroke may present with asymmetry in stride length, step length, and step width; asymmetry often increases as the condition becomes chronic.25 Poor motor recovery (Brunnstroms Motor Recovery Stage for the LE stage III), and slow walking velocity (< .34 m/s) are also associated greater gait asymmetry.26 Asymmetry may Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 12 contribute to difficulty with obstacle avoidance even in individuals who are relatively high functioning post stroke.29 Subjectively, survivors of stroke relate impaired ability to move the lower limb to limited mobility in the community.2,21 Improvements in gait asymmetries may lead to improved walking ability.8 Gait velocity, a temporal measure of walking, is considerably reduced after stroke compared to age-matched norms.7,23,25-26 Slower velocity is associated with greater gait asymmetry23,25 and mobility disability28,30 and has been found to be a reliable predictor of household versus community ambulators.31-32 Ambulation within the community is an integral part of adult life.22 Impaired velocity, decreased capacity for distance, and decreased ability to avoid obstacles or adapt to environmental obstacles, greatly impact community mobility.8,29-30 Shumway-Cook et al30 found that individuals with mobility disabilities, defined as needing assistance to walk .8 km or as needing assistance to climb stairs, made fewer trips are made into the community and got less done when they were out. Impaired gait velocity contributes to mobility limitations within the community and is evident post stroke. Another aspect to independent, safe, and efficient gait in the home and community is the ability to avoid unexpected obstacles and alter gait in response to changing environmental terrain.8,28-30 Obstacle avoidance, negotiation through changing terrain, and fall avoidance require dynamic stability such that one limb can fully support the body weight while a stable head, trunk, and arm orient to the changing task, driven in part by the free limb and the supporting limb. Spatial and temporal asymmetry and altered kinematic execution after stroke impair the individuals ability to make efficient adaptive responses for successful obstacle avoidance and environmental accommodation.8,29-30 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 13 Gait Remediation Following Stroke The effect of physical therapy intervention on gait post stroke has been investigated by many researchers.5-8,10-12,14,22,24,33 A search of the literature resulted in finding several reviews, Cochrane6,7,14,22 and other,5,8,12,33 and a large RCT24 which will be discussed in the following paragraph. Intervention and outcome measurement in domains of body function and structure6,14,24 and activity6,7,8,14,24 are the most commonly utilized and reported, even though the ultimate goal is to positively affect participation in life roles.14,22 Interventions investigated in the gait studies reviewed included low and high technology approaches. Some researchers investigated the impact of one type of intervention6,7,14,22,33 while others compared two or more interventions.5,8,24 Low technology interventions included OGT,6,8,24 therapist manual guidance,6 verbal cueing,6 auditory cueing with rhythmic stimulus,6,8,33 pre-gait activities such as stationary weight shifting, repetitive stepping, reaching,6 community-based gait,22 and use of an ankle foot orthosis (AFO).8 Higher technology interventions included functional electrical stimulation (FES),8 TT with7,24 or without BWS,7 and robotic assisted training overground or on a treadmill.5 Environments utilized vary from clinic6,7,14,24 to home7,14,24 to community.7,14,22 The phrase repetitive task training or repetitive task practice was used often without a consistent definition across studies. French et al14 in a Cochrane Systematic Review investigated the effects of RTT and defined RTT as an intervention where an active motor sequence was performed repetitively within a single training session, and where the practice was aimed towards a clear functional goal.14(p3) This definition allowed the inclusion of pre-gait and single task studies into the review. Pre-gait and single task studies were included as long as they Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 14 required repetitive, complex, multi-joint movements and had combined elements of intensity and functional relevance.14 Using the French et al14 definition of RTT, a critique of the study outcomes shows common RTT interventions include pre-gait, continuous OGT, TT, and community ambulation. Community ambulation had no effect compared to other gait-based interventions for improving participation, gait speed or endurance.22 Pre-gait exercises/activities showed a positive effect on lower limb function (e.g. 6MWT, sit to stand, TUG), walking distance and functional ambulation,14 but not on gait function as measured with multidimensional, ordinal measures of walking function (Rivermead Motor Assessment, Motor Assessment Scale, Stroke Rehabilitation Assessment of Movement, Barthel Index).6 When used alone, pre-gait exercises showed a trend towards a positive effect for gait speed, but when used in combination with OGT, they did not.6 Overground gait training showed a positive effect lower limb function (e.g. 6MWT, sit to stand, TUG), walking distance and functional ambulation,14 but not on gait function as measured with multidimensional, ordinal measures of walking function (Rivermead Motor Assessment, Motor Assessment Scale, Stroke Rehabilitation Assessment of Movement, Barthel Index).6 When used alone, OGT showed a trend towards a positive effect for gait speed, but when used in combination with pre-gait exercises, it did not.6 Treadmill training with7,8,12,24 or without BWS7,8 showed a positive effect for functional walking category (based on gait speed)24 and walking endurance,7,24 compared to usual care.24 Evidence for improving gait speed is conflicting with some reporting positive effects7,24 and others reporting no effect.8 The positive effects may be more beneficial if ambulatory prior to use of the TT.7 Some researchers found less effect for gait speed and walking endurance7 for Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 15 individuals with chronic stroke but others found improved cardiovascular fitness and walking function.12 Use of TT did not have an effect on level of independence in walking7 or on gait coordination measured through temporal and spatial parameters.8 In a 2016 document for the American Heart Association/American Stroke Association, endorsed by the American Academy of Physical Medicine and Rehabilitation and the American Society of Neurorehabilitation, Winstein et al5 produced Guidelines for Adult Stroke Rehabilitation and Recovery. This broad detailed guide reports the best evidence for intervention outcomes for gait remediation is found with intensive, repetitive, mobility-task training or with the use of an ankle-foot orthosis (AFO) in individuals who meet select criteria (levels of evidence, class I, level A). Group circuit training, cardiovascular exercise and strengthening interventions are reasonable approaches to improve walking (levels of evidence, class IIa, level A). Neuromuscular electric stimulation is reasonable to manage foot drop (level of evidence, class IIa, level A). Circuit training incorporates intensive, repetitive, mobility- task training.6 Several other physical therapy interventions for mobility (gait) were evaluated including treadmill training (with or without body weight support, robot-assisted), acupuncture, transcutaneous electrical nerve stimulation (TENS), rhythmic auditory cueing, electromyographic biofeedback, virtual reality, neurophysiological approaches (neurodevelopmental treatment, proprioceptive neuromuscular rehabilitation), aquatic therapy, and pharmaceutical intervention. These interventions are graded as class IIb, level A (treadmill and robotic therapy) or level B (all others) except for pharmaceutical intervention (class IIb, level C). Interventions rated at level IIb, class A are considered reasonable to include, sometimes depending upon specific patient populations post stroke. Those evaluated as class IIb, level B Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 16 have a recommendation of benefit uncertain or benefit not well established, except for virtual reality training which is recommended as may be beneficial.5 The evidence reviewed suggests that repetitive, task-oriented gait and mobility training yields positive gait outcomes for individuals living with chronic stroke. Progressive challenge and intense work appear to be important factors in driving change.5-6,8,14,24 Standardized protocols for design and dosing do not exist in the research lab or clinic.6,14 While some research protocols may yield higher levels of dosing,24 the use of progressive challenge and intense work has not necessarily become standard practice in the clinic. In a follow-up study from Lang et als34 earlier work, Kimberly et al13 found that therapists provided a mean of 37.25 ( 47.52) repetitions of active lower limb activity and 185.20 ( 130.1) steps with gait training per therapy session when either was included for patients status post stroke in an acute care and rehabilitation hospitals. The therapy sessions lasted a mean of 29.11 ( 12.14) minutes.13 In addition to lack of consistency in protocol for type and dosing, most studies relative to gait intervention do not address the impact or show effect of the intervention on the individual at the participation level.5-6,8,24 Constraint-Induced Movement Therapy In UE rehabilitation following stroke, CIMT therapy utilizes standardized protocols for participant selection and dosing.16,18,35-40 The origin for CIMT can be traced back to the 1950s to the principle work of neuroscientist Edward Taub and associates.18,37-38 Taub and others18,37-38 studied the neurophysiology of motor control and were interested in the role of sensory feedback in movement and motor learning. In his early studies with monkeys, one upper limb was deafferented. This led to complete sensory loss and a period of spinal shock in which motor responses were absent. After the spinal shock resolved, Taub and others18,37-38 observed that Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 17 although the monkeys had the ability to use the lesioned limb, they did not. The monkeys learned to compensate quite well performing all daily tasks (movement, postural adjustments, manipulation) with the three intact limbs. Taub and colleagues37-38 discovered if the intact upper limb was restrained, use of the deafferented limb would begin almost immediately. Continued use of the deafferented limb would result in increased skill. If the restraint was removed too quickly (1-2 days) the monkey would resort to neglect of the deafferented limb even though use was possible. If the restraint was maintained for a longer period (3 days or longer) use of the deafferented limb continued even after removal of the restraint. Training that utilized various food-based reinforcement techniques to encourage limb use improved use during the training sessions but did not carry over to the natural setting. Operant conditioning or shaping was then applied to part-task activities. The task was broken down into components. As the monkey successfully completed the part of the task, a reward was given. The task was gradually made more difficult; success was rewarded on a consistent and frequent basis. As the skill improved, various parts of the task were carried out for longer periods with more complex steps. This process shaped the motor response. The use of shaping techniques resulted in generalizability of use to the natural environment not seen with the restraint alone.37-38 Taub and colleagues18,37-38 theorized that the deafferentation with subsequent permanent sensory but temporary motor loss led to compensation with intact limbs which contributed to learned non-use of the deafferented limb. Intervention that restricted use of the intact limb made use of the affected limb more appealing and overcame learned non-use. As research on neuroplasticity evolved and as CIMT studies were carried out with human subjects, Taub19 and others15,17 began to recognize that cortical reorganization may be a mechanism to partially Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 18 explain the positive outcomes associated with CIMT. Increased use of the limb promoted cortical reorganization and, in turn, this cortical reorganization made use of the limb easier.15,17-19 Constraint-Induced Movement Therapy: The Upper Extremity Protocol Inclusion criteria. The inclusion criteria for participation in CIMT studies has remained largely unchanged since the intervention was initially applied to participants status post stroke.15 Participants must have some residual function in the more-affected limb. Standard inclusion criteria include: at least 20 degrees of active wrist extension and 10 degrees of active finger extension at each metacarpalangeal and interphalangeal joint, all digits.36,38 Wolf et al16,39 in a multi-center RCT found statistically significant improved outcomes for two CIMT groups, one considered high functioning (meeting common inclusion criteria above) and one low-functioning (at least 10 degrees active wrist extension, at least 10 degrees thumb abduction/extension and at least 10 degrees of extension in two other digits). Both intervention groups (high and low functioning) had statistically significant positive outcomes compared to usual care. The low functioning group had no statistically significant differences in outcomes compared to the high functioning group. Intervention elements. Morris et al15 provide a detailed description of the treatment components of the CIMT protocol in a 2006 paper. The three components are: 1) repetitive, taskoriented training, 2) adherence-enhancing behavioral strategies (also called the transfer package), and 3) constraint. The repetitive, task-oriented training is broken down into two sub-components called shaping and task practice. The shaping sub-component of repetitive, task-oriented training consists of part-task practice. Shaping is a behavioral technique. In the context of CIMT, shaping as a sub-component describes part-task practice where frequent, positive reinforcement is used to enhance motor performance. Reference is additionally made to the use of shaping as a behavioral Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 19 approach applied less frequently during task practice. Task practice, as a sub-component of repetitive, task-oriented training focuses on performance of a functional task. Positive feedback and successive challenge are also provided, although less frequently compared to the shaping sub-component. Adherence-enhancing behavioral strategies are outlined in the transfer package. This component includes multiple strategies designed to continue elements of the protocol outside the clinic, during the intervention period. The final component is the constraint. The constraint typically takes the form of a bulky mitt worn on the less-affected UE. The mitt limits the assistance that can be provided by the more functional UE and serves as a reminder not to use it.15 Repetitive, task-oriented practice: shaping. The term shaping comes from the psychology literature and studies utilizing operant conditioning.38 When part-task training is used for motor skill development, the task is broken down into parts, as described in the original research on monkeys. The parts of the task are then utilized as an exercise or activity and performed in succession, although not necessarily until the whole can be achieved.37 In CIMT, the therapist or assistant selects a part-task that the participant has the capacity to complete. Success is rewarded with praise. The part-task is then made more difficult; the participant is encouraged through praise and knowledge of results and the cycle continues.15,17-19,38,40-41 Shaping involves: a) providing immediate and very frequent feedback concerning improvements in the quality of movement, b) selecting tasks that are tailored to address the motor deficits of individual participants, c) modeling, prompting, and cuing of task performance, and Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 20 d) systematically increasing the difficulty level of the task performed in small steps when improvement is present for a period of time.41(p1) To elaborate further, an example of shaping for the UE is provided. Part of the task of picking up a block is to reach with extended fingers. In part-task training, the individual may be asked to tap a block positioned one foot away with extended fingers. As the individual reaches for the block with extended fingers, he is praised as he nears or reaches the target. The individual received both internal and external confirmation of task achievement. To increase the complexity of this task, the block may be moved further away or the individual may be challenged to increase the number of repetitions completed in a given period. Cueing (i.e. stretch your fingers) or other forms of assistance (i.e. a physical support to make reaching easier) can also be provided. If the task is too difficult, it is made easier. Success is important. As success is achieved, the goal is extended and the motor response is shaped.15,17-19,38,40 Repetitive, task-oriented practice: Task practice. While shaping is focused on parttask practice with frequent positive reinforcement, task practice focuses on performance of whole tasks.15 Positive reinforcement and purposeful task selection to ensure success remain integral to this sub-component. To extend the example from above into task practice, the individual may be instructed to pick up the cup and place the cup on a shelf, as if putting dishes away. Shaping and task practice activities do not have to be related. Additional examples for task practice included folding laundry or making a sandwich.15,17-19,38,40 Adherence-enhancing strategies: The transfer package. The transfer package is designed to assist with adherence to the protocol when out of the clinic. The transfer package is comprehensive. The elements are: behavioral contract, daily home diary, Motor Activity Log, problem solving, home skill assignment, home skill assignment after treatment, and post- Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 21 treatment telephone contact.41 The behavioral contract is signed by the participant and caregiver and is an attestation to intent to comply with all recommendations. The daily home diary is used to record daily activity completed as specified in the behavioral contract. The Motor Activity Log (MAL) is a tool by which performance of 30 common ADLs is tracked. Participants rate their ease in completing the tasks with the more-affected UE. Problem solving occurs daily as the therapist reviews the home diary and MAL. When problems are identified the therapist and participant work together to find solutions. For example, if a participant is worried about spilling his drink, the therapist might suggest filling the cup half-full. The home skill assignment requires daily task practice at home. Participants are given five easy and five more difficult ADL tasks they are to complete using the more affected limb. The home skill assignment after treatment is developed towards the end of treatment. Seven skill lists are developed for use each day of the week. The list contains three repetitive 15 30 minute tasks and seven ADLs. Post-treatment telephone calls are made weekly for one month after treatment to continue problem solving.15,41 Constraint. The most common form of constraint is the bulky mitt. However, the constraint can also include any mechanism used that promotes use of more-affected limb such as verbal cueing.15 Dosing. The protocol duration is six hours per day of therapist or assistant supervised repetitive task-oriented training, with adherence strategies employed during all outside-of-clinic time (mornings, evenings, weekend(s) and constraint of the more affected limb 90% of the waking hours. This protocol is maintained for two to three weeks, with individuals who have more severe impairments receiving three weeks.15 Intensity is managed through progressively increasing task difficulty. Shaping is dosed in ten 30-second trials for each part-task exercise or activity.15 In an online supplement to work Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 22 published in 2013, Taub et al41 describe the dosing more specifically as sets of 10 discrete 30 sec trials with 1 min rests between trials and longer rests between sets of trials as needed to reduce fatigue. Approximately twenty-five trials are given per hour41(p1) Task practice activities are performed for 15 to 20 minutes.15 The placement and cycling of shaping and task practice within the six-hour day are not specified in the literature. Rest is offered between and within the two intervention subcomponents.15 Review of the literature from researchers in Taubs lab shows reference to a large bank of tasks used for shaping and task practice, with progressions outlined.15,35-36 Only limited examples are provided in published work. The transfer package is designed to help the participant make a transition from use of the more involved UE in the clinic to use in the home (and community) environment. As detailed above, the transfer package is very extensive. Adherence to the package increases the use of the more affected extremity and is an integral part of the CIMT protocol.15,41 Constraint-Induced Movement Therapy Upper Extremity: The Evidence The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial39 was a prospective, multicenter, single-blind, RCT completed January 2001 through January 2003. Two hundred twenty-two individuals participated in the trial. The experimental group (n = 106) received CIMT and the control group (n = 116) received usual care which consisted of no care, pharmacological care or physical therapy care. Time since stroke ranged three to nine months. The experimental group was stratified into low and high functioning as described in the inclusion criteria (for the CIMT protocol) above. The study protocol included repetitive, task-oriented practice with sub-components of shaping and task practice as described above, restraint use as described above, and use of the transfer package as described above except the home skill Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 23 assignment consisted of two to three home assignments versus ten as in the original protocol. The home skill assignment after treatment was altered to encouraging 30 minutes of task practice daily after the intervention period ended. There were only minor differences in the groups at baseline (comorbidity of diabetes and performance on one component of a baseline test). Retention testing occurred at four, eight and 12 months. Seventy-six percent returned for retention testing as 12 months. The CIMT group showed larger improvements in most primary and secondary measures for quality and speed of movement and quality and amount of use of the more affected UE, at post-treatment testing (P .05). Most of these outcomes persisted at 12 months.39 There are numerous published studies of various rigor regarding modified versions of CMIT.9,42-44 A quick search on Pubmed yields 165 studies. The purpose of this section is to provide a brief overview of some of the manipulations with outcomes relative to work with the stroke population to convey the breadth of the work. Page et al44 utilized a single-blinded RCT with participants a least 12 months post stroke. The experimental group received 30 minutes of one-on-one therapist sessions three times per week for 10 weeks. Sessions consisted of shaping similar to the procedures described in the shaping section above. Throughout the 10 weeks, the participants also wore a constraining hemi-sling five hours per day, weekdays, during the hours they would most likely need to use the UE for ADLs. A behavioral contract was utilized to assist with adherence. There were no significant differences in the baseline characteristics of the groups (mCIMT, usual care and no treatment). The mCIMT group had significant increases in outcome measures for Amount of Use and Quality of Movement scales. Participants in the mCIMT group reported doing more with the more affected limb throughout the study period. The intervention helped them realize they were capable of doing more with the affected limb.44 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 24 Lin et al43 use a pre-test, post-test RCT with two groups; participants were at least 12 months post stroke. The experimental group received two hours of intensive training per weekday and wore a mitt on the less affected hand six hours per weekday for three consecutive weeks. Intensive training included activities such as picking up marbles and combing hair. Baseline characteristics were similar in both groups. Kinematic analysis showed significant positive change in favor of the experimental group for reaching and grasping (P = .02) and movement strategy use with better feedforward control (P = .05). Improvements were also positive in favor of the mCIMT group for improvements on the Motor Activity Log (P .001) and Functional Independence Measure (P = .02).43 Brogrdh and Sjlund42 utilized the standard protocol of six hours per day, two weeks, and components shaping, task practice, and the mitt 90% of the walking day. Instead of one-onone sessions, small group sessions were utilized with two to three patients per one therapist or other staff. In addition to shaping and task practice, participants completed fine motor tasks, strengthening with use of weights and ADLs such as cleaning, playing games and indoor sports. After the two-week training period, the participants were randomized into continued mitt use group or discontinue mitt use group. The mitt use group wore the mitt for 90% of the day, every other day for periods of two weeks, during three months. Hand function, amount of use and quality of use significantly improved following the mCIMT intervention. There were not additional benefits from the extended mitt use and adherence was difficult.42 Brogrdh and Flansbjer9 reassessed the participants after four years and found the improvements in hand function were maintained. Taub et al35 stated that the TP is missing from many studies that purport to utilize the CIMT or a modified CIMT (mCIMT) protocol. Improved use outside the clinic is the most Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 25 important outcome of any intervention. The TP is designed to assist with adherence and subsequently carryover of function obtained in the clinic to home.15,41 To examine the contributions of the TP and shaping to the CIMT protocol, Taub et at35 used a 2x2 factorial components analysis to assess the role of the TP and shaping. The four groups were shaping plus TP (n = 11), repetition plus TP (n = 11), shaping without TP (n = 12) and repetition without TP (n = 11). The intervention lasted 10 consecutive weekdays for three and one half hours per day training. The amount of contact with in-laboratory treatment and therapists was equal in all groups. The with-TP groups wore the mitt 90% of the waking hours. The without-TP only wore the mitt during laboratory practice. Shaping and task practice (referred to repetition in the study) were completed as outlined in the CIMT UE protocol section of this paper. The TP was completed as described in the same section, including the home skill assignment after treatment and follow-up phone calls. Eighty-nine percent completed the study with dropouts dispersed equally among groups.35 Outcome measures consisted of the MAL and the WMFT. Results indicated that inclusion of the TP with shaping or task practice yielded 2.4 times greater use of the affected extremity (P < 0.001) compared to use of either component without use of the TP. These gains persisted at 12-month follow-up. Use of the TP and shaping protocol enhanced motor capacity of the affected UE greater than TP and task practice (P < .05). The TP had the greatest individual effect but shaping also brought statistically significant improvements. In a sub-study, an additional group was randomly selected to receive repetition without use of TP, however this group then received weekly phone calls the first four months following treatment. The baseline characteristics of the sub-study group and the outcome from repetition without TP were consistent with findings of the same group that received the same intervention in the main study. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 26 Six months after treatment, the sub-study group made half the gains that the repetition plus TP group made compared to the repetition group without TP. The gains were not sustained at 12 months. The authors concluded that the sub-study indicates other elements of the TP, not just the follow-up phone calls, are necessary to make long-term MAL gains. For the main study, the authors concluded that the use of TP enhances spontaneous use of the more affected UE and maximum motor capacity and shaping more specifically enhances the later.35 In a 2015 Cochrane Review, Corbetta et al45 sought to assess the effects of constraintinduced movement therapy (CIMT) on ability to manage daily activities and on the recovery of movement in the paralyzed (sic) arm after a stroke.45(p2) Forty-two studies published through January 2015 were utilized for the review, including several reported on in this paper.37,39,43-44 Collectively, study participants had some residual function in the UE most-affected by stroke. Methods varied between hours of constraint and amount of active use required with the more affected UE; CIMT and mCIMT studies were included. Intervention groups were compared to either usual care or no intervention. Eleven studies assessed the effect of CIMT on improving disability. There is no evidence from these studies that CIMT (meaning CIMT or mCIMT) has a positive effect on overcoming disability. Significant improvements were not made or reported in ability to use the more affected UE for ADLs. Twenty-eight studies demonstrated that CIMT (meaning CIMT or mCIMT) was superior to usual care or no treatment in improving movement of the more affected UE. The quality of the evidence was considered low for disability and very low for movement. The authors noted that these findings differ from a 2009 Cochrane Review in which 19 studies were evaluated.45 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 27 Constraint-Induced Movement Therapy Applied to the Lower Extremity Constraint induced movement therapy applied to the LE is considered mCIMT.10-11 Interest in applying CIMT to LE intervention and gait following stroke has grown over that past decade and more studies have been published. The concept of learned non-use may not be fully applicable to the LE as the LE cannot be fully neglected following stroke if some form of transfer, standing, and/or gait is attempted. However, impaired sensorimotor status may lead to compensatory patterns previously described in the Common Lower Extremity Impairments section of this paper. The term learned misuse has been proposed to replace learned nonuse.15,18,19 Misuse also contributes to cortical reorganization after stroke, but in a manner that may hinder, not facilitate recovery in the more affected limb.15,17,19 Lower extremity CIMT protocols vary in many regards. Selection criteria ranged from barely ambulatory to ambulatory18; with or without assistive device and/or orthosis10-11; some active flexion and extension at the hip, knee, and ankle of the affected LE11; or remaining motor impairment in the affected limb10; and six months or longer post stroke.10-11 Most studies10-11 excluded participants who had cardiopulmonary and/or orthopedic conditions that would affect their ability to participate in a rigorous exercise program. Sample size ranged from five10 to 38.19 Duration of the intervention varied among studies. Taub et al18 initially used seven hours per day for three weeks, but over time implemented an initial start of six hours per day with a gradual decrease to three hours per day over a three-week course.19 Six hours per day for two weeks was common.10-11 Interventions for the LE CIMT included massed practice with functional activities such as treadmill walking (with or without body-weight support),11,18 sit to stand,18 lie to sit,18 step climbing18,10 cycling,10 pool work,10 functional strength training,10 coordination, speed, and range Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 28 of motion exercises,11 weight transfer,10 and weight bearing11 activities and walking over a variety of surfaces.10-11 If specified, dosing for the active portion ranged from 15 30 minute bouts throughout the day11 to 40 minutes of activity every hour.10 The protocol for the transfer package ranged from nothing10 to one-half hour per day19 to wearing of a mildly noxious stimulus (nubby insole) on the less affected side 90% of the waking hours to remind the participant to avoid overweighting the less affected side.11 One study protocol included the use of a restraint of the less affected LE during the clinic intervention period.10 Others used various mechanisms to provide sensory feedback to minimize use of the less affected LE11,19 or to increase use of the more affected LE.19 Most studies reported a one to one ratio for participant to assistant10,19; one used a group design with three to four participants for one to two assistants.11 Gains reported included improved ambulation status from fully dependent to fully independent or minimal assist,18 improved gait coordination,18 statistically significant improvement on some outcome measures including LE function10 (Fugl-Meyer), fall risk10-11 (Timed Get Up and Go), LE weight distribution,10 gait speed,11 dynamic balance11 (Four Square Step Test) and walking endurance10 (Six Minute Walk Test). Retention of results was reported as positive for many outcomes at three and six months,10 one year,11 and two years.19 Limitations included lack of control groups,10-11,18-19 lack of blinded assessors,10-11 small sample sizes,10-11,18 poor generalizability of results to the larger stroke population with multiple sequalae,11 and difficulty measuring application to the real world.18 Critical details were lacking in the LE CIMT studies reviewed. Methodology was often not described in detail, especially relative to the application of shaping10-11,18-19 and results were sometimes reported in general terms (i.e. significant gains made) versus objective data.18-19 Many authors10-11,18-19 referred to the Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 29 use of shaping in their methods, but without sufficient detail to allow replication of their LE shaping protocol. Authors did not make a distinction between whole and part-task activities but primarily described the repetitive, whole task activities.10-11,18-19 There was more discussion on the inclusion of whole-task practice or continuous gait (treadmill training and overground walking most specifically) than inclusion of pre-gait, part-task activities.10-11,18-19 Shaping, in UE CIMT, is applied more frequently and systematically to part-task activities.15,41 The LE CIMT intervention appears to rely heavily on task practice vs. shaping. In UE CIMT shaping enhanced maximum motor capacity.35 Study Hypothesis Individuals living with chronic stroke experience ongoing body function and structure impairments, activity limitations and participation restrictions. Impairments in the more affected limb likely contribute to compensatory patterns that further decrease use of the limb and/or encourage compensation with overuse of the less affected lower limb. Impairments contribute to activity limitations and participation restrictions.2,4,21 Rehabilitation literature reveals a long history of intervention for gait following stroke. Many interventions show positive effects.5-6,8,1011,14,19 The most consistent variable in gait intervention studies with positive effects is the inclusion of intensive, repetitive practice.5,14 The dosing for intensive, repetitive practice is not standardized. Constraint-Induced Movement Therapy utilizes a standardized protocol for UE intervention post stroke and application of CIMT to the UE motor control and function has been studied extensively with positive and long-lasting results reported.15-19,35,38-41,44-46 Application of the UE protocol to LE studies has been less consistent with researchers adopting part but not all Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 30 of the UE protocol. The application of shaping to part-task activities for LE intervention has not been specifically studies. Part-task, pre-gait exercises, or activities should address common lower limb impairments including lower limb coordination,21 adaptability,8,29 increased stance time and swing efficiency.8,25-30 Gait-related exercise should incorporate activities such as holding items while stepping, reaching and stepping, head turns and stepping, and stepping in different directions. The LE exercises should be performed on a variety of compliant and non-compliant surfaces and may include stepping up and down from various height stools.30 This study aimed to determine the feasibility of applying the principles of shaping to LE part-task, pre-gait activities for individuals with chronic stroke who live in the community and continue to experience mobility impairment. Method Study Design A prospective, repeated-measures within-group design was used to evaluate the primary study hypothesis of feasibility and the secondary hypothesis of positive treatment effect when incorporating a shaping protocol into a LE exercise program for people with chronic stroke. Participants were evaluated three times across the study before, immediately after, and 16-19 weeks after completion of the intervention (baseline, post-test, and retention, respectively). The study was approved by the Institutional Review Boards (IRB) at the University of Indianapolis (study #0646) and Gannon University (14-06-02) prior to participant recruitment. Approval from both institutions was retained throughout the study period. Data were collected August 2014 February 2016. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 31 Participants Several authors47-49 make recommendations for feasibility study sample size. The sample must be representative of the study population and large enough to provide data regarding the feasibility aspect of the study. Moore et al47 cited the work of van Belle50 and Julious51 to recommend a sample size of 10 to 15, with 12 being the preferred minimum number of participants for pilot or feasibility studies. Moore et al47 reported that increasing the sample to 12 participants made a profound difference in the width of confidence intervals for mean response, whereas increasing the sample size beyond 12 participants did not.(p6) A convenience sample was recruited from the greater Erie, Pennsylvania area within a 25-mile radius of Gannon University where the study was held. The aim was to enroll 12 to 15 individuals. Inclusion criteria. The following inclusion criteria were used: Community dwelling (lives in home or apartment alone or with another whos primary role is not caretaker) Age 18 years or older Sustained an ischemic or hemorrhagic stroke at least six months prior to the start of the study Ambulatory with or without an assistive device, with or without orthosis, requiring no more than occasional minimal assistance for balance to ambulate short distances within their home Presence of self-reported residual motor impairments in the involved LE affecting movement patterns and gait, confirmed by observation and subsequently during baseline testing (Fugl-Meyer Sensorimotor Assessment (LE) and electronic walkway) Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 32 Ability to follow a three-step command with or without supplemental visual demonstration Received medical clearance to participate in the study Agreed to attend all intervention sessions throughout the entire study period Exclusion criteria. The following exclusion criteria were used: History of second or recurrent stroke including a transient ischemic attack Inability to participate in intermittent standing activities for greater than one hour Presence of co-morbidities or pre-existing cardiovascular conditions that would prohibit gait training and exercise Presence of a pre-existing neurological or current musculoskeletal conditions that limit gait ability separate from the effects of the stroke Participating in physical therapy sessions during the intervention period Data Collection The onsite principle researcher was responsible for data collection. Data collection forms were utilized during testing and intervention, as detailed below and shown in appendices. Data were transferred from the forms to an Excel spreadsheet after all data were collected. This process was completed by the primary onsite researcher and checked by two assistants. The Participant: Eligibility and General Information Form (Appendix E) was used to screen interested persons for the study, prior to informed consent. The Demographic Form (Appendix F) was used to confirm eligibility criteria and to collect demographic information used to describe the study participants. The test tracking form (Appendix G) was used to record data from baseline, post- and retention-test sessions. The Daily Intervention Log (Appendix H) was used to record attendance, reasons for absence, vital signs, trial and bout summary, and notes Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 33 (observations, participant statements). Trial and bout summary information was taken from the Trial Tracking Form. Finally, the Trail Tracking form (Appendix I) was used to record repetitions for each trial, trial length (e.g. 30 seconds), total time for each bout, rate of perceived exertion (RPE) before and after each bout, and number of exercises completed per intervention day. Instruments The Fugl-Meyer Assessment Lower Extremity. The Fugl-Meyer Assessment Lower Extremity [FMA-LE (Appendix A)] is considered a gold standard for quantifying recovery of function following stroke and has been used in many clinical trials.52-54 A 3-point ordinal scale is used to objectify motor impairment and function. The scale covers five domains for motor and sensory function, balance, range of motion and pain. Subscales further quantify upper and LE function. The LE motor subscale was used in this study.52-54 Intrarater reliability on the LE subscale has been found to be excellent in several studies (r = .96). Construct validity for the FMA-LE motor subtests was considered good when compared to several functional scales.54 Outcomes Primary hypothesis: feasibility. Study process: intervention attendance rate. Attendance was calculated as the number of days a participant attended the intervention. The intervention attendance rate was calculated as the number of participants who attended all 10 days. A benchmark was set at 80% will attend all 10 intervention sessions. While 100% attendance for all 10 days was desired, 80% accounted for unexpected events in 20% of participants. Study process: intervention completion rate. The intervention was considered complete if a participant attended all 10 sessions, was absent but returned to finish the intervention within the Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 34 10 day intervention period or if the participant missed the first or final day for reasons unrelated to the study. The intervention completion rate was calculated as a percentage of those who completed the intervention. A benchmark was set at 80% will complete the intervention. While 100% completion was desired, 80% accounted for unexpected events in 20% of participants. Study protocol: safety. Protocol safety was measured by fall rate (#falls/#participants) and emergency medical call rate (#calls/#participants). A benchmark was set at 0% will fall or require emergency medical care. It was expected that study personnel would be able to provide sufficient guarding, a safe exercise environment, and individually tailored exercises to prevent falls. It was expected that study personnel would be able to utilize measures of physiological tolerance, participant RPE and monitoring for signs and symptoms of physiological intolerance to alter the intervention if signs of intolerance developed. Zero percent was reasonable for a small sample size. Study protocol: tolerance. Tolerance for the planned dose was measured by the percentage of participants who were able to complete the intervention using 30-second trials for each bout of each exercise, each day. A benchmark was set at 80% will complete the intervention using 30-second trials. Since tolerance for this dosing is not known, it is reasonable that 20% may not be able to complete the intervention using 30-second trials. Study protocol: repetitions. Mean of repetitions from the first three days was compared to the final session count. Using the mean repetitions of the first three days for baseline allowed the focus to be on identifying the best exercises to use for the remainder of the sessions versus on accruing repetitions. Management: study personnel. Number of study personnel needed to safely and efficiently implement the testing and intervention was monitored. It was anticipated that at least Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 35 two were needed per participant. While two is not ideal for use in the clinic, it was anticipated that one would be needed to guard the participant and one needed to set-up, implement and track the activity/exercise associated with the given trial and bout. A benchmark was set at 80% will require two or fewer assistants for safety and process. It was reasonable to expect that 20% may need more than two study personnel to maintain safety or manage the exercise process. Management: ease of providing positive reinforcement. The application of positive reinforcement is an integral part of shaping. Because it was anticipated that the implementation of the intervention bout would be hectic, no attempt was made to track positive reinforcement. The importance of providing positive reinforcement was stressed during training of study personnel. This management construct was described in general terms in the results, but not directly measured by the research team. Allocated resources. Space and equipment utilized were consistent with what would be found in a physical therapy clinic of a medium size hospital. It was anticipated that the resources allocated for space and equipment would be sufficient. The resources construct was described in general terms in the results, but not directly measured by the research team. Secondary hypotheses: treatment effect. Lower extremity motor function. The Five Times Sit to Stand [5xSTS (Appendix B)] is a body structure and function-domain performance-based functional measure of LE strength.31 In this ratio scale measure, five repetitions of sit to stand are timed. Time has been significantly associated with knee flexor strength in subjects with stroke (P < .006). Intrarater, interrater, and test-retest reliability were found to be excellent [intraclass correlation coefficient (ICC) = .97.98, 1.00, .99-.1.00, respectively].55 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 36 Gait activity. Gait activity was measured with the Functional Gait Assessment [FGA Appendix C)] and the ProtoKinetics Zeno electronic walkway and PKMAS software (Zeno Corp., Havertown, PA). The FGA is an activity-domain performance-based measure of gait and gait tasks.31,53 This ordinal scale measure utilizes a four-point scale to rank performance on 10 gait tasks that are commonly associated with functional and efficient gait.31,53,56 Postural stability (use of assistive device or personal assistance), path of travel (ability to maintain forward/backward direction in a 12 inch path of travel) and gait efficiency (speed, change in speed, change in gait pattern) are evaluated. Tasks require gait on level surface, gait with a change in speed, gait with horizontal, gait with vertical head movements, gait with a turn and stop, continuous gait that requires stepping over an obstacle, gait with a narrow base of support, gait with eyes closed, backwards gait, and gait up and down stairs. Minimal Detectable Change (MDC) has been established at 4.2 points or 14.1% change for persons with chronic stroke. Testretest reliability was found to be excellent (ICC .95). Floor and ceiling effects were excellent.56 Cut-off scores for predicting falls in older adults (60 90 years of age) have been established for a score of 22/30 (sensitivity 100%, specificity 72%, positive likelihood ratio [LR] = 3.6 and negative LR = 0).57 The ProtoKinetics Zeno electronic walkway provides ratio-level measures of gait and was used to capture spatial (step length) and temporal (stance time, swing time, velocity) measures of gait. The Zeno electronic walkway with video is 4 foot in width and 16 foot in length, constructed of 36,864 pressure sensors arranged on 0.5-inch centers in a 96 x 384 grid. The active pressure sensors are 0.4-inch squares with 16 levels of dynamic pressure, dual control. The PKMAS software detects footfalls, alongside assistive devices, and outputs temporal (timing), spatial (distance), pressure, and center of mass estimated (COMe) data. The Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 37 software exports 140 variables including velocity, cadence, step length, step time, toe in/out angle, instantaneous center of pressure (COP), COMe, COP for individual footfalls, total pressure, and path efficiency. Symmetry values for step length, swing time and stance time23,2526,29 and gait velocity23,25,27-28,30-32 were obtained through walkway data. Meaningful change categories for gait speed change have been established in older adults with mobility impairments, patients with subacute stroke and community-dwelling older adults. Small meaningful change ranges .04 to .06 m/s and substantial change ranges .08 to .14 m/s.58 Participation. The Activities-Specific Balance Confidence Scale [ABC (Appendix D)] is considered both an activity-domain and a participation-domain self-report tool which measures confidence in balance while performing various walking tasks.52,59 This ratio scale measure requires users to rate their confidence in performing 16 walking tasks on a scale of 0 (no confidence) to 100 (completely confident). Tasks vary in complexity from walking around the house, to walking in a crowded mall and being bumped into, to stepping onto or off-of an escalator while holding packages such that the railing cannot be held. Test-retest reliability for all items combined has been found to be excellent (ICC .85); item level test-retest reliability has been found to be adequate to excellent (ICC ranged from .53 [walking up/down stairs] to 0.93 [walking up/down a ramp]).60 A score of 81.1 predicted that an individual with chronic stroke was not likely to have a history of multiple falls (positive LR = 3.6; negative LR = 0.00), thus establishing a cut-off score.61 Floor and ceiling effects were found to be minimal for three items and zero for the total score.62 Scores lower than 50 indicated a low level of function. Scores between 50 and 80 were associated with a moderate level of function and over 80 with a relatively high level of function.63 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 38 Procedures Testing procedures, exercises, safety procedures and safety monitoring used during testing and intervention were considered standard care, not experimental. The manner in which the exercises was delivered was experimental. Recruitment. Participants were recruited locally through distribution of a flyer (Appendix J) and through word of mouth. Flyers were placed in public and private facilities including local medical and physical therapy clinics. Individuals were solicited by flyer through the local stroke support groups and through the Gannon Doctor of Physical Therapy Community Volunteer pool. This study was open to all individuals who met study inclusion and exclusion criteria. Eligibility determination. Interested persons were told about the study using the Initial Contact Script (Appendix K). Individuals who indicated continued interest were screened using the Participant: Eligibility and General Information Form. If it was determined during the baseline consent screening that the interested person did not qualify for the study, personal information was not kept unless the individual requested contact information be kept for future studies. If the interested person appeared to meet eligibility criteria and wanted to continue with study enrollment, an appointment was made for study orientation. Orientation and informed consent. Study purpose, potential benefits and risks, and participation requirements were reviewed during orientation and through the informed consent process (Appendix L). The potential participant was allowed to have a support person present during the process. Potential participants and support persons if applicable had the opportunity to ask questions. If the potential participant wanted to continue, Informed Consent was signed and witnessed. A copy was issued to the participant. Once consent was obtained, demographic Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 39 information was obtained using the Demographic Form. At this time, the eligibility criteria were verified through medical history; the form for medical release (Appendix M) completed. Testing. There were three testing periods, baseline, post-test and retention testing. Each testing session took approximately 90 minutes. Vital signs [heart rate (HR), blood pressure (BP), respiratory rate (RR), partial oxygen saturation (PaO2)] were taken after the participant rested five minutes. If resting vital signs were high (BP 140/90mmHg, HR > 100bpm, RR > 20 bpm) or low (PaO2 90%) or were considered not normal for participant by self-report prior to testing, additional rest was given and then measured again. If vital signs remained high or low for the given participant or if the participant was symptomatic, the participants primary care physician, who provided the medical clearance for the study, was contacted for advice. The order of testing was randomized for each participant and then maintained each testing period. The Test Tracking Form was utilized to record data and organize the testing session. Baseline testing was completed three to five days prior to intervention. Baseline testing included the FMA-LE, FGA, 5xSTS, ABC, and gait metrics on the ZenoWalkway. Post-testing was completed three to five days following the last day of intervention. One participant was tested 10 days following the last day intervention secondary to hospitalization during the posttest period. Post-tests included FGA, 5xSTS, ABC, and gait metrics on the ZenoWalkway. Retention testing was completed 16 to 19 weeks following that last day of intervention and included the same post-test measures. Testing and intervention occurred over a 14 month period with intervention dates 8/11/14 8/22/14, 9/8/14 9/19/14, 10/6/14 10/17/14, 4/27/15 5/8/15, 9/14/15 9/25/15, and 10/5/15 10/16/15. Fugl-Meyer Assessment of Lower Extremity. The FMA-LE was use during baseline to confirm limb coordination impairment and to classify participants according to severity. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 40 Functional Gait Assessment. Items 1 7 and 9 were completed over the Zeno electronic walkway and video recorded. Item 8 (walking with eyes closed) was completed over tile as the walkway edge may have provided unwanted cues as to position. Item 10 was completed in a stairwell. Taped walkways 1x20 feet were positioned on the Zeno electronic walkway and tile, per test instructions. Walkway data, including video were not utilized in data analysis but were available if needed for review. Participants were allowed to sit and rest between test items if needed. Five times Sit to Stand. Participants held arms across chest (if able) and moved from sitting to full stand to sitting, five times, as quickly as possible, using a standard height chair. If necessary, participants were allowed to push from the armrest. Participants had 1 to 2 warm-ups as needed to assure understanding and readiness. The timer started at the word GO and ended after sitting the last time. The test was timed once. Activities Specific Balance Confidence Scale. Test instructions were read and/or reviewed with the participant and reiterated as needed. If a participant was unsure as to how to answer an item, the item was re-read with the instructions how confident are you that you would be able to _____ without losing your balance or becoming unsteady. Gait measures. Participants completed four passes across the 4 foot by 30 foot Protokinetics Zeno electronic walkway at their self-selected, usual gait speed. Participants used an assistive device and/or orthotic if they typically used such when walking within their home. Participants started walking off the walkway, turned off the walkway at the opposite end and repeated twice for four passes. While multiple gait measures were captured, only spatiotemporal measures of gait velocity, step length symmetry, stance time symmetry, and swing time symmetry were used.25-26 The video data were not utilized for this study but were available for Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 41 recheck of data if needed. Walkway data were edited to remove data from any assistive device, foot drag, heel drag, incomplete footfalls and footfalls in the pass after incomplete footfalls. A footfall was considered incomplete if less than 90%, estimated by visual inspection, was on the walkway file. Additionally, footfalls in the first and last four feet of the walkway file were eliminated allow the participant to achieve a steady state for walking speed. For this edit, if more than 50%, estimated by visual inspection, was in the deletion zone, it was deleted. Intervention. The intervention consisted of 10 sessions over five weekdays for two consecutive weeks. All exercises were done in standing with support if needed. Exercises were part-task, pre-gait exercises that required repetitive, alternating, random, patterned rhythmic stepping and/or kicking. There were no whole-task, continuous gait activities. Exercises were made more challenging in a number of ways including decreasing UE support, increasing repetitions, standing on an unstable surface, closing eyes, holding a glass of water. More details are provided below. All variables in this Intervention section were tracked and recorded on the Trial Tracking Form and/or Daily Intervention Log. Monitoring physiological tolerance. Vital signs (HR, BP, RR, PaO2) were taken at the beginning and ending of each intervention day, after the participant rested five minutes. If resting vital signs were high (BP > 140/90mmHg, HR > 100bpm, RR > 20 bpm) or low (PaO2 90%) or were considered not normal for the participant by self-report prior to testing, additional rest was given and then measured again. If resting vital signs remained high or low for the given participant or if the participant was symptomatic, the participants primary care physician, who provided the medical clearance for the study, was contacted for advice. If the participant demonstrated an abnormal response to exercise, monitored through signs and symptoms, including HR, BP, RR, PaO2, the activity was slowed or stopped, rest was Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 42 allowed with continued monitoring of signs and symptoms. This data, along with self-reported perceived rate of exertion, and observation (color, diaphoresis, anxiety) were utilized to determine if the participant would be allowed to continue, required to rest, if the physician needed to be contacted or if an emergency call was indicated. A BCI handheld pulse oximeter (BCI Pulse Oximeter System, Hand-Held, Model 3301 from Smiths Medical ASD, Inc.) was used to measure HR and O2 sat. A Polar Heart Rate Monitor (Polar F1 Heart Rate Monitor, from http://www.polar.com) was worn by each participant to allow continual monitoring of HR throughout the intervention, although it was recognized this might not have provided an accurate measure of tolerance if the individual was on a beta-blocker. Therefore, multiple measures were used to determine tolerance. Monitoring self-reported tolerance. The RPE is a 15-point ordinal measure for selfreporting level of exertion,64-65 used during intervention. The bottom of the scale, 6 equates to no exertion at all; the top of the scale, 20 equates to maximal exertion. Participants self-rated RPE prior to and after exercise. If a participant stopped the exercise secondary to self-reported intolerance, he/she was asked to provide an RPE from the exercise, once resting. Self-reported RPE between 11 (fairly light) and 14 (somewhat hard) and stable vital signs and symptoms were considered an acceptable measure of physiological stress65 and the activity/exercise was continued after rest. Monitoring pain. At the beginning of each intervention session and throughout the session as indicated, participants were asked, How are you feeling. If pain was reported, the Numeric Pain Rating Scale (NPRS)66-67 was utilized to provide a self-report measure of pain. This commonly used is an 11-point self-report tool used to quantify pain experienced by the rater. Users rate pain on a zero to 10 scale. Zero is no pain and 10 is the worst pain imaginable.31 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 43 Once pain was reported, the level of pain was tracked until the rating was low (i.e. 2) and the participant indicated the pain was not excessive or interfering with intervention exercises or activities during the day. The development of pain was used to guide activity/exercise development or modification and to determine if physician or if an emergency medical call needed to be made. Exercise design, selection, and implementation. Guidelines for exercise design were developed from the literature reviewed on shaping techniques,15,38,40-41 part-task pre-gait exercises,8 and common impairments in gait23,25-26 and related LE coordination following stroke.8,28-29 A bank of exercises was developed and utilized for this study to guide exercise progression (Appendix N). a. Bout/trial: a bout of exercise consisted of 10 trials. One trial lasted 30 seconds. If a participant could not tolerate 30-second trials, trials were shortened to 20 seconds. Refer to Figure 1. b. Rest period: a rest period was taken at the conclusion of each bout. The initial rest period lasted a minimum of 5 minutes. It was extended if indicated by participant tolerance. After the third day, rest times were shortened if indicated by participant tolerance. The three-day wait period allowed the study personnel to assess for delayed onset muscle soreness66 which further guided exercise decisions. c. Repetitions: the number of successful repetitions for each trial was tracked in realtime using a manual tally counter; recorded on the Trial Tracking Form and Daily Intervention Log. When the activity involved stepping, movement of the limb away from or movement towards the midline of the body or starting point was considered one repetition. For example stepping forward and then backward was counted as two Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 44 repetitions. Kicking activities were counted as one repetition per kick. Repetitions that did not meet the activity goal were not counted. For example, if a participant kicked at and missed the ball, it was not be counted. d. Exercise selection: exercises were selected to address stance, swing, alternate stepping, random or patterned rhythmic stepping goals. Bouts were most often alternated between stance and swing or stance or swing and alternating, random, or patterned rhythmic stepping. If a participant reported leg fatigue or to avoid leg fatigue, trials within a bout were alternated between stance and swing guided by participant preference. The majority of exercises required transition over the stance limb (e.g. stepping forward and backward in stride stance). Bilateral and in-place exercises (e.g. knee bends, marching in place, standing knee flexion) were used to further accommodate fatigue. e. Orthotics: if the individual used an orthotic device for gait inside the home, use was encouraged during intervention. An orthotic was only required if exercising without it contributed to unwanted instability or toe drag. f. Upper extremity support: bilateral or unilateral UE support was used when needed to maximize ability to move LE and/or to achieve exercise goal. Support was provided from parallel bars, an Eva walker, bedside table, straight cane or through hand-held assist from research personnel. g. Standing surfaces: included flat tile, foam, and steps. h. Activity/exercise tools: small every-day items were used to help create movement goals. Bright colored pom-poms were randomly thrown near one foot to create a random stepping activity. Bright orange practice golf balls were used for kicking Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 45 activities. Hard plastic brown two-inch diameter furniture protectors provided a more difficult target for kicking. Badminton birdies, net down, provided a difficult toe or heel-touch target. Bright colored tape or flat bright colored discs were placed on the floor to create stepping targets. Several different step stools and a set of training stairs with bilateral handrails were used for toe or heel-touch activities or step-up/stepdown activities. A metronome was occasionally used for rhythmic goals. A plastic squirt bottle with narrow opening could be held by the participant and was used to add challenge to the gait activity. The bottle could be filled with various amounts of water and could be replaced with a plastic cup to further increase the challenge. i. Demonstration and manual cueing: was provided as needed to help the participant understand the movement goal, to assist with stability, safety, and quality of the movement. These techniques were decreased as soon as possible. j. Training environment: coaching, verbal reinforcement, and praise were given throughout the trial, bout and day. Every repetition was marked with the use of a tally counter that gave an audible click each time the target was reached. At the end of most trials, the repetitions completed were stated aloud as they were recorded on the trial tracking form. When the participant was moving quickly (i.e. 30 contacts in a 30second trial), occasional credit was given for a missed target. The study personnel and participant worked together to make sure the count was accurate. Most participants set personal goals for repetitions (i.e. beat the previous trial or yesterdays total) and everyone cheered when goals were met. The environment was positive, energizing and fun. Negative feedback minimized. Every attempt was made to replace phrases such as dont do that with do this. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 46 k. Movement goal: perfection in movement was not required. If the movement goal was too difficult or easy, the parameters or activities were altered. Exercise parameters used to shape the movement goal included number of repetitions completed in a trial, bout, or day; maintenance of pace with a metronome; connection with a target (step to a target, kick a ball to a target, step to a height, etc) with distance, direction or speed altered. Exercise difficulty was also increased by adding in head turning, holding a cup of water, standing on an unstable surface and/or keeping eyes closed, based on progress made, participant interest, and study personnel informal assessment of ability to benefit. Study personnel. Study personnel completed the following tasks: guarding, monitoring, setting timers, and activity/exercise management during each activity/exercise. The complexity of these tasks varied depending upon participant needs, movement goals and activity. Guarding required either close supervision or light contact. This could be minimized for more ableparticipants through exercise set-up. For example, a more able participant may be safe working in the parallel bars, hovering hands over bars, with a chair behind in case quick sitting was needed. Study personnel monitored the participant for signs and symptoms of exercise intolerance and for achievement of movement goals. Multiple timers were set: 30-second timers, total bout timer; rest timer and intervention time. Activity/exercise management included set-up before, during and after the activity. For example, kicking exercises required continual manual placement of the target in front of the foot. The onsite principle researcher was a licensed physical therapist with over 30 years of clinical experience. The onsite principle researcher oriented and trained the research assistants who were graduate students in the Gannon Doctor of Physical Therapy Program. The Study Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 47 Personnel Training checklist (Appendix O) outlines the training covered. Study personnel received an orientation to the purpose of the study, signs/symptoms of exercise intolerance, study protocol for management of intolerance and emergency management procedures. Participant privacy rights and right to refuse continued participation were reviewed. Research assistant certification in CPR, First Aid and Collaborative Institutional Training Institute (CITI) Training were confirmed. Data Storage Data were collected through paper-pencil and electronic means. Hard copy paper-pencil data were stored in a locked file in the faculty office of the onsite principle investigator. Access to the locked file was limited. Electronically stored data were secured with a passcode that only the principle, co-investigators, and research assistants had access to. The data were de-identified prior to analysis. Data Analysis Descriptive statistics were conducted for all variables to assess data quality, identify patterns of missing and out-of-range values, and evaluate the assumptions of statistical tests. Feasibility data (completion rate, attendance, study personnel required, falls, emergency calls, repetitions, trial length, increase in repetitions) are reported as frequency and percentages against benchmarks established a priori. Continuous variables (age, time since stroke, FMA, 5xSTS, ABC, FGA, gait speed, stance time symmetry, swing time symmetry, step length symmetry, repetitions) are reported as mean with standard deviation or median and interquartile range dependent on whether or not the data were normally distributed. Categorical variables (side of hemiparesis, type of stroke, gender, marital status, race/ethnicity) are reported as frequency and Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 48 percentage. For continuous variables, the assumption of normality was assessed using the Shapiro-Wilks test. Repeated measures ANOVA was used to analyze differences across time using a lastobservation-carried-forward approach39 for missing data for one participant post to retention. Sphericity was assessed using the Mauchlys test and if the assumptions of sphericity were violated, the Greenhouse-Geisser results are reported. Bonferroni tests were used for post hoc analysis. Freidmans ANOVA was used to analyze differences across time for data that were not normally distributed, using the same carrying forward procedure for the one participant, post to retention. Post-hoc analysis of significant results was completed using Wilcoxon signed-ranks test and a Bonferroni correction at an adjusted alpha significance of .017. Outcome measures with significant findings were analyzed at post and retention time periods for correlation to total number of repetitions performed using Pearson for parametric data and Spearman rho statistics for non-parametric data. Correlations coefficients were interpreted based on the following: little, if any correlation was r = .00 - .25; low correlation was r = .26 - .49; moderate was .50 - .69; high was .70 - .89. and very high was .90 1.0068 Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY) and all comparisons were two-tailed and the level of statistical significance was set at P < .05. Results Fourteen individuals responded to solicitation. Three did not meet study inclusion criteria. One respondent was excluded secondary to a diagnosis of heat stroke and two were excluded through the screening and orientation process. One of the excluded had a recent history of dizziness with head turns and one had no observable gait disturbances. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 49 Eleven individuals consented to participate in the study. Of those, 10 completed the entire study, including intervention and three test periods. One participant could not participate in the retention testing due to an injection in the LE prior to that testing period. The mean age of participants was 61 years and most participants were white, male, married, with left side paresis. Participant characteristics are presented in Table 1. Primary Hypothesis: Feasibility Results of the analysis of the feasibility data are presented in Table 2. Results of each objective that was addressed to determine the feasibility of the study process and protocol are presented below. Study process: Intervention attendance rate. Attendance rate benchmark 80% will attend 10/10 sessions was not met. Seven of 11 (63.6%) participants attended 10/10 of the intervention sessions. Three participants had absences not related to the study. One fell at home at night and cancelled the subsequent session to allow rest. A second participant missed one session with reports of not feeling well with hesitation to provide specific details. A third participant was ill the final day and subsequently admitted to the hospital for prostatitis. One participant had a study-related absence. This participant was referred back to his physician with calf pain that was subsequently diagnosed as a gastrocnemius muscle strain (affected side). This participant missed two intervention sessions. Study process: Intervention completion rate. The completion rate benchmark of 80% will complete the intervention was met. Eleven of 11 participants completed at least 80% of the intervention. Study protocol: Safety. Study protocol safety benchmarks of 0% falls and 0% emergency medical calls were met. Contact was made to six of the participants referring Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 50 primary care physician (PCP). The PCP for a participant with chronically high blood pressure was contacted during the baseline visit. The participant was under ongoing care and was asymptomatic. Blood pressure readings were reported to the PCP after each session and the physician provided continuing clearance for participation. This eventually resulted in PCP alteration of medication, as reported at the retention testing visit. During intervention, a PCP was contacted once for four participants secondary to high or low blood pressure. All contacts resulted in continued clearance with requests for ongoing monitoring during exercise. Two contacts led to physician follow-up with changes in blood pressure medication. As stated in the attendance rate section above, one PCP was contacted secondary to participant complaints of calf pain. The participant presented on day six of the intervention with complaints of affected-side calf pain. He initially attempted to participate but pain increased and the session was stopped without a complete bout. He was referred to his physician and that day was diagnosed with a calf strain. He missed the subsequent day and resumed day eight to complete the study, with clearance from the physician. Study protocol: Tolerance. The study tolerance benchmark of 80% will complete 30second trials was met. Ten of the 11 (90.9%) participants tolerated 30-second trials. A few participants occasionally needed to rest between trials of one bout and several needed increased rest time between some bouts, especially during the first week. These rests did not violate the protocol. The participant who subsequently developed the calf strain required modification day one to 20 second bouts with increased rest periods that were gradually decreased although the trial length was never increased. Study protocol: Repetitions. The study benchmark to increase repetitions by 15% or greater was met. All participants demonstrated an increase in the number of repetitions by 15% Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 51 or greater. In addition, there was a statistically significant increase in the mean number of repetition completed during the first three days compared to the final session count 594.09 (154.67) and 1026.72 (273.22), respectively, P = .003. Management: Study personnel. The management benchmark that 80% will require two or fewer assistants for safety and process was met (100%). Testing could be completed with one study personnel. Ten (90.9%) participants required two study personnel for intervention to manage safety, data collection during trials, exercise set-up during and between trials, and the provision of positive feedback. One participant completed the intervention with one study personnel. Management: Ease of providing positive reinforcement. Positive verbal feedback was routinely, but not systematically provided during intervention. Repetition totals were routinely, but not systematically stated following each trial and/or bout and/or as a daily summary. Use of the tally counter for successful attempts provided clear, positive knowledge of results through the audible click. When a participants pace of the intervention was fast, use of the tally counter was difficult, with occasional miscounts during a trial. When counting was off with the tally counter, the participant and researchers would work together to correct mistakes. The mistake frequency was not tracked; but mistakes did not frequently occur. Allocated resources. The resources allocated for physical space and exercise equipment were sufficient to carry out the study plan. The intervention could be completed with equipment typically found in a physical therapy clinic including parallel bars, assistive devices, step stools, and items to create the exercise (e.g. non-slip targets to step on; items to kick). Low-tech, low cost items were purchased including bright tape, practice golf balls, and bad mitten whiffles. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 52 Secondary Hypothesis: Treatment Effect Results of the comparison of the 5xSTS scores, FGA scores, and ABC scores across time, from baseline to the retention visit are reported in Table 3. Each objective addressed to determine the effectiveness of the treatment are presented below. Lower extremity motor function. There was a statistically significant increase in 5xSTS scores over time (P = .004). Post hoc analysis showed a significant increase between time period baseline to retention (P = .004) and but not baseline to post (P = .04) or post to retention (P = .96). Little to low correlations without significance were found between change scores of 5xSTS and total number of reps completed between time period baseline to post (r = -.06, P = .85), baseline to retention (r = .44, P = .42), and post to retention testing (r = .26, P = .45). Gait Activity. Functional Gait Analysis. There was a statistically significant increase in FGA scores over time (P = .003). Post hoc analysis showed a significant increase from baseline to retention (P = .006), but not baseline to post (P = .36) or post to retention (P = .18). Three (27.27%) participants met or exceeded the established MDC value of 14.1% between baseline to post testing and baseline to retention testing. Two additional participants exceeded the MDC value between baseline to retention testing, resulting in five (45.45%) individuals demonstrating clinical improvement over time. Low correlations without significance were found between change scores of the FGA and total number of repetitions completed between time periods baseline to post (r =.32, P = .34), baseline to retention (r = .27, P = .42) and a negligible correlation was found from post to retention (r = -.04, P = .90). There were no statistically significant differences over time for symmetry with stance time, swing time, or step length (spatiotemporal parameters of gait). In addition, there was no Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 53 statistically significant difference over time for gait speed. However, from baseline to post, of the 11 participants five (45.45%) had improved gait speeds with change that ranged from .01 to .09 m/s. However, six (54.54%) had slower gait speeds with change that ranged from -.05 to -.10 m/s. Of the five participants who had improved gait speed at post, four continued to have improved gait speed at retention with final change scores ranging .07 to .20 m/s. One was not tested at retention. Of the six participants who did not have improved gait speed at post, three had improved gait speed at retention with final change scores ranging .02 to .06 m/s. The change scores for the remaining three participants who did not have improvement in gait speed at post continued to show a slowing of gait speed at retention with final change scores ranging from .07 to -.20 m/s. Several participants met the criteria established by Perera et al58 for meaningful change. From baseline to post, three participants demonstrated small meaningful change (.05 to .06 m/s) and one demonstrated substantial change (.10 m/s). From baseline to retention, three demonstrated small meaningful change (.04 to .07 m/s) and three demonstrated substantial change (.15 to .21 m/s). Participation. There were no statistically significant change in ABC scores over time with baseline to post change range -28.00 to +35.00 and baseline to retention change range 32.00 to +40.00. Discussion The purpose of this study was to investigate the feasibility and effects of applying the principles of shaping to part-task, pre-gait activities in persons with chronic stroke. It was hypothesized that shaping part-task, pre-gait exercises would be feasible and result in positive treatment effects across all levels of the ICF. All benchmarks for feasibility set a priori, except Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 54 attendance, were met. Three participants missed one session for non-study related reasons. One missed two days secondary to the calf strain. The participants worked hard, increasing mean repetitions from 594 to 1026 over the course of 10 sessions. Of the 11 participants, five (45.45%) had blood pressure readings prior to testing or exercise that led to follow-up phone calls with the referring physician. Ongoing monitoring assisted the physicians in making decisions to alter medications for two participants. One participant had an increase in dosage during the intervention. One had BP medication discontinued secondary to low blood pressure readings. All five were cleared by their PCP for continued participation in the study protocol. The study protocol was feasible and safe to implement with this sample with chronic stroke. The protocol yielded a high number of repetitions in a short, intense time period with a positive treatment effect for functional measures of LE strength and gait activity. Adding a level of fitness requirement for inclusion and/or having a more specific process to build the workload more slowly may prevent a calf strain or similar problem in a future study or in clinical application. Implementation of the study protocol as executed in this study would be difficult to carry out with one therapist, unless minimal guarding was needed. Guarding, set-up and monitoring were performed continuously during the intervention. Progressive physical therapy intervention for gait remediation often required increased manpower.10,24 Two10 to three24 personnel may be needed to provide manual cueing for limb placement24 and guarding.10,24 Some have reported implementation of LE CIMT using one to two therapists for three to four participants,11 although the exact role and use of individualized guarding during the intervention were not well described. Upper extremity CIMT, on the other hand, can typically be performed with one interventionist15 and has been implemented effectively in a group setting with two to three participants per one staff person.42 Guarding for safety is not needed during UE CIMT part-task practice when Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 55 shaping is intensely applied. Whole task activities, in UE CIMT are selected based upon the participants interests and abilities. Tasks could be performed in sitting, decreasing the postural demand.15 The need for more than one staff person to implement a protocol does reduce feasibility for clinic use.11,42 The use of an overhead harness with this LE study protocol may be sufficient to allow one therapist to set-up, implement and monitor the trials. Providing positive reinforcement, a required element of shaping, was an essential aspect of this feasibility assessment. Praise and reporting of repetitions were planned procedures for providing positive reinforcement in this study protocol. The clicking sound of the tally counter also provided positive reinforcement. Often, the participant was so focused on the movement goal that the only noise in the room was the click of the tally counter. The audible click provided immediate positive feedback in the form of knowledge of results. Once the trial was completed, the repetitions were announced and praise provided. Most participants started setting their own goals to beat previous repetitions during trials and/or bouts. Success also provided positive reinforcement. Verbal feedback was sometimes difficult to provide during the actual trial as many variables were being monitored (participant safety, participant performance, success, setup, time). However, the audible clicking and regular reporting of repetitions, along with cheers and high-fives contributed to a positive, energetic and fun environment. In UE CIMT the reporting of repetitions, a positive environment and encouragement to improve on personal best are critical components of shaping.15,41 Lower extremity CIMT studies report the use of shaping, but do not elaborate.10-11 Multiple responsibilities of the research assistants in this study, including guarding for safety, negatively impacted their ability to systematically apply positive praise during trial performance. However, the environment remained positive with systematic feedback applied through the audible tally counter. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 56 The role of the audible clicking in the provision of positive feedback was not empirically studied or manipulated. The value of feedback from the audible click was not anticipated prior to implementation of this LE intervention protocol. All but two participants appeared to be very attentive to the clicking and would provide feedback to the research assistants if they felt they were incorrectly awarded clicks. A search of multiple databases did not reveal any published studies regarding the use of a clicker or similar device for use in providing positive feedback or knowledge of results. Using a systematic review of six studies, Wittwer et al33 found that synchronized walking to rhythmic auditory cueing brought short-term improvements in gait speed and stride length in patients with stroke. In these studies, the pace was set by the therapist. In this LE shaping study, the sound was made in reaction to the participant event and was tied to success. Consistent with the CIMT literature,41 the immediate feedback from the auditory clicks and reporting of repetitions, appeared to be rewarding and motivating for most participants. It cannot be determined if the auditory clicking had any influence over the participants pacing of the motor response. Use may have been tied to increased repetitions over the course of the intervention and/or to the positive treatment effects. Use of a tally counter could be easily implemented in a clinic setting. Further investigation the influence of the audible click on intervention outcomes, including increasing repetitions may assist with evidence-based decisionmaking. The protocol used in this study clearly resulted in an increased number of repetitions over the course of the intervention days. Many researchers now emphasize the importance of repetitive, task-oriented training in bringing positive outcomes for lower limb and gait function following stroke, even in the chronic stages.5-6,13-17,24,39 High-intensity, task-specific exercise appears to have the best potential to drive cortical reorganization following stroke; perhaps Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 57 yielding the best promise for permanent change.13,17 Participants in this study performed a mean of 1026 (range 610 to 1647) repetitions on the last day of intervention. This varies considerably from Lang et al34 findings for a mean number of 33.4 (33.4) repetitions of active LE exercise, 8 (12.3) purposeful movements, and 292 (351.0) steps when exercise and gait (respectively) were addressed in out-patient settings for individuals status post stroke. Kimberly et al13 subsequently found therapists provided a mean of 37.25 ( 47.52) repetitions of active lower limb activity and 185.20 ( 130.1) steps with gait training per therapy session when either was included for patients status post stroke in an acute care and rehabilitation hospitals. Use of this protocol generated a feasible method for achieving high repetitions in a one-hour therapy session. Secondary Hypothesis The secondary hypothesis of this study was that there would be a positive treatment effect across all levels of the ICF. Part-task, pre-gait activity yielded significant improvements on a unidimensional, functional measure of LE motor function (5xSTS)55 and on one measure of gait function (FGA).56-57 Five times Sit to Stand is significantly associated with knee flexor strength in individuals post stroke but is not associated with balance as tested with the Berg Balance Scale and limits of stability testing, dynamic posturography.55 The FGA test items require postural stability56-57; the test is highly correlated with the Postural Assessment Scale for Stroke Patients (PASS).56 Therefore, the treatment effects found in this study may be related to improved postural stability and lower extremity strength within our sample participants, and directly correspond with the types of pre-gait exercises performed in the study intervention. Gait function, as measured through gait parameters of symmetry and velocity, did not show an effect. The lack of continuous gait in the intervention protocol may have influenced this Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 58 outcome. Others factors may have contributed to lack of effect. Examination of the raw data revealed that two participants (18%) had longer step lengths and one (9%) had longer stance time on the opposite limb at post-test compared to baseline (27% collectively). One participant retained the change at retention. Reporting of symmetry values does not capture those changes. Changes in gait speed were highly variable. Some participants demonstrated slower gait speeds at post and retention testing and some had improved gait speed with meaningful change at post, post and retention, or just retention. While most exercises addressed improving swing velocity through increased repetitions in a given period, some exercises were designed to slow swing time with a motor goal of increasing contralateral stance time. Some researchers have found a relationship between improved gait speed and continuous gait activities6,8,14,24 or pre-gait activities6,8,14 including circuit training,69 but not when whole, continuous gait and pre-gait are combined.8 Others have found statistically significant increases in gait speed with a home exercise program that specifically excluded continuous gait activity24; while others22 did not find a statistically significant relationship between continuous gait activity (community ambulation, virtual reality, treadmill and imagery) and gait speed. The preliminary findings of this study support previous reports that part-task, pre-gait activities do not affect continuous gait parameters such as symmetry and gait speed. This study, although small, supports the results of prior findings that pre-gait activities do not improve continuous gait activities. A larger sample size is needed to better assess this outcome. A comparison between whole and part-task practice would be critical to determine this effect. In this current study, there was no correlation between total number of repetitions performed or an increase in repetitions from early to late intervention and 5xSTS or FGA outcomes. Using a systematic review, French et al14 found statistically significant, positive Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 59 effects with RTT in adults with stroke, for changes in walking distance, sit to stand and functional ambulation. However, no effect was found for timing of delivery relative to onset of stroke, type of training (whole, part or mixed), and larger versus smaller duration in hours of training. There was insufficient evidence in the French et al14 review to investigate an effect from number of repetitions completed. The authors suggested that variables such as task shaping might influence the outcome of RTT.14 In this current study, the lack of statistically significant correlation between repetitions and positive treatment effects may have been due to the small sample size. Alternatively, the positive, statistically significant effects may have resulted from the manner in which movements and motor abilities were shaped versus the number of repetitions completed. A randomized-controlled trial with both groups receiving part-task, pregait exercises and the experimental group receiving shaping, may provide clearer evidence for the contribution of shaping to pre-gait, part-task exercise. Participation, as measured with the ABC52 did not show a positive effect. This finding is consistent with many gait studies and systematic reviews examining LE function, gait, exercise, and participation.6-8,14,22 Therefore this finding in the current study is not surprising. The ultimate goal of rehabilitation following stroke is improved participation and survivors of stroke associate impaired lower limb function with activity limitations and participation restrictions.2,4,21 Physical therapists must continue to assess the impact of intervention on participation. Not all sources recognize the ABC as a participation measure31; different participation measures should be considered in a follow-up study. Shaping Shaping involves (1) providing immediate and frequent feedback regarding quality of movement; (2) task selection specific to movements the person has the most potential to Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 60 improve, (3) modeling, prompting and cueing to help the person understand the movement goal, and (4) systematically and incrementally increasing the difficulty of the task once the movement goal is consistently achieved.41 This current study protocol addressed all requirements with items one and three described above. Requirement two, task selection should be guided by consideration of joint movements with the most pronounced deficits, deficits that have the greatest potential for improvement, and patient preference within the parameters of potential for improvement.36,41 This level of detail for task selection was not fully addressed with this feasibility study protocol. Exercises were selected and modified based on knowledge of common gait deficits, observation of participant gait deficits, and assessment of participant performance of the exercise. The addition of motion analysis26 and muscle performance testing70 may provide additional guidance for exercise selection. The necessity of this level of detail is not known. The extra time and cost involved may not be warranted given the positive treatment effect using observation and foundational knowledge to establish motor goals. Requirement four was addressed but quantification of the manipulation was not. If there was limited improvement after two to three intervention days, if the participant was uncomfortable, despite attempts at modification and/or if the participant did not like the exercise, the exercise was modified or abandoned. Likewise, exercises were modified when they became easy as determined through variables such as researcher observation of improved postural stability and/or ease of limb movement, reduced RPE and/or participant feedback. The primary parameter shaped was repetitions. Other parameters shaped included stepping longer, faster, slower or higher; completing the activity with eyes closed, while holding a glass of water or while standing on foam. Changes were specific to the participants needs, abilities and interests. The decision to use upper limb support or not, was difficult as both decisions could be beneficial. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 61 Participant input on this decision was weighted heavily; some chose a support-free environment to address balance, while other participants chose to use support in order to focus more on increasing repetitions of the activity. Other reasons for use of UE support included fear of falling, reports of fatigue, decreased strength or decreased balance. Upper extremity support helped reassure some participants and allowed participants to push themselves to reach the exercise goal. Postural demand is not specifically manipulated in UE CIMT shaping; tasks completed during UE task practice are selected within the participants ability to maintain safe and efficient postural control.15,41 The manipulations used to address task difficulty (item four in shaping criteria41) were recorded in detailed logs for each participant (swing, stance, 1 UE support, bilateral UE support, floor surface, tactile cueing, other). However, systematic analysis of use was not performed secondary to the small sample size and reliance on numerous variables for decision-making. Finding a more systematic way in which to manipulate the exercise parameters for a given participant or group may be beneficial. Randomly allocating homogeneous participants to a group with or a group without UE support may yield data useful in clinical decision-making. In the signature UE CIMT literature, inclusion of a transfer package combined with shaping enhances the motor capacity greater than use of a transfer package with task practice.35 Individually, the comprehensive transfer package as described in Taub et al35 had the greatest single effect on outcomes in UE CIMT. In this current study, the decision was made to focus solely on the application of shaping to part-task, pre-gait LE exercise. A transfer package was not utilized in order to minimize confounding variables. Use of a comprehensive transfer package that includes behavioral contracts, exercises and activities and follow-up phone calls to Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 62 assist with compliance may positively contribute to the utilization of shaping applied to LE parttask, pre-gait exercise. Clinical Relevance The application of shaping to part-task, pre-gait exercise, as applied in this study could be replicated in the clinic. Use of a tally counter, frequent positive verbal feedback and regular reporting of repetitions may provide a positive and motivating environment that could result in a high number of repetitions. Tasks designed to maximize success could be altered using a systematic, incremental and progressive approach, once the movement goal is achieved. The therapist could use his or her skills in modeling, prompting and cueing to help assure the patient understands the movement goal. These procedures do not require additional time or skill. They provide a mechanism for systematic and progressive challenge during repetitive task training. They could be easily integrated into a 45 or 60-minute session. The need for two clinic staff to maintain safety and implement the protocol may be decreased to one with the use of an overhead harness. If two staff are used, an unlicensed assistant could be trained to assist the clinician. The positive effects following a relatively short intervention period warrant consideration for clinic use. Limitations There were some threats to internal and statistical conclusion validity which may have contributed to a type II error include lack of homogeneity (FMA and gait speed range), and small sample size without sufficient power to detect a true difference. Post hoc power analysis using G-Power, Version 3.1.9.2 (Faul, Erdfelder, Lang, & Buchner, 2009) for the non-significant results showed that the study was underpowered to find differences for gait velocity, stance time symmetry, swing time symmetry, step length symmetry and ABC. Power ranged 13 to 64%. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 63 Additional threats to validity included participant illness, resumption of or increased physical activity and/or change in medication after completion of the intervention period. Illness was reported and may have affected the performance of one participant (9%) at post testing and three (27%) participants at retention. Individuals who reported for testing not feeling well were given the option of rescheduling; one postponed testing for one week but was still recovering at testing. During the post to retention period, six participants (55%) resumed their prior exercise/activity routines (two were substantial consisting of approximately 45 minutes of exercise at least three times per week). Four (36%) initiated a new program consisting of approximately 10 to 20 minutes of regular exercise several times per week. Two received physical therapy, one for gait/LE exercise (9%) and one for UE exercise (9%). Participants were required to refrain from physical therapy and were discouraged from completing formal, home exercise during the study intervention period. Participants were not encouraged or discouraged from participation in regular exercise and/or physical therapy during the post to retention period; that was considered overreaching and perhaps unethical. One participant (9%) had a change in BP medication to lower BP during the intervention period. One participant (9%), at post testing, had a change in medication to address spasticity. During the post to retention period, one participant (9%) was taken off medications for BP and diabetes and one (9%) had a change in medication for headache management. Future research is warranted using a larger sample size, control group and/or blind assessors. Manipulation of additional variables such as UE support, continuous gait and a transfer package may yield clinically important data. The protocol lends itself to easy manipulation of variables and could be used to systematically examine which variable has the most significant impact on which domain(s) of the ICF. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 64 Participant comments throughout the study were very positive. Comments have not been reported because a formal methodology to capture and analyze the comments was not implemented. Use of an additional or different outcome measure assessing participation and/or use of a focus group, may increase the richness of information regarding the study protocol and outcome from the participant perspective. A mixed-method design with a control group and additional participation-level measures may yield additional helpful information that will further guide clinical decision-making. Lengthening the duration of the protocol beyond a two-week time-period, with less visits per week may improve attendance. Conclusion This study offers a protocol that is feasible to implement (safe, tolerable, manageable) in most physical therapy clinic settings where two individuals are available to provide assistance. An overhead harness may provide sufficient (and perhaps superior) guarding and decrease personnel required to one. The protocol yields a high number of repetitions that can easily be counted. The counting with an audible tally counter and reporting of counts appears to provide positive reinforcement for the activity. Analysis of variables related to the secondary hypotheses suggest that participants continued to improve following completion of the two-week intervention, as evidenced by the improved scores on retention testing for 5xSTS, ABC, FGA and gait speed, with 5xSTS and FGA reaching a positive, significant difference from baseline to retention. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 65 References 1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics-2015 update: a report from the American Heart Association. [Published online before print December 17, 2014]. Circulation. 2015;131:e29-e322, doi:10.1161/CIR.0000000000000152. 2. Bouffioulx , Arnould C, Thonnard J. Satisfaction with activity and participation and its relationships with body functions, activities, or environmental factors in stroke patients. Arch Phys Med Rehabil. 2011;92(9):1404-1410. 3. Rhoda A, Mpofu R, De Weerdt W. 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Statistical Analysis of Relationships: The Basics. In: Carter RE, Lubinsky J, Domholdt E. Rehabilitation Research. 4th ed. St. Louis, MO: Elsevier Saunders;2011:314-324. 69. Yang Y, Wang R, Lin K, Chu M, Chan R. Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clin Rehabil. 2006;20(10):860-870. 70. Pattern C, Lexell J, Brown HE. Weakness and strength training in persons with poststroke hemiplegia: rationale, method and efficacy. J Rehabil Res Dev. 2004;41:293312. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study Table 1. Participant General Characteristics Variables Age (years), M (SD) Time post stroke (months), Mdn (IQR) Fugl-Meyer Lower Extremity Score, M (SD) Side of hemiparesis, N (%) Left Type of stroke, N (%) Ischemic Hemorrhagic Brainstem Do not know Gender, N (%) Male Marital Status, N (%) Married Widowed Single/never married Race/ethnicity, N (%) White Hispanic/Latino All Participants N = 11 61.2 (10.4) 18.0 (10.0) 26.6 (4.3) 7.0 (63.6) 5.0 (45.5) 1.0 (9.1) 1.0 (9.1) 4.0 (36.4) 6.0 (54.5) 9.0 (81.8) 1.0 (9.1) 1.0 (9.1) 10.0 (90.9) 1.0 (9.1) 74 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 75 Table 2. Primary Hypothesis: Feasibility Benchmarks and Outcomes (N = 11) Measure Study process Attendance, N (%)a Completion ratea Study protocol Emergency medical calls, N (%)b Falls, N (%)b Tolerance of trial length, N (%)a Increase in repetitionsa Study management Study personnel, N (%)b a b Benchmark Outcome N (%) Benchmark Met 80% attend 10/10 intervention days 80% complete the intervention 7.0 (63.6) No 11.0 (100.0) Yes 0.0 (100.0) 0.0 (100.0) 10.0 (90.9) Yes Yes Yes 11.0 (100.0) Yes 11.0 (100.0) Yes 0% emergency medical calls 0% falls 80% complete 30 second trials 15% increase from days 1-3 (mean) to final day 80% require two or fewer assistants for safety, process intervention only baseline , post-, and retention-testing and intervention Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 76 Table 3. Comparison of Outcome Measures Over Time (N = 11) Variables 5xSTS, sec* ABC, % FGA Gait Speed, m/s Stance Time Ratio Swing Time Ratio* Step Length Ratio* Baseline M (SD) Post-test M (SD) Retention M (SD) P 15.15 (8.44) 11.61 (8.12) 12.68 (6.15) .01 69.00 (20.72) 71.82 (24.17) 72.73 (22.87) .29 11.73 (3.69) 12.82 (3.46) 14.36 (4.78) .01 0.61 (0.23) 0.59 (0.24) 0.64 (0.25) .26 0.86 (0.07) 0.85 (0.10) 0.84 (0.10) .32 1.43 (0.58) 1.60 (0.10) 1.58 (0.90) 1.01 (0.70) 1.00 (0.41) 1.05 (0.44) * Median (IQR) reported 5xSTS = Five times sit to stand; ABC = Activities Specific Balance Confidence Scale; FGA = Functional Gait Assessment .35 .34 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 77 Figure 1 Relationship Between Bouts, Trials, Rest and Session Bouta Bout Daily 60-minute sessionc Ten 30-second trialsb o Repetitions tracked for each trial Ten 30-second trials o Repetitions tracked for each trial o Rest if needed o Rest if needed o Set-up time if o Set-up time if needed Multiple exercise bouts Whole bouts (ten trials) only needed a Each bout was one exercise b Each exercise was performed for ten 30-second trials, with rest between trials if needed; set-up time between trials also added time to the bout, depending upon the nature of the exercise c Multiple bouts were completed in a 60 minute session Note: Mandatory 5-minute rest between bouts for the first three days was weaned as sufficient endurance was demonstrated. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 78 Appendix A: Fugl-Meyer Motor Function Lower Extremity TEST I. Reflex Activity ITEM Achilles SCORE SCORING CRITERIA 0 No reflexes can be elicited 2- Reflex activity can be elicited Patellar II. Flexor synergy (in supine) Hip flexion Knee flexion 0-Cannot be performed at all 1-Performed partially 2- Performed faultlessly Ankle dorsiflexion III. Extensor synergy (in sidelying) Hip extension Adduction 0-Cannot be performed at all 1-Performed partially 2- Performed faultlessly Knee extension Ankle plantar flexion IV. Movement combining synergies (sitting: knees free of chair) Knee flexion beyond 90 Ankle dorsiflexion V. Movement out of synergy (Standing, hip at 0) Knee flexion Ankle dorsiflexion VI. Normal reflexes (sitting) VII. Coordination/speed sitting; Heel to opposite knee (5 repetitions in rapid succession) Knee flexors, patellar, Achilles (This item is only tested if the patient achieves maximum score on all previous items. If person has not achieved full score to this point, enter 0) Tremor Dysmetria Speed TOTAL LOWER EXTREMITY TOTAL 0-No active motion 1-From slightly extended position, knee can be flexed, but not beyond 90 2-Knee flexion beyond 90 0-No active flexion 1-Incomplete active flexion 2-Normal dorsiflexion 0-Knee cannot flex without hip flexion 1-Knee begins flexion without hip flexion, but does not reach 90m or hip flexes during motion 2-Full motion 0-No active motion 1-Incomplete active motion 2-Normal motion 0-At least 2 of the 3 phasic reflexes are markedly hyperactive 1-One reflex is markedly hyperactive, or at least 2 are lively 2-No more than one reflex is lively and none are hyperactive 0-Marked tremor 1-Slight tremor 2-No tremor 0-Pronounced or unsystematic dysmetria 1-Slight or systematic dysmetria 2-No dysmetria 0-Activity is more than 6 seconds longer than unaffected side 1-Activity is 2-5.9 second longer than unaffected side 2-Less than 2 second difference MAXIMUM = 34 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 79 Appendix B: Five Times Sit to Stand From Rehabmeasures.org Five times sit to stand Test Administration: 1. Patient sits with arms folded across chest and with their back against the chair. With patients who have had a stroke, it is permissible to have the impaired arm at the side or in a sling 2. Use a standard chair with arms (keep testing chair consistent for each retest). Chair heights recorded in literature vary, generally 43-45 cm 3. Ensure that the chair is not secured (i.e. against the wall or mat) 4. Patient Instructions: "I want you to stand up and sit down 5 times as quickly as you can when I say 'Go'." o Instruct to stand fully between repetitions of the test and not to touch the back of the chair during each repetition. o It is OK if the patient does touch the back of the chair, but it is not recommended 5. Timing begins at "Go" and ends when the buttocks touches the chair after the 5th repetition. 6. Provide one practice trial before measurements are recorded. If you are concerned that the patient may fatigue with a practice trial, it is OK to demonstrate to the patient and have the patient do two repetitions to ensure they understand the instructions 7. Inability to complete five repetitions without assistance or use of upper extremity support indicates failure of test. (Any modifications should be documented) 8. Try NOT to talk to the patient during the test (may decrease patients speed) 9. Document speed and assist level (CGA, supervision, Mod I, or I) in the PT Standing Balance Section Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 80 Appendix C: Functional Gait Assessment Requirements: A marked 6-m (20-ft) walkway that is marked with a 30.48-cm (12-in) width. ______1. GAIT LEVEL SURFACE Instructions: Walk at your normal speed from here to the next mark (6 m [20 ft]). Grading: Mark the highest category that applies. (3) NormalWalks 6 m (20 ft) in less than 5.5 seconds, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width. (2) Mild impairmentWalks 6 m (20 ft) in less than 7 seconds but greater than 5.5 seconds, uses assistive device, slower speed, mild gait deviations, or deviates 15.2425.4 cm (610 in) outside of the 30.48-cm (12-in) walkway width. (1) Moderate impairmentWalks 6 m (20 ft), slow speed, abnormal gait pattern, evidence for imbalance, or deviates 25.4 38.1 cm (1015 in) outside of the 30.48-cm (12-in) walkway width. Requires more than 7 seconds to ambulate 6 m (20 ft). (0) Severe impairmentCannot walk 6 m (20 ft) without assistance, severe gait deviations or imbalance, deviates greater than 38.1 cm (15 in) outside of the 30.48-cm (12-in) walkway width or reaches and touches the wall. ______2. CHANGE IN GAIT SPEED Instructions: Begin walking at your normal pace (for 1.5 m [5 ft]). When I tell you go, walk as fast as you can (for 1.5 m [5 ft]). When I tell you slow, walk as slowly as you can (for 1.5 m [5 ft]). Grading: Mark the highest category that applies. (3) NormalAble to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast, and slow speeds. Deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width. (2) Mild impairmentIs able to change speed but demonstrates mild gait deviations, deviates 15.2425.4 cm (6 10 in) outside of the 30.48-cm (12-in) walkway width, or no gait deviations but unable to achieve a significant change in velocity, or uses an assistive device. (1) Moderate impairmentMakes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, deviates 25.438.1 cm (1015 in) outside the 30.48-cm (12-in) walkway width, or changes speed but loses balance but is able to recover and continue walking. (0) Severe impairmentCannot change speeds, deviates greater than 38.1 cm (15 in) outside 30.48-cm (12-in) walkway width, or loses balance and has to reach for wall or be caught. _______3. GAIT WITH HORIZONTAL HEAD TURNS Instructions: Walk from here to the next mark 6 m (20 ft) away. Begin walking at your normal pace. Keep walking straight; after 3 steps, turn your head to the right and keep walking straight while looking to the right. After 3 more steps, turn your head to the left and keep walking straight while looking left. Continue alternating looking right and left every 3 steps until you have completed 2 repetitions in each direction. Grading: Mark the highest category that applies. (3) NormalPerforms head turns smoothly with no change in gait. _______4. GAIT WITH VERTICAL HEAD TURNS Instructions: Walk from here to the next mark (6 m [20 ft]). Begin walking at your normal pace. Keep walking straight; after 3 steps, tip your head up and keep walking straight while looking up. After 3 more steps, tip your head down, keep walking straight while looking down. Continue alternating looking up and down every 3 steps until you have completed 2 repetitions in each direction. Grading: Mark the highest category that applies. (3) NormalPerforms head turns with no change in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. (2) Mild impairmentPerforms task with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 15.2425.4 cm (610 in) outside 30.48-cm (12-in) walkway width or uses assistive device. (1) Moderate impairmentPerforms task with moderate change in gait velocity, slows down, deviates 25.438.1 cm (1015 in) outside 30.48-cm (12-in) walkway width but recovers, can continue to walk. (0) Severe impairmentPerforms task with severe disruption of gait (eg, staggers 38.1 cm [15 in] outside 30.48-cm (12-in) walkway width, loses balance, stops, reaches for wall). _______5. GAIT AND PIVOT TURN Instructions: Begin with walking at your normal pace. When I tell you, turn and stop, turn as quickly as you can to face the opposite direction and stop. Grading: Mark the highest category that applies. (3) NormalPivot turns safely within 3 seconds and stops quickly with no loss of balance. (2) Mild impairmentPivot turns safely in _3 seconds and stops with no loss of balance, or pivot turns safely within 3 seconds and stops with mild imbalance, requires small steps to catch balance. (1) Moderate impairmentTurns slowly, requires verbal cueing, or requires several small steps to catch balance following turn and stop. (0) Severe impairmentCannot turn safely, requires assistance to turn and stop. Instructions: Begin walking at your normal speed. When you come to the shoe box, step over it, not around it, and keep walking. Grading: Mark the highest category that applies. (3) NormalIs able to step over 2 stacked shoe boxes taped together (22.86 cm [9 in] total height) without changing gait speed; no evidence of imbalance. (2) Mild impairmentIs able to step over one shoe box (11.43 cm [4.5 in] total height) without changing gait speed; no evidence Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. (2) Mild impairmentPerforms head turns smoothly with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 15.2425.4 cm (610 in) outside 30.48-cm (12-in) walkway width, or uses an assistive device. (1) Moderate impairmentPerforms head turns with moderate change in gait velocity, slows down, deviates 25.438.1 cm (1015 in) outside 30.48-cm (12-in) walkway width but recovers, can continue to walk. (0) Severe impairmentPerforms task with severe disruption of gait (eg, staggers 38.1 cm [15 in] outside 30.48-cm (12-in) walkway width, loses balance, stops, or reaches for wall). _______7. GAIT WITH NARROW BASE OF SUPPORT Instructions: Walk on the floor with arms folded across the chest, feet aligned heel to toe in tandem for a distance of 3.6 m [12 ft]. The number of steps taken in a straight line are counted for a maximum of 10 steps. Grading: Mark the highest category that applies. (3) NormalIs able to ambulate for 10 steps heel to toe with no staggering. (2) Mild impairmentAmbulates 79 steps. (1) Moderate impairmentAmbulates 47 steps. (0) Severe impairmentAmbulates less than 4 steps heel to toe or cannot perform without assistance. _______8. GAIT WITH EYES CLOSED Instructions: Walk at your normal speed from here to the next mark (6 m [20 ft]) with your eyes closed. Grading: Mark the highest category that applies. (3) NormalWalks 6 m (20 ft), no assistive devices, good speed, no evidence of imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. Ambulates 6 m (20 ft) in less than 7 seconds. (2) Mild impairmentWalks 6 m (20 ft), uses assistive device, slower speed, mild gait deviations, deviates 15.2425.4 cm (610 in) outside 30.48-cm (12-in) walkway width. Ambulates 6 m (20 ft) in less than 9 seconds but greater than 7 seconds. (1) Moderate impairmentWalks 6 m (20 ft), slow speed, abnormal gait pattern, evidence for imbalance, deviates 25.438.1cm (1015 in) outside 30.48-cm (12-in) walkway width. Requires more than 9 seconds to ambulate 6 m (20 ft). (0) Severe impairmentCannot walk 6 m (20 ft) without assistance, severe gait deviations or imbalance, deviates greater than 38.1 cm (15 in) outside 30.48-cm (12-in) walkway width or will not attempt task. 81 of imbalance. (1) Moderate impairmentIs able to step over one shoe box (11.43 cm [4.5 in] total height) but must slow down and adjust steps to clear box safely. May require verbal cueing. (0) Severe impairmentCannot perform without assistance. ______9. AMBULATING BACKWARDS Instructions: Walk backwards until I tell you to stop. Grading: Mark the highest category that applies. (3) NormalWalks 6 m (20 ft), no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. (2) Mild impairmentWalks 6 m (20 ft), uses assistive device, slower speed, mild gait deviations, deviates 15.2425.4 cm (610 in) outside 30.48-cm (12-in) walkway width. (1) Moderate impairmentWalks 6 m (20 ft), slow speed, abnormal gait pattern, evidence for imbalance, deviates 25.438.1 cm (1015 in) outside 30.48-cm (12-in) walkway width. (0) Severe impairmentCannot walk 6 m (20 ft) without assistance, severe gait deviations or imbalance, deviates greater than 38.1 cm (15 in) outside 30.48-cm (12-in) walkway width or will not attempt task. ________10. STEPS Instructions: Walk up these stairs as you would at home (ie, using the rail if necessary). At the top turn around and walk down. Grading: Mark the highest category that applies. (3) NormalAlternating feet, no rail. (2) Mild impairmentAlternating feet, must use rail. (1) Moderate impairmentTwo feet to a stair; must use rail. (0) Severe impairmentCannot do safely. TOTAL SCORE: ______ MAXIMUM SCORE 30 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 82 Appendix D: Activities Specific Balance Confidence Scale Script: For each of the following, please indicate your level of confidence in doing the activities without losing your balance or becoming unsteady by choosing one of the percentage points on the scale from 0% to 100%. If you do not currently do the activities in question, try and imagine how confident you would be if you had to do these activities. If you normally use a walking aid to do the activities or hold onto someone, rate your confidence as if you were using these supports. If you have questions about answering any of these things, please ask the administrator. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% No Confidence Completely Confident How confident are you that you will not lose your balance or become unsteady when you 1. Walk around the house? % 2. Walk up or down stairs? % 3. Bend over and pick up a slipper from the front of a closet floor? % 4. Reach for a small can off a shelf at eye level? % 5. Stand on your tiptoes and reach for something above your head? % 6. Sweep the floor? % 7. Walk outside of the house to a parked car in the driveway? % 8. Stand on a chair and reach for something? % 9. Get in or out of a car? % 10. Walk across the parking lot to the mall? % 11. Walk up or down a ramp? % 12. Walk in a crowded mall where people rapidly walk past you? % 13. Are bumped into by people as you walk through the mall? % 14. Step onto or off of an escalator while you are holding onto a rail? 15. Step onto or off of an escalator while holding onto parcels such that you cannot hold onto the railing? 16. Walk outside on a wet or slippery sidewalk? % Mean % % % Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study Appendix E: Participant: Eligibility and General Information Form Date of Initial Contact with Co-Investigator:__________________________________ [ ] phone intake [ ] in-person intake [ ] AFO [ ] no AFO Eligibility Determination: (Check all that apply) [ ] fall history _________ lives in community at least 6-months post stroke has only experienced one stroke between the ages of 21-80 able to walk with or without the use of an assistive device and/or orthosis requires no more than occasional minimal assistance for balance reports LE coordination/strength/control problems currently not receiving physical therapy services no co-morbidities or pre-existing cardiovascular conditions that would prohibit gait training and exercise no pre-existing neurological or current musculoskeletal conditions that would limit gait ability separate from the effects of stroke no complications from other health conditions that could influence walking able to follow at least three-step verbal instructions available for the entire period of the study able to travel to and from research measurement and intervention sessions medically stable with a physician release stating approval to enter an exercise program Eligible for study? (Y/N)__________ Date Eligibility determined: ________________ General Participant Information Name: _______________________________________________________________ Address:______________________________________________________________ Home phone: _______________________Cell phone:___________________________ Emergency Contact (Name/phone):__________________________________________ Physician Name/phone:___________________________________________________ Participant Number:____________________________ 83 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 84 Appendix F: Demographics Demographics Pre-Test only Date of birth: / / Age: _________ What is your current marital status? Married Member of an unmarried couple Widowed Divorced Male Female Single and never been married Separated Which single race group best describes you? Black/African Asian American American White Gender: Hispanic/Latino Native American Indian/Alaskan Other Native Hawaiian/Pacific Islander no answer Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 85 Stroke Characteristics Pre-Test only Diagnosis of Stroke: Yes No Do not remember Date of stroke: Month _______ Year_________ Time since stroke: <1 year 2-5 years 5-10 years >10 years How old were you when you had your stroke? _________ years Are you weaker because of your stroke? Right hemiparesis Dominant hand: Right Type of stroke: Yes No Left hemiparesis Left Ischemic Hemorrhagic Brainstem Do not remember What therapies did you have after your stroke? OT / PT / ST / RT / Psych (circle) Other:________ What other health conditions have you been diagnosed with?___________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you had any surgeries in the past? If so, what?___________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Did you fall when or shortly after you had the stroke? Have you fallen since your stroke? If Yes, how often? Other___________ Yes No Daily Weekly Were you injured? Yes No Do you currently exercise? Yes Yes No Do not remember Do not remember Monthly Just once Do not remember No If Yes, what type of exercise(s)?_____________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study Names and dosages of current medications: Medication name Daily dose 86 Purpose 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Any recent changes in medications? Yes No Do not remember/know If so, please explain: ___________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 87 Appendix G: Test Tracking Tracking for pre/post/retention testing Participant #___________________________ pre-test date: __________________ intervention: __________________ post-test date: __________________ retention test date: __________________ Item PrePostretention testing testing informed consent (pre-testing only) issued copy discussed what to wear polar HR monitor demographics vital signs ____ BP ____ HR ____ RR ____O2 sat (pre) ____ BP ____ HR ____ RR ____O2 sat (post) ____ BP ____ HR ____ RR ____O2 sat (retention) confirm dates for intervention and post-intervention testing set date for retention testing Indicate order of testing ____ ABC ____ spatiotemporal gait parameters ____ Fugl-Meyer ____5x sit to stand ____FGA ____ 6MWT RPE: ____ (pre) ____ (post) ____ (retention) ____ Post-intervention survey ____ retention-testing interview Notes: (record any helpful information here including confirm no PT during intervention; f/u on exercise during intervention and PT and/or ex following intervention be specific as possible with dates, frequency, duration, intensity) Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 88 Appendix H: Intervention Log Sheet Participant #__________________________ Exertion Ratings Total Time on Task _____ RPE Minimum Rating Date:____________________ END OF DAY SUMMARY Total Reps ____ Bilateral stance (parallel or stride) _____ RPE Maximum Rating Total Reps Involving: ____ 1 or ____ 2 UE support ____ reaching to goal ____ speed goal ( or ) ____ eyes open ____ distance goal ( or ) ____ head turns ____ holding object (affected, unaffected, bilateral) ____ standing on foam ____ eyes closed ____ Affected stance limb Initial resting: HR O2 sat Post resting: HR O2 sat RR BP # of ex completed: ____ affected swing limb ____ alternating RR BP Notes: Shaping Exercise # Exertion Ratings _____ RPE Minimum Rating Total Time on Task Total Reps Brief Description: ____ Affected stance limb Total Reps Involving: (circle specifics) ____ BUE ____ reaching to goal ( or multi) ____ affected or unaffected UE support for stability ____ eyes open ____ eyes closed ____ affected swing limb ____ speed goal ( variable) ____ alternating ____ distance goal ( variable) ____ Bilateral stance (parallel or stride) _____ RPE Maximum Rating HR/BP/RR (prn): ____ head turns ( multi) ____ standing on foam ____ holding object (affected, unaffected, bilateral) Notes: Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 89 Appendix I: Trial Tracking Participant # ____________ Time start: ____________ Ex # RPE 1 Trial 1 Trial 2 Notes: Date:__________________ Time end ex: _____________ Trial 3 Trial 4 Trial 5 Trial 6 Trial 7 Time end rest: ______________ Trial 8 Trial 9 Trial RPE 2 10 Task Time other Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study Appendix J: Study Flyer 90 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 91 Appendix K: Initial Contact Script First: Introduce self and describe the study: Thank you for contacting us about our study. I am Beth Gustafson. I am on faculty here at the Gannon University in the Doctor of Physical Therapy Program. I am a co-Investigator for the study you are calling about. The purpose of this study is to examine the feasibility of an exercise program for people who have had a stroke. I will also be measuring differences in standing tolerance, strength, balance, walking ability, and confidence in performing walking tasks. All of the testing and exercises will be performed at Gannon University under the supervision of a physical therapist and student physical therapists. Exercises will include standing and stepping activities. These activities will be gradually increased in difficulty. It will include a total of 10 treatment sessions over a period of 2 weeks in 60 minute sessions. Participants will be able to sit and rest as needed. Also, as part of the research, we will conduct 3 testing sessions here on the campus of the Gannon University, during the weeks immediately before and after the 2-week training period and then again 3 to 4 months after the training period. Each testing session will take about 1 hour. Do you have any questions? Second: After answering questions, ask the potential participant if interested in determining if eligible to participate in the study Are you interested in determining if you are eligible to participate in our study? Third: Determine eligibility using Eligibility and Contact Information Form Fourth: A. If the potential participant meets all of the eligibility requirements, then ask if interested in learning more about the study. You are eligible to participate in the study. Would you like to learn more about the study? B. I am sorry, but at this time you are not eligible to participate in the study for the following reason(s) __________________. Are you interested in being contacted in the future for other studies? Fifth: If the potential participant is eligible and interested in learning more about the study, then invite them to meet with the primary investigator and student researchers at Gannon University to go over the informed consent form, answer any other questions and to further determine eligibility based on observation of gait (must have obvious gait impairment). Schedule a time to meet with the potential participant at this time and fill in contact information on the eligibility form. I would like to invite you to meet with me and some of the student co-investigators to go over the informed consent form, answer any other questions you might have about the study and to further determine your eligibility for the study through an informal observation of your walking. With your permission, we will then seek medical clearance from your physician. Can we set up a time to meet? **At any time if the potential participant is not interested in hearing more about the study or does not meet the eligibility requirements, then the contact is terminated. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 92 Appendix L: Informed Consent Date: _________________ Dear Participant, You are invited to enter a research study. The title of the study is Lower extremity shaping exercises for community dwelling adults with chronic stroke: a feasibility study. The study is conducted by a physical therapist at Gannon University, Beth Gustafson. The purpose is to test the feasibility of a leg exercise program for people who have had a stroke. This program will address strength, coordination, balance and walking. We will also look at your confidence in performing walking tasks. You may find benefits in these areas from participation. Your participation will help us gain a better understanding of exercise following stroke. We will seek your opinion on the benefits of and interest in the exercise program. Physical or mental risks from participating are no greater than would be found in a typical physical therapy session. If you have an unknown medical condition, the exercise could become problematic. You will be monitored closely for signs of trouble. All of the exercises will be performed in standing. You will be able to rest in sitting. It is possible you may initially be sore or tired. This should go away over the course of the exercise program. The procedures used are standard research procedures, not experimental ones. Your physician will need to sign a letter of medical clearance for you to participate. Your pulse, blood pressure, breathing, and effort will be monitored. You will be asked to slow down or stop if you show any signs of trouble. If it is determined that the exercise is not safe for you, you will be withdrawn from the study. You will be referred back to your physician. No provision will be made for financial payments or other forms of compensation (such as lost wages, medical cost reimbursement, lost time or discomfort) with respect to injuries as a result of this study. If you are found to be eligible you will continue with pre-testing. There will be three testing sessions. One will occur the week before the exercise program. One will occur the week after the exercise program. One will occur three to four months after the exercise program. Each will take about an hour. The exercise program will run daily for two weeks in a row. The sessions will take about an hour and a half. Your performance and the test results will be recorded in several ways. We will use electronic means, paper, video and audio to record results. An individual file will be created to carefully store your testing results. Please see the summary at the end of this letter for information on how all of this data will be stored. All tests and observations obtained by the researchers will remain confidential. You may be testing or exercising with others who are participating in the study. The researchers cannot monitor or control what other participants share. However, each is encouraged to be respectful of each other. Some of the tests or exercises may occur when other students, faculty or visitors are in the area. It is expected that the volume of this kind of traffic will be low. The researchers will be very careful to make sure your private information, including test results are not shared with others. It is possible others will hear you receive feedback such as good job or you completed 10 yesterday. If you prefer to test or exercise in a private area, you may let the researcher know. You may request this at any time. Your participation is voluntary. You may end your participation at any time without penalty. If you have questions about the research or experience any discomfort or injury from participation, contact Beth Gustafson, PT, MSEd at (814) 871-7709. Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 93 If you have questions about your rights as a research participant, contact Dr. Ryan Leonard, Chairperson, Gannon University Institutional Review Board at (814) 871-5875 or Greg E. Manship, IRB Coordinator & Human Protections Administrator, University of Indianapolis, Fountain Square Center, A313, 901 South Shelby Street, Indianapolis, IN, 46203. 317/781-5774 (Office) 317/791-5945 (Fax) You will be given a copy of this form to keep. I volunteer to participate in this study. I have had the opportunity to ask questions. Participant name (print) __________________________________ Participant signature _____________________________________ Date ______________ Witness signature _______________________________________ Date ______________ Check here to see the results when the study is over. Document storage Electronic files (includes video): hard drive: folder with secure password; jump drive file with secure password locked in file cabinet in Co-Investigator Gustafson locked office Paper files: locked in file cabinet in Co-Investigator Gustafson locked office All paper documents will be kept for 3 years following publication and will be shredded after this time point. --------------------------------------------------------------------------------------------------------------------Using language that is understandable and appropriate, I have discussed this research with the above participant. Researcher signature _____________________________________Date _________________ Note: font decreased by 1 to accommodate proposal margins Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 94 Appendix M: Medical Release Form Physicians Approval Statement Patient:__________________________________ Date of Birth: _____________________ I release my patient named above to participate in the study entitled Lower extremity shaping exercises for community dwelling adults with chronic stroke: a feasibility study. I understand that my patient will be participate in 10 exercise sessions over 2 weeks for 60 minutes of standing and stepping exercises per session. Participants will work with moderate intensity (Rate of Perceived Exertion (RPE) 11-14) during the training. Vital signs will be monitored. During each session standing and stepping exercises will be modified to progressively challenge the participant in gait-related activities. For example, one exercise may consist of repetitively stepping and a progression may be stepping with a head turn or stepping with eyes closed. Testing will take place one week before (pre-test), one week after (post-test), and 3 to 4-months after (retention) the intervention period. Gait velocity, limb symmetry, endurance, quality of gait pattern, gait with functional tasks and confidence in completing walking tasks will be measured during all testing sessions. A follow-up interview will also occur. The interventions and testing sessions will be carried out at Gannon University by trained physical therapy students and faculty. Physicians name (please print) ______________________________________________ Physicians signature: ______________________________________Date:___________ Please return signed form to: Beth Gustafson, PT, MSEd (Co-Investigator) Assistant Professor Gannon University Doctor of Physical Therapy Program, MS60 109 University Square Erie, PA 16451 Or fax to: (814) 871-5548 I agree to allow the research team to obtain approval from my physician to participate in study, Lower extremity shaping exercises for community dwelling adults with chronic stroke: a feasibility study. Participants Signature: _________________________________ Date: ________________ Participant Date of Birth: _______________________________ Physician name:_______________________________________ Phone:________________ Note: font and spacing decreased to accommodate proposal margins Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 95 Appendix N: Table of Contents for Bank of Exercises See separate document for exercises Title Four Square Weights shifts Heel and Toe Rocks Big Steps, stance more affected Big Steps, swing more affected Good Ole Strengthening Ex Lunge to dots, stance more affected Lunge to dots, swing more affected Toe Touch Steps, stance more affected Toe Touch Steps, swing more affected Squish the pom pom, stance more affected Squish the pom pom, swing more affected Kick the golf ball, SB, stance more affected Kick the golf ball, SB, swing more affected Kick the disc, stance more affected Kick the disc, swing more affected Dont squish the Birdie, stance more affected Dont squish the Birdie, swing more affected Auto steps (BESTest) Flamingo on kickball, stance more affected Flamingo on kickball, swing more affected Stand on one leg Dips, stance Page N2 N3 N4 N7 N13 N19 N20 N24 N28 N33 N38 N42 N46 N50 N54 N58 N62 N66 N70 N71 N77 N82 N83 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 96 Appendix O: Study Personnel Training Research assistant name: ____________________________ Date: _____________ Research assistant orientation and exercise intolerance/emergency management training for research study: Lower extremity shaping exercises for community dwelling adults with chronic stroke: a feasibility study. CPR certification, Professional Rescuer or higher expiration date: First Aid certification expiration date: Review signs/symptoms of exercise intolerance shortness of breath/labored breathing diffuse diaphoresis change in color (pale, red, blue) appears anxious chest, shoulder, arm or jaw pain muscle cramping Walk to AED locations (in Morosky Academic Center prior to September, in the Human Performance Lab during September) Review protocol for managing intolerance slow down stop and sit monitor HR, BP, RR, signs/symptoms, RPE rest until vital signs, signs/symptoms return to pre-intervention levels proceed back into exercise with exercise previously tolerated, if signs/symptoms or intolerance have cleared and participant desires to continue If this occurs more than twice during the entire study period for an individual, a review of the participants data will occur and a discussion with the physician will ensue Emergency management procedures Shout out for help any researchers present in the area assist participants they are working with into a safe sitting position, preferably out of site of the person in distress if this will not add time to response time and respond to call for help Provide First Aid or CPR (initiate rescue breaths and send someone for AED and help) Call Gannon University Campus Police at 871-7777 (posted in all rooms) or call 911 Shaping Applied to Lower Extremity Part-Task Exercise: Feasibility Study 97 if possible, send someone to the 10th street entrance (Morosky, before September) or the 6th street entrance (Human Performance Lab, September on) to flag emergency personnel Review participant right to ask for private testing or intervention room (may require rescheduling) Review participant right to end session copy of emergency procedures given to research assistant Orientation and training provided by: ________________________________ (signature) Beth Gustafson, PT, MSEd Assistant Professor Doctor of Physical Therapy Program Appendix N: Table of Contents for Bank of Shaping Exercises Title Four Square Weights shifts Heel and Toe Rocks Big Steps, stance more affected Big Steps, swing more affected Good Ole Strengthening Ex Lunge to dots, stance more affected Lunge to dots, swing more affected Toe Touch Steps, stance more affected Toe Touch Steps, swing more affected Squish the pom pom, stance more affected Squish the pom pom, swing more affected Kick the golf ball, SB, stance more affected Kick the golf ball, SB, swing more affected Kick the disc, stance more affected Kick the disc, swing more affected Dont squish the Birdie, stance more affected Dont squish the Birdie, swing more affected Auto steps (BESTest) Flamingo on kickball, stance more affected Flamingo on kickball, swing more affected Stand on one leg Dips, stance Page N2 N3 N4 N7 N13 N19 N20 N24 N28 N33 N38 N42 N46 N50 N54 N58 N62 N66 N70 N71 N77 N82 N83 2 Four Square Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Bilateral Stand in center of four square; step with less affected first, more affected second Sequence of stepping (L, L, R, R or L, R, L, R, etc) predictable or random sequence Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Return to start or stay in boxes EO/EC Repetitions per 30 or 45 second trial Time in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Adaptable, coordinated movement between limbs Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 3 Weight shifts Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results bilateral Use as a guide for progression, maintain one activity for trial but can alter trials within the set; emphasize area of challenge [ ] BUE >> less affected UE >> more affected UE >> no BUE support (start with the least amount of support needed) [ ] lateral [ ] A/P [ ] diagonal [ ] oval [ ] figure 8 Range of movement QOM (symmetry, hip and trunk extension) Range of movement (you hit these three quadrants really welltry to emphasize this one next time; keep trying for this one, I know it is tough) quietness of stance/relaxed upper body and limbs QOM: hip and trunk extension; symmetry of weight; weight on more affected; knee control Ankle strategy hip extension trunk extension knee control (use wedge if needed) ankle control static dynamic Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 4 Heel and toe rocks Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Bilateral, level surface, EO/EC Shift weight from toes to heals; can add reach to target to facilitate weight shift if needed; start with EO, progress to EC Position of limbs (stride, symmetrical) Excursion Speed movement to metronome EC Seconds in synch with metronome QOM: hip and trunk extension; symmetry of weight; weight on more affected; knee control A/P ankle strategy hip extension trunk extension knee control (stand on wedge if needed to help control hyperextension) concentric hip flexion/knee extension dorsiflexion /plantar flexion Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 5 Heel and toe rocks Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Bilateral, foam, EO/EC Stand on foam; shift weight from toes to heals; can add reach to target to facilitate weight shift if needed, start with EO, progress to EC Position of limbs (stride, symmetrical) Excursion Speed movement to metronome EC Foam compliance Seconds in synch with metronome QOM: hip and trunk extension; symmetry of weight; weight on more affected; knee control A/P ankle strategy hip extension trunk extension knee control (stand on wedge if needed to help control hyperextension) concentric hip flexion/knee extension dorsiflexion /plantar flexion Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 6 Heel and toe rocks Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Bilateral, foam, holding a glass of water Stand on foam and hold a glass of water; shift weight from toes to heals; can add reach to target to facilitate weight shift if needed, start with EO, progress to EC Type of container holding water and/or amount of water (less or more open/full) Position of limbs (stride, symmetrical) Excursion Speed movement to metronome EC Foam compliance Seconds in synch with metronome control over water QOM: hip and trunk extension; symmetry of weight; weight on more affected; knee control A/P ankle strategy hip extension trunk extension knee control (stand on wedge if needed to help control hyperextension) concentric hip flexion/knee extension dorsiflexion /plantar flexion Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 7 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, level surface Step with less affected limb to target, maintain A hip extension throughout; start in stride stance progress to bilateral Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (trailing, bilateral, other) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 8 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, EC Step with less affected limb to target, EC, maintain A hip extension throughout; start in stride stance progress to bilateral Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (trailing, bilateral, other) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 9 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; stand on foam Stand on foam; step with less affected limb to target, maintain A hip extension throughout; start in stride stance progress to bilateral Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (trailing, bilateral, other) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 10 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; head turns Step with less affected limb to target while simultaneously looking to specific direction (Left, right, up, down, diagonal right, diagonal left, random), maintain A hip extension throughout; start in stride stance progress to bilateral (must have practiced to target first) Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (trailing, bilateral, other) Predictable or random head turn direction Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Direction of turning Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 11 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; reach for object Step with less affected limb towards target while reaching for an object, maintain A hip extension throughout; start in stride stance progress to bilateral Distance to target (measure from stance heel) FWB to toe touch on landing Starting position of stepping limb (trailing, bilateral, other) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome number of times object reached Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Direction of reaching Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 12 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; holding cup of water Step with less affected while holding a glass of water, return to start, maintain A hip extension throughout Type of container holding water and/or amount of water (less or more open/full) Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (trailing, bilateral) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome control over water Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 13 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, level surface Step to target with more affected, return to start; start in asymmetrical stance and progress to symmetrical (start in easier position) Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved step length Improved hip flexion Improved heel contact Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 14 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, EC Step to target with more affected, EC, return to start; start in asymmetrical stance and progress to symmetrical (start in easier position) Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved step length Improved hip flexion Improved heel contact Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 15 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; stand on foam Stand on foam less affected; step to target with more affected, return to start; start in asymmetrical stance and progress to symmetrical (start in easier position) Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved step length Improved hip flexion Improved heel contact Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 16 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; head turns Step with more affected onto step while simultaneously looking to specific direction (Left, right, up, down, diagonal right, diagonal left, random), return to start Distance to target (measure from stance heel) FWB to heel touch Predictable or random head turn direction Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Better balance with head turns Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 17 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; reach for object Step to target with more affected onto step while simultaneously reaching for an object (Left, right, up, down, diagonal right, diagonal left, random), return to start, maintain A hip extension throughout Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial Repetitions in sync with metronome number of times object reached Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Direction of reaching Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 18 Big Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; holding cup of water Step with more affected to target while holding a glass of water, return to start Type of container holding water and/or amount of water (less or more open/full) Distance to target (measure from stance heel) FWB to heel touch Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved control of water Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 19 Good Ole strengthening ex Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Bilateral, alternating limbs Alternate limbs for any or all of the following exercises (one trial per exercise) [ ] knee bends [ ] toe rises [ ] heel rises [ ] hamstring curls [ ] marching in place [ ] hip abduction (left/right alternating) [ ] hip extension (left/right alternating) Reps per trial Total reps per set Continuous metronome pace across all trials Seconds in pace with metronome per trial QOM Seconds in synch with metronome QOM: hip and trunk extension; symmetry of weight; weight on more affected; knee control depends upon movement but general goal is trunk and hip stability with superimposed movement (static/dynamic controlled mobility) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 20 lunge to dots Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected Bilateral stance; use colored discs for targets; step into lunge on colored disc Position of dots Number of dots Predictable or unpredictable sequence of stepping pattern Starting position of stepping limb (bilateral, trailing) Return to start or move to dots Number of discs used Repetitions per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 21 lunge to dots Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; stand on foam Bilateral stance; use colored discs for targets; step into lunge on colored disc Position of dots Number of dots Predictable or unpredictable sequence of stepping pattern Starting position of stepping limb (bilateral, trailing) Return to start or move to dots Number of discs used Repetitions per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 22 lunges to dots Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; holding cup of water Bilateral stance; use colored discs for targets; step into lunge on colored disc Type of container holding water and/or amount of water (less or more open/full) Position of dots Number of dots Predictable or unpredictable sequence of stepping pattern Starting position of stepping limb (bilateral, trailing) Return to start or move to dots Number of discs used Repetitions per 30 or 45 second trial Repetitions in sync with metronome control over water Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 23 lunges to dots Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; holding cup of water AND standing on foam Bilateral stance; stand on foam; use colored discs for targets; step into lunge on colored disc Type of container holding water and/or amount of water (less or more open/full) Position of dots Number of dots Predictable or unpredictable sequence of stepping pattern Starting position of stepping limb (bilateral, trailing) Return to start or move to dots Number of discs used Repetitions per 30 or 45 second trial Repetitions in sync with metronome control over water Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 24 lunge to dots Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, level surface Bilateral stance; use colored discs for targets; step into lunge on colored disc Position of dots Number of dots Predictable or unpredictable sequence of stepping pattern Starting position of stepping limb (bilateral, trailing) Return to start or move to dots Number of discs used Repetitions per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Improved landing on forward foot Swing limb Hip flexion (goal: from trailing limb position) Initial contact Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 25 lunge to dots Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; stand on foam Bilateral stance; stand on foam; use colored discs for targets; step into lunge on colored disc Position of dots Number of dots Predictable or unpredictable sequence of stepping pattern Starting position of stepping limb (bilateral, trailing) Return to start or move to dots Number of discs used Repetitions per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Improved landing on forward foot Swing limb Hip flexion (goal: from trailing limb position) Initial contact Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 26 lunges to dots Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; holding cup of water Bilateral stance; use colored discs for targets; step into lunge on colored disc Type of container holding water and/or amount of water (less or more open/full) Position of dots Number of dots Predictable or unpredictable sequence of stepping pattern Starting position of stepping limb (bilateral, trailing) Return to start or move to dots Number of discs used Repetitions per 30 or 45 second trial Repetitions in sync with metronome control over water Improved hip extension (standing straight) Improved speed Improved control (slower speed) Improved landing on forward foot Swing limb Hip flexion (goal: from trailing limb position) Initial contact Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 27 lunges to dots Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; holding cup of water AND standing on foam Bilateral stance; use colored discs for targets; step into lunge on colored disc Type of container holding water and/or amount of water (less or more open/full) Position of dots Number of dots Predictable or unpredictable sequence of stepping pattern Starting position of stepping limb (bilateral, trailing) Return to start or move to dots Number of discs used Repetitions per 30 or 45 second trial Repetitions in sync with metronome control over water Improved hip extension (standing straight) Improved speed Improved control (slower speed) Improved landing on forward foot Swing limb Hip flexion (goal: from trailing limb position) Initial contact Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 28 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, level surface Place unaffected onto step, return to start, maintain A hip extension throughout Distance to step (measure from stance heel) Height of step (4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved height Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 29 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; stand on foam Stand on foam, place unaffected onto step, return to start, maintain A hip extension throughout Distance to step (measure from stance heel) Height of step (4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved height Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 30 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; head turns Place unaffected onto step while simultaneously looking to specific direction (Left, right, up, down, diagonal right, diagonal left, random), return to start, maintain A hip extension throughout Distance to step (measure from stance heel) Height of step (4.25, 6.25, _____) Toe touch to FWB Predictable or random head turn direction Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved height Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Better balance with head turns Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Direction of turning Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 31 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; reach for object Place unaffected onto step while simultaneously reaching for an object (Left, right, up, down, diagonal right, diagonal left, random), return to start, maintain A hip extension throughout Distance to step (measure from stance heel) Height of step (4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial Repetitions in sync with metronome number of times object reached Improved height Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Direction of reaching Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 32 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; holding cup of water Place unaffected onto step, return to start, maintain A hip extension throughout Type of container holding water and/or amount of water (less or more open/full) Distance to step (measure from stance heel) Height of step (4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome control over water Improved height Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 33 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, level surface Place more affected limb onto step, return to start Distance to step (measure from stance heel) Height of step (foam mat, 4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved height Improved step length Improved hip flexion Improved landing on foot Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 34 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; stand on foam Less affected stand on foam; place more affected limb onto step, return to start Distance to step (measure from stance heel) Height of step (foam mat, 4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved height Improved step length Improved hip flexion Improved landing on foot Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 35 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; head turns Place more affected onto step while simultaneously looking to specific direction (Left, right, up, down, diagonal right, diagonal left, random), return to start Distance to step (measure from stance heel) Height of step (foam mat, 4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Predictable or random head turn direction Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome Improved height Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Better balance with head turns Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 36 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; reach for object Place more affected onto step while simultaneously reaching for an object (Left, right, up, down, diagonal right, diagonal left, random), return to start, maintain A hip extension throughout Distance to step (measure from stance heel) Height of step (4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial Repetitions in sync with metronome number of times object reached Improved height Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Direction of reaching Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 37 Toe Touch Steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; holding cup of water Place more affected onto step, return to start Type of container holding water and/or amount of water (less or more open/full) Distance to step (measure from stance heel) Height of step (foam mat, 4.25, 6.25, _____) Toe touch to FWB Starting position of stepping limb (bilateral, trailing) Self-paced repetitions Slow repetitions (45, 30, 15 bpm) Fast repetitions (60, 75, 100 bpm) Static hold time (up to 45 seconds) Repetitions per 30 or 45 second trial repetitions in sync with metronome control over water Improved height Improved step length Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stepping limb Hip flexion (minimize pelvic elevation if possible) land with heel first or foot flat (determine if possible in AFO) relaxed stable trunk Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 38 Squish the pom pom Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected Roll a pom pom within reach of less affected LE; individual squishes pom pom Size of pom pom Predictable placement of pom pom to promote weight shift over stance limb forward, lateral, backward, diagonal, cross midline Random placement of pom pom Speed of delivery/repetitions per trial Number of pom poms squished Control of stance limb Improved hip extension (standing straight) Improved speed Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 39 Squish the pom pom Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, stand on foam (or wedge) Stance limb on foam, roll a pom pom within reach of less affected LE; individual squishes pom pom Size of pom pom Predictable placement of pom pom to promote weight shift over stance limb forward, lateral, backward, diagonal, cross midline Random placement of pom pom Speed of delivery/repetitions per trial Number of pom poms squished Control of stance limb Improved hip extension (standing straight) Improved speed Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 40 Squish the pom pom Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, hold cup of water Hold a glass of water, roll a pom pom within reach of less affected LE; individual squishes pom pom Type of container holding water and/or amount of water (less or more open/full) Size of pom pom Predictable placement of pom pom to promote weight shift over stance limb forward, lateral, backward, diagonal, cross midline Random placement of pom pom Speed of delivery/repetitions per trial Number of pom poms squished control over water Control of stance limb Improved hip extension (standing straight) Improved speed Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 41 Squish the pom pom Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, stand on foam, hold cup of water Stance limb on foam, hold a glass of water, roll a pom pom within reach of less affected LE; individual squishes pom pom Type of container holding water and/or amount of water (less or more open/full) Size of pom pom Predictable placement of pom pom to promote weight shift over stance limb forward, lateral, backward, diagonal, cross midline Random placement of pom pom Speed of delivery/repetitions per trial Number of pom poms squished control over water Control of stance limb Improved hip extension (standing straight) Improved speed Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 42 Squish the pom pom Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, level surface roll a pom pom within reach of more affected LE; individual squishes pom pom Size of pom pom Predictable placement of pom pom to promote reaching with swing limb forward, lateral, backward, diagonal, cross midline Random placement of pom pom Speed of delivery/repetitions per trial Number of pom poms squished Quality of initial contact Limb extension to reach pom pom Limb coordination to reach pom pom Improved speed Swing limb Hip flexion adaptive response: flexion, abduction, extension, adduction limb extension stable, quick, spontaneous foot contact Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 43 Squish the pom pom Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, stand on foam Stand on foam, less affected, roll a pom pom within reach of more affected LE; individual squishes pom pom Size of pom pom Predictable placement of pom pom to promote reaching with swing limb forward, lateral, backward, diagonal, cross midline Random placement of pom pom Speed of delivery/repetitions per trial Number of pom poms squished Quality of initial contact Limb extension to reach pom pom Limb coordination to reach pom pom Improved speed Swing limb Hip flexion adaptive response: flexion, abduction, extension, adduction limb extension stable, quick, spontaneous foot contact Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 44 Squish the pom pom Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, hold cup of water Hold a cup of water; roll a pom pom within reach of more affected LE; individual squishes pom pom Type of container holding water and/or amount of water (less or more open/full) Size of pom pom Predictable placement of pom pom to promote reaching with swing limb forward, lateral, backward, diagonal, cross midline Random placement of pom pom Speed of delivery/repetitions per trial Number of pom poms squished Quality of initial contact control over water Limb extension to reach pom pom Limb coordination to reach pom pom Improved speed Swing limb Hip flexion adaptive response: flexion, abduction, extension, adduction limb extension stable, quick, spontaneous foot contact Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 45 Squish the pom pom Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, stand on foam, hold cup of water Stand on foam, less affected; hold a cup of water; roll a pom pom within reach of more affected LE; individual squishes pom pom Type of container holding water and/or amount of water (less or more open/full) Size of pom pom Predictable placement of pom pom to promote reaching with swing limb forward, lateral, backward, diagonal, cross midline Random placement of pom pom Speed of delivery/repetitions per trial Number of pom poms squished Quality of initial contact control over water Limb extension to reach pom pom Limb coordination to reach pom pom Improved speed Swing limb Hip flexion adaptive response: flexion, abduction, extension, adduction limb extension stable, quick, spontaneous foot contact Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 46 Kick the golf ball, SB Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected Kick a golf ball to a target, less affected limb Use with a SB or without Stationary ball or rolled ball Distance of target Width of target Position of target Limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Stability in stance limb and trunk Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 47 Kick the golf ball, SB Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, stand on foam (or wedge) Stand on foam; kick a golf ball to a target, less affected limb Use with a SB or without Stationary ball or rolled ball Distance of target Width of target Position of target Limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Stability in stance limb and trunk Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 48 Kick the golf ball, SB Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, hold cup of water Hold a glass of water; Kick a golf ball to a target, less affected limb Type of container holding water and/or amount of water (less or more open/full) Use with a SB or without Stationary ball or rolled ball Distance of target Width of target Position of target Limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Control over water Stability in stance limb and trunk Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 49 Kick the golf ball, SB Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, stand on foam, hold cup of water Stand on foam, hold a glass of water; kick a golf ball to a target, less affected limb Type of container holding water and/or amount of water (less or more open/full) Use with a SB or without Stationary ball or rolled ball Distance of target Width of target Position of target Limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Control of water Stability in stance limb and trunk Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 50 Kick the golf ball, SB Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected Kick a golf ball to a target, more affected limb Use with a SB or without Stationary ball or rolled ball Distance of target Width of target Position of target Limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Control of ankle/use of foot and ankle to strike ball Swing limb Knee flexion eccentric knee extension concentric hip flexion/knee extension dorsiflexion low-limb clearance Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 51 Kick the golf ball, SB Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, stand on foam Stand on foam; kick a golf ball to a target, more affected limb Use with a SB or without Stationary ball or rolled ball Distance of target Width of target Position of target Limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Control of ankle/use of foot and ankle to strike ball Swing limb Knee flexion eccentric knee extension concentric hip flexion/knee extension dorsiflexion low-limb clearance Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 52 Kick the golf ball, SB Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, hold cup of water hold a glass of water; kick a golf ball to a target, more affected limb Type of container holding water and/or amount of water (less or more open/full) Use with a SB or without Stationary ball or rolled ball Distance of target Width of target Position of target Limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Control of water Control of ankle/use of foot and ankle to strike ball Swing limb Knee flexion eccentric knee extension concentric hip flexion/knee extension dorsiflexion low-limb clearance Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 53 Kick the golf ball, SB Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, stand on foam, hold cup of water Stand on foam; hold a glass of water; kick a golf ball to a target, more affected limb Type of container holding water and/or amount of water (less or more open/full) Use with a SB or without Stationary ball or rolled ball Distance of target Width of target Position of target Limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Control of water Control of ankle/use of foot and ankle to strike ball Swing limb Knee flexion eccentric knee extension concentric hip flexion/knee extension dorsiflexion low-limb clearance Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 54 Kick the disc Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected Kick a disc to a target, less affected limb Size of disc (Frisbee, floor protector, large button, small button) Distance of target Width of target Position of target/limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Size of disc Stability in stance limb and trunk Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 55 Kick the disc Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, stand on foam (or wedge) Stand on foam, more affected; kick a disc to a target, less affected limb Size of disc (Frisbee, floor protector, large button, small button) Distance of target Width of target Position of target/limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Size of disc Stability in stance limb and trunk Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 56 Kick the disc Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, hold cup of water Hold a glass of water, kick a disc to a target, less affected limb Type of container holding water and/or amount of water (less or more open/full) Size of disc (Frisbee, floor protector, large button, small button) Distance of target Width of target Position of target/limb starting position (neutral, trailing, terminal stance) # times target hit control over water Distance achieved Path of object Size of disc Stability in stance limb and trunk Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 57 Kick the disc Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected, stand on foam, hold cup of water Stand on foam, more affected; hold a glass of water, kick a disc to a target, less affected limb Type of container holding water and/or amount of water (less or more open/full) Size of disc (Frisbee, floor protector, large button, small button) Distance of target Width of target Position of target/limb starting position (neutral, trailing, terminal stance) # times target hit control over water Distance achieved Path of object Size of disc Stability in stance limb and trunk Stance limb Hip extension forward, lateral, posterior progression knee control (avoid hyperextension, emphasize flexion) ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 58 Kick the disc Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected kick a disc to a target, more affected limb Size of disc (Frisbee, floor protector, large button, small button) Distance of target Width of target Position of target/limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Size of disc Stability in stance limb and trunk Swing limb Knee flexion eccentric knee extension concentric hip flexion/knee extension dorsiflexion low-limb clearance Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 59 Kick the disc Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, stand on foam Stand on foam (less affected) kick a disc to a target, more affected limb Size of disc (Frisbee, floor protector, large button, small button) Distance of target Width of target Position of target/limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved Path of object Size of disc Stability in stance limb and trunk Swing limb Knee flexion eccentric knee extension concentric hip flexion/knee extension dorsiflexion low-limb clearance Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 60 Kick the disc Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, hold cup of water Hold cup of water, kick a disc to a target, more affected limb Size of disc (Frisbee, floor protector, large button, small button) Distance of target Width of target Position of target/limb starting position (neutral, trailing, terminal stance) # times target hit Distance achieved control over water Path of object Size of disc Stability in stance limb and trunk Swing limb Knee flexion eccentric knee extension concentric hip flexion/knee extension dorsiflexion low-limb clearance Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 61 Kick the disc Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, stand on foam, hold cup of water Stand on foam less affected, hold a cup of water, kick a disc to a target, more affected limb Size of disc (Frisbee, floor protector, large button, small button) Distance of target Width of target Position of target/limb starting position (neutral, trailing, terminal stance) # times target hit control over water Distance achieved Path of object Size of disc Stability in stance limb and trunk Swing limb Knee flexion eccentric knee extension concentric hip flexion/knee extension dorsiflexion low-limb clearance Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 62 Dont squish the birdie Stance, more affected Activity Description Place birdies or birdies and cones around the moving limb; touch birdie or cone with heel or toe Position of birdies/cones Birdies only or birdies and cones Number of birdies/cones Pattern of birdies and cones (repetitive, random) Starting position of stepping limb (bilateral, trailing) Return to start or move to birdies/cones Number of objects used Number of hits without squishes Repetitions per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results 63 Dont squish the birdie Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; stand on foam Stand on foam with more affected; place birdies or birdies and cones around the moving limb; touch birdie or cone with heel or toe Position of birdies/cones Birdies only or birdies and cones Number of birdies/cones Pattern of birdies and cones (repetitive, random) Starting position of stepping limb (bilateral, trailing) Return to start or move to birdies/cones Number of objects used Number of hits without squishes Repetitions per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 64 Dont squish the birdie Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; holding cup of water Hold a glass of water; Place birdies or birdies and cones around the moving limb; touch birdie or cone with heel or toe Type of container holding water and/or amount of water (less or more open/full) Position of birdies/cones Birdies only or birdies and cones Number of birdies/cones Pattern of birdies and cones (repetitive, random) Starting position of stepping limb (bilateral, trailing) Return to start or move to birdies/cones Number of objects used Number of hits without squishes Control over water Repetitions per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 65 Dont squish the birdie Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; holding cup of water AND standing on foam Hold a glass of water and standing on foam; Place birdies or birdies and cones around the moving limb; touch birdie or cone with heel or toe Type of container holding water and/or amount of water (less or more open/full) Position of birdies/cones Birdies only or birdies and cones Number of birdies/cones Pattern of birdies and cones (repetitive, random) Starting position of stepping limb (bilateral, trailing) Return to start or move to birdies/cones Number of objects used Number of hits without squishes Control over water Repetitions per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 66 Dont squish the birdie Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, level surface place birdies or birdies and cones around the moving limb; touch birdie or cone with heel or toe Position of birdies/cones Birdies only or birdies and cones Number of birdies/cones Tap with heel or toe (predictable or random) Pattern of birdies and cones (repetitive, random) Starting position of stepping limb (bilateral, trailing) Return to start or move to birdies/cones Number of objects used Number of hits without squishes Repetitions per 30 or 45 second trial Repetitions in sync with metronome Quality of contact (heel/toe) Improved speed Improved control (slower speed) Swing limb Hip flexion (goal: from trailing limb position) Initial contact Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 67 Dont squish the birdie Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; stand on foam Stand on foam; place birdies or birdies and cones around the moving limb; touch birdie or cone with heel or toe Position of birdies/cones Birdies only or birdies and cones Number of birdies/cones Tap with heel or toe (predictable or random) Pattern of birdies and cones (repetitive, random) Starting position of stepping limb (bilateral, trailing) Return to start or move to birdies/cones Number of objects used Number of hits without squishes Repetitions per 30 or 45 second trial Repetitions in sync with metronome Quality of contact (heel/toe) Improved speed Improved control (slower speed) Swing limb Hip flexion (goal: from trailing limb position) Initial contact Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 68 Dont squish the birdie Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; holding cup of water place birdies or birdies and cones around the moving limb; touch birdie or cone with heel or toe Type of container holding water and/or amount of water (less or more open/full) Position of birdies/cones Birdies only or birdies and cones Number of birdies/cones Tap with heel or toe (predictable or random) Pattern of birdies and cones (repetitive, random) Starting position of stepping limb (bilateral, trailing) Return to start or move to birdies/cones Number of objects used Number of hits without squishes Control over water Repetitions per 30 or 45 second trial Repetitions in sync with metronome Quality of contact (heel/toe) Improved speed Improved control (slower speed) Swing limb Hip flexion (goal: from trailing limb position) Initial contact Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 69 Dont squish the birdie Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; holding cup of water AND standing on foam place birdies or birdies and cones around the moving limb; touch birdie or cone with heel or toe Type of container holding water and/or amount of water (less or more open/full) Position of birdies/cones Birdies only or birdies and cones Number of birdies/cones Tap with heel or toe (predictable or random) Pattern of birdies and cones (repetitive, random) Starting position of stepping limb (bilateral, trailing) Return to start or move to birdies/cones Number of objects used Number of hits without squishes Control over water Repetitions per 30 or 45 second trial Repetitions in sync with metronome Quality of contact (heel/toe) Improved speed Improved control (slower speed) Swing limb Hip flexion (goal: from trailing limb position) Initial contact Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 70 Auto steps Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Bilateral Use theraband to encourage ankle strategy; release theraband slightly with unpredictable timing to promote stepping response Predictability of release Direction of sway Amount of sway EO/EC Successful catches without assist per 30 or 45 second trial Stability of limbs Stability of trunk Automatic postural reactions Ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 71 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected Less affected on kick ball Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 72 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; stand on foam Stand on foam, Less affected on kick ball Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 73 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; EC Less affected on kick ball, EC Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 74 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; reach for object Less affected on kick ball, reach for object Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Stance limb Hip extension forward progression knee control (use wedge to help control hyperextension if necessary) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 75 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; holding cup of water Hold cup of water; Less affected on kick ball Type of container holding water and/or amount of water (less or more open/full) Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Control of water Improved control (slower speed) Stance limb Hip extension forward progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 76 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance, more affected; head turns Less affected on kick ball, while simultaneously looking to specific direction (Left, right, up, down, diagonal right, diagonal left, random) Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Control of water Improved control (slower speed) Balance with head turns Stance limb Hip extension forward progression knee control (avoid hyperextension, emphasize flexion) ankle stability/ankle strategy Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 77 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, level surface More affected on kick ball Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Swing limb coordination of swing limb, light and moveable Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 78 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, EC More affected on kick ball, EC Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Swing limb coordination of swing limb, light and moveable Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 79 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected, reach for object more affected on kick ball, reach for object Position of object Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Swing limb coordination of swing limb, light and moveable Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 80 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; stand on foam Stand on foam, more affected on kick ball Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Swing limb coordination of swing limb, light and moveable Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 81 Flamingo on kick ball Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Swing, more affected; head turns more affected on kick ball, while simultaneously looking to specific direction (Left, right, up, down, diagonal right, diagonal left, random) Hold foot on ball Roll ball A/P with foot on it Roll ball lateral with foot on it Roll ball in circle (switch directions each trial) with foot on it Roll ball with foot on it, respond to random direction Time foot on ball per 30 or 45 second trial Repetitions in sync with metronome Improved hip extension (standing straight) Improved speed Improved control (slower speed) Swing limb coordination of swing limb, light and moveable Adaptive limb response (hip abduction, hip extension, hip adduction) Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Repetitions per trail (record for each of 10 trials) Seconds per trail in which beat was maintained (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 82 Stand on one leg Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results Stance stability, more and less affected Stand on one leg progression [ ] less affected leg first, using UE support if needed [ ] allow standing rest between trials to shake-out limb [ ] BUE >> less affected UE >> more affected UE >> no BUE support (start with the least amount of support needed) [ ] Once 25 30 seconds is achieved per trial, add in EC or foam [ ] follow same progression with more affected LE Stance limb Maximum hold per trial Total seconds per set QOM Maximum hold time Adding seconds to totalthat is good quietness of stance/relaxed upper body and limbs QOM: hip and trunk extension; symmetry of weight; weight on more affected; knee control Stance limb hip extension trunk extension knee control (use wedge if needed) ankle control static dynamic Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done 83 Dips Activity Description Parameters to Shape Potential Feedback Parameters Movements Emphasized Recorded Results stance Stand on stool, lower limb NWB limb to ground, return to stool, repeat Alternate sides per trial; allow standing rest in any position within trial as needed Reps per trial L/R reps Total reps per set Range of movement (control with stool height, use two side by side if necessary to have just a small difference) QOM (symmetry, hip and trunk extension) Number of reps/trial Decreasing rest time within trial effort quietness of stance/relaxed upper body and limbs QOM: hip and trunk extension; symmetry of weight; weight on more affected; knee control strengthening hip extension knee extension concentric/eccentric gastroc trunk extension knee control Before (minimum) and after (maximum) RPE HR max from HR monitor Shaping parameter Two, one or no UE assist Trial time (30 or 45 seconds) Successes per trial (record for each of 10 trials) In notes: indicate if AFO was worn; recommendations for continuing or progressing or modifying the activity; any signs of intolerance and what was done  ...

... SPIDER ILLUSTRATION By Elizabeth Wells An Honors Project submitted to the University of Indianapolis Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Dr. Marc Milne. August 31, 2017. Approved by: __________________________________________________________________ Marc Milne, Faculty Advisor ______________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College ______________________________________________________________________ First Reader ______________________________________________________________________ Second Reader Abstract The erigonine subfamily (family linyphiidae) currently consists of about 2,000 tiny (< 2mm) spiders. Little is known about their taxonomy and classification due to their small size and that female erigonines lack a taxonomic key to aid in species identification (Hormiga 2000). Therefore, in order to identify erigonine females, their epigyna (female reproductive structures) must be examined at 30-120x magnification using a dissecting microscope and compared against existing illustrations or photographs of known species (Sandlin 2011). Illustrations serve as efficient visual aids for identification because they are simplified and emphasize key parts of the animals. However, many erigonine illustrations are old (pre-1940s), poor in quality, and may be inaccurate (Blake 1892). To improve the ability of researchers to identify erigonines, females from eight species that currently possess insufficient material for proper identification were selected for illustration. Spider epigyna were then illustrated free-hand using pencil, pen, and a sketch pad while observing specimens under a dissecting microscope. Drawings were then edited in Photoshop to fix small errors and enhance the background. Upon completion, these illustrations were put on display on the LinEpig (short for Linyphiidae epigyna) website hosted by the Field Museum of Chicago, where they currently accompany erigonine epigyna photographs taken by Nina Sandlin (Sandlin 2011). E. Wells iii Special thanks to : Dr. Marc Milne Nina Sandlin and the Field Museum of Chicago California Academy of Sciences Museum of Comparative Zoology Dr. Kevin Gribbins Prof. James Viewegh My Mother E. Wells iv Table of Contents Cover Page ............................................................................................................... i Abstract .................................................................................................................. ii Acknowledgement ................................................................................................. iii Statement of Purpose ...............................................................................................1 Introduction ..............................................................................................................1 Method/Procedure ....................................................................................................5 Analysis/Conclusion ................................................................................................6 Reflection .................................................................................................................7 References ................................................................................................................8 Appendices ......................................................................................................... 9-27 Appendix A: CITI Training .........................................................................9 Appendix B: Product Produced..11 Appendix C: Work Development...16 E. Wells 1 Statement of Purpose The purpose of this project was to create clearer visual aids than were currently available for scientists and naturalists wishing to identify female dwarf spiders from the sub-family Erigoninae. My goal was to illustrate the reproductive structures of 5-10 female erigonine spiders, emphasizing the key characteristics that distinguish each spider. The species that I used for these illustrations were selected from collections from the Field Museum of Natural History, the California Academy of Sciences, the Museum of Comparative Zoology, and my advisor. These illustrations were first drawn in pencils and pens and then finished digitally in Photoshop. The illustrations are displayed on the website of the Field Museum of Natural History alongside photographs taken by Nina Sandlin. Introduction The Erigoninae is a subfamily of the Linyphiidae and consists of incredibly small sheet-web weaving spiders. These spiders range from 1-6mm, although most are approximately 2mm (Hormiga, 2000). They are so small that they are able to travel through the air by a process called ballooning, which involves releasing loops of silk that catch wind and lift the spider for aerial distribution (one may think of the spiders in Charolettes web for example). These spiders place their webs on the ground, usually under and on leaves, where they weave convex, sheet-shaped webs to catch their prey. Prey items are small and mostly consist of herbivorous insects, such as aphids and springtails. E. Wells 2 Linyphiidae is the second most diverse spider family in the world and is the most diverse group in North America. There are about 4,533 species of linyphiid spiders, and Erigoninae is its largest subfamily within this taxa (World Spider Catalog, 2016). This subfamily consists of at least 2,000 species, 650 of which are in North America (Hormiga, 2000). However, while Linyphiidae itself has now been divided into 601 genera, classification within Erigoninae is highly debatable and in much need of revision (World Spider Catalog, 2016). As a result, many of these spiders binominal nomenclatures change as revisions are made to their phylogenetic relationships. Studies in spider taxonomy require collecting and then preserving spiders. Collection of this group of spiders is accomplished through both active and passive methods. The active methods include the use of hand tools, such as sweep nets, beat sheets, sifters, and aspirators. The passive methods include the use of traps, such as pitfall traps or Berlese funnels. Once the spiders have been caught, they are immediately stored in ethanol alcohol to kill and preserve the specimens (Cushing, 2005). Spiders that are being evaluated for species identification are taken out of the storing alcohol and examined microscopically. For this type of analysis, there are also multiple preparatory techniques. A common technique is to place the spider in a dish of sand to stabilize the specimen and then submerge it in alcohol to keep it preserved, after which it is then placed under a dissecting microscope. This allows one to more easily observe the outer structure of the spider, as well as examine some internal structures that are visible through more transparent tissues of the specimen. To more closely examine the internal structure of the reproductive parts of female specimens, the spiders E. Wells 3 epigynum may be placed in clove oil or a 10% KOH solution to digest the outer soft tissue exposing internal anatomical structures. For detailed analysis of external features, the use of a scanning electron microscope (SEM) may also be used (Hormiga, 2000). One of the advantages of the SEM is that it allows one to see more surface detail of the specimen. However, the processes necessary to prepare and view a specimen under the SEM may alter the specimens shape. Further details, such as color of the specimen, cannot be visualized in this technique, which may be useful to identification of the spider. E. Wells 4 Spider identification guides have clear descriptions of taxa, and species descriptions are often accompanied by illustrations of their reproductive structures as further aid for identification (e.g. Bishop, 1930). The reproductive organs are generally illustrated because these structures are highly specialized for each species of spider to prevent crossbreeding between species (Foelix, 1996). Thus, these structures allow for successful speciation and therefore accurately Figure 2. Bishops Figure 1. Blakes(1930) (1892)illustration illustrationofof Corniculara formosa Neophanes pallidus morphologically delineate species boundaries. The male reproductive organs are present on the spiders pedipalps (a structure present in both males and females but altered in males to store sperm), while the females reproductive structure is called the epigynum, where eggs are developed internally after mating (Foelix, 1996). Many identification guides have very simple illustrations without sufficient details, such as clear distinction of external form or internal organs (Figure 1). The simplicity of these drawings may lead the researcher to misidentify the species. This is especially seen in many older illustrations, such as The Spider Fauna of the Upper Cayuga Lake Basin (Blake, 1892). Other illustrative guides, such as Studies in American Spiders: Genera Ceratinopsos, Ceratinopsidis and Tutaibo (Bishop, 1930) show a combination of outline, stippling (making patterns through dots), and shading to give the reader a better understanding of the identification structures for that species (Figure 2). The most recent illustrative guides show a combination of pen and pencil techniques to outline and shade illustrations to create a realistic depiction of the structures in question E. Wells 5 (e.g. Paquin and Duperre, 2003). Because of their accuracy and ability to point out minute details, these latest iterations of illustrations are the best method by which proper species identifications may be made. Spider identification guides may also be accompanied by photographs. Like illustrations, photographs are useful for distinguishing between species. The process for photographing a spider is slightly similar to that of illustrating it. A spider is first placed in sand and alcohol and posed effectively. The spider is then cleaned from all debris before photographing and is afterwards edited in Photoshop. The final product allows one to Figure 3. Crosby and Bishop's (1925) illustration of Ceratinella brunnea see the form of the spider as well as color differentiation (Sandlin 2011). In the case of tiny spiders such as erigonines however, the photographs are blurry due to the need for such high magnification. The image quality may be so poor in some cases that it is almost impossible to distinguish species. Illustrations are then preferred to photographs because, if drawn well, they offer a clearer image and highlight the critical structures needed for identification. Multiple older illustrations of spiders exist that are still used today despite the availability of photographs, due to clarity and highlight of structures (Figure 3). In fact, this preference for illustrations extends to peer-reviewed scientific journals. For example, Zootaxa, a large, peer-reviewed, international journal for zoology publications (including those of E. Wells 6 arachnology) instructs authors that line drawings are preferred to photographs (Zootaxa, 2014). Despite the limitations of photography, for many species of female erigonine spiders this is the only visual reference available. These images have recently been created by Nina Sandlin, a taxonomist at the Field Museum of Chicago. She has photographed more than 290 female erigonine species to date. She updates her images onto a one of a kind online database called LinEpig, (found on the website of the Field Museum of Chicago). Compared to other photographs of tiny spiders found in journals, the images on this database are of good quality. The images show distinctions in form, inner organs, and color. This allows them to be used by Figure 4. Sandlin's (2011) photograph of Ceraticelus atriceps arachnologists around the world to identify females of these small, hard-to-identify spiders (Sandlin n.d). However, illustrations would greatly supplement this database due to the ability of illustrations to pull out minute details that photographs may miss. Method/Procedure This project was overseen by my advisor, Dr. Marc Milne. In addition, I received some guidance from Prof. James Viewegh on my illustrations and from Dr. Kevin Gribbins about making a final product in Photoshop. Throughout the project, I E. Wells 7 documented my progress via photograph starting with beginning sketches and finishing with the completed product. I started the first stage of the project by figuring out which species keys would most benefit from updated illustrations. This was done by Dr. Milne and Nina Sandlin (an erigonine expert at the Field Museum of Chicago) by examining the existing literature and illustrations of female erigonines. Once a list of needed species was obtained, I chose eight species to illustrate. I received these spiders through my professors collection, and through loans from the California Academy of Science and the Museum of Comparative Zoology at Harvard. Upon receiving the loans, I took one spider at a time to pose and illustrate. To do this, I placed the spiders in shallow dishes with fine sand added to stabilize them and ethyl alcohol to keep them preserved. I then placed them under a dissecting microscope so that I could arrange and examine the specimens. I drew the epigynum of each spider in a sketchbook with pencil and pen. This part of the project took up the majority of my time and I often had to redraw and revise my illustrations until they were accurate representations. Dr. Milne helped me to assure this accuracy by assessing my illustrations and allowing me to use his microscope to examine the spiders under higher magnification than I possessed. To further assist my accuracy, he photographed the spiders at 120x magnification and I was then able to use both photographs and the actual specimen to create the illustrations. Once the illustrations were completed by hand, I finished them digitally in Photoshop. For this part of the project, I transferred the illustrations into a digital format via a scanner. I then digitally removed the background (to create a blank white E. Wells 8 background), added onto the image where anatomical parts of the spider were missing, fixed any errors, and otherwise finished the illustrations into a polished and final project. After digitally editing the illustrations, I sent the final images to Nina Sandlin at the Field Museum. There the images were published on the museums website in the LinEpig ID gallery, where they accompany photographs Nina uses to help researchers with species identification. To display my completed project I created a poster containing all eight finished illustrations. This is accompanied by my sketchbook drawings, copies of my finished digital images, and photographs of my work in progress. In addition to presenting my work for Honors College, I presented my poster at the Indiana Academy of Science meeting in March 2016. Analysis/Conclusion I believe the work that I have created effectively depicts the key parts of each spider needed for identification. They have been created using illustration techniques generally used to create successful identification pieces (Paquin and Duperre, 2003). They are satisfactory to both my advisor and the museum for which they have been drawn and so require no further revision. Should the illustrations ever need to be revised however, it would be rather simple to switch out an image with an updated one. These illustrations are perhaps not my most aesthetically pleasing pieces, but are not meant to be and are certainly not the easiest to create. That being said, they have a beauty of their own that I find quite interesting. I therefore find this project to have been successful accomplished. E. Wells 9 Reflection I learned that drawing spiders is not as simple as it appears. At first I thought it might be like drawing animals that I am accustomed to. I have a great passion for drawing vertebrate animals and find myself able to form their shapes quite readily. Drawing spider epigyna is not like drawing vertebrates. It is more like drawing alien and almost abstract art, but in such a way that is still true and even essential to the animals form and identity. This is something which I had never done and so this project required a rather large learning curve for me. I can say then that I have learned a lot by doing this project. Not only have I learned how to draw erigonine spiders, but I also learned factual information and the science surrounding these organisms. I have done this by learning to capture and preserve spiders myself and to note the differences between species. I have learned about the taxonomy of erigonines and how difficult a task their classification is. I have been able to see how scientists go about identifying and classifying these species and how they aid each other through collaboration. Finally, I have had the opportunity to contribute to this collaboration by producing images that scientists will continue to use long after this project is completed. E. Wells 10 References Bishop, S. Crosby, C. (1925). Studies in New York Spiders: Genera Ceratinella and Ceraticelus. University of the State of New York. No 264. Bishop, S. Crosby, C. (1930). Studies in American Spiders: Genera Ceratinopsis, Ceratinopsidis and Tutaibo. Journal of the New York Entemological Society. 38th ed. pp. 15-33. Blake, N. (1892). The Spider Fauna of the Upper Cyuga Lake Basin. Proceedings of the Academy of Natural Sciences of Philadelphia. 44th ed. pp. 11-81. Cushing, P.E. Paquin, P. Roth, V. Ubick. (2005). Spiders of North America: an identification manual. New Hampshire: Arachnological Society. Duperre, N. (2013). Zootaxa. New Zealand, Auckland: Magnolia Press. Foelix, R. (1996). Biology of Spiders. New York: Oxford University Press. 2nd ed. Hormiga, G. (2000). Higher Level Phylogenetics of Erigonine Spiders (Araneae, Linyphiidae, Erigoninae). Washington, D.C: Smithsonian Institution Press. Lissner, J. (2011). The Spiders of Greenland. Retrieved 2015. Retrieved from http://www.jorgenlissner.dk/greenlandspiders.aspx Paquin, P. Duperre, N. (2003). Guide didentification des araginees (Araneae) du Quebec. Association des entomologists amateurs de Quebec. Sandlin, N. (n.d) About the Project. Retrieved 2015. Retrieved from fieldmuseum.org/science/special-projects/dwarf-spider-id-gallery/about-project Sandlin, N. (2011). LinEpig at the Scientific American. The Field Museum of Chicago. Retrieved 2016. Retrieved from https://www.fieldmuseum.org/science/blog/linepig-scientific-American. Sandlin, N. (2012). 200 Species in LinEpig Dwarf Spider Gallery. Retrieved 2015. Retrieved from fieldmuseum.org/science/blog/200-species-linepig-dwarf-spidergallery World Spider Catalog (2016). Family: Linyphiidae Blackwall, 1859. Natural History Museum Bern. Retrieved 2016. Retrieved from http://wsc.nmbe.ch/familydetail/48. Zootaxa. (2014). Information for authors. Magnolia Press. Retrieved 2016. Retrieved from http://www.mapress.com/zootaxa/support/author.html E. Wells 11 Appendices Appendix A: CITI Training E. Wells 12 E. Wells 13 Appendix B: Product Produced Finished Digital Works E. Wells 14 E. Wells 15 E. Wells 16 E. Wells 17 Poster Iiogu8og9pgi u b feaehh E. Wells 18 Appendix C: Work Documentation E. Wells 19 Practice Styloctetor purporescens E. Wells 20 Originatus rostratus E. Wells 21 Montilaria uta E. Wells 22 E. Wells 23 Ceraticelus savannus E. Wells 24 Collinsia perplexus E. Wells 25 Collinsia ksenia E. Wells 26 Idionella Formosa E. Wells 27 E. Wells 28 Scylaceus pallidus E. Wells 29  ...

... Running head: SEXUAL RECOVERY PROGRAMMING 1 Sexual Recovery Programming: A Mechanism for Influencing Occupational Therapy Practice Methods Kelsie Long 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: Beth Ann Walker, PhD, OTR SEXUAL RECOVERY PROGRAMMING 2 A Capstone Project Entitled Sexual Recovery Programming: A Mechanism for Influencing Occupational Therapy Practice Methods 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 Kelsie Long 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 SEXUAL RECOVERY PROGRAMMING 3 Abstract Neglecting to address sexuality in OT practice contributes to societal oppression and deprives individuals with disabilities from exploring this occupation (Sakellariou & Sim Algado, 2006a). Therapist discomfort, lack of educational preparedness, and not having enough time are some noted barriers to addressing sexuality in OT practice (Hattjar, 2012). This Doctoral Capstone Experience (DCE) explored the inclusion of sexuality and intimacy in practice at Community Rehabilitation Hospital. Following a needs assessment, a gap was found in provision of holistic practice methods. Former patients were concerned about sex post injury, but these needs went unresolved as therapists never initiated the conversation of sexuality during patient recovery. Knowledge and time were identified by OT clinicians as the greatest barriers to implementation of sexuality. Sexual recovery programming was designed to address the gap through creating a screening tool, developing resources, leading patient education, and providing OT staff in-services. These implementation components were intended to increase confidence in abilities, debunk common myths and stigmas, and equip OT clinicians with knowledge to promote consistent incorporation of sexuality into OT practice. Sexual recovery programming created a professional and theoretical method for OT clinicians to address sexuality and intimacy with patients during the rehabilitation process. Based on these findings, an annual in-service and monthly discussions on addressing sexuality in healthcare were recommended for continuation of holistic service delivery. Similar methods should be pursued in additional practice areas to promote an inclusive healthcare environment and ensure client-centered practice through honoring the holistic values of the OT profession. SEXUAL RECOVERY PROGRAMMING 4 Introduction Sexuality is often portrayed as an intimate and taboo topic in an idealistic society. This societal view sets the foundation for stigmatization and promotes an exclusive environment, in terms of addressing sexuality, within the context of health care provision. The Occupational Therapy Practice Framework: Domain and Process, 3rd Edition recognizes sexual activity as an activity of daily living and identifies intimacy as a form of social participation (AOTA, 2014). Though sexual activity and intimacy are supported in the Occupational Therapy (OT) framework, OT clinicians are not addressing sexuality at a desired rate (McGrath & Sakellariou, 2016). Stigma of Sexuality and Disability The term sexuality is holistic in nature, encompassing components of the human experience. MacRae (2013) defines sexuality as, a core characteristic and formative factor for human beingsbasic to our sense of self (para 1). Mechanisms to express sexuality include holding hands, flirting, touching, kissing, masturbating, and having sexual intercourse (MacRae, 2013). Despite the recognition of sexuality as an aspect of humanity, societal norms often steer both direction and portrayal of sexuality. According to Tepper (2000), sex is portrayed as a privilege of the white, heterosexual, young, single, and non-disabled (p. 285). This stigma amplifies for individuals with disabilities, often leading to the notion of asexuality amongst this population (Tepper, 2000). Internalization of these societal views have the ability to affect confidence, desire, and self-concept (Esmail, Darry, Walter, & Knupp, 2010). In a focus group conducted by Fritz, Dillaway, & Lysack (2015), one participant who sustained a SCI offered perspective on the impact of societal perceptions. She stated, I think the hardest thing that Ive had to come to grips with is that people look at me as an asexual beingI just think its a SEXUAL RECOVERY PROGRAMMING 5 common response to women with disabilities (Fritz et al., 2015, p.7). These stigmas perpetuate negative bias towards sexuality and disability, which stifles potential for open conversation, education, and relevant information (Esmail et al., 2010). Individuals with disabilities are not immune to sexual or intimate feelings. As clinicians it is necessary to address sexuality, within the scope of OT practice, to promote healthy sexual expression and well-being. Barriers to Holistic Practice The field of OT has adopted a client-centered, holistic approach to patient care reflected in addressing psychosocial components along with physical or cognitive impairments. Considering this concept, electing to exempt sexuality from practice, challenges the values of the OT profession as a whole. The opportunity to explore the role of OT in terms of sexuality and disability begins in the classroom. Areskoug-Joefsson, Larsson, Gard, Rolander, & Juuso (2016) investigated attitudes of healthcare students towards addressing sexual health with patients. Researchers found physical therapy (PT) and OT students were not educated on sexual health at the rate of other healthcare students, and healthcare students as a whole did not feel prepared to address sexual health with patients (Areskough-Joefsson et al., 2016). This lack of educational preparation may influence practice methods of future OT clinicians. Hattjar (2012) outlines potential barriers to acknowledging sexuality consistently in OT practice. These contributing factors include: therapist discomfort, lack of educational preparedness regarding sexuality, assuming other health care disciplines are addressing the topic, and not having enough time due to productivity standards (Hattjar, 2012). As consumers of society, OT clinicians may also thread bias into practice, failing to recognize clients as sexual beings or address sexuality during the therapeutic process (Sakellariou & Sim Algado, 2006b). The failure to recognize sexuality in OT practice contributes to societal oppression and deprives individuals with disabilities of an SEXUAL RECOVERY PROGRAMMING 6 opportunity to explore this occupation, creating an occupational injustice (Sakellariou & Sim Algado, 2006a). McGrath & Sakellariou (2016) propose OT clinicians should view sexuality through a rights-based approach, emphasizing sexuality as a human right for individuals with disabilities (McGrath & Sakellariou, 2016). Overcoming these barriers will be essential to honoring the values of the OT profession and ensure provision of holistic and client-centered care. Sexual Recovery and Disability Individuals with life-altering disabilities such as stroke, traumatic brain injury (TBI), spinal cord injury (SCI), or amputation must learn to adapt occupations during the recovery process. Sexuality must not be excluded from the process of adaptation, as this occupation holds meaning to individuals recovering from injury. Sexual recovery, in this context, refers to the journey of sexual rediscovery and expression post injury (Beckwith & Kwai-sung Yau, 2013). This process of recovery should be guided by qualified healthcare professionals, namely OT clinicians, to promote holistic care (Fritz et al., 2015). Several studies have investigated client views of sexuality post injury. Beckwith & Kwai-song Yu (2013) and Fritz et al. (2015) explored perceptions of women post SCI finding that participants viewed resources received on sexuality as lacking. During the recovery process, no education or resources were provided directly by OT clinicians (Fritz et al., 2015). Robinson, Forest, Ellis, & Hargreaves (2011) suggested that resources on sexuality were outdated, poor quality, and focused on males. There is a distinct need to establish appropriate resources, as sexuality is a concern of individuals with disabilities post injury. Common concerns regarding sexuality post SCI have included lack of bowel and bladder control during intimacy (Robinson et al., 2011; Fritz et al., 2015). In addition, the impact of the caregiver role post injury, particularly when in a SEXUAL RECOVERY PROGRAMMING 7 relationship, has the potential to shift dynamics. Women with SCI felt objectified, degraded, and humiliated during times the partner assumed a caregiver role (Robinson et al., 2011, p. 16). It is critical for OT clinicians to assist clients with navigating these concerns and provide relevant resources. In a study on sexual health issues and individuals with physical disabilities and chronic disease, researchers found 67.0% of participants wanted help with sexuality and 9.0% did not know the appropriate health professional to contact (Kedde, Van De Wiel, Schultz, & Vanwesenbeek, 2016). The method of addressing sexuality in OT practice has neglected to incorporate client-centered interventions and has not accounted for specific needs of clients (Robinson et al., 2011). Song, Oh, Kim, & Seo (2011) conducted a 1-day sexual rehabilitation program for stroke patients and spouses and found sexual knowledge did not improve, but sexual satisfaction and frequency increased (Song et al., 2011). These findings support the need for OT clinicians to integrate sexual recovery in practice. Clients clearly have concerns about sexuality post injury, and it is the role of OT clinicians to initiate conversation and acknowledge the importance of addressing this widely neglected topic in practice. Recognition Model The process of integrating sexuality in practice poses a challenge for many OT clinicians. However, this challenge does not eliminate the need to address sexuality with clients during recovery. The Recognition Model was born from results of a research study that found individuals sexual needs were not being recognized by healthcare professionals at a desired rate (Couldrick, Sadlo, & Cross, 2010). This model sought to present an inclusive, systematic process to address sexuality in practice. Couldrick, Sadlo, & Cross (2010) identify the 4 stages of this model as follows: (stage 1) recognition of the service user as a sexual being, (stage 2) provision of sensitive, permission giving, strategies, (stage 3) exploration of the sexual problem/concern, SEXUAL RECOVERY PROGRAMMING 8 (stage 4) address issues that fit within the teams expertise and boundaries, and (stage 5) referral on when necessary. The first stage establishes the foundation for addressing sexuality with clients and requires the OT clinician to view sexuality as a natural component to the human experience. Once this open mindset has been embraced, the client is offered an opportunity to express any concerns. Should the client indicate disinterest in the topic, privacy is respected and sexuality is not addressed. However, if the client indicates interest, the therapist then collaborates with client to explore concerns, provide resources or relevant evidence-based intervention strategies, and identify wants and needs. These services should only be provided within the scope of OT practice, and a referral to another health specialist may be necessary in certain instances (Couldrick et al., 2010). This model was utilized as a tool and resource for OT clinicians to professionally and ethically guide the conversation of sexuality with clients who demonstrate interest. It was the basis for the sexual recovery program. The aim was to increase comfortability with discussion and provide support for initiating the topic. The structure of the Recognition model may also increase confidence with addressing sexuality within practice (Valvano et al., 2014). Sexual Assessment Framework Although navigating the realm of sexuality for OT clinicians may be a daunting task, an established guide to assess and treat may help to extinguish discomfort when approaching the topic. The Sexual Assessment Framework provides an inclusive approach to addressing seven components of sexuality (Kokesh, 2016). Kokesh (2016) outlines these components which include: Sexual Knowledge; Sexual Behavior; Sexual Self-View; Sexual Interest; Sexual Response; Fertility and Contraception; and Sexual Activity. Sexual knowledge encompasses the values of sexuality and supports client education, while Sexual Behavior focuses on the sexual SEXUAL RECOVERY PROGRAMMING 9 relationship. Sexual Self-View regards recognition of the self as a sexual being and Sexual Interest hones in on the desire component of sexual activity. Sexual Response includes the process of arousal and Fertility and Contraception refers to medication management. Sexual Activity involves client factors related to the act of sex (Kokesh, 2016). This framework was utilized and explored in conjunction with the Recognition Model to ensure a holistic approach to addressing sexuality in OT practice. Sexuality and Inpatient Rehabilitation Inpatient rehabilitation provides an ideal setting to address sexuality with clients. Community Health Network (https://www.ecommunity.com/services/inpatient-rehabilitation) is home to an inpatient rehabilitation facility (IRF) that serves individuals who have experienced SCI, amputation, TBI, and stroke. Inpatient rehab is intensive, as individuals must tolerate three hours of therapy per day, five to six days per week. There were no formal means of addressing sexuality at Community Rehabilitation Hospital, which created an opportunity for the development of a sexual recovery program aimed at integrating sexuality into OT practice. This program was devoted to sexual recovery for individuals with life-altering disabilities and implementation reflected the PRECEDE-PROCEED model. Gielen, McDonald, Gary, & Bone (2008) described this client-centered model as having a strong focus on health promotion and development of a foundation to apply ideals, through a series of phases, in order to plan and evaluate programs to create change. The first set of phases include: (phase 1) social assessment, (phase 2) epidemiological, behavioral, and environmental assessment, (phase 3) educational and ecological assessment, and (phase 4) administrative and policy assessment and intervention alignment. The second set of phases include: (phase 5) implementation, (phase 6) process evaluation, (phase 7) impact evaluation, and (phase 8) outcome evaluation (Gielen, McDonald, SEXUAL RECOVERY PROGRAMMING 10 Gary, & Bones, 2008). These phases served as a guide to plan and implement the sexual recovery program to bridge the gap in holistic service delivery regarding sexuality and disability. Methodology/ Instrumentation Designing the context of a sexual recovery program at Community Rehabilitation Hospital required extensive consideration of the current issue. OT clinicians are not addressing sexuality in practice and patients are experiencing a gap in holistic care as a result (Sakellariou & Sim Algado, 2006a). Investigating this neglected area of practice included an in-depth evaluation of service providers and consumers. Conduction of a needs assessment was the first step in determining current practice methods and establishing a sound foundation for sexual recovery programming (Bonnel & Smith, 2018). Participants Thirty OT clinicians and 286 former patients affiliated with the Community Rehabilitation Hospital support groups were invited to participate in a survey regarding sexuality and OT practice, specific to the IRF setting. Purposive sampling was utilized to recruit participants. Participant criteria included former patients who sustained SCI, amputation, TBI, or stroke, as well as licensed OT clinicians currently employed and practicing at the site. Former patients were required to be graduates of the inpatient rehabilitation process and sampling was achieved through contacting members of support groups who met inclusion criteria. The Program Lead of Community Rehabilitation Hospital served as the liaison, contacting support group members and eligible OT clinicians via e-mail. Two e-mails were drafted by the student investigator, which contained a brief description of the project. The e-mail specific to OT clinicians included the survey as an attached word document, while the e-mail to former patients included a link to an online survey. These drafts were then forwarded to participants by the SEXUAL RECOVERY PROGRAMMING 11 Program Lead. Individuals with SCI, amputation, TBI, or stroke were targeted specifically as these injuries are recognized as life-altering. AOTA (2016) describes a life-altering change as having to make many physical and psychological adjustments to be able to participate fully in everyday life (p. 1). Sexuality and intimacy after injury often requires these adjustments and modifications, which are within the scope of practice for OT clinicians (MacRae, 2013). Design and Procedure A mixed-methods approach was utilized to collect data on the perceptions of OT clinicians and former patients in relation to addressing sexuality and intimacy during the recovery process. Quantitative data were yielded from a survey, while qualitative data were developed from open-ended questions and informal interviews with OT staff. Informal interviews with OT staff were conducted in the acute therapy office at Community Rehabilitation Hospital. Respondents were contacted via e-mail and invited to participate in a voluntary survey with instructions to complete within one week. Anonymity of each participant was ensured to respect ethical guidelines. Printed copies of the survey were also available in designated locations for OT clinicians. Survey questions were formulated from themes identified in literature and included quantitative and qualitative components. The surveys and interview guide were reviewed by an associate professor of the School of Occupational Therapy at the University of Indianapolis, who has experience with survey development and research related to sexuality and disability. Suggestions for improvement were incorporated and necessary revisions were applied. Survey content, though qualitative and quantitative in nature, differed between OT clinicians and former patients. Both surveys focused on sexuality and intimacy. However, survey content for OT clinicians focused on clinical practice methods, while the patient survey focused on the experience of sexual recovery during the rehabilitation process. SEXUAL RECOVERY PROGRAMMING 12 Assessment of Need The patient survey was designed electronically and intended to identify specific needs of patients at this site. Evidence directed the survey content, as there continues to be a distinct need for sexuality to be addressed during the recovery process. Fritz et al. (2015) found women with SCI experienced significant challenges navigating sexual positioning in relation to level of injury. The only education these participants received on sexuality was related to reproduction post injury (Fritz et al., 2015). Kedde et al. (2016) found 50% of individuals with chronic disabilities wanted professional guidance with adapting to sexuality post-disability (Kedde et al., 2016). With respect to these literature findings, survey content focused on sexuality and intimacy in relation to type of injury, level of concern, availability of resources, and initiation of the topic during rehabilitation. Survey material consisted of 12 questions including multiple choice, yes or no, and open-ended. The survey distributed to OT clinicians was intentionally designed in pre-post format to measure level of comfortability, education, knowledge, attitudes, confidence, current practice methods, and barriers in regards to addressing sexuality in OT practice. In addition to the presurvey, an informal face-to-face group interview with OT staff and an informal face-to-face individual interview with the Director of Rehabilitation Services was conducted. These interviews were devised to gather feedback regarding current practice methods and provided an open forum for OT staff to offer input for sexuality program development. Interview and survey questions reflected current literature findings, which indicate that approaching the topic of sexuality is often difficult for patients, and healthcare professionals are not providing desired education (Esmail et al., 2010). Furthermore, intervention practices often do not include sexuality and intimacy, as the significance of integrating sexuality within healthcare is not SEXUAL RECOVERY PROGRAMMING 13 emphasized in academia (Esmail et al., 2010). Considering these findings, questions were aimed at understanding the perceptions of OT clinicians in regards to incorporating sexuality and intimacy into OT practice. The pre-post survey consisted of 16 items. Occupational therapy clinicians were informed of the intent and encouraged to refrain from participating in the post-survey if electing not to partake in the pre-survey, as this would negatively impact consistency of outcome measures. The format included multiple choice, 10-point rating scale, 5-point Likert scale, ranking of barriers, and one open-ended item. Participants were asked to rank perceived barriers from 1-5, 1 being the most prevalent barrier and 5 being the least prevalent barrier. These barriers included: Comfortability, Knowledge, Priority, Time, and Support. Occupational therapy clinicians were also asked to identify level of comfortability discussing sexuality with clients across 6 components on a 10-point rating scale, 1 being least comfortable and 10 being most comfortable. These 6 components included: initiating the conversation of sexuality, providing resources on sexuality and intimacy, discussing resources on sexuality and intimacy, incorporating scenarios regarding sexuality and intimacy in therapy sessions, educating on adaptive equipment utilized for sexual intercourse, and leading a support group focused on sexual recovery after a disability. Perceptions of the OT Clinician. There were a total of 11 OT clinicians (36.67%) who completed the attached pre-survey. However, it should be noted one participant partially completed the survey. Responses from this participant were considered only when presenting demographic information and data related to level of comfortability addressing sexuality with clients. Quantitative data were analyzed in Microsoft Excel. Demographic information for OT clinicians were coded and assigned a number prior to analysis. The level of experience varied among OT clinicians. Some had been practicing for 30+ years (27.27%, n=3), while others had SEXUAL RECOVERY PROGRAMMING 14 been practicing 0-5 years (36.36%, n=4). The majority held a Masters degree in OT (63.64%, n=7), and sexuality was recalled to be addressed only occasionally within their prior academic curricula (45.45%, n=5). With respect to level of confidence addressing sexuality and intimacy with clients, the majority of OT clinicians either strongly disagreed (40%, n=4) or disagreed (50%, n=5) with feeling confident in abilities. In regards to frequency of addressing sexuality in OT practice, most OT clinicians never addressed sexuality (54.55%, n=6). In addition, the majority of OT clinicians strongly disagreed they incorporated components of sexuality and intimacy into intervention sessions with clients (80%, n=8). For the purpose of this experience, addressing should be thought of as a general term intended to represent the OT process as a whole, while incorporating into intervention should be regarded as one method of addressing sexulality. Modes were calculated for barriers to integrating sexuality in OT practice. Occupational therapy clinicians ranked these barriers in the following order: (I) Knowledge, (II) Time, (III) Priority, (IV) Comfortability, and (V) Support. These findings highlighted knowledge as the most prevalent barrier. A total of 50% (n=5) of OT clinicians strongly disagreed with having adequate knowledge on sexuality and intimacy in relation to client care. While half of participants agreed sexuality and intimacy is essential to address in this practice setting (50%, n=5), the majority of respondents were impartial to OT clinicians being a designated healthcare provider to address the topic (70%, n=7). Averages were calculated in Microsoft Excel regarding level of comfortability discussing sexuality with clients and then ranked from least comfortable to most comfortable, according to the 10-point scale. In regards to sexuality and intimacy, participants were mildly uncomfortable discussing (5) and providing (4.73) resources and initiating the conversation (3.91). Participants were least comfortable leading a support group SEXUAL RECOVERY PROGRAMMING 15 (2.64), incorporating scenarios into therapy sessions (3.09), and educating on adaptive equipment utilized for intercourse (3.18). These findings connected to the informal feedback gained in face-to-face interviews. OT clinicians expressed concern with not having formal education or knowledge to provide adequate services related to sexuality. Consequently, some OT clinicians were most interested in hands-off resources, such as educational videos to offer patients. Most all participants wanted diagnosis specific resources related to sexuality and intimacy. Patient length of stay was also posed as a concern, as the IRF utilizes the Functional Independence Measure (FIM) to guide evaluation and intervention. One PT, who serves as the therapy lead and was present during the informal interview with the Director of Rehabilitation Services, commented on the documentation system. The PT mentioned the documentation system does not include sexuality and intimacy, which fails to cue therapists to address this component of care. The open-ended question of the survey, which allowed participants to identify additional barriers to integrating sexuality into OT practice, provided informative responses. One OT clinician commented on the impact of length of stay and prioritization of care, stating, there is such a short amount of time to accomplish so much. Cognitive barriers, not having supported handouts, and lack of knowledge base for specific diagnoses and interventions were also cited as barriers to integrating sexuality into OT practice. Understanding OT clinician perspectives on addressing sexuality and intimacy in practice allows for recognition of current issues in order to develop meaningful solutions. Perceptions of the Patient. Twenty-one former patients (7.34%) completed the electronic survey. The majority of participants were stroke survivors, with a 57.14% response rate (n=12). Four participants (19.05%) were individuals with SCI, while three (14.29%) participants had an amputation. Participants with TBI (4.76%, n=1) and a diagnoses identified as SEXUAL RECOVERY PROGRAMMING 16 other (4.76%, n=1) provided the lowest response rate. Of the 21 participants, 42.86% (n=9) were concerned about sex post injury. Though majority of participants were not concerned about sex post injury, over half of participants were interested in attending a support group on sexuality and intimacy after injury (57.14%, n=12). However, 95.24% (n=20) were not given any information or resources on sexuality during rehabilitation. Regarding accessibility of resources, the majority of former patients were unaware sexuality resources were available in designated locations at the IRF (66.67%, n=14). Though some respondents indicated concern about sex, only one (4.76%) participant asked a therapist about sex post injury. During the rehabilitation process, therapists never initiated the conversation of sexuality post injury with participants. When asked to identify if therapists initiated the discussion of sex post injury, 100% (n=21) of participants responded therapists did not start the conversation. Understanding specific needs of OT clinicians, as well as patients served, was a vital component to ensure development of a holistic, feasible, and beneficial sexual recovery program. Discussion of Need. These findings suggest a significant gap in holistic OT practice methods in relation to patient care and are concurrent with current literature. There is a lack of inclusion of sexuality in curricula of OT programs as indicated by results of the survey, which leaves OT clinicians unprepared to address the topic in practice (Areskough-Joefsson et al., 2016). OT clinicians lack of agreement with incorporating sexuality into intervention sessions established a potential connection in regards to lack of knowledge as the most prevalent barrier to implementation. Though OT clinicians indicated knowledge and time were the greatest barriers to implementation, the participants felt supported by managers and coworkers to address sexuality with clients. However, productivity standards create less time and little priority in the recovery process, which are reflected by rankings of the perceived barriers (Hattjar, 2012). OT SEXUAL RECOVERY PROGRAMMING 17 clinicians should be equipped to navigate these barriers to provide client-centered care regardless of extraneous factors. Many former patients were concerned about sex post injury, but these needs went unresolved. This often leaves individuals to explore concerns independently and without professional guidance (Fritz et al., 2015). OT clinicians lack of knowledge, education, and confidence in abilities may contribute to the shortcomings of OT practice with respect to addressing sexuality and intimacy. The topic of sexuality was never initiated with former patients, and though OT clinicians are mildly uncomfortable providing and discussing resources, only one former patient was given the opportunity to receive information. Failure to recognize sexuality and intimacy as the role of OT may relate to this lack of initiation. Most OT clinicians expressed feeling indifferent to the role of addressing sexuality belonging to the OT profession. However, many acknowledged sexuality and intimacy was essential to address in an IRF setting. This finding supports a need to advocate for the role of OT clinicians when addressing sexuality and intimacy. Extinguishing the gap in patient care through development of relevant resources, inservice presentations focused on sexuality education, and advocating for the importance of addressing sexuality in this practice setting was the priority for inclusion of OT clinicians in the sexual recovery program. The main focus was to increase the confidence in abilities, debunk common myths and stigmas, and equip OT clinicians with knowledge to promote preparation and integration of sexuality into OT practice. In addition, patient education was a pertinent component of the sexual recovery program. Most former patients expressed interest in attending a support group on sexuality and intimacy. This was achieved through leading diagnosis specific SEXUAL RECOVERY PROGRAMMING 18 support groups with information on the topic and increasing accessibility of resources for individuals interested. Integration of Theory In an effort to integrate sexuality and intimacy consistently in OT practice, a screening tool was developed with the intention of distribution within the first week of each patients stay at the IRF. The Meaningful Activity Tool (MAT) was inspired by the lack of non-sexuality specific tools available to screen for interest in the topic. Kielhofner & Neville (1983) revised the Interest Checklist developed by Matsutsuyu (1969), creating the Modified Interest Checklist (Henry, 1998). The Modified Interest Checklist is a client-centered tool focused on identifying the level of participation in meaningful leisure activities (Henry, 1998). This tool has been utilized across multiple populations in OT practice, from first-time mothers to individuals with progressive conditions such as multiple sclerosis (Horne, Corr, & Earle, 2005; Cahill, Connolly, & Stapleton, 2010). The Modified Interest Checklist is intended to explore meaningful interests of clients to identify level of occupational engagement (Horne et al., 2005). Though the Modified Interest Checklist includes dating as an activity choice, sexuality and intimacy are not included in the tool. Therefore, there was a need to develop a non-invasive screening tool, incorporating instrumental activities of daily living as well as sexuality and intimacy to determine client interest and promote OT clinician initiation of the topic. The MAT was reviewed by an Associate Professor of OT at the University of Indianapolis, as well as the Director of Rehabilitation Services, and feedback was applied. The MAT focuses on leisure and social participation across 10-domains, which offers a less intrusive mechanism to screen for sexuality and intimacy concerns. These domains include: Household Management, Pet Care, Outdoor Activities, Exercise, Hobbies, Games, Meal Preparation, Community Outings, Sexuality & Intimacy, and SEXUAL RECOVERY PROGRAMMING 19 Communication. Included under each domain are three activities related to the heading and patients are instructed to circle meaningful activities to be addressed during the rehabilitation process. Domains and activities included in the MAT are threaded throughout The Occupational Therapy Practice Framework: Domain and Process, 3rd Edition (AOTA, 2014). Refer to Appendix A to reference the MAT. The intent was to prepare patients for participation in these meaningful activities after recovery. The MAT respects the first and second stage of the Recognition Model (Couldick et al., 2010). By distributing this tool to all patients during the first week of rehabilitation, the OT clinician recognizes the patient as a sexual being and offers permission for the patient to indicate concerns related to sexuality and intimacy after injury. Should the patient not indicate sexuality and intimacy as a concern, privacy on the topic is respected. However, this provides a unique opportunity to also incorporate meaningful leisure and social activities into intervention sessions to promote holistic, client-centered care. If the patient indicates sexuality and intimacy as a concern, the next proposed step was to distribute the Sexuality Questionnaire developed by Hattjar (2012), which addresses type of concerns, current beliefs, relationships, and desired method of receiving education. Patients may also indicate if they prefer not to discuss sexuality and intimacy in therapy sessions (Hattjar, 2012). The Sexuality Questionnaire honors stage 3 and stage 4 of the Recognition Model (Couldick et al., 2010). This questionnaire delves deeper into exploring patient concerns and encourages OT clinicians to further address sexuality and intimacy in OT practice, within level of expertise. To respect the fifth stage of the Recognition Model, the OT clinician may refer to a qualified professional (Couldick et al., 2010). This referral should be made if the patient wishes to discuss sexuality and intimacy with another health professional or if the OT clinician feels concerns are outside the OT scope of practice. SEXUAL RECOVERY PROGRAMMING 20 Effectiveness of the sexual recovery program was measured using the Goal Attainment Scale (GAS). As a whole, the sexual recovery program encompassed: development and accessibility of updated resources for OT staff and patients, integration of the MAT and Sexuality Questionnaire, educational in-services to OT staff, and support groups for patients to address concerns identified in the needs assessment. Three specific overall goals for the sexual recovery program were procured based on specific needs of OT clinicians and patients at the site. Refer to Appendix B to reference detailed goals and objectives. Methodology/ Intervention Findings from the assessment of need support an inconsistency among OT clinician practice methods in terms of addressing sexuality in OT practice. Neglecting to address this area of practice, which is considerate of human nature, creates a negative impact on provision of holistic services (Sakellariou & Sim Algado, 2006a). Therefore, development of meaningful implementation strategies was a fundamental element of program development to promote client-centered practice, address patient concerns, and improve current practice methods of OT clinicians regarding sexuality and intimacy (Bonnel & Smith, 2018). Components of Implementation In order to support program sustainability, implementation strategies had to reflect specific needs of OT clinicians and patients at the site. Occupational therapy clinicians identified knowledge and time as most prevalent barriers to addressing sexuality and expressed concerns with the lack of formal education on the topic. In addition, OT clinicians desired diagnosis specific resources and supported handouts on sexuality and intimacy, which reflected their mild level of discomfort discussing and providing resources. Despite this mild level of discomfort, the majority of former patients were not given information or resources on sexuality, nor were they SEXUAL RECOVERY PROGRAMMING 21 informed of availability. Some former patients were concerned about sex after injury and most expressed interest in attending a support group on the topic; however many reported that therapists never initiated the conversation of sexuality post injury. Based on these identified needs, components of implementation sought to improve holistic practice methods of OT clinicians to better serve patients during the rehabilitation process. Robinson et al. (2011) suggested, specific guidelines for sexuality in rehabilitation for women should be formulated and included in the role and the scope of practice for occupational therapists (p. 16-17). This suggestion was considered during development of sexual recovery programming and integrated on a broader level to include patients with life-altering disabilities. Though specific guidelines were not formally developed, a theoretical based method of addressing sexuality in at the IRF was proposed and implemented to integrate sexuality and intimacy within the scope of practice for OT clinicians. Meaningful Activity Tool. The first component of sexual recovery programming was development of the MAT. It is important to note this is an informal screening measure, as it was developed by the student investigator, and should be viewed as a non-standardized, site specific tool. It should also be noted the development and implementation of the MAT satisfies components of the Commission of Accreditation of Rehabilitation Facilities (CARF) standards related to sexuality (CARF International, 2018). CARF International (2018) is an accreditation service with a mission to promote the quality, value, and optimal outcomes of services through a consultative accreditation process and continuous improvement services that center on enhancing the lives of persons served (CARF International, 2018, para 1). The sexuality standards CARF (2017) outlines include sexual counseling, sexual health, sexual function, and intimacy in relation to patient care. Though the sexuality-based standards specifically reference SEXUAL RECOVERY PROGRAMMING 22 individuals with limb loss and spinal cord dysfunction, the content also extends to encompass individual goals and needs of patients served. One standard in particular requires provision of services to screen and assess for sexual function in individuals with spinal cord dysfunction (CARF, 2017). Therefore, improving standards related to sexuality at the site was partially achieved through integration of the MAT in this setting. While the MAT offers a solution to screen and informally initiate the topic of sexuality and intimacy in OT practice, it also requires accountability on the part of the OT clinician. Integration of the tool ensures some form of sustainability and consistency in regards to integrating sexuality and intimacy in OT practice at the site. Ultimately, distribution of the MAT within the first week of evaluation is at the discretion of the therapist; therefore, gleaning input from OT clinicians was an integral aspect to consider prior to solidifying the MAT. This input was obtained through a brief, informal meeting held in the acute therapy gym. Occupational therapy clinicians were contacted via e-mail and invited to attend a meeting to discuss the proposed screening tool. The student investigator led the meeting, which introduced the role of OT in addressing sexuality, outlined the CARF standards related to sexuality, and explained the intention and format of the screening tool. The Recognition Model was also explained, particularly as it related to the MAT and Sexuality Questionnaire. Paper copies of the MAT, Sexuality Questionnaire, CARF standards, and a document outlining the Recognition Model were distributed to all in attendance. These documents were reviewed during the meeting and explained briefly. OT clinicians were informed of the intended screening process, including distribution of the MAT within the first week of evaluation. Should the patient indicate interest in sexuality and intimacy on the MAT, the Sexuality Questionnaire was presented as a follow-up method to understand the best way to approach the topic. Occupational SEXUAL RECOVERY PROGRAMMING 23 therapy clinicians were receptive of presented information and appreciated the user friendly nature of the MAT. One OT clinician appreciated the screening tool was one page due to perceived time constraints. Another therapist commented that distributing the tool would be relatively easy on the day of evaluation. In reference to suggestions for edits, a few OT clinicians expressed concern that patients would indicate interest in all topics and proposed a ranking system in place of circling items. While this suggestion was understood and appreciated, it was explained the tool is designed to be simplistic in nature to account for patients with cognitive difficulties. As a potential compromise, the student investigator proposed this situation as an opportunity to converse with the patient and provide professional guidance with ranking activities of most importance. With exception to this concern, the OT clinicians in attendance were in agreement with utilizing the MAT in OT practice and expressed interest in incorporating the tool immediately. The student investigator explained educational in-services would be held in the near future to discuss the integration of sexuality into OT practice in-depth. The MAT and Sexuality Questionnaire were then e-mailed to the Director of Rehabilitation Services, who placed both documents in the facility t-drive for OT clinicians to easily access. Occupational therapy clinicians were notified of the location of noted documents through an e-mail drafted by the student investigator. A recap of meeting content, along with attachments distributed during the session, was outlined in the e-mail for those who could not attend. The Director of Rehabilitation Services approved included content prior to distribution of the e-mail. Sexuality Resources. Once a method of integrating sexuality into the evaluation process has been established, updating resources and developing meaningful handouts for the site was a critical component. To promote accessibility of resources, a dedicated folder on the facility t- SEXUAL RECOVERY PROGRAMMING 24 drive was created for sexuality and intimacy education materials. The sexuality and intimacy folder is available under the OT section of the t-drive. Two subfolders were also included in this section of the t-drive. One folder was labeled Patient Handouts and Resources, while the other was titled Resources for OT clinicians. The subfolder including patient education materials are easily accessed by OT clinicians for distribution to patients as necessary, pending the functional concern. However, the subfolder designed specifically for OT clinicians focused more on materials to improve their clinical knowledge on sexuality and intimacy as desired. The Patient Handouts and Resources subfolder included diagnosis specific resources, handouts, and links on existing online resources. Specific diagnoses included the following lifealtering disabilities: TBI, stroke, SCI, and amputation. Relevant literature and reliable sources were utilized to guide development of evidence-based resources to address patient needs. The student investigator reviewed sexuality and intimacy related handouts currently utilized at the site and updated as necessary to improve educational materials available to patients. Creation of updated resources reflected needs and concerns identified in the survey of former patients, as well as suggestions obtained from former patients during support groups. During the support group for individuals with stroke, TBI, amputation, and SCI, members were invited to offer feedback regarding resources that were desired during their recovery process. Patients expressed concerns including but not limited to: desire, safety of resuming sex after injury, impact of level of injury on sexuality, and perception of the partner following injury. This feedback was intently considered and applied during the process of resource development for patients. Newly developed resources cover sexuality and intimacy as related to the following: bowel and bladder management, pain and medication management, positioning, adaptive equipment, body image SEXUAL RECOVERY PROGRAMMING 25 and self-view, desire post injury, impact of the caregiver role, energy conservation strategies, and sensation. The subfolder labeled Resources for OT Clinicians was intended to offer OT clinicians the opportunity to expand professional knowledge relative to sexuality and intimacy. As evident by the pre-survey results, half of OT clinicians did not feel they had adequate knowledge on sexuality and intimacy as it applied to patient care. Therefore, this subfolder included evidencebased research articles and evidence-based intervention strategies on sexuality and intimacy. As OT clinicians expressed desire for diagnosis specific resources, the content focused on evidencebased literature including: TBI, stroke, amputation, and SCI. The PowerPoint presentations on sexuality and intimacy, developed for scheduled OT in-services, were also included in this subfolder for reference. Resources for OT clinicians are intended to promote evidence-based practice methods when addressing sexuality and intimacy in OT practice. Robinson et al. (2011) discussed the shortcomings of therapists when providing intervention on sexuality and stated, occupational therapists...need to identify the clients specific needs and problems and allow this to direct the intervention provided (p. 16). While the OT clinicians desired diagnosis specific resources, it should be noted therapists were encouraged to approach sexuality and intimacy through a functional lens considering specific needs, rather than simply providing resources based on deficit. In addition, the Sexual Assessment Framework was utilized as a guide for development of content, which reflected the following: Sexual Knowledge; Sexual Behavior; Sexual SelfView; Sexual Interest; Sexual Response; Fertility and Contraception; and Sexual Activity (Kokesh, 2016). Educational materials were included within these areas of sexual assessment to SEXUAL RECOVERY PROGRAMMING 26 ensure a theoretical approach to evidence-based resources for OT clinicians. This approach intended to supply resources through a holistic, client-centered view. In-Services for OT Clinicians. Educational in-services for OT staff were scheduled to increase knowledge and comfortability regarding addressing sexuality and intimacy in OT practice. Fronek, Kendall, Booth, Eugarde, & Geraghty (2011) conducted a 2-year follow-up study measuring changes in comfort, knowledge, and attitudes of healthcare professionals after a 1-day educational session on sexuality and SCI. Researchers found participants involved in the training experienced improvements in confidence, knowledge, and comfortability with addressing sexuality with clients. The healthcare professionals involved in the study placed the importance of addressing sexuality as equivalent to bowel and bladder issues after the educational session and expressed a desire for in-services and regular updates to maintain knowledge (Fronek et al., 2011). With respect to these findings, two in-service topics were covered, and a total of 4 in-services were held. In an effort to educate both full-time and parttime OT staff, the two in-service topics were each presented twice to educate all OT staff. The first in-service focused on addressing sexuality and intimacy in OT practice. Components included: stigma and disability, literature findings, results of the needs assessment, feedback from former patients, value of holistic practice methods, sexuality and the role of OT in relation to patient care, and an in-depth description of DCE implementation components. The second inservice covered sexuality and intimacy and the OT process in greater detail. Diagnosis specific intervention methods for TBI, stroke, amputation, and SCI were a main focus. Additionally, a case study was presented and discussed in the lecture to provide an interactive experience. It was critical to model a holistic approach to this in-service, as it was an opportunity for OT clinicians to practice addressing sexuality and intimacy. Each session was 45 minutes. Thirty minutes were SEXUAL RECOVERY PROGRAMMING 27 designated for the lecture portion, while the last 15 minutes were devoted to discussion and reflection. Once both educational in-services had been presented, the post-survey was distributed to OT clinicians. Occupational therapy clinicians were notified of the post-survey through an email, which was attached as a word document. Verbiage of this e-mail outlined criteria to participate in the post-survey, which stated only those who completed the pre-survey should participate. Respondents were given one week to complete the post-survey. Following the allotted time period, pre-survey results were then compared to post-survey results to measure level of effectiveness of educational in-services. Measurable survey components included: level of comfortability, education, knowledge, attitudes, confidence, current practice methods, and barriers to addressing sexuality in OT practice. Patient Support Groups. Patient education was provided through leading support groups on sexuality and intimacy. Community Rehabilitation Hospital has monthly support groups for individuals with stroke, amputation, TBI, and SCI. Results from the needs assessment indicated patients were interested in attending support groups on sexuality and intimacy after injury. Support groups benefit the individual by normalizing the experience of recovery and increasing the survivors self-efficacy through education and resource sharing, support groups have the potential to strengthen the survivors coping (Trauma Survivors Network, 2018, para 1). Therefore, the student investigator led four interactive diagnosis specific support groups on sexuality and intimacy, addressing common concerns after injury. To respect the first stage of the recognition model, all support group participants were notified of the group content in advance via monthly flyers. The monthly flyer listed the student investigator as a guest speaker and offered a brief description of intended topic information. Feedback from the survey guided presented content, as themes from the open-ended questions were generated based on diagnosis. SEXUAL RECOVERY PROGRAMMING 28 In regards to sex, participants recovering from stroke inquired about desire, relationship changes, and safety after stroke. One individual with TBI was concerned about desirability and performance post injury. Those with SCI were concerned about bowel and bladder control, level of injury and impact on sexuality, and the caregiver role. Those with amputation worried about self-esteem and body image. Group dynamics and limits were respected, as thorough discussions with the Program Lead, who typically leads the support groups, were held prior to the group. The Program Lead offered personal insight and requested content on sexuality and intimacy be presented directly or indirectly, pending the dynamic of group members. A handout on sexuality and intimacy after injury was created prior to each group with respect to the diagnosis. Handout content discussed components of sexuality including societal stigma, sexual expression, common concerns, and links to online resources. These handouts were distributed during each support group session. Relevant research and resources were intently reviewed in preparation for the group session. Outlines with information on sexuality and intimacy, as well as discussion questions, were created as a tentative guide for each group session. Each support group began with formal introductions. Beyond this, groups were non-structured, as the members were welcome to partake in an open discussion throughout the group. Conversation on sexuality and intimacy varied, from discussing body image and self-esteem to positioning and adaptive equipment. Post-satisfaction surveys were distributed after each group for support group members to fill out. The post-satisfaction survey included a smiley face scale and prompted group members to offer one like, one dislike, or any additional comments about the group. This created a mechanism to measure satisfaction and improve content as directed by suggestions and feedback. SEXUAL RECOVERY PROGRAMMING 29 Advocating for the Role of OT. There were no formal means of addressing sexuality at Community Rehabilitation Hospital prior to development of the sexual recovery program. Therefore, advocating for sexuality to be integrated in practice and designated to the role of OT required leadership and professionalism. Significant research on addressing sexuality and intimacy in the rehabilitation process was vital, as these evidence-based literature findings offered a window of opportunity to educate OT staff on the significant need to address the topic in therapy. This was further supported by findings of the needs assessment, as former patients of the rehabilitation process expressed concern with sexuality post injury. Presenting these findings to OT staff in a professional manner allowed the student investigator to expand on effective communication strategies through conducting informal meetings and providing staff education during educational in-services. Leading patient support groups also required professional communication through advocating for the role of OT and addressing concerns within the scope of OT practice. These components of implementation further developed leadership skills and improved confidence in relation to educating on sexuality and intimacy and OT practice. Results/Outcomes Implementation strategies were devised to bridge the gap in holistic service delivery, regarding addressing sexuality and intimacy in OT practice, through program development. The sexual recovery program was the first formal means of addressing sexuality and intimacy at this site. Therefore, formative and summative measures were utilized as quality improvement (QI) strategies to measure effectiveness of implementation components and determine program success (Bonnel & Smith, 2018). SEXUAL RECOVERY PROGRAMMING 30 Outcome Tools Formative evaluations were intended to provide ongoing feedback on strengths and weaknesses throughout the implementation process, whereas summative measures offered overall feedback on effectiveness of the process as a whole (Tatian, 2016). Kringos et al. (2015) suggested, awareness, attitude, knowledge of and understanding performance data were all essential facilitators for the implementation of QI interventions (Kringos, et al., 2015, p. 9). Efforts to modify the approach and content of sexual recovery programming were influenced by feedback gleaned throughout the implementation process. Formative evaluations included postsatisfaction surveys distributed after each support group, as well as informal feedback from OT clinicians during the discussion period after each in-service. In addition, the pre-post survey distributed to OT clinicians was utilized to measure change in perceptions regarding addressing sexuality and intimacy in OT practice. Components of the implementation process as a whole were depicted through specific goals for program development. These goals represented the summative program evaluation and were presented in the GAS. Formative evaluations throughout the implementation process, in conjunction with a summative evaluation at the end of the process, allowed for meaningful interpretation of program development outcomes. Feedback from OT Clinicians. One of the main aspects of the sexual recovery program was to provide education to OT clinicians in relation to the role of OT in addressing sexuality and intimacy in the rehabilitation setting. Ultimately, the OT clinicians were responsible for consistently integrating sexuality and intimacy in OT practice upon the departure of the student investigator. Therefore, advocating for the role of OT while addressing this area of practice was vital to ensure sustainability of programming. Education of OT staff was achieved through the two in-services, which focused on specific needs of OT clinicians as identified in the needs SEXUAL RECOVERY PROGRAMMING 31 assessment. The primary goal of the in-service format was to increase comfortability, knowledge, and confidence in OT staff when addressing sexuality and intimacy in OT practice. At the cessation of each educational in-service, there was a 15-minute discussion period intended for OT staff in attendance to provide feedback on content, pose questions, and discuss integration of sexuality and intimacy in OT practice. Overall, OT clinicians were receptive of in-service content and verbalized understanding the need for integrating sexuality into OT practice. One OT clinician in particular commented on the shift in her attitude regarding the topic. Originally, she felt addressing sexuality was not feasible. However, after the first in-service, she expressed those views had changed, and she was more open to the idea of incorporating sexuality in practice. As a group, OT clinicians brainstormed practical approaches to integrating sexuality into OT practice. Some discussed threading the topic in existing diagnosis specific education groups, while others proposed sexuality and intimacy as a topic to be added to the discharge form. Nevertheless, OT clinicians were seeking a method of accountability to discuss sexuality during rehabilitation. While distribution of the MAT is one form of accountability, this discussion period offered OT clinicians the freedom to openly discuss ideas and provide feedback to be considered for improving implementation components. Pre-Post Survey Results. Occupational therapy clinicians who participated in the presurvey were invited to partake in the post-survey at the end of the final in-service. The survey was designed to measure effectiveness of in-service content in regards to influencing level of comfortability, knowledge, attitudes, confidence, current practice methods, and perceived barriers related to addressing sexuality in OT practice. Post-survey data were analyzed in the exact manner as outlined for the pre-survey results. There were a total of 10 OT clinicians (90.9%) who participated in the post-survey. Results indicated level of confidence addressing SEXUAL RECOVERY PROGRAMMING 32 sexuality and intimacy with clients increased, as the majority of OT clinicians agreed to feeling confident in abilities (60%, n=6). This was an improvement from pre-survey results, which found 50% (n=5) disagreed and 40% (n=4) strongly disagreed to feeling confident. In regards to frequency of addressing sexuality, post-survey findings indicated the majority of OT clinicians addressed the topic once a year or more (40%, n=4) or never (30%, n=3). These results differed from pre-survey findings, which indicated the majority of OT clinicians never addressed sexuality in practice (54.55%, n=6). In the initial survey, OT clinicians strongly disagreed to incorporating components of sexuality into intervention sessions at a higher rate as compared to the post-survey. While the pre-survey found 80% (n=8) of OT clinicians strongly disagreed to incorporating into intervention, the post-survey indicated 40% (n=4) strongly disagreed and 30% (n=3) neither agreed nor disagreed. Perceived barriers to implementing sexuality in OT practice did not greatly differ from pre-survey to post-survey. Knowledge continued to be the largest perceived barrier to implementation, followed by priority and time, comfortability, and support. Priority and time were both the second highest perceived barriers to implementation. However, OT clinicians agreed to having adequate knowledge on sexuality at a higher rate on the post-survey as compared to initial findings. The majority of OT clinicians on the post-survey either agreed (40%, n=4) or neither agreed nor disagreed (40%, n=4) with having adequate knowledge, while half of OT clinicians (50%, n=5) strongly disagreed with this statement on the initial survey. Post-survey findings indicated the majority of OT clinicians either agreed (30%, n=3) or strongly agreed (30%, n=3) sexuality is essential to address in this practice setting, and participants agreement with OT clinicians being the designated healthcare provider to address the topic greatly increased. Initially, respondents were impartial to OT clinicians assuming the role of SEXUAL RECOVERY PROGRAMMING 33 addressing sexuality in the healthcare setting (70%, n=7). However, after partaking in implementation components, the majority of OT clinicians either agreed (40%, n=4) or strongly agreed (30%, n=3) with OT clinicians being the designated healthcare provider to address the topic. Level of comfortability addressing sexuality improved across all components (Figure 1). The majority of OT clinicians were comfortable providing resources (7.7), discussing resources (6.9), and initiating the conversation (6.3) at a higher rate than indicated on the pre-survey. Comfortability also improved in relation to educating on adaptive equipment utilized for sexual intercourse (5.1), incorporating scenarios into therapy sessions (4.5), and leading a support group (3.7). These findings suggest sexual recovery programming positively influenced OT practice methods at Community Rehabilitation Hospital. Perceived level of comfortability, knowledge, attitudes, confidence, and current practice methods improved after participation in educational in-services on addressing sexuality and intimacy in practice. These implementation components did not greatly influence perceived barriers, as knowledge, time, and priority remained the greatest barriers to addressing sexuality in OT practice. However, OT clinicians indicated a higher level of agreement with having adequate knowledge and confidence addressing sexuality as compared to pre-survey results. Support Group Participation. Patient education was the second area of focus for the sexual recovery program. Leading four diagnosis specific support groups on sexuality and intimacy was the main mode of accomplishing this vision. Seven participants attended the support group for individuals with amputation. Two of these participants were spouses of the individual with amputation, and one participant was an OT student. Six participants attended the support group for individuals with TBI. One of these participants was a caregiver and another SEXUAL RECOVERY PROGRAMMING 34 participant was a spouse. There were a total of 9 participants in the support group for individuals with stroke. Two of these participants were undergoing the rehabilitation process as inpatients at Community Rehabilitation Hospital, six participants were former patients, and one participant was a PT student from a local university. Six participants attended the support group for individuals with SCI. Two of the members were former patients, while four of the participants were therapy students from a local university. Two of the four therapy students in attendance from a local university were familiar with the student investigator, which posed a potential conflict of interest. Therefore, these two students were the only participants of the SCI support group who did not complete a post-satisfaction survey. All participants from the support group for individuals with stroke and TBI completed the post-satisfaction survey, while six members of the support group for individuals with amputation participated in the survey. The counts described do not include the Program Lead, who was present for each session, or the student investigator, who led each session. It should be noted the presence of therapy students offered the ability to provide education within the realm of sexuality and intimacy as related to the rehabilitation process. As discussed, sexuality and intimacy are not traditionally included in curricula of academic programs; therefore, this was a unique opportunity to present the topic of sexuality and intimacy within the context of disability to therapy students who have the power to impact future practice methods. Post-Satisfaction Survey Results. Support group members completed post-satisfaction surveys at the end of each session. The post-satisfaction surveys were anonymous and format consisted of a smiley face scale, as well as three open-ended questions. Open-ended questions asked support group members to describe one like and one dislike about the session, while the SEXUAL RECOVERY PROGRAMMING 35 last question offered support group members the option to convey any additional comments regarding the session. Overall, support group participants rated positive feelings toward the sessions on the post-satisfaction survey. There were a few participants who rated the session with a neutral smiley face. One support group member disliked that the session was too early, as noted on the post-satisfaction survey. The context of this comment is unknown, though the student investigator speculated the feedback was in reference to the participants recovery process. It is possible the participant was not ready to discuss sexuality and intimacy, which displays the importance of recognizing the individualistic nature of this topic. Another participant commented it would have been beneficial to have a nurse practitioner present to answer questions about medications. During each session, a brief discussion about medication side effects and impact on sexuality took place. Participants were notified in-depth discussion and medication recommendations were outside the scope of OT practice. In regards to aspects of the session support group members liked, feedback included: the fact sexuality was discussed at all, talking about a taboo subject, getting information on the topic, discussing a topic of importance, and not feeling embarrassed during the session. Others commented on the dynamic, stating they liked the open, honest, and relaxed nature of the session. A few of the support group participants requested more sessions on sexuality and intimacy and wished to review the references listed on the handout in a future session, noted in the additional comment portion of the post-satisfaction survey. Goal Attainment Scale. The goals developed for the sexual recovery program aligned with the implementation process. In reference to goal formation for the GAS, Turner-Strokes (2009) suggested three to five goals as adequate (p. 364). Three goals were definitively outlined for sexual recovery programming and may be referenced in detail per Appendix B. SEXUAL RECOVERY PROGRAMMING 36 Successful integration of programming was achieved across implementation components and measured by the level of attainment at the end of the implementation period. Goals were rated on a 5-point scale, and achievement was dependent upon whether the expected level of outcome was reached, exceeded, or not fully met (Turner-Strokes, 2009). The 5-point scale has ratings from -2 (much less than expected) to +2 (much more than expected). Goal composition for integration of sexuality and intimacy included: holding interactive in-services for OT clinicians, leading support groups for former patients, and developing resources and a screening tool to be utilized at the site. For the purpose of sexual recovery programming, goals of holding interactive in-services and leading support groups resulted in a 0 score, indicating these goals met the expected level of outcome. The goal related to resource development and creation of a screening tool scored +2, indicating this goal exceeded expectations and was met much more than expected. Refer to Appendix B for a detailed outline and explanation of goals. Sustainability of Sexual Recovery Programming Each component of implementation was intended to equip OT clinicians with necessary support and mechanisms for addressing sexuality and intimacy in OT practice. Sustainability of sexual recovery programming is at the discretion of each OT clinician. The foundation has been set, complete with education on sexuality and intimacy, integration of the MAT and sexuality questionnaire as a means to consistently initiate the topic, establishment of accessible sexuality resources, and discussion of the needs identified by former patients. These strategies were intended to advocate for the need to address the topic and offer a solution to professionally integrate sexuality and intimacy into OT practice methods. The Director of Rehabilitation Services demonstrated significant support for addressing sexuality and intimacy at this site, through both verbal and written communication with OT clinicians, which reinforces the need to SEXUAL RECOVERY PROGRAMMING 37 sustain programming. Recommendations for monthly discussions on sexuality and intimacy, as well as an annual in-service presentation were made to the Director of Rehabilitation. An open style format for discussions was suggested, which included a proposed lunch and learn designed for OT clinicians to review an evidence-based article on addressing sexuality in healthcare. Discussions would encourage an open dialogue among OT clinicians to review evidence-based findings in a group format to remain up to date on current issues and address changing needs. The student investigator is hopeful OT clinicians will continue to acknowledge the importance of addressing sexuality within OT practice and make a consistent effort to honor the values of the OT profession through provision of holistic and client-centered care. Discussion Sexual recovery programming was intended to address sexuality and intimacy as it pertained to the divide between current OT practice methods and provision of client-centered care. The notion of client-centered practice aligns with Vision 2025 of AOTA (2018) 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 (p.19). As addressing sexuality and intimacy are often stigmatized and neglected areas of OT practice, sexual recovery programming served as an opportunity to positively influence OT practice methods and promote client-centered care at Community Rehabilitation Hospital. Creating a mechanism, guided by theory and evidence, for OT clinicians to consistently initiate the topic of sexuality and intimacy with patients was a main priority of the sexual recovery program. Establishing the MAT, providing the sexuality questionnaire, and educating OT clinicians through educational in-services provided an avenue to advocate for the importance of threading sexuality and intimacy into OT practice methods. These components promote SEXUAL RECOVERY PROGRAMMING 38 initiating the conversation early on during patient recovery, to ensure patient concerns regarding sexuality and intimacy are not neglected. With respect to this newly designed, systematic approach to addressing sexuality in OT practice, patients have the opportunity to openly discuss concerns and receive professional guidance within the scope of OT practice. Limitations The relatively small sample size of both OT clinicians and former patients limited generalizability of findings. The small response rate must be considered, as only 7.34% (n=21) of former patients and 36.67% (n=11) of OT clinicians completed the initial surveys for the needs assessment. Response rate may have been impacted by the sensitive nature surrounding the topic of sexuality and intimacy. With respect to the nature of the topic, participant bias may have been present, as those with positive feelings or interest in sexuality and disability may have been more likely to participate. As a result, survey findings may not have represented perceptions of OT clinicians and former patients as a whole. In addition, attendance of diagnosis specific support groups was also relatively low, which may have been influenced by the stigma surrounding sexuality and disability. Support group members may not have felt comfortable discussing sexuality and intimacy in a group format, which may have limited amount of patient education achieved. Consequently, participant bias may have impacted post-satisfaction survey results, as support group members in attendance may have been eager or interested in discussing sexuality and intimacy. With consideration of these limitations, future research should expand inclusion criterion to include patients with a variety of diagnoses and compare OT practice methods regarding sexuality and intimacy across a variety of practice settings to expand level of participation and improve generalizability of findings. SEXUAL RECOVERY PROGRAMMING 39 Professional Communication Establishing the sexual recovery program from the ground up required development and utilization of effective communication skills. Communicating evidence-based research findings to OT staff and presenting survey findings in a relatable manner was the first step to advocate for the need. Communication was achieved through written and verbal communication. Email was utilized as a method to inform OT staff on upcoming meetings and provide updates on the progress of program development. Interaction with OT clinicians was threaded throughout the implementation process, including holding informal meetings and presenting educational inservices. Educating former patients also required professional communication. The handouts distributed each support group session represented written communication, while discussion was guided through verbal cueing to encourage member participation. Essentially, the student investigator aimed to normalize the conversation and desensitize OT clinicians and support group members to the taboo nature of the topic. Whilst working to achieve this intention, the student investigator developed self-confidence in regards to addressing sexuality and intimacy in OT practice. Need for Advancement As implicated by the results of the sexual recovery program, establishing a professional and theoretical basis to address sexuality and intimacy within the scope of OT practice is attainable. Sexual recovery programming created an intentional means of consistently addressing sexuality and intimacy in OT practice. Though integration of sexuality and intimacy was achieved at Community Rehabilitation Hospital, similar methods should be explored and pursued in additional practice areas. The need for furtherance and advancement of routinely addressing sexuality and intimacy, within the OT profession as a whole, is indisputable. Electing to exclude SEXUAL RECOVERY PROGRAMMING 40 sexuality and intimacy from the healthcare environment inadvertently devalues a fundamental aspect of the identity of individuals served. As demonstrated by evidence-based literature findings and results of the needs assessment, failure to address the topic deprives patients from exploring the occupation of sexuality and intimacy (Sakellariou & Sim Algado, 2006a). OT clinicians have the power to bridge this gap in healthcare provision and positively influence practice methods simply through honoring the client-centered principles of the OT profession. AOTA (2018) encourages OT clinicians to promote positive change stating, Think big: No other profession is like OT. Be comfortable being a trail blazer (p. 19). This process begins with declaring freedom from the societal chains and stigmatization surrounding sexuality and disability. SEXUAL RECOVERY PROGRAMMING 41 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. AOTA. (2016). The Occupational Therapy Role in Rehabilitation for the Person with an Upperlimb Amputation. Retrieved from https://www.aota.org/About-OccupationalTherapy/Professionals/RDP/upper-limb-amputation.aspx AOTA. (2018). Positioning to meet new challenges: Vision 2025. 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The issue is- why has so little progress been made in the practice of occupational therapy in relation to sexuality? American Journal of Occupational Therapy, 70(1), 1-5. Robinson, J., Forrest, A., Pope-Ellis, C., & Hargreaves, A. T. (2011). A pilot study on sexuality in rehabilitation of the spinal cord injured: Exploring the womans perspective. South African Journal of Occupational Therapy, 41(2), 13-17. Sakellariou, D. & Sim Algado, S. (2006a). Sexuality and disability: A case of occupational justice. British Journal of Occupational Therapy, 69(2), 69-76. SEXUAL RECOVERY PROGRAMMING 44 Sakellariou, D. & Sim Algado, S. (2006b). Sexuality and occupational therapy: Exploring the link. British Journal of Occupational Therapy, 69(8), 350-356. Song, H., Oh, H., Kim, H., & Seo, W. (2011). Effects of a sexual rehabilitation intervention program on stroke patients and their spouses. Neuro Rehabilitation, 28, 143-150. Tatian, P. A. (2016). Performance Measurement to Evaluation. Retrived from https://www.urban.org/sites/default/files/publication/78571/2000555-performancemeasurement-to-evaluation-march-2016-update_1.pdf Tepper, M. S. (2000). Sexuality and disability: The missing discourse of pleasure. Sexuality and Disability, 18(4), 283-290. Trauma Survivors Network. (2018). Peer Support Groups. Retrieved from https://www.traumasurvivorsnetwork.org/pages/peer-support-groups Turner-Strokes. (2009). Goal attainment scaling in rehabilitation: A practical guide. Clinical Rehabilitation, 29, 362-370. Valvano, A. K., West, L. M., Wilson, C. K., Macapagal, K. R., Penwell-Waines, L. M., Waller, J. L., & Stepleman, L. M. (2014). Health professions students perceptions of sexuality in patients with physical disability. Sexuality and Disability, 32, 413-427. SEXUAL RECOVERY PROGRAMMING 45 Figure 1. Comparison of pre-post survey results for OT clinician perceived level of comfortability with addressing sexuality in OT practice. SEXUAL RECOVERY PROGRAMMING 46 Appendix A SEXUAL RECOVERY PROGRAMMING 47 Appendix B GOAL ATTAINMENT SCALE Level Of Attainment Goal 1: Goal 2: Goal 3: -2 Much less than expected (Present Level) Did not educate OT staff through providing interactive in-service regarding addressing sexuality and intimacy in OT practice. Educate clients on sexuality and intimacy, within the scope of OT practice, through holding 2 or less interactive support groups. Did not create and provide resources on sexuality and intimacy for staff and clients to utilize. -1 Somewhat less than expected (Progress) Educate OT staff through providing 1 interactive inservice regarding addressing sexuality and intimacy in OT practice. Educate clients with disabilities on sexuality and intimacy, within the scope of OT practice, through holding 3 interactive support groups. Create and provide resources on sexuality and intimacy through resources on the t-drive and updated handout materials for staff and clients to utilize. 0 Expected level of outcome (Annual Goal) Educate OT staff through providing 2 interactive in-services regarding addressing sexuality and intimacy in OT practice. Educate clients with disabilities on sexuality and intimacy, within the scope of OT practice, through holding 4 interactive support groups. Create and provide resources on sexuality and intimacy through resources on the t-drive, updated handout materials, and development of a screening tool for staff and clients to utilize. +1 Somewhat more than expected (Exceeds annual goal) Educate OT staff through providing 3 interactive inservices regarding addressing sexuality and intimacy in OT practice. Educate clients with disabilities on sexuality and intimacy, within the scope of OT practice, through holding 5 interactive support groups. Create and provide diagnosis specific resources on sexuality and intimacy through resources on the t-drive, updated handout materials, and development of a screening tool for staff and clients to utilize. SEXUAL RECOVERY PROGRAMMING +2 Much more than expected (Far exceeds annual goal) Educate OT staff through providing 3 or more interactive in-services regarding addressing sexuality and intimacy in OT practice. 48 Educate clients with disabilities on sexuality and intimacy, within the scope of OT practice, through holding 6 or more interactive support groups. Create and provide diagnosis specific resources on sexuality and intimacy through support group outlines, resources on the tdrive, updated handout materials, and development of a screening tool for staff and clients to utilize.  ...