Problem Statement: A paucity of research exists describing the relationship between lateral epicondylalgia (LE) and upper extremity (UE) strength, range of motion or joint characteristics, between the shoulder, elbow and wrist despite the close kinetic relationship. The primary purpose of this study was to describe these characteristics of the UE in female tennis players and a control group. Methods: This was a descriptive study of three groups: sample of active adult females with no elbow pain (control), non-symptomatic tennis players (NSTP), and symptomatic tennis players (STP) with LE. A convenience sample of three groups, 21 women each was recruited. A questionnaire was completed by each participant and a screening procedure was performed to confirm group assignment and gather tennis specific information. The dependent variables were collected at a one-time session for the dominant extremity of each subject and included UE passive motion, mean UE adjusted strength values, strength ratios, elbow carrying angle, posterior shoulder tightness, anterior glenohumeral joint (GHJ) laxity and shoulder impingement tests. Results: The STP group demonstrated significantly greater passive forearm pronation, higher internal/external rotation strength ratios, increased frequency of anterior GHJ hyperlaxity and positive Hawkins-Kennedy test results. Grip strength taken in elbow extension was significantly weaker in the STP group compared with the NSTP and control groups. The strength ratio of the upper/lower trapezius was significantly greater in the STP compared to NSTP group, but was not significantly different from the control group. The STP group demonstrated a trend toward greater passive motion in elbow hyperextension and supination, and a higher wrist flexion/extension ratio that did not reach statistical significance. Both tennis player groups demonstrated limited passive wrist flexion and shoulder internal rotation when compared to controls. No significant differences were found in tennis playing factors between the groups. Conclusion: Impairments in strength, range of motion, or motor control are hypothesized to contribute to the altered kinematics of the UE and may potentially lead to LE in recreational tennis players. Recognizing risk factors a priori may provide a framework to guide the physical evaluation, treatment plan and preventative techniques for the tennis player exhibiting symptoms of LE.

Purpose. Clinical education is a critical component of the education of physical therapists (PT). Clinical instructors (CIs) are primarily responsible for coordinating and supervising this clinical learning. However, little has been published about how CIs make decisions and solve problems related to clinical teaching and how this instructional reasoning changes with experience with clinical teaching. Therefore, the purpose of this study was to explore the instructional reasoning of novice and experienced CIs. Methods. A qualitative multiple case-study design was used. Data were collected through in-depth interviews and review of clinical teaching artifacts. A coding framework was developed for coding each individual case. Cross-case analysis to examine the impact of experience on clinical teaching was performed. Trustworthiness was established through peer review of data. Credibility was established through triangulation of the data and member checks. Participants. A sample of convenience of PTs who were credentialed as CIs in Indiana was used. Six participants with a range of experience as CIs and clinicians were selected and consented to participate. Results. Four major themes emerged to describe the instructional reasoning of CIs. These themes were communicating expectations for the student's role in the learning process, creating an environment conducive to learning, facilitating student achievement of learning goals, and balancing dual roles and responsibilities. The more experienced CIs clarified expectations for students to be active participants in a challenging learning environment and used well-defined teaching strategies to facilitate student achievement of learning goals that were integrated into the patient care responsibilities. The novice CIs were less likely to clarify expectations and to connect learning goals with teaching strategies. They focused on creating a comfortable environment for learning and were challenged by balancing the dual roles of clinical teacher with responsibilities for patient care. Conclusions. This study provided an in-depth description of the instructional reasoning of CIs and how this instructional reasoning changes with experience. The results indicated that instructional reasoning matures with clinical teaching experience. Clinical education faculty should consider developing strategies to support the development of novice CIs. Strategies to supplement development of student clinical reasoning should also be considered.

Background: Patients with primary reports of neck pain often present with impairments of mobility, proprioception and motor control within the cervical spine, and these impairments can negatively impact patient outcomes. Cervical spine manipulation (CSM), which involves the use of thrust techniques, has been shown to be effective for some patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision making tool, such as a clinical prediction rule (CPR), that could accurately identify that subgroup of patients that would respond dramatically to CSM. The purpose of this project was to develop that CPR. Research Design and Methods: A prospective, cohort study of consecutive patients referred to physical therapy with a primary complaint of neck pain. Eligible patients who consented to participate completed a series of self-report measures, and then received a detailed standardized history and physical examination consisting of a variety of factors commonly used to assess patients with neck pain. Regardless of the results of the clinical examination, all patients received a standardized treatment regimen consisting of CSM and exercise. Depending on response to treatment, patients were treated for one to two treatment sessions over approximately 1 week. At the end of their participation in the study, patients were classified as having experienced a successful outcome or not based on a well-accepted patient-reported reference standard of success, the Global Rating of Change Scale. Analysis: Sensitivity, specificity, and positive and negative likelihood ratios were calculated for all potential predictor variables. Univariate techniques and step-wise logistic regression were used to determine the most parsimonious set of variables for prediction of treatment success. Variables retained in the regression model were used to develop a multivariate CPR to identify patients with neck pain likely to benefit from CSM. Results: Eighty-two patients were included in data analysis of which 32 (39%) had achieved a successful outcome. A CPR with 4 variables (symptom duration < 38 days, positive expectation that manipulation will help, difference in cervical rotation range of motion to either side ¡Ý 10 degrees, and pain with spring (PA) testing of the middle cervical spine) was identified. If 3 of the 4 variables (+LR 13.5) were present the chance of experiencing a successful outcome improved from 39% to 90%. Discussion: The CPR should improve decision-making for patients with neck pain by providing the ability to a priori identify patients with neck pain who are likely to benefit from CSM and exercise. However, this is only the first step in the process of developing and testing a CPR as future studies will be necessary to validate the results and should also include long-term follow-up and a comparison group to further examine the predictive value of the variables identified in the CPR.

Study Design: Cross Sectional Objectives: To develop a functional measurement tool to assess the physical abilities in male gymnasts and to evaluate the test-retest reliability and face validity of that measurement tool. Background: Despite the availability of physical fitness field-tests for many competitive sports, a reliable and valid test to measure the physical abilities (strength, endurance, balance, coordination, agility, and flexibility) of male gymnasts has not been explored or developed. The Men's Gymnastics Functional Measurement Tool (MGFMT) is a set of functional measurements used to objectively measure physical abilities required of male gymnasts. The MGFMT is a field-test designed to improve coaches' abilities to monitor their gymnasts' physical fitness levels and to help identify physical weaknesses that can be improved to create a more all-around physically fit gymnast. Methods: Eighty-three, 7 to 18 year-old competitive male club gymnasts (Level 4-10) were assessed. From these 83 total subjects, a convenience sample of 30 subjects was chosen to participate to establish the test-retest reliability of individual items and performance of the entire tool. These 30 subjects were retested with the MGFMT one week after initial testing. Test conditions and administration were consistent between the 2 administrations of the MGFMT including warm-up and item order. Statistics: Test-retest reliability was analyzed for each of the individual items using Intraclass Correlation Coefficient. Validity was analyzed using linear regression of the athletes' USA-Gymnastics competition level, predicting the component-test raw scores as well as the MGFMT total test score, resulting in a coefficient of determination (r2). Hypotheses: 1) The MGFMT individual items and the MGFMT total composite score demonstrated good test re-test reliability (Intraclass Correlation coefficient (ICC) >0.80). 2) There is a strong relationship between the MGFMT total composite score and the current competitive level of the gymnasts tested (r > 0.80). Results: The mean age of participating subjects was 11.07 years (range 7 - 18) with subjects reporting participation in competitive gymnastics for a mean of 4.36 years. Mean height and weight of the subjects were 37.5 kg and 142.8 cm respectively. Thirteen potential component tests were originally considered for inclusion in the MGFMT. Three component tests were eliminated based on physical ability tested, ease of test application, statistical analysis, and consultation with an informal panel of experts. Several of the relationships between the subjects' current USA Gymnastics competitive level and individual component test item raw scores were statistically significant, however, those relationships ranged from poor to good based on r2 scores (r2 = 0.004-0.64). The relationship between MGFMT composite test score (out of a possible score of 100) and the subjects' current USA Gymnastics competitive level was found to be good (r2 = 0.63). To rule out alternative explanations for the relationship between USA Gymnastics competitive level and MGFMT composite test scores, the relationships between MGFMT composite test scores and age, MGFMT composite test scores and bodyweight and MGFMT total composite scores and total hours training per week were also explored (r2 = 0.30, 0.48, and 0.56, respectively). Reliability testing of the MGFMT composite test score showed excellent test-retest reliability over a one-week period (ICC=0.97). Test-retest reliability of the individual component tests ranged from good to excellent (ICC = 0.75-0.97). Conclusion: The MGFMT, a 10-component field test of male gymnast physical abilities was found to be reliable and valid.

Purpose: This study had three objectives. The first objective was to develop the contents of a continuing professional development module (CPDM) for physical therapists geared toward increasing the use of standardized balance measures examine patients with balance dysfunction. The second objective was to assess the impact of the CPDM by measuring change in the clinicians' choice of measures using a patient case as well as the degree to which they changed their practice. The final purpose was to identify barriers and facilitators of knowledge translation using a CPDM. Subjects: A sample of convenience was used to recruit therapists through two home care agencies. Forty therapists participated in a one-day continuing professional development module (CPDM) regarding the use of standardized balance measures for patients with balance dysfunction. Method: A CPDM was designed based on the literature on adult learning, knowledge translation, and continuing professional development formats. Overlapping themes derived from this literature were combined to develop and present the module. Balance measures chosen for the content of the course were based on the literature and clinical relevance. Several tools were developed and administered to collect data on four levels of evaluation including: 1) participation using return rate of commitment to change forms, 2) satisfaction using a 5-point Likert evaluation form, 3) change in learning using change in pre/post case study scoring and a self assessment tool, and 4) change in performance using a commitment to change form and interview themes. Statistical tests used included descriptive, paired t-tests, and wilcoxon ranked sign test. In addition, semi-structured interviews were utilized. Results: Subjects satisfaction in the module was excellent and there was an 80% return rate of the commitment to change (CTC) forms. Statistically significant change scores were found in pre/post case study testing and self-assessment questions in regards to learning occurring following the module. Commitment to change forms and interview themes supported an actual change in clinicians' performance. Conclusion: Knowledge transfer can occur in a CPDM. The changes appeared to result from utilizing principles including accountability, multiple teaching strategies and facility support. The results of this study support the development of a CPDM to facilitate knowledge transfer in this specific area of physical therapy practice, as well as provide a model for other knowledge translation studies in the profession of physical therapy.

PURPOSE: This study aimed to investigate how physical therapy mentors instill clinical judgment and competence during residency training. The researcher investigated effective mentoring behaviors and techniques in physical therapy residency training. SUBJECTS: Participants included physical therapy residency faculty, physical therapy residents currently enrolled in U.S. residency programs credentialed by the American Physical Therapy Association (APTA), and resident graduates (ie, within the past 2 years) from APTA programs. METHOD: A quantitative survey design was used to gain information about effective mentoring behaviors and techniques of physical therapy residency faculty who foster clinical expertise in physical therapy residents. Two online surveys were created: one for residency program faculty and one for current and past residents. RESULTS: Findings revealed that most mentors felt confident to mentor residents based on their past experiences instructing students and mentoring residents in physical therapy. Most mentor respondents had not taken APTA's Credentialed Clinical Instructor Program (CCIP), and fewer had taken Advanced CCIP (ACCIP). Mentor respondents who had taken both courses felt that CCIP was less helpful in mentoring residents than was ACCIP. Findings indicated important resident benefits, mentor behaviors, and characteristics of mentor-mentee relationships in residency programs. Results revealed mentoring and teaching strategies that were most effective for different stages of residency programs. CONCLUSIONS: These findings will help guide residency program faculty in effective mentoring practices and have added to the literature about how mentoring methods impact development of clinical expertise in physical therapy residents. These results (a) revealed a need for advanced training specific to mentoring residents, (b) can be used to determine what mentoring behaviors and techniques work best with residents, and (c) can serve as a basis for further developing residency training curricula. RECOMMENDATIONS: Further investigation is needed to determine which components of mentoring help residency faculty feel prepared to mentor residents. Further development and testing of mentor training programs are warranted. Additional research using qualitative methodology and this study's findings related to important resident benefits, mentor behaviors, and characteristics of mentor-mentee relationships in residency programs is necessary. Further research is also needed to investigate how reflection is used in mentoring in residency programs.

Purpose: This study aimed to determine entry-level characteristics of new Doctor of Physical Therapy (DPT) graduates from the perspective of physical therapist employers (PTE), academic faculty (PTF), and final affiliation clinical instructors (CI); determine consensus of those characteristics; and determine if new DPT graduates met entry-level expectations in the adult, acute rehabilitation practice setting or where they have fallen short of expectations. Subjects: Participants included 35 CIs, 40 PTEs, and 43 PTFs, recruited from CARF accredited adult, acute rehab facilities (PTEs and CIs) and PT education programs with DPT graduates (PTFs). Method: A 4-round classic Delphi study was conducted with 3 participant panels through SurveyMonkey TM . Participants rated suggested characteristics and definitions for agreement and ranked them for importance on 5-point Likert scales ranging from “strongly disagree ” to “strongly agree ” and “very unimportant ” to “very important ”, respectively. Controlled feedback to participants included median and interquartile range with a summary of rating rationale responses by round. Results: Percent response of Likert scale agreement ratings and importance rankings determined consensus for “strongly agree ” and “very important ”. Overall Delphi study participation was 60.2%. Agreement and importance opinions of 53 participant generated entry-level characteristics and definitions showed a lack of consensus amongst participants. Five characteristics met 80% consensus for importance: safe, ethical, integrity, communication, and recognition of red flags for PT; only safe achieved consensus for agreement. Seventy-nine percent of participants agreed that new DPT graduates are meeting expectations, 15% agreed with concerns and 6% disagreed. Conclusions: Results appear to indicate consensus of select entry-level characteristics and majority agreement that new DPT graduates are meeting expectations albeit with some concerns in the adult, acute rehab practice setting. Agreement ratings and importance rankings appear to indicate divergence in opinions of new graduate characteristics. Recommendations: Further investigation is needed to understand differences in participant group opinions of entry-level expectations and determine consensus in other practice settings.

Purpose: To determine the effect of Strain Counterstrain (SCS) on strength, dynamic balance and subjective sense of instability in individuals with chronic ankle instability (CAI). Subjects: Twenty seven volunteers (17 females and 10 males) between the ages of 18 and 55 (mean ± SD age: 33.6 ± 8.8) with a history of CAI who met the inclusion/exclusion criteria were randomly assigned to the control group (n= 13) and the experimental group (n=14). Methods: All subjects signed an informed consent, completed a demographic questionnaire and the foot and ankle ability measure (FAAM), and underwent a standard evaluation, ankle isokinetic testing and the star excursion balance test (SEBT) at the onset of the study. All subjects participated in a home exercise program and received a SCS treatment or a sham treatment once a week. At four weeks all subjects repeated the initial testing and completed a global rating of change (GROC) form. The primary aim was examined with a 2-way analysis of variance (ANOVA) with the treatment group (SCS versus sham) as the between subjects independent variable and time (baseline and four weeks) as the within subjects independent variable. Results: A significant group-by-time interaction was found for seven directions in the SEBT (p< 0.031) while no significant interaction was found for ankle strength (p>0.76). For subjective measures, no significant group-by-time interaction was found for the FAAM (p>0.548), but the GROC revealed a significant difference (p=0.014) in the mean score for the experimental group (3.92 ± 1.66) when compared to the control group (2.43 ± 1.66). Conclusions: Although SCS does not appear to have an effect on strength and subjective ankle function in subjects with CAI, it appears that SCS can lead to an improvement in dynamic ankle stability and the subjective sense of ankle instability. Recommendations: Continued research on the effectiveness of SCS in CAI and other sprain injuries is needed to confirm the results of this study. Given the significant rate of ankle sprain recurrence in this population, long-term studies are necessary. Lastly, very little evidence exists on the effects of SCS and the theoretical framework of this technique.

Abstract: The purpose of this study was to determine if a correlation exists between suicide and CAG repeat length in Huntington’s disease. Methodology: A case-control study using the COHORT Study de-identified database was conducted. Responses were collected from 163 participants. Depression, substance abuse history and use of benzodiazepines were covariates. Responses to the UHDRS behavioral section pertaining to the frequency and severity of suicidal ideation (“feels life is not worth living”, “has suicidal thoughts”) were analyzed. Results: Despite taking depression, benzodiazepine use, and history of substance abuse into account, there was a predictive relationship between CAG repeat length and frequency of suicidal ideation (p = .010). When the effect of depression was taken into account, there was no significant relationship between CAG repeat length and the severity of suicidal ideation. Recommendations: The findings from this quantitative analysis supported using CAG length in a clinician’s risk factor assessment to determine the frequency of suicidality.

This dissertation was used to addresses a group of individuals who work as eye bank coordinators. These individuals call families and approach them for eye donations from a loved one who has just passed away. An interpretative phenomenological analysis (IPA) was used to explain the lived experience of eye bank coordinators who call families for consent of eye tissue. The focus was to understand the dedication of the coordinators to giving the gift of sight and exploring the positive and negative experiences of eye bank coordinators. IPA is used for a keen understanding of eye bank coordinators, and the investigator gained insight as to why their role and well-being is important to eye banks by conducting and analyzing the interviews through the lived experiences of eye bank coordinators. The theoretical underpinnings of this research were based on the theory of planned behavior and self-perception theory. Four participants were interviewed as to their positive and negative experiences in their daily work. The research questions were What are the positive and negative experiences of eye bank coordinators when requesting permission for eye donations from bereaved families (RQ1)? and How do the positive and negative lived experience of eye bank coordinators influence their adjustment of strategies when requesting permission for eye donations from bereaved families (RQ2)? Encountering positive and enthusiastic family donors, needing to understand the situation or grief of family members, encountering closed-minded family members, and limited negative encounters experienced were the main themes that addressed RQ1. The main themes that addressed RQ2 were having the energy and motivation to seek for more donors, ensuring the right information was conveyed to the families, feeling more relaxed and comfortable, continuing to explain and ensure the correct information was conveyed, coaching and collecting oneself back, knowing how to read the actions and reactions of families, and learning from experiences and becoming more cautious.