THE RELATIONSHIP BETWEEN THE AMOUNT OF EDUCATIONAL TRAINING AND UTILIZATION OF JOINT MOBILIZATION IMPLEMENTED BY THE CERTIFIED ATHLETIC TRAINER A THESIS Submitted to the Faculty of the School of Graduate Studies and Research of California University of Pennsylvania in partial fulfillment of the requirements for the degree of Master of Science by Natalie Myers Research Advisor, Dr. Linda Meyer California, Pennsylvania 2009 ii iii ACKNOWLEDGEMENTS I would like to start by recognizing the most important people in my life: Mom, Dad, Celeste, and Davy. Mom, you have always known how to calm me down. You are the one person I can count on in my life to sit me down and make me realize that everything is going to be okay. You are the kindest person I know, and I would not be the person I am today without you in my life. Dad, you always know how to make me laugh; I can honestly say after all these years that I have inherited your sense of humor. You never doubted any of my educational decisions, but instead backed me up, and encouraged me to push myself. I can talk to you about anything, and I cherish the relationship we have. Celeste, you have always supported me as my sister and a friend. life happen. You get so excited when good things in my You have listened to all my frustrations even though you have your own to deal with; you are my best friend and I could not ask for a move loving sister. but certainly not least Davy. Last I have specific memories with you as a little girl; you were so good to me as a child. I wanted to be just like you when I grew up. You have always supported me, and encouraged me to do what makes me happy. Now that I am grown I see you with your own iv family, and know you are a wonderful husband and father. I love you very much, and thank you for all your support. To Jana, my second sister, thank you for always being there for me; you and Davy have the two most beautiful children who are lucky to have parents like you. I cherish the time I get to spend with both Caroline and Sara Page. To my grandmother and grandfather thank you so much for constantly showing your support not only during graduate school, but throughout my entire life. Your phone calls, and my visits to Miami always lift my spirits, and make me realize how lucky I am to have both of you in my life. To my other grandparents, even though they have passed on, I know have been looking down on me supporting every move I make. I will never forget my visits with you in West Virginia, and wish you could have been here to see me grow into an adult. I would also like to thank all my friends from high school, Elon, and Cal U. The late night calls and the constant support I receive from each of you means the world to me. To Chris, Kevin, and Dane without you three I might have possibly gone insane. You three were always there to make me laugh, and the friendships I have made with you all v will never be forgotten. I’m not going to wish you good luck in your future endeavors because that would mean goodbye. Always know that wherever I am there is an open door in which you all are welcome. I would also like to thank my committee members; Ellen West and Jodi Dusi. Your support, knowledge, and guidance during this process was been greatly appreciated. I would also like to thank Tom West for his Microsoft Word skills! I think I would still be sitting at my computer trying to format my thesis if it was not for you. Your overall guidance throughout this year has made me a better student and professional. Lastly, I would like to thank my thesis chair – Dr Linda Platt Meyer and my professor Dr. Thomas Kinsey. Meyer you constantly believed in me as a student. Dr. I am grateful for your never-ending support with my thesis and as a new professional. Your encouragement gave me the confidence to want to succeed. To Dr. Kinsey, I cannot thank you enough for your support throughout this entire year. encompass my thanks to you. thesis research better. whole is incredible. Words really cannot Your help has truly made my Your knowledge on research as a You are a one of a kind professor who I am lucky to have gotten to know. vi TABLE OF CONTENTS Page SIGNATURE PAGE . . . . . . . . . . . . . . . ii AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii TABLE OF CONTENTS . . . . . . . . . . . . . . vii LIST OF TABLES . . . . . . . . . . . . . . . ix INTRODUCTION . . . . . . . . . . . . . . . . 1 METHODS . . . . . . . . . . . . . . . . . . 7 Research Design . . . . . . . . . . . . . . . 7 Subjects . . . . . . . . . . . . . . . . . 8 Preliminary Research . . . . . . . . . . . . . 9 Instruments . . . . . . . . . . . . . . . . 11 Procedures . . . . . . . . . . . . . . . . 13 Hypothesis . . . . . . . . . . . . . . . . 14 Data Analysis RESULTS . . . . . . . . . . . . . . . . 14 . . . . . . . . . . . . . . . . . 16 Pilot Study Testing . . . . . . . . . . . . . 16 Demographic Data . . . . . . . . . . . . . . 22 Hypothesis Testing . . . . . . . . . . . . . 38 DISCUSSION . . . . . . . . . . . . . . . . . 63 Discussion of the Results . . . . . . . . . . 63 Implications to the Profession . . . . . . . . 72 Recommendations for Future Research . . . . . . 73 vii REFERENCES. . . . . . . . . . . . . . . . . . 76 APPENDICES . . . . . . . . . . . . . . . . . 78 APPENDIX A: Review of Literature . . . . . . . . 79 Introduction . . . . . . . . . . . . . . . . 80 Joint Mobilization . . . . . . . . . . . . . 81 Principles behind Joint Mobilizations . . . . . . 86 Effects of Joint Mobilizations . . . . . . . . 92 Education about Joint Mobilization . . . . . . . 96 Summary . . . . . . . . . . . . . . . . . . 101 APPENDIX B: The Problem . . . . . . . . . . . . 103 Statement of the Problem . . . . . . . . . . . 104 Definition of Terms . . . . . . . . . . . . . 104 Basic Assumptions . . . . . . . . . . . . . . 105 Limitation of the Study . . . . . . . . . . . 106 Delimitation of the Study . . . . . . . . . . 106 Significance of the Study . . . . . . . . . . . 107 APPENDIX C: Additional Methods . . . . . . . . . 108 Panel of Experts Cover Letter (C1) . . . . . . . 109 Table of Specifications (C2) . . . . . . . . . 112 Feedback from Panel Members (C3) . . . . . . . . 114 Reliability Cover Letter (C4) . . . . . . . . . 126 Follow-up Reliability Cover Letter (C5) . . . . . 128 Educational Predictor on Joint Mobilization Usage Survey (C6) . . . . . . . . . . . . . . . . . . 130 viii Education Predictor on Joint Mobilization Usage Survey: Coded Data (C7) . . . . . . . . . . . . . . 136 Institutional Review Board (C8) . Subject Cover Letter (C9) . . . . . . . 143 . . . . . . . . . . 150 Follow-up Subject Cover Letter (C10) . . . . . . 153 REFERENCES . . . . . . . . . . . . . . . . . 155 ABSTRACT . . . . . . . . . . . . . . . . . 158 ix LIST OF TABLES Table Title Page 1 Reliability Testing of The Educational Predictor for Joint Mobilization Usage Survey . . . . . . . 18 2 Frequency of Highest Level of Education . . . . 23 3 Frequency of Different Types of Doctoral Degrees. 23 4 Frequency of Credentials . . . . . . . . . . 25 5 Frequency of Place of Employment . . . . . . . 26 6 Current Employment Position . . . . . . . . . 27 7 Coverage of Joint Mobilization During UATEP 8 Coverage of Joint Mobilization Theory During UATEP . . . . . . . . . . . . . . . . . 28 9 Coverage of Joint Mobilization Skills/Techniques During UATEP . . . . . . . . . . . . . . . 28 10 Encouragement to Practice Joint Mobilization . . 29 11 Joint Mobilization Usage Since Completion of UATEP . . . . . . . . . . . . . . . . . 29 12 Why Participants Have Not Used Joint Mobilization Since UATEP . . . . . . . . . . . . . . . 30 13 Coverage of Joint Mobilization During Graduate School . . . . . . . . . . . . . . . . . 31 14 Coverage of Joint Mobilization Theory During Graduate School . . . . . . . . . . . . . 32 15 Coverage of Joint Mobilization Skills/Techniques During Graduate School . . . . . . . . . . . 32 16 Continuing Education Course on Joint Mobilization . . . . . . . . . . . . . . . 33 . . 28 x 17 Anatomical Areas Covered During the CEU Course(s) . . . . . . . . . . . . . . . . 33 18 Frequency of Techniques of Joint Mobilization . . . . . . . . . . . . . . . 34 19 Is Joint Mobilization a Helpful Rehab Tool 20 When is Joint Mobilization Most Helpful . . . . 35 21 Comfortable Assessing/Determining When to Use Joint Mobilization . . . . . . . . . . . . 36 22 Reasons for Not Taking a CEU Course on Joint Mobilization . . . . . . . . . . . . . . 37 23 Descriptive Statistics for the First Stepwise . . . . . . . . . . . . . . . . 40 24 Correlations for First Stepwise . . . . . . . 41 25 Variable Entered/Removed for First Stepwise 26 Model Summary: First Predictive Model . . . . . 44 27 ANOVA Regression for Model 3: First Predictive Model . . . . . . . . . . . . . . . . . 45 28 The Predictive Model: Anatomical Areas Athletic Trainers Have Used Joint Mobilization Based on their Education Training . . . . . . . . . . . . 46 29 Descriptive Statistics for the Second Stepwise . . . . . . . . . . . . . . . . 47 30 Correlations for Second Stepwise . . . . . . . 49 31 Variables Entered/Removed for Second Stepwise . . . . . . . . . . . . . . . . 51 32 Model Summary: Second Predictive Model 33 ANOVA Regression for Model 2: Second Predictive Model . . . . . . . . . . . . . . . . . 53 34 The Predictive Model: Anatomical Areas Athletic . . 35 . . 43 . . . . 52 xi Trainers Feel Most Confident When Using Joint Mobilization Based on their Educational Training . . . . . . . . . . . . . . . . 54 35 Descriptive Statistics for the Third Stepwise . . . . . . . . . . . . . . . . 55 36 Correlations for Third Stepwise . . . . . . . 57 37 Variables Entered/Removed for Third Stepwise . . 59 38 Model Summary: Third Predictive Model . . . . . 60 39 ANOVA Regression for Model 2: Third Predictive Model . . . . . . . . . . . . . . . . . 61 40 The Predictive Model: Anatomical Areas Athletic Trainers Use Joint Mobilization on the Most Based On their Educational Training . . . . . . . . 62 1 INTRODUCTION Joint mobilization is a manual therapy technique used by athletic trainers (ATs) to control pain and increase range of motion at a joint.1-2 Research shows that the use of joint mobilization is effective in decreasing pain and restoring joint motion and function.3 Application of joint mobilization requires clinical decision making as well as precise clinical skills. Specifically, clinicians utilize different grades of mobilization based upon the desired clinical outcomes. A study done on osetoarthritic knee joints revealed that large amplitude anterior-to-posterior glides done on the tibiofemoral joint had immediate local and widespread hypoalgesic effects on the patient.4 Conroy et al. studied primary shoulder impingement.5 This study revealed that grade I and II mobilizations in combination with a comprehensive treatment plan decreased the patient’s twenty-four hour pain and pain with the subacromical compression test.5 A study examining patients with frozen shoulder discovered that end range mobilizations were more effective than mid-range mobilizations in increasing shoulder mobility.6 In addition to making clinical judgments regarding grades of mobilization, clinicians also need to demonstrate accurate clinical skills. Factors such 2 as joint position and patient clinical position will have a significant impact on the effectiveness of joint mobilization. Since athletic trainers deal with both pain and hypomobility after injury is sustained a concrete understanding of joint mobilization needs to be implemented into undergraduate and graduate athletic training programs along with continuing education hours post board of certification.7 Thus, athletic trainers utilizing joint mobilization must be appropriately trained both clinically and academically. With positive outcomes on joint mobilization research, education on this manual therapy technique is extremely important. Prior to 1999 only some entry-level athletic training programs introduced joint mobilization at the undergraduate level.7 However, joint mobilization has now been included in both the Third and Fourth Edition of the NATA Educational Competencies. Therefore, students enrolled in entry-level athletic training programs post 1999 have been exposed to joint mobilization.8 Since joint mobilization is now a part of Performance Domain IV: Treatment, Rehabilitation, and Reconditioning, this manual therapy technique should be considered for use by practicing athletic trainers.9 3 Athletic trainers who want to stay current in the profession should seek additional training in joint mobilization. Such training could be obtained in graduate school in which academic coursework can reinforce the principles of joint mobilization, and encourage athletic trainers to use this rehabilitation tool on athletes suffering from pain and/or hypomobility. Another way ATs can become more educated in the area of joint mobilization is by attending continuing education courses. It is important to understand where ATs stand on the use of joint mobilization; however, there is limited up-to-date research in this area as the only updated research done on ATs and joint mobilization education was in 1984. In 1984 A Western States Survey of Certified Athletic Trainers’ Use of Joint Mobilization in Treatment Programs was implemented in order to determine educational levels and use of this manual therapy in the clinical setting.10 One would expect that the wider an ATs knowledge base on treatment protocols the faster and more efficient he or she will return the athlete to play. different results from her survey: Reasoner gathered several 4 1) ATs relied mainly on their colleagues as a primary education source when and if joint mobilization needed to be used. 2) Universities and sports medicine clinics reported the highest rate of joint mobilization use. 3) The majority of ATs participating in this survey used joint mobilization sparingly.10 With this information known, it is evident that joint mobilization education needs to be refined and implemented into undergraduate athletic training programs. There is no current research on the prevalence of joint mobilization use by ATs since it has been made a mandatory part of the curriculum. A survey sent out to physical therapists discovered entry-level physical therapy education programs were expanding their curriculum in order to enhance the treatment of joint dysfunction through the use of joint mobilization.3 Athletic training and physical therapy are two closely related professions; however, joint mobilization seems to be more prevalent in the physical therapy setting. Ben- Sorek et al. discovered that joint mobilization were becoming increasingly more popular between the years of 1970 and 1986.3 The 1970 survey revealed entry level physical therapy education programs only taught joint 5 mobilization as a subunit within nine out of fifty-one programs;11 while the 1986 survey showed an increasingly larger amount of physical therapy education programs teaching separate courses in joint mobilization, along with teaching joint mobilization as a subunit.3 Joint mobilization is now mandatory in every physical therapy curriculum as depicted in the curricular guidelines in the Normative Model of Physical Therapy Education. Therefore, all physical therapy programs now teach joint mobilization. Sorek et al. also studied whether or not physical therapists received instruction outside of the entry-level program, and compared the data to that of Volpe, the author of a similar study done in 1979. In both studies, continuing education was the instruction that was studied outside the entry-level.3,12 Continuing education in joint mobilization did increase between the years of 1979 and 1986; thus, increasing the opportunities for physical therapists to utilize joint mobilization in the clinical setting.3 Therefore, is seems reasonable that the more emphasis put on education the more likely physical therapists are to use joint mobilization. Undergraduate and graduate athletic training programs need to incorporate more education on joint mobilization. Research shows that this manual therapy technique decreases 6 pain and improves range of motion and function, but is not routinely utilized within the clinical setting. Continuing education courses are one way for ATs to keep up with their skills on this manual therapy technique. With educational increases on joint mobilization, results may be seen on the use of this technique by the athletic trainer; similar to the increases seen in the study done on physical therapists. Therefore, the purpose of this study is to develop a predictive model based on joint mobilization utilization. This model will predict the level of usage of joint mobilization based on the educational training of certified athletic trainers. Consequently, a predicted model will be developed through the use of a survey to determine if educational training levels predict joint mobilization utilization. If an effective model can be predicted it will affect undergraduate, graduate, and continuing education, which will enhance future athletic training curriculums. With an educational growth in joint mobilization student athletic trainers and certified athletic trainers will utilize this manual therapy technique more when treating pain and increasing range of motion. 7 METHODS The primary purpose of this study was to develop a predictive model to determine if educational training levels predicted joint mobilization utilization. This model predicted the level of usage of joint mobilization based on the educational training of certified athletic trainers. The model that was developed will affect undergraduate, graduate, and continuing education, which will enhance future athletic training curriculums. The methods section describes how this research was carried out and includes the following: research design, subjects, instruments, procedures, hypotheses, and data analysis. Research Design A descriptive research design was used in conjunction with the Educational Predictor on Joint Mobilization Usage Survey (EPJMUS)(Appendix C6) to conduct this study. A predictive model was developed, which allowed the researcher to measure education that predicted joint mobilization usage in undergraduate, graduate, and continuing educational training. The researcher designed the majority of the survey; however, some survey questions 8 from the study “Joint Mobilization Education and Clinical Use in the United States” were also utilized.3 The variables that were tested in this survey are as follows: undergraduate training, graduate training, continuing education training (all independent variables), and utilization of joint mobilization (dependent variable). This model predicted the use of joint mobilization based on educational training received during undergraduate education, graduate education, and continuing education post certification. Subjects The subjects used in this research included Certified Athletic Trainers from the Mid-Atlantic Athletic Trainers’ Association (District 3). District 3 includes: South Carolina, North Carolina, Virginia, West Virginia, District of Columbia, and Maryland. The reasons the researcher chose to survey District 3 members are twofold: 1) This population was familiar with California University of Pennsylvania. 2) Sample of convenience. The National Athletic Trainers’ Association (NATA) randomly selected 1,000 members within District 3. These 9 1,000 members were greeted with a cover letter (Appendix C9) written by the researcher introducing herself, and explaining the purpose of the study. The subjects then completed the survey online over the Internet, and informed consent by the athletic trainers was implied through their anonymous return of the survey. The Institutional Review Board at California University of Pennsylvania approved the study (Appendix C8), and each participant was assured that his or her responses would remain confidential. Preliminary Research Before any research was conducted, the researcher conducted a pilot study to ensure the instrument showed content validity and reliability. To determine validity, the survey was sent to a panel of six experts; three out of the six panelists responded to the researcher’s request for feedback. The panel of experts included one athletic trainer (AT), one AT who was the chairperson for the Department of Athletic Training, and one AT who was the director of an accredited graduate athletic training program. The researcher chose these experts because of their extensive background in joint mobilization. The three panel members were provided with the survey (Appendix 10 C6), table of specifications (appendix C2), and cover letter (appendix C1) explaining the research and their role as a panel member. The cover letter asked the experts to answer five questions: 1) Are the items of this survey appropriate and related to the goal of the survey? 2) Are the items of this survey written in ways that are understandable to the target population of athletic trainers? 3) Are there any questions that should be excluded from the survey? 4) Are there any questions that should be added to the survey? 5) Do you have any other suggestions or comments that would improve the overall quality of this survey? The panel of experts provided their feedback (Appendix C3) on the survey to make sure the instrument was measuring the specific variables of the study. After receiving their suggestions, changes to the survey were made in order to proceed with reliability testing. Before the survey was sent to 1,000 certified athletic trainers, the researcher conducted a mini-study to discover the reliability of The Educational Predictor for Joint Mobilization Usage Survey. The survey was sent via e-mail 11 to 30 athletic trainers employed at California University of Pennsylvania and Elon University located in Elon, North Carolina. The researcher waited a week and a half before another e-mail was sent to the participants requesting that if they completed the survey once to please complete the survey one more time. After the participants completed the survey twice the researcher downloaded the data into excel, and grouped participants with the same IP address together. The subjects with the same IP address were the participants who completed the researcher’s survey twice. thirty individuals completed the survey twice. Eleven out of After the researcher grouped and coded the data into excel the numbers were downloaded into SPSS where a Cronbach’s alpha was run to show the reliability of certain survey questions (Table 1). Most statistical experts state that a coefficient of reliability is an alpha coefficient of 0.7 to 1.0. The reliability testing allowed the researcher to catch any errors in the experimental process. Instruments The researcher created the majority of the survey with some items derived from the research study “Joint Mobilization Education and Clinical Use in the United 12 States.”3 Demographics that were collected included the following: gender, years of experience as an athletic trainer, credentials, current occupation, and level of education. Additional items related to educational training in joint mobilization received during undergraduate level, graduate level, and continuing education courses were split into 3 sections within the survey. Items 10-16 incorporated undergraduate educational training levels, while items 17-23 were strictly dedicated to graduate educational training levels, and items 24-26 included post Board of Certification continuing education courses. Items 28-30 were directed towards joint mobilization utilization such as: anatomical areas subjects have used, are most confident using, and use joint mobilization on most often. The survey allowed the researcher to predict which independent variables had the greatest effect when predicting joint mobilization utilization. The independent variables included: hours spent learning joint mobilization theories and skill/techniques during undergraduate and graduate educational training, prevalence of joint mobilization utilization if participants had a graduate assistantship, and hours spent on continuing education in 13 courses that included joint mobilization. As subjects returned the survey their answers were coded into numbers that were made up by the researcher (Appendix C7). For example, an individual who spent 2 hours learning joint mobilization theories during undergraduate training received a 2. For open-ended questions that did not have a number in the answer choices the researcher came up with coded numbers. For example, participants were asked to report how many continuing education hours he or she had on joint mobilization. received a 10. Therefore, someone how had 10 hours The dependent variables include questions such as, anatomical areas that participants have used joint mobilization, anatomical structures participants feel most confident when using joint mobilization, and anatomical areas that participants use joint mobilization on the most. The subjects chose from 13 different joints on the body. Therefore, if subject one picked 6 joints he or she received a 6. Procedures The Institutional Review Board (IRB) at California University of Pennsylvania reviewed the study before it was sent to any participants. After approval from the IRB the 14 researcher requested a contact list form the NATA Research and Graduate Study Department. In this form the district of interest was specified, a cover letter was written, and the EPJMUS was sent ready to be completed using Survey Monkey. The form was then sent to the District 3 Secretary for processing. After approval from the District Secretary, NATA sent the survey to 1,000 participants. The survey was designed to be completed in less than twenty minutes. Hypothesis The following was the hypothesis examined in this research. 1. Certified athletic trainers with more knowledge and understanding on joint mobilization will be more inclined to use this manual therapy technique in their clinical setting. Data Analysis A step-wise regression analysis was used to develop a predictive model based on joint mobilization utilization. Regression can be used as a model for prediction when 15 trying to find significant relationships between two variables. The data was gathered and described using frequency tables, percentages, correlations, and other pertinent observations. The components that were run through the step-wise regression analysis were grouped into 2 sections: educational training and joint mobilization usage. The data was analyzed using SPSS version 16.0. 16 RESULTS The following section will reveal pilot study testing, demographic data, and hypothesis testing obtained through the Educational Predictor for Joint Mobilization Usage Survey. The primary purpose of this original study was to develop a predictive model of joint mobilization utilization. This model will predict the level of usage of joint mobilization based on the educational training of certified athletic trainers. Pilot Study Testing Before the survey was sent to 1,000 certified athletic trainers, the researcher conducted a pilot study to discover the content validity and reliability of The Educational Predictor for Joint Mobilization Usage Survey. The survey demonstrated validity based on the comments and suggestions received from the panel of three experts (Appendix C3). A Cronbach’s alpha was performed to show the reliability of certain survey questions. Most statistical experts state that a coefficient of reliability is an alpha coefficient of 0.7 to 1.0. The following table 17 (Table 1) shows the reliability of several survey questions tested in the pilot study. 18 Table 1. Reliability Testing of The Educational Predictor for Joint Mobilization Usage Survey Questions Alpha Level Gender 1.000 How many years have you been BOC certified athletic trainer? 1.000 Which of the following did you attend in order to obtain your entry-level athletic training education? 1.000 In what year did you complete your entry-level athletic training education? 0.985 What is your highest level of education completed? 1.000 Was joint mobilization theory covered as part of a required course during your entry-level undergraduate athletic training education program? 0.671 19 Approximately how much time was spent learning the theories associated with joint mobilization in the required course(s)? 0.399 Were joint mobilization skills/techniques covered as part of a required course during your entry-level undergraduate athletic training education program? 0.624 Approximately how much time was spent learning joint mobilization skills/techniques in the required course(s)? * Were you encouraged to practice your joint mobilization skills during your clinical experience/clinical rotations? 0.81 Was joint mobilization covered during your graduate level education? 1.000 Was joint mobilization theory covered as part of a required course during your graduate education program? 0.607 Approximately how much time was spent learning the theories associated with joint mobilization in the required course(s)? 0.759 20 Were joint mobilization skills/techniques covered as part of a required course during your graduate education program? 0.607 Approximately how much time was spent learning the skills/ techniques in the required course(s)? 0.907 If you had a graduate assistantship while in graduate school how often did you use joint mobilization on your patients? 0.951 Have you taken a continuing education course post BOC certification that included joint mobilization? 1.000 Approximately how many continuing education contact hours (CEUs) have you have in courses that included joint mobilization? 1.000 Do you feel comfortable in assessing/determining when it is appropriate to use joint mobilization? 1.000 * Reliability could not be determined because one of the variables had zero variance 21 All but one of the survey questions run through the Cronbach alpha showed good to excellent reliability. The following question: Approximately how much time was spent learning the theories associated with joint mobilization in the required course(s) showed a reliability of 0.399. There could be a couple of different reasons as to why this number was lower than the others. When the researcher transferred the survey questions over to SurveyMonkey one of the question before this one accidently omitted; the question being: Was joint mobilization covered during your entry-level undergraduate athletic training education program? The researcher wants to point out this error because the same question on approximately how much time was spent learning the theories associated with joint mobilization was asked in terms of graduate education training, and the reliability came back to be 0.759. The researcher included the introduction question asking if the subjects had covered joint mobilization during their graduate level education. displayed a Another reason this question low reliability is the fact that the researcher asked a somewhat difficult question for each subject to think back on how many hours were actually spent reviewing joint mobilization theories. This could be a hard task for a subject that has not been enrolled in their 22 entry-level program for ten or more years. Therefore, the low reliability of this question needs to be taken into consideration when reading the following results. Demographic Data The Educational Predictor for Joint Mobilization Usage Survey was sent to 1,000 District 3 members, and 234 certified athletic trainers completed the survey. The following information will reveal demographic and descriptive data found within this study. Out of the 234 participants 43.6 percent were male and 56.4 percent were female. Participants were also asked to report when they completed their entry-level athletic training education program. The average year of completion was 1999.91 with the earliest year dating back to 1967 and the most recent year being 2008. Participants in this study were asked to mark their highest level of education. Table 2 illustrates the frequency of individuals who received a bachelors, masters, and/or doctoral degree. 23 Table 2: Frequency of Highest Level of Education Degree Frequency Percentage Bachelors 78 33.3 Masters 142 60.7 Doctoral 14 6.0 Table 3 examines the type of doctoral degrees held by the participants in this study. Table 3. Frequency of Different Types of Doctoral Degrees Degree Frequency Percentage None 218 93.2 DPT 5 2.1 EdD 3 1.3 PhD 6 2.6 Other 2 0.9 24 Table 4 shows how many subjects possess other credentials other than ATC. The researcher’s survey showed that none of the subjects who participated in this study were a Medical Doctor, Occupational Therapist Assistant, Doctor of Osteopathic Medicine, Doctor of Chiropractic, or Registered Nurse. 25 Table 4. Frequency of Credentials Credentials Frequency Percentage Physical Therapist 12 5.1 Physical Therapist Assistant 5 2.1 Occupational Therapist 1 0.4 Certified Strength and Conditioning Specialist 30 12.7 Performance Enhancement Specialist 14 5.9 Emergency Medical Technician 23 9.7 Teacher Certification 41 17.3 None 112 47.3 The next two tables illustrate the subject’s current place of employment (Table 5) and current employment position (Table 6). 26 Table 5. Frequency of Play of Employment Place of Employment Frequency Percentage University/CollegeAcademic 19 8.0 University/CollegeClinical 63 26.6 University/CollegeAcademic/Clinical 31 13.1 Professional Sports 9 3.8 Industrial 3 1.3 Military 6 2.5 Secondary Schools 82 34.6 Out-patient clinic 33 13.9 Hospital (In-patient Clinic) 6 2.5 27 Table 6. Current Employment Position Employment Position Frequency Percentage Academic Faculty 48 20.3 Clinical Faulty 21 8.9 Clinical Staff 111 46.8 Other 86 36.3 The following tables reveal response frequency to yes or no questions based on undergraduate joint mobilization educational training. Table 7 reports whether or not joint mobilization was covered during the subjects’ entry-level undergraduate athletic training education program (UATEP). Table 8 concentrates on joint mobilization theory while table 9 examines joint mobilization skills/techniques. Subjects were also asked if they were encouraged to use joint mobilization in their undergraduate clinical setting (Table 10), and if they have used joint mobilization since the completion of their entry-level undergraduate education program (Table 11). 28 Table 7. Coverage of Joint Mobilization During UATEP Responses Frequency Percentage Yes 168 71.8 No 66 28.2 Individuals who represent “No” in table 7 were not included in the frequencies of tables 8 and 9. Table 8. Coverage of Joint Mobilization Theory During UATEP Responses Frequency Percentage Yes 144 61.5 No 24 10.1 Table 9. Coverage of Joint Mobilization Skills/Techniques During UATEP Responses Frequency Percentage Yes 152 65.0 No 16 6.8 29 Table 10. Encouragement to Practice Joint Mobilization Responses Frequency Percentage Yes 132 56.4 No 102 43.6 Table 11. Joint Mobilization Usage Since Completion of UATEP Responses Frequency Percentage Yes 191 81.6 No 43 18.4 Forty-three participants stating that they did not use joint mobilization since they completed their entry-level undergraduate education program. Therefore, table 12 examines why these participants have not used joint mobilization since then. 30 Table 12. Why Participants Have Not Used Joint Mobilization Since UATEP Responses Frequency Percentage Not confident enough in your own skill level 26 11.0 Afraid of causing permanent injury 3 1.3 To time consuming 9 3.8 Do not believe it is an effective treatment 3 1.3 Prefer other manual therapies 8 3.4 Lack of knowledge in area(never had instruction) 9 3.8 Lack of knowledge in area(insufficient instruction) 16 6.8 Lack of skill in area(never had instruction of skill) 5 2.1 31 Lack of skill in area(insufficient instruction of skill) 19 8.0 Lack of sufficient time to do techniques effectively 218 92.0 Do not perceive the need for it in my patient population 18 7.6 The following tables will examine response frequency to yes or no questions based on graduate joint mobilization educational training. The graduate portion of the survey investigated the same areas as undergraduate educational training: coverage of joint mobilization (Table 13), joint mobilization theory (Table 14), and joint mobilization skills/techniques (Table 15). Table 13. Coverage of Joint Mobilization During Graduate School Responses Frequency Percentage Yes 88 37.6 No 109 46.6 Did Not Attend 37 15.8 32 Individuals who represent “No” or “Did Not Attend” in table 13 were not included in the frequencies of tables 14 and 15. Table 14. Coverage of Joint Mobilization Theory During Graduate School Responses Frequency Percentage Yes 75 32.1 No 13 5.6 Table 15. Coverage of Joint Mobilization Skills/Techniques During Graduate School Responses Frequency Percentage Yes 75 32.1 No 13 5.6 Continuing Education (CEU) is the last educational training area examined in this survey. Table 16 will reveal if the subjects have ever taken a formal CEU course(s) on joint mobilization post BOC certification, 33 while table 17 will show the area of concentration of the course(s). Table 16. Continuing Education Course on Joint Mobilization Responses Frequency Percentage Yes 62 26.5 No 172 73.5 Individuals who represent “No” in table 16 were not included in the frequencies of table 17. Table 17. Anatomical Areas Covered During the CEU Course(s) Responses Frequency Percentage Extremities 27 11.5 Spine 4 1.7 Both 34 14.5 Table 18 illustrates several different clinicians who adopted different techniques of joint mobilization. 34 Participants in this study were asked to choose which of the following technique they used most often. Table 18. Frequency of Techniques of Joint Mobilization Clinicians Frequency Percentage Cyriax 99 41.8 Kaltenborn 46 19.4 Maitland 140 59.1 Paris 7 3.0 Mennel 35 14.8 Unknown 56 23.6 Participants in the survey were asked general questions on joint mobilization such as: if they thought joint mobilization was a helpful rehabilitation (rehab) tool (Table 19), the purpose of joint mobilization (Table 20), and if they were comfortable assessing/determining when to use joint mobilization (Table 21). 35 Table 19. Is Joint Mobilization a Helpful Rehab Tool Responses Frequency Percentage Yes 227 97.0 No 7 3.0 Table 20. When is Joint Mobilization Most Helpful Responses Frequency Percentage Increase ROM 71 30.3 Decrease Pain 1 .4 Increase Function 6 2.5 All of the Above 156 66.7 36 Table 21. Comfortable Assessing/Determining When to Use Joint Mobilization Responses Frequency Percentage Yes 178 76.1 No 56 23.9 The last table (Table 22) examines the frequency rates on the reasons why participants in this survey have not taken a CEU course on joint mobilization. 37 Table 22. Reasons for Not Taking a CEU Course on Joint Mobilization Responses Frequency Percentage Timing or scheduling conflict 103 43.5 Costs too much 76 32.1 Do not perceive a need for it in my patient population 21 8.9 Not interested in it 23 9.7 Believe that I am adequately prepared/ trained in joint mobilization from athletic training education 18 7.6 38 Hypothesis Testing The Educational Predictor on Joint Mobilization Usage Survey was divided into 4 main sections: 1) Undergraduate Educational Training, 2) Graduate Educational Training, 3) Continuing Education Contact Hours (CEUs), and 4) Joint Mobilization Usage. Undergraduate educational training (independent variable) included the amount of time spent learning joint mobilization theories (ugthyhrs) and the amount of time spent learning joint mobilization skills (ugskillh). Graduate educational training (independent variable) also included the amount of time spent learning joint mobilization theories (grthehrs) and skills (grskillh) along with how often participants used joint mobilization during graduate school if they had a graduate assistant position (gaassist). Continuing education training (independent variable) included the amount of contact hours participants had (ceuhours). Joint mobilization usage (dependent variable) was defined in three different ways: on which anatomical areas have participants used joint mobilization (usejtmob), on which anatomical areas do participants feel most confident using joint mobilization (conjtmob), and on which anatomical areas do participants use joint mobilization the most 39 (dousejtm). The following hypothesis was investigated by this study. Hypothesis 1: Certified athletic trainers with more knowledge and understanding on joint mobilization will be more inclined to use this manual therapy technique in their clinical setting. Conclusion: Three different stepwise regression analyses were run to determine which independent variables affected joint mobilization usage. Table 23 illustrates to the readers the descriptive statistics of the first stepwise regression analysis. 40 Table 23: Descriptive Statistics for the First Stepwise Variables Mean Std. Deviation N Usejtmob (Ŷ1) 4.7 3.19 234 Ugthyhrs (X1) 1.8 1.83 234 Ugskillh (X2) 1.9 1.78 234 Grthehrs (X3) 1.0 1.62 234 Grskillh (X4) 1.1 1.70 234 Gaassist (X5) 2.6 1.42 234 Ceuhours (X6) 4.5 11.69 234 The first dependent variable the researcher examined was usejtmob (Ŷ1). Usejtmob is short for the following: on what anatomical areas have the participants of this study used joint mobilization. Statistically significant correlations are seen between several of the independent variables to the dependent variable. correlations. Table 24 examines these significant The top portion of the table indentifies correlation matrixes while the bottom portion of the table identifies significant correlation 41 Table 24: Correlations for First Stepwise Sig. (1-tailed) Pearson Correlation Variables usejtmob Ugthyhrs Ugskillh Grthehrs Grskillh Gaassist Usejtmob(Ŷ1) 1.000 Ugthyhrs(X1) -0.043 1.000 Ugskillh(X2) -0.044 0.87 1.000 Grthehrs(X3) 0.334 0.131 0.087 1.000 Grskillh(X4) 0.389 0.094 0.081 0.851 1.000 Gaassist(X5) 0.309 0.13 0.085 0.305 0.343 1.000 Ceuhours(X6) 0.39 -0.25 -0.271 0.129 0.096 -0.090 usejtmob(Ŷ1) . Ugthyhrs(X1) 0.255 . Ugskillh(X2) 0.252 .000 . Grthehrs(X3) .000 0.023 0.092 . Grskillh(X4) .000 0.076 0.11 .000 . Gaassist(X5) .000 0.023 0.097 .000 .00 . Ceuhours(X6) .000 .000 .000 0.025 0.071 0.084 Ceuhours 1.000 . 42 Table 24 shows the reader that the amount of time spent learning joint mobilization theories (grthehrs X3) and skills (grskillh X4) in graduate school, along with how often participants used joint mobilization during graduate school if they had a graduate assistant position (gaassist X5), and the amount of contact hours participants had in joint mobilization continuing education (ceuhours X6). All of the above variables showed significance when predicting on what anatomical areas have the participants used joint mobilization (usejtmob Ŷ1). However, grthehrs (X3) and grskillh (X4) show such similar significance that grthehrs (X3) was not included in the model because it would not make the model any more significant. Table 25 reports the variables included in the stepwise regression, exclusion criteria, and inclusion criteria SPSS used to determine which variables were significant. 43 Table 25: Variables Entered/Removed for First Stepwise Model Variables Entered Variables Removed Method 1 Ceuhours (X6) - Stepwise(Criteria: Probability-of-F-toenter <= .050, Probability-of-F-toRemove >=.100) 2 Grskillh (X4) - Stepwise(Criteria: Probability-of-F-toenter <= .050, Probability-of-F-toremove >=.100) 3 Gaassist (X5) - Stepwise(Criteria: Probability-of-F-toenter <= .050, Probability-of-F-toremove >=.100) 44 Table 26 views the actual predictive model. Model 1 includes ceuhours (X6) only, while model 2 includes ceuhours (X6) and grskillh (X4), and model 3 includes ceuhours (X6), grskillh (X4), and gaassist (X5). Table 26: Model Summary: First Predictive Model Model R R Square 1 .390 .152 2 .526 .277 3 .577 .332 Model 1: Ceuhours Model 2: Ceuhours, Grskillh Model 3: Ceuhours, Grskillh, Gaassist Table 26 shows the predictive model, while table 27 suggests to the reader that there is statistical significance within all three models. reports Model 3. Table 27 only The following ANOVA results in a p-value of equal to or less than .000. Therefore, based on the traditional p-value of .05 the results are held to be significant. 45 Table 27: ANOVA Regression for Model 3: First Predictive Model Model Sum of Squares df Mean Square 3 Regression 789.188 3 263.063 3 Residual 1584.850 230 3 Total 2374.038 233 F 38.177 Sig .000 6.891 In order to predict on what anatomical areas athletic trainers have used joint mobilization on, the following equations must be understood: Ŷ1 = a + bX6 + bX4 + bX5, Ŷ1 = predictive joint mobilization usage, a = the constant (intersection of where the line hits the y-axis, b = the slope of the line, X6 = ceuhours, X4 = grskillh, and X5 = gaassist. Table 28 illustrates this predictive equation in more depth. 46 Table 28: The Predictive Model: Anatomical Areas Athletic Trainers Have Used Joint Mobilization based on their Educational Training Unstandardized Coefficient Model 3 B Std Error Constant 2.2 0.38 Ceuhours(X6) .11 0.02 Grskillh(X4) .50 0.11 Gaassist(X5) .57 0.13 47 Conclusion: The second dependent variable the researcher examined was conjtmob (Ŷ2). Conjtmob is short for the following: on what anatomical areas did the participants of this study you feel most confident when using joint mobilization. Table 29 shows the readers the descriptive statistics of the second stepwise regression analysis. Table 29: Descriptive Statistics for the Second Stepwise Variables Mean Std. Deviation Conjtmob(Ŷ2) 3.6 2.66 234 Ugthyhrs(X1) 1.8 1.82 234 Ugskillh(X2) 1.9 1.78 234 Grthehrs(X3) 1.0 1.62 234 Grskillh(X4) 1.1 1.70 234 Gaassist(X5) 2.6 1.42 234 Ceuhours(X6) 4.5 11.69 234 Statistically significant correlations are seen between several of the independent variables to the N 48 dependent variable. correlations. Table 30 examines these significant The top portion of the table indentifies correlation matrixes while the bottom portion of the table identifies significant correlations. 49 Table 30: Correlations for Second Stepwise Sig. (1-tailed) Pearson Correlation Variables conjtmob Ugthyhrs Ugskillh Grthehrs Grskillh Gaassist Conjtmob(Ŷ2) 1.000 Ugthyhrs(X1) -0.093 1.000 Ugskillh(X2) -0.094 0.870 1.000 Grthehrs(X3) 0.189 0.131 0.087 1.000 Grskillh(X4) 0.225 0.094 0.081 0.851 1.000 Gaassist(X5) 0.263 0.130 0.085 0.305 0.343 1.000 Ceuhours(X6) 0.374 -0.250 -0.271 0.129 0.096 -0.090 Conjtmob(Ŷ2) . Ugthyhrs(X1) 0.078 . Ugskillh(X2) 0.075 .000 . Grthehrs(X3) 0.002 0.023 0.092 . Grskillh(X4) .000 0.076 0.110 .000 . Gaassist(X5) .000 0.023 0.097 .000 .000 . Ceuhours(X6) .000 .000 .000 0.025 0.071 0.084 Ceuhours 1.000 . 50 Table 30 shows the reader that participants that had a graduate assistantship during graduate school and used joint mobilization (gaassist X5), and the amount of contact hours participants had in joint mobilization continuing education (ceuhours X6) show significant correlations when predicting on what anatomical structures participants felt most confident when using joint mobilization (conjtmob Ŷ2). Table 31 reports the variables included in the stepwise regression, exclusion criteria, and inclusion criteria SPSS used to determine which variables were significant. 51 Table 31: Variables Entered/Removed for Second Stepwise Model Variables Entered Variables Removed Method 1 Ceuhours(X6) - Stepwise(Criteria: Probability-of-F-toenter <= .050, Probabiilty –of-F-to Remove >=.100) 2 Gaassist(X5) - Stepwise(Criteria: Probability-of-F-toenter <= .050, Probability-of-F-toRemove >=.100) 52 Table 32 views the actual predictive model. Model 1 includes ceuhours (X6) only while model 2 includes ceuhours (X6) and gaassist (X5). Table 32: Model Summary: Second Predictive Model Model R R Square 1 .374 .140 2 .478 .228 Model 1: Ceuhours Model 2: Ceuhours, Gaassist Table 32 shows the predictive model, while table 33 demonstrates to the reader there is statistical significance within both models. Table 33 only reports Model 2. The following ANOVA results in a p- value of equal to or less than .000. Therefore, based on the traditional p-value of .05 the results are held to be significant. 53 Table 33: ANOVA Regression for Model 2: Second Predictive Model Model Sum of Squares df Mean Square F 2 Regression 375.473 2 187.737 32.204 2 Residual 1267.911 231 2 Total 1643.385 233 Sig .000 5.489 In order to predict on what anatomical areas athletic trainers feel most confident using joint mobilization the following equations must be understood: Ŷ2 = a + bX6 + bX5, Ŷ2 = predictive joint mobilization usage, a = the constant (intersection of where the line hits the y-axis, b = the slope of the line, X6 = ceuhours, and X5 = gaassist. Table 34 illustrates this predictive equation in more depth. 54 Table 34: The Predictive Model: Anatomical Areas Athletic Trainers Feel Most Confident When Using Joint Mobilization Based on their Educational Training Unstandardized Coefficient Model 2 B Std Error Constant 1.7 0.34 Ceuhours(X6) .09 0.01 Gaassist(X5) .56 0.11 55 Conclusion: The third dependent variable the researcher examined was dousejtm (Ŷ3). Dousejtm is short for the following: on what anatomical areas do the participants use joint mobilization most. Table 35 illustrates to the readers the descriptive statistics of the third stepwise regression analysis. Table 35: Descriptive Statistics for the Third Stepwise Variables Mean Std. Deviation N Dousejtm(Ŷ3) 2.5 1.99 234 Ugthyhrs(X1) 1.8 1.83 234 Ugskillh(X2) 1.9 1.78 234 Grthehrs(X3) 1.0 1.62 234 Grskillh(X4) 1.1 1.70 234 Gaassist(X5) 2.6 1.42 234 Ceuhours(X6) 4.5 11.69 234 Statistically significant correlations are seen between several of the independent variables to the dependent variable. Table 36 examines these significant correlations. The top portion 56 of the table indentifies correlation matrixes while the bottom portion of the table identifies significant correlations. 57 Table 36: Correlations for Third Stepwise Sig. (1-tailed) Pearson Correlation Variables Dousejtm Ugthyhrs Ugskillh Grthehrs Grskillh Gaassist Dousejtm(Ŷ3) 1.000 Ugthyhrs(X1) -0.060 1.000 Ugskillh(X2) -0.074 0.870 1.000 Grthehrs(X3) 0.179 0.131 0.087 1.000 Grskillh(X4) 0.218 0.094 0.081 0.851 1.000 Gaassist(X5) 0.177 0.130 0.085 0.305 0.343 1.000 Ceuhours(X6) 0.410 -0.250 -0.271 0.129 0.096 -0.090 Dousejtm(Ŷ3) . Ugthyhrs(X1) 0.180 . Ugskillh(X2) 0.128 .000 . Grthehrs(X3) 0.003 0.023 0.092 . Grskillh(X4) .000 0.076 0.110 .000 . Gaassist(X5) .003 0.023 0.097 .000 .000 . Ceuhours(X6) .000 .000 .000 0.025 0.071 0.084 Ceuhours 1.000 . 58 Table 36 shows the reader that participants that had a graduate assistantship during graduate school and used joint mobilization (gaassist X5), and the amount of contact hours participants had in joint mobilization continuing education (ceuhours X6) show significant correlations when predicting on what anatomical structures participants use joint mobilization on the most (dousejtm Ŷ3). Table 37 reports the variables included in the stepwise regression, exclusion criteria, and inclusion criteria SPSS used to determine which variables were significant. 59 Table 37: Variables Entered/Removed for Third Stepwise Model Variables Entered Variables Removed Method 1 Ceuhours(X6) - Stepwise(Criteria: Probability-of-F-toenter <= .050, Probability-to-F-t0Remove >=.100) 2 Gaassist(X5) - Stepwise(Criteria: Probability-of-F-toenter <= .050, Probability-of-F-toRemove >=.100) 60 Table 38 views the actual predictive model. Model 1 includes ceuhours (X6) only while model 2 includes ceuhours (X6) and gaassist (X5). Table 38: Model Summary: Third Predictive Model Model R R Square 1 .410 .168 2 .463 .214 Model 1: Ceuhours Model 2: Ceuhours, Gaassist Table 38 shows the predictive model, while table 39 substantiates to the reader there is statistical significance within both models. Model 2. Table 39 only reports The following ANOVA results in a p-value of equal to or less than .000. Therefore, based on the traditional p-value of .05 the results are held to be significant. 61 Table 39: ANOVA Regression for Model 2: Third Predictive Model Model Sum of Squares df Mean Square 2 Regression 155.122 1 98.870 2 Residual 726.606 231 2 Total 924.346 233 F 31.432 Sig .000 3.145 In order to predict on what anatomical areas athletic trainers use joint mobilization on the most the following equations must be understood: Ŷ3 = a + bX6 + bX5, Ŷ3 = predictive joint mobilization usage, a = the constant (intersection of where the line hits the y-axis, b = the slope of the line, X6 = ceuhours, and X5 = gaassist. 40 gives more details to this predictive equation. Table 62 Table 40: The Predictive Model: Anatomical Areas Athletic Trainers Use Joint Mobilization on the Most Based on Their Educational Training Unstandardized Coefficient Model 2 B Std Error Constant 1.3 0.25 Ceuhours(X6) .07 0.01 Gaassist(X5) .30 0.82 63 DISCUSSION The discussion section will be divided into three subsections: 1) Discussion of the Results, 2) Implications to the Profession, and 3) Recommendations for Future Research. Discussion of the Results The purpose of this study was to create a predictive model through the use of a survey to determine if educational training levels predict joint mobilization utilization. Joint mobilization is a manual therapy used on individuals suffering from pain or hypomobility.1-2 Previous research has shown that joint mobilization is effective in decreasing pain and restoring joint motion and function.3 Since 1999 athletic training students enrolled in entry-level athletic training programs have been exposed to joint mobilization.8 However, there is no current research on the prevalence of joint mobilization use by athletic trainers since it has now been made a mandatory part of the curriculum. Therefore, research on whether or not undergraduate, graduate, and/or continuing educational training affects the use of joint mobilization is essential 64 in order to discover the level of usage of this manual therapy technique. Consequently, the researcher believes that certified athletic trainers with more knowledge and understanding on joint mobilization will be more inclined to use this manual therapy technique in their clinical setting. This research study found that educational training does in fact play a role in the use of joint mobilization. Joint mobilization was defined three different ways: 1) On which anatomical areas have you used joint mobilization (usejtmob Ŷ1), 2) On which anatomical structures do you feel most confident when using joint mobilization (conjtmob Ŷ2), and 3) On which anatomical structures do you use joint mobilization most (dousejtm Ŷ3)? Each one of these variables was analyzed individually via a stepwise regression. The first predictive model is shown in Table 26. This predictive model is made up of the following variable: (Table 26) continuing education hours (ceuhours X6), hours spent learning skills/techniques in graduate school (grskillh X4), and how often joint mobilization were used if participants had a graduate assistantship (gaassist X5). Table 26 introduces the predictive model, while Table 27 verifies for the readers that these three variables are 65 statistically significant when predicting usejtmob (Ŷ1). Usejtmob is short for the following: on what anatomical areas have the participants of this study used joint mobilization. If the researcher were to plot model 1 (refer to Table 26) on a graph usejtmob (Ŷ1) would be the y-axis while Ceuhours (X6) would be the x-axis. Since 62 out of the 234 participants (refer to Table 16) had taken a CEU on joint mobilization there would be 62 dots ranging from 0-100. An ascending line would then run through this plotted data acting as a predictive line. Therefore, “r” in Table 26 is the correlation of the line to the data set, while “r square” in table 26 is the percent of variability that is explained by the line. Thus, 15% of variability in the use of joint mobilization is predicted by ceuhours (X6). In order to predict anatomical areas athletic trainers have used joint mobilization on, the following predictive equation must be understood: Ŷ1 = a + bX6 + bX4 + bX5. Since Model 3 showed statistical significance in three variables the equation was broken down as follows (numbers are derived from Table 28): Ŷ1 = 2.2 +.11(ceuhours) + .50(grskillh) + .57(Gaassist). Participants in this survey were asked an open-ended question on how many hours they thought they received on 66 joint mobilization continuing education. Participants who covered joint mobilization in graduate school were asked to mark approximately how much time was spent learning joint mobilization skills/techniques; subjects could choose 1 hour, 2 hours, 3 hours, more than 3 hours, or unknown. Subjects were also asked if they had a graduate assistantship in graduate school how often they would use joint mobilization; participants could choose from the following: did not have a graduate assistantship, never, limited, moderately, often, or very often. The researcher coded these responses as follows: did not have a graduate assistantship = 1 never = 2, limited = 3, moderately = 4, often = 5, and very often = 6. Therefore, a participant who completed this survey and had 6 hours of CEU training, 2 hours of skills/techniques training, and used joint mobilization moderately will have an equation that looks like this (numbers derived from Table 28): Ŷ1 = 2.2 +.11(6) + .50 (3) + .57(4) ↓ Ŷ1 = 2.2 + .66 + 1.5 + 2.28 ↓ Ŷ1 = 6.6 Thus, 6.6 is the predicted amount of joint mobilization usage with a subject who has had 6 hours of CEU training, 3 67 hours of graduate skill training, and used joint mobilization moderately on their athletes while they were a graduate assistant. It is evident that ceuhours (X6) by itself was the most statistically significant independent variable; however, the most important variable in model 3 was gaassist (X5) because it shows the largest coefficient of .57 seen in Table 28. With this information known an individual who has used joint mobilization uses this manual therapy because he or she was very hands-on during their graduate assistantship. The researcher believes this is an accurate result because graduate assistantships require hands-onlearning, compared to a continuing education course that might not give the participant active interaction needed to advance joint mobilization skills. Hours spent learning skills and techniques in graduate school also played a significant role in joint mobilization utilization. graduate The researcher thinks students that go to school in athletic training may not attend to necessarily learn new ways of doing things, but instead wish to perfect skills undergraduate education. example of this. and techniques taught in Joint mobilization is just one The researcher thought that undergraduate education would have played the most significant role on 68 joint mobilization use; however, as the results of this study were education revealed, plays a it does make statistically sense that significant skills are being improved and refined. graduate role because Not only are manual therapy skills being practiced in the classroom, but the student has the opportunity to apply and perform the skills on their athletes in the clinic. The second predictive model is shown in Table 32, and states that ceuhours (X6) and gaassist (X5) show statistical significance (Table 33) when predicting on what anatomical structures participants felt most joint mobilization (conjtmob Ŷ2). confident when using If the researcher were to plot model 1 (refer to Table 32) on a graph conjtmob (Ŷ2) would be the y-axis while ceuhours (X6) would be the x-axis. An ascending line would then run through this plotted data acting as a predictive line. the correlation of the Therefore, “r” in Table 32 is line to the data set, while “r square” in Table 32 is the percent of variability that is explained by the line. areas individuals feel Thus, 14% of variability in the most confident using joint mobilization is predicted by ceuhours. In order to predict joint mobilization utilization and how confident individuals are when using joint mobilization the following predictive equation must be understood: 69 Ŷ2 = a + bX6 + bX5. Since Model 2 showed statistical significance in two variables the equation was broken down as follows (numbers are derived from Table 34): Ŷ2 = 1.7 +.09(ceuhours) + .56(Gaassist). With this information known, a participant who completed this survey and had 6 hours of CEU training and used joint mobilization moderately will have an equation that looks like this: Ŷ2 = 1.7 +.09(6) + .56(4) ↓ Ŷ2 = 1.7 + .54 + 2.24 ↓ Ŷ2 = 4.5 Thus, 4.5 is the predicted amount of joint mobilization usage with a subject who has had 6 hours of CEU training and used joint mobilization moderately on their athletes while they were a graduate assistant. Similar ceuhours to (X6) the and first gaassist predictive (X5) model showed significance when predicting conjtmob (Ŷ2). discussed statistical Again, ceuhours (X6) shows the most significance while gaassist (X5) shows the most importance with a larger coefficient of .56 seen in Table 28. The researcher believes the gaassist (X5) is more important than the ceuhours (X6) because more hands-on- 70 learning takes place with a graduate assistantship compared to a continuing education course. The third predictive model is shown in Table 38, and states that ceuhours (X6) and gaassist (X5) show statistical significance (Table 39) when predicting on what anatomical structures participants use joint mobilization most often (dousejtm Ŷ3). If the researcher were to plot model 1 (refer to Table 38) on a graph dousejtm (Ŷ3) would be the yaxis while ceuhours (X6) would be the x-axis. An ascending line would then run through this plotted data acting as a predictive line. Therefore “r” in Table 38 is the correlation of the line to the data set, while “r square” in Table 38 is the percent of variability that is explained by the line. areas that predicted amount Thus, 16% of variability on the anatomical participants by ceuhours of joint (X6). different mobilization, use Therefore, joints individuals mobilization to increase participants need to most attend use is the joint continuing education conferences on this manual therapy technique. In order to predict anatomical areas athletic trainers use joint mobilization on most often the following predictive equation must be understood: Ŷ3 = a + bX6 + bX5. Since Model 2 showed statistical significance in two 71 variables the equation was broken down as follows (numbers are derived from Table 40): Ŷ3 = 1.3 +.07(ceuhours) + .30(Gaassist). With this information known, a participant who completed this survey and had 20 hours of CEU training and used joint mobilization often will have an equation that looks like this: Ŷ3 = 1.3 +.07(20) + .30(5) ↓ Ŷ3 = 1.3 + 1.4 + 1.5 ↓ Ŷ3 = 4.2 Thus, 4.2 is the predicted amount of joint mobilization usage with a subject who has had 20 hours of CEU training and used joint mobilization often on their athletes while they were a graduate assistant. Similar ceuhours to (X6) the and second gaassist predictive (X5) model showed significance when predicting dousejtm (Ŷ3). discussed statistical Again, ceuhours (X6) shows the most significance while gaassist (X5) shows the most importance with a larger coefficient of .30 seen in table 28. The researcher believes the gaassist (X5) is more important than the ceuhours (X6) because more hands-on- 72 learning takes place with a graduate assistantship compared to a continuing education course. Implications to the Profession With a predictive model constructed on the level of usage of joint mobilization the researcher wants to discuss several ways the athletic training profession can implement this information into entry-level curriculums and post continuing education courses. This research studied six variables to predict joint mobilization utilization, and three of the variables showed significance. This leaves the researcher with educational areas that need to be improved upon in order for joint mobilization to be used more readily in the clinical setting. The researcher’s study showed that time spent learning theories, skill, and techniques on joint mobilization during undergraduate educational training had no affect on the level of usage for this manual therapy. Therefore, undergraduate curriculums need to spend more time educating athletic training students on joint mobilization, and then emphasizing techniques learned in the classroom in the clinical setting. One of the best ways to perfect joint mobilization is to actually practice the technique. Hence, 73 why gaassist (X5) showed the most importance when predicting joint mobilization use. This research can also be useful to individuals who have already gained their bachelor and masters degrees. A person in this situation who already has their degrees, but wants to be proficient in using joint mobilization may take continuing education courses. As the predictive model shows ceuhours (X6) is the most statistically significant variable when predicting joint mobilization use. Therefore, instead of suggesting this person go back to graduate school to learn joint mobilization skills and techniques; the suggestion of continuing education should be discussed. This implication can be made because the predictive model states that continuing education affects joint mobilization utilization. Recommendations for Future Research Based on the results of this study, the following suggestions for future research will be made. The researcher’s survey tested the following areas of undergraduate education in relation to joint mobilization: how much time the spent learning the theories and skill behind joint mobilization, and if participants were 74 encouraged to use joint mobilization during their clinical experiences/rotations. This research found that undergraduate education had no effect on joint mobilization utilization. Therefore, there needs to be research done on how undergraduate athletic training programs teach, implement, and reinforce joint mobilizations into their programs. This study showed a lack of undergraduate training when it came to predicting joint mobilization utilization. Thus, ways to increase joint mobilization education in the classroom and the clinic in undergraduate programs needs to be researched. Secondly, there is a need for future research to discover what an acceptable level for the Ŷ variable would be. Thus, what number (Ŷ variable) is going to make someone proficient at using joint mobilization? If a standard number for the Ŷ variable is found then athletic trainers looking for professionals that are competent in joint mobilization can use this predictive model to calculate how proficient someone is in using joint mobilization, or how many continuing education hours someone needs to become proficient with this manual therapy. For example, the researcher believes if a subject’s Ŷ variable is equal to or higher than 10 he or she is proficient at using joint mobilization. The subject 75 used joint mobilization often during his or her graduate assistantship but does not have any continuing education hours on this manual therapy technique. Therefore, with the help of this predictive model this subject could calculate how many continuing education hours he or she needed to receive a Ŷ variable of 10 of higher making him or her proficient at using joint mobilization. 76 REFERENCES 1. Houglum PA. Therapeutic Exercise for Musculoskeletal Injuries. Champaign, IL: Human Kinetics; 2005. 2. Kahanov L, Kato M. Therapeutic Effect of Joint Mobilization: Joint Mechanoreceptors and Nociceptors. ATT. 2007;12:28-31. 3. Ben-Sorek S, Davis CM. Joint Mobilization Education and Clinical Use in the United States. Phys Ther. 1988;68:1000-1004. 4. Moss P, Sluka K, Wright A. The initial effects of knee joint mobilization on osteoarthritic hyperalgesia. Man Ther. 2007;12:109-118. 5. Conroy DE, Hayes KW. The Effect of Joint Mobilization as a Component of Comprehensive Treatment for Primary Shoulder Impingement Syndrome. J Orthop Sports Phys Ther. 1998;28:3-14. 6. Yang J, Chang C, Chen S, Wang S, Lin J. Mobilization Techniques in Subjects With Frozen Shoulder Syndrome: Randomized Multiple-Treatment Trial. Phys Ther. 2007;87:1307-1315. 7. Mangus BC, Hoffman LA, Hoffman MA, Altenburger P. Basic Principles of Extremity Joint Mobilization Using a Kaltenborn Approach. J Sport Rehabil. 2002;11:235250. 8. National Athletic Trainers’ Association. Athletic Training Educational Competencies: 4th Edition. Dallas: NATA; 2006. 9. Board of Certification. Role Delineation Study: For The Entry-Level Certified Athletic Trainer Fifth Edition. Omaha: National Athletic Trainers’ Association Board of Certification, INC; 2004. 10. Reasoner AE. A Western States Survey of Certified Athletic Trainers’ Use of Joint Mobilization in Treatment Programs. J Athl Train. 1984:267-271. 77 11. Stephens EB. Manipulative Therapy in Physical Therapy Curricula. Phys Ther. 1973;53:40-50. 12. Volpe M. Use of Joint Mobilization by Physical Therapists in Massachusetts. Master’s Thesis. Boston, MA, Sargent College of Allied Health Professions, Boston University, 1979. 78 APPENDICES 79 APPENDIX A Review of Literature 80 REVIEW OF THE LITERATURE Joint mobilization is a manual therapy technique used by athletic trainers when pain needs to be decreased and range of motion needs to be increased. Understanding the anatomical positioning of a joint is important when implementing these techniques. Standard protocols on joint mobilization have been implemented into rehabilitation plans based off clinicians such as Maitland, Kaltenborn, Cyriax, Mennel, and Paris. Depending on the treatment goals of the patient each one of these clinician’s protocols for joint mobilization should be considered before executing the manual therapy. Research shows that joint mobilization does work when wanting to decrease pain and/or increase range of motion;1 however, these techniques seem limited throughout the clinical setting. Thus, the purpose of this literature review is to: describe joint mobilization, describe the principles behind joint mobilization, describe the effects of joint mobilization, and review the education on joint mobilization in the clinical setting. 81 Joint Mobilization The musculoskeletal system includes the body’s joints, muscles, and bones. This system works as one to allow for everyday movement, and provides the human body with protection from outside forces. In order for joints to move appropriately in everyday activity small motions must occur at the joints. When these small movements at the joint become restricted, range of motion needs to be restored in order to perform daily activities of living.2 Joint mobilizations are just one clinical rehabilitation tool that can be used by certified athletic trainers to restore range of motion.2 When a joint suffers a severe amount of trauma certain degrees of range of motion are usually lost; this is known as hypomobility. A decrease in range of motion can be caused by edema formation, pain after injury, and capsular restrictions. Joint mobilization not only work on restoring loss of motion, but decreasing pain as well.3-4 Joint Biomechanics It is important to understand the biomechanics of a joint before discussing how joint mobilization works. Joint motions are a combination or both: physiological and 82 accessory movements.3 Physiological joint motions include movements such as flexion, extension, abduction, adduction, and rotation; the patient can control these motions.3-4 Accessory joint motions cannot be controlled by the patient and are commonly referred to as arthrokinematics.4 Arthrokinematics refers to the way bones move within the joint space.3 Five different movements can occur within all joints: roll, slide, spin, compression, and distraction. “Roll occurs when a new point of one surface meets a new point of the opposing surface.”3 For example, when a pen is rolled on the table each part of the pen will come in contact with the surface of the table. “Slide occurs when one point of one surface contacts new points on the opposing surface.”3 For example, a pen will come in contact with multiple surfaces of the table, but the table will only contact one part of the pen. “Spin occurs when one bone rotates around a stationary axis.”3 spinning a pen on the surface of a table. For example, Compression is when the joint space decreases, while distraction increases the joint space.3 Understanding joint arthrokinematics is essential when learning the purposes behind joint mobilization and how it works. 83 Joint Mobilization and Range of Motion Physiology As previously stated joint mobilization is used to increase range of motion. There are numerous articles on the impact joint mobilization plays on range of motion, and how this manual therapy technique has been known to benefit patients with hypomobility. Hypomobility can result in a decrease in joint function resulting in other joints overcompensating for the trauma.5 When there is a decrease in range of motion there is a concurrent decrease in capsular mobility.5 capsule.5 All joints are surrounded by a joint The joint capsule protects the joint from outside forces and supplies the joint with synovial fluid, which lubricates the entire joint, joint surfaces, and provides nutrition to the joint.5 When outside forces are applied to the joint, stretching of the capsule occurs which in turn will decrease the amount of hypomobility. Not only is hypomobility addressed with this manual therapy, but joint mobilization also inhibits pain receptors within the joint, which in turn will decrease overall pain. 84 Joint Mobilization and Pain Physiology Pain can be a debilitating symptom of trauma when an athlete or patient is trying to recover from an injury. Most often an athletic trainer’s primary goal is to decrease pain levels, which will allow for progressive treatment. If an athlete is pain-free, he or she will have more incentive to move forward in his or her rehabilitation process. There are many different techniques that can be used to decrease pain, and joint mobilization is just one option. Joint mobilization activates joint mechanoreceptors.4 There are three different sensory mechanoreceptors found in the joint or around the joint that are sensitive to specific joint motions when joint mobilization is utilized.4 Ruffini endings, Pacinian corpuscles, and Golgi ligament endings are all mechanorecptors which transmit information to the central nervous system via Type I, Type II, and Type III nerves.4 Ruffini endings are located in the superficial part of the joint capsule. This particular mechanorecptor can be found in all joint capsules within the body.4 Ruffini endings are sensitive to stretch within the capsule, and have a low activation threshold.4 Therefore, when small amplitude joint motions are administered Ruffini endings are stimulated.4 85 Pacinian corpuscles are located within joint capsules and fat pads.4 They adapt rapidly to deep pressure, stretch, and vibration of high frequencies.4 Thus, these mechanorecptors react to a rapid increase of tension in the joint capsule.4 Golgi ligament endings are found within collateral ligaments. These mechanorecptors transmit information on ligament tension during active or passive stretching to the central nervous system.4 Golgi ligament endings have a high activation threshold; therefore, only being activated at the end-range of motion during joint mobilization.4 Activation of mechanoreceptors prevent nociceptors from becoming stimulated thus interrupting the pain stimulus from the spinal cord to the brain stem.4 Nociceptors are free nerve endings found in the joint capsule that generate pain impulses. When small amplitude joint movements are applied to a joint the stimulation of nociceptors becomes decreased, thus decreasing the perception of pain.4 Now that the physiology behind range of motion and pain has been reviewed it is essential that basic principles of joint mobilizations be discussed in order to understand how they are used. 86 Principles of Joint Mobilization To understand the full premise behind joint mobilization it is imperative to understand the principles, and the clinicians who influenced the teaching of this manual therapy. There are several different clinicians who developed and refined the idea of joint mobilization. One of the most common joint mobilization techniques is that of Maitland’s Five-Grade Mobilization System.6 Freddy Kaltehnborn, James Cyriax, James Mennell, and Stanley Paris also contributed to the teachings and findings of joint mobilization.3-4 Athletic trainers must determine which technique is the best in regards to treating the patient depending on the goals of the overall treatment.5 Each clinician uses the same overall principle with different uses of accessory glides incorporated into the joint movements.4,6 James Cyriax’s theory involved the search for the particular tissue that is causing the problem.4 Once that tissue is identified Cyriax utilized strong passive movements in order to restore ROM.4 James Mennell’s theory emphasized the importance of normal joint function. He concluded that in order for full joint motion to occur small accessory movements are necessary.3 Mennell’s 87 mobilization techniques are more specific to the extremities instead of the spine.3 Stanley Paris has a more diverse approach to arthrokinematics which incorporated both chiropractic and osteopathic techniques.3 Paris’s general rule with his patients was that his or her pain level would not be a guide for treatment protocols.3 The last two clinicians, Maitland and Kaltenborn, divide their joint mobilization into five or three grades of movement. Grades of Joint Mobilization Since one of the common grades of joint mobilization come from Maitland it is important to review the principles behind his five-grade system of joint motions.6 Maitland incorporates various degrees of amplitude on joint tissue causing mechanoreceptors to be stimulated and joint capsules to become stretched. Grade I is used to decrease pain and involves small amplitude motions at the beginning of the range of motion.3,5 Grade II is also used to decrease pain and involves large amplitude motions applied midway through the full range of motion.3,5 Grade III is used to increase range of motion and involves large amplitude motions applied at the end of range of motion.3,5 Grade IV is used to increase range of motion and involves small amplitude motions applied at the end of range of 88 motion.3,5 Grade V mobilizations are beyond the scope of certified athletic trainers and require manipulation of the joint beyond its normal range of motion.3,5 Kaltenborn, another clinician, uses a three-grade joint mobilization system. traction and glide.5 These grades incorporate A Grade I movement involves distraction of a joint, a Grade II movement combines distraction and joint glides, and lastly, a Grade III movement utilizes joint traction and stretching to increase the joint capsule and surrounding structures that limit range of motion.5 Both Maitland and Kaltenborn’s treatments are effective, but all the research present in this literature review will be based on Maitland’s five-grade mobilization techniques. No matter which clinician’s technique is used during the rehabilitation process there are two rules that have to be understood before applying joint mobilization to a patient: the concave-convex rule and the convex-concave rule. The Concave-Convex Rule and the Convex-Concave Rule Once the grades of mobilization are established treatment is enforced through the rule depending on the surface of the joint being manipulated. In order for joint mobilization to be utilized this fundamental concept needs 89 to be understood. The concave-convex rule is as follows: when there is a concave surface moving on a convex surface the swing of the bone and the glide of the joint move in the same direction.3,5 The convex-concave rule is as follows: when there is a convex surface moving on a concave surface the swing of the bone and the glide of the joint move in opposite directions.3,5 This concept is more easily understood when an example is provided. A patient is suffering from adhesive capsulitis and shoulder abduction is very limited. Through the use of joint mobilization shoulder abduction can be increased. The convex-concave rule needs to be implemented in this situation. The convex surface would be the humeral head and the concave surface would be the glenoid fossa. Since there is a convex surface moving on a concave surface an inferior glide needs to be performed on the joint. Not only does a clinician need to understand the above rule in order to administer the joint mobilization, but also he or she always needs to be aware of the joint positioning before joint mobilization techniques are implemented.5 Positioning of the Joint During Mobilization There are two positions a joint can be in: closepacked position and loose-pack position. A close-packed 90 position is when the joint and articular surfaces are compressed and congruent with one another such as: the glenohumeral joint as it reaches full abduction and external rotation.3 Thus, the surrounding ligaments and the actual capsule are tight. If the ligaments and capsule are taut then traction of the joint is not easily obtained.3 Joints suffering from hypomobility should not initially be mobilized in a close-packed position. A loose-packed position is any position that is not close-packed.3 Therefore, the joint capsule and surrounding ligaments are lax, and the surfaces are not congruent.3 This is known as the joint’s resting position, and early joint mobilization techniques should be performed in this position. For example, the glenohumeral joint is resting at fifty-five degrees shoulder flexion with twenty to thirty degrees of horizontal abduction; while the closed packed position is full abduction with full lateral rotation.3 It is not only important to position the joint correctly but the patient’s overall body position needs to be considered upon delivery or this manual therapy. Positioning of the Patient/Clinician During Mobilization Stevenson et al. discuss the importance of four cardinal principles before administering joint 91 mobilization.7 the clinician.7 The first is positioning of the patient and The purpose of proper positioning is to minimize all discomfort. The athletic trainer always needs to make sure the patient is in the optimal position for delivery, comfort, and safety.7 Minimal strain on the patient and the clinician is very important. Stabilization is the second principle and refers to both the patient’s extremity segments and the control of the extremity the athletic trainer has while performing the joint mobilization.7 It is only when stabilization is administered that effective treatment will be achieved. The third principle is mobilization, and this incorporates the importance of understanding the concave-convex rule.7 When performing a joint mobilization one bone at the joint needs to remain stable to achieve true arthrokinematic results. For example, if there is a lack of knee extension the femur can be held stable while the tibia receives anterior glides, or the tibia can be held stable while the femur receives posterior glides. Lastly, comfort needs to be incorporated into a joint mobilization regime.7 If maximum comfort is achieved then this manual therapy technique will be easily administered and little stress will be put on the patient and the athletic trainer. 92 Effects of Joint Mobilizations With the above information known, one has to actually wonder if joint mobilization is effective when decreasing pain and increasing range of motion. There is research that supports the effectiveness of joint mobilization and the role it plays in the clinic. Joint mobilization can be performed on any joint in the body, but the most common areas joint mobilization are used on are the knee and shoulder;5 however, there are research articles that discuss the use of this manual therapy on the ankle, low back, cervical spine, and hip. The Effect Joint Mobilization Has on Pain Non-specific low back pain in the athletic population is very common, and athletic trainers are always looking for ways to decrease the athlete’s pain level. Hanrahan et al. examined the effects Grade I and II joint mobilizations had on low back dysfunction, and found that these type of graded joint motions decreased patient’s pain in the short-term stages of back pain.8 The joint mobilization group in this study received ice and stretching as well. 93 Conroy et al. found similar results in their study; however, it was geared toward primary shoulder impingement.9 This study combined joint mobilization with a comprehensive treatment plan that incorporated hot packs, active range of motion, physiologic stretching, muscle stretching, and patient education. Grade I and II mobilization were applied and if these grades became less painful Grades III and IV were applied. In the end, the combination of joint mobilization and rehabilitation decreased the patient’s twenty-four hour pain and pain with the subacromial compression test.9 Another study done on nonspecific low back pain took posterior-to-anterior mobilization and the press-up exercise, and examined the effects those two interventions had on pain when patients performed standing extension and lumbar extension.10 Grades I and II mobilizations were used prior to grades III and IV. Both interventions decreased the average pain with standing extension, but no significant evidence was found to which method worked better.10 Mackawan et al. did a study on Thai massage verses joint mobilization on subjects with nonspecific low back pain.11 Grade II mobilization was used at the level of L2- L5, or Thai massage was given to the surrounding low back 94 muscles for five minutes. In the end the study determined that both interventions decreased the patient’s pain; however, Thai massage was more beneficial.11 Lastly, Moss et al. did a study on osteoarthritic knee joints and the effect large amplitude joint motions have on pain.12 Anterior-to-posterior glides were done on the tibiofemoral joint, and the authors of the study found that this mobilization had immediate local and widespread hypoalgesic effects on the patient.12 Joint mobilizations may be a manual therapy technique that can be used to decrease pain. When joint mobilizations are added into comprehensive treatment plans they have a better overall effect than just being used by themselves to decrease pain.9 Evidence shows joint mobilizations alone help to decrease pain; however, other techniques may be just as beneficial. The Effect Joint Mobilization Has on Range of Motion Joint mobilization is more commonly seen in the clinic when range of motion is restricted.5 A study discussed earlier by Conroy et al. on joint mobilizations as a component of comprehensive treatment for primary shoulder impingement syndrome not only looked at pain but mobility as well.9 This research revealed that joint mobilization 95 may not be as effective at increasing mobility; however Grade I and II mobilizations were implemented into the research protocol,9 and according to Maitland, these are to relieve pain not increase range of motion. Another study was done on the effects proprioceptive neuromuscular facilitation stretching and joint mobilization had on increasing posterior shoulder mobility.13 Grade III and IV posterior glenohumeral joint mobilizations were provided, and Goldman et al. discovered that both treatment protocols were equally effective in increasing posterior shoulder mobility. Vermeulen et al. discovered that high grade mobilization techniques (Grade III and IV) were more effective at increasing mobility in patients with adhesive capsulitis than low-grade mobilization techniques (Grade I and II).14 These results should make sense because Grade III and IV joint mobilization are specifically used to increase range of motion.3 Another study on adhesive capsulitis syndrome done by Yang et al. determined that end-range mobilization where more effective in increasing mobility than mid-range mobilization.15 Lastly, McNair et al. examined Grade III mobilization on the cervical spine in one patient suffering from acute 96 neck pain.16 The patient made improvements in flexion, extension, left rotation, and left lateral rotation range of motion. This study revealed that Grade III mobilization techniques do work when increasing range of motion, however, the sample size is small so reliability is definitely questioned.16 The literature does provide evidence that joint mobilization works in decreasing pain and increasing range of motion. However, there are limited studies actually done by certified athletic trainers on joint mobilization in comparison to other research. Therefore, it is important to explore when athletic trainers were introduced to this manual therapy, and teaching methods behind joint mobilization. Education about Joint Mobilization Athletic trainers (ATs) have an extensive background in rehabilitation.17 Mangus et al. reported that twenty-one percent of certified athletic trainers work in a rehabilitation setting; working closely with physical therapists.5 However, there seems to be a lack of time spent educating athletic training students and certified athletic trainers (ATCs) on joint mobilization. Since ATs come in 97 contact with athletes that present with signs and symptoms of pain and lack of joint motion after injury it is important for them to be familiar with different treatment protocols used to address the pathology. ATs are constantly submerging themselves in the literature in order to learn new ways and methods for enhancing patient outcomes; joint mobilization is one technique that can do this.5 Prior to 1999 only some entry-level athletic training programs introduced joint mobilization at the undergraduate level.5 However, joint mobilization has now been included in both the third and fourth edition of the NATA educational competencies.18 Therefore, students enrolled in entry-level athletic training programs post 1999 have been exposed to joint mobilization.18 Since joint mobilization is now a part of Performance Domain IV: Treatment, Rehabilitation, and Reconditioning, this manual therapy technique should be considered for use by practicing athletic trainers.19 Athletic trainers that want to stay current in the profession should seek additional training in joint mobilization. Such training could be obtained through continuing education credits or in graduate school in which academic coursework can reinforce the principles of joint mobilization, and encourage athletic trainers to use this 98 rehabilitation tool on athletes suffering from pain and/or hypomobility. It is important to understand where ATs stand on the use of joint mobilization; however, there is limited research in this area. Athletic Training Education on Joint Mobilization In 1984 a “Western States Survey of Certified Athletic Trainers’ Use of Joint Mobilization in Treatment Programs”20 was implemented in order to determine the education and use of this manual therapy in the clinical setting.20 The wider an ATs knowledge base on treatment protocols the faster and more efficient he or she will return the athlete to play. Reasoner gathered several different results from her survey: ATs relied mainly on their colleagues as a primary education source when and if joint mobilization needed to be used, seventy-two percent of ATs used joint mobilization reference sources more than once a month, universities and sports medicine clinics reported the highest rate of joint mobilization use, the majority of ATs participating in this survey used joint mobilization sparingly, and lastly, ATs that underwent formal education in joint mobilization used it more frequently compared with those who had less formal education.20 99 With this information known it is evident that joint mobilization education needs to be refined and implemented into undergraduate athletic training programs. It is apparent through this research that a lack of education is prevalent in the utilization of joint mobilization by the ATC. Athletic training curriculums need to spend more time educating future professionals on this manual therapy technique. A survey sent out to physical therapists discovered entry-level physical therapy education programs are expanding their curriculum in order to enhance the treatment of joint dysfunction through the use of joint mobilization.1 Physical Therapy Education on Joint Mobilization Athletic training and physical therapy are two closely related professions; however, joint mobilization seems to be more prevalent in the physical therapy setting. Ben- Sorek et al. discovered that joint mobilizations were becoming increasingly more popular between the years of 1970 and 1986.1 Therefore, more education was emphasized on this manual therapy technique during entry-level physical therapy education. From the 1970 survey, fifty-one entrylevel physical therapy education programs were reviewed, none of which had a separate course offered in joint 100 mobilization; however, joint mobilization was taught as a subunit in nine of the programs.21 In the 1986 survey thirty-seven percent of physical therapy education programs taught a separate course in joint mobilization, while sixty percent offered joint mobilization as a subunit.1 Therefore, joint mobilizations implemented into entry-level programs have expanded from 1970 to 1986,1 and according to Normative Model of Physical Therapy Education, joint mobilization should be included in all physical therapy curriculums. Sorek et al. also studied whether or not physical therapists received instruction outside of the entry-level program, and compared the data to that of Volpe, the author of a similar study done in 1979. In both studies, continuing education was the instruction that was studied outside the entry-level.1,22 Continuing education in joint mobilization did increase between these years; thus, increasing the opportunities for physical therapists to utilize joint mobilization in the clinical setting.1 The more emphasis put on education the more likely physical therapists are to use joint mobilization. If undergraduate and graduate athletic training programs took the time to incorporate joint mobilization as a more important subunit of therapeutic exercise this 101 manual therapy would be used more readily in the clinical setting. Education on joint mobilization plays an important role in the use of the manual therapy. Research showed that the more education ATs had on the technique the more inclined they are to use it.20 Summary Joint Mobilization is a manual therapy technique that can be used to decrease pain or increase range of motion. This technique should be strongly considered for a rehabilitation plan during bouts of pain or hypomobility. Research shows that joint mobilization is effective, and with proper training this manual therapy can be easily incorporated during the rehabilitation phase of treatment. With the latest research done in 1984 on the use of joint mobilization implemented by athletic trainers,20 there is a need for updated research to determine if educational training predicts the use of joint mobilization. When the 1984 research was done joint mobilization was only implemented in some entry-level athletic training programs.5 However, as of 1999, it was required that entry-level education programs teach athletic trainers this manual therapy.18 With educational increases on joint mobilization, 102 results may be seen on the use of this technique by the athletic trainer; similar to the increases seen in the study done on physical therapists.1 Discussing these studies builds an argument that joint mobilization can be used to increase range of motion and/or decrease pain. With evidence known that this manual therapy technique does work athletic trainers need to become fully educated on the indications, contraindications, theories, use, and principles of joint mobilization. Once these basic principles are formed athletic trainers can begin to use this manual therapy on their patients. Joint mobilization is a manual therapy that will enhance rehabilitation protocols, which in turn will improve patient outcomes. 103 APPENDIX B The Problem 104 Statement of the Problem For the past ten years joint mobilization has been incorporated into undergraduate entry-level athletic training curriculums. Thus, knowledge on this rehabilitation technique should be utilized within the clinical setting. However, there is minimal research on joint mobilization implemented by the athletic trainer in comparison to physical therapists. Therefore, the purpose of this study was to develop a predicted model based on joint mobilization utilization. A survey was used to measure athletic trainer’s undergraduate, graduate, and continuing education experiences on joint mobilization. The survey also examined the utilization of this manual therapy. Therefore, if an effective model can be predicted it will affect undergraduate, graduate, and continuing education to enhance future athletic training curriculums. Definition of Terms The following definitions are provided, for clarification: 1) Joint Mobilization – A manual therapy technique used to control pain and/or increase range of motion at a joint. 105 2) Utilization of Joint Mobilization – Items 28-30 on The Educational Predictor of Joint Mobilization Usage Survey (EPJMUS) that measure anatomical areas of use confidence levels, and frequency. 3) Undergraduate Education Training – Incorporated hours spent learning the theories, skills, and techniques of joint mobilization. Items 10-16 on the survey are dedicated to undergraduate educational training. 4) Graduate Education – Incorporated hours spent learning the theories, skills, and techniques of joint mobilization. Also included frequency on use if a graduate assistantship was obtained during graduate school. Questions 17-23 on the survey are dedicated to graduate educational training. 5) Continuing Education – Incorporated post BOC certification continuing education courses on joint mobilization, the number of course hours, and what the course covered. Items 24-256 on the survey are dedicated to continuing education. Basic Assumptions The following assumptions were made in regards to this study: 106 1) All survey questions were answered honestly, correctly, and to the best of the ability of the athletic trainer. 2) The sample obtained for this research was a representation of the population. 3) All athletic trainers who graduated after 1999, will have been formally educated on joint mobilization techniques, since joint mobilization was included in both the third and fourth edition of the NATA educational competencies. 4) Athletic trainers who graduated before 1999 may or may not have had any formal training in joint mobilization as part of their entry-level education. Limitation of the Study The following statement reflects the potential limitation of the study: 1) The subjects participating in the survey were volunteers who represent enthusiastic individuals within the athletic training profession. Delimitation of the Study The following statement reflects the potential delimitation of the study: 107 1) Only District 3 members with a valid e-mail address were surveyed. Significance of the Study Joint mobilization has been part of the entry-level education program since 1999, prior to 1999 athletic trainers may not have had formal education on joint mobilization. Since joint mobilization has been incorporated into both the third and fourth edition of the NATA educational competencies, athletic trainers should be proficient with using this manual therapy. However, there is minimal research on joint mobilization implemented by the certified athletic trainer in comparison to physical therapists. Since research shows this manual therapy technique works toward decreasing pain and increasing range of motion there is a need to investigate the amount of educational training athletic trainers receive. Therefore, a predicted model was developed through the use of a survey to determine if educational training levels predicted joint mobilization utilization. 108 APPENDIX C Additional Methods 109 APPENDIX C1 Panel of Experts Cover Letter 110 October 24, 2008 Dear __________: My name is Natalie Myers and I am currently a graduate student at California University of Pennsylvania pursuing a master’s degree in Athletic Training. Part of the graduate study curriculum is to fulfill the thesis requirement through conducting research; mine will be survey research, and I am working with my Thesis Chair, Dr. Linda Platt Meyer to investigate my research question. The purpose of my study is to develop a predicted model, which will allow me to predict the usage of joint mobilization based on the educational training of athletic trainers. Thus, based on undergraduate, graduate, and continuing education a prediction will be made on the use of joint mobilization techniques implemented by certified athletic trainers. I would like to know if you would be willing to serve as a member of my panel of experts to assess the content validity of my survey. You have been chosen based on your expertise in joint mobilization techniques and/or survey research. Your knowledge and experience within the profession would greatly enhance the quality of this survey. Once I receive your thoughts and suggestions on how to improve upon this instrument I will make revisions and create the final survey. The final survey will be distributed to certified athletic trainers within District 3. Your responses would be greatly appreciated, and would make for an overall better study. All responses that I obtain back from this panel of experts will remain confidential. I have attached the table of specifications and survey questions to this e-mail. Please answer the following questions and if possible submit your responses within 10 days. If you have any additional comments please provide them to me using the track changes feature. You may return this survey back to me via an e-mail attachment. If you have any questions, please feel free to contact me at mye8558@cup.edu. Goal of the Survey: To determine whether certified athletic trainers with more educational training in joint mobilization techniques will use this manual therapy technique more so compared to those with less educational training in joint mobilization. 111 1. Are the items of this survey appropriate and related to the goal of the survey? 2. Are the items of this survey written in a way that are understandable to the target population of athletic trainers? 3. Are there any questions that should be excluded from the survey? 4. Are there any questions that should be added to the survey? 5. Do you have any other suggestions or comments that would improve the overall quality of this survey? Thank you and I greatly appreciate your time and effort put into this task. Sincerely, Natalie Myers, ATC California University of Pennsylvania 112 APPENDIX C2 Table of Specifications 113 Table of Specifications Demographic Data Gender Years of experience as an AT Level of Education Other Credentials Current position and setting of work 1 2 3 4 5-6 Undergraduate education on joint mobilization Formal education in lecture Formal education in laboratory Reviewing in clinical setting 7-8 9 10-11 Graduate education on joint mobilization Time spent learning joint mobilization 12-13 If GA, how often did you use joint mobilization 14-15 Continuing education hours spent on joint mobilization Courses taken in joint mobilization 16 Hours spent on joint mobilization training 17 Course Coverage 18 Use of joint mobilization Joint mobilization techniques 19 Specific areas of use 20 Specific areas of most confidence and use 21-22 Most helpful applications of joint mobilization 23-25 Reasons for not using joint mobilization 26 Reasons for not taking courses on joint mobilization27 114 APPENDIX C3 Feedback from Panel Members 115 Comments from Panel Member 1 116 117 118 c 119 Comments from Panel Member 2 120 121 122 Comments from Panel Member 3 123 124 125 126 APPENDIX C4 Reliability Cover Letter 127 January 7, 2009 Dear Fellow Certified Athletic Trainer: My name is Natalie Myers and I am currently a graduate student at California University of Pennsylvania pursing a master’s degree in Athletic Training. Part of the graduate study curriculum is to fulfill the thesis requirement through conducting research. I am conducting survey research to determine if educational training predicts joint mobilization usage. Educational training is defined as undergraduate education, graduate education, and continuing education hours and/or courses. If an effective model can be predicted it will affect undergraduate, graduate, and continuing education. Therefore, future curriculums can spend more time incorporating the theories, skills, and techniques of joint mobilization into their programs. Before I conduct my final survey research I am asking a small group of members to complete my survey so I can assess its reliability. The final survey will be distributed to certified athletic trainers within District 3. Your responses would be greatly appreciated, and would make for an overall better study. The California University of Pennsylvania Institutional Review Board has approved the educational predictor on joint mobilization usage survey. Please click the following link to access the survey http://www.surveymonkey.com/s.aspx?sm=cARgeiJPYgogYM7BD9_2baQA_3d _3d. All surveys will be kept confidential, and informed consent will be assumed upon return of the survey. I ask that you please take this survey at your earliest convenience returning it no later than January 23rd. If you have any questions, please feel free to contact me at mye8558@cup.edu or 757-870-2564. Thank you in advance for taking the time to take part in my thesis research. I greatly appreciate your time and effort put into this task. Sincerely, Natalie Myers, ATC California University of Pennsylvania 128 APPENDIX C5 Follow-up Reliability Cover Letter 129 January 19, 2009 Dear Fellow Certified Athletic Trainer: I want to again thank everyone who participated in my survey research; however, I have one more favor to ask of you. I have to inform you that a necessity of my survey’s legitimacy mandates participants to complete the survey one more time. In order to gain the best results from this reliability testing I need you to complete my survey so I can compare the consistency of your answers to my questions. Therefore, those of you who already completed my survey once, can you please complete it again. Before I can conduct my true data analysis I need to secure the reliability of my instrument. Again, you may access my survey by clicking the following link: http://www.surveymonkey.com/s.aspx?sm=cARgeiJPYgogYM7BD9_2baQA_3d _3d. I ask that you please take this survey at your earliest convenience returning it no later than January 26th, 2009. If you have any questions, please feel free to contact me at mye8558@cup.edu or 757-870-2564. I know it is a busy time, and I truly appreciate all the effort you have put into helping me conduct my thesis research. Sincerely, Natalie Myers, ATC California University of Pennsylvania 130 APPENDIX C6 Educational Predictor for Joint Mobilization Usage Survey 131 Educational Predictor on Joint Mobilization Usage Survey 1. Gender: ______Male ______Female 2. How many years have you been a BOC certified athletic trainer? ________ 3. Which of the following did you attend in order to obtain your entry-level athletic training education? ______Accredited/approved program ______Internship program ________________Other (Please specify) 4. In what year did you complete your entry-level athletic training education? _________ 5. What is your highest level of education completed? _____Bachelors Degree ______Masters Degree ______ Doctoral Degree 6. If you obtained a doctoral degree what type of degree did you receive? ______None ______DPT ______EdD ______PhD ______Other (Please specify)______ 7. In addition to the ATC credential, please check below all other professional credentials that you possess ______PT ______PTA ______MD ______OT _____OTA ______ DO ______DC ______CSCS ______PES ______EMT ______RN ______Teacher Certification ______None ______Other (Please specify) ______________ 8. In which type(s) of clinical setting do you currently work? (Check all that apply) ______University/College – Academic ______University/College-Clinical ______University/College – Academic/Clinical _____Professional Sports ______Industrial ______Military ______ Secondary Schools ______Out-patient clinic ______Hospital (In-patient clinic) ______Other (Please specify) __________________ 9. What is your current employment position? (Check all that apply) ______Academic Faculty _____Clinical Faculty _____Clinical Staff ______Other (Please specify) ______________ 132 10. Was joint mobilization covered during your entry-level undergraduate athletic training education program? _____Yes _____No If you answered “No” to question 10, skip to question 15 11. Was joint mobilization theory covered as part of a required course during your entry-level undergraduate athletic training education program? ______Yes ______No If you answered “No” to question 11, skip to question 13 12. Approximately how much time was spent learning the theories associated with joint mobilization in the required course(s)? ______1 hour ______2 hours ______3 hours ______More than 3 hours ______Unknown 13. Were joint mobilization skills/techniques covered as part of a required course during your entry-level undergraduate athletic training education program? ______Yes ______No If you answered “No” to question 13, skip to question 15 14. Approximately how much time was spent learning joint mobilization skills/techniques in the required course(s)? ______1 hour ______2 hours ______3 hours ______More than 3 hours ______Unknown 15. Were you encouraged to practice your joint mobilization skills during your clinical experiences/clinical rotations? ______Yes _____No 16. Have you used joint mobilization techniques since you completed your entry-level undergraduate education as an athletic trainer? ______Yes ______No If NO, why not? Check all those that apply below. ______Not confident enough in your own skill level ______Afraid of causing permanent injury ______To time consuming ______Do not believe it is an effective treatment ______Prefer other manual therapies 133 ______Prefer other modalities ______Lack of knowledge in area (never had instruction) ______Lack of knowledge in area (insufficient instruction) ______Lack of skill in area (never had instruction of skill) ______Lack of skill in area (insufficient instruction of skill) ______Lack of sufficient time to do techniques effectively ______Do not perceive the need for it in my patient population ______Other (Please specify) ___________________________ 17. Was joint mobilization covered during your graduate level education? _____Yes ______No ______Did not attend graduate school If you answered “No” or did not attend graduate school to question 17, skip to question 23 18. In what discipline did you receive your masters degree? ______________ 19. Was joint mobilization theory covered as part of a required course during your graduate education program? ______Yes ______No If you answered “No” to question 19, skip to question 21 20. Approximately how much time was spent learning the theories associated with joint mobilization in the required course(s)? ______1 hour ______2 hours ______3 hours ______More than 3 hours ______Unknown 21. Were joint mobilization skills/techniques covered as part of a required course during your graduate education program? ______Yes ______No If you answered “No” to question 21, skip to question 23 134 22. Approximately how much time was spent learning joint mobilization skills/techniques in the required course(s)? ______1 hour ______2 hours ______3 hours ______More than 3 hours ______Unknown 23. If you had a graduate assistantship while in graduate school how often did you use joint mobilization on your patients? ______Did not have a graduate assistantship ______Never ______Limited ______Moderately _____Often ______Very often 24. Have you taken a continuing education course post BOC certification that included joint mobilization? ______Yes ______No If you answered “No” to question 24, skip to question 27 25. Approximately how many continuing education contact hours (CEUs) have you had in courses that included joint mobilization? ______ 26. What did the formal (CEU) course(s) include? (Select only one) ______Extremities ______Spine _____Both 27. What techniques of joint mobilization do you most often use? (Check all that apply) ______Cyriax – passive mobilization ______Kaltenborn – sustained mobilization ______Maitland – oscillating mobilization ______Paris – based on chiropractic care ______Mennel – small accessory mobilization ______Unknown 28. On which anatomical areas have you used joint mobilization? (Check all that apply) ______Digits ______Hand ______Wrist ______Forearm ______Elbow ______Shoulder ______Hip ______ Knee ______Ankle ______Foot _____Cervical Spine ______ Thoracic Spine ______ Lumbar Spine 29. On which anatomical structures do you feel most confident when using joint mobilization? (Check all that apply) ______Digits ______Hand ______Wrist ______Forearm ______Elbow ______Shoulder ______Hip ______ Knee ______Ankle ______Foot _____Cervical Spine ______ Thoracic Spine ______ Lumbar Spine 135 30. On what anatomical structures do you use joint mobilization most? ______Digits ______Hand ______Wrist ______Forearm ______Elbow ______Shoulder ______Hip ______ Knee ______Ankle ______Foot _____Cervical Spine ______ Thoracic Spine ______ Lumbar Spine 31. Do you think joint mobilization is a helpful rehabilitation tool? ______Yes ______No 32. To what end do you perceive joint mobilization to be most helpful? ______Increase range of motion ______Decrease pain ______Increase function ______All of the above 33. Do you feel comfortable in assessing/determining when it is appropriate to use joint mobilization? ______Yes ______No 34. If you have not taken a formal CEU course on joint mobilization, what is(are) your reason(s) (check all that apply) ______Timing or scheduling conflict ______Costs too much ______Do not perceive a need for it in my patient population ______Not interested in it ______Believe that I am adequately prepared/trained in joint mobilization from athletic training education ______Other (Specify)__________________________________________________ ___ 136 APPENDIX C7 Educational Predictor for Joint Mobilization Usage Survey: Coded Data 137 Educational Predictor on Joint Mobilization Usage Survey: Coded Data Gender 1. Gender: ___1___Male ___2___Female BOCYEARS 2. How many years have you been a BOC certified athletic trainer? ________ Educate 3. Which of the following did you attend in order to obtain your entry-level athletic training education? ___1___Accredited/approved program ___2___Internship program _______3_________Other (Please specify) Entryed 4. In what year did you complete your entry-level athletic training education? _________ Highed 5. What is your highest level of education completed? ___1__Bachelors Degree ___2___Masters Degree ___3___ Doctoral Degree Docdegre 6. If you obtained a doctoral degree what type of degree did you receive? ___1___None ___2___DPT ___3___EdD ___4___PhD ___5___Other (Please specify)______ Credent 7. In addition to the ATC credential, please check below all other professional credentials that you possess ___1___PT ____2__PTA ___3___MD ___4___OT __5___OTA ___6___ DO ___7___DC __8____CSCS ___9___PES ___10___EMT ___11___RN ___12___Teacher Certification ____13__None ___14___Other (Please specify) ______________ Currwork 8. In which type(s) of clinical setting do you currently work? (Check all that apply) __1____University/College – Academic __2____University/College-Clinical ___3___University/College – Academic/Clinical ___4__Professional Sports __5____Industrial ___6___Military ____7__ Secondary Schools ____8__Out-patient clinic ___9___Hospital (In-patient clinic) ___10___Other (Please specify) __________________ 138 Curwork1 9. What is your current employment position? (Check all that apply) __1____Academic Faculty ___2__Clinical Faculty ___3__Clinical Staff ___4___Other (Please specify) ______________ Ugmob 10. Was joint mobilization covered during your entry-level undergraduate athletic training education program? __1___Yes __2___No If you answered “No” to question 10, skip to question 15 Ugmobthy 11. Was joint mobilization theory covered as part of a required course during your entry-level undergraduate athletic training education program? ___1___Yes ___2___No If you answered “No” to question 11, skip to question 13 Ugthyhrs 12. Approximately how much time was spent learning the theories associated with joint mobilization in the required course(s)? __1____1 hour ___2___2 hours ___3___3 hours ___4___More than 3 hours __5____Unknown Ugskill 13. Were joint mobilization skills/techniques covered as part of a required course during your entrylevel undergraduate athletic training education program? ___1___Yes ___2___No If you answered “No” to question 13, skip to question 15 Ugskillh 14. Approximately how much time was spent learning joint mobilization skills/techniques in the required course(s)? ___1___1 hour ___2___2 hours ___3___3 hours ___4___More than 3 hours ___5___Unknown Ugencor 15. Were you encouraged to practice your joint mobilization skills during your clinical experiences/clinical rotations? ____1__Yes __2___No 139 Compleyg 16. Have you used joint mobilization techniques since you completed your entry-level undergraduate education as an athletic trainer? ___1___Yes ____2__No Ynotuse If NO, why not? Check all those that apply below. ___1___Not confident enough in your own skill level ___2___Afraid of causing permanent injury ___3___To time consuming ___4___Do not believe it is an effective treatment ____5__Prefer other manual therapies ____6__Lack of knowledge in area (never had instruction) ___7___Lack of knowledge in area (insufficient instruction) ___8___Lack of skill in area (never had instruction of skill) ____9__Lack of skill in area (insufficient instruction of skill) ___10___Lack of sufficient time to do techniques effectively ___11___Do not perceive the need for it in my patient population ___12___Other (Please specify) ___________________________ Grmob 17. Was joint mobilization covered during your graduate level education? __1___Yes ___2___No ___3___Did not attend graduate school If you answered “No” or did not attend graduate school to question 17, skip to question 23 18. In what discipline did you receive your masters degree? ______________ Grtheory 19. Was joint mobilization theory covered as part of a required course during your graduate education program? ___1___Yes ____2__No If you answered “No” to question 19, skip to question 21 140 Grthehrs 20. Approximately how much time was spent learning the theories associated with joint mobilization in the required course(s)? ____1__1 hour ___2___2 hours ___3___3 hours ___4___More than 3 hours ___5___Unknown Grskill 21. Were joint mobilization skills/techniques covered as part of a required course during your graduate education program? ___1___Yes ___2___No If you answered “No” to question 21, skip to question 23 Grskillh 22. Approximately how much time was spent learning joint mobilization skills/techniques in the required course(s)? __1____1 hour ___2___2 hours ___3___3 hours ___4___More than 3 hours ___5___Unknown Gaassist 23. If you had a graduate assistantship while in graduate school how often did you use joint mobilization on your patients? ___1___Did not have a graduate assistantship ___2___Never ___3___Limited ___4___Moderately __5___Often ___6___Very often Ceumob 24. Have you taken a continuing education course post BOC certification that included joint mobilization? ___1___Yes ___2___No If you answered “No” to question 24, skip to question 27 Ceuhours 25. Approximately how many continuing education contact hours (CEUs) have you had in courses that included joint mobilization? ______ Cecourse 26. What did the formal (CEU) course(s) include? (Select only one) ___1___Extremities __2____Spine __3___Both Jttech 27. What techniques of joint mobilization do you most often use? (Check all that apply) ____1__Cyriax – passive mobilization ___2___Kaltenborn – sustained mobilization ____3__Maitland – oscillating mobilization ___4___Paris – based on chiropractic care ___5___Mennel – small accessory mobilization ___6___Unknown 141 Usejtmob 28. On which anatomical areas have you used joint mobilization? (Check all that apply) ______Digits ______Hand ______Wrist _____Forearm ______Elbow ______Shoulder ______Hip ______ Knee ______Ankle ______Foot _____Cervical Spine ______ Thoracic Spine ______ Lumbar Spine (Coding depends on how many areas were checked) Conjtmob 29. On which anatomical structures do you feel most confident when using joint mobilization? (Check all that apply) ______Digits ______Hand ______Wrist ______Forearm ______Elbow ______Shoulder ______Hip ______ Knee ______Ankle ______Foot _____Cervical Spine ______ Thoracic Spine ______ Lumbar Spine (Coding depends on how many areas were checked) Dousejtm 30. On what anatomical structures do you use joint mobilization most? ______Digits ______Hand ______Wrist ______Forearm ______Elbow ______Shoulder ______Hip ______ Knee ______Ankle ______Foot _____Cervical Spine ______ Thoracic Spine ______ Lumbar Spine (Coding depends on how many areas were checked) jmobreha 31. Do you think joint mobilization is a helpful rehabilitation tool? ____1__Yes ___2___No Helpful 32. To what end do you perceive joint mobilization to be most helpful? ___1___Increase range of motion ___2___Decrease pain ___3___Increase function __4____All of the above Assjtmob 33. Do you feel comfortable in assessing/determining when it is appropriate to use joint mobilization? ___1___Yes ___2___No Ynotceu 34. If you have not taken a formal CEU course on joint mobilization, what is(are) your reason(s) (check all that apply) ___1___Timing or scheduling conflict ___2___Costs too much ___3___Do not perceive a need for it in my patient population ____4__Not interested in it 142 ___5___Believe that I am adequately prepared/trained in joint mobilization from athletic training education ___6___Other (Specify)__________________________________________________ ___ 143 APPENDIX C8 Institutional Review Board 144 145 146 147 148 149 150 APPENDIX C9 Subject Cover Letter 151 February 17, 2009 Dear Fellow Certified Athletic Trainer: My name is Natalie Myers and I am currently a graduate student at California University of Pennsylvania pursing a master’s degree in Athletic Training. Part of the graduate study curriculum is to fulfill the thesis requirement through conducting research. I am conducting survey research to determine if educational training predicts joint mobilization usage. Educational training is defined as undergraduate education, graduate education, and continuing education hours and/or courses. If an effective model can be predicted it will affect undergraduate, graduate, and continuing education. Therefore, future curriculums can spend more time incorporating the theories, skills, and techniques of joint mobilization into their programs. One thousand randomly selected certified athletic trainers from district 3 are being asked to submit this survey; however, you do have the right to choose not to participate. The California University of Pennsylvania Institutional Review Board has approved the Educational Predictor on Joint Mobilization Usage Survey. The survey has also been found to be valid and reliable. Please click the following link to access the survey http://www.surveymonkey.com/s.aspx?sm=cARgeiJPYgogYM7BD9_2baQA_3d _3d. All surveys are kept confidential, and informed consent will be assumed upon return of the survey. I ask that you please take this survey at your earliest convenience as it will take approximately 15 minutes to complete. If you have any questions, please feel free to contact me at nmyers02@gmail.com. Thank you in advance for taking the time to take part in my thesis research. I greatly appreciate your time and effort put into this task. Sincerely, Natalie Myers, ATC California University of Pennsylvania 250 University Ave California, PA 15419 152 nmyers02@gmail.com Participants for this survey were selected at random from the NATA membership database according to the selection criteria provided by the student doing the survey. This student survey is not approved or endorsed by NATA. It is being sent to you because of NATA’s commitment to athletic training education and research. 153 APPENDIX C10 Follow-up Subject Cover Letter 154 March 1, 2009 Dear Fellow Certified Athletic Trainer: This is a follow up e-mail regarding your participation in my Educational Predictor on Joint Mobilization Survey. Thank you to those who have already completed my survey. Your participation will make for an overall better study. If you have not yet completed the survey your involvement would be greatly appreciated. Please click the following link to access the survey http://www.surveymonkey.com/s.aspx?sm=cARgeiJPYgogYM7BD9_2b aQA_3d_3d. The California University of Pennsylvania Institutional Review Board has approved the Education Predictor on Joint Mobilization Survey. The survey has also been found to be valid and reliable. All surveys will be kept confidential, and informed consent will be assumed upon return of the survey. I ask that you please take this survey at your earliest convenience returning it no later than Monday March 9th, 2009. The survey will take approximately 15 minutes to complete. If you have any questions, please feel free to contact me at nmyers02@gmail.com. Thank you in advance for taking the time to take part in my thesis research. I greatly appreciate your time and effort put into this task. Sincerely, Natalie Myers, ATC California University of Pennsylvania 250 University Ave California, PA 15419 nmyers02@gmail.com Participants for this survey were selected at random from the NATA membership database according to the selection criteria provided by the student doing the survey. This student survey is not approved or endorsed by NATA. It is being sent to you because of NATA’s commitment to athletic training education and research. 155 REFERENCES 1. Ben-Sorek S, Davis CM. Joint Mobilization Education and Clinical Use in the United States. Phys Ther. 1988;68:1000-1004. 2. Stone JA. 3. Houglum PA. Therapeutic Exercise for Musculoskeletal Injuries. Champaign, IL: Human Kinetics; 2005. 4. Kahanov L, Kato M. Therapeutic Effect of Joint Mobilization: Joint Mechanoreceptors and Nociceptors. ATT. 2007;12:28-31. 5. Mangus BC, Hoffman LA, Hoffman MA, Altenburger P. Basic Principles of Extremity Joint Mobilization Using a Kaltenborn Approach. J Sport Rehabil. 2002;11:235-250. 6. Maitland GD, Hengeveld E, Banks K. Maitland’s Vertebral Manipulation, 7th ed. London: Butterworths Heinemann; 2006. 7. Stevenson JR, Vaughn DW. Four Cardinal Principles of Joint Mobilization and Joint Play Assessment. J Man Manip Ther. 2003;11:146-152. 8. Hanrahan S, Van Lunen B, Tamburello M, Walker ML. The Short-Term Effects of Joint Mobilizations on Acute Mechanical Low Back Dysfunction in Collegiate Athletes. J Athl Train. 2005;40:88-93. 9. Conroy DE, Hayes KW. The Effect of Joint Mobilization as a Component of Comprehensive Treatment for Primary Shoulder Impingement Syndrome. J Orthop Sports Phys Ther. 1998;28:3-14. Joint Mobilization. ATT. 1999;4:59-60. 10. Powers CM, Beneck GJ, Kornelia K, Landel RF, Fredericson M. Effects of a Single Session of Posterior-to Anterior Spinal Mobilization and Pressup Exercise on Pain Response and Lumbar Spine Extension in People With Nonspecific Low Back Pain. Phys Ther. 2008;88:485-493. 156 11. Mackawan S, Eungpinichpong W, Pantumenthakul R, Chatchawan U, Hunsawong T, Arayawichanon P. Effects of traditional Thai message versus joint mobilization on substance P and pain perception in patients with non-specific low back pain. Journal of Bodywork and Movement Techniques. 2007;11:9-16. 12. Moss P, Sluka K, Wright A. The initial effects of knee joint mobilization on osteoarthritic hyperalgesia. Man Ther. 2007;12:109-118. 13. Goldman BR. The acute effectiveness of PNF stretching and joint mobilization for increasing posterior shoulder mobility of the professional baseball player. J Athl Train. 2004;39:64. 14. Vermeulen HM, Rozing PM, Obermann WR, Cessie SL. Comparison of High-Grade and Low-Grade Mobilization Techniques in the Management of Adhesive Capsulitis of the Shoulder: Randomized Controlled Trial. Phys Ther. 2006;86:355-368. 15. Yang J, Chang C, Chen S, Wang S, Lin J. Mobilization Techniques in Subjects With Frozen Shoulder Syndrome: Randomized Multiple-Treatment Trial. Phys Ther. 2007;87:1307-1315. 16. McNair PJ, Portero P, Chiquet C,Mawston G, Lavaste F. Acute neck pain: Cervical spine range of motion and position sense prior to and after joint mobilization. Man Ther. 2007;12:390-394. 17. National Athletic Trainers’ Association. Athletic Training Education Overview. Available at: http://www.nata.org/consumer/docs/EducationalOverview Revised_final_011008.pdf. Accessed October 23, 2008. 18. National Athletic Trainers’ Association. Athletic Training Educational Competencies: 4th Edition. Dallas: NATA; 2006. 19. Board of Certification. Role Delineation Study: For The Entry-Level Certified Athletic Trainer Fifth Edition. Omaha: National Athletic Trainers’ Association Board of Certification, INC; 2004. 157 20. Reasoner AE. A Western States Survey of Certified Athletic Trainers’ Use of Joint Mobilization in Treatment Programs. J Athl Train. 1984:267-271. 21. Stephens EB. Manipulative Therapy in Physical Therapy Curricula. Phys Ther. 1973;53:40-50. 22. Volpe M. Use of Joint Mobilization by Physical Therapists in Massachusetts. Master’s Thesis. Boston, MA, Sargent College of Allied Health Professions, Boston University, 1979. 158 ABSTRACT Title: THE RELATIONSHIP BETWEEN THE AMOUNT OF EDUCATIONAL TRAINING AND UTILIZATION OF JOINT MOBILIZATION IMPLEMENTED BY THE CERTIFIED ATHLETIC TRAINER Researcher: Natalie L. Myers Advisor: Dr. Linda Meyer Date: May 2009 Research Type: Master’s Thesis Content: Joint mobilization has been shown to be an effective rehabilitation tool. However, most studies are directly related to physical therapy patients in comparison to athletes. Therefore, the researcher wanted to examine via survey if educational training is directly related to how much athletic trainers use this manual therapy. Objective: The purpose of this study is to develop a predictive model of joint mobilization utilization. This model will predict the level of usage of joint mobilization based on the educational training of certified athletic trainers. Design: Descriptive research study. Setting: The National Athletic Trainers’ Association (NATA) disrupted via e-mail The Educational Predictor on Joint Mobilization Usage Survey (EPJMUS). Participants: Two hundred and thirty four certified athletic trainers from District 3 completed the EPJMUS. Interventions: A pilot study was completed in order to determine validity and reliability of the instrument. The EPJMUS was found to be valid and reliable after performing a 159 Cronbach’s Alpha. The greeted 1,000 randomly trainers chosen by the letter and link to the researcher then selected athletic NATA with a cover survey. Main Outcome Measures: The EPJMUS was divided into four main sections. The independent variable included educational training, while the dependent variable included joint mobilization utilization. Items 10-16 incorporated undergraduate educational training, items 17-23 incorporated graduate educational training, items 24-26 incorporate post Board of Certification continuing education, and items 28-30 included question related to the use of joint mobilization. The survey questions were coded via the researcher, and a stepwise regression analysis was run to determine which independent variables would best predict the use of joint mobilization. Results: The primary findings of this study incorporated a predictive model that revealed how many continuing education hours the participants had, and how often subjects used joint mobilization in their graduate assistantship position had the most affect when predicting joint mobilization utilization. The independent variables had a significance level of less than or equal to .000. Conclusion: This study revealed that graduate assistantships and continuing education had the greatest affect on joint mobilization utilization. Therefore, undergraduate curriculums need to spend more time educating athletic training students on joint mobilization, and then emphasizing techniques learned in the classroom in the clinical setting.