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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.
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.
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2.
Stone JA.
3.
Houglum PA. Therapeutic Exercise for Musculoskeletal
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Kahanov L, Kato M. Therapeutic Effect of Joint
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5.
Mangus BC, Hoffman LA, Hoffman MA, Altenburger P.
Basic Principles of Extremity Joint Mobilization
Using a Kaltenborn Approach. J Sport Rehabil.
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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.
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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.
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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.