Changes in Attitudes and Perceptions About Research in Physical Therapy Among Professional Physical Therapist Students and New Graduates.

Although physical therapists now often appear to be discussing the necessity of performing outcomes research for the documentation of the effectiveness of commonly used interventions, the discussion has been ongoing for a considerable number of years. In 1978, Michels, a prominent figure in physical therapy, stated that opinion is not enough to justify what is done in physical therapy.[1] He further stated that standards for practice should be established and based on research evidence of the effectiveness of the methods used.[1] Over the years, other researchers in physical therapy have stated that research is important to: (1) validate physical therapy services, (2) provide information on the effectiveness of treatment, (3) improve patient care by making intelligent clinical decisions based on research findings, and (4) provide answers to therapists' questions.[2-4] The American Physical Therapy Association (APTA) has emphasized the importance of research among its members through numerous publications, professional seminars, grants, and standards of practice.[5-10]

Today the health care literature is filled with arguments about the importance of outcomes research and evidence-based practice.[11-16] Therefore, we believe the examination of currently used and new treatment procedures should be of importance to new graduates, to the practicing clinician, to the educator, and to the full-time researcher. In addition, the goals of APTA include: "Stimulate research to further the science of physical therapy, to influence current and emerging health care trends, and to advance the profession."[17] This goal, in our opinion, should drive the profession to create an environment for evidence-based practice in order to best serve the needs of patients and clients. We believe that the need for research regarding the effectiveness of physical therapy interventions is critical because of changes in the health care system, including increased enrollment in managed health care organizations, capitation of services, decreased third-party reimbursement, and expanded interest in health promotion and disease prevention. Due to increasing health care costs and competition for available health care dollars, health services that are reimbursed, according to many experts, will need to be justified based on the contribution they make to overall patient outcome, as well as to their cost-effectiveness.[15] Members of the physical therapy profession, we believe, must assume the responsibility to perform the research necessary to determine whether physical therapy interventions work and to base clinical practice on procedures that have been demonstrated to be the most effective interventions.[1-4,15]

The physical therapy profession, through accreditation standards for research[9] and the APTA normative model of professional education,[10] has addressed the importance of educating physical therapist students in the basic principles of research. The expectations that students can "[e]valuate published studies related to physical therapy practice, research, and education; secure and critically evaluate information related to new and established techniques and technology, legislation, policy, and environments related to patient or client care; and participate in scholarly activities to contribute to the body of physical therapy knowledge" are clearly outlined in the Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists.[9(pp98-29)] More in-depth explanations of the professional expectations for the physical therapy graduate in the area of critical inquiry and clinical decision making are presented in A Normative Model of Physical Therapist Professional Education,[10] a document that was jointly developed by academicians and clinicians through a series of consensus conferences. As stated in the normative models, examples of outcomes for properly educating physical therapists include: use of effectiveness studies to establish patient or client care protocols, application of the principles of Clinical decision making in the delivery of care, assessment of published studies for the adequacy of adherence to research protocols, valuing research and clinical inquiry, and participation in collecting data using standardized assessment and measurement tools.[10]

A review of the literature indicates concern among educators and clinicians about the most effective methods of producing graduates who possess knowledge about research and an appreciation of the importance of basing treatment methods on research findings.[14,16,18-23] A variety of opinions have been expressed on the manner in which these goals are best accomplished in a professional (ie, entry-level) curriculum. Opinions range from having students critique published research, to writing research proposals but not actually carrying out projects, to adopting and assisting with a faculty research project, to actually completing an independent research project.[2,14,19-22] Rothstein[23] proposed that education programs should discontinue the practice of requiring research projects of professional students. He based this proposal on his assumptions that "within the confines of professional education, students cannot possibly understand the nuances of questions, assimilate the background literature, develop theoretical bases, and comprehend measurement and design issues."[23(p332)] Rothstein further proposed that the projects of professional students might be credible, scientific case studies.

Numerous real or perceived barriers to participating in physical therapy research seem to exist among physical therapists once they enter clinical practice.[14,16,18-21,24] Ballin et al[18] studied a sample of California therapists and assessed the importance of research to them, as well as factors that impeded their involvement in research and the extent to which they used published research. Although they reported that 100% of the respondents agreed about the importance of research, among the barriers to participation in research were the inability to give up revenue-producing time, lack of administrative financial support, and unfamiliarity with research methods. The APTA 1996 Practice Profile Reporter[25] revealed that only about 58% of graduates from both baccalaureate and postbaccalaureate programs indicated that they had sufficient knowledge of research methods and design to critically read and evaluate research reports published in scholarly journals. Likewise, a study of critical appraisal of research literature revealed that one half of the inexperienced physical therapy researchers indicated low levels of self-reported comfort with research.[26]

The lack of knowledge or familiarity with research methods is one problem that we believe can and must be addressed in physical therapist education programs. In this environment, students can become knowledgeable in the basic methods, terminology, and statistics of research so that they will become competent, critical consumers of the scientific literature.[2-4,14,21,22] A mastery of this knowledge, in our view, is a critical link in the process of incorporating the results of sound, scientific studies into clinical practice. Equally important for students is the development of positive attitudes toward the importance of research to the growth of the body of knowledge in physical therapy, realization of the need to incorporate research findings in practice, and acceptance of personal responsibility to prompt, encourage, or participate in research.[4,14,19,23,24] The importance of research education also has been recognized by other health care professions as a crucial link to validating clinical practice and to closing the gap between published research in professional journals and actual practice in the clinical setting.[20,27,28] We believe that the resources and Faculty with research experience are increasingly more available to students in physical therapy. The number of physical therapists with doctoral degrees as the highest degree has increased over time (3.3% in APTA's 1996 Practice Profile Report[25]). However, having a doctoral degree does not ensure that the physical therapist either in academia or in the clinical setting has adequate resources for research.

A longitudinal study of physical therapist students' attitudes, perceptions, and feelings of competence regarding research, of their ability to critically review the scientific literature, of the importance of reading the literature, and of the value of research to the profession has not been done. Because uncertainty about research knowledge and skills has been demonstrated in cross-sectional studies among students and therapists,[25,26] we chose to do a longitudinal study to examine how values and perceptions regarding research change over time and to determine the level of support present in the clinical setting for the knowledge and values that we believe are developed by students during their education programs. Therefore, the purpose of our study was to examine: (1) the perception of knowledge and behaviors of students with respect to research, (2) the perception of the source of authority for clinical decision making, and (3) the perception of clinical norms related to research of therapists from their student days through the first year of practice.

Our hypothesis was that students' attitudes and perceptions of knowledge about research, the importance of research to the profession, the importance of regularly reviewing the literature, and basing clinical decisions on scientifically sound methods would undergo a change in a positive direction as they were exposed to didactic and clinical experiences involving research.

Method

Students

The sample consisted of 115 senior physical therapist students (24 men; 91 women; mean age=24.3 years, SD=3.37, range=21-37) enrolled in 2 consecutive classes in the professional baccalaureate physical therapy program at the University of Tennessee Health Science Center (Memphis, Tenn). Data were collected between March 1995 and December 1997. Participation in the study was voluntary, and students were recruited before the first research course was taught. Students were assured that nonparticipation would not affect their grades. Only data obtained from those students who completed all 4 questionnaires and included their identification code number on each questionnaire were included in the final data analysis. Thirty-one percent of the students (n=34) who started the project completed all 4 questionnaires with identification numbers so that their responses could be tracked and analyzed.

Graduates from the program typically practice upon graduation throughout the state of Tennessee and in the neighboring states of Alabama, Arkansas, Mississippi, Kentucky, and North Carolina. Clinical education experiences during the education program occur in sites throughout the Southeast, Midwest, and Atlantic Coast states. Therefore, the students' observations of utilization of or participation in research in clinical settings does not occur predominantly in practices close to the education program location. No differences were found for age between those students who completed all 4 questionnaires (mean age=24.5 years, SD=3.50) and the total sample (mean age=24.5 years, SD=3.38). Likewise, no difference was found for gender between those students who completed all 4 questionnaires and the total sample. Therefore, the students who completed all 4 questionnaires are representative of the total sample. All students signed informed consent statements prior to participation.

Instrumentation

We designed a questionnaire containing 10 items. We did this with input from faculty in the physical therapy program as well as with assistance from biostatisticians from the University of Tennessee Health Science Center. The items were designed to assess the students' self-reports of knowledge and behaviors related to research. This included their self-reports of their comfort level and confidence in reading and applying research findings, their personal habits regarding reading the professional literature, and their beliefs regarding the importance of research to their profession. We also attempted to measure the students' perceived source of authority for clinical decision making (ie, evidence-based practice or anecdotal stories) and their beliefs about how research is viewed by practitioners. Following the initial item determination, a draft of the questionnaire was sent to a panel selected from members of the APTA Section on Research. This panel of experts, selected due to their research knowledge and productivity, reviewed each item for clarity, content validity, and construct validity to ensure that the questions accurately reflected objectives of the study. Based on the expert review, the final questionnaire (Appendix) was developed using a 5-point Likert-type scale that ranged from 1 (strongly agree) to 5 (strongly disagree) to assess the students' degree of agreement with each statement. The final items were formulated to determine whether changes occurred across time.

Data Collection

The 10-item questionnaire was administered on 4 occasions to those students who chose to participate: (1) immediately preceding the students' introduction to the research methods course (N=115), (2) immediately after the completion of that course (n=112), (3) immediately following the second research course, which included statistics and completion of a research proposal (n=92 due to omission of identification numbers by 20 students), and (4) 12 months after graduation (n=34). The participants were able to complete the questionnaire in approximately 5 minutes. The questionnaire also included an identification coding system so that data analysis techniques would be able to track individual students' attitude changes across time. Thirty-four students included the necessary coding number on each of the 4 assessment forms, and their responses were used in the data analysis. The final number of students in the study was low at the time of the final test administration due to (1) our inability to locate some graduates, (2) the failure of some graduates to return the form, and (3) the failure of some graduates to provide an identification number.

Data Analysis

The biostatistical division of the University of Tennessee Health Science Center provided statistical analysis for the study. Demographic characteristics of the entire sample and of those students who completed all 4 phases of the study were analyzed for age by a t test for independent samples and for sex by a chi-square test of independence. The Friedman analysis of variance (ANOVA) was used to analyze the nonparametric data obtained with the Likert-type measurement scale. The Friedman ANOVA was used as an omnibus test to detect differences across time. The .05 alpha level was considered significant for the Friedman ANOVA, the t test for independent samples, and the chi-square test of independence. A follow-up analysis using the Wilcoxon signed-rank procedure to examine differences between baseline data and data obtained during each follow-up was done for all items. For the Wilcoxon signed-rank procedure, Bonferroni adjustments were made and each comparison was tested against an alpha of .17. The SAS system(*) was used to analyze data from the questionnaire.

Results

Results of the Wilcoxon signed-rank test, which was a follow-up analysis for significant items on the Friedman ANOVA, are presented in the Table and in Figures 1 through 3. Group mean ranks are presented for each of the 10 items on each of the 4 attitude survey administrations. The level of significance for each significant item is indicated in the Table. The results showed changes in student attitudes for 5 of the 10 items (items 1-5). For 3 of the items (item 2, necessary academic background; item 3, comfort with knowledge; and item 5, clinical practice based on research), all 3 posttest administrations of the survey had more favorable responses than the pretest administration of the survey. For 1 of the items (item 4, published findings relevant), the only change from the baseline responses came after the completion of the second research course. For item 1 (regularly read journals), the only change from the baseline responses was at the final administration of the survey 12 months after graduation. Figures 1 through 3 display a graphic plot using mean ranks of the students' responses to each item and demonstrate the direction of change on each item over the 4 administrations of the survey.

[ILLUSTRATIONS OMITTED]

Table.
Mean Ranks for Students' Attitudes Toward Research(a)

Question             Posttest   Posttest   Posttest
No.        Pretest   1          2          3

 1         2.85      2.85       2.54       1.75(b)
 2         3.53      2.35(c)    2.03(c)    2.09(c)
 3         3.70      2.11(c)    2.20(c)    2.00(c)
 4         2.93      2.37       2.12(b)    2.59
 5         3.16      2.43(d)    2.07(c)    2.34(d)
 6         2.23      2.68       2.70       2.39
 7         2.75      2.40       2.29       2.56
 8         2.79      2.57       2.15       2.49
 9         2.52      2.39       2.43       2.66
10         2.64      2.57       2.25       2.54

(a) Wilcoxon signed-rank test results.

(b) P<.01/3, criterion=.0033.

(c) P<.001/3, crilerion=.0003.

(d) P<.05/3, criterion=.0167.

Discussion

The data suggest that the students' self-reported knowledge and behavior toward research increased over time. They expressed a level of confidence in their ability to critically review the professional literature and believed they had accepted the responsibility of keeping current in the research literature by reading peer-reviewed professional journals. According to the Commission on Accreditation in Physical Therapy Education accreditation standards, professional students are expected to: (1) "evaluate published studies related to physical therapy practice, research, and education," (2) "secure and critically evaluate information related to new and established techniques and technology, legislation, policy, and environments related to patient or client care," and (3) "participate in scholarly activities to contribute to the body of physical therapy knowledge (eg, case reports, collaborative research)."[9] The findings on the items that were related to self-reported knowledge and behaviors in research seemed to indicate that the students believed the criteria identified in the accreditation standards were met. Two items (2 and 3) designed to assess beliefs about levels of competence in research terminology, methodology, and design as well as perceived academic background to critically review professional literature changed, in the students' opinion, to a higher ability to apply their knowledge and skills following the research education component. These changes indicate to us that a research education component included in an overall curriculum that we believe emphasizes the importance of research can be effective, at least in the short term, in addressing one of the major identified barriers (ie, lack of knowledge) to research participation by physical therapists. Moreover, we believe that these changes support the argument that knowledge of the research process should be addressed in professional education. In a study by Domholdt et al,[26] however, self-reported comfort with research was not found to be a useful indicator of critical appraisal skills. They found no consistent differences in clinical appraisal skills for those therapists with high or low levels of comfort with research.

Items 4 and 5, which we designed to assess students' perceptions of the importance of published research to clinical practice and treatment effectiveness, indicated to us that change occurred in these areas as well. However, for item 4, differences found during the education program were not sustained after 1 year of practice. We speculate that the new graduates may not see evidence-based practice (eg, the application of research to patient care) being applied in the clinical setting. Another possibility was that these new graduates were not supported in their attempts to apply new research findings in the clinical setting and were urged to continue traditional treatment protocols.

Numerous authors[13-16,19,20] have advocated the need to base clinical treatment methods on what valid and reliable scientific study has demonstrated to be efficacious. However, our findings revealed that professional students, after modifying their beliefs about appropriate sources of authority for treatment decisions during their education, do not sustain their changed beliefs once they are involved in clinical practice. In 1995, Robertson[29] reviewed the literature regarding accumulation of a knowledge base in physical therapy and found that clinical or craft-based knowledge was prevalent. She urged that the physical therapy profession increase the emphasis on research-related practice so that more cohesive research programs would be developed. Robertson's assumption that physical therapy practice may be based on informally communicated knowledge bases that have not been critically analyzed seems to be supported by our findings. This trend is disturbing because APTA is striving to have members of the profession support outcomes research and to develop appropriate systems to measure the results of patient or client management.

We used items 7 to 10 to assess the students' perceptions about their professional responsibilities in relation to research and their perceptions about the value to research to physical therapists. None of these items showed a change over time, although a positive change had been noted during the education program. The importance of clinician participation in research has been discussed, but the definition of participation is not always the same.[14-16,20-22] However, APTA's 1996 Practice Profile Report[25] indicated that 93.4% of the therapists surveyed reported no work-related involvement with conducting research. Gross et al[30] reported that 63% of their sample of physical therapists regularly read Physical Therapy, although only 12.2% reported current involvement in research.

We contend that if clinical physical therapy research is important for the continued growth of the profession, graduates of professional programs with familiarity with the research process must be stimulated to accept the responsibility to use research after graduation as well as during the education program. Unfortunately, despite our hope that student attitudes toward personal involvement in research would improve during their education and be sustained in the clinic, the items on the questionnaire related to personal involvement in research (item 9) and the priority placed on research by physical therapists (item 10) did not change.

Limitations and Recommendations for Future Research

The small response rate of 31% is an obvious limitation of our study. Similar response rates, however, have been noted in 2 other studies that were related to the development of critical appraisal skills in research.[26,31] Domholdt et al[26] had a response rate of 26.7% from alumni on a comparison of critical appraisal skills by expert and inexperienced physical therapy researchers. An even smaller response rate of 5% was found in medical students who were offered $25 to complete a computer-aided instruction program aimed at improving critical appraisal skills.[31] External validity was limited by using a non-randomly selected sample, yet this was done to increase the level of participation by using students in the same professional physical therapy program.[26] Commitment to the university has been cited as the primary reason for individuals in a sample to respond to questionnaires.[31] Thus, we had hoped to increase the number of subjects responding by using students from our institution.

The use of repeated testing also possibly threatened the external validity of our findings. We developed a new instrument for this project because no survey instrument existed that would yield valid and reliable measurements for students' attitudes regarding research. Survey items used were assessed for clarity and content validity with regard to assessing our stated research course objectives by a panel of members of the APTA Section on Research. The items used were similar to those used in previous APTA membership surveys and in a study of student attitudes.[21,23,27,28] However, this instrument was developed to assess a broader range of attitudes on research-related topics. We believe that future research needs to be focused on instruments that can validly and reliably assess educational outcomes in research and other content areas.

In future research on this topic, there should be a larger sample size from a number of different professional physical therapist programs. Evaluating the attributes of the clinical site in which the physical therapist is employed also would give more insight into why some of the beliefs toward research changed once the student was employed in a clinical setting.

Conclusions

In this descriptive study of professional physical therapist students, we have attempted to assess the students' self-reported feelings of comfort and confidence in reading and applying research findings published in the literature, their personal habits regarding reading the professional literature, and their general beliefs regarding the importance of research to their professional careers and of basing clinical practice on research findings. The results indicated a positive change in 5 of the 10 items, although some of the changes were not sustained after the graduates had been in a clinical setting for 12 months. Our findings indicate that positive changes were noted by the end of the education program but that long-lasting changes in attitudes about research have not occurred in areas such as personal desire to be involved in research and the priority that physical therapists place on research. Perhaps barriers other than familiarity with the research process (eg, inability to give up revenue-producing time, lack of administrative financial support) continue to be the major barriers to clinical research in physical therapy.

(*) SAS Institute Inc, PO Box 8000, Cary, NC 27511.

References

[1] Michels E. Evaluation and research in physical therapy. Phys Ther. 1982:62:828-834.

[2] Payton OD. Research: The Validation of Clinical Practice. 3rd ed. Philadelphia, Pa: FA Davis Co; 1994.

[3] Domholdt E. Physical Therapy Research Principles and Applications. Philadelphia, Pa: WB Saunders Co; 1993.

[4] Currier DP. Elements of Research in Physical Therapy. 3rd ed. Baltimore, Md: Williams & Wilkins; 1990.

[5] Standards of Practice in Physical Therapy. Alexandria, Va: American Physical Therapy Association; 1996.

[6] Goals of Clinical Research in Physical Therapy. Alexandria, Va: American Physical Therapy Association; 1997.

[7] Analysis and Development Division Organizational Research Agenda. Alexandria, Va: American Physical Therapy Association; 1994.

[8] Guidelines for Physical Therapy Practice in Tennessee. Nashville, Tenn: Tennessee Physical Therapy Association; April 1993.

[9] Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, Va: American Physical Therapy Association; 1996.

[10] A Normative Model of Physical Therapist Professional Education, Version 97. Alexandria, Va: American Physical Therapy Association; 1997: 72-73.

[11] Buss IC, Halfens RJ, Abu-Saad HH, Kok G. Evidence-based nursing practice: both state of the art in general and specific to pressure sores. J Prof Nurs. 1999;15:73-83.

[12] French P. The development of evidence-based nursing. J Adv Nurs. 1999;29:72-78.

[13] Parkin J. Evidence-based practice: the arguments for and against. Nurs Crit Care. 1998;3:67-72.

[14] Etminan M, Wright JM, Carleton BC. Evidence-based pharmacotherapy: review of basic concepts and applications in clinical practice. Ann Pharmacother. 1998;32:1192-1200.

[15] Greenhalgh J, Long AF, Brettle AJ, Grant MJ. Reviewing and selecting outcome measures for use in routine practice. J Eval Clin Pract. 1998;4:339-350.

[16] Morrissey MC, Kanda LT, Brewster CE. Development of a clinical physical therapy research program. Phys Ther. 1987:67:1110-1114.

[17] Goals for 1999-2000. In: Minutes of the House of Delegates Meeting. Alexandria, Va: American Physical Therapy Association; June 1999.

[18] Ballin AJ, Breslin WM, Wierenga KA, Shepard KF. Research physical therapy: philosophy, barriers to involvement, and use among California therapists. Phys Ther. 1980;60:888-895.

[19] Tracy JE. The role of research in the entry-level physical therapy curriculum. Journal of Physical Therapy Education. 1992;6(1):28-32.

[20] Zhang JQ. Research attitudes among chiropractic college students. J Manipulative Physiol Ther. 1996;19:446-553.

[21] Nolan MF. Breaking the barriers to clinical research: the physical therapist's perspective. Clinical Management. 1987;7(1):24-29.

[22] Warren SC, Pierson FM. Comparison of characteristics and attitudes of entry-level bachelor's and master's degree students in physical therapy. Phys Ther. 1994;74:333-348.

[23] Rothstein JM. Editor's note: Living without student research projects. Phys Ther. 1992;72:332-334.

[24] Hofmann PB. Breaking the barriers to clinical research: the administrator's perspective. Clinical Management. 1986;6(3):28-29.

[25] 1996 Practice Profile Report. Alexandria, Va: American Physical Therapy Association; 1996.

[26] Domholdt E, Flaherty JL, Phillips JM. Critical appraisal of research literature by expert and inexperienced physical therapy researchers. Phys Ther. 1994;74:853-860.

[27] Bostrom J, Wise L. Closing the gap between research and practice. J Nurs Adm. 1994;24(5):22-27.

[28] Timmerman L, Schmidt C, Heater SL. Increasing occupational research: is it time to try something new? Am J Occup Ther. 1994;48: 647-648.

[29] Robertson VJ. Research and the cumulation of knowledge in Physical Therapy. Phys Ther. 1995;75:223-236.

[30] Gross MT, Sekerak DK, Allen DD. Effect of including a clinical example on the ability of physical therapists to apply information in a technical research report. Phys Ther. 1994;74:963-968.

[31] Ashber JR. Letter to the editor. JAMA. 1990;264:3143.

Appendix. Attitudinal Survey Instrument

Self-Reported Knowledge and Behaviors

1. I now regularly read either Physical Therapy or other peer-reviewed professional journals in my areas of interest.

2. I have the necessary academic background to critically review the professional literature and draw my own conclusions about the validity and utility of the findings.

3. I currently feel comfortable with my level of knowledge in research terminology, research design, and validity and reliability issues as well as in ethical issues in physical therapy research.

Source of Authority for Clinical Decision Making

4. The research findings published in Physical Therapy or similar professional journals are relevant to my own clinical practice and expertise.

5. Clinical practice should be based on outcome measure research and scientific studies that assess the usefulness of particular treatment regimens or protocols.

6. Clinical practice should be based on what other therapists and specialists have used as treatment protocols over the years and on what experts say works.

Clinical Norms and Values About Research

7. Keeping current in the research literature in physical therapy is a lifelong professional responsibility of practicing physical therapists.

8. Research in the profession of physical therapy is one of the responsibilities of the physical therapy clinician practicing in the field.

9. I personally hope to be involved in the research process in the future on a regular basis.

10. The physical therapists I have been exposed to in the field appear to place a high priority on the professional research in the field of physical therapy.

BH Connolly, PT, EdD, is Professor and Chair, Department of Physical Therapy, College of Allied Health Sciences, University of Tennessee Health Science Center, 822 Beale St, Memphis, TN 38363 (USA) ([e-mail]). Address all correspondence to Dr Connolly.

NS Lupinnaci, PT, MS, is currently in private practice. She was a faculty member at the University of Tennessee Health Science Center when this research was completed.

AJ Bush, PhD, is Professor, Division of Biostatistics and Epidemiology, College of Medicine, University of Tennessee Health Science Center. Dr Bush also holds a joint appointment as Associate Professor in the Department of Physical Therapy.

Dr Connolly and Ms Lupinnaci provided concept/research design, and all authors provided writing. Dr Connolly provided data collection, subjects, and facilities/equipment. Ms Lupinnaci provided project management and fund procurement. Dr Connolly and Dr Bush provided data analysis and institutional liaisons. Dr Connolly and Margaret A Ayers provided clerical support.

This study was approved by the Institutional Review Board of the University of Tennessee Health Science Center.

This study was supported in part by the Tennessee Physical Therapy Association.

This article was submitted August 16, 1999, and was accepted January 8, 2001.