Opinions of physical therapy education program directors on essential functions.

Key Words: Americans With Disabilities Act, Educational programs, Essential functions, Physical therapist students.

Forty-three million persons in the United States have disabilities.[1] Occasionally, persons with disabilities may choose to pursue careers in the health professions. There are numerous examples of medical, nursing, and physical therapist students with disabilities.[2-11] Graduates with disabilities also have been successful finding employment.[4,12,13]

Persons with disabilities who participate in programs and services provided by the public and private sectors encounter barriers. French[4] surveyed health care professionals and students with disabilities and reported that the majority of the respondents did not believe that they experienced discriminatory practices related to admissions to health professions education programs. One half of the respondents, however, believed that their professors displayed negative attitudes and that some professors were unwilling to make reasonable accommodations.

Hartman and Hartman[5] discussed three primary concerns related to admissions of students with disabilities into health care professions. The first concern was that students could seek only a few specialty areas within the profession. The authors suggested that early specialization by students with disabilities should not be viewed negatively because medical students without disabilities also begin the specialization process early through enrollment in elective courses.

The second concern dealt with the anticipated expense of providing accommodations. Funding mechanisms often exist for the purchase of equipment and assistive devices that would greatly enhance the education of a person with a disability. Often, these devices or the means of providing the educational experience are inexpensive. Additional faculty time may also be required to present material in a nontraditional manner.[5]

The third concern related to the fear of having to lower the standards for students with disabilities. With assistance, students with disabilities may be able to design alternative techniques for performing the essential skills required by the programs.[5] Hartman and Hartman,[5] for example, suggested that an Optacon(*) may be used for reading electrocardiograms. Additional reasonable accommodations have been reported for persons with disabilities attending medical schools, nursing programs, and physical therapy programs.[3,11,13] The authors implied that programs did not lower the academic standards for students with disabilities because they used accommodations.

The Americans With Disabilities Act (ADA) ensures the qualified applicant with a disability the opportunity to pursue program admission at public institutions. To determine whether an individual is a qualified applicant for programs or services, the ADA states that applicants must meet essential eligibility requirements.[1]

Prior to 1990, legal decisions related to persons with disabilities were influenced by the Rehabilitation Act of 1973.[14] The US Supreme Court's decision in Southeastern Community College v Frances B Davis[15] granted college programs the authority to establish technical standards that students must be capable of completing in the course of their professional education. Southeastern Community College denied admission to Davis, an individual with bilateral sensorineural hearing loss. The nursing faculty of the college contended that Davis would be unable to complete the clinical portion of the curriculum secondary to an inability to "participate safely" without being able to hear. They hypothesized that the applicant could not utilize her mode of communication, lip reading, in the surgical environment, where surgical masks cover mouths. The US Supreme Court upheld the denial of admission to the program because the applicant did not meet the program's requirements.[15]

To avoid discriminating against students with disabilities, academic institutions have been advised to establish requirements that apply to all students.[6,8,16-23] Without these requirements, qualified applicants with disabilities could be excluded based solely on biases rather than actual abilities. Mirone[16] recommended that physical therapy programs publish the essential functions that students must be capable of completing prior to graduation and that they share this information with applicants before the admission process.

In 1993, a study was conducted to determine the number of physical therapy programs that had written descriptions of the essential functions that students must be able to complete to graduate, with or without reasonable accommodations. One hundred physical therapy program directors (79%) completed the survey. Only 8 (8%) of the directors of accredited professional (entry-level) physical therapy programs described documents that listed essential functions. Preferred essential functions have not been developed by the American Physical Therapy Association (APTA).[24]

The primary purpose of this study, therefore, was to identify the essential functions that should be required for graduation of professional physical therapist students. This study attempted to answer the question: What do physical therapy education program directors think are the essential functions that a physical therapist student, as a potential physical therapy practitioner, must be capable of completing, with or without reasonable accommodation?

Because all of the programs prepare students for similar professional roles and meet the same accreditation criteria, I assumed that there would be no systematic differences of opinion among program directors based on factors such as degree level of the program, funding status (public or private) of the institution, or class size. A secondary purpose of this study was to test this assumption.

Method

Subjects

The study population included all directors of professional physical therapy education programs in the United States accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE) as of 1994. A list of 129 programs was supplied by APTA. The population comprised 64 programs that awarded professional master's degrees and 65 programs that awarded bachelor's degrees in physical therapy. The population contained 82 public institutions and 47 private institutions. The District of Columbia and 45 states were represented.

Procedure

The Delphi technique was selected to determine the opinions of the physical therapy program directors concerning essential functions. The Delphi technique, developed in the 1950s by the Rand Corporation, consists of a series of questionnaires to identify the opinions of a designated group of experts on a particular issue.[25-27]

In this study, there were three rounds of questionnaires. I developed a questionnaire for each round of the survey based on the results of the previous round. In an effort to ensure content validity, a former director of an accredited physical therapy program participated as a consultant in the review of the submitted lists of essential functions. The consultant assisted with the identification of the items to be included in each questionnaire.

Initially, an introductory letter was mailed to each program director, requesting participation in the study. In addition, all program directors were asked to identify the essential functions required of students in their programs.

A cover letter describing the study and requesting full participation through the series of questionnaires accompanied the first questionnaire. Subjects were presented with a starting list of nine essential functions, derived from the documents identified in a previous survey[24] and the introductory study request letter. In reviewing the submitted documents, two of the nine functions consistently (ie, 7/9 documents) had lengthy subcategories: treatment procedures and assessment procedures. Therefore, a similar format was followed for the survey.

There was, however, one type of information that was included in the submitted documents that I did not incorporate into the survey. Several documents included vague descriptions of physical characteristics such as "adequate vision" or "adequate hearing." Because the ADA states that "a public entity shall not impose or apply eligibility criteria that screen out or tend to screen out an individual with a disability,"[1] I judged that the inclusion of such physical characteristics was inappropriate.

Participants were directed to make modifications to any of the items listed. A comments section was included under each item. A section at the end of the questionnaire provided space for the participants to list additional essential functions not included in the survey and the rationale for adding the items to the list. The first questionnaire also included demographic questions related to type of degree awarded by the program (bachelor's or professional master's), funding source (public or private), and size of class.

The results of the comments from the first round were summarized and categorized. The consultant reviewed all comments and assisted with modifications and additions to the list. A second questionnaire was developed incorporating the results of the first round. Four additional items recommended in the first round were added to the list of essential functions. In addition, based on suggestions from the participants, the wording was modified in four of the items.

In the second round, participants were requested to rate each item using an ordinal scale. Four categories were selected for the scale: definitely essential, probably essential, probably not essential, and definitely not essential. Participants were given the opportunity to provide any additional comments at the end of the questionnaire. A return deadline of 4 weeks was stated. A follow-up reminder letter was sent to those participants who did not meet the deadline.

The results of the second round of questionnaires were analyzed. The third questionnaire incorporated these results and listed the group median response for each item. In addition, the participants were given their previous responses to each item. During this final round, participants were given the opportunity to change their rating for any items. A reason was requested for any ratings different from the group median. A cover letter providing directions accompanied the third round of questionnaires. A return deadline of 4 weeks was stated. A follow-up reminder letter was sent to participants who had not responded by the deadline.

The survey questionnaires were distributed by mail during the months of April to August 1994. Postage-paid return envelopes were provided for the participants during each round of questionnaires. All questionnaires were coded for tracking purposes. This tracking was required to ensure that individuals participating in each round received the subsequent survey questionnaire. I maintained the only copy of the program identification key.

Respondents were assured of their confidentiality. I did not refer to the program identification key when reviewing the responses of any of the participants. Reference was never made to the response of any particular program director.

Data Analysis

The frequency of responses was calculated for each category ("definitely essential" to "definitely not essential") for each item for each round using the Statistical Analysis System.([dagger]) In addition, the median response to each item was calculated. The responses in the comments section for each round were reviewed.

Comparisons were conducted between the responses generated from the various groups. The dependent variable was the essential function, and the independent variables were the degree awarded by the program (bachelor's or master's), size of class (0-40 students or [is greater than] 40 students), and funding source (private or public). The Mann-Whitney U test with a correction for ties was utilized for the ordinal data. The level of significance was set at [Alpha] =.05.

Results

Existing Essential Function Documents

In the preliminary stage of the study, the directors of nine programs (7%) submitted existing essential function documents. The majority of these programs were public institutions (67%) and awarded professional master's degrees (78%). The geographical distribution encompassed eight states.

The essential functions noted on the existing documents consisted of the following major categories: (1) skills in communication, (2) performance of physical therapy assessment procedures, (3) determining patient needs, (4) developing a plan of care, (5) performing treatment procedures, (6) applying universal precautions, (7) demonstrating administrative skills, (8) practicing safely, ethically, and legally, and (9) participating in scientific inquiry. Subcategories of assessment and treatment procedures were listed for those essential functions.

Demographic Characteristics of the Delphi Survey Participants

Directors from 58 programs in 27 states representing all geographic areas of the country responded to round 1 of the Delphi study. Fifty-nine percent of responding programs were affiliated with public institutions. Forty percent of responding programs awarded bachelor's degrees, and 60 of responding programs awarded master's degrees. Class size ranged from 18 to 107 students, with a median of 40 students. The sample of respondents was similar to the population of accredited programs, with 63% of the programs housed at public institutions and with an almost equal number of bachelor's and master's degree programs.

Round 1

Comments from the participants included modifications, clarifications, and additions to the items listed in the survey. The comments were categorized for each of the existing functions. The majority of participants did not suggest changes to the wording of the items. The range of agreement was 59% to 90%, depending on the essential function.

After reviewing the comments, the consultant assisted with changes to the round 1 list for round 2. The modifications and clarifications did not change the focus of the items. Five essential functions were not changed. These essential functions were the skills needed to determine patient needs; perform treatment procedures; demonstrate universal precautions; practice safely, ethically, and legally; and participate in scientific inquiry. Agreement with stated wording ranged from 76% to 90% on these skills.

Four essential functions were added in accordance with the suggestions of the participants. These essential functions were the following categories: psychosocial skills, teaching and learning application, professional development, and ability to apply prevention and health promotion. Three assessment procedures were also added: assessment of endurance, segmental length and volume, and peripheral nerve function.

Round 2

All respondents who participated in round 2 of the survey participated in round 1. Respondents rated each item using the following scale: 4 = definitely essential, 3 = somewhat essential, 2 = somewhat not essential, and 1 = definitely not essential.

The median rating for most items was 4, or "definitely essential." Participation in the process of scientific inquiry and two items in the treatment procedures list had median ratings of 3, or "somewhat essential." The procedures were massage and taping and wrapping techniques. Consensus was achieved regarding two essential functions: (1) utilizing appropriate verbal, nonverbal, and written communications with patients, families, and others and (2) practicing in a safe, ethical, and legal manner. Both functions were rated as "definitely essential" by all participants responding to those items.

The comments from round 2 were reviewed. Three participants noted that one procedure was synonymous with another procedure listed. The consultant agreed with the comment, and the item (de, manual therapy) was eliminated from the list for round 3.

Round 3

Round 3 of the Delphi survey allowed the participants to review the median scores from round 2 and indicate a final rating. Fifty-two of the 58 participants (90%) responded to round 3 (Tab. 1). They represented the directors of 31 master's degree programs (60%) and 21 bachelor's degree programs (40%). The funding source for round 3 was 32 public institutions (62%) and 20 private institutions (38%). The population was similarly divided.

Table 1.
Response Rates for Each Delphi Round

                     No. of
                     Program
                     Directors  No. of
Delphi Round         Contacted  Respondents  Percentage

Initial request for
existing lists       129        9              7
1st questionnaire    129        58            45
2nd questionnaire     58        58           100
3rd questionnaire     58        52            90

Participants were reminded of the primary study question: What do physical therapy education program directors think are the essential functions a physical therapist student, as a potential physical therapy practitioner, must be able to complete, with or without reasonable accommodation?"

Participants were consistent with their responses across the three rounds. Little change of opinion was noted. Table 2 lists, in rank order, the percentage scores for functions rated as "definitely essential" by the program directors. The same functions that were rated as "definitely essential" by all participants in round 2 remained with full agreement in round 3. These items were related to communication with patients, families, and others and practicing in a safe, ethical, and legal manner. No other items had full agreement.

Table 2.
Essential Functions Rated "Definitely Essential" Ranked by Percentage
(N = 521)

Essential Function                                    Percentage

Utilize appropriate verbal, nonverbal, and written
communication with patients, families, and
others                                                100

Practice in a safe, ethical, and legal manner         100

Determine the physical therapy needs of any
patient with potential movement dysfunction            98

Demonstrate ability to apply universal precautions     96

Safely, reliably, and efficiently perform
appropriate physical therapy procedures used to
assess the function of the movement system             92

Perform treatment procedures in a manner that is
appropriate to the patient's status and desired
goals                                                  90

Develop and document a plan of care for a patient
with movement dysfunction                              88

Recognize the psychosocial impact of dysfunction
and disability and integrate the needs of the
patient and family into the plan of care               88

Demonstrate responsibility for lifelong professional
growth and development                                 88

Demonstrate management skills, including
planning, organizing, supervising, delegating,
and working as a member of a multidisciplinary
team                                                   81

Develop and apply programs of prevention and
health promotion                                       79

Apply teaching/learning theories and methods in
health care and community environments                 75

Participate in the process of scientific inquiry       50

There was nearly universal agreement (95%-99%) for two skills: "determining physical therapy needs of any patient with perceived or potential movement dysfunction" and "applying universal precautions." The performance of assessment procedures and the performance of treatment procedures were rated as "definitely essential" by at least 90% of the participants. The least agreement was noted for the essential function of participating in scientific inquiry. One half of the respondents rated this function as "definitely essential."

Tables 3 and 4 list the ranked percentage scores for the subcategories of assessment procedures and treatment procedures rated as "definitely essential." Agreement was higher for assessment procedures, with a range of 71% to 94%. Ten assessment skills were rated as "definitely essential" by at least 90% of the participants: functional abilities, vital signs, pain, gait, cranial and peripheral nerve function, strength, balance, movement patterns, posture, and sensation (Tab. 3).

Table 3.
Assessment Procedures Rated "Definitely Essential" Ranked by
Percentage (N = 52)

Assessment Procedure                   Percentage

Functional abilities                   94
Vital signs                            94
Pain                                   92
Gait                                   92
Cranial and peripheral nerve function  92
Strength                               91
Balance                                90
Movement patterns                      90
Pasture                                90
Sensation                              90
Endurance                              88
Skin and vascular integrity            88
Coordination                           87
Joint motion/play                      87
Wound status                           86
Cognitive/mental status                85
Soft tissue                            83
Tone                                   83
Assistive device fit/use               79
Developmental stage                    79
Reflexes                               79
Segmental length, girth, and volume    79
Pulmonary system                       71
Table 4.
Treatment Procedures Rated "Definitely Essential" Ranked by
Percentage (N = 52)

Treatment Procedure                      Percentage

Balance training                         87
Cardiopulmonary resuscitation            87
Exercise techniques                      87
Gait training                            85
Activities of daily living training and
functional activities                    83
Bed mobility                             83
Transfers                                83
Coordination training                    79
Postural correction                      79
Prosthetic/orthotic training             79
Joint mobilization                       75
Wound care                               75
Wheelchair prescription and mobility     75
Electrotherapy                           73
Soft tissue mobilization                 73
Techniques of neurosensory approaches    71
Thermal agents                           71
Cardiopulmonary rehabilitation           69
Developmental activities                 69
Hydrotherapy                             69
Recommendations for architectural
adjustments                              69
Tilt table                               65
Massage                                  61
Relaxation techniques                    61
Postural drainage                        59
Traction                                 46
Taping and wrapping techniques           33

The range of agreement for treatment procedures rated as "definitely essential" was 33% to 87% (Tab. 4). Agreement was greatest for balance training, cardiopulmonary resuscitation, and exercise techniques. These items were rated as "definitely essential" by 87% of the respondents. The least agreement was for taping and wrapping techniques (33%).

The median rating for most items was "definitely essential." The median rating of "somewhat essential" was given for participation in scientific inquiry, traction, and taping and wrapping techniques. The median rating of massage, a treatment procedure, changed from "somewhat essential" in round 2 to "definitely essential" in round 3.

Participants were asked to provide a rationale for all items in which they were not in agreement with the median rating. The majority of the comments were related to specific items listed in the treatment procedures list. The most frequent comment was that physical therapist assistants could perform the procedures and, therefore, the items were not essential functions of a physical therapist. Several participants commented that developmental activities and techniques related to neurosensory approaches were difficult to rate. One participant responded that developmental activities and techniques related to neurosensory approaches lack scientific support.

Thirteen participants provided written comments in support of a higher rating for the participation in the process of scientific inquiry. Their comments indicated their opinions concerning the importance of research to the profession.

The Mann-Whitney U test with continuity correction for ties was utilized to answer the additional study questions. There was no difference of opinion regarding the desired essential functions required of professional master's versus bachelor's degree programs, public versus private institutions, or large versus small programs.

Discussion

The ADA was established to empower persons with disabilities to pursue employment opportunities and access to services.[1] The literature documents the discriminatory practices that were affecting opportunities for persons with disabilities prior to the passage of the ADA.[28] The ADA also addresses issues related to "qualified" persons with disabilities in their pursuit of access to programs offered through the public sector. To determine the applicant's qualifications, he or she must "meet the essential eligibility requirements."[1]

My study attempted to identify the technical standards or essential functions that should be required for graduation of physical therapist students. Because program directors are separated by distance, the Delphi technique served as an economical method for surveying the directors. Participants were able to identify the functions, rate the items utilizing an ordinal scale, see the median ratings of their peers, and make comments and suggestions without having to be physically present as a group. A limitation of the Delphi technique is that it requires multiple responses from participants, and some individuals may choose not to participate in the lengthy process. The response rate for this study was 45%. In review of the demographic information, the participants appeared to be representative of the population under study.

The essential functions identified through the study resembles some of the expectations of graduates of physical therapy programs, as outlined in section 4 of the accreditation evaluative criteria.[29] The document appears to include essential functions that are currently in practice in clinical settings. The last analysis of the practice of physical therapy, however, was conducted several years ago. An updated study by the Federation of State Boards of Physical Therapy is in progress.[30]

The findings of this study indicate general uniformity of opinion. In comparing the ratings of the essential functions by programs on the basis of degree awarded, institutional funding source, and class size, the data lead to the conclusion that there is no statistical difference of opinion between the groups.

Ranked at the top was the essential function dealing with legal, safe, ethical practice. This finding was not surprising because programs prepare students for unsupervised practice as licensed professionals. The licensure boards, in the role of public protection, depend on education programs to graduate only persons who will practice safely. The Americans With Disabilities Act Title II Technical Assistance Handbook addresses the safety issue: "An individual who poses a direct threat to the health or safety of others will not be `qualified.'"[31](p7)

The ability to perform assessment procedures was rated higher than the ability to perform treatment procedures. Several participants argued that many treatment procedures could be delegated but that assessment procedures must be performed by a physical therapist.

Interestingly, of all the items listed in the survey, participation in scientific inquiry received the least support. The diverse opinions noted in this study could be expected based on previous discussions of this issue.[32-34] One of the program directors stated: "We need to be able to validate our existence." Another respondent commented that the participation in scientific inquiry is "necessary" if physical therapy is to be considered a "science." Some of the participants may have interpreted "participation" in the process as conducting research projects. Other participants may have assumed that this function could include basic skills of reviewing scientific literature.

Several participants had difficulty with the issue of reasonable accommodations. A reasonable accommodation at one institution may not be reasonable at another institution, depending on resources. Some participants believed that delegating tasks to a physical therapist assistant or a technician could be interpreted as a reasonable accommodation. In the interpretation guidelines for the ADA, the Equal Employment Opportunity Commission indicated that if a task is considered an essential function, a reasonable accommodation might be to have someone assist with the performance of the essential function, but not actually perform the entire function for the individual with a disability.[31]

One of the program directors raised the question: "How would a prospective student determine whether he or she would be able to carry out the essential functions?" Added to that question is the issue related to faculty also making those judgments during the application phase, before prospective students have been taught how to do the essential functions. There are a variety of methods available for applicants of physical therapy programs to investigate the field of physical therapy. One example might be for applicants with disabilities to observe in physical therapy settings. This avenue allows opportunities to view clinicians performing many of the essential functions. During this observation time, applicants could explore possible reasonable accommodations that would allow them to perform the skill at a later date. In addition, one concept that warrants study is the use of practical evaluations of all applicants, similar to job testing.

Recommendations for the use of the results of the study are:

1. The results should be used as a reference for physical therapy programs as faculty develop the essential eligibility requirements for their programs. Because the essential function dealing with safety is critical to the profession and the public, it seems appropriate for programs to begin with a preface statement including this standard. Each program should then publish and share the requirements with all potential applicants.

2. During the admissions process, programs should indicate to all applicants that they should notify the department if they need reasonable accommodations to participate in any interview process that is used. Questions concerning an applicant's disabilities are not permitted during the interview process.[1] Applicants may be asked, however, whether they can complete the essential functions. Once admitted, the student with a disability should indicate the need for reasonable accommodations to complete the essential functions. Additional strategies for implementing the ADA in medical education programs have been cited.[35,36]

Based on the review of literature, it is apparent that limited information is available on reasonable accommodations that could be made for physical therapist students with disabilities. Therefore, the following additional recommendations are suggested:

1. A resource manual should be developed by APTA, providing suggestions of reasonable accommodations for the essential functions. This manual should be updated at least annually in light of changing technology. The manual cannot serve as a standard for particular disabilities, because each person with a disability has unique concerns.

2. Professional education courses and videotapes for faculty and clinicians should be developed, highlighting alternative methods of completing the essential functions other than the traditional methods generally taught in physical therapy programs. These courses and videotapes should incorporate the use of various types of reasonable accommodations that are available.

3. Physical therapist students, as future employers in the profession, should be educated about issues related to physical therapists with disabilities and reasonable accommodations.

This study focused solely on the opinions of physical therapy education program directors concerning the essential functions to be required of physical therapist students. Similar research could be conducted to determine the opinions of practicing physical therapy clinicians who serve as clinical instructors of physical therapist students and employers of the future physical therapists. A similar study could be conducted concerning the essential functions that should be required of physical therapist assistant students.

Additional research is indicated in the area of reasonable accommodations. Technological advancements, especially in the area of computerization, may enhance the capabilities of persons previously thought to be unable to perform the essential functions.

Conclusions

The results of this study suggest that there is agreement among the physical therapy education program directors concerning essential functions that should be required of students. Thirteen essential functions were rated "definitely essential" or "somewhat essential" by the majority of the participants. All participants rated two of the functions as "definitely essential": (1) practicing in a safe, legal, and ethical manner and (2) communication skills with patients, families, and others. Four additional functions were rated as "definitely essential" by the vast majority of the participants. The least agreement was noted with the participation in scientific inquiry.

Programs should utilize the results of the study in the development of essential eligibility requirements for their respective institutions. The results are not intended to become a mandated list that all programs must follow.

In a profession that promotes the abilities of persons with disabilities, it appears only natural that we pioneer opportunities for persons with disabilities who choose to become physical therapists.

Acknowledgments

I wish to express my appreciation to the participating program directors and to the consultant for the study, J Randy Walker, PhD, PT, acting dean of the College of Health and Human Services at the University of Tennessee at Chattanooga.

(*) TeleSensory Inc, 455 N Bernardo Ave, Mountain View, CA 94041.

([dagger]) SAS Institute Inc, PO Box 8000, Cary, NC 27511.

References

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[10] Weatherby F, Moran M. Admission criteria for handicapped students. Nurs Outlook. 1989;37:179-181.

[11] Woods EN. When the student has a disability. PT--Magazine of Physical Therapy. 1993;1(6):44.

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[13] Woods EN. When it's the physical therapist who has the disability. PT--Magazine of Physical Therapy. 1993;1(6):42-47.

[14] Rehabilitation Act of 1973 (Pub L No. 93-112), 29 USC [sections] 794.

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[24] Ingram D. Essential functions required by physical therapist and physical therapist assistant programs. Journal of Physical Therapy Education. 1994;8:2.

[25] Cunningham W. Systematic Planning for Educational Change. Mountain View, Calif: Mayfield Publishing Co; 1982.

[26] Moore C. Group Techniques for Idea Building. Beverly Hills, Calif: Sage Publications Inc; 1987.

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

[33] Robertson VJ. Research and the cumulation of knowledge in Physical Therapy. Phys Ther. 1995;75:223-232.

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D Ingram, EdD, PT, is Academic Coordinator of Clinical Education and UC Foundation Assistant Professor, Physical Therapy Department, University of Tennessee at Chattanooga, 615 McCallie Ave, Chattanooga, TN 37403 (USA) ([e-mail]).

This study was completed in partial fulfillment of the requirements for Dr Ingram's Doctor of Education degree, University of Tennessee at Knoxville.

This article was adapted from a presentation at the Combined Sections Meeting of the American Physical Therapy Association; February 10, 1995; Reno, Nev.

This study was approved by the University of Tennessee Committee for Research Involving Human Subjects.

The Tennessee Physical Therapy Association provided funding for this study.

This article was submitted September 12, 1995, and was accepted August 28, 1996.