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PHYS THER
Vol. 86, No. 9, September 2006, pp. 1251-1262
DOI: 10.2522/ptj.20050382
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Research Reports

Impact of Continuing Education Interventions on Clinical Outcomes of Patients With Neck Pain Who Received Physical Therapy

Gerard P Brennan, Julie M Fritz and Stephen J Hunter

GP Brennan, PT, PhD, is Director for Clinical Quality and Outcomes, Rehabilitation Agency, Intermountain Health Care, Salt Lake City, Utah
JM Fritz, PT, PhD, ATC, is Associate Professor, Division of Physical Therapy, University of Utah, and Clinical Outcomes Research Scientist, Intermountain Health Care, 520 Wakara Way, Salt Lake City, UT 84108 (USA)
SJ Hunter, PT, OCS, is Director, Rehabilitation Agency, Intermountain Health Care

Address all correspondence to Dr Fritz at: julie.fritz{at}hsc.utah.edu


Submitted December 6, 2005; Accepted April 28, 2006


   Abstract
 
Background and Purpose. Physical therapists frequently attend continuing education courses with the goal of providing better care, yet the effectiveness of continuing education for improving outcomes has not been examined. Subjects. Data were obtained for all eligible patients (n=1,365; mean age=42.1 years, SD=14.0 years; 69.9% female) with a chief complaint of neck pain who were treated in 13 physical therapy clinics over a 24-month period. Disability data (Neck Disability Index scores) from the initial and final therapy sessions were recorded from clinical databases. Methods. Thirty-four of 57 physical therapists employed within the 13 clinics attended a 2-day continuing education course. Eleven of the 34 attendees also participated in an ongoing clinical improvement project for patients with neck pain. Clinical outcomes were compared in the pre- and post-course periods for therapists attending or not attending the course, and for therapists participating or not participating in the ongoing project. Results. There were no differences in clinical outcomes based on attendance at the continuing education course. There was an interaction between time and participation in the ongoing project, such that participants achieved greater change in disability after the course. The percentage of patients achieving at least the minimum detectable amount of change in disability with treatment increased significantly for participants after the course. Discussion and Conclusion. Attendance at a 2-day continuing education course was not associated with improvement in clinical outcomes, but participation in an ongoing improvement project did result in greater clinical improvement for patients with neck pain. Further investigation of educational methods to improve clinical outcomes is needed. These results suggest that traditional continuing education formats may not be effective for improving patient care.

Key Words: Continuing education • Health care • Neck pain • Outcome assessment


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion and Conclusions
 References
 
The goal of health care providers to offer patients the best possible care stems from good intentions and supports a large enterprise of continuing education (CE) in the United States. The assumption is that CE will increase a heath care provider's knowledge, leading to a change in practice behavior and ultimately resulting in improved health care outcomes for patients.1 Surveys of physicians report an average of at least 40 to 60 hours per year spent attending CE.2,3 Despite the assumption of improved clinical performance, and the significant time and financial resources devoted to CE, relatively little research has examined the effectiveness of CE in changing behavior or improving clinical outcomes.4–6

Continuing education has traditionally used passive educational models (eg, lectures, conferences), sometimes combined with interactive learning (eg, workshops with opportunities for hands-on practice of skills).7,8 Often, CE is delivered at a single point in time (eg, weekend course); however, other CE opportunities occur longitudinally, such as Web-based courses or ongoing educational or quality-improvement programs. Research that has been performed on the effectiveness of CE has generally shown interactive learning with opportunities to practice skills to be more effective than passive learning alone,6,9,10 and the use of strategies to reinforce new knowledge over time is more effective than a single point-in-time intervention.8,11

Physical therapists are also frequent consumers of CE.12 A recent survey of physical therapists in the United States reported that an average of about 30 hours per year is spent on CE.13 Similar to physicians, the primary motivation given by physical therapists for attending CE courses is a desire to acquire new knowledge and skills pertinent to their current practice and related to their area of interest.14,15 Among physical therapists in Australia and the United Kingdom, the second most common rationale identified for selecting a particular intervention was instruction received from a CE course.16 Despite research questioning the effectiveness of single point-in-time CE courses, the majority of CE accessed by physical therapists appears to still be delivered in this traditional manner. Concerns about the methods and content of CE have been voiced for many years17; however, there has been no research to date examining the impact of CE on clinical outcomes among physical therapists.

Recent research conducted with patients who had neck pain with or without headaches has shown improved clinical outcomes with the use of manual therapy in combination with exercise.18–20 Therefore, instruction in manual therapy and corresponding exercise interventions supported by this evidence would be anticipated to improve clinical outcomes. One purpose of this study was to examine the impact of a CE intervention provided to a group of physical therapists on the treatment of patients with neck pain. Effectiveness of the CE intervention was based on the clinical outcomes of patients with neck pain who were treated by therapists before and after they attended a 2-day CE course compared with the clinical outcomes of patients with neck pain who were treated by therapists who did not attend the course. A second purpose was to determine whether physical therapists who attended the CE course and participated in an ongoing clinical improvement project after completion of the course achieved more improvement in clinical outcomes than therapists who attended the CE course but did not participate in the clinical improvement project.


   Method
Top
 Abstract
 Introduction
 Method
Results
 Discussion and Conclusions
 References
 
Data for this study were collected from outpatient physical therapy clinics of Intermountain Health Care (IHC), a private, nonprofit, integrated health care delivery system. For this project, 13 clinics located throughout the state of Utah participated. Beginning in January 2002, each participating clinic began tracking clinical outcomes for all patients who were receiving physical therapy. Data obtained from each new patient are entered into the Rehab Outcomes Management Systems (ROMS) electronic database using an Intranet Java Web application. At each visit, a condition-specific disability outcome score and a 0–10 numeric pain rating scale anchored with the phrases "no pain" and "worst imaginable pain"21 are collected and entered into the ROMS. During the 24-month time period of this study, outcome data were successfully collected on 81% of the patients who were attending the participating clinics.

The Neck Disability Index (NDI)22 is the region-specific disability scale used for patients with a chief complaint of neck pain in the participating clinics. The NDI consists of 10 items related to neck pain and the patient's tolerance of daily activities, with each item scored from 0 to 5. The total score is summed and expressed as a percentage of disability. The NDI is the most commonly used region-specific scale for patients with neck pain23 and has been demonstrated to be a reliable and valid outcome measure for patients with neck pain.24–26 Financial information related to utilization (visits) and physical therapy charges is tracked using a computer software application (AS-400)* and integrated with the ROMS database. The numbers of visits, length of stay in physical therapy, and total charges for physical therapy were recorded for each patient.

CE Course

A 2-day CE course focusing on manual therapy of the spine and corresponding exercise interventions supported by evidence was conducted for physical therapists at the participating clinics during October 2003. Two experienced educators and physical therapist clinicians with Fellowship status in the American Academy of Orthopedic Manual Therapy taught the course. The course included lecture and interactive hands-on practice sessions, with the instructors in approximately equal proportions. The evidence for manual therapy interventions for patients with neck pain was reviewed.19,20,27 Written educational materials and course notes were provided to all participants. Therapists at participating clinics were not required to attend the CE course. A total of 57 physical therapists at the participating clinics were invited to attend the CE course, of which 34 therapists (59.6%) chose to attend. Figure 1 shows the characteristics of the physical therapists. Age and years of clinical practice were unavailable for 5 therapists among the nonattendees. Six therapists had obtained Orthopaedic Specialty Certification (OCS) status (3 attended and 3 did not). No therapists had Fellowship status in the American Academy of Orthopaedic Manual Therapy. Therapists who chose to attend the course tended to be older (P=.051), with trends toward greater years of clinical practice (P=.12) and more male therapists (P=.10).


Figure 1
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  		Figure 1. Characteristics of the physical therapists (OCS=Orthopaedic Certified Specialist).

 
Clinical Improvement Project for Patients With Neck Pain

After completion of the CE course, a separate clinical improvement project was conducted in 4 of the 13 physical therapy clinics. The 4 clinics were selected for the project because they had a high volume of patients with neck pain and the clinic directors expressed a desire to participate. Of the 34 therapists who attended the CE course, 11 (32.4%) also were participants in the clinical improvement project. There were no differences in therapist age, sex, or years of clinical practice between participant and nonparticipant therapists (Fig. 1).

The purposes of the clinical improvement project were to standardize the assessment, to track the interventions used, and to examine the clinical outcomes of treatment for patients with neck pain. Following the CE course, therapists participating in the project met to review standardized forms for collecting baseline, intervention, and follow-up information. The collection of information on interventions used was standardized, but no specific protocols or algorithms were used. Beginning in December 2003, participating therapists met approximately once per month and reviewed the examination and manual therapy techniques taught in the CE course using facilitators and an instructional CD-ROM as learning resources. Five months after the CE course, therapists who participated in the clinical improvement project also participated in an additional small-group (5–6 therapists) follow-up, a 4-hour period of "hands-on" instruction with one of the original CE course instructors.

Data Analysis

Clinical outcome of patients with neck pain were based on the change in NDI scores, rate of change per visit for the NDI, and achieving a minimum detectable difference in NDI scores. Data of patients who attended fewer than 3 physical therapy sessions and those with initial NDI scores less than 10% were excluded from all analyses. We also excluded patients who were referred after surgery or over age 60 years because manual therapy is less likely to be indicated in these patients, and these groups were excluded from the primary studies supporting manual therapy and exercise interventions for patients with neck pain. Change scores for the NDI were calculated as the difference between initial and final follow-up scores. Change per visit was calculated by dividing the change score by the number of visits for each patient. Minimum detectable change (MDC) represents the smallest amount of change in an outcome measure that likely reflects true change rather than measurement error alone.28 The MDC for the NDI was defined by Westaway et al29 as 8 points. We therefore categorized any patient with a change score of 8 or greater as achieving the MDC, while patients with a change score of 8 or less were categorized as not achieving the MDC. For analysis of the MDC, we excluded patients with an initial NDI score less than 20% because the MDC was calculated in a sample of patients in which most of the patients had initial scores above this level.29 The number of physical therapy visits, length of stay, and total physical therapy charges also were recorded for each patient.

The effectiveness of the 2-day CE course was examined by comparing the clinical outcomes of patients who were treated by attending or nonattending therapists during the year preceding the CE course (pre-course period) with the outcomes in the year following the CE course (post-course period). Data of patients with an admission date from October 1, 2002, through September 30, 2003, were included in the pre-course analysis. Data of patients with admission dates between November 1, 2003, and October 31, 2004, were included in the post-course analysis. The data of any patient whose treatment crossed the dates of the CE course (October 9–12, 2003) were not included in the analysis (Fig. 2).


Figure 2
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  		Figure 2. Time line for study procedures. ROMS=Rehab Outcomes Management Systems.

 
Baseline characteristics of patients were compared for each time period (pre- and post-course) on the basis of age, sex, and initial NDI and pain scores using t tests or chi-square tests for continuous or categorical variables, respectively. A 2-way analysis of covariance (ANCOVA) was performed with time period (pre- or post-course) and CE attendance (attendee or nonattendee) as the independent variables and change in NDI scores as the dependent variable. Age, sex, and baseline NDI and pain scores were used as covariates. A separate ANCOVA was performed substituting rate of NDI change as the dependent variable. Of particular interest was the interaction effect between time period and CE attendance, examining the hypothesis that clinical outcomes were dependent on both time period and attendance. A chi-square test was used to compare the proportions of patients achieving the MDC for the NDI within each time period. Mann-Whitney U tests were used to compare physical therapy visits and charges between patient groups for the pre- and post-course periods.

We further explored for trends in the clinical outcomes by dividing the pre- and post-course periods into thirds based on the initial examination date. We divided the time periods into thirds in order to examine the data for trends that might be occurring over time independent of the educational interventions. In particular, dividing the pre-course period into thirds instead of considering it as a single time period allowed us to examine for trends occurring as a result of other factors (eg, co-payment changes) prior to any educational intervention. A one-way ANOVA was used to test for a linear trend in the change in NDI scores in pre- and post-course periods for attendees and nonattendees.

To examine the effectiveness of the clinical improvement project, we examined the outcomes of only those patients who were treated by attendees of the CE course. We compared clinical outcomes between patients of CE attendees who were also project participants with those of CE attendees who were project nonparticipants during the pre- and post-course periods using ANCOVA and chi-square procedures as described previously. Differences in physical therapy visits and charges also were examined using Mann-Whitney U tests. We also examined for trends in clinical outcomes using ANOVA procedures as previously described. Statistical significance was defined as P<.05 for all analyses.


   Results
Top
 Abstract
 Introduction
 Method
 Results
Discussion and Conclusions
 References
 
Overall, data for 2,105 patients with neck pain were included in the ROMS database during the 25-month time period of the study, with data for the 1,365 patients who were eligible for inclusion used in this analysis. The reasons for exclusion are outlined in Figure 3. The mean age of all eligible patients was 42.2 years (SD=14.0), 69.9% were female, 700 patients (51.3%) were treated in the pre-course period, and 665 patients (48.7%) in the post-course period. There were no differences in the characteristics or clinical outcomes between patients treated during the pre- and post-course periods (Tab. 1).


Figure 3
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  		Figure 3. Reasons for exclusion of patients from the analysis. NDI=Neck Disability Index.

 

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  		Table 1. Comparison of Baseline Characteristics and Clinical Outcomes of Patients Who Were Treated in the Pre- and Post-Course Periodsa

 
Effectiveness of the CE Course

The 34 therapists who attended the CE course treated 529 and 482 patients in the pre- and post-course periods, respectively, compared with 171 and 183 patients in the corresponding time periods for the nonattendees. In the pre-course period, patients meeting the inclusion criteria who were treated by attendees had lower baseline NDI scores than patients who were treated by nonattendees had (37.5 versus 40.8, P=.021). Patients who were treated by attendees in the post-course period were younger than those who were treated by nonattendees in the post-course period (41.7 versus 45.2 years, P=.004) and those who were treated by the attendees in the pre-course period (41.7 versus 42.3 years, P=.002) (Tab. 2). There were no differences between attendees and nonattendees in either the pre- or post-course period for baseline pain or NDI scores, number of visits, length of stay, or physical therapy charges (Tab. 2).


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  		Table 2. Comparison of Characteristics of Patients Who Were Treated by Therapists Attending or Not Attending the Continuing Education Course in the Pre- and Post-course Periodsa

 
The ANCOVAs comparing clinical outcomes between CE attendees and nonattendees, adjusted for age, sex, and baseline NDI and pain scores, did not show any significant interactions between time period (pre- or post-course) and attendance for either NDI change scores or rate of change in NDI, and no significant main effects for time period or attendance were observed (Tab. 3). Of the 1,365 patients whose data were included in the analysis, 1,191 patients (87.3%) had an initial NDI score ≥20%, and their data were included in the analysis of rate of achievement of the MDC for the NDI. The percentage of patients whose data were excluded from the MDC analysis did not differ based on attendance or time period. There were no differences in the percentage of patients who achieved the MDC based on attendance at the CE course or time period (Tab. 2). These results demonstrate that clinical outcomes did not differ in the pre- or post-course time period or based on therapist attendance at the CE course, or the interaction of these 2 factors, indicating that therapists who attended the CE course did not show improvement during the post-course period relative to therapists who did not attend the CE course.


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  		Table 3. Results of the 2-Way Analyses of Covariance Comparing Clinical Outcomes (Change in Neck Disability Index [NDI] Scores and Rate of Change in NDI Scores) Between Continuing Education Course Attendees and Nonattendees in the Pre- and Post-course Periodsa

 
The mean change in NDI for the pre- and post-course periods divided into thirds is illustrated in Figure 4. The one-way ANOVA comparing the mean changes scores across the 6 time periods was not significant for either the attendee or nonattendee therapists. No significant linear trends were found across time for either group.


Figure 4
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  		Figure 4. Mean change in Neck Disability Index scores for the attendees and nonattendees of the continuing education course during pre- and post-course periods divided into thirds. No significant linear trends were found for either attendees or nonattendees.

 
Effectiveness of the Clinical Improvement Project

Of the 34 therapists who attended the CE course, 11 therapists participated in the clinical improvement project and 23 therapists did not participate. Participant therapists treated 213 patients in the pre-course period and 196 patients in the post-course period. Nonparticipant therapists treated 316 and 286 patients in the pre- and post-course periods, respectively. In the pre-course period, patients who were treated by participant therapists had fewer visits (median=5 versus 6, P=.009) and lower physical therapy charges (median=$545.59 versus $652.95, P=.001) than patients who were treated by nonparticipant therapists had (Tab. 4). In the post-course period, patients who were treated by participant therapists continued to have lower physical therapy charges (median=$561.84 versus $678.89, P=.002). The length of stay was greater in the post-course period for patients who were treated by participant therapists (median=20 versus 22 days, P=.031).


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  		Table 4. Comparison of Characteristics of Patients Treated by Therapists Who Attended the Continuing Education Course and Who Participated or Did Not Participate in the Clinical Improvement Project in the Pre- and Post-course Periodsa

 
The ANCOVAs comparing clinical outcomes between participants and nonparticipants, adjusted for age, sex, and baseline NDI and pain scores, revealed a significant interaction between time (pre- or post-course) and participation when NDI change scores were the dependent variable (P=.037, mean difference=4.03, 95% confidence interval=1.30–6.76) (Tab. 5). The interaction effect on NDI change scores is graphed in Figure 5, indicating that therapists who attended the CE course and who participated in the clinical improvement project showed improved clinical outcomes from the pre- to post-course period, whereas therapists who attended the CE course and who did not participate in the clinical improvement project experienced a decrease in clinical outcomes over the same time period. The percentage of patients who achieved the MDC did not differ between therapists based on project participation in either time period (Tab. 4). However, among participant therapists, a significant increase in the percentage of patients who achieved the MDC was observed between the pre- and post-course periods (61.1% versus 71.4%, P=.038).


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  		Table 5. Results of the 2-Way Analyses of Covariance (ANCOVAs) Comparing Clinical Outcomes (Change in Neck Disability Index [NDI] Scores and Rate of Change in NDI Scores) Between Continuing Education Course Attendees Who Participated or Did Not Participate in the Clinical Improvement Project in the Pre- and Post-course Periodsa

 

Figure 5
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  		Figure 5. Graph of the interaction between time period and participation in the clinical improvement project. The dependent variable is mean change in Neck Disability Index (NDI) scores adjusted for age, sex, and baseline NDI score.

 
The mean change in NDI scores for the pre- and post-course periods divided into thirds is shown in Figure 6. The one-way ANOVA comparing the mean changes scores across the 6 time periods was not significant for either the participant or nonparticipant therapists. A significant linear trend toward less NDI change was found across time for the nonparticipant therapists (P=.015). A significant linear trend toward greater NDI change was present for participant therapists only when the last time period during the post-course was not considered (P=.018). If the last time period was included, the linear trend was no longer significant (P=.31).


Figure 6
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  		Figure 6. Mean change in Neck Disability Index scores for participants and nonparticipants in the clinical improvement project during pre- and post-course periods divided into thirds. A significant linear trend was observed for the nonparticipants (P=.015). The linear trend was significant for the nonparticipants over the first 5 time periods (P=.018), but was nonsignificant if the final time period (post-course 3) was included (P=.31).

 

   Discussion and Conclusions
Top
 Abstract
 Introduction
 Method
 Results
 Discussion and Conclusions
References
 
The impact of physical therapist CE on clinical and financial outcomes of patient care has not been reported in the literature. We examined the effects of a 2-day evidence-based CE course by comparing the outcomes of patients with neck pain who were treated by therapists who attended the course with the outcomes of patients who were treated by therapists who were nonattendees. The results did not show any significant improvements in clinical outcomes for patients who were treated by the attendees. Clinical education course attendance did not appear to impact clinical or financial outcomes in any way.

Most of the previous research on the impact of CE has focused on the outcomes of changing provider attitudes or behavior, with few studies examining changes in the clinical outcomes of patients.6 The research that has been performed indicates that changing attitudes or knowledge with CE is more easily achieved than improving clinical outcomes, and the accomplishment of the former does not automatically lead to the latter.30 We chose to focus on clinical outcomes because the ultimate goal of CE is to improve patient care. Because we did not measure the therapists' attitudes toward the CE content or provider behavior (ie, integrating new skills and evidence into practice), we are not able to determine whether the lack of effect of the CE course was due to the inability of the course to change therapist attitudes, poor adoption of new knowledge into practice, or insufficient skill attainment. What is evident from our results was the ineffectiveness of the CE course alone for altering clinical outcomes.

Previous research performed with physicians on changing provider behavior and improving clinical outcomes through integration of evidence into clinical practice concur with our results showing the ineffectiveness of a traditional CE approach for accomplishing these goals.31,32 More recent research suggests that newer approaches involving ongoing interaction with clinicians in smaller groups occurring within the context of the clinicians' practice setting may be more effective for changing clinical performance.9,33,34 The results of our study generally support the hypothesis that an ongoing, small-group, educational intervention may be more effective than traditional CE delivery methods for improving clinical outcomes. Therapists who participated in the ongoing clinical improvement project demonstrated improved clinical outcomes, based on amount of change in disability during therapy and increased percentage of patients achieving the MDC for change in disability during the post-course time period. Therapists who attended the traditional CE session but who were not participants in the ongoing project did not demonstrate this improvement following the course, instead showing a significant trend toward less change in disability over the time of the study. The participant therapists were able to improve their clinical outcomes for patients with neck pain while maintaining significantly lower median physical therapy charges than nonparticipant therapists, suggesting improved cost-effectiveness of care.

The ongoing clinical improvement project was able to change clinical outcomes even though the project was focused on standardizing examination procedures and tracking clinical outcomes, instead of on treatment protocols or algorithms. Therapists who participated in this project met monthly following the 2-day CE course, providing opportunities for them to discuss their experiences working with patients with neck pain with other therapists and to discuss barriers to standardization. Clinical outcome data, including disability scores, visits, and costs, were presented at these meetings to track progress and reinforce the practice behavior changes identified as favorable to promote better outcomes. "Clinician facilitators" also were available to discuss cervical treatment techniques, evidence-based literature, and the evaluation process. In addition, a follow-up, hands-on review session was conducted approximately 6 months after the original CE course to review hands-on evaluation and treatment skills.

We chose to use a pragmatic approach to studying the effects of the CE interventions on clinical outcomes. The advantage of this approach is that it examines the impact of the CE interventions in their actual "real-world" context,35 in which there is a diversity of both therapist and patient characteristics and where the choice to attend CE and to apply the techniques and decision-making strategies learned in everyday clinical practice is left to the individual therapist. Previous research conducted with physicians has shown the efficacy of alternative approaches to CE,6 but the effectiveness of implementing small-group, on-going CE interventions with physical therapists has not been previously investigated.

The pragmatic approach taken in this research also creates limitations in interpretation of the results. Alternative explanations exist for the differences observed among the therapists in this study. Therapists were not randomly assigned to attend or not attend the traditional CE session, but self-selected to attend or not attend. It is possible that therapists who were already skilled in manual therapy and practicing as manual therapists may have chosen not to attend the course. We approached the participants in the ongoing clinical improvement project about participation based on volume of patients and geographic considerations. A selection bias may have existed in this process. The atmosphere in the facilities that were chosen and the influence of colleagues within those facilities could influence the effect of training; however, these factors are difficult to model in the analyses performed. The project participants treated a greater volume of patients with neck pain than most of the nonparticipants treated, which may have provided more opportunities for refinement of skills. Prospective, randomized studies are needed in physical therapy to examine different educational strategies for improving clinical outcomes.

The magnitude of the differences in mean NDI changes based on project participation and time period was statistically significant, but smaller than the MDC for the NDI scores (mean difference=4 points, MDC=8 points). We anticipated a smaller treatment effect in our study because of the heterogeneity of the patient sample and the lack of standardization in the treatment. We also included an examination of the effect of the CE intervention at the individual patient level because of concerns that statistically significant changes in aggregate outcomes (ie, mean changes in disability) may not represent clinically important changes at the individual patient level (ie, achieving the MDC).36 Although the average amount of improvement in disability among all patients who were treated by the participants in the pre- and post-course periods did not reach the threshold of the MDC, a significantly greater percentage of patients who were treated by the participants met the MDC threshold in the post-course period, indicating that more individual patients were receiving a benefit in the post-course period and suggesting that the intervention may have had a clinically important effect on outcomes.

Measurement is an important component for improving health care quality.37 We help our patients and our profession by measuring the outcomes of our interventions, whether related to the treatment of patients or continuing education interventions for the professional development of physical therapists. Professional development through CE demands a significant investment of resources for the expressed purpose of improving the quality of patient care. In order to rationalize sustaining the investment in continuing education, we need to understand the most effective CE formats and measure the outcomes of the process.


   Footnotes
 
Dr Fritz provided concept/idea/research design and data collection and analysis. Dr Brennan and Dr Fritz provided writing. Dr Brennan provided project management, subjects, and institutional liaisons. Dr Hunter provided facilities/equipment.

This research was approved for exempt review by the Institutional Review Board of Intermountain Health Care.

This research, in part, was presented as an abstract at the Combined Sections Meeting of the American Physical Therapy Association; February 23–27, 2005; New Orleans, La.

* IBM Corp, 1133 Westchester Ave, White Plains, NY 10604. Back


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion and Conclusions
 References
 

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