Aittama - 83
Authorization To Participate in a Home Physical Therapy Study
You are invited to participate in a study of the effectiveness of home Physical therapy
treatment after stopping treatment under a licensed Physical Therapist. My name is
Tracey Aittama and I am a graduate student at Michigan State University, Social Work
Department. From the study we hope to find that a home program can be just as effective
as a Licensed program and less cost effective for the patient. You were selected as a
participant in this study because of your diagnosis with a shattered left kneecap two years
ago and undergoing outpatient Physical Therapy treatment ever since. Due to the fact
you were recently discharged from your treatment under a licensed therapist you are the
perfect candidate for the study and your knee still needs continuos therapy to gain
strength, endurance and to be able to run on the knee.
I (print name) __________________________ agree to participate in the study under the
direction of Tracey Aittama. The study will be conducted at our home in Hubbell, MI. I
understand that the time to complete the survey will be six weeks, 2 weeks with
measurement at my baseline, 2 weeks with active therapy and another 2 weeks without
therapy to measure increased strength from the physical therapy treatment along with the
level of pain.
[PLEASE GIVE MORE ATTENTIONTO DESCRIBING PROCEDURAL DETAILS]
I understand that the purpose of this study is to examine the level of pain along with
strength gained from home physical therapy treatment. I also understand that in order for
the experimenter to examine this topic I will be asked to complete five different types of
home exercise treatments, that include bike riding, walking, treadmill, stair climbing or
stepper. I am aware I may experience different levels of pain from the increase in activity
during this time period. I will be asked to participate in a pain tolerance scale throughout
the study as well as measuring my ability to increase in repetitions and tolerance to the
therapy.
[EXPLICITLY STATE POTENTIAL BENEFITS]
I understand that I may talk with the experimenter about the experiment at anytime if I
desire. I can contact the experimenter, Tracey Aittama at 906-222-9666. I understand that
every effort will be made to keep my data confidential and no information will be
disclosed without my permission.
[NO DISCUSSION OF ALTERNATIVE PROCEDURES]
I understand that I may withdraw my consent and discontinue my participation at anytime
without receiving any negative consequences. I have been given the opportunity to ask
questions concerning the procedure and any questions have been answered to my
satisfaction.
I have read and understand the above.
Participant’s Signature____________________________________ Date_____________
I have explained and defined in detail the research procedure in which the participant has
agreed to participate and I have given him a copy of this informed consent form.
Experimenter’s Signature______________________________ Date_________________