Objective concurrent feedback on force parameters improves performance of lumbar mobilisation, but skill retention declines rapidly

New learning technique based on real-time kinematic feedback from an inertial sensor for manual therapy in shoulder joint: a randomised trial

BACKGROUND

Reducing teacher subjectivity and checking skill corrections have an impact on the manual therapy learning, one of the most crucial components of physical therapy clinical practise. The aim of this study was to analyse the effectiveness of a kinematic real-time feedback strategy (KRTF) with an inertial sensor as a new methodology for the learning of glenohumeral joint mobilisation, comparing it with the traditional teaching method.

METHODS

This study was a randomised trial. 59 undergraduate students without experience in manual therapy were randomised into two different groups (G1: Traditional methods group; G2: KRTF group). G1: students would practice the technique while an expert in manual therapy would supervise them. G2: could perform the mobilisation and observe the kinematic characteristics of the technique on a laptop. For the two movements that compose the mobilisation (angulation and translation), the result variables extracted were: maximum displacement, minimum displacement, area under the curve and the difference between the area under the curve of angulation and translation. In addition, the consistency of the measurement and reliability were calculated, too.

RESULTS

Some significant differences were observed within groups, between groups and in the group x time interaction, the difference between the angulation and translation area. The synchronization of the movements in in the post comparison was better in G2 because the differences in the areas of both movements were significantly smaller (Mean Difference G1 vs. G2 = 1111.4°s (p > 0.05)).

CONCLUSIONS

After comparing the kinematic variables recorded between the two intervention groups analysed in the present study, we observed that the kinematic registers were significantly different between the two groups, with a higher evolution in the KRTF group compared to the traditional learning method. The effectiveness of KRTF was proved over the traditional teaching methods in facilitating the learning process of the glenohumeral joint mobilisation.

CLINICALTRIALS

GOV ID

NCT02504710, 22/07/2015.

Teaching Physiotherapy Students Physical Examination Skills by Using Photogrammetry: A Randomized Control Trial of 3- Versus 2-Dimensional Images

INTRODUCTION

Education research explains how healthcare professional training could be more efficient and effective by integrating simulation technology. Despite its relevance in training medical students, the evidence of its effectiveness in the manual skill training of physiotherapy students remains limited. The aim of this study was to compare the effectiveness of 3-dimensional (3D) images of real objects produced by photogrammetry and traditional 2-dimensional (2D) images when introducing manual therapy skills to undergraduate physiotherapy students via an online course.

METHODS

In a randomized controlled trial, a group of first-year physiotherapy bachelor honor degree students participated in a 2-hour online course on 3 manual assessment skills: cervical compression, distraction, and flexion-rotation tests. They demonstrated 2 sets of learning materials, including either 3D images of real rotating objects using close-range photogrammetry (experimental group) or traditional 2D images (control group). After their respective training, an Objective Structured Clinical Evaluation procedure was conducted to demonstrate their knowledge about the techniques. A standardized 9-item practical performance test was used as the primary outcome measure for the analyses.

RESULTS

Seventy-seven students participated in the study. The average Objective Structured Clinical Evaluation score for the experimental group (n = 40) was 41.3/50 (±3.9) and the control group (n = 37) was 39.1/50 (±4.5, P = 0.02).

CONCLUSIONS

For learning 3 cervical spine assessment skills, this study shows that photogrammetry creates 3D images of real rotating objects that are more effective than 2D images for first-year physiotherapy students.

Reliability and accuracy of an expert physical therapist as a reference standard for a manual therapy joint mobilization trial

Objective: Previous studies on learning joint mobilization techniques have used expert practitioners as the reference standard as there is no current evidence on what ideal forces would be for effective mobilizations. However, none of these trials have documented the reliability or accuracy of the reference standard. Therefore, the purpose of this study was to report both the reliability and accuracy of an expert physical therapist (PT) acting as a reference standard for a manual therapy joint mobilization trial.Methods: A secondary analysis was performed using data from a published randomized, controlled, crossover study. The mobilization technique studied was the central posterior to anterior (PA) joint mobilization of the L3 vertebra. Reliability and accuracy data for the reference standard were collected over four time periods spanning 16 weeks.Results: Intrarater reliability of the expert PT for R1 and R2 joint forces was excellent (R1 Force ICC_3,3 0.95, 95%CI 0.76-0.99 and R2 Force ICC_3,3 0.90, 95%CI 0.49-0.99). Additionally, the expert PT was 92.3% accurate (mean % error±SD, 7.7 ± 5.5) when finding Grade III mean peak mobilization force and 85.1% accurate (mean % error±SD, 14.9 ± 8.3) when finding Grade IV mean peak mobilization force. Finally, correlations between actual applied forces and computed ideal forces were excellent (Pearson r 0.79-0.92, n = 24, P < 0.01 for all correlations).Discussion: The expert PT in this manual therapy joint mobilization trial showed excellent reliability and accuracy as the reference standard. The study supports the use of implementing quantitative feedback devices into the teaching of joint mobilization when a reliable and accurate reference standard has been identified.Level of Evidence: 2b.

High-velocity, low-amplitude spinal manipulation training of prescribed forces and thrust duration: A pilot study

OBJECTIVE

High-velocity, low-amplitude spinal manipulation (HVLA-SM) may generate different therapeutic effects depending on force and duration characteristics. Variability among clinicians suggests training to target specific thrust duration and force levels is necessary to standardize dosing. This pilot study assessed an HVLA-SM training program using prescribed force and thrust characteristics.

METHODS

Over 4 weeks, chiropractors and students at a chiropractic college delivered thoracic region HVLA-SM to a prone mannequin in six training sessions, each 30 minutes in duration. Force plates embedded in a treatment table were used to measure force over time. Training goals were 350 and 550 Newtons (N) for peak force and ≤150 ms for thrust duration. Verbal and visual feedback was provided after each training thrust. Assessments included 10 consecutive thrusts for each force target without feedback. Mixed-model regression was used to analyze assessments measured before, immediately following, and 1, 4, and 8 weeks after training.

RESULTS

Error from peak force target, expressed as adjusted mean constant error (standard deviation), went from 107 N (127) at baseline, to 0.2 N (41) immediately after training, and 32 N (53) 8 weeks after training for the 350 N target, and 63 N (148), -6 N (58), and 9 N (87) for the 550 N target. Student median values met thrust duration target, but doctors' were >150 ms immediately after training.

CONCLUSION

After participation in an HVLA-SM training program, participants more accurately delivered two prescribed peak forces, but accuracy decreased 1 week afterwards. Future HVLA-SM training research should include follow-up of 1 week or more to assess skill retention.

COVID 19 and manual therapy: international lessons and perspectives on current and future clinical practice and education

BACKGROUND

The COVID-19 pandemic has altered clinical practice and education in manual therapy globally. Social distancing has limited in-person care and changed health-care provision. Education in manual therapy has moved to online platforms with in-person instruction restricted. The global impact on the clinical practice of manual therapy and education has to date not been explored.

METHODS

a questionnaire survey methodology was used. A sample of convenience of global leaders in manual therapy practice and education received an electronic link to two surveys: one on clinical practice and one on education. Contributors could complete one or both surveys.

RESULTS

Twenty-five surveys were received on clinical practice and 23 on education in manual therapy, representing the six major continents. Global themes in clinical practice demonstrated a sudden and dramatic shift away from patient contact, with limited modifications to manual therapy in patient care currently adopted. Themes in education were of a major shift to online learning, development of new modes of student instruction including video-based assessment and virtual case-based instruction.

CONCLUSION

The international perspectives provided demonstrate a major change in manual therapy practice and education globally. Various approaches have been taken in practice and education without a uniform approach being demonstrated.

Simulation-based education improves student self-efficacy in physiotherapy assessment and management of paediatric patients

BACKGROUND

The Australian Physiotherapy Council mandates that physiotherapy clinical education be sufficient to produce graduates who are competent to practice across the lifespan. Due to a lack of opportunities for paediatric clinical placements, there is a risk of graduates not having the opportunity to develop competency in paediatric physiotherapy. To address this risk, simulation-based education (SBE) has been proposed as an educational strategy to address the placement shortfall. Despite encouraging evidence for its use in physiotherapy education, there is limited evidence supporting its use specifically in paediatric populations. The aims of this research were to investigate the effect of SBE on student self-efficacy in the physiotherapy assessment and management of paediatric clients, and to determine student satisfaction with SBE as a learning strategy.

METHODS

Three interactive SBE sessions were run during the undergraduate paediatric physiotherapy unit at the campus of one Australian university. Self-efficacy was surveyed before and after each session, to determine confidence in clinical skills, clinical decision-making, treatment preparation and planning, communication skills; evaluating and modifying interventions, and interprofessional practice. Student satisfaction with SBE as a learning strategy was surveyed after the final SBE session.

RESULTS

For the 164 participants included in this study, self-efficacy survey response rate varied from 77 to 96% for each session. Significant increases in mean student self-efficacy were recorded for all questions (p <  0.001). A total of 139 (85%) responded to the learning reactionnaire with 78.6% indicating they were very satisfied with SBE as a learning strategy. Written comments from 41 participants identified 'experience' as the primary theme.

CONCLUSION

SBE had a significant positive effect on student self-efficacy in the physiotherapy assessment and management of paediatric patients. Students also perceived SBE to be a valuable learning experience. Future research is needed to investigate whether the improvement in self-efficacy achieved through SBE translates into improved student performance during workplace-based clinical placements.

The effect of real-time feedback on learning lumbar spine joint mobilization by entry-level doctor of physical therapy students: a randomized, controlled, crossover trial

OBJECTIVE

To examine the effects of real-time, objective feedback on learning lumbar spine joint mobilization techniques by entry-level Doctor of Physical Therapy (DPT) students.

METHODS

A randomized, controlled, crossover design was used. Twenty-four 1st Year DPT students were randomized into two groups. Group 1 (n = 12) practiced with the real-time feedback device first and then without it, while Group 2 (n = 12) practiced without the device first and then with it. Both practice periods with and without the device were 4 weeks long. Data were collected at Baseline, 5 weeks, 11 weeks, and 16 weeks. The crossover period was 5 weeks long, during which neither group practiced with or without the device. Eight force parameters were measured: R1 force; R2 force; Grade III and Grade IV mean peak force, frequency, and amplitude.

RESULTS

When students practiced with the real-time feedback device, they more closely matched the reference standard for two outcomes: 1) the mean difference in R2 force between student and reference standard was better with device (38.0 ± 26.7 N) than without it (51.0 ± 38.5 N); P = .013; and 2) the mean difference in Grade III peak to peak amplitude force was also better with device (8.9 ± 9.3 N) than without it (11.8 ± 11.0); P = .026. All other force parameters improved when students practiced with the real-time feedback device, however, the differences between when they practiced without the device were not statistically significant.

DISCUSSION

Real-time, objective feedback using a direct force measurement device improved learning for some aspects of lumbar spine joint mobilization by entry-level physical therapy students.

LEVEL OF EVIDENCE

2b.

The development and evaluation of a novel repurposing of a peripheral gaming device for the acquisition of forces applied to a hydraulic treatment plinth

This technical note details the stages taken to create an instrumented hydraulic treatment plinth for the measurement of applied forces in the vertical axis. The modification used a widely available low-cost peripheral gaming device and required only basic construction and computer skills. The instrumented treatment plinth was validated against a laboratory grade force platform across a range of applied masses from 0.5-15 kg, mock Gr I-IV vertebral mobilisations and a dynamic response test. Intraclass correlation coefficients demonstrated poor reliability (0.46) for low masses of 0.5 kg improving to excellent for larger masses up to15 kg respectively; excellent to good reliability (0.97-0.86) for the mock mobilisations and moderate reliability (0.51) for the dynamic response test. The study demonstrates how a cheap peripheral gaming device can be repurposed so that forces applied to a hydraulic treatment plinth can be collected reliably when applied in a clinically reasoned manner.

Effective teaching of manual skills to physiotherapy students: a randomised clinical trial

CONTEXT

To date, despite the relevance of manual skills laboratories in physiotherapy education, evidence on the effectiveness of different teaching methods is limited.

OBJECTIVES

Peyton's four-step and the 'See one, do one' approaches were compared for their effectiveness in teaching manual skills.

METHODS

A cluster randomised controlled trial was performed among final-year, right-handed physiotherapy students, without prior experience in manual therapy or skills laboratories. The manual technique of C1-C2 passive right rotation was taught by different experienced physiotherapist using Peyton's four-step approach (intervention group) and the 'See one, do one' approach (control group). Participants, teachers and assessors were blinded to the aims of the study. Primary outcomes were quality of performance at the end of the skills laboratories, and after 1 week and 1 month. Secondary outcomes were time required to teach, time required to perform the procedure and student satisfaction.

RESULTS

A total of 39 students were included in the study (21 in the intervention group and 18 in the control group). Their main characteristics were homogeneous at baseline. The intervention group showed better quality of performance in the short, medium and long terms (F_1,111  = 35.91, p < 0.001). Both groups demonstrated decreased quality of performance over time (F_2,111  = 12.91, p < 0.001). The intervention group reported significantly greater mean ± standard deviation satisfaction (4.31 ± 1.23) than the control group (4.03 ± 1.31) (p < 0.001). Although there was no significant difference between the two methods in the time required for teaching, the time required by the intervention group to perform the procedure was significantly lower immediately after the skills laboratories and over time (p < 0.001).

CONCLUSIONS

Peyton's four-step approach is more effective than the 'See one, do one' approach in skills laboratories aimed at developing physiotherapy student competence in C1-C2 passive mobilisation.

Kinematic real-time feedback is more effective than traditional teaching method in learning ankle joint mobilisation: a randomised controlled trial

BACKGROUND

To analyse the effect of real-time kinematic feedback (KRTF) when learning two ankle joint mobilisation techniques comparing the results with the traditional teaching method.

METHODS

Double-blind randomized trial.

SETTINGS

Faculty of Health Sciences.

PARTICIPANTS

undergraduate students with no experience in manual therapy. Each student practised intensely for 90 min (45 min for each mobilisation) according to the random methodology assigned (G1: traditional method group and G2: KRTF group). G1: an expert professor supervising the student's practice, the professorstudent ratio was 1:8. G2: placed in front of a station where, while they performed the manoeuvre, they received a KRTF on a laptop.

OUTCOME MEASURES

total time of mobilisation, time to reach maximum amplitude, maximum angular displacement in the three axes, maximum and average velocity to reach the maximum angular displacement, average velocity during the mobilisation.

RESULTS

Among the pre-post intervention measurements, there were significant differences within the two groups for all outcome variables, however, G2 (KRTF) achieved significantly greater improvements in kinematic parameters for the two mobilisations (significant increase in displacement, velocity and significant reduction in the mobilisations runtime) than G1. Ankle plantar flexion: G1's measurement stability (post-intervention) ranged between 0.491 and 0.687, while G2's measurement stability ranged between 0.899 and 0.984. Ankle dorsal flexion mobilisation: G1 the measurement stability (post-intervention) ranged from 0.543 and 0.684 while G2 ranged between 0.899 and 0.974.

CONCLUSION

KRTF was proven to be more effective tool than traditional teaching method in the teaching - learning process of two joint mobilisation techniques.

TRIAL REGISTRATION

NCT02504710.

Use of Simulation Learning Experiences in Physical Therapy Entry-to-Practice Curricula: A Systematic Review

PURPOSE

To review the literature on simulation-based learning experiences and to examine their potential to have a positive impact on physiotherapy (PT) learners' knowledge, skills, and attitudes in entry-to-practice curricula.

METHOD

A systematic literature search was conducted in the MEDLINE, CINAHL, Embase Classic+Embase, Scopus, and Web of Science databases, using keywords such as physical therapy, simulation, education, and students.

RESULTS

A total of 820 abstracts were screened, and 23 articles were included in the systematic review. While there were few randomized controlled trials with validated outcome measures, some discoveries about simulation can positively affect the design of the PT entry-to-practice curricula. Using simulators to provide specific output feedback can help students learn specific skills. Computer simulations can also augment students' learning experience. Human simulation experiences in managing the acute patient in the ICU are well received by students, positively influence their confidence, and decrease their anxiety. There is evidence that simulated learning environments can replace a portion of a full-time 4-week clinical rotation without impairing learning.

CONCLUSIONS

Simulation-based learning activities are being effectively incorporated into PT curricula. More rigorously designed experimental studies that include a cost-benefit analysis are necessary to help curriculum developers make informed choices in curriculum design.

Training and certification of doctors of chiropractic in delivering manual cervical traction forces: Results of a longitudinal observational study

Objective : Doctors of chiropractic (DCs) use manual cervical distraction to treat patients with neck pain. Previous research demonstrates variability in traction forces generated by different DCs. This article reports on a training protocol and monthly certification process using bioengineering technology to standardize cervical traction force delivery among clinicians. Methods : This longitudinal observational study evaluated a training and certification process for DCs who provided force-based manual cervical distraction during a randomized clinical trial. The DCs completed a 7-week initial training that included instructional lectures, observation, and guided practice by a clinical expert, followed by 3 hours of weekly practice sessions delivering the technique to asymptomatic volunteers who served as simulated patients. An instrument-modified table and computer software provided the DCs with real-time audible and visual feedback on the traction forces they generated and graphical displays of the magnitude of traction forces as a function of time immediately after the delivery of the treatment. The DCs completed monthly certifications on traction force delivery throughout the trial. Descriptive accounts of certification attempts are provided. Results : Two DCs achieved certification in traction force delivery over 10 consecutive months. No certification required more than 3 attempts at C5 and occiput contacts for 3 force ranges (0-20 N, 21-50 N, and 51-100 N). Conclusions : This study demonstrates the feasibility of a training protocol and certification process using bioengineering technology for training DCs to deliver manual cervical distraction within specified traction force ranges over a 10-month period.

Inertial sensor real-time feedback enhances the learning of cervical spine manipulation: a prospective study

BACKGROUND

Cervical Spinal Manipulation (CSM) is considered a high-level skill of the central nervous system because it requires bimanual coordinated rhythmical movements therefore necessitating training to achieve proficiency. The objective of the present study was to investigate the effect of real-time feedback on the performance of CSM.

METHODS

Six postgraduate physiotherapy students attending a training workshop on Cervical Spine Manipulation Technique (CSMT) using inertial sensor derived real-time feedback participated in this study. The key variables were pre-manipulative position, angular displacement of the thrust and angular velocity of the thrust. Differences between variables before and after training were investigated using t-tests.

RESULTS

There were no significant differences after training for the pre-manipulative position (rotation p = 0.549; side bending p = 0.312) or for thrust displacement (rotation p = 0.247; side bending p = 0.314). Thrust angular velocity demonstrated a significant difference following training for rotation (pre-training mean (sd) 48.9°/s (35.1); post-training mean (sd) 96.9°/s (53.9); p = 0.027) but not for side bending (p = 0.521).

CONCLUSION

Real-time feedback using an inertial sensor may be valuable in the development of specific manipulative skill. Future studies investigating manipulation could consider a randomized controlled trial using inertial sensor real time feedback compared to traditional training.