The virtual haptic back: a simulation for training in palpatory diagnosis

Pelvic Palpatory Tests in Manual Therapy and Osteopathy: A Critical Review of the Literature and Suggestions for New Research

Manual therapists apply physical interventions to the entire structure of the body to promote healing, prevent pathologies, and improve patient health. In osteopathic practice, palpatory evaluation is considered a fundamental clinical practice requirement for identifying somatic dysfunction. Most of the articles published in this area have failed to demonstrate a level of reproducibility that supports palpation in evidence-based clinical practice. When considering the poor reliability of the palpatory tests highlighted in the literature, a discrepancy is noted with what is known about the tactile sensitivity of human hands. For static touch, the minimum size that can be detected, in the absence of applied movement or vibration, is approximately 0.2 mm. Yet, it seems that this high level of precision is insufficient to ensure reliability in the tests used to evaluate osteopathic somatic dysfunction. The purpose that underscores this article is to determine how these two contradictory elements, high sensitivity and low reliability, can be present in palpatory tests. The article reports the literature findings regarding palpatory tests of pelvic, which is an important structure for clinical purposes. Additionally, a critical review of how these studies were conducted is provided to identify any elements that may justify the obtained results. Following recent accredited guidelines present in the literature, we propose suggestions on vision training methods, manual perception refinement training, the search for anatomical markers, and the position of the examiner in relation to the examinee that may be useful for future studies on the topic covered by the article.

Perception and knowledge of learners about the use of 3D technologies in manual therapy education - a qualitative study

OBJECTIVES

Manual therapy is a specific hands-on approach used and taught by various professions such as physiotherapy and osteopathy. The current paradigm of teaching manual therapy incorporates the traditional 'See one, do one, teach one' approach. However, this 'teacher centred' approach may not enable learners to develop the complex clinical skills of manual therapy. In this context, 3D technologies such as virtual reality may facilitate the teaching and learning of manual therapy. Hence the aim of the current study was to investigate the perception, knowledge and attitude of manual therapy learners about the use of 3D technologies in manual therapy education.

METHODS

An exploratory qualitative research design using semi-structured interviews was used in this study. A total of ten manual therapy (5 physiotherapy and 5 osteopathic) students (mean age = 32; 80% female) enrolled in an appropriate physiotherapy or osteopathic degree provided by a New Zealand recognized institution (e.g., university or polytechnic) participated in this study. Data saturation was achieved after 10 interviews (average duration: 35 min) that provided thick data. A thematic analysis was used for data analysis.

RESULTS

Six factors were identified which appeared to influence participants' perception of role of technology in manual therapy education. These were (1) the sufficiency of current teaching method; (2) evolution as a learner (a novice to an expert); (3) need for objectivity; (4) tutor feedback; (5) knowledge and (6) barriers and enablers. These six factors influenced the participants' perception about the role of 3D technologies in manual therapy education with participants evidently taking two distinct/polarized positions ('no role' (techstatic) versus a 'complete role' (techsavvy)).

CONCLUSION

Although 3D technology may not replace face-to-face teaching, it may be used to complement the traditional approach of learning/teaching to facilitate the learning of complex skills according to the perceptions of manual therapy learners in our study. The advantage of such an approach is an area of future research.

Evaluation of a 3D Computer Model of the Equine Paranasal Sinuses as a Tool for Veterinary Anatomy Education

Detailed knowledge of anatomical systems is vital for clinical veterinary practice. However, students often find it difficult to transfer skills learned from textbooks to real-life practice. In this study, a three-dimensional computer model representing equine paranasal sinus anatomy (3D-ESM) was created and evaluated for its contribution to student understanding of the 3D dynamic nature of the system. Veterinary students and equine professionals at the University of Bristol were randomly allocated into experimental (3D model) and control (2D lecture) groups. A pre-/post-study design was used to evaluate the efficacy of the 3D model through a pre-/post-multiple-choice question (MCQ) anatomical knowledge exam and a pre-/post-questionnaire gathering information on participant demographics, confidence, and satisfaction. No statistically significant difference was found between 3D and 2D groups' post-MCQ exam scores (t39 = 1.289, p = .205). 3D group participant feedback was more positive than 2D group feedback, and 3D group satisfaction scores on Likert questions were significantly higher (t118 = -5.196, p < .001). Additionally, confidence scores were significantly higher in the 3D group than in the 2D group immediately following the study (p < .05). Participants' open-text responses indicated they found the 3D model helpful in learning the complex anatomy of the equine paranasal sinuses. Findings suggest the 3D-ESM is an effective educational tool that aids in confidence, enjoyment, and knowledge acquisition. Though it was not better than traditional methods in terms of anatomy knowledge exam scores, the model is a valuable inclusion into the veterinary anatomy curriculum.

The perceived value and impact of virtual simulation-based education on students' learning: a mixed methods study

BACKGROUND

Virtual simulations are used throughout healthcare training programs to enable development of clinical skills, however the potential for virtual simulation to enhance cognitive and affective skills is less well understood. This study explored pre-clinical optometry students' perceptions of the impact of virtual simulation on the development of core competency skills including patient-centred care, communication, scientific literacy, and evidence-based practice.

METHODS

A mixed methods study was conducted using pre-existing anonymized data from an electronic survey distributed to pre-clinical optometry students enrolled in the double degree Bachelor of Vision Science/Master of Optometry at Deakin University, Australia. The data were interpreted using descriptive statistics and qualitative analysis using constant comparison for thematic analysis.

RESULTS

A total of 51 responses were analyzed. Students reported that virtual simulation motivated them to become an optometrist (93%) and to learn beyond the course material (77%). Students reported that after participating in the virtual simulation, their core competency skills improved: patient-centered care (100%) evidence-based practice (93%) and clinical reasoning (93%). The themes identified through qualitative analysis were: enablers to cognitive experience in virtual simulation in optometry education, realism of the virtual simulation design, dimensions of fidelity in virtual simulations design replicated the complexity of the optometric environment, virtual simulation as an enabler for learning and assessment in optometry education, a place to develop cognitive and affective skills and application of learning in the virtual simulation developed an appreciation of future roles and professional identity.

CONCLUSION

Optometry students perceived virtual simulation in optometric education as a valuable training and assessment strategy enabled by qualities that generate contextual, cognitive, functional, task and psychological fidelity. The data provide insight to inform how optometry educators can incorporate simulation into the curriculum.

Learning Curves in Health Professions Education Simulation Research: A Systematic Review

SUMMARY STATEMENT

Learning curves are used in health professions education to graphically represent paths to competence and expertise. However, research using learning curves often omit important information. The authors conducted a systematic review of the reporting quality of learning curves in simulation-based education research to identify specific areas for improvement. Reviewers extracted information on graphical, statistical, and conceptual elements. The authors identified 230 eligible articles. Most learning curve elements were reported infrequently, including use of an optimal linking function, detailed description of feedback or learning intervention, use of advanced visualization techniques such as overlaying and stacking, and depiction of competency thresholds. Reporting did not improve over time for most elements. Reporting of learning curves in health professions education research is incomplete and often underutilizes their desirable properties. Recommendations for improvement of the statistical, graphical, and conceptual reporting of learning curves, as well as applications to simulation research and education, are presented.

The Stiffness Comparison Test: A pilot study to determine inter-individual differences in palpatory skill related to gender, age, and occupation-related experience

BACKGROUND

Manual palpation is a core skill in physical examination. Assessing elastic properties such as tissue stiffness has the potential for being an important diagnostics tool in the detection of cancer and other diseases.

OBJECTIVE

The study describes the newly developed Stiffness Comparison Test (SCT). The aim of our study was to test the SCT as a tool to detect interindividual differences in palpation skill related to gender, age and occupational experience.

METHODS

We used eight pairs of polyuterhane gel pads with the stiffness difference decreasing from the first to the last pair. Test subjects were asked to palpate each pair and determine stiffness differences.

PARTICIPANTS

We recruited 25 osteopaths, 48 other manual therapists and 50 participants from other non-manual professions.

RESULTS

As hypothesized there was no significant difference in SCT performance between the sexes (t(121) = 0.288, p = .774). To investigate if an age-related decline would have an effect on palpation skill, we carried out a linear regression. As hypothesized, the model did not predict any significant associations (F(1, 121) = 2.733, b = -0.149, p = .101, R² = 0.022). To compare the effect of occupational groups on SCT performance a one-way ANOVA was conducted. There were no statistically significant differences between group means (F(2, 120) = 0.598, p = .552).

CONCLUSIONS

The SCT can be used as simple and affordable tool for assessment, teaching and training in all disciplines of manual medicine. Further refinements of the tool are suggested to advance its discrimination power.

Simulation can offer a sustainable contribution to clinical education in osteopathy

Background

Clinical education forms a substantial component of health professional education. Increased cohorts in Australian osteopathic education have led to consideration of alternatives to traditional placements to ensure adequate clinical exposure and learning opportunities. Simulated learning offers a new avenue for sustainable clinical education. The aim of the study was to explore whether directed observation of simulated scenarios, as part replacement of clinical hours, could provide an equivalent learning experience as measured by performance in an objective structured clinical examination (OSCE).

Methods

The year 3 osteopathy cohort were invited to participate in replacement of 50% of their clinical placement hours with online facilitated, video-based simulation exercises (intervention). Competency was assessed by an OSCE at the end of the teaching period. Inferential statistics were used to explore any differences between the control and intervention groups as a post-test control design.

Results

The funding model allowed ten learners to participate in the intervention, with sixty-six in the control group. Only one OSCE item was significantly different between groups, that being technique selection (p = 0.038, d = 0.72) in favour of the intervention group, although this may be a type 1 error. Grade point average was moderately positively correlated with the manual therapy technique station total score (r = 0.35, p < 0.01) and a trivial relationship with the treatment reasoning station total score (r = 0.17, p = 0.132).

Conclusions

The current study provides support for further investigation into part replacement of clinical placements with directed observation of simulated scenarios in osteopathy.

"Princess and the pea" - an assessment tool for palpation skills in postgraduate education

BACKGROUND

In osteopathic medicine, palpation is considered to be the key skill to be acquired during training. Whether palpation skills are adequately acquired during undergraduate or postgraduate training is difficult to assess. The aim of our study was to test a palpation assessment tool developed for undergraduate medical education in a postgraduate medical education (PME) setting.

METHODS

We modified and standardized an assessment tool, where a coin has to be palpated under different layers of copy paper. For every layer depth we randomized the hiding positions with a random generator. The task was to palpate the coin or to determine that no coin was hidden in the stack. We recruited three groups of participants: 22 physicians with no training in osteopathic medicine, 25 participants in a PME course of osteopathic techniques before and after a palpation training program, 31 physicians from an osteopathic expert group with at least 700 h of osteopathic skills training. These experts ran the test twice to check for test-retest-reliability. Inferential statistical analyzes were performed using generalized linear mixed models with the dichotomous variable "coin detected / not detected" as the dependent variable.

RESULTS

We measured a test-retest reliability of the assessment tool as a whole with 56 stations in the expert group of 0.67 (p <  0.001). For different paper layers, we found good retest reliabilities up to 300 sheets. The control group detected a coin significantly better in a depth of 150 sheets (p = 0.01) than the pre-training group. The osteopathic training group showed significantly more correct coin localizations after the training in layer depths of 200 (p = 0.03) and 300 sheets (p = 0.05). This group also had significantly better palpation results than the expert group in the depth of 300 sheets (p = 0.001). When there was no coin hidden, the expert group showed significantly better results than the post-training group (p = 0.01).

CONCLUSIONS

Our tool can be used with reliable results to test palpation course achievements with 200 and 300 sheets of paper. Further refinements of this tool will be needed to use it in complex assessment designs for the evaluation of more sophisticated palpatory skills in postgraduate medical settings.

Real-time Visualisation and Analysis of Clinicians' Performance during Palpation in Physical Examinations

OBJECTIVE

Motivated by the fact that palpation skills are challenging to learn and teach, particularly during Digital Rectal Examinations (DRE), and the lack of understanding of what constitutes adequate performance, we present a visualisation and analysis system that uses small position and pressure sensors located on the examining finger, allowing the quantitative analysis of duration, steps and pressure applied.

METHODS

The system is first described, followed by an experimental study of twenty experts from four clinical specialties performing ten DREs each on a benchtop model using the proposed system. Analysis of the constitutive steps was conducted to improve understanding of the examination. A Markov model representing executed tasks and analysis of pressure applied is also introduced.

RESULTS

The proposed system successfully allowed the visualisation and analysis during the experimental study. General Practitioners and Nurses were found to execute more tasks compared to Urologists and Colorectal Surgeons. Urologists executed the least number of tasks and were the most consistent group compared to others.

CONCLUSION

The ability to "see through" allowed us to better characterise the performance of experts when conducting a DRE on a benchtop model, comparing the performance of relevant specialties, and studying executed tasks and the pressure applied. The Markov model presented summarises task execution of experts and could be used to compare performance of novices against that of experts.

SIGNIFICANCE

This approach allows for the analysis of performance based on continuous sensor data recording that can be easily extended to real subjects and other types of physical examinations.

Teaching and Assessment of High-Velocity, Low-Amplitude Techniques for the Spine in Predoctoral Medical Education

Although national didactic criteria have been set for predoctoral education and assessment in osteopathic manipulative treatment, there is no criterion standard for teaching methods and assessments of osteopathic manipulative treatment competence in colleges of osteopathic medicine. This issue is more pressing with the creation of the single graduate medical education accreditation system by the American Osteopathic Association and Accreditation Council for Graduate Medical Education, which introduced the creation of "osteopathic recognition" for residencies that want to incorporate osteopathic principles and practice into their programs. Residencies with osteopathic recognition may include both osteopathic and allopathic graduates. Increased standardization at the predoctoral level, however, is recommended as osteopathic principles and practice training applications are expanded. The objectives of this article are to review the standards for teaching osteopathic medical students high-velocity, low-amplitude (HVLA) techniques for the spine; to review and discuss the methods used to assess medical students' proficiency in using HVLA; and to propose baseline standards for teaching and assessing HVLA techniques among medical students.

Fingertip-Based Feature Analysis for the Push and Stroke Manipulation of Elastic Objects

In this study, to quantitatively understand finger operations used to manipulate elastic objects, we explore robust fingertip-based feature descriptors that are invariant to operator, finger position, and target object. To measure the tactile information generated when an object is directly touched by a fingertip, we used a wearable system that enables the simultaneous measurement of fingertip position and strain without inhibiting the operator's sense of touch. This paper focuses on the quantitative classification of the push and stroke operations of a single finger, and conducted user experiments to obtain time-series fingertip position and strain from 10 subjects touching nine types of elastic objects. The recognition rate was investigated by binary classification using a support vector machine and cross validation. The results show that the two-dimensional features obtained from fingertip position and strain within a 0.9-s time frame can stably recognize push and stroke operations on elastic bodies of different shapes, stiffnesses, and thicknesses at a higher recognition rate.

Evaluation of Pseudo-Haptic Interactions with Soft Objects in Virtual Environments

This paper proposes a pseudo-haptic feedback method conveying simulated soft surface stiffness information through a visual interface. The method exploits a combination of two feedback techniques, namely visual feedback of soft surface deformation and control of the indenter avatar speed, to convey stiffness information of a simulated surface of a soft object in virtual environments. The proposed method was effective in distinguishing different sizes of virtual hard nodules integrated into the simulated soft bodies. To further improve the interactive experience, the approach was extended creating a multi-point pseudo-haptic feedback system. A comparison with regards to (a) nodule detection sensitivity and (b) elapsed time as performance indicators in hard nodule detection experiments to a tablet computer incorporating vibration feedback was conducted. The multi-point pseudo-haptic interaction is shown to be more time-efficient than the single-point pseudo-haptic interaction. It is noted that multi-point pseudo-haptic feedback performs similarly well when compared to a vibration-based feedback method based on both performance measures elapsed time and nodule detection sensitivity. This proves that the proposed method can be used to convey detailed haptic information for virtual environmental tasks, even subtle ones, using either a computer mouse or a pressure sensitive device as an input device. This pseudo-haptic feedback method provides an opportunity for low-cost simulation of objects with soft surfaces and hard inclusions, as, for example, occurring in ever more realistic video games with increasing emphasis on interaction with the physical environment and minimally invasive surgery in the form of soft tissue organs with embedded cancer nodules. Hence, the method can be used in many low-budget applications where haptic sensation is required, such as surgeon training or video games, either using desktop computers or portable devices, showing reasonably high fidelity in conveying stiffness perception to the user.

Pain Assessment--Can it be Done with a Computerised System? A Systematic Review and Meta-Analysis

Background: Mobile and web technologies are becoming increasingly used to support the treatment of chronic pain conditions. However, the subjectivity of pain perception makes its management and evaluation very difficult. Pain treatment requires a multi-dimensional approach (e.g., sensory, affective, cognitive) whence the evidence of technology effects across dimensions is lacking. This study aims to describe computerised monitoring systems and to suggest a methodology, based on statistical analysis, to evaluate their effects on pain assessment. Methods: We conducted a review of the English-language literature about computerised systems related to chronic pain complaints that included data collected via mobile devices or Internet, published since 2000 in three relevant bibliographical databases such as BioMed Central, PubMed Central and ScienceDirect. The extracted data include: objective and duration of the study, age and condition of the participants, and type of collected information (e.g., questionnaires, scales). Results: Sixty-two studies were included, encompassing 13,338 participants. A total of 50 (81%) studies related to mobile systems, and 12 (19%) related to web-based systems. Technology and pen-and-paper approaches presented equivalent outcomes related with pain intensity. Conclusions: The adoption of technology was revealed as accurate and feasible as pen-and-paper methods. The proposed assessment model based on data fusion combined with a qualitative assessment method was revealed to be suitable. Data integration raises several concerns and challenges to the design, development and application of monitoring systems applied to pain.

The Robotic Lumbar Spine: Dynamics and Feedback Linearization Control

The robotic lumbar spine (RLS) is a 15 degree-of-freedom, fully cable-actuated robotic lumbar spine which can mimicin vivohuman lumbar spine movements to provide better hands-on training for medical students. The design incorporates five active lumbar vertebrae and the sacrum, with dimensions of an average adult human spine. It is actuated by 20 cables connected to electric motors. Every vertebra is connected to the neighboring vertebrae by spherical joints. Medical schools can benefit from a tool, system, or method that will help instructors train students and assess their tactile proficiency throughout their education. The robotic lumbar spine has the potential to satisfy these needs in palpatory diagnosis. Medical students will be given the opportunity to examine their own patient that can be programmed with many dysfunctions related to the lumbar spine before they start their professional lives as doctors. The robotic lumbar spine can be used to teach and test medical students in their capacity to be able to recognize normal and abnormal movement patterns of the human lumbar spine under flexion-extension, lateral bending, and axial torsion. This paper presents the dynamics and nonlinear control of the RLS. A new approach to solve for positive and nonzero cable tensions that are also continuous in time is introduced.

Evaluation of a training model to teach veterinary students a technique for injecting the jugular vein in horses

In this study, a newly-developed model for training veterinary students to inject the jugular vein in horses was evaluated as an additional tool to supplement the current method of teaching. The model was first validated by 19 experienced equine veterinarians, who judged the model to be a realistic and valuable tool for learning the technique. Subsequently, it was assessed using 24 students who were divided randomly into two groups. The injection technique was taught conventionally in a classroom lecture and a live demonstration to both groups, but only group 1 received additional training on the new model. All participants filled out self-assessment questionnaires before and after group 1 received training on the model. Finally, the proficiency of both groups was assessed using an objective structured clinical evaluation (OSCE) on live horses. Students from group 1 showed significantly improved confidence after their additional training on the model and also showed greater confidence when compared to group 2 students. In the OSCE, group 1 had a significantly better score compared to group 2: the median (with inter-quartile range) was 15 (0.7) vs. 11.5 (2.8) points out of 15, respectively. The training model proved to be a useful tool to teach veterinary students how to perform jugular vein injections in horses in a controlled environment, without time limitations or animal welfare concerns. The newly developed training model offers an inexpensive, efficient, animal-sparing way to teach this clinical skill to veterinary students.

Evaluating an automated haptic simulator designed for veterinary students to learn bovine rectal palpation

INTRODUCTION

Simulators provide a potential solution to some of the challenges faced when teaching internal examinations to medical or veterinary students. A virtual reality simulator, the Haptic Cow, has been developed to teach bovine rectal palpation to veterinary students, and significant training benefits have been demonstrated. However, the training needs to be delivered by an instructor, a requirement that limits availability. This article describes the development and evaluation of an automated version that students could use on their own.

METHODS

An automated version was developed based on a recording of an expert's examination. The performance of two groups of eight students was compared. All students had undergone the traditional training in the course, namely lectures and laboratory practicals, and then group S used the simulator whereas group R had no additional training. The students were set the task of finding the uterus when examining cows. The simulator was then made available to students, and feedback about the "usability" was gathered with a questionnaire.

RESULTS

The group whose training had been supplemented with a simulator session were significantly better at finding the uterus. The questionnaire feedback was positive and indicated that students found the simulator easy to use.

CONCLUSIONS

The automated simulator equipped students with useful skills for examining cows. In addition, a simulator that does not need the presence of an instructor will increase the availability of training for students and be a more sustainable option for institutions.

The anatomy of anatomy: a review for its modernization

Anatomy has historically been a cornerstone in medical education regardless of nation or specialty. Until recently, dissection and didactic lectures were its sole pedagogy. Teaching methodology has been revolutionized with more reliance on models, imaging, simulation, and the Internet to further consolidate and enhance the learning experience. Moreover, modern medical curricula are giving less importance to anatomy education and to the acknowledged value of dissection. Universities have even abandoned dissection completely in favor of user-friendly multimedia, alternative teaching approaches, and newly defined priorities in clinical practice. Anatomy curriculum is undergoing international reformation but the current framework lacks uniformity among institutions. Optimal learning content can be categorized into the following modalities: (1) dissection/prosection, (2) interactive multimedia, (3) procedural anatomy, (4) surface and clinical anatomy, and (5) imaging. The importance of multimodal teaching, with examples suggested in this article, has been widely recognized and assessed. Nevertheless, there are still ongoing limitations in anatomy teaching. Substantial problems consist of diminished allotted dissection time and the number of qualified anatomy instructors, which will eventually deteriorate the quality of education. Alternative resources and strategies are discussed in an attempt to tackle these genuine concerns. The challenges are to reinstate more effective teaching and learning tools while maintaining the beneficial values of orthodox dissection. The UK has a reputable medical education but its quality could be improved by observing international frameworks. The heavy penalty of not concentrating on sufficient anatomy education will inevitably lead to incompetent anatomists and healthcare professionals, leaving patients to face dire repercussions.