Text messaging to improve resident knowledge: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Advances in technology present opportunities to develop and test innovative teaching methods. We sought to evaluate whether text messaging could improve medical resident knowledge in musculoskeletal medicine. METHODS: Eleven U.S. family medicine residency programs with a total of 269 residents participated in this randomized, controlled trial. Residents were invited to complete a pretest to assess musculoskeletal medicine knowledge. The residents randomized to the intervention group were then offered to receive text messages termed electronically Generated Educational Messages (eGEMs) three times per week during a 12-week period. The primary outcome was change in pretest and posttest scores among residents in an intervention group (those who received text messages) as compared to a control group (those who did not receive the text messages). Focus groups were conducted to assess resident acceptability and usefulness of text messaging as a teaching tool. RESULTS: Sixty-three residents completed the pretests and posttests. The intervention group's score improved from 55% of questions answered correctly to 64%; the control group improved from 56% to 61%. While these pretest/posttest changes each were statistically significant, the difference in improvement between the two groups was not. Focus groups revealed that participants liked the intervention, but suggestions for improvement included ability to tailor the eGEMs. CONCLUSIONS: The use of eGEMs as initially developed did not increase resident knowledge based on exam scores. Further study is needed to determine if a more tailored intervention is effective.

Ischaemic diverticular disease may mimic acute appendicitis.

An 81-year-old man with a medical history significant for diverticulosis and irritable bowel syndrome presented to the emergency department with a 1-day history of periumbilical pain that woke him from sleep and ultimately localised to his right lower quadrant. He reported nausea, anorexia and chills but denied vomiting, diarrhoea, melena, hematochezia or fever. His physical exam was notable for focal tenderness at McBurney's point. Diagnostic information included a normal white blood cell count and an abdominal CT scan that demonstrated a normal appendix with no other pathology noted. The patient opted to proceed with laparoscopy where a normal appendix was found. The caecum, however, contained a large ischaemic diverticulum not noted on CT scan. Following laparoscopic ileocecectomy, pathology demonstrated haemorrhage, inflammation, oedema and full thickness necrosis of the caecal wall. Recovery was uneventful; the patient was discharged from the hospital 3 days following surgery.

Surgical treatment of swan-neck deformity in hemiplegic cerebral palsy.

PURPOSE: Previously described surgical treatments for dynamic swan-neck deformity in cerebral palsy are technically difficult and time consuming. Typically only a few fingers could be addressed at one sitting, and postoperative swelling and stiffness were often incurred. An easy procedure of central slip tenotomy is described that allows for multiple fingers to be addressed, with minimal postoperative morbidity. METHODS: Fifteen patients (33 fingers) with hemiplegic cerebral palsy and dynamic swan-neck deformities of their fingers were treated. Only swan-neck deformities of greater than 20 degrees were considered for treatment. Pre- and postoperative measurements of swan-neck deformity were recorded. A central slip tenotomy was performed through a transverse incision proximal to the proximal interphalangeal joint. The joint was pinned in 10 degrees of flexion for 4 weeks, and then active extension was allowed to 10 degrees short of full extension and blocked with an oval-8 splint. Average patient age was 16 years (range 5-44 years). All patients had concurrent procedures performed on the extremity. Average follow-up evaluation was 23 months (+/-12 months). RESULTS: Improvement in dynamic swan-neck deformity averaged 32 degrees . Preoperative swan-neck deformity averaged 38 degrees and postoperative swan-neck deformity averaged 6 degrees . No swan-neck deformity was worse than its preoperative state, and no patient developed boutonniere deformity. No patient lost active or passive flexion after the procedure. All patients would repeat the procedure. CONCLUSION: Central slip tenotomy is a reliable treatment for dynamic swan-neck deformity in cerebral palsy in patients without dynamic metacarpophalangeal flexion deformity. Because of the simplicity of the procedure, it can easily be added to the treatment of the entire upper extremity in cerebral palsy.

Psychosocial factors related to physical activity and weight loss in overweight women.

PURPOSE: This study examined whether psychosocial factors related to physical activity in overweight, previously sedentary women were affected by a 6-month behavioral weight loss program. In addition, these psychosocial factors were examined across levels of weight loss and self-reported physical activity in response to a weight loss intervention. METHODS: Data from 165 overweight (body mass index (BMI) = 32.7 +/- 4.2 kg.m(-2)) women (age = 37.6 +/- 5.5 yr) who participated in a comprehensive behavioral weight loss program that included behavioral education, moderate caloric restriction, and progressive home-based exercise were examined. Body weight was assessed at 0 and 6 months. Perceived benefits and barriers, physical activity self-efficacy, and physical activity processes of change were assessed at 0 and 6 months. Physical activity (minutes per week of at least moderate-intensity activity) was assessed using the 7-Day Physical Activity Recall at 0 and 6 months. RESULTS: The intervention resulted in increases in physical activity self-efficacy, behavioral processes of change, and several cognitive processes of change(P < 0.05). There was a reduction in expected barriers for physical activity (P < 0.05). Individuals with > or = 10% weight loss reported higher levels of physical activity self-efficacy, greater use of behavioral strategies to elicit social support, and fewer barriers to physical activity than those with lower levels of physical activity and less weight loss (P < 0.05). Individuals reporting higher levels of exercise also reported higher levels of physical activity self-efficacy, greater use of behavioral strategies, and fewer barriers to physical activity than those individuals with lower levels of physical activity (P < 0.05). CONCLUSION: Targeting self-efficacy, behavioral strategies, and barriers in weight management programs may improve physical activity, which may result in improved weight loss in overweight adults.

Evaluation of the SenseWear Pro Armband to assess energy expenditure during exercise.

PURPOSE: To assess the accuracy of the SenseWear Pro Armband for estimating energy expenditure during exercise. METHODS: : Forty subjects (age = 23.2 +/- 3.8 yr; body mass index = 23.8 +/- 3.1 kg x m) performed four exercises (walking, cycling, stepping, arm ergometry) with each exercise lasting 20-30 min and workload increasing at 10-min intervals. Subjects wore the SenseWear Pro Armband on the right arm, and energy expenditure was estimated using proprietary equations developed by the manufacturer. Estimated energy expenditure from the SenseWear Pro Armband was compared with energy expenditure determined from indirect open-circuit calorimetry, which served as the criterion measure. RESULTS: : When a generalized proprietary algorithm was applied to the data, the SenseWear Pro Armband significantly underestimated total energy expenditure by 14.9 +/- 17.5 kcal (6.9 +/- 8.5%) during walking exercise, 32.4 +/- 18.8 kcal (28.9 +/- 13.5%) during cycle ergometry, 28.2 +/- 20.3 kcal (17.7 +/- 11.8%) during stepping exercise, and overestimated total energy expenditure by 21.7 +/- 8.7 kcal (29.3 +/- 13.8%) during arm ergometer exercise (P < or = 0.001). At the request of the investigators, exercise-specific algorithms were developed by the manufacturer and applied to the data that resulted in nonsignificant differences in total energy expenditure between indirect calorimetry and the SenseWear Pro Armband of 4.6 +/- 18.1 kcal (2.8 +/- 9.4%), 0.3 +/- 11.3 kcal (0.9 +/- 10.7%), 2.5 +/- 18.3 kcal (0.9 +/- 11.9%), and 3.2 +/- 8.1 kcal (3.8 +/- 9.9%) for the walk, cycle ergometer, step, and arm ergometer exercises, respectively. CONCLUSIONS: It appears that it is necessary to apply exercise-specific algorithms to the SenseWear Pro Armband to enhance the accuracy of estimating energy expenditure during periods of exercise. When exercise-specific algorithms are used, the SenseWear Pro Armband provides an accurate estimate of energy expenditure when compared to indirect calorimetry during exercise periods examined in this study.

Home forced use in an outpatient rehabilitation program for adults with hemiplegia: a pilot study.

The objective of this study was to examine the effectiveness of a program of traditional outpatient neurological rehabilitation that included home forced use. In total, 17 patients with chronic stroke and 1 patient with subacute stroke (mean time poststroke = 27.6 months) completed an individualized program consisting of seven 2-hour treatment sessions composed of 1 hour of occupational therapy and 1 hour of physical therapy. Therapy sessions were completed over a 2- to 3-week period and included instruction on the use of a restraining mitt at home during functional activities. The Wolf Motor Function Test (WMFT) was used to assess upper extremity impairment and function at baseline, midway through treatment, and posttreatment. Patients demonstrated statistically significant improvements (P < 0.05 corrected for multiple comparisons) in mean time for completion in 12 of 17 WMFT subtasks when comparing baseline to posttreatment. The preliminary results suggest that the forced-use component of constraint-induced therapy may be effective when applied within a traditional outpatient rehabilitation program. However, additional investigation is required to examine the effectiveness of using forced use within typical outpatient rehabilitation under more experimentally controlled conditions.

Effect of exercise duration and intensity on weight loss in overweight, sedentary women: a randomized trial.

CONTEXT: A higher duration and intensity of exercise may improve long-term weight loss. OBJECTIVE: To compare the effects of different durations and intensities of exercise on 12-month weight loss and cardiorespiratory fitness. DESIGN, SETTING, AND PARTICIPANTS: Randomized trial conducted from January 2000 through December 2001 involving 201 sedentary women (mean [SD] age, 37.0 [5.7] years; mean [SD] body mass index, 32.6 [4.2]) in a university-based weight control program. INTERVENTION: Participants were randomly assigned to 1 of 4 exercise groups (vigorous intensity/high duration; moderate intensity/high duration; moderate intensity/moderate duration; or vigorous intensity/moderate duration) based on estimated energy expenditure (1000 kcal/wk vs 2000 kcal/wk) and exercise intensity (moderate vs vigorous). All women were instructed to reduce intake of energy to between 1200 and 1500 kcal/d and dietary fat to between 20% and 30% of total energy intake. MAIN OUTCOME MEASURES: Body weight, cardiorespiratory fitness, and exercise participation. RESULTS: After exclusions, 184 of 196 randomized participants completed 12 months of treatment (94%). In intention-to-treat analysis, mean (SD) weight loss following 12 months of treatment was statistically significant (P <.001) in all exercise groups (vigorous intensity/high duration = 8.9 [7.3] kg; moderate intensity/high duration = 8.2 [7.6] kg; moderate intensity/moderate duration = 6.3 [5.6] kg; vigorous intensity/moderate duration = 7.0 [6.4] kg), with no significant difference between groups. Mean (SD) cardiorespiratory fitness levels also increased significantly (P =.04) in all groups (vigorous intensity/high duration = 22.0% [19.9%]; moderate intensity/high duration = 14.9% [18.6%]; moderate intensity/moderate duration = 13.5% [16.9%]; vigorous intensity/moderate duration = 18.9% [16.9%]), with no difference between groups. Post hoc analysis revealed that percentage weight loss at 12 months was associated with the level of physical activity performed at 6 and 12 months. Women reporting less than 150 min/wk had a mean (SD) weight loss of 4.7% [6.0%]; inconsistent (other) pattern of physical activity, 7.0% [6.9%]; 150 min/wk or more, 9.5% [7.9%]; and 200 min/wk or more of exercise, 13.6% [7.8%]. CONCLUSIONS: Significant weight loss and improved cardiorespiratory fitness were achieved through the combination of exercise and diet during 12 months, although no differences were found based on different exercise durations and intensities in this group of sedentary, overweight women.

Exercise considerations for the sedentary, overweight adult.

The significant rise in the prevalence of overweight and obesity has increased the importance of addressing this significant public health problem. Exercise appears to be an important factor for addressing the obesity epidemic. This review will focus on the role of exercise in the management of body weight and factors that should be considered when prescribing exercise to overweight adults.

Constraint-induced therapy for a child with hemiplegic cerebral palsy: a case report.

A 12-year-old boy with hemiplegic cerebral palsy (CP) presented with decreased function in his left upper extremity. He was treated with a 3-week protocol of constraint-induced therapy (CIT) consisting of six 2-hour sessions of physical and occupational therapy, plus home practice. Improvements in upper-extremity function were found in the mean and median time for completion of the Wolf Motor Function Test immediately posttreatment and at 8-month follow-up. Also, improvements in functional use of the arm were documented with the Assessment of Motor and Process Skills and by patient self-report of use of the upper extremity at home. The results suggest that CIT may be useful in the treatment of upper-extremity dysfunction in hemiplegic CP. Larger, experimentally controlled investigations of the efficacy of CIT and the mechanism of recovery in patients with CP are warranted. The effects of the duration and intensity of CIT protocols need additional study to increase its clinical application.

Impact of weight-cycling history on bone density in obese women.

OBJECTIVE: The purpose of this study was to examine the effect of weight cycling (as defined by the frequency and magnitude of intentional weight loss) on bone mineral density and bone mineral content in obese sedentary women. RESEARCH METHODS AND PROCEDURES: Bone mineral content and density measured by DXA, submaximal physical fitness assessment, nutrient intake, oral contraceptive use, and weight-cycling history were assessed in 195 healthy, overweight sedentary women (age, 21 to 45 years; body mass index, 27 to 40 kg/m(2)) before beginning a behavioral weight-loss intervention. RESULTS: After controlling for body weight, multivitamin use, oral contraceptive/estrogen use, and calcium and magnesium intake, women who had a history of weight cycling did not have significantly lower total-body bone mineral content or density or total femur bone mineral density. In addition, 99% of subjects were above or within one SD of age and gender normative data for total femur bone mineral density. DISCUSSION: It does not seem that a history of weight cycling has an adverse affect on total femur and total-body bone mineral density in overweight sedentary premenopausal women.

Self-regulated cycling using the Children's OMNI Scale of Perceived Exertion.

PURPOSE: An estimation and production paradigm was used to determine whether clinically normal 8- to 12-yr-old female (N = 18) and male (N = 18) children could (a) self-regulate intermittent cycle ergometer exercise using a prescribed target rating of perceived exertion (RPE), (b) discriminate between target RPEs, and (c) produce intermittent target RPEs in both an ascending and descending sequence. METHODS: Overall body RPE was assessed with the Children's OMNI Scale (0-10). Subjects underwent (a) one orientation trial, (b) one estimation (E) trial, and (c) two production (P) trials. During E, RPE was estimated each minute of a progressive cycle ergometer test. During the 3-min intermittent P trials, subjects titrated cycle brake force to produce either an RPE sequence of 2 and 6 (ascending) or 6 and 2 (descending). The P trials simulated short, intermittent exercise typical of children's play. RESULTS: Oxygen uptake (VO2) did not differ between E and P at a target RPE of 2 (0.63 versus 0.66 L x min(-1)) and 6 (1.27 vs 1.21 L x min(-1)). Heart rate (HR) did not differ between E and P at a target RPE of 2 (104.1 vs 102.6 beats.min-1) and 6 (153.7 vs 154.5 beats x min(-1)). Both VO2 and HR were higher (P < 0.01) at a target RPE-6 than -2. Responses were not affected by gender or production sequence. CONCLUSION: Young female and male children were able to use the OMNI Scale to self-regulate short-duration intermittent cycle exercise intensity.

Ratings of perceived exertion during low- and high-intensity resistance exercise by young adults.

Ratings of perceived exertion (RPE) are commonly used to monitor the intensity of aerobic exercise. Whether ratings of perceived exertion can be used similarly during resistance exercise is unclear. To examine this question, perceived exertion was measured at 30% and 90% of the one-repetition maximum (1-RM), while holding work constant between intensities. Ratings for the active muscles and for the overall body were examined during both intensities. 10 male (age=23.2 +/- 3.6 yr.) and nine female (age=21.8 +/- 2.7 yr.) volunteers underwent a one-repetition maximum procedure for each of the following exercises: bench press, leg press, latissimus pull down, triceps press, biceps curl, shoulder press, and calf raise. All subjects then completed two experimental trials on separate days. The high-intensity trial consisted of one set of five repetitions at 90% of the one-repetition maximum. The low-intensity trial consisted of one set of 15 repetitions at 30% of the one-repetition maximum. Active muscle and overall body ratings of perceived exertion were obtained immediately at termination of each of the seven exercises at both intensities. A two-factor (RPE x Intensity) repeated-measures analysis of variance was performed separately for each exercise. Both active muscle and overall body ratings of perceived exertion were higher (p<.01) for the high-intensity trial than for the low-intensity trial. Active muscle ratings were higher (p<.01) than overall body ratings for all exercises. Ratings of perceived exertion during resistance exercise are related to intensity of the resistance exercise (percentage of the one-repetition maximum). This information suggests that ratings of perceived exertion can provide information regarding the intensity of resistance exercise. Furthermore, sensations of exertion in the active muscles during resistance exercise are greater than sensations for the overall body.

Perceived exertion, electromyography, and blood lactate during acute bouts of resistance exercise.

PURPOSE: This study examined ratings of perceived exertion (RPE) during resistance exercise in women. In addition, changes in blood lactic acid and biceps muscle activity assessed using electromyography (EMG) were investigated as potential mediators of RPE during resistance exercise. METHODS: Twenty female volunteers (age, 25 +/- 4 yr) performed one set of biceps curl exercise at 30%, 60%, and 90% of their one-repetition maximum (1-RM). Total work was held constant by varying the number of repetitions during each of the three intensities. The three intensities were performed in random order. RPE responses were assessed for both the active muscle (RPE-AM) and the overall body (RPE-O) following each intensity. EMG data were collected from the biceps brachii muscle during each intensity. Blood samples were taken before and following the intensities and analyzed for blood lactic acid concentration. RESULTS: A two-factor repeated-measures ANOVA showed a significant RPE (region) x intensity interaction (P < 0.02). Both RPE-AM and RPE-O increased as the intensity of exercise increased. EMG activity increased significantly (P < 0.01) as the intensity of exercise increased. A two-factor repeated measures ANOVA performed on the blood lactate data showed a significant (P < 0.04) time x intensity interaction. Postexercise [Hla] was significantly greater (P < 0.01) at 90% 1-RM than at 30% 1-RM. No significant differences were found in [Hla] between 30% and 60% 1-RM, or between 60% and 90% 1-RM. CONCLUSION: These results indicate that monitoring RPE may be a useful technique for regulating resistance exercise intensity. Moreover, blood lactate and activity of the involved muscle may mediate the relation between RPE and resistance exercise intensity.

Ratings of perceived exertion in active muscle during high-intensity and low-intensity resistance exercise.

This investigation compared ratings of perceived exertion specific to the active muscles used during resistance exercise (RPE-AM) using the 15-category Borg scale during high-intensity (HIP) and low-intensity (LIP) weight lifting. Ten men (23.2 +/- 3.6 years) and 10 women (21.8 +/- 2.7 years) performed 2 trials consisting of seven exercises: bench press (BP), leg press, latissimus dorsi pull down, triceps press, biceps curl, shoulder press, and calf raise. The HIP and LIP protocols were completed in counterbalanced order. During HIP, subjects completed 5 repetitions using 90% of 1 repetition maximum (1RM). RPE-AM was measured after every repetition. During LIP, subjects completed 15 repetitions using 30% of 1RM. RPE-AM was measured after every third repetition. RPE-AMs were greater (p