Qualitative and quantitative evaluation of an interprofessional workshop between physical therapy and medical students.

Interprofessional education (IPE) is an important component of medical education, preparing students for the collaboration necessary for high-quality patient care. This study aimed to compare IPE readiness in pre-qualification physical therapy (PT) and medical (MD) students before and after an interprofessional workshop and identify factors influencing the workshop's perceived educational value. In two consecutive years, students were surveyed with the Readiness for Interprofessional Learning Scale (RIPLS) following a four-hour, case-based workshop. During the second year, students were also surveyed before the workshop and answered open-ended questions about its educational value. PT and MD students had similar mean pre-workshop RIPLS scores (83.0, SD 5.3 vs. 80.7, SD 7.9; p = .27), but post-workshop scores were higher among PT students (86.3, SD 6.5 vs. 80.3, SD 8.8; p < .001). Qualitative thematic analysis of responses to open-ended questions revealed students valued IPE within the workshop. However, MD students in particular identified improvement opportunities in workshop delivery, timing, and content. These factors undermined the perceived educational value for MD students and may have contributed to their lower post-workshop RIPLS scores. This study suggests that a brief workshop can improve readiness for IPE among pre-professional students and highlights the importance of content, delivery, and timing to IPE success.

Educating Medical Students on the Roles of Occupational and Physical Therapy.

BACKGROUND: It is crucial for physicians to understand the roles of occupational therapy (OT) and physical therapy (PT) to ensure accurate patient referrals and to optimize patient care. Unfortunately, medical students often do not receive sufficient education or interprofessional opportunities regarding OT and PT services. OBJECTIVE: To evaluate the impact of an educational workshop on medical students' familiarity with the roles of OT and PT and on their confidence in referring to these therapy services. METHODS: Thirty-seven fourth-year medical students participated in a 2-hour workshop focused on the roles and benefits of OT and PT. After the didactic portion, students were given case scenarios relevant to their chosen specialty to discuss roles of OT and PT specific to their case. MAIN OUTCOME MEASUREMENTS: The students completed before and after surveys that assessed perceived knowledge and students' perspectives on the value of the work¬shop. LEVEL OF EVIDENCE: 3 (case-control study). RESULTS: From before to after the workshop, the students showed significant improvements in their familiarity with OT and PT and in their confidence to appropriately make a referral to these services. CONCLUSIONS: The tailored curriculum hosted in a workshop format improved students' knowledge regarding the role and services of OT and PT as well as their confidence in making accurate referrals.

The "Near-Peer" Approach to Teaching Musculoskeletal Physical Examination Skills Benefits Residents and Medical Students.

BACKGROUND: The musculoskeletal physical examination (MSK PE) is an essential part of medical student training, and it is best taught in a hands-on, longitudinal fashion. A barrier to this approach is faculty instructor availability. "Near-peer" teaching refers to physicians-in-training teaching their junior colleagues. It is unknown whether near-peer teaching is effective in teaching this important physical examination skill. OBJECTIVE: To investigate attitudes of medical students and physical medicine and rehabilitation (PM&R) residents regarding near-peer teaching in an MSK PE curriculum. DESIGN: Qualitative, anonymous paper and online surveys. SETTING: Tertiary academic center with a medical school and PM&R training program. PARTICIPANTS: Ninety-nine second- and third-year medical students and 13 PM&R residents in their third or fourth postgraduate year. METHODS: Attitudes of second- and third-year medical students were measured immediately after their MSK PE course. Resident attitudes were measured in a single cross-sectional sample. MAIN OUTCOME MEASUREMENTS: Student attitudes were assessed via a questionnaire with 5-point Likert scales and a free-text comment section. The resident questionnaire included a combination of multiple-choice questions, rankings, free-text responses, and Likert scales. RESULTS: All 99 students completed the questionnaire. The majority of students (n = 79 [80%]) reported that resident involvement as hands-on instructors of examination skills was "very useful," and 87 (88%) indicated that resident-led small discussion groups were "very helpful" or "somewhat helpful." Fifty-seven of 99 students (58%) reported that the resident-facilitated course was "much better" than courses without resident involvement. Twelve of 13 eligible residents completed the survey, and of those, 8 found teaching "very helpful" to their MSK knowledge, and 11 became "somewhat" or "much more confident" in clinical examination skills. CONCLUSIONS: Our study supports educational benefits to medical students and resident instructors in our MSK PE program. We recommend including near-peer teaching in medical student education, particularly for hands-on skills; we also recommend providing opportunities for PM&R residents to participate in formal near-peer education. LEVEL OF EVIDENCE: Not applicable.

Sonographic evaluation of the extensor carpi ulnaris in asymptomatic tennis players.

OBJECTIVE: To determine the prevalence of structural abnormalities and instability affecting the extensor carpi ulnaris (ECU) tendons of asymptomatic recreational tennis players by the use of high-resolution ultrasonography. DESIGN: Cross-sectional observational study. SETTING: Academic sports medicine center. PARTICIPANTS: Twenty-six asymptomatic, recreational male and female tennis players. METHODS: A single, experienced operator completed bilateral static and dynamic ultrasound examinations of the ECU tendons of 26 asymptomatic, long-term, recreational tennis players ages 26-61 years (11 male, 15 female, average 24.4 ± 14.2 years of tennis participation). Tendons were evaluated for tendinosis and tearing, tendon sheath effusion and tenosynovitis, and instability via a standardized scanning protocol and predetermined diagnostic criteria. MAIN OUTCOME MEASUREMENTS: The prevalence of static structural ECU tendon abnormalities (eg, tendinosis, tenosynovitis, tears) and dynamic ECU instability (eg, subluxation, dislocation). RESULTS: Thirty-nine of 52 wrists (75%) demonstrated static ECU tendon abnormalities, the most common finding being a partial-thickness tear located just distal to the ulnar groove. Overall, 92% (24/26) of players exhibited tendinosis or tearing in at least one wrist. Dynamic ECU instability was detected in 42% of wrists (22/52) and 91% (20/22) of the time manifested as subluxation. Only 2 ECU tendon dislocations were observed, both occurring in the same individual. Overall, 73% (19/26) of players exhibited ECU instability in at least one wrist. There was no relationship between static and dynamic ECU tendon abnormalities within the methodological limits of the investigation. Complete ECU tearing, tendon sheath effusion, tenosynovitis, and static dislocation were not seen in any wrist. CONCLUSION: Sonographic evidence of ECU tendinosis, partial-thickness tearing, full-thickness tearing, and subluxation can be seen in long-term, asymptomatic, recreational tennis players, whereas tendon sheath effusions, tenosynovitis, and tendon dislocation are uncommon. Further research is warranted to determine the clinical significance of asymptomatic ECU tendon abnormalities among long-term tennis players at multiple skill levels.

The physiatrists' crucial role in the development and implementation of a longitudinal musculoskeletal physical examination curriculum in a medical school.

The musculoskeletal physical examination (MSK PE) is a critical clinical skill that should be mastered by all medical students. The authors believe that physiatrists should have a crucial role in undergraduate musculoskeletal education. This article outlines the successful integration of an MSK PE curriculum taught by physiatrists into the first 2 yrs of medical school. During year 1, a basic MSK PE is taught concomitantly with the human anatomy course and focuses on anatomical correlation with physical examination maneuvers. In year 2, the MSK PE is taught concomitantly with the musculoskeletal didactic block. Special musculoskeletal tests, basic neurologic evaluation, and case correlation are also added to expand on the examination skills learned in the first year. At the end of the second year and before beginning third-year clinical rotations, students take a practical test to demonstrate their competency in the MSK PE. The authors believe that an important component of their MSK PE educational sessions is a low student-to-instructor ratio (4:1), with ample hands-on supervision of physical examination skills practice. Residents in the Department of Physical Medicine and Rehabilitation assist with the teaching. With their intensive training and clinical experience in musculoskeletal medicine, physiatric staff and residents are ideal faculty for teaching the MSK PE. The authors are hopeful that this article encourages other physiatrists to construct similar programs aimed to develop MSK PE skills in medical students.

Anxiety levels, fear-avoidance beliefs, and disability levels at baseline and at 1 year among subjects with acute and chronic low back pain.

OBJECTIVE: To compare anxiety levels, fear-avoidance beliefs, and disability levels over 1 year for patients with acute (< or =3 months) and chronic (>3 months) low back pain (LBP). DESIGN: Prospective study with questionnaire measurements. SETTING: Tertiary care clinic. PATIENTS: Patients with acute or chronic LBP who resided in a 3-county local area and presented to our clinic for initial evaluation. METHODS: Administration of and results analysis from Fear-Avoidance Beliefs Questionnaire, Oswestry Disability Index, Pain and Impairment Relationship Scale, and Spielberger State-Trait Anxiety Inventory at baseline and 12 months. Trait anxiety was measured at baseline only. MAIN OUTCOME MEASUREMENTS: Scores from questionnaires assessing fear-avoidance beliefs and state and trait anxiety, as well as LBP disability levels. RESULTS: In total, 138 patients with acute LBP and 107 with chronic LBP were enrolled. Of these patients, 111 with acute and 86 with chronic LBP completed the study. The 2 groups were statistically indistinguishable at baseline on all measures except trait anxiety scores, which were significantly higher in the group with chronic LBP than in the acute group (P = .01). At 1 year, the acute group had a statistically significant improvement in all outcome measures except state anxiety. The group with chronic LBP had significant improvement in all measures except fear-avoidance beliefs and state anxiety. Overall, the group with acute LBP improved more in all measurement instruments than the chronic LBP group (a statistically significant difference) except state anxiety. CONCLUSIONS: The group with chronic LBP exhibited a higher level of trait anxiety at baseline than those with acute LBP and, unlike the acute LBP group, did not have improved fear-avoidance beliefs over 1 year. The relationship between anxiety and chronic LBP is novel. Because anxiety is potentially modifiable, future studies that evaluate the relationship between LBP and anxiety are warranted.

Musculoskeletal education for medical students.

Musculoskleletal conditions comprise the second most common reason for physician visits and have the greatest negative impact on health-related quality of life in the industrialized world. Therefore, all medical schools should provide education for their students in these disorders. Physiatrists play a unique role in musculoskeletal care and hence, should play a leading role in medical student education. The Association of Academic Physiatrists formed a task force in 2007 to make recommendations as to how physiatrists could contribute to musculoskeletal education for medical students. This report contains those recommendations.

Is a videotape to change beliefs and behaviors superior to a standard videotape in acute low back pain? A randomized controlled trial.

BACKGROUND CONTEXT: Cognitive behavioral therapy has been used successfully in acute low back pain (LBP) treatment, but the use of a cognitive behavioral videotape as an adjunct to treatment has not been studied. PURPOSE: To determine outcomes for patients with acute LBP receiving a videotape designed to change beliefs and behaviors compared with a standard instructional videotape. STUDY DESIGN/SETTING: Randomized controlled trial; multidisciplinary clinic in an academic setting. PATIENT SAMPLE: Consecutive subjects with less than 3 months of LBP. Of 224 eligible subjects, 138 participated and completed the initial questionnaires. OUTCOME MEASURES: Oswestry Disability Index, Pain and Impairment Relationship Scale, Fear-Avoidance Beliefs Questionnaire; medical costs related to LBP and total medical costs incurred by participants during 1 year of follow-up. METHODS: Subjects were randomly assigned to receive a behavioral videotape or a control videotape. Other than the videotape, usual care was provided to each patient. RESULTS: No significant differences in any outcome measures or medical costs between the two groups at 12 months. However, baseline Vermont Disability Prediction Questionnaire was significantly lower in those who completed the entire study compared with those who did not complete the study. CONCLUSIONS: Compared with a standard instructional videotape, a behavioral videotape did not change beliefs, outcomes, or costs over 1 year. Cost-effective behavioral interventions with high patient retention rates are needed, especially for those at greatest risk of high utilization of resources.

Intramuscular hemangioma of the foot: a diagnostic dilemma.

Intramuscular hemangioma is a rare but important cause of pain and potentially decreased performance in athletes. These benign tumors occur more often in the lower extremity and usually present during the first three decades of life. Symptomatic intramuscular hemangiomas usually present with pain and swelling, which often worsen with activity. Diagnosis can be difficult, resulting in frustration and prolonged activity limitations for these patients. Magnetic resonance imaging and clinical findings can often suggest the diagnosis. Recommended treatment is usually wide total excision, but there are certain cases in which excision is not possible. In difficult areas such as the hands or feet, a sclerosing agent can be injected into the hemangioma to reduce the size of the hemangioma, decrease pain, and improve function.

Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening.

The objective of this study was to evaluate the effectiveness of eccentric strengthening. Ninety-four subjects (50 men) with chronic lateral epicondylitis were allocated randomly into three groups: stretching, concentric strengthening with stretching, and eccentric strengthening with stretching. Subjects performed an exercise program for six weeks. All three groups received instruction on icing, stretching, and avoidance of aggravating activities. The strengthening groups received instruction on isolated concentric and eccentric wrist extensor strengthening, respectively. At six weeks, significant gains were made in all three groups as assessed with pain-free grip strength, Patient-rated Forearm Evaluation Questionnaire, Disabilities of the Arm, Shoulder, and Hand questionnaire, Short Form 36, and visual analog pain scale. No significant differences in outcome measures were noted among the three groups. Although there were no significant differences in outcome among the groups, eccentric strengthening did not cause subjects to worsen. Further studies are needed to assess the unique effects of a more intense or longer eccentric strengthening program for patients with lateral epicondylitis.

Sensitivity of the Patient-rated Forearm Evaluation Questionnaire in lateral epicondylitis.

The purpose of this study was to examine the sensitivity, reliability, and concurrent validity of the Patient-rated Forearm Evaluation Questionnaire (PRFEQ). Reliability on three consecutive days was evaluated with 22 of 94 subjects who had chronic lateral epicondylitis (LE) and who concomitantly participated in an outcome study. The PRFEQ results were compared with results of the Visual Analogue Scale; the Disabilities of the Arm, Shoulder, and Hand questionnaire; the Medical Outcomes Study 36-Item Short Form Health Survey; and the pain-free grip strength measurement. Questionnaires were completed at baseline, six weeks, and 12 weeks. Reliability was excellent using variance components and interclass correlation coefficients (PRFEQ function subscale, 0.92; PRFEQ pain subscale, 0.96; PRFEQ total scale, 0.96). Generally, correlations were moderate between the PRFEQ subscales and total scale and the other outcome scales. Effect size and standardized response mean were good in many outcome scales, being slightly higher in the PRFEQ than in the other outcome measures. The PRFEQ is reliable, reproducible, and sensitive for assessment of LE. It is at least as sensitive to change as the other outcome tools tested. The PRFEQ should be a standard primary outcome measure in LE research.

Muscle activation patterns in subjects with and without low back pain.

OBJECTIVE: To analyze muscle activation patterns during various footplate perturbations, used as proprioceptive challenges in patients with low back pain (LBP) and in controls. DESIGN: A prospective and controlled comparative study. SETTING: Outpatient clinic. PARTICIPANTS: Twenty subjects with chronic LBP and 20 age- and sex-matched controls. INTERVENTIONS: The subjects underwent 5 sets of footplate perturbations in 3 directions with 16 perturbations for each set. MAIN OUTCOME MEASURES: Latency, frequency, and asymmetry of muscle activation of the erector spinae, rectus abdominus, anterior tibialis, and gastrocnemius muscles were measured bilaterally with surface electromyography. RESULTS: In the toes-up movements, subjects with LBP were significantly less likely to activate their rectus abdominus muscles (P=.02), and they were more likely to exhibit asymmetric muscle activation in the smaller forward movements (odds ratio=4.1, P=.03). The latter result appears to be driven by asymmetric contraction of the erector spinae and rectus abdominus. CONCLUSIONS: Significantly more subjects with LBP than control subjects exhibited absent firing of trunk muscles during 2 of the 5 footplate perturbations. These results suggest an abnormality of the neuromuscular loop and may represent altered proprioception.