Online vs in-person musculoskeletal ultrasound course: a cohort comparison study.

BACKGROUND: Point-of-care musculoskeletal (MSK) ultrasound (US) courses are typically held in-person. The COVID-19 pandemic guidelines forced courses to switch to online delivery. To determine this impact, we conducted an observational cohort study, comparing homework completion and image quality between an Online and a historical In-person cohort. METHODS: The In-person (n = 27) and Online (n = 24) cohorts attended two learning sessions spaced six months apart. The course content was the same, while the process of delivery differed. As homework, participants submitted US images biweekly for up to five months after each session. Expert faculty provided written feedback to all participants, and two independent reviewers rated the image quality for a subset of participants in each group who had completed at least 70% of their homework (In-person, n = 9; Online, n = 9). Participants self-reported their satisfaction through post-course evaluation. RESULTS: 63% of In-Person and 71% of Online cohort participants submitted their homework images. We observed no differences in the mean amount of homework images submitted for In-person (M = 37.3%, SD = 42.6%) and Online cohorts (M = 48.1%, SD = 38.8%; p > 0.05, Mann-Whitney U Test). At course end, the cohorts did not differ in overall image quality (p > 0.05, Wilcoxon Signed-rank Test). All participants reported high levels of satisfaction. CONCLUSIONS: A convenience sample of participants attending a basic MSK US course in-person and online did not differ statistically in homework completion, quality of submitted US images, or course satisfaction. We add to literature suggesting online learning remains a viable option post-pandemic.

Patient, Rheumatologist and Therapist Perspectives on the Implementation of an Allied Health Rheumatology Triage (AHRT) Initiative in Ontario Rheumatology Clinics.

PURPOSE: The objective of this qualitative study was to explore patient, rheumatologist, and extended role practitioner (ERP) perspectives on the integration of an allied health rheumatology triage (AHRT) intervention in Ontario rheumatology clinics. Triage is the process of identifying the urgency of a patient's condition to ensure they receive specialist care within an appropriate length of time. This research explores the clinical/logistical impact of triage by occupational and physical therapists with advanced arthritis training (ERPs), including facilitators and barriers of success, and recommendations for future application. PARTICIPANTS AND METHODS: Semi-structured telephone interviews were held with participating rheumatologists, ERPs, and a sample of patients from each clinical site (4 community, 3 hospital) in five Ontario cities. Interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed using basic qualitative description. Two independent researchers compared coding and achieved consensus. RESULTS: Patients (n=10), rheumatologists (n=6), and ERPs (n=5) participated in the study and reported reduced wait-times to rheumatology care, diagnosis, and treatment for those with inflammatory arthritis (IA). Rheumatologists and ERPs perceived that the intervention improved clinical efficiency and quality of care. Patients reported high satisfaction with ERP assessments, valuing early joint examination/laboratory tests, urgent referral if needed, and the provision of information, support, and management strategies. Facilitators of success included: supportive clinical staff, regular communication and collaboration between rheumatologist and ERP, and sufficient clinical space. Recommendations included extending ERP roles to include stable patient follow-up, and ERP care between scheduled rheumatology appointments. CONCLUSION: Findings support the integration of ERPs in a triage role in the community and hospital-based rheumatology models of care. Future research is needed to explore the impact of utilizing ERPs for stable patient follow-up in rheumatology settings.

The Effect of Triage Assessments on Identifying Inflammatory Arthritis and Reducing Rheumatology Wait Times in Ontario.

OBJECTIVE: We evaluated the influence of triage assessments by extended role practitioners (ERP) on improving timeliness of rheumatology consultations for patients with suspected inflammatory arthritis (IA) or systemic autoimmune rheumatic diseases (SARD). METHODS: Rheumatologists reviewed primary care providers' referrals and identified patients with inadequate referral information, so that a decision about priority could not be made. Patients were assessed by an ERP to identify those with IA/SARD requiring an expedited rheumatologist consult. The time from referral to the first consultation was determined comparing patients who were expedited to those who were not, and to similar patients in a usual care control group identified through retrospective chart review. RESULTS: Seven rheumatologists from 5 communities participated in the study. Among 177 patients who received an ERP triage assessment, 75 patients were expedited and 102 were not. Expedited patients had a significantly shorter median (interquartile range) wait time to rheumatologist consult: 37.0 (24.5-55.5) days compared to non-expedited patients [105 (71.0-135.0) days] and controls [58.0 (24.0-104.0) days]. Accuracy comparing the ERP identification of IA/SARD to that of the rheumatologists was fair (κ 0.39, 95% CI 0.25-0.53). CONCLUSION: Patients triaged and expedited by ERP experienced shorter wait times compared to usual care; however, some patients with IA/SARD were missed and waited longer. Our findings suggest that ERP working in a triage role can improve access to care for those patients correctly identified with IA/SARD. Further research needs to identify an ongoing ERP educational process to ensure the success of the model.

Getting a Grip on Arthritis Online: Responses of rural/remote primary care providers to a web-based continuing medical education programme.

INTRODUCTION: Physicians are often challenged with accessing relevant up-to-date arthritis information to enable the delivery of optimal care. An online continuing medical education programme to disseminate arthritis clinical practice guidelines (CPGs) was developed to address this issue. METHODS: Online learning modules were developed for osteoarthritis (OA) and rheumatoid arthritis (RA) using published CPGs adapted for primary care (best practices), input from subject matter experts and a needs assessment. The programme was piloted in two rural/remote areas of Canada. Knowledge of best practice guidelines was measured before, immediately after completion of the modules and at 3-month follow-up by assigning one point for each appropriate best practice applied to a hypothetical case scenario. Points were then summed into a total best practice score. RESULTS: Participants represented various professions in primary care, including family physicians, physiotherapists, occupational therapists and nurses (n = 89) and demonstrated significant improvements in total best practice scores immediately following completion of the modules (OA pre = 2.8/10, post = 3.8/10, P < 0.01; RA pre = 3.9/12, post = 4.6/12, P < 0.01). The response rate at 3 months was too small for analysis. CONCLUSIONS: With knowledge gained from the online modules, participants were able to apply a greater number of best practices to OA and RA hypothetical case scenarios. The online programme has demonstrated that it can provide some of the information rural/remote primary care providers need to deliver optimal care; however, further research is needed to determine whether these results translate into changes in practice.

Introduction: Il est souvent difficile pour les médecins d'accéder à de l'information pertinente et à jour sur l'arthrite dans le but de dispenser des soins optimaux. Un programme en ligne de formation médicale continue visant à disséminer les lignes directrices de pratique clinique sur l'arthrite a été créé pour résoudre ce problème. Méthodes: Des modules d'apprentissage en ligne sur l'arthrose et la polyarthrite rhumatoïde (PR) ont été élaborés à l'aide des lignes directrices de pratique clinique publiées ayant été adaptées pour les soins de première ligne (pratiques exemplaires), des commentaires des spécialistes en la matière et d'une évaluation des besoins. Le programme a été mis à l'essai dans deux régions rurales et éloignées du Canada. La connaissance des lignes directrices de pratique exemplaire a été mesurée avant, immédiatement après avoir terminé les modules et au suivi de trois mois en accordant un point à chaque pratique exemplaire appropriée appliquée à un scénario de cas hypothétique. La somme des points indiquait le score de pratique exemplaire. Résultats: Les participants représentaient diverses professions de première ligne, dont médecins de famille, physiothérapeutes, ergothérapeutes et infirmières (n = 89) et ont affiché une amélioration significative des scores totaux de pratique exemplaire immédiatement après avoir terminé les modules (arthrose avant = 2,8/10, après = 3,8/10, P < 0,01; PR avant = 3,9/12, après = 4,6/12, P < 0,01). Le taux de réponse à trois mois était trop faible pour l'analyse. Conclusions: Grâce aux connaissances acquises dans les modules en ligne, les participants ont pu appliquer un plus grand nombre de pratiques exemplaires aux scénarios de cas hypothétiques d'arthrose et de PR. Le programme en ligne a montré pouvoir fournir une part de l'information que les fournisseurs de soins en région rurale et éloignée ont besoin pour dispenser des soins optimaux, cependant des recherches plus poussées sont nécessaires pour déterminer si ces résultats se traduisent par des changements de la pratique. Mots-clés: Polyarthrite rhumatoïde, arthrose, lignes directrices de pratique clinique, système en ligne, évaluation des besoins.

The bidirectionality of motor learning in the vestibulo-ocular reflex is a function of cerebellar mGluR1 receptors.

Bidirectional changes in synaptic transmission have the potential to optimize the control of movement. However, it can be difficult to establish a causal relationship between the bidirectionality of synaptic plasticity and bidirectional changes in the speed of actual movements. We asked whether metabotropic glutamate receptor 1 (mGluR1) receptors, which participate in cerebellar long-term depression (LTD), are necessary for bidirectional motor learning in the vestibulo-ocular reflex (VOR). Cerebellar LTD and long-term potentiation (LTP) are thought to cause increases and decreases, respectively, in the gain of the VOR; the direction of learning depends on the behavioral protocol. We injected either the mGluR1 agonist (S)-DHPG or the antagonist YM 298198 bilaterally into the flocculus of alert cats, and then induced motor learning. In the presence of YM 298198, the VOR gain decreased in gain-up, as well as in gain-down protocols. (S)-DHPG augmented gain-up learning. Gain-down learning was not significantly affected by either drug. These results supported the hypothesis that gain-up learning relies on cerebellar LTD, but gain-down learning relies on a different mechanism. In the absence of mGluR1 activity, cerebellar LTD may be replaced with LTP, permitting learning in only one direction.

Consolidation and disruption of motor memory generalize across stimulus conditions in the vestibulo-ocular reflex.

The vestibulo-ocular reflex (VOR) exhibits motor learning that initially depends on synaptic plasticity in the cerebellar cortex. Learned decreases in VOR gain can be disrupted by rotation in darkness immediately following learning, but consolidate rapidly if the disruption stimulus is delayed. Disruption may simply reverse the synaptic changes that have recently occurred, or it may reflect new learning at other sites. The alternative to disruption, rapid consolidation, also may take place by altering the existing memory trace or may require changes at other locations. To test these possibilities, we induced decreases in the gain of the VOR in cats that wore miniaturizing goggles. Using a range of frequencies of rotation, we investigated the patterns of generalization for disruption and for rapid consolidation of the learned changes in gain. Learning was most effective at the particular frequencies that were used during training. However, disruption and rapid consolidation were not more effective at the rotation frequencies that were used during training. Instead, after consolidation, the memory retained the frequency tuning that had been established during the learning process. We conclude that disruption and rapid consolidation may not require new learning.

Rapid consolidation of motor memory in the vestibuloocular reflex.

Motor memory is relatively labile immediately after learning but can become more stable through consolidation. We investigated consolidation of motor memory in the vestibuloocular reflex (VOR). Cats viewed the world through telescopic lenses during 60 min of passive rotation. Learned decreases (gain-down learning) and increases in the VOR gain (gain-up learning) were measured during sinusoidal rotation at 2 Hz. We found that if rotation in darkness immediately followed learning, the gain of the VOR reverted toward its prelearning value, indicating that expression of the memory was disrupted. If after gain-down learning the cat spent another 60 min stationary without form vision, subsequent disruption did not occur, suggesting that memory had consolidated. Consolidation was less robust for gain-up learning. We conclude that memory in the VOR is initially labile but consolidates rapidly and consistently after gain-down learning.

Adaptive rescaling of central sensorimotor signals is preserved after unilateral vestibular damage.

Adaptive rescaling is a widespread phenomenon that dynamically adjusts the input-output relationship of a sensory system in response to changes in the ambient stimulus conditions. Rescaling has been described in the central vestibular neurons of normal cats. After recovery from unilateral vestibular damage, the vestibulo-ocular reflex (VOR) remains nonlinear for rotation toward the damaged side. Therefore, rescaling in the VOR pathway may be especially important after damage. Here, we demonstrate that central vestibular neurons adjust their input-output relationships depending on the input velocity range, suggesting that adaptive rescaling is preserved after vestibular damage and can contribute to the performance of the VOR. We recorded from isolated vestibular neurons in alert cats that had recovered from unilateral vestibular damage. The peak velocity of 1-Hz sinusoidal rotation was varied from 10 to 120 degrees/s and the sensitivities and dynamic ranges of vestibular neurons were measured. Most neuronal responses showed significant nonlinearities even at the lowest peak velocity that we tested. Significant rescaling was seen in the responses of neurons both ipsilateral and contralateral to chronic unilateral damage. On the average, when the peak rotational velocity increased by a factor of 8, the average sensitivity to rotation decreased by roughly a factor of 2. Rescaling did not depend on eye movement signals. Our results suggest that the dynamic ranges of central neurons are extended by rescaling and that, after vestibular damage, adaptive rescaling may act to reduce nonlinearities in the response of the VOR to rotation at high speeds.