High-dose cervical mobilization to improve central sensitization for a patient with post-fusion neck pain.

BACKGROUND: Few studies have addressed the appropriate joint mobilization dosage for neck pain. Furthermore, the efficacy of manual therapy in patients with post-spinal fusion neck pain is unreported. CASE DESCRIPTION: A 63-year-old man with a 2-year history of unresolved neck pain post-cervical fusion presented to therapy with an exacerbation of neck and left-shoulder pain. The patient presented with cervical impairments of intervertebral hypo-mobility above and below the fusion site. He exhibited a high Numeric Pain Rating Scale (NPRS) score of 8/10 related to his neck pain. Additionally, he demonstrated marked loss of cervical mobility. Indicators of central sensitization were present, including both hyperalgesia and allodynia. High-dose cervical joint mobilization was applied for durations of up to 10 minutes. Corrective exercises were added to improve muscle strength and endurance. Treatment was applied for 12 sessions over 4 months. OUTCOMES: At the time of discharge, this patient reported a full recovery of neck function. This treatment reduced pain, improved passive joint accessory motion, and restored upper quarter function. The patient demonstrated a 33-point improvement in his Neck Disability Index (NDI) score and his pain was reduced to 0-1/10 on the NPRS. Markers of central sensitization were resolved. Intervertebral passive accessory joint mobility was pain free in addition to concurrent restoration of functional mobility. CONCLUSION: A paucity of evidence exists for appropriate dosage with manual therapy interventions. This case report demonstrates marked improvement of pain and function with the use of high-dose joint mobilization. Improved cervical accessory joint mobility and central pain modulation were achieved with high-dose joint mobilization.

A Pre-Clerkship Medical Education Elective as Catalyst for Student Learning, Faculty Teaching, and Curricular Improvement.

Recent reviews of student-as-teacher programs call for early, longitudinal, and timely training in both learning principles and applied teaching skills. We describe a longitudinal elective for pre-clerkship students that includes interactive meetings addressing a range of theoretical and practical teaching topics and the tools needed to conduct medical education research.

Teaching Trans-Centric Curricular Content Using Modified Jigsaw.

Introduction: Transgender (trans) individuals have unique medical needs and difficulty accessing quality health care, exacerbated by inadequate provider knowledge. Incorporation of trans health care into medical school curricula has increased recently to address this gap. Jigsaw activities emphasize positive interdependence through structured cooperative learning, resulting in increased interest and self-confidence. We implemented a voluntary 2-hour modified jigsaw exercise on trans health care with changes designed to optimize the structure for medical students. Methods: The session was implemented both in person and virtually over 2 years with preclerkship medical students at the end of their endocrine/reproduction physiology course. The session featured a knowledge test with answer discussion followed by a clinical correlation-either a case discussion or video discussion. A pre- and posttest design compared students' knowledge, attitudes, and beliefs. Results: Eighty-nine students participated. Their initial attitudes and beliefs regarding trans health care were highly positive and remained elevated. Participants showed increases in knowledge and self-confidence discussing gender identity and clinical care postsession. All expressed interest in further training and felt the session enhanced their understanding of trans health and reproductive physiology. On 1-year follow-up, students showed decreased knowledge and self-confidence in discussing trans health; however, scores remained higher than presession. Student surveys suggested formal integration of more trans health education into the curriculum. Discussion: Medical students increased their knowledge and self-confidence regarding trans medicine and felt the modified jigsaw exercise was an effective teaching method. The results suggest that ongoing education is an important tool in optimizing trans health care.

Development of a Novel Peer-sharing Application to Supplement Learning from Cadaveric Dissection.

Gross anatomy dissection in contemporary medical education must balance the traditional value of learning from the cadaver with the possibilities created by the use of digital tools as supplemental resources that personalize and deepen the student learning experience. This study broadly examined the design, implementation, and use of AnatomyShare, a novel iPad application employing learner-generated content that allows students to securely share annotated images of their dissections with each other and take faculty-generated image-based quizzes during their first-year medical school gross anatomy course. Almost all students enrolled in the course used the application (N = 176; 91% use based on analytics). Seventy-five students responded to a survey asking how and when they used the application, along with their perceptions of its usefulness and contribution to learning. More students reported using the application outside of laboratory (97.3%) than during laboratory (85.3%), despite only in-laboratory use being required. Taking quizzes using the "Exam" feature was the highest rated use of AnatomyShare, and students cited that the application exposed them to anatomical variation and motivated them to correctly identify structures during dissection. While steps need to be taken to combat low-quality learner-generated content and to enhance meaningful student interaction and collaboration, AnatomyShare was a feasible and highly rated supplement to dissection that provided valuable assessment opportunities for students. Future research will examine the impact of use on course grades and engagement in gross anatomy dissection.

Three Decades Later: A Scoping Review of the Literature Related to the United States Medical Licensing Examination.

PURPOSE: To conduct a scoping review of the timing, scope, and purpose of literature related to the United States Medical Licensing Examination (USMLE) given the recent impetus to revise USMLE scoring. METHOD: The authors searched PubMed, PsycInfo, and ERIC for relevant articles published from 1990 to 2019. Articles selected for review were labeled as research or commentaries and coded by USMLE Step level, sample characteristics (e.g., year(s), single/multiple institutions), how scores were used (e.g., predictor/outcome/descriptor), and purpose (e.g., clarification/justification/description). RESULTS: Of the 741 articles meeting inclusion criteria, 636 were research and 105 were commentaries. Publication totals in the past 5 years exceeded those of the first 20 years.Step 1 was the sole focus of 38%, and included in 84%, of all publications. Approximately half of all research articles used scores as a predictor or outcome measure related to other curricular/assessment efforts, with a marked increase in the use of scores as predictors in the past 10 years. The overwhelming majority of studies were classified as descriptive in purpose. CONCLUSIONS: Nearly 30 years after the inception of the USMLE, aspirations for its predictive utility are rising faster than evidence supporting the manner in which the scores are used. A closer look is warranted to systematically review and analyze the contexts and purposes for which USMLE scores can productively be used. Future research should explore cognitive and noncognitive factors that can be used in conjunction with constrained use of USMLE results to inform evaluation of medical students and schools and to support the residency selection process.

Mindfulness Meditation for Medical Students: a Student-Led Initiative to Expose Medical Students to Mindfulness Practices.

PURPOSE: To explore the feasibility and impact of a brief mindfulness training for medical students and to learn about the perceptions, expectations, and problems associated with mindfulness practices in the context of medicine and medical education. METHOD: Forty-one medical students were randomized into either an introductory mindfulness class only or an introductory mindfulness class plus an 8-week mindfulness meditation course. Quantitative and qualitative data were collected from both groups after the introductory class and again after the full course. Qualitative data was subject to close iterative reading as part of a grounded-theory-guided content analysis, generating a list of codes which were then assigned to statements and arranged into overarching themes. RESULTS: Mindfulness and awareness were negatively correlated with stress and depression. Students who took the full mindfulness course emerged with a greater familiarity with and willingness to utilize mindfulness modalities. There was no significant difference on wellness outcomes between the introductory-course-only group and the full-mindfulness-course group. Thematic analysis revealed student aspirations for a mindfulness alternative in medicine and medical education but also a recognition of the challenges inherent in applying such an alternative. CONCLUSION: A mindfulness course for medical students is feasible and has potential as a wellness and educational initiative. Shorter duration mindfulness interventions may increase accessibility without significantly reducing benefit. Interpretation of overarching themes derived from the grounded theory analysis illuminates the subject of mindfulness for medical students from the perspective of students themselves.

Four Web-Based Interactive Endocrine Case Studies for Use in Undergraduate Medical Education.

INTRODUCTION: This resource is a collection of four case-based exercises intended to provide medical students with structured and focused opportunities to link basic science with clinical application. The cases are designed to help students self-evaluate their knowledge and develop a robust and well- integrated understanding of endocrine physiology and pathophysiology in the context of a representative range of endocrine disorders involving adrenal cortical, thyroid, and reproductive function. Although these cases were designed for, and used by, first-year students, they are also suitable for more advanced students. METHODS: Each case opens with a brief vignette containing a patient presentation and a history of present illness. The student first formulates a differential diagnosis and then sequentially narrows the differential by selecting from lists of diagnostic tests; correct answers with feedback are provided at each step. A diagnosis is ultimately required, and the student may be prompted to propose a treatment plan. RESULTS: End-of-course survey results from 128 first-year medical students suggest that the use of these interactive case studies was considered to be a worthwhile use of study time, and that knowledge gained in the correlate endocrine course was required to work through the cases. Students indicated that the levels of case and task complexity, along with feedback, were appropriate and helpful. DISCUSSION: These cases provide a resource for meeting the need for clinically relevant scenarios in the preclerkship years.

Teaching Spinal Cord Neuroanatomy through Drawing: An Interactive, Step-Wise Module.

INTRODUCTION: This interactive, case-based module was created to provide medical students with self-guided practice to improve their confidence with, and understanding of, neuroanatomy. The module was created to supplement neuroanatomy instruction. It is based on the idea that pictures and drawings are effective tools for teaching clinical neuroanatomy, especially when paired with a step-wise approach to solving clinical cases. METHODS: The learning module focuses on the basics of spinal cord anatomy and lesion localization, topics fundamental to neuroanatomy. Students who have had a basic introduction to these topics in their neuroanatomy course will find this module a useful educational supplement. A full version of the module, which includes a self-drawing component for additional reinforcement, can be completed in approximately an hour. A shorter version without the self-drawing component, can be completed in less time. The materials associated with the module include an answer packet to use as a guide through the module cases, and both pre- and postmodule practice questions for self-evaluation. Both modules were tested at our institution by separate groups of second-year medical students in the early portion of their neuroanatomy course. RESULTS: Both module versions showed significant improvement in confidence levels when describing spinal cord anatomy and lesion localization. Furthermore, students were highly satisfied with the material and reported they were likely to reuse it for additional studying. DISCUSSION: The use of this module by medical students during their neuroanatomy course provides a step-wise, case-based approach that simplifies the learning of learning neuroanatomy, and improves their confidence through pictures and drawings.

Exploring the Role of Peer Advice in Self-Regulated Learning: Metacognitive, Social, and Environmental Factors.

This Conversation Starters article presents a selected research abstract from the 2016 Association of American Medical Colleges Northeast Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the pilot study. These thoughts explore the metacognitive, social, and environmental mechanisms whereby advice plays a role in self-regulated learning.

The use of manual therapy post-hip arthroscopy when an exercise-based therapy approach has failed: a case report.

STUDY DESIGN: Case report. BACKGROUND: Although there is a growing body of literature on both surgical intervention and postsurgical rehabilitation of acetabular labral repairs and femoroacetabular impingement, there is a paucity of information on how to manage individuals who show a lack of progress postsurgery. CASE DESCRIPTION: A 30-year-old woman underwent surgical labral repair with femoroacetabular impingement osteochondroplasty. Postsurgery, she was initially treated with an exercise-based approach, but experienced an increase in hip pain and further decline in function. Her primary functional deficits were difficulty standing and pain (6/10) with ambulation. A combination of soft tissue mobilization and trigger point dry needling was used to address perceived muscle dysfunction, and nonthrust manipulation was used to address perceived hip joint hypomobility. OUTCOMES: Following 12 therapy sessions over 120 days, the patient returned to her demanding occupation with minimal residual symptoms. By the end of the period of care, the patient's Harris hip score had improved from 56 to 96 and her Lower Extremity Functional Scale score had improved from 26 to 70. DISCUSSION: This case describes a multimodal manual therapy approach and the health outcomes of a patient following labral repair with femoroacetabular impingement decompression who did not respond to an initial exercise-based postsurgical rehabilitation approach. Level of Evidence Therapy, level 4.