Diagnostic Palpation in Osteopathic Medicine: A Putative Neurocognitive Model of Expertise

This thesis examines the extent to which the development of expertise in diagnostic palpation in osteopathic medicine is associated with changes in cognitive processing. Chapter 2 and Chapter 3 review, respectively, the literature on the role of analytical and non-analytical processing in osteopathic and medical clinical decision making; and the relevant research on the use of vision and haptics and the development of expertise within the context of an osteopathic clinical examination. The two studies reported in Chapter 4 examined the mental representation of knowledge and the role of analogical reasoning in osteopathic clinical decision making. The results reported there demonstrate that the development of expertise in osteopathic medicine is associated with the processes of knowledge encapsulation and script formation. The four studies reported in Chapters 5 and 6 investigate the way in which expert osteopaths use their visual and haptic systems in the diagnosis of somatic dysfunction. The results suggest that ongoing clinical practice enables osteopaths to combine visual and haptic sensory signals in a more efficient manner. Such visuo-haptic sensory integration is likely to be facilitated by top-down processing associated with visual, tactile, and kinaesthetic mental imagery. Taken together, the results of the six studies reported in this thesis indicate that the development of expertise in diagnostic palpation in osteopathic medicine is associated with changes in cognitive processing. Whereas the experts’ diagnostic judgments are heavily influenced by top-down, non-analytical processing; students rely, primarily, on bottom-up sensory processing from vision and haptics. Ongoing training and clinical practice are likely to lead to changes in the clinician’s neurocognitive architecture. This thesis proposes an original model of expertise in diagnostic palpation which has implications for osteopathic education. Students and clinicians should be encouraged to appraise the reliability of different sensory cues in the context of clinical examination, combine sensory data from different channels, and consider using both analytical and nonanalytical reasoning in their decision making. Importantly, they should develop their skills of criticality and their ability to reflect on, and analyse their practice experiences in and on action

Validation of the Haptic Cow: A simulator for training veterinary students

A virtual reality simulator, the Haptic Cow, has been developed using touch feedback technology for training veterinary students to perform bovine rectal palpation of the reproductive tract. The simulator was designed to supplement existing training and address some of the difficulties associated with teaching palpation-based skills. Students need to achieve a certain level of proficiency by graduation but this has become increasingly difficult because of problems with current training methods and a reduction in the number of opportunities to practice. A simulator- based teaching tool was developed as a potential solution. The first step involved designing a simulator on the basis of requirements established through consultation with both veterinary surgeons, as teachers, and students, as learners. Research was then undertaken to validate the simulator by following a set of established criteria described for the evaluation of new technologies used in medical education. The virtual models were assessed by experts as realistic enough representations of the same structures in the cow. An experiment to assess the effect of simulator training compared the performance of one group of students, whose training was supplemented with a simulator session, with another group of traditionally trained students. The subsequent performance for finding and identifying the uterus when examining cows for the first time, was significantly better for the simulator trained group, indicating that skills learned in the simulator environment transferred to the real task. A project was also undertaken to integrate the simulator into a curriculum, with training included as part of the farm animal course at the University of Glasgow Veterinary School. The training was well received by students, useful feedback was gathered and the simulator continues to be used as part of the course. Further developments were undertaken with the aim of creating a more versatile teaching tool and addressing some of the questions and issues raised. An automated version of the Haptic Cow was designed for students to use on their own, with computer guidance replacing the instructor's role. An evaluation found that the new version of the teaching tool was both usable and an effective way of equipping students with the skills required to find and identify the uterus. The potential to use haptic technology to investigate various aspects of performance was also explored in relation to the question of hand choice for certain palpation-based skills: differentiating between objects on the basis of softness and size. Ongoing research and development options are discussed, with the aim of building on the current work by expanding the role of haptic technology in veterinary education in the future

Facteurs influencing haptic shape perception

Le but de cette étude était de déterminer la contribution de plusieurs facteurs (le design de la tâche, l’orientation d’angle, la position de la tête et du regard) sur la capacité des sujets à percevoir les différences de formes bidimensionnelles (2-D) en utilisant le toucher haptique. Deux séries d'expériences (n = 12 chacune) ont été effectuées. Dans tous les cas, les angles ont été explorés avec l'index du bras tendu. La première expérience a démontré que le seuil de discrimination des angles 2-D a été nettement plus élevé, 7,4°, que le seuil de catégorisation des angles 2-D, 3,9°. Ce résultat étend les travaux précédents, en montrant que la différence est présente dans les mêmes sujets testés dans des conditions identiques (connaissance des résultats, conditions d'essai visuel, l’orientation d’angle). Les résultats ont également montré que l'angle de catégorisation ne varie pas en fonction de l'orientation des angles dans l'espace (oblique, verticale). Étant donné que les angles présentés étaient tous distribués autour de 90°, ce qui peut être un cas particulier comme dans la vision, cette constatation doit être étendue à différentes gammes d'angles. Le seuil plus élevé dans la tâche de discrimination reflète probablement une exigence cognitive accrue de cette tâche en demandant aux sujets de mémoriser temporairement une représentation mentale du premier angle exploré et de la comparer avec le deuxième angle exploré. La deuxième expérience représente la suite logique d’une expérience antérieure dans laquelle on a constaté que le seuil de catégorisation est modifié avec la direction du regard, mais pas avec la position de la tête quand les angles (non visibles) sont explorés en position excentrique, 60° à la droite de la ligne médiane. Cette expérience a testé l'hypothèse que l'augmentation du seuil, quand le regard est dirigé vers l'extrême droite, pourrait refléter une action de l'attention spatiale. Les sujets ont exploré les angles situés à droite de la ligne médiane, variant systématiquement la direction du regard (loin ou vers l’angle) de même que l'emplacement d'angle (30° et 60° vers la droite). Les seuils de catégorisation n’ont démontré aucun changement parmi les conditions testées, bien que le biais (point d'égalité subjective) ait été modifié (décalage aux valeurs inférieurs à 90°). Puisque notre test avec le regard fixé à l’extrême droite (loin) n'a eu aucun effet sur le seuil, nous proposons que le facteur clé contribuant à l'augmentation du seuil vu précédemment (tête tout droit/regard à droite) doit être cette combinaison particulière de la tête/regard/angles et non l’attention spatiale.The purpose was to determine the contribution of several factors (design of the task, angle orientation, head position and gaze) to the ability of subjects to perceive differences in twodimensional (2-D) shape using haptic touch. Two series of experiments (n=12 each) were carried out. In all cases the angles were explored with the index finger of the outstretched arm. The first experiment showed that the mean threshold for 2-D angle discrimination was significantly higher, 7.4°, than for 2-D angle categorization, 3.9°. This result extended previous work, by showing that the difference is present in the same subjects tested under identical conditions (knowledge of results, visual test conditions, angle orientation). The results also showed that angle categorization did not vary as a function of the orientation of the angles in space (oblique, upright). Given that the angles presented were all distributed around 90°, and that this may be a special case as in vision, this finding needs to be extended to different ranges of angles. The higher threshold with angle discrimination likely reflects the increased cognitive demands of this task which required subjects to temporarily store a mental representation of the first angle scanned, and to compare this to the second scanned angle. The second experiment followed up on observations that categorization thresholds are modified with gaze direction but not head position when the unseen angles are explored in an eccentric position, 60° to the right of midline. This experiment tested the hypothesis that the increased threshold when gaze was directed to the far right might reflect an action of spatial attention. Subjects explored angles located to the right of midline, systematically varying the direction of gaze (away from or to the angles) along with angle location (30° and 60° to the right). Categorization thresholds showed no change across the conditions tested, although bias (point of subjective equality) was changed (shift to lower angle values). Since our testing with far right gaze (away) had no effect on threshold, we suggest that the key factor contributing to the increased threshold seen previously (head forward/gaze right) must have been this particular combination of head/gaze/angles used and not spatial attention

An analysis of the pedagogical concepts used by anatomy teachers to facilitate the teaching and learning of anatomy to physiotherapy undergraduates in the United Kingdom: A constructivist grounded theory study

Anatomy is a challenging subject to learn because it is voluminous, requires three-dimensional cognitive skills and is easily forgotten. Furthermore, anatomy is facing diminishing teaching attention and time. There is a scarcity of literature offering pedagogical guidance for teaching anatomy for physiotherapy in the UK, despite anatomical knowledge underpinning an ever widening scope of physiotherapy. The study provides a pedagogical theory and guidance on how anatomy for physiotherapy undergraduates could be taught more effectively in the UK. The research design generated data through in-depth semi-structured interviews with eight anatomy teachers for physiotherapy from an identified sample of 50 participants in the UK who taught anatomy modules and were registered physiotherapists. The combined interview transcripts generated 72,292 words of data that were analysed using coding techniques of grounded theory. Chronologically, the study found that anatomy teachers explicitly taught anatomy during the 1st year, largely through practical anatomy tutorials. During the 2nd and 3rd years, clinical physiotherapy lecturers implicitly revised anatomy during their teaching sessions, while student placement supervisors implicitly reinforced anatomical knowledge and skills during hospital placements. Conceptually, five pedagogical concepts emerged that are supported by literature for medical education and were explained using the Four-Component-Instructional-Design framework derived from the Cognitive-Load theory. The anatomy-teachers-for-physiotherapy used a spirally arranged curriculum, extensive use of visual anatomical imagery, promoted kinaesthetic anatomical skills, applied anatomical knowledge and skills to physiotherapy situations and used anatomical principles for metacognitive strategies. The study deviated from the Cognitive-Load theory in three ways. The long-term memories of physiotherapy students had limited capacities that stored temporary anatomical information, instead of having unlimited capacities for permanent information. The teachers used haptic learning that is ignored by the Cognitive-Load theory. Recommendations were made on how anatomical teaching could be improved and are addressed to Anatomy Theme-Leads, anatomy-teachers-for-physiotherapy and the Chartered Society of Physiotherapy