Tension of the ulnar, median, and radial nerves during ulnar nerve neurodynamic testing : Observational cadaveric study

Background: The ulnar nerve upper limb neurodynamic test (ULNT3) uses upper limb positioning to investigate symptoms arising from the ulnar nerve. It is proposed to selectively increase tension of the nerve; however, this property of the test is not well established. Objective: The aim of this study was to determine the upper limb position that results in: (1) the greatest tension of the ulnar nerve and (2) the greatest difference in tension between the ulnar nerve and the other 2 major nerves of the upper limb: median and radial. Design: This was an observational cadaver study. Methods: Tension (in newtons) of the ulnar, median, and radial nerves was measured simultaneously using 3 buckle force transducers in 5 upper limb positions in 10 embalmed human cadavers (N=20 limbs). Repeated-measures analysis of variance (ANOVA) with Bonferroni post hoc tests determined differences in tension among nerves and among limb positions. Results: The addition of shoulder horizontal abduction (H.Abd; 12.62 N; 95% confidence interval [95% CI]=10.76, 14.47) and combined shoulder abduction and internal rotation (H.Abd+IR; 11.86 N; 95% CI=9.96, 13.77) to ULNT3 (scapular depression, shoulder abduction and external rotation, elbow flexion, forearm pronation, and wrist and finger extension) produced significantly greater ulnar nerve tension compared with the ULNT3 alone (8.71 N; 95% CI=7.25, 10.17). The ULNT3+H.Abd test demonstrated the greatest difference in tension among nerves (mean difference between ulnar and median nerves=11.87 N; 95% CI=9.80, 13.92; mean difference between ulnar and radial nerves=8.47 N; 95% CI=6.41, 10.53). Limitations: These results pertain only to the biomechanical plausibility of the ulnar nerve neurodynamic test and do not account for other factors that may affect the clinical application of this test. Conclusions: The ULNT3+H.Abd is a biomechanically plausible test for detecting peripheral neuropathic pain related to the ulnar nerve. In situations where the shoulder complex will not tolerate the combination of shoulder external rotation in abduction, performing upper limb neurodynamic tests with internal rotation instead of external rotation is a biomechanically plausible alternative

Injury incidence, characteristics and timing in amateur male rugby union: A prospective cohort study

Rugby union has a high incidence of match injuries. However, there is limited information regarding the incidence and characteristics of match injuries in male amateur players. In particular, there is a lack of information regarding injury rates per match quarter. Investigating this may inform injury prevention strategies. The aim is to determine whether the rate and characteristics of injury vary with match quarter in male amateur rugby union players, regardless of whether the injury resulted in time loss from play. This prospective cohort study recorded and examined the number and characteristics of injuries during match quarters across a season of amateur rugby union. Team match exposure was recorded. Injuries were recorded by a team physiotherapist consistent with Rugby Injury Consensus Group guidelines. Matches were divided into quarters for data analysis, and statistical significance was determined using Chi-square analysis. 127 players sustained 207 injuries across 18 games. The injury incidence was 164 injuries/1000 match hours. There was a significant (p<0.001) difference in the number of injuries between match quarters, with the greatest number in the fourth, followed by the second, third, and first quarter. Forwards had a statistically significant higher rate of injury between quarters. Injury incidence in amateur rugby is higher than previously reported. Injury rates in amateur male rugby increase at the end of each match half, peaking in the fourth quarter. These findings contribute to the understanding of the aetiology of injury in amateur rugby union

Clinical Educator and Student Perceptions of iPad™ Technology to Enhance Clinical Supervision: The Electronically-Facilitated Feedback Initiative (EFFI)

Purpose: Growing demands placed upon healthcare systems require more health professionals to be trained. Clinical placement education is an integral component of health professional training, however accommodating increasing numbers of student placements is a challenge for health services. Personal digital assistants such as iPads™ may assist in delivery of clinical education, by facilitating transfer of knowledge and skills from clinical educators to health professional students, however such an initiative has not been formally investigated. The present study sought to explore perceptions of clinical educators and allied health students regarding the impact of an iPad™-based feedback delivery system on student reflection and learning. Methods: A pilot study was performed using iPads™ with specialised software to deliver electronic formative feedback to physiotherapy, occupational therapy and speech pathology students during clinical placements. Students and clinical educators completed a questionnaire exploring advantages and disadvantages of the technology. Results: Nine clinical educators and 14 students participated and completed the survey. Clinical educators largely (n=7, 78%) reported the electronic feedback system was easy to use and 67% (n=6) reported it improved the quality of feedback provided to students. Five (56%) clinical educators thought electronic feedback improved student performance. Most students (n=10, 71%) reported electronic feedback facilitated reflection upon performance, and 64% (n=9) reported improved performance as a result. Disadvantages included poor wireless internet access and software inefficiencies (n=7 [78%] clinical educators, n=7 [50%] students), and difficulties using iPads™ in settings requiring infection control (n=2 [22%] clinical educators). Conclusions: Clinical educators and students perceived electronic feedback as a positive adjunct to student learning on clinical placement, however technological and software interface factors need to be considered for implementation in some settings

Wiki activities in blended learning for health professional students: enhancing critical thinking and clinical reasoning skills

Health professionals use critical thinking, a key problem solving skill, for clinical reasoning which is defined as the use of knowledge and reflective inquiry to diagnose a clinical problem. Teaching these skills in traditional settings with growing class sizes is challenging, and students increasingly expect learning that is flexible and interactive. This paper describes the implementation and evaluation of a blended method for teaching clinical reasoning using a wiki. Groups of undergraduate physiotherapy students presented a patient case to their peers in class and on a wiki. Evaluation included student surveys, focus groups, and online participation. Students were actively involved in the wiki (mean contribution of 21.0 web pages (IQR 7.5-34.5). Most students (74%) agreed the in-class sessions were valuable, compared to 48% for the wiki. From the educator's perspective, the wiki facilitated collaboration, ensuring demonstrated reasoning skills in class. Combining wiki with in-class activities enhances student collaboration and learning of critical thinking skills

Performance of cervical spine mobilisation

Research Doctorate - Doctor of Philosophy (PhD)Background and Purpose: Physiotherapists commonly use cervical mobilisation to treat neck pain and headaches. Ensuring similar amounts of mobilisation force are applied by different therapists is a necessary first step in establishing optimal parameters for achieving patient outcomes. A series of studies was designed to quantify cervical mobilisation forces applied by physiotherapists and students, explain any differences identified in applied forces, and determine if real-time objective feedback improves consistency in performance of cervical mobilisation techniques. Methods: To quantify cervical mobilisation techniques, the forces applied by physiotherapists (n = 116) and undergraduate physiotherapy students (n = 120) were recorded using an instrumented treatment table. Each participant mobilised the C2 and C7 vertebrae of one asymptomatic subject using four grades of mobilisation, with one spinal level repeated after 20 minutes. Factors potentially associated with the applied forces, including spinal stiffness, were investigated. To investigate the effects of real-time objective feedback on cervical mobilisation forces, visual targets based on force data recorded from an expert physiotherapist mobilising 21 asymptomatic subjects were provided to 50 students. They each mobilised one of these 21 subjects on two occasions. Students’ forces were recorded before and after practising mobilisations with real-time visual feedback of forces (experimental group) or without (control). Results: Cervical mobilisation forces varied between individuals (ICC [2,1], therapist vertical mean peak force, 0.32, 95% CI 0.20 to 0.53), but intra-therapist repeatability was high (0.93, 95% CI 0.92 to 0.94). The highest resultant mean peak force was applied centrally on C7 by therapists (91.8 N, 95% CI 83.4 to 100.2), with students generally using lower forces. For both therapists and students, higher forces were associated with male gender (therapist, student or mobilised subject), and lower forces with greater C2 spinal stiffness in the mobilised subject. Students who received real-time feedback applied forces that were more similar to the expert’s peak forces (median difference 4.0 N, IQR 1.9 to 7.7) than did the controls (14.3 N, IQR 6.2 to 26.2, p < 0.001), and this difference was maintained one week later. Conclusions: The quantification of cervical mobilisation forces and explanations of differences in forces, together with the new technology developed, provide objective data about cervical mobilisation techniques, making effective feedback on performance possible. This will support strategies to improve consistency of mobilisation forces between therapists, as well as students. In turn, this approach provides the basis for future research to determine the mobilisation parameters that are optimal for treating a range of cervical spine disorders

Objective concurrent feedback on force parameters improves performance of lumbar mobilisation, but skill retention declines rapidly

Objective: To determine the optimum practice for students to apply lumbar mobilisations with force parameters consistent with an experienced therapist. Design: Thirty physiotherapy students attended three practice sessions over two weeks where they performed lumbar mobilisations on a fellow student. Students viewed feedback on their applied forces (measured using an instrumented treatment table) in real-time on a computer screen. Performance was tested before and after feedback at each practice session and at follow up sessions one week and three months later. Outcome measures: A greater accuracy in manual force application was defined as a smaller difference between each student-applied force parameter (mean peak force (N), force amplitude (N), and oscillation frequency (Hz)), and that previously applied by an expert. Test data from each session was analysed using Friedman's and Wilcoxon signed rank tests to determine student learning and retention. Results: Students were more accurate after feedback at Session 1 (median difference between student and expert force parameters 7.7 N, IQR 3.2–15.3) than before feedback (median 17.5, IQR 7.3–33.6, <i>P</i> < 0.001). Increased practice improved performance, with the greatest accuracy after feedback at Session 3 (median 7.0, IQR 3.5–11.9, <i>P</i> < 0.01). Retention however was poor, with performance at follow-up sessions no different to baseline. Conclusions: Students apply more consistent and accurate mean peak force, force amplitude and oscillation frequency after practising with objective, concurrent feedback. Additional practice sessions further improve performance, however retention is poor

Thumb pain in physiotherapists: potential risk factors and proposed prevention strategies

Work related injury to the thumb has become a recognised problem for physiotherapists who perform manual techniques in the treatment of patients with orthopaedic musculoskeletal disorders. Pain in the thumb often causes physiotherapists to alter their methods of treatment, which may decrease the effectiveness of physiotherapy services and lead to increased financial costs for patients and their funding agencies. Substantial numbers of physiotherapists have changed their specialty area or left the profession because of work-related injury, which further burdens education and healthcare systems. The extent of the influence of individual risk factors and preventive strategies on the development of thumb pain in physiotherapists has not been conclusively determined. This paper discusses the potential causes and consequences of thumb pain in physiotherapists, and reviews the supporting evidence on the incidence, risk, prevention, and treatment of this common occupational injury in physiotherapists