Evaluating the baseline auscultation abilities of second-year chiropractic students using simulated patients and high-fidelity manikin simulators: A pilot study.

OBJECTIVE: To assess the ability of 2nd-year students to identify normal and abnormal findings during cardiac and lung auscultation using high-fidelity manikin simulators and standardized patients. A secondary objective was to assess students' perceived competence and confidence in their abilities. METHODS: This was a descriptive pilot study of randomly selected 2nd-year students at 1 chiropractic training program. Participants were asked to perform cardiac and lung auscultation on high-fidelity manikins (2 stations) and standardized human patients (2 stations) with normal and abnormal auscultation sounds. Participants described the auscultated sound as "abnormal" or "normal" and were also asked to score their confidence in describing the sound and competence in performing auscultation on a 100-mm visual analog scale. Descriptive statistics were calculated for all study variables. RESULTS: Thirty-two students (23 women and 9 men) were included. For lung auscultation, 15.6% were incorrect on the human subject and 6.2% were incorrect on the manikin. For cardiac auscultation, 62.5% were incorrect on the human subject and 40.6% were incorrect on the manikin. Confidence mean scores ranged from 34.8 to 60. Competence mean scores ranged from 34.8 to 50. CONCLUSION: Results identified that 2nd-year students from 1 institution were correct in identifying an abnormal sound during lung auscultation but reported low levels of perceived competence or confidence in their responses. They performed poorly on cardiac auscultation and reported low perceived confidence and competence in their abilities to perform cardiac auscultation and identify sounds.

Effects of Distinct Force Magnitude of Spinal Manipulative Therapy on Blood Biomarkers of Inflammation: A Proof of Principle Study in Healthy Young Adults.

OBJECTIVES: The purpose of this preliminary study was to determine the influence of thoracic spinal manipulation therapy (SMT) of different force magnitudes on blood biomarkers of inflammation in healthy adults. METHODS: Nineteen healthy young adults (10 female, age: 25.6 ± 1.2 years) were randomized into the following 3 groups: (1) control (preload only), (2) single thoracic SMT with a total peak force of 400N, and (3) single thoracic SMT with a total peak force of 800N. SMT was performed by an experienced chiropractor, and a force-plate embedded treatment table (Force Sensing Table Technology) was used to determine the SMT force magnitudes applied. Blood samples were collected at pre intervention (baseline), immediately post intervention, and 20 minutes post intervention. A laboratory panel of 14 different inflammatory biomarkers (pro, anti, dual role, chemokine, and growth factor) was assessed by multiplex array. Change scores from baseline of each biomarker was used for statistical analysis. Two-way repeated-measures analysis of variance was used to investigate the interaction and main effects of intervention and time on cytokines, followed by Tukey's multiple comparison test (P ≤ .05). RESULTS: A between-group (800N vs 400N) difference was observed on interferon-gamma, interleukin (IL)-5, and IL-6, while a within-group difference (800N: immediately vs 20 minutes post-intervention) was observed on IL-6 only. CONCLUSION: In this study, we measured short-term changes in plasma cytokines in healthy young adults and found that select plasma pro-inflammatory and dual-role cytokines were elevated by higher compared to lower SMT force. Our findings aid to advance our understanding of the potential relationship between SMT force magnitude and blood cytokines and provide a healthy baseline group with which to compare similar studies in clinical populations in the future.

Characteristics of Forces at the Clinician-Patient and Patient-Table Interfaces During Thoracic Spinal Manipulation in Asymptomatic Adults Are Consistent With Deformable Body Models.

Investigating all forces exerted on the patient's body during high-velocity, low-amplitude spinal manipulative therapy (SMT) remains fundamental to elucidate how these may contribute to SMT's effects. Previous conflicting findings preclude our understanding of the relationship between SMT forces acting at the clinician-patient and patient-table interfaces. This study aimed to quantify forces at the clinician-participant and participant-table interfaces during thoracic SMT in asymptnomatic adults. An experienced clinician provided a posterior to anterior SMT centered to T7 transverse processes using predetermined force-time characteristics to 40 asymptomatic volunteers (20 females; average age = 27.2 [4.9] y). Forces at the clinician-participant interface were recorded by triaxial load cells; whereas, forces at the participant-table interface were recorded by the force-sensing table technology. Preload force, total peak force, time to peak, and loading rate at each interface were analyzed descriptively. Total peak vertical forces at the clinician-participant interface averaged 532 (71) N while total peak forces at the participant-table interface averaged 658 (33) N. Forces at the participant-table interface were, on average, 1.27 (0.25) times larger than the ones at the clinician-participant interface. Larger forces at the participant-table interface compared with the ones at the clinician-participant interface during thoracic SMT are consistent with mathematical models developed to investigate thoracic impact simulating a dynamic force-deflection response.

COVID-19: how has a global pandemic changed manual therapy technique education in chiropractic programs around the world?

BACKGROUND: Manual therapy is a cornerstone of chiropractic education, whereby students work towards a level of skill and expertise that is regarded as competent to work within the field of chiropractic. Due to the COVID-19 pandemic, chiropractic programs in every region around the world had to make rapid changes to the delivery of manual therapy technique education, however what those changes looked like was unknown. AIMS: The aims of this study were to describe the immediate actions made by chiropractic programs to deliver education for manual therapy techniques and to summarise the experience of academics who teach manual therapy techniques during the initial outbreak of COVID-19 pandemic. METHODS: A qualitative descriptive approach was used to describe the immediate actions made by chiropractic programs to deliver manual therapy technique education during the COVID-19 pandemic. Chiropractic programs were identified from the webpages of the Councils on Chiropractic Education International and the Council on Chiropractic Education - USA. Between May and June 2020, a convenience sample of academics who lead or teach in manual therapy technique in those programs were invited via email to participate in an online survey with open-ended questions. Responses were entered into the NVivo software program and analysed using a reflexive thematic analysis by a qualitative researcher independent to the data collection. RESULTS: Data from 16 academics in 13 separate chiropractic programs revealed five, interconnected themes: Immediate response; Move to online delivery; Impact on learning and teaching; Additional challenges faced by educators; and Ongoing challenges post lockdown. CONCLUSION: This study used a qualitative descriptive approach to describe how some chiropractic programs immediately responded to the initial outbreak of the COVID-19 pandemic in their teaching of manual therapy techniques. Chiropractic programs around the world provided their students with rapid, innovative learning strategies, in an attempt to maintain high standards of chiropractic education; however, challenges included maintaining student engagement in an online teaching environment, psychomotor skills acquisition and staff workload.

A pilot study to determine the consistency of peak forces during cervical spine manipulation utilizing mannequins.

OBJECTIVE: Cervical spine manipulation is a complex motor skill used to treat musculoskeletal ailments such as neck pain. There is evidence demonstrating the effectiveness of objective feedback and mannequins for the teaching of spinal manipulation (SM) in the thoracic and lumbar spine. This paper examines the effectiveness of an educational intervention combining both mannequins and force-sensing technology for teaching cervical SM. METHODS: Fourth-year chiropractic interns were separated into 2 groups: an intervention group and a group trained with the standard curriculum. The intervention included a 60-minute educational session focused on targeting 100 N total peak force cervical manipulations on mannequins, with objective feedback through force-sensing table technology. Pre- and post-CMs were recorded on both a mannequin and a paired student partner, with an attempt to have a target total peak force of 100 N. RESULTS: Ninety students were recruited. The invention group (n = 46) scored significantly better at the outcome compared to the control group (n = 44) when manipulating the mannequin (p = .003). These improvements did not carry over when manipulating a paired human partner (p = .067). CONCLUSION: Following a 1-hour cervical SM educational intervention utilizing thrusting on mannequins and force-sensing table technology, students demonstrated improved peak force control for SM delivered on the mannequin. However, this improvement was not carried over to SM delivered on human subjects.

Construct validity and reliability of the Concussion Knowledge Assessment Tool (CKAT).

OBJECTIVE: To evaluate the test-retest reliability and construct validity of the concussion knowledge assessment tool (CKAT) as a measure of knowledge of concussion and its management among chiropractic subgroups and to compare these properties for two scoring strategies for the CKAT. METHODS: Three chiropractic subgroups (first year students, interns and sports chiropractors) completed the CKAT via SurveyMonkey with as second administration two to six weeks later for a subset of respondents. Scatter plots and Intraclass Correlation Coefficients (ICC) were used for test-retest reliability. A priori hypotheses regarding the relationship of CKAT scores across known subgroups, and with concussion knowledge self-rankings were established prior to data collection. Distributions of CKAT scores were compared across the subgroups using boxplots and ANOVA for known groups validity, and correlation of CKAT scores with concussion knowledge self-ranking was examined. RESULTS: Test-retest ICC for the revised scoring was 0.68 (95%CI 0.51-0.80). First year students had a mean revised CKAT (out of 49) of 36.9 (SD= 4.7), interns 39.9 (SD=3.0) and sports chiropractors 41.8 (SD=3.2) which are significantly different (F2,125=17.54; p<0.0001). CONCLUSIONS: The CKAT distinguished between chiropractic subgroups expected to have different levels of knowledge, supporting construct validity, however, it did not achieve adequate test-retest reliability.

OBJECTIF: Évaluer la fiabilité du test-retest et interpréter la validité du Concussion Knowledge Assessment Tool (CKAT)) servant à évaluer les connaissances sur la commotion cérébrale et sa prise en charge par des sous-groupes de chiropraticiens et comparer ces propriétés pour deux stratégies de cotation du CKAT. MÉTHODOLOGIE: On a demandé à trois sous-groupes de chiropraticiens (étudiants de première année, internes et chiropracticiens du sport) de remplir le questionnaire CKAT par SurveyMonkey et de deux à six semaines plus tard, on l'a utilisé une deuxième fois auprès d'un sousensemble de répondants. Des diagrammes de dispersion et des coefficients de corrélation intraclasse (CCI) ont été utilisés pour évaluer la fiabilité du test-retest. Des hypothèses a priori sur le rapport des scores CKAT dans les sous-groupes connus et les auto-évaluations des connaissances sur la commotion cérébrale ont été établis avant la collecte des données. On a comparé les répartitions des scores CKAT entre les sous-groupes à l'aide de diagrammes de dispersion et ANOVA pour la validité des groupes connus et la corrélation des scores CKAT et on a examiné les auto-évaluations des connaissances sur la commotion cérébrale. RÉSULTATS: Les CCI du test-retest pour le score révisé était de 0,68 (IC à 95 % : 0,51­0,8). Pour Les étudiants de première année, le score révisé moyen CKAT (sur 49) était de 36,9 (ÉT = 4,7), pour les internes de 39,9 (ÉT = 3) et pour les chiropraticiens du sport de 41,8 (ÉT =3,2) ce qui constitue d'importantes différences (F2,125=17,54; p < 0,0001). CONCLUSIONS: Le score CKAT variait entre les sousgroupes de chiropraticiens qui sont censés avoir de différents degrés de connaissances, ce qui prouve la validité de l'interprétation. Cependant, le degré de fiabilité du test-retest n'est pas suffisant.

Manipulation Peak Forces Across Spinal Regions for Children Using Mannequin Simulators.

OBJECTIVE: The purpose of this work was to create an exploratory database of manipulation treatment force variability as a function of the intent of an experienced clinician sub-specializing in the care of children to match treatment to childhood category. Data of this type are necessary for realistic planning of dose-response and safety studies on therapeutic benefit. METHODS: The project evaluated the transmitted peak forces of procedures applied to mannequins of different stature for younger and older children. Common procedures for the cervical, thoracic, and lumbar spine and sacroiliac joint were administered to estimate variability by a single experienced practitioner and educator in pediatric manipulation attempting to modulate for childhood category. Results described for peak components in the cardinal axes and for peak total forces were cataloged and compared with consensus estimates of force from the literature. RESULTS: Mean force values for both components and total force peaks monotonically increased with childhood category analogous to consensus expectations. However, a mismatch was observed between peak values measured and consensus predictions that ranged by a factor of 2 to 3.5, particularly in the upper categories. Quantitative data permit a first estimate of effect size for future clinical studies. CONCLUSIONS: The findings of this study indicate that recalibration of spinal manipulation performance of experienced clinicians toward arbitrary target values similar to consensus estimates is feasible. What is unclear from the literature or these results is the identity of legitimate target values that are both safe and clinically effective based on childhood categories in actual practice.

Changes in Manipulative Peak Force Modulation and Time to Peak Thrust among First-Year Chiropractic Students Following a 12-Week Detraining Period.

OBJECTIVE: The purpose of this study was to analyze differences in peak force modulation and time-to-peak thrust in posterior-to-anterior (PA) high-velocity-low-amplitude (HVLA) manipulations in first-year chiropractic students prior to and following a 12-week detraining period. METHODS: Chiropractic students (n=125) performed 2 thrusts prior to and following a 12-week detraining period: total peak force targets were 400 and 600 N, on a force-sensing table using a PA hand contact of the participant's choice (bilateral hypothenar, bilateral thenar, or cross bilateral). Force modulation was compared to defined target total peak force values of 600 and 400 N, and time-to-peak thrust was compared between data sets using 2-tailed paired t-tests. RESULTS: Total peak force for the 600 N intensity varied by 124.11 + 65.77 N during the pre-test and 123.29 + 61.43 N during the post-test compared to the defined target of 600 N (P = .90); total peak force for the 400 N intensity varied by 44.91 + 34.67 N during the pre-test and 44.60 + 32.63 N during the post-test compared to the defined target of 400 N (P = .57). Time-to-peak thrust for the 400 N total peak force was 137.094 + 42.47 milliseconds during the pre-test and 125.385 + 37.46 milliseconds during the post-test (P = .0004); time-to-peak thrust for the 600 N total peak force was 136.835 + 40.48 milliseconds during the pre-test and 125.385 + 33.78 milliseconds during the post-test (P = .03). CONCLUSIONS: The results indicate no drop-off in the ability to modulate force for either thrust intensity, but did indicate a statistically significant change in time-to-peak thrust for the 400 N total peak force thrust intensity in first-year chiropractic students following a 12-week detraining period.

Whole body vibration and cerebral palsy: a systematic review.

PURPOSE: The goal of this review is to evaluate the effects of whole body vibration on outcomes in patients with cerebral palsy. The findings in this review may help clinicians make evidence informed decisions on the use of whole body vibration for cerebral palsy. METHODS: A systematic search was conducted on April 29, 2014.The following search terms were used to search of several databases: (whole body vibration OR whole-body vibration OR whole body-vibration OR WBV) AND (cerebral palsy). Articles that met the inclusion criteria were assessed using the Scottish intercollegiate guidelines network (SIGN) rating system to assess the methodology and bias of the articles for randomized control trials. RESULTS: The search produced 25 articles, of which 12 duplicates were identified and removed. Another seven articles were not considered since they did not fit the inclusion criteria, leaving a total of five studies for review. Four of the articles analyzed the effects of WBV in children while the other study focused on adults with cerebral palsy. There was one low quality article, four acceptable quality articles and one high quality article when assessed using the SIGN criteria. CONCLUSIONS: It appears that whole body vibration has the potential to provide symptomatic relief for patients with cerebral palsy. Whole body vibration may improve spasticity, muscle strength and coordination. There is a lack of research to conclusively determine whether it does alter bone mineral density.

OBJECTIF: L'objectif de cette étude est d'évaluer les effets de la vibration du corps entier sur les résultats chez les patients atteints de paralysie cérébrale. Les conclusions de cette étude peuvent aider les cliniciens à prendre des décisions éclairées par des données probantes sur le recours à des vibrations du corps entier pour la paralysie cérébrale. MÉTHODOLOGIE: Une recherche systématique a été effectuée le 29 avril 2014. Les termes de recherche suivants ont été utilisés pour la recherche de plusieurs bases de données : (whole body vibration OR whole-body vibration OR whole body-vibration OR WBV) AND (cerebral palsy) [(vibration du corps entier) ET (paralysie cérébrale)]. Les articles qui répondaient aux critères d'inclusion ont été évalués à l'aide du système de notation SIGN (Scottish intercollegiate guidelines network) pour évaluer la méthodologie et la partialité des articles pour des essais cliniques randomisés. RÉSULTATS: La recherche a permis de recenser 25 articles, dont 12 qui étaient doubles ont été éliminés. Sept autres articles n'ont pas été retenus, car ils ne répondaient pas aux critères d'inclusion, laissant au total cinq articles pour l'étude. Quatre des articles analysaient les effets de la vibration du corps entier chez les enfants tandis que l'autre étude portait sur des adultes atteints de paralysie cérébrale. L'évaluation de la qualité des articles selon les critères SIGN a révélé un article de qualité médiocre, quatre articles de qualité acceptable et un article de bonne qualité. CONCLUSIONS: Il semble que le traitement par vibrations du corps entier a le potentiel de fournir un soulagement symptomatique chez les patients atteints de paralysie cérébrale. La vibration du corps entier peut améliorer la spasticité, la force musculaire et la coordination. Les recherches ne sont pas suffisantes pour permettre de déterminer de façon concluante si elle modifie la densité minérale osseuse.

Consistency and malleability of manipulation performance in experienced clinicians: a pre-post experimental design.

OBJECTIVE: The purpose of this study was to sample the stability of spinal manipulation performance in peak impulse force development over time and the ability of clinicians to adapt to arbitrary target levels with short-duration training. METHODS: A pre-post experimental design was used. Human analog mannequins provided standardized simulation for performance measures. A convenience sample was recruited consisting of 41 local doctors of chiropractic with 5 years of active clinical practice experience. Thoracic impulse force was measured among clinicians at baseline, after 4 months at pretraining, and again posttraining. Intraclass correlation coefficient values and within-subject variability defined consistency. Malleability was measured by reduction of error (paired t tests) in achieving arbitrary targeted levels of force development normalized to the individual's typical performance. RESULTS: No difference was observed in subgroup vs baseline group characteristics. Good consistency was observed in force-time profiles (0.55 ≤ intraclass correlation coefficient ≤ 0.75) for force parameters over the 4-month interval. With short intervals of focused training, error rates in force delivery were reduced by 23% to 45%, depending on target. Within-subject variability was 1/3 to 1/2 that of between-subject variability. Load increases were directly related to rate of loading. CONCLUSION: The findings of this study show that recalibration of spinal manipulation performance of experienced clinicians toward arbitrary target values in the thoracic spine is feasible. This study found that experienced clinicians are internally consistent in performance of procedures under standardized conditions and that focused training may help clinicians learn to modulate procedure characteristics.

The examination of soft tissue compliance in the thoracic region for the development of a spinal manipulation training mannequin.

PURPOSE: To determine if the soft tissue compliance of the thoracic paraspinal musculature differs based on gender and body type to help create a foam human analogue mannequin to assist in the training of spinal manipulative therapy. METHODS: 54 volunteers were grouped based on their gender and body types. In the prone position, thoracic paraspinal soft tissue compliance was measured at T1, T3 T6, T9 and T12 vertebrae levels bilaterally using a tissue compliance meter. RESULTS: There was no significant difference in tissue compliance when comparing the genders except at T1 (p=0.026). When comparing body types, significantly higher tissue compliance was found between endomorphs and the other groups. No significant difference was found between ectomorphs and mesomorphs. The compliance for the participants in this study ranged from 0.122 mm/N to 0.420 mm/N. CONCLUSION: There are significant differences in thoracic spine soft tissue compliance in healthy asymptomatic patients between genders in the upper thoracic spine, and between different body types throughout the thoracic spine. It may be beneficial to create multiple versions of practice mannequins to simulate variations amongst different patients.

OBJECTIF: Déterminer si la compliance des tissus mous de la masse musculaire thoracique paradorsale diffère selon le sexe et le type corporel afin de créer un mannequin en mousse de forme humaine pour aider à la formation en traitement par manipulation dorsale. MÉTHODOLOGIE: On a regroupé 54 volontaires en fonction de leur sexe et de leur type corporel. En position allongée, on a mesuré la compliance des tissus mous thoraciques paradorsaux au niveau des vertèbres T1, T3, T6, T9 et T12 bilatéralement à l'aide d'un dispositif de mesure de compliance. RÉSULTATS: Il n'y a pas de grande différence sur le plan de la compliance des tissus lorsqu'on compare les sexes, sauf à la vertèbre T1 (p = 0,026). En comparant les types corporels, une compliance des tissus bien plus élevée a été remarquée chez les endomorphes par rapport aux autres groupes. Il n'y a pas de différence importante entre les ectomorphes et les endomorphes. La compliance pour les participants à cette étude allait de 0,122 mm/N à 0,420 mm/N. CONCLUSION: Il existe de grandes différences entre la compliance des tissus mous thoraciques dorsaux chez les patients en santé asymptomatiques entre les sexes dans la colonne thoracique supérieure et entre les différents types corporels dans toute la colonne thoracique. Il peut être bénéfique de créer plusieurs versions de mannequins de pratique pour simuler les variations chez les différents patients.

Participation strategies and student performance: An undergraduate health science retrospective study.

OBJECTIVE: This research explores participatory evidence-based teaching methods in a health science course to see if a relationship emerged between the level of student participation and course performance, the type of participation and course performance, or the amount of participation and course performance and level of demonstrated learning. METHODS: Level of student participation was dichotomous (100% or <100%), and differences between groups on a knowledge test were compared using an unpaired t test. Type of participation was also dichotomous (in class or out), and differences in course performance on the knowledge test were compared using the unpaired t test. Amount of participation and course performance and level of demonstrated learning were also tested after the knowledge test was measured using a matrix based upon Bloom's taxonomy. RESULTS: Students who participated 100% of the time scored 6% higher on average than students with less than 100% participation (t[183] = 3.55, p = .0005, d = 0.52). There was no difference between groups when assessing for differences in course performance by type of participation. Students with 100% participation scored higher on the short answer question section of the examination (t[183] = 4.58, p = .0001, d = 0.68), but there was no difference on the multiple choice question part of the examination. CONCLUSION: Full participation in the course was related to higher examination scores and higher scores on examination questions assessing higher levels in the cognitive domain.

Observed improvements in an intern's ability to initiate critical emergency skills in different cardiac arrest scenarios using high-fidelity simulation.

Objective : The objective of this study was to report observed changes in an intern's ability to initiate critical emergency skills in different cardiac arrest scenarios with high-fidelity simulation over a 10-month period. Methods : One intern's performance was retrospectively analyzed using video recordings of 4 simulations at different stages in the training program. The key outcome was the duration of time expired for 4 critical skills, including activating the emergency response system, initiating cardiopulmonary resuscitation (CPR), using an automated external defibrillator (AED), and passively administrating oxygen. Results : The intern became more efficient in each subsequent simulation for activating the emergency response system and initiating CPR. The time to use the AED stayed relatively constant. The administration of oxygen was inconsistent. Conclusion : An improvement in the speed of applying emergency critical skills was observed with this intern. These improvements in skill may improve patient outcomes and survival rates. We propose further educational research with high-fidelity simulation in the area of assessing emergency skills.