Does spaced education improve clinical knowledge among Family Medicine residents? A cluster randomized controlled trial.

Spaced education is a learning strategy to improve knowledge acquisition and retention. To date, no robust evidence exists to support the utility of spaced education in the Family Medicine residency. We aimed to test whether alerts to encourage spaced education can improve clinical knowledge as measured by scores on the Canadian Family Medicine certification examination. METHOD: We conducted a cluster randomized controlled trial to empirically and pragmatically test spaced education using two versions of the Family Medicine Study Guide mobile app. 12 residency training programs in Canada agreed to participate. At six intervention sites, we consented 335 of the 654 (51%) eligible residents. Residents in the intervention group were sent alerts through the app to encourage the answering of questions linked to clinical cases. At six control sites, 299 of 586 (51%) residents consented. Residents in the control group received the same app but with no alerts. Incidence rates of case completion between trial arms were compared using repeated measures analysis. We linked residents in both trial arms to their knowledge scores on the certification examination of the College of Family Physicians of Canada. RESULTS: Over 67 weeks, there was no statistically significant difference in the completion of clinical cases by participants. The difference in mean exam scores and the associated confidence interval did not exceed the pre-defined limit of 4 percentage points. CONCLUSION: Further research is recommended before deploying spaced educational interventions in the Family Medicine residency to improve knowledge.

Correction: Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline.

Authors Victoria L. Goosey-Tolfrey and Karen M. Smith were listed under the incorrect affiliations at the time of publication.

Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline.

OBJECTIVES: To describe the process and outcomes of using a new evidence base to develop scientific guidelines that specify the type and minimum dose of exercise necessary to improve fitness and cardiometabolic health in adults with spinal cord injury (SCI). SETTING: International. METHODS: Using Appraisal of Guidelines, Research and Evaluation (AGREE) II reporting criteria, steps included (a) determining the guidelines' scope; (b) conducting a systematic review of relevant literature; (c) holding three consensus panel meetings (European, Canadian and International) to formulate the guidelines; (d) obtaining stakeholder feedback; and (e) process evaluation by an AGREE II consultant. Stakeholders were actively involved in steps (c) and (d). RESULTS: For cardiorespiratory fitness and muscle strength benefits, adults with a SCI should engage in at least 20 min of moderate to vigorous intensity aerobic exercise 2 times per week AND 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week (strong recommendation). For cardiometabolic health benefits, adults with a SCI are suggested to engage in at least 30 min of moderate to vigorous intensity aerobic exercise 3 times per week (conditional recommendation). CONCLUSIONS: Through a systematic, rigorous, and participatory process involving international scientists and stakeholders, a new exercise guideline was formulated for cardiometabolic health benefits. A previously published SCI guideline was endorsed for achieving fitness benefits. These guidelines represent an important step toward international harmonization of exercise guidelines for adults with SCI, and a foundation for developing exercise policies and programs for people with SCI around the world.

The SETPACE Trial: Stroke Survivors Impressions of the Education and Teaching Provided Regarding Physical Activity and Patient Confidence Regarding Exercise.

OBJECTIVE: The aim of the study is to investigate the association between patient self-efficacy, impression of exercise education, and physical activity among stroke survivors. We hypothesized that low self-efficacy and/or poor impressions of exercise education after stroke would be associated with reduced exercise participation. DESIGN: This is a cross-sectional investigation of patients' poststroke with physical activity as the primary outcome variable. Physical activity was measured with the Physical Activity Scale for Individuals with Physical Disabilities. Self-efficacy was measured with the Self-Efficacy for Exercise questionnaire. Impression of exercise education measured by the Exercise Impression Questionnaire. RESULTS: There was a low but significant correlation between Self-Efficacy for Exercise questionnaire and Physical Activity Scale for Individuals with Physical Disabilities ( r (66) = 0.272, P = 0.012). There was an insignificant correlation between Exercise Impression Questionnaire and Physical Activity Scale for Individuals with Physical Disabilities ( r (66) = 0.174, P = 0.078). There was a low but significant correlation between age and Physical Activity Scale for Individuals with Physical Disabilities ( r (66) = -0.269, P = 0.013). There was no correlation between sex and Physical Activity Scale for Individuals with Physical Disabilities ( r (66) = 0.051, P = 0.339). Age, sex, Exercise Impression Questionnaire, and Self-Efficacy for Exercise questionnaire predict 17.1% of Physical Activity Scale for Individuals with Physical Disabilities variance ( R2 = 0.171). CONCLUSION: Self-efficacy was the strongest predictor of physical activity participation. There was a lack of association between the impressions of exercise education and physical activity. Addressing patient confidence to complete exercise has the potential to improve exercise participation in patients after stroke.

Cognitive -behavioral therapy for managing depressive and anxiety symptoms after stroke: a systematic review and meta-analysis.

BACKGROUND: Post-stroke anxiety and depression can be disabling and result in impaired recovery. Cognitive-behavioral therapy (CBT) has been demonstrated to be effective for anxiety and depression; however, determining its efficacy among those with stroke is warranted. Our objectives to evaluate CBT for anxiety and depression post-stroke . METHODS: This review was registered with PROSPERO (REG# CRD42020186324). Medline, PsycInfo, and EMBR Cochrane were used to locate studies published before May 2020, using keywords such as stroke and CBT. A study was included if: (1) interventions were CBT-based, targeting anxiety and/or depression; (2) participants experienced a stroke at least 3 months previous; (3) participants were at least 18 years old. Standardized mean differences ± standard errors and 95% confidence intervals were calculated, and heterogeneity was determined. The Cochrane Risk of Bias tool was used. RESULTS: The search yielded 563 articles, of which 10 (N = 672) were included;6 were randomized controlled trials. Primary reasons for exclusion included: (1) wrong population (2) insufficient data provided for a meta-analysis; (3) wrongoutcomes. CBT showed large effects on reducing overall anxiety (SMD ± SE: 1.01 ± 0.32, p < .001) and depression (SMD ± SE: 0.95 ± 0.22, p < .000) symptoms at the end of the studies. CBT moderately maintained anxiety (SDM ± SE: 0.779 ± 0.348, p ˂.025) and depression (SDM ± SE: 0.622 ± 0.285, p ˂ .029) scores after 3-months. Limitations included small sample size, limited comparators, and lack of follow-up data. CONCLUSION: The results of this meta-analysis provide substantial evidence for the use of CBTto manage post-stroke anxiety and depression.

Impressions on Reliability and Students' Perceptions of Learning in a Peer-Based OSCE.

BACKGROUND: Peer assessment of performance in the objective structured clinical examination (OSCE) is emerging as a learning instrument. While peers can provide reliable scores, there may be a trade-off with students' learning. The purpose of this study is to evaluate a peer-based OSCE as a viable assessment instrument and its potential to promote learning and explore the interplay between these two roles. METHODS: A total of 334 medical students completed an 11-station OSCE from 2015 to 2016. Each station had 1-2 peer examiners (PE) and one faculty examiner (FE). Examinees were rated on a 7-point scale across 5 dimensions: Look, Feel, Move, Special Tests and Global Impression. Students participated in voluntary focus groups in 2016 to provide qualitative feedback on the OSCE. Authors analysed assessment data and transcripts of focus group discussions. RESULTS: Overall, PE awarded higher ratings compared with FE, sources of variance were similar across 2 years with unique variance consistently being the largest source, and reliability (r φ ) was generally low. Focus group analysis revealed four themes: Conferring with Faculty Examiners, Difficulty Rating Peers, Insider Knowledge, and Observing and Scoring. CONCLUSIONS: While peer assessment was not reliable for evaluating OSCE performance, PE's perceived that it was beneficial for their learning. Insight gained into exam technique and self-appraisal of skills allows students to understand expectations in clinical situations and plan approaches to self-assessment of competence.

Screening Adherence for Depression Post Stroke: Evaluation of Outpatients, a London Experience (SAD PEOPLE).

BACKGROUND: Post stroke depression (PSD) is common, and the transition home following discharge may be especially challenging for stroke survivors. OBJECTIVES: This study aimed to determine how well specific Canadian Best Practice Recommendations for PSD screening were adopted within a stroke rehabilitation outpatient clinic before and after the utilization of a standardized clinical form. METHODS: Practices were evaluated through retrospective chart review before and after the implementation of the standardized form which cued physicians to administer the Patient Health Questionnaire 9 (PHQ-9) at the first outpatient visit. Participants included those aged ≥18 years with a primary diagnosis of stroke. RESULTS: One hundred thirty-five subjects' charts were reviewed. Form implementation was associated with increased rates of PSD screening (93.8% versus 0%) and charting regarding mood (55.4% versus 15.7%). CONCLUSION: This study highlights the frequency of depressive symptoms in an outpatient cohort and demonstrates how screening rates can be improved by using a standardized form. Routine PHQ-9 completion at the first outpatient visit was associated with more physician-patient discussion and documentation regarding mood.

Correlates of depressive symptoms in individuals attending outpatient stroke clinics.

Background and purpose Depressive symptoms are common post-stroke. We examined stroke deficits and lifestyle factors that are independent predictors for depressive symptomology. Methods A retrospective chart review was performed for patients' post-stroke who attended outpatient clinics at a hospital in Southwestern Ontario between 1 January 2014 and 30 September 2014. Demographic variables, stroke deficits, secondary stroke risk factors and disability study measures [Patient Health Questionnaire-9 (PHQ-9) and Montreal Cognitive Assessment (MoCA)] were analyzed. Results Of the 221 outpatients who attended the stroke clinics (53% male; mean age = 65.2 ± 14.9 years; mean time post-stroke 14.6 ± 20.1 months), 202 patients were used in the final analysis. About 36% of patients (mean = 5.17 ± 5.96) reported mild to severe depressive symptoms (PHQ-9 ≥ 5). Cognitive impairment (CI), smoking, pain and therapy enrollment (p < 0.01) were significantly associated with depressive symptoms. Patients reporting CI were 4 times more likely to score highly on the PHQ-9 than those who did not report CI (OR = 4.72). While controlling for age, MoCA scores negatively related to depressive symptoms with higher PHQ-9 scores associated with lower MoCA scores (r= -0.39, p < 0.005). Conclusions High levels of depressive symptoms are common in the chronic phase post-stroke and were partially related to cognition, pain, therapy enrollment and lifestyle factors. Implications for Rehabilitation Stroke patients who report cognitive deficits, pain, tobacco use or being enrolled in therapy may experience increased depressive symptoms. A holistic perspective of disease and lifestyle factors should be considered while assessing risk of depressive symptoms in stroke patients. Patients at risk for depressive symptoms should be monitored at subsequent outpatient visits.

The use of virtual reality for balance among individuals with chronic stroke: a systematic review and meta-analysis.

BACKGROUND: Virtual reality (VR) is becoming a popular alternative to traditional upper and lower limb rehabilitation following a stroke. OBJECTIVE: To conduct a systematic review and meta-analysis on the effectiveness of VR interventions for improving balance in a chronic stroke (≥6 months) population. DATA SOURCES: A literature search of Pubmed, Scopus, CINAHL, Embase, Psycinfo, and Web of Science databases was conducted. STUDY SELECTION: English randomized controlled trials published up to September 2015 assessing balance with VR in chronic stroke participants. DATA EXTRACTION: Mean and standard deviations from outcome measures were extracted. Pooled standard mean differences ± standard error were calculated for the Berg Balance Scale (BBS) and the Timed Up and Go test (TUG). RESULTS: In total, 20 studies were selected which assessed the Nintendo® Wii Fit balance board (n = 7), treadmill training and VR (n = 7), and postural training using VR (n = 6). Significant improvements were found for VR interventions evaluating the BBS (n = 12; MD = 2.94 ± 0.57; p < 0.001) and TUG (n = 13; MD = 2.49 ± 0.57; p < 0.001). Sub-analyses revealed postural VR interventions had a significant effect on BBS (n = 5) and TUG (n = 3) scores (BBS: MD = 3.82 ± 0.79; p < 0.001 and TUG: MD = 3.74 ± 0.97; p < 0.001). VR and treadmill training (n = 5) had a significant effect on TUG scores (MD = 2.15 ± 0.89, p = 0.016). CONCLUSION: Overall, VR interventions compared to conventional rehabilitation had significant improvements. The meta-analyses also suggest that the Nintendo® Wii Fit balance board may not be effective, although further confirmatory studies are necessary. Results should be interpreted with caution due to differences in therapy intensities and effect sizes within the included studies.

Spinal accessory nerve injury: A potentially missed cause of a painful, droopy shoulder.

BACKGROUND: Spinal accessory nerve (SAN) injury can be an overlooked cause of scapular winging and shoulder dysfunction. The most common etiology is iatrogenic injury following surgical procedures at the posterior triangle of the neck. We present three cases of isolated injury to the SAN following trauma. OBJECTIVE: To improve detection of SAN injuries through highlighting the clinical presentation, diagnosis and treatment via three cases in which the injuries were initially missed. METHODS: Clinical case series and narrative review. RESULTS: Three (3) patients were evaluated by history, physical exam and electrodiagnostic study (EMG). Clinical symptoms included, a painful, droopy shoulder and difficulties with overhead activities. Clinical signs included the observation of scapular winging, and focal atrophy of the trapezius and in some cases the sternocleidomastoid (SCM). Novel clinical signs such as the active elevation lag sign and triangle sign were also helpful clinically to highlight the SAN as the site of pathology. EMG revealed denervation and reduced motor unit recruitment in the trapezius and SCM. CONCLUSIONS: Early detection of SAN injuries can be improved through appropriate clinical suspicion, a detailed history and careful physical exam. EMG testing can help guide prognosis, direct conservative and surgical treatment, and reduce patient morbidity.