Effect of peer instruction pedagogy on concept mastery in a first professional year pharmacy self-care course.

INTRODUCTION: As active learning is being encouraged in pharmacy education, valid active learning pedagogies should be investigated. Peer instruction pedagogy has yet to be explored in the pharmacy education setting. Peer instruction assesses student understanding of a topic through multiple choice questions called ConcepTests. When the class scores below a threshold, students are given time to discuss the ConcepTest. They are then given an opportunity to repeat the same ConcepTest. METHODS: Peer instruction pedagogy was implemented in the 2017 fall semester of PHAR 6112: Introduction to Self-Care. Changes in student responses were recorded via Turning Technologies software to identify if peer instruction increased the number of students who answered ConcepTests correctly. Changes in responses were analyzed via a paired t-test and McNemar test. Students were also surveyed on their perceptions of the pedagogy. RESULTS: A total of 51 questions proceeded through the entirety of the peer instruction algorithm. Peer instruction was associated with an increase in correct response (P < .001). Students' total number of correct responses to ConcepTest questions increased by an average of 16.1 (31.5%) following peer instruction (P<.001). Over 86% of students would recommend that other instructors use ConcepTests. CONCLUSIONS: Peer instruction resulted in an increase in correct responses to session ConcepTests. This pedagogy has potential as an active learning method to deliver pharmacy material.

Integrating Health Literacy and Cultural Competency Concepts Across the Doctor of Pharmacy Curriculum.

Objective. To determine the longitudinal impact of integrating health literacy and cultural competency content throughout the professional pharmacy curriculum and the impact of additional changes made to the curriculum based on the results of a longitudinal analysis. Methods. Health literacy and cultural competency concepts were integrated throughout a four-year professional pharmacy curriculum. A cohort of students were assessed using health literacy and cultural competency survey instruments at baseline, the end of the fall semester of the first professional (P1) year, and the end of each subsequent academic year. From the four-year assessment, a need for additional reinforcement in the spring P1 semester was identified, so a health literacy activity was incorporated into an introductory pharmacy practice experience (IPPE) for two cohorts of students. The outcomes were compared to those of a single cohort of students who had completed their P1 year prior to integration of the additional content. A health literacy survey instrument was given at the beginning and after completion of the semester to assess change. Preceptors also completed a brief survey. Results. Curricular integration improved health literacy and cultural competency attitudes and self-perceived ability in P1 students, as assessed by the instruments. However, declines in students' health literacy and cultural competency were identified when the students were retested in the spring semester. After implementing the health literacy IPPE activity, the health literacy scores of P1 students in the two subsequent years improved. Preceptors also gave positive feedback on the utility of this activity. Conclusion. Integrating health literacy and cultural competency content throughout the curriculum resulted in improvement in students' scores in these areas from the first to the fourth professional year, but when there were no integrated activities, scores dropped. Implementing additional activities improved student-perceived HL skills. Thus, it may be important to ensure there is inclusion of content in each semester of the curriculum to maximize effects.

Evaluation of student perceptions of introductory pharmacy practice experiences.

INTRODUCTION: Introductory pharmacy practice experiences (IPPEs) are focused on sharpening the student's knowledge, skills, abilities, and attitudes related to becoming an effective member of the healthcare team. Currently, the literature on student pharmacists' perceptions focused only on advanced pharmacy practice experiences (APPEs). This study gathered perceptions of IPPEs from pharmacy students in their first through third year professional years. METHODS: A voluntary pre- and post-survey instrument was administered to 367 first through third year professional students from Northeast Ohio Medical University (NEOMED) and Cedarville University at the beginning and end of the 2017-2018 academic year. Each survey utilized questions with Likert scales designed to detect differences in student expectations and experiences related to IPPE training. Questions primarily focused on demographics, objectives, goals, interprofessional teamwork, application of knowledge, and preceptor engagement. Students ages 18 and older who were enrolled at the participating institutions were eligible for inclusion in this study. Survey completion was voluntary, and students were not incentivized to participate. RESULTS: Sixty-six students completed the pre- and post- surveys with matching, identifiable data for analysis. Twenty-nine items demonstrated a more negative perception of IPPEs between the pre- and post-surveys (p < 0.05). Eight items demonstrated a difference by institution (p < 0.05), while three items demonstrated a difference between professional years (p < 0.05). CONCLUSIONS: Student expectations of IPPEs were significantly less positive in the pre-survey than in the post-survey. Future studies should examine the implications of these results on student IPPE performance and methods to impact student perception of the value of IPPE training.

Muscle Contributions to Balance Control During Amputee and Nonamputee Stair Ascent.

Dynamic balance is controlled by lower-limb muscles and is more difficult to maintain during stair ascent compared to level walking. As a result, individuals with lower-limb amputations often have difficulty ascending stairs and are more susceptible to falls. The purpose of this study was to identify the biomechanical mechanisms used by individuals with and without amputation to control dynamic balance during stair ascent. Three-dimensional muscle-actuated forward dynamics simulations of amputee and nonamputee stair ascent were developed and contributions of individual muscles, the passive prosthesis, and gravity to the time rate of change of angular momentum were determined. The prosthesis replicated the role of nonamputee plantarflexors in the sagittal plane by contributing to forward angular momentum. The prosthesis largely replicated the role of nonamputee plantarflexors in the transverse plane but resulted in a greater change of angular momentum. In the frontal plane, the prosthesis and nonamputee plantarflexors contributed oppositely during the first half of stance while during the second half of stance, the prosthesis contributed to a much smaller extent. This resulted in altered contributions from the intact leg plantarflexors, vastii and hamstrings, and the intact and residual leg hip abductors. Therefore, prosthetic devices with altered contributions to frontal-plane angular momentum could improve balance control during amputee stair ascent and minimize necessary muscle compensations. In addition, targeted training could improve the force production magnitude and timing of muscles that regulate angular momentum to improve balance control.

Muscle Function and Coordination of Stair Ascent.

Stair ascent is an activity of daily living and necessary for maintaining independence in community environments. One challenge to improving an individual's ability to ascend stairs is a limited understanding of how lower-limb muscles work in synergy to perform stair ascent. Through dynamic coupling, muscles can perform multiple functions and require contributions from other muscles to perform a task successfully. The purpose of this study was to identify the functional roles of individual muscles during stair ascent and the mechanisms by which muscles work together to perform specific subtasks. A three-dimensional (3D) muscle-actuated simulation of stair ascent was generated to identify individual muscle contributions to the biomechanical subtasks of vertical propulsion, anteroposterior (AP) braking and propulsion, mediolateral control and leg swing. The vasti and plantarflexors were the primary contributors to vertical propulsion during the first and second halves of stance, respectively, while gluteus maximus and hamstrings were the primary contributors to forward propulsion during the first and second halves of stance, respectively. The anterior and posterior components of gluteus medius were the primary contributors to medial control, while vasti and hamstrings were the primary contributors to lateral control during the first and second halves of stance, respectively. To control leg swing, antagonistic muscles spanning the hip, knee, and ankle joints distributed power from the leg to the remaining body segments. These results compliment previous studies analyzing stair ascent and provide further rationale for developing targeted rehabilitation strategies to address patient-specific deficits in stair ascent.

The influence of ankle-foot orthosis stiffness on walking performance in individuals with lower-limb impairments.

BACKGROUND: Passive-dynamic ankle-foot orthoses utilize stiffness to improve gait performance through elastic energy storage and return. However, the influence of ankle-foot orthosis stiffness on gait performance has not been systematically investigated, largely due to the difficulty of manufacturing devices with precisely controlled stiffness levels. Additive manufacturing techniques such as selective laser sintering have been used to successfully manufacture ankle-foot orthoses with controlled stiffness levels. The purpose of this study was to use passive-dynamic ankle-foot orthoses manufactured with selective laser sintering to identify the influence of orthosis stiffness on walking performance in patients with lower-limb neuromuscular and musculoskeletal impairments. METHODS: Thirteen subjects with unilateral impairments were enrolled in this study. For each subject, one passive-dynamic ankle-foot orthosis with stiffness equivalent to the subject's clinically prescribed carbon fiber orthosis, one 20% more compliant and one 20% more stiff, were manufactured using selective laser sintering. Three-dimensional kinematic and kinetic data and electromyographic data were collected from each subject while they walked overground with each orthosis at their self-selected velocity and a controlled velocity. FINDINGS: As the orthosis stiffness decreased, ankle range of motion and medial gastrocnemius activity increased while the knee became more extended throughout stance. Minimal changes in other kinematic, kinetic and electromyographic quantities were observed. INTERPRETATION: Subjects effectively compensated for changes in ankle-foot orthosis stiffness with altered gastrocnemius activity, and the stiffness levels analyzed in this study had a minimal effect on overall walking performance.

How does ankle-foot orthosis stiffness affect gait in patients with lower limb salvage?

BACKGROUND: Ankle-foot orthoses (AFOs) are commonly prescribed during rehabilitation after limb salvage. AFO stiffness is selected to help mitigate gait deficiencies. A new custom dynamic AFO, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), is available to injured service members but prescription guidelines are limited. QUESTIONS/PURPOSES: In this study we ask (1) does dynamic AFO stiffness affect gait parameters such as joint angles, moments, and powers; and (2) can a given dynamic AFO stiffness normalize gait mechanics to noninjured control subjects? METHODS: Thirteen patients with lower limb salvage (ankle arthrodesis, neuropathy, foot/ankle reconstruction, etc) after major lower extremity trauma and 13 control subjects who had no lower extremity trauma and wore no orthosis underwent gait analysis at a standardized speed. Patients wore their custom IDEO with posterior struts of three different stiffnesses: nominal (clinically prescribed stiffness), compliant (20% less stiff), and stiff (20% stiffer). Joint angles, moments, powers, and ground reaction forces were compared across the varying stiffnesses of the orthoses tested and between the patient and control groups. RESULTS: An increase in AFO compliance resulted in 20% to 26% less knee flexion relative to the nominal (p = 0.003) and stiff (p = 0.001) conditions, respectively. Ankle range of motion and power generation were, on average, 56% (p < 0.001) and 63% (p < 0.001), respectively, less than controls as a result of the relatively fixed ankle position. CONCLUSIONS: Patients with limb salvage readily adapted to different dynamic AFO stiffnesses and demonstrated few biomechanical differences among conditions during walking. None of the stiffness conditions normalized gait to controls. CLINICAL RELEVANCE: The general lack of differences across a 40% range of strut stiffness suggests that orthotists do not need to invest large amounts of time identifying optimal device stiffness for patients who use dynamic AFOs for low-impact activities such as walking. However, choosing a stiffer strut may more readily translate to higher-impact activities and offer less chance of mechanical failure.

Selective laser sintered versus carbon fiber passive-dynamic ankle-foot orthoses: a comparison of patient walking performance.

Selective laser sintering (SLS) is a well-suited additive manufacturing technique for generating subject-specific passive-dynamic ankle-foot orthoses (PD-AFOs). However, the mechanical properties of SLS PD-AFOs may differ from those of commonly prescribed carbon fiber (CF) PD-AFOs. Therefore, the goal of this study was to determine if biomechanical measures during gait differ between CF and stiffness-matched SLS PD-AFOs. Subject-specific SLS PD-AFOs were manufactured for ten subjects with unilateral lower-limb impairments. Minimal differences in gait performance occurred when subjects used the SLS versus CF PD-AFOs. These results support the use of SLS PD-AFOs to study the effects of altering design characteristics on gait performance.