Determining factors for compensatory movements of the left arm and shoulder in violin playing.

Introduction: Despite a large number of available ergonomic aids and recommendations regarding instrument positioning, violin players at any proficiency level still display a worrying incidence of task-specific complaints of incompletely understood etiology. Compensatory movement patterns of the left upper extremity form an integral part of violin playing. They are highly variable between players but remain understudied despite their relevance for task-specific health problems. Methods: This study investigated individual position effects of the instrument and pre-existing biomechanical factors likely determining the degree of typical compensatory movements in the left upper extremity: (1) left elbow/upper arm adduction ("Reference Angle α", deviation from the vertical axis), (2) shoulder elevation ("Coord x", in mm), and (3) shoulder protraction ("Coord y", in mm). In a group of healthy music students (N = 30, 15 m, 15 f, mean age = 22.5, SD = 2.6), "Reference Angle α" was measured by 3D motion capture analysis. "Coord x" and "Coord y" were assessed and ranked by a synchronized 2D HD video monitoring while performing a pre-defined 16-s tune under laboratory conditions. These three primary outcome variables were compared between four typical, standardized violin positions varying by their sideward orientation ("LatAx-CSP") and/or inclination ("LoAx-HP") by 30°, as well as the players' usual playing position. Selected biomechanical hand parameter data were analyzed as co-factors according to Wagner's Biomechanical Hand Measurement (BHM). Results: Mean "Reference Angle α" decreased significantly from 24.84 ± 2.67 to 18.61 ± 3.12° (p < 0.001), "Coord x" from 22.54 ± 7.417 to 4.75 ± 3.488 mm (p < 0.001), and "Coord y" from 5.66 ± 3.287 to 1.94 ± 1.901) mm (p < 0.001) when increasing LatAx-CSP and LoAx-HP by 30°. Concerning the biomechanical co-factors, "Reference Angle α", "Coord y", but not "Coord x", were found to be significantly increased overall, with decreasing passive supination range (r = -0.307, p = <0.001 for "Passive Supination 250 g/16Ncm", and r = -0.194, p = <0.001 for "Coord y"). Compensatory movements were larger during tune sections requiring high positioning of the left hand and when using the small finger. Discussion: Results may enable to adapt individually suitable instrument positions to minimize strenuous and potentially unhealthy compensation movements of the left upper extremity.

Muscle Activation and Subjectively Perceived Effort in Typical Violin Positions.

Violinists display a high incidence of task-specific musculoskeletal problems. Sources pertaining to violin playing and teaching traditions as well as musicians' medicine research offer only imprecise and contradictory recommendations regarding suitable instrument positions. The aim of this study was to add to a growing scientific base for teaching and medical counseling regarding violin positioning. The study evaluated muscle activation (EMG) and subjectively perceived effort (Borg scale) in four standardized typical violin positions, as well as the violinists' normally used one. The hypothesis, the smaller the angle between the instrument's longitudinal axis (LoAx) and the player's central sagittal plane (CSP) and the angle between its lateral axis (LatAx) and the player's horizontal plane (HP), the more muscle activation and perceived effort in the violinist's left arm, was confirmed: Decreasing the LoAx-CSP angle from 50° to 20° and the LatAx-HP angle from 50° to 20° resulted in a highly significant and independent increase of EMG and Borg scale self-ratings mean values. Results may allow for a first step in decision-making on violin positioning for ergonomic adaptations in teaching as well as prevention and therapy of playing-related health problems at all levels of proficiency.

Effects of improved patient participation in primary care on health-related outcomes: a systematic review.

BACKGROUND: In primary care, many consultations address symptom-based complaints. Recovery from these complaints seldom exceeds placebo effects. Patient participation, because of its supposed effects on trust and patient expectancies, is assumed to benefit patients' recovery. While the idea is theoretically promising, it is still unclear what the effects of increased patient participation are on patient outcomes. Aim. To review the effects of controlled intervention studies aiming to improve patient participation in face-to-face primary care consultations on patient-oriented and/or disease-oriented outcomes. METHODS: This study is a systematic review. A systematic search was undertaken for randomized controlled trials designed to measure the effects of interventions that aimed to improve adult patients' participation in primary care visits. The CINAHL, Cochrane, EMBASE, PsycINFO and PubMed databases were searched. RESULTS: Seven different trials fulfilled the inclusion criteria. Three of the studies were related to symptom-based complaints. Five studies measured patient-oriented outcomes, the primary outcome of interest for this review. All studies suffered from substantial bias. Studies varied widely in their aims, types of complaints/diseases, strength of the interventions and their outcomes. The effects on patient-oriented outcomes and disease-oriented outcomes were ambiguous. CONCLUSION: Little research has been performed on health outcomes of interventions aiming to increase patient participation in general practice visits among patients suffering from symptom-based complaints. The results still are non-conclusive. The quality of the trials has been weak, possibly due to the complexity of the concept. This weak quality may explain the lack of conclusive results. Proposals for future research designs are offered.

The validity of using analogue patients in practitioner-patient communication research: systematic review and meta-analysis.

When studying the patient perspective on communication, some studies rely on analogue patients (patients and healthy subjects) who rate videotaped medical consultations while putting themselves in the shoes of the video-patient. To describe the rationales, methodology, and outcomes of studies using video-vignette designs in which videotaped medical consultations are watched and judged by analogue patients. Pubmed, Embase, Psychinfo and CINAHL databases were systematically searched up to February 2012. Data was extracted on: study characteristics and quality, design, rationales, internal and external validity, limitations and analogue patients' perceptions of studied communication. A meta-analysis was conducted on the distribution of analogue patients' evaluations of communication. Thirty-four studies were included, comprising both scripted and clinical studies, of average-to-superior quality. Studies provided unspecific, ethical as well as methodological rationales for conducting video-vignette studies with analogue patients. Scripted studies provided the most specific methodological rationales and tried the most to increase and test internal validity (e.g. by performing manipulation checks) and external validity (e.g. by determining identification with video-patient). Analogue patients' perceptions of communication largely overlap with clinical patients' perceptions. The meta-analysis revealed that analogue patients' evaluations of practitioners' communication are not subject to ceiling effects. Analogue patients' evaluations of communication equaled clinical patients' perceptions, while overcoming ceiling effects. This implies that analogue patients can be included as proxies for clinical patients in studies on communication, taken some described precautions into account. Insights from this review may ease decisions about including analogue patients in video-vignette studies, improve the quality of these studies and increase knowledge on communication from the patient perspective.

Electrodermal activity in response to empathic statements in clinical interviews with fibromyalgia patients.

OBJECTIVE: To study patients' electrodermal response (1) to an interviewer's empathic statements vs. inattention to emotional concerns and (2) to the emotional content in clinical interviews. METHODS: Patients with fibromyalgia (n=48) were given a clinical interview in a randomized 2×2 design, in which interviewer empathic or inattentive behavior (scenario A) and the emotional or neutral content of the interview (scenario B) were manipulated. Electrodermal activity (EDA) was measured during the interview. The patients' affective state (PANAS) and patient satisfaction were also assessed. RESULTS: In scenario A a significant main effect of empathy was found, indicating an increased tonic EDA (skin conduction level, SCL) during the empathy condition (p<.05). In scenario B there was a main effect of empathy (p<.01) and a significant empathy×content interaction effect (p<.01). There was a strong positive association between empathy and patient satisfaction (p<.0001). CONCLUSIONS: Empathic statements by the interviewer were associated with increased SCL in patients, most so in interviews with emotional content. PRACTICE IMPLICATIONS: Psychophysiological variables such as EDA may be applied in clinical communication research on emotional communication, but the limitations of such measures should also be recognized.

Is pain patients' psychophysiological arousal while watching their videotaped medical interview similar to their arousal during participation in this medical interview?

Showing videos of medical consultation as a proxy for participation is being increasingly applied in research in order to let patients (re-)experience social interaction in medical settings. If subjects do indeed experience the interaction process when watching this on video, then they should show similar patterns in physiological arousal as when actually participating. We assessed whether watching one's own interaction in a medical setting on video lead to the same skin conductance activity (SC) as when participating in that interaction. Fifteen women with fibromyalgia participated in a medical interview and, after a break, watched the video of this interview. Skin conductance activity was measured throughout the medical interview and, again, while the participants watched their own video. Coherence in SC between these two conditions was assessed. In eleven subjects (73%) a significant positive coherence between the two measurements was found, indicating that watching your own videotaped consultations evokes comparable psychophysiological arousal in most but not all participants. This physiological coherence might be an indication that people are capable of re-experiencing their interaction process by watching replays of these situations, although further research is needed. The positive coherence also supports skin conductance as a reliable moment-to-moment measure for physiological arousal throughout the doctor-patient interaction process. The next step should be linking the changes in physiological arousal to what exactly is happening at that moment in the interaction between doctor and patient. This could provide support for the validity of experimental designs in which standardized videotaped medical visits are shown to patients. More research is needed on predictors of (non-)coherence in certain subjects.

Development of the Verona coding definitions of emotional sequences to code health providers' responses (VR-CoDES-P) to patient cues and concerns.

OBJECTIVE: To present a method to classify health provider responses to patient cues and concerns according to the VR-CoDES-CC (Del Piccolo et al. (2009) [2] and Zimmermann et al. (submitted for publication) [3]). The system permits sequence analysis and a detailed description of how providers handle patient's expressions of emotion. METHODS: The Verona-CoDES-P system has been developed based on consensus views within the "Verona Network of Sequence Analysis". The different phases of the creation process are described in detail. A reliability study has been conducted on 20 interviews from a convenience sample of 104 psychiatric consultations. RESULTS: The VR-CoDES-P has two main classes of provider responses, corresponding to the degree of explicitness (yes/no) and space (yes/no) that is given by the health provider to each cue/concern expressed by the patient. The system can be further subdivided into 17 individual categories. Statistical analyses showed that the VR-CoDES-P is reliable (agreement 92.86%, Cohen's kappa 0.90 (±0.04) p<0.0001). CONCLUSION: Once validity and reliability are tested in different settings, the system should be applied to investigate the relationship between provider responses to patients' expression of emotions and outcome variables. PRACTICE IMPLICATIONS: Research employing the VR-CoDES-P should be applied to develop research-based approaches to maximize appropriate responses to patients' indirect and overt expressions of emotional needs.

The effects of physicians' affect-oriented communication style and raising expectations on analogue patients' anxiety, affect and expectancies.

OBJECTIVE: Patients' affect and expectancies can set off placebo effects and thus impact patients' health. We assessed the relative effects of physicians' affect-oriented communication style and raising expectations on patients' affective state and outcome expectancies. METHOD: Thirty healthy women presented severe menstrual pain in a scripted consultation with a general practitioner (GP). In a 2x2 randomized controlled trial, the GP communicated in a warm, empathic or cold, formal way and raised positive or uncertain expectations. Effects on subjects' state anxiety, affective state and outcome expectancies were assessed. RESULTS: Only warm, empathic communication combined with positive expectations led to a significant and relevant decrease in state anxiety. Subjects' positive and negative affects were influenced by GPs affect-oriented communication style. Negative affect and outcome expectancies are influenced by GP suggestions about outcomes. CONCLUSION: Manipulations in physicians' affect-oriented and expectancy-related communication can have a large impact on patients' affective state and outcome expectations. A combination of a warm, empathic communication style and raising positive expectations resulted in optimal subject outcomes. PRACTICE IMPLICATIONS: Physicians should take into account that communicating in warm, empathic way combined with raising positive expectations seems to lead to the most favorable effects on patients' state anxiety and outcome expectancies.

The silent healer: the role of communication in placebo effects.

Placebo effects have an ambiguous reputation, as they are associated with sham treatment and deceit on the one hand and as interesting phenomena, which might be clinically relevant on the other. The goal of this paper is to demonstrate that placebo effects are relevant and can be used as an effective part of many treatments by using communication targeting placebo effect mechanisms. We examined the history of placebos and the placebo effect, addressing common misconceptions and disentangling ambiguities. We then reviewed whether the placebo effect can be robustly shown in the current literature, and zoomed in on the plausible mechanisms (conditioning, expectancies and affect manipulation) through which the placebo effect might be produced. Observing the link with the doctor-patient communication literature, and pleading for a better integration of the two research traditions we conclude by setting out a research agenda for testing the role of communication in placebo effects.

Looking for trouble: the added value of sequence analysis in finding evidence for the role of physicians in patients' disclosure of cues and concerns.

BACKGROUND: Not knowing patient concerns can lead to misunderstandings, incomplete diagnoses, patient dissatisfaction, and nonadherence. Although many studies show relations between physician communication and patients' expression of cues or concerns, most of these studies are cross-sectional, thus limiting the interpretation of these relationships. Sequence analysis can show the immediate effects of physician communication behaviors. OBJECTIVE: To show the added value of sequence analysis in finding evidence for the role of physician communication in patients' disclosure of cues and concerns. RESEARCH QUESTIONS: Which physician communication predicts patients' expression of cues or concerns when using 2 different types of analysis: sequence analysis and cross-sectional analysis? METHODS: In a sample of 99 videotaped medical encounters with hypertensive patients in General Practice, we coded communication with Roter Interaction Analysis System and timed physician eye contact. For the cross-sectional analyses, we performed Poisson regression analyses to establish which physician communication is related to the total amount of patient cues and concerns. For the sequential analyses, we performed logistic regression analyses to establish which physician communication is directly followed by cues or concerns. We report incidence rate ratios and odds ratios (ORs), respectively. RESULTS: Both methods show that physicians' facilitative communication (1.21 and 2.33, respectively), eye contact (1.02 and 1.51, respectively), and psychosocial questions (2.42 and 3.50, respectively) are related to more disclosure of cues and concerns. Moreover, sequence analysis shows that patients' expression of cues or concerns is less often preceded by physician social talk (OR = 0.49), giving instructions (OR = 0.38) and providing biomedical information (OR = 0.45) or counseling (OR = 0.39). In the cross-sectional analyses, these relations are absent or-before controlling for confounding variables-even in the opposite direction. All reported results are significant at P < 0.01 or P < 0.001. CONCLUSIONS: Although cross-sectional analyses and sequence analyses show grossly the same results, sequence analysis is more precisely in demonstrating the direct influence of physician communication on subsequent cues and concerns by the patient. Physicians should avoid long monologues with medical information and should use facilitative communication, eye contact, and psychosocial questions to help patients express themselves.

Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients.

BACKGROUND: Departing from the hypotheses that over the past decades patients have become more active participants and physicians have become more task-oriented, this study tries to identify shifts in GP and patient communication patterns between 1986 and 2002. METHODS: A repeated cross-sectional observation study was carried out in 1986 and 2002, using the same methodology. From two existing datasets of videotaped routine General Practice consultations, a selection was made of consultations with hypertension patients (102 in 1986; 108 in 2002). GP and patient communication was coded with RIAS (Roter Interaction Analysis System). The data were analysed, using multilevel techniques. RESULTS: No gender or age differences were found between the patient groups in either study period. Contrary to expectations, patients were less active in recent consultations, talking less, asking fewer questions and showing less concerns or worries. GPs provided more medical information, but expressed also less often their concern about the patients' medical conditions. In addition, they were less involved in process-oriented behaviour and partnership building. Overall, these results suggest that consultations in 2002 were more task-oriented and businesslike than sixteen years earlier. CONCLUSION: The existence of a more equal relationship in General Practice, with patients as active and critical consumers, is not reflected in this sample of hypertension patients. The most important shift that could be observed over the years was a shift towards a more businesslike, task-oriented GP communication pattern, reflecting the recent emphasis on evidence-based medicine and protocolized care. The entrance of the computer in the consultation room could play a role. Some concerns may be raised about the effectiveness of modern medicine in helping patients to voice their worries.