Blinding, sham, and treatment effects in randomized controlled trials for back pain in 2000-2019: A review and meta-analytic approach
BACKGROUND/UNASSIGNED:Blinding aims to minimize biases from what participants and investigators know or believe. Randomized controlled trials, despite being the gold standard to evaluate treatment effect, do not generally assess the success of blinding. We investigated the extent of blinding in back pain trials and the associations between participant guesses and treatment effects. METHODS/UNASSIGNED:We did a review with PubMed/OvidMedline, 2000-2019. Eligibility criteria were back pain trials with data available on treatment effect and participants' guess of treatment. For blinding, blinding index was used as chance-corrected measure of excessive correct guess (0 for random guess). For treatment effects, within- or between-arm effect sizes were used. Analyses of investigators' guess/blinding or by treatment modality were performed exploratorily. RESULTS/UNASSIGNED:â€‰=â€‰0.046). CONCLUSION/UNASSIGNED:Participants in active treatments in back pain trials guessed treatment identity more correctly, while those in sham treatments tended to display successful blinding. Excessive correct guesses (that could reflect weaker blinding and/or noticeable effects) by participants and investigators demonstrated larger effect sizes. Blinding and sham treatment effects on back pain need due consideration in individual trials and meta-analyses.
Safety and feasibility of a novel in-bed resistance training device in older inpatients [Meeting Abstract]
Background: Deconditioning from prolonged bedrest during hospitalization predisposes older patients to loss of mobility and the need for additional rehabilitation post-discharge. Despite recognition of the harms of prolonged bedrest and evidence that resistance training (RT) reverses deconditioning, few interventions have provided such exercise for hospitalized older adults. We evaluated the safety and feasibility of a novel exercise device used in a high-intensity RT routine in older age inpatients.
Method(s): In collaboration with the NYU Grossman School of Medicine Center for Healthcare Innovation and Delivery Science we developed a lightweight, portable RT device, which attaches to a hospital bed footboard and allows for over 20 exercises in 4 categories: upper-body, lower-body, back and core. We recruited and trained willing patients to use this device with a goal of completing 7 exercises per workout. We included inpatients (age > 70) on a general medical unit with a PT/OT order. Those having exercise limiting orthopedic or neurologic disability, and acute cardiopulmonary limitations were excluded. Each workout included exercises from each category, 10-20 isometric 3-second holds per exercise, and minimal rest. Patients were: (1) evaluated on their ability to complete each workout; (2) surveyed on their experience with the device; and (3) monitored for adverse events.
Result(s): 11 patients were trained using the device for an average of 2.0 total sessions per hospitalization (mean age: 80.9 years, range: 71-101; 54.5% female). Reasons for fewer sessions included early discharge, delirium, and contact precautions. Patients completed 89.3% of the exercises they performed. We noted no adverse events. 72.7% stated they would use the device on their own and 90.9% believed there is not enough exercise performed in hospitals.
Conclusion(s): This pilot study provides evidence of the safety and feasibility of a novel RT device to prevent inpatient deconditioning. Patients were eager and able to participate in RT. We did not observe fear of safety or views of high intensity RT as inappropriate for older hospitalized patients. Whether use of RT will change discharge-related outcomes requires further study
Bilateral subacute radial head fractures after a fall: A case report [Meeting Abstract]
Case Description: The patient is a right-hand dominant female who presented with right greater than left wrist and elbow pain after falling on outstretched hands 1 month prior. At the time of injury, she was assessed by a physician who recommended no imaging or intervention. On presentation to us, she described the pain as non-radiating, 3/10, exacerbated with weight-bearing, and improved with NSAIDs. Physical examination revealed moderate swelling at bilateral elbows, decreased pronation of bilateral forearms, and tenderness over bilateral radial heads.
Setting(s): Outpatient office Patient: 54-year-old female with bilateral wrist and elbow pain after a fall. Assessment/Results: Imaging revealed bilateral nondisplaced, healing, subacute fractures of the radial head with moderate joint effusions and preserved joint spaces. As the patient was found to have a type I Mason Classification fracture, she was treated conservatively with occupational therapy utilizing therapeutic exercise, which successfully decreased her pain. Although improved, she continued to have mildly decreased range of motion.
Discussion(s): This is the first reported case of delayed diagnosis of bilateral radial head fractures due to mechanical fall. During initial evaluation, this diagnosis was missed due to low suspicion as bilateral radial head fractures are rare. The radial head is susceptible to fracture when a patient falls on an outstretched hand because of a 15-degree angle between the radial neck and shaft. Diagnosis can be confirmed with xray imaging. Radial head fractures are classified by the Mason classification system, with Mason type 1 fractures indicating nondisplaced fractures and having an excellent prognosis. However, if patients are not mobilized within 2-3 weeks post-fracture they are prone to decreased range of motion, as was the case with our patient.
Conclusion(s): Physicians should have high clinical suspicion for bilateral radial head fractures, as early diagnosis and appropriate management are essential in improving elbow mobility and function
Constructing a Shared Mental Model for Feedback Conversations: Faculty Workshop Using Video Vignettes Developed by Residents
Introduction/UNASSIGNED:Providing feedback is a fundamental principle in medical education; however, as educators, our community lacks the necessary skills to give meaningful, impactful feedback to those under our supervision. By improving our feedback-giving skills, we provide concrete ways for trainees to optimize their performance, ultimately leading to better patient care. Methods/UNASSIGNED:In this faculty development workshop, faculty groups used six feedback video vignettes scripted, enacted, and produced by residents to arrive at a shared mental model of feedback. During workshop development, we used qualitative analysis for faculty narratives combined with the findings from a focused literature review to define dimensions of feedback. Results/UNASSIGNED:Twenty-three faculty (physical medicine and rehabilitation and neurology) participated in seven small-group workshops. Analysis of group discussion notes yielded 343 codes that were collapsed into 25 coding categories. After incorporating the results of a focused literature review, we identified 48 items grouped into 10 dimensions of feedback. Online session evaluation indicated that faculty members liked the workshop's format and thought they were better at providing feedback to residents as a result of the workshop. Discussion/UNASSIGNED:Small faculty groups were able to develop a shared mental model of dimensions of feedback that was also grounded in medical education literature. The theme of specificity of feedback was prominent and echoed recent medical education research findings. Defining performance expectations for feedback providers in the form of a practical and psychometrically sound rubric can enhance reliable scoring of feedback performance assessments and should be the next step in our work.
3AC: dealing with tensions in assessment (and elsewhere) [Comment]
Faculty feedback that begins with resident self-assessment: motivation is the key to success
CONTEXT/BACKGROUND:The seeking and incorporating of feedback are necessary for continuous performance improvement in medicine. We know that beginning feedback conversations with resident self-assessment may reduce some of the tensions experienced by faculty staff. However, we do not fully understand how residents experience feedback that begins with self-assessment, and whether any existing theoretical frameworks can explain their experiences. METHODS:We conducted a constructivist grounded theory study exploring physical medicine and rehabilitation residents' experiences as they engaged in a structured self-assessment and faculty staff feedback programme. Utilising purposive sampling, we conducted 15 individual interviews and analysed verbatim transcripts iteratively. We implemented several procedures to enhance the credibility of the findings and the protection of participants during recruitment, data collection and data analysis. After defining the themes, we reviewed a variety of existing frameworks to determine if any fitted the data. RESULTS:Residents valued self-assessment followed by feedback (SAFF) and had clear ideas of what makes the process useful. Time pressures and poor feedback quality could lead to a process of 'just going through the motions'. Motivation coloured residents' experiences, with more internalised motivation related to a more positive experience. There were no gender- or year of training-related patterns. CONCLUSIONS:Self-determination theory provided the clearest lens for framing our findings and fitted into a conceptual model linking the quality of the SAFF experience and residents' motivational loci. We identified several study limitations including time in the field, evolving characteristics of the SAFF programme and the absence of faculty voices. We believe that by better understanding residents' experiences of SAFF, educators may be able to tailor the feedback process, enhance clinical performance and ultimately improve patient care.
Entrustable Professional Activities For Residency Training in Physical Medicine and Rehabilitation
Entrustable professional activities are observable units of professional practice that can potentially provide a link between competency-based medical education and clinical practice. The authors, part of a subcommittee of the Association of Academic Physiatrists Education Committee, identified a set of entrustable professional activities that would serve residency training programs in the specialty of physical medicine and rehabilitation. Using a modified Delphi process, residency program directors in the field reviewed and validated a set of entrustable professional activities. The final set of 19 entrustable professional activities is presented in this article.
Clinical Reasoning Workshop: Lumbosacral Spine and Hip Disorders
Introduction/UNASSIGNED:Helping physicians-in-training develop effective clinical reasoning skills may facilitate progression to expertise, reduce diagnostic errors, and improve patient safety. Using our previous experience, we developed a workshop that reviews musculoskeletal lumbar spine and hip conditions. This workshop also uses deductive and inductive modes of clinical reasoning and provides opportunities for learners to practice toggling from one to another while reviewing. Methods/UNASSIGNED:Using exemplar musculoskeletal vignettes, this workshop allows residents to practice engaging and toggling between both modes of information processing. This workshop also includes pre- and posttests, small-group learning, and a small-group competition. Results/UNASSIGNED:The workshop was implemented with a group of 26 physical medicine and rehabilitation residents. Although residents did well on the pretest, the workshop improved their test performance. Residents liked the workshop and thought it improved their diagnostic ability. Discussion/UNASSIGNED:A workshop that included team- and case-based learning, key features assessment, script theory, and gamification was effective in engaging residents and resulted in high resident satisfaction and the perception of increased ability to tackle clinical problems. Learning from our experience with the previous workshop resulted in significant reduction in faculty time required, and increased the number of residents who were able to complete both pre- and posttests.
Clinical Reasoning Workshop: Cervical Spine and Shoulder Disorders
Introduction/UNASSIGNED:Information processing and cognitive factors may be a cause of physician diagnostic errors. While the conceptual framework of dual processing in clinical reasoning is widely accepted, how can residents be taught to switch between automatic and reflective modes, and will doing so improve their decision making? Developing effective clinical reasoning habits while in training may facilitate progression to expertise, reduce diagnostic errors, and improve patient safety. Methods/UNASSIGNED:This workshop allows residents to practice engaging in and toggling between both modes of information processing using exemplar musculoskeletal vignettes. Originally implemented with a group of 26 physical medicine and rehabilitation residents, the workshop includes pre- and posttests, small-group learning, and a small-group competition. Results/UNASSIGNED:Posttest scores improved on pretest scores. In an online session evaluation, residents indicated they liked the workshop and thought it improved their diagnostic ability. Discussion/UNASSIGNED:This workshop, which includes team- and case-based learning, key features assessment, dual processing theory, and gamification, was effective in engaging residents and resulted in high resident satisfaction and perception of increased ability to tackle clinical problems. Faculty time required was moderate after the initial setup, which in our case primarily involved uploading content into an online learning management system.
Anterior cruciate liagment and posterior cruciate ligament tears
Cham, Switzerland : Springer,