Article

Real-time feedback improves accuracy of manually applied forces during cervical spine mobilisation

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Abstract

To determine if real-time feedback enables students to apply mobilisation forces to the cervical spine that are similar to an expert physiotherapist. An instrumented treatment table collected mobilisation force data with feedback about forces displayed on a computer screen. An expert physiotherapist performed posteroanterior mobilisation of C7 on 21 asymptomatic subjects while forces were recorded. These data were used as force targets for 51 students who mobilised one of the asymptomatic subjects on two occasions. Students' forces were recorded before and after practice either with (experimental group) or without real-time feedback (control group). Improved performance was defined as a smaller difference between expert and student forces, comparing groups with non-parametric statistics. Students receiving feedback applied more accurate forces than controls (median difference between student and expert forces in the experimental group, 4.0N, inter-quartile range (IQR) 1.9-7.7; in controls, 14.3N, IQR 6.2-26.2, difference between groups p<0.001). One week later, these students still applied forces that more closely matched the expert's compared to controls (p<0.01), but the differences between the students' and expert's forces were greater (6.4N, IQR 3.1-14.7). Practice with real-time objective feedback enables students to apply forces similar to an expert, supporting its use in manual therapy training.

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... CSM is commonly included in the curriculum of the manual therapies (Physiotherapy, Osteopathy and Chiropractic) [6]. Students are expected to practice autonomous manual therapy in clinical practice, therefore competence is essential when implementing spinal manipulation [7][8][9][10][11]. ...
... This study determined no increase in displacement following real-time feedback, a finding consistent with previous studies [8][9][10][11]29]. This maybe an important consideration regarding the safety of learning with such techniques as excessive displacement places the arterial structures at greater risk [30]. ...
... Previous studies have measured the extent of intrasubject reliability in CSM [10,18,29]. They all demonstrated high reliability in the variables observed, but there were important differences between the methods employed. ...
... All rights reserved. doi:10.1016/j.physio.2011.02.002 that concurrent feedback improves accuracy in mean peak force application [22][23][24][25], but no identified study has investigated the effect of feedback on the application of force amplitude or oscillation frequency. Further, there is little data available on student learning of lumbar mobilisations, with only one identified study reporting grade II force applications [23]. ...
... Students participated in pairs, with each student applying mobilisations to the lumbar spine of their partner and acting as a spinal model. Power and sample size calculations indicated that a difference in accuracy of 5 N between measurement occasions could be detected with 90% power with a sample of 29 subjects [24,34]. ...
... A custom-designed program displayed real-time feedback on force parameters on a computer screen [24]. Individual force parameter targets were programmed for different subjects and mobilisation grades, loaded via a configuration window (Fig. 1). ...
Article
To determine the optimum practice for students to apply lumbar mobilisations with force parameters consistent with an experienced therapist. Thirty physiotherapy students attended three practice sessions over two weeks where they performed lumbar mobilisations on a fellow student. Students viewed feedback on their applied forces (measured using an instrumented treatment table) in real-time on a computer screen. Performance was tested before and after feedback at each practice session and at follow up sessions one week and three months later. A greater accuracy in manual force application was defined as a smaller difference between each student-applied force parameter (mean peak force (N), force amplitude (N), and oscillation frequency (Hz)), and that previously applied by an expert. Test data from each session was analysed using Friedman's and Wilcoxon signed rank tests to determine student learning and retention. Students were more accurate after feedback at Session 1 (median difference between student and expert force parameters 7.7N, IQR 3.2-15.3) than before feedback (median 17.5, IQR 7.3-33.6, P<0.001). Increased practice improved performance, with the greatest accuracy after feedback at Session 3 (median 7.0, IQR 3.5-11.9, P<0.01). Retention however was poor, with performance at follow-up sessions no different to baseline. Students apply more consistent and accurate mean peak force, force amplitude and oscillation frequency after practising with objective, concurrent feedback. Additional practice sessions further improve performance, however retention is poor.
... CSM is commonly included in the curriculum of the manual therapies (Physiotherapy, Osteopathy and Chiropractic) [6]. Students are expected to practice autonomous manual therapy in clinical practice, therefore competence is essential when implementing spinal manipulation [7][8][9][10][11]. ...
... This study determined no increase in displacement following real-time feedback, a finding consistent with previous studies [8][9][10][11]29]. This maybe an important consideration regarding the safety of learning with such techniques as excessive displacement places the arterial structures at greater risk [30]. ...
... Previous studies have measured the extent of intrasubject reliability in CSM [10,18,29]. They all demonstrated high reliability in the variables observed, but there were important differences between the methods employed. ...
Article
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Background Cervical Spinal Manipulation (CSM) is considered a high-level skill of the central nervous system because it requires bimanual coordinated rhythmical movements therefore necessitating training to achieve proficiency. The objective of the present study was to investigate the effect of real-time feedback on the performance of CSM. Methods Six postgraduate physiotherapy students attending a training workshop on Cervical Spine Manipulation Technique (CSMT) using inertial sensor derived real-time feedback participated in this study. The key variables were pre-manipulative position, angular displacement of the thrust and angular velocity of the thrust. Differences between variables before and after training were investigated using t-tests. Results There were no significant differences after training for the pre-manipulative position (rotation p = 0.549; side bending p = 0.312) or for thrust displacement (rotation p = 0.247; side bending p = 0.314). Thrust angular velocity demonstrated a significant difference following training for rotation (pre-training mean (sd) 48.9°/s (35.1); post-training mean (sd) 96.9°/s (53.9); p = 0.027) but not for side bending (p = 0.521). Conclusion Real-time feedback using an inertial sensor may be valuable in the development of specific manipulative skill. Future studies investigating manipulation could consider a randomized controlled trial using inertial sensor real time feedback compared to traditional training.
... [15][16][17][18][19] In the lumbar and cervical spine, researchers have analyzed biomechanical parameters such as force, frequency, and amplitude in clinician applied mobilizations. [19][20][21][22][23][24][25][26] Understanding joint mobilization biomechanical parameters and clinician reliability may help refine teaching methods, determine safety of use, establish dose effects, improve mobilization grading schemes, and suggest suitability for use in different patient populations. 20,23,25,[27][28][29] However, there is limited ability to quantify these parameters. ...
... [19][20][21][22][23][24][25][26] Understanding joint mobilization biomechanical parameters and clinician reliability may help refine teaching methods, determine safety of use, establish dose effects, improve mobilization grading schemes, and suggest suitability for use in different patient populations. 20,23,25,[27][28][29] However, there is limited ability to quantify these parameters. Authors have consistently reported poor to fair inter-clinician reliability for joint mobilization biomechanical measurements. ...
... Authors have consistently reported poor to fair inter-clinician reliability for joint mobilization biomechanical measurements. 20,21,23,25,[27][28][29] Measurement error stems from individual clinicians, instruments and variability of the attribute, notably the patient. 30 Clinician demographic and anthropometric characteristics may influence mobilization technique application. ...
Article
Full-text available
This study determined biomechanical force parameters and reliability among clinicians performing knee joint mobilizations. Sixteen subjects with knee osteoarthritis and six therapists participated in the study. Forces were recorded using a capacitive-based pressure mat for three techniques at two grades of mobilization, each with two trials of 15 seconds. Dosage (force-time integral), amplitude, and frequency were also calculated. Analysis of variance was used to analyze grade differences, intraclass correlation coefficients determined reliability, and correlations assessed force associations with subject and rater variables. Grade IV mobilizations produced higher mean forces (P<0.001) and higher dosage (P<0.001), while grade III produced higher maximum forces (P = 0.001). Grade III forces (Newtons) by technique (mean, maximum) were: extension 48, 81; flexion 41, 68; and medial glide 21, 34. Grade IV forces (Newtons) by technique (mean, maximum) were: extension 58, 78; flexion 44, 60; and medial glide 22, 30. Frequency (Hertz) ranged between 0.9-1.1 (grade III) and 1.4-1.6 (grade IV). Intra-clinician reliability was excellent (>0.90). Inter-clinician reliability was moderate for force and dosage, and poor for amplitude and frequency. Force measurements were consistent with previously reported ranges and clinical constructs. Grade III and grade IV mobilizations can be distinguished from each other with differences for force and frequency being small, and dosage and amplitude being large. Intra-clinician reliability was excellent for all biomechanical parameters and inter-clinician reliability for dosage, the main variable of clinical interest, was moderate. This study quantified the applied forces among multiple clinicians, which may help determine optimal dosage and standardize care.
... 12 The use of real-time feedback tools for the student enabling them to receive objective information regarding the manipulation could complement traditional teaching methods of spinal manipulation and reduce the learning period. 13 In the training and study of mobilization and manipulation, the application of high-velocity-low-amplitude techniques was used recursively, with variables and kinetic parameters such as peak force (amplitude), 2,8,9,[13][14][15][16][17][18][19][20][21][22][23][24][25] mean force, 8,9,[13][14][15][16][17][18][19][20][21] time, 2,16-25 force direction, 8,9,[13][14][15]18,19,25 or force production rate. 2,16,[20][21][22][23][24][25] These parameters were set during cervical, 8,[13][14][15][16]20,24 thoracic, 20,24,25 and lumbar manipulations, 2,9,16,19,20 and recorded using different instruments such as a hand-held force transducer, 16,18 an instrumented manikin, 22,23 or an instrumented treatment (Table 2). ...
... 12 The use of real-time feedback tools for the student enabling them to receive objective information regarding the manipulation could complement traditional teaching methods of spinal manipulation and reduce the learning period. 13 In the training and study of mobilization and manipulation, the application of high-velocity-low-amplitude techniques was used recursively, with variables and kinetic parameters such as peak force (amplitude), 2,8,9,[13][14][15][16][17][18][19][20][21][22][23][24][25] mean force, 8,9,[13][14][15][16][17][18][19][20][21] time, 2,16-25 force direction, 8,9,[13][14][15]18,19,25 or force production rate. 2,16,[20][21][22][23][24][25] These parameters were set during cervical, 8,[13][14][15][16]20,24 thoracic, 20,24,25 and lumbar manipulations, 2,9,16,19,20 and recorded using different instruments such as a hand-held force transducer, 16,18 an instrumented manikin, 22,23 or an instrumented treatment (Table 2). ...
... 12 The use of real-time feedback tools for the student enabling them to receive objective information regarding the manipulation could complement traditional teaching methods of spinal manipulation and reduce the learning period. 13 In the training and study of mobilization and manipulation, the application of high-velocity-low-amplitude techniques was used recursively, with variables and kinetic parameters such as peak force (amplitude), 2,8,9,[13][14][15][16][17][18][19][20][21][22][23][24][25] mean force, 8,9,[13][14][15][16][17][18][19][20][21] time, 2,16-25 force direction, 8,9,[13][14][15]18,19,25 or force production rate. 2,16,[20][21][22][23][24][25] These parameters were set during cervical, 8,[13][14][15][16]20,24 thoracic, 20,24,25 and lumbar manipulations, 2,9,16,19,20 and recorded using different instruments such as a hand-held force transducer, 16,18 an instrumented manikin, 22,23 or an instrumented treatment (Table 2). ...
Article
The purpose of this study was to analyze the effect of real-time feedback on the learning process for posterior-anterior thoracic manipulation (PATM) comparing 2 undergraduate physiotherapy student groups. The study design was a randomized controlled trial in an educational setting. Sixty-one undergraduate physiotherapy students were divided randomly into 2 groups, G1 (n = 31; group without feedback in real time) and G2 (n = 30; group with real-time feedback) participated in this randomized controlled trial. Two groups of physiotherapy students learned PATM, one using a traditional method and the other using real-time feedback (inertial sensor). Measures were obtained preintervention and postintervention. Intragroup preintervention and postintervention and intergroup postintervention scores were calculated. An analysis of the measures' stability was developed through an interclass correlation index. Time, displacement and velocity, and improvement (only between groups) to reach maximum peak and to reach minimum peak from maximum peak, total manipulation time, and stability of all outcome measures were the outcome measures. Statistically significant differences were found in all variables analyzed (intragroup and intergroup) in favor of G2. The values of interclass correlation ranged from 0.627 to 0.706 (G1) and between 0.881 and 0.997 (G2). This study found that the learning process for PATM is facilitated when the student receives real-time feedback. Copyright © 2015. Published by Elsevier Inc.
... In contrast to simple motor tasks, learning of complex tasks with concurrent visual feedback has predominantly been reported to be effective. In physical therapy, practice of complex mobilization skills was facilitated by concurrently displayed bars or force-time plots indicating the deviation from the target force: Snodgrass, Rivett, Robertson, and Stojanovski (2010) compared a group receiving combined concurrent and terminal feedback with a no-feedback group and reported superiority of the feedback group in retention tests (Snodgrass et al., 2010). In the study by Lee, Moseley, and Refshauge (1990), the concurrent feedback group also outperformed the no-feedback group (Lee et al., 1990). ...
... In summary, it seems that the more complex a task is, the more the learner can profit from concurrent visual feedback. Positive effects of concurrent feedback have been demonstrated in quite different tasks, such as mobilization in physical therapy Lee et al., 1990;Snodgrass et al., 2010), interlimb out-of-phase coordination tasks (Kovacs & Shea, 2011;Swinnen et al., 1997;Wishart et al., 2002), a slalom type movement on a ski simulator Wulf et al., 1998), a balancing task on a stabilometer , ball throwing (Schack et al., 2008;Schack & Heinen, 2007), running (Crowell & Davis, 2011), indoor rowing (however, without testing retention) (Anderson, Harrison, & Lyons, 2005), and table tennis (Todorov et al., 1997). In early learning phases of complex task learning, concurrent visual feedback can prevent cognitive overload (Wulf & Shea, 2002), make the relevant information more accessible, and help the learner to build up a first movement representation/motor program. ...
... In complex tasks, visual feedback has also been provided by abstract visualizations (Crowell & Davis, 2011;Debaere, Wenderoth, Sunnaert, Van Hecke, & Swinnen, 2003, 2004Eaves et al., 2011;Eriksson et al., 2011;Hurley & Lee, 2006;Kovacs & Shea, 2011;Lee et al., 1990;Lee, Swinnen, & Verschueren, 1995;Maslovat et al., 2009;Smethurst & Carson, 2001;Snodgrass et al., 2010;Swinnen et al., 1998;Swinnen et al., 1997;Wishart et al., 2002;Wulf et al., 1999;Wulf et al., 1998). For complex interlimb coordination tasks, a displacement-displacement plot (Lissajous figure) has been used in many studies as an abstract concurrent feedback (Debaere et al., 2003(Debaere et al., , 2004Kovacs & Shea, 2011;Maslovat et al., 2009;Ronsse, Puttemans, et al., 2011;Smethurst & Carson, 2001;Swinnen et al., 1998;Swinnen et al., 1997). ...
Article
It is generally accepted that augmented feedback, provided by a human expert or a technical display, effectively enhances motor learning. However, discussion of the way to most effectively provide augmented feedback has been controversial. Related studies have focused primarily on simple or artificial tasks enhanced by visual feedback. Recently, technical advances have made it possible also to investigate more complex, realistic motor tasks and to implement not only visual, but also auditory, haptic, or multimodal augmented feedback. The aim of this review is to address the potential of augmented unimodal and multimodal feedback in the framework of motor learning theories. The review addresses the reasons for the different impacts of feedback strategies within or between the visual, auditory, and haptic modalities and the challenges that need to be overcome to provide appropriate feedback in these modalities, either in isolation or in combination. Accordingly, the design criteria for successful visual, auditory, haptic, and multimodal feedback are elaborated.
... This characterization of parameters and reliability for joint mobilization techniques may help refine teaching methods, determine safety and dosages, drive theories of mechanisms of effect, and suggest suitability for use in different populations. [24][25][26][27][28][29][30] Biomechanical parameters describe the techniques and also provide an opportunity to examine their reliability. Existing evidence indicates overall fair to poor inter-rater reliability for force measurements during spinal mobilization or palpatory assessments, which improves for intrarater measures. ...
... Existing evidence indicates overall fair to poor inter-rater reliability for force measurements during spinal mobilization or palpatory assessments, which improves for intrarater measures. [24][25][26][27]29,30 The fair to poor inter-rater and intrarater reliability for manual mobilization assessments and techniques is a central issue affecting reproducibility, dosage determination, force quantification, and training methods for these techniques. Little is known about the magnitude of forces applied during knee mobilization. ...
... Several studies reporting biomechanical parameters of joint mobilization such as force or oscillation frequency have not included reliability calculations. 46,48,49 However, recent work in the cervical spine 29,45,47,50 included both similar biomechanical parameters and reliability calculations and provides an opportunity to put our results in context. Though there are differences in raters, calculations and instrumentation, our reliability was equal to or greater than that reported in the cervical spine. ...
Article
Full-text available
The purpose of this study was to quantify the biomechanical properties of specific manual therapy techniques in patients with symptomatic knee osteoarthritis. Twenty subjects (7 female/13 male, age 54±8 years, ht 1·7±0·1 m, wt 94·2±21·8 kg) participated in this study. One physical therapist delivered joint mobilizations (tibiofemoral extension and flexion; patellofemoral medial-lateral and inferior glide) at two grades (Maitland's grade III and grade IV). A capacitance-based pressure mat was used to capture biomechanical characteristics of force and frequency during 2 trials of 15 second mobilizations. Statistical analysis included intraclass correlation coefficient (ICC(3,1)) for intrarater reliability and 2×4 repeated measures analyses of variance and post-hoc comparison tests. Force (Newtons) measurements (mean, max.) for grade III were: extension 45, 74; flexion 39, 61; medial-lateral glide 20, 34; inferior glide 16, 27. Force (Newtons) measurements (mean, max.) for grade IV were: extension 57, 76; flexion 47, 68; medial-lateral glide 23, 36; inferior glide 18, 35. Frequency (Hz) measurements were between 0·9 and 1·2 for grade III, and between 2·1 and 2·4 for grade IV. ICCs were above 0·90 for almost all measures. Maximum force measures were between the ranges reported for cervical and lumbar mobilization at similar grades. Mean force measures were greater at grade IV than III. Oscillation frequency and peak-to-peak amplitude measures were consistent with the grade performed (i.e. greater frequency at grade IV, greater peak-to-peak amplitude at grade III). Intrarater reliability for force, peak-to-peak amplitude and oscillation frequency for knee joint mobilizations was excellent.
... Allerdings sollte beachtet werden, dass eine Vielzahl der Studien Mängel bei der Beschreibung der Studienpopulation (z. B. Alter, Geschlecht, Anzahl pro Gruppe) aufwies [4,7,18,19,22,23,24,28,33]. Außer in der Studie von Hirthe et al. [10] fehlen in den meisten Publikationen Hinweise zur Stichprobenkalkulation. Weiter fällt auf, dass die Fallzahlen im Mittel bei 36 liegen, was besonders für eine Aufteilung in mehrere Gruppen klein ausfällt [7,28]. ...
... CONSORT-Statement und genaue Angaben zu Dropouts bzw. zur Anzahl der ausgewerteten Datensätze/Probanden [2,4,7,19,22,25,34]. Dies wäre aber anstelle einer Intention-to-treat-Analyse wichtig gewesen, auch wenn es sich nicht um Interventionsstudien handelt. ...
... 1. Gruppe: 4 Studien untersuchten den Unterschied zwischen (3 von 4 visuell quantitativ) Feedback und keinem Feedback [22,28,34], wobei nur die Arbeit von Watson u. Radwan [28] keinen Unterschied ermittelte. ...
Article
Hintergrund Mobilisationen und Manipulationen werden häufig von Chiropraktikern, Ärzten, Osteopathen, Physiotherapeuten und Heilpraktikern angewandt. Bisher fehlen jedoch in der Schulung von Therapeuten objektive Mess- bzw. Feedbackinstrumente. Der vorliegende Beitrag soll die Evidenz für die Effekte von unterschiedlichen Feedbackverfahren beim Erlernen von manuellen Techniken prüfen und Hinweise für einen sinnvollen Einsatz in der Schulung von Studenten liefern. Methode Die Recherche wurde in den Datenbanken Medline/PubMed, Cochrane Library, CINAHL und PEDro durchgeführt. Insgesamt 13 klinische Arbeiten wurden in Bezug auf ihre Methodik und zur Beantwortung der Fragestellung herangezogen und bewertet. Ergebnisse Beim Erlernen von Manipulations- und Mobilisationstechniken konnte der Effekt von Feedback und insbesondere quantitativem visuellem Feedback anhand einer signifikanten Verbesserung von biomechanischen Parametern und damit bei der Entwicklung von manipulativen Fähigkeiten nachgewiesen werden. Schlussfolgerungen Für den Effekt von Feedbackverfahren beim Erlernen von Manipulationstechniken existiert moderate bis gute Evidenz. Lernen unter Feedback verbessert die Manipulationstechnik hinsichtlich biomechanischer Parameter wie Krafteinsatz und Variabilität. Die für eine Technik relevanten physikalische Größen lassen sich mittels objektiver Messsysteme erfassen. Nichtsdestotrotz muss die klinische Relevanz diskutiert werden.
... An oscillation frequency target zone was displayed as a vertical bar on the right, with an indicator that moved up or down, representing an increase or decrease in oscillation rate. 50 The force parameters measured were MPF (N), force amplitude (N), and oscillation frequency (Hz). ...
... Students performed 12 practice trials of grade II central PA mobilization to the L3 vertebra of their partner, who was lying in the prone position. The number of practice trials was chosen based on previous studies 38, 50 and because it would likely be tolerable for a single session of mobilization. Grade II, defined as a large-amplitude movement within the resistance-free range, 33 was selected because it shows the greatest variation in forces applied by students 45 and is applied with a relatively gentle force that would be tolerated for multiple repetitions. ...
... A control group receiving no feedback was not included in the study design, because it has been previously demonstrated that practice with concurrent feedback is better than no feedback. 9,32,50 Students attended a single practice session at which data were recorded for 10 seconds without feedback, and the average over the 10-second period was calculated for each force parameter. Data were recorded for each student pretest (before any feedback was given), followed by 12 practice trials of 30 seconds of grade II central PA mobilization to the L3 vertebra (while receiving feedback). ...
Article
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Controlled laboratory study, longitudinal. To investigate the effects of frequency and self-control of feedback on physiotherapy students learning lumbar spinal mobilization. Posterior-to-anterior mobilization is included in most physiotherapy curricula. However, force application varies between therapists and the optimal feedback for learning is unknown. Sixty-two physiotherapy students were randomized to 3 feedback groups: constant (100% of practice trials), intermittent (33%), and self-controlled (varied according to student choice) feedback. Students performed 12 practice trials of grade II posterior-to-anterior mobilization to the third lumbar vertebra while receiving real-time feedback. The differences between students' force parameters (mean peak force [N], force amplitude [N], and oscillation frequency [Hz]) and those of a physiotherapist expert were compared between groups posttest and at a follow-up of 5 to 7 days using analysis of covariance. Students completed a survey regarding their perceptions of feedback. Students in the self-controlled group applied mean peak force (mean difference between student and expert, 6.7 N; 95% confidence interval [CI]: 4.4, 9.0) and force amplitude (6.3 N; 95% CI: 4.2, 8.4) that more closely matched the expert's than those applied by the constant group (13.7 N; 95% CI: 8.7, 18.6; P = .021, and 13.1 N; 95% CI: 8.9, 17.4; P = .028) at posttest, with similar results at follow-up for force amplitude only (self-controlled, 9.5 N; 95% CI: 5.8, 18.1; constant, 21.0 N; 95% CI: 13.3, 28.7; P = .018). There were no other significant differences. All students reported a better understanding of manual force application, but feedback preferences varied. Self-controlled feedback appears to be more beneficial than constant feedback for students learning to apply forces during lumbar mobilization.
... There are limited published normative values related to the amount of force required to execute a particular manual technique with clinical effectiveness. [3][4][5] Clinically, there is also significant variability in what would be considered appropriate force application based on patient morphology and clinical presentation. As a result, the clinician needs to use their tactile skills to assess tissue texture and passive tissue and joint resistance when determining the appropriate amount of manual force to exert onto the patient's body. ...
... Such technologies can quantify the performance of a skilled clinician, allowing for direct comparison between a novice learner's skills and those of the expert. 5,8,9 The field of chiropractics has started to develop normative values of force and speed to quantify the targeted load applied to tissues during manipulation techniques. 4 Snodgras et al. 5 reported that students demonstrated similar force applications of cervical mobilization, compared to expert physical therapists, when real-time pressure-sensor feedback was utilized. ...
... 5,8,9 The field of chiropractics has started to develop normative values of force and speed to quantify the targeted load applied to tissues during manipulation techniques. 4 Snodgras et al. 5 reported that students demonstrated similar force applications of cervical mobilization, compared to expert physical therapists, when real-time pressure-sensor feedback was utilized. Other professions, such as endoscopy, are finding ways to quantify manual skills and allow a direct comparison between learner and expert, which also clarifies for the learner the desired target performance. ...
Article
Full-text available
Purpose Physical therapy educators are responsible for ensuring that learners demonstrate sufficient skill acquisition for safe and effective clinical practice, which includes the learners’ ability to execute manual skills in a reliable and accurate manner. This study is the first attempt to assist physical therapy educators in assessing the feasibility of including new manual skills in the educational curriculum by using criteria for assessment of student learning. An example using these criteria is illustrated by a pilot experiment using the Vertical Compression Test (VCT) and Saliba Postural Classification System (SPCS), which are currently taught predominantly at the post-graduate level. Methods Physical therapy students (SPT) were trained in the VCT and SPCS during the first year of the educational curriculum. Six SPTs and two experienced clinicians (PT) participated in the experiment. An SPT and a PT applied the VCT to subjects in their normal resting posture (PPre) and in a corrected posture (PCor). Data collection measured quantity of force, duration of application, subjects’ sway, SPT/PT interpretation of test results, and students’ confidence in order to determine feasibility of inclusion. Results There were no differences in quantified manual compression forces with a significant correlation between SPT and PT. Movements of the center of pressure indicated test subjects stood steadier during VCT performed by PT compared to SPT, but not to a clinically significant degree. Interpretation of VCT and SPCS test results was excluded as a focus of this study due to curricular limitations that influenced the study design. Student feedback indicated satisfaction with the learning experience. Discussion The use of the proposed criteria for assessment of student learning confirmed feasibility of inclusion of the VCT in the entry-level physical therapy education curriculum. First-year DPT students demonstrated ability to perform the VCT with appropriate technique after minimal training.
... Prior research has also found that a visual external feedback display further benefits motor learning as this so-called augmented feedback permits the learner to view real-time feedback of personal movement (Kovacs & Shea, 2011;Snodgrass et al., 2010). For example, Kovacs et al., (2009) demonstrated that augmented visual feedback decreased the number of errors and time necessary to acquire a bimanual coordination task, although there was a drop in performance later, when the feedback was removed. ...
... In a later study, Kovacs and Shea (2011) found that gradually decreasing the frequency of augmented feedback overtime prevented this deterioration in performance. Snodgrass et al. (2010) demonstrated that augmented visual feedback enabled students to manually apply forces during a cervical spine mobilization that were similar to the forces applied by experts. In both the acquisition and retention phases, students who received augmented visual feedback applied forces that were similar to those of experts, while students in the control group did not. ...
Article
Many medical skills are complex due to their requirements for integration of declarative (biomedical) knowledge with perceptual–motor and perceptual–cognitive proficiency. While feedback generally helps learners guide their actions, it is unclear how feedback supports the integration of declarative knowledge with skills. Thus, we investigated the effect of expert and augmented feedback on acquisition and retention of a complex medical skill (acquiring a transthoracic echocardiogram) in a simulation study. We randomly assigned 36 medical undergraduate students to one of three feedback sources: Expert (EF), Augmented visual (HS), and Expert plus Help Screen (EF + HS). Participants practiced until reaching proficiency. Outcome measures (knowledge test and practical skill ratings on a 5-point scale), were gathered at initial acquisition and at retention after 11 days, the time needed to obtain the images and the quality of images obtained. We divided the knowledge test into three topics: names of the images, manipulation of the probe, and anatomy of the heart. At acquisition, immediately after training, EF group participants were faster at obtaining images than participants in the two other groups. On the retention test, there were no group differences for speed of obtaining images, but the EF + HS group scored significantly higher than the other two groups on image quality. Thus, expert feedback best assisted initial acquisition and combined augmented and expert feedback best assisted retention of this complex medical task. Expert assistance reduced learners’ cognitive load during initial practice, helping learners integrate declarative knowledge with physical skills.
... 10 Similarly, in physiotherapy education, skills laboratories represent promising strategies for developing clinical competence, 11 despite the fact that evidence on their effectiveness is quite limited. 12 In the field of manual therapy with reference to the acquisition of skills such as joint mobilisation, only a few studies have investigated the effectiveness of the provision of real-time visual feedback on a computer screen in terms of students' ability to establish optimal force and demonstrate adequate performance in cervical 13 and lumbar 14 spine mobilisations, both of which are competences expected at physiotherapy entry level. 15 The effectiveness of different teaching approaches in skills laboratories is still debated in the literature. ...
... Participants were mainly male, young, of normal weight and engaged in sports activities, in line with the student profile already documented in the literature. 13,14 Participants were characterised by a kinaesthetic learning style, and thus preferred practical exercises, examples and cases 43 as in the skills laboratories. Moreover, they also reported moderate scores on the GSE Scale, thereby indicating a general sense of perceived self-efficacy that may facilitate the goal setting, investment of effort and persistence 45 required in learning processes. ...
Article
Context: To date, despite the relevance of manual skills laboratories in physiotherapy education, evidence on the effectiveness of different teaching methods is limited. Objectives: Peyton's four-step and the 'See one, do one' approaches were compared for their effectiveness in teaching manual skills. Methods: A cluster randomised controlled trial was performed among final-year, right-handed physiotherapy students, without prior experience in manual therapy or skills laboratories. The manual technique of C1-C2 passive right rotation was taught by different experienced physiotherapist using Peyton's four-step approach (intervention group) and the 'See one, do one' approach (control group). Participants, teachers and assessors were blinded to the aims of the study. Primary outcomes were quality of performance at the end of the skills laboratories, and after 1 week and 1 month. Secondary outcomes were time required to teach, time required to perform the procedure and student satisfaction. Results: A total of 39 students were included in the study (21 in the intervention group and 18 in the control group). Their main characteristics were homogeneous at baseline. The intervention group showed better quality of performance in the short, medium and long terms (F1,111 = 35.91, p < 0.001). Both groups demonstrated decreased quality of performance over time (F2,111 = 12.91, p < 0.001). The intervention group reported significantly greater mean ± standard deviation satisfaction (4.31 ± 1.23) than the control group (4.03 ± 1.31) (p < 0.001). Although there was no significant difference between the two methods in the time required for teaching, the time required by the intervention group to perform the procedure was significantly lower immediately after the skills laboratories and over time (p < 0.001). Conclusions: Peyton's four-step approach is more effective than the 'See one, do one' approach in skills laboratories aimed at developing physiotherapy student competence in C1-C2 passive mobilisation.
... [26][27][28][29][30]32,33,[39][40][41] However, few studies have evaluated these new technologies for training students or clinicians in the delivery of mobilization procedures. [42][43][44][45][46] Gudavalli and colleagues recently described the development of an audible/visual and graphical feedback technology to measure cervical traction force delivery. 47 Here, we report on a training protocol and monthly certification process that used this technology to standardize the cervical traction forces delivered by 2 experienced DCs over a period of 10 months during a randomized controlled trial (RCT) of MCD. ...
... Several investigators have used instrumented mannequins, tables, or other devices to obtain force feedback during high-velocity, low-amplitude spinal manipulation (HVLA-SM) and posterior-to-anterior mobilizations. [26][27][28][29][30]32,33,39,40,[42][43][44][45][46] The present study differs in 3 substantive ways. First, our study is based on combined real-time audible/visual and immediate graphical feedback for a traction-type procedure used by chiropractors. ...
Article
Full-text available
Objective Doctors of chiropractic (DCs) use manual cervical distraction to treat patients with neck pain. Previous research demonstrates variability in traction forces generated by different DCs. This article reports on a training protocol and monthly certification process using bioengineering technology to standardize cervical traction force delivery among clinicians. Methods This longitudinal observational study evaluated a training and certification process for DCs who provided force-based manual cervical distraction during a randomized clinical trial. The DCs completed a 7-week initial training that included instructional lectures, observation, and guided practice by a clinical expert, followed by 3 hours of weekly practice sessions delivering the technique to asymptomatic volunteers who served as simulated patients. An instrument-modified table and computer software provided the DCs with real-time audible and visual feedback on the traction forces they generated and graphical displays of the magnitude of traction forces as a function of time immediately after the delivery of the treatment. The DCs completed monthly certifications on traction force delivery throughout the trial. Descriptive accounts of certification attempts are provided. Results Two DCs achieved certification in traction force delivery over 10 consecutive months. No certification required more than 3 attempts at C5 and occiput contacts for 3 force ranges (0–20 N, 21–50 N, and 51–100 N). Conclusions This study demonstrates the feasibility of a training protocol and certification process using bioengineering technology for training DCs to deliver manual cervical distraction within specified traction force ranges over a 10-month period.
... 9, 10 These studies similarly applied a force plate or joint translation simulator to provide real-time visual feedback when students were practicing their manual skills to measure their consistency. [11][12][13][14][15] Previous studies focused on student feedback during their practice, but the effectiveness on skill improvement was unclear. [11][12][13][14][15] Meanwhile, other research has demonstrated that structured, instructional materials are more effective than traditional teaching materials for medical/nursing students to master clinical skills. ...
... [11][12][13][14][15] Previous studies focused on student feedback during their practice, but the effectiveness on skill improvement was unclear. [11][12][13][14][15] Meanwhile, other research has demonstrated that structured, instructional materials are more effective than traditional teaching materials for medical/nursing students to master clinical skills. 16,17 Therefore, using a close-range photogrammetry technique, the aim of this study is to compare the use of 3D images that entail real rotating objects with traditional 2D images for training undergraduate physiotherapy students in 3 manual clinical skills. ...
Introduction Education research explains how healthcare professional training could be more efficient and effective by integrating simulation technology. Despite its relevance in training medical students, the evidence of its effectiveness in the manual skill training of physiotherapy students remains limited. The aim of this study was to compare the effectiveness of 3-dimensional (3D) images of real objects produced by photogrammetry and traditional 2-dimensional (2D) images when introducing manual therapy skills to undergraduate physiotherapy students via an online course. Methods In a randomized controlled trial, a group of first-year physiotherapy bachelor honor degree students participated in a 2-hour online course on 3 manual assessment skills: cervical compression, distraction, and flexion-rotation tests. They demonstrated 2 sets of learning materials, including either 3D images of real rotating objects using close-range photogrammetry (experimental group) or traditional 2D images (control group). After their respective training, an Objective Structured Clinical Evaluation procedure was conducted to demonstrate their knowledge about the techniques. A standardized 9-item practical performance test was used as the primary outcome measure for the analyses. Results Seventy-seven students participated in the study. The average Objective Structured Clinical Evaluation score for the experimental group (n = 40) was 41.3/50 (±3.9) and the control group (n = 37) was 39.1/50 (±4.5, P = 0.02). Conclusions For learning 3 cervical spine assessment skills, this study shows that photogrammetry creates 3D images of real rotating objects that are more effective than 2D images for first-year physiotherapy students.
... Visual feedback is critical when learning a novel visuomotor task (Melendez-Calderon, Masia, Gassert, Sandini, & Burdet, 2011), which requires voluntary visuomotor corrections (D. W. Franklin & Wolpert, 2008;Lee, Moseley, & Refshauge, 1990;Saunders & Knill, 2003;Snodgrass, Rivett, Robertson, & Stojanovski, 2010;Swinnen et al., 1997). For example, retention and transfer of the practiced task is superior for individuals who received visual feedback during practice than those who did not (Snodgrass et al., 2010;Swinnen et al., 1997). ...
... W. Franklin & Wolpert, 2008;Lee, Moseley, & Refshauge, 1990;Saunders & Knill, 2003;Snodgrass, Rivett, Robertson, & Stojanovski, 2010;Swinnen et al., 1997). For example, retention and transfer of the practiced task is superior for individuals who received visual feedback during practice than those who did not (Snodgrass et al., 2010;Swinnen et al., 1997). Therefore, the use of visual feedback is a critical factor for motor learning. ...
Article
Although movement is controlled by different descending pathways, it remains unknown whether the integration of visual feedback and motor learning differs for movements controlled by different descending pathways. Here, we compare motor control and learning of the ankle joint and tongue because they are primarily controlled by the corticospinal and corticobulbar pathways, respectively. Twelve young adults (19.63 ± 2.11 years, 6 females) practiced a tracking task (combination of 0.02, 0.37, 0.5, and 1 Hz) with ankle dorsiflexion and with tongue elevation for 100 trials. The participants practiced each effector (ankle and tongue) in different days and the order of the effector was counterbalanced. Following practice, participants performed the same tracking task with concurrent contractions of the tongue and ankle (dual tracking task; transfer) with three different visual feedback conditions (no visual feedback, visual feedback only for ankle, visual feedback only for tongue). We quantified the force accuracy (RMSE) from each effector during the practice and transfer periods. During practice, the force accuracy and performance improvement to the visuomotor task was greater for the ankle dorsiflexion than tongue elevation. During the transfer task, the ankle dorsiflexion was more accurate than tongue elevation, independent of whether visual feedback was given for the ankle or tongue. The greater performance improvement for the ankle dorsiflexion during practice was related to superior transfer performance. These findings suggest that the corticospinal pathway integrates visual feedback more efficiently than the corticobulbar pathway, which enhances performance and learning of visuomotor tasks.
... There is evidence that practicing a manipulation type of therapy with real-time feedback helps students learn to apply the appropriate forces. [12][13][14][15] Snodgrass et al. found that using real-time force measurement and providing students with feedback helped them to learn cervical spine mobilization. 13 Another study demonstrated that novice chiropractors learned to apply forces more consistent with those applied by experienced chiropractors when performing chiroprac-tic LVVA SMT. ...
... [12][13][14][15] Snodgrass et al. found that using real-time force measurement and providing students with feedback helped them to learn cervical spine mobilization. 13 Another study demonstrated that novice chiropractors learned to apply forces more consistent with those applied by experienced chiropractors when performing chiroprac-tic LVVA SMT. 16 In that study, the investigators used a system designed to provide clinicians with real-time visual graphic feedback on the magnitude of forces applied to the participant's lumbar spine. ...
Article
Full-text available
Objective: We compared traditional training alone and with the addition of force feedback training for learning flexion-distraction chiropractic technique. Methods: Participants were randomly allocated to two groups (traditional or traditional plus force feedback training). Students' forces were measured before training and after force feedback training. Students rated the helpfulness of the training and the comfort of the force transducer. Results: Thirty-one students were enrolled. Both groups delivered similar forces at baseline. Group 1 students' subsequent force measurements were higher after force feedback training. Group 2 students' forces were unchanged. Group 2 students were trained with force feedback for week 2 of the class, and forces were higher after feedback and similar to those in group 1. Students rated the training as very or somewhat helpful. Students also experienced discomfort as a patient and a student-doctor due to the force transducer that was used. Students who received force feedback training learned to deliver higher forces, which were closer to the forces delivered by experienced doctors of chiropractic. Students who did not receive force feedback continued to deliver lower forces. Conclusion: Force feedback helped students deliver forces closer to the desired force level and to learn this delivery faster than students who were not trained with force feedback.
... [26][27][28][29][30]32,33,[39][40][41] However, few studies have evaluated these new technologies for training students or clinicians in the delivery of mobilization procedures. [42][43][44][45][46] Gudavalli and colleagues recently described the development of an audible/visual and graphical feedback technology to measure cervical traction force delivery. 47 Here, we report on a training protocol and monthly certification process that used this technology to standardize the cervical traction forces delivered by 2 experienced DCs over a period of 10 months during a randomized controlled trial (RCT) of MCD. ...
... Several investigators have used instrumented mannequins, tables, or other devices to obtain force feedback during high-velocity, low-amplitude spinal manipulation (HVLA-SM) and posterior-to-anterior mobilizations. [26][27][28][29][30]32,33,39,40,[42][43][44][45][46] The present study differs in 3 substantive ways. First, our study is based on combined real-time audible/visual and immediate graphical feedback for a traction-type procedure used by chiropractors. ...
Conference Paper
Full-text available
Objective: Neck pain is a prevalent musculoskeletal (MSK) complaint and costly societal burden. Doctors of chiropractic(DCs) provide manual therapies for neck pain patients to relieve discomfort and improve physical function. Manual cervical distraction (MCD) is a chiropractic procedure for neck pain. During MCD, the patient lies face down on a specially designed chiropractic table. The DC gently moves the head and neck in a cephalic direction while holding a gentle broad manual contact over the posterior neck, to create traction effects. MCD traction force profiles vary between clinicians making standardization of treatment delivery challenging. This paper reports on a bioengineering technology developed to provide clinicians with auditory and graphical feedback on the magnitude of cervical traction forces applied during MCD to simulated patients during training for a randomized controlled trial (RCT). Methods: The Cox flexion-distraction chiropractic table is designed with a moveable headpiece. The table allows for long axis horizontal movement of the head and neck, while the patient's trunk and legs rest on fixed table sections. We instrument-modified this table with three-dimensional force transducers to measure the traction forces applied by the doctor. Motion Monitor software collects data from force transducers. The software displays the magnitude of traction forces graphically as a function of time. Real-time audible feedback produces a steady tone when measured traction forces are <20N, no tone when forces range between 20-50N, and an audible tone when forces exceed 50N. Peer debriefing from simulated patients reinforces traction force data from the bioengineering technology. Results: We used audible and graphical feedback to train and certify DCs to apply traction forces to the cervical spine of simulated patients within three specific ranges. This technology supports a RCT designed to assess the ability of clinicians to deliver MCD within specified force ranges to patients randomized to different force dosages as an intervention. Future applications may include training chiropractic students and clinicians to deliver the MCD treatment.
... Of the studies included in this review, 5 studies specifically examined the effects of feedback on the performances of joint mobilizations in learners (Table 4). [20][21][22][23][24] The effect of combined real-time auditory and visual feedback was investigated in 3 studies, with the other 2 studies examining the effect of real-time visual feedback alone. Gonza´lez-Sa´nchez et al 20 observed significant changes in ankle-joint-mobilization outcomes (ie, total time to reach max amplitude, maximum angular displacement, maximum and average velocity to reach maximum displacement, and average velocity throughout the entire mobilization) both the control group and experimental groups (P .05). ...
... Similar results were also reported in a study examining the combined effect of auditory and visual feedback in the learning of cervical spine mobilizations. 24 Although improved force application parameters were noted immediately after intervention (P , .001), the accuracy and the magnitude of the applied forces decreased significantly after 1 week (P ¼ .008). Sheaves et al 23 reported similar results, while also evaluating the role of frequency of Athletic Training Education Journal j Volume 15 j Issue 3 j July-September 2020 this specific form of feedback. ...
Article
Objective To investigate the influences of feedback on manual therapy skill acquisition as presented in the literature. Data Source(s) An electronic search was conducted across 4 databases: PubMed, EBSCOhost, SPORTDiscus, and CINAHL. The key words that were used in the search included manual therapy, physiotherapy, mobilizations, manipulation, education, instruction, feedback, intrinsic feedback, and extrinsic feedback. The Boolean phrases AND and OR were used to combine the search terms. Study Selections Studies that collected outcomes related to manual therapy skill acquisition from inception of the databases to September 2019 were included. Studies were excluded if they examined solely patient-rated or clinical outcomes of manual therapy or did not use feedback as the primary instructional intervention. Data Synthesis After quality appraisal with the Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies, the articles included in the review were categorized according to generalized manual therapy skills. Joint distraction/traction was the skill examined in 2 studies. The effect of feedback on joint mobilizations was investigated in 5 studies. Studies examining joint manipulations represented the largest portion of the articles in this review, with 11 total studies being included. The primary forms of feedback that were examined in the literature included visual, verbal, and combined forms of auditory and visual feedback. Conclusion(s) Visual feedback that provides learners with graphical representations of their performance, such as force-time relationships, appear to have the greatest effects in improving force-related parameters. Visual feedback can be useful during the initial acquisition phases of manual therapy skills, as indicated by the concentration of significant findings immediately after use in training sessions. A limited number of studies examining outcomes at long-term follow-up reported that training effects decrease rapidly over time. Thus, future studies should investigate if optimal dosages or scheduling strategies exist to increase the retention of effects.
... Previous studies have shown that student physical therapists demonstrate a high degree of variability when applying manual therapy forces as compared with experienced therapists [33][34][35][36][37][38][39]. However, research has also demonstrated that students can learn to be more consistent and accurate in applying manual forces when they receive more objective feedback [9,[40][41][42][43][44]. One of the challenges in comparing studies on PA mobilizations is the inconsistency in the manual force application [12,45]. ...
... Variability in joint mobilization skill performance between expert and novice practitioners Previous research has shown there is a wide variation between students and trained physical therapists when applying manual forces to the spine during mobilization [33][34][35][36][37][38][39]. However, when provided with objective feedback, student performance can become more accurate and consistent [9,[40][41][42][43][44]. The results of our study support these conclusions and are represented in Table 3. ...
Article
Objective: To examine the effects of real-time, objective feedback on learning lumbar spine joint mobilization techniques by entry-level Doctor of Physical Therapy (DPT) students. Methods: A randomized, controlled, crossover design was used. Twenty-four 1st Year DPT students were randomized into two groups. Group 1 (n = 12) practiced with the real-time feedback device first and then without it, while Group 2 (n = 12) practiced without the device first and then with it. Both practice periods with and without the device were 4 weeks long. Data were collected at Baseline, 5 weeks, 11 weeks, and 16 weeks. The crossover period was 5 weeks long, during which neither group practiced with or without the device. Eight force parameters were measured: R1 force; R2 force; Grade III and Grade IV mean peak force, frequency, and amplitude. Results: When students practiced with the real-time feedback device, they more closely matched the reference standard for two outcomes: 1) the mean difference in R2 force between student and reference standard was better with device (38.0 ± 26.7 N) than without it (51.0 ± 38.5 N); P = .013; and 2) the mean difference in Grade III peak to peak amplitude force was also better with device (8.9 ± 9.3 N) than without it (11.8 ± 11.0); P = .026. All other force parameters improved when students practiced with the real-time feedback device, however, the differences between when they practiced without the device were not statistically significant. Discussion: Real-time, objective feedback using a direct force measurement device improved learning for some aspects of lumbar spine joint mobilization by entry-level physical therapy students.
... Concurrent feedback is even more effective than training with a real trainer (Todorov, Shadmehr, & Bizzi, 1997), terminal feedback (for older adults; Wishart, Lee, Cunningham, & Murdoch, 2002), or no feedback (Swinnen, Lee, Verschueren, Serrien, & Bogaerds, 1997;Lee, Moseley, & Refshauge, 1990). Concurrent feedback was also shown to be effective in combination with terminal feedback (Snodgrass, Rivett, Robertson, & Stojanovski, 2010), and to be equally effective as terminal feedback (Chang, J. Y., Chang, G. L., Chien, Chung, & Hsu, 2007). ...
... For many simple tasks, the task-relevant variables have been displayed visually by abstract graphs (e.g., Ruffaldi et al., 2009;Schmidt & Wulf, 1997;Yang, Bischof, & Boulanger, 2008). In complex tasks, visual feedback has also been provided by abstract visualizations (e.g., Debaere, Wenderoth, Sunaert, Van Hecke, & Swinnen, 2004;Hurley & Lee, 2006;Lee, Swinnen, & Verschueren, 1995;Maslovat, Brunke, Chua, & Franks, 2009;Smethurst & Carson, 2001;Snodgrass et al., 2010;Swinnen et al., 1998;Wishart et al., 2002;Wulf et al., 1999;Wulf et al., 1998). However, feedback about multidimensional movements, that is, about movements in 3D space, may require more elaborate visualizations, such as virtual teachers that simultaneously display the body, limb, or end-effector movement of the learner and of the target movement. ...
Article
In general, concurrent augmented feedback has been shown to effectively enhance learning in complex motor tasks. However, to optimize technical systems that are intended to reinforce motor learning, a systematic evaluation of different augmented feedback designs is required. Until now, mainly visual augmented feedback has been applied to enhance learning of complex motor tasks. Since most complex motor tasks are mastered in response to information visually perceived, providing augmented concurrent feedback in a visual manner may overload the capacities of visual perception and cognitive processing. Thus, the aim of this work was to evaluate the practicability of auditory feedback designs supporting a three-dimensional rowing-type movement in comparison with visual feedback designs. We term a feedback design practical if the provided information can easily be perceived and interpreted, and immediately be used to support the movement. In a first experiment, it became evident that participants could interpret three-dimensional auditory feedback designs based on stereo balance, pitch, timbre, and/or volume. Eleven of 12 participants were able to follow the different target movements using auditory feedback designs as accurately as with a very abstract visual feedback design. Visual designs based on superposition of actual and target oar orientation led to the most accurate performance. Considering the first experimental results, the feedback designs were further developed and again evaluated. It became evident that a permanent visual display of the target trajectories could further enhance movement accuracy. Moreover, results indicated that the practicability of the auditory designs depends on the polarity of the mapping functions. In general, both visual and auditory concurrent feedback designs were practical to immediately support multidimensional movement. In a next step, the effectiveness to enhance motor learning will be systematically evaluated.
... Peak forces were measured using load cells fitted to an instrumented treatment table on which the participant lay, 55 and the therapist used real-time feedback via a computer monitor to ensure mean peak force levels remained consistent. 60 Both force levels were applied with the therapist using the conceptual definition of a grade III mobilization, defined as "large amplitude movement moving into stiffness." 42 Oscillation frequency was standardized at 1.0 Hz for both force conditions, which is the average frequency used by physiotherapists when applying a grade III cervical mobilization. ...
Article
Full-text available
Study design: Randomized controlled trial. Objective To determine if force magnitude during posterior-to-anterior mobilization affects immediate and short-term outcomes in patients with chronic, nonspecific neck pain. Background: The optimal dose of mobilization to effectively treat patients with neck pain is not known. Methods: Patients with neck pain of at least 3 months in duration (n = 64) were randomized to receive a single treatment of posterior-to-anterior mobilization applied with 30 N or 90 N of mean peak force (3 sets of 30 seconds) or a placebo (detuned laser) on the spinous process at the painful spinal level. Pressure pain threshold, pain measured with a visual analog scale (range, 0-100 mm), cervical range of motion, and spinal stiffness at the painful spinal level (measured with a custom device and normalized as a percentage of C7 stiffness) were assessed before, immediately after, and at a mean ± SD follow-up of 4.0 ± 1.8 days following treatment. Repeated-measures analysis of covariance and Bonferroni-adjusted post hoc tests determined group differences for each outcome measure after treatment and at follow-up. Results: At follow-up, the 90-N group had less pain than the 30-N group (mean difference, 11.3 mm; 95% confidence interval: 0.1, 22.6 mm; P = .048) and lower stiffness than the placebo group (mean difference, 17.5%; 95% confidence interval: 4.2%, 30.9%; P = .006). These differences were not present immediately after treatment. There were no significant between-group differences in pressure pain threshold or range of motion after treatment or at follow-up. Conclusion: A specific dose of mobilization, in terms of applied force, appears necessary for reducing stiffness and potentially pain in patients with chronic neck pain. Changes were not observed immediately after mobilization, suggesting that its effects are not directly mechanical. Trial registration: Australian and New Zealand Clinical Trials Registry ( http://www.anzctr.org.au/): ACTRN12611000374965. Level of evidence: Therapy, level 1b-.
... 16,[21][22][23][24][25] Most of these studies focused on HVLA-SM, with the majority evaluating the thoracic and lumbar spine. 16;21-24 Few studies have measured the biomechanical characteristics of HVLA-SM delivery to the cervical spine 24,25 , and few studies on these parameters with mobilization procedures [26][27][28][29] . James Cox, DC developed manual distraction, or the flexion distraction procedure, to treat patients with spinal problems. ...
Article
A form of chiropractic procedure known as Cox flexion-distraction is used by chiropractors to treat low back pain. Patient lies face down on a specially designed table having a stationery thoracic support and a moveable caudal support for the legs. The Doctor of Chiropractic (DC) holds a manual contact applying forces over the posterior lumbar spine and press down on the moving leg support to create traction effects in the lumbar spine. This paper reports on the development of real-time feedback on the applied forces during the application of the flexion-distraction procedure. In this pilot study we measured the forces applied by experienced DCs as well as novice DCs in using this procedure. After a brief training with real-time feedback novice DCs have improved on the magnitude of the applied forces. This real-time feedback technology is promising to do systematic studies in training DCs during the application of this procedure.
... In an early stage of complex task learning, concurrent feedback may accelerate learning by mediating a general idea of the movement (Huegel & O'Malley, 2010;Liebermann et al., 2002) and by preventing cognitive overload (Wulf & Shea, 2002). Indeed, concurrent visual feedback has facilitated learning of different complex tasks (Kovacs & Shea, 2011;Snodgrass, Rivett, Robertson, & Stojanovski, 2010;Swinnen et al., 1997;Todorov, Shadmehr, & Bizzi, 1997;Wishart, Lee, Cunningham, & Murdoch, 2002;Wulf, Hörger, & Shea, 1999). Research on feedback principles such as the guidance hypothesis has predominantly addressed the visual modality, thereby neglecting a comparison with feedback in other modalities such as auditory and haptic feedback (Sigrist, Rauter, Riener, & Wolf, 2013). ...
Article
Full-text available
ABSTRACT Augmented feedback, provided by coaches or displays, is a well-established strategy to accelerate motor learning. Frequent terminal feedback and concurrent feedback have been shown to be detrimental for simple motor task learning but supportive for complex motor task learning. However, conclusions on optimal feedback strategies have been mainly drawn from studies on artificial laboratory tasks with visual feedback only. Therefore, the authors compared the effectiveness of learning a complex, 3-dimensional rowing-type task with either concurrent visual, auditory, or haptic feedback to self-controlled terminal visual feedback. Results revealed that terminal visual feedback was most effective because it emphasized the internalization of task-relevant aspects. In contrast, concurrent feedback fostered the correction of task-irrelevant errors, which hindered learning. The concurrent visual and haptic feedback group performed much better during training with the feedback than in nonfeedback trials. Auditory feedback based on sonification of the movement error was not practical for training the 3-dimensional movement for most participants. Concurrent multimodal feedback in combination with terminal feedback may be most effective, especially if the feedback strategy is adapted to individual preferences and skill level.
... Peak forces were measured using load cells fitted to an instrumented treatment table on which the participant lay, 55 and the therapist used real-time feedback via a computer monitor to ensure mean peak force levels remained consistent. 60 Both force levels were applied with the therapist using the conceptual definition of a grade III mobilization, defined as "large amplitude movement moving into stiffness." 42 Oscillation frequency was standardized at 1.0 Hz for both force conditions, which is the average frequency used by physiotherapists when applying a grade III cervical mobilization. ...
... Important aspects of task-related information are ignored during feedback training such as environmental or task-inherent cues and intrinsic feedback, i.e., proprioception. However, concurrent feedback has been found to be effective for learning more complex tasks (Kovacs and Shea 2011;Marschall et al. 2007;Sigrist et al. 2013b;Snodgrass et al. 2010, Swinnen et al. 1997Todorov et al. 1997;Wishart et al. 2002;Wulf et al. 1998Wulf et al. , 1999. It is assumed that concurrent feedback facilitates the discovery of skills required for the novel task (Huegel and O'Malley 2010;Liebermann et al. 2002) and the understanding of the novel structure of the task (Braun et al. 2010;Wolpert and Flanagan 2010;Wolpert et al. 2011). ...
Article
Concurrent augmented feedback has been shown to be less effective for learning simple motor tasks than for complex tasks. However, as mostly artificial tasks have been investigated, transfer of results to tasks in sports and rehabilitation remains unknown. Therefore, in this study, the effect of different concurrent feedback was evaluated in trunk-arm rowing. It was then investigated whether multimodal audiovisual and visuohaptic feedback are more effective for learning than visual feedback only. Naïve subjects (N = 24) trained in three groups on a highly realistic virtual reality-based rowing simulator. In the visual feedback group, the subject's oar was superimposed to the target oar, which continuously became more transparent when the deviation between the oars decreased. Moreover, a trace of the subject's trajectory emerged if deviations exceeded a threshold. The audiovisual feedback group trained with oar movement sonification in addition to visual feedback to facilitate learning of the velocity profile. In the visuohaptic group, the oar movement was inhibited by path deviation-dependent braking forces to enhance learning of spatial aspects. All groups significantly decreased the spatial error (tendency in visual group) and velocity error from baseline to the retention tests. Audiovisual feedback fostered learning of the velocity profile significantly more than visuohaptic feedback. The study revealed that well-designed concurrent feedback fosters complex task learning, especially if the advantages of different modalities are exploited. Further studies should analyze the impact of within-feedback design parameters and the transferability of the results to other tasks in sports and rehabilitation.
... It has been demonstrated that performance on the delayed retention test was better after a reduced KR condition vs. every trial practice condition (Anderson et al., 2005;Leukel & Lundbye-Jensen, 2013;Schmidt et al., 1989). In addition, the effectiveness of online KR has been demonstrated with students in delayed (one week) retention tests after practicing complex tasks (practice with feedback vs. no-feedback) (Snodgrass et al., 2010); however, Fujii et al. (2016) reported better performance retention in the 100% KR condition. Previously, it has been concluded that children use feedback in a different manner from that of adults and that children may require longer periods of practice, with gradual feedback reduction (Sullivan et al., 2008). ...
Article
Improving acquisition and retention of new motor skills is of great importance. This study investigated the effects of progressive task difficulty manipulation (TD), combined with varying knowledge of results frequencies (KR) on performance accuracy and consistency when learning novel fine motor coordination tasks, and examined relationships between novel fine motor task performance and executive function (EF), working memory (WM), and perceived difficulty (PD). Thirty-six, right-handed, novice physical-education students (age ¼ 10.72 ± 0.89 years) participated; participants were separated into three groups, receiving varying KR frequency (100%KR, 50%KR, and 33%KR). For each group, distance to the target was increased progressively (2 m, 2.37 m, and 3.56 m) to obtain three difficulty levels. We assessed performance during test sessions (pretest, post-test, Retention1 and Retention2) under free (FC) and time pressure (TPC) conditions. Results revealed that under FC, 100%KR improved significantly. Results revealed significant linear improvements in accuracy for 50%KR and 33%KR under TPC. New findings indicate that the association between TD and KR (50%KR) may provide more appropriate cognitive loads compared to 33%KR and 100%KR groups. These have implications for practitioners because, while strategies are clearly necessary for improving learning, the efficacy of the process appears to be based on the characteristics of the learners.
... Abstract visual display is often used also in form of graphs that show the time course of motion variables (e.g. acceleration in running [6], force onset in skiing [35], or for manual therapies [31]) and graphs, which present the relationship between two different motion variables (e. g. force as a function of the paddle's angle in rowing) [30]. ...
Article
Full-text available
Numerous studies have established that using various forms of augmented feedback improves human motor learning. In this paper, we present a system that enables real-time analysis of motion patterns and provides users with objective information on their performance of an executed set of motions. This information can be used to identify individual segments of improper motion early in the learning process, thus preventing improperly learned motion patterns that can be difficult to correct once fully learned. The primary purpose of the proposed system is to serve as a general tool in the research on impact of different feedback modalities on the process of motor learning, for example, in sports or rehabilitation. The key advantages of the system are high-speed and high-accuracy tracking, as well as its flexibility, as it supports various types of feedback (auditory and visual, concurrent or terminal). The practical application of the proposed system is demonstrated through the example of learning a golf swing.
... Indeed, real-time objective feedback can enable students to apply cervical mobilization forces that more closely match those of a practicing therapist. 34 Despite this, the levels of force that are more effective for treating patients with spinal conditions are unknown. Nevertheless, if we are able to increase consistency in the levels of force that are applied for individual techniques and grades, then investigation of the optimal levels of force for effective treatment becomes possible. ...
Article
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Clinical measurement, cross-sectional. To compare cervical mobilization forces applied by physiotherapists and students, and the factors associated with forces for each group. Cervical spine joint mobilization is a common manual technique for treating patients with mechanical neck pain. But little is known about the forces applied during this technique. Potential variability between therapists may result from clinical experience or may be due to factors present in individuals prior to clinical practice exposure. One hundred sixteen practicing physiotherapists and 120 physiotherapy students without clinical experience applied grades I through IV posteroanterior mobilization to the premarked C2 and C7 spinous and articular processes of 1 of 67 asymptomatic subjects. An instrumented table recorded applied forces (N), force amplitudes (N), and oscillation frequencies (Hz), and a custom device measured subjects' spinal stiffness (N/mm). Independent t tests were used to compare the forces applied by therapists and students, intraclass correlation coefficients were used to determine variability, and linear regression was used to establish factors associated with applied forces. Students' forces were generally lower (mean difference, 15.7 N for grades III and IV; P<.001) and applied with slower oscillation frequencies (0.12 Hz; P<.001) than therapists' forces. Similar factors were associated with applied forces for both groups: male gender and greater subject body weight were associated with higher applied forces, and greater C2 stiffness with lower forces. Having thumb pain was associated with lower applied forces for therapists but higher ones for students. Students apply lower forces than therapists. Similar factors appear to affect applied forces regardless of clinical experience.
... Continuous feedback was ascertained from the patient with each technique's applica tion to ensure localization and appropriateness of force. 29 Initial METs were dosed at 3 to 5 repetitions and progressed according to patient response. ...
Article
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Background and Purpose: A surgical procedure commonly performed for many patients with head and neck cancer is a modified radical neck dissection. The use of therapeutic interven­ tion postoperatively has been shown to be beneficial; however, documented use of manual therapy techniques (ie, mobilization, muscle energy technique (MET), and soft tissue mobilization) in these cases is limited. The purpose of this case report is to describe and demonstrate the benefits of using manual therapy techniques following a modified radical neck dissection of a patient with head and neck cancer. Case Description: A 49­year­old man completed 3 weeks of physical therapy following a modified radical neck dissection due to head and neck cancer. The patient reported pain, decreased cervical mobility, and function at baseline. Outcomes: The patient experienced a 12 point reduction in the Neck Disability Index at discharge and 30 point reduction at 4 month follow­up. Subjective pain levels improved from 3/10 to 0/10. Cervical mobil­ ity increased by 7°­20° in most ranges and strength of scapular muscles improved from 4+/5 to 5/5. The patient was able to return to work without limitation. Discussion: The patient described in this case report experienced less pain and improved physical func­ tion and outcome measure scores after intervention and 4 month follow­up. Manual therapy techniques such as joint mobilization, muscle energy technique, and soft tissue mobilization were safely and effectively applied to this patient with head and neck cancer. Randomized controlled clinical trials are needed to evaluate the efficacy of these manual interventions following a modified radical neck dissection of a patient with head and neck cancer.
... Additionally, feedback given in settings with large faculty-student ratios and by instructors with high variability in force production can negatively impact motor skill mastery [22,29,30]. Fortunately, research has shown that when students are provided with objective feedback, they more consistently and accurately apply the desired manual therapy forces [18,19,21,25,[31][32][33][34][35][36][37]. Joint force measurement devices that provide quantitative feedback allow an expert clinician to share objective force parameters with students in a classroom setting. ...
Article
Objective: Previous studies on learning joint mobilization techniques have used expert practitioners as the reference standard as there is no current evidence on what ideal forces would be for effective mobilizations. However, none of these trials have documented the reliability or accuracy of the reference standard. Therefore, the purpose of this study was to report both the reliability and accuracy of an expert physical therapist (PT) acting as a reference standard for a manual therapy joint mobilization trial. Methods: A secondary analysis was performed using data from a published randomized, controlled, crossover study. The mobilization technique studied was the central posterior to anterior (PA) joint mobilization of the L3 vertebra. Reliability and accuracy data for the reference standard were collected over four time periods spanning 16 weeks. Results: Intrarater reliability of the expert PT for R1 and R2 joint forces was excellent (R1 Force ICC3,3 0.95, 95%CI 0.76–0.99 and R2 Force ICC3,3 0.90, 95%CI 0.49–0.99). Additionally, the expert PT was 92.3% accurate (mean % error±SD, 7.7 ± 5.5) when finding Grade III mean peak mobilization force and 85.1% accurate (mean % error±SD, 14.9 ± 8.3) when finding Grade IV mean peak mobilization force. Finally, correlations between actual applied forces and computed ideal forces were excellent (Pearson r 0.79–0.92, n = 24, P < 0.01 for all correlations). Discussion: The expert PT in this manual therapy joint mobilization trial showed excellent reliability and accuracy as the reference standard. The study supports the use of implementing quantitative feedback devices into the teaching of joint mobilization when a reliable and accurate reference standard has been identified. Level of Evidence: 2b.
... A game therapy approach promotes implicit learning [45] based on the intrinsic feedback to the user through self-evaluation on task performance and enhanced motivation [1,46]. Furthermore, this high-frequency, concurrent feedback on a relatively complex task has been suggested to be effective for learning, potentially through the automation of movement control [46,47]. Applying these techniques to wrist therapy, which is a less frequently targeted treatment by robotic rehabilitation systems, has the potential to reduce impairment because functional gains in upper extremity movements are dependent on coordinated distal motion (i.e., wrist/hand) [45]. ...
Article
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Rehabilitation requires repetitive and coordinated movements for effective treatment, which are contingent on patient compliance and motivation. However, the monotony, intensity, and expense of most therapy routines do not promote engagement. Gesture-controlled rehabilitation has the potential to quantify performance and provide engaging, cost-effective treatment, leading to better compliance and mobility. We present the design and testing of a gesture-controlled rehabilitation robot (GC-Rebot) to assess its potential for monitoring user performance and providing entertainment while conducting physical therapy. Healthy participants (n = 11) completed a maze with GC-Rebot for six trials. User performance was evaluated through quantitative metrics of movement quality and quantity, and participants rated the system usability with a validated survey. For participants with self-reported video-game experience (n = 10), wrist active range of motion across trials (mean ± standard deviation) was 41.6 ± 13° and 76.8 ± 16° for pitch and roll, respectively. In the course of conducting a single trial with a time duration of 68.3 ± 19 s, these participants performed 27 ± 8 full wrist motion repetitions (i.e., flexion/extension), with a dose-rate of 24.2 ± 5 reps/min. These participants also rated system usability as excellent (score: 86.3 ± 12). Gesture-controlled therapy using the GC-Rebot demonstrated the potential to be an evidence-based rehabilitation tool based on excellent user ratings and the ability to monitor at-home compliance and performance.
... This phenomenon is explained by the guidance hypothesis [18,19,20]. However, for complex motor tasks, which have several degrees of freedom and involve larger movements, concurrent visual or auditory feedback has been shown to reduce cognitive demand during task execution, and is effective in improving complex motor performance when the 70 feedback is withdraw [18,21,22]. In comparison, terminal feedback provides information at the end of or after task execution [16,1], which in some cases has been shown to have a better facilitatory effect on simple motor task acquisition rather than has been seen with complex motor tasks [23,24]. ...
Preprint
Although it has been shown that augmented multimodal feedback has a facilitatory effect on motor performance for motor learning and music training, the functionality of haptic feedback combined with other modalities in rhythmic movement tasks has rarely been explored and analysed. In this paper, we evaluate the functionality of visual-haptic feedback in a rhythmic sketch task by comparing it with other multimodal conditions. Further, we examine the possibility of accessing the quality of task execution through kinematic analysis. Based on participants' speed profiles, we investigate the quality of motor control and movement smoothness under different feedback conditions. Results revealed better motor control ability with auditory feedback and improved movement smoothness with haptic feedback. Finally, we propose that haptic feedback can be integrated with other modal stimuli for different interaction purposes, and that kinematic analysis can be a complementary approach to gesture analysis as well as providing subjective evaluation of interaction performance.
... Some studies that use complicated learning tasks, such as athletic movements, reported that the CVF may contribute to motor learning, but no research has reported that the effect exceeds the learning effect with TVF 13,22,[25][26][27] . These previous studies did not consider differences in the learners' skill levels. ...
Article
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[Purpose] No previous studies have confirmed whether the effects of visual feedback on motor learning vary according to learner skill level for a learning task. The purpose of this study was to clarify whether differences in skill influence the effects of visual feedback on motor learning. [Participants and Methods] Sixty-four participants were assigned to one of four different feedback groups (concurrent-100%, concurrent-50%, terminal-100%, or terminal-50%). The learning task was to adjust the load amount continuously to the left lower limb in accordance with sound stimulation at intervals of 1 Hz. The four groups performed a pretest, practice sessions, and a retention test 24 hours after practice. After completing these measurements, the participants were classified as either high- or low-skilled based on the results of the pretest. [Results] Only the groups of low-skilled participants who used concurrent feedback showed lower root mean square errors in the retention test compared to in the pretest. [Conclusion] Differences in skill level for the same task influenced the effects of visual feedback on motor learning. Furthermore, concurrent visual feedback can help improve motor learning in low-skilled learners for the same task.
... This method provided real-time visual feedback of the applied force during the intervention, improving the accuracy of the manually applied forces during the mobilizations. 38 The amplitude of the applied force was standardized to range between 100 N and 200 N for the 2 Hz and 0.5 Hz, respectively. This range of force application characterized a large amplitude mobilization, whereas in the placebo intervention a quasi-static 50-N force was applied constantly. ...
Article
Objective: The primary aim of this study was to determine the effects of different rates of thoracic spine passive accessory intervertebral mobilization (PAIVM) on pressure pain threshold (PPT) at T4. The secondary aim was to investigate the widespread effects of different rates of thoracic PAIVM. Methods: Twenty asymptomatic participants were randomly assigned to 3 experimental conditions: posteroanterior rotatory thoracic PAIVM at 2 Hz, 0.5 Hz, and placebo. Each participant received all 3 experimental conditions in a random order with a washout period of at least 48 hours between each procedure. The PPT was measured in 3 different points: pre-treatment, immediately after, and 15 minutes after the treatment at C7 and T4 spinous process, first interossei dorsal on the right and left hands and tibial tuberosity bilaterally. A repeated-measures analysis of covariance adjusted by baseline values was used to assess between-group differences at each point. Pairwise comparisons were adjusted for multiple tests with a Bonferroni correction. A P value < .05 was considered significant. Results: There was no between-group differences on PPT at T4 when comparing 0.5 Hz (mean difference -0.29; 95% CI -0.99 to 0.42; P = .999) or 2 Hz (mean difference -0.37; 95% CI -1.1 to 0.33; P = .528) to placebo. Conclusion: None of the mobilization techniques in this study (0.5 Hz, 2 Hz, and placebo) showed a significant change of PPT both locally and at distant sites at any point in asymptomatic participants.
... Physiotherapy students have been trained previously to deliver specific forces and duration in oscillatory lumbar mobilization. However, skill retention after 1 week has been mixed, 26,27 suggesting that this may be important to assess during HVLA-SM training. ...
Article
Objective:: High-velocity, low-amplitude spinal manipulation (HVLA-SM) may generate different therapeutic effects depending on force and duration characteristics. Variability among clinicians suggests training to target specific thrust duration and force levels is necessary to standardize dosing. This pilot study assessed an HVLA-SM training program using prescribed force and thrust characteristics. Methods:: Over 4 weeks, chiropractors and students at a chiropractic college delivered thoracic region HVLA-SM to a prone mannequin in six training sessions, each 30 minutes in duration. Force plates embedded in a treatment table were used to measure force over time. Training goals were 350 and 550 Newtons (N) for peak force and ≤150 ms for thrust duration. Verbal and visual feedback was provided after each training thrust. Assessments included 10 consecutive thrusts for each force target without feedback. Mixed-model regression was used to analyze assessments measured before, immediately following, and 1, 4, and 8 weeks after training. Results:: Error from peak force target, expressed as adjusted mean constant error (standard deviation), went from 107 N (127) at baseline, to 0.2 N (41) immediately after training, and 32 N (53) 8 weeks after training for the 350 N target, and 63 N (148), -6 N (58), and 9 N (87) for the 550 N target. Student median values met thrust duration target, but doctors' were >150 ms immediately after training. Conclusion:: After participation in an HVLA-SM training program, participants more accurately delivered two prescribed peak forces, but accuracy decreased 1 week afterwards. Future HVLA-SM training research should include follow-up of 1 week or more to assess skill retention.
... For example, in the learning of a simple task, visual feedback increased performance in acquisition but not retention tests [29,30]. Contradicting the guidance hypothesis, studies that analyzed more complex tasks observed high positive effects of concurrent visual feedback [31,32]. Other problems arise from the design of the task, as devising tasks that are objectively quantifiable is not an easy feat. ...
Article
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Background:‪The aim was to compare the effects of two different types of concurrent feedback administration on biomechanical performance during a swimming-specific task.Material and methods:‪A counterbalanced repeated measures design was used to compare the execution of the butterfly stroke (the propulsion phase only) on a modified Smith machine. Twenty repetitions were performed in each condition of feedback (visual vs. verbal). Fourteen college swimmers (age x̄ = 22.21 ±1.85 years, height x̄ = 173.71 ±8.65 cm, mass x̄ = 71.32 ±10.64 kg) were recruited. An incremental force test was administered for each participant to determine the mean propulsive velocity in which maximal power was produced. Feedback addressed correct execution velocity of the pulling movement that corresponded to the maximal power production as determined in an incremental force test.Results:‪T testing revealed no statistically significant differences between the verbal and visual feedback conditions. Visual feedback elicited a correct response in 76.11% of total feedback compared with 72.06% in the verbal feedback condition.Conclusions:‪Considering total feedback response, the visual feedback condition elicited 4.05% more correct responses than verbal feedback. However, this difference did not attain statistical significance and, therefore, the underlying hypothesis could not be confirmed.
... For example, in the learning of a simple task, visual feedback increased performance in acquisition but not retention tests [29,30]. Contradicting the guidance hypothesis, studies that analyzed more complex tasks observed high positive effects of concurrent visual feedback [31,32]. Other problems arise from the design of the task, as devising tasks that are objectively quantifiable is not an easy feat. ...
Article
The aim was to compare the effects of two different types of concurrent feedback administration on biomechanical performance during a swimming-specific task. A counterbalanced repeated measures design was used to compare the execution of the butterfly stroke (the propulsion phase only) on a modified Smith machine. Twenty repetitions were performed in each condition of feedback (visual vs. verbal). Fourteen college swimmers (age x̄ = 22.21 ±1.85 years, height x̄ = 173.71 ±8.65 cm, mass x̄ = 71.32 ±10.64 kg) were recruited. An incremental force test was administered for each participant to determine the mean propulsive velocity in which maximal power was produced. Feedback addressed correct execution velocity of the pulling movement that corresponded to the maximal power production as determined in an incremental force test. T testing revealed no statistically significant differences between the verbal and visual feedback conditions. Visual feedback elicited a correct response in 76.11% of total feedback compared with 72.06% in the verbal feedback condition. Considering total feedback response, the visual feedback condition elicited 4.05% more correct responses than verbal feedback. However, this difference did not attain statistical significance and, therefore, the underlying hypothesis could not be confirmed.
... En cuanto a la aplicación de simulación clínica para el dominio musculoesquelético, hay reportes con uso de equipos de simulación para entrenamiento de habilidades táctiles propias de la terapia manual, como las utilizadas para movilización vertebral 42 , con la finalidad de brindar realimentación objetiva para estandarizar las fuerzas óptimas durante las movilizaciones vertebrales 43 . También del uso de la simulación para la movilización de la articulación glenohumeral bajo el modelo Kalterborn, facilitando la realimentación durante la movilización articular, con mayor efectividad en el aprendizaje de la habilidad 44 . ...
Article
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Resumen Los escenarios de simulación clínica han sido explorados en medicina y enfermería como estrategia de aprendizaje y han demostrado ser efectivos para la adquisición de competencias acercando a los estudiantes a su práctica clínica real. En fisioterapia, su utilización ha sido recientemente incluida y aún no se ha documentado su potencial como estrategia de fortalecimiento curricular. Este trabajo buscó revisar en la literatura el empleo de la simulación clínica como estrategia pedagógica para la fisioterapia. Para ello, se desarrolló un proceso integrativo con base en el análisis de competencias transversales o específicas. Sus resultados señalan que la simulación mejora la calidad y competencia del fisioterapeuta en formación; el dominio donde más se usa la simulación es el cardiovascular pulmonar, seguido del musculoesquelético. Sin embargo, en fisioterapia se requiere incrementar el uso de simulación en todos los dominios para poder cualificar aún más la formación.
... Concurrent visual feedback has been effective in rehabilitation of complex motor skills (J. Y. Chang, Chang, Chien, Chung, & Hsu, 2007;Snodgrass, Rivett, Robertson, & Stojanovski, 2010). Yet, the guidance hypothesis states that continued concurrent feedback can be detrimental for long-term retention and that terminal feedback must be introduced to encourage internalization of the new skill (Bernier, Chua, & Franks, 2005;Heuer & Hegele, 2008;Sülzenbrück & Heuer, 2011). ...
Article
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Background: Gait retraining using real-time biofeedback (RTB) may have positive outcomes in decreasing knee adduction moment (KAM) in healthy individuals and has shown equal likelihood in patients with knee osteoarthritis (OA). Currently, there is no consensus regarding the most effective gait modification strategy, mode of biofeedback or treatment dosage. Objective: The purpose of this review was: i) to assess if gait retraining interventions using RTB are valuable to reduce KAM, pain, and improve function in individuals with knee osteoarthritis, ii) to evaluate the effectiveness of different gait modifications and modes of RTB in reducing KAM in healthy individuals, and iii) to assess the impact of gait retraining interventions with RTB on other variables that may affect clinical outcomes. Methods: Seven electronic databases were searched using five search terms. Studies that utilized any form of gait retraining with RTB to improve one or a combination of the following measures were included: KAM, knee pain, and function. Twelve studies met the inclusion criteria, evaluating eleven distinctive gait modifications and three modes of RTB. Results: All but one study showed positive outcomes. Self-selected and multi-parameter gait modifications showed the greatest reductions in KAM with visual and haptic RTB being more effective than auditory. Conclusions: Current evidence suggests that gait modification using RTB can Positively alter KAM in asymptomatic and symptomatic participants. However, the existing literature is limited and of low quality, with the optimal combination strategies remaining unclear (gait and biofeedback mode). Future studies should employ randomized controlled study designs to compare the effects of different gait modification strategies and biofeedback modes on individuals with knee OA.
... For the past one decade, augmentation of sensory feedback has been widely used to improve peoples' task performance related to the activities of daily living (Sigrist et al., 2013). Recent studies have reported that people's task performance can be improved by applying various types of augmented sensory feedback such as visual feedback (Franz et al., 2014;Sülzenbrück and Heuer, 2011;Snodgrass et al., 2010;Huet et al., 2009;Ranganathan and Newell, 2009;Blandin et al., 2008), auditory feedback (Secoli et al., 2011;Helmer et al., 2011;Eriksson et al., 2011;Sigrist et al., 2011;Riskowski et al., 2009), and haptic feedback (Marchal-Crespo et al., 2012;Powell and O'Malley, 2011;Chen et al., 2011;Reinkensmeyer and Patton, 2009). There exist various approaches and practical applications related to the augmented sensory feedbacks. ...
Article
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Cutaneous sensory feedback can be used to provide additional sensory cues to a person performing a motor task where vision is a dominant feedback signal. A haptic joystick has been widely used to guide a user by providing force feedback. However, the benefit of providing force feedback is still debatable due to performance dependency on factors such as the user’s skill-level, task difficulty. Meanwhile, recent studies have shown the feasibility of improving a motor task performance by providing skin-stretch feedback. Therefore, a combination of two aforementioned feedback types is deemed to be promising to promote synergistic effects to consistently improve the person’s motor performance. In this study, we aimed at identifying the effect of the combined haptic and skin-stretch feedbacks on the aged person’s driving motor performance. For the experiment, fifteen healthy elderly subjects (age 72.8±6.6 years) were recruited and were instructed to drive a virtual power-wheelchair through four different courses with obstacles. Four augmented sensory feedback conditions were tested: no-feedback, force feedback, skin-stretch feedback, and a combination of both force and skin-stretch feedbacks. While the haptic force was provided to the hand by the joystick, the skin-stretch was provided to the steering forearm by a custom-designed wearable skin-stretch device. We tested two hypotheses: i) an elderly individual’s motor control would benefit from receiving information about a desired trajectory from multiple sensory feedback sources, and ii) the benefit does not depend on task difficulty. Various metrics related to skills and safety were used to evaluate the control performance. Repeated measure ANOVA was performed for those metrics with two factors: task scenario and the type of the augmented sensory feedback. The results revealed that elderly subjects’ control performance significantly improved when the combined feedback of both haptic force and skin-stretch feedback was applied. The proposed approach suggest the feasibility to improve people’s task performance by the synergistic effects of multiple augmented sensory feedback modalities.
Article
In general, concurrent augmented feedback has been shown to effectively enhance learning in complex motor tasks. However, to optimize technical systems that are intended to reinforce motor learning, a systematic evaluation of different augmented feedback designs is required. Until now, mainly visual augmented feedback has been applied to enhance learning of complex motor tasks. Since most complex motor tasks are mastered in response to information visually perceived, providing augmented concurrent feedback in a visual manner may overload the capacities of visual perception and cognitive processing. Thus, the aim of this work was to evaluate the practicability of auditory feedback designs supporting a three-dimensional rowing-type movement in comparison with visual feedback designs. We term a feedback design practical if the provided information can easily be perceived and interpreted, and immediately be used to support the movement. In a first experiment, it became evident that participants could interpret three-dimensional auditory feedback designs based on stereo balance, pitch, timbre, and/or volume. Eleven of 12 participants were able to follow the different target movements using auditory feedback designs as accurately as with a very abstract visual feedback design. Visual designs based on superposition of actual and target oar orientation led to the most accurate performance. Considering the first experimental results, the feedback designs were further developed and again evaluated. It became evident that a permanent visual display of the target trajectories could further enhance movement accuracy. Moreover, results indicated that the practicability of the auditory designs depends on the polarity of the mapping functions. In general, both visual and auditory concurrent feedback designs were practical to immediately support multidimensional movement. In a next step, the effectiveness to enhance motor learning will be systematically evaluated.
Article
This technical note details the stages taken to create an instrumented hydraulic treatment plinth for the measurement of applied forces in the vertical axis. The modification used a widely available low-cost peripheral gaming device and required only basic construction and computer skills. The instrumented treatment plinth was validated against a laboratory grade force platform across a range of applied masses from 0.5-15 kg, mock Gr I-IV vertebral mobilisations and a dynamic response test. Intraclass correlation coefficients demonstrated poor reliability (0.46) for low masses of 0.5 kg improving to excellent for larger masses up to15 kg respectively; excellent to good reliability (0.97-0.86) for the mock mobilisations and moderate reliability (0.51) for the dynamic response test. The study demonstrates how a cheap peripheral gaming device can be repurposed so that forces applied to a hydraulic treatment plinth can be collected reliably when applied in a clinically reasoned manner.
Thesis
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This thesis comprises several chapters on the relation between aspects of the curriculum and students’ knowledge development and skill acquisition at different levels, ranging from the effect of feedback characteristics to the effect of massed or spaced curricula. The main research question of this thesis is: How do aspects of the curriculum relate to students’ knowledge development and skill acquisition? To answer our research questions and because of the complexity of studying aspects of the curriculum, we used different methodologies. In Chapter 2 and 3 the relation between curriculum characteristics and knowledge development was explored. In order to do so we choose oncologic knowledge since many medical disciplines are represented in this topic. In Chapter 2, students’ knowledge development was explored by analyzing data from the Dutch progress test on 1440 medical students of four undergraduate medical schools. To better understand the differences between the curricula, the four oncology curriculum coordinators were interviewed. Students’ knowledge development was compared using mixed model analysis. The results demonstrated that two curriculum characteristics seem to have a positive impact on students’ knowledge development: the presence of a pre-internship course and concentration of the discipline in one semester. Although it seems that these two characteristics benefit students’ knowledge development, this study was exploratory and, therefore, implications based on the results do not presuppose causality. In Chapter 3, the findings of Chapter 2 were investigated in more depth and in a more controlled environment, although the study was still conducted in a naturalistic setting. For this purpose, the development of students’ knowledge of oncology in one medical school was compared between students who were taught in a concentrated semester and students who were taught in a spaced format. The medical school offers a six-year medical training; the first three years are predominantly preclinical and the last years predominately clinical. Comparing these two parallel cohorts decreased the number of confounders, since the context (within the same university), teachers, teaching methods and assessment were similar in both cohorts. The results showed that at the beginning of preclinical training, students in the spaced curriculum scored higher and at the end of preclinical training, students in the spaced curriculum scored lower than students in the concentrated semester. The results of Chapter 2 and 3 suggest that students’ knowledge development may be related to the way the content is presented over time: distributed over a longer period or concentrated in one semester. In Chapter 4 and 5 the relation between assessment characteristics and knowledge development was investigated. Medical students do not only acquire knowledge, but they are also expected to apply knowledge and reflect on it. In Chapter 4, the development of students’ ability to apply their knowledge and their judgment of knowledge were investigated. Since we were interested in students’ scores on lower and higher order questions during their preclinical and clinical training, progress test data from the beginning and end of their preclinical or clinical training were analyzed. To investigate students’ cognitive processing development, specific assessment characteristics were used, based on Bloom’s taxonomy: lower-order questions requiring students to only recall their knowledge and higher-order requiring students to apply their knowledge. To investigate the educational aspect of the judgment of knowledge, the question mark option in successive progress tests was used. Subsequently, the growth in students’ ability to apply and judge their knowledge was compared in the preclinical and clinical phase. Whereas preclinical (Year 1 and 3) and Year 4 students scored lower on vignette questions (higher order), the Year 6 students scored higher on vignette questions than on simple questions (lower order). Students’ judgement of knowledge decreased over time for both cohorts, possibly indicating that the question mark option does not support students’ judgment of knowledge development. In addition to investigating the educational aspect of judgement of knowledge (Chapter 4), it is important to verify the effect of adding the “question mark option” as an assessment characteristic on students’ scores. In Chapter 5, the psychometric properties of two scoring methods, a number-right scoring and the formula scoring (with “question mark option”), were compared. More specifically, we investigated whether the question mark option as an assessment characteristic provides less dysfunctional items and a more reliable score in a 2x2 crossover design. The majority of dysfunctional items was found in the formula scoring test condition. Furthermore, the reliability for the tests using number-right scoring were higher than for formula scoring. Chapter 4 and 5 suggest that adding the question mark option as an assessment characteristic may not be optimal for two reasons. First, as students progress, more questions were guessed and answered incorrectly. Second, the addition of the question mark decreases the reliability of the test and increase the number of dysfunctional items. In Chapter 6 and 7 the relation between curriculum characteristics and skill acquisition was investigated. During medical training, medical students do not only acquire knowledge, but also skills. Students should have the opportunity to practice and receive feedback during their skill acquisition and retention. Without practice and feedback, learning a new technical skill would be very challenging. Trainees may practice either in one session, known as massed training, or in multiple sessions spread over time, known as spaced training. In Chapter 6 a systematic review was conducted to investigate the effect of spacing training sessions on long-term retention of surgical skills. The Medline, PsycINFO, Embase, Eric and Web of Science online databases were searched. Only randomized trials with a sample of medical trainees acquiring surgical motor skills in which the spacing effect was reported were included in the study. The quality and bias of the articles were assessed using the Cochrane Collaboration’s risk of bias assessment tool. 11 articles met all inclusion criteria and were included. The overall quality of the articles was “moderate”. Students in the spaced condition scored higher on a retention test than students in the massed condition. Although the optimal gap between study sessions remains unclear, our systematic review suggests that when designing a technical skill training, spacing the training sessions improves students’ skill retention when compared to massed practice. In Chapter 7 a randomized experiment was conducted to investigate the effect of expert and augmented feedback on the acquisition and retention of a complex medical skill. 36 medical students were randomly assigned to one of three types of feedback: expert feedback only (EF), augmented visual feedback (simulator help screen) (HS), and expert feedback with augmented visual feedback (EF+HS). Immediately after the training, students in the EF group were faster than students in the two other groups. After 11 days, students in the EF+HS group scored significantly higher for image quality than students in the two other groups. This thesis has demonstrated that there is a relation between a few aspects of the curriculum and knowledge development and skill acquisition. Furthermore, this thesis has shown how and when the spacing effect may benefit students’ knowledge development and skill acquisition, how the “I don’t know” option affects students’ scores and, finally, that different sources of feedback are needed to enhance students’ skill acquisition and retention.
Article
Hintergrund Manipulationen werden häufig angewandt. Bisher ist unklar, wie sich die Technikparameter von Lernenden und Experten unterscheiden. Die vorliegende Literaturarbeit soll die Evidenz für die Beantwortung dieser Frage prüfen und Hinweise für einen sinnvollen Einsatz in der Schulung von Studenten liefern. Weiter wird die klinische Relevanz diskutiert. Methode Die Recherche wurde in den Datenbanken Medline/PubMed, Cochrane Library, CINAHL und PEDro durchgeführt. Insgesamt wurden 4 klinische Arbeiten bezüglich ihrer Methodik und zur Beantwortung der Fragestellung herangezogen und bewertet. Ergebnisse Die biomechanischen Parameter einer Manipulation verändern sich im Laufe des Ausbildungsprozesses. Diese Veränderung geschieht für wenigstens einen Parameter gemäß Definition. Am stärksten variiert hierbei die Geschwindigkeit in Form einer Zunahme. Diese ist nicht zwingend an eine proportionale Kraftzunahme gekoppelt. Auch die Variabilität des Krafteinsatzes und der Geschwindigkeit ändert sich in Form einer Abnahme. Schlussfolgerungen Technikparameter variieren zwischen den einzelnen Erfahrungsjahren, aber auch innerhalb eines Jahrgangs. Dabei scheint unabhängig vom Ausbildungstand eine gewisse Varianz der Technikwerte nicht vermeidbar zu sein. Ein individuelles, auf den einzelnen Studenten abgestimmtes Lernprozedere erscheint demnach sinnvoll.
Article
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Abstract The aim of this study was to review the literature dealing with the force-time characteristics of different forms of physical activity performed with upper limbs by the elderly and the disabled (Nordic Walking and using a wheelchair, respectively) and of manual techniques used by physiotherapists. Values of work and power were analysed as well. Based on the analysis of the literature concerning the substantive areas included in this article, we believe that objective measurements will expand the present knowledge about values of force developed by upper limbs during different forms of human activity. It seems to be of particular significance in the application of manual therapy techniques, because currently values of force exerted upon the patient while applying these techniques are selected by a physiotherapist intuitively and are neither objective nor systematically controlled. The identification of the values of force developed with upper limbs by the elderly, the disabled and physiotherapists during the aforementioned forms of activity will make an original contribution to the broadly defined physical culture, especially rehabilitation and health promotion.
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Background: Spinal manipulations (SMT) and mobilizations (MOB) are interventions commonly performed by many health care providers to manage musculoskeletal conditions. The clinical effects of these interventions are believed to be, at least in part, associated with their force-time characteristics. Numerous devices have been developed to measure the force-time characteristics of these modalities. The use of a device may be facilitated or limited by different factors such as its metrologic properties. Objectives: This mixed-method scoping review aimed to characterize the metrologic properties of devices used to measure SMT/MOB force-time characteristics and to determine which factors may facilitate or limit the use of such devices within the context of research, education and clinical practice. Methods: This study followed the Joanna Briggs Institute's framework. The literature search strategy included four concepts: (1) devices, (2) measurement of SMT or MOB force-time characteristics on humans, (3) factors facilitating or limiting the use of devices, and (4) metrologic properties. Two reviewers independently reviewed titles, abstracts and full articles to determine inclusion. To be included, studies had to report on a device metrologic property (e.g., reliability, accuracy) and/or discuss factors that may facilitate or limit the use of the device within the context of research, education or clinical practice. Metrologic properties were extracted per device. Limiting and facilitating factors were extracted and themes were identified. Results: From the 8,998 studies initially retrieved, 46 studies were finally included. Ten devices measuring SMT/MOB force-time characteristics at the clinician-patient interface and six measuring them at patient-table interfaces were identified. Between zero and eight metrologic properties were reported per device: measurement error (defined as validity, accuracy, fidelity, or calibration), reliability/repeatability, coupling/crosstalk effect, linearity/correlation, sensitivity, variability, drift, and calibration. From the results, five themes related to the facilitating and limiting factors were developed: user-friendliness and versatility, metrologic/intrinsic properties, cost and durability, technique application, and feedback. Conclusion: Various devices are available to measure SMT/MOB force-time characteristics. Metrologic properties were reported for most devices, but terminology standardization is lacking. The usefulness of a device in a particular context should be determined considering the metrologic properties as well as other potential facilitating and limiting factors.
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This study evaluated the effectiveness of using visual feedback to facilitate pitch control by a speaker using a pressure sensitive onset controlled electrolarynx (EL). This proof-of-concept study was conducted with one healthy adult. The participant-speaker was provided with computer generated visual feedback over five sessions within a consecutive period of three weeks. Changes in force control accuracy were gathered and analyzed. An improvement in finger (thumb) force control accuracy from the first to the last training session was documented. The results of this study provide data toward the development of a clinical training protocol for the use of a pressure sensitive onset controlled EL by laryngectomized speakers. Further, these results highlight the importance of developing a relevant multimodality training protocol for the improvement of postlaryngectomy EL speech production.
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This study aims to quantify the force applied during posterior-to-anterior lumbar vertebrae mobilizations of different grades (I to IV) and compare that force between experienced physiotherapists and final year physiotherapy students. Four experienced physiotherapists and four final year physiotherapy students participated in this study along with five healthy asymptomatic individuals. A manual therapy table positioned over three force plates allowed for measurements of the force oscillation frequency and intensity applied during grade I, II, III and IV posterior-to-anterior (PA) mobilizations at two lumbar vertebral levels (L2 and L4). Mixed model ANOVAs were used to compare the force applied between the experienced physiotherapists and students, and between the various grades. The results showed that the mean oscillation frequency was similar between the groups for all grades. Grade I and grade IV PA mobilizations showed similar mean oscillation frequency as did grade II and III PA mobilizations. The minimum and maximum force applied was higher for the physiotherapists than for the students for all mobilization grades (p values < 0.05). Similar mean maximum force values were recorded for PA mobilizations between grade I and II and between grade III and grade IV. Grade III and IV PA mobilizations yielded higher mean maximum force values than those recorded during grade I and grade II PA mobilizations. The method used in this study allowed for quantification of the force applied during lumbar PA mobilizations. Experienced physiotherapists apply greater force than physiotherapy students across all grades, despite similar oscillation frequency. Copyright © 2015 Elsevier Ltd. All rights reserved.
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Objective To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. Design Economic evaluation alongside a randomised controlled trial. Setting Primary care. Participants 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n = 60, spinal mobilisation), physiotherapy (n = 59, mainly exercise), or general practitioner care (n = 64, counselling, education, and drugs). Main outcome measures Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between. groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. Results The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (C447; pound273; $402) were around one third of the costs of physiotherapy (C1297) and general practitioner care (C1379). These differences were significant: P < 0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P = 0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. Conclusions Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
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Objective To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. Design Economic evaluation alongside a randomised controlled trial. Setting Primary care. Participants 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs). Main outcome measures Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. Results The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (€447; £273; $402) were around one third of the costs of physiotherapy (€1297) and general practitioner care (€1379). These differences were significant: P < 0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. Conclusions Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
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This study was designed to investigate whether concurrent quantitative feedback of performance could improve the learning of a joint mobilization technique. A group of 110 physical therapy students had been randomly divided into two groups for teaching purposes. All students had previously learned mobilization of peripheral joints and were currently learning spinal mobilization. From one of the groups, 22 students volunteered to comprise a control group, which was taught a spinal mobilization technique in the traditional way. Additional concurrent quantitative feedback of the level of force applied to the patient was given to 31 volunteers from the other group. These students formed the experimental group. A force plate was used for force measurement, and the feedback was given via an oscilloscope. The average force applied by the students' instructors was taken as an "ideal" force. The oscilloscope showed both the applied force and the "ideal" force. Consistency was measured by the variance of the group's performance. Accuracy was assessed by calculating the difference between the applied force and the "ideal" force. Results indicated that this feedback was associated with a significant improvement in accuracy and consistency in the application of the mobilizing force. This improvement was still present at a follow-up test conducted one week later. This result supports a greater use of such feedback in the teaching and practice of joint mobilization techniques, although the need for further research is emphasized.
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The aim of this study was to evaluate whether postgraduate physical therapy students studying manipulation could learn to accurately produce specific forces during palpation of an intervertebral joint. The 12 subjects (7 female, 5 male), aged 26 to 36 years (X = 29.5, SD = 2.9), had each completed a 4-year degree course in physical therapy and had worked between 3 and 10 years in clinical practice. All subjects were enrolled in a 12-month postgraduate manipulative therapy diploma course. Subjects in the experimental group (n = 6) trained to apply specific forces of 1, 5, 10, 15, 20, and 25 kiloponds using bathroom scales. They practiced for 10 minutes per day for 30 days. Their ability to produce these forces on command was measured using a force platform as they applied posteroanterior passive accessory intervertebral joint movements to the lumbar spine of the healthy subjects. This testing was done prior to training (pretest), immediately after training (posttest), and 1 month following cessation of training (retention test). The control group subjects (n = 6) had no training with scales but were also students of the postgraduate manipulative physical therapy course. In comparison with the control group, the experimentally trained group showed reduced error in force production both immediately after training and 1 month later. This improvement was significant for the retention test. For the retention test, the experimental group subjects were also tested on the trained task (ie, their ability to apply specific forces to the scales). They developed higher levels of accuracy than did the control group. Experimental training, therefore, was an effective addition to normal training, suggesting that therapists can learn to quantify applied forces, with significant implications for communication and evaluation of joint behavior.
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This overview reports the efficacy of conservative treatments (drug therapy, manual therapy, patient education, physical medicine modalities) in reducing pain in adults with mechanical neck disorders. Computerized bibliographic database searches from 1985 to December 1993, information requests from authors, and bibliography screenings were used to identify published and unpublished research. Applying strict criteria, two investigators independently reviewed the blinded articles. Each selected trial was evaluated independently for methodologic quality. Twenty-four randomized controlled trials (RCTs) and eight before-after studies met our selection criteria. Twenty RCTs rated moderately strong or better in terms of methodologic quality. Five trials using manual therapy in combination with other treatments were clinically similar, were statistically not heterogeneous (p = 0.98), and were combined to yield an effect size of -0.6 (95% CI: -0.9, -0.4), equivalent to a 16 point improvement on a 100 point pain scale. Four RCTs using physical medicine modalities were combined using the inverse chi-square method: two using electromagnetic therapy produced a significant reduction in pain (p < 0.01); and two using laser therapy did not differ significantly from a placebo (p = 0.63). Little or no scientific evidence exists for other therapies, including such commonly used treatments as medication, rest and exercise. Within the limits of methodologic quality, the best available evidence supports the use of manual therapies in combination with other treatments for short-term relief of neck pain. There is some support for the use of electromagnetic therapy and against the use of laser therapy. In general, other interventions have not been studied in enough detail adequately to assess efficacy or effectiveness. This overview provides the foundation for an evidence-based approach to practice. More robust design and methodology should be used in future research, in particular, the use of valid and reliable outcomes measures.
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A large number of studies demonstrated the beneficial effects of contextual interference (CI) created by a random practice of different task variations during training on the retention and transfer of motor skills. Current interpretations of this phenomenon assume that random practice engages the subjects in deep and elaborate processing of movement related information, whereas blocked practice results in more superficial processing leading to poorer performance on later retention and transfer tests. According to this line of interpretation, we hypothesised that the complexity of the task to be learned could modulate the effects of CI. If the task is sufficiently complex, it could force the subjects to rely on such elaborate processing, and the beneficial effects of the intertask interference created by random practice could be obscured in that case. We tested this hypothesis by analysing the effects of practice schedule (random vs. blocked), on the acquisition, retention and transfer of learning in a drawing task where subjects had to reproduce accurately, without visual control, geometrical patterns presented on a video screen, as a function of task complexity defined by the number of segments (two, three or four) of each pattern. The results indicated a clear beneficial effect of random over blocked practice on delayed retention and transfer. However, this CI effect was only observed in subjects who learned the simplest movements, and was not observed in subjects who practised the more complex task. These results are discussed in terms of intratask interference created by the planning of multiple movements and the processing of knowledge of results (KR) when the number of drawing movements is increased. These findings support the assumption that the level of cognitive effort in which the subjects are engaged during training is a main factor influencing long-term retention and transfer of motor skills.
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This study examined individuad differences in the preference for and effectiveness of the type of attentional focus for motor learning. In two experiments, participants practicing a balance task (stabilometer) were asked to find out whether focusing on their feet (internal focus) or on two markets in front of their feet (external focus) was more effective. In Experiment 1, participants switched their attentional focus from trial to trial on Day 1 and used their preferred attentional focus on Day 2. In Experiment 2, participants were free to switch their attentional focus any time during 2 days of practice. Retention tests were performed on Day 3. Most participants chose an external focus. Also, they were more effective in retention than participants who preferred an internal focus.
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We review research related to the learning of complex motor skills with respect to principles developed on the basis of simple skill learning. Although some factors seem to have opposite effects on the learning of simple and of complex skills, other factors appear to be relevant mainly for the learning of more complex skills. We interpret these apparently contradictory findings as suggesting that situations with low processing demands benefit from practice conditions that increase the load and challenge the performer, whereas practice conditions that result in extremely high load should benefit from conditions that reduce the load to more manageable levels. The findings reviewed here call into question the generalizability of results from studies using simple laboratory tasks to the learning of complex motor skills. They also demonstrate the need to use more complex skills in motor-learning research in order to gain further insights into the learning process.
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To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. Economic evaluation alongside a randomised controlled trial. Primary care. 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs). Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (447 euro; 273 pounds sterling; 402 dollars) were around one third of the costs of physiotherapy (1297 euro) and general practitioner care (1379 euro). These differences were significant: P<0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
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Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence. Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy. Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.
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Spinal manipulation for low back complaints is an intervention supported by randomized clinical trials and its use recommended by clinical practice guidelines. Physical therapists in this country and internationally have used thrust spinal manipulation at much lower-than-expected rates, despite evidence supporting its efficacy for the treatment of acute low back pain (LBP). The purpose of this clinical commentary is to describe a physical therapist professional degree curriculum in thrust spinal manipulation and outline a method of monitoring ongoing student performance during the clinical education experience. Increased emphasis on evidence-based decision making and on the psychomotor skills of thrust spinal manipulation was introduced into a physical therapist professional degree curriculum. As part of ongoing student performance monitoring, physical therapy students on their first full-time (8-week) clinical education experience, collected practice pattern and outcome data on individuals with low back complaints. Eight of 18 first-year students were in outpatient musculoskeletal clinical settings and managed 61 individuals with low back complaints. Patients were seen for an average (+/-SD) of 6.2 +/- 4.0 visits. Upon initial visit the student therapists employed spinal manipulation at a rate of 36.2% and spinal mobilization at 58.6%. At the final visit, utilization of manipulation and mobilization decreased (13% and 37.8%, respectively), while the utilization of exercise interventions increased, with 75% of patients receiving some form of lumbar stabilization training. Physical therapist students used thrust spinal manipulation at rates that are more consistent with clinical practice guidelines and substantially higher then previously reported by practicing physical therapists. Education within an evidence-based framework is thought to contribute to practice behaviors and outcomes that are more consistent with best practice guidelines.
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To determine if conservative treatments (manual therapies, physical medicine methods, medication, and patient education) relieved pain or improved function/disability, patient satisfaction, and global perceived effect in adults with acute, subacute, and chronic mechanical neck disorders (MND) by updating 11 systematic reviews of randomized controlled trials (RCT). Two independent authors selected studies, abstracted data, and assessed methodological quality from computerized databases. We calculated relative risks and standardized mean differences (SMD) when possible. In the absence of heterogeneity, we calculated pooled effect sizes. We studied 88 unique RCT. The mean methodological quality scores were acceptable in 59% of the trials. We noted strong evidence of benefit for maintained pain reduction [pooled SMD -0.85 (95% CI -1.20, -0.50)], improvement in function, and positive global perceived effect favoring exercise plus mobilization/manipulation versus control for subacute/chronic MND. We found moderate evidence of longterm benefit for improved function favoring direct neck strengthening and stretching for chronic MND, and for high global perceived effect favoring vertigo exercises. We noted moderate evidence of no benefit for botulinium-A injection [pooled SMD -0.39 (95% CI -01.25, 0.47)]. We found many treatments demonstrating short-term effects. Exercise combined with mobilization/manipulation, exercise alone, and intramuscular lidocaine for chronic MND; intravenous glucocorticoid for acute whiplash associated disorders; and low-level laser therapy demonstrated either intermediate or longterm benefits. Optimal dosage of effective techniques and prognostic indicators for responders to care should be explored in future research.
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Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain.
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The purpose of this study was to determine the accuracy of verbal feedback given by manipulative physiotherapy students after a fellow student had applied Passive Accessory Intervertebral Movements (PAIVMs). Twelve students working in pairs acted in turn as model and therapist. Student therapist performance in producing a Grade-III movement was compared subjectively by student models to that of an experienced therapist. Their performance was also objectively compared using a force platform measurement system. Performances were assessed in terms of peak force and the frequency and amplitude of force oscillations. The feedback provided by student models was found to be inconsistent and unreliable. Alternate teaching methods seem necessary in order to provide student therapists with feedback appropriate for learning.
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The role of intrinsic and extrinsic information feedback in learning a new bimanual coordination pattern was investigated. The pattern required continuous flexion-extension movements of the upper limbs with a 90 ° phase offset. Separate groups practiced the task under one of the following visual feedback conditions: (a) blindfolded (reduced FB group), (b) with normal vision (normal FB group), or (c) with concurrent relative motion information (enhanced FB group). All groups were subjected to three different transfer test conditions at regular intervals during practice. These tests included reduced, normal vision, and enhanced vision conditions. Experiment 1 showed that the group receiving augmented information feedback about its relative motions in real-time produced the required coordination pattern more successfully than the remaining two groups, irrespective of the transfer conditions under which performance was evaluated. Experiment 2 replicated and extended the superiority of the enhanced feedback group during acquisition and retention. Experiment 3 demonstrated that successful transfer to various transfer test conditions was not a result of test-trial effects. Overall, the data suggest that the conditions that optimized performance of the coordination pattern during acquisition also optimized transfer performance.
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Feedback frequency effects on the learning of a complex motor skill, the production of slalom-type movements on a ski-simulator, were examined. In Experiment 1, a movement feature that characterizes expert performance was identified. Participants (N = 8) practiced the task for 6 days. Significant changes across practice were found for movement amplitude and relative force onset. Relative force onset is considered a measure of movement efficiency; relatively late force onsets characterize expert performance. In Experiment 2, different groups of participants (N = 27) were given concurrent feedback about force onset on either 100% or 50% of the practice trials; a control group was given no feedback. The following hypothesis was tested: Contrary to previous findings concerning relatively simple tasks, for the learning of a complex task such as the one used here, a high relative feedback frequency (100%) is more beneficial for learning than a reduced feedback frequency (50%). Participants practiced the task on 2 consecutive days and performed a retention test without feedback on Day 3. The 100% feedback group demonstrated later relative force onsets than the control group in retention; the 50% feedback group showed intermediate performance. The results provide support for the notion that high feedback frequencies are beneficial for the learning of complex motor skills, at least until a certain level of expertise is achieved. That finding suggests that there may be an interaction between task difficulty and feedback frequency similar to the interaction found in the summary-KR literature.
Article
The effects of reduced frequency of presentation of relative-liming knowledge of results (KR) on constant and serial practice and whether response stability is associated with increased generalized motor program (GMP) learning were examined. Participants (N = 40) were asked to sequentially depress 4 keys (2, 4, 8, and 6) on the numeric pad portion of the computer keyboard by using the index fingers of their right hands. The frequency (50% and 100%) with which relative-timing KR was presented was manipulated in constant and in serial practice conditions. The tasks used in both the constant and the serial conditions had the same relative-timing structure, but serial practice had 3 different absolute-timing requirements. The results, which indicated that reduced KR frequency enhances GMP learning in the serial practice condition, replicate the findings of Wulf, Lee, and Schmidt (1994). The reduced frequency of KR effect was not evident for the constant practice groups, however. More interesting was the finding that constant practice was significantly better than serial practice for the development and learning of the GMP. The data also showed that after either constant practice or reduced frequency of KR, response stability was enhanced in comparison with the stability of responses following serial practice and frequent KR. Those findings suggest that when response stability is improved either by reducing the frequency with which KR is presented or by reducing the number of task variations practiced, the development of the GMP is enhanced but parameter specification in transfer tasks tends to be degraded.
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There is little information on manual forces applied during cervical mobilization, a common treatment technique. Potential variability of applied forces between therapists and treatment occasions, and factors associated with different force applications are unknown. The purpose of this study is to establish the baseline mechanical properties of cervical spine mobilization and to determine if the applied forces are affected by the characteristics of therapists and mobilized subjects. Physiotherapists (n = 116) applied 4 grades of posteroanterior mobilization to the premarked C2 and C7 spinous (central technique) and articular processes (unilateral technique, one right and one left) of 1 of 35 asymptomatic subjects. Techniques were performed in randomized order, and the first one was repeated after 20 minutes. Load cells attached to the treatment table recorded forces in 3 directions. Before mobilization, subjects' spinal stiffness at the C2 and C7 spinous processes was measured using a custom device. Analyses of variance with Bonferroni post hoc tests determined technique and grade differences, intraclass correlation coefficients the reliability between therapists, and linear regression the factors associated with forces. Therapists apply distinct manual forces for different techniques and grades (P < .001). Variability between therapists is high, but intratherapist reliability is good (intraclass correlation coefficient [2,1] for different force parameters, 0.84-0.93). Mean peak forces increase from grades I to IV, ranging from 22 to 92 N for resultant forces. Greater vertical and caudad-cephalad forces are applied to C7 than C2 (P < .01), with higher mediolateral forces during unilateral techniques (P < .001). Male sex of the therapist or the mobilized subject is associated with higher forces, and C2 stiffness, thumb pain and postgraduate training with lower (P < .05). These results quantify cervical mobilization forces, which will inform future research aimed at improving its application and clinical effectiveness.
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Spinal manipulative therapy has been widely recognized in the medical fields as a conservative treatment modality for spinal dysfunction and pain. Spinal manipulative therapy consists of an application of a thrusting force on a specific part of the spine in a well-defined direction. The magnitude of this force has been associated with positive treatment effects, such as realigning vertebral bodies, mobilizing spinal joints, relaxing back musculature through reflex pathways, and producing a respiratory burst. However, direct force measurements during spinal manipulative therapy in a clinically relevant situation have not been performed to date. The purpose of this study was to measure the forces exerted onto patients during spinal manipulative therapy on various locations of the spinal column. Force measurements were obtained using a thin, flexible pressure mat. The results indicate that peak and preload forces are considerably smaller for spinal manipulative therapy performed on the cervical spine compared to corresponding values obtained on the thoracic spine and sacroiliac joint. Furthermore, for treatments on the thoracic spine and sacroiliac joint, a significant relation was found to exist between preload and peak forces.
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In two experiments we investigated the role of continuous concurrent visual feedback in the learning of discrete movement tasks. During practice the learner's actions either were or were not displayed on-line during the action; in both conditions the participant received kinematic feedback about errors afterward. Learning was evaluated in retention tests on the following day. We separated (a) errors in the fundamental spatial-temporal pattern controlled by the generalized motor program from (b) errors in scaling controlled by parameterization processes. During practice concurrent feedback improved parameterization but tended to decrease program stability. Based on retention tests, earlier practice with continuous feedback generally interfered with the learning of an accurate motor program and reduced the stability of time parameterization. Continuous feedback during acquisition degrades the learning of not only closed-loop processes in slower movements (as has been found in earlier studies) but also motor programs and their parameterization in more rapid tasks. Implications for feedback in training and simulation are discussed.
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Previous studies have demonstrated that manual judgments of lumbar posteroanterior (PA) stiffness show poor reliability. One explanation for this poor reliability may be that the method of training students using feedback provided by physiotherapy tutors is ineffective. The aim of the current study was to investigate whether immediate quantitative feedback, provided from a highly reliable mechanical device, could improve physiotherapy students' ability to judge lumbar PA stiffness. Four physiotherapy student raters assessed 75 stiffness stimuli (provided by the lumbar spines of asymptomatic volunteers) during pre-test, training and post test sessions held over a 3 week period. During the training sessions raters were provided with accurate and immediate feedback regarding each judgment of PA stiffness at the L3 vertebral level of asymptomatic lumbar spines. No significant difference in mean absolute error between the pre and post tests was found (P = 0.31). Provision of information about the true PA stiffness of each lumbar spine judged, therefore, did not improve the accuracy of physiotherapy students' judgments of lumbar stiffness. Copyright 1996 Harcourt Publishers Ltd.