Physical Maneuvers Research Articles

Prevalence of and Theoretical Explanation for Type 2 Benign Paroxysmal Positional Vertigo.

A variant of benign paroxysmal positional vertigo (BPPV) involves the subjective report of vertigo without the coinciding nystagmus. This presentation includes truncal retropulsion when sitting up from the ipsilesional provocative test (ie, Dix-Hallpike), which we term type 2 BPPV. The primary objective of this study is to prospectively determine the prevalence and describe the clinical course of type 2 BPPV. We offer a theoretical explanation for the absence of nystagmus. Prospective, observational study carried out in 2 tertiary hospitals. One hundred eighty patients (134 women, 46 men) met the inclusion criteria and were included between January 10, 2018, and October 30, 2019. Efficacy of physical therapy maneuvers was determined at 1-week follow-up. Three-dimensional reconstructions of the planes of the semicircular canal cupula from histological preparations are offered as evidence for the theoretical explanation. One-third of the patients met the criteria for type 2 BPPV; the remainder had typical posterior or horizontal semicircular canal involvement. Symptoms from type 2 BPPV were longer in duration yet responded favorably to physical therapy maneuvers. Upon repeat testing, 19 patients treated for posterior canalithiasis developed a slight, persistent positional downbeat nystagmus in the Dix-Hallpike position that we propose as evidence the otoconia entered the short arm of the posterior semicircular canal. Our data and 3-dimensional rendering suggest the report of vertigo, yet absent nystagmus in type 2 BPPV is from otoconia aligning with the gravitoinertial vector during provocative testing that precludes cupular stimulation. Type 2 BPPV appears to be a common and treatable form of vertigo.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A372).

The STAMP Test: A Novel Clinical Test in Diagnosing Achilles Tendon Ruptures

Category:AnkleIntroduction/Purpose:Achilles tendon ruptures are common injuries, and an estimated 20-25% injuries are missed acutely. Chronic and acute Achilles tendon rupture patients typically present with nonspecific complaints and physical exam findings. Commonly used physical exam maneuvers such as the Thompson test have variable sensitivity and reliability for the examiner. The patient with an Achilles tendon rupture will have expected plantar-flexion weakness, however clinical data utilizing plantarflexion weakness to develop a physical exam maneuver is lacking. We propose two new tests with sensitivity and specificity analysis to evaluate this understanding in the clinical setting: the Stand and Maintain Plantarflexion (STAMP) and Tendo-Achilles Rise (TAR) tests. We hypothesize that the STAMP and TAR exams maneuvers will have high sensitivity for diagnosis of acute and chronic Achilles tendon rupture.Methods:Data was collected from a single surgeon's practice at two large urban treatment centers. Data was retrospectively acquired over a period of 7 years and then prospectively acquired over a period of 5 years. Patients with mid-substance Achilles tendon rupture confirmed with MRI imaging or operative treatment were included. We examined clinical data regarding ambulation, resting tension, palpable Achilles gap, Thompson test, and STAMP and TAR tests on initial presentation. The STAMP test is performed by the patient attempting a wall assisted double leg heel rise and lifting the uninjured foot off the ground. It is consistent with an Achilles tendon rupture if the patient is unable to maintain this position for five seconds. The TAR test is performed by the patient attempting a wall assisted single leg heel rise. It is consistent with an Achilles tendon rupture if the patient is unable to maintain this position for five seconds.Results:71 patients with complete mid-substance Achilles tendon ruptures that met inclusion criteria were identified. 45 (63%) presented acutely and 26 patients (37%) presented chronically. The Thompson test displayed a diagnostic sensitivity of (12 26 46%) for chronic ruptures and (38 45 84%) for acute ruptures. The STAMP and TAR tests displayed a diagnostic sensitivity of (22 26 85%) for chronic ruptures and (45 45 100%) for acute ruptures with a diagnostic specificity of (89%).Conclusion:Achilles tendon ruptures can be difficult to diagnose due to inconsistent symptoms and clinical exam findings. The STAMP and TAR physical exam tests have high sensitivity to clinically diagnose Achilles tendon rupture both in the acute and chronic setting and are superior to well-described physical exam tests. The findings support that the addition of the STAMP and TAR diagnostic protocol may be clinically beneficial when diagnosing Achilles tendon ruptures in both the acute and chronic setting. Future work should be focused on providing direct comparison to other exam maneuvers as well as identifying data reliability.

Running gait biomechanics in female runners with sacroiliac joint pain.

[Purpose] To identify running gait biomechanics associated with sacroiliac (SI) joint pain in female runners compared to healthy controls. [Participants and Methods] In this case-control study, treadmill running gait biomechanics of female runners diagnosed SI joint pain, (by ultrasound-guided diagnostic SI joint injection and/or ≥2 positive SI physical exam maneuvers) were compared with age, height, mass, and BMI matched healthy female runners. Sagittal and coronal plane treadmill running video angles were measured and compared. [Results] Eighteen female runners with SI pain, and 63 matched controls, were analyzed. There was no difference in age, height, mass, or BMI between groups. At the point of initial contact, runners with SI joint pain demonstrated less knee flexion, greater tibial overstride, and greater ankle dorsiflexion, compared to controls. In midstance, runners with SI pain had greater contralateral pelvic drop compared to controls. For unilateral SI joint pain cases (N=15), greater contralateral pelvic drop was observed when loading their affected side compared to the unaffected side. [Conclusion] Female runners with SI joint pain demonstrated greater contralateral pelvic drop during midstance phase; along with less knee flexion, greater “tibial overstride”, and greater ankle dorsiflexion at initial contact compared to controls.

The virtual peripheral nerve academy: education for the identification and treatment of peripheral nerve disorders

Millions of people around the globe suffer peripheral nerve injuries caused by trauma and medical disorders. However, medical school curricula are profoundly deficient in peripheral nerve education. This lack of knowledge within the healthcare profession may cause inadequate patient care. We developed the Virtual Peripheral Nerve Academy (VPNA) as a reusable virtual learning environment to provide medical students with detailed education on the peripheral nervous system (PNS). Students are introduced to the PNS through virtual 3D rendering of the human body, wherein they visualize individual nerves through dissection and observe normal motor and sensory function associated with each nerve. PNS structures that are absent from traditional texts are included in this visualization, ranging from the innervation of joints to the normal anatomic variation required for differential diagnosis of pain after an injury. Detailed modules on peripheral nerve disorders allow students to observe pathophysiological mechanisms, associated symptomatology, and appropriate treatments. Students are briefed on a patient clinical case, then interact with a patient avatar to learn the appropriate diagnostics, including physical exam maneuvers and electrodiagnostic testing. Interactive modules on peripheral nerve surgeries detail surgical techniques. The VPNA data and analytics dashboards allow medical students and course instructors to assess skill improvement and identify specific learning needs. The built-in learner management system and availability on both computer-based and virtual reality platforms facilitate integration into any existing medical school curricula. Ultimately, this immersive technology enables every medical student to learn about the peripheral nervous system and gain competency in treating real-life nerve pathologies.

Pain fingerprinting using multimodal sensing: pilot study

Pain is a complex phenomenon, the experience of which varies widely across individuals. At worst, chronic pain can lead to anxiety and depression. Cost-effective strategies are urgently needed to improve the treatment of pain, and thus we propose a novel home-based pain measurement system for the longitudinal monitoring of pain experience and variation in different patients with chronic low back pain. The autonomous nervous system and audio-visual features are analyzed from heart rate signals, voice characteristics and facial expressions using a unique measurement protocol. Self-reporting is utilized for the follow-up of changes in pain intensity, induced by well-designed physical maneuvers, and for studying the consecutive trends in pain. We describe the study protocol, including hospital measurements and questionnaires and the implementation of the home measurement devices. We also present different methods for analyzing the multimodal data: electroencephalography, audio, video and heart rate. Our intention is to provide new insights using technical methodologies that will be beneficial in the future not only for patients with low back pain but also patients suffering from any chronic pain.

The University of Colorado Virtual Physical Examination for Spine Surgeons: A Preliminary Study.

As coronavirus disease 2019 (COVID-19) reached pandemic status, in-person orthopedic clinics across the United States were forced to close as many states adopted stay-at-home orders. Previously, the use of telemedicine in orthopedic practices was minimal for a variety of reasons, one being the inability to perform a physical examination in a specialty reliant on direct patient contact for diagnosis and treatment. A prospective cohort of 52 patients consented to participate in a novel virtual physical examination protocol during routine telemedicine visits at a large, tertiary orthopedic spine practice. Participants were asked to perform a series of carefully designed physical maneuvers using readily available household objects to allow their provider to better assess sensory and motor function in the tele-medicine setting. Patients were then asked to complete a short satisfaction survey. In total, 52 patients completed the physical examination and survey. Males and females were distributed evenly among the cohort at 50%. The mean age was 52.1±15.5 years. The average score for ease of understanding the examination (1=easiest, 5=hardest) was 1.1, while the average score for ease of performance was 1.5. Most participants (97.56%) felt their provider was better able to understand their condition using the virtual examination findings. This study highlights the utility of a virtual physical examination for assessment of spine patients in the telemedicine setting. Furthermore, this study illustrates the ease with which such an examination can be implemented and performed to improve patient evaluation and satisfaction. [Orthopedics. 2022;45(1):e7-e10.].

Influencing Human Escape Maneuvers With Perceptual Cues in the Presence of a Visual Task

Visual engagement is common in many situations where human operators must perform tasks in challenging environments. This visual engagement has the potential to impact the safety of these operators when dealing with dynamic threats. Perceptual cues have been shown to elicit physical evasion maneuvers, thereby improving safety. In this article, we investigate the effects of cues and visual engagement on rapid whole-body responses. The visual task, inspired by the Trail Making Test (TMT), served as a proxy for visual engagement in the real world. Our continuous TMT minigame and threat simulation are implemented in a virtual reality environment. Participants attempt to maximize their performance score by quickly solving TMTs and dodging dynamic threats from various in-plane directions. They are provided with no cues (control), visual cues, and vibrotactile cues indicating impending threat directions. Participant’s ability to dodge threats is quantified by failure rate and reaction time within field of view and for all approach directions. An index of difficulty highlighted perceptual cue response sensitivity to varying threat speeds and sizes. This article provides two core key contributions and other interesting findings: 1) the results illustrate that tactile cues enable statistically significantly better dodging rates than visual cues or with human vision alone (control condition); and 2) that visual engagement degrades human evasion performance in a statistically significant way. Finally, tactile cue responses appear to be less sensitive than visual cues to visually engaging tasks within the higher portion of difficulty index range that is investigated.

An extra pair of hands: Versatile use of tape in dermatologic procedures

Performing surgery and other procedures can be very challenging with limited exposure of the skin lesion, which can often occur between the intergluteal folds (Fig 1, A), between the toes (Supplementary Fig 1, A available via Mendeley at https://data.mendeley.com/datasets/m27wdz7fzg/1), and at the postauricular area (Supplementary Fig 2, A). Methods to expose the skin include using leg holders, ideal positioning of the patient, and physical maneuvers accomplished by an assistant. However, in areas where medical resources and personnel are limited, a single physician may have to perform the procedure without any assistance.

Manual Lachman Test Underestimates Tibial Translation Compared to Standardized Generated Force: A Biomechanical Study of Cadaveric Anterior Cruciate Ligament Repair Using Internal Brace (205)

Objectives:With an increasing incidence over time, anterior cruciate ligament (ACL) rupture can produce functionally limiting knee instability that requires operative treatment to address the instability as well as prevent the development of osteoarthritis. Anteroposterior instability forms the basis of the most sensitive physical exam maneuver to examine the ACL for rupture, the Lachman test. This investigation has two goals: to assess the precision and accuracy of the manual Lachman test by comparing anterior tibial translation generated to that of a standardized applied force Lachman test, and to compare the anteroposterior stability of cadaver specimens with simulated ACL ruptures which were repaired with and without internal suture tape augmentation.Methods:The tibial plateau in ten cadaveric knees was divided into medial, middle and lateral reference points, which were monitored digitally during testing using Optotrak. Intact knees were subjected to both manual Lachman tests at 30 degrees of flexion and standardized 150N force Lachman tests utilizing a hook and pulley system with force transducer. The ACL’s of all specimens were then transected, and the ACL deficient knees were subjected to both the manual and standardized Lachman tests. The specimens were then randomly divided into two groups to be repaired with or without internal suture tape augmentation, and subsequently underwent 100, 250, and 500 cycles from 90 degrees of flexion through full extension with a frequency of .1Hz, after which the same standardized Lachman test was performed on all repaired specimens. Comparison of variances were made using a two-sample F-Test for variances. Comparison of means were made using a two sample t-test assuming unequal variances and one-way ANOVA. Significance was set at p </= 0.05.Results:Comparing ACL intact to ACL deficient states, the standardized Lachman test detected a significant difference in tibial translation at the medial (14.1mm versus 20.3mm, p=.031), middle (17.5mm versus 24.6mm, p=.011), and lateral (14.8mm versus 21.5mm, p=.050) reference points while the manual Lachman test only detected a significant difference at the middle (12.6mm versus 19.8mm, p=.026) reference point. In ACL deficient knees, there was a statistically significant underestimation in tibial translation when using the manual method as compared to the standardized method (17.4mm versus 22.3mm, p=0.046). When comparing the precision of the testing methods, F-Tests for variance did not yield significant differences between variances in measured tibial translation for the manual and standardized Lachman tests in either intact or ACL deficient knees. There were no statistically significant differences in measured tibial translation between specimens with intact ACL, ACL repair, and ACL repair with internal brace at the medial (14.1mm versus 13.7mm versus 16.45mm, p=0.462), middle (17.5mm versus 16.6mm versus 18.3mm, p=0.767), lateral (14.8mm versus 15.9mm versus 15.9mm, p=0.934), or call (15.5mm versus 15.2mm versus 16.9mm, p=0.748) reference points.Conclusions:Tibial translation generated by Lachman tests performed manually may be underestimated when compared to Lachman tests performed with a standard force, lending to difficulty detecting the ACL deficient state. ACL repair both with and without internal brace augmentation allowed for a return to pre-rupture levels of anteroposterior stability.

Teaching Benign Paroxysmal Positional Vertigo to Emergency Medicine Residents by Using Gagne’s Nine Steps of Instructional Design

IntroductionPatients commonly seek medical advice with dizziness symptoms. One of the common subtypes of dizziness is benign paroxysmal positional vertigo (BPPV). The American Academy of Neurology recommends that physicians should be trained in the physical maneuvers for the treatment of BPPV.MethodologyThe study participants were educated about BPPV using Gagne’s instructional strategy. Before and after the education, three parameters were used for assessing their knowledge and skills about BPPV. Twenty MCQs for knowledge assessment and two skill stations, Dix–Hallpike test (DH) and canalith repositioning maneuver (CR) were used. An experienced emergency medicine (EM) faculty supervised the assessment.ResultsNineteen EM residents participated in the study; mean age was 28.4 years (±1.7). Twelve (63.15%) were male, and seven (36.9%) were female. The median score before the course for the DH test was 2 (1.7–3.0) and improved to 5(4.0–5.0). Similarly, CR’s median score improved from 2 (1.0–2.3) to 5 (4.7–5.0). Both of these skills improved by 60%. Pre-intervention MCQs mean score was 15.2 (14.4–16.1), which increased to 18.0 (17.4–18.6). MCQs improvement was recorded as 14%.ConclusionThe educational plan delivered by utilizing the Gagne’s instructional design has resulted in significant improvement of the knowledge about BPPV.

The Telemedicine-Based Pediatric Examination of the Back and Lower Limbs: A Narrative Review.

The COVID-19 pandemic has accelerated the transition to virtual healthcare while also prompting an abundance of new literature highlighting telemedicine’s capabilities and limitations for various medical applications, notably musculoskeletal examinations. Telemedicine provides an opportunity to deliver timely patient- and family-centred care while maintaining physical distancing and improving access to remote communities. This review aims to narrate the current state of the literature on telemedicine applied in the context of a musculoskeletal examination for children aged 3 to 18 years. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. The general examination components relevant to the back and lumbosacral spine, hip, knee, ankle/foot, and gait are described. These components include inspection, palpation, range of motion, motor, and sensory examination as well as special testing. There is general feasibility, validity, and substantial reliability in performing most examination components, and primary diagnoses established virtually were found to be either the same or similar in the vast majority of cases. Despite the current literature focusing mainly on adult populations, we describe how each aspect of the exam can be reliably incorporated into a virtual appointment specific to the pediatric population. Currently available smartphone-based applications that measure joint range of motion were generally found to have high reliability and validity. Caregivers are needed for most of the consultation, especially in younger children, but select physical exam maneuvers can be self-performed by older children and adolescents alone. By providing an overview of the available smartphone tools as well as the reliability and validity of remote assessments, this review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase providers’ confidence in incorporating telemedicine into their practice.

Assessment of sensory organization testing in benign paroxysmal positional vertigo patients before and after repositioning manoeuvre

Introduction and objectiveBenign paroxysmal positioning vertigo is considered the most common disorder of the peripheral vestibular system. After successful physical manoeuvres for BPPV, a number of patients complain of non-positional sustained imbalance of variable duration called residual dizziness lasting for several days. The objective of this study was to compare the posturographic changes before and one week after successful repositioning manoeuvres in patients with idiopathic BPPV. Materials and methodsThis study was a case–control study, where the first group was composed of 20 patients with confirmed BPPV diagnosis regardless of the affected canal or pathology. Twenty age and gender matched normal subjects constituted the control group. The sensory organization test was performed before and one week after a repositioning manoeuvre in BPPV patients. ResultsAll 20 BPPV patients, except 6 who had no significant improvement of symptoms even after disappearance of classic vertigo and nystagmus, had substantial improvement in sensory scores after CRPs in the antero-posterior visual and vestibular scores and the medio-lateral visual and global scores. All antero-posterior and medio-lateral scores before and after CRPs, except for the AP preferential score, were considerably poorer in BPPV patients than healthy subjects. The 6 patients, who showed no improvement after CRPs, presented with a history of non-specific symptoms i.e., light-headedness or sense of floating. ConclusionsSensory organization test might have a role in the assessment of residual dizziness in patients with BPPV after CRPs.

Systematic Review on Vestibular Symptoms in Patients With Enlarged Vestibular Aqueducts.

Enlarged vestibular aqueduct (EVA) is a congenital condition that can lead to various outcomes in pediatric patients including hearing loss and vestibular dysfunction. Our goal was to critically appraise the literature on the proportion of patients with EVA who report vestibular dysfunction, determine relevant risk factors for the development of these symptoms, and describe vestibular tests and interventions used to improve outcomes. A systematic review was performed in accordance with the PRISMA guidelines. We queried the EMBASE, Ovid Medline, and Cochrane Library databases for relevant literature. Studies were included if they had n > 10, reported vestibular symptoms or vestibular function testing in patients with EVA, and were published in English. Nonhuman studies, systematic reviews, and review articles were excluded. Of 808 identified studies, 20 met inclusion criteria. Subjective vestibular symptoms included dizziness, episodic vertigo, and imbalance. Seventeen studies reported subjective vestibular symptoms, ranging from 2% to 71% of patients between studies. Seventeen studies performed some form of vestibular function test, including physical exam maneuvers (Dix-Hallpike), caloric testing, electronystagmography, and vestibular evoked myogenic potentials. Of those who had vestibular function testing, 7% to 92% had an abnormal result. Two studies identified head trauma as a risk factor. One study successfully treated patients with BPPV using the Epley maneuver, but other vestibular symptoms were not targeted with treatment. The degree to which vestibular symptoms impact patients with EVA varies significantly. Performing vestibular function testing may help identify asymptomatic patients with vestibular dysfunction. Future studies should target improving treatment of vestibular symptoms in EVA patients. Laryngoscope, 132:873-880, 2022.

P41. The University of Colorado virtual physical exam for spine surgeons: A preliminary study

<h3>BACKGROUND CONTEXT</h3> As COVID-19 reached pandemic status, in-person orthopedic clinics across the United States were forced to close as many states adopted stay-at-home orders. Previously, the use of telemedicine in orthopedic practices was minimal for a variety of reasons, one being the inability to perform a physical exam in a specialty reliant on direct patient contact for diagnosis and treatment. <h3>PURPOSE</h3> To evaluate the administration of a novel virtual physical exam for evaluation of spine patients in the telehealth setting. <h3>STUDY DESIGN/SETTING</h3> Prospective consecutive cohort at a large academic spine center. <h3>METHODS</h3> A prospective cohort of 52 patients consented to participating in a novel virtual physical exam protocol during routine telemedicine visits at a large, tertiary orthopedic spine practice. Participants were asked to perform a series of carefully designed physical maneuvers using readily available household objects to allow their provider to better assess sensory and motor function in the telemedicine setting. Patients were then asked to complete a short satisfaction survey. <h3>RESULTS</h3> In total, 52 patients completed the physical exam and survey. Males and females were distributed evenly among the cohort at 50%. The average age was 52.1 +/- 15.5 years. The average score for ease of understanding the exam (1 = easiest, 5 = hardest) was 1.1 while the average score for ease of performance was 1.5. There were 97.56% of participants who felt their provider was better able to understand their condition using the virtual exam findings. <h3>CONCLUSIONS</h3> This study highlights the utility of a virtual physical exam for assessment of spine patients in the telemedicine setting. Furthermore, this study illustrates the ease with which such an exam can implemented and performed to improve patient evaluation and satisfaction. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Sacroiliac joint dysfunction: pathophysiology, diagnosis, and treatment.

To review the anatomy and function of the sacroiliac joint (SIJ), as well as the pathophysiology, clinical presentation, diagnostic criteria, and treatment options for SIJ dysfunction. The SIJ serves an extremely crucial function in mobility, stability, and resistance against shear forces. Joint mobility becomes increasingly limited with age-related cartilaginous changes that begin in puberty and continue throughout life. Pain can also be localized to the SIJ itself, known as SIJ dysfunction. A literature review was performed on the anatomy, etiology, risk factors, diagnostic modalities, and treatment options for SIJ dysfunction. SIJ dysfunction is an under-recognized source of low back pain. Dysfunction can result from various clinical conditions, as well as abnormal motion or malalignment of the joint. Diagnosis and evaluation of SIJ dysfunction are difficult, with use of physical maneuvers and image-guided anesthetic injection. Non-operative treatment options are considered first-line due to high surgical complication rates. Such options include conservative management, radiofrequency treatment, nerve blocks, and articular injections. Surgical management involves open and percutaneous approaches. With the aging nature of the population, SIJ dysfunction has emerged as an extremely prevalent issue. Current research into the pathophysiology and risk factors of SIJ dysfunction is extremely important for planning preventative and therapeutic strategies. Various treatment options exist including conservative management, radiofrequency, nerve blocks, intra-articular or peri-articular injections, and surgical fixation. Improved diagnostic methods in clinical practice are thus critical to properly identify patients suffering from SIJ dysfunction, plan early intervention, and hasten return to function. Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

INTER-RATER RELIABILITY OF THE PRONE APPREHENSION RELOCATION TEST (PART)

Background:Hip dysplasia and related instability can cause pain, limit hip function, and ultimately result in osteoarthritis. The Prone Apprehension Relocation Test (PART) augments existing radiographic markers and clinical provocative maneuvers in diagnosing hip dysplasia. Reproducibility of the PART between examiners has not been previously studied.Hypothesis/Purpose:One measure of the potential clinical utility of the PART depends on the reproducibility of test results by evaluating providers including physicians, licensed athletic trainers, and physical therapists. The purpose of this study is to determine the inter-rater reliability of the PART between health care professionals.Methods:We retrospectively identified patients in our institution’s hip preservation registry who presented between September 2017 and June 2019 for evaluation of hip pain. Patients included in the study had the PART performed by two health care professionals who were blinded to the other’s results. Inter-rater reliability was assessed using the Cohen 𝜅, with a value of 𝜅 ≥ 0.75 considered excellent inter-rater reliability, between 0.75 and 0.40 moderate, and ≤ 0.40 poor.Results:96 patients (190 hips) were included, with 63 females and 35 males, average age 32 ± 12.1 years. 23 hips had a positive PART from both examiners. Inter-rater reliability was excellent between health care professionals for the PART when evaluating the right hip (𝜅 = 0.80), left hip (𝜅 = 0.82), and when combining the results for left and right (𝜅 = 0.81). A sub-analysis of patients who had a positive PART from both raters demonstrated that 19 of the 23 hips had a lateral center edge angle > 25°.Conclusion:Our study demonstrates that the PART is a reliable physical exam maneuver in the evaluation of hip pain.

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN).

An expert committee was formed to reach consensus on the use of Tilt Table Testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous ones. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to perform (1) additional provocation tests, such as the active standing test carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.

Snapping Hip Syndrome: A Comprehensive Update.

This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques. Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature. SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs.external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.

Cancer Care during Covid-19: A multi-institutional qualitative study on physician and patient perspectives on telemedicine.

e13611 Background: The COVID19 pandemic has had significant effects on cancer care, including disruptions or delays to screening, diagnosis, treatment, and follow-up for cancer patients as well as shifts from in-person visits to telemedicine to allow for continued access to care. Methods: We conducted semi-structured in-depth interviews with fifty radiation oncologists, medical oncologists, surgical oncologists, and cancer patients or their caregivers. These physicians and patients were recruited from four different hospitals in varying geographic regions and of varying practice settings. Interviews were conducted between October 2020 and May 2021. Interviews were transcribed, then thematically coded to consensus by three researchers. Results: The COVID19 pandemic shifted cancer care from in-person visits towards telemedicine. Providers recognized the necessity and benefit of telemedicine in increasing access to care, but were generally dissatisfied with use of telemedicine. These reasons included: (1) difficulty conducting physical exam maneuvers and assessing patient status; (2) technological failures, exacerbating barriers to care; (3) absence of “connection” with patients; (4) decreased access to interdisciplinary care teams. Patient perspectives on telemedicine were similarly varied, but were overall positive. Patients appreciated the convenience of accessing telemedicine at home, particularly for those who travel long distances or have difficulty traveling. Patients cited challenges similar to their physicians: technological difficulties and the loss of human connection usually conveyed through touch and physical presence. Conclusions: Telemedicine has been a key tool to allow for continued access to care and may continue to be a visit modality after the pandemic subsides. However, telemedicine poses numerous challenges for both physicians and patients and creative solutions to allow for “human connection” via telemedicine should be sought. Further evaluation is needed to determine the effect of telemedicine on quality of care.

Musculoskeletal Anatomy and Clinical Skills Combine to Deliver a Pandemic Safe Curriculum

Introduction The pandemic of 2020 presented an opportunity to evaluate options for changing the delivery of the anatomy curriculum to first year medical students. We describe the integration of small group anatomy and clinical skills sessions to accomplish this. Objective Albany Medical College switched to a completely virtual curriculum during March 2020. However, learning anatomy requires more than just lectures and small group conversations. Both clinical skills and anatomy courses require a hands-on curriculum. Although the lecture portion of these courses can be delivered virtually, the hands-on sessions contribute to the students’ ability to see and experience three-dimensional integration. Materials 1). Lectures in both Anatomy and Clinical Skills, 2). 3-D Anatomy modules using the Toltec Virtual Human Dissector platform, 3). Anatomical prosections, 4). Virtual cases, using the SECTRA Table platform, and 5). Clinical Skills sessions with ultrasound demonstrations. Methods In the fall semester of 2020, the first-year class of 145 was randomly divided into 6 groups of about 24 students. During the musculoskeletal theme, there were 8 anatomy lab sessions and 4 clinical skills sessions. On days with corresponding clinical skills sessions, a group of 24 students came to the lab for a one-hour review of the anatomy on prosected specimens and Sectra Table cases. Several structures were tagged in each cadaver and students were provided with a key. This allowed for self-assessment and a chance to apply knowledge gained from lectures and 3-D anatomy directly to real anatomy. Faculty rotated to address questions and to quiz the students on the anatomy topics. Each group spent one hour in the anatomy lab and then immediately rotated to the clinical skills session. The emphasis in the clinical skills portion was the connection between musculoskeletal anatomy and function, along with physical exam maneuvers. Each session began with a demonstration highlighting an aspect of musculoskeletal ultrasound to correlate anatomy with 2-D imaging. Faculty rotated to address questions and provide demonstrations of maneuvers when indicated. Results There were no differences in exam scores when compared to previous classes for either anatomy or physical diagnosis topics. Conclusion Student feedback revealed the correlation of anatomy followed by clinical skills helped them better understand the anatomy and connection to the physical exam without the risks of exposure to large groups of students. Significance The new curriculum demonstrates that we can still teach the material and deliver the content in an effective manner despite the limitations of the COVID pandemic. Implication: The success of this model resulted in new and preferred structure of these classes.