Undergraduate research implementation in physiotherapy: a hands-on and real experience of a randomised controlled trial

BACKGROUND

Evidence-based practice (EBP) is the gold standard approach in physiotherapy, and it is essential that students are aware that it is the appropriate way to provide the patient with the best possible treatment. Undergraduate research (UR) can positively influence learning outcomes and research competencies related to EBP compared to traditional methods of higher education. The aim of this study was to evaluate the effect of implementing a research-based activity (i.e., active participation in a randomised controlled trial [RCT]) in the UR programme on the learning and acquisition of research methodology-related competencies by first-year physiotherapy students.

METHODS

Students in the first academic year of the Bachelor´s Degree in Physiotherapy of University of Deusto (Donostia-San Sebastian, Spain) who were enrolled in the subject 'Introduction to Research Methodology' were invited to take part in a real RCT which consisted of three groups: intervention, placebo, and control group. While the RCT was carried out, researchers and/or participants roles were combined among students during the semester. At the end, a questionnaire that included open and closed questions was used to evaluate the effectiveness of the UR strategies used in students´ acquisition of theoretical knowledge, research competencies, self-efficacy of RCT skills and procedures. Lecturers also completed the questionnaire to evaluate their experience.

RESULTS

From the 114 students enrolled in the subject, 102 participated in the RCT and 110 answered the final questionnaire. Regarding the development of research competencies, UR had a positive or very positive impact on critical thinking (67% and 18%, respectively) and in the assessment of methodological quality (66% and 23%, respectively). Furthermore, most students reported that the implementation of the RCT facilitated their knowledge of placebo, detection of bias, development of critical thinking and a better understanding of methodological issues in research. Lecturers reported an additional burden that was difficult to reconcile with daily duties.

CONCLUSION

The novel UR program provided students with a new opportunity to improve their knowledge of RCT procedures, thus making the learning process more meaningful. Therefore, ways of teaching and learning focused on improving research and inquiry attitudes should be considered and integrated into the health care curriculum, especially in physiotherapy programs, to ensure the transfer of EBP for the provision of the best care.

TRIAL REGISTRATION

Australian New Zealand Clinical Registry: ACTRN12622000263796p (14/02/2022).

High-resolution ultrasound tendon-to-bone distances in partial and complete finger flexor A2 pulley ruptures simulated in human cadaver dissection: toward understanding imaging of partial pulley ruptures

Introduction: The A2 pulley tear is the most common injury in rock climbing. Whereas complete A2 pulley ruptures have been extensively researched, studies focused on partial A2 pulley ruptures are lacking. A2 pulleys rupture distally to proximally. High-resolution ultrasound imaging is considered the gold-standard tool for diagnosis and the most relevant ultrasound measurement is the tendon-to-bone distance (TBD), which increases when the pulley ruptures. The purpose of this study was to establish tendon-to-bone distance values for different sizes of partial A2 pulley ruptures and compare these values with those of complete ruptures. Material and methods: The sample consisted of 30 in vitro fingers randomly assigned to 5 groups: G1, no simulated tear (control); G2, simulated 5 mm tear (low-grade partial rupture); G3, simulated 10 mm tear (medium-grade partial rupture); G4, simulated 15 mm tear (high-grade partial rupture); and G5, simulated 20 mm or equivalent tear (complete rupture). A highly experienced sonographer blinded to the randomization process and dissections examined all fingers. Results: The tendon-to-bone distance measurements (medians and interquartile ranges) were as follows: G1, 0.95 mm (0.77-1.33); G2, 2.11 mm (1.78-2.33); G3, 2.28 mm (1.95-2.42); G4, 3.06 mm (2.79-3.28); and G5, 3.66 mm (3.55-4.76). Significant differences were found between non-torn pulleys and simulated partial and complete pulley ruptures. Discussion: In contrast, and inconsistent with other findings, no significant differences were found among the different partial rupture groups. In conclusion, the longer the partial pulley rupture, the higher the tendon-to-bone distance value. The literature is inconsistent regarding the tendon-to-bone distance threshold to diagnose a partial A2 pulley rupture. The minimum tendon-to-bone distance value for a partial rupture was 1.6 mm, and tendon-to-bone distance values above 3 mm suggest a high-grade partial pulley rupture (15 mm incision) or a complete pulley rupture.

Self-reported bio-psycho-social factors partially distinguish patellar tendinopathy from other knee problems and explain patellar tendinopathy severity in jumping athletes: A case-control study

OBJECTIVE

To determine what combinations of self-reported factors distinguish patellar tendinopathy (PT) from other knee problems, and explain PT severity variance.

DESIGN

Case-control study.

SETTING

Social media, private practice and National Health Service.

PARTICIPANTS

An international sample of jumping athletes diagnosed with either PT (n = 132; 30.7 ± 8.9 years; 80 males; VISA-P = 61.6 ± 16.0) or another musculoskeletal knee condition (n = 89; 31.8 ± 9.9 years; 47 males; VISA-P = 62.9 ± 21.2) by a clinician in the last 6 months.

MAIN OUTCOME MEASURES

We considered clinical diagnosis (case = having PT vs control = having other knee problems) as the dependent variable. Severity and sporting impact were defined by VISA-P and availability, respectively.

RESULTS

A model comprising seven factors distinguished PT from other knee problems; training duration (OR = 1.10), sport type (OR = 2.31), injured side (OR = 2.28), pain onset (OR = 1.97), morning pain (OR = 1.89), condition acceptability (OR = 0.39) and swelling (OR = 0.37). Sports-specific function (OR = 1.02) and player level (OR = 4.11) explained sporting availability. 44% of PT severity variance was explained by quality of life (β = 0.32), sports-specific function (β = 0.38) and age (β = -0.17).

CONCLUSION

Sports-specific, biomedical and psychological factors partially distinguish PT from other knee problems. Availability is mainly explained by sports-specific factors, while psychosocial factors impact on severity. Adding sports-specific and bio-psycho-social factors into assessments could help better identification and management of jumping athletes with PT.

Achilles tendon forces and pain during common rehabilitation exercises in male runners with Achilles tendinopathy. A laboratory study

OBJECTIVES

To estimate Achilles tendon forces and their relationship with self-reported pain in runners with Achilles tendinopathy (AT) during common rehabilitation exercises.

DESIGN

Cross-sectional.

SETTING

Laboratory.

PARTICIPANTS

24 recreational male runners (45.92 (8.24) years old; 78.20 (8.01) kg; 177.17 (6.69) cm) with symptomatic AT.

MAIN OUTCOME MEASURES

Kinematic and kinetic data were collected to estimate Achilles tendon forces during 12 commonly prescribed exercises. Achilles tendon forces were estimated from biomechanical data and normalised to the participant's bodyweight. The secondary aim was to investigate the relationship between Achilles tendon forces and pain during these exercises.

RESULTS

Two exercise clusters were identified based on Achilles tendon forces. Cluster1 included various exercises including double heel raises, single heel raises, and walking (range: 1.10-2.76 BWs). Cluster2 included running, jumping and hopping exercises (range: 5.13-6.35 BWs). Correlation between tendon forces and pain was at best low for each exercise (range: -0.43 - 0.20). Higher force exercises lead to more tendon load for a given amount of pain (R² = 0.7505; y = 0.2367x + 0.6191).

CONCLUSION

This study proposes a hierarchical exercise progression based on Achilles tendon forces to guide treatment of runners with AT. Achilles tendon forces and pain are not correlated in runners with AT.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis

INTRODUCTION

Biomechanical alterations during running and hopping in people with Achilles tendinopathy (AT) may provide treatment and prevention targets. This review identifies and synthesises research evaluating biomechanical alterations among people with AT during running, jumping and hopping.

METHOD

MEDLINE, EMBASE, CiNAHL and SPORTDiscus were searched in July 2018 for case control, cross-sectional and prospective studies investigating kinematics, kinetics, plantar pressures and neuromuscular activity in AT participants during running or hopping. Study quality was assessed with a modified version of the Downs and Black quality checklist, and evidence grading applied.

RESULTS

16 studies reported 249 outcomes, of which 17% differed between groups. Reduced peroneus longus (standardized mean difference [95%CI]; -0.53 [-0.98, -0.09]) and medial gastrocnemius (-0.60 [-1.05, -0.15]) amplitude in AT runners versus control was found (limited evidence). Increased hip adduction impulse 1.62 [0.69, 2.54], hip peak external rotation moment (1.55 [0.63, 2.46] and hip external rotation impulse (1.45 [0.55, 2.35]) was found in AT runners versus control (limited evidence). Reduced anterior (-0.94 [-1.64, -0.24] and greater lateral (-0.92 [-1.61, -0.22]) displacement of plantar pressure preceded AT in runners (limited evidence). Delayed onsets of gluteus medius (1.95 [1.07, 2.83] and gluteus maximus (1.26 [0.48, 2.05] and shorter duration of gluteus maximus activation (-1.41 [-2.22, -0.61] was found during shod running in the AT group versus control (limited evidence). Earlier offset time of gluteus maximus (-1.03 [-1.79, -0.27] and shorter duration of activation of gluteus medius (-0.18 [-0.24, -0.12] during running in AT runners versus control was found (limited evidence). Reduced leg stiffness was found in the affected side during submaximal hopping (-0.39 [-0.79, -0.00]) (limited evidence).

CONCLUSION

This review identified potential biomechanical treatment targets in people with AT. The efficacy of treatments targeting these biomechanics should be assessed.

SYSTEMATIC REVIEW REGISTRY

PROSPERO registration number: CRD42016048636.

New concepts on carbon redirection in wastewater treatment plants: A review

Wastewater treatment plants (WWTPs) are no longer considered pollution removal systems but rather resources (nutrients and energy) recovery plants. Legislation imposing more stringent effluent requirements and the need energy self-sufficient or even energy-positive plants are the main drivers for the research and development of new WWTP configurations. While a lot of effort has been focused on developing new processes for nutrient recovery, limited efforts have been allocated to maximizing energy recovery from the organic load. Within this context, high-rate activated sludge (HRAS) is the most promising alternative technology to redirect carbon (organic compounds) towards energy as biogas. This is a critical review of the last decade's development of new alternatives for carbon redirection to improve the energy balance of WWTPs on both the laboratory and the industrial scale.

Recovery of ammonia from domestic wastewater effluents as liquid fertilizers by integration of natural zeolites and hollow fibre membrane contactors

The integration of up-concentration processes to increase the efficiency of primary sedimentation, as a solution to achieve energy neutral wastewater treatment plants, requires further post-treatment due to the missing ammonium removal stage. This study evaluated the use of zeolites as a post-treatment step, an alternative to the biological removal process. A natural granular clinoptilolite zeolite was evaluated as a sorbent media to remove low levels (up to 100mg-N/L) of ammonium from treated wastewater using batch and fixed bed columns. After being activated to the Na-form (Z-Na), the granular zeolite shown an ammonium exchange capacity of 29±0.8mgN-NH₄⁺/g in single ammonium solutions and 23±0.8mgN-NH₄⁺/g in treated wastewater simulating up-concentration effluent at pH=8. The equilibrium removal data were well described by the Langmuir isotherm. The ammonium adsorption into zeolites is a very fast process when compared with polymeric materials (zeolite particle diffusion coefficient around 3×10^-12m²/s). Column experiments with solutions containing 100mgN-NH₄⁺/L provide effective sorption and elution rates with concentration factors between 20 and 30 in consecutive operation cycles. The loaded zeolite was regenerated using 2g NaOH/L solution and the rich ammonium/ammonia concentrates 2-3g/L in NaOH were used in a liquid-liquid membrane contactor system in a closed-loop configuration with nitric and phosphoric acid as stripping solutions. The ammonia recovery ratio exceeded 98%. Ammonia nitrate and di-ammonium phosphate concentrated solutions reached up to 2-5% wt. of N.

Two-step partial nitritation/Anammox process in granulation reactors: Start-up operation and microbial characterization

A two-stage Partial Nitritation (PN)/Anammox process was carried out at lab-scale conditions to treat reject water from a municipal WWTP. PN was achieved in a granular SBR obtaining an effluent with a NH4(+)-N/NO2(-)-N molar ratio around 1.0. The microbial characterization of this reactor revealed a predominance of Betaproteobacteria, with a member of Nitrosomonas as the main autotrophic ammonium oxidizing bacterium (AOB). Nitrite oxidizing bacteria (NOB) were under the detection limit of 16S rRNA gene pyrosequencing, indicating their effective inhibition. The effluent of the PN reactor was fed to an Anammox SBR where stable operation was achieved with a NH4(+)-N:NO2(-)-N:NO3(-)-N stoichiometry of 1:1.25:0.14. The deviation to the theoretical stoichiometry could be attributed to the presence of heterotrophic biomass in the Anammox reactor (mainly members of Chlorobi and Chloroflexi). Planctomycetes accounted for 7% of the global community, being members of Brocadia (1.4% of the total abundance) the main anaerobic ammonium oxidizer detected.

Intensive care practices in brain death diagnosis and organ donation

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Effects of histamine H3 receptor ligands in experimental models of anxiety and depression

Histamine H3 receptor ligands have been proposed to be of potential therapeutic interest for the treatment of different central nervous system disorders; however, the psychopharmacological properties of these drugs have not been studied extensively. In this work, we investigated the possible involvement of histamine H3 receptor function in experimental models of anxiety (elevated plus-maze) and depression (forced swimming test). Male Sprague-Dawley rats were treated i.p. with the histamine H3 receptor agonist R-alpha-methylhistamine (10 mg/kg) or the histamine H3 receptor antagonist thioperamide (0.2, 2 and 10 mg/kg) and 30 min afterwards the time spent in the open arms of an elevated plus-maze was registered for 5 min. The immobility time of male OF1 mice in the forced swimming test was recorded for 6 min, 1 h after the i.p. administration of R-alpha-methylhistamine (10 and 20 mg/kg), thioperamide (0.2, 2, 10 and 20 mg/kg) or another histamine H3 receptor antagonist, clobenpropit (5 mg/kg). The locomotor activity of mice was checked in parallel by means of an activity meter. Both saline controls and active drug controls were used in all the paradigms. Neither thioperamide nor R-alpha-methylhistamine significantly changed animal behaviour in the elevated plus-maze. R-alpha-methylhistamine and the higher dose of thioperamide assayed (20 mg/kg) were also inactive in the forced swimming test. By contrast, thioperamide (0.2-10 mg/kg) dose-dependently decreased immobility, the effect being significant at 10 mg/kg (33% reduction of immobility); clobenpropit produced an effect qualitatively similar (24% reduction of immobility). None of these histamine H3 receptor antagonists affected locomotor activity. These preliminary results suggest that the histamine H3 receptor blockade could be devoid of anxiolytic potential but have antidepressant effects. Besides, the stimulation of these receptors does not seem to be followed by changes in the behavioural parameters studied.

[Electroconvulsive therapy in Parkinson disease. Description of three cases]

Electroconvulsive therapy (ECT) has demonstrated to be useful in psychiatric patients with parkinsonism as well as patients with Parkinson's disease (PD) without associated psychopathology. We prospectively evaluated three patients with PD and major depression in whom ECT proved to be efficacious. These patients experimented a marked improvement measured by the Unified Parkinson's Rating Scale (UPDRS). In two cases the ECT allowed for a reduction in their drug treatment, and in one case complex fluctuations disappeared. In the two patients who continued with ECT fortnightly, the improvement observed inicially has remained. Since ECT has shown a good tolerance, we conclude that this therapy should be considered as an alternative approach for PD patients with a poor answer to conventional treatment.

[Parapharyngeal carcinoma of the larynx: current clinical and pathological aspects and reports of a clinical case]

Schwannomas (neurilemmomas) are benign tumors of the nerve sheath arising from the Schwann cells in the neural sheath of cranial and spinal nerves. The most frequent sites are the peripheral nerves of the head and neck and the flexor surfaces of the upper extremities. Parapharyngeal schwannomas are rare, which makes them interesting for ear, nose and throat specialists. A new case of schwannoma of the parapharyngeal space is reported. Our experience with the clinical management and surgical treatment of cervical schwannomas is discussed and the literature is reviewed.