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Kristen de Vries, OMS-III1, Rebecca Brown OMS-II1, Min-Kyung Jung PhD2, George Cheriyan, DO3, Sheldon Yao, DO3, and Michael Terzella, DO3 1 New York Institute of Technology College of Osteopathic Medicine (NYIT-COM), Old Westbury, NY; 2 Office of Research, NYIT-COM, Old Westbury, NY

3 Department of Osteopathic Manipulative Medicine, NYIT-COM, Old Westbury, NY

The Effect of Ultrasound Imaging on Student Learning of Shoulder Anatomy and Landmarks

RESULTS

CONCLUSION

Landmarks Group Pre Post Mean change p-value

Bicipital tendon 1 2.5 4.5 2.0

0.031* 2 1.7 5.3 3.6

Coracoid process 1 4.3 5.9 1.6

0.035* 2 3.8 6.9 3.1

Supraspinatus tendon

1 2.29 4.81 2.5 0.36

2 2.28 5.34 3.1

T1 transverse process (TP)

1 6.9 8.2 1.3 0.76

2 6.5 7.8 1.3

OBJECTIVE To determine whether the use of ultrasound as an educational supplement will improve osteopathic medical students’ confidence in identifying and palpating anatomic landmarks.

•  Total number of subjects: 63

•  Group 1: n = 31

•  Group 2: n = 32

•  The mean Likert score changes for the bicipital tendon were 2.0 in Group 1 and 3.6 in Group 2. This was statistically significant.

•  The mean Likert score changes for the coracoid process were 1.6 in Group 1 and 3.1 in Group 2. This was statistically significant.

•  The mean Likert score changes for the supraspinatus tendon were 2.5 in Group 1 and 3.1 in Group 2. This was not statistically significant.

•  The mean Likert score changes for the T1 TP were 1.3 in Group 1 and 1.3 in Group 2. This was not statistically significant.

•  There was no significant difference between groups in the pre-survey Likert scores.

Table 1: Summary of the pre and post Likert scores, as well as the mean difference between scores for Groups 1 and 2. *Statistically significant result p < 0.05

Figure 3: Mean difference in Likert scores.

The results of this study indicate that ultrasound increased the confidence levels of this group of osteopathic medical students in identifying and palpating certain landmarks. To our knowledge, this is the first study to explore the effects of ultrasound training on confidence levels of osteopathic medical students when teaching palpatory skills.

Strengths The subjects were first year osteopathic medical students who had no previous experience with musculoskeletal ultrasound and little exposure to palpation. There were no significant differences between groups in baseline comfort levels with palpation of these specific landmarks.

Limitations This is a small sample size. Also, this was not a part of the standard curriculum, so there may have been some difference in the level of engagement of the participating subjects.

Future Research Subsequent studies could explore the use of ultrasound in other anatomical areas and the effects of more intensive ultrasound training. The increase in confidence levels demonstrated here is a promising start to integrating the use of ultrasound into pre-clinical medical education. Future research in training students to use ultrasound imaging in conjunction with palpation may help to improve current standards on how to teach anatomic landmarks and develop palpatory skills.

The physical examination is a fundamental skill for all physicians, yet recent research has shown a steady decline in physical examination proficiency amongst clinicians.1

One component of the structural exam is the assessment of the shoulder. Although shoulder pain is a common complaint, studies show that physicians’ accuracy in locating anatomical landmarks of the shoulder is dismal.2

There is a clear need for improved anatomical identification skills and this should start already at the pre-clinical level. Ultrasound imaging has become exceedingly common as a diagnostic tool in clinical practice, and should be taken into consideration as a useful modality in educating future physicians.4 The growing use of ultrasound in clinical practice shows a necessity for its integration into medical education, but may be particularly useful in the osteopathic manipulative medicine curriculum as it may allow students to better identify and palpate anatomical and musculoskeletal landmarks.5

BACKGROUND

•  Randomized-controlled trial, IRB approval obtained 12/9/2014 by NYIT-COM (IRB #BHS-1079). •  Subjects who had any prior experience in utilizing and interpreting ultrasound diagnostic imaging and who were previously trained foreign physicians or healthcare professionals were excluded from this study.

•  Both groups were given a tutorial on anatomic landmarks of the shoulder, followed by time for palpation practice (with or without assistance of ultrasound). See Figure 2.

• Group 1: Control group did not use ultrasound.

• Group 2: Experimental group used ultrasound.

•  Subjects completed a survey before and after the teaching/palpation practice session. The following question was asked: “How confident are you in palpating (each landmark)?” The survey was created using a 10-point Likert scale (0 Not at all – 10 Extremely).

•  SPSS was used to run an Independent-Samples Mann-Whitney U Test to compare the mean difference of scores pre and post each intervention.

METHODS

Group 1: Palpation Practice

Group 2: Ultrasound Tutorial Palpation Practice

Pre Survey

Video Session: Anatomy of the Shoulder

Post Survey Figure 2 (Above): Protocol Flow Chart

REFERENCES 1. Butter J, Grant TH, Egan M, Kaye M, Wayne DB, Carrión-Carire V, McGaghie WC. “Does ultrasound training boost Year 1 medical student competence and confidence when learning abdominal examination?”. Med Educ. 2007 Sep;41(9):843-8. 2. Gregory P. Gazzillo, MD, Jonathan T. Finnoff, DO, Mederic M. Hall, MD, Yusef A. Sayeed, MD, MPH, M. Eng, Jay Smith, MD. “Accuracy of Palpating the Long Head of the Biceps Tendon: An Ultrasonographic Study”. PM&R. 2011 Nov(3): 1035-1040. 3. The Netter Presenter Human Anatomy Collection Version 2.0. From the Atlas of Human Anatomy, 3rd Edition. 2003 Icon Learning Systems, LLC. Accessed 3/10/2016. 4. Mircea PA, Badea R, Fodor D, Buzoianu AD. “Using ultrasonography as a teaching support tool in undergraduate medical education - time to reach a decision”. Med Ultrason. 2012 Sep;14(3):211-6. 5. Arroyo-Morales M, Cantarero-Villanueva I, Fernández-Lao C, Guirao-Piñeyro M, Castro-Martín E, Díaz-Rodríguez L. “A blended learning approach to palpation and ultrasound imaging skills through supplementation of traditional classroom teaching with an e-learning package”. Man Ther. 2012 Oct;17(5):474-8.

This study was supported by a grant from the American Association of Colleges of Osteopathic Medicine and the Osteopathic Heritage Foundation. We would like to thank all of the subjects, faculty, staff, and medical student volunteers for their contributions to this study.

ACKNOWLEDGEMENTS

Supraspinatus tendon

Biciptal tendon (long head, cut)

Coracoid process

The introduction of ultrasound into pre-clinical medical education has demonstrated promising results. Practice with ultrasound prepares medical students for future clinical practice and may improve their understanding of anatomical concepts and palpatory skills. This randomized-controlled study was performed to determine whether the use of ultrasound as an educational supplement will improve osteopathic medical students’ confidence in identifying landmarks. Students were divided into two groups to palpate four specific landmarks: the experimental group used ultrasound to assist with locating each landmark, while the control group did not. The results of this study indicate that ultrasound may increase medical students’ confidence levels as they learn to identify and palpate certain landmarks.

ABSTRACT

Figure 1: Shoulder Anatomic Landmarks palpated by students in this study.3

Figure 3 (left): Subjects engaging in ultrasound tutorial and practice.

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0.5

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1.5

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Bicipital Tendon Coracoid Process Supraspinatus Tendon T1 TP

Control Group

Ultrasound Group