Learner preferences regarding integrating, sequencing and aligning virtual patients with other activities in the undergraduate medical curriculum: A focus group study

CONTEXT: E-learning resources, such as virtual patients (VPs), can be more effective when they are integrated in the curriculum. To gain insights that can inform guidelines for the curricular integration of VPs, we explored students' perceptions of scenarios with integrated and non-integrated VPs aimed at promoting clinical reasoning skills. METHODS: During their paediatric clerkship, 116 fifth-year medical students were given at least ten VPs embedded in eight integrated scenarios and as non-integrated add-ons. The scenarios differed in the sequencing and alignment of VPs and related educational activities, tutor involvement, number of VPs, relevance to assessment and involvement of real patients. We sought students' perceptions on the VP scenarios in focus group interviews with eight groups of 4-7 randomly selected students (n = 39). The interviews were recorded, transcribed and analysed qualitatively. RESULTS: The analysis resulted in six themes reflecting students' perceptions of important features for effective curricular integration of VPs: (i) continuous and stable online access, (ii) increasing complexity, adapted to students' knowledge, (iii) VP-related workload offset by elimination of other activities, (iv) optimal sequencing (e.g.: lecture--1 to 2 VP(s)--tutor-led small group discussion--real patient) and (V) optimal alignment of VPs and educational activities, (vi) inclusion of VP topics in assessment. CONCLUSIONS: The themes appear to offer starting points for the development of a framework to guide the curricular integration of VPs. Their impact needs to be confirmed by studies using quantitative controlled designs.

Predicting smoking cessation and its relapse in HIV-infected patients: the Swiss HIV Cohort Study

OBJECTIVES: The aim of the study was to assess whether prospective follow-up data within the Swiss HIV Cohort Study can be used to predict patients who stop smoking; or among smokers who stop, those who start smoking again. METHODS: We built prediction models first using clinical reasoning ('clinical models') and then by selecting from numerous candidate predictors using advanced statistical methods ('statistical models'). Our clinical models were based on literature that suggests that motivation drives smoking cessation, while dependence drives relapse in those attempting to stop. Our statistical models were based on automatic variable selection using additive logistic regression with component-wise gradient boosting. RESULTS: Of 4833 smokers, 26% stopped smoking, at least temporarily; because among those who stopped, 48% started smoking again. The predictive performance of our clinical and statistical models was modest. A basic clinical model for cessation, with patients classified into three motivational groups, was nearly as discriminatory as a constrained statistical model with just the most important predictors (the ratio of nonsmoking visits to total visits, alcohol or drug dependence, psychiatric comorbidities, recent hospitalization and age). A basic clinical model for relapse, based on the maximum number of cigarettes per day prior to stopping, was not as discriminatory as a constrained statistical model with just the ratio of nonsmoking visits to total visits. CONCLUSIONS: Predicting smoking cessation and relapse is difficult, so that simple models are nearly as discriminatory as complex ones. Patients with a history of attempting to stop and those known to have stopped recently are the best candidates for an intervention.

Logical omniscience as infeasibility

Logical theories for representing knowledge are often plagued by the so-called Logical Omniscience Problem. The problem stems from the clash between the desire to model rational agents, which should be capable of simple logical inferences, and the fact that any logical inference, however complex, almost inevitably consists of inference steps that are simple enough. This contradiction points to the fruitlessness of trying to solve the Logical Omniscience Problem qualitatively if the rationality of agents is to be maintained. We provide a quantitative solution to the problem compatible with the two important facets of the reasoning agent: rationality and resource boundedness. More precisely, we provide a test for the logical omniscience problem in a given formal theory of knowledge. The quantitative measures we use are inspired by the complexity theory. We illustrate our framework with a number of examples ranging from the traditional implicit representation of knowledge in modal logic to the language of justification logic, which is capable of spelling out the internal inference process. We use these examples to divide representations of knowledge into logically omniscient and not logically omniscient, thus trying to determine how much information about the reasoning process needs to be present in a theory to avoid logical omniscience.

Alignment between learning needs and learning goals of Mini-CEX in clerkships

Background: Defining learning goals (LG) in alignment with learning needs (LN) is one of the key purposes of formative workplace-based assessment, but studies about this topic are scarce. Summary of Work: We analysed quantitatively and qualitatively how often trainer-student pairs identified the same LN during Mini Clinical Evaluation Exercises (Mini-CEX) in clerkships and to what degree those LNs were in line with the recorded LGs. Multilevel logistic regression models were used to predict LGs by identified LNs, controlling for context variables. Summary of Results: 512 trainers and 165 students conducted 1783 Mini-CEX (98% completion rate). Concordantly, trainer-student pairs most often identified LNs in the domains ‘clinical reasoning’ (23% of 1167 complete forms), ‘organisation / efficiency’ (20%) and ‘physical examination’ (20%). At least one ‘defined’ LG was noted on 313 student forms (18% of 1710), with a total of 446 LGs. Of these, the most frequent LGs were ‘physical examination’ (49% of 446 LGs) and ‘history taking’ (21%); corresponding LNs as well as context variables (e.g. clinic size) were found to be predictors of these LGs. Discussion and Conclusions: Although trainer-student pairs often agreed in their identified LNs, many assessments did not result in an aligned LG or a LG at all. Interventions are needed to enhance the proportion of (aligned) LGs in Mini-CEX in order to tap into its full potential not only as a ‘diagnostic’ but also as an ‘educational tool’. Take-home messages: The sparseness of LGs, their dependency on context variables and their partial non-alignment with students’ LNs raise the question of how the effectiveness of Mini-CEX can be further enhanced.

Virtual Patients in continuing medical education and residency training: a pilot project for acceptance analysis in the framework of a residency revision course in pediatrics.

AIM Virtual patients (VPs) are a one-of-a-kind e-learning resource, fostering clinical reasoning skills through clinical case examples. The combination with face-to-face teaching is important for their successful integration, which is referred to as "blended learning". So far little is known about the use of VPs in the field of continuing medical education and residency training. The pilot study presented here inquired the application of VPs in the framework of a pediatric residency revision course. METHODS Around 200 participants of a pediatric nephology lecture ('nephrotic and nephritic syndrome in children') were offered two VPs as a wrap-up session at the revision course of the German Society for Pediatrics and Adolescent Medicine (DGKJ) 2009 in Heidelberg, Germany. Using a web-based survey form, different aspects were evaluated concerning the learning experiences with VPs, the combination with the lecture, and the use of VPs for residency training in general. RESULTS N=40 evaluable survey forms were returned (approximately 21%). The return rate was impaired by a technical problem with the local Wi-Fi firewall. The participants perceived the work-up of the VPs as a worthwhile learning experience, with proper preparation for diagnosing and treating real patients with similar complaints. Case presentations, interactivity, and locally and timely independent repetitive practices were, in particular, pointed out. On being asked about the use of VPs in general for residency training, there was a distinct demand for more such offers. CONCLUSION VPs may reasonably complement existing learning activities in residency training.

The Role for Virtual Patients in the Future of Medical Education

The medical education community is working-across disciplines and across the continuum-to address the current challenges facing the medical education system and to implement strategies to improve educational outcomes. Educational technology offers the promise of addressing these important challenges in ways not previously possible. The authors propose a role for virtual patients (VPs), which they define as multimedia, screen-based interactive patient scenarios. They believe VPs offer capabilities and benefits particularly well suited to addressing the challenges facing medical education. Well-designed, interactive VP-based learning activities can promote the deep learning that is needed to handle the rapid growth in medical knowledge. Clinically oriented learning from VPs can capture intrinsic motivation and promote mastery learning. VPs can also enhance trainees' application of foundational knowledge to promote the development of clinical reasoning, the foundation of medical practice. Although not the entire solution, VPs can support competency-based education. The data created by the use of VPs can serve as the basis for multi-institutional research that will enable the medical education community both to better understand the effectiveness of educational interventions and to measure progress toward an improved system of medical education.

Developing an alternative response format for the script concordance test

Introduction: Clinical reasoning is essential for the practice of medicine. In theory of development of medical expertise it is stated, that clinical reasoning starts from analytical processes namely the storage of isolated facts and the logical application of the ‘rules’ of diagnosis. Then the learners successively develop so called semantic networks and illness-scripts which finally are used in an intuitive non-analytic fashion [1], [2]. The script concordance test (SCT) is an example for assessing clinical reasoning [3]. However the aggregate scoring [3] of the SCT is recognized as problematic [4]. The SCT`s scoring leads to logical inconsistencies and is likely to reflect construct-irrelevant differences in examinees’ response styles [4]. Also the expert panel judgments might lead to an unintended error of measurement [4]. In this PhD project the following research questions will be addressed: 1. How does a format look like to assess clinical reasoning (similar to the SCT but) with multiple true-false questions or other formats with unambiguous correct answers, and by this address the above mentioned pitfalls in traditional scoring of the SCT? 2. How well does this format fulfill the Ottawa criteria for good assessment, with special regards to educational and catalytic effects [5]? Methods: 1. In a first study it shall be assessed whether designing a new format using multiple true-false items to assess clinical reasoning similar to the SCT-format is arguable in a theoretically and practically sound fashion. For this study focus groups or interviews with assessment experts and students will be undertaken. 2. In an study using focus groups and psychometric data Norcini`s and colleagues Criteria for Good Assessment [5] shall be determined for the new format in a real assessment. Furthermore the scoring method for this new format shall be optimized using real and simulated data.

Computerbasierte Prüfung von klinischem Denken in der klinischen Ausbildung: Ein Mixed-Method Vergleich von Key Feature Problemen mit fallbasierten Multiple Choice Typ A Fragen

Fragestellung/Einleitung: Es ist unklar inwiefern Unterschiede bestehen im Einsatz von Key Feature Problemen (KFP) mit Long Menu Fragen und fallbasierten Typ A Fragen (FTA) für die Überprüfung des klinischen Denkens (Clinical Reasoning) in der klinischen Ausbildung von Medizinstudierenden. Methoden: Medizinstudierende des fünften Studienjahres nahmen an ihrer klinischen Pädiatrie-Rotation teil, die mit einer summativen Prüfung endete. Die Überprüfung des Wissen wurde pro Prüfung elektronisch mit 6-9 KFP [1], [3], 9-20 FTA und 9-28 nichtfallbasierten Multiple Choice Fragen (NFTA) durchgeführt. Jedes KFP bestand aus einer Fallvignette und drei Key Features und nutzen ein sog. Long Menu [4] als Antwortformat. Wir untersuchten die Perzeption der KFP und FTA in Focus Gruppen [2] (n of students=39). Weiterhin wurden die statistischen Kennwerte der KFP und FTA von 11 Prüfungen (n of students=377) verglichen. Ergebnisse: Die Analyse der Fokusgruppen resultierte in vier Themen, die die Perzeption der KFP und deren Vergleich mit FTA darstellten: KFP wurden als 1. realistischer, 2. schwerer, und 3. motivierender für das intensive Selbststudium des klinischen Denkens als FTA aufgenommen und zeigten 4. insgesamt eine gute Akzeptanz sofern gewisse Voraussetzungen berücksichtigt werden. Die statistische Auswertung zeigte keinen Unterschied im Schwierigkeitsgrad; jedoch zeigten die KFP eine höhere Diskrimination und Reliabilität (G-coefficient) selbst wenn für die Prüfungszeit korrigiert wurde. Die Korrelation der verschiedenen Prüfungsteile war mittel. Diskussion/Schlussfolgerung: Die Studierenden erfuhren die KFP als motivierenden für das Selbststudium des klinischen Denkens. Statistisch zeigten die KFP eine grössere Diskrimination und höhere Relibilität als die FTA. Der Einbezug von KFP mit Long Menu in Prüfungen des klinischen Studienabschnitts erscheint vielversprechend und einen „educational effect“ zu haben.

Cerebellar Pathology Does Not Impair Performance on Identification or Categorization Tasks

In comparison to the basal ganglia, prefrontal cortex, and medial temporal lobes, the cerebellum has been absent from recent research on the neural substrates of categorization and identification, two prominent tasks in the learning and memory literature. To investigate the contribution of the cerebellum to these tasks, we tested patients with cerebellar pathology (seven with bilateral degeneration, six with unilateral lesions, and two with midline damage) on rule-based and information-integration categorization tasks and an identification task. In rule-based tasks, it is assumed that participants learn the categories through an explicit reasoning process. In information-integration tasks, optimal performance requires the integration of information from multiple stimulus dimensions, and participants are typically unaware of the decision strategy. The identification task, in contrast, required participants to learn arbitrary, color-word associations. The cerebellar patients performed similar to matched controls on all three tasks and performance did not vary with the extent of cerebellar pathology. Although the interpretation of these null results requires caution, these data contribute to the current debate on cerebellar contributions to cognition by providing boundary conditions on understanding the neural substrates of categorization and identification, and help define the functional domain of the cerebellum in learning and memory.

Guessing Harmonic Oscillator Wavefunctions Using Maple

The guessing of eigenfunctions is not trivial at higher quantum numbers, no matter what the system being considered. Instead of guessing, one can employ a symbolic calculus progam (Maple in this case) to aid in the reasoning process.

Desarrollo de un proceso de razonamiento visual para la valoración del patrimonio

El tema de la presente tesis es la valoración del patrimonio y en ella se considera que el patrimonio es un proceso cultural interesado en negociar, crear y recrear recuerdos, valores y significados culturales. Actualmente el patrimonio como proceso se está consolidando en la literatura científica, aunque la idea de que es una ‘cosa’ es dominante en el debate internacional y está respaldada tanto por políticas como prácticas de la UNESCO. El considerar el patrimonio como un proceso permite una mirada crítica, que subraya la significación. Es decir, supone el correlato que conlleva definir algo como ‘patrimonio’, o hacer que lo vaya siendo. Esta visión del concepto permite la posibilidad de comprender no sólo lo que se ha valorado, sino también lo que se ha olvidado y el porqué. El principal objetivo de esta investigación es explorar las características de un proceso de razonamiento visual para aplicarlo en el de valoración del patrimonio. Éste que se presenta, implica la creación de representaciones visuales y sus relaciones, además su meta no está centrada en producir un ambiente que sea indiferenciado de la realidad física. Con él se pretende ofrecer la posibilidad de comunicar la dimensión ‘poliédrica’ del patrimonio. Para que este nuevo proceso que propongo sea viable y sostenible, existe la necesidad de tener en cuenta el fin que se quiere lograr: la valoración. Es importante considerar que es un proceso en el cual las dinámicas de aprendizaje, comportamientos y exploración del patrimonio están directamente relacionadas con su valoración. Por lo tanto, hay que saber cómo se genera la valoración del patrimonio, con el fin de ser capaces de desarrollar el proceso adaptado a estas dinámicas. La hipótesis de esta tesis defiende que un proceso de razonamiento visual para la valoración del patrimonio permite que las personas involucradas en el proceso inicien un proceso de interacción con un elemento patrimonial y su imagen mental para llegar a ciertas conclusiones con respecto a su valor y significado. El trabajo describe la metodología que da lugar al proceso de razonamiento visual para el patrimonio, que ha sido concebido sobre un modelado descriptivo de procesos, donde se han caracterizado tres niveles: meta-nivel, de análisis y operacional. En el modelado del proceso los agentes, junto con el patrimonio, son los protagonistas. El enfoque propuesto no es sólo sobre el patrimonio, sino sobre la compleja relación entre las personas y el patrimonio. Los agentes humanos dan valor a los testimonios de la vida pasada y les imbuyen de significado. Por lo tanto, este enfoque de un proceso de razonamiento visual sirve para detectar los cambios en el valor del patrimonio, además de su dimensión poliédrica en términos espaciales y temporales. Además se ha propuesto una nueva tipología de patrimonio necesaria para sustentar un proceso de razonamiento visual para su valoración. Esta tipología está apoyada en la usabilidad del patrimonio y dentro de ella se encuentran los siguientes tipos de patrimonio: accesible, cautivo, contextualizado, descontextualizado, original y vicarial. El desarrollo de un proceso de razonamiento visual para el patrimonio es una propuesta innovadora porque integra el proceso para su valoración, contemplando la dimensión poliédrica del patrimonio y explotando la potencialidad del razonamiento visual. Además, los posibles usuarios del proceso propuesto van a tener interacción de manera directa con el patrimonio e indirecta con la información relativa a él, como por ejemplo, con los metadatos. Por tanto, el proceso propuesto posibilita que los posibles usuarios se impliquen activamente en la propia valoración del patrimonio. ABSTRACT The subject of this thesis is heritage valuation and it argues that heritage is a cultural process that is inherited, transmitted, and transformed by individuals who are interested in negotiating, creating and recreating memories and cultural meanings. Recently heritage as a process has seen a consolidation in the research, although the idea that heritage is a ‘thing’ is dominant in the international debate and is supported by policies and practice of UNESCO. Seeing heritage as a process enables a critical view, underscoring the significance. That is, it is the correlate involved in defining something as ‘heritage’, or converting it into heritage. This view of the concept allows the possibility to understand not only what has been valued, but also what has been forgotten and why. The main objective of this research is to explore the characteristics of a visual reasoning process in order to apply it to a heritage valuation. The goal of the process is not centered on producing an environment that is undifferentiated from physical reality. Thus, the objective of the process is to provide the ability to communicate the ‘polyhedral’ dimension of heritage. For this new process to be viable and sustainable, it is necessary to consider what is to be achieved: heritage valuation. It is important to note that it is a process in which the dynamics of learning, behavior and exploration heritage are directly related to its valuation. Therefore, we need to know how this valuation takes place in order to be able to develop a process that is adapted to these dynamic. The hypothesis of this thesis argues that a visual reasoning process for heritage valuation allows people involved in the process to initiate an interaction with a heritage and to build its mental image to reach certain conclusions regarding its value and meaning. The thesis describes the methodology that results in a visual reasoning process for heritage valuation, which has been based on a descriptive modeling process and have characterized three levels: meta, analysis and operational -level. The agents are the protagonists in the process, along with heritage. The proposed approach is not only about heritage but the complex relationship between people and heritage. Human operators give value to the testimonies of past life and imbue them with meaning. Therefore, this approach of a visual reasoning process is used to detect changes in the value of heritage and its multifaceted dimension in spatial and temporal terms. A new type of heritage required to support a visual reasoning process for heritage valuation has also been proposed. This type is supported by its usability and it covers the following types of heritage: available, captive, contextualized, decontextualized, original and vicarious. The development of a visual reasoning process for heritage valuation is innovative because it integrates the process for valuation of heritage, considering the multifaceted dimension of heritage and exploiting the potential of visual reasoning. In addition, potential users of the proposed process will have direct interaction with heritage and indirectly with the information about it, such as the metadata. Therefore, the proposed process enables potential users to be actively involved in their own heritage valuation.

Una propuesta de modelado del estudiante basada en ontologías y diagnóstico pedagógico-cognitivo no monótono

Los recientes avances tecnológicos han encontrado un potencial campo de explotación en la educación asistida por computador. A finales de los años 90 surgió un nuevo campo de investigación denominado Entornos Virtuales Inteligentes para el Entrenamiento y/o Enseñanza (EVIEs), que combinan dos áreas de gran complejidad: Los Entornos Virtuales (EVs) y los Sistemas de Tutoría Inteligente (STIs). De este modo, los beneficios de los entornos 3D (simulación de entornos de alto riesgo o entornos de difícil uso, etc.) pueden combinarse con aquéllos de un STIs (personalización de materias y presentaciones, adaptación de la estrategia de tutoría a las necesidades del estudiante, etc.) para proporcionar soluciones educativas/de entrenamiento con valores añadidos. El Modelo del Estudiante, núcleo de un SIT, representa el conocimiento y características del estudiante, y refleja el proceso de razonamiento del estudiante. Su complejidad es incluso superior cuando los STIs se aplican a EVs porque las nuevas posibilidades de interacción proporcionadas por estos entornos deben considerarse como nuevos elementos de información clave para el modelado del estudiante, incidiendo en todo el proceso educativo: el camino seguido por el estudiante durante su navegación a través de escenarios 3D; el comportamiento no verbal tal como la dirección de la mirada; nuevos tipos de pistas e instrucciones que el módulo de tutoría puede proporcionar al estudiante; nuevos tipos de preguntas que el estudiante puede formular, etc. Por consiguiente, es necesario que la estructura de los STIs, embebida en el EVIE, se enriquezca con estos aspectos, mientras mantiene una estructura clara, estructurada, y bien definida. La mayoría de las aproximaciones al Modelo del Estudiante en STIs y en IVETs no consideran una taxonomía de posibles conocimientos acerca del estudiante suficientemente completa. Además, la mayoría de ellas sólo tienen validez en ciertos dominios o es difícil su adaptación a diferentes STIs. Para vencer estas limitaciones, hemos propuesto, en el marco de esta tesis doctoral, un nuevo mecanismo de Modelado del Estudiante basado en la Ingeniería Ontológica e inspirado en principios pedagógicos, con un modelo de datos sobre el estudiante amplio y flexible que facilita su adaptación y extensión para diferentes STIs y aplicaciones de aprendizaje, además de un método de diagnóstico con capacidades de razonamiento no monótono. El método de diagnóstico es capaz de inferir el estado de los objetivos de aprendizaje contenidos en el SIT y, a partir de él, el estado de los conocimientos del estudiante durante su proceso de aprendizaje. La aproximación almodelado del estudiante propuesta ha sido implementada e integrada en un agente software (el agente de modelado del estudiante) dentro de una plataforma software existente para el desarrollo de EVIEs denominadaMAEVIF. Esta plataforma ha sido diseñada para ser fácilmente configurable para diferentes aplicaciones de aprendizaje. El modelado del estudiante presentado ha sido implementado e instanciado para dos tipos de entornos de aprendizaje: uno para aprendizaje del uso de interfaces gráficas de usuario en una aplicación software y para un Entorno Virtual para entrenamiento procedimental. Además, se ha desarrollado una metodología para guiar en la aplicación del esta aproximación de modelado del estudiante a cada sistema concreto.---ABSTRACT---Recent technological advances have found a potential field of exploitation in computeraided education. At the end of the 90’s a new research field emerged, the so-called Intelligent Virtual Environments for Training and/or Education (IVETs), which combines two areas of great complexity: Virtual Environments (VE) and Intelligent Tutoring Systems (ITS). In this way, the benefits of 3D environments (simulation of high risk or difficult-to-use environments, etc.) may be combined with those of an ITS (content and presentation customization, adaptation of the tutoring strategy to the student requirements, etc.) in order to provide added value educational/training solutions. The StudentModel, core of an ITS, represents the student’s knowledge and characteristics, and reflects the student’s reasoning process. Its complexity is even higher when the ITSs are applied on VEs because the new interaction possibilities offered by these environments must be considered as new key information pieces for student modelling, impacting all the educational process: the path followed by the student during their navigation through 3D scenarios; non-verbal behavior such as gaze direction; new types of hints or instructions that the tutoring module can provide to the student; new question types that the student can ask, etc. Thus, it is necessary for the ITS structure, which is embedded in the IVET, to be enriched by these aspects, while keeping a clear, structured and well defined architecture. Most approaches to SM on ITSs and IVETs don’t consider a complete enough taxonomy of possible knowledge about the student. In addition, most of them have validity only in certain domains or they are hard to be adapted for different ITSs. In order to overcome these limitations, we have proposed, in the framework of this doctoral research project, a newStudentModeling mechanism that is based onOntological Engineering and inspired on pedagogical principles, with a wide and flexible data model about the student that facilitates its adaptation and extension to different ITSs and learning applications, as well as a rich diagnosis method with non-monotonic reasoning capacities. The diagnosis method is able to infer the state of the learning objectives encompassed by the ITS and, fromit, the student’s knowledge state during the student’s process of learning. The proposed student modelling approach has been implemented and integrated in a software agent (the student modeling agent) within an existing software platform for the development of IVETs called MAEVIF. This platform was designed to be easily configurable for different learning applications. The proposed student modeling has been implemented and it has been instantiated for two types of learning environments: one for learning to use the graphical user interface of a software application and a Virtual Environment for procedural training. In addition, a methodology to guide on the application of this student modeling approach to each specific system has been developed.

Conocimiento de geometría especializado para la enseñanza en educación primaria

El objetivo de este estudio fue identificar características del conocimiento de geometría especializado en estudiantes para maestro en relación con el razonamiento configural. Los resultados indican la existencia de dos factores claves en el proceso de razonamiento configural en los estudiantes para maestro: la identificación de una sub-configuración relevante, y la manera en la que se organizan las proposiciones geométricas a partir de las aprehensiones discursivas. En particular, y en relación con este segundo factor, se han identificado dos momentos en el uso de las aprehensiones discursivas cuando se asocian hechos geométricos a la configuración inicial y cuando se infiere nueva información al relacionar conocimientos geométricos conocidos con hechos asociados a la configuración geométrica.

Foot orthotics in the treatment of lower limb conditions: A musculoskeletal physiotherapy perspective

Orthotic therapy is frequently advocated for the treatment Of musculoskeletal pain and injury of the lower limb. The clinical efficacy, mechanical effects, and Underlying mechanism of the action of foot orthotics has not been Conclusively determined making it difficult for practitioners to agree on a reliable and valid clinical approach to their application and indeed even their fabrication. This problem is compounded by evidence suggesting that the most commonly used approach for orthotic prescription, the (Biomechanical Evaluation of the Foot. Vol. 1. Clinical Biomechanics Corporation, Los Angeles, 1971) approach, has poor validity and many of the associated clinical measurements of that approach lack adequate levels of reliability. This paper proposes a new approach that is based on two key elements. One is the identification, verification and quantification of physical tasks that serve as client specific outcome measures. The second is the application of specific physical manipulations during the performance of these physical tasks. The physical manipulations are selected on the basis of motion dysfunction and their immediate effects on the client specific outcome measures serve as the basis to making an informed decision on the propriety of using orthotics in individual clients. The motion dysfunction also guides the type of orthotic that is applied. Practical case examples as well Lis generic and specific guidelines to the application of this clinical assessment process and orthotics are provided in this paper. (C) 2004 Published by Elsevier Ltd.

Occupational therapists' decision making in three therapy settings in Australia

Can a work setting with its organizational, cultural, and practical considerations influence the way occupational therapists make decisions regarding client interventions? There is currently a paucity of evidence available to answer this question. This study aimed to investigate the influence of work setting on therapists’ clinical reasoning in the management of clients with cerebral palsy and upper limb hypertonicity. Specifically the study aimed to examine therapists’ objective and stated policies, and their intervention decisions using Social Judgement Theory methodology. Participants were eighteen occupational therapists with more than five years experience with clients with cerebral palsy who were asked to make intervention decisions for clients represented by 90 case vignettes. They worked in three settings, hospitals (5), schools (6), and community (6). The results indicated that therapy settings did influence therapists’ decisions about intervention choices but not their objective and subjective policy decisions.