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Figure 5. Correct Answers on Written Pretest/Posttest Anatomy Items n=82 matched learners Figure 6. Injection Placement in Anatomy Lab n=188 100% Intended to make a change to their practice 100% Actually made a change to their practice Patients with upper limb spasticity (ULS) can benefit greatly from injections of botulinum neurotoxin serotype A (BoNT-A) 1 , and use of instrumental guidance when injecting results in safer, more effective treatment. 2-4 However, clinicians are not equipped to use this therapy, showing gaps in their knowledge, competence, and performance, including difficulties in identifying and appropriately targeting muscles for injection, as well as using guidance methods. 3,5,6 Methods Figure 1. Didactic Lecture Figure 2. Patient Narrative Figure 3. Anatomy Lab Figure 4. Ultrasound Lab Designing Education to Improve Clinician Performance in Treating Upper Limb Spasticity: A Continuing Medical Education Case Report RESULTS ANATOMY LAB: CONVINCING CLINICIANS OF THEIR EDUCATIONAL NEED 42% 58% SCAN ME The CME workshop series provided an effective, engaging, educational experience that improved learner knowledge, competence, and performance related to the use of BoNT-A injections to treat ULS. Participants were motivated to learn and subsequently modify their practice. Assessments by learners and faculty identified that further education, and specifically more hands-on practice, is needed to continue to improve clinicians’ knowledge and skills. References 1. Chen S. Clinical uses of botulinum neurotoxins: current indications, limitations and future developments. Toxins. 2012;4(10):913-939. 2. Chan AK, Finlayson H, Mills PB. Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review. Clin Rehabil. 2017;31(6):713-721. 3. Schwabe AL. Botulinum toxin in the treatment of pediatric upper limb spasticity. Semin Plast Surg. 2016;30(1):24-28. 4. Grigoriu AI, Dinomais M, Rémy-Néris O, Brochard S. Impact of injection-guiding techniques on the effectiveness of botulinum toxin for the treatment of focal spasticity and dystonia: a systematic review. Arch Phys Med Rehabil. 2015;96(11):2067-2078. 5. Schnitzler A, Roche N, Denormandie P, Lautridou C, Parratte B, Genet F. Manual needle placement: accuracy of botulinum toxin A injections. Muscle Nerve. 2012;46(4):531-534. 6. Smania N, Colosimo C, Bentivoglio AR, Sandrini G, Picelli A. Use of botulinum toxin type A in the management of patients with neurological disorders: a national survey. Funct Neurol. 2013;28(4):253-258. • 9 Regional workshops • Expert-led discussions, patient narratives, and small group hands-on lab exercises • Targeted neurologists and physiatrists, as well as residents and fellows o 52% neurology, 48% physical medicine & rehabilitation (PM&R) o 51% practicing physicians, 49% residents/fellows Figure 7. Correct Answers on Written Pretest/Posttest Ultrasound Items n=82 matched learners ULTRASOUND LAB: GIVING CLINICIANS OPPORTUNITY TO PRACTICE EVIDENCE-BASED TECHNIQUES Figure 8. Performance Assessments in Ultrasound Lab n=73 matched learners 1=Poor, 2=Fair, 3=Good, 4=Excellent 1.7 1.6 1.6 1.5 3.1 3.1 3.1 3.1 0 1 2 3 4 Properly read ultrasound display Localize target muscles Properly read ultrasound display Localize target muscles First attempt Last attempt Faculty Assessments Learner Assessments 39% 38% 46% 87% 85% 98% 0% 20% 40% 60% 80% 100% Distinguish target muscles associated with spasticity responsive to BoNT-A injections Select and use BoNT-A formulations for patients with spasticity Identify the benefits and drawbacks of nonguided and guided treatment methods for selecting injection areas to ensure accurate delivery of BoNT-A Preactivity Postactivity Annette Schwind, MS, CHCP Paradigm Medical Communications, LLC METHODS BACKGROUND CONCLUSIONS DISCUSSION: IMPACT ON CLINICIAN PRACTICE Learners scored well on multiple-choice questions regarding anatomy and physiology related to ULS Learners displayed considerable knowledge of facts about guided treatment methods such as ultrasound Faculty observations revealed that learners had less of a practical grasp of anatomy Initial self and faculty assessments revealed low competence and performance scores Theory (Pretest) Practice (Labs) Figure 9. Learners Rating Themselves as Confident or Very Confident n=82 matched learners Incorporate ultrasound/EMG guidance to improve injection localization Increase use of BoNT to treat ULS Use better understanding of anatomy to improve assessment of ULS Increased use of ultrasound-guided injections for ULS Following dosing recommendations Hands-on continuing education workshops help clinicians translate knowledge from theory into practice to treat ULS with injectable BoNT-A. This educational initiative was supported by an educational grant from Merz North America, Inc. 82% improvement Learner confidence more than doubled in key clinical tasks after the workshops Figure 10. Postactivity Commitment to Change n=98 n=4 PRETEST POSTTEST Knowledge 90% 71% PRETEST POSTTEST Competence 94% 70% PRETEST POSTTEST Competence 94% 70% PRETEST POSTTEST Knowledge 96% 84% 94% improvement 94% improvement 107% improvement Correct placement Incorrect placement Figure 11. 2-Month Follow-up Changes Made
