Training evaluation for a practice in spasticity-related techniques

Medical management practices for muscle overactivity, or spasticity, such as botulinum toxin (BTX) injections, neuromuscular blocs (NMB) or chemical neurolyses, require a high level of anatomical knowledge and technical training .

One-day training workshops on spasticity-related techniques have been organized for PMR practitioners three times a year since 2006 at the École européenne de chirurgie in Paris, France. Given the importance of dissection in teaching anatomy , teachings were based on cadaveric models (body donations), and supervised by a surgeon and one or two Physical Medicine and Rehabilitation (PMR) practitioners. Besides learning anatomy, such settings allowed trainees to train and test the accuracy of their needle placement practices .

Teaching and its planning is a dynamic process, which requires regular evaluations . In order to provide feedback for past workshops and to guide their future evolution, a formal evaluation was planned.

The evaluation was carried out through a questionnaire survey. In January 2013, questionnaires were sent by postal mail along with a return letter to the professional addresses of all practitioners who had participated in training workshops between 2006 and 2012.

Questionnaires addressed the subjective views of participants on past workshops and on their impact on participants’ practice, in seven binary or Likert-scale questions. The questionnaires addressed in a second part the expectations regarding delivery (for example organization) and contents of future teachings, with 10 binary or Likert-scale questions and two open-ended questions, which requested participants’ suggestions. In the thematic analysis of answers to open-ended questions, only the themes that were expressed by at least two participants were considered.

1 Results

Among 307 practitioners who attended to workshops, 118 (38%) answered the questionnaire. Most of them (57%) had received one training session, 31% had received two. Their mean injection experience was 7.3 ± 4.7 years; a quarter of them had less than one year of experience.

Satisfaction level with previous workshops was high: 92% of respondents wished to renew similar trainings. Impact on clinical practice of BTX injections was perceived as high: 78% declared having improved (highly or moderately) their injection techniques following the trainings, 87% declared having optimized the results of their injections. Impact was perceived as smaller regarding NMB techniques: 26% had learned new NMB techniques and 30% had optimized results of NMB. Most frequently learned NMB techniques were NMB of tibial, musculocutaneous, median, and ulnar nerves.

Regarding future sessions’ organization, 78% of respondents approved the one-day time frame, 69% wished to keep the participant number low (5 to 10). As to expected teaching contents, 81% wished teachings to be structured around clinical cases, and 78% approved of having to prepare a case-based clinical problem before the training. Most participants (73%) approved of workshops based on pre-determined themes, while 57% wished workshop programs to be individualized. Seventy-seven percent wished the trainings to be followed by attendance to multidisciplinary spasticity-related clinical visits.

In addition, answers to open-ended questions yielded the following themes (in parentheses, number of respondents who expressed this theme):

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groups of homogeneous-experience participants (2);
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teaching methods:
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  based on clinical cases, use of videos, gait analysis reports, decision trees (16),
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  observations of spasticity-related clinical visits (5),
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  sessions based on specific themes (2);
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techniques:
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  clinical indications and techniques of NMB (11),
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  ultrasound-guided injections (9),
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  selective neurolyses (5),
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  difficulties in targeting or in electrical nerve stimulation (4),
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  percutaneous tenotomy (2),
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  injections in paediatric populations (2),
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  BTX doses for given muscles (2);
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anatomical sites: iliopsoas muscle (5); neck anatomical region (3); challenging forearm muscles (3); trunk anatomical region (2); gluteus muscles (2); subscapular muscle (2);
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themes for courses:
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  biomechanics and functional anatomy, especially in upper-limb (4),
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  limits and alternatives to BTX treatments (3),
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  clinical evaluation and standardized scales (3),
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  changes and novelties in the management of spasticity (2),
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  neuro-orthopaedics (2).