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JAOA/AACOM Medical Education  |   January 2018
Effect of Ultrasonography on Student Learning of Shoulder Anatomy and Landmarks
Author Notes
  • From the Department of Internal Medicine in the Jacobi Medical Center at the Albert Einstein College of Medicine in Bronx, New York (Dr de Vries); the Department of Osteopathic Manipulative Medicine (Drs Yao and Terzella) at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury (Student Doctor Brown and Dr Jung); and the Department of Radiology at NYU Winthrop Hospital in Mineola (Dr Mazzie). This study was presented as a poster at the American Academy of Osteopathy's Convocations in March 2016 in Orlando, Florida, and in March 2017 in Colorado Springs, Colorado. 
  • Financial Disclosures: None reported. 
  • Support: This study was supported by a grant from the American Association of Colleges of Osteopathic Medicine and the Osteopathic Heritage Foundation (Grant No. MT-26). A portion of this grant was used to pay Dr Mazzie for his role in performing and reading the musculoskeletal ultrasonographs and for his expertise in writing, reviewing, and editing the manuscript. 
  •  *Address correspondence to Michael J. Terzella, DO, Department of Osteopathic Manipulative Medicine, New York Institute of Technology College of Osteopathic Medicine, PO Box 8000, Old Westbury, NY 11568-8000. Email: mterzell@nyit.edu
     
Article Information
Imaging
JAOA/AACOM Medical Education   |   January 2018
Effect of Ultrasonography on Student Learning of Shoulder Anatomy and Landmarks
The Journal of the American Osteopathic Association, January 2018, Vol. 118, 34-39. doi:10.7556/jaoa.2018.006
The Journal of the American Osteopathic Association, January 2018, Vol. 118, 34-39. doi:10.7556/jaoa.2018.006
Web of Science® Times Cited: 1
Abstract

Context: Ultrasonography is becoming more common in clinical use, and it has been shown to have promising results when introduced into medical school curricula.

Objective: To determine whether the use of ultrasonography as an educational supplement can improve osteopathic medical students’ confidence and ability to locate 4 specific shoulder anatomical landmarks: the coracoid process, the transverse process of T1, the long head of the biceps within the bicipital groove, and the supraspinatus tendon.

Methods: In this randomized controlled study, first-year osteopathic medical students aged 18 years or older were recruited and randomly assigned to a group with exposure (ultrasonography group) or without exposure (control group) to an ultrasonography machine. First, a survey was administered to measure students’ baseline knowledge of shoulder anatomy, confidence in palpation skills, and opinion on anatomical landmark identification teaching methods. Next, students were shown presentations on shoulder anatomy and allowed to practice locating and palpating the specified landmarks. Students in the ultrasonography group were also given instruction on the use of ultrasonography. All students were asked to locate each of the 4 specified anatomical landmarks and then given a follow-up survey. A Mann Whitney U test was used to compare the confidence of the students before and after the intervention. A secondary analysis was performed to compare the degree of deviance from the correct position of the specified anatomical landmark between the ultrasonography and control groups. P values less than .05 were considered statistically significant.

Results: Sixty-four students participated. Compared with the control group, students in the ultrasonography group had a greater increase in confidence after the session in their ability to locate the coracoid process, bicipital tendon, and supraspinatus tendon (P=.022, P=.029, P=.44, respectively). Students in the ultrasonography group were also able to more accurately palpate the landmarks than those in the control group, with a significant difference in accurate palpation of the bicipital tendon (P=.024). The ultrasonography group showed less deviation with palpation of the other 3 landmarks compared with the control group, but these results were not significant (P=.50, P=.82, P=.29, respectively).

Conclusion: Ultrasonography in the preclinical curriculum may improve medical students' confidence in and accuracy of palpation.

Performing a physical examination is a fundamental skill for all physicians, yet research has shown a steady decline in physical examination proficiency among physicians.1 This skill is particularly important to osteopathic physicians, who may also perform osteopathic structural examinations (OSEs) in clinical practice. This examination puts an emphasis on the neuromusculoskeletal system and diagnosing somatic dysfunctions through palpation. 
One component of the OSE is the assessment of the patient's shoulder. Although shoulder pain is a common symptom, a study2 showed that a sample of residents, fellows, and board-certified physicians were able to find the bicipital tendon with only 5.3% accuracy. Improved anatomical landmark identification skills are needed because, without accurate identification of the proper anatomical landmarks, the OSE cannot be effective. 
Ultrasonography has become a common diagnostic tool in clinical practice, and it should be taken into consideration as a useful modality in medical education.3 As a low-cost, noninvasive imaging method, ultrasonography is used for a variety of clinical purposes, including musculoskeletal imaging. In addition to helping physicians diagnose various pathologic conditions, such as cardiovascular dysfunctions, gallbladder stones, and tendonitis, it also allows them to locate anatomical landmarks.4 The use of ultrasonography may help physicians identify bony landmarks under the surface of the skin and soft tissue landmarks, including muscles, tendons, and ligaments. The growing use of ultrasonography in clinical practice, including triaging in the emergency department and outpatient rheumatologic evaluation, shows a necessity for its integration into medical education, but it 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 
Studies have shown the positive effects that ultrasonography use can have on medical students when it is introduced into their preclinical curriculum.6-8 Not only does the use of ultrasonography prepare students for its future clinical use, but it may also help strengthen their understanding of basic anatomical concepts.7 The aim of this study was to determine whether ultrasonography use can improve confidence levels and the ability of osteopathic medical students to accurately palpate and identify anatomical landmarks of the shoulder. 
Methods
This study was approved by the New York Institute of Technology Institutional Review Board. 
Participants
The study was announced to students during a first-year osteopathic manipulative medicine (OMM) laboratory class and lecture, and flyers were posted around the New York Institute of Technology College of Osteopathic Medicine campus. Students were given the option to sign up for the study after the OMM laboratory or via email. On arrival, each student was given an informed consent form to review with an investigator (K.D.D., R.B., or M.J.T.), and any questions they had were addressed. After the informed consent form was signed, the eligibility of each student was determined. Osteopathic medical students in their first year at the New York Institute of Technology College of Osteopathic Medicine and aged at least 18 years at the time of the study were included. Students were excluded if they had previous experience using and interpreting ultrasonographic imaging or if they were previously trained as a nurse practitioner, physician assistant, physician, physical therapist, chiropractor, or any other health care professional with musculoskeletal or musculoskeletal ultrasonography training. Each student who completed the study received a $40 Amazon gift card. 
Intervention
Students who fit the inclusion criteria were randomly assigned to the ultrasonography group or the control group. The groups were then each evenly divided into 3 subgroups, for a total of 6 subgroups. Three 1.5-hour sessions were held, with 1 subgroup from the ultrasonography and control groups attending each session. At the start of the sessions, each student completed a baseline 14- or 13-item (ultrasonography and control group, respectively) written assessment that was used to assess the students’ knowledge of shoulder anatomy, their confidence in their ability to locate the 4 anatomical landmarks, their comfort with their general palpation skills and ability to use an anatomy atlas to help locate shoulder landmarks, and their opinion on how different methods of providing didactic information works with teaching landmarks and palpation. The survey given to students in the ultrasonography group also assessed their confidence in using ultrasonography to locate landmarks. Responses were measured on an 11-point Likert scale, ranging from 0 (not at all) to 10 (extremely). After the assessment, both subgroups watched a prerecorded presentation on the shoulder joint, which explained the 4 shoulder anatomical landmarks they would be asked to palpate—the coracoid process, the transverse process of T1, the long head of the biceps within the bicipital groove, and the supraspinatus tendon—followed by a recorded demonstration of shoulder inspection and palpation. 
After the presentations, students were randomly paired with another student in their respective group. Each pair was given 30 minutes to practice inspection and examination of the shoulder joint. Both groups were given a standard anatomical atlas and had a faculty member present to answer questions. The ultrasonography group was also given instruction on ultrasonography and its use in locating boney landmarks, as well as an ultrasonography machine, which they could use during 10 of the 30 minutes of practice time. 
After the 30 minutes were up, students completed a practical assessment that tested their ability to identify the 4 shoulder anatomical landmarks, which were then verified by a board-certified radiologist (J.M.). For this assessment, students were instructed to mark the palpated landmark using a skin marker. The radiologist determined the degree of deviance in millimeters from the marked point to the closest edge of the landmark using ultrasonography. 
The students then completed a written survey similar to the baseline assessment, which assessed the students’ confidence in palpating the 4 anatomical shoulder landmarks, their comfort level with using ultrasonography, their ability to identify landmarks, and their self-perceived improvement in their ability to identify the landmarks. 
Statistical Analysis
The primary outcome measure was the students’ comfort level in locating and palpating the landmark as measured on an 11-point Likert scale, and the secondary outcome measure was the degree of deviance from the correct position of the landmark. To describe the data, the frequency and proportion were computed for categorical measurements, and the mean (SD) was computed. As a primary analysis, a Mann Whitney U test was performed to compare the change in the confidence level before and after the session between the ultrasonography and control groups. As a secondary analysis, an independent samples t test was performed to compare the degree of deviance from the correct position of the landmark between the control group and the experimental group. All analyses were performed using SPSS (IBM). For all analyses, a P value of less than .05 was considered statistically significant. 
Results
A total of 64 students were included in the analyses: 32 in the ultrasonography group and 32 in the control group. Students were divided into 6 subgroups (4 subgroups of 11 students and 2 subgroups of 10). One student who was initially assigned to the control group joined the ultrasonography group when the practice time began. That student's assessments were excluded from the analysis, and, therefore, the sample size for these data was 32 students in the ultrasonography group and 31 in the control group. The student's data for the practical examination were included in the ultrasonography group, but the sample size for the practical examination data varied because not all students located the correct anatomical landmarks. Therefore, data for the students who did not locate the correct anatomical landmarks were excluded from the analysis. 
 Table 1 shows the results of both the baseline and postintervention surveys. In terms of confidence levels in locating and palpating specific landmarks, the ultrasonography group had a greater mean (SD) increase in confidence levels compared with the control group in locating the coracoid process, long head of the biceps, and supraspinatus tendon (3.06 [2.14] vs 1.65 [2.63], 3.56 [2.14] vs 2.03 [3.15], and 3.06 [2.38] vs 2.52 [3.10], respectively). This difference was significant for the coracoid process and biceps tendon (P=.022 and P=.029, respectively). 
Table 1.
First-Year Osteopathic Medical Students’ Confidence Levels in Palpating Shoulder Anatomical Landmarks (N=63)a
Mean (SD)
Landmark Baseline After Intervention Improvement P Value
Coracoid Process
 Ultrasonography Group 3.81 (2.47) 6.88 (1.64) 3.06 (2.14) .022
 Control Group 4.32 (3.18) 5.97 (2.48) 1.65 (2.63)
T1 Transverse Process
 Ultrasonography Group 6.53 (2.06) 7.81 (1.73) 1.28 (1.63) .86
 Control Group 6.87 (2.08) 8.23 (1.45) 1.35 (1.72)
Long Head of the Biceps
 Ultrasonography Group 1.72 (2.05) 5.28 (2.04) 3.56 (2.14) .029
 Control Group 2.48 (2.06) 4.52 (3.04) 2.03 (3.15)
Supraspinatus Tendon
 Ultrasonography Group 2.28 (1.96) 5.34 (1.77) 3.06 (2.38) .44
 Control Group 2.29 (2.48) 4.81 (2.69) 2.52 (3.10)

a Students’ confidence levels were based on a 11-point Likert scale, with ϕ indicating no confidence and 10 indicating the highest level of confidence. Data included 32 students in the ultrasound technology group and 31 students in the control group.

Table 1.
First-Year Osteopathic Medical Students’ Confidence Levels in Palpating Shoulder Anatomical Landmarks (N=63)a
Mean (SD)
Landmark Baseline After Intervention Improvement P Value
Coracoid Process
 Ultrasonography Group 3.81 (2.47) 6.88 (1.64) 3.06 (2.14) .022
 Control Group 4.32 (3.18) 5.97 (2.48) 1.65 (2.63)
T1 Transverse Process
 Ultrasonography Group 6.53 (2.06) 7.81 (1.73) 1.28 (1.63) .86
 Control Group 6.87 (2.08) 8.23 (1.45) 1.35 (1.72)
Long Head of the Biceps
 Ultrasonography Group 1.72 (2.05) 5.28 (2.04) 3.56 (2.14) .029
 Control Group 2.48 (2.06) 4.52 (3.04) 2.03 (3.15)
Supraspinatus Tendon
 Ultrasonography Group 2.28 (1.96) 5.34 (1.77) 3.06 (2.38) .44
 Control Group 2.29 (2.48) 4.81 (2.69) 2.52 (3.10)

a Students’ confidence levels were based on a 11-point Likert scale, with ϕ indicating no confidence and 10 indicating the highest level of confidence. Data included 32 students in the ultrasound technology group and 31 students in the control group.

×
Table 2 shows the results of the practical examination completed by the students. The ultrasonography group showed significantly less deviation from the actual landmark location with palpation and identification of the long head of biceps than the control group (mean [SD], 41.4 [32.7] mm vs 62.9 [37.5] mm, respectively; P=.024). The ultrasonography group showed less deviation with palpation of the other 3 landmarks (the coracoid process, the transverse process of T1, and the supraspinatus tendon) compared with the control group, but these results were not statistically significant. 
Table 2.
First-Year Osteopathic Medical Students’ Average Degree of Deviance in Palpation of Each Shoulder Anatomical Landmarka
Landmark Distance From the Landmark, Mean (SD) mm P Value
Coracoid Process
 Ultrasonography Group 11.6 (16.6) .82
 Control Group 12.7 (18.4)
T1 Transverse Process
 Ultrasonography Group 6.3 (6.5) .29
 Control Group 8.5 (9.4)
Long Head of the Biceps
 Ultrasonography Group 41.4 (32.7) .024
 Control Group 62.9 (37.5)
Supraspinatus Tendon
 Ultrasonography Group 37.4 (39.6) .50
 Control Group 43.6 (30.7)

a Data from the students who did not locate the correct anatomical landmarks were excluded from the analysis.

Table 2.
First-Year Osteopathic Medical Students’ Average Degree of Deviance in Palpation of Each Shoulder Anatomical Landmarka
Landmark Distance From the Landmark, Mean (SD) mm P Value
Coracoid Process
 Ultrasonography Group 11.6 (16.6) .82
 Control Group 12.7 (18.4)
T1 Transverse Process
 Ultrasonography Group 6.3 (6.5) .29
 Control Group 8.5 (9.4)
Long Head of the Biceps
 Ultrasonography Group 41.4 (32.7) .024
 Control Group 62.9 (37.5)
Supraspinatus Tendon
 Ultrasonography Group 37.4 (39.6) .50
 Control Group 43.6 (30.7)

a Data from the students who did not locate the correct anatomical landmarks were excluded from the analysis.

×
Discussion
Studies have examined the use of ultrasonography for the visualization and location of landmarks, as well as the integration of ultrasonography into the first 2 years of a college of osteopathic medicine's osteopathic manipulative medicine curriculum to identify and measure musculoskeletal structures.1,9 This is the first study, to our knowledge, to examine the role of ultrasonography in improving students’ palpation skills and confidence in palpating anatomical landmarks. The results of the current study showed improved confidence and accuracy in palpating landmarks after using ultrasonography, which further support the growing number of studies that have established the benefit of using ultrasonography in medical education. Our findings also provide evidence for the use of ultrasonography to improve the confidence and palpation skills required of osteopathic medical students to appropriately diagnose and manage somatic dysfunctions. 
A strength of this study is that only first-year medical students, naive to the use of ultrasonography and with little previous exposure to palpatory skills, were included. These criteria allowed for a true measurement of improvement in confidence. Also, because the study was conducted at the beginning of the students’ first year of medical school, no significant difference was found in their baseline comfort levels of palpation of these specific landmarks. 
One limitation of this study is the small sample size. Future studies may attempt to collect data from an entire class of students, which would provide a larger sample. Another limitation could have been a varying level of effort from each student, as this study was not part of the students’ curriculum, which may have caused lesser degrees of participation and engagement. 
Because students in the ultrasonography group had a direct view of the selected landmarks, they became more confident and accurate in finding them on palpation. The improvement in confidence levels and accuracy of these students after just 10 minutes of using ultrasonography shows a great degree of potential for future studies of ultrasonography in osteopathic medical education, perhaps with a greater degree of ultrasonography training. 
In the face of declining physical examination skills among physicians, the integration of ultrasonography into osteopathic medical school curricula may help improve students’ physical examination skills as well as their ability to locate, palpate, and manage somatic dysfunctions based on an improved understanding of musculoskeletal anatomy. Subsequent studies could also focus on various landmarks throughout the body and may prove helpful in both learning and teaching basic anatomy, palpation skills, and, ultimately, the detection and subsequent management of somatic dysfunctions. 
Conclusion
Physical examination is a fundamental skill for all physicians, especially for osteopathic physicians who may also perform OSEs to diagnose and manage somatic dysfunctions. The results of this study demonstrated that there may be an important role for ultrasonography in teaching anatomical landmarks and palpation skills to preclinical medical students. Future research may help to further substantiate these findings and improve the quality of education offered to osteopathic medical students so that they are better prepared to identify and manage somatic dysfunctions in their patients. 
Acknowledgments
We thank George Cheriyan, DO, assistant professor in the Department of Osteopathic Manipulative Medicine at NYITCOM, for his help as a faculty supervisor during this study. 
References
Butter J, Grant TH, Egan M, et al Does ultrasound training boost year 1 medical student competence and confidence when learning abdominal examination? Med Educ. 2007;41(9):843-848. [CrossRef] [PubMed]
Gazzillo GP, Finnoff JT, Hall MM, Sayeed YA, Smith J. Accuracy of palpating the long head of the biceps tendon: an ultrasonographic study. PM R. 2011;3(11):1035-1040. doi: 10.1016/j.pmrj.2011.02.022 [CrossRef] [PubMed]
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;14(3):211-216. [PubMed]
Hempel D, Stenger T, Campo Dell’ Orto M, et al Analysis of trainees’ memory after classroom presentations of didactical ultrasound courses. Crit Ultrasound J. 2014;6(1):10. doi: 10.1186/2036-7902-6-10 [CrossRef] [PubMed]
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;17(5):474-478. doi: 10.1016/j.math.2012.04.002 [CrossRef] [PubMed]
Brown B, Adhikari S, Marx J, Lander L, Todd GL. Introduction of ultrasound into gross anatomy curriculum: perceptions of medical students. J Emerg Med. 2012;43(6):1098-1102. doi: 10.1016/j.jemermed.2012.01.041 [CrossRef] [PubMed]
Swamy M, Searle RF. Anatomy teaching with portable ultrasound to medical students. BMC Med Educ. 2012;12:99. doi: 10.1186/1472-6920-12-99 [CrossRef] [PubMed]
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Table 1.
First-Year Osteopathic Medical Students’ Confidence Levels in Palpating Shoulder Anatomical Landmarks (N=63)a
Mean (SD)
Landmark Baseline After Intervention Improvement P Value
Coracoid Process
 Ultrasonography Group 3.81 (2.47) 6.88 (1.64) 3.06 (2.14) .022
 Control Group 4.32 (3.18) 5.97 (2.48) 1.65 (2.63)
T1 Transverse Process
 Ultrasonography Group 6.53 (2.06) 7.81 (1.73) 1.28 (1.63) .86
 Control Group 6.87 (2.08) 8.23 (1.45) 1.35 (1.72)
Long Head of the Biceps
 Ultrasonography Group 1.72 (2.05) 5.28 (2.04) 3.56 (2.14) .029
 Control Group 2.48 (2.06) 4.52 (3.04) 2.03 (3.15)
Supraspinatus Tendon
 Ultrasonography Group 2.28 (1.96) 5.34 (1.77) 3.06 (2.38) .44
 Control Group 2.29 (2.48) 4.81 (2.69) 2.52 (3.10)

a Students’ confidence levels were based on a 11-point Likert scale, with ϕ indicating no confidence and 10 indicating the highest level of confidence. Data included 32 students in the ultrasound technology group and 31 students in the control group.

Table 1.
First-Year Osteopathic Medical Students’ Confidence Levels in Palpating Shoulder Anatomical Landmarks (N=63)a
Mean (SD)
Landmark Baseline After Intervention Improvement P Value
Coracoid Process
 Ultrasonography Group 3.81 (2.47) 6.88 (1.64) 3.06 (2.14) .022
 Control Group 4.32 (3.18) 5.97 (2.48) 1.65 (2.63)
T1 Transverse Process
 Ultrasonography Group 6.53 (2.06) 7.81 (1.73) 1.28 (1.63) .86
 Control Group 6.87 (2.08) 8.23 (1.45) 1.35 (1.72)
Long Head of the Biceps
 Ultrasonography Group 1.72 (2.05) 5.28 (2.04) 3.56 (2.14) .029
 Control Group 2.48 (2.06) 4.52 (3.04) 2.03 (3.15)
Supraspinatus Tendon
 Ultrasonography Group 2.28 (1.96) 5.34 (1.77) 3.06 (2.38) .44
 Control Group 2.29 (2.48) 4.81 (2.69) 2.52 (3.10)

a Students’ confidence levels were based on a 11-point Likert scale, with ϕ indicating no confidence and 10 indicating the highest level of confidence. Data included 32 students in the ultrasound technology group and 31 students in the control group.

×
Table 2.
First-Year Osteopathic Medical Students’ Average Degree of Deviance in Palpation of Each Shoulder Anatomical Landmarka
Landmark Distance From the Landmark, Mean (SD) mm P Value
Coracoid Process
 Ultrasonography Group 11.6 (16.6) .82
 Control Group 12.7 (18.4)
T1 Transverse Process
 Ultrasonography Group 6.3 (6.5) .29
 Control Group 8.5 (9.4)
Long Head of the Biceps
 Ultrasonography Group 41.4 (32.7) .024
 Control Group 62.9 (37.5)
Supraspinatus Tendon
 Ultrasonography Group 37.4 (39.6) .50
 Control Group 43.6 (30.7)

a Data from the students who did not locate the correct anatomical landmarks were excluded from the analysis.

Table 2.
First-Year Osteopathic Medical Students’ Average Degree of Deviance in Palpation of Each Shoulder Anatomical Landmarka
Landmark Distance From the Landmark, Mean (SD) mm P Value
Coracoid Process
 Ultrasonography Group 11.6 (16.6) .82
 Control Group 12.7 (18.4)
T1 Transverse Process
 Ultrasonography Group 6.3 (6.5) .29
 Control Group 8.5 (9.4)
Long Head of the Biceps
 Ultrasonography Group 41.4 (32.7) .024
 Control Group 62.9 (37.5)
Supraspinatus Tendon
 Ultrasonography Group 37.4 (39.6) .50
 Control Group 43.6 (30.7)

a Data from the students who did not locate the correct anatomical landmarks were excluded from the analysis.

×