A Prototype Web Site for Clinical Education: Implementation of Guidelines for Preventing Upper Limb Pain in People with Spinal Cord Injury

Christine M. Heiner, BA1, 2 ; Laura McClure, MPT1, 3 ; Zachary Talmadge1, 4 ; Michael L. Boninger, MD1, 2

1 Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA
2 Department of Physical Medicine and Rehabilitation, University of Pittsburgh
3 Department of Rehabilitation Science and Technology, University of Pittsburgh
4 Department of Mathematics/Department of Physics, Washington and Jefferson College


Rehabilitation experts developed clinical practice guidelines to educate clinicians about the risks and prevention of upper limb pain and injury in people with spinal cord injury (SCI). Research shows that passive dissemination of healthcare guidelines is ineffective at changing clinical practice and behavior. We published a prototype website with customized training documents, tutorials, quizzes, and an online discussion forum to more effectively teach these guidelines to clinicians worldwide. We hope to change both clinician and patient behavior to decrease the prevalence of upper limb pain and injury with the website’s interactive training techniques.


spinal cord injury, adult education, internet education, implementation of guidelines, preservation of upper limb function


The Consortium for Spinal Cord Medicine and Paralyzed Veterans of America (PVA) published the Clinical Practice Guidelines on Preventing Upper Limb Pain in People with SCI in 2005. An expert panel wrote the guidelines to teach health care providers about upper limb pain and injury risks. The panel recommends various ways to prevent upper limb pain in wheelchair users. The guidelines teach proper wheelchair propulsion and transfer techniques that decrease upper limb strain, the need for lightweight wheelchairs and specific wheelchair customization, the importance for wheelchair users to maintain physical fitness and normal body weight, arm positions to avoid when positioning patients with SCI, and treatment options for patients with upper limb injuries. We are currently teaching these guidelines to clinicians to implement with new SCI patients as part of a research study.

We need to educate clinicians about the guidelines on a mass scale to translate the guidelines into clinical practice worldwide. PVA currently provides the guidelines in print and PDF formats; however, many clinicians do not realize that the guidelines exist.  Research has shown that passive dissemination of healthcare guidelines does not affect clinical practice.  Clinicians report that they do not have time to read the guidelines and they are not easily translated into clinical practice. (1), (2)

Scholarly literature shows a need for structured clinical practice guideline distribution methods to change practice (3), (4), and (5). One alternative dissemination method is online learning. Internet education has proven effective at increasing medical practice knowledge and changing practice, especially when a clinical tool is provided (6). Web pages can be updated more quickly, easily, and more cost-effectively than print materials. Anyone with online access can review the materials anytime and anywhere, which has proven to promote learning and improve trainee satisfaction (7). Additionally, web sites provide the potential for interactive tools such as discussion boards and quizzes, as well as multimedia technologies such as video and animations. Such technologies may prove to be more interesting and effective for clinicians than print materials.


As an alternative to passive dissemination, we are developing a website to teach the Clinical Practice Guidelines on Preventing Upper Limb Pain in People with SCI. We completed the first functional prototype web site in 2008. The site is currently password protected to only the web developers to prevent access while the site is still in the prototype stage. The site uses simple 508 compliant html web pages. The current structure and content of the web site is as follows:

Home Page

: This screenshot shows the home page of the web site, displaying the basic site structure.
Figure 1. (Click for larger view)

The home page (Figure 1) briefly describes the guidelines and the website’s purpose: to emphasize education of the guidelines and test the site users’ knowledge on the guidelines. A link to the PVA website is provided to allow clinicians to download the guidelines in their original format. The home page also explains the structure and content of the website.

Training Modules

The right screenshot shows the modules page of the website with clinician and patient targeted content clearly separated. The left screenshot shows a patient-targeted PDF module that demonstrates proper wheelchair propulsion techniques.
Figure 2. (Click for larger view)

This page provides printable PDF files that outline recommendations from the clinical practice guidelines. The PDFs are not simply reprinted material from the published guidelines. These documents were rewritten in simple, directive language and are currently used by our institution to train clinicians who treat new SCI patients. Many documents include photos demonstrating recommended techniques. Additionally, the PDF modules are divided into 2 columns indicating materials targeted towards clinicians and those targeted towards patients. Documents in each category were written at the expected education level of either the clinician or patient audience. (Figure 2)


This screen shows a users’ scored quiz on the tutorials page of the website; the users’ percentage and number of correct responses as well as the answers to the quiz questions are displayed.
Figure 3. (Click for larger view)

Here, clinicians can test their knowledge of the guidelines by taking a quiz on each module. Upon completing each quiz, the user is prompted to click a “check quiz” button which displays the user’s number and percentage of correct answers. The correct answers to each question are also displayed. Next, the user will click a “submit” button which collects their quiz answers into a database for our analysis (Figure 3).

Discussion Board

This hyperlink will take the user to an online discussion board where users can converse with one another through posts and threads.  “Posts” are user submitted messages enclosed into a box that contain the user’s details and the date and time sent. Posts are contained in “threads”, which are continued discussions on different topics. Posts that follow in the thread are meant to continue discussion about the initial post, or respond to other users’ replies. Users can also find specific threads by using the discussion board’s search feature.

Our discussion board is currently hosted on an outside free discussion board forum, www.freeboards.com. Users wishing to use the discussion board must create an account on the site. Although the discussion board is hosted outside our domain, we are able to administer and moderate all activity on the discussion board.


This page contains hyperlinks to other interesting and useful websites pertaining to spinal cord injury, clinical practice guidelines, and wheelchair research such as the National Spinal Cord Injury Association web site and the National Guideline Clearinghouse web site.

We plan to conduct a clinician focus group to evaluate this prototype website and provide suggestions for revision and improvement before it is finalized and released to the public. Additional grant funding for this project would provide the opportunity for a more professional site redesign, administration of user accounts to control site access, and/or acquisition of more powerful web development tools to allow us to host the discussion board internally. Publishing video or animation of techniques on the site could aid users in understanding the guidelines and make the site more appealing. Once completed, we plan to release and advertise the web site to patients and the healthcare community.


We believe the website’s structured teaching format will train clinicians and subsequently patients to practice the guidelines more effectively then the current standard of care. The online modules written for clinicians to provide to patients convey the key information they need to learn more directly than the full version of the guidelines; they exclude unnecessary medical jargon and include more illustrations and to-the-point descriptions and instructions.  The online quizzes enable clinicians to learn the guidelines in small sections instead of forcing them to review all the guidelines at once. Online quiz scoring shows clinicians specific areas in which they need to become more knowledgeable, allowing them to focus on learning specific skills. The discussion board allows clinicians worldwide to interact and communicate with each other.  Discussing clinical problems with peers can significantly improve a clinician’s understanding of a problem and can help her/him change clinical practice.(5) Finally, web sites are more cost-effective than print publishing, and online content can be updated immediately as opposed to print materials which can take months to be produced.

This web site provides us the potential to measure and analyze clinician knowledge of the guidelines since we are capturing user’s quiz data from the site. These results will contribute to the current research on the effectiveness of online education of medical guidelines.

People with SCI and the clinicians who treat them must learn and utilize the clinical practice guidelines on preventing upper limb pain and injuries. Practicing the guidelines will improve wheelchair users’ quality of life, independence and reduce medical costs associated with treating arm, wrist, and shoulder pain and injuries. We hope to provide this educational web site to clinicians as an additional cost-effective tool to improve therapy services.


  1. Consortium for Spinal Cord Medicine. (2005). Preservation of upper limb function following spinal cord injury: A clinical practice guideline for health-care professionals.
  2. Jette, D.U., Bacon, K., Batty, C., Carlson, M., Ferland, A., Hemmingway, R.D., et al. (2003). Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Physical Therapy, 83, 786-805.
  3. Freemantle, N., Harvey, E.L., Wolf, F., Grimshaw, J.M., Grilli, R., & Bero, L.A. (2000). Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database Syst. Rev., 2, CD000172.
  4. Davis, D.A., Thomson, M.A., Oxman, A.D., & Haynes, R.B. Changing physician performance. A systematic review of the effect of continuing education medical strategies. (1995). JAMA, 274, 700-705.
  5. Oxman, A.D., Thomson, M.A., Davis, D.A., & Haynes, R.B. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. (1995). Can Med Assoc J., 153, 1423-1431.
  6. Shafer, M.B., Tebb, K.P., Pantell, R.H., et al. Effect of a clinical practice improvement intervention on chlamydial screening among adolescent girls. (2002). JAMA, 288, 2846-2852.
  7. Pullen, D.L. An evaluative case study of online learning for healthcare professionals. (2006).  J Contin Educ Nurs,. 37, 225-232.
  8. Delva, D.M., Kirby, J., Schultz, K., & Godwin, M. Assessing the relationship of learning approaches to workplace climate in clerkship and residency. (2004).  Acad Med., 79, 1120-1126.
  9. Hoa, D., Micheau, A., & Gahide, G. Creating an interactive web-based e-learning course: A practical introduction for radiologists. (2006).  Radiographics, 10.1148/rg.e25.


This study was supported by the National Institute of Disability and Rehabilitation Research (NIDRR), grant number H133N060019.

Author contact info:

Christine Heiner, Human Engineering Research Labs, VA Pittsburgh Healthcare System, Pittsburgh, PA 15206, Phone: (412) 954-5290, Fax: (412) 954-5340, Email:heinercm@pitt.edu.