Idea for the literature review came from my personal experiences, first as a student learning physical therapy (PT) content, followed by my fifteen years of serving as a Master clinician and clinical instructor for PT students in various universities and more recently in my current role as an Adjunct Faculty at New York University (NYU). My responsibilities at NYU include co-teaching pediatric content and coordination of the clinical sciences coursework which includes pharmacology, radiology and pathology content.

At the ‘Second Annual Physical Therapy Education Forum’, one of the table talk ideas focused on interprofessional education and more specifically on how to design curriculum that ensures all Doctor of Physical Therapy (DPT) students are prepared for the future of working as part of the interdisciplinary team (Davis and Tschoepe, 2016). Dr. Deusinger, the keynote speaker at the forum, called to ‘standardize PT education with the use of evidenced-based principles for teaching and learning’ (Davis and Tschoepe, 2016, p.53).

To become a Physical therapist in US, students are required to complete an entry-level doctorate degree and pass a licensing examination. Intensity of the studies and variability of the courses where students are required to gain didactic knowledge, clinical reasoning skills,manual skills, interpersonal skills, and effective problem solving abilities, creates a need for a flexible pedagogical approach which can deliver required content effectively.

Students' individual learning styles bring an additional layer to this problem. When making a decision which pedagogical approach will be most effective in delivering a PT curriculum, it is important to first consider what kind of learners the PT students are (DiBartola, L.M., 2006). Students’ whose learning style matches to the teaching style of the instructors demonstrate better performance on the exams (Katz, 1990).

In my current role as an educator and coordinator of interdisciplinary content I plan to invest my time in identifying most effective teaching approach to deliver content to PT students in a way that is complementary to their learning styles and prepares them for being part of an interdisciplinary team. Present literature review focuses on identifying peer-reviewed publications which provide information on the preferred learning style of PT students.

Assessment of adult learning styles and learning outcomes in students of health related fields has been researched since the 1970s. Taylor & Hamdy (2013) published a guide discussing commonly used adult learning theories and how these can be used to enhance student and faculty learning. When discussing Kolb’s (1984) experiential learning which falls under instrumental learning theory, Taylor and Hamdy wrote that it influenced adult education by "making educators responsible for creating, facilitating access to and organising experiences in order to facilitate learning" (e1562).

"Knowledge results from the combination of grasping and transforming experience” (Kolb, 1984, p41).

Both Bruner’s (1966) discovery learning and Piaget’s (1952) theory of cognitive development ideas support Kolb's experiential learning approach (ELT). Kolb's ELT model (4 modes) is presented in a cycle below.

Hawk & Shah (2007) reviewed five learning style instruments meant to give insight on how to enhance student learning. Links below can serve as an introduction to each of the instruments. All of these have been reported in literature as tools used to assess learning styles of PT students, with Kolb’s Learning Style Indicator (LSI) being the most common (Stander et al, 2019).

• The Kolb Learning Style Indicator
• The Gregorc Style Delineator
• The Felder–Silverman Index of Learning Styles
• The VARK Questionnaire, and the Dunn and Dunn Productivity Environmental Preference Survey

Kolb's 'The Learning Style Inventory was designed to measure the degree to which individuals display the different learning styles derived from experiential learning theory. The original Learning Style Inventory (LSI 1) was created in 1969 (Kolb, Rubin, and McIntyre 1971) and has been updated several times with version 4 (2013) being the most recent. Authors who used the older version of LSI report the learning style of students in 4 learning style categories. Newer LSI Version 4 (KLSIv4) has 9 different learning styles, which are combinations of 4 previous learning styles.

Katz & Heimann (1991) used Kolb’s LSI to compare learning styles of students and practitioner in five health professions, PT being one of them. 57 PT students and practitioners participated demonstrating preference to learn in active over reflective mode (p.243). Overall, PT, occupational therapy, social work and nursing students have similar learning preference and can be effective learners in the same environment (p.243). Clinical psychology field seems to interest dissimilar learners to the other four professions (p.243).

Stander, J., Grimmer, K., & Brink, Y. (2019) performed a systematic scoping review to explore which has been published on the learning styles of physical therapists. 15 studies were included in this review with the total population of 910 undergraduates, 361 postgraduates, 23 professionals in developed countries.

Outcome measures included different versions of Kolb’s Learning Style Inventory (9 studies), the visual-aural-read/write-kinesthetic questionnaire, Gregorc style delineator (2 studies), Felder Silverman’s Index of Learning Survey, and Honey and Mumford’s Learning Style Questionnaire.

The preferred physical therapy learning styles, according to Kolb's ELT, are:

• Converger (learns “hands-on” and applying previously attained knowledge) and
• Assimilator (gathers and organises information to make the most sense).

The preferred physical therapy learning styles, according to Gregoric style delineator, are:

• Duel learning style (combination of learning styles) and
• Concrete-sequential (ordered sequence in learning with concrete examples).

It is difficult to make definitive conclusions on a specific learning style that physical therapy students demonstrate due to poor consistency of the assessment tools used in the research. Looking at the tools most commonly used in the literature physical therapy students and professionals have a preference for “active participation, underpinned with practical examples of theoretical concepts" (Stander, 2019, p8). This sample included students from both undergraduate, post professional programs as well as practitioners. For future research, it is imperative to begin using one tool and assess entry-level DPT students. Data from a valid and reliable learning style outcome measure can provide more concrete information on how to adjust our curriculum to meet the needs of DPT students.

Brudvig, Matson and Guarino (2016) did just that. Authors used KLSIv4 to assess 61 entry-level DPT students (77% women, mean age 23.6) learning styles.

According to KLSIv4 students were evenly distributed across 7 out of 9 learning styles, except balance and thinking (p.8):

• Imagining (Imagining the possibilities through reflection & observations about the experience), 16%
• Reflecting (Connecting experiences and ideas through reflection), 16%
• Initiating (Ability to initiate action when dealing with experiences), 14%
• Acting (Strong motivation for a goal-directed action that integrates tasks and people), 14%
• Experiencing (finding meaning by deeply involving oneself in experience), 12%
• Analysing (integrating ideas and models through deep reflection), 12%
• Deciding (Using models and theories to solve problems and decide on a course of action), 12%
• Balancing (Weighing the pros and cons of feeling and thinking and acting and reflecting, 2%
• Thinking (Deep involvement in rationale thinking and logical reasoning), 2%

With this newer data which is more closely representative of the current population of learners in DPT programs, we can see that as a group students are multimodal. This group would benefit from pedagogical approach which includes a variety of activities when learning presented content. Presenting information in one way only will put at disadvantage 80% of the class.

Lowdermilk, M., Lampley, J., & Tweed, S. (2017) also looked at the learning styles of the DPT students as well as physical therapy assistant (PTA) students. Authors goal was to identify any association between students’ learning styles, gender and age. Participants included 337 DPT and PTA students in Tennessee and southwest Virginia. Felder (1996) and Soloman Index of Learning Styles (ILS) was used to determine learning style preferences within 4 learning style dimensions (active-reflective, sensing-intuitive, visual-verbal, and sequential global).

Results revealed that there was no significant difference between the learning styles of DPT and PTA students.

Both the DPT and PTA student’s preferences are:

• Balanced on the active-reflective dimension with a preference toward the active (learn by trying things out and enjoy working in groups)
• Sensing on the sensing-intuitive dimension (concrete thinkers, practical, and oriented toward facts and procedures)
• Visual on the visual-verbal dimension (prefer visual representations of presented material such as pictures, diagrams, and flow charts)
• Balanced on the sequential-global dimension with a preference toward sequentia (learn in small incremental steps and prefer linear thinking processes).

A statistically significant difference was not found among DPT students across any learning style dimension based on age. PTA students age 24 and younger reported preference for active learning style more frequently than those age 25 and older. Overall, Lowdermilk and et al (2017) determined that PT students are typically ‘active learners’ who like group work and need opportunities to just ‘try things out’ (Lowdermilk, 2017, p.78). They learn information best using visual materials and prefer ‘linear thinking processes’ (Lowdermilk, 2017, p.79). They are also ‘concrete thinkers and oriented towards facts and procedures’ (Lowdermilk, 2017, p.78).

Currently at New York University and most onsite DPT programs, the coursework is taught by the licensed physical therapists via face to face lectures with laboratory hours provided to practice hands on skills. Clinical reasoning opportunities are sprinkled throughout the curriculum and might be accomplished using problem based learning pedagogy and collective learning. However, clinical science content such as radiology, pharmacology, and pathology do not follow that approach. These are mostly covered by other health professionals who are part of multidisciplinary team, but are not physical therapists. These courses are taught using traditional lecture based method where students are passive listeners about 87% of the time (Stains, 2018). Content provided is expected to be memorized for the examination with little translation to the clinical PT practice.

Traditional pedagogical approach is the most commonly used in higher education. Research assessing learning styles of PT students demonstrates their preference for 'active/ hands on' and 'think and watch' learning style (Lowdermilk, 2017; Pei-Jung, 2013; Stander, 2019). There is also evidence that entry-level DPT students specifically are multimodal learners (Brudvig, 2019). This group would benefit from pedagogical approach which includes a variety of activities when learning presented content. Presenting information in one way only will put at disadvantage 80% of the class. For future research, it is important to consider using the same learning style instrument across all DPT programs to have comparable information. There is a need for further studies looking at the association between learning styles and various pedagogical approaches. As per sparse publications, students' performance does not seem to be impacted across four learning style (Pei-Jung, 2013) however, the interview confirmed 'specific characteristics of favorite and disliked courses among students with different learning styles'. There is also data demonstrating a significant but weak correlation to critical thinking skills acquisition (Brudvig, 2019). More studies are needed with valid assessment tools to make any conclusions on these associations. What is clear from research so far is that traditional style or a single style of information delivery does not compliment PT students learning preferences (Lowdermilk, 2017; Brudvig, 2019; Stander, 2019). While students find a way to be successful in the program despite outdated information delivery, it is important to also consider students' perception and preferences for learning.

Across various fields of study, technology-enhanced instruction is being implemented. Huges (2018) shared that after just 90 minutes of instructional session on two tech tools, PT educators perceived that they can promote ‘higher order thinking’ and increase students ‘communication and collaboration within learning opportunities’ (Hughes, 2018). There is a need to identify a more effective pedagogical method to teaching clinical science content. Also, in order to address the future of PT education goals (Davis & Tschoepe, 2016), it is critical to create opportunities of learning with other discipline professionals. Physical therapy, occupational therapy, social work and nursing students have similar learning preferences (Katz & Heimann, 1991). This creates an opportunity to design lectures and experiences where multi discipline students are learning together, mimicking the real time practices.

With the technology literally at our fingertips, the conceptual lens is changing on how the students expect to receive information and what helps them to effectively learn. Unfortunately, students are not always part of the pedagogical conversation. Lack of students’ participation in the program mission, curriculum design and evaluation is one of the weaknesses identified in the DPT curriculum when it was reviewed against the World Federation of Medical Education standards (Rehman, 2018). Incorporating students' perception of how successful was the pedagogical approach in teaching specific content and not to rely purely on their performance in a course is imperative to address this weakness while identifying the most effective content delivery method and development critical reasoning skills.