EPS 431: Literature Review - Evolution of Physical Therapy Education
- Anna Len
- Oct 20, 2019 at 6:39 PM
For the past 15 years I have worked as a physical therapist (PT) and concurrently as an educator in both clinical and academic settings. Technological advancements made since I was a student myself to now and how the state of physical therapy education has been influenced by them is an interest of mine. My recent literature review on learning styles of physical therapy students revealed that specifically entry level doctor of physical therapy students have a preference for active learning and display variety of learning style preference thus needing a multimodal learning environment (Brudvig et al, 2016; Lowdermilk et al, 2017). Below is the video discribing ideas of multimodal learning.
Didactic approach where students are passive learners is still the single most commonly used pedagogy in academia (Stains, 2018) however, using a singular pedagogical approach puts a large group of students into a strenuous learning situation. Furthermore, students are rarely are part of the conversation or have a choice on how the information is delivered. This prompted my interest in looking further into pedagogical approaches which have been used in the physical therapy education.
The goal of this literature review is to learn about the history of physical therapy education and identify physical thearpy research which explores various pedagogical approaches to deliver content in academia and clinical settings and students' perception of its effectiveness.
Historical Background
Physical therapy practice, as we know it today, along with the educational requirements needed to train physical therapists has evolved tremendously over the past 100 years. Holzknecht (2017) documentary on History of PT in US provides a detailed look into PT profession which I have summarized below.
PT originally grew from physical education and nursing professions. The development of the profession was very much driven by the historical events, such as polio epidemics and the World wars. Doctors needed support personnel to help with rehabilitation. Recreational aids ‘first adopted and later on adapted’ (Holzknecht, 2007) the knowledge from physical education and nursing, specifically therapeutic touch and muscle training. Recreational aids developed ways to assess muscle strength and how to build it back or substitute those functions with different muscle groups or adaptive equipment.
First recreational aids program initiated at Reid’s college with the focus of treating children effected by polio epidemics of 1916 and injuries solders acquired from the World War I. In the 1940s, with the new wave of polio and an influx of solders with musculoskeletal and neurological injuries, the need for physical therapists was significant. This led to creation of six months intensive trainings to fill the void. Once the post war influx of injured diminished, the new large group of physical therapists expanded their work to civilian population.
As the roles of physical therapists continued to increase, there was also a need for increased standards in education. USA has attained major educational milestones faster than other countries (Balogan, 2018) and continues to lead the way.
Video: History of PT in US (link requires subscription to APTA)
James Holzknecht (Producer), (2007). History of Physical Therapy in the United States. Austin, TX: Castalia Media. [Streaming Video]. Retrieved from video.alexanderstreet.com/watch/history-of-physical-therapy-in-the-united-states database
Early education which took place at Walter Reid’s college and Reid’s Army Medical Center were basically crash programs for graduates from gymnasia programs or nurses. Early programs were in the hospital setting and education was provided with a more authentic model. Physical therapy is a hands-on profession and learning handling techniques in the environment, where one will be applying them was very intuitive and natural. It was also more conducive to interdisciplinary model. However, on its own, on-site education struggles to offer accurate assessment of quality learning opportunities across student experiences (McCallum, 2013).
The move of the formal education to the university marked a major milestone in PT. The programs at university required curriculum and specific faculty standards. This made a significant impact on the quality of PT education. The content delivery in the curriculum transitioned from purely authentic learning, which took place in medical centers, to the combination of didactic pedagogy at the university and clinical expereinces at the medical facilities to ensure students attained required level of clinical reasoning and practical skills. “Clinical reasoning is a cognitive decision-making required for examination, evaluation, and management of a patient” (Jones, 1992). Success of physical therapy education is assessed during CAPTE review, by evaluting the currculum, surveying the students’ perception, reviewing their performance during clinical experience and the rate of passing the national license exam.
PT education at the university level was originally a post baccalaureate programs, then regressed to bachelorette, moved to master and finally doctorate level. Today, as a profession, physical therapy requires a doctoral level as an entry level education for the professional practice. Universities undergo accreditation to ensure quality education through CAPTE. Physical therapy curriculum requires both academic content and clinical education content.
Video: How to become a physical therapist
Literature Review: Academic Education
Through this literature review, several methods of how the physical therapy academic content is currently delivered to students in higher education emerged.
Traditional lecture-based approach (didactic), where students are passive recipients of the information, followed by out-of-class homework continues to be the most commonly used method to deliver information to students in higher education (Stander, 2019).
However, in the last 10 years there is a rise in research exploring new learning pedagogical approaches, such as blended or hybrid learning (Drysdale, et al, 2013; ) and flipped classroom design (Akcayir, 2018). Both approached offer students an ability to recieve information in through various modes and demonstrate positive response.
Barbyar et al (2010) published a study to assess the “Pedagogical tools to develop clinical reasoning: Physical therapy students’ perspective”.
Authors grouped academic curriculums into three delivery methods: traditional (didactic), problem-based learning (PBL) and hybrid or combination of PBL and traditional pedagogy. Hislop’s 4-step theoretical model (Hislop, 1985) for optimal clinical performance was used as a theoretical framework.
"Hislop’s model shows a progression from memory, the acquisition of information; to knowledge, the synthesis or interpretation of information; to competence, the use of information; and, finally to performance, the actual management of the patient” (Barbyar,S., Pivko, S., Rosen, E., 2010).
Pedagogical tools to develop clinical reasoning: Physical therapy students' perspective - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Academic-and-clinical-italics-pedagogical-tools-incorporated-into-the-survey_fig1_49698415 [accessed 14 Sep, 2019]
Interestedly, while most participants characterized their academic programs as a hybrid of traditional-based curriculum with cases studies imbedded within the didactic learning situations (Barbyer, 2010; CAPTE, 2019), only half of the students reported faculty-mentored problem-solving and memorization of didactic material used in all course types (Barbyer, 2010).
Thirty-three program representatives participated in the study with their students and 91 students completed the survey. The results demonstrated that the highest total percentage of preparedness (adequately to extremely well-prepared range) for clinical reasoning was reported by the students in the hybrid model curriculum (Barbyer, 2010). Authors also reported that “no single pedagogical tool stood out as “Not at All Helpful” across all parts of the academic curriculum. If a pedagogical tool was used, participants found some value in its use for learning clinical reasoning”.
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). These students would benefit from pedagogical approach which includes a variety of activities to grasp the content. Conclusion maybe drawn that didactic pedagogy has its place in PT academic education but only as part of a hybrid model. Research is needed to assess the effectiveness of the pedagogical approaches used to present content to students in an academic setting. Future research is also needed to develop valid tools to accurately assess students' clinical reasoning as an outcome.
Literature Review: Clinical Education
Physical therapist education programs (PTEPs) devote 44.9% of professional (entry-level) physical therapist education curricula to Clinical education (CE) (CAPTE, 2019).
CAPTE governs the quality of the academic program, but the clinical education (CE) construct of quality and methodological rigor has been difficult to measure and standardize, as it falls on the individual practitioners who are teaching outside of the university (McCallum, 2013). Lekkas, P. et al (2007) conducted a literature review to determine the best model for CE.
Authors reviewed 44 publications, educational models were catagorized into six types:
- one-educator-to-one-student (1:1)
- one-educator-to-multiple-students (1:2)
- multiple-educators-to-one-student (2:1)
- multiple-educators-to-multiple-students (2:2)
- non-discipline-specific-educator and student-as-educator
Models were examined for productivity; student assessment; and advantages, disadvantages, and recommendations for implementation. Authors concluded that there was insufficient evidence and methodological rigor to support or favor one particular CE model. "The perception that one model is superior to any other is based on anecdotes and historical precedents, rather than on meaningful, robust, comparative studies" (p19).
McCallum, C.A., et al, (2013) reviewed 54 articles which were categorized by primary quality themes (see below) and scored on rigor in 14 areas.
- CE framework
- CE sites
- Structure of CE
- Assessment in CE
- CE faculty
The results of this systematic review revealed that the methodological rigor of studies on quality in physical therapist CE varies, regardless of study design. Authors believed that due to lack of cohesiveness across the studies, it was difficult to draw conclusions specifically in the areas of framework and sites. There were several studies which demonstrated higher rigor in the areas of structure, assessment and faculty. However, authors smmarized, that "the conclusions did not bring us closer to defining quality or best practice for physical therapist CE" (p.1309). Future research is needed with sound methodology and valid outcomes assessments not for just students' performance but also students' perception on expereinces with various models.
Conclusion
Holzknecht (2017) documentary shows the first physical therapists discovering how best to rehabilitate the movement system after an injury through practical work. They were very much part of the knowledge building at the time. One of the PT goals today is to be equal in every sense to other medial professions. Research will continue to play a vital role in the future of the profession in terms of evidence-based practice and best practices in education arena.
As technology continues to develop there is a decreased need for memorization, which is the focus of didactic pedagogy. DPT students multimodal learning preferences (Brudvig, 2019) seek ability to access information through different modes such as hybrid curriculum (CAPTE, 2019). Opportunity for dialectic work with the clinical instructor is one of the most valued factors by the students in their development of clinical reasoning (Babyak, et al 2010). Difficlty with finding ability to account for all the variables in CE and to find single "gold methodology" (Lekkas, P., et al, 2007; McCallum, C.A., et al, 2013) might be a sign to stop looking for it. Instead, maybe we should take advantage of the variability of students' experiences and create a platform to harness it instead as the collective intelligence.
To move PT education forward we may actually need to go back. Back to the way reconstruction aids learned, but enhance it with the use of new technology. Our students need to be contributors to the creation of knowledge for their cohorts. One way to create a more balanced experience for students in clinical education, is to give them a platform where they can find resources and also continuously share new experiences, discuss successes and challenges with their classmates moving the education in the direction of transformative learning.
References
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