_{[Physical Therapy Image]. Retrieved from https://images.app.goo.gl/Zvy5wRKGBDQHL9Xb6}

There is an interesting and powerful confluence among theory, research, technology, and practice, especially when it comes to the integration of curriculum, instruction, and assessment (Pellegrino & Quellmalz, 2010, p. 130)

This literature review will be my third work that looks into physical therapy education and students' learning. This line of inquiry 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 comprises of pharmacology, radiology and pathology content.

In my current role as an educator and coordinator of interdisciplinary content I invest my time in identifying effective pedagogical approach to deliver specific content to PT students in a way that is complementary to their learning styles and prepares them for being part of an interdisciplinary team. Through my own learning journey so far and interactions with the students, it is becoming increasingly clear that accurate, relevant and valid assessments of the knowledge the students are gaining, is a major part of the educational curriculum as a whole. The change of the content delivery method without considering the assessment of gained knowledge in the way we expect the students to use the information in the field, does not seem to produce positive learning experiences or prepare students for clinical work.

This review focused on the in-program assessments of knowledge students gained from in classroom instruction that are used in physical therapy education programs.

_{[Physical Therapy Education Image]. Retrieved from https://smhs.gwu.edu/physical-therapy/degree-program/clinical-education/clinical-education-students}

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).

Physical therapy profession grew directly from physical education. Physical therapy curriculum was modeled on swidish gymnastics, the curriculum developed by Pehr Henrik Ling in 1800s and physical education curriculum developed by Aleen Sargent Sargentn 1970's. Modern physical therapy was developed in the late 1900s and was promoted as a profession after the polio outbreaks and world wars. Mary McMillan is a physical therapist whose name is synonymous with physical therapy profession and PT education in US. She and her colleagues laid the foundations for research in the physical therapy field (Holzknecht, 2007). The first school of physical therapy was established at Walter Reed Army Hospital in Washington, D.C. The training was initially carried out through authentic pedagogical approach in the clinics. However, as the educational program moved to the universities, the curriculum transitioned to a hybrid of traditional lecture based coursework in the classroom and clinical experience in the hospital or clinic.

The level of training physical therapists are expected to gain to practice grew significantly. In 1942, physical therapists attended the nine-month certificate program consisting of six months of lectures, demonstrations and laboratory classes and three months of clinical training. As of 2001 physical therapists are earning a three-year professional Doctorate of Physical Therapy (DPT).

In my recent literature reviews ``Evolution of Physical Therapy Education '' and "Learning Styles of Physical Therapy Students' ', I looked at the pedagogical approaches used to deliver the physical therapy curriculum since 1942. The in-classroom work continues to utilize the traditional in classroom format in most universities despite the multimodal learning preferences of the students. Only a few programs beginning to explore flipped classroom design, hybrid and online format to deliver content to the students (Len, 2019), (Len, 2019).

The expectation for the future practitioner is to use new technology to enhance the efficiency in service provision and maybe quality of service. While digital tools will decrease the need for memorization, the demands on creativity, problems solving and working collaboratively with other professionals will be a central skill. 21st century learners grow up with the experience of receiving information from multiple sources instantaneously and become comforable in participatory role during engagement through social media and gaming. This ‘participatory media cultures’ (Jenkins, et al, 2006) and opportunity to make choices in those engagements, creates certain expectations from the educators. Our student do not learn the same way and they will be expected to perform in a health field that is rapidly changing. The learning environment and assessment of gained knowledge should consider the changing landscape of how new learners see education and what method and type of assessments are best to assess skills they will need for success in the health field.

Vendrely, A. (2002) performed a literature review on student assessment methods in physical therapy education. Below is the schematic of the assessment categories in PT education the author identified.

(Vendrely, A., 2002)

Vendrely (2002) describes each categry and provides an examples of each type of assessments found in PT education. See artcle below for further detail.

Vendrely, A. (2002). Student assessment methods in physical therapy education: An overview and literature review. Journal of Physical Therapy Education, 16(2), 64-69.

Vendrely (2002) lists midterm exams, quizzes and teacher observation as examples of the traditional formative assessments used in PT education. Interestingly, in our program, I find that midterms and quizzes with traditional set up are frequently used to test information students' learned up to that point, while the final examination focuses on information learned from the midterm on. This means that this type of testing actually falls into the summative assessment category. Also, when looking at the grade composition, student observation is not incorporated into the analytics of students' performance and is done in a more informal way during laboratory work. I also need to note that supply responses tend to be used as a preference of the teacher instead of determining which content should be assessed with selected versus supply responses.

Alternative assessments in physical therapy education are very much needed specifically because of the complexity of skills required in clinical practice which can not be assessed using traditional methods. While extended performance can only be offered during clinical experiences, restricted performances through practicals, and reflective writing, as well as standardized patients simulations can be offered at the university. Simulations specifically have some support in literature, but do present economical concerns (Pritchard, S. & Blackstock, F., et al., 2016).

Timmis, S., Broadfoot, P., and Sutherland, R. et al adapted Technology Enhanced Assessment (TEA) as the term to use and define it as the use of digital technologies for the purposes of enhancing formal or informal educational assessment for both formative and summative purposes (Timmis, 2016). Authors examined the history and scope of TEA, its use within formative and summative assessment and the potential affordances and challenges it brings (Timmis, 2016). The paper included: literature review, briefings and associated discussions. The summary of critiques in the literature included an over emphasis on technology for "efficiency and the potential for standardising, grading and recording data instead of developing more creative methods of assessment" (Timmis, 2016, p. 458). Authors referred to the work of Thornton (2012) and Shute & Kim (2013) who reported that technology is being used to replicate existing methods of assessment instead of looking for innovative methods to redefine what assessment should measure and than using current technology to support it.

Timmis, et al (2016) discussed seven opportunities afforded by technology enhanced assessment:

• New forms of representing knowledge and skills
• Crowd sourcing and decision-making opportunities in assessment
• Increasing flexibility
• Supporting and enhancing collaboration
• Assessing complex problem-solving skills
• Enhancing feedback to students
• Exploiting learning analytics locally and nationally

_{Clark, D., Asbell-Clarke, J., Kathy Perkins, K. (2019, February 28). Technology in the K-12 Classroom. [YouTube Channel]. Retreived from https://www.youtube.com/watch?v=66ZSpwFDnJ0#action=share}

Research using specifically TEA and TEL overall in the health field is very limited. Taylor (2016) looked at virtual simulators as a viable and safe environment for physical therapy students to practice interdisciplinary professional education (IPE) skills to aid in advocacy for their patients. Mitra & Barua (2015) looked at the use of computer based formative tests with automated feedback for medical students. However, most of the research in physical therapy is focused on non-technology based assessments of performance and clinical competence such as rubrics (Yeung & Kulasagarem et al, 2016), standardized verbal assessments (Fu, 2015), (Panzarella & Manyon, 2008).

Technology Enhanced Learning (TEL) encapsulates the role of digital technologies in supporting or enhancing learning across all sectors of education (Timmis, 2016). While more innovative pedagogical approaches with TEL are emerging in physical therapy education, there is a significant gap in assessment research overall and none in specifically with TEA. WIth the new demands in healthcare field, it is imperative to engage in the assessments research concurrently with innovative curriculum delivery methods under one pedagogical umbrella instead of seeing it something to do at the end.

Most of the current physical therapy education research focuses on innovative content delivery methods (Len, 2019) and performance assessment during clinical experiences. There is little focus on formative assessments or use of TEA in physical therapy education. Summative assessment such as written exams with most often multiple choice seem to be the accepted form of assessing student learning in the physical therapy programs. This may be driven mainly by the fact that the licensing exam is also made up of multiple choice questions, targeting recalling, memorization and entry level clinical reasoning. Practicals, which fall under restrictive alternative assessments, are usually in person examinations with written sample patient cases. These are used to assess manipulation skills and clinical reasoning with student partners and take place at the university. While practicals do offer additional/alternative measure of students learning they again fall under a form of summative assessments. Critique of this form of alternative assessment is the limited instructor feedback on handling techniques, as there is not enough time to have students' demonstrate skills on all available cases. Students' also do not have access to the usual modes of research they would have in the real world so the assessment only looks at memorization and clinical reasoning on a spot with a small sample of handling and manual techniques.

There is limited research specifically looking at the impact formative versus summative assessment methods and the impact these may make on physical therapy students' performance; on whether specific pedagogical approach or content delivery methods benefits from a specific assessment type. Does a specific method of assessment show increased benefits for students' readiness before clinical experience. It would also be important to assess how the type of assessment method impacts student perception, not just performance.

Over the past 100 years, physical therapy education requirements have grown from a certificate program to the doctoral level education. However, there has been significantly less focus on education research and the most effective delivery methods of the physical therapy curriculum. The effectiveness of the traditional teaching approach as the expectations of the future practitioner needs to be assessed. Further, there are a lot of unanswered questions around assessments that future research has to consider. As we look towards how do we prepare our future practitioners and look to technology to help us fill in the gaps in both content delivery and assessment I would like to quote Timmis (2015) work:

"Innovations should be based on a ‘pedagogically driven model’ that ‘can allow students to take more control of their own learning and become more reflective’ (Whitelock & Watt, 2008, p. 152), as opposed to new forms of assessment being driven by the possibilities of the technology itself (Timmis, 2015, p. 465)".