Impact of computerized simulation education, video-based learning, and kinesthetic learning in delivering the wrist and hand assessment among physiotherapy students – A qualitative study

INTRODUCTION

In the current times, teaching-learning in healthcare education has transitioned from teacher-centered to student-centered approaches. Previous teaching-learning methods focused more on knowledge rather than psychomotor skills or the affective domain.^[1] Thus, there was no adoption of holistic learning approaches. With the era of technology, various devices and software’s are now available to teach the students, thereby not only making teaching easier but also learning better for students.

A study done by Luginbuehl et al. shows that learning a psychomotor skill in physiotherapy using prerecorded videos of the instructor was easier for understanding because the learning was self-paced as well allowed optimal skill demonstration with equal exposure to all students.^[2] Likewise, another study highlighted that video-based learning prepared the students for practical examinations, considering the anxiety levels associated with the demonstration of the techniques were lesser.^[3] Thus, there is a foundation of evidence stating that video-based learning is known to improve the psychomotor skills of the learners.

Similar to video-based learning, there is another innovative teaching-learning technique under the subset of simulation education. It is a way to represent a condition or situation similar to a real life situation. For instance, a model can represent a patient for learning purposes. There is evidence of the use of simulation education to enhance clinical competence among undergraduate and postgraduate medical students with the advantage of improving patient safety and reducing the health care costs.^[4] It is also known to be effective in teaching treatment algorithms in emergency medicine training.^[5] Computerized simulation education, a subset of simulation-based training, is the most upcoming teaching-learning method employed among various disciplines of medical education. However, there is a dearth in literature on the use of the above techniques in physiotherapy education, especially in India.

Bachelor of Physiotherapy is a four-and-a-half-year course in India, wherein 3^rd and final year have considerable clinical skill-based and case-based teaching.^[6] As per a study based on the perceptions of Indian physiotherapy students, a properly planned academic schedule and a good hands-on skill with early clinical exposure helps in building a good clinical competency in the future.^[7] Advocation of an innovative teaching method is a determinant of good learning outcomes and better clinical competency.^[6,7] Competency must improve in physiotherapy assessment, optimal diagnosis, as well as management of the patient. The roots of being an accomplished practitioner dwell in the learnings during the undergraduate days.

There is a common trend among students to dislike or give less weightage to topics which are not that well understood or are too complex to be understood in one attempt. The wrist and hand is known to have intricate anatomical makeup and biomechanical function.^[8] Given the complexity of the structures and its functioning, it becomes a relatively underexplored area, which is why physiotherapy undergraduate students must be taught the same with more innovative teaching-learning methods to obtain better outcomes of understanding among them.

MATERIAL AND METHODS

Methods

Before the session, a general survey was done on the lines of Visual, Aural, Read/Write, and Kinesthetic (VARK) analysis, which told us about the learning preferences among the students. About 82% were in favor of more visual and kinesthetic learning over auditory and read/write methods, which formed the four major domains of learning and understanding as per VARK.^[9]

Thereafter, sessions were divided into four parts. The first session was of 2 hours wherein participants were engaged into anatomy and biomechanics using computerized simulations (from various sites such as tenor and make a gif) as shown in Figure 1 and assessment fundamentals including wrist and hand specific history taking.

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Figure 1:

Showing the computerized simulated images (a) Highlighting the important landmarks on the volar aspect of the hand, (b) showing a screenshot of the computer simulation of the bones of the hand, and (c) showing a screenshot of a computer simulation video demonstrating a thenar muscle action.

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The second session which lasted for 3 hours involved teaching wrist and hand assessment techniques to the participants using photo- and video-based learning, as shown in Figure 2. These pictures and videos were taken after obtaining consent from the patients with wrist and hand dysfunction who visited the physiotherapy outpatient departments of a tertiary care hospital affiliated with the physiotherapy institute.

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Figure 2:

Showing the various photographs of patients with wrist and hand dysfunction to observe the multiple signs (a) to differentiate swelling in hand, (b) to appreciate muscle wasting, (c) to observe the scar, (d) to observe the swan neck deformity, and (e) to appreciate the discolouration of hand post surgery near the scar.

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The third session again was scheduled for 3 hours which involved kinesthetic learning using performance-based outcome measures (including special tests) like Jamar hand-held dynamometer, Jamar pinch meter, Jebson Taylor Hand Function Test, Box and Block test, and finally, the use of sensory kit involving the discriminator on wrist and hand further allowing students to practice on models using them. They were also introduced to recent evidences in assessment, including smartphone applications like Neuri Orthopaedic Institute’s Recognize app (used for right left discrimination), goniometer apps etc. The last part involved a case-based discussion for 2 h wherein participants presented a case of the patient (Colles’ fracture) in a group to a musculoskeletal faculty member. At the end of the sessions, anonymous feedback in the form of self-reflections was noted from all the participants. Observations were noted from the case presented by the participants. Retention was assessed using a ten marks surprise quiz after 14 days of completion of all the sessions.

RESULTS

It was found that 95.45% participants perceived this teaching method superior for learning, understanding, and retention. Thematic analysis of feedback from participants revealed three major domains, namely, student engagement, clarity and understanding, and unique learning opportunities which are summarized in Figure 3. Participants also requested for more sessions to practice on models, and thereafter, assessments on patients to understand sequence of assessment better and about 4 (18.18%) participants thought pre-reading added to this would have been more helpful in assimilation of the topic better. One specific question whose feedback was asked to the students was to describe the difference in the current session versus the didactic session taken by the same faculty who conducted sessions of the knee joint assessment. This was to understand whether they considered the current teaching-learning pattern better or the didactic better in terms of understanding and retention.

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Figure 3:

Thematic analysis of the feedback in the form of reflections, provided by the participants, at the end of the sessions.

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Furthermore, observations noted from the faculty who took their case presentation were that participants portrayed confidence in history taking and demonstrated satisfactory assessment skills. However, it was noted that they needed to work on the reasoning skills. The surprise quiz taken for the 22 participants showed a median score of seven out of ten marks with an interquartile range of 5–9 marks. In the quiz, it was noted that a question pertaining to the mechanism of action of a special test and another question which asked about pathological deviations in hand in a particular condition got the least correct response. Rest of the questions were answered correctly by the majority of the study population.

DISCUSSION

Our study aligns with the findings of various educational theories that advocate for diverse learning modalities, particularly in clinical education.^[6] But before designing the teaching-learning method, we need to get a reasonable understanding in to learning styles and preferences among the students. A study by Brown et al. suggests this insight underscores the necessity for educators to tailor their teaching strategies to align with students’ learning preferences, thereby enhancing engagement and comprehension.^[10] Only if engagement is better, will the complex topics such as wrist and hand be understood well.

The incorporation of multimedia resources and active learning techniques appears to cater to these preferences, thereby fostering an interactive environment where students can actively participate in their learning journey, which can assist in conceptual clarity for complex subjects.^[11] A study by Blackford et al. states simulating real-life scenarios, students can apply theoretical knowledge to practical situations, reinforcing their learning and promoting critical thinking.^[12] Thus, we introduced computer simulation education along with widely used video-based and kinesthetic learning. The innovative computer simulation education can improve the clinical decision-making ability of physiotherapy students by enhancing their assessment and treatment skills.^[13]

Moreover, kinesthetic learning aligns with experiential learning theories, which emphasize the importance of “learning by doing” which builds confidence in clinical skills, which is a vital attribute for future physiotherapists.^[14] Previous studies have shown Kinesthetic learning to be maximally preferred by physiotherapy students as a mode of understanding various topics.^[15]

While the study highlights the advantages of using computerized simulation education, there may be a few challenges and limitations to using the same. It may require various audiovisual resources and internet connectivity.^[16] Some software utilized may have paid versions for a full-fledged use. Instructors must be technically sound to operate complex simulation equipment and the tailor-made designing of virtual simulations may not be easy. Thus, it could be time-consuming and resource-intensive for the faculty members.^[16]

While the findings are promising, the study does have limitations, including the small sample size, single institution participants, and the qualitative nature of the data. Future research could benefit from a larger, more diverse participant pool and a quantitative approach to complement the qualitative insights gained. In addition, longitudinal studies could be conducted to assess the long-term impact of these teaching methods on clinical competency.

CONCLUSION

Computer simulation in combination which video-based and kinesthetic learning proved to have a better outcome in understanding and retention as compared to the traditional didactic learning method.