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Table 2 Characteristics of the included studies: randomized controlled trials (RCTs) and cohort studies

From: Digital learning designs in physiotherapy education: a systematic review and meta-analysis

Author, year, country, study design Population Digital learning design, intervention, comparison Outcome
Arroyo-Morales et al., 2012, [30] Spain, RCT Under-graduate
Physiotherapy students second year
n = 46
Digital learning design: Blended learning
Context: Theoretical acquisition and skills training on campus
Subject/skills: Palpation and ultrasound examination of the knee joint
Duration: In-class: two 2-h sessions, traditional lectures; self-studies: 20 h
Intervention: In-class: traditional lectures; post-class: free access to the Ecofisio interactive website/app
Comparison: In-class: two 2-h sessions, traditional lectures, access to documents and books on the topic
Both groups: 3-week self-study period
MCQ: 20 MCQs (max 10 points); and assessed knowledge of ultrasound physics (5 questions), ultrasound technology (5questions), clinical applications (5 questions), and anatomy (5questions)
OSCE: Skills in palpation and ultrasound imaging of the knee; grading system: 3 = excellent, 0 = incorrect (max 15 points each)
Also measured the time taken by the student to generate a reliable ultrasound image and to localize a specific knee structure by palpation
Students’ evaluation: Quality of the educational intervention: competence of the teacher, students’ acquisition of knowledge/skills, students’ interest in participating in the study for another anatomic region and—for the experimental group—satisfaction with the Ecofisio website; also asked whether they would have preferred to be in another study group; 5-point Likert scale (5 = strongly agree, 1 = disagree)
Bartlett and Smith, 2020, [39] USA, RCT Under-graduate
Physiotherapy students
first year
n = 20
Digital learning design: Blended learning
Context: Skills training on campus
Subject/skills: Cardiovascular and pulmonary physical therapy
Duration: 45-min laboratory session
Intervention: Mobile app only group and demonstration plus mobile app group. Mobile app only group: 5-min. Tutorial on how to navigate, no professorled demonstration of instruction of the clinical skills, then practiced the skills in a lab. Sessions. Demonstration plus mobile app group given the same demonstration and verbal information as the control group, take notes and ask questions. 5-min. Tutorial on how to navigate through the iPad and then participated in a lab. Sessions
Comparison: Demonstration-only group: demonstration and practice of the skills in a laboratory session
Practical exam: Students tested on their psychomotor skills related to their ability to perform and interpret clinical skills; assessed using a mock patient not related to the study; 1 = satisfactory or 0 = unsatisfactory (max score 18); 3 examiners
Blackstock et al., 2013, [25] Australia, 2 RCTs Under-graduate
Physiotherapy
students first year
n = 349
Digital learning design: Blended learning
Context: Simulation training on campus and clinical placement Subject/skills: Cardiorespiratory
Duration: 4 weeks
Intervention 1: Simulated learning environment videos; 1 week in the simulated learning environment, then 3 weeks in clinical immersion
Intervention 2: 50% of day in the simulated learning environment and 50% in clinical immersion during the first 2 weeks (equal to 1 full-time simulation week), then 2 weeks in clinical immersion
Comparison: 4 weeks in clinical immersion
Practical exam: Assessment of competency to practice in the cardio-respiratory field, measured using two clinical examinations based on the Assessment of Physiotherapy Practice; 7 key standards; score range: 0 = infrequently/rarely demonstrates performance indicators, 4 = demonstrates most performance indicators to an excellent standard, N/A = not applicable and not assessed
Students’ evaluation: Scales for analysis of student’s self-rating of confidence with patients in communication, assessment and management; 13 Likert items; checked for reliability (Cronbach’s α)
Cantarero-Villanueva et al., 2012, [31] Spain, Single-blinded RCT Under-graduate
Physical therapy students,
n = 44
Digital learning design: Blended learning
Context: Theoretical acquisition and practical training on campus
Subject/skills: Musculoskeletal palpation and ultrasound assessment of the lumbopelvic area
Duration: 1 semester
Intervention: 6 classroom hours (traditional lectures and practical training) and 20 self-study hours plus free access to an interactive website/app (Ecofisio) on musculoskeletal palpation and ultrasound assessment
Comparisons: In-class: traditional lectures and practical training; 20 self-study hours: access to documents and books on the topic
OSCE: Ultrasound imaging, two components: musculoskeletal and skills in ultrasound imaging; grading system: 3 = excellent, 0 = incorrect; maximum score: 9 (musculoskeletal) and 15 (ultrasound imaging); validated
After OSCE: Students invited to establish 2 additional measurements in the same model; graded one at a time using the same human model
Students’ evaluation: Quality of the educational programme, 5-point Likert scale (5 = strongly agree, 1 = disagree); participant assessments included teacher’s competence, participants’ own acquisition of knowledge/skills, complexity of the knowledge/skills, possibility of participation using e-learning and (for the experimental group) satisfaction with the Ecofisio website
da Costa Vieira et al., 2017, [35] Brazil, Prospective crossover RCT Under-graduate
Physiotherapy students second to fourth year,
n = 72
Digital learning design: Blended learning
Context: Theoretical acquisition on campus
Subject/skills: Physiotherapy in oncology
Duration: 2 days and 6 modules (3 modules/day)
Intervention: Group A sequence: e-learning/traditional lectures/e-learning; had the same e-learning classroom (storage material) as Group B, 5 min given to study using the computer
Group B sequence: Traditional lectures/e-learning/traditional lectures; 5-min discussion with the teacher after the content ended; studied the slides’ content without access to professors for discussion
Same content given to Groups A and B simultaneously; after each model, students had 30 min to change to the other classroom
Written exam: 7 relevant objectives, 7 questions per module; questions had few words to minimize students’ reading time and increase the test’s reliability; 3 answer choices: true, false or do not know; 126 questions; summative evaluation at end of each module using an objective assessment with 21 questions, same answer choices
Students’ evaluation: Level of satisfaction with the different teaching methodologies and course content; open-ended questions to gather information about the course, evaluation format and suggestions/criticisms
Fernandez-Lao et al., 2016, [32] Spain, Single-blinded RCT Under-graduate
Physiotherapy students
first semester,
n = 49
Digital learning design: Blended learning
Context: Theoretical acquisition and skills training on campus
Subject/skills: Musculoskeletal assessment competencies
Duration: 6 learning lessons and 20 self-study hours
Intervention: Free access to interactive/app (Ecofisio) as supplement to traditional lectures
Comparison: In-class, traditional lectures and access to documents and books on the topic
Written exam: 20 MCQs, maximum 10 points
OSCE: Ultrasound and palpation skills assessed; grading system: 3 = excellent, 0 = incorrect; maximum scores: 15 (ultrasound) and 12 (palpation)
Students’ evaluation: Quality of the intervention; 5-point Likert scale (5 = strongly agree, 1 = strongly disagree); 11-numeric-point rating scale (10 = totally satisfied, 0 = totally unsatisfied)
Huhn et al., 2013, [40] USA, RCT DPT programme, first year,
n = 53
Digital learning design: Blended learning
Context: Theoretical acquisition and skills training on campus
Subject/skills: Pathology II
Duration: 1 semester
Intervention: Virtual patient simulation on clinical reasoning, knowledge acquisition, transfer of knowledge and students’ perception of their learning; 6 patient cases; worked individually in campus computer laboratory with the faculty facilitator available only to answer technical questions related to the function of the virtual reality program
Comparison: In-class, large group discussions; 6 patient cases
Written exam: 50 MCQs
Health Science Reasoning Test: Clinical reasoning prior to and after completing 6 patient cases in their respective group; 30-item test designed to assess induction, deduction, analysis, evaluation and inference skills; overall score and scores for 5 sub-scales
OSCE: Measure of transfer of learning; observed and scored by a faculty member using a tool developed by the faculty; students graded on professional behaviour and communication, safety, examination, evaluation and interventions using a 5-point scale
Hyland et al., 2010, [41] USA, RCT Entry-level
Physical therapy students,
third year,
n = 33
Digital learning design: Distance learning
Context: Theoretical acquisition on campus
Subject/skills: Administration and management
Duration: 1 semester, 9 days
Intervention: CAI: unlimited access to the course website (Campus Pipeline); received professor’s notes online in a lecture-style format, special examples included within the notes; also received the same PowerPoint presentation, study questions and lecture online as the control group; students could ask questions and share personal experiences via email or online discussion
Comparison: In-class: PowerPoint presentations; traditional lecture instruction, 4 h per meeting
Written exam: Pre- and post-test examination: 25 and 50 MCQs, respectively; score: percentage of questions answered correctly; final course evaluative criteria: final exam (25%), final project (20%), health and wellness assignment (20%), ethics paper (15%) and 2 case studies (10% each)
Lozano-Lozano et al., 2020 [34], Spain, Double-blinded RCT Under-graduate
Physiotherapy
Students
first and second year,
n = 110
Digital learning design: Blended learning
Context: Theoretical acquisition and skills training on campus
Subject/skills: Ultrasound imaging
Duration: In-class:4 h theoretical lessons and 4 h of practical lessons; self-studies: 2 weeks
Intervention: In-class: 4 h of theoretical lessons and 4 h of practical lessons; post-class: free access to the Ecofisio interactive website/app
Comparison: In-class: Two 2-h sessions, traditional lectures; access to books and journal papers on the topic
Both groups: 2-week self-study period
OSCE: Measured participants’ hands-on ultrasound management skills
Written exam: Evaluation of students’ theoretical knowledge; 20 MCQs; max score: 10 points
Students’ evaluation: Satisfaction survey with 5-point Likert questionnaire (1 = disagree, 5 = strongly agree); Ecofisio group also completed another satisfaction questionnaire, scores ranged from 0 = totally unsatisfied to 10 = totally satisfied
Maloney et al., 2013, [28] (pilot) Australia, RCT Under-graduate
Physiotherapy students,
third year, 2010,
n = 49
Digital learning design: Blended learning
Context: Skills training on campus
Settings: Theoretical acquisition and skills training on campus
Subject/skills: Complex clinical skills
Duration: First half of students’ third year
Intervention: 1) 30-min pre-recorded video tutorials: demonstration of the skill, text prompts, trigger and problem solving; 2) Students produced self-video of clinical performance without tutor input or guidance
Comparison: In-class: traditional teaching with live demonstration of the entire skill; pre-recorded video also shown during practical class with no replay opportunity
OSCE: Clinical performance, written patient scenario; grades out of 50 for each performance, 10 set performance criteria: completed well (full marks), partially completed (half marks) or inadequate (zero marks); grades converted to a percentage
Students’ evaluation: 10-min group-specific survey; questionnaire: perceptions of utility and satisfaction with the teaching methods, 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) and open-ended questions
Maloney et al., 2013, [28] (main) Australia, RCT Under-graduate
Physiotherapy
Students,
third year, 2009,
n = 60
Digital learning design: Blended learning
Context: Skills training on campus
Subject/skills: Clinical skills acquisition
Duration: 2 weeks
Intervention: Students created a 5-min self-produced video recording; video reviewed by remote online tutors, often with group feedback on common strengths and weaknesses observed; students reflected on their strengths and areas for improvement; students’ own video clips and the peer benchmark ‘exemplar’ video clip remained online throughout the semester
Comparison: In-class: clinical skills with regular practical tutoring
OSCE: Two clinical skill stations, formative (quantitative and qualitative) feedback to the student on their performance
Students’ evaluation: Students’ perceptions and experiences: paper-based questionnaire; 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) and open-ended questions
Moore and Smith, 2012, [42] USA, RCT DPT, Physical therapy students, first year,
n = 33
Digital learning design: Blended learning
Context: Theoretical acquisition and skills training on campus
Subject/skills: Psychomotor skills
Duration: 3 weeks
Intervention: Video podcasting (videoclips): lecture and podcast demonstrations of transfer skills; students encouraged to review assigned readings and lecture notes and to practice podcast skills; formal class meeting: 2.5 h of lecture and laboratory; students moved directly to the laboratory component of the interaction, beginning with practice and case studies, and utilized the skills depicted in the podcasts in complex patient scenarios
Comparison: In-class: live instructor demonstration of basic psychomotor skills
Written exam: Written post-test on cognitive performance
Practical exam: Psychomotor performance using a scenario-based practical post-test, graded for safety, fluency and accuracy
Students’ evaluation: Survey of the 2 learning methods and reported study time; 7 Likert statements and 5 free-response questions
Nicklen et al., 2016, [29] Australia, RCT Under-graduate
Physiotherapy students,
third year,
n = 38
Digital learning design: Blended learning
Context: Theoretical acquisition and skills training on campus
Subject/skills: Case: Rachel’s pregnancy, the role of the physiotherapist during stages of pregnancy
Duration: 1 week
Intervention: Remote-online CBL learning using the same case; web-conferencing with participants physically isolated from one another on campus; WebEx software (written text and audio-visual)
Comparison: In-class: same case used
Both groups: Attended the first session (30 min) that introduced key features of interacting via web-conference
Written exam: Post-intervention test after second computer session: learning and self-assessed perception of learning, satisfaction and participants’ demographics; 10 MCQs
Students’ evaluation: Perception of learning measured for each examinable learning objective; 3-point scale: superficial, moderate and in-depth; satisfaction with the remote-online CBL measured on a 5-point scale (1 = strongly disagree, 5 = strongly agree)
Noguera et al., 2013, [33] Spain, Crossover RCT Under-graduate
Physiotherapy students,
second year,
n = 70
Digital learning design: Blended learning
Context: Skills training on campus
Subject/skills: Practical manual therapy course in a laboratory
Duration: Two 5-h practical lessons
Intervention: Anatomy-learning app for mobile devices; Group 1: mobile device used during first practical session; Group 2: mobile device used during second practical session
Comparison: Description of different manipulative techniques and a practical demonstration performed by the professor; afterwards, students practiced their manipulation technique in pairs (one of them simulating a patient)
Written exam: Post-test immediately after each practical session to assess anatomical knowledge; first test: 8 MCQs; second test: 4 open questions and 4 MCQs; score: number of correct answers out of 8
Students’ evaluation: Questions 1–17: Likert scale (range 1–5), Questions 19 and 20: Likert scale (range 1–10), Questions 21 and 22: open questions
Rocha et al., 2017, [36] Brazil, RCT Under-graduate
Physiotherapy
Students
8th semester
n = 71
Digital learning design: Blended learning
Context: Theoretical acquisition on campus
Subject/skills: Professional Practice and Ethics in Physiotherapy discipline
Duration: Once a week for 17 weeks
Intervention: Regular classes with extra time for educational video game (quiz type); game room was available until a new room was built with new questions; four formats: the more resources students earned, the more moves they could make
Comparison: Regular in-person classes
Written exam: Specific knowledge test (final exam); 80 questions: single and multiple choice, relationships between columns and true/false
Students’ evaluation: Satisfaction with the discipline, 5-point Likert scale (1 = not at all satisfied, 5 = very satisfied); perception of learning content, 5-point Likert scale (1 = learned nothing, 5 = learned a lot)
Silva et al., 2012, [37] Brazil, RCT Under-graduate
Physiotherapy students,
fourth year,
n = 16
Digital learning design: Blended learning
Context: Theoretical acquisition on campus
Subject/skills: Respiratory therapy field
Duration: 1 semester
Intervention: Multimodal online environment including multimedia resources (videos, animations and figures) and conventional course classes attended in person; after the end of the course, 2-week access to teachers to ask questions and to the online material to study; access to online material discontinued after 2 weeks, when all students had to take a final exam
Comparison: In-class: traditional course classes on bronchial hygiene techniques; 2-week access to teachers to ask questions and to online and conventional material to study
Knowledge test: 20 questions assessing students’ knowledge of therapeutic indications (8 questions), contraindications for the use of Bronchial Hygiene Techniques (6 questions) and concepts (6 questions); each correct answer scored 0.5 points
Ulrich et al., 2019, [38] Denmark, RCT Under-graduate
Physiotherapy
Students,
3 groups:
1: n = 28
2: n = 26
3: n = 27
Digital learning design: Blended learning
Context: Theoretical acquisition and skills training on campus
Subject/skills: Learning practical skills
Duration: 1 month
Intervention: 360° video used as e-learning; after pre-test, Group 1 received lesson using 360° video (Samsung Gear VR), Group 2 received lesson using regular video (laptop)
Comparison: Group 3 received traditional in-class lesson from an instructor
Written exam: Pre-test: MCQs on the learning requirements for the treatments
Practical exam post-test: after treatment, tested on learning, practical setting: patient (volunteer) and a teacher in physiotherapy education recorded the results; graded: pass/fail for each question or task
Students’ evaluation: Questionnaire about students’ learning satisfaction and perception of the learning climate in each treatment group (given after final test)
Covill and Cook, 2019, [43] USA, Comparative cohort study DPT, Physiotherapy first year, 3 classes:
A: n = 47
B: n = 54
C: n = 47
Digital learning design: Flipped classroom
Context: Theoretical acquisition
Subject/skills: Musculoskeletal content, patient management of the lower quadrant
Duration: 81 lecture hours and 79 laboratory hours
Intervention: Classes B and C: flipped classroom (alternating lecture hours); pre-class: pre-recorded lectures, readings, non-graded quizzes and discussion questions; in-class: faculty-led large group question and case discussion, small group question and case discussion, polling software and quiz discussion;
Comparison: Class A: 18 h of traditional lectures and 31 h of laboratory work
Written exam: 10 tests total, delivered every 2 weeks; 83 MCQs across all 3 cohorts specific to the content delivered
Students’ evaluation: Classes B and C (flipped classroom) received a post-course survey specific to student perceptions of the flipped method; 5-point Likert scale
Day, 2018, [44] USA, Cohort DPT, Physical therapy first two semesters,
n = 112
Digital learning design: Flipped classroom
Context: Theoretical acquisition and skills training on campus
Subject/skills: Gross anatomy course
Duration: 15 week-long courses
Intervention: Flipped classroom; pre-class: 15-min instructor-created lecture videos prior to class (less than 60 min per week); in-class: 130 min/week, included the same activities from previous year; students also participated in a prosected cadaver laboratory 90 min per week
Comparison: Traditional in-class lectures and prosected cadaver laboratory for 90 min per week ×  15 weeks
Written exam: 120 MCQs. All final examination MCQs were divided into two levels. Lower-level MCQs (LL-MCQ) were define as “remember” and “understand” and included questions that required recall of definitions and terms. Higher-level MCQs (HL-MCQ) were defined as “apply”and “analyse.” These questions required participants to use higher-order cognitive skills to apply knowledge to new situations. No items were “create” or “evaluate,” due to the nature of the MCQ examination.
In total, 13 final examination MCQs were determined to be at a higher cognitive domain; apply or analyse. The HL-MCQs included anatomical identification on MRI images and clinical scenarios that required students to analyse the facts of the case to determine the location of an injury or possible symptoms present.
During the subsequent kinesiology course, students received 3 MCQ unit examinations that remained consistent between the two groups; traditional and flipped classroom format. Each examination was not cumulative, and no final examination was given. Student’s kinesiology grades from each of the examinations and the overall semester grade was obtained from the instructor of record.
Deprey, 2018, [45] USA, Cohort Under-graduate
Physiotherapy students, fifth year, 3 groups:
1: n = 44
2: n = 49
3: n = 50
Digital learning design: Flipped classroom
Context: Theoretical acquisition and skills training on campus
Subject/skills: Neurological disorders
Duration: 2-h time blocks, 3 days per week
Intervention 1: Fully integrated flipped; pre-class: 5 pre-recorded lectures, in-class: worked in groups to answer instructor-posed questions and complete scenarios; internet searches or open book or note reviews; focus: student questions
Intervention 2: Partially integrated flipped; pre-class: recorded lectures, in-class: reiteration of recorded lectures and discussion without special in-class work, opportunity to ask questions or clarify concepts
Both: 2-h balance test and measures lab
Comparison: Five 2-h in-class lectures, individual homework and 2-h balance test and measures lab
Written exam: Given at completion of each of the 3 units; exams 1 and 2 included the same items for all 3 years of the study; exam scores assessed for objective change in content knowledge; primary outcome: scores on the second unit exam; changes in scores from exam 1 to exam 2 were compared
Green and Whitburn, 2016, [26] Australia, Retrospective cohort Under-graduate
Physiotherapy students,
second year,
3 groups:
1: n = 150
2: n = 160
3: n = 151
Digital learning design: Blended learning
Context: Theoretical acquisition and skills training on campus
Subject/skills: Gross anatomy
Duration: 15 week-long courses
Intervention: Group 3: fully blended; pre- and in-class: online video clips, face-to-face lectures, practical classes, clinical anatomy classes, face-to-face tutorials
Comparison: Group 1: in-class, traditional lectures; Group 2: in-class lectures and some online content (video clips)
Practical and written exam: Aggregate practical test mark (expressed as a percentage to avoid differences in weighting between cohorts) and final written examination mark (expressed as percentage) between the cohorts
Students’ evaluation: Questionnaire, 5-point Likert scale (5 = strongly agree, 1 = strongly disagree), open-ended questions
Murray et al., 2014, [46] USA, Cohort Under-graduate
Physiotherapy students,
third semester,
2 groups:
1: n = 43
2: n = 35
Digital learning design: Flipped classroom
Context: Theoretical acquisition and skills training on campus
Subject/skills: Pathological conditions of the extremities
Duration: 1 semester
Intervention: Flipped classroom; pre-class: 10 to 25-min asynchronous online lectures in SAKAI (course management system), students encouraged to take notes and bring questions to class for discussion; face-to-face in-class meeting: 15 min to clarify any information that was unclear from online lectures, 20 to 30-min PowerPoint presentation integrating the online lecture content into examination sequence, 120 to 240-min group discussions of cases with emphasis on clinical decision making
Comparison: Traditional face-to-face lectures
Final exam: 105 MCQs; correct answers tallied in aggregate and by cohort based on 5 areas: [1] total exam score, [2] score on examination/evaluation questions, [3] score on intervention questions, [4] score on lower-level questions and [5] score on higher-level questions
  1. RCT Randomized controlled trial, DPT Doctor of Physical Therapy, MCQ Multiple choice question, OSCE Objective structured clinical evaluation, App Application, CAI Computer-assisted instruction, CBL Case-based learning
  2. DPT Doctor of Physical Therapy; MCQ Multiple choice question