research skills in physiotherapy

• Open access
• Published: 14 March 2013

What supports physiotherapists’ use of research in clinical practice? A qualitative study in Sweden

• Petra Dannapfel 1 ,
• Anneli Peolsson 1 &
• Per Nilsen 1  

Implementation Science volume  8 , Article number:  31 ( 2013 ) Cite this article

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Evidence-based practice has increasingly been recognized as a priority by professional physiotherapy organizations and influential researchers and clinicians in the field. Numerous studies in the past decade have documented that physiotherapists hold generally favorable attitudes to evidence-based practice and recognize the importance of using research to guide their clinical practice. Research has predominantly investigated barriers to research use. Less is known about the circumstances that actually support use of research by physiotherapists. This study explores the conditions at different system levels that physiotherapists in Sweden perceive to be supportive of their use of research in clinical practice.

Patients in Sweden do not need a referral from a physician to consult a physiotherapist and physiotherapists are entitled to choose and perform any assessment and treatment technique they find suitable for each patient. Eleven focus group interviews were conducted with 45 physiotherapists, each lasting between 90 and 110 minutes. An inductive approach was applied, using topics rather than questions to allow the participants to generate their own questions and pursue their own priorities within the framework of the aim. The data were analyzed using qualitative content analysis.

Analysis of the data yielded nine favorable conditions at three system levels supporting the participant’s use of research in clinical practice: two at the individual level (attitudes and motivation concerning research use; research-related knowledge and skills), four at the workplace level (leadership support; organizational culture; research-related resources; knowledge exchange) and three at the extra-organizational level (evidence-based practice guidelines; external meetings, networks, and conferences; academic research and education).

Conclusions

Supportive conditions for physiotherapists’ use of research exist at multiple interdependent levels, including the individual, workplace, and extra-organizational levels. Research use in physiotherapy appears to be an interactive and interpretative social process that involves a great deal of interaction with various people, including colleagues and patients.

Peer Review reports

The need for a more research-informed physiotherapy practice was recognized decades ago, yet the issue did not receive high visibility until the emergence of the evidence-based practice (EBP) movement in the 1990s. Research use is considered an important aspect of EBP, which has been defined as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ [ 1 ]. Other definitions of EBP have a wider perspective that encompasses the views of patients and clinicians’ experience-based knowledge for clinical decision-making alongside the role of research evidence. Since the late 1990s, professional organizations have identified EBP as a priority and influential researchers and clinicians have argued that physiotherapists have a moral and professional obligation to base their practice on research findings and move away from techniques based on anecdotal testimonies or opinion [ 2 – 9 ]. However, concerns have been raised about some aspects of EBP, including the usefulness of randomized controlled trials to provide clinically applicable physiotherapy evidence and the low priority afforded qualitative research in the evidence-based hierarchy of evidence [ 10 – 16 ].

Numerous studies in the past decade have documented that physiotherapists hold generally favorable attitudes to EBP and recognize the importance of using research findings to achieve a more evidence-based clinical practice [ 17 – 24 ]. However, there are many challenges and barriers to physiotherapists’ research use, including time restrictions, limited access to research studies, poor confidence in skills to identify and critically appraise research, and inadequate support from colleagues, managers and other health professionals [ 17 – 23 , 25 – 27 ]. The barriers to EBP in physiotherapy are largely similar to those pertaining to other healthcare professions [ 23 , 28 ]. There is also a paucity of research in some areas of physiotherapy, which constitutes an obstacle to practicing evidence-based physiotherapy [ 4 , 13 ].

Despite the fact that research in several fields has identified barriers to research use at different system levels, from the individual to the organization, interventions to achieve a more EBP have predominantly targeted individual healthcare professionals to influence their attitudes, beliefs, knowledge, and skills as a means of changing clinical practice [ 28 , 29 ]. It has been argued that implementation research has ‘failed to fully recognize or adequately address the influence and importance of healthcare organizational factors’ [ 2 , 30 ]. However, the importance of contextual conditions for use of research in healthcare has increasingly been recognized [ 31 – 36 ].

This study addresses important knowledge gaps concerning the use of research to guide physiotherapy practice. While barriers to research use are fairly well established in previous research, it is not self-evident that the removal or reduction of these barriers results in increased use of research in clinical practice. Hence, it is important to investigate the circumstances that physiotherapists have found to actually support their use of research findings in routine practice. Using focus group interviews, the aim of this study was to explore the conditions at different system levels that physiotherapists in Sweden perceive to be supportive for their research use in clinical practice.

Study setting

This study took place in Sweden. Healthcare in Sweden is publicly funded, i.e. , residents are insured by the state, with equal access for the entire population and fees regulated by law. The provision of healthcare services is the responsibility of the 21 county councils in Sweden [ 37 ]. There are approximately 21,000 authorized physiotherapists in Sweden [ 38 ]. They are employed by county councils (public sector), occupational healthcare organizations (private or public sector), or work in private organizations, as employers or employees (private sector).

Patients in Sweden do not need a referral from a physician to consult a physiotherapist and are free to choose a physiotherapist from the private or public sector. Physiotherapists in Sweden have a great deal of autonomy. They are entitled to choose and perform any physiotherapeutic treatment technique they find suitable for the individual patient.

Study design and participants

A qualitative approach with focus group interviews was used to investigate Swedish physiotherapists’ perceptions of conditions that support research use in clinical practice. The aim of focus groups is to explore experiences, attitudes, and ideas concerning a specific set of issues in a given cultural context [ 39 ]. The group dynamic of focus groups can facilitate the participants’ discussions and reflections as they listen to one another’s opinions, potentially generating new insights, ideas, experiences, or perspectives about the topic that might not arise in individual interviews.

Eleven focus group interviews were conducted from March to June 2011 involving 45 physiotherapists from five county councils in Sweden. Participants for the focus groups were recruited through managers and other key people in different clinical settings in Sweden via an e-mail in which the study was briefly described. The request was sent to 50 hospitals, primary care units, and private physiotherapy clinics. All who answered positively were asked to invite physiotherapists in their department, unit, or clinic to participate in the study. They were encouraged to invite whole teams of physiotherapists to avoid bias due to selection of specific physiotherapists. Each focus group consisted of physiotherapists from the same workplace, but they did not necessarily work as part of the same team although they shared the same management. The focus groups included physiotherapists of different seniority, educational degrees, and age. In order to encourage free responses, none of the managers of those participating in the focus groups were present.

A purposeful selection approach was used to achieve a heterogeneous sample of physiotherapist groups, which represented a broad spectrum of experiences and contexts to strengthen the validity of the study [ 40 ]. Variety was sought according to clinical setting, geographic location, the number of years of practice, and educational levels (Table  1 ). The study was approved by the regional ethical review board at Linköping University, Sweden.

Data collection

An inductive approach was applied in the study, using topics rather than questions to allow the participants to generate their own questions and pursue their own priorities within the framework of the aim. The topics were developed by the authors of the study and were scrutinized in a seminar with ten physiotherapists, most of whom combined research with physiotherapy practice. In addition, four physiotherapists who took part in the seminar participated in a pilot focus group before the interviews were carried out; this pilot interview was not included in the study due to the participants’ experience of conducting their own research.

Each focus group interview began with an open question asking the physiotherapists to describe their work and workplace. The interview then focused on four topics: perception and experience of research use; organizational routines and/or structures supportive to research use; organizational conditions that support, enable, or facilitate research use; and collaboration with organizations conducting research.

The focus group interviews were conducted during regular working hours to facilitate participation. Each focus group interview lasted between 90 and 110 minutes. Before the start of the interview, the participants filled in a questionnaire with a few background questions (Table  1 ).

The participants were informed of the confidentiality of their contribution, that participation was voluntary, and that they could withdraw at any time during the interview. Two moderators attended all focus groups except for one interview. The first author of this study led the interviews and asked follow-up questions. The second moderator took field notes and made observations. The information recorded by the second moderator was used to discuss interpretations of the interview with the interviewer if there were discrepancies or lack of understanding of what was said. In general, discussions in the groups were fluent and little steering from the moderator was needed. The open climate encouraged everyone to express their opinions.

Data analysis

Interviews were recorded on tape and later transcribed verbatim by the first author. The data were analyzed using qualitative content analysis in accordance with Krippendorff [ 41 ]. Content analysis is a technique for analyzing texts based on empirical data with an explorative and descriptive character, and entails a structured analysis process to code and categorize the data [ 41 ].

The focus group interviews were analyzed in several steps. Each author read all the transcripts to obtain an understanding of the whole. The first author reviewed the transcripts and indentified coding units in the text that captured various key statements and thoughts in relation to the study aim. All the researchers scrutinized the coding units and reviewed the text several times. During this process, the coding units were merged into context units by the three authors. The context units included several coding units and reflected more than one key statement or thought. The context units were combined into categories based on similarity of the content by the three authors. These categories were based on conditions that the focus group participants mentioned as being supportive to research use. The categories were merged into three overarching system levels based on their characteristics by the three authors.

During the process, all authors discussed the content of the categories using triangulating analysis, i.e. , the authors independently analyzed the same data and compared their findings. The discussions continued until no inconsistencies existed and a shared understanding was reached to prevent researcher bias and strengthen the internal validity [ 40 ]. Quotations were identified to report the findings and illustrate the content, and were translated from Swedish to English.

Research use was interpreted in the analysis in accordance with well-established definitions. We accounted for both instrumental research use (changes in the physiotherapists’ practice based on research findings), and conceptual research use (changes in their understanding, knowledge, and attitudes), which reflects changes in thinking rather than actual behaviour [ 42 ].

Analysis of the data yielded nine categories that the participants discussed in relation to conditions that have supported or facilitated research use in their clinical practice. These categories corresponded with three overarching system levels (Table  2 ).

Individual level

Attitudes and motivation concerning research use.

The physiotherapists believed that having positive attitudes to research and a strong motivation to use research in clinical practice provided favorable conditions for research use. However, they noted that interest in research varied among their colleagues:

‘Some are really into this [reading research], while others start at eight and go home at five, do what they have always done, and then they retire or go on parental leave. The interest varies a lot. I guess that’s how it is everywhere else too’ (physiotherapist 2, unit 8).

Attitudes and motivation were premised on several factors, including having previous experience with research in one way or another, participation in basic and continuing education and training that involved research issues, as well as being generally curious and keen to learn more to develop as a physiotherapist:

‘I think we are so interested in further training that we do not see it as an obligation. It is more of an opportunity’ (physiotherapist 2, unit 11).

‘We want to treat our patients in the same way. They should get the same tests and treatment regardless of whether they consult with me or anyone else. It [using research] is a kind of quality assurance’ (physiotherapist 3, unit 9).

Research-related knowledge and skills

The physiotherapists mentioned that various research-related knowledge and skills were helpful to apply research in clinical practice. One of these competencies was critical or analytical thinking, which they believed facilitated critical appraisal of research studies to determine, for instance, the strength of evidence and whether findings or an approach could be feasible in routine practice:

‘We have made a folder where we have critically appraised all the instruments we use for measuring. Are they really evidence-based? We have also examined if there might be other options, so we are trying to ascertain what is best’ (physiotherapist 1, unit 11).

Several physiotherapists believed qualitative studies are important to obtain a better understanding of many issues, although they regarded physiotherapy research as predominantly quantitative:

‘Qualitative studies may not have the same status, but the ‘soft side’ and other dimensions are starting to be recognized. Also mixed-method studies are emerging. I think this is a positive development’ (physiotherapist 3, unit 6).

Workplace level

Leadership support.

The physiotherapists made it clear that individual managers and leaders played an important role in enabling research use. Many underscored the importance of active encouragement, although the extent to which managers supported research use appeared to vary a great deal:

‘We have had several managers during the years and you notice that they emphasize the importance [of research] differently. Our immediate manager is a paramedic, then there is the manager of the clinic and there are also other people who put pressure on us [to use research results]’ (physiotherapist 1, unit 1).

Some physiotherapists mentioned that their clinics had set goals of improved competence levels for all employees, which contributed to increased research use:

‘It’s not only about the individual; it is about the development of the clinic. If you have been very clinically focused [on patients] for some time, the manager might ask for more efforts that contribute to the development of the whole clinic. It has happened that I have been given the responsibility to investigate or implement new knowledge’ (physiotherapist 1, unit 8).

‘In an ideal world, my ambitions for personal development go hand in hand with the organization’s interest. But it’s the manager’s task to view things in the organization’s best interest, to ensure that there is sufficient breadth of competence in the clinic’ (physiotherapist 2, unit 8).

As well as informal encouragement or support, the physiotherapists also pointed to the importance of formal and explicit management decisions on the desirability of using research in clinical practice. Expectations and strategies concerning research use and a more EBP must be communicated and made clear, according to the physiotherapists:

‘It is absolutely necessary to have the management on your side to get weight behind decisions. Especially since we physiotherapists are often strong-willed individuals, sometimes with disparate ambitions. There has to be a strong leadership behind decisions and the decisions have to be sound’ (physiotherapist 1, unit 8).

Organizational culture

The physiotherapists believed that an organizational culture that supports learning and competence in development activities provides favorable circumstances for research use. Although managers’ attitudes and decisions influenced this culture, the physiotherapists also suggested that culture was an independent factor:

‘It’s ingrained, it’s tacit, it’s integrated in the way you work and think in the clinic. It’s about the communication and dialogue, is there space for that kind of discussion and reflection in the clinic?’ (physiotherapist 6, unit 2).

‘It’s important that you work in an environment where you can learn and develop’ (physiotherapist 3, unit 1).

‘We all have different competencies; there is competence breadth. Then there are some who have very narrowly focused competence. But in a positive climate, there are opportunities to learn from those who are very skilled’ (physiotherapist 3, unit 11).

The physiotherapists mentioned that there are higher expectations and demands on them to conduct their own research at a university hospital. They believed this creates a culture in which research is an integral element. Proximity to research competence and participation in ongoing research studies were also mentioned as factors that promote research use for physiotherapists at a university hospital, where research tends to be more integrated in daily practice:

‘I believe it might be different at a university hospital [where] it is more of a tradition and is expected of all professions [to use research]. It’s ingrained in the organization and a way of thinking. You’re closer to ongoing research; patients at a university hospital may be involved in different studies. I believe the use of research is determined by the scope for scientific dialogue’ (physiotherapist 5, unit 2).

Research-related resources

The physiotherapists mentioned several types of resources that facilitated research use. An obvious enabler was access to research, including databases that contain research articles. Most physiotherapists had access to such databases. However, they often did not have access to full texts, typically having to rely on abstracts or summaries. This was sometimes solved if a colleague was studying at a university where full-text articles were accessible. Most clinics where the study participants worked subscribed to a physiotherapy journal, usually of a more popular-science nature:

‘ Fysio [a physiotherapy journal that presents research in a user-friendly format] is not more than 10 pages per issue and it usually includes something about current research, what it [research] says, and everything is summarized, and it’s in Swedish. Then you can go on and dig deeper. It’s very good to have [the journal] here at the clinic’ (physiotherapist 4, unit 3).

Financial and personnel resources also played an important part in giving the physiotherapists opportunities to participate in research-informed courses and conferences and conduct research and development projects:

‘We can apply for funding for [research and development] projects from the County Council. As a first step, you can get funding for two weeks during which you are free to just work with your project idea’ (physiotherapist 4, unit 6).

Financial issues were also deemed important for obtaining any technology that might be required for new research-based treatment approaches:

‘There are costs involved that make it impossible to incorporate new technology that has been found to be effective in research. For example, shockwave is a new thing that has been shown to be effective in research studies, but it’s too expensive so I don’t think we will get it here’ (physiotherapist 3, unit 10).

The physiotherapists also identified time as an important resource that affected their ability to apply research findings in clinical practice. Developing a more EBP approach requires time to identify and appraise research, reflect on its applicability, and apply it in clinical practice:

‘Clinical practice changes take time and energy; it is not possible to just snap your fingers and the change happens. Time and energy and repetition of the change messages are things I believe are necessary to achieve changes in the direction of increased use of research in clinical practice’ (physiotherapist 3, unit 8).

The physiotherapists recognized an obvious conflict between time for production and time for activities that involved learning associated with a more evidence-based physiotherapy practice: ‘In the same breadth that they say that you should take the time to reflect, they mention that you need to see seven patients each day’ (physiotherapist 3, unit 10).

They believed it was necessary to set aside time for individual or group reflection and learning related to EBP: ‘We have regular meetings within the organization, so there are learning opportunities’ (physiotherapist 4, unit 8).

Knowledge exchange

The physiotherapists described several forms of knowledge exchange that they believed supported their research use. The discussions that take place with colleagues in the clinic could be both informal, such as everyday conversations about the merits of a specific treatment approach, and more formal with specific meetings devoted to reflection on research studies and new findings and knowledge to facilitate competence development:

‘If someone has participated in a course, they share what they have learned in the course with their colleagues. We allocate one or two hours to that sort of knowledge sharing’ (physiotherapist 4, unit 6).

The physiotherapists reported that their colleagues are the first people they turn to when they need more knowledge or a second opinion about a certain treatment method or to obtain support for testing a new approach. More experienced colleagues are often trusted to have more knowledge about certain patient problems:

‘We cannot continue to treat patients with ineffective methods. If you’re unsure, you ask for a second opinion. We also discuss patients with more complex problems and learn from that. That’s a way to acquire knowledge and implement it’ (physiotherapist 1, unit 11).

The ability to work or collaborate with one or more colleagues with a PhD degree or previous research experience was identified as an important facilitator for research use by some of the physiotherapists. Physiotherapists with a PhD could share information and knowledge about new research and thus provide a resource for colleagues with questions and need for guidance:

‘They [physiotherapists with a PhD degree] are very good to discuss and reflect with. They provide inspiration because they have also been like us, ‘ordinary’ physiotherapists. If you have them [physiotherapists with a PhD degree] in the clinic the ‘distance’ to research doesn’t feel so great’ (physiotherapist 2, unit 6).

Knowledge exchange with clinicians from other professions was also mentioned as an enabling factor for research use. Many of the physiotherapists collaborated with occupational therapists and some worked in multi-professional teams that included nurses and physicians. The physiotherapists believed that this sort of informal inter-professional knowledge exchange contributed to their overall competence development and research use in clinical practice. Mutual trust and respect for one another’s contribution and expertise were critical elements of collaboration that facilitated research use:

‘Implementing something new, as suggested by physiotherapists, depends on how complicated it is to implement it and if they [physicians] believe it’s a good thing. You have to have them ‘on board,’ on your side’ (physiotherapist 2, unit 11).

Knowledge exchange also occurred with patients who might have complex problems or are inquisitive. The physiotherapists noted that today’s patients are generally well-informed about their problems. Many patients have already investigated and done Internet searches so they come prepared for the meeting with the physiotherapist. This was generally found to be motivational and encouraged physiotherapists to keep up with new research findings. Meeting patients with unusual problems also provided a learning opportunity that was supportive of future research use:

‘For the first time, I had a patient suffering from a rare disease. If you know little about what it is you have to do, a lot of reading and learning is necessary to understand the disease and the prognosis. We had a lot of questions and so did he [the patient]. He asked if he was going to get better. To answer that I had to check the statistics of his prognosis. The patient learned a lot from this and I as a physiotherapist did, too’ (physiotherapist 1, unit 7).

Extra-organizational level

Ebp guidelines.

The physiotherapists acknowledged that they are expected to adhere to the latest research-based evidence as a basis for best practice. However, they also recognized that the sheer volume of physiotherapy research in the last decade has made it virtually impossible to keep abreast of all new findings. Evidence-based guidelines to assist decisions about appropriate treatment are helpful for research use:

‘National guidelines for stroke and rehabilitation are a way to secure [EBP]. They have done an awful lot of groundwork concerning what is evidence-based and what the recommendations should be. We are encouraged by our manager to form small groups to examine care in terms of stroke and ensure that we work according to the evidence’ (physiotherapist 1, unit 7).

The physiotherapists made frequent use of the Internet to search for research and check on the guidelines published by the National Board of Health and Welfare (a government department in Sweden under the Ministry of Health and Social Affairs that is responsible for publishing healthcare and social welfare guidelines). They expressed that they wanted to strive towards a more uniform approach to treating their patients although each patient is unique. Guidelines seemed to provide a benchmark from which to start when considering different treatment options:

‘Guidelines make it possible to save time, to go ahead and start treating patients quicker, because it takes time to understand a diagnosis. Guidelines save energy and make work simpler and more effective’ (physiotherapist 6, unit 9).

Involvement in external meetings, networks, and conferences

Most of the physiotherapists attended external meetings and/or took part in networks and regional/national conferences at which research is an important topic. They considered this exchange of knowledge and experience with other physiotherapists to be very important for their competence development and commitment to using research in daily clinical practice. Specifically, regularly taking part in conferences was seen as critically important to learn about the latest research developments and findings:

‘Different conferences typically focus on specific topics and have speakers from all over the world talking about the current status concerning that particular research topic; they really explore certain topics at these conferences’ (physiotherapist 4, unit 5).

Some of the physiotherapists had participated in conferences where they presented research and development projects or patient cases.

Informal visits to other clinics were also mentioned as opportunities to learn more and exchange knowledge on research matters with colleagues. Network participation could fulfil similar positive learning and research objectives as conferences:

‘The other week we had a network meeting with physiotherapists from the same region to exchange thoughts. Many things were discussed at these meetings. We feel that we are on the same track’ (physiotherapist 2, unit 9).

These networks could be both formal professional networks and more informal self-established networks comprised of physiotherapists in different clinics from the same region. Some physiotherapists complained that time for engagement in more formal network activities was often limited:

‘Some of the networks are more formal but you often use your personal network if you have are uncertain about how best to treat a patient’ (physiotherapist 2, unit 3).

Involvement in academic research and education

Several physiotherapists collaborated with researchers and teachers from nearby universities. Some of the physiotherapists were also engaged in teaching activities and participated in developing curricula for physiotherapy courses. They believed this sort of interaction and involvement contributed positively to their interest in keeping up to date on research and using research as part of their daily practice:

‘Several of us participate in the physiotherapist program, giving lectures and training the students in more hands-on skills. We have also been involved in the examination of students and discussed how the students should be appraised’ (physiotherapist 3, unit 2).

Some of the physiotherapists had participated in research projects led by university researchers and/or taken part in various local research and development projects. Most of the physiotherapists had experience with physiotherapy graduates doing studies and writing their theses at their clinics:

‘I am involved in a research project conducted at the department of physiotherapy at the university, where they are performing an international neck study. I’m working for six weeks with patients who have had neck surgery’ (physiotherapist 3, unit 8).

Nine favorable conditions at three system levels were identified: two conditions at the individual level, four at the workplace level, and three at the extra-organizational level. Conditions at the three levels appear to interact to influence the physiotherapists’ use of research. Hence, physiotherapists are involved in constructing their context, but are in turn influenced by the context, for example, the interpersonal relationships and organizational culture in which they are embedded [ 43 ]. Understanding the process of research use in healthcare requires an interdependent, multi-level system perspective, which is echoed in many frameworks and models of implementation, including the Promoting Action on Research Implementation in Health Services (PARIHS) model [ 32 , 33 , 35 ], the Iowa Model of Evidence-Based Practice [ 31 ], the Knowledge-to-Action Framework [ 34 ] and the Consolidated Framework for Implementation Research [ 36 ].

We found that positive attitudes and motivation to use research, as well as research-related knowledge and skills, provided important individual-level conditions that were perceived as supportive to research use. These factors are likely interdependent, such that research-related knowledge and skills affect attitudes and motivation to use research and vice versa. Attitudes to research have emerged as the single most important factor shaping the use of research among nurses [ 28 ]. Findings on determinants for allied health practitioners’ use of research are less consistent; only six studies of relatively weak quality were included in a recent systematic review [ 44 ]. Although research has shown that physiotherapists in general are positive to a more EBP, converting these attitudes into changed practice has met with considerable difficulty. The physiotherapists in our study recognized that changing clinical practice is a process that takes time. Several studies have documented that many physiotherapists continue to base practice decisions on knowledge obtained during their initial education and/or personal experience, rather than findings from research [ 24 , 45 – 48 ]. It has been shown that physiotherapists use treatment techniques with strong or moderate evidence of effectiveness alongside approaches for which evidence is limited or absent [ 24 , 45 , 46 , 48 – 50 ].

The fact that we identified many conditions at the workplace and extra-organizational levels clearly points to the importance of accounting for this influence on the use of research by individual physiotherapists. However, interventions to achieve increased research use in various fields have predominantly targeted individual clinicians [ 28 , 29 , 51 ]. It is ultimately the individual healthcare professionals who decide whether or not to use research in their practice, which may provide an explanation for the individualized view of research use processes and why many interventions are directed at individuals. However, although research has increasingly recognized the relevance of the workplace or organizational level to research use, Nutley et al. [ 51 ] believe that knowledge is still lacking on how research might be used at the organizational level and what types of interventions might facilitate increased organizational use of research.

At the workplace level, we identified leadership support, organizational culture, research-related resources, and knowledge exchange as four important conditions that supported the use of research by the physiotherapists, underscoring the significance of achieving an environment that is conducive to the translation of research into practice. Similar to the factors at the individual level, the factors at the organizational level must be considered highly interdependent. For example, a favorable organizational culture is strongly associated with effective leadership in organizations [ 52 – 54 ]. The organizational culture influences how successful leaders are at implementing changes [ 55 , 56 ]. The culture is also related to opportunities for knowledge sharing, learning, reflection, and competence development activities in organizations [ 57 ]. Learning, in turn, depends on the availability of some research-related resources, such as time and financial and personnel resources.

The physiotherapists in our study emphasized the importance of formal and informal leadership support for research use. They believed that, to a large extent, research use is a management responsibility, which is consistent with earlier research in various healthcare fields that has shown that healthcare professionals often consider research use to be as much an organizational as an individual responsibility [ 33 , 58 , 59 ]. Previous physiotherapy research has identified inadequate support from managers as a barrier to research use [ 19 , 21 , 22 , 60 ]. Nilsagård and Lohse [ 22 ] have proposed that the level of EBP skills (including the ability to find and read research studies, critically appraise evidence, and integrate new findings into their practice) should be considered when recruiting future managers to ensure progression towards more evidence-based physiotherapy. Stevenson et al. [ 19 ] argue that EBP-skilled opinion leaders, who are not necessarily managers, can be an important influence on other physiotherapists’ commitment to using research. Research in various fields, including healthcare, has shown that opinion leaders— i.e. , individuals with specific influence on the attitudes, beliefs, and actions of their colleagues—can indeed be an important strategy to improve the use of research, although opinion leader support alone may not be sufficient to effect practice changes [ 51 ].

The physiotherapists believed that an organizational culture that provides opportunities for learning, reflection, and competence development activities facilitated research use. Achieving EBP is reliant on clinicians who acquire EBP skills, that is, the new skills required of today’s physiotherapists (and other healthcare professionals), emphasizing the importance of learning to develop a more EBP. A learning-oriented culture has often been highlighted as a prerequisite for achieving a more EBP in various healthcare fields [ 61 , 62 ]. Similar to our findings, Barnard and Wiles [ 17 ] observed that physiotherapists working in university hospitals felt they were part of a research-oriented culture although this was dependent on support from leaders for implementing change and research use. Culture and context are recognized in many of the frameworks and models used in implementation research [ 63 ] and in theories concerning concepts such as organizational readiness for change [ 64 ] and implementation climate [ 65 ]. There is an emerging recognition that findings from organizational and management research can inform implementation research to improve understanding of how the gap between healthcare research and practice can be narrowed [ 66 – 68 ].

Resources such as having access to research studies and sufficient financial and personnel resources and time were identified as important conditions for using research in clinical practice. These factors correspond well with previously identified barriers to physiotherapy research [ 17 – 22 , 26 , 27 ]. Lack of sufficient time has almost unanimously been reported as a major hindrance to a more EBP across different healthcare professions. The physiotherapists in our study believed that dedicated time to discuss research was needed. Various solutions have been proposed in the literature, but there appears to be consensus that time must be set aside to provide a formal, scheduled opportunity to meet and discuss relevant research-related matters and that meetings should focus on reflection on research findings and clinical guidelines rather than discussions based on experiential or anecdotal knowledge not linked to research [ 6 , 21 , 69 ]. However, Heiwe et al. [ 24 ] have argued that more research is needed into various aspects of the lack of time concept before it is possible to reduce the impact of this factor on implementation of EBP. Limited time is certainly not unique to physiotherapy or healthcare in general, as there is a difficult trade-off between short-term production requirements and longer-term ambitions for learning and development in many work contexts [ 70 ].

The physiotherapists in our study stated that knowledge exchange with their physiotherapist peers and colleagues from other healthcare professions supported research use. The importance of peer learning in physiotherapy has been highlighted in previous research on physiotherapists [ 21 ] and the lack of peer support and perceived isolation from colleagues have been noted as obstacles to the use of research [ 21 , 22 , 71 ]. Physiotherapists typically face difficulties when choosing the optimal treatment taking into account the limited evidence base for many of the options, underscoring that peers and colleagues are very important for physiotherapists’ informal learning and their use of research to guide their practice. Knowledge exchange with patients was also found to be conducive to the physiotherapists’ use of research. Patients have been identified in previous research as a key source of knowledge for physiotherapists [ 26 , 72 ]. Physiotherapists listen to the patients’ stories and attempt to understand the context of their life in determining treatment and they collaborate with patients to support regained function and enhance quality of life. Obviously, the holistic nature of much physiotherapy practice does not fit comfortably with the biomedical model of medicine, something that has contributed to considerable debate in the physiotherapy field. Herbert et al. [ 4 ] succinctly summed up this discussion on physiotherapy when they titled an editorial ‘Evidence-based practice—imperfect but necessary.’

With regard to the extra-organizational level, we identified three conditions that the physiotherapists considered to be supportive of research use: evidence-based guidelines, participation in external meetings, networks, and conferences, as well as involvement in academic research and education. The system level can be seen as an outer context ( i.e. , factors external to the organization that are related to the wider social, economic, and political context within which organizations reside) that might influence research use via its impact on the workplace and its groups and individuals.

Evidence-based guidelines were seen as supportive to the physiotherapists’ use of research. Clinical practice guidelines are ‘systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances’ [ 73 ], a definition adopted by the European Region of the World Confederation for Physical Therapy [ 74 ]. By making research findings available to healthcare professionals in a user-friendly format, guidelines are aimed at facilitating EBP. Although physiotherapy has followed the example of other healthcare fields and is producing many guidelines, it lags behind the medical profession in evaluating adherence to and effects of guidelines as well as the effectiveness of various strategies intended to increase their use [ 75 , 76 ].

The physiotherapists believed that various external forums meetings, networks, and conferences were important for research use, which is congruent with research in other fields that has indicated the importance of both formal and informal networks [ 77 ]. Recent research has pointed to the critical importance of to healthcare professionals of social networks for the adoption of new practices in healthcare [ 78 , 79 ]. Parchman et al. [ 80 ] argued that efforts to understand the research–practice gap have been hindered by a lack of recognition of the social networks within which healthcare professionals are embedded. Networks have increasingly emerged as a strategy by governments to facilitate the transfer of more research into clinical practice in healthcare [ 66 ].

Involvement in academic research and education was conducive to the physiotherapists’ use of research. Clinical practice and research were interconnected through interaction with colleagues with research experience and with external academic institutions. Our findings lend credence to strategies that have been proposed in various studies, including increased involvement by physiotherapists in research and joint initiatives between academia and healthcare professionals such that students are developing research competence and physiotherapists provide a working laboratory for inquiry [ 3 , 69 , 81 , 82 ]. Strategies aimed at strengthening the link between researchers and healthcare professionals as a means to encourage use of research have shown promise in promoting both conceptual and instrumental research use [ 51 ]. However, more research is needed to explore how physiotherapists can take part in the research cycle, from planning and conducting studies to the publication, dissemination and implementation of findings.

Several of our results—including the relevance of knowledge exchange with colleagues and patients, interaction with academic institutions, and participation in different external forums—indicate that physiotherapists learn about research through diverse routes. Personal contacts have been found to be an importance source of information about research for professionals in many fields [ 83 , 84 ], and it has been shown that interaction and dialogue can significantly increase the chances that research will be used in various settings [ 77 , 85 , 86 ].

Our findings suggest that research use in physiotherapy is rarely a simple process of transferring findings from research to practice. It is a complex and dynamic social process that involves a great deal of interaction and knowledge exchange with various people, both internal and external to the workplace. The challenge, according to Greenhalgh et al. [ 87 ]: [426], is to ‘expose the tensions, map the diversity and communicate the complexity’ to understand the process of using research. The view of research use as an interactive and interpretative social process, rather than as a result of straightforward adoption of research findings, implies that research use is associated with a degree of adaptation of the research itself. This raises the question of whether this process undermines the effectiveness demonstrated by the original research and the extent to which physiotherapy practice can be described as evidence-based. This is an important issue that warrants further investigation.

This study has some shortcomings that must be considered when interpreting the findings. The study was conducted in Sweden and the transferability of the findings beyond the context of the Swedish healthcare system might be limited. Swedish physiotherapists are highly autonomous because they do not depend on referrals from physicians or other healthcare providers, and they can use any physiotherapeutic treatment technique they find suitable. Furthermore, the focus groups may not have been fully representative of all types of physiotherapists in Sweden despite the fact that a heterogeneous purposeful sample was sought.

Research use was not defined by the researcher in the interview situations because the aim was to explore the physiotherapists’ viewpoint of research use. Hence, the physiotherapists had the interpretive prerogative on the meaning of research use because we relied on their subjective interpretation and understanding of research use. They discussed small and large changes due to research, from changes in their understanding and perspectives of issues in physiotherapy to more visible changes in their actual practice, that is, both conceptual and instrumental research use [ 42 ].

We identified nine factors at three interdependent system levels that physiotherapists in Sweden perceived to support their use of research, the individual, workplace, and extra-organizational levels. Research use in physiotherapy appears to be an interactive and interpretative social process that involves considerable interaction with various people, both internal and external to the workplace. The extent to which this process leads to adaptation of the research and affects the effectiveness established in research studies remains unclear.

In terms of clinical implications, this study proposes that interventions to achieve more EBP in physiotherapy through increased use of research in clinical practice must account for a complex interplay between interdependent factors at different system levels. Interventions directed at individual physiotherapists’ skills, knowledge, attitudes, and motivation concerning research use must be considered in a wider context of influences on clinical behaviour. Individually-oriented initiatives for increased research use should be supported by facilitating organizational structures and processes as there is a dynamic interplay between the individual and workplace levels.

Authors’ information

Petra Dannapfel, PhD student, Division of Community Medicine, Department of Medicine and Health, Linköping University, SE-581 83 Linköping, Sweden

Anneli Peolsson, Associate professor, Division of Physiotherapy, Department of Medicine and Health, Linköping University, SE-581 83 Linköping, Sweden

Per Nilsen, Associate professor, Division of Healthcare Analysis, Department of Medicine and Health, Linköping University, SE-581 83 Linköping, Sweden

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Dannapfel, P., Peolsson, A. & Nilsen, P. What supports physiotherapists’ use of research in clinical practice? A qualitative study in Sweden. Implementation Sci 8 , 31 (2013). https://doi.org/10.1186/1748-5908-8-31

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Research-based education in undergraduate occupational therapy and physiotherapy education programmes: a scoping review

• Kjersti Velde Helgøy 1 ,
• Tore Bonsaksen 2 , 3 &
• Kari Røykenes 4  

BMC Medical Education volume  22 , Article number:  358 ( 2022 ) Cite this article

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In a research-based learning environment, students learn how to become critical thinkers and lifelong learners, and to generate discipline-enriching knowledge. Research training is important for all healthcare professionals and the integration of research in education can be one approach to improve evidence-based practice among future professionals. The purpose of this scoping review was to identify studies reporting on research-based education in undergraduate occupational therapy and physiotherapy curricula to document the current state of knowledge and to map factors that reflect and support the implementation of research-based education in undergraduate occupational therapy and physiotherapy programmes.

A scoping review was used to systematically select and summarize existing literature. The search was conducted using a combination of keywords and MeSH terms in the following databases: EBSCO (Academic Search Elite, CINAHL, ERIC), MEDLINE, Embase, Education Source and grey literature. A thematic analysis identified strategies used to implement and promote research-based education in occupational therapy and physiotherapy bachelor programmes.

The database search identified 3068 records. 75 were eligible for full-text assessment and 27 studies were included. The studies were published between 1999 and 2021 and were conducted in Norway, Canada, South Africa, Australia, the United Kingdom, the United States, New Zealand, Ireland, Taiwan, Italy, and Iran. The study designs were mainly quantitative and qualitative, and studies included primarily occupational therapy and physiotherapy students. We identified the following four strategies: ‘student engagement in research’, ‘curriculum improvement regarding EBP’, ‘EBP teaching’ and ‘journal club’, where ‘EBP teaching’ was most frequently identified.

Conclusions

Findings from this scoping review suggest that ensuring students’ competence in research methods is necessary for students to be able to read and understand research articles, which are important as foundational skills in undergraduate research training. Journal clubs can be a foundation for student engagement with research literature, and students’ basic research skills may be facilitated through their involvement in research projects and by conducting systematic reviews. Further, cooperation with clinical practice is important, and the awareness of research-based education should be increased among both faculty members and students.

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In a research-based learning environment, students learn about research processes by developing research skills, such as the ability to critically analyse and reflect [ 1 ]. Research skills are necessary for future professionals, as previous studies have indicated that implementing clinical guidelines and research evidence into routine daily practice is challenging [ 2 , 3 ]. Based on the Sicily statement on evidence-based practice (EBP), all healthcare professionals need to adopt a critical stance towards their own practice and the underlying evidence [ 4 ]. Without such a critical stance, professionals will be unable to provide ‘best practice’. Professional education is believed to play an important role in the development of positive attitudes towards EBP skills [ 5 , 6 ]. One approach to improving EBP uptake in clinical practice is through the integration of research in education [ 7 , 8 ].

The link between research and teaching in higher education has been explored in several studies [ 1 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. One strategy for linking research and teaching is to bring research into the classroom, e.g., through academics presenting their research relevant to the subject and discussing research outcomes and methods with students [ 1 ]. Different models of research-based education currently exist, and in this study we have used Huet’s model [ 1 ]. We included this model to guide our study since it is more recent and represents a further development of previous models within research-based education. This model uses the terms research-based teaching and research-led teaching. Research-based teaching occurs when students are engaged in research or research-related tasks, while research-led teaching occurs when teachers use their competence as researchers, or use research conducted by others, to inform teaching. In this model these terms are connected, and research and teaching are described as two integrated parts.

Previous studies have described strategies to support faculty in integrating research and inquiry in the curriculum [ 20 , 21 ]. Engaging students in research and inquiry from the beginning of their first study year has been recommended [ 20 ]; moreover ensuring coherence in curriculum planning as well as systematic thinking regarding how students can obtain skills to engage in research — whether that is reading research articles, taking part in research methods courses or participate in research projects — seems important [ 21 ]. Huet [ 1 ] has suggested four actions regarding the implementation of research-based education in the curriculum. First, clear guidelines for embracing a research-based education model are needed. Second, the time needed to conceptualize, plan and deliver research-based and research-led teaching approaches must be considered. Third, research and teaching should be considered as two integrated activities. Fourth, pedagogic support needs to be provided to develop learning and teaching strategies that are sustained in research-led or research-based approaches in the early stages of the programme. Based on these recommendations, it seems beneficial to embrace a research-based education model in the education programme, and to integrate this way of linking research and teaching in the organization of that programme [ 1 ].

Research-based undergraduate education has received increased attention in countries such as the United States, the United Kingdom, Australia and Sweden [ 22 ]. In Norway, it is required that higher education is research-based [ 21 ]. According to the relevant legislation, education must be on the cutting edge in terms of research and development work [ 21 ]. Accreditation of health profession education programmes also has relevance for discussions regarding research-based education, as it is concerned with quality within teaching and research [ 23 ]. It has been argued that accreditation is essential to a profession as it ensures that students who have graduated are competent to practice safely and effectively [ 23 ]. To ensure research-based education, educators research competence is significant. Hence, in some countries, it is not uncommon to expect that approximately 25% of faculty members hold a PhD. In Norway, 20% of the faculty members teaching in bachelor programmes must hold a PhD or equivalent [ 24 ]. Research-based education has also been emphasized in a recent White Paper on quality in higher education, where research-based education is defined as education that is linked to a research environment; is conducted by staff who also carry out research; builds on existing research in a particular field; provides knowledge about the philosophy of science and research methods; and provides opportunities for students to learn how research is conducted from staff or students themselves conducting research as part of their studies [ 25 ]. This definition has some similarities with Huet’s [ 1 ] definition of research-based education, such as describing elements of both research-based and research-led education; however, the White Paper provides additional examples.

As such, research-based education and EBP are different concepts. Research-based education consists of an educational environment where academics and students teach and learn through inquiry and research [ 1 ], while EBP is concerned with using the best evidence from high-quality studies with a clinician’s expertise and patient’s preferences and values in the provision of healthcare [ 26 ]. Research-based education can take various forms, such as developing research skills through learning about research and research methods and taking part in research projects [ 21 ]. Further, it may vary according to the discipline [ 21 ]. In occupational therapy education, for example, learning outcomes have been described as ‘the candidate should have knowledge about EBP and knowledge about philosophy of science, research ethics and research methods, and how this has significance for knowledge development in occupational therapy’ [ 27 ]. Teaching methods related to EBP have relevance for research-based education, as EBP emphasizes that research should underpin clinical decisions. For professionals in occupational therapy and physiotherapy, EBP skills are important. Health-care graduates should be able to gain, assess, apply and integrate new knowledge, and one approach to achieve this is to train students in developing these skills through the five-step model of EBP [ 4 ]. Previous reviews have investigated teaching strategies focusing on EBP among various health educations [ 28 , 29 , 30 , 31 , 32 , 33 ]. Results indicate that EBP teaching in nursing should include knowledge transfer to clinical situations [ 29 , 31 ]; moreover, information literacy is considered among the most important competences for EBP [ 29 ], and a combination of lectures, seminars, discussion, exams, assignments, small-group work, team-based learning, case-study analysis and individual learning are recommended [ 30 ]. In previous reviews, multifaceted approaches—including lectures, tutorials, workshops and journal clubs—have also been found to be best-suited for teaching EBP to health students from programmes including medicine, physiotherapy and occupational therapy [ 32 , 33 ]. However, the majority of the included studies were not conducted among occupational therapy and physiotherapy students. Further, research courses, workshops and collaboration with clinical practice are recommended methods for teaching EBP to undergraduate healthcare students [ 28 ].

Compared to studies focusing on teaching strategies in EBP, fewer studies have investigated strategies to implement and support research-based education across healthcare programmes. However, one scoping review investigated research competencies among rehabilitation students, including physiotherapy and occupational therapy students [ 34 ]. Several core research competencies were identified in this study [ 34 ], and most fell within two research domains: inquiry/literature review and methodology/processes. Research competencies within the inquiry/literature review included recognizing gaps in the literature, searching for and locating relevant literature and critical evidence-appraisal skills. Within methodology/processes, research competencies such as knowledge of research design, data collection skills and data analysis skills were described. As the uptake and integration of research in education programmes is believed not only to improve students’ research skills but also to support their future use of research in practice, it is important to gain more knowledge about the ways in which research-based education is reflected and supported. Previous studies investigating research-based education are limited, especially in bachelor programmes in healthcare [ 22 ]. Studies concerned with occupational therapy and physiotherapy bachelor programmes seem particularly scarce compared to other programmes, and it is therefore important to gain more knowledge regarding research-based education in these education programmes. In this scoping review, the purpose was to identify studies reporting on research-based education in undergraduate occupational therapy and physiotherapy curricula to document the current state of knowledge. A further objective was to map factors that reflect and support the implementation of research-based education in undergraduate occupational therapy and physiotherapy programmes.

A scoping review was conducted to identify studies reporting on research-based education in occupational therapy and physiotherapy curricula, and to map factors that reflect and support the implementation of research-based education in these programmes. We followed the framework for scoping reviews developed by Arksey and O’Malley [ 35 ] and further developed by Levac et al. [ 36 ] and Khalil et al. [ 37 ]. We used a protocol based on Arksey and O’Malley’s framework [ 35 ] to address each of the five steps for undertaking a scoping review: 1) identifying the research question; 2) identifying relevant studies; 3) selecting studies; 4) charting the data; and 5) summarizing and reporting the results. The Joanna Briggs Institute Manual for Evidence Synthesis (hereafter, the JBI manual) was also used throughout the scoping review process to ensure a systematic methodology [ 38 ].

Step 1: identifying the research question

The objective of the current study was:

To explore the extent and range of research on research-based education conducted in occupational therapy and physiotherapy education.

To explore research methods and design used in research on research-based education in occupational therapy end physiotherapy education.

To explore strategies used to implement and promote research-based education in occupational therapy and physiotherapy education.

Step 2: identifying relevant studies

As recommended in the JBI manual [ 38 ], the search strategy was developed in consultation with a research librarian. The search strategy was reviewed by another research librarian before the search was conducted. This was an iterative process. Publications in English, Norwegian, Swedish and Danish published between 1 January 1990 to 15 June 2021 were included in this review. The searches were conducted in the following databases: EBSCO (Academic Search Elite, CINAHL, ERIC), MEDLINE, Embase and Education Source, using a combination of keywords and MeSH terms. These databases cover both health and education. Grey literature was searched for in Nora, Bibliotek DK, Libris, Norart, SveMed+, Bielefeld Academy Search Engine, CADTH, Current Awareness Service for Health, Copac, CORE, EThOS, King’s Fund, MedNar, NDLTD, OAIster, Open Access Theses and Dissertations, National Institute for Clinical Excellence and OpenGrey. Table  1 provides a list of specific search queries used in all databases.

Step 3: selecting studies

The research librarian exported all search results into Rayyan, a web-based app for systematic reviews [ 39 ]. After the duplicates were excluded, two reviewers independently screened the titles and abstracts of the remaining articles for relevance to the research question and the inclusion/exclusion criteria. As recommended in the JBI manual [ 38 ], a pilot test was conducted by a research team before the included articles were read. In this pilot test, three full-text articles were read and assessed by three researchers, and full agreement among the researchers were reached. All full-text articles were then read and assessed. They were further checked for relevance by two independent reviewers. If there was any disagreement, a third reviewer was included in the process.

Inclusion criteria

Studies reporting on students and/or faculty members in occupational therapy and physiotherapy bachelor programmes were included. Studies with allied health students or faculty members were included if they also included occupational therapy and physiotherapy bachelor programmes.

Studies with research-based education as the main concept were investigated in this review. That is, studies were included if they emphasized research in education, such as students’ use of research, students’ learning of research skills (including research methods and philosophy of science), and student involvement in research. Further, included studies focused on use of educational strategies to promote and implement research in curricula. Studies investigating faculty members’ use of research in teaching and involvement in research projects were also included. Finally, included studies focused on EBP and research utilization in occupational therapy and physiotherapy bachelor programmes.

Included studies involved typical educational settings, e.g., classroom teaching, clinical placement or simulation training.

Exclusion criteria

Studies conducted among bachelor students in other health disciplines—such as nursing and radiography—were excluded. Studies including students from master’s degree education programmes were excluded, as were studies focusing on occupational therapy and physiotherapy clinicians. We also excluded studies presented in languages other than English, Danish, Norwegian or Swedish.

Step 4: charting the data

We used a pre-defined extraction form to analyse the results, as recommended in the JBI manual [ 38 ] (see Supplementary file Data Abstraction Table). The selected articles were reviewed by two independent reviewers. The data extraction tools formed the basis for the final presentation of the results in Tables  2 and 3 . Study characteristics included first author, year of publication, title, country of origin, study design/purpose, study participants, context and main study findings. We used thematic analysis inspired by Aveyard [ 40 ] to identify strategies for implementing and promoting research-based education in occupational therapy and physiotherapy bachelor programmes. In accordance with Aveyard’s thematic analysis, we first identified themes from the results section of each included study. We used different colours to mark the parts that had relevance for our research questions. Further, we developed our themes by merging results with the same theme. Next, we named our themes after assessing the results from the included studies again, and then compared the themes to ensure that the names were suitable. The last step was to examine the themes, looking for similarities and differences in the material. Further, we analysed these to determine whether there were any recommendations regarding when to include the strategy in the curriculum, and where —i.e., in clinical placements, in the classroom or a combination of the two.

Literature search

A total of 3068 records were identified in the following databases: ERIC ( n  = 595), Academic Search Elite ( n  = 315), AMED ( n  = 18), CINAHL with full text ( n  = 1311), Education Source ( n  = 388), Embase ( n  = 359) and MEDLINE ( n  = 82). The database search returned 2639 records after duplicates were removed. Further, grey literature was identified in 18 databases ( n  = 210). One article [ 34 ] was recommended by another researcher, and we included this article in the review after we checked it against the inclusion and exclusion criteria. The entire process of study identification and inclusion/exclusion is presented in Fig.  1 .

Modified PRISMA flow diagram illustrating the scoping review process

Study characteristics

Study characteristics are presented in Table  2 . Studies were spread across the years 1999–2021. The studies were conducted in Norway ( n  = 6), Canada ( n  = 5), South Africa ( n  = 5), Australia ( n  = 3), the United Kingdom ( n  = 2), the United States ( n  = 1), New Zealand ( n  = 1), Ireland ( n  = 1), Taiwan ( n  = 1), Italy ( n  = 1) and Iran ( n  = 1). The study designs were qualitative ( n  = 9), quantitative ( n  = 9), mixed methods ( n  = 2), review ( n  = 2), opinion piece ( n  = 1), model presentation ( n  = 1), curriculum design ( n  = 2) and designing and implementing teaching activities ( n  = 1). Study participants included physiotherapy students ( n  = 5), occupational therapy students ( n  = 5), allied health students (including occupational therapy and physiotherapy students; ( n  = 2), occupational therapy and physiotherapy students ( n  = 1), EBP teachers ( n  = 2), faculty members ( n  = 4), students and faculty members ( n  = 2), students, faculty members and clinical instructors ( n  = 2), occupational therapy students and clinicians ( n  = 1), occupational therapy education ( n  = 2) and physiotherapy education ( n  = 1).

Step 5: summarizing and reporting the results (synthesis of results)

Based on a thematic analysis of the included studies ( n  = 27), we identified strategies to implement research-based education in occupational therapy and physiotherapy bachelor programmes. We also tried to identify where the strategies could be included in the curriculum and when they could be placed in the curriculum. The included studies were classified into four major themes: ‘student engagement in research’ ( n  = 6), ‘curriculum improvement regarding EBP’ ( n  = 2), ‘EBP teaching’ ( n  = 18) and ‘journal club’ ( n  = 1). These strategies are presented in Table  3 .

Strategies for implementing research-based education across physiotherapy and occupational therapy bachelor programmes

Only one of the included studies focused on research-based education. Two of the included studies investigated curriculum improvement regarding EBP. The majority of the included studies focused on EBP teaching ( n  = 18). Although only one of the studies recommended journal clubs as the main strategy, several of the other studies also recommended journal clubs as a strategy. Findings from the four identified themes are described below.

Student engagement in research

Six of the included studies focused on student engagement in research [ 34 , 43 , 46 , 47 , 51 , 55 ], whereas only one study had a specific focus on research-based education [ 51 ]. In this study [ 51 ], emphasizing research in occupational therapy education was perceived as important to ensure students’ future best practice. Moreover, introducing research early in the programme, setting high expectations regarding students’ use of research and achieving skills in research methods were highlighted as necessary. The significance of role models both in clinical placements and among faculty members was described [ 51 ]. With regards to the other included studies focusing on research, two had a specific focus on student participation in research projects [ 46 , 55 ]. In one of these studies [ 46 ], occupational therapy students participated in small-scale research projects during their clinical placements and the action learning and action research (ALAR) model contributed to a scholarship of practice where the students, clinical educators and residents of a dementia unit all experienced the value of research. This study [ 46 ] indicated that the positive outcomes for students in clinical placements may be complemented by the positive outcomes for practitioners, as they, too, are able to participate in research towards EBP: the authors concluded that a positive approach to research as part of undergraduate training should therefore be emphasized. Further, among students in occupational therapy and physiotherapy programmes, engagement in research might be enhanced if students’ autonomy and influence on factors such as research participation, research topics and groups are structured in the curriculum [ 55 ].

Two of the other included studies recommended that student involvement in research could be facilitated by introducing students to systematic reviews [ 66 ] and by students themselves to conduct systematic reviews [ 43 ]. The authors argued that such experience will give students the opportunity to acquire basic research skills and become clinicians who provide EBP services in clinical practice [ 43 ]. Moreover, they recommended that introduction to systematic reviews and searching for appraised evidence resources should be covered earlier in EBP courses [ 66 ]. In one study, the use of a Students-Oriented Learning Outline in Research Education (SOLO) was effective in helping to structure the research course to facilitate student learning. A SOLO provides a structure for learning objectives, special instructions and feedback on student progress, as well as flexibility for faculty members to include a variety of instructional methods [ 47 ]. Further, 45 research competencies for undergraduate rehabilitation students were identified, in which research methodology and research inquiry/literature reviews are best represented [ 34 ]; in this study, five recommendations regarding strategies to develop research and EBP competencies among undergraduates were suggested: collaboration, teaching methods/curriculum design, supervision, assessment and translation of research evidence.

Curriculum improvement regarding EBP

Two of the included studies, conducted in Norway and Australia, focused on improving the curriculum regarding EBP [ 52 , 58 ]. Here, based on evaluation of EBP in healthcare courses, participatory action research methodology was a recommended approach for curriculum improvement [ 58 ]. Moreover, authors argued that there should be clear EBP competence goals and a progression, and research-based knowledge needs to be highlighted to a larger degree in the curriculum [ 52 ].

EBP teaching

The majority of the included studies focused on EBP teaching [ 41 , 42 , 45 , 48 , 49 , 50 , 53 , 54 , 56 , 57 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ]. Several of these studies recommended teaching and learning EBP in clinical placements in addition to the classroom [ 49 , 53 , 56 , 57 , 59 , 64 , 65 , 66 ]. Findings indicate that EBP in clinical placements can serve as an ideal platform for collaboration between students, occupational therapy faculty members and clinical instructors. Further, EBP teaching and workshops during clinical placements is necessary and journal clubs have been suggested as a way to foster collaboration [ 65 ]. EBP teaching should be integrated in routine clinical practice and be considered a real-time continuous and flexible process [ 66 ].

Collaboration with clinical practice regarding EBP

Four of the included studies focused on collaboration with clinical practice regarding EBP [ 50 , 53 , 59 , 64 ]. Further efforts to include EBP in clinical curricula was emphasized by West [ 64 ], who highlighted the importance of collaboration between students and clinical instructors and the impact of attitudes held by clinicians. The use of discussion groups in clinical placements between students and supervisors and the use of research in treatment plans have been recommended in physiotherapy education [ 59 ]. In occupational therapy education, Johnson [ 53 ] highlighted that EBP teaching and its associated assignments should include the active involvement of both students and clinical instructors. Moreover, faculty members should involve and collaborate with clinical instructors, so that students can present and discuss the results of research articles and implement EBP in clinical placements: journal clubs might represent one way to foster this kind of collaboration between students and clinical instructors [ 53 ]. Collaboration with practice to achieve more effective EBP training—such as through online communities of practice or integrated knowledge translation research projects— has also been suggested [ 50 ].

EBP teaching strategies

Regarding EBP teaching in classroom, one study recommended more time for EBP, journal club activities and a formal assessment in the first year [ 45 ]. McEvoy [ 56 ] argued that an EBP course in combination with clinical placements resulted in significant changes in students’ self-reported domains regarding EBP. There should be a link between academic subjects and practice: two of the included studies had a focus on physiotherapy faculties teaching [ 48 , 57 ], where Frantz [ 48 ] argued that physiotherapy educators should be proactive by improving teaching and encouraging teaching based on current, relevant research. The authors of [ 61 ] argued that physiotherapy teaching staff have the right to be active in research and to have this research inform teaching, and that all facets of physiotherapy education should be driven by cutting-edge research and reflect EBP. One of the studies [ 65 ] focused on problem-based learning (PBL) as an approach to EBP instruction, concluding that PBL promotes improvement in EBP skills, communication, teamwork and EBP team self-efficacy. Further, scaffolded learning for early stage EBP competence is required and a PBL approach allowed greater emphasis on research processes. EBP training should be emphasized throughout the curriculum [ 60 , 61 ], allowing repetition, consolidation and application of EBP knowledge and skills [ 61 ]. The importance of teaching all EBP steps has been highlighted in two of the studies [ 62 , 63 ] and case-based methods were suitable for students EBP learning [ 62 ]. One of the studies [ 56 ] highlighted that professional thinking should be taught as an overarching topic within curricula where EBP is included. Collaboration between the faculty member and the librarian was a success in teaching students EBP skills [ 42 ]. Strategies for students to be able to translate knowledge to practice have been suggested, including discussions with peers and clinicians, hands-on practice in the application of knowledge in research projects and the use of knowledge tools and social media [ 49 ].

Journal club

One of the included studies had a specific focus on the use of journal clubs in occupational therapy education [ 44 ]. In this study, the journal club was included in the first year of the programme and the authors recommended the use of journal club in small groups of approximately 12 students with a subgroup of 3 students [ 44 ]. The authors highlighted participation in journal clubs at an early stage as a foundation for engagement with professional literature and the recognition of the importance of EBP. Five of the other included studies also recommended use of journal clubs in addition to other teaching strategies [ 45 , 49 , 52 , 53 , 65 ]. Journal club was not a part of their study design, however. One of these studies highlighted that student- and clinician-driven journal clubs are recommended among occupational therapy students related to knowledge translation [ 49 ]. The use of journal clubs has also been suggested to strengthen the cooperation between occupational therapy students, scientific staff and clinical instructors [ 52 , 53 , 65 ]. A recommendation from one of the studies is that, among physiotherapy undergraduates, the use of journal clubs should be increased in the curriculum [ 45 ].

Where and when to include the strategy in the curriculum

Five of the included studies [ 42 , 43 , 47 , 54 , 55 ] recommended that the teaching strategy be included on campus, 6 [ 46 , 49 , 59 , 60 , 64 , 65 ] recommended that it be included in clinical placements and 15 [ 34 , 41 , 44 , 45 , 50 , 51 , 52 , 53 , 57 , 58 , 61 , 62 , 63 , 66 , 67 ] recommended a combination between campus and clinical placements. One of the studies [ 48 ] did not specify this aspect. Four of the included studies [ 42 , 44 , 51 , 54 ] recommended including the teaching strategy early in the curriculum, two [ 43 , 65 ] recommended its inclusion in the final year/late stages of the curriculum and eight [ 41 , 45 , 52 , 57 , 58 , 60 , 61 , 62 ] proposed that it be included throughout the curriculum. Thirteen of the studies did not specify when the teaching strategy should be included in the curriculum.

In this scoping review, the purpose was to identify studies reporting on research-based education in undergraduate occupational therapy and physiotherapy curricula to document the current state of knowledge. Further, an objective was to map factors that reflect and support the implementation of research-based education in undergraduate occupational therapy and physiotherapy programmes. Based on a systematic and thorough process, 27 studies were included. Of these studies, 16 were published within the last 10 years, indicating an increased perceived importance of training students to be critical users of research. The current state of knowledge indicates that studies investigating research-based education are scarce. The majority of the studies focused on aspects of EBP; however, EBP and research-based education are different concepts. The goal of EBP is to use the highest possible quality of knowledge in providing care to ensure the greatest impact on patients’ health status and healthcare outcomes [ 26 ]. EBP entails making professional decisions based on systematically retrieved research evidence, experiential knowledge and patient preferences in a given situation [ 4 , 68 ]. By contrast, research-based education has a wider focus and is more concerned with creating a learning environment where academics and students teach and learn through inquiry and research [ 1 ]. Further, research-based education consists of both research-led and research-based teaching [ 1 ]. Nevertheless, EBP has relevance for discussions regarding research-based education when it comes to using research evidence in professional practice. With regards to implementing and supporting research-based education in occupational therapy and physiotherapy programmes, we identified the following four strategies: ‘student engagement in research’, ‘curriculum improvement regarding EBP’, ‘EBP teaching’ and ‘journal club’. The majority of the included studies recommended implementing the suggested strategy in a combination of classroom and clinical placements and throughout the curriculum. Since 13 of the included studies did not specify where to include the strategy in the curriculum, it is difficult to make conclusions regarding the timing of each of the suggested strategies. The findings discussed below are related to the strategies most frequently identified in our thematic analysis and discussed in light of previous research, conceptual frameworks and curriculum strategies regarding research-based education.

Studies included in the current review highlight the importance of emphasizing research in the education programme to ensure that students have the skills to provide future best practice [ 51 ] and develop students research skills and competence [ 34 , 43 , 51 , 66 ]. This may be accomplished by participation in research projects [ 46 , 55 ]. Previous research among occupational therapy and physiotherapy students has identified positive attitudes towards research, particularly related to reading research literature and applying research findings to improve practice [ 69 ]. Learning research skills to improve practice and benefit healthcare outcomes has also been highlighted as important in nursing education, where student–faculty collaborative projects have been recommended [ 70 , 71 ]. This is in agreement with previous research in medical education, where developing students research skills has been highlighted as important for ensuring that students make informed decisions in their future practice [ 72 ]. Moreover, student participation in research has improved their scientific productivity, knowledge, interest and attitudes towards research [ 73 , 74 ]. Based on the reviewed literature relating to occupational therapy and physiotherapy education programmes, it appears important that students’ engagement in research clearly links with professional practice. Moreover, students need to develop research skills suitable to provide future best practice; one approach is by introducing research methods to students early and facilitating participation in inquiry-based activities throughout the education programme. Studies investigating inquiry-based activities and students’ engagement with research appear to be useful: these will hopefully expand in number and scope, as more knowledge regarding students’ experiences and learning outcomes from such activities is needed.

Regarding curriculum, clear EBP competence goals and a progression has been suggested, and research-based knowledge should be highlighted to a larger degree [ 52 ]. This is in line with policy documents, such as those from the World Federation of Occupational Therapists [ 75 ] and World Physiotherapy [ 76 ]. These documents recommend a curriculum that includes critical thinking, problem-solving, EBP, research and lifelong learning [ 75 ], and encourage and support a curriculum which is evidence-based/informed and develops students’ research skills [ 76 ]. Moreover, physiotherapists’ education framework emphasizes EBP, literature searches and reviews, research methodologies and research in physiotherapy education [ 77 ]. This is in agreement with the AMEE Guide [ 78 ], which centres on curriculum design related to developing undergraduates’ research skills in medical education. In this guide, it is highlighted that medical students must understand research methods and the benefits that research brings to their profession. Students’ active participation in research activities is suggested, and adopting a student-centred approach in the curriculum may facilitate developing students research skills [ 78 ]. Here, suitable methods may include project-based learning, case-based learning, inquiry-based learning or PBL methodologies within the curriculum design [ 78 ]. The role of accreditation will also have an impact on the integration of research in the curriculum, as the expectations of both faculty members’ and students’ research skills may increase [ 23 ]. Further, accreditation has the potential to improve health-care outcomes, with its ability to influence and standardize the quality of education programmes [ 23 ]. Strengthening the research integration in curricula had a positive effect on research-related student learning outcomes among first-year medical students [ 79 ].

Few of the included studies in our review focused on curriculum design or improvement; instead, the focus was mainly on EBP. However, previous studies have focused on strategies to support faculty in teaching students research and inquiry [ 20 , 21 ]. It has been argued that engaging students in research and inquiry early on and ensuring a progression in research and inquiry in the education programme is important [ 20 ]. Further, ensuring systematic thinking and coherence in the curriculum regarding how students can obtain the needed skills to engage with research has been highlighted [ 21 ]. Moreover, inquiry-based learning seems to be one of the key aspects of research-based education, and student-active learning can be beneficial for developing students’ analytical and critical thinking skills [ 21 ]. Huet [ 1 ] focused on implementing research-based education in curricula and recommended four actions to succeed. First, the institution must have clear guidelines for embracing a research-based education model at all levels of the study programme. Second, the institutional policies must take into account the time needed to conceptualize, plan and deliver research-based and research-led teaching approaches. Third, the importance of facilitating a culture of research and teaching must be highlighted as two integrated activities. Fourth, academics must be provided with pedagogic support, preparing them to develop learning and teaching strategies that are sustained in research-led or research-based approaches in early stages in the curriculum. Based on these recommendations, it seems beneficial to embrace a research-based education model in the education programme and to integrate research with teaching in the organization of that programme. Related to occupational therapy and physiotherapy curricula the emphasis on research should be increased to ensure that students have research skills that can benefit their professional practice and healthcare outcomes. Learning and teaching strategies may be designed in agreement with research-based teaching and research-led teaching [ 1 ].

The most frequently identified strategies in our review were related to EBP teaching. Findings from these studies indicate that the teaching and learning of EBP should be emphasized in clinical placements [ 49 , 53 , 56 , 57 , 59 , 64 , 65 , 66 ] and in collaboration with clinical practice [ 50 , 53 , 59 , 64 ]. Further, early EBP education led to adequate knowledge, confidence and positive attitudes [ 56 ]. Teaching should be based on cutting-edge research and reflect EBP [ 57 ], and educators should be proactive by improving teaching and encouraging teaching based on current research as well as being active in research themselves [ 48 ]. Having research inform teaching and educators be active in research projects coincides with research-led teaching, as described by Huet [ 1 ]. However, Huet emphasized that educators do not need to be active researchers or perform cutting-edge research, but they do need to be engaged in a scholarly manner within their field [ 1 ]. Moreover, findings from studies included in our review indicate that all the EBP steps should be included in teaching [ 62 , 63 ]: this is in agreement with previous research that indicates that most EBP educational interventions focus on teaching only some of the EBP steps [ 80 ]. Further, multifaceted approaches including lectures, tutorials, workshops and journal clubs have also been found to be beneficial when teaching EBP to health students from programmes such as medicine, physiotherapy and occupational therapy [ 32 , 33 ]. Among professional bachelor degree healthcare programmes, research courses, workshops and collaboration with clinical practice are recommended as methods for teaching EBP [ 28 ].

Summarizing the above, collaboration with clinical practice and emphasizing teaching and learning of EBP in clinical placements seems to be beneficial in occupational therapy and physiotherapy education programmes; further, multifaceted approaches in teaching EBP should be emphasized, and teaching activities could be based on cutting-edge research and reflect EBP.

Findings from studies included in our review indicate that journal clubs are a well-suited means to increase students’ engagement with professional literature and to recognize the importance of EBP [ 44 ]. Journal clubs may be suitable as a method for students to implement research skills in clinical placements and to facilitate collaboration with clinical instructors [ 52 , 53 , 65 ]. Moreover, journal clubs have been proposed to support knowledge translation [ 49 ], and more frequent use of journal clubs in undergraduate curricula has been advocated [ 45 ]. Similar to the findings in our review, previous studies have argued that journal clubs can assist students’ EBP learning process [ 81 ] and add to their EBP skills, particularly regarding students’ ability to search the literature and to comprehend and appraise research articles [ 82 ]. However, other studies did not find improvement in critical appraisal skills from students’ participation in journal clubs [ 83 , 84 , 85 ]; nevertheless, students have reported an overall positive experience from participating in them, especially with a view towards discussing research utilization [ 86 ]. Further, journal clubs can be suitable as a learning and collaboration method between education and practice [ 87 , 88 ]. Previous reviews among medical students, as referenced by Young et al. [ 33 ], have described a positive effect of journal clubs as a method for teaching EBP [ 83 , 84 , 85 , 89 ].

We did not identify many studies investigating journal clubs among occupational therapy and physiotherapy students, and more studies are needed. In view of the above, it appears that implementing journal clubs in occupational therapy and physiotherapy education can offer advantages, such as improving students’ searching and reading skills, helping them stay up-to-date and facilitating research utilization in clinical placements and future practice. Journal clubs can be introduced in the first year as a part of a research or EBP course, facilitated by academic staff.

What can be learned from this scoping review?

Based on the findings from our review, knowledge regarding research-based education and strategies to support the implementation of research-based education in occupational therapy and physiotherapy curricula are scarce. EBP has been emphasized to a greater degree in studies in these programmes, and more knowledge is needed to implement research-based education in curricula. Only one of the included studies explored research-based education [ 51 ]. However, some elements of both research-led and research-based teaching were described in the included studies. Emphasizing students’ active involvement in research projects, conducting systematic reviews and participation in journal clubs may be perceived as a practical means of implementing research-based teaching. Similarly, research-led teaching is exemplified by educators who utilize cutting-edge research findings and use their own research to support their teaching.

Research training is important for all health science professions [ 34 ], and in professional programmes such as occupational therapy and physiotherapy it is important that the emphasis on research is linked to professional practice and implementing research as a part of EBP. As described earlier, EBP and research-based education are different concepts. However, EBP has relevance for discussions regarding research-based education when it comes to using research evidence in professional practice. As highlighted by Brew, ‘some of the best examples of undergraduate students engaging in inquiry processes in order to learn come from professional areas. As professions become increasingly evidence based, valuing the use of research as an integral part of professional practice, students are also increasingly being required to engage in inquiring into aspects of practice in order to learn’ ([ 90 ] , p. 19). Creating a research-based learning environment thus has benefits for occupational therapy and physiotherapy students, as they can learn how to become critical thinkers and lifelong learners and to generate discipline-enriching knowledge [ 1 ]. These skills are important for their future professional practice.

Implications for educational practice

Based on the included studies in our review, we recommend that students’ learning of research methods should be prioritized. More methodological competence seems to be needed for students to be able to read and understand research articles—it is therefore foundational for undergraduate research training [ 34 , 51 ]. Research should be introduced early in the education programme, including introducing students to systematic reviews and searching for appraised evidence [ 66 ]. Involving students in research projects might be a good learning arena, as it may encourage students’ engagement in research and promote collaboration with clinical practice [ 46 , 55 ]. Students conduct systematic reviews could be emphasized, as this might provide basic research skills and encourage the use of EBP in future clinical practice [ 43 , 66 ].

The majority of the strategies identified in this review were related to ‘EBP teaching’. Based on the included studies, we recommend that the teaching and learning of EBP should take place in clinical placements in addition to classroom teaching [ 49 , 53 , 56 , 57 , 59 , 64 , 65 , 66 ]. Further, all EBP steps should be included in teaching where case-based methods may be a suitable approach [ 62 , 63 ]. It is recommended that educators should base their teaching on current relevant research and be active researchers themselves [ 57 ]. Journal clubs should be emphasized in the curriculum as it can be a foundation for engagement with professional literature and the recognition of the importance of EBP [ 44 ]. Journal clubs have also been recommended as a means for cooperation between occupational therapy students, scientific staff and clinical instructors [ 52 , 53 , 65 ]. Moreover, there should be increased focus on research-based knowledge in the curriculum, and progression needs to be ensured [ 52 ]. To succeed with implementing research-based education, awareness of the research-based education model should be increased in education programmes, and different teaching and learning strategies should be explored [ 1 ]. Elements of research-based education should be reinforced at all level of the study programme, and introduced early [ 1 ]. Relevant organizational units, such as faculties and departments, must take responsibility for raising students’ and educators’ awareness of the importance of linking research and education, and how the implementation and use of research in education can be promoted in different ways [ 1 ]. In professional programmes such as occupational therapy and physiotherapy, research-based education will preferably be designed such that learning and teaching activities are relevant to the specific fields of professional practice [ 22 , 51 ].

Strengths and limitations

A strength with this scoping review is that it complies with the key steps outlined in the Arksey and O’Malley 2005 [ 35 ] framework, and further developed by Levac et al. 2010 [ 36 ] and Khalil et al. 2016 [ 37 ], to systematically select and summarize existing literature focusing on research-based education. We also used the JBI manual for conducting scoping reviews to ensure a systematic methodology [ 38 ]. Our scoping review presents an overview of existing literature describing research-based education in occupational therapy and physiotherapy bachelor programmes. However, some limitations need to be addressed. There is a possibility that relevant studies were included in this review, although several databases and grey literature were searched. The quality of the included studies was not assessed as a part of this scoping review, as according to Arksey and O’Malley [ 35 ] there is no attempt made to present a view regarding the ‘weight’ of evidence in relation to particular interventions or policies. This is because the scoping study does not seek to assess quality of evidence and consequently cannot determine whether particular studies provide robust or generalizable findings.

This scoping review has provided an extensive overview of literature describing research-based education in occupational therapy and physiotherapy programmes. However, only a few of the included studies in this review had specifically investigated aspects of research-based education. The most frequently identified strategies in our review were related to EBP teaching. Overall, our findings show that ensuring students’ competence in research methods is necessary for students to be able to read and understand research articles, which are important foundational skills in undergraduate research training. Journal clubs may give students a foundation for engaging with research literature. Moreover, students’ basic research skills may be facilitated through their involvement in research projects and by conducting systematic reviews. Cooperation with clinical practice is important in occupational therapy and physiotherapy education. Faculty members should be proactive by improving teaching based on current, relevant research, and the awareness of research-based education should be increased among both faculty members and students.

Based on our findings, research-based education appears to be a new and relatively unexplored research field in the context of occupational therapy and physiotherapy education programmes, and we argue that more studies investigating research-based education in these programmes are needed. As so few of the included studies focused on faculty members, more studies among faculty members—concerning their views, experiences and practices related to research-based education—are needed. Moreover, future research could investigate viable and effective strategies for teaching research methods to undergraduate healthcare students, students’ learning outcomes regarding research methods and students’ research skills and involvement in research projects. Further, cooperation between education programmes and clinical placements regarding research implementation should be explored. Scant studies investigating curriculum design for integrating research seem to exist, and more such studies are needed in this area. Future studies may benefit from investigating curriculum design in accordance with research-based education curriculum and based on the policy documents concerned with implementing research and developing students’ research skills.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

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Acknowledgements

The authors would like to thank the participants who volunteered to take part in this study. In addition, we would like to thank the librarian Anna Kirsten Nygaard (VID Specialized University, Bergen, Norway) for conducted the literature searches and the librarian Irene Hunskår (VID Specialized University, Bergen, Norway) for reviewing the search strategy. We would also like to thank Nina Rydland Olsen (Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway) for her ideas and supervision at an early stage of the work with this scoping review. In addition, we would like to thank Jens-Christian Smeby (Centre for the Study of Professions, OsloMet—Oslo Metropolitan University, Oslo, Norway) for his ideas and critical reading of this manuscript.

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Helgøy, K.V., Bonsaksen, T. & Røykenes, K. Research-based education in undergraduate occupational therapy and physiotherapy education programmes: a scoping review. BMC Med Educ 22 , 358 (2022). https://doi.org/10.1186/s12909-022-03354-2

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15 October 2014

15 oct 2014, getting into research.

Every practising CSP member is involved in assessing research evidence. Taking a step into presenting or doing research might not be as daunting as it looks, says CSP adviser Nina Paterson.

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All CSP members – including students and support workers – are critical users of evidence. So when I was asked to write about how to ‘get into research’, and to encourage readers to think about going from ‘using’ to ‘doing’ research, I knew I wouldn’t be short of material. Evaluating the effectiveness of your service or your own practice is, or should be, a normal part of everyday life for anyone working in health and social care. For example, you might be benchmarking what you do using local or national guidelines, measuring the effectiveness of a particular intervention, or changing your practice after reviewing the available evidence. Whatever area of physiotherapy you work in, as part of a structured organisation such as the NHS or as a lone private practitioner, your responsibility to provide the best possible care to your patients, service users or clients means that you have a professional obligation to be ‘into research’. Many of you will have just come back from Physiotherapy UK 2014, having listened to great platform presenters and reviewed posters. Like any conference you attend, it will have made you think, taught you something new, consolidated your knowledge, and ultimately changed your practice. By being able to present your work, not only are you evidencing your professional development, but you’re also increasing the profession’s evidence base, demonstrating that physiotherapy works.

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As my colleague Imogen Scott-Plummer, CSP research adviser, notes: ‘Abstract submissions for Physiotherapy UK doubled this year.’ It is also great to know that the CSP received more enquiries from members thinking laterally about research – seeking advice about how to present findings; from quality audits, service evaluation and projects, not only randomised controlled trials. Another colleague works for a large trust, where staff can access a range of opportunities that develop research skills, such as journal clubs, best practice, audit and research forums. They regularly produce posters and present project and research findings in a multidisciplinary setting. If you are fortunate and work somewhere similar, where organisational processes support your development, make the most of such opportunities. Going a step further and presenting at a conference shouldn’t be that daunting, you’ve had great practice. Down the line you might also want to share your experiences and support others who may not have had the same opportunities. The description above may be a world away from your workplace. The responsibility may rest with you in your own time to keep up-to-date with research but even if this is the case, that shouldn’t stop you. Think carefully about what’s in it for your employer, focusing on the benefit it will bring to the team and organisation. Think about what support you might need time to write up, financial support for travel, poster production, time off to present and so on. When negotiating this level of support, it is important to do your homework – know what your employer’s policies are, who to speak to, what funds are available and how to access them. If you need financial help, the CSP Charitable Trust has awards available. Full information about these can be found on the CSP website, but both the Conference and Presentation Award and the Robert Williams International Award would be worth exploring. There are a number of support routes available. The Council for Allied Health Professions Research is one example, CSP research advisers another. The iCSP research network is also thriving. If you are lucky to have formal mentoring routes at work, make the most of them as well as informal routes such as a friend or colleague who present regularly. There are any number of books, blogs, information websites that address the process of writing and submitting.  You’ll find some tips to get you started, but you’ll also find links to some of articles in the box. As with the last continuing professional development article (1 October 2014), no specific activity has been suggested – simply think about your own work and what you would be interested in writing up - what would you need to do to disseminate? Make a plan: identify what you will need to do to achieve your goal. Set realistic timescales and think through solutions to any potential barriers. And finally, give it a go! Remember if your proposal doesn’t get accepted the first time, take on board any feedback and try again. Even seasoned researchers experience this. This article assumes that you have a research topic area that you want to present. If you are reading this and you’re not at that point yet, then hold that thought. A forthcoming article in this CPD series will look at ‘data and its uses’. So stick a marker in this article and come back to it later. fl

Rather than making your research ‘fit’, look for a conference whose themes match your research use the submission criteria to help you shape your abstract rationale - that’s what you’re being scored against make a note of the submission deadlines. Leave plenty of time to edit; whatever the word count it won’t be enough, and leave enough time to submit via the online portal.

Don’t give up. If you aren’t successful the first time, try again

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‘There’s so much to it’: the ways physiotherapy students and recent graduates experience practice

• Published: 08 December 2017
• Volume 23 , pages 387–406, ( 2018 )

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• S. Barradell   ORCID: orcid.org/0000-0002-9823-0060 1 , 2 ,
• T. Peseta 2 , 3 &
• S. Barrie 2 , 3  

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Health science courses aim to prepare students for the demands of their chosen profession by learning ways appropriate to that profession and the contexts they will work and live in. Expectations of what students should learn become re-contextualised and translated into entry-level curriculum, with students operating as a connection between what is intended and enacted in curriculum, and required in the real world. Drawing on phenomenology, this paper explores how students understand practice —the collective, purposeful knowing, doing and being of a community—in entry-level physiotherapy programs. Ways of thinking and practising (WTP)—a framework attentive to the distinctive nature of a discipline, its values, philosophies and world-view (McCune and Hounsell in High Educ 49(3):255–289, 2005 )—provides the conceptual lens. Six themes describing how students see the WTP of physiotherapy practice emerged from the analysis: discovery of new knowledge ; problem solving client related contexts ; adopting a systems based approach to the body ; contributing to a positive therapeutic alliance ; developing a sense of self and the profession ; and the organisation of the workforce . The study produces knowledge about practice by focusing on physiotherapy students’ experiences of disciplinary learning. Including students in educational research in this way is an approach that can help students realise their potential as part of a community of practice.

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Barradell, S., Peseta, T. & Barrie, S. ‘There’s so much to it’: the ways physiotherapy students and recent graduates experience practice. Adv in Health Sci Educ 23 , 387–406 (2018). https://doi.org/10.1007/s10459-017-9804-z

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Patient-centeredness in physiotherapy: What does it entail? A systematic review of qualitative studies

Affiliations.

• 1 a Department of Physiotherapy , Human Physiology and Anatomy, Vrije Universiteit Brussel , Brussels , Belgium.
• 2 b Transcare, Transdisciplinary Outpatient Treatment Centre , Groningen , The Netherlands.
• 3 c Pain in Motion International Research Group , Brussels , Belgium.
• 4 d Department of physiotherapy , Fysio Stiens , Stiens , The Netherlands.
• 5 e Faculty of Health Psychology and Social Care, Manchester Metropolitan University , Manchester , UK.
• 6 f UMC Utrecht Cancer Center, University Medical Centre Utrecht , Utrecht , The Netherlands.
• 7 g Department of Physiotherapy , Hanze University of Applied Sciences, School of Health Studies , Groningen , The Netherlands.
• PMID: 28820617
• DOI: 10.1080/09593985.2017.1357151

Purpose: The literature review is aimed at examining and summarizing themes related to patient-centeredness identified in qualitative research from the perspectives of patients and physiotherapists. Following the review, a secondary aim was to synthesize the themes to construct a proposed conceptual framework for utilization within physiotherapy.

Methods: A systematic search of qualitative studies was conducted including all articles up to 2015 September. Methodological quality was examined with a checklist. The studies were examined for themes suggestive of the practice of patient centeredness from perspective of the therapists and/or the patients. Data were extracted using a data extraction form and analyzed following "thematic synthesis."

Results: Fourteen articles were included. Methodological quality was high in five studies. Eight major descriptive themes and four subthemes (ST) were identified. The descriptive themes were: individuality (ST "Getting to know the patient" and ST "Individualized treatment"), education, communication (ST "Non-verbal communication"), goal setting, support (ST "Empowerment"), social characteristics of a patient-centered physiotherapist, a confident physiotherapist, and knowledge and skills of a patient-centered physiotherapist.

Conclusions: Patient-centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals in a treatment in which the patient is supported and empowered with a physiotherapist having social skills, being confident and showing specific knowledge.

Keywords: Models (theoretical); patient-centered care; physiotherapy; qualitative research; qualitative review; review.

Publication types

• Systematic Review
• Communication
• Patient Education as Topic
• Patient-Centered Care*
• Physical Therapy Modalities
• Physical Therapy Specialty / standards*
• Precision Medicine
• Social Support

151+ Research Topics For Physiotherapy Students [Updated]

Welcome to the world of physiotherapy, where movement is medicine, and every step leads to healing. In the area of physiotherapy education, research is a powerful tool. It helps us understand the human body better, discover new techniques for rehabilitation, and improve the quality of life for countless individuals. Today, we dive into the diverse and fascinating world of research topics for physiotherapy students. 

Whether you’re a student, a curious reader, or someone passionate about health and well-being, this journey promises to be enlightening.

What is Physiotherapy Research?

Table of Contents

Physiotherapy research is the investigation and exploration of various aspects of physical therapy. It delves into the effectiveness of different treatments, the impact of exercises on specific conditions, and the development of innovative techniques to enhance rehabilitation. This research isn’t just about lab coats and test tubes; it’s about real people, real struggles, and real triumphs.

Why Research Matters in Physiotherapy Education

Research isn’t just an academic exercise—it’s the heartbeat of progress in physiotherapy. For students, engaging in research opens doors to understanding the science behind the practice. It fosters critical thinking, hones problem-solving skills, and prepares future physiotherapists to deliver evidence-based care.

Most importantly, research enhances the quality of care patients receive, ensuring they benefit from the latest advancements in the field.

How Do I Choose A Research Topic For Physiotherapy Students?

Choosing a research topic for physiotherapy students involves several considerations to ensure it aligns with your interests, the field’s needs, and feasibility. Here’s a step-by-step guide:

• Identify Your Interests
• Passion: Choose a topic that genuinely interests you. Your enthusiasm will drive your motivation throughout the research process.
• Personal Experience: Reflect on any personal experiences or observations in physiotherapy that sparked your curiosity.
• Consider Relevance
• Field Needs: Look into current trends and gaps in physiotherapy research. What areas need more exploration or improvement?
• Clinical Significance: Choose a topic with practical applications in clinical settings. Will your research contribute to better patient outcomes or practice?
• Review Literature
• Literature Search: Conduct a thorough literature review to understand what’s been done. Identify gaps where your research can make a valuable contribution.
• Read Journals: Explore recent publications in physiotherapy journals to get ideas and understand the latest advancements.
• Discuss with Peers and Mentors
• Peer Feedback: Discuss potential topics with classmates or colleagues. They might offer insights or suggest areas you hadn’t considered.
• Mentor Guidance: Seek advice from professors or experienced researchers. They can guide you towards viable topics and methodologies.
• Assess Feasibility
• Resources: Consider the resources available to you, such as access to equipment, databases, and funding.
• Timeframe: Evaluate the time you have for research. Ensure your topic is manageable within the given timeframe.
• Narrow Down and Define
• Specificity: Narrow your topic to a specific question or problem. Broad topics can be overwhelming and challenging to research effectively.
• Clear Objective: Define a clear research question or hypothesis. This guides your study’s direction and methods.
• Brainstorm Potential Topics
• Use the Outline: Refer to the outline provided earlier for inspiration. Consider topics in musculoskeletal, neurological, pediatric, geriatric, or cardiovascular physiotherapy.
• Innovative Approaches: Explore the use of technology, patient compliance, psychological aspects, or sports-related research.
• Evaluate Ethical Considerations
• Ethical Approval: Ensure your chosen topic aligns with ethical guidelines. Consider factors like informed consent, patient privacy, and data handling.
• Choose Your Topic!
• Final Selection: After considering all these factors, select a topic that excites you, addresses a gap in the field, and is feasible within your resources and timeframe.

Remember, choosing a research topic is an exciting journey. Embrace the opportunity to contribute to the field of physiotherapy, improve patient care, and expand your knowledge and skills.

151+ Research Topics For Physiotherapy Students: Category Wise

Musculoskeletal physiotherapy.

• Effectiveness of Kinesio Taping in Ankle Sprains
• Comparison of Manual Therapy and Exercise for Low Back Pain
• The Role of Pilates in Improving Core Strength and Stability
• Efficacy of Dry Needling in Myofascial Pain Syndrome
• Impact of Virtual Reality on Rehabilitation After ACL Reconstruction
• Muscle Imbalance and its Relationship to Injury Risk
• Use of Blood Flow Restriction Training in Muscle Rehabilitation
• Effectiveness of Cupping Therapy for Musculoskeletal Pain
• Effects of Different Running Techniques on Knee Joint Stress
• Long-Term Effects of High-Intensity Interval Training on Muscle Function

Neurological Physiotherapy

• Rehabilitation Strategies for Improving Balance in Multiple Sclerosis
• Impact of Aquatic Therapy on Motor Function in Parkinson’s Disease
• Effectiveness of Constraint-Induced Movement Therapy in Stroke Recovery
• Virtual Reality for Upper Limb Rehabilitation in Stroke Patients
• Gait Training Techniques for Individuals with Cerebral Palsy
• Neuroplasticity and its Implications for Rehabilitation
• Role of Robotics in Neurological Rehabilitation
• Effects of Tai Chi on Balance and Fall Prevention in Older Adults with Stroke
• Music Therapy for Motor Rehabilitation in Stroke Survivors
• Vestibular Rehabilitation in Patients with Vestibular Disorders

Cardiovascular and Pulmonary Physiotherapy

• Cardiac Rehabilitation Programs: Effectiveness and Adherence Rates
• Inspiratory Muscle Training for COPD Patients
• Role of Yoga in Improving Cardiovascular Health
• Exercise Prescription for Patients with Heart Failure
• Effects of High-Altitude Training on Lung Function
• Pulmonary Rehabilitation in Patients with Chronic Respiratory Diseases
• Non-Invasive Ventilation in Neuromuscular Disorders
• Effects of Smoking Cessation on Respiratory Function
• Impact of Breathing Exercises on Asthma Control
• Exercise Interventions for Pulmonary Hypertension

Pediatric Physiotherapy

• Early Intervention Programs for Children with Developmental Delays
• Hydrotherapy for Pediatric Rehabilitation
• Motor Learning Strategies in Children with Autism Spectrum Disorder
• Constraint-Induced Movement Therapy in Pediatric Hemiplegia
• Sensory Integration Therapy for Children with Sensory Processing Disorder
• Effects of Biking on Gross Motor Skills in Children
• Role of Play-Based Therapy in Pediatric Rehabilitation
• Pediatric Obesity and its Impact on Musculoskeletal Health
• Effects of Early Mobility in Preterm Infants
• Dance Therapy for Children with Cerebral Palsy

Geriatric Physiotherapy

• Falls Risk Assessment and Prevention Strategies in Older Adults
• Effectiveness of Chair Yoga in Elderly Fall Prevention
• Role of Physical Activity in Cognitive Function in the Elderly
• Home-Based Exercise Programs for Aging Adults
• Effects of Tai Chi on Balance and Mobility in Elderly
• Impact of Nutritional Interventions on Sarcopenia
• Role of Multidisciplinary Teams in Geriatric Rehabilitation
• Frailty Screening Tools and Interventions
• Effects of Ageism on Physical Activity in Older Adults
• Dementia and Exercise: Benefits and Challenges

Sports Physiotherapy

• Prevalence and Risk Factors of Sports Injuries in Soccer Players
• Effectiveness of Taping Techniques in Athletes
• Return to Play Guidelines Following ACL Reconstruction
• Role of Biomechanics in Running Injury Prevention
• Sports-Specific Rehabilitation Protocols
• Impact of Sports Specialization on Injury Risk in Youth Athletes
• Effects of Cryotherapy on Muscle Recovery
• Psychological Factors in Sports Injury Rehabilitation
• Nutritional Strategies for Performance Enhancement in Athletes
• Role of Physiotherapy in eSports Injury Prevention

Women’s Health and Pelvic Physiotherapy

• Pelvic Floor Muscle Training for Stress Urinary Incontinence
• Effects of Pregnancy on Musculoskeletal Health
• Postpartum Exercise Programs and Recovery
• Role of Physiotherapy in Pelvic Organ Prolapse Management
• Chronic Pelvic Pain Management Strategies
• Diastasis Recti: Assessment and Rehabilitation
• Impact of Menopause on Bone Health and Exercise
• Role of Physiotherapy in Breast Cancer Rehabilitation
• Pre- and Post-Operative Physiotherapy for Gynecological Surgeries
• Pelvic Girdle Pain in Pregnancy: Assessment and Treatment

Orthopedic Physiotherapy

• Manual Therapy Techniques for Frozen Shoulder
• Effects of TENS Therapy on Osteoarthritis Pain
• Post-Operative Rehabilitation Following Total Knee Replacement
• Role of Physiotherapy in Rotator Cuff Tears
• Conservative Management of Lumbar Disc Herniation
• Motor Control Exercises for Patellofemoral Pain Syndrome
• Effects of PNF Techniques on Range of Motion
• Role of Physiotherapy in Ankle Instability
• Prehabilitation Programs for Anterior Cruciate Ligament Tears
• Postural Correction Strategies for Neck Pain

Occupational Physiotherapy

• Ergonomics and Workplace Injury Prevention
• Role of Physiotherapy in Work Rehabilitation Programs
• Return to Work Interventions for Musculoskeletal Injuries
• Job Demands Analysis and Physical Capacity Assessments
• Effects of Standing Desks on Musculoskeletal Health
• Role of Physiotherapy in Hand Rehabilitation
• Post-Operative Rehabilitation Following Hand Surgery
• Workplace Stress and its Impact on Musculoskeletal Health
• Functional Capacity Evaluations in Occupational Settings
• Role of Physiotherapy in Ergonomic Design Consultations

Pain Management

• Multimodal Approaches to Chronic Pain Management
• Effects of Mindfulness-Based Stress Reduction on Pain Perception
• Role of Physiotherapy in Fibromyalgia Management
• Cognitive Behavioral Therapy for Chronic Pain
• Pain Neuroscience Education for Patients with Persistent Pain
• Effects of Acupuncture on Chronic Low Back Pain
• Role of Physiotherapy in Complex Regional Pain Syndrome
• Telehealth for Pain Management
• Pain Catastrophizing and its Influence on Treatment Outcomes
• Effects of Sleep Quality on Pain Perception

Rehabilitation Technology

• Wearable Technology for Monitoring Physical Activity
• Virtual Reality for Motor Rehabilitation
• Robotics in Rehabilitation: Current Trends and Future Directions
• Smart Textiles for Monitoring Muscle Activity
• Tele rehabilitation: Benefits and Challenges
• 3D Printing in Orthopedic Rehabilitation
• Biofeedback Systems for Muscle Rehabilitation
• Wearable Sensors for Gait Analysis
• Virtual Reality for Phantom Limb Pain
• Brain-Computer Interfaces in Stroke Rehabilitation

Health Promotion and Wellness

• Effects of Exercise on Mental Health and Wellbeing
• Role of Physiotherapy in Obesity Management
• Exercise Programs for Older Adults in Assisted Living Facilities
• Workplace Wellness Programs: Impact on Employee Health
• Community-Based Exercise Programs for Cardiovascular Health
• Effects of Mindfulness Meditation on Stress Reduction
• Role of Physiotherapy in Smoking Cessation Programs
• Nutritional Counseling for Chronic Disease Prevention
• Exercise Prescription for Mental Health Disorders
• Impact of Social Support on Physical Activity Adherence

Rehabilitation in Specific Populations

• Effects of Exercise on Bone Density in Postmenopausal Women
• Role of Physiotherapy in Refugee Rehabilitation
• Rehabilitation Needs of LGBTQ+ Individuals
• Cultural Competence in Physiotherapy Practice
• Effects of Exercise on Immune Function in Cancer Patients
• Role of Physiotherapy in Prison Rehabilitation Programs
• Rehabilitation Challenges in Homeless Populations
• Effects of Exercise on Quality of Life in HIV/AIDS Patients
• Role of Physiotherapy in Rehabilitation After Human Trafficking
• Exercise Programs for Individuals with Disabilities

Innovative Approaches in Rehabilitation

• Biofeedback Training for Improving Motor Control
• Effects of Exergaming on Physical Function in Older Adults
• Role of Photobiomodulation Therapy in Tissue Healing
• Virtual Reality for Pain Management in Burn Patients
• Mindfulness-Based Interventions for Chronic Fatigue Syndrome
• Role of AI and Machine Learning in Rehabilitation
• Effects of Hippotherapy on Balance and Coordination
• Role of Music Therapy in Rehabilitation
• Hydrogen Water Therapy for Musculoskeletal Injuries
• Role of Graded Motor Imagery in Chronic Pain Rehabilitation

Ethics and Professionalism in Physiotherapy

• Informed Consent Practices in Physiotherapy Research
• Confidentiality in Telehealth Consultations
• Role of Physiotherapists in Health Advocacy
• Ethical Considerations in Exercise Prescription
• Cultural Competence in Patient Care
• Role of Physiotherapists in End-of-Life Care
• Patient Autonomy and Shared Decision-Making in Treatment
• Professional Boundaries in Physiotherapy Practice
• Ethical Implications of Social Media Use for Physiotherapists
• Conflict of Interest in Physiotherapy Research

Global Health and Physiotherapy

• Role of Physiotherapists in Disaster Relief Efforts
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• Open access
• Published: 13 April 2022

Potential of digitalization within physiotherapy: a comparative survey

• Katharina Estel 1 ,
• Julian Scherer 2 ,
• Heiko Dahl 3 ,
• Eva Wolber 3 ,
• Noah D. Forsat 4 &
• David A. Back 1  

BMC Health Services Research volume  22 , Article number:  496 ( 2022 ) Cite this article

4946 Accesses

10 Citations

Metrics details

Due to the global digitalization, implementation of digital elements into daily work can support physiotherapists’ work but may also pose some challenges. Only little is known about physiotherapists’ attitude towards digitalization. This study primarily aimed to analyze physiotherapists’ attitude towards digitalization and to what extend digital tools have been implemented into their daily work. In second analysis, participants’ characteristics such as age, working place, gender and mode of survey participation were assessed.

A 12-main-item survey amongst voluntary course participants of one physiotherapeutic training center was conducted via paper-based as well as online questionnaires between July 2018 and June 2019 including questions on participants’ general as well as particular attitude towards digitalization, the use of (mobile) applications and possible advantages and disadvantages of the ongoing digital transformation. Sub-analysis was performed for age (≤40 years versus > 40 years), gender, mode of participation (paper vs. online) and working place (practice vs. hospital).

Overall, 488 physiotherapists participated in the survey. In comparison of the age groups, younger participants had more concerns about data security ( p  = 0.042) and insufficient financial remuneration ( p  < 0.001). Younger participants stated higher satisfaction with data literacy than their counterparts ( p  = 0.0001). Physiotherapists working in the outpatient sector, rather than in hospitals, expected digitalization to increase more in relevance ( p  < 0.001). The online respondents (OG) indicated that they had more knowledge about key aspects of the current legal situation regarding digitalization than participants completing the paper-based survey ( p  = 0.002). 50.4% of the considered digitalization as useful for their job.

Conclusions

The majority of participants saw high potential for digitalization in the physiotherapy sector. Younger physiotherapists seem to be more concerned about data security and insufficient financial remuneration. Physiotherapists in the outpatient sector seem to see more potential in digital transformations. General concerns like missing reimbursement, lack of data security or knowledge on legal frameworks should be addressed in the future. Further studies should focus on identifying specific digital tools which can support physiotherapists.

Peer Review reports

The current digital transformation can be seen as a central topic of our modern society and is also affecting the healthcare sector to a vast extend [ 1 ]. While some medical disciplines, such as radiology, have already been highly influenced by digital innovations, others with need for a physical examination, such as orthopedics, are rather in an early stage of digital adaptation [ 2 ]. As a healthcare discipline with close and intense patient contact, but also with many aspects of transportable digital knowledge, physiotherapy is also increasingly affected by digital influences [ 3 , 4 ].

The use of electronic documentation can increase work efficiency by standardizing work processes and can help monitoring measured physical parameters such as the range of motion (ROM) [ 5 ]. In the context of telehealth, studies have shown, that a physiotherapeutic assessment of the knee with digital tools (e.g., telehealth) appears to be feasible and reliable [ 6 , 7 ]. Furthermore, telehealth offers the possibility to reach many patients and to reduce costs while being also available for patients in remote areas [ 8 , 9 , 10 , 11 ]. For surgical patients, telehealth has been shown to be as effective as usual hands-on care in specific settings [ 12 , 13 ]. Therefore, telehealth can have a positive impact on health outcomes and patients’ satisfaction [ 5 , 9 , 10 ]. As another relevant digital field, mobile health applications (mHealth) have been reported to support physiotherapeutical treatment with a high level of patient satisfaction [ 14 ]. In combination with mobile applications, wearable devices can be successfully used for real-time and comprehensive patient monitoring [ 15 ]. Positive attitudes towards mHealth instruments amongst physiotherapists have been shown in a previous study [ 16 ]. On the other hand, several studies have shown that patients as well as physiotherapists are generally concerned about data security, which seems to remain a disadvantage of digitalization [ 17 , 18 , 19 ].

Besides many promising digital devices and procedures, the field of physiotherapy has some challenges to face [ 5 ]. For example, certain groups of patients, such as children or elderly people, may have trouble using telehealth [ 20 ]. Furthermore, in some countries, digital practices are not recognized by health-insurance companies, and therefore are not adequately reimbursed [ 5 , 21 , 22 ]. However, during the rapid spread of digitalization within the healthcare system, the legal framework can be expected to be further adapted.

Especially during the SARS-CoV-19 pandemic, digitalization has gained enormous importance [ 23 ]. Several studies have shown an increased use of telehealth due to governmental measurements and in order to protect staff as well as patients, underlining the need for new digital tools [ 24 , 25 ].

The present study aimed to identify physiotherapists’ attitude towards digitalization and how far digital features have already found their way into their everyday work before the Covid-19 pandemic. Furthermore, we aimed to identify factors contributing to participants’ attitudes such as gender, working place, age and – as potential bias [ 26 , 27 ] – online versus hard-copy participation (mode of participation).

Study design

A survey amongst physiotherapists was conducted at a large physiotherapeutic training center with participants from all over Germany (Physio-Akademie gGmbH Wremen, Wurster Nordseeküste, Germany). The Physio-Akademie is an educational institution and scientific institute offering continuous education and training, research as well as development in physiotherapy. It cooperates with universities and scientific institutions and offers classes and online courses for physiotherapists. In 2021, approximately 3.200 participants from all over Germany attended courses, making the Physio-Akademie one of Germany’s biggest physiotherapeutic training institutions. The survey was conducted from July 2018 to June 2019 among course participants. The participants were asked to either complete the survey online using SurveyMonkey® (SurveyMonkey Inc., Oregon, USA) (online group = OG) or using hard copies (presence group = PG). The allocation of the participants to one of the two modes of survey completion was random. Further subgroups were formed for age (≤40 years versus > 40 years, arbitrary threshold), working place (outpatient sector versus hospital sector) and gender (female versus male).

Participation was voluntary and anonymity was granted. All participants received a written information explaining the aim of the study and processing of their data. By answering the questionnaire, participants gave consent to the use of the data that they had provided. Ehtical approval was granted by the local ethics committee.

Questionnaire

The questionnaire was developed based on a non-published questionnaire for orthopedic and trauma doctors. The further literature backgrounds were a German survey conducted by the German medical association “Marburger Bund” among 1800 employed physicians in september/october 2017 on the topic of digitalization [ 28 ] and a survey by Blumenthal et al. among 76 physiotherapists in Canada [ 16 ]. The questionnaire was validated by a group of physiotherapists and physicians (KE, JS, HD, EW, NDF, DAB). The final questionnaire consisted of 12 questions, aiming to assess the attitude and the use of digital tools amongst physiotherapists. The questions were divided into three groups that addressed the following areas of interest:

Sociodemographic data (age, gender) and place of employment (three questions).

Attitude towards digitalization and the use of digital features: Participants’ opinion, own digital knowledge (= data literacy), use of applications, the perceived potentials and pitfalls of digitalization, the importance of “Big Data” or “artificial intelligence”, the use of digital services in the work environment and the existing knowledge about essential aspects of the current legal situation regarding digitalization (eight questions).

In a concluding open question, participants were able to report comments (one question).

In three questions, where rating scales were used, the number “1” was set as the highest positive consent.

Data analysis

For statistical analysis, SPSS (version 27.0, IBM Corp., Armonk, NY, USA) was used. Non-parametric median-test was applied for analysis of non-categorical data. Categorical data were analyzed by chi-square test. A subgroup analysis was performed for the above-mentioned topics, age, gender, working sector and online versus hard copy participation. The level of significance was set at p  < 0.05. The free-text answers were analyzed by two independent experts for repetitive sequences. A systematic rule-driven qualitative text analysis was performed using techniques of qualitative content analysis according to Mayring: the free-text responses were selected from the questionnaires and examined for essential question content; a summary was performed to reduce the responses to a short text, and the summaries were analyzed; the results were interpreted; and a quality analysis was performed to ensure that the appropriate criteria were met [ 29 ].

Sociodemographic data

A total of 488 physiotherapists participated in the survey (167 male, 314 female, 7 missing, 1.4%). Of all participants, 263 (53.9%) conducted the survey online and 225 (46.1%) on paper sheets. 269 (55.1%) of the participants were 40 years of age or younger, compared to 197 (40.4%) participants with an age of more than 40 years (22 missing, 4.5%). 54 (11.1%) participants were from the hospital sector, whereas 427 (87.5%) were employed in the outpatient sector (7 missing, 1.4%).

Opinion on digitalization

50.4% ( n  = 246) of all participants stated (rating scale 1–5), that digitalization was interesting and that they would use it, if any benefit was seen. No statistical differences were assessed for gender, mode of participation, participants’ age groups or job assignments. Further results are shown in Table  1 .

Data literacy

On a given scale from 1 (very good) to 6 (insufficient), one third ( n  = 176 (36.1%), 27 missing) stated that they were satisfied with their data literacy (mean 2.92, SD 1.03). Younger participants rated a higher satisfaction than older ones ( p  = 0.0001). Further results are shown in Table 1 .

Smartphone app usage

In regards of mobile app usage, 99 (20.3%) participants stated that they used it for their own organizational support, 135 (27.7%) for their professional support, 252 (51.6%) for communication with colleagues, 61 (12.5%) for communication with patients (e.g., own practice app, apps for therapy documentation, etc.) and 96 (19.7%) participants indicated that they did not want to use any apps for work purposes. Significant differences for the comparisons of age groups, mode of participation, and job assignments are shown in Table 1 .

Potential of digitalization

With regards to the potential of digitalization (with multiple answers possible) most participants stated that digitalization could make work easier (67.6%), followed by better communication between colleagues (58.2%) and with patients (32.8%) [Fig.  1 ]. Differences between the sub-groups are shown in Table 1 . Figure  2 shows an overview of the potential problems reported by the participants, with most answers agreeing on data protection concerns ( n  = 264, 54.1%), followed by concerns about the high effort regarding a successful implementation of new digital tools ( n  = 222, 45.5%) and concerns about insufficient financial compensation ( n  = 193, 39.5%). Further results are shown in Table 1 .

Potential of digitalization within the field of physiotherapy estimated by the survey participants ( n  = 488; multiple answers possible)

Potential problems associated with digitalization within the field of physiotherapy by the survey participants ( n  = 488; multiple answers possible)

Importance of big data or artificial intelligence

When asked about the importance of Big Data or artificial intelligence (AI) (rating scale 1–4), 24 (4.9%), physiotherapists indicated that both will significantly shape the way of their work and 256 (52.5%) stated that this topic will increase in relevance. 70 (14.3%) of the participants stated that Big Data or AI will not play a significant role in physiotherapy and 88 (18.0%) stated that both will be irrelevant for their work (50 answers missing, 10.2%). Further results are shown in Table 1 .

Digital services in use

When asked about digital services already used for their work, 74.8% ( n  = 365) indicated that they were using a website and 74% ( n  = 361) were using emails. Only 6 participants (1.2%) were using online video consultations [Fig.  3 ]. Further results are shown in Table 1 .

Digital services already used by the survey participants ( n  = 488; multiple answers possible)

Awareness of current legal situation

The majority of the surveyed physiotherapists ( n  = 252, 45 missing) stated that they were rather unaware of key aspects of the current legal situation regarding digitalization (mean 2.74, SD 0.68) (rating scale 1–4, with one being aware and 4 being completely unaware). PG participants were lesser informed than OG ( p  = 0.002). Further results are shown in Table 1 .

Free comments on “digitalization”

Most comments focused on the wish to uniform laws and an implementation of the acquisition of data literacy in training/studies. In addition, the hope for easier cooperation with other professional groups in the future was mentioned. Concerns were lacking data security and financial remuneration, and that contact with patients could change negatively.

With the current digital transformation of the healthcare system, also physiotherapy is increasingly affected by new developments [ 3 , 4 , 30 ]. Various elements like electronic documentation, telehealth and mHealth can make physiotherapists’ daily work easier and increase their efficiency [ 5 , 6 , 14 ]. Thus, the primary aim of the present study was to investigate the attitude towards different aspects of digitalization amongst physiotherapists. Furthermore, a sub-analysis of participants’ age, workplace, gender, and mode of survey participation aimed to assess factors contributing to the surveyed physiotherapists’ attitudes.

Half of all participants stated that digitalization was interesting and that they would use elements of it, if it suited their work. In addition, most of the participants considered the potential of digitalization very high. This result is consistent with findings of a previous study, which showed that the work of physiotherapists can be made easier and more efficient by implementing digital tools [ 5 ]. Younger participants agreed with this statement significantly more often than their elderly counterparts. Furthermore, this group also stated significantly more often that communication with colleagues would be more feasible compared to the older group of participants. To our knowledge, this facet of digitalization has not yet been investigated in other studies, but a stronger affinity to digitalization among the younger generation of physiotherapists [ 31 ].

Websites and e-mails were the most frequently utilized digital services in the surveyed participants. Only a few physiotherapists, especially the participants over 40 and those working in the outpatient sector, had used online video consultations. This is unexpected since several studies have shown that telehealth can be equivalent to conventional treatments, and other health disciplines are already using this digital tool [ 12 , 13 , 24 , 25 ]. This finding suggests that several digital tools have not yet been implemented widely amongst physiotherapists [ 32 ] and might go along with the findings presented in this study, that only one third of those surveyed stated, that they were satisfied with their data literacy. To our knowledge, there is no comparative data in the literature on digital skills for physiotherapists and possible reasons for this finding remain unclear. However, a survey of nurse trainees on eHealth skills showed that 45% of respondents were satisfied with their internet skills [ 33 ]. E-Health can be referred to as the use of information and communications technologies in support of health and health-related fields [ 34 ]. Nevertheless, another study on eHealth competence among college students revealed a relatively high percentage of incorrect self-assessment for these abilities [ 35 ], so that the presented results should be examined further in future studies.

Almost one fifth of physiotherapists in the present study had not yet used digital applications in their everyday work. The literature also showed that mHealth is not yet considered an integral part amongst health care professionals and especially not physiotherapists [ 36 , 37 ], although several studies have proved advantages of digital tools regarding patients’ satisfaction [ 14 , 38 ]. Insufficient knowledge and low experience were identified as potential causes of low digital usage in health professions in a previous study [ 37 ]. Other authors reported that available mHealth tools did not meet physiotherapists’ usage expectations [ 16 ].

Most of the participants in the present study stated, that they used digital tools to organize their own work or practice. This can be seen as promising for the future, since the use of mHealth in surgical patients, in the peri- and postoperative phases, showed to have a positive effect and treatment plan adherence [ 39 ].

Amongst several positive aspects of digitalization, this study also assessed concerns of the surveyed participants. Previous studies have identified lacking security and privacy of data as potential disadvantages [ 40 , 41 ], which were also the main concern in the present study. Younger participants as well as participants in the online survey stated these concerns more frequently than their counterparts. Furthermore, especially younger physiotherapists had concerns about the integration of new technologies into existing systems, which is consistent with findings of a previous study [ 40 ].

Like in all other areas, digitalization within physiotherapy also includes the topics “Big Data” and “artificial intelligence”, which are becoming increasingly important [ 42 ]. Large-scale patient-related data analysis can successfully help developing new treatment strategies [ 32 , 43 ]. Furthermore, with the help of personal data, clinical records, exercise evaluations and videos, physiotherapists may receive support for the assessment and evaluation of treatment results [ 40 ]. Most of the physiotherapists in the present cohort also considered these topics important for their future work. However, nearly 20% of respondents said that Big Data and AI were not increasingly relevant to them. Female physiotherapists and physiotherapists working in the outpatient sector considered this topic to be less relevant. To the author’s believe, possible reasons for this phenomenon are lack of data, lack of experience in using digital tools [ 37 ], or reluctance to include digital tools into one’s work.

In our study, most physiotherapists stated that they were unaware of key aspects of the current legal situation regarding digitalization. In Germany, the first newer legislative initiatives on digitalization of the healthcare system by the government have taken place since 2015 and have been significantly expanded since then [ 43 ]. Thus, the attitude and engagement of physiotherapists to digitalization might have changed till today, especially also in the context of the current Covid-19 pandemic. Yet, it also must be taken into consideration that political goals and strategies for implementing digitalization may vary between countries and hence also physiotherapists’ attitudes in a multinational comparison . Amongst the few who stated to have better knowledge of this, physiotherapists over 40 years, and online respondents were predominant. For the group of elderly participants, this could be due to greater work experience. There are no existing comparative studies for physiotherapists in this regard. However, the legal situation regarding digitalization within the healthcare system may vary between national and international levels [ 44 , 45 ]. This could make it more difficult for an individual user to build up knowledge about the key aspects of the current legal situation. Physiotherapeutic associations and societies can play a front role for providing information and orientation to address this issue.

The study is limited by the number of participants compared to the number of active physiotherapists in Germany, making it not representative. Therefore, − especially in the current situation with the Sars-CoV-19 pandemic – the presented data should be further validated in multi-center studies with a larger sample size and also in direct relation to measurable improvements of digital tools in medicine. In this context, another limitation is the self-reporting character and thus subjective source of the current data, making a more objective data generation necessary. Since the presented results must be considered incongruent, this study cannot give deduction on a relevant bias of online versus paper-based surveys on digital topics. Another serious limitation of this study was that a definite survey response rate could not be stated, since the exact number of recipients was distorted due to unclear numbers of not-received emails and absences in the courses at the day of evaluation.

A further limitation is the fact that the survey participation in a paper-based or online mode was defined by the authors, which may have influenced the outcome. Additionally, questions on the potential advantages as well as potential problems of digitalization, had predefined answer options. This means that the entire range of answers was most likely not fully covered, which should be addressed in further surveys by adding a free-text comment option. Furthermore, we conducted a post-hoc-power analysis for the working-place subgroup, which revealed inhomogeneous results ranging from 9.8 to 87.1%.

The majority of participants saw high potential for digitalization in the physiotherapy sector. Younger physiotherapists seem to be more concerned about data security and insufficient financial remuneration but showed higher digital affinity and a significant higher satisfaction with their data literacy. Physiotherapists in the outpatient sector seem to see more potential in digital transformations. General concerns like missing reimbursement, lack of data security or knowledge on legal frameworks should be addressed in the future. Further studies should focus on identifying specific digital tools which can support physiotherapists, preferably in close cooperation with active physiotherapists to enhance acceptance within the physiotherapeutical society.

Availability of data and materials

The datasets generated during and analyzed during the current study are not publicly available since the authors did not obtain consent from the participants to publish raw data publicly but are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to thank A. Broughton for the kind support in native proofreading of the manuscript.

This research did not receive any specific grant or funding.

Author information

Authors and affiliations.

Clinic for Traumatology and Orthopedics, Bundeswehr Hospital Berlin, Scharnhorststrasse 13, 10115, Berlin, Germany

Katharina Estel & David A. Back

Department of Traumatology, University Hospital of Zurich, Raemistrasse 100, 8091, Zürich, Switzerland

Julian Scherer

Physio-Akademie gGmbH Wremen, Wremer Specken 4, 27639, Wuster Nordseeküste, Germany

Heiko Dahl & Eva Wolber

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KE, HD, EW and DAB designed the analysis. HD and EW collected the data. KE, JS, NDF and DAB performed the analysis. All authors participated in writing the manuscript. All authors read and approved the final version of the manuscript.

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Estel, K., Scherer, J., Dahl, H. et al. Potential of digitalization within physiotherapy: a comparative survey. BMC Health Serv Res 22 , 496 (2022). https://doi.org/10.1186/s12913-022-07931-5

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ORIGINAL RESEARCH article

Improved motor skills in autistic children after three weeks of neurologic music therapy via telehealth: a pilot study.

• 1 Music and Health Science Research Collaboratory, Faculty of Music, University of Toronto, Toronto, ON, Canada
• 2 College of Music and Performing Arts, Belmont University, Nashville, TN, United States
• 3 Bloorview Research Institute, University of Toronto, Toronto, ON, Canada
• 4 Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
• 5 KITE Research Institute, University Health Network, Toronto, ON, Canada
• 6 Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada

Background: Many autistic children experience motor skill deficits which can impact other areas of functioning, and research on therapeutic interventions for motor skills in autism is in a preliminary stage. Music-based therapies have been used extensively to address motor skills in non-autistic populations. Though a handful of studies exist on the effects of music-based therapies for movement in autistic children, none have investigated the possibility of administering sessions via telehealth. This mixed-methods pilot study investigated whether nine Neurologic Music Therapy (NMT) ® sessions via telehealth would improve motor and attention skills in autistic children.

Methods: Five autistic children between five and 10 years of age participated in the study, with support from their caregivers. Motor skills were assessed using the Bruininks-Oseretsky Test of Motor Proficiency second edition, short form (BOT-2 SF), and a selective attention and sustained attention task were taken from the Test of Everyday Attention for Children, Second Edition (TEA-Ch2). Caregivers and the two neurologic music therapists involved in the study provided qualitative input about the perceived effectiveness of telehealth NMT for the children involved. Their responses were analyzed using qualitative content analysis. Caregivers also filled out a Sensory Profile 2 assessment prior to the onset of sessions so that each child’s sensory profile could be compared to their motor and attention results.

Results: Statistically significant improvements in motor skills were observed between pre-test assessment and a two-week follow-up assessment. Results from attention test scores were not significant. Caregivers and neurologic music therapists generally perceived sessions positively and noted the importance of having caregivers actively involved. When compared with individual progress on the BOT-2 SF assessment, sensory profile results revealed that children with fewer sensory sensitivities tended to improve the most on motor skills. The improvements in motor skills and positive caregiver and therapist views of telehealth indicate that NMT motor interventions administered via telehealth are a promising avenue of therapeutic support for movement skill development in autistic children.

1 Introduction

Autism spectrum disorders (ASD, or autism) comprise a range of conditions involving difficulties with social communication and interaction as well as restricted or repetitive patterns of behaviors and interest ( American Psychiatric Association, 2013 ). The prevalence of autism diagnoses has been increasing globally. The United States (U.S.) Centers for Disease Control and Prevention (CDC) reported that in the year 2000, around 1 in 150 children in the U.S. were diagnosed with the condition while with the most recent data from 2020, 1 in 36 eight-year-old children in the U.S. were diagnosed with autism ( Centers for Disease Control and Prevention, 2023 ). In addition to the main diagnostic markers, autistic individuals often experience sensory hypo- and hyper-sensitivities, struggles with attention, and difficulties with motor skills ( Fournier et al., 2010 ; Liu, 2013 ; LaGasse et al., 2019 ). Music-based interventions have increasingly been used to support neurodevelopmental skills in autistic individuals, including movement skills ( Braun Janzen and Thaut, 2018 ). In recent years, clinicians and researchers have been exploring how to implement therapeutic interventions for autistic individuals via online video platforms as well as in-person ( Solomon and Soares, 2020 ).

Though movement difficulties are not an official part of the primary autism diagnostic criteria, researchers have increasingly recognized what Kanner and Lesser (1958) observed, that autistic persons also display difficulties with motor functioning ( Fournier et al., 2010 ; Bhat et al., 2011 ; Colombo-Dougovito and Block, 2019 ). In fact, technology that measures movement on a precise level can detect an autism diagnosis with extremely high reliability using movement differences alone ( Torres et al., 2013 ; Milano et al., 2023 ). It is estimated that up to 90% of autistic children may experience motor difficulties such that they can receive a co-occurring diagnosis of developmental coordination disorder ( Miller et al., 2021 ). Difficulties can be observed in gait and balance, arm motor functions such as reaching and grasping, speech motor functions, movement planning, and coordination ( Fournier et al., 2010 ). Many of these motor difficulties in autism involve fundamental movement skills that are essential to child development and socialization: balance, locomotion, and object manipulation ( Gandotra et al., 2020 ). Indeed, motor functioning is not just important to address for its own sake; poor motor skills are also associated with decreased outcomes in social, language, and cognitive areas like attention, memory, and executive functioning ( Wilson et al., 2018 ; Zampella et al., 2021 ). High-quality intervention studies involving motor outcomes for autistic individuals are few though increasing [for reviews, see Colombo-Dougovito and Block (2019) , Gandotra et al. (2020) , Ruggeri et al. (2020) , Frazão et al. (2023) , and Ji et al. (2023) ]. There is ample room for expansion of this research topic, particularly toward identifying replicable and generalizable interventions addressing motor skills for individuals on the spectrum.

The potential for music to be used as a motor intervention for autistic individuals is high ( Hardy and LaGasse, 2013 ). There is substantial evidence for positive effects of standardized music-based interventions on motor impairments in conditions other than autism including cerebral vascular accident (stroke), Parkinson’s disease, traumatic brain injury, cerebral palsy, and more [reviewed in Braun Janzen et al. (2022) ]. Music-based interventions are often successful in treating motor aspects of neurological conditions because the auditory system has extensive connections with motor areas in the brain such as premotor areas, basal ganglia, and the cerebellum ( Grahn and Brett, 2007 ; Chen et al., 2008 ). Isochronous (and thus predictable) auditory cues entrain neurons of the auditory cortex, and prime motor areas to become ready to move [discussed in Braun Janzen et al. (2022) ]. Engaging in active therapeutic music making has also been associated with improvements in neural connectivity and associated functional motor recovery across clinical populations ( Sharda et al., 2018 ; Braun Janzen et al., 2022 ). Music-based therapies have been used to address many issues in autism such as social skill challenges, language and communication issues, and emotional/coping skills [see Braun Janzen and Thaut (2018) , for a review]. This may be because autistic individuals often respond well to music, potentially due to increased sensitivity to musical parameters like pitch and a greater response in the inferior frontal gyrus (speech area) to sung versus spoken language ( Kuhl et al., 2005 ; Lepistö et al., 2005 ; Sharda et al., 2015 ). Recent studies indicate that auditory-motor pathways appear to be functioning typically in individuals on the autism spectrum even though they often struggle with movement and sensorimotor integration ( Tryfon et al., 2017 ; Edey et al., 2019 ; Jamey et al., 2019 ). Because autism is a highly heterogeneous condition, not every autistic person may respond well to musical stimuli ( Ferrari and Harris, 1981 ; Ingersoll et al., 2003 ).

The research on music interventions used specifically for movement in autistic individuals is increasing. Srinivasan and Bhat (2013) reviewed a handful of studies investigating the effects of music-based interventions for motor difficulties in autistic persons, with many reports of positive results. More recently, Sharda et al. (2018) found that an 8–12-week music therapy intervention improved auditory motor connectivity in autistic children ages 6–12 years old. Srinivasan et al. (2015) found that autistic children engaged in a rhythmic-movement-imitation intervention (along with those in a robotics-movement group) improved on the body coordination composite of a motor assessment compared to a control group. Shemy and El-Sayed (2018) found significant improvements in bilateral coordination, balance, running speed and agility, and strength in 8–10-year-old children on the autism spectrum who received a three-month, three times-per-week Rhythmic Auditory Stimulation (RAS ® ) intervention compared to a control group who received physiotherapy. Imankhah et al. (2018) found that autistic boys who received 15 twice-weekly sessions involving music- and rhythm-based play and movement activities improved significantly more on motor coordination than those who did not receive treatment. Finally, a study by Shukla et al. (2022) sought to use traditional Indian Tabla drumming to promote upper-extremity motor skills needed for tooth-brushing. They reported basing their protocol on the recommendations of Thaut (1984) who promoted the use of carefully structured clinical music improvisation to address clinical goals with autistic children. Significant improvements were found in motor and social skills after the intervention in Shukla et al. (2022) study. These studies have promising results regarding the effects of music on movement in autistic individuals.

In addition to motor challenges, individuals on the autism spectrum are known to experience hypo- and hyper-sensitivities to sensory stimuli ( American Psychiatric Association, 2013 ). Sensation (particularly in the visual and proprioceptive realms) is critical for motor functioning, and thus difficulties in sensory processing such as poor sensory integration or sensory sensitivities can influence motor difficulties in autistic individuals ( Baranek, 2002 , Liu, 2013 ; Muthusamy et al., 2021 ; Purpura Cerroni et al., 2022 ). Sensory sensitivities can thus affect autistic persons’ ability to engage in therapeutic or other activities. Thus, when developing interventions to address motor skills in autistic individuals, sensory sensitivities must be considered. Related to sensory issues is attention. Autistic individuals sometimes experience difficulty utilizing selective attention to focus on one aspect of incoming sensory information and inhibit others ( LaGasse et al., 2019 ).

Research on interventions for sensory difficulties in autism is increasing [for reviews, see Case-Smith et al. (2015) and Weitlauf et al. (2017) ]. Berger (2002) wrote a book on music therapy for sensory integration in autistic children, which provides a helpful conceptual overview on the topic based on her experience as a clinician along with anecdotal evidence. The book claimed that music engagement helps to anchor and organize autistic children’ sensory systems so that they can engage intentionally in their environments. Mertel (2014) outlined a protocol in which the NMT technique Auditory Perception Training (APT) ® can be used to facilitate sensory integration for populations including autistic individuals. In APT, individuals engage in interventions structured by an isochronous auditory beat along with multiple sensory inputs. By engaging in such interventions, sensory integration occurs, creating positive downstream effects on other areas of functioning such as cognition, executive functions, and execution of more complex movement skills. High-quality evidence for benefits of music-based interventions to address sensory difficulties in autism remains scarce. In their feasibility study, Lagasse et al. (2019) found that a music therapy attention intervention seemed to improve sensory gating in autistic children, though results were not statistically significant. The current study did not directly target sensory functioning aside from sensory-focused warm-ups at the beginning of sessions, as needed. The sensory profile of each child was considered when implementing motor interventions and interpreting results.

Online health services or telehealth was utilized in therapy with autistic persons prior to the 2019 Coronavirus Disease (COVID-19) pandemic, but its use increased dramatically since the pandemic began ( Ellison et al., 2021 ). Telehealth has been used extensively with autistic individuals especially since the pandemic for diagnosis and therapeutic interventions [for reviews, see Stavropoulos et al. (2022) and Kane and DeBar (2023) ]. Benefits of telehealth included: lower costs due to decreased travel time for therapists/clients ( Lindgren et al., 2016 ; Kalvin et al., 2021 ; Su et al., 2021 ), increased parental engagement in therapy resulting in more transfer of skills to everyday life ( Su et al., 2021 ), access for rural or remote clients ( Ameis et al., 2020 ; Solomon and Soares, 2020 ; Simacek et al., 2021 ), and better engagement with the therapist online due to lower anxiety being in the comfort of their own homes ( Kalvin et al., 2021 ). Disadvantages of telehealth therapy with autistic clients included: increased distractedness on computers or in the home environment ( Kalvin et al., 2021 ), frustrations due to technical difficulties ( Solomon and Soares, 2020 ; Su et al., 2021 ), and greater difficulty providing resources to parents ( Solomon and Soares, 2020 ; Kalvin et al., 2021 ).

Prior to the pandemic, studies concerning the efficacy of online music therapy for autistic clients were limited to a single case study about an autistic teen by Baker and Krout (2009) . The teen had previously engaged in in-person music therapy, later switching to music therapy via telehealth. Baker and Krout (2009) reported that telehealth music therapy was more effective in promoting self-expression and emotional engagement in therapy than in-person therapy. Williams et al. (2024) reported that a music intervention for language goals implemented via telehealth yielded higher engagement in autistic children than a non-music telehealth intervention for language goals. Liu et al. (2023) reported that parents perceived their autistic children broadly improved in social and play skills after a 10 weeks of hour-long Music Enhanced Reciprocal Imitation Training sessions. In previous work by Richard Williams et al. (2022) , qualitative survey data from music therapists working with autistic children over telehealth indicated that telehealth music therapy was possible and music therapists continued to address clinical goal areas for autistic clients, given sufficient technological resources and caregiver support. Attention skills were reported as another important mediating factor associated with the ability to engage in telehealth ( Richard Williams et al., 2022 ). Given the importance of attention for sensory regulation and engagement in telehealth, it was important to assess attention skills as part of the current study.

Research on motor interventions implemented over telehealth for autistic people is limited to one study with preliminary results by Cleffi et al. (2022) . In their report, Cleffi et al. (2022) described an ongoing randomized control trial that they translated from in-person to telehealth. They worked with autistic children and their caregivers over Zoom ( Zoom Video Communications Inc., 2016 ), providing deliveries of materials to each family, and guiding them through various games and play-based interventions that addressed motor skills. Cleffi et al. (2022) described that movement interventions implemented with family assistance appeared successful over telehealth, and pre- and post-testing using the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition (BOT-2) ( Bruininks and Bruininks, 2005 ) and Test of Gross Motor Development (TGMD) will reveal whether there is a difference in results between telehealth motor groups and a parallel in-person motor intervention group. There are currently no published studies examining the effects of music-based interventions on movement in autistic children over telehealth.

The current study piloted the implementation of Neurologic Music Therapy (NMT) ® interventions (rhythmic auditory stimulation [RAS ® ], patterned sensory enhancement [PSE ® ], and therapeutic instrumental music performance [TIMP ® ]) via telehealth in collaboration with caregivers to address motor functioning in autistic children. NMT is an evidence-based set of music-based interventions grounded in research of music perception and cognition ( Thaut and Hoemberg, 2014 ). The three techniques used in the current study, RAS, PSE, and TIMP are motor techniques that have been researched extensively in other clinical populations ( Braun Janzen et al., 2022 ), but very little with autistic persons ( Shemy and El-Sayed, 2018 ), and never directly researched in an intervention study over telehealth ( Cole et al., 2021 ). Music-based therapists practicing NMT lost significantly fewer clinical hours than music-based therapists practicing other models of music therapy, indicating that NMT interventions may be particularly transferable to telehealth ( Richard Williams et al., 2024 ).

The current pilot study was designed to investigate: (1) Do NMT motor techniques (RAS, TIMP, PSE) applied via telehealth improve (a) motor skills and (b) attention in autistic children? (2) What did caregivers and parents perceive as the positive and challenging aspects of the sessions? (3) Did the degree of sensory challenges affect children’s ability to participate in and benefit from telehealth NMT?

2 Materials and methods

2.1 participants.

Five autistic children aged five to 10 years old (four male, one female) and their caregivers were recruited from a large organization serving a diverse population in the Greater Toronto Area. All parents signed a consent form on behalf of their children prior to participating in the study, and each child also signed an assent form which explained the study in a simplified manner. See Table 1 for demographic information. The study also involved four neurologic music therapists: one as the assessor, two who ran sessions (from hereon “therapists”), and one other who helped with qualitative content analysis and acted as a second assessor for one participant to assess inter-assessor reliability. Neurologic music therapists are certified music therapists who have taken additional training in NMT theory and techniques from the Academy of Neurologic Music Therapy ® . The therapists who carried out the assessment sessions and intervention sessions had experience working with autistic clients.

Table 1 . Participant demographics.

2.2 Methodology

This pilot study employed a mixed-methods approach. Mixed-methods research is employed when neither qualitative nor quantitative data alone are sufficient to adequately address a problem, and when more insight can be gained from a combination of both qualitative and quantitative approaches ( Creswell, 2015 ). Telehealth music therapy is a fairly new approach, so gathering qualitative in addition to quantitative data in the current study helped to provide rich information about whether telehealth music therapy was an effective and feasible method for addressing motor skills in autistic children with the support of their caregivers. Quantitative data (including descriptive data) helped to provide a more objective measure of whether telehealth music therapy was effective in addressing specific goal areas.

The current study’s design utilized a version of an explanatory sequence method within an intervention mixed methods design ( Creswell, 2015 ). In an explanatory sequence model, quantitative data are collected and analyzed before and after a clinical intervention is applied, and qualitative data are collected and analyzed at the end of the study to help explain or interpret the quantitative data. Because all interview forms and assessment instruments had to be submitted during the research ethics approval phase, qualitative interview forms were created at the outset of the study, and quantitative and qualitative data were integrated during the final, interpretive stage of data analysis. This study received ethics approval from the University of Toronto Research Ethics Board.

2.2.1 Philosophical approach

The first author’s philosophical approach for the current study is pragmatic. A pragmatic study identifies a specific, practical problem, and often uses mixed methods to better understand and address the problem from multiple viewpoints ( Creswell and Poth, 2018 ). The current study identified the problem as: Can NMT motor interventions be implemented effectively online with autistic children who are supported during sessions by their caregivers?

2.3 Intervention sessions and materials

2.3.1 materials and overall structure.

Each family was loaned a bin of instruments and assessment materials for the duration of the training and assessment period. Sessions included one pre-intervention assessment, nine 45-min music therapy sessions spread over three weeks (three sessions per week), a post-assessment, and a follow-up assessment session that took place two weeks after the post-assessment session (12 sessions in total, including assessment and intervention sessions). The instrument/assessment kit was picked up after the final assessment, sanitized, and then used for subsequent participants. All intervention and assessment sessions were led by therapists over Zoom ( Zoom Video Communications Inc., 2016 ). Caregivers participated in all sessions with their child and helped to facilitate some aspects of interventions led by the therapist.

2.3.2 The intervention

Intervention sessions were largely comprised of NMT interventions tailored to address motor skills assessed on the BOT-2 SF such as fine motor precision and integration, manual dexterity, bilateral coordination, balance, ambulation, upper-limb coordination, and strength. Three NMT motor interventions were used: TIMP, which involves engaging the participant in playing musical instruments to practice certain movements, for example tapping a castanet to practice finger dexterity; PSE, which involves a therapist providing accompaniment that supports and drives movement, for example using rhythmic music with an ascending and descending melody to support pressing arms up and controlling a downward motion during push-ups; and RAS, which is the use of a metronome to assist with repetitive rhythmic movements such as gait. Participants who presented with signs of sensory-seeking behaviors that made it difficult for them to engage in the motor interventions right away received a brief sensory input intervention. The therapist would direct the participant’s caregiver to deliver squeezes or pats to the child’s body (feet, calves, quads, hips, head, back/chest, shoulders, arms, and hands/fingers), spending 1–2 min for each body part. A rhythmic song with directive lyrics and metronome helped to guide the sensory exercise. All intervention sessions were video-recorded with written permission of participants. See Supplementary Table S1 for the description of intervention protocols.

2.4 Assessment

2.4.1 timeline of assessments.

Prior to the motor and attention assessments, caregivers filled out an intake form collecting demographic data and information on musical preferences. Assessment tools included in the pre-test, post-test, and two-week follow-up included the short form of the BOT-2 (BOT-2 SF), and a selective attention and sustained attention task taken from the Test of Everyday Attention for Children, Second Edition (TEA-Ch2) ( Bruininks and Bruininks, 2005 ; Manly et al., 2016 ). Assessment tools included in pre-test only were the SP2 ( Dunn, 2014 ) and an intake form collecting demographic data and information on musical preferences. A qualitative questionnaire regarding the caregiver experience, and a qualitative questionnaire regarding neurologic music therapist experience were administered after the final assessment session (two-week follow-up). Finally, after each session, therapists would fill out a checklist to report on the amount of time the child spent fully engaged during each session and report any parent questions or any deviations from protocol. A copy of this checklist can be found in Supplementary Material S2 . Informal conversations between the researcher, assessor, and therapists regarding the feasibility of aspects of the study were recorded and comprise additional qualitative data.

2.4.2 Implementation of assessments

BOT-2 SF and TEA-Ch2 assessments were implemented on video by a trained assessor over according to directions from the publisher Pearson on virtual assessment implementation. Testing objects were loaned to families along with the instrument kit, and caregivers helped to set up materials for assessments according to directions from assessors. Assessment elements that could be scored live utilized live scoring by the assessor, and other portions involving paper were scored once the box of musical instruments and assessment resources were returned after the study was complete. Assessment sessions were not recorded except for P5’s assessment sessions, which were additionally scored by a second assessor to evaluate consistency of assessment.

2.4.3 Instruments

The BOT-2 ( Bruininks and Bruininks, 2005 ) it is one of the most reliable assessments used to assess progress in motor skills in motor-intervention studies for autistic children ( Dietz et al., 2007 ; Wilson et al., 2018 ; Downs et al., 2020 ; Ruggeri et al., 2020 ). It has been used to measure motor outcomes for autistic children via telehealth ( Cleffi et al., 2022 ). The longer BOT-2 assesses motor functioning in four sub-areas: fine motor control, manual coordination, body coordination (balance, posture), and strength/agility. The short form provides a measure of general motor functioning amalgamated across the four sub-areas from the larger form. Sample tasks on the short form include tracing different shapes, sorting pennies, bouncing a ball between two hands, standing balance exercises, and sit-ups. Each task is scored, and total points calculated as a single number, which is then scaled according to the child’s age and sex. Though the BOT-2 SF test is reported to have a high degree of reliability ( Downs et al., 2020 ), we had a second assessor independently score assessment videos recorded for one of the participants to double-check the reliability of the primary assessor’s work. The two assessments for the participant were within one scaled point of one another and had identical slopes between the three time-points.

The TEA-Ch2 ( Manly et al., 2016 ) is a collection of tasks designed to assess different types of attention: selective, sustained, divided, and alternating. Other NMT intervention studies have used the TEA-Ch2 to assess progress in attention in autistic children as a result of NMT attention interventions ( LaGasse et al., 2019 ; Sa, 2020 ). The current study was not implementing attention interventions, but because engaging in the motor interventions required attention, and participants were required to sustain their attention during each 45-min session (although most took breaks), we wanted to measure if there were secondary effects on selective and sustained attention. Thus, subtests from the TEA-Ch2 measuring selective and sustained attention were included in the study: the Hector Line Cancelation Test (selective attention, paper test involving crossing off specific lines) and Sustained Attention to Response Task (SART, computer test). The selective attention (line crossing) task was included in paper booklets given to families in the instrument kit dropped off at their homes. The SART task involved watching a series of shapes appear on a computer screen and tapping a key in response to each shape except one specific shape.

The Sensory Profile 2 (SP2) is questionnaire given to parents regarding their child’s level of sensory responsiveness ( Dunn, 2014 ) and is one of the most tools for assessing and discussing sensory sensitivity for autistic individuals ( He et al., 2023 ). The SP2 includes various booklets for appropriate for various age categories, and is grounded in neuroscientific understanding of how children respond to sensory stimuli in their environment ( Dunn, 2014 ). The SP2 aims to identify the child’s neurological sensory threshold and pattern of behavioral self-regulation in seven areas of sensory processing: general, auditory, visual, somatosensory (touch), vestibular (movement/balance), proprioceptive (body position), oral sensory, and overall sensory processing. Thus, the questionnaire helps to place the child in one of the four quadrants of the Dunn (2014) SP2 diagram for each sensory area. The SP2 questionnaire booklet appropriate for each participant’s age was included in the box of instruments. Parents were instructed to fill it out before intervention sessions began and kept it in the box of instruments to be returned and scored by the lead researcher once sessions were complete.

Questionnaires were given to the therapists and each participant’s caregiver after the final (follow-up) assessment session. For each participant with whom they worked, therapists were asked: (1) What was the most positive aspect of facilitating sessions/assessments? (2) What was the most challenging aspect of facilitating sessions/assessments? (3) Is there anything that could be helpful for other neurologic music therapists facilitating sessions/assessments via Zoom? (4) Is there anything else you would like to say about your experience as therapists in this study?

Each caregiver was asked: (1) What was the most beneficial aspect of the study for your child and for you? (2) What was the most challenging aspect of this study for you and your child? How would you rate your experience of online Zoom sessions, from a scale of 0 (not beneficial) to 10 (extremely beneficial). (3) Is there anything else you would like to say about your experience with the study? (4) If it was possible, would you be interested in registering your child for online or in-person NMT sessions?

2.5 Data analysis

2.5.1 motor and attention outcomes.

Due to difficulties the clients had performing the sustained attention assessment, attention data collected from the SART was determined not meaningful and was not analyzed. The assessor reported that the SART was extremely difficult to administer over telehealth.

Aggregate data from the BOT-2 test and selective attention (line-crossing) tasks were analyzed using one-way repeated-measures ANOVAs in the data analysis software R ( R Core Team, 2022 ). Tests of normality and homogeneity of variance were performed on the motor and selective attention data sets. Mauchly’s test of Sphericity was calculated as part of the analysis, and if needed, Greenhouse-Geisser corrections were automatically applied to any factors violating this assumption.

In the motor data, there were no extreme outliers, and the Shapiro–Wilk test indicated that the data was normally distributed (all p- values were > 0.05). In the selective attention data, there was one extreme outlier in the first time point, and the data in the first time-point violated the Shapiro–Wilk test of normality ( p  = 0.04).

2.5.2 Qualitative analysis

A qualitative content analysis (QCA) was performed on the answers to questions in the assessments to search for and identify common themes. QCA assesses data in domains that are not yet well-understood, particularly in healthcare ( Hsieh and Shannon, 2005 ; Elo and Kyngäs, 2008 ). Two individuals performed the QCA: the first author and another PhD candidate who was not one of the therapists or main assessors. Both individuals read the responses to questions, and independently identified and categorized responses according to common themes in an electronic codebook. Software was not used in the qualitative analysis. When interpreting and categorizing participants’ contributions, both individuals strived to maintain awareness of biases and opinions which could influence this process by writing down thoughts in the margins of the codebook as they pertained to the emerging themes ( Creswell, 2015 ). After independently coding responses, the first author compared both codebooks and compiled themes into a single document. The two individuals discussed the themes and finalized which categories seemed to be the most salient. The two therapists whose data were assessed are colleagues of the two individuals assessing the data. No relationships between either of the individuals performing the QCA and the caregivers existed beyond contact made by the author and the caregivers during the recruiting process. Member checking was employed with therapists, but not participants’ caregivers.

2.5.3 Sensory profile comparison

Motor results, qualitative responses, and data from the SP2 ( Dunn, 2014 ) were compared alongside one another to illuminate possible trends or connections between sensory sensitivities on the SP2 and ability to engage in the telehealth intervention sessions.

3.1 Motor outcomes

A one-way repeated-measures ANOVA was conducted on the scaled scores of the BOT-2 SF assessment results to ascertain the effects of the intervention on participants’ motor performance over time (pre, post, and two-week follow-up). The ANOVA was performed using R ( R Core Team, 2022 ). There was a statistically significant difference between average scores for at least two time points p  = 0.03. A Tukey Post Hoc test could not identify at α = 0.05 significance level the exact location the difference, which trended to be between the pre-test and two-week follow-up test ( p  = 0.23). Visual inspection of a graph of the BOT-2 SF scaled scores corroborate that the scores increased between the pre- and follow-up test. See Table 2 and Figure 1 .

Table 2 . Means, standard deviations, and one-way analyses of variance in BOT-2 SF and selective attention (line crossing) scores.

Figure 1 . Individual scaled BOT-2 scores across the three assessment time-points.

3.2 Attention outcomes

The TEA-Ch2 Line Crossing Task was completed by most participants independently. Two participants struggled with the task on certain trials, and caregivers either helped them or simply allowed them to perform the task incorrectly (e.g., connecting lines rather than crossing them out). The one-way repeated measures ANOVA was not statistically significant ( p  = 0.92). See Table 2 .

3.3 Qualitative outcomes

The QCA found three major themes across both the caregiver and therapist responses: (1) Caregiver involvement was necessary and beneficial, (2) clients benefited from sessions, and (3) engagement was sometimes limited due to distractions. The three major themes along with constituent categories are represented in Supplementary Table S3 . Quotes from caregivers are marked with a “C” while quotes from the therapists are marked with a “T.” In general, caregivers as well as therapists held a positive view of the music therapy sessions. Caregivers often remarked that their child engaged well over Zoom for music therapy in a way that they did not for other (non-music-based) therapies. Therapists also perceived participant skill improvements during music therapy sessions. The limits of virtual sessions were acknowledged, since distractions and sensory needs made it difficult for participants to engage at times. Caregivers articulated benefits of being involved in sessions themselves, and therapists similarly articulated that sessions would not be possible without caregiver support and involvement. Please refer to Supplementary Table S3 for a delineation of therapist and caregiver responses.

3.4 Sensory outcomes and comparison

Results from each client’s SP2 ( Dunn, 2014 ) assessment given prior to the intervention period was compared alongside individual quantitative results. See Table 3 . Patterns emerged, although with the small sample generalization is not possible. Those with the three highest percent-change in motor scores also had each four or fewer areas of sensory sensitivity and were reported to have consistent engagement. The two children with the most sensory sensitivities showed the lowest percent-change improvements in their BOT-2 scores.

Table 3 . Comparison of participant sensory factors, age, and engagement.

Participants with greater sensory struggles, particularly if they were younger, perhaps would have benefited from more direct intervention to address sensory issues alone prior to engaging in intensive sessions addressing motor skills.

4 Discussion

4.1 motor improvements.

The participants showed statistically significant increases in motor skill performance measured by the BOT-2 SF test. Visual inspection of data revealed that motor assessment scores on the final (follow-up) assessment were higher than those on the initial test. This result implies that motor skills continued to improve in the two weeks after the final intervention. One possible explanation for this pattern of results is that that offline gains may have occurred between the assessment that occurred soon after the last session and the two-week follow up, allowing for motor skills to solidify and be observed on the final follow-up assessment. The term “offline gains” refers to improvements in motor skill that happen following an interval of time in which motor skills previously practiced are consolidated, but not actively practiced ( Lugassy et al., 2018 ). Motor consolidation occurs when sleep and rest occur after intentional motor practice, as first observed by Brashers-Krug et al. (1996) . The present study intentionally spaced sessions at least 48 hours apart to allow for motor consolidation between training sessions. Future studies could explore the effects of music-motor interventions on functional connectivity in autistic individuals, along with behavioral motor assessment measures. Previous studies have set a promising precedent for such research: Sharda et al. (2018) found that engaging in 8–12 sessions of music therapy targeting social interaction increased functional connectivity between auditory and motor areas in autistic children, relative to those in a control group. Their study also saw a decrease in over-connectivity between auditory and visual-association areas. There is theoretical support for improvement based on music-based interventions targeting motor skills also. D’Mello and Stoodley (2015) reported that autistic individuals show overconnectivity between the cerebellum and motor cortices, which is associated with underconnectivity in cerebro-cerebellar pathways for language and social interaction. Braun Janzen and Thaut (2018) further theorized that music-based motor engagement could help to improve cerebro-cerebellar connectivity, given that music and rhythm activates the cerebellum along with motor areas. Future research can investigate the relationship between scores on a motor assessment and neural correlates such as functional connectivity between cerebellar and cortical brain regions.

Another possible explanation for the increased scores after the two-week follow-up period is that parents may have begun to practice motor skills with their children even after the therapy period was complete. Though no parents directly shared that they were practicing the motor skills after sessions were complete, some parents did report gaining new skills to support their child, so this possibility cannot be ruled out.

Although the current study contains many of the limiting factors described in Srinivasan and Bhat (2013) such as a small sample size and no control group which limit generalizability, the NMT interventions used in this study (TIMP, PSE, and RAS) are specific and replicable. Results indicate that follow-up research can be conducted using these consistent NMT intervention protocols to investigate replications of the current outcomes.

The promising motor results echo those of Srinivasan et al. (2015) , Imankhah et al.’s (2018) , Shemy and El-Sayed (2018) , and Shukla et al. (2022) , who all found that music-based interventions improved movement skills in autistic participants. In particular, Imankhah et al. (2018) used exercises which resemble the techniques used in the current study such as TIMP and RAS. The current study adds to previous data by providing evidence that it may be possible to address motor skills in autistic children via telehealth, and supports the development of larger studies to investigate the benefits of NMT motor interventions for children on the autism spectrum.

4.2 Inconclusive attention data

Due to many participants being unable to complete the SART assessment independently, attention outcomes for the sustained attention were inconclusive. Analyses for the selective attention assessment were not statistically significant. These results imply that, first, the SART attention task was either too advanced for the children taking the tests, too difficult to administer via telehealth, or both. Second, the lack of even a trend toward improvement in the selective attention task indicates that selective attention did not improve over the course of the study, which perhaps should not be surprising given that the interventions in the study were not targeting attention skills. Though studies by Pasiali et al. (2014) , Lagasse et al. (2019) , and Sa (2020) found that NMT improved attention skills (measured by the TEA-Ch2) in autistic adolescents, the subjects in that study received attention-specific interventions and were older, so better able to carry out the assessments. It is not possible to make any firm conclusions related to attention in the current study.

4.3 Positive qualitative responses

Caregivers and therapists expressed an overall positive view of the telehealth sessions, despite the presence of occasional challenges. This result is in keeping with prior research indicating that the opportunity to access services online is seen positively ( Cole et al., 2021 ; White et al., 2021 ). None of the families in the study had previously accessed music therapy, and several of the families found sessions beneficial enough that they requested information about how to find NMT services for their child after the study was complete. None of the caregivers specifically mentioned (nor were they directly asked) whether the number of sessions (nine, over 3 weeks) felt feasible for them, but noteably each of the five participants and their caregivers attended each one of their assessment and training sessions, with only one participant ending a session early one time. This 100% study participation rate indicates that implementing NMT motor interventions over telehealth is not only likely effective for motor development, but feasible for families. Anecdotal comments from some parents (outside the qualitative questionnaires) indicated that they perceived their children to be benefitting tremendously from the sessions and were learning new ways to support their children because of the sessions.

4.4 Sensory implications

Like results found in White et al. (2021) and Richard Williams et al. (2022) , participants with fewer sensory sensitivities tended to engage more consistently over telehealth and made more progress in motor skills than their peers with greater sensory sensitivities. This result resonates with recent research that found autistic children with sensory sensitivities tend to struggle with attention ( Dellapiazza et al., 2018 ), and that challenging behaviors in autistic children (including inattention) can be explained to a high degree by the presence of sensory sensitivities ( Dellapiazza et al., 2020 ). Thus, participants with more sensory issues may have struggled to maintain attention and behave in ways conducive to engagement over telehealth during sessions more than others who had fewer sensory difficulties.

Therapists indicated on the fidelity checklists ( Supplementary Material S2 ) that all participants spent the goal minimum of 75% of session time doing NMT motor interventions. Therapists sometimes provided a proprioceptive-input intervention at the beginning of sessions, but this intervention may not have been sufficient in terms of length and the fact that only one sensory area (proprioception) was addressed. It is possible that children with higher sensory needs could benefit from full sessions directly addressing these sensory needs as a prerequisite to working on movement skills directly. Future studies should investigate the impact of degree and type of sensory sensitivities and age on ability to engage in telehealth music therapy. Research should also investigate the efficacy and feasibility for NMT interventions for sensory needs in autistic children.

4.5 Limitations

The small sample and lack of control group limit the generalizability of these outcomes but the study results provide a promising and replicable context for future investigations. In terms of the motor assessment results, the pattern of improvement from pre-test to follow-up test only occurred clearly for two participants, whereas the others there was more of a plateau after the post-test. Along these lines, it is possible that one participant (participant two) may have been driving the change. Replicating this study with a much larger sample would help to identify if these results are meaningful and generalizable. The impact of sensory challenges on motor skills must be interpreted with caution as it was underpowered for formal analysis. In addition, because the presence of other autism symptoms was not directly measured, it is possible that participants with greater sensory challenges also had more intense autism symptoms in general which impacted their ability to benefit from the intervention. There are several other limitations that should be considered to improve upon this pilot study in the future. The fact that therapists sometimes began sessions with a brief sensory intervention may have introduced a confound, as it is not possible to know if gains in the sessions could be due to the motor interventions or also in part to the sensory interventions. In terms of assessment, because the same assessor was present at all three time points, it is possible that assessor bias was introduced that influenced the interpretation of motor scores as improving over time. The addition of a second assessor for one of the participants, who was blinded to the time of assessment and found a similar pattern of results, helps to mitigate the possibility of bias only partially. Finally, the attention tasks were largely too difficult for children to do, and difficult to implement via Zoom.

5 Conclusion

This small pilot study found improvements in motor skills in autistic children following nine sessions of motor-based interventions delivered by neurologic music therapists. Caregivers and therapists felt that the children improved during NMT sessions, and caregivers felt that they learned new strategies for helping their children during sessions. Observations of sensory sensitivities combined with individual session progress indicated that participants with fewer sensory sensitivities, or who were older, tended to engage the most consistently over telehealth and improve the most in motor skills. The results from this pilot study support the initiation of future research with larger samples and a control group in ascertaining how NMT motor interventions can benefit autistic children both in-person and via telehealth.

Data availability statement

The datasets presented in this article are not readily available because of the small sample. Requests to access the datasets should be directed to [email protected] .

Ethics statement

The studies involving humans were approved by University of Toronto Research Ethics Board. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

Author contributions

NR: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Visualization, Writing – original draft, Writing – review & editing. CH-T: Supervision, Writing – review & editing. JB: Supervision, Writing – review & editing. LT: Supervision, Writing – review & editing. MP: Data curation, Writing – review & editing. JT: Data curation, Project administration, Writing – review & editing. MTa: Data curation, Writing – review & editing. JK: Formal analysis, Writing – review & editing. MTh: Supervision, Writing – review & editing.

The author(s) declare that financial support was received for the publication of this article. Belmont University funded the open access fee for publication of this article.

Acknowledgments

NR wishes to thank each of the participants and their caregivers for engaging in the study, and N. B. Williams for all-around support and proof-reading.

Conflict of interest

NR has occasionally aided with educational endeavors and received small honoraria from The Academy of Neurologic Music Therapy.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2024.1355942/full#supplementary-material

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Keywords: autism, neurologic music therapy, motor, telehealth, sensory, BOT-2

Citation: Richard Williams N, Hurt-Thaut C, Brian J, Tremblay L, Pranjić M, Teich J, Tan M, Kowaleski J and Thaut M (2024) Improved motor skills in autistic children after three weeks of neurologic music therapy via telehealth: a pilot study. Front. Psychol . 15:1355942. doi: 10.3389/fpsyg.2024.1355942

Received: 14 December 2023; Accepted: 22 April 2024; Published: 08 May 2024.

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Copyright © 2024 Richard Williams, Hurt-Thaut, Brian, Tremblay, Pranjić, Teich, Tan, Kowaleski and Thaut. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Nicole Richard Williams, [email protected]

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