Five factors were identified which appeared to influence participants’ perception of role of technology in manual therapy education. These were;
Sufficiency of current teaching method
Sufficiency of current teaching method was a key factor contributing to participants’ perception about the role of technology in manual therapy education. Participants who felt that their current teaching was sufficient believed that technology had no or little role in manual therapy education.
“I can’t think of another way of doing it than the way they do it. To me what they do is great but it’s maybe because I’ve never thought about [it]”. (P6).
“I feel like it is sufficient…for us to be a better therapist [and] to learn better with our hands” (P2).Participants who perceived the current teaching of manual therapy to be sufficient tended to be osteopathic students learning manual therapy from year one of their program. Being exposed early to hands-on manual therapy courses may have influenced their perception and embedded an established routine for learning.
“[The] actual practical part side of it I think is really good, like they have a routine. They’ll show us a technique or like a special test or whatever they do, and then we’ll go away in our little groups and practise that, and I think that’s really like effective. Then the teachers come round and like adjust us if needed and just like help us and give us like random tips and stuff” (P7).
Conversely some participants perceived that their current teaching of manual therapy was insufficient and inadequate.
“I’d like to say yes but no, not really. I almost feel as if a lot of it is just left up to you to try and work out if you’re doing it right. The tutor can’t feel exactly what you’re doing. They can only look and think it does look you’re pressing to hard or light or whatever. It would be really good if there was some way that you could actually have some sort of measurement of exactly how you do it or whether you’re doing it right or what you’re feeling is the correct thing” (P9).
Participants who felt that the manual therapy teaching was insufficient were most likely enrolled in a blended learning pathway where they are on campus for block teaching weeks and off-campus during the rest of the learning period. This model of delivery meant that a lot of content was taught in a short period of time. This made them feel that they lacked time to reflect on their learning and made them feel completely ‘overwhelmed’ while trying to grasp the complex manual therapy skills.
“The way it’s been working is we have these eight hour long days and we have to cram/study all this information in the morning, have lunch, and then come back and cram the rest of the knee and maybe even the whole lower limb for the rest of the day and we just go away at night just feeling so overwhelmed, and then write an essay on a completely different subject” (P1).
Need for objectivity
The need for objectivity appeared to contribute towards the perception of participants regarding the role of technology in manual therapy education. Some participants felt that the current teaching paradigm was subjective and lacked reliability with different tutors teaching different things.
“I think there’s a bit of confusion between the tutors and how they do things. One would put the hand below the pelvis and one would put it above the lower back for the same technique. I thought to start with that if at least the three tutors agreed, or four tutors, agreed on what they’re teaching us and teach us this at least there’s no like, yeah but you can do it like this” (P4).
The use of different approaches by different tutors and an apparent lack of objectivity lead to self-doubt among some participants about their ability and the correct method.
“Yeah the palpation or even when getting the tests done to see how it feels, from someone who feels confident in doing it, whereas us students, you know you’re always wondering ‘oh am I doing it right?’ or if things are a bit fiddly” (P3).
These participants perceived that technology therefore could enhance their confidence by negating subjectivity.
”… it would definitely be helpful to have something that means you’re more confident and that you’re practising the correct thing when you don’t have the tutor right there. So if there’s some way that it can help it would, yeah. It would be quite helpful” (P3).
Participants who required measurements or an objective way to do things were more likely to believe that technology such as VR is required as part of manual therapy education. They were more likely to perceive that VR would guide them to palpate the structure that they need to thereby improve accuracy of palpation.
“I almost feel as if a lot of it is just left up to you to try and work out if you’re doing it right. The tutor can’t feel exactly what you’re doing. They can only look and think it does look you’re pressing to hard or light or whatever. It would be really good if there was some way that you could actually have some sort of measurement of exactly how you do it or whether you’re doing it right or what you’re feeling is the correct thing” (P9).
Further, by enabling to visualise various layers within the body, technology can be a powerful tool especially for visual learners. In turn, this kind of learning experience authentic by enhancing fidelity (realness). for the learners. When presenting examples of the use of VR and how this might enhance understanding and ability to perform skills completely, they responded:
“The reason I thought this would be really cool is because the first thing I thought of is if I can see something… then I can sort of match where I’m going. That’s where things stick for me. I don’t know what kind of VR technology you have but if you could see that’s the skin but then under it you’ve got a layer of bones or whatnot then you can match up. I think that would be really good for a lot of visual learners… I think it would be quite powerful in learning” (P8).
“It would be really interesting if you could use your hands to move and manipulate the body or even just to touch it, to highlight a particular muscle or muscle group… perhaps it would make it feel a whole lot more real to me” (P1).
Evolution as a learner (novice to expert)
The perception of role of 3D technology in manual therapy education depended on the expertise level/evolution of the learners. Participants who were early on in their educational journey felt that the current teaching methods (see one, do one approach) to be adequate. They were comfortable learning gross motor skills (e.g. holding a leg) that does not require deeper palpation skills.
“At the moment because I’m a first year I’m getting comfortable with touching people and making sure that when you’re holding their leg they feel like she’s got me. That’s what we’re working on at the moment” (P6).
Conversely participants who were at the later stage of their educational journey emphasized the need for technology to support the development of finer motor skills required for deeper and subtle palpation.
“I’m finding it really difficult because you don’t know what you’re trying to feel. Don’t know what you’re feeling for and trying to translate a description into trying to work out what I’m feeling. I’m actually struggling with that a little bit. Generally the more obvious techniques are great but when it comes to really subtle palpation it’s really difficult to try and understand what you’re meant to be feeling for” (P9).
It was noted that participants’ who had already completed manual therapy courses before were likely to perceive that the current teaching methods were adequate and the need for technology to be minimal. Participants with manual therapy experience felt that students who have not done manual therapy before would require more support.
“ I have worked in massage now for five years, so I’ve got a lot of palpatory hands on experience but it doesn’t make me like an osteopath or anything, but for some of the school leavers, they come straight out of school and they’ve probably only touched their own skin never mind someone else’s “ (P2).
Tutor feedback
A key factor mandatory for learner development is feedback from tutors. Most participants felt that the current teaching methods were inadequate and unsustainable as often there is often only one tutor running a teaching session. This meant that they did not receive enough feedback where they could refine their manual therapy skills.
“Often we then break off into little groups or pairs to practise it but then it’s very hard for that one tutor to get round all of those pairs to make sure they’re doing it correctly. And often people have questions and then they go caught up talking, so a lot of the time you might be trying to do one practical thing” (P3).
“The way they explain things don’t make sense. It might not be the best example but we have to manipulate the cervicals. She said you do it like this and she shows. But we can’t even see the fingers underneath the neck so it’s a bit complicated for us”(P6).
Participants that received less tutor feedback explained that they were trying to learn complex manual therapy skills from 2d images or PowerPoints which can be challenging. Hence, they perceived that 3D technology such as VR would be important in enhancing their leaning.
“Everything I’m trying to learn is via a PowerPoint or videos which can be challenging. I’m a practical learner so if we don’t do the practical I struggle in connecting stuff where others pick it up quite well. I don’t learn that way” (P8).
“Apart from PowerPoints and a few videos or something like that is about the most digital we get I think” (P9).
In contrast some participants felt that they received good feedback from their teachers, which meant that they relied less on technology.
“He gave us specific landmarks that we would look for. For example, C7 would be the most prominent one that sticks out in forward neck flection and that was a good baseline in order to help us when we would palpate for cervical spine. He would give us points in which they were quite useful for our learning” (P5).
Specifically, these participants felt that they learnt more when the tutors placed their hands on top of theirs and showed them how to do a certain technique. This human interaction therefore was key in learning manual therapy.
“One thing I found effective with a clinical supervisor I have is we had a patient and he put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me” (P1).
“…we were doing a technique called ‘functional’ on the like upper thoracic and the person is lying down, and you like put your hands under and she comes along, she [tutor] came along, and put her hand under our hand and so she could feel where it needed to go and stuff, so that was really good” (P7).
Barriers and enablers:
Some factors were both barriers and enablers for using 3D technologies as part of manual therapy education. These factors include (1) cost (2) knowledge about technology (3) accessibility and (4) ethical issues.
Almost all the participants felt that cost was a significant barrier if technology such as VR to be used in manual therapy education.
“I’m sure that the cost of it is one main problem. People even thinking about it. People developing it and being paid to develop it and then people would have to buy that technology” (P6).
“The cost. I think that would be a big thing would be the cost really. That would really be the only barrier that I can think of” (P9).
The participants believed that the cost on students could be reduced if the institutions could bear some or most of it thereby enabling students to access technology.
“I doubt they’ll let us as students take one home because they’re so expensive. If institutions can pay for it so we students can still access it a reduced cost perhaps” (P8).
“Obviously that financial one may play a big part so I guess having one of those facilitators such as a support might be necessary” (P5).
All participants indicated that they would be keen to try technology if it is available. However, some required further knowledge about technology. They thought that using technology without completely understanding it or if the technology did not work properly, may discourage them from using it.
“…People’s knowledge in the tech, around the technology as well if it would be something that people don’t work with a lot and they’re being bombarded with a whole lot of other new information… If it doesn’t work properly the first time it can be rather annoying, or discouraging, would be another barrier to it” (P3).
“Yep absolutely, if there was adequate training I would be very open to using it yeah.” (P2).
Some participants thought that ease of access could a barrier from using technology such as VR. They felt that using technology for a long time can lead to fatigue and discourage further use.
“… [I] don’t know how long you can stay in goggles like this before it gives you a headache” (P6).
“ [I] think one thing is that I can get fatigue from being on technology for a while” (P3).
In terms of ease of access, internet connection was identified as another barrier.
“Maybe internet connections. I don’t know if you need to internet to download specific stuff” (P5).
”Connections, issues, are a big one, I’ve noticed that my connections been shocking so it kind of breaks in and out throughout classes which is tricky. Maybe attitude towards technology, I personally, I don’t mind using it but I know some people don’t enjoy using technology, and I guess accessibility for some people as well” (P4).
Few participants were concerned about ethical issues such as cultural responsiveness that may arise using technology such as VR as part of manual therapy education.
“There’s got to be like a level of cultural responsiveness or just appropriateness or ethics what would need to, student would have to get. Or it would just have to, the simulation would have to have restrictions” (P1).
Conversely, these ethical issues could be overcome by completely explaining the design of VR.
“…the only thing I can think of is like consent and making sure people are okay with what they’re seeing and also by enabling limiters so students” (P2).
The five factors discussed above in turn influenced the participants’ perception about the role of 3D technologies in manual therapy education with participants evidently taking two distinct/polarized positions (‘no role’ (techstatic) versus a ‘complete role’ (techsavvy)). Figure 1 depicts the interplay between the five factors and how they influence the learns position as either being techsavvy or being techstatic.
Participants that perceived that technology had no role in manual therapy education tended to view that the current (“see one, do one”) approach was best suited for manual therapy education.
“I think the current way manual therapy is taught is sufficient. I don’t know how else they could do it really. Just putting your hands on and getting used to that and getting better palpation, you can do that through practise” (P7).
These participants believed that technology cannot replace human interaction and that ‘face to face’ sessions are important to learn the complex manual therapy skills.
“Technology has a place, but again I think you can’t replace face to face learning. I think there needs to be that sense of community still, like there’s nothing better than being in class with our classmates” (P4).
With a strong emphasis on human interaction, they conceptualised manual therapy education as an approach that should involve “hands on hand” feedback. One participant explains this as:
“He put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me because I was like ‘oh that’s how you do it, that’s how it’s supposed to feel, that’s what you’re doing’ and I could sort of feel through my hands” (P1).
Participants on the opposite end of the continuum perceived technology as ‘futuristic’ and an ‘advanced’ way to learn manual therapy.
“…if you had goggles on and you had a fake patient in front of you, how you would be able to see everything quite clearly and if they had designed some cool gloves then maybe you could actually feel what it would feel like to touch the patient… that’s going way advanced” (P2).
These participants believed that the repeated practice opportunity that technology offers, provides an ‘objective’ way to learn manual therapy skills.
“Oh totally, yeah big time. Now I think it’s just a matter of time. I think technology such as VR is futuristic and may help learn things objectively” (P10).
“Technology is awesome, I think most of our learning in manual therapy is self-directed…technology will provide repeated practice opportunity given that we can use them [technology] at home” (P6).
Participants’ perception about the role of 3D technologies in manual therapy education can be viewed as on a continuum, from ‘no role’ (techstatic) to ‘complete role’ (techsavvy). Some participants’ perception lay at the extreme ends of the continuum whereas others fell in between the two extremes. Participants that perceived that technology had no role in manual therapy education tended to view that the current (“see one, do one”) approach was best suited for manual therapy education.
“I think the current way manual therapy is taught is sufficient. I don’t know how else they could do it really. Just putting your hands on and getting used to that and getting better palpation, you can do that through practise” (P7).
These participants believed that technology cannot replace human interaction and that ‘face to face’ sessions are important to learn the complex manual therapy skills.
“Technology has a place, but again I think you can’t replace face to face learning. I think there needs to be that sense of community still, like there’s nothing better than being in class with our classmates” (P4).
With a strong emphasis on human interaction, they conceptualised manual therapy education as an approach that should involve “hands on hand” feedback. One participant explains this as:
“He put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me because I was like ‘oh that’s how you do it, that’s how it’s supposed to feel, that’s what you’re doing’ and I could sort of feel through my hands” (P1).
Participants on the opposite end of the continuum perceived technology as ‘futuristic’ and an ‘advanced’ way to learn manual therapy.
“…if you had goggles on and you had a fake patient in front of you, how you would be able to see everything quite clearly and if they had designed some cool gloves then maybe you could actually feel what it would feel like to touch the patient… that’s going way advanced” (P2).
These participants believed that the repeated practice opportunity that technology offers, provides an ‘objective’ way to learn manual therapy skills.
“Oh totally, yeah big time. Now I think it’s just a matter of time. I think technology such as VR is futuristic and may help learn things objectively” (P10).
“Technology is awesome, I think most of our learning in manual therapy is self-directed…technology will provide repeated practice opportunity given that we can use them [technology] at home” (P6).