Mobile-Learning App to Improving Skills in the Design of Therapeutic Exercise Program: Perception, Satisfaction and Physiotherapy Student ´s Demand

Background: E-learning tools for students in health sciences present low levels of barriers and benets for the student and the educator. No evidence is available using e-learning tools to design therapeutic exercise program skills. Research and different uses of technology in physiotherapy students are justied. The present study aimed to evaluate perception and satisfaction with an e-learning tool in ve Spanish physiotherapy Universities. To evaluate the students' perception as an innovative learning experience identifying aspects to be improved and their perception respect to traditional teaching. Methods: A descriptive study in ve health sciences faculties in Spain during the 2018-2020 academic years. The use of the tool is carried out under the supervision of physiotherapy teachers in diverse disciplines. Results: Results conrm that an e-learning tool to design therapeutic home exercise program is considered a satisfactory and innovative instrument that brings improvements in the learning of physiotherapy students with a high degree of satisfaction. Students declare aspect to be improved. All items have been valued positively with an average score of 3.41 in the set of 20 questions. It is considered a useful and necessary tool, compatible with traditional education. Conclusions: Our research provides new knowledge using innovative technologies enhancing learning skills. Students strongly recommend the use of the e-learning tool along the physiotherapy academic period. Regarding the open-ended (Question 18) a total of 26 comments (39%) was obtained. That question seeks to identify the student's perception of traditional teaching compared with the e-learning tool. Students' answers are listed and grouped in two categories: Answers that consider m-learning advantageous over traditional education the software you more to problems you certain general


Introduction
The use of mobile apps in health care is growing [1]. Current and future practitioners must be equipped with the skills to utilize apps in patient care, yet few strategies exist for training health care professional students on the usage of apps [1]. The Global Observatory for eHealth de ned mHealth or mobile health as medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices [2].
The customary use of smartphones and tablets by health science students has enabled mobile learning (m-learning) to become an important component of education [3]. Therefore online technologies have become an indispensable part of the lives of students and academics in higher education, in uencing learning strategies [4]. Health sciences faculty strive to stimulate learning and actively engage students in the classroom. The promotion of student work, the increase of attention, the improvement of the interaction between teachers and students, and the creation of a more relaxed atmosphere in class are some of the reasons that are driving the use of technologies in the educational eld [4]. The rapid evolution of web-based information platforms, social media, and mobile apps has made the internet the primary source of information for many health professions students [5]. Today, apps, computer-assisted instruction, web-based education simulation and virtual reality are some of the technologies frequently used to support graduate education, among others [6].
The popularity of this type of interactive technologies is progressively increasing in the teaching-learning process of higher education. Scienti c research publications con rm that generates a considerable increase in student learning, both for teaching with large groups and in small groups [7]. Researches on technological tools in health sciences students have been published including different elds [4,[7][8][9][10][11][12].
Most education apps have speci c functions or aims, such as providing resources for reference while learning or in practice, learning activities and games, or organizing activities related to learning. Apps can be found by keyword search in the app stores (Google Play Store, iOS App Store), through determined categories [13].
The use of online technologies as teaching tools has shown mixed results (bene ts or no difference to traditional) in health professionals' education [14]. A systematic review of the use of training tools in physiotherapy students collected the varieties of technologies used, concluding that this technology presents low levels of barriers to its use and a high number of bene ts for the student and the educator [14]. Given the variety of tools and outcomes it is clear that there is a wide range of opportunities to explore. Research and different uses of mobile technology in the education of physiotherapy students are justi ed [15][16][17][18].
One of the most widely used physiotherapy clinical skills is the design of therapeutic exercise programmes; a regimen of physical activities designed with speci c therapeutic objectives [19]. Its purposes include restoring normal musculoskeletal function, reduce pain, prevent and reduce the risk of injury, disability and its sequelae [19]. Prescribing exercise as part of a structured, safe, and effective program that includes aerobic, resistance, exibility, and neuromotor training is essential to improving and maintain physical condition and health [20]. The American College of Sports Medicine, recommend de ning programme characteristics such as exercise types and sequences, repetitions, resistance, intensity, speed, progression rules, progressive overload, rest periods and frequency for novice, intermediate and advanced training [21].
Physiotherapists require several skills including under standing of the underlying disease process or pathology, exercise physiology, biomechanics, physical principles, evidence base supporting the area as well as an awareness of psychological and safety issues. Physiotherapist must also be able to identify appropriate treatment goals in conjunction with the patient [22]. Previous research with e-learning, con rm that online technologies have many bene ts to offer for physiotherapy teaching and learning including enhancing practical skills performance and knowledge acquisition, providing students with entertaining, easy accessible resources, enhancing deep learning and encouraging re ection [14].
However, no evidence is available for designing therapeutic exercise programme skills, theoretical and practical, using m-learning apps. To our knowledge, this is the rst study to explore the potential for mlearning in clinical skills acquisition in physiotherapy student's in this eld.
The main objective of this study was to evaluate the potential for m-learning in clinical skills acquisition using a speci c exercise prescription app. As secondary objective to evaluate student's perception and areas for improvement regarding the learning experience.

Study Design and Recruitment
A descriptive study in 5 physiotherapy health sciences faculties in Spanish Universities was performed. A total of 67 physiotherapy students enrolled in second and third years, degree of Physiotherapy at the Universities of Malaga, University of Cadiz, University of Osuna, University of Castilla La Mancha and Catholic University of Valencia accessed freely and voluntarily to complete the questionnaire after 1 years focused m-learning experience use of the app. Participants were recruited through personalized email to inform about the survey, how to access and complete it. In addition, there is a professor who coordinates the implementation of the software in each university who inform the class on how to access the questionnaire.

Description of m-Learning Experience
In this study we use the Physiotec exercise prescription app ( Fig. 1), with a free license for the use of the students during their university period. This app has been used as an intervention tool in recent research (17)(18)(19), it allows the student to create and simulate patients, create personalized programmes according to particular clinical case. The app offers a video library with more than 7000 exercises grouped by thematic modules. The use of the Physiotec app was carried out under the supervision and guidance of physiotherapy teachers in theoretical and practical sessions during the period 2018-2021. During this mlearning experience, students are engaged with didactic, workshop, and project-based experiences focused on nding, evaluating, and using the Physiotec exercise prescription app in patient care. This app educational experience was integrated into different subjects. An example of its use in the classroom is shown in Fig. 2.

Evaluation of m-Learning Experience
Students completed an ad hoc questionnaire in online format during the 2018-2020 academic year. Students were informed about the importance and objectives of the questionnaire. Participation was voluntary, anonymous and con dential. Students were informed by their teachers that their voluntary participation in the questionnaire implied their acceptance and consent to the research. The authorization of the ethics committee is not required following Law 8/2020 of January 30th, which regulates the organs of health care ethics and biomedical research in Andalusia (Spain) [23].
Furthermore, students were informed of the importance of responding sincerely to the issues raised. Participants must to be enrolled in any of the universities involved in the research and have active their free license for academic use of the Physiotec app.

Questionnaire Design
The initial questionnaire items were derived from earlier published instruments and modi ed to suit the context of technology in the education of physiotherapists [24][25][26][27][28]. Our aim was to include a comprehensive and representative set of measures that would allow for the validity and comprehensibility of the questionnaire. For this purpose, the elaboration of an ad hoc structured questionnaire related to satisfaction, learning and innovation, perception and interpretation outcomes with a total of 20 items was used. The questionnaire was structured in four sections as shown in Table 1. Questionnaire is available as additional le (Annex I) Evaluation of the learning experience and its innovative methodology Two nal questions regarding the recommendation to other universities and its use throughout the period of physiotherapy study were included. Questions 19 and 20 of the Questionnaire.
SPSS statistic 22 was used for the management and statistical analysis of the data. Maximum and minimum values, mean score and standard deviation were determined for each item. Frequency and percentage analyses were carried out, presenting the information in tables and descriptive statistical graphs.

Quantitative approach
A high degree of satisfaction with the m-learning app to design exercise programme was shown. All items have been valued positively with an average score of 3.41 in the set of 20 questions. None of the questions presented mean values lower than 3 on the Likert scale. No negative answered was reported by the students. Characteristics of participants is shown in Table 2. The question with the highest average score of 3,687 was speci cally aimed at the student identifying his general assessment of the m-learning tool as an educational innovation for physiotherapy students (Question Nº 1). Results of the rst construct of the questionnaire (Satisfaction, Impact, Usability, Functionality, Design and Accessibility) (Questions 1-6) is show in Table 3. Results of the second construct of the questionnaire (Evaluation of the learning experience and its innovative methodology) (Questions 7-16) is show in Table 4.  Qualitative approach Qualitative approach shown heterogeneity in the aspects to be improved like usability, previous pathologies knowledge, design and teacher support.
Results of the open-ended question (Question Nº 17) with a qualitative approach show many of the aspects that students report to be improved; a total of 27 comments (40%) was obtained. Students' answers are listed and grouped in the following categories: Improve its use through mobile device A better mobile app Mobile application must work properly Improve prior knowledge of pathologies, the function of therapeutic exercises and the design of exercise programmes.
As a student, the use of the application is done with faculty work or any doubt you have had in particular, but until we have speci c areas to apply we will not give it a higher use.
Exercise programmes already developed depending on the pathology (Protocol) A better previous description of the different techniques is needed so the student could better understand the function to be achieved with each exercise. Real images and videos would make it easier to understand.

Wider treatment eld in pathologies
The way to do exercise programs Improved exercise descriptions Improve the explanations of some exercises Veracity of some exercises and use from mobile.
For my part it is a great application, the only thing that would improve is that putting a speci c injury you get the exercises that bene t him, because as a student I still do not have the knowledge to know what type of exercise would be best for each pathology and sometimes I do not know what to put so that I get the speci c exercises to improve the injury.

Improve teacher support
The mobile application for Android does not allow the use of the platform. I have to access through the computer to search for the exercises and create my programs.
To develop an app, since from the web, it is something complicated to move, and always it is necessary to resort to the laptop or computer.
Increased teacher support in the use of applications and programs such as this one Offers more possibilities The use of this application allows us to go deeper into the treatments of different pathologies rather than traditional teaching, which is adjusted to a programme that must be carried out in a speci c period of time.
You apply knowledge better than just seeing theory With this technology it is easier to access any doubt that arises.

More visual and intuitive
More useful

Cases that you nd in real life
Greater accessibility to the different practical exercises Innovations always make the experience generally more entertaining It seems to me that it is much more didactic and it is very good because you can see a great variety of exercises, which give you great ideas.
Much more useful and focused on real life practice Offers an up-to-date and useful resource in professional practice Answers that do not consider software to be advantageous over traditional education The teaching is irreplaceable Both are the perfect complement. Traditional teaching provides a more theoretical learning but it is necessary to know the basics of the eld of physiotherapy. Complementing these classes with applications such as this will achieve greater involvement and learning of students.
It is something complementary that helps you understand that what you are taught traditionally as well as giving you new ideas.
Regarding Question Nº 19 about the recommendation of the application for use in other physiotherapy universities, 100% of the students answered a rmative.
Regarding Question Nº 20 about the recommendation of its use throughout the training period of the physiotherapy degree studies, 97% of the students answered positively.

Discussion
This study examined the potential for m-learning in clinical skills acquisition using a speci c exercise prescription app and evaluate student's perception. Results show a high degree of satisfaction with the speci c app and aspects that students consider should be improved.
This educational m-learning app intervention is the rst interactive method to educate physiotherapy students in designing therapeutic exercise program skills. The usefulness of e-learning to develop clinical competencies and speci c physiotherapy skills was previously reported [5,6,[34][35][36][37][38], however to our knowledge this study is the rst to explore users' perceptions and satisfaction focused in designing therapeutic home exercise program skills.
Current literature reveals that healthcare trainees in a variety of practice environments share similar trends and perceptions of health care apps. Our ndings were similar to those obtained by other elearning experiences assessing students experiences and perceptions [37,39,40].
In the present study the app was used as a supplement to on campus education to enhance the knowledge and training of students. Students used the tool in the resolution of clinical cases, individual and group tasks in various contents such as musculoskeletal and neurological pathologies, injury prevention and risk of falls. This exibility to be used in different elds of physiotherapy can be considered an important advantage over applications focused on a single eld of action.
Positive responses about the m-learning experience and positive responses about innovative methodology con rm that students are interested in using customary technologies. In this context, the change of attitude of the students is becoming more and more evident. They participate, become involved and show great a nity especially when they use known technologies that they encounter on a daily basis [41] what could be considered an important advantage compared to face-to-face master classes. Nevertheless, students continue to point out that these learning tools should be a complement to classroom training, which they consider irreplaceable. This is a clear disadvantage of mobile learning.
Some experts have pointed out, software and hardware issues, distraction and misuse as frequent disadvantages of mobile learning while variety of content and access from anywhere in the world and anytime are recognized as the main advantages [42,43].
Positive results of the rst construct of the questionnaire, especially questions about impact and usability, allows us to hypothesize on the adoption of educational strategies to facilitate self-learning in designing therapeutic exercise programmes may expand the implementation of this assessment approach in routine clinical practice.
E-learning has an evident potential to increase re-training for students and professionals promoting selflearning strategies [44]. Students who responded to the open-ended questions insisted on the need to expand their use to mobile technologies (laptops, cell phones, tablets, etc.), a question that had been suggested in previous research in higher education as it can help revive constructivist learning [45]. In student´s opinion, m-learning cannot replace on-campus learning of physiotherapy student's skills but it appears to be valuable as an additional or complementary activity as expressed by students during the survey.
Within app stores, star ratings and reviews are the main indicators of app quality or value; however, these can be subjective and only relevant if the reviewer has needs and expectations similar to the potential app user. In this context there is evolving literature aiming to identify apps for health conditions, to support self-management, education, or behavior change and to evaluate app quality [46]. For instance, a rubric for evaluating educational apps emphasizes the teaching and learning component of an app; a balance between general and speci c criteria is needed to ensure that the rubric is both reliable and objective [47].
Satisfaction with m-learning in university students has been evaluated with multiple instruments [48]; online questionnaires and surveys was a widely used tool [49]. The speci cations of the m-learning tools, the student pro les and the outcomes to be measured, make the validity, reliability and objectivity of these evaluations di cult. In our research the use of an ad hoc questionnaire intends to approach the speci cations of the m-learning tool and the particularities of the Spanish physiotherapy students.
The most commonly investigated technologies in physiotherapy e-learning tools were websites and discussion boards as has been shown in previous systematic reviews [14]. Websites show improvement in theoretical and practical skills and con rm that student need less time to perform a task [14,36,37].
Of special interest is the development of qualitative research with focus groups that include both students and faculty and that allow the achievement of solid constructs, issues that are on the immediate agenda of the authors of this study. In this research we present each of the answers offered by the students in their own words. Although we have grouped the answers into categories, pointing out their own words allows a better qualitative interpretation.
Most of students consider the use of this m-learning tool advantageous from traditional education and conclude with unanimous agreement to recommend the use in universities along the physiotherapy academic period. The students expressed openness and sincerity in their positive and negative responses and continue working with this educational tool in the current academic year.
An additional factor that is relevant for health-related mobile apps is the credibility of the app content. In the education setting, when learning clinical skills, it is critical to learn skills that are relevant and accurate in the local health care environment. Apps that focus on clinical skills provide opportunities for just-intime learning in clinical settings where textbooks are not available [50,51].
While promising, there are a number of limitations of the current study that need to be addressed in future research including the limited sample size and lack of a true control group. Another limitation is the frame of reference, that is, that the measurement properties of the questionnaire are only evaluated when applied to one unique app and in one context.

Conclusion
This research provides new knowledge in the perception and satisfaction using a speci c m-learning apps. Study results respond to the objectives set, reporting a high degree of general satisfaction and presenting a homogeneous level of positive valuation in the set of questionnaire items.
These results con rm that an m-learning app to design therapeutic exercise program is considered a satisfactory and innovative instrument that brings improvements in the learning of physiotherapy students.
Future physiotherapists will likely be the generation to formally adopt mobile technology into their work ow and clinical practice. This research con rm that m-learning experience focus in the design of therapeutic program skills with the Physiotec app, is an educational innovation for physiotherapy students and is considered a didactic tool recommended for use throughout the education period.
Research with larger sample size, qualitative research including students and faculty, questionnaire validation research, and clinical trials comparing the tool with campus education must bring greater strength to the statements provided by this study.
Students strongly recommend the use of the m-learning app along the physiotherapy academic period.

Declarations
Ethics and consent to participate Participation was voluntary, anonymous and con dential. Student's skills acquisition using an exercise prescription app

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. AppendixA.AdHocQuestionnaireEnglishversion25.06.21.pdf