research skills in physiotherapy

Physical Therapy: Research Skills

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Physiotherapy

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Tips to get you started on a database search

• Review the assignment question and identify key concepts e.g. 'physiotherapy' and 'aged'
• Brainstorm alternative terms for each concept e.g. 'physical therapy', 'elderly'
• Use brackets to group like terms together e.g. ("physical therapy" OR physiotherapy")
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For more detailed, step-by-step instruction, check out the User Guides sub-tab (under Finding Articles), or go to the Help menu on any database.

• UNC Libraries | Evaluate The University of North Carolina is widely renowned for expertise in information literacy. Try out their fantastic tutorial on evaluating resources.

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Research Skills

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
• Health Disparities in Access to Physiotherapy Services
• Physiotherapy in Low-Resource Settings: Challenges and Solutions
• Cross-Cultural Communication in Physiotherapy Practice
• Role of Physiotherapists in Addressing Climate Change Health Impacts

Ethical Considerations in Physiotherapy Research

• Informed Consent: Ensuring patients fully understand the research and voluntarily agree to participate.
• Confidentiality of Patient Information: Safeguarding patient privacy and protecting their personal data.
• Data Collection and Storage: Using secure methods to collect, store, and analyze research data.
• Research Ethics Committee Approval: Obtaining ethical approval before conducting any research involving human participants.

Research in physiotherapy is a dynamic and essential part of the field. For students embarking on their research journeys, the possibilities are limitless. 

From improving rehabilitation techniques to enhancing patient care, each study contributes to a brighter, healthier future.

So whether you’re intrigued by the mysteries of the musculoskeletal system or fascinated by the potential of technology in therapy, there are  research topics for physiotherapy students waiting for you to explore. Together, let’s continue pushing the boundaries of knowledge and empowering individuals to move, heal, and thrive.

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• Research article
• Open access
• Published: 28 September 2015

Online technology use in physiotherapy teaching and learning: a systematic review of effectiveness and users’ perceptions

• Aleksandra K. Mącznik 1 ,
• Daniel Cury Ribeiro 1 &
• G. David Baxter 1  

BMC Medical Education volume  15 , Article number:  160 ( 2015 ) Cite this article

15k Accesses

49 Citations

10 Altmetric

Metrics details

The use of online technologies in health professionals’ education, including physiotherapy, has been advocated as effective and well-accepted tools for enhancing student learning. The aim of this study was to critically review the effectiveness, and user perceptions of online technology for physiotherapy teaching and learning.

Following databases were systematically searched on the 31 st of August 2013 for articles describing implementation of online technologies into physiotherapy teaching and learning: ERIC, CINAHL, Web of Science, Academic search complete, ProQuest Nursing and Allied Health Source, Medline, Embase, and Scopus. No language, design or publishing date restrictions were imposed. Risk of bias was assessed using the 2011 Mixed Methods Appraisal Tool checklist (MMAT).

A total of 4133 articles were retrieved; 22 articles met the inclusion criteria and were accepted for final analysis: 15 on the effectiveness of technology, and 14 on users’ perceptions. Included studies used three designs: case study (14 articles), controlled trial (3), and randomized controlled trial (5). Studies investigated both pre-registration physiotherapy students (1523) and physiotherapy professionals (171). The quality of studies ranged from 67 to 100 % on the MMAT checklist which can be considered moderate to excellent. More than half of the studies (68 %) received scores greater than 80 %. Studies typically investigated websites and discussion boards. The websites are effective in enhancing practical skills performance, and discussion boards in knowledge acquisition, as well as in development of critical and reflective thinking. Students’ perceptions of the use of websites were mostly positive, providing students with entertaining, easy accessible resources. Perceived barriers to the use of websites included difficulties with internet connection, insufficiently interactive material, or personal preference for paper-based materials. Discussion boards were perceived as deepening students’ thinking and facilitating reflection, allowing for learning from multiple perspectives, and providing easy communication and support.

Conclusions

The results of this review suggest that online technologies (i.e., websites and discussion boards) have many benefits to offer for physiotherapy teaching and learning;

There was minimal evidence of barriers for the use of online technologies, however, addressing the identified ones could enhance adherence to use of online technologies in health professionals’ education.

Peer Review reports

Online technologies can be defined as any service and communication tools available on or utilising the internet including social networks, web-based resources and discussion boards. Online technologies have become an indispensable part of students and academics’ life in higher education, influencing strategies for learning [ 1 – 3 ]. Students in the health professions seem to access the internet daily, as part of which they are engaged in diverse online activities, focused mainly around social media platforms [ 4 ]. The rapid evolution of web-based information platforms, and social media in particular, has made the internet the primary source of information for many health professions students [ 5 ], meaning that medical textbooks and paper-based materials are no longer the main source of knowledge for student learning. Such embracing of online technologies into health professionals’ education is considered as inevitable and desired by some authors [ 2 , 6 ], but more recently others advise caution and moderation [ 7 , 8 ]. It is therefore important and timely to review and critically appraise the evidence from the empirical studies.

The broader incorporation of online technology into health professionals’ education is increasingly advocated, with claimed benefits including incorporation of quality content, support of life-long learning, flexibility of access, enrichment and personalisation of learner experience, and improved communication networks [ 9 – 11 ]. However, the use of online technologies as teaching tools has shown mixed results (benefits or no difference to traditional methods in facilitating knowledge or skills acquisition) in health professionals’ education. Previous reviews have focused on the use of technology in dental [ 11 ], medical [ 12 ], nursing education [ 13 ], and also for health professions’ faculty development [ 14 ]. To date however, there is a lack of reviews focusing on the use of online technology in physiotherapy education, and reviews conducted on mixed health professionals groups frequently do not include physiotherapy studies [ 15 , 16 ]. Therefore a systematic review of the outcomes of online technology use in physiotherapy teaching was indicated to inform conclusions about their usefulness.

The aim of this study was twofold. First, we aimed to assess current evidence for the effectiveness of technology in physiotherapy teaching and learning in enhancing students’ skills and knowledge. Second, we aimed to summarize perceptions of physiotherapy students (or professionals) on the use of online technology.

The research questions were:

What is the effectiveness of technology on teaching and learning in physiotherapy in respect to student learning outcomes (i.e., students’ grades)?

What are the users’ perceptions (physiotherapy students and professionals) of benefits and barriers for use of technology in physiotherapy teaching and learning?

PRISMA guidelines were used to design and report this systematic review [ 17 ].

Eligibility criteria

Articles published in peer-reviewed journals describing implementation of any online technology for teaching and learning in physiotherapy (Am: physical therapy) were included in this review. Articles could present designs such as case study (CS), controlled trial (CT), or randomised controlled trial (RCT). No restrictions on publication date or language were imposed.

Articles were excluded if: in studies with wide professional focus, results of the physiotherapy sample were impossible to separate from those for other allied health professions; at least one of effectiveness of, or perceptions of, online technologies were not investigated in the study; or if articles were of a review type.

For the purpose of this review, we adopted a pragmatic approach, and used effectiveness in a broad sense. Studies could investigate the effect of any online technology on knowledge or skills acquisition, engagement and participation, critical thinking and similar. Perceptions of online technologies were defined as mainly qualitative comments provided by physiotherapy students and practitioners in the studies.

Search strategy

To capture maximum data and reduce bias in this review, a systematic search methodology was used to identify relevant articles. The systematic searches were performed on the 31 st of August 2013 in the following databases: ERIC, CINAHL, Web of Science, Academic search complete, ProQuest Nursing and Allied Health Source, Medline, Embase, and Scopus. A combination of key words related to the ‘technology’ and ‘physiotherapy’ was used. An example of the search strategy is presented in Table  1 .

Selection of the studies

The process of study selection is presented in Fig.  1 . After duplicates removal, title and abstract screening, were performed with use of the bibliographic software EndNote X7.1 [ 18 ]. Two reviewers screened the references independently, with each adopting a different strategy for screening. In the first screening strategy, using EndNoteX6, one reviewer (AKM) applied two filters on all the records, namely ‘teaching’ and ‘learning’ , and then title- and abstract-screened. The second reviewer (DCR), also using EndNoteX6, applied the following filters: teaching, learning, higher education, physiotherapy or physical therapy. Records for each filter were combined, and title- and abstract-screened for eligibility. Studies identified as eligible, were then compared with those identified by the first reviewer. Any disagreement regarding inclusion of articles was discussed to reach consensus. Remaining articles were then full-text screened and analysed.

Search strategy and flow of the studies. (Prepared in accordance with PRISMA guidelines [ 17 ])

Assessment of risk of bias

Risk of bias was assessed using the 2011 Mixed Methods Appraisal Tool checklist (MMAT) [ 19 ], which allows for the assessment of studies with quantitative, qualitative, and mixed methodological designs. This checklist consists of two initial questions applicable to all study designs, and four questions applicable to each of the designs. Only the questions relevant to each study design are scored, and the number of ‘yes’ answers to these questions summed. This number is divided by the total number of relevant questions and multiplied by 100, giving a final percentage score.

Risk of bias in individual studies was independently assessed by two reviewers (AKM, DCR) and all discrepancies resolved by discussion to reach consensus. Inter-rater agreement on the risk of bias assessment was calculated by means of Cohen’s Kappa [ 20 ] using SPSS software v.16 [ 21 ].

Data extraction and analysis

Studies were classified based on each of the two research questions of this review. One focused on the effectiveness of online technology to enhance learning and teaching in physiotherapy, and the other on the perceptions of learners on the use of technology. Study characteristics such as design, sample size and type, technology implemented, physiotherapy course, type of outcome measures and main findings, were extracted to a (pre-agreed) tabular form by one review author (AKM) and checked by the second review author (DCR). Disagreements were resolved by discussion between the two reviewers. Risk of bias was then assessed and added to the tables. The main findings from both groups of studies were analysed and narratively summarized.

Findings of the studies, designs and risk of bias were taken into account to draw the recommendations for some of the technologies.

Search results

The flow and number of the studies screened through each stage of this review are presented in Fig.  1 . A total of 4133 articles were retrieved. After excluding duplicates, 1836 articles were left, and underwent screening to leave 22 articles that met the inclusion criteria and were accepted for final analysis.

Study characteristics

All articles were published in English, but original studies were conducted in seven countries (i.e., Australia, Canada, Hong Kong, South Africa, Spain, the UK, and the USA). In general, studies used three designs: case study (14 articles), controlled trial (3), and randomized controlled trial (5). In total, included studies investigated 1694 participants, both pre-registration physiotherapy students (baccalaureate (1182), doctor of physical therapy (341), postgraduate (148)) and physiotherapy professionals (23). Studies investigated the use of online technologies, principally including websites and discussion boards across basic sciences (e.g., anatomy), physiotherapy disciplines (e.g., paediatric physiotherapy), to physiotherapy research (e.g., research methods). Eight studies investigated the effectiveness of technology in teaching and learning in physiotherapy, seven studies explored perceptions of physiotherapy students or professionals related to the use of such technology, and a further seven studies investigated both aspects. The map of technologies used in physiotherapy teaching and learning is presented in Fig.  2 .

Map of technologies use in physiotherapy teaching and learning. (Green – disciplines in physiotherapy, blue – technologies used, yellow – studies; physio – physiotherapy)

Quality of the articles

The quality of studies ranged from 67 to 100 % on the MMAT checklist, which can be considered moderate to excellent. More than half of the studies (68 %) received scores greater than 80 %. Cohen’s Kappa for inter-rater agreement was 0.75, indicating “substantial agreement” between raters (range 0.61–0.80) [ 22 ]. None of the studies were excluded from the analysis on the basis of the MMAT score.

Results of the individual studies

Review results are presented in two domains related to the research questions: the effectiveness of online technology, and perceptions of online technology.

Effectiveness of technology on physiotherapy teaching and learning

A summary of individual studies investigating the effectiveness of technologies in physiotherapy teaching and learning is presented in Table  2 . In total, 15 articles investigated effectiveness of technology in physiotherapy teaching and learning. The designs used included randomised controlled trial (RCT) (5 studies), non-randomised controlled trial (CT) (3 studies) and case study (CS) (7 studies). The most commonly investigated technologies were websites (5 articles) and discussion boards (7 articles). The remaining three articles described the use of video podcasts, collaborative wikis, and blogging, respectively.

Effects of websites on practical skills performance was investigated in five studies: four RCTs [ 23 – 26 , 27 ] and one CT [ 27 ]. The websites included web-based tutorials, or online repositories with videos and patient-therapist simulations. All showed an improvement in practical skills in the groups using websites. Findings from three RCTs [ 23 – 25 ] suggested also that groups using websites needed less time to perform a task; a single RCT [ 23 ] reported the website group to require more time for performing a task. Two RCTs [ 23 , 26 ] found no differences between groups’ knowledge acquisition. One RCT [ 25 ] showed no differences between traditional text-based cases and website simulations for teaching clinical reasoning, but reported lower costs associated with the implementation of website (simulations) when compared to traditional teaching costs.

Discussion boards

Seven studies explored the effect of discussion boards on knowledge acquisition, as well as on development of critical and reflective thinking. Two case studies [ 28 , 29 ] found significant improvements in knowledge acquisition (measured by students’ final marks) through the use of discussion boards. Two other studies investigated influence of discussion boards on critical thinking. Results from a controlled trial [ 30 ] suggested a significant improvement in critical thinking in the experimental group (exposed to a discussion board) compared to the control group (not exposed to a discussion board). A case study [ 31 ] similarly indicated enhanced critical thinking related to literature evaluation. Another case study [ 32 ] reported positive effects on reflective practices, and one controlled trial [ 33 ] found evidence of benefits in reflective thinking (with no difference between peer-facilitated and mentor-facilitated discussion boards). Peer-facilitated and mentor-facilitated discussion boards were both found to facilitate conclusion drawing, but a greater degree of higher-order thinking in mentor-facilitated group was observed [ 33 ]. Other case studies reported discussion forums being effective in increasing active participation in discussion of journal articles [ 31 ] and in increasing students’ awareness of core professional values [ 34 ].

Other technologies

Case studies have shown no improvement in grades using collaborative wikis [ 35 ], but that students demonstrated a range of clinical reasoning and metacognitive skills using blogging [ 36 ]. Another RCT study [ 37 ] using podcasts found no significant effect on written nor practical exam scores.

Perceptions of benefits and barriers for use of technology in physiotherapy teaching and learning

A summary of individual studies investigating perceptions related to online technology use in physiotherapy teaching and learning is presented in Table  3 . Perceptions of physiotherapy students and professionals on technologies used were investigated in 14 articles, of which four were randomised controlled trials, two were non-randomised controlled trials, and eight were case studies.

Seven studies investigated users’ perceptions of websites focusing mostly on positive feedback [ 23 , 24 , 26 , 27 , 38 – 40 ]. Websites contained repositories of course related materials, web-based tutorials, and also videos and quizzes. Participants’ feedback described the use of websites as entertaining, easy to access, ‘great for learning’ [ 27 ], and a beneficial tool. Websites allowed participants to access all materials in one place, and enabled enjoyable, independent learning. One of participants stated: ‘I found that everything was there that you needed… you didn’t need to go and ask’ [ 39 ]. Only two studies explored barriers in using websites [ 26 , 39 ]: common issues identified included difficulties with internet connection, insufficiently interactive material, or simply preference for paper-based materials.

Three studies investigated feedback related to the use of discussion boards [ 30 , 39 , 41 ]; all combined analysis of discussion boards with other technologies such as chat, website, or e-diary. Discussion boards were perceived as deepening the thinking and facilitating reflection, allowing for learning from multiple perspectives, and facilitating communication and support. Also, discussion boards allowed students to ‘collect their thoughts before responding’ while ‘not put on the spot’ [ 41 ].

Users’ perceptions of other online technologies were investigated in eight studies, which investigated chat [ 41 ], video link [ 30 ], blogging [ 42 ], e-diary [ 30 ], bulletin [ 30 ], video podcasts [ 37 ], collaborative wikis [ 35 ], personal digital assistants [ 43 ], and an audience response system [ 44 ]. In general, these technologies facilitated communication, reflection, quick and timely access to information, self-assessment and comparison to others.

This study is the first to systematically review the effectiveness of, and users’ perceptions of, online technology in physiotherapy teaching and learning. This review included a total of 22 articles (15 on the effectiveness of technology, and 14 on users’ perceptions of the use of technology). Articles included in this review used different methods (e.g., quantitative, qualitative, and mixed methods), study designs (RCT, CT, case study), and outcome measures. Therefore, it was not possible to conduct meta-analysis. Despite the heterogeneity of study designs, interventions, and outcome measures, all included studies were considered as of low risk of bias.

The effectiveness of interventions varied according to the technology used (Table  2 ). Websites improved practical skills performance; however, their effect on time to perform a given task is inconclusive. Furthermore, no added benefit was found with the use of websites on knowledge acquisition or clinical reasoning; however, their use resulted in lower costs. In contrast, discussion boards were found to improve knowledge acquisition, critical and reflective thinking, and increase students’ awareness of core professional values and active participation in discussion on journal articles. Overall, our results suggest benefits of websites and discussion boards for facilitating learning, and enhancing the development of practical skills and knowledge acquisition (although it is noted that two studies reported no difference between knowledge acquisition using websites).

Users’ perceptions of the use of technologies for teaching and learning purposes were mostly positive (Table  3 ). Users acknowledged technologies such as websites and discussion boards for allowing access to all relevant materials in one place, for representing an enjoyable and entertaining learning experience, for facilitation of thinking, reflection, and learning from multiple perspectives. However, this positive view may be biased due to paucity of studies focusing on barriers to online technology use.

Results from this review are in agreement with previous reviews investigating the use of online and computer-related technologies in medical, dental, and nursing education. Previous reviews have shown equal or superior learning outcomes with the use of online technologies [ 11 , 15 ] with few studies showing negative results for the use of web-technologies in teaching and learning [ 12 , 13 ]. Similarly to this review, previous reviews conducted with other health professions have shown that most studies reported positive attitudes from medical, dental and nursing students towards technology [ 15 ]. Combined, findings from the present and previous reviews suggest that technology has a place in health professional education, but its incorporation into learning and teaching practices needs to be carefully planned.

From the date the searches were commenced for the current review, five additional articles have been published on the topic. These five articles were case studies, four were published in English language and one article was published in French [ 45 ]. Two studies investigated the use of videos as a way of gathering feedback on practical skills performance [ 46 ] or delivering lectures [ 47 ]. The outcomes suggested positive students’ perceptions towards these teaching approaches. Two other studies investigated blogging for the development of reflection on practice. Blogging elicited reflection on students’ practice; however the results suggested some barriers, such as technical difficulties in posting [ 48 ]. Blogging also facilitated the development of reflection and research skills [ 49 ]. The fifth study [ 45 ] investigated the use of simulation software on development of clinical reasoning in cardiorespiratory physiotherapy. The reported results suggested students perceived it as a positive and satisfactory method. These additional five studies reported similar findings to those identified through our original search, suggesting that web-technologies may be useful instruments for strengthening teaching methods in undergraduate and postgraduate levels.

Research on the use of web-based technologies in physiotherapy is at its infancy, which impacted on the present review in several respects. First, the included studies had different study designs, outcome measures, used different technologies (interventions), and explored the use of web-based technologies in different physiotherapy courses and populations. Therefore, it is difficult to identify the optimum approaches and practices for the use of web-based technology on teaching and learning in physiotherapy. It also precluded meta-analysis of results. Second, only five out of 15 studies were RCTs, limiting the classification of the level of evidence regarding the effectiveness of interventions being evaluated. Finally, the definition of online technologies used in this study might not have been exhaustive and this is recognised as limitation. This field of research is rapidly evolving with a paucity of studies and varying definitions. There is a need for clarification of the definitions as the literature expands.

Future research should focus on the identification of barriers for the use of online technologies for teaching and learning in physiotherapy. Addressing such barriers may optimize adherence to the use of online technologies, enhancing learning outcomes. Also, physiotherapy education would benefit from studies evaluating individual online technologies in robust methodologically designs (e.g., added benefit type RCT), and the adoption of reporting guidelines such as CONSORT [ 50 ] or COREQ [ 51 ].

The results of this review suggest that online technologies (i.e., websites and discussion boards) have many benefits to offer for physiotherapy teaching and learning. These include enhancing practical skills performance and knowledge acquisition, providing students with entertaining, easy accessible resources, enhancing deep learning and encouraging reflection. Such benefits allow for learning to occur from multiple perspectives. Perceived barriers included difficulties with internet connection, insufficiently interactive material, or personal preference for paper-based materials. Although there was minimal evidence of barriers for the use of online technologies, addressing the identified ones could enhance adherence to use of online technologies in health professionals’ education.

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The authors gratefully acknowledge Dr Ben Daniel, Mr Bill Anderson, and Mr Richard German.

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Mącznik, A.K., Ribeiro, D.C. & Baxter, G.D. Online technology use in physiotherapy teaching and learning: a systematic review of effectiveness and users’ perceptions. BMC Med Educ 15 , 160 (2015). https://doi.org/10.1186/s12909-015-0429-8

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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

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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.

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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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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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Language: English | Arabic

The barriers of scientific research in physiotherapy

Najla f. alsiri.

a Physical Therapy and Rehabiliation Department, Al-Razi Orthopedics and Rehabilitation Hospital, Kuwait

Fatimah H. Alansari

b Physical Therapy and Rehabiliation Department, Alrashed Allergy Center, Kuwait

Aminah H. Sadeq

c Department of Physical Therapy, Kuwait University, Kuwait

Scientific discoveries and updates are increasingly needed to enhance how healthcare is conducted and implemented for various specialties. Research in physiotherapy in Kuwait is limited. The study aimed to explore the barriers to research in physiotherapy in Kuwait.

A cross-sectional research design and an online questionnaire method were used. The ethics committee of Kuwait's Ministry of Health approved the study (ref. 2019/1076). The questionnaire was constructed on the basis of an intensive literature review. Expert committee meetings were held to approve the items and review the content, accuracy and construction. The questionnaire consisted of four domains: participants' characteristics, research background, research barriers and encouragement for future research.

Of the 311 physiotherapists who responded to the questionnaire, 67% were women, and 80% were 25–44 years of age. A total of 55% of the participants read academic articles monthly. The major research barriers were lack of time (45%), followed by lack of research skills (41%) and lack of resources (40%). Other identified factors included workload (29%), difficulties in gaining ethical approval (27%), lack of motivation (26%), lack of support (25%), lack of participants (22%) and lifetime responsibilities (21%). Respondents indicated that encouragement for future research came from research workshops and lectures (75%), awards and recognition (52%), and encouragement from the department heads (45%).

Physiotherapy research can be advanced in Kuwait by targeting the barriers identified herein, to strengthen physiotherapy research and advance the physiotherapy profession.

الملخص

أهداف البحث.

هناك حاجة متزايدة للاكتشافات العلمية والتحديثات لتعزيز إدارة وتنفيذ الرعاية الصحية لمختلف التخصصات. النشاط البحثي في العلاج الطبيعي في الكويت محدود، لذلك هدفت الدراسة إلى استكشاف عوائق البحث في العلاج الطبيعي في الكويت.

طرق البحث

استخدم تصميم البحث المقطعي وطريقة استبانة عبر الإنترنت ووافقت لجنة الأخلاقيات بوزارة الصحة الكويتية على الدراسة (المرجع: 2019/1076). بُنيت الاستبانة على أساس مراجعة الأدبيات المكثفة. وعُقدت اجتماعات لجنة الخبراء لاعتماد البنود، ومراجعة محتواها ودقتها وصياغتها. وبذلك تتكون الاستبانة من أربع أجزاء هي: خصائص المشاركين، وخلفية البحث، وعوائق البحث، والتشجيع على البحث المستقبلي. تم جمع البيانات من قبل اختصاصيي العلاج الطبيعي العاملين في الكويت في القطاعين الحكومي والخاص. لاعتبار المشاركين للدخول في البحث يجب أن يكون اختصاصي العلاج الطبيعي مسجل ولديه رخصه مهنية من قبل وزاره الصحة الكويتية.

النتائج

استجاب 311 اختصاصي علاج طبيعي للاستبانة على النحو التالي: خصائص المشاركين تتمثل بما نسبته 67٪ من الإناث ونسبة 80٪ تتراوح أعمارهم ما بين 25 و44 سنة. وكان 55٪ من المشاركين يقرأ المقالات الأكاديمية على أساس شهري. عوائق البحث الرئيسية التي عُثر عليها هي: ضيق الوقت عند 45٪؛ يليه نقص في مهارات البحث ونقص في الموارد بنسبة 41٪ و40٪ على التوالي. كما حُددت عوامل أخرى، بما في ذلك عبء العمل بنسبة 29٪؛ والصعوبات في الحصول على الموافقة الأخلاقية بنسبة 27٪؛ ونقص الحافز بنسبة 26٪؛ ونقص الدعم بنسبة 25٪؛ وقلة المشاركين بنسبة 22٪، والمسؤوليات الحياتية بنسبة 21٪. للتشجيع على البحث العملي المستقبلي اقترحت ورش عمل ومحاضرات بحثية بنسبة 75٪، في حين اقترحت الجوائز والتقدير بنسبة 52٪. وقد اقترح 45٪ من المشاركين التشجيع من رؤساء الأقسام.

الاستنتاجات

يمكن تطوير أبحاث العلاج الطبيعي في الكويت من خلال استهداف العوائق التي حُددت والتي يمكن أن تعزز أبحاث العلاج الطبيعي والمهنة.

Introduction

Scientific research can significantly improve healthcare and enhance the understanding of health-related issues, because it involves clinicians, researchers and healthcare organizations. 1 , 2 Scientific research can also inform decisions associated with health policies, programs and practices supporting the delivery of health services, through the use of quantitative, qualitative or mixed method research designs. 3 , 4 Research can contribute to more effective healthcare by solving health problems and assisting practitioners and policy makers. 4 However, research is strongly associated with social, cultural, economic, political, legal and institutional factors. 4 Furthermore, the influence of context on the implementation of research necessitates exploring certain health-related issues at the national level to aid in research implementation. Moreover, low levels of research activity are a major challenge for policymakers and stakeholders in some countries, thus complicating decision-making. Physiotherapy is an essential profession for managing and preventing health issues, and improving overall quality of life and public health; therefore, it must be evidence-based. 5 However, in Kuwait, the activity of scientific research in physiotherapy is highly limited by several barriers. The Kuwait Physical Therapy Administration provided us with the number of ethical approval applications submitted to their ethics committee. The records of the ethics committee of the Physiotherapy Administration of Kuwait Ministry of Health showed that in the years 2017–2019, only 12 studies applied for ethical approval. All ethical applications for physiotherapy-related research in Kuwait are directed from the Ministry of Health main ethics committee for approval by the ethics committee of the Physiotherapy Administration. Therefore, exploring the physiotherapy research barriers in Kuwait would provide valuable information to support administrative officials in evaluating and combating those barriers to advance and strengthen physiotherapy research, and consequently advance physiotherapy toward evidence-based practice.

Research barriers have been explored in various cohorts, including psychologists, psychiatrists, social workers, residents and medical students, and among a more general cohort of medical professionals. 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 The barriers to implementing evidence-based practice in physiotherapy have been systematically reviewed to improve the proficiency of clinical practice. 15 Evidence-based practice in physiotherapy has been found not to translate into consistent high-quality practice, in terms of knowledge, attitude and implementation. 15 However, the literature is limited in studies specifically exploring the research barriers and obstacles to conducting scientific research in the physiotherapy profession, which, as an autonomic discipline, has a unique clinical nature in practice. Additionally, the barriers to conducting scientific research have been explored in various countries such as the United Kingdom, Australia, Africa, South America, China and India. 6 , 10 , 12 ; however, only three studies have been conducted in the Middle East region, including Egypt, KSA and Iran. 7 , 8 , 9 Therefore, the objective of this study was to explore the barriers to conducting scientific research in physiotherapy in Kuwait. The findings of the current exploration may aid in the implementation of strategic plans and policies to overcome the barriers and obstacles to research conducted by physiotherapy professionals in Kuwait, as a representative of the Middle East region.

Materials and Methods

Study design and ethics.

This study used an observational cross-sectional survey design with an online questionnaire. The questionnaire method is useful and effective for investigating specific practices by including a representative sample population with different characteristics. 14 The study was approved by the regional ethics committee of the Kuwait Ministry of Health (ref. 2019/1076). Confidentiality, anonymity and informed consent were fundamental ethical characteristics of the questionnaire. People who responded to the questionnaire were invited to participate without coercion. Submission of the questionnaire was considered to constitute informed consent.

Questionnaire development process

The questionnaire was developed in two stages. The first stage was based on an intensive review of the literature to identify the potential barriers to conducting research and to aid in formulating the primary question. The second stage aimed to develop the questionnaire through expert committee meetings. A literature review was conducted to explore a wide range of original articles and reviews associated with barriers to research in physiotherapy. The PubMed and Medline search engines were searched with the key words of barriers, obstacles, research, physical therapy or physiotherapy, from January to March of 2019. No study was identified that specifically explored research barriers in the physiotherapy profession. Because of the lack of research on barriers to conducting physiotherapy research, the literature review was expanded to other medical professions, to aid in constructing the primary question. The terms “physiotherapy” and “physical therapy” were excluded from the search strategy. Nine studies and reviews exploring the research barriers among other medical professions were identified ( Table 1 ). According to the review, the primary question of the questionnaire was formulated, which consisted of 14 answers. The most frequently discussed research barriers in the previous literature were a lack of time, research skills and resources ( Table 1 ). Other barriers were also frequently discussed, including workload, lack of support, lifetime responsibility, lack of volunteers, fear of failure to publish the study, difficulty in gaining ethical approval, high cost of resources, long time periods for acquisition of results, complicated regulations and infrastructure, research not being included in job descriptions and lack of motivation ( Table 1 ). The primary question was constructed accordingly.

Table 1

Literature review of studies exploring the barriers to conducting scientific research.

An expert committee meeting was held after the primary question was formulated, which consisted of physiotherapists with master's and/or PhD degrees in physiotherapy who had experience in conducting research. The committee approved the formulated research barrier question and identified the variables, relevant to the Kuwaiti context, according to the review. An initial questionnaire was then designed. The developed questionnaire consisted of four main domains: participants' characteristics, research background, research barriers and encouragement for future research. The questionnaire included mainly closed-ended questions and was drafted in English. The English language is generally well understood by Arabic and non-Arabic speaking physiotherapists who are registered with the Ministry of Health.

The experts committee reviewed the content, accuracy, construction problems and grammatical errors, and ensured that the items did not contain offensive content or bias toward particular respondents. The next step was to reduce the statements and discard any redundancies. The code of ethics was considered during the questionnaire development process, including the following: 1) voluntary participation was ensured through allowing participants the freedom to complete or withdraw from the research, 2) participation was anonymous, and informed consent was assumed when the participants successfully submitted fully completed questionnaires, and 3) the aim and content of the questionnaire were clearly stated on the introduction page. Additionally, the questionnaire items did not include any invasive or personal questions; the questions were associated with basic demographic data and general background information, without requiring disclosure of any private, personal or sensitive information. The face validity and specific content validity were developed via peer expert review. After three drafts, the final questionnaire was approved, ensuring the implementation of the ethics code ( Table 2 ). SurveyMonkey Inc. (San Mateo, California, USA) was used to create an online questionnaire. Concise, explicit and simple English was used on the welcome page, clarity was maintained throughout all items, and instructions were included to maximize respondents’ understanding. 16 The questionnaire contained a total of 11 items ( Table 2 ). The average length of time needed to complete the questionnaire was approximately 5–10 min. To determine the minimum number of participants needed for the study we used the subject to item ratio, a prevalent guideline for determining a prior sample size for studies using questionnaires. 16 Because the questionnaire included 11 items, and a subject to item ratio of 20:1 was used, a minimum of 220 participants were need for the study. 16

Questionnaire developed to explore the barriers to conducting scientific research in physiotherapy in Kuwait.

Study sample

The data were collected from physiotherapists working in Kuwait in the government and private sectors, with all levels of physiotherapy qualifications. Approximately 768 physiotherapists, including BSc, MSc, PhD and DPT holders, were registered according to the Kuwait Physiotherapy Administration annual statistics of 2019. To be considered eligible for the study, physiotherapists were required to be licensed and registered with the Ministry of Health of Kuwait.

Questionnaire distribution and data collection and management

Data collection started on September 16, 2019 and continued for 7 weeks. The study invitation, participation announcement and an online link to the questionnaire were distributed by the Physical Therapy Administration via their WhatsApp network for all Kuwaiti hospitals. The heads of the physiotherapy departments of Kuwaiti hospitals received an official invitation letter to encourage participation among their staff. Two weeks before the deadline, a reminder WhatsApp message was sent to all registered physiotherapists through the same WhatsApp network to increase the response rate. On December 2, 2019, the online questionnaire was closed, and the data analysis began. Data were collected with SurveyMonkey, which provided detailed descriptive statistics of percentages and the frequency distribution. Both completed and incomplete surveys were included.

With a response rate of 40.5%, a total of 311 surveys were received from 768 invited physiotherapists. In terms of the demographic characteristics, 80% of the respondents were 25–44 years of age, and 67% of the respondents were women ( Table 3 ). Most the respondents had more than 15 years of work experience in physiotherapy at 36%, and 78% held a Bachelor's degree in physiotherapy ( Table 3 ). Regarding the respondents' research background, 56% indicated that they read academic articles on a monthly basis, whereas 53% indicted that they had conducted research previously ( Table 4 ).

Table 3

Demographic characteristics of respondents, including age and gender. Years of work experience and qualifications are also shown (n = 311).

Table 4

Research interest and background regarding the frequency of reading academic articles (n = 308) and previous experience in conducting research (n = 309).

A total of 309 of the 311 respondents answered the research barrier questions. The main reasons indicated were a lack of time (45%); lack of research skills (41%); and lack of resources, including funding, research software and database access (40%; Table 5 ). Some respondents indicated that workload (29%), difficulties in gaining ethical approval (28%), lack of motivation (26%) and lack of support (25%) were reasons for the dearth of research in physiotherapy in Kuwait ( Table 5 ). Table 5 and Figure 1 detail the barriers to conducting physiotherapy research. Most respondents (77%) indicated that workshops and lectures in research could be an effective way to improve and encourage physiotherapists to conduct research in the future ( Table 5 ). More than half the respondents (53%) reported that awards and recognitions for researchers could improve and encourage research in physiotherapy. Table 5 details the suggested solutions to improve and encourage physiotherapy research.

Table 5

Barriers to conducting physiotherapy research (n = 309) and suggested solutions to improve and encourage physiotherapy research (n = 301).

Bar graph illustrating the barriers to conducting physiotherapy research.

To our knowledge, this is the first study to examine the research barriers among physiotherapy professionals in Kuwait and to investigate the reasons for the low research activity. The overall response to the questionnaire was encouraging, despite the initial reluctance of a sizable proportion to participate. Most respondents were female physiotherapists, and the most prevalent age range was 25–44 years of age. Most respondents had more than 15 years' work experience including clinical, administrative and academic experience. Additionally, most respondents acknowledged the importance of research and frequently read research studies. The findings from the questionnaire yielded satisfactory results, which may aid in addressing these research barriers in the future to improve physiotherapy research in Kuwait. One of the most common barriers was lack of time (44.9%); other studies, including a systematic review, have reported this barrier as a major obstacle to conducting research in areas including the United Kingdom, Australia and Iran. 1 , 5 , 7 , 15 , 16 , 17 , 18 This barrier may be due to personal obstacles, such as family responsibilities or part-time work other clinics. The questionnaire also revealed that 21% of respondents (n = 64/306) indicated lifetime responsibilities, and some indicated that the workload at their clinics has prevented them from conducting research (29.13%, n = 90/309). Both these reasons may be associated with a lack of time. One respondent, elaborating on workload, stated: “The Physiotherapy Administration is mainly concerned about the caseload in statistics, so we can't minimize the caseload.” Balancing workload with attention to conducting research is crucial; this balance can be supported by developing new research policies for clinical physiotherapists and encouraging innovative research ideas.

Other major organizational barriers described by respondents were a lack of research skills (40.78%), and a lack of resources (40.13%) such as funding, research facilities and equipment, research software programs and library access to databases. The findings of the current study support those of Pager, Holden and Golenko (2012), who have surveyed allied health professionals in Australia, 11 and of Dadipoor et al. (2019), who have surveyed medical students in Iran. 16 The findings of the current study among physiotherapists indicated an awareness of the importance of high standards in research skills. Such skills are crucial for physiotherapists in Kuwait to enable them to conduct high quality research studies. The major barriers obstructing progress in clinical research were a lack of financial resources, lack of skilled personnel, and regulatory and administrative issues. These barriers have also been found in a major systematic review investigating research barriers 6 and a recent study investigating researcher and non-researcher students in medical sciences in Iran. 17

Other organizational barriers include difficulties in approving physiotherapists' research proposals to gain ethical approval (28%, n = 86/309), complicated regulations (11.33%) and a lack of support from the Ministry of Health (25.24%, n = 78/309). One respondent noted: “ We don't lack research in physiotherapy; we lack research by physiotherapists in Kuwait because of lack of support .” According to this response, these organizational barriers may be associated with reactions such as fear of failure and feelings of distress regarding publishing a research study (10.68%). Some respondents found that attempts to obtain outcomes for certain studies are slow because of bureaucratic procedures (7.44%), such as in studies including follow-up investigations. Another respondent's answer, associated with gaining faster results, described “unrealistic meeting points between research results and evidence-based practice.” In addition, the low numbers of volunteers willing to participate in research studies (22%, n = 69/309) was found to be a barrier that has prevented and demotivated physiotherapists from pursuing potential research studies. Most of these organizational barriers have been found in other articles to be the main barriers to conducting research. 1 , 6 , 8 , 18 , 19

In Kuwait, conducting research studies is not part of physiotherapists' job descriptions, particularly for those who work at government hospitals; therefore, 7% (n = 21/309) of the respondents believed that this is a barrier that prevents them from conducting research. However, more than half (53.49%, n = 161/309) the respondents reported that awards and recognition for researchers could encourage research and compensate for research not being part of physiotherapists’ job descriptions. Many studies have found that financial compensation is essential to encouraging researchers in the healthcare system to conduct more research. 1 , 6 , 8 , 19 , 20 The benefits of research are understood by both junior and senior physiotherapists, along with awareness of the need for more knowledge and training in research methods and enhancing and developing research skills. Therefore, many respondents (77.08%, n = 232/301) indicated that workshops and more research lectures should be offered, given that these resources are often limited to physiotherapy undergraduate students. With that aspect in mind, many respondents (46.84%, n = 141/301) reported that encouragement from heads of departments could encourage physiotherapists to conduct research while balancing their workload. In addition, new policies and regulations should be developed by the Ministry of Health to provide a clear path for physiotherapists, and to motivate and prepare them for research.

Another barrier that could be both personal and organizational was a lack of motivation (25.89%). In future studies, a lack of motivation could be further investigated to discover whether a higher correlation exists with personal or organizational barriers, and which barriers are more likely to demotivate physiotherapists and prevent them from conducting research. A lack of motivation has been found to prevent other clinicians in other developing countries from conducting research. 6 , 8 When the participants were asked about whether they had conducted a research study themselves, more than half (52.75%) answered yes. However, this question should be further explored in the future, to differentiate among the types of studies conducted and when the studies were conducted, for example, whether a study was university or work-related research.

Three studies were previously conducted in relatively similar geographical and cultural areas of the Middle East region, including KSA, Iran and Egypt. 7 , 8 , 9 In KSA, the perception, attitudes and practices toward research have been explored among 170 senior medical students at the King Saud University with a self-administered questionnaire. 7 In Iran, research barriers have been explored among 213 physicians, nurses, obstetrician and health experts who attended research workshops at the Mazandaran University of Medical Sciences, through a cross-sectional survey design and mail/hardcopy questionnaire. 8 Moreover, Alemayehu, Mitchell and Nikles (2018) have systematically reviewed the barriers to conducting clinical trials in developing countries, including investigators from Egypt and medical staff from KSA. 9 Regardless of the discrepancy in the professions explored in previous studies conducted in the Middle East, high similarities exist between the research barriers identified in this study and prior studies, although the percentages differ. Lack of time was the main research barrier identified in the present study, at 44.98%, whereas the percentage was 72.3% in KSA and 18.85% in Iran. 7 , 8 A lack of resources was also found in the current study, including funding, research software and database access, at 40.13%. Similarly, in KSA, poor accessibility to databases was noted by 70.6% of respondents, and a lack of funding was described by 54.1% of respondents. 6 In Iran, a lack of library services and devices was identified by 25.92% of respondents. 8 Although the exact percentages for the identified barriers were not specified in the systematic review by Alemayehu, Mitchell and Nikles (2018), which included a sample from Egypt and KSA, their findings agree with the current findings, which highlighted that a lack of financial support, funding, research material/facilities and time were major barriers to conducting scientific research. 9 The fluctuations observed in the percentages of the identified barriers among the Middle East countries is mainly associated with the nature of the explored profession. For example, the study in KSA was on medical students, thus explaining the finding that the highest percentage was for a lack of time (70.6%), given medical students’ study requirements. 7

Stakeholders and health policymakers should implement effective strategies for overcoming the identified barriers to improve health through evidence-based practice by encouraging and increasing the activity of scientific research. Strict rules and regulations should be set to face the main challenge of a lack of time. Clearly, researchers lack the time necessary for conducting research. In Kuwait, physiotherapists have similar patient loads regardless of whether they are conducting research. Setting rules to reduce patient load among physiotherapists who are performing research will be essential. Such a rule should encourage an increase in research activity. Additionally, the Kuwait Ministry of Health receives the largest annual budget from the government; however, the lack of funds for research is a major challenge. Setting an annual budget for physiotherapy research to cover the resources needed for research would provide a solution. Kuwait's physiotherapists lack access to full text articles, which is essential for conducting research. Accessing the full text of studies requires institutional subscriptions. However, the Kuwait Ministry of Health—the main governmental employer of physiotherapists in Kuwait, including all Kuwait governmental hospitals and clinics—does not provide employees, including physiotherapists, open access to research articles and databases allowing the full text of articles to be read without a subscription. Only physiotherapists affiliated with Kuwait University have access to full text articles through the medical library. Reading the full text of studies is essential for conducting research, and this restriction must be resolved. Additionally, some research studies require special equipment for examination, yet no budget has been set by the Kuwait Ministry of Health for the equipment needed for research. The ethics committee of the Physical Therapy Administration receives all applications for physiotherapy research in Kuwait and has a powerful review board that could evaluate research proposals with high and promising value, and recommend funding for equipment and other expenses. Additionally, research budgets could be used for awarding and recognizing researchers as an encouragement, and for planning research workshops and courses.

The validity measure is essential for newly developed questionnaires to examine the ability to measure the intended parameters. 21 , 22 However, the questionnaire used in the present study cannot be considered a newly developed questionnaire, because all questionnaire items were retrieved from nine previously published studies and reviews. 6 , 7 , 8 , 10 , 11 , 12 , 13 , 14 , 18 Three studies from the retrieved literature were conducted in countries with populations of similar ethnicity to the population of Kuwait (KSA, Egypt and Iran) and also studied health professionals. 7 , 8 , 9 A review of the methods for enhancing the validity of research indicated that using or adapting existing questions or surveys with demonstrated validity is preferable, with appropriate acknowledgment and citation; this practice greatly decreases the burden of formally testing new questionnaires. 23 , 24 Although quantifiable statistical data are not provided with face and content validity, both types of validity were considered in the current study. Face validity, a subjective assessment of a questionnaire, was used to examine the face value in terms of feasibility, readability, consistency of style and formatting, and clarity of the language, according to input from individuals with expertise in survey methods in research. 25 Essential elements of content validity were also used to test the questionnaire's items theoretically for having true meaning relevant to the specific topic explored. 23 Content validity was ensured through an exhaustive literature review to extract the items, and evaluation by experts in the same research field indicated that the items were necessary and useful. However, the content validity ratio was not calculated, mainly because the items were extracted from previously published and validated questionnaires. Through multiple drafts, the face validity, essential elements of content validity and the implementation of the ethics codes were ensured. Additionally, the questionnaire consisted of closed questions. The aim of the questionnaire was not to measure or assess a sensitive topic but to determine common topics that every physiotherapist might encounter, and the target respondents were educated and had good English proficiency.

A pilot study was not conducted, and this absence could be considered a study limitation. However, the implemented questionnaire was not newly developed but was adapted from previous studies; it used simple language and direct, closed-ended questions; provided instructions; and had no nominal scale. Additionally, only two respondents did not answer the primary question on research barriers, and 96.7% of the respondents answered all the questions, thus indicating that the questionnaire had appropriate formatting and language with no errors. 26 The questionnaire consisted mainly of closed-ended questions, thus limiting the exploration of more research barriers. Another limitation is that the current study was conducted on physiotherapists registered with the Ministry of Health of Kuwait; thus, the results cannot be generalized beyond this sample population.

Physiotherapy is an essential healthcare profession, and further population-based studies must be conducted to solve national issues related to the specific context of each country. The lack of research activity in physiotherapy in Kuwait is a major challenge for policymakers. However, the barriers to research identified by the current study could be targeted to improve research activity in the physiotherapy profession in Kuwait to move toward better evidence-based practice.

Source of funding

The study was supported by the Physical Therapy Administration of Kuwait Ministry of Health (fund number 2019-1076).

Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

The ethics committee of the Kuwait Ministry of Health approved the study (ref. 2019/1076) in accordance with the declaration of Helsinki. Date: 2019.

Authors contributions

NA conceived and designed the study, conducted research, provided research materials, organized data, analyzed and interpreted data, and wrote the initial and final drafts of the article. FA conceived the study, conducted research, provided research materials, interpreted data and wrote the initial draft of the article. AS conceived the study, conducted research, provided research materials, collected and organized data, interpreted data, and wrote the initial and final drafts of the article. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Acknowledgment

We thank Laila Almansouri and Dr. Ali Al-Attar for their help in this research.

Peer review under responsibility of Taibah University.

Teaching and learning communication skills in physiotherapy: what is done and how should it be done?

Affiliation.

• 1 Collaboration for Leadership in Applied Health Research and Care, Business School and School of Community Health Sciences, University of Nottingham, Nottingham NG7 2TU, UK. [email protected]
• PMID: 19892094
• DOI: 10.1016/j.physio.2009.05.003

Objectives: To survey practice and opinion regarding school-based teaching of communication skills, to summarise relevant research evidence from physiotherapy and beyond, to reflect on practice in light of evidence, and to propose associated recommendations.

Design: Survey using customised questionnaires. Basic descriptive statistical analysis and thematic content analysis were used. The results were compared with evidence from systematic reviews to derive recommendations. SURVEY PARTICIPANTS AND SETTING: Educators in all UK centres delivering physiotherapy qualifying programmes in 2006.

Results: A response rate of 69% was achieved. The majority of respondents reported delivering communication-specific modules. Lecturing was common, and more experiential methods were also used. Assessment was mainly by written work. Educators commented on challenges and strategies involved in student engagement, provision of authentic experiences, availability of teaching time and expertise, and physiotherapy-specific teaching resources. Evidence from allied health profession, medical and nursing education research emphasises the importance of experiential teaching, formative feedback, observational assessment and a substantial evidence base on which to ground course content. In physiotherapy, the latter is emerging but incomplete. There are also gaps in direct evidence about advantages or otherwise of stand-alone modules and benefits of pre-qualification communication training. Evidence suggests that effective training requires substantial teaching time, expertise and a body of empirical research on specific communication practices and their effects.

Conclusion: Curriculum designers and educators should endeavour to maximise the degree to which training in this area is experiential, provide training when students have already had some contact with patients, and assess students by observation if at all possible. Due to gaps in the evidence, some important questions about optimal practice remain unanswered.

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Kinesiology students tackle questions and build skills through research

Critical questions, like how the benefits of physical activity can be observed at the brain level, are the core of Mariane Bacelar’s Skill Acquisition and Psychophysiology Lab . Bacelar, an assistant professor of kinesiology, helps her students get to the bottom of questions such as:

If you say you want to exercise and don’t, why is that? And what would change the situation for you?

How have you acquired a certain motor skill? Has motivation played a part?

How do rewards of various types shape your behavior?

How do you apply feedback to learn a certain skill? How do you translate that information into action?

Bacelar’s lab was built when Bacelar joined Boise State in the fall of 2022 after completing her doctoral program at Auburn University. She serves as the lab’s director. The lab’s physical space opened this spring.

Joined by six undergraduate students and one graduate student, she investigates questions related to motor skill acquisition and physical activity. They mostly focus on young adults, however, and as a result of a new grant, older adults will be the focus of study in the future.

Because the team examines motor learning and physical activity using neuropsychological measures to uncover the neural mechanisms underlying these phenomena, the lab is housed in Department of Kinesiology. But because human movement – and its hows and whys – is universal, the research and findings are important and applicable to most human endeavors.

Engaging student researchers

Along with groundbreaking research, students who sign up for the lab experience also embark on other meaningful work. They’re learning practical skills and helping to rebuild the credibility of the scientific community at the same time.

The student researchers learn how to apply behavioral and neurophysiological methods, such as electroencephalography (commonly referred to as EEG) to record brain activity and metascience techniques into research. They’re also learning how to collect and analyze data, design experiments, present research findings, think critically and work as part of a research team. Every other week, student teams present on scientific articles with group discussions to follow.

“It has a broader impact,” Bacelar said.

“Some students may not know how important research is. Some people may associate this experience with wanting to become a researcher, but this helps develop a lot of skills. It’s not necessarily ‘for’ research. It’s ‘through’ research.” –Mariane Bacelar, assistant professor of kinesiology

And while it’s early days for the lab and lab findings, the lab is succeeding in the ways its director has envisioned.

“We’re still collecting data, but we have a couple of predictions,” Bacelar said, adding that it has become apparent that a fundamental premise underpinning these parts of science is still, in fact, an open question.

“We often assume that motivation is associated with learning, but we’re learning that it has not been established,” she said.

The lab is built on the concept of “open science,” the idea that science should be transparent, accessible and collaborative. Bacelar and many others are hopeful that these principles roll back some of the criticism and skepticism the sciences have faced in recent years, what she describes as a “replication crisis.”

“Our goal is to enhance reliability in our research findings,” she said. “We need to be able to verify our findings, and we need to be transparent, and we need to have rigor.”

Bacelar encourages students from across the university’s disciplines to get involved – but there’s a catch. Because she wants to ensure a quality experience, she’s able to accept only a handful of student researchers. And this year’s lab team will likely be next year’s as well.

“We welcome all types of researchers,” she said. “I think having research experience as an undergrad is valuable. It should be a meaningful experience.”

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Research priorities

Physiotherapy research priorities focus research and funding in areas of practice requiring urgent evidence. They sit within the context of wider health research priorities across the UK.

Current research priorities

The CSP and the James Lind Alliance Priority Setting Partnership recently identified the top priorities for physiotherapy research.

Patients, carers and physiotherapists told us the questions they wanted to ask where research could make a real difference to people receiving physiotherapy. Their questions were about

• Physiotherapy treatments
• Self-management
• Improving health and preventing disease and injury
• How services are accessed and delivered

The top priority

When health problems are developing, at what point is physiotherapy most/least effective for improving patient results compared to no physiotherapy? What factors affect this?

• Take a look at the top ten physiotherapy research priorities
• See all 65 priorities

Final report

Read the Discovering research priorities report:

• Full report
• Executive summary
• Apprendices

These priorities are future facing multifaceted open priorities with flex to be nimble and responsive to the reality of health economics, developing health knowledge and technology landscapes.  Their impact will help optimise individual lives which is the heart of physiotherapy. Sarah Westwater-Wood, Steering Group member

Find out more

The project is funded by the  CSP Charitable Trust .

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News Release

Wednesday, April 24, 2024

Gene-based therapy restores cellular development and function in brain cells from people with Timothy syndrome

NIH-supported study shows potential treatment pathway for neurodevelopmental disorder.

In a proof-of-concept study, researchers demonstrated the effectiveness of a potential new therapy for Timothy syndrome , an often life-threatening and rare genetic disorder that affects a wide range of bodily systems, leading to severe cardiac, neurological, and psychiatric symptoms as well as physical differences such as webbed fingers and toes. The treatment restored typical cellular function in 3D structures created from cells of people with Timothy syndrome, known as organoids, which can mimic the function of cells in the body. These results could serve as the foundation for new treatment approaches for the disorder. The study, supported by the National Institutes of Health (NIH), appears in the journal Nature .

"Not only do these findings offer a potential road map to treat Timothy syndrome, but research into this condition also offers broader insights into other rare genetic conditions and mental disorders," said Joshua A. Gordon, M.D., Ph.D., director of the National Institute of Mental Health, part of NIH.

Sergiu Pasca, M.D., and colleagues at Stanford University, Stanford, California, collected cells from three people with Timothy syndrome and three people without Timothy syndrome and examined a specific region of a gene known as CACNA1C that harbors a mutation that causes Timothy syndrome. They tested whether they could use small pieces of genetic material that bind to gene products and promote the production of a protein not carrying the mutation, known as antisense oligonucleotides (ASOs), to restore cellular deficits underlying the syndrome.

In the lab, researchers applied the ASOs to human brain tissue structures grown from human cells, known as organoids, and tissue structures formed through the integration of multiple cell types, known as assembloids. They also analyzed organoids transplanted into the brains of rats. All of the methods were created using cells from people with Timothy syndrome. Applying the ASOs restored normal functioning in the cells, and the therapy's effects were dose-dependent and lasted at least 90 days.

"Our study showed that we can correct cellular deficits associated with Timothy syndrome," said Dr. Pasca. "We are now actively working towards translating these findings into the clinic, bringing hope that one day we may have an effective treatment for this devastating neurodevelopmental disorder.

The genetic mutation that causes Timothy syndrome affects the exon 8A region of the CACNA1C gene. The gene contains instructions for controlling calcium channels—pores in the cell critical for cellular communication. The CACNA1C gene in humans also contains another region (exon 8) that controls calcium channels but is not impacted in Timothy syndrome type 1. The ASOs tested in this study decreased the use of the mutated exon 8A and increased reliance on the nonaffected exon 8, restoring normal calcium channel functioning.

Grants: MH115012 , MH119319

About the National Institute of Mental Health (NIMH):  The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the  NIMH website .

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov .

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Driving Innovations in Biostatistics with Denise Scholtens, PhD

“I'm continually surprised by new data types. I think that we will see the emergence of a whole new kind of technology that we probably can't even envision five years from now…When I think about where the field has come over the past 20 years, it's just phenomenal.”  —  Denise Scholtens, PhD  

• Director, Northwestern University Data Analysis and Coordinating Center (NUDACC)  
• Chief of Biostatistics in the Department of Preventive Medicine  
• Professor of Preventive Medicine in the Division of Biostatistics and of Neurological Surgery  
• Member of Northwestern University Clinical and Translational Sciences Institute (NUCATS)  
• Member of the Robert H. Lurie Comprehensive Cancer Center  

Episode Notes 

Since arriving at Feinberg in 2004, Scholtens has played a central role in the dramatic expansion of biostatistics at the medical school. Now the Director of NUDACC, Scholtens brings her expertise and leadership to large-scale, multicenter studies that can lead to clinical and public health practice decision-making.    

• After discovering her love of statistics as a high school math teacher, Scholtens studied bioinformatics in a PhD program before arriving at Feinberg in 2004.  
• Feinberg’s commitment to biostatistics has grown substantially in recent decades. Scholtens was only one of five biostatisticians when she arrived. Now she is part of a division with almost 50 people.  
• She says being a good biostatistician requires curiosity about other people’s work, knowing what questions to ask and tenacity to understand subtitles of so much data.   
• At NUDACC, Scholtens and her colleagues specialize in large-scale, multicenter prospective studies and clinical trials that lead to clinical or public health practice decision-making. They operate at the executive level and oversee all aspects of the study design.  
• Currently, Scholtens is involved with the launch of a large study, along with The Ohio State University, that received a $14 million grant to look at the effectiveness of aspirin in the prevention of hypertensive disorders in pregnancy.  
• Scholtens first started her work in data coordinating through the Hyperglycemia Adverse Pregnancy Outcome (HAPO) study, which looked at 25,000 pregnant individuals. This led to a continued interest in fetal and maternal health.   
• When it comes to supportive working environments, Scholtens celebrates the culture at Feinberg, and especially her division in biostatistics, for being collaborative as well as genuinely supportive of each other’s projects. She attributes this to strong leadership which established a culture with these guiding principles.   

Additional Reading  

• Read more about the ASPIRIN trial and other projects taking place at NUDACC   
• Discover a study linking mothers’ obesity-related genes to babies’ birth weight, which Scholtens worked in through the HAPO study   
• Browse all of Scholtens recent publications 

Recorded on February 21, 2024.

Continuing Medical Education Credit

Physicians who listen to this podcast may claim continuing medical education credit after listening to an episode of this program..

Target Audience

Academic/Research, Multiple specialties

Learning Objectives

At the conclusion of this activity, participants will be able to:

• Identify the research interests and initiatives of Feinberg faculty.
• Discuss new updates in clinical and translational research.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this Enduring Material for a maximum of 0.50  AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

American Board of Surgery Continuous Certification Program

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement(s) of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

All the relevant financial relationships for these individuals have been mitigated.

Disclosure Statement

Denise Scholtens, PhD, has nothing to disclose.  Course director, Robert Rosa, MD, has nothing to disclose. Planning committee member, Erin Spain, has nothing to disclose.  FSM’s CME Leadership, Review Committee, and Staff have no relevant financial relationships with ineligible companies to disclose.

Read the Full Transcript

[00:00:00] Erin Spain, MS: This is Breakthroughs, a podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, host of the show. Northwestern University Feinberg School of Medicine is home to a team of premier faculty and staff biostatisticians, who are the driving force of data analytic innovation and excellence here. Today, we are talking with Dr. Denise Scholtens, a leader in biostatistics at Northwestern, about the growing importance of the field, and how she leverages her skills to collaborate on several projects in Maternal and Fetal Health. She is the Director of the Northwestern University Data Analysis and Coordinating Center, NUDACC, and Chief of Biostatistics in the Department of Preventive Medicine, as well as Professor of Preventive Medicine and Neurological Surgery. Welcome to the show.  

[00:01:02] Denise Scholtens, PhD: Thank you so much.  

[00:01:02] Erin Spain, MS: So you have said in the past that you were drawn to this field of biostatistics because you're interested in both math and medicine, but not interested in becoming a clinician. Tell me about your path into the field and to Northwestern.  

[00:01:17] Denise Scholtens, PhD: You're right. I have always been interested in both math and medicine. I knew I did not want to be involved in clinical care. Originally, fresh out of college, I was a math major and I taught high school math for a couple of years. I really enjoyed that, loved the kids, loved the teaching parts of things. Interestingly enough, my department chair at the time assigned me to teach probability and statistics to high school seniors. I had never taken a statistics course before, so I was about a week ahead of them in our classes and found that I just really enjoyed the discipline. So as much as I loved teaching, I did decide to go ahead and invest in this particular new area that I had found and I really enjoyed. So I wanted to figure out how I could engage in the field of statistics. Decided to see, you know, exactly how studying statistics could be applied to medicine. At the time, Google was brand new. So I literally typed in the two words math and medicine to see what would come up. And the discipline of biostatistics is what Google generated. And so here I am, I applied to grad school and it's been a great fit for me.  

[00:02:23] Erin Spain, MS: Oh, that's fantastic. So you went on to get a PhD, and then you came to Northwestern in 2004. And so tell me a little bit about the field then and how it's changed so dramatically since.  

[00:02:36] Denise Scholtens, PhD: So yes, I started here at Northwestern in 2004, just a few months after I had defended my thesis. At the time there was really an emerging field of study called bioinformatics. So I wrote my thesis in the space of genomics data analysis with what at the time was a brand new technology, microarrays. This was the first way we could measure gene transcription at a high throughput level. So I did my thesis work in that space. I studied at an institution with a lot of strengths and very classical statistics. So things that we think of in biostatistics like clinical trial design, observational study analysis, things like that. So I had really classic biostatistics training and then complimented that with sort of these emerging methods with these high dimensional data types. So I came to Northwestern here and I sort of felt like I lived in two worlds. I had sort of classic biostat clinical trials, which were certainly, you know, happening here. And, that work was thriving here at Northwestern, but I had this kind of new skillset, and I just didn't quite know how to bring the two together. That was obviously a long time ago, 20 years ago. Now we think of personalized medicine and genomic indicators for treatment and, you know, there's a whole variety of omics data variations on the theme that are closely integrated with clinical and population level health research. So there's no longer any confusion for me about how those two things come together. You know, they're two disciplines that very nicely complement each other. But yeah, I think that does speak to how the field has changed, you know, these sort of classic biostatistics methods are really nicely blended with a lot of high dimensional data types. And it's been fun to be a part of that.  

[00:04:17] Erin Spain, MS: There were only a handful of folks like you at Northwestern at the time. Tell me about now and the demand for folks with your skill set.  

[00:04:26] Denise Scholtens, PhD: When I came to Northwestern, I was one of a very small handful of biostatistics faculty. There were five of us. We were not even called a division of biostatistics. We were just here as the Department of Preventive Medicine. And a lot of the work we did was really very tightly integrated with the epidemiologists here in our department and we still do a lot of that for sure. There was also some work going on with the Cancer Center here at Northwestern. But yeah, a pretty small group of us, who has sort of a selected set of collaborations. You know, I contrast that now to our current division of biostatistics where we are over 20s, pushing 25, depending on exactly how you want to count. Hoping to bring a couple of new faculty on board this calendar year. We have a staff of about 25 statistical analysts. And database managers and programmers. So you know, when I came there were five faculty members and I think two master's level staff. We are now pushing, you know, pushing 50 people in our division here so it's a really thriving group.  

[00:05:26] Erin Spain, MS: in your opinion, what makes a good biostatistician? Do you have to have a little bit of a tough skin to be in this field?  

Denise Scholtens, PhD: I do think it's a unique person who wants to be a biostatistician. There are a variety of traits that can lead to success in this space. First of all, I think it's helpful to be wildly curious about somebody else's work. To be an excellent collaborative biostatistician, you have to be able to learn the language of another discipline. So some other clinical specialty or public health application. Another trait that makes a biostatistician successful is to be able to ask the right questions about data that will be collected or already have been collected. So understanding the subtleties there, the study design components that lead to why we have the data that we have. You know, a lot of our data, you could think of it in a simple flat file, right? Like a Microsoft Excel file with rows and columns. That certainly happens a lot, but there are a lot of incredibly innovative data types out there: wearables technology, imaging data, all kinds of high dimensional data. So I think a tenacity to understand all of the subtleties of those data and to be able to ask the right questions. And then I think for a biostatistician at a medical school like ours, being able to blend those two things, so understanding what the data are and what you have to work with and what you're heading toward, but then also facilitating the translation of those analytic findings for the audience that really wants to understand them. So for the clinicians, for the patients, for participants and the population that the findings would apply to.   

Erin Spain, MS: It must feel good, though, in those situations where you are able to help uncover something to improve a study or a trial.  

[00:07:07] Denise Scholtens, PhD: It really does. This is a job that's easy to get out of bed for in the morning. There's a lot of really good things that happen here. It's exciting to know that the work we do could impact clinical practice, could impact public health practice. I think in any job, you know, you can sometimes get bogged down by the amount of work or the difficulty of the work or the back and forth with team members. There's just sort of all of the day to day grind, but to be able to take a step back and remember the actual people who are affected by our own little niche in this world. It's an incredibly helpful and motivating practice that I often keep to remember exactly why I'm doing what I'm doing and who I'm doing it for.  

[00:07:50] Erin Spain, MS: Well, and another important part of your work is that you are a leader. You are leading the center, NUDACC, that you mentioned, Northwestern University Data Analysis and Coordinating Center. Now, this has been open for about five years. Tell me about the center and why it's so crucial to the future of the field.  

[00:08:08] Denise Scholtens, PhD: We specialize at NUDACC in large scale, multicenter prospective studies. So these are the clinical trials or the observational studies that often, most conclusively, lead to clinical or public health practice decision making. We focus specifically on multicenter work. Because it requires a lot of central coordination and we've specifically built up our NUDACC capacity to handle these multi center investigations where we have a centralized database, we have centralized and streamlined data quality assurance pipelines. We can help with central team leadership and organization for large scale networks. So we have specifically focused on those areas. There's a whole lot of project management and regulatory expertise that we have to complement our data analytics strengths as well. I think my favorite part of participating in these studies is we get involved at the very beginning. We are involved in executive level planning of these studies. We oversee all components of study design. We are intimately involved in the development of the data capture systems. And in the QA of it. We do all of this work on the front end so that we get all of the fun at the end with the statistics and can analyze data that we know are scientifically sound, are well collected, and can lead to, you know, really helpful scientific conclusions.  

[00:09:33] Erin Spain, MS: Tell me about that synergy between the clinicians and the other investigators that you're working with on these projects.  

[00:09:41] Denise Scholtens, PhD: It is always exciting, often entertaining. Huge range of scientific opinion and expertise and points of view, all of which are very valid and very well informed. All of the discussion that could go into designing and launching a study, it's just phenomenally interesting and trying to navigate all of that and help bring teams to consensus in terms of what is scientifically most relevant, what's going to be most impactful, what is possible given the logistical strengths. Taking all of these well informed, valid, scientific points of view and being a part of the team that helps integrate them all toward a cohesive study design and a well executed study. That's a unique part of the challenge that we face here at NUDACC, but an incredibly rewarding one. It's also such an honor and a gift to be able to work with such a uniformly gifted set of individuals. Just the clinical researchers who devote themselves to these kinds of studies are incredibly generous, incredibly thoughtful and have such care for their patients and the individuals that they serve, that to be able to sit with them and think about the next steps for a great study is a really unique privilege.  

[00:10:51] Erin Spain, MS: How unique is a center like this at a medical school?  

[00:10:55] Denise Scholtens, PhD: It's fairly unique to have a center like this at a medical school. Most of the premier medical research institutions do have some level of data coordinating center capacity. We're certainly working toward trying to be one of the nation's best, absolutely, and build up our capacity for doing so. I'm actually currently a part of a group of data coordinating centers where it's sort of a grassroots effort right now to organize ourselves and come up with, you know, some unified statements around the gaps that we see in our work, the challenges that we face strategizing together to improve our own work and to potentially contribute to each other's work. I think maybe the early beginnings of a new professional organization for data coordinating centers. We have a meeting coming up of about, I think it's 12 to 15 different institutions, academic research institutions, specifically medical schools that have centers like ours to try to talk through our common pain points and also celebrate our common victories.  

[00:11:51] Erin Spain, MS: I want to shift gears a little bit to talk about some of your research collaborations, many of which focus on maternal and fetal health and pregnancy. You're now involved with a study with folks at the Ohio State University that received a 14 million grant looking at the effectiveness of aspirin in the prevention of hypertensive disorders in pregnancy. Tell me about this work.  

[00:12:14] Denise Scholtens, PhD: Yes, this is called the aspirin study. I suppose not a very creative name, but a very appropriate one. What we'll be doing in this study is looking at two different doses of aspirin for trying to prevent maternal hypertensive disorders of pregnancy in women who are considered at high risk for these disorders. This is a huge study. Our goal is to enroll 10,742 participants. This will take place at 11 different centers across the nation. And yes, we at NUDACC will serve as the data coordinating center here, and we are partnering with the Ohio State University who will house the clinical coordinating center. So this study is designed to look at two different doses to see which is more effective at preventing hypertensive disorders of pregnancy. So that would include gestational hypertension and preeclampsia. What's really unique about this study and the reason that it is so large is that it is specifically funded to look at what's called a heterogeneity of treatment effect. What that is is a difference in the effectiveness of aspirin in preventing maternal hypertensive disorders, according to different subgroups of women. We'll specifically have sufficient statistical power to test for differences in treatment effectiveness. And we have some high priority subgroups that we'll be looking at. One is a self-identified race. There's been a noted disparity in maternal hypertensive disorders, for individuals who self identify according to different races. And so we will be powered to see if aspirin has comparable effectiveness and hopefully even better effectiveness for the groups who really need it, to bring those rates closer to equity which is, you know, certainly something we would very strongly desire to see. We'll also be able to look at subgroups of women according to obesity, according to maternal age at pregnancy, according to the start time of aspirin when aspirin use is initiated during pregnancy. So that's why the trial is so huge. For a statistician, the statisticians out there who might be listening, this is powered on a statistical interaction term, which doesn't happen very often. So it's exciting that the trial is funded in that way.  

[00:14:27] Erin Spain, MS: Tell me a little bit more about this and how your specific skills are going to be utilized in this study.  

[00:14:32] Denise Scholtens, PhD: Well, there are three biostatistics faculty here at Northwestern involved in this. So we're definitely dividing and conquering. Right now, we're planning this study and starting to stand it up. So we're developing our statistical analysis plans. We're developing the database. We are developing our randomization modules. So this is the piece of the study where participants are randomized to which dose of aspirin they're going to receive. Because of all of the subgroups that we're planning to study, we need to make especially sure that the assignments of which dose of aspirin are balanced within and across all of those subgroups. So we're going to be using some adaptive randomization techniques to ensure that that balance is there. So there's some fun statistical and computer programming innovation that will be applied to accomplish those things. So right now, there are usually two phases of a study that are really busy for us. That's starting to study up and that's where we are. And so yes, it is very busy for us right now. And then at the end, you know, in five years or so, once recruitment is over, then we analyze all the data,  

[00:15:36] Erin Spain, MS: Are there any guidelines out there right now about the use of aspirin in pregnancy. What do you hope that this could accomplish?  

 Prescribing aspirin use for the prevention of hypertension during pregnancy is not uncommon at all. That is actually fairly routinely done, but that it's not outcomes based in terms of which dosage is most effective. So 81 milligrams versus 162 milligrams. That's what we will be evaluating. And my understanding is that clinicians prescribe whatever they think is better, and I'm sure those opinions are very well informed but there is very little outcome based evidence for this in this particular population that we'll be studying. So that would be the goal here, would be to hopefully very conclusively say, depending on the rates of the hypertensive disorders that we see in our study, which of the two doses of aspirin is more effective. Importantly, we will also be tracking any side effects of taking aspirin. And so that's also very much often a part of the evaluation of You know, taking a, taking a drug, right, is how safe is it? So we'll be tracking that very closely as well. Another unique part of this study is that we will be looking at factors that help explain aspirin adherence. So we are going to recommend that participants take their dose of aspirin daily. We don't necessarily expect that's always going to happen, so we are going to measure how much of their prescribed dose they are actually taking and then look at, you know, factors that contribute to that. So be they, you know, social determinants of health or a variety of other things that we'll investigate to try to understand aspirin adherence, and then also model the way in which that adherence could have affected outcomes.  

Erin Spain, MS: This is not the first study that you've worked on involving maternal and fetal health. Tell me about your interest in this particular area, this particular field, and some of the other work that you've done.  

[00:17:31] Denise Scholtens, PhD: So I actually first got my start in data coordinating work through the HAPO study. HAPO stands for Hyperglycemia Adverse Pregnancy Outcome. That study was started here at Northwestern before I arrived. Actually recruitment to the study occurred between 2000 and 2006. Northwestern served as the central coordinating center for that study. It was an international study of 25,000 pregnant individuals who were recruited and then outcomes were evaluated both in moms and newborns. When I was about mid career here, all the babies that were born as a part of HAPO were early teenagers. And so we conducted a follow up study on the HAPO cohort. So that's really when I got involved. It was my first introduction to being a part of a coordinating center. As I got into it, though, I saw the beauty of digging into all of these details for a huge study like this and then saw these incredible resources that were accumulated through the conduct of such a large study. So the data from the study itself is, was of course, a huge resource. But then also we have all of these different samples that sit in a biorepository, right? So like usually blood sample collection is a big part of a study like this. So all these really fun ancillary studies could spin off of the HAPO study. So we did some genomics work. We did some metabolomics work. We've integrated the two and what's called integrated omics. So, you know, my work in this space really started in the HAPO study. And I have tremendously enjoyed integrating these high dimensional data types that have come from these really rich data resources that have all, you know, resulted because of this huge multicenter longitudinal study. So I kind of accidentally fell into the space of maternal and fetal health, to be honest. But I just became phenomenally interested in it and it's been a great place.  

[00:19:24] Erin Spain, MS: Would you say that this is also a population that hasn't always been studied very much in biomedical science?  

[00:19:32] Denise Scholtens, PhD: I think that that is true, for sure. There are some unique vulnerabilities, right, for a pregnant individual and for the fetus, right, and in that situation. You know, the vast majority of what we do is really only pertaining to the pregnant participant but, you know, there are certainly fetal outcomes, newborn outcomes. And so, I think conducting research in this particular population is a unique opportunity and there are components of it that need to be treated with special care given sort of this unique phase of human development and this unique phase of life.  

[00:20:03] Erin Spain, MS: So, as data generation just really continues to explode, and technology is advancing so fast, faster than ever, where do you see this field evolving, the field of biostatistics, where do you see it going in the next five to ten years?  

[00:20:19] Denise Scholtens, PhD: That's a great question. I think all I can really tell you is that I'm continually surprised by new data types. I think that we will see an emergence of a whole new kind of technology that we probably can't even envision five years from now. And I think that the fun part about being a biostatistician is seeing what's happening and then trying to wrap your mind around the possibilities and the actual nature of the data that are collected. You know, I think back to 2004 and this whole high throughput space just felt so big. You know, we could look at gene transcription across the genome using one technology. And we could only look at one dimension of it. Right now it just seems so basic. When I think about where the field has come over the past 20 years, it's just phenomenal. I think we're seeing a similar emergence of the scale and the type of data in the imaging space and in the wearable space, with EHR data, just. You know, all these different technologies for capturing, capturing things that we just never even conceived of before. I do hope that we continue to emphasize making meaningful and translatable conclusions from these data. So actionable conclusions that can impact the way that we care for others around us. I do hope that remains a guiding principle in all that we do.  

[00:21:39] Erin Spain, MS: Why is Northwestern Medicine and Northwestern Feinberg School of Medicine such a supportive environment to pursue this type of work?  

[00:21:47] Denise Scholtens, PhD: That's a wonderful question and one, honestly, that faculty candidates often ask me. When we bring faculty candidates in to visit here at Northwestern, they immediately pick up on the fact that we are a collaborative group of individuals who are for each other. Who want to see each other succeed, who are happy to share the things that we know and support each other's work, and support each other's research, and help strategize around the things that we want to accomplish. There is a strong culture here, at least in my department and in my division that I've really loved that continues to persist around really genuinely collaborating and genuinely sharing lessons learned and genuinely supporting each other as we move toward common goals. We've had some really strong, generous leadership who has helped us to get there and has helped create a culture where those are the guiding principles. In my leadership role is certainly something that I strive to maintain. Really hope that's true. I'm sure I don't do it perfectly but that's absolutely something I want to see accomplished here in the division and in NUDACC for sure.  

[00:22:50] Erin Spain, MS: Well, thank you so much for coming on the show and telling us about your path here to Northwestern and all of the exciting work that we can look forward to in the coming years.  

[00:22:59] Denise Scholtens, PhD: Thank you so much for having me. I've really enjoyed this.  

[00:23:01] Erin Spain, MS: You can listen to shows from the Northwestern Medicine Podcast Network to hear more about the latest developments in medical research, health care, and medical education. Leaders from across specialties speak to topics ranging from basic science to global health to simulation education. Learn more at feinberg. northwestern.edu/podcasts.  

Restoring sight is possible now with optogenetics

People suffering from macular degeneration, along with other diseases that impair sight, may soon benefit from gene therapy

As a child, Max Hodak learned to develop film in a darkroom with his late grandfather who was almost blind.

Hodak’s grandfather had retinitis pigmentosa, a congenital disease that affects one out of every 5,000 people — more than 2 million worldwide. Most people with the condition are born with their sight intact. Over time they lose peripheral vision first, then central vision, and finally, their sight, sometimes as early as middle age.

“He clearly had this career and was a photographer, and I saw that,” Hodak said of his grandfather, who became an aerospace engineer and briefly worked on heat shields for spacecraft. “But most of my memories as a kid was that he was pretty profoundly blind.”

Possible solutions, though, are within reach. Science, a start-up company in Alameda, Calif., has designed a visual prosthesis called the Science Eye which could restore vision, albeit in a limited form, in people with retinitis pigmentosa. Hodak, its CEO, co-founded the startup after a stint at Elon Musk’s company Neuralink. Other companies such as Paris-based biotechnology company GenSight Biologics and Bionic Sight in New York are also experimenting with methods to restore sight.

All are basing their work on a research tool in neuroscience called optogenetics, a form of gene therapy that delivers proteins called opsins via injection into the eye to boost the light sensitivity of cells in the retina, the layer of tissue at the rear of the eyeball.

Therapeutic optogenetic therapy for vision restoration certainly has promise, according to Anand Swaroop, a senior investigator at the National Eye Institute in Bethesda, Md., who has worked on inherited retinal degeneration for close to four decades. But there’s still room for improvement.

“At least at this stage, it seems to be very good in cases where someone is completely blind,” Swaroop said. “You should be able to find your way around. You’re not going to bump into things, which is great. But you’re not going to be distinguishing many different features.”

How optogenetics work

In normal vision, light enters the eye through the lens and forms an image on the retina. The retina itself is composed of several different types of cells, mainly photoreceptors. Photoreceptors are light-sensing cells shaped like rods and cones that contain opsins. Normally, photoreceptors convert light into electrical signals that travel to the retina’s ganglion cells, which in turn transmit those electrical signals via the optic nerve into the brain. That’s how you’re reading the words on this page right now.

In retinitis pigmentosa, the rods and cones in the photoreceptors break down and ultimately die. First the peripheral vision goes, and people develop tunnel vision: They have to turn their whole head just to view the world around them. Many people with tunnel vision require a cane to assist in navigating the world (and to avoid bumping into things, like furniture.) Blindness follows not long after. The breakdown of the photoreceptors, however, doesn’t diminish the brain’s ability to process electrical signals — and, critically, the ganglion cells remain intact.

Optogenetics seeks to circumvent the usual choreography by delivering opsin proteins directly to the ganglion cells, meaning they can be stimulated by light in order to send signals to the brain.

The Science Eye contains two elements. The first is an implant composed of a wireless power coil and an ultrathin, flexible micro-LED array that’s applied directly over the retina — surgery that’s more extensive compared to other eye procedures like repairing cataracts. According to Hodak, the array — prototypes of which are being tested in rabbits — provides eight times the resolution of an iPhone screen.

The second element is a pair of frameless glasses, similar in size and shape to regular prescription glasses, that contain miniature infrared cameras and inductive power coils.

Put it all together and the process looks like this:

Inject opsins into the ganglion cells of the eye.

Install the implant.

The glasses activate the modified ganglion cells by wirelessly communicating information from the visual world; in turn, the new light-sensitive ganglion cells transmit that information through the optic nerve to the brain.

The eye isn’t receiving an image anymore, but rather digital information. And the results?

“You should be able to walk across town to buy a sandwich without being hit by a car,” Hodak said.

More research into retinitis pigmentosa

Other companies are already helping to bring back vision in people with retinitis pigmentosa.

GenSight Biologics uses an optogenetics-plus-glasses approach to amplify light that genetically edited ganglion cells can decode. According to clinical trial results published in 2021 in the journal Nature Medicine, GenSight’s method was able to help in locating objects on a table. That patient, a 58-year-old man, was diagnosed with retinitis pigmentosa at age 18.

Innovations

Bionic Sight has firsthand experience with patients beginning to make distinctions between features. Its method involves a gene-therapy vector that transfers an opsin called Chronos via injection into the eyes of their patients to boost the light sensitivity of intact ganglion cells. For those with tunnel vision, the injection of the opsin seems to be enough.

For patients with more impaired vision, Bionic Sight pairs the optogenetic therapy with a pair of goggles containing a camera and a neurocoding device: The camera takes in images and converts them to code, which is then sent out as light pulses to activate the opsin in the genetically modified ganglion cells. So far Bionic Sight has treated 13 people, ranging from the very blind to patients with tunnel vision.

“It’s really significantly helping,” said Sheila Nirenberg, founder of Bionic Sight as well as a professor of computational neuroscience at Weill Cornell Medical College.

Consider the large letter “E” on the eye chart you might examine during a visit to the doctor’s office. The visual acuity of a person who is nearly blind is 20/200: What someone with 20/20 vision is able to see at 200 feet away is only visible at 20 feet away to someone who is nearly blind.

Many of her patients with retinitis pigmentosa, Nirenberg said, can’t see a letter like the big “E” from just two feet away. But one patient whose visual acuity was 20/150 — he had to stand 20 feet away from the chart in order to see the letters, whereas a normally-sighted person could stand 150 feet away and see the same letters — is now down to 20/40. Another patient was unable to distinguish the suits on playing cards. After receiving the opsin, the patient was not only able to tell the difference between clubs and diamonds, for instance, but he was also able to notice the differences in color.

Another challenge had him trying to spot differences between plastic fruits arranged in front of him. He was able to spot the stem of the apple to tell it apart from oranges and peaches. Finally, he was asked to walk a maze with black squares on the bottom — and made it through successfully.

“I can’t explain to you how thrilling it is,” Nirenberg said. “It’s very hopeful.”

One form of gene therapy for treating blindness has been available for over five years. Luxturna, a prescription approved by the Food and Drug Administration in 2017, is for children and adults with a rare genetic mutation that impacts the retinal pigment epithelium, the membrane at the back of the retina on which the photoreceptors sit. The prescription adds in a functional version of the gene to create an epithelium more favorable to the photoreceptors.

“It might slow the progression of the disease,” Hodak said. “But it does not regenerate any loss.”

That, ultimately, is the goal of Science Eye. Clinical trials should begin, Hodak said, sometime in the next 18 months. The company is also looking at ways to use Science Eye to help people with dry age-related macular degeneration, which unfolds slightly differently compared with retinitis pigmentosa: Patients lose central, high-resolution vision first, and then their peripheral vision.

There are milestones to cross for every company using optogenetics to help people improve their eyesight. More patients enrolled in clinical trials should help refine both opsin delivery and the ability to improve light sensitivity in retinal cells. But Hodak predicts that over the next five years, there will be products on the market for people like his grandfather.

“You always have to be really careful with what you say to patients because they’re holding on for any piece of hope,” Hodak said. “But there’s a lot of things on the horizon that are converging. It’s not at a point where any one thing will fail and derail the whole field. Real progress is coming.”

About this story

Bionic Eye illustrations by Washington Post; Science. Editing by Bronwen Latimer. Copy editing by Paola Ruano. Design and development by Audrey Valbuena. Design editing by Betty Chavarria. Photo editing by Haley Hamblin. Project development by Evan Bretos and Hope Corrigan. Project editing by Marian Chia-Ming Liu.

The neuroscience of singing: How choirs help our brains and bodies recover from burnout

For some, the sensation feels like fireworks exploding out of their brain into the night sky.

For others, there’s a kind of buzz — electricity or vibration. Goosebumps cover their whole body.

"A bit like a warm hug." A moment of "collective happiness", "clarity", and feeling totally grounded. Entering some kind of "flow state".

This is what it's like to sing in harmony as part of a community choir.

Humans have come together in song for — at least —  tens of thousands of years. Through ancient songlines and sacred hymns, in times of celebration and in grief.

And if you ask any of those who dedicate a window of their everyday lives to this practice, they'll tell you just how good it feels.

Many say it's a form of therapy, and that without it, they're not sure they would survive.

Scientists have been singing the praises   of choirs for decades. These musical gatherings seem to support social and emotional wellbeing for all sorts of groups — among small or large crowds, those with established connections and those who are just getting to know each other, and across cultures.

Researchers have established how group singing can support and even facilitate recovery in patients with Parkinson's disease , post-natal depression and some types of cancer — and they say they've only just begun to scratch the surface on the cognitive possibilities.

A safe place to recover and reconnect

Emily Fleming went in search of a choir as part of her recovery from chronic illnesses that worsened after an episode of severe burnout.

In her mid-20s, Emily was diagnosed with myalgic encephalomyelitis, also known as chronic fatigue syndrome or ME/CFS. She became so unwell she was unable to leave her house for about a year, feeling isolated, disconnected, and confused about the road to recovery.

"Most health professionals would say, 'this is something you'll have forever, you won't ever be able to run again, you won't be able to go out and do the things you used to do', which is just devastating. And so I guess in the back of my mind, I'd always thought that recovery for me looks like getting back into the community," she says.

When Emily eventually became well enough to venture out into the world again, she set her sights on a community choir run by Brisbane musician Emma Dean.

"I had wanted to join a choir for so long because I loved music at school, it was a big part of my life. And then as an adult, I felt like there was a part of me missing … I thought, I'm just gonna do it. Because I think it's what my soul is longing for."

It's a common refrain at Cheep Trill. Every week, choristers gather in community halls — one on Brisbane’s north side and one on the south — to sing together. Manager Corinne Buzianczuk and musical assistant Tony Dean lead the choir in a physical and vocal warm-up before Emma takes the reins to work on the one of the arrangements she's been teaching the group for their end-of-term performance.

Section by section, sopranos, altos, tenors and basses practise their do-dos and woah-ohs, listening intently and frequently bursting into applause when their fellow singers nail a phrase — or a kind giggle when someone flubs a lyric.

There's a break for tea and biccies before switching to a fresh song for the second half of rehearsals. A hum of friendly chatter fills the hall once more as people stack and pack away the chairs, wash up the mugs and wander back out into the night.

From her first rehearsal, Emily says she felt an instant connection with her fellow singers.

"Choir people are just the best, because it's so inclusive …  I didn't get to connect with people for such a long time and so I do miss having that kind of connection with people of different ages. That for me has been what Cheep Trill has given me — intergenerational friendships," she says.

"To have this community of people that are from different walks of life, and in different stages of life, and to really understand that we're kind of going through the same thing."

This sense of community is more than just a hunch — there's an extensive volume of research that shows how singing as part of a group can alleviate feelings of loneliness and isolation, and increase self-efficacy and self-esteem.

Researchers led by Genevieve Dingle, director of clinical psychology programs at the University of Queensland, have found choirs are particularly powerful for people experiencing chronic ill health or significant social disadvantages .

Rockelle Duffy, who joined Cheep Trill in 2023, says it has been a lifeline — a safe space in a particularly dark period.

She had been struggling with what she now understands is functional neurological disorder and fibromyalgia on top of a major depressive disorder and anxiety. Like Emily, Rockelle became unable to work or leave her home.

"I found that I was really reclusive. I had incredibly terrifying dark thoughts constantly running in my brain, screaming at me … I became fearful of going out. So while that's going on in one part of my mind, this little creative spark kept trying to light up and grab my attention," Rockelle says.

She decided to join Cheep Trill after accompanying a friend and long-term member, David Truong .

"I remember going the first night of that term … I just was turned into this blubbering mess. I was streaming tears, my nose was full of snot, my body was shaking … I felt really safe just to sit there and go through whatever was going on for me,” Rockelle says.

“During the course of that term, one of the few things that would get me out of the house aside from attending to the multitude of medical appointments and so forth was choir."

Through the choir, Rockelle has been able to connect with her creativity, process difficult emotions and explore new opportunities — she's started singing in a rock band and writing her own music.

But she says the biggest change has been regaining her self-worth and learning to show up for herself day after day.

What's happening to our bodies when we sing together?

It perhaps goes without saying that in a room full of self-confessed musical theatre nerds, there's a lot of talk about feelings. But the benefits of group singing go beyond the mushy stuff.

Professor Sarah Wilson, a clinical psychologist credited with pioneering music neuroscience research in Australia, explains it as "an internal therapy tool" that engages several parts of the brain at once.

That "singing network", as Professor Wilson calls it, includes areas that control complex motor activity, auditory processing, language, emotion and memory.

Vocal motor control networks activate and coordinate the right muscles to project our voice and manage our airflow. Auditory and language networks help us to pitch our notes correctly, adjust our volume and sing the right lyrics.

Professor Wilson explains that in choir singing, higher level executive functions are also involved, "making sure we come in at the right time, on the right note, and that hold note in our mind … timing it and coordinating relative to the music and the other singers".

Long-term, engaging in musical activities has been shown to support neuroplasticity — that is, the ability to heal and adapt, creating new pathways over time — in healthy ageing brains.

Some of Professor Wilson's work has focused on using singing, through Melodic Intonation Therapy, to help rehabilitate speech in patients recovering from severe strokes .

"We're watching their brain rewire itself, in real time, and switching back on parts of the language network to support their rehabilitation and brain plasticity," she says.

"So it's a really powerful, innate tool … both for our brain plasticity and cognitive health, but also our mental health."

There are also physiological factors at play — our heartbeats and breathing sync up when we sing together .

Both Emily and Rockelle say they've noticed the regular practice has helped in other ways, too.

“I first thought that it would be purely for my mental health … What I wasn't expecting was how much of a physical difference [choir] has made for me," Emily says.

"With the conditions that I have, standing up for a long period of time is really challenging. With choir, for two hours a week [I'm] standing up and down, and just sort of practising those movements. So that has really improved my standing tolerance."

Rockelle says singing has become part of her "self-deigned therapy program" in managing her FND and chronic pain.

"When my body doesn't want to behave the way we think it should, when the signals aren't working properly, I tune into music. I get out the choir [guide tracks], and I look at the [sheet music] … and I'll sway and I'll dance on the spot. It gets that cognitive conversation happening … to get me moving again," she says.

Rockelle says learning about how to engage and switch between her chest voice and head voice has been helpful for regulating her breathing during bouts of extreme anxiety or panic attacks.

The academic jury is still out on exactly how singing in a group affects our levels of oxytocin — that warm, fuzzy feel-good brain chemical.

Professor Wilson says we know singing directly activates the brain's reward network, and there is evidence to suggest choir practice can reduce cortisol levels — an indicator of stress — and even boost immune function.

In two recent studies that measured hormone response in choir singers — one from the University of Regensburg in 2017 , and a smaller pilot study from the University of Toronto in Canada in 2021 — researchers found that positive effects of singing were more pronounced after group singing compared with solo singing.

In addition, Professor Wilson explains that choir singing engages the mirror neuron system, which plays a powerful part in social bonding.

"When we have a verbal conversation, we can't do it together, we have to take turns — otherwise, it's impossible, we're just talking over each other. Whereas singing is this one chance where we get to use our voices in unison," she says.

"Our brain activity is mirroring each other. That activates our own circuitry, and it helps us put ourselves in their shoes. And that facilitates that bonding that we experience when we're singing in a choir."

Cultivating a community around creativity

Cheep Trill is just one of the hundreds — possibly thousands — of community choirs in Australia that focus on bringing amateur singers together in a non-auditioned and non-competitive format.

The purpose of these groups is as much about connection as it is about crafting perfect harmonies.

That people feel supported, welcomed, and held in this space is no coincidence. It's a culture that every single one of the dozen or so 'Trillers' who spoke to the ABC puts down — at least in part — to their musical director, Emma Dean.

In 2014, Emma had been slogging it out to make a name in New York, working as a kids' entertainer and performing late-night opening sets for off-Broadway drag and cabaret artists, making very little money and careening towards total burnout.

With her marriage falling apart and a deep depression setting in, Emma says she had reached rock bottom when a friend suggested that she should start a choir. 

And so she returned to Brisbane and started singing with a small group of musical mates on a friend's verandah. Something clicked into place — watching other people shine gave Emma a new purpose.

“This choir, this strange little group of people who gathered on this verandah, saved me. Really genuinely saved my life," she says.

"They saved my love of music, because I kind of felt like music had betrayed me at some point. I knew that that wasn't completely the truth, but I knew I had to reignite the spark I felt for music."

In the 10 years since, the choir has evolved into a buzzing community of singers from all walks of life, welcoming fresh faces and expanding their repertoire each term.

It's seen new friendships blossom, family ties strengthen, and set the backdrop for at least one marriage proposal.

There are practical and intentional decisions that have allowed Cheep Trill to grow — finding a space that wheelchair users and singers with assistance dogs can navigate seamlessly, making sure there are vegan and gluten-free snacks available during the break, crafting arrangements that share melodies equally between parts, and working on creative solutions for singers with particular sensory needs.

Many community choirs have found ways to offer concessions on term fees or open up sponsored spots for choristers to pay it forward for singers who don’t have the financial means to join.

Emma says above all, she tries to conduct and teach in a way that "creates a space that is safe for people to explore their voice, to explore their creativity", without fear of judgement.

"We're not doing brain surgery. We're just singing a song. I actually quite like mistakes. They're fabulous," she says.

"It's also about facilitating a meeting place where people who have never come across other sorts of people are kind of forced to listen to each other."

Whatever the reasons behind it, there's just something magical that happens when people sing together.

What does it feel like to sing together in a choir?

On an almost-chilly Saturday morning earlier this month, the hundred-or-so Cheep Trillers gathered to share that magic with crowds wandering through the West End markets.

Diligently dressed in their brightest colours, the northside and southside chapters came together to perform four pieces for a small crowd under the shade of a mighty fig tree on the banks of the Brisbane River.

After 10 weeks spent working towards their creative debut, it was a big moment.

Rockelle noticed the feelings in her body, like "a ray of sunshine" penetrating from head to toe.

"My ears are soothed, my tummy settles and my heart swells with love," she says. "I feel light, I feel bright. I feel like I'm worthy. And that there's something here for me — let's keep going."

For Emily, it was a feeling of pure clarity. "Like that is the only thing that I'm thinking of in that moment. I'm not even thinking of the fact that I'm singing and remembering the words, I'm just thinking about how it sounds together, how we're blending our voices together."

There's a synchrony, too, in the way these singers talk about working creatively towards a common goal.

"That's the power of a choir. It's supportive, like you're an instrument in an orchestra, and everyone's voice is part of that," says Piet, who adds Cheep Trill has become like "a second family".

Liz Bremer joined this term as part of a challenge to herself after her father's death to do something each year that scares her.

"When it clicks, everybody starts to sound like one voice and you sort of don't even hear yourself. And that's when as soon as the song's finished, you just feel elated. It's really energising," she says.

"It feels electric," adds her new friend Lucy, another alto-slash-tenor who's new to Cheep Trill. "There's something beautiful about doing something where you can mess up and maybe embarrass yourself in public, but then you don't ... even if you sing off-key or you accidentally sing the wrong lyric, it is such a safe place."

Lucy passes the mic back to Liz: "It reminds you that you're not alone."

Professor Wilson calls it kama muta, a Sanskrit phrase that roughly translates to "being moved by love".

"It's that real sense of being moved by music … and being part of maybe something that's bigger, a communal sense, a higher connection," she says.

In fact, this suspected link between music and feelings of nostalgia or kama muta is currently under investigation by one of Professor Wilson's PhD students at the University of Melbourne. That research is still underway, but Professor Wilson says the hypothesis is that this overwhelming communal feeling is an important evolutionary function of music.

On a basic level, Emma says there is "this great joy, and a great relief that comes from being a part of something bigger than yourself".

"Singing solo is a very different experience to singing in a group … you feel lifted, you feel supported by so many other people around you," she says.

"You are creating something so special, that is not only making the people in the choir happy, but also the people listening to it. You're giving this incredible gift to people witnessing this magic."

Again, the science supports that sentiment. Another study from Professor Dingle and her fellow UQ researchers in 2023  found that watching a choir performance "can foster admiration, respect and positive regard toward choristers" among members of the audience.

The crowd watching Cheep Trill seemed to agree. Uplifting, engaging, playful, a little bit whimsical — a good vibe all round, was how some enjoying the performance put it afterwards.

They did notice, however, one singer standing towards the back who became a bit teary during a moving rendition of REM's Nightswimming. Overcome with emotion, perhaps. The choir sang on while she gathered herself — it's a safe space, after all.

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