original research article anatomical knowledge …manisha r. dayal, john owens, william gibson,...

Int J Anat Res 2017, 5(1):3474-79. ISSN 2321-4287 3474

Original Research Article

ANATOMICAL KNOWLEDGE RETENTION IN PHYSIOTHERAPYSTUDENTS: A PRELIMINARY ASSESSMENTManisha R. Dayal *1, John Owens 2, William Gibson 3, Goran Štrkalj 4.

ABSTRACT

Address for Correspondence: Manisha R. Dayal, Anatomy Lecturer, School of Science & Health,Western Sydney University, Australia, 2751. E-Mail: [email protected]

Introduction: Anatomical knowledge and understanding are key components of physiotherapy education andpractice. Traditionally, anatomy has been taught as a foundation stream within the first year(s) of physiotherapyeducation. This curricular model is based on the assumption that further learning in subsequent years buildsupon the knowledge gained in the early stages of the program. However, the retention rate in all basic scienceshas often been called into question. In anatomy, several studies suggest that anatomy knowledge enduresconsiderable attrition, highlighting the need for the evaluation of retention rates. This paper aimed at making apreliminary assessment of the knowledge and retention of anatomy among physiotherapy students.Materials and Methods: We used a carpal bone identification test and assessed 129 first year and 113 fourthyear physiotherapy students.Results: 20% of the students managed to identify all bones while 47% were able to identify more than five bones.The best recognised bones were pisiform and scaphoid while the most difficult to identify were trapezium andtrapezoid.Conclusion: Overall, first year students performed better than their fourth year counterparts which suggestedattrition of anatomical knowledge. Educational strategies based on revision, integration and clinical applicationof anatomy could contribute towards the decrease of attrition of anatomical knowledge.KEY WORDS: Anatomy Education, Retention, Physiotherapy, Carpal Bones.

INTRODUCTION

International Journal of Anatomy and Research,Int J Anat Res 2017, Vol 5(1):3474-79. ISSN 2321-4287

DOI: https://dx.doi.org/10.16965/ijar.2016.485

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DOI: 10.16965/ijar.2016.485

*1 Lecturer, School of Science and Health, Western Sydney University, Australia.2 Lecturer, School of Physiotherapy and Excercise Science, Curtin University, Australia.3 Senior Lecturer, School of Physiotherapy, The University of Notre Dame, Australia.4 Associate Professor, Department of Chiropractic, Macquarie University, Australia.

Received: 22 Nov 2016Peer Review: 22 Nov 2016Revised: None

Accepted: 20 Dec 2016Published (O): 28 Feb 2017Published (P): 28 Feb 2017

environmental interactions.Anatomy has figured prominently among thebasic sciences, being of particular importancein some professions and specialties. In physio-therapy, anatomy has a central place in educa-tion as detailed knowledge of the structures ofthe human body, particularly the musculoskeletal

The education of health professionals tradition-ally starts with a good grounding in basicsciences, which are meant to impart studentswith a good understanding of the structures andfunctions of the human body at different organi-nisational levels as well as its development and


Manisha R. Dayal, John Owens, William Gibson, Goran Strkalj. ANATOMICAL KNOWLEDGE RETENTION IN PHYSIOTHERAPY STUDENTS: APRELIMINARY ASSESSMENT.

al system, is essential for safe and efficientpractice. Indeed, in Australia where this researchwas carried out, anatomy played a key role inphysiotherapy curricula since the first programswere established at the beginning of the twen-tieth century. In these early curricula anatomywas taught in detail and through dissection, overboth years of what was then a two year diplomacourse [1,2].One of the main issues in teaching and learningbasic sciences in general and anatomy inparticular has been the retention rate. It wasestimated in a recent review that “ in thegeneral educational domain as well as inmedical education, approximately two-third tothree-fourth of knowledge will be retained afterone year, with a further decrease to slightlybelow fifty percent in the next year” [3]. Thereis, therefore, a considerable concern amongmedical educators that the attrition of basicscience knowledge might have negative impli-cations in regards to acquiring clinical skills.Consequently, a number of educational strate-gies were devised in order to improve theretention rate, all based on the need to repeat,revise and apply the knowledge from basicsciences [3].The regular assessments of the level of basicscience knowledge at different stages of studyand of its retention rate are therefore anecessity in constantly evolving health curricula.This, however, is a complex process as recentresearch demonstrates considerable differencesbetween different basic sciences and, indeed,diverse retention rates between various subjectsand topics within the same discipline [3-5].The aim of this study was to provide a prelimi-nary assessment of the retention of anatomyknowledge among the physiotherapy studentsat Curtin University in Perth, Australia. CurtinUniversity is one of the nineteen tertiaryinstitutions in Australia offering a degree inphysiotherapy [6]. Anatomy instruction at thisuniversity, similarly to most of the others, iscarried out predominantly in the first year ofstudies. Anatomy teaching at Curtin has a strongpractical component where students inspect andstudy (but do not dissect) prosected cadaversin the anatomy laboratory. Although all systemsare covered, the main focus in anatomy educa-

tion is on the structures belonging to the mus-culoskeletal system.The preliminary assessment of the retention ratein anatomy was investigated through the use ofa simple test in which students were asked toidentify carpal bones [7]. This “carpal bone test”and different versions of it has already beenutilised in a number of studies to provide aninitial estimate of the level of knowledge andretention rate in anatomy among the studentsand recent graduates in a number of healthdisciplines [7-11].MATERIALS AND METHODS

Ethical clearance for this study was obtainedfrom the Curtin University Human ResearchEthics Committee. The carpal bone test wascompleted by first and fourth year physiotherapystudents. The fourth year students were acohort of pre-registration physiotherapystudents with no formal anatomical educationwithin the previous two years while the cohortof first year students had just completed theirfoundational anatomy course. The studentswere approached to complete the test based onthe identification of carpal bones from adiagram to evaluate their knowledge of anatomy.Students had no prior knowledge of the task.The fourth year physiotherapy students weregiven the test at the end of their final year priorto completing their final qualifying examination.The first year students were given the test aftertheir final anatomy examination. Both sets ofstudents were given a maximum time of fiveminutes to complete the task. The tests werethe same for both sets of students andparticipation in the completion of the task wascompletely voluntary. The students werenotified that this test was not part of theirUniversity assessment and thus no names orstudent numbers were collected with thecompleted task. Returning an attempt of the testconstituted consent to participate. The test alsoincluded an information sheet to state theobjectives of the study.The test consisted of a diagram illustrating theskeleton of the hand and the wrist regioncontaining all of the carpal bones in situ.Students were asked to identify and name eachof the carpal bones on the diagram.



Tests were corrected and the results wereevaluated using IBM SPSS, statistical softwareversion 22.0 (IBM Corp, Armonk, NY). Achi-squared test was employed to determine thedifference in frequencies between the first andfourth year responses across three bands ofcorrect response (all correct, six or morecorrect and four or more correct) with alpha setat 0.05.

Of the 181 first year students enrolled, 129completed the tasks, while 113 of the 141enrolled students in the fourth year completedthe task. This resulted in a response rate of 71%and 80% respectively for the first and fourthyears. Responses to the test were evaluated aseither: correct, incorrect or not attempted.The results are reported separately for first andfourth years and then together as a cohort ofphysiotherapy students (Figs. 1-3). The pisiformwas correctly identified most of the times by thefirst year students (Fig. 1), while the scaphoidwas the most correctly identified carpal boneby the fourth year students (Fig. 2). The capi-tate was mostly not attempted in both thegroups. The trapezoid and trapezium were thetwo bones that were the most incorrectlyidentified by both groups (Fig. 3).All eight bones were correctly identified by 49(20%) students out of the 242 respondents(Fig. 4). Of these 49 students, 39 were first yearstudents. A total of 114 (47%) students wereable to identify more than five bones correctlyand 74 of these were first years. Seventeenpercent of the entire cohort was not able toidentify any of the carpal bones. This includedthe students who had not even attempted toidentify any of the bones.The number of bones most correctly identifiedby first years was eight (Fig. 4), while fourth yearstudents correctly identified four bones, but thesame percentage of fourth year students alsodid not correctly identify any bones (Fig. 4).Thirty nine first year students and ten fourth yearstudents correctly identified all eight carpalbones indicating a statistically significantassociation between year group and correctidentification of all carpals (2

(1) = 17.1,

RESULTS

p = 0.005). Similar significant associations werefound between year group and number ofcorrect responses when performed examiningstudents who got six or more bones correct (62year 1 vs 29 year 4; 2

(1) = 12.9.1, p = 0.005) andthose students who got four or more bones cor-rect (86 year 1 vs 61 year 4; 2

(1) = 4.1, p = 0.04).There was no statistical difference between “notattempted” response rates between years(2

(1)= 0.6, p = 0.439).Fig. 1: The percentage of students in the first year thatcorrectly identified; incorrectly identified and did notattempt identifying the carpal bones.

Fig. 2: The percentage of students in the fourth year thatcorrectly identified; incorrectly identified and did notattempt identifying the carpal bones.

Fig. 3: The percentage of all students in the first andfourth year that correctly identified; incorrectlyidentified and did not attempt identifying the carpalbones.



Fig. 4: The percentage of correctly identified carpal bonesfor the first year and fourth year students.

The results of this study indicate good knowl-edge of the carpal bones anatomy of the stu-dents who have just finished their anatomycourse and somewhat lower level of knowledgeamong the students in their final year. While itis difficult to generalise these results, one mighthypothesise that, as anatomy is taught in thefirst year of study at most of the Australianuniversities (and those from other countries),similar patterns could be expected in some ofthe other physiotherapy programs. Whether thislevel of knowledge is satisfactory and sufficientfor the safe practice is difficult to establishwhen these results are looked in isolation[12,13]. When compared to the results of othersimilar studies, however, certain relevant edu-cational issues and patterns start to emerge(Table 1).

DISCUSSION

Table 1: Comparison of the percentage of correctlyidentified carpal bones.

7, 8 30 42 3 33 35 135, 6 16 18 24 39 22 233, 4 36 13 23 39 18 28

0,1,2 18 27 51 0 25 36

4th Year Physiotherapy

Physical Theray

Present studySpielmann et al. 2005 [7]

Strkalj et al. 2011 [8]

Valenza et al. 2012 [9] Meyer et al. 2015 [11]

113

Most frequently identified bone Scaphoid Pisiform Capitate Capitate Pisiform Pisiform Scaphoid

50 84 80 54 47 44Completed

questionnairesScaphoid,

Lunate

5th Year Chiropractic

2nd Year Chiropractic

129

48 98

52 2

Number of bones Medical Chiropractic Medical1st Year

Physiotherapy

There are some commonalities in students’performance across different levels of study,health professions and institutions. The bonemost frequently identified by most groups ofstudents previously tested, including those fromthe current study, was the scaphoid while

trapezium and trapezoid seem to be the mostcommonly unrecognised, misidentified andmixed up. With the scaphoid being the carpalbone most often fractured, this pattern of iden-tification clearly demonstrates the importanceof application of anatomical knowledge anddeep learning associated with it. In the reversecase of the trapezium and trapezoid - bones withsimilar names and closely associated in theirposition within the carpus – students’ failure toidentify them may show how the complexitiesof anatomical terminology strongly affect thelearning process.A study carried out at the University of Granadain Spain [9] suggested that third year physicaltherapy students performed better at the carpalbone test than third year medical students [9].The results of the present study corroborate thisas our sample of physiotherapy students alsoperformed better than the medical students inSpain and those from the UK, tested at theEdinburgh University Medical School [7]. This isto be expected as physical therapy/physio-therapy students generally study the musculosk-eletal system in more detail and depth than theirmedical counterparts, who usually adopt moreof the relevant anatomy only if they specialisein one of the areas that requires such knowl-edge, such as orthopaedic surgery. Thus,although both groups of students at the Univer-sity of Granada received similar instruction onthe carpal bones in their first year, subsequentphysical therapy education included “specificmusculoskeletal area” focus while the medicalwas “a broader education covering manydifferent systems and areas” [9].The fact that the final year students in this studyshowed less knowledge of carpal bonesanatomy than their first year colleagues mightbe a reason for some concern. In contrast, inthe test of first and fourth year podiatry studentsfrom three Spanish universities (who were,appropriately, tested on the anatomy of tarsal,rather than carpal bones) there was no signifi-cant difference in performance between the twogenerations [10]. In a similar study utilising thecarpal bones test, fifth year chiropractic studentsat Australia’s Murdoch University performedbetter than their second year counterparts, whohad just finished their anatomy course [11].


some of the educational paradigms such as‘Problem Based Learning’ have been conceivedto, among other advantages, facilitate integra-tion and application of knowledge, starting atthe early stages of study [16].Some strategies to improve retention of anatomyhave proven particularly valuable. At The Cleve-land Clinic Learner College of Medicine of CaseWestern Reserve University these strategieswere efficiently introduced within the so-callednesting approach [17,18]. This approach at CaseWestern Reserve characterised by intensive twohalf-day, cadaver-based revision sessions for thethird year medical students. The nesting ap-proach in anatomy was further developed at TheGeorge Washington University Medical Schoolwere it includes testing of students to assesstheir knowledge and area of weaknesses, to-gether with combined e-modules and laboratorybased revision sessions, both structured with aspecial reference to clinical anatomy.We argue that the application of this andsimilar strategies should be highly profitablewithin the physiotherapy curricula. Theseapproaches could now be applied easily and withlittle financial strain, following the recentadvancements in anatomy education. Indeed,anatomy education has transformed ratherdramatically in the last few decades as the oldmodes of teaching based on rote learning andadoption of excessive degree of anatomicaldetail (often irrelevant in clinical practice)evolved into more focused, clinically orientedand better integrated ways of delivery whichfavour deep learning [19,20]. Blended learning[21] in particular, could be successfully appliedin this context as within this educational modeconsiderable amount of work is carried outon-line and at the convenience of both studentand academics. The wealth of materials can nowbe presented to students on-line via differentmedia (medical images, video recordings,interactive softwares, three-dimensionalimages, etc.), providing ample opportunities forquick and efficient testing, feedback andrevision.This study has some limitation. The carpal bonetest is rather limited in its scope as it focuseson the osteology of a single anatomical region.

However, research conducted on medicalstudents and recent graduates from theEdinburgh University study, suggests that oncethe graduates enter the internship and clinicalpractice, their knowledge increases significantly.Thus, it was suggested that the “gaps inanatomical knowledge are filled by the timejunior doctors become SHOs (senior houseofficers), especially if working in surgery or A &E [Accident and Emergency]” [7]. One mighttherefore expect that similar trends would befound among the junior physiotherapists as theyprogress through their clinical years.While the attrition in anatomical knowledgedetected in physiotherapy students tested atCurtin University were, therefore, to beexpected, there may be some scope for imple-mentation of strategies aimed at avoiding thisattrition, which would lead to a better retentionrate. Again, similar issues with attrition werenoted in other programs. For example, in a com-prehensive assessment of the retention rate, thethird year medical students at The George Wash-ington Medical School [5] were given anatomytests covering different regions as they enteredgeneral surgery and obstetrics/gynaecologyclerkships. The results were compared with thestudents’ performance in their first year anatomytests. The study revealed that the knowledge ofsurgical anatomy among the third year studentswas characterised by the significant attritionrate and was rather poor. The performance andretention varied considerably between differentanatomical structures – from 12.8% (59.1% dropin retention rate) correct answers on esophagealvarices to 97.2% (1.6% drop) on lymphatic drain-age. The results of The George WashingtonMedical School study highlighted the need toimprove students’ retention and the necessityfor the educational strategies which will facili-tate this process to be based on a good assess-ment of students’ current knowledge in variousareas of anatomy [5].The main features of strategies to improve re-tention of anatomy in medical education werethe need to repeat and revise previously adoptedknowledge, integrate this knowledge with thatfrom other pre-clinical and clinical subjects and,perhaps most importantly, apply this knowledgewithin the clinical context [3,5,14,15]. Indeed,



More comprehensive tests which would includea practical component based on cadavers,medical images and living anatomy as well as abattery of clinically oriented questions areneeded for the full assessments of anatomyknowledge. We would also like to know moreabout student perceptions regarding theirosteology education and experience, level oflearning, satisfaction, or gained knowledgethroughout their program. Furthermore, oursample of students was relatively small and onlyone institution was represented. Because of thisour results must be seen as only preliminary,hopefully leading to more comprehensive testsat a number of different institutions.

CONCLUSION

The physiotherapy students tested by thecarpal bone test at Curtin University showedgood knowledge of anatomy in their first yearof study, while the final year students showedsome attrition of anatomy knowledge. Strategiesto improve retention rate in anatomy based onrevision, integration and application of anatomi-cal knowledge would be highly profitable inphysiotherapy curricula. Future studies based onmore comprehensive testing of bigger and morediverse sample of students are needed to throwmore light on the issue of retention and to helpdevise strategies for its improvement.

[6]. Physiotherapy Board of Australia. Approved Programsof Study. Australian Health Practitioner RegulationAgency, Canberra, ACT, Australia. [http://w w w . p h y s i o t h e r a p y b o a r d . g o v . a u /Accreditation.aspx].

[7]. Spielmann, PM, and Oliver CW. The carpal bones: Abasic test of medical students’ and junior doctors’knowledge of anatomy. Surgeon 2005;3: 257–259.

[8]. Štrkalj G, Schroder T, Pather N, Solyali V. A prelimi-nary assessment of the fifth-year chiropractic stu-dents’ knowledge of anatomy. J Altern ComplementMed 2011;17:63–66.

[9]. Valenza MC, Castro-Martín E, Valenza G, Guirao-PiñeiroM, De-la-Llave-Rincón AI, Fernández-de-las-PeñasC. Comparison of third-year medical and physicaltherapy students’ knowledge of anatomy using thecarpal bone test. J Manipulative Physiol Ther2012;35:121–126.

[10]. Castillo-López JM, Díaz-Mancha JA, Heredia-Rizo AM,Lourdes María Fernández-Seguín, Polo-Padillo J,Domínguez-Maldonado G, Munuera PV. The tarsalbone test: A basic test of health sciences students’knowledge of lower limb anatomy. BioMed Res Int2014;Article ID 939163,6 pages.

[11]. Meyer AJ, Armson A, C. D. Losco, Losco B, Walker BF.Factors influencing student performance on the car-pal bone test as a preliminary evaluation of ana-tomical knowledge retention. Anat Sci Educ2015;8:133–139.

[12]. Prince KJAH, Scherpbier AJAA, Van Mameren H, DrukkerJ, Van der Vleuten CPM. Do students have sufficientknowledge of clinical anatomy? Med Educ2005;39:326–332.

[13]. Bergman EM, Prince KJAH, Drukker J, Van der VleutenCPM, Scherpbier AJAA. How much anatomy is enough?Anat Sci Educ 2008;1:184–188.

[14]. Pandey P, Z imitat C. Medical students’ learning ofanatomy: Memorisation, understanding and visu-alization. Med Educ 2007;41:7–14.

[15]. Logan JM, Thompson AJ, Marshak DW. Testing to en-hance retention in human anatomy. Anat Sci Educ2011;4:243–248.

[16]. Louw G, Eizenberg N, Carmichael SW. The place ofanatomy in medical education: AMEE Guide no 41.Med Teach 2009;31:373–386.

[17]. Drake RL. A unique, innovative, and clinically ori-ented approach to anatomy education. Acad Med2007;82:475–478.

[18]. Goldman E, Schroth WS. Deconstructing integration:A framework for the rational application of integra-tion as a guiding curricular strategy. Acad Med2012;87:729–734.

[19]. Sugand K, Abrahams P, Khurana A, The anatomy ofanatomy: A review for its modernization. Anat SciEduc 2010;3:83–93.

[20]. Chan LK, Pawlina W (Editors). Teaching Anatomy: APractical Guide. New York: Springer; 2015.

[21]. Pereira JA, Pleguezuelos E, Merí A, Molina-Ros A,Molina-Tomás MC, Masdeu C. Effectiveness of usingblended learning strategies for teaching and learn-ing human anatomy. Med Educ 2007;41:189–195.

Conflicts of Interests: None

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How to cite this article: Manisha R. Dayal, John Owens, William Gibson, Goran Strkalj.ANATOMICAL KNOWLEDGE RETENTION IN PHYSIOTHERAPY STUDENTS: A PRELIMINARYASSESSMENT. Int J Anat Res 2017;5(1):3474-3479. DOI: 10.16965/ijar.2016.485


original research article anatomical knowledge …manisha r. dayal, john owens, william gibson,...

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