Anatomy is the foundation stone of medical education internationally.1,2 Rituals for the dead in ancient Egypt incorporated a crude form of dissection and in 1235 the anatomy curriculum was born when the first medical school was opened in Salerno in Italy.1 In the 16th century, Vesalius was instrumental in fighting to get mandatory human anatomy dissection into the medical curriculum.2 Preclinical medical education in the United States of America in the 1900s was dominated by anatomy.3
Recently the teaching of human anatomy is influenced by less available instructional time,3 financial constraints and fewer suitably qualified anatomy teachers.4-6 However, it was reported that suitably qualified staff/student ratios across the African continent were comparatively high when compared to those in the Western world.7 The availability of fewer cadavers has led to changes in the approach to gross anatomy pedagogy. A 2010 article reported on the percentages of cadaveric donations in the United States of America, the United Kingdom and the African continent and how this influences the use of cadavers in gross anatomy education.8 Furthermore, the difficulties arising from the practical management of cadavers and the religious and cultural beliefs of some students are creating challenges pertaining to the use of cadavers in anatomical education.9 Since the beginning of the 21st century, these time constraints have seen a decline in the standard of anatomy teaching outcomes: a decrease in medical students’ anatomical knowledge with resultant decreased clinical competency and an increase in the concern for the safety of patients treated by such clinicians.1,2 In particular, work done by the Van der Vleuten group10 who looked at the level of Dutch medical students’ knowledge of case-based anatomy concluded that the students tested did not know enough about human gross anatomy. In addition, it was reported that between 1995 and 2000, there was a seven-fold increase in claims associated with anatomical mistakes in the United Kingdom.11 However, the results of a South African survey of second year dental students done in 2015, where there were limited human resources for teaching and increased use of technology, showed that the students’ learning of anatomy was not adversely affected by those limitations.12 Information relating to the effect of these instructional anatomy time constraints on the quality of physiotherapy clinical practice specifically has not been documented in the available literature.
A survey of undergraduate physiotherapy students at the Universities of Almeriá and Jaén in Spain found anatomy to be a “highly appropriate” inclusion in their course.13 By its very name, physiotherapy requires that its students and practitioners become well versed in the way in which the body moves in an optimally functional way. To achieve this goal, pre-clinical physiotherapy students have to know the musculoskeletal components of the human body in detail. They have to know how neuro-anatomy impacts on the functioning of these components and be able to discern whether, for example, a specific lobe of the lung is functioning optimally and direct their treatment accordingly. In many different ways, knowledge of human anatomy will play an integral role in the competency of a physiotherapist in future clinical practice.
The term pedagogy in the gross anatomy context is defined as teaching methodologies such as dissection, didactic lecturing and computer instruction that are used to improve the anatomy learning experience.2 It has been stated that human dissection is the preferred gross anatomy pedagogy.14,15 In 2006, it was reported that dissection is important as the basis for the development of medical professional ethics.16 The inclusion of dissection as part of the gross anatomy pedagogy continues, but in many cases it has been decreased in line with time constraints brought about by the teaching of extra topics included in the curriculum and the use of new methods of teaching. In some instances, it has been retired completely in favor of modern technological applications such as interactive multimedia and digital imaging.2 However, in 2011 second year medical students were surveyed to assess their perceptions of learning anatomy through the use of dissection alone. Positive feedback with regard to the understanding of anatomy in more depth and increased anatomical knowledge was recorded.17
New types of gross anatomy pedagogy are being considered in the hope that the subject will be taught within the limitations previously mentioned, while still maintaining a high standard of anatomical education overall. Three-dimensional concepts are difficult to visualize with traditional anatomical teaching,18 while simulation by using easily accessible 3D models19 and the construction of anatomical models are ways to add to a student's perception of the functionality of anatomy.20 “Muscle cutout and paste exercises” can improve learning outcomes in health sciences students.21 In 2012, a survey of 280 undergraduate medical and anatomy students about their opinion on the use of plastinated specimens in the anatomy lab found that 75% of the respondents considered this a very useful anatomical tool.22 Furthermore, the use of such specimens, together with cadaveric specimens, was proposed by 78% of the respondents.22 Computer-assisted instruction can be used alone23-25 or to compliment traditional instruction for physiotherapy students as well as medical students.2,26,27 Full body digital X-ray images can be used to enhance a student's ability to locate anatomical structures in the surface anatomy context.28 With regards to other adjunct learning techniques that can be incorporated into an undergraduate physiotherapy anatomy program, there are asynchronous online discussion groups,29 remedial teaching via constant remedial visual internet input,30 team-based learning programs5,31 and the rotation of student groups between dissection and peer demonstrations that have been shown to produce positive outcomes6,32 with no decline in practical examination performance.33 Peer teaching in the gross anatomy laboratory involving undergraduate physiotherapy students has also been documented34,35 and can be used together with an audience response system to enhance teaching methods for a gross anatomy class.36 A study in Brazil reported on the use of a peer-mentoring program in an inter-professional and interdisciplinary allied health intervention. It reported that the students who participated achieved better academic results than those who had not participated.37 It has been stated that both medical students and physical therapy students require knowledge of anatomy, and these two groups of students integrate well for inter-professional education (IPE) in a gross anatomy dissection course.38 In recent years, in physiotherapy gross anatomy education, there has been an increase in the use of IPE39 and its application as a near-peer intervention to foster IPE teamwork in gross anatomy.40 Furthermore, an IPE study involving medical and physical therapy students, where students from one of the academic programs were responsible for teaching a part of the human body that they had dissected to the other group and vice-versa, resulted in useful interprofessional bonds established and the appreciation of collaborative learning and teamwork.41
Systematic curriculum development addresses those to be taught, what the content will be, how it will be taught and the interaction between subject matter.42 Gross anatomy course designs have to consider clinically relevant, integrated systems and a learning outcomes-based approach in the development of a course curriculum.43 A number of authors have suggested that a gross anatomy curriculum for physiotherapy students should incorporate input from physiotherapists44,45 and be clinically relevant to physiotherapy practice.46,47 The different types of physiotherapy degree programs offered worldwide are designed to accommodate the needs that pertain to the specific physiotherapy practice in each of those countries.48 In South Africa, physiotherapists assume the role of first-line practitioners.49 These physiotherapists are permitted to have access to patients without having to have them referred to by another healthcare professional and can therefore work independently, can offer a diagnosis pertaining to the patient's illness within their scope of practice and can refer a patient to a specialist clinician if they feel that the condition is beyond their scope of practice. They can also write sick notes for patients and administer prescribed medicines.50 First-line physiotherapy practitioners are also found in Australia51 and in New Zealand52 but in many countries, including the United Kingdom, physiotherapists have not been given first-line status.53
A preliminary search was undertaken in the, Academic Search Complete, CINAHL, Cochrane Library, Education Search Complete, ERIC, PEDRO PubMed and SCOPUS databases to establish whether systematic or scoping reviews published or underway on this topic already exist and none were found. This fact, together with the aforementioned points, serves to highlight problems with regard to the teaching of gross anatomy. It is still not clear what teaching style or which combination of styles should be included in an anatomy curriculum framework for undergraduate physiotherapy students. The choice of gross anatomical curriculum, type of gross anatomy pedagogy and method of delivering the information to undergraduate physiotherapy students not only to prepare them for examination but also for clinical competency seems dependent on the interaction of many factors.
Types of participants
The current review will consider participants who are undergraduate physiotherapy students enrolled in a gross anatomy course at a university level and participants who are anatomy educators, physiotherapy educators or clinicians who have participated in research relating to gross anatomy curriculum and/or pedagogy for undergraduate physiotherapy students.
The current concepts of interest are gross anatomy curricula and pedagogies available for the education of undergraduate physiotherapy students. Within the existing literature, a number of different terms have been identified that pertain to this concept overall. Below follows a non-exclusive list of potential topics to be considered for inclusion:
- Gross anatomy pedagogy looking at dissection, prosection, the use of anatomical models, body painting, living anatomy and spatial gross anatomy muscle relationships.
- Computer-assisted instruction/learning including the concept of advanced 3D visual learning and asynchronous online discussion forums.
- Learning management and types of education including: peer group education, vertical integration, IPE, problem-based learning and case-based learning.
- Curricular developments such as the possibility of the development of a global gross anatomy core syllabus for allied healthcare students.
- Outcomes measured in relation to types of gross anatomy pedagogical interventions and curricular changes for the student population under review.
The current scoping review will be conducted using information gleaned from the available literature that looks at gross anatomy programs for undergraduate physiotherapy students studying at universities.
Types of sources
All available qualitative papers, mixed methods studies, descriptive studies, quantitative descriptive studies, randomized control trials, systematic reviews, meta-analyses and conference papers or abstracts from such papers on the gross anatomy curriculum and pedagogy for undergraduate physiotherapy students will be eligible for inclusion.
Published and unpublished studies in all languages will be considered for inclusion. The inclusion date for studies is open-ended, and this is dictated by the dearth of information on this topic. In this regard, the term open-ended can be defined as having no predetermined date limits to the database search to retrieve as much information as possible about the topic under review. This is due to the fact that there is little specific information relating singularly to undergraduate physiotherapy students. Usually studies of this population of students are in combination with medical or other health sciences students, and the collected data do not necessarily differentiate between the groups. Hence, a protracted search is necessary to retrieve all relevant data. Eventually, the date of the earliest and latest papers will be ascertained through the literature search process. A three-step search strategy will be used in this review. An initial limited search will be conducted using the MEDLINE (PubMed) and SCOPUS databases. An analysis of the retrieved titles and abstracts will then be undertaken to identify key words and index terms used to describe the article. Second, a search using all the identified keywords and index terms will be undertaken across all included databases. Finally, the reference lists of all identified articles and reports will be searched for additional relevant studies. The authors of primary studies will be contacted if further information is needed. Gray literature will be sourced using Google.
A search will be undertaken in the following databases for published studies:
Academic Search Complete
Cochrane Database of Systematic Reviews
Education Search complete
A search will be undertaken in the following databases for unpublished studies:
The American Association of Clinical Anatomists website/conferences
The Anatomical Society of Southern Africa web site/conferences
University of the Witwatersrand website – library archives for theses on the topic
Key words and key phrases to be used in the initial search will include the following:
Undergraduate; students; physiotherapy; physical therapy; gross anatomy; pedagogy; teaching methods; curriculum; education; dissection
Consideration for inclusion
As this is a scoping review, no assessment of methodological quality will be performed. Two independent reviewers will assess whether a study should be included. If these two reviewers cannot reach consensus on the inclusion of a study, a third independent reviewer will be called upon to resolve the matter.
Two independent reviewers will extract data (qualitative and quantitative) from each study relevant to the review question. The results will be charted to record the key information of the source that is relevant to the review question. A data extraction instrument for this scoping review has been developed (Appendix I). However, this may be further modified at the review stage. Key information that might be charted include the following:
Year of publication
Type of study/design
Location of study
Aim(s) or purpose of study
Population and sample size
Description of anatomy teaching methods and/or type of curriculum in the study
Length of the intervention (if applicable)
Conclusions relevant to scoping review question
Presentation of the results
The number of studies found, included and excluded will be shown in an adapted PRISMA flow-diagram.54 Extracted results will be presented in the form of a table the same or similar to that already developed for this protocol document. A summary of the results will incorporate the aims and purposes of the reviewed studies methodologies applied and a synopsis of the results obtained relevant to the review questions. Conclusions will be made and suggestions will follow as to possible systematic review questions arising from those conclusions.
Appendix I: Data extraction instrument
The authors would like to thank the South African Physiotherapy Society Research Foundation for providing a researcher bursary for this research.
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