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Mobile Devices and Software Applications to Promote Learning in a Musculoskeletal Physical Therapy Class: A Case Report

Hoglund, Lisa T. PT, PhD, OCS, Cert MDT

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Journal of Physical Therapy Education: Volume 29 - Issue 2 - p 54-61
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Class size in professional level physical therapy programs in the United States (US) is growing, presenting instructional challenges to physical therapy faculty.1 In order to manage larger classes, faculty may consider innovative teaching methods to promote learning, including the use of mobile devices. Mobile devices have become ubiquitous and mobile tablet personal computer (PC) use is rapidly growing. An estimated 195.4 million tablets were sold in 2013 and it is predicted that 270.7 million tablets will be sold in 2014.2 Mobile devices are increasingly providing users with access to information wherever they can connect to mobile networks, but adopting them for the promotion of academic learning has been slow-moving.3 This is changing, though, and several universities are responding to emerging technology by requiring all incoming undergraduate students to purchase mobile tablets (eg, iPads).4 Alternatively, some universities provide students with iPads.4 Knowing that requiring mobile devices for a class does not necessarily enhance learning, educators should consider the underlying pedagogical goals to determine the best strategy to achieve these goals.5,6

Mobile learning (ie, m-learning) is an extension of technology-enhanced learning.7,8 M-learning has been defined as “the exploitation of ubiquitous handheld technologies, together with wireless and mobile phone networks, to facilitate, support, enhance and extend the reach of teaching and learning.”9 Information may be accessed anytime, anywhere using wireless internet technology and handheld devices.7,10 Twenty-first century educators may use technology to design active learning experiences rather than transmit knowledge in face-to-face lectures.11 In addition, m-learning may better promote learning since it is personalized, asynchronous, learner centered, beyond the classroom or home (anytime, anywhere), and offers the opportunity to use spare time for learning.7,8 As Sharples and colleagues12 point out, these concepts of learning align well with mobile technology features: “personal, user centered, mobile, networked, ubiquitous, and durable.” This rich definition of m-learning affords educators the opportunity to apply a wide variety of learning theories to design m-learning experiences, including (but not limited to) situated learning, ubiquitous learning, behaviorist learning, collaborative learning, and constructivist learning.10,12,13

Understanding the definition (ie, the “what”) of m-learning and the ability of innovative educators to apply various learning theories to achieve identified pedagogical goals is only the first step to achieve these goals.5 Underlying theories and assumptions lead to action strategies to achieve identified learning goals (ie, the “how”) of applying m-learning. The strategy of m-learning is equally critical to assessment of teaching interventions. In a literature review of technology-enhanced learning, Kirkwood and Price7 identified 3 basic types of interventions using technology based upon the goals of “(1) replicating existing teaching practices, (2) supplementing existing teaching, and (3) transforming teaching and/or learning processes and outcomes.” Knowledge of these underlying goals for technology—enhanced learning, combined with knowledge of capabilities of mobile devices—may be useful to design learning activities.

Since m-learning is a relatively new phenomenon, there are limited reports of its use to enhance learning. Shih and Mills14 modified a university literature class by using mobile devices for student access to course documents, discussion board response, and communication via text messages in short message service (SMS). A student survey showed the experience improved motivation, enhanced communication, and encouraged collaboration.14 In contrast, undergraduate students in a digital media course were neutral regarding the added benefit of a mobile device to access course content via Blackboard MobileTM Learn, a software application for the Blackboard learning management system.15 Bruce-Low and colleagues16 conducted a randomized trial comparing independent study with a textbook-based approach and an interactive mobile tablet PC approach to develop electrocardiography knowledge in undergraduate medical and sports sciences students. The mobile group performed better than the textbook group on a posttest.16 During a randomized, controlled trial of nursing students, Wu and colleagues17 compared use of a personal digital assistant (PDA) for instruction and immediate feedback to traditional demonstration for learning of respiratory system physical assessment. The PDA group performed better on written posttests and physical assessment skill compared to the traditional group.17

Mobile learning technology includes mobile handheld devices, such as cell phones and tablet PCs, as well as the software applications (apps) on these devices.2 The small size and portability of these devices has the potential to promote learning in various contexts, including face-to-face classrooms, distance learning, and in clinical settings.2 Their ability to provide the user with written, audio, and video content allows supplementary instruction and feedback for cognitive content as well as psychomotor skill.18,19 Mobile technology offers easy use of computer-assisted instruction (CAI) via the internet, which was found to be more effective than textbook instruction for psychomotor skill acquisition and retention.20 Commercially available (and cost affordable) high quality apps that provide written and audio description and video demonstration of physical therapy examination and intervention techniques offer the potential to capitalize on the benefits of CAI for promotion of skill development and knowledge by making it available anytime, anywhere.21 Apps that provide video and audio content have the potential to improve learning of content taught in face-to-face labs by instructional scaffolding, as students view them multiple times during practice.21–23 Since mobile apps are regularly updated by the manufacturers, they offer the opportunity for timely correction of any errors as well as addition of new content. Educators have the responsibility to review the content provided by mobile apps since they may be produced by a wide variety of manufacturers without critical content reviews. In addition, educators should have pedagogically sound learning goals concerning the use of m-learning to replicate, supplement, or transform teaching and learning in specific courses.7

Although the use of mobile devices is becoming pervasive, including their use by consumers and health care professionals to research health care information,24 m-learning to promote knowledge and psychomotor skill in face-to-face physical therapy classes has not been reported.25,26 The purpose of this case report is to describe the implementation of m-learning for supplemental instruction and assessment in a face-to-face musculoskeletal physical therapy class, the impact m-learning has on student performance, and how faculty and student use of the iPad and other apps promote better learning.


The physical therapy major at University of the Sciences (USciences) is a 3+3 professional level program, with 3 undergraduate and 3 professional years of study. Students may enter the program as college freshmen and receive a bachelor's degree in health science following the first 4 years and a Doctor of Physical Therapy (DPT) degree at the conclusion of 6 years of study. Post-baccalaureate students may enter the program at the beginning of the first professional year of study and receive the DPT degree following 3 academic years. A typical cohort is comprised of 20%-40% post-baccalaureate students and 60%-80% freshmen-entry students.

Several key factors promoted use of mlearning in this case report. The institution provided the iPad 2 (16 gigabyte, WiFi enabled) and $10 credit for purchase of apps to all PT students in the first professional year (academic year 2011–2012). After the feasibility of using mobile devices and apps in the classroom was established, the physical therapy faculty voted to require all students to purchase iPads at the start of the first professional year. Students were familiar with the technology, having used their iPads in gross anatomy and pathophysiology courses in active learning during the 2011–2012 academic year. Therefore, with the support of the Academic Technology (AT) Department, it was logical for the instructor of “Musculoskeletal PT I” to initiate a program of m-learning in 2012–2013. Mobile devices and apps were used to deliver content, promote active learning, and assess learning.

Musculoskeletal PT I” is the first of 3 courses in the musculoskeletal course sequence of the physical therapy curriculum at USciences and is offered during the second professional year. The 5-credit course covers physical therapy examination and intervention for musculoskeletal conditions of the extremities. Course assessments include quizzes and tests of cognitive content, 8 psychomotor competency tests (4 musculoskeletal “special tests,” 4 joint mobilization/manipulation), and 1 final practical examination of a patient case (including examination and intervention). If a learner scores less than 80% on competency tests or on the practical examination, he/she is required to retest. Competency tests must be retaken until the learner demonstrates competency by scoring at 80% or above. A maximum of 1 retest is permitted for the final practical examination.

During the fall 2012 semester, the “Musculoskeletal PT I” instructor used m-learning with iPads to supplement teaching musculoskeletal special test content with a commercially available app called Clinical ORthopedic Exam (CORE).27 The instructor of record selected this app for the following reasons: step-by-step instructions, references for psychometric properties linked directly to PubMed which allows abstract review and article retrieval, links to internet videos demonstrating proper performance, and reasonable price (Figure 1). The instructor utilized this app as a required reference for the class. Where necessary, face-to-face lab instruction in performance of a few musculoskeletal examination tests was modified to be consistent with CORE. Reference was made to the app on lab handouts. Students were encouraged to reference CORE outside of class to review proper skill performance and to prepare for in-class competency tests and the practical examination.

Figure 1. iPad Screenshot of the CORE App
Figure 1. iPad Screenshot of the CORE App:
27 Video Demonstration of an Orthopaedic Examination Test

In addition to using iPads for supplementary content, the mobile devices were used for formative and summative assessment. The Blackboard Learning Management System (LMS) with the MobileTM Learn app allowed for course instructional content and quiz assessments.28 Quizzes were constructed by the instructor using question types and methods of presentation to make these quizzes mobile. There were 7 Blackboard mobile question types at the time: (1) true/false, (2) multiple choice, (3) short answer, (4) fill in multiple blanks, (5) calculated numeric, (6) file response, and (7) hot spot (identification of a location on an image) (Figure 2). Some of these (eg, multiple choice) were automatically graded by the LMS, while some (eg, short answer) required manual grading. When manually grading questions on a computer, the LMS provided an opportunity for course instructors and students to interact electronically at user-centered times. For example, instructors had the option of inserting feedback to the learner. The LMS also offered the option to hide test results from learners and make them visible at a later date. Learners were able to take these tests using any webenabled device, including tablet PCs, smart phones, or laptop computers. Most students used iPads to take the quizzes, but some used laptop computers or smart phones. Quizzes were designed to allow only 1 attempt and were administered during class time. Following manual grading, the instructor made the quizzes and grades visible to learners. This summative quiz feedback allowed students to review the content at any point and enabled the instructor to use classroom time more efficiently.

Figure 2. iPad Screenshot of a Blackboard MobileTM Learn
Figure 2. iPad Screenshot of a Blackboard MobileTM Learn:
28 Hot Spot Question

Formative feedback for student comprehension of material covered during face-toface lectures was provided using polls and an iPad app for an audience response system (ARS), ResponseWare®, by Turning Technologies.29 The instructor of record created questions covering course content and used them during several face-to-face lectures. The ARS gave the instructor and learners immediate feedback regarding student comprehension of course concepts. The discussion that followed created opportunities to review and reinforce learning. While the app for this ARS is free, the students are required to purchase a license to use the system. Licenses may be used on any web-enabled device to participate in polls. Students who owned ARS “clicker” data collection devices of the same brand were able to use those devices instead of purchasing a license to use the mobile app. A limited number of students were able to participate with their iPads using several ARS licenses purchased by the university.

The impact of this program of supplementary course content and transformed student assessment with m-learning was measured by comparing student course outcomes of the m-learning cohort to the previous cohort. Student knowledge and psychomotor skills were evaluated through written examinations, practical exams, and psychomotor competency tests. Grading rubrics and test format for competency tests and the practical examination were the same for both cohorts. Four of 7 lab instructors conducting these psychomotor tests were the same for both courses. Class average scores for assessments and the number and percentage requiring psychomotor retests were calculated.30 Student satisfaction regarding use of select iPad apps to learn course material was assessed using anonymous surveys following completion of the course.


Demographics and statistics of the 2 cohorts are reported in Table 1. The first professional year grade point average (GPA) for the fall 2012 (m-learning) cohort was greater than that of the fall 2011 (traditional lecture and laboratory) cohort.

Table 1
Table 1:
Cohort Demographic Data

The instructor of record observed anecdotally that the m-learning cohort required fewer retests of psychomotor competency tests and practical examinations as compared to the previous cohort. The difference in retests was most pronounced in musculoskeletal special tests and practical examinations (Table 2). An attempt was made to measure the impact of m-learning with supplementary teaching on student performance. There were no differences between the groups for final course grade, final written examination, competency test, or the practical examination grade percentages (Table 3).

Table 2
Table 2:
Psychomotor Competency and Practical Examination Retests and Time Spent by Instructor of Record in Student Remediation
Table 3
Table 3:
Assessment Results

The instructor of record perceived that less time was spent remediating students for psychomotor tests and practical examinations in 2012 compared to 2011. This was assessed by comparing time spent by the instructor in 2 areas: (1) special request meetings with students and (2) conducting retests of the psychomotor test and the practical examination. Total time spent by the instructor in these activities decreased 12% during 2012 compared to 2011 (Table 2). The lower amount of time required for these meetings and remediation during 2012 was due to less time spent conducting retests (Table 2).

Student satisfaction for supplementary instruction and in-class quizzes with iPads was assessed with a voluntary, anonymous survey following course completion (Table 4). Students used the CORE app frequently to prepare for psychomotor tests, with 57.5% reporting they used it at least twice per week. One student noted that the “app was really useful to practice for comps!” Another student reported that he/she used it during experiential learning following the course. “I used it frequently; I also used it in my clinical affiliation. They loved it and wished they had it because sometimes you forget all of the tests!”

Table 4
Table 4:
Online Survey of Satisfaction With Use of iPads and Apps

Student satisfaction with use of iPads and the Blackboard MobileTM Learn app to take in-class quizzes was not as favorable (Table 4). Forty-two of the 47 survey respondents (89.4%) used the iPad or other mobile device to take at least 1 of the 4 quizzes. Students reported encountering several problems, including the inability to connect or slow connection speed (n = 37), accidental quiz submission (n = 11), quiz freezing (n = 17), difficulty using the keyboard for short answer questions (n = 19), and difficulty responding to hot spot questions (n = 27). Only 2 students reported no problems using the iPad for quizzes. However, students liked reviewing online quizzes to prepare for traditional exams (91.5% agree/strongly agree).

Overall student satisfaction with the course was greater in the fall 2012 (m-learning) cohort compared to the fall 2011 (traditional) cohort. This was indicative through the use of a Likert scale of 1 (worst level of satisfaction) to 5 (best level of satisfaction). The 2012 score came to a 4.9, while the 2011 score was a 4.8. Similarly, the fall 2012 cohort believed the instructor to be a more effective teacher compared to the fall 2011 cohort (4.9 in 2012 versus 4.7 in 2011). This was felt to be important, as the larger class size in 2012 may have reduced student satisfaction due to reduced contact with the instructor.


This case report has shown how m-learning with iPads and apps was used to supplement instruction and transform formative and summative assessments in a musculoskeletal physical therapy course. In this class, mlearning was equally as effective for student learning of psychomotor skill and clinical decision-making as traditional face-to-face lecture and lab instruction alone. M-learning with commercially available apps may be a method to maintain and promote student learning of physical therapy psychomotor skills despite larger class size. Time spent by the instructor conducting special request student meetings and retests for the m-learning cohort was 12% less than time spent on these activities with the previous cohort (despite a 17% increase in class size). The m-learning cohort required fewer retests of practical examinations and competency tests of orthopaedic examination measures compared to the traditional cohort. Students were satisfied with m-learning with the CORE app, reporting that the app was user-friendly and helpful to learn course content. The majority of students did not enjoy using iPads and apps for in-class summative assessment and reported several technical problems.

Although this case did not show significant differences in learning between m-learning and traditional class cohorts, the student and faculty experiences were intriguing. The smaller number and lower class percentage of retests may have been due to use of the CORE app as a supplement to face-to-face lab instruction. Particular benefits to m-learning with the CORE app revealed learning to be ubiquitous, personalized, asynchronous, and learner centered.7,8,12 Learners could watch videos of proper performance with written instructions as often as they liked. This gave learners the opportunity to review content taught in face-to-face labs and reinforce proper technique.21 Scaffolding promotes proper learning and avoids the necessity of correction of skills learned and incorrect practice.25 More time spent viewing models/experts performing psychomotor skills may be a source of feedback from self-assessment.22 It may also be an opportunity for peer feedback when students practice skills together.

M-learning with iPads and the LMS Blackboard MobileTM Learn app was used to transform a course summative assessment into a more active learning experience.7 The app was used for in-class quizzes that could be reviewed by learners in any situation. This may have promoted learning of course concepts, possibly resulting in improved performance on psychomotor tests. Although limited, use of the ARS during face-to-face lectures may also have promoted learning through improved student engagement and formative feedback.

This case report demonstrates some possible benefits (in terms of efficiency) of the use of iPads and commercially available apps for supplementary instruction. Despite the larger class size for the m-learning cohort, the time spent by the instructor of record in remediation of psychomotor skills and practical examinations was slightly less than with the previous cohort. This is similar to results of a case report of a hybrid learning class using custom recorded videos of psychomotor skills.6 Although the instructor of record spent slightly less time with students in remediation, additional time was required for the instructor to learn to use the iPad and apps. Time spent with this course modification, however, would decrease with familiarity and practice, as with any other new teaching technique. Use of m-learning and apps that include easily accessible videos and step-by-step instructions of physical therapy examination tests and interventions may minimize time used by instructors to answer questions about basic technique6 and allow for more time spent in higher level skills, such as clinical decision-making.23,26

The use of m-learning for in-class assessments revealed some negative factors of emerging technology, as the majority of students reported significant technical difficulties. Our finding of technical problems with mobile devices is consistent with reports of these challenges with computer-based testing with nursing students.31 Technical problems have been reported to be a source of student anxiety for nursing students in a distance education program.32 The students in this musculoskeletal physical therapy class likely experienced anxiety due to technical problems, which was in addition to the typical anxiety many students feel during graded assessments. The instructor relied on the university's AT Department to investigate technical problems and propose solutions. This investigation did not reveal a primary common problem, but several possible problems emerged, including wireless network connectivity, different operating systems on the iPads, and students taking the quiz in a mobile web browser or through a laptop computer instead of through the Blackboard MobileTM Learn app, as indicated through email communication from an AT professional. At the time of this email communication, the USciences AT Department recommended use of mobile quizzes for surveys or low stakes testing only. The assistance of the AT Department was critical to transformation of learning activities for this course. The instructor collaborated with AT staff while planning the course and periodically throughout the semester. In addition, AT staff worked closely with the instructor to resolve technical problems with in-class mobile tests and ResponseWare® polling. Finally, as part of the USciences iPad pilot program, CORE app licenses were purchased by the AT Department for all students at 50% cost through a volume discount program.

There are several limitations to this case report. Comparison of the cumulative GPA for the professional courses prior to entry into the course revealed a significant difference. Despite this difference between cohorts, assessment grades were similar. Although not significantly different, the m-learning cohort did have fewer competency test and practical examination retests, which involved skills supplemented by use of the CORE app. Similar assessment grades for the m-learning and traditional cohorts may have been due to several factors. Although the m-learning cohort had the CORE app available, it is unknown how much time learners spent using this app to learn and review examination measures. Some examination measures taught in “Musculoskeletal PT I” were not available on CORE. Therefore, learners in both cohorts received the same face-to-face instruction. Although the grading rubrics for the competency tests and practical examination were the same for both cohorts, 3 of the 7 lab instructor graders were different. Therefore, psychomotor test and practical examination scores should be viewed with caution. Future study should be conducted using validated outcome measures to assess the impact of m-learning for physical therapy psychomotor skills, cognitive knowledge, and clinical reasoning.

Physical therapy faculty members are being challenged by increased enrollment in classes. This case report describes the use of m-learning with iPads and apps as supplementary teaching methods in attempts to promote psychomotor and cognitive learning in a musculoskeletal physical therapy class. The iPads were also used to increase active learning activities using polling software and LMS apps. Problems encountered with the technology are described. Course assessment outcomes for m-learning were similar to the previous cohort without m-learning, despite increased class size. Although not significant, fewer psychomotor skill and practical examination retests were necessary for the m-learning cohort. This resulted in less time spent by the instructor of record in student remediation. Students were satisfied with the use of m-learning, except for difficulty with in-class mobile quiz assessments. This case demonstrates the need for collaboration with AT specialists to prepare and troubleshoot any technical difficulties.


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Mobile learning; Musculoskeletal; Psychomotor skills; Physical therapist education; Technology

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