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Outcomes of Flipped Classroom Instruction in an Entry-Level Physical Therapy Course

Deprey, Sara M., PT, DPT, MS, GCS

Journal of Physical Therapy Education: September 2018 - Volume 32 - Issue 3 - p 289–294
doi: 10.1097/JTE.0000000000000035
Case Report

Background and Purpose. Instead of relying exclusively on traditional lecture classes, instruction known as “flipped classrooms” provides students a more interactive learning environment. In a flipped classroom, students are required to listen to prepared prerecorded course content before they come to class. Rather than homework following a lecture, students complete assignments in the classroom on concepts specifically drawn from the lecture. Flipped classrooms are gaining more popularity; however, quantitative studies on their ability to improve learning are lacking.

Case Description. This is a retrospective review over 3 consecutive years that describe outcomes of three teaching methods within one unit of an entry-level physical therapy course. Examination scores from a traditional lecture (TRAD) classroom (n = 44), a partially flipped (pFLIP) (n = 49), and a fully integrated flipped (full FLIP) classroom (n = 50) were compared.

Outcomes. Students receiving instruction in a full FLIP classroom demonstrated the greatest improvements from examination 1 to examination 2. The pFLIP cohort demonstrated statistically significant lower scores compared to full FLIP cohort on examination 2.

Discussion and Conclusion. The TRAD class received in-class lectures with homework, whereas the pFLIP cohort received in-class question and discussion of content, while the full FLIP cohort received intentional in-class work. A full FLIP classroom requires active participation by students, and in doing so, it simultaneously provides an enhanced opportunity to apply new content to contextualize new information with prior knowledge to solve problems. This opportunity to apply content along with the availability of the instructor to provide feedback in real time may have led to greater understanding of the course material.

Sara M. Deprey is an associate professor at Carroll University, 100 N East Avenue, Waukesha, WI 53186 ( Please address all correspondence to Sara M. Deprey.

The author reports no conflicts of interest.

Received February 06, 2018

Accepted February 27, 2018

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A classroom that incorporates active participation by students as opposed to passive listening has been shown to increase engagement and learning in undergraduate science, engineering, technology, and mathematic courses.1 There are, however, a few studies that have compared the effects of active learning to traditional lecture instruction in physical therapy.2,3 Lake2 compared course grades of physical therapist students in a physiology course when students were engaged in active learning (self-directed group discussion) versus traditional lecture presentations. The author found that students engaged in group discussion (active learning) had statistically higher course grades than those who received traditional lecture instruction.2 Veneri and Gannotti3 used technology in a physical therapy neurological rehabilitation course to enhance active participation of students. The authors developed computer-assisted learning (CAL) modules. The CAL modules included edited videos clips of patient examination or intervention with questions embedded in the modules to foster critical thinking. Students would view the video and answer questions outside of class. The authors found that the physical therapy cohort of students who received CAL modules in addition to traditional instruction and laboratories had statistically significant higher scores on the final course examination than the cohort who received only traditional instruction and laboratory. Study participants and authors suggested the use of a flipped classroom model, that is, viewing the CAL modules in class, as a way to facilitate active learning in a physical therapy classroom.3

The flipped classroom, also known as the inverted classroom or repurposed classroom, is a form of active learning and is becoming popular in higher education. Flipped classrooms have been used by faculty from disciplines, including physics, mathematics, engineering, sociology, and humanities.4 More recently, physical therapy programs have begun to report on this model.5 The flipped classroom occurs when students listen and/or view an interactive computer-based content lecture, which is normally given during class time, prior to coming to class.6 Rather than homework following a lecture, students in a flipped class engage in “homework” assignments or activities in the classroom on concepts specially drawn from the lecture that encourage further exploration of the content.7,8 This is hypothesized to lead to a greater depth of understanding and application of material versus simply memorizing facts.7

Graduate programs are implementing variations of the flipped classroom. One study by Tune et al9 compared a traditional classroom with a “modified” flipped classroom in a graduate physiology course. The modified flipped class included prerecorded lectures and in-class work comprising quizzes or class problems and discussion, which made up 25% of the course grade. The authors found that students who participated in the modified flipped classroom scored significantly higher on content examinations than those learning in a traditional classroom. However, the participants who received the flipped approach were required to take frequent quizzes on the prerecorded lecture material, whereas traditional class participants did not, which may account for the higher scores.9

Gillispie10 compared outcomes of a traditional classroom with a flipped classroom in a graduate medical obstetrics and gynecology clerkship. The flipped classroom was similar to the one of Tune et al9 modified classroom and included prerecorded lectures prior to class and in-class instructor-facilitated problem-based case discussions. The author found that only half of the groups who received instruction through a flipped classroom performed statistically better on multiple-choice unit examinations, with one flipped group performing statistically lower on a unit examination. However, all groups who received flipped instructions demonstrated statistically higher scores on a clinical skills examination.10 It was unclear if there was consistency among instructors and consistent in-class time for each group.

Given that physical therapy by nature is an interactive discipline similar to medicine, an active pedagogical approach, such as flipping a classroom, may be beneficial. Emerging use of the flipped classroom in physical therapy was qualitatively demonstrated by Bouche et al.5 The authors incorporated out-of-class preparation utilizing online lectures, readings, and questions in a first-year musculoskeletal curriculum. Postcourse survey of students and faculty demonstrated positive feedback and future suggestions for the flipped approach. However, there is no standardization for the flipped classroom model. Therefore, the question remains if there are specific classroom formats (traditional, modified, or fully flipped classrooms) that would produce the best learning in physical therapy. Currently, there is a gap in quantitative evidence that a flipped classroom is beneficial to learning. Consequently, there are no studies that compare traditional lecture style of learning with a flipped style of learning in a physical therapy neurological course. Thus, the purpose of this case report is to describe student performance on unit examinations in a physical therapy course after using traditional lecture, partially flipped, or fully flipped styles of instruction.

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This was a retrospective review of course assessment outcomes after two unit examinations in an entry-level physical therapy course. The participants for this review were three cohorts of physical therapist students in an entry-level doctor of physical therapy education program. Each year, most (>80%) of the students are admitted directly as freshman to the physical therapy program and complete the program within 6 years. Students participating in this report were registered for PTH 506 Neurological Disorders I. This course has been taught in the fifth year of a 6-year program by the same instructor for the last 7 years. All students registered for PTH 506 met program and course prerequisites. Course outcomes for this report were collected over 3 consecutive years for course grading purposes and for internal assessment. Normal education practices were employed; however, different types of pedagogy, specifically pFLIP or flipped lectures, were implemented in 2013 and 2014, respectively. Thus, as part of the course assessment, different instructional strategies were compared. This report (IRB #15-021) received exemption under 45 CFR 46.101(b)(4) for research compiling/reviewing existing publicly available data.

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Neurological Disorders I Course Description

Current and emerging conceptual frameworks and approaches for assessing and retraining motor control in individuals with movement disorders are analyzed in PTH 506 Neurological Disorders I. Normal and abnormal motor and postural control are analyzed across gender, culture, and the life span. Instruments, tests, screens, and evaluations to detect neurological impairments and functional limitations and therapeutic interventions used in the treatment of people with neurological impairments are presented. Students must apply knowledge from previous courses to integrate new knowledge. This course is taught in 2-hour time blocks 3 days per week.

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Operational Definitions of Instructional Styles

Pedagogical and assessment outcomes of three cohorts of students from 3 consecutive years, 2012, 2013, 2014, were retrospectively reviewed. Three different instructional styles were compared during one unit of a neurological course: traditional classroom, a modified or pFLIP classroom, and a fully integrated “flipped” classroom. The traditional classroom (TRAD) included in-class lectures with homework. The partially “flipped” classroom (pFLIP) included prerecorded narrative Power Point lectures that were to be viewed prior to class. The pFLIP in-class work involved reiteration of the lecture and discussion. The fully integrated “flipped” classroom (full FLIP) included the same narrative Power Point lectures as the pFLIP class with applicable in-class work. All cohorts received traditional lecture instruction during the first 2 weeks of the course, considered the first unit. This unit served as the baseline for all cohorts. During the second unit of the course, three different pedagogical styles, TRAD, pFLIP, or full FLIP, were used to deliver course content. The three instructional styles were considered the independent variables. The instructor spent the same amount of face-to-face class time with all cohorts. End of unit examination scores were assessed for objective changes in content knowledge and were considered the dependent variables.

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Course Design

Neurological Disorders I is divided into three units, with a content examination concluding each unit. The first unit presents 10 hours of information on neurological physiology and common impairments seen in a population with involvement of the neurological system. Integration of this material is essential for understanding future course content. Thus, neurological physiology is the foundation on which all other class material builds on. As stated previously, all three cohorts received traditional instruction (in-class traditional lectures) for this unit, which served as a baseline to compare the other types of classroom instruction. The second unit included 12 hours of class instruction (2-hour class, 3 times per week for 2 weeks) studying postural control. Each cohort received a different type of instruction for the second unit of postural control. The TRAD cohort received traditional instruction with five 2-hour in-class lectures, individual homework (application of a patient case) and one 2-hour balance test and measures laboratory (reviewing common balance assessments, including Berg Balance test,11 Timed Up and Go,12 and Functional Reach13). The pFLIP cohort received lectures that were prerecorded. Students viewed lectures prior to class with reiteration of the lecture during in-class discussion without specific in-class work. Prerecorded lectures had questions embedded in the lecture that served as prompts for content understanding and reflection of the material. Students were given the opportunity to ask questions or clarify concepts during the five 2-hour class periods. The unit included the same 2-hour balance test and measures laboratory as the TRAD cohort. The full FLIP received five prerecorded lectures (same lectures as the pFLIP) and in-class work completed during five 2-hour class periods. As the other cohorts, the full FLIP cohort participated in one 2-hour balance test and measures laboratory. In-class work involved working in groups, if desired, to answer specific instructor-posed questions and complete scenarios that applied the material and required Internet research or open book or note review. The in-class work focused students on the questions to ask, rather than coming up with their own questions about the lectures. It also required students to act out a scenario to determine the correct answer. An example of focus questions might be

  1. Compare and contrast the hip and ankle strategy muscle activation patterns.
  2. Explain the center of mass movement between the hip and ankle strategy.
  3. When treating a patient with an inefficient synergistic response to a perturbation what should you do?

Table 1 demonstrates the types of instruction and face-to-face class time per cohort.

Table 1

Table 1

The final unit in the course culminated with motor and sensory development and motor control theories. This unit was taught by different instructors during the 3-year period and are not included in this report.

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The primary outcome measure for this case report was scores on the second unit examination when the three instructional styles were varied. In addition, change in scores from examination 1 to examination 2 was compared. Unit examinations included knowledge-, comprehension-, and application-level questions according to Bloom's taxonomy14 presented in multiple choice and short response question formats. Unit examinations were given at the completion of each unit before progressing to the next unit. For example, the neurophysiology unit examination, considered the first examination, was given at the completion of the first unit, that is, after 10 hours of neurophysiology review. The first examination was given prior to starting the second course unit, postural control. Likewise, the postural control unit examination was given at the completion of the second unit prior to the motor and sensory development unit. Unit examinations 1 and 2 included the same items for the 3 years of the study.

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Analysis of Outcomes

Descriptive and analysis of variance (ANOVA) statistics were used to determine if there were differences in baseline characteristic of each cohort specifically, age, sex, American College Testing (ACT) and Graduate Records Examination (GRE) written, and verbal and quantitative scores that could account for the results. An ANOVA was used to determine if there were demographic differences between the 3 cohorts and differences on examination 1 and examination 2. Tukey’s HSD post hoc test was used to determine where differences occurred between groups. Percentage of change from examination 1 to examination 2 is also reported. Cohen’s d was used to determine effect size of statistically significant findings. To determine the magnitude of effect, sizes of 0.01, 0.06, and 0.14 were used to determine small, medium, and large effects, respectively.15 SPSS 23.0 (Armonk, NY)16 and Microsoft Excel (Redmond, WA)17 were used for statistics.

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Demographic and Examination Scores

Student demographics from each cohort and student course grades on the two unit examinations are described in Table 2. There were no differences in student demographics from each of the 3 cohorts except that the fully flipped cohort was on average, 1 year younger than the other 2 cohorts. The full FLIP cohort demonstrated statistically lower baseline examination scores than the TRAD or pFLIP cohort. However, by the second examination, the full FLIP cohort demonstrated the highest scores. These statistical differences exhibited a medium effect. The pFLIP cohort demonstrated statistically lower second examination scores compared to the full FLIP classroom. Interestingly, there were no statistical difference in scores between the TRAD and full FLIP cohort on the second examination. The full FLIP cohort, however, demonstrated a positive increase in their examination scores from examination 1 to examination 2, while the other 2 cohorts, TRAD and pFLIP, did not (Figure 1).

Table 2

Table 2

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Flipped classrooms are becoming more popular. However, there is a paucity of quantitative studies that demonstrate a flipped classroom is better for learning. This report describes the quantitative changes in unit examination scores after using traditional, partially flipped, and fully flipped instructional styles. Students who received one unit of fully flipped classroom instruction demonstrated higher scores on the unit examination and greatest improvements in scores than those who received instruction through traditional lecture or partially flipped classrooms. The first unit examination in this course covered foundational course information. All three cohorts each year received the same type of traditional lecture instruction and the same first examination. The traditional lecture and pFLIP cohort received similar first examination grades, whereas the full FLIP cohort received statistically lower scores on the first examination. Yet the full FLIP cohort received the highest scores on the next examination when instructional styles were different. Furthermore, the full FLIP cohort had a positive increase in scores from examination 1 to examination 2 perhaps suggesting better integration and use of prior information versus simply memorizing information for the particular examination. A medium effect size was calculated when the flipped classroom was used in this review, suggesting that there may be a true practical difference between the pedagogies.

This report supports what Bergman and Sams7 have proposed, namely, that flipping a classroom can promote better integration and a deeper understanding of course material.7 Others have suggested that viewing prerecorded video lectures may help manage cognitive load, that is, the amount of information one can successfully retain.18 Students can watch the prerecorded video lectures at their own pace, fast forwarding, rewinding, or reviewing self-selected portions to enhance their understanding of information.18 There is a dearth of quantitative studies that have compared traditional lectures to flipped classrooms in graduate education. Tune et al9 found that participants who received physiology content using a modified or pFLIP classroom did better on content examinations than those receiving traditional classroom learning. However, in this current report, the pFLIP classroom displayed the lowest examination scores and the least amount of change from the first to the second examination compared to a full FLIP or traditional classroom.

A potential explanation as to why the pFLIP cohort did not score as high on the second examination might be due to the specific in-class work the full FLIP cohort received. Simply changing the mode of knowledge transmission is unlikely to demonstrate gains in learning.18 In addition to the prerecorded lecture the pFLIP cohort received, the full FLIP cohort received in-class work. The in-class work was designed to provide an opportunity to contextualize new information by giving students specific questions to problem solve that required the use of multiple cognitive and physical resources to give meaning and thus understanding of the concepts.7 After viewing the prerecorded lectures, the students in the pFLIP classroom were given an opportunity to ask questions in class and discuss the material. However, this did not lead to the same increases in scores as the full FLIP cohort. When students are learning novel information, it may be overwhelming or difficult to know what questions to ask, as time and application are needed to process the new information.

Thus, the key to depth of learning may be not only the collaborative peer questioning but also the application and construction of material that helps with longer-term retention.19,20 Therefore, the discussions (questions and answers) that occurred in pFLIP model may not truly represent the active learning component as previous studies have suggested2,9,21 and may explain why the pFLIP class demonstrated lower scores in this report.

Outcomes from this report also suggest that a fully flipped classroom did not demonstrate significant differences in second examination scores compared to the cohort who received traditional lectures. Nevertheless, the full FLIP cohort displayed the greatest score improvements from examination 1 to examination 2, compared to the traditional cohort. Perhaps, in order to increase understanding, deliberate questions that encourage manipulation of the material are needed to help students contextualize the information and use it at a later date. This may also suggest that the variable that increases learning and retention is not necessarily the flipped classroom but active engagement of the material, which is consistent with what others have found in their studies.1,18,20–22

As more literature on flipped classrooms is becoming available, standard definitions and designs for the flipped classroom are emerging.6,18,23 Despite the slight differences currently in flipped classroom definitions, it seems a common thread to a flipped classroom is the interactive, meaningful, and motivational activities that occur during face-to-face class time. This could suggest that in-class face-to-face time is an opportunity for instructors to engage students in course material. An instructor's role then in a flipped classroom changes from “transmitter” of information to facilitator, allowing students to construct meaning of information and provide opportunities for clinical application of concepts.18,19

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Recommendations for Further Study

Future physical therapy students may be more adept and familiar with “online” learning and open to active learning techniques, as suggested by Gillispie10 when working with medical students. Therefore, it may be interesting to investigate if successful course outcomes are due to specific teaching techniques or if the learning patterns of physical therapy students tend to favor a more hands on problem-solving approach. On the contrary, a student who learns best by lecture and relies on memorization may not do well with a flipped or active classroom environment.24 Thus, it may be worthwhile to determine if specific learning styles of physical therapy students correlate with successful outcomes after active learning approaches.24

Part of the active learning that occurs in a flipped classroom is the in-class group work and the peer-to-peer interaction and mentoring that is encouraged. However, in this report, the instructor did not control for the amount of in-class work each student contributed to the working groups. Some students may have benefited from the assigned problem solving, while others in the group may have passively received the information from their peers, mirroring a traditional lecture. Thus, the outcomes in this report cannot determine if the active or passive approach accounted for the test scores. Future studies that investigate active group learning are encouraged to not only assess the style of instruction but also assess individual participation within each peer group.

In this case report, all students received the same unit examinations. Both unit examinations incorporated multiple cognitive levels of questions, that is, knowledge-, comprehension-, and application-level questions according to Bloom's taxonomy.14 However, a traditional style of lecture may lend itself to better results on knowledge-level examination questions, whereas a more active classroom approach may lend itself to better outcomes on an examination that is primarily application.10 Hackathorn et al21 examined the effects of four different teaching techniques, that is, lecture, demonstration, discussion, or in-class activities, on specific level of examination questions. The authors found that in-class activities resulted in higher overall scores on examinations, despite the level of question.21 However, it was suggested that each teaching technique has value and may be dependent on the instructor's strengths and goals for the level of learning.21 Thus, an interesting direction to investigate would be determining the most appropriate teaching technique based on the instructor's strengths and learning outcomes of the course. For example, which techniques are best for physical therapy classes that focus primarily on foundational knowledge and memorization compared to an application course such as a skills-based course.

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Physical therapist students in an entry-level neurological disorders class who received course instruction using a flipped classroom approach demonstrated increases in unit examination scores and greater improvement of examination scores compared to a partially flipped or traditional lecture classroom approach. For this particular course content, a flipped classroom that provided students an opportunity to construct meaning of course content in class, along with the availability of the instructor to provide feedback in real time, may explain the increase in examination scores. A flipped classroom is one form of active learning and may provide an alternative mode of instruction that encourages active participation by students.

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The author thanks Dr. Lori Kelly, PhD, and Ms. Brayton Deprey, BA, for their editorial assistance.

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Active learning; Flipped classroom; Education

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