Obstetrics-gynecology in the physical therapy curriculum: a follow-up study.

Obstetrics-Gynecology in the Physical Therapy Curriculum: A Follow-up Study Obstetrics-gynecology (Ob-Gyn) physical therapy in the United States has developed primarily in the last 10 to 15 years. Even though postpartum massage and exercise were documented in the 1930s and prepartum-postpartum exercise continued to be recommended throughout the sixties and seventies, undergraduate physical therapy education did not include Ob-Gyn physical therapy. [1-6] As Noble stated in 1976,

Unlike other countries, American PTs [physical therapists] traditionally have not been trained in OB/GYN as undergraduates, employed by women's hospitals or otherwise involved this field apart from recent participation in childbirth education. [6]

The American Physical Therapy Association's establishment of the Section on Obstetrics and Gynecology in 1976 accomplished three things. First, it stimulated promotion of the role of physical therapy in Ob-Gyn. Second, it facilitated training for physical therapists wanting to specialize in Ob-Gyn. Finally, it established a research base in this area. [7]

Since 1980, childbirth education and exercise have become more accepted as part of a pregnant women's plan of care. In a study by Barman, 89% of obstetricians and gynecologists recommended exercise to most of their patients. [8] Physical therapists in growing numbers are providing childbrith education and exercise classes for pregnant women. Concurrently with physical therapists' increased involvement in childbirth and exercise classes, the specialty areas of preventive health care and sports medicine emerged. There is thus a new interest within the broader spectrum of Ob-Gyn physical therapy--involvement with women, including an emphasis on Ob-Gyn problems that occur throughout their life span and that are related to the full range of life's activities. Obstetrics-gynecology physical therapy has come to include evaluation and treatment of the individual for specific problems as well as group instruction in childbirth education and exercise classes. [9]

A study by Hulme et al in 1981 documented the role of physical therapy programs in educating physical therapists in obstetrics. [10] The results indicated that 68% of the responding programs included a unit in obstetrics with an average of 7.5 hours for obstetric education. Wallis et al reported that 82% of APTA Section on Obstetrics and Gynecology members practicing in the obstetrics area had received education in Ob-Gyn at the entry level and that 8% had received education at the graduate level. [9] The purposes of this follow-up study were 1) to investigate the present status of Ob-Gyn physical therapy in educational settings and 2) to compare the present status with the 1981 data from the study by Hulme et al. [10]

Method

A questionnaire and stamped self-addressed envelope were mailed to 101 accredited physical therapy programs in the United States. The items on the questionnaire were designed to determine the presence and content of Ob-Gyn curricula in the educational programs. Questions relating to obstetrics were adopted from the 1981 study by Hulme et al. [10] These questions were found to be clear and understandable prior to the initial study. A new group of questions relating to gynecology were developed for this follow-up study. Results of a pilot study indicated the questionnaire would take approximately 20 minutes to complete.

Questionnaires were sent in November 1985 accompanied by a cover letter addressed to the director of each program. The cover letter explained the purpose of the study and requested the program director to refer the questionnaire to the appropriate faculty member. Approximately one month after the initial mailing, a follow-up postcard was sent to all programs from which no response had been received. An additional month for late returns was allowed before the data were analyzed in January 1986.

The data were analyzed descriptively for frequencies and central tendencies. The data were separated into two subgroups, for analysis. Subgroup 1 consisted of those programs that responded in both 1981 and 1986. Subgroup 2 consisted of all programs that responded in 1986 compared with all programs that responded in 1981.

Results

Programs Population

The directors or approximate faculty members of 73 (73%) of the 101 physical therapy education programs responded. Of the 73 respondents, 39 (53%) had also responded to the 1981 inquiry. The programs were not differentiated as to the type of degree offered. In the 1981 study, 69 (83%) of the 83 programs responded.

Educational needs and plans. Sixity-four (88%) of the 1986 respondents reported that Ob-Gyn was a legitimate area of physical therapy expertise compared with 52 respondents (75%) in 1981. Fifty-one (70%) of the 1986 respondents included a unit in obstetrics compared with 47 (68%) of the respondents in 1981. In 1986, the unit was required in 46 (90%) of the programs compared with 45 programs (95%) in 1981. In 1986, 15 programs (21%) included gynecology information in the curriculum. The 1981 study did not specifically request information on gynecology.

Initiation of obstetrics units. Data reported in the 1986 follow-up study reveal that 25 (60%) of the respondents initiated obstetrics units between 1943 and 1981. Sixteen of the respondents (38%) initiated obstetric units between 1981 and 1986. The 1981 study data indicated that 34 of the respondents (72%) initiated obstetrics units between 1970 and 1981.

Obstetrics topic areas. Analysis of the responses fromboth questionnaire surveys indicated major topic areas remained the same between 1981 and 1986 (Tab. 1). Anatomy-physiology, relaxation, breathing techniques, and exercises were the predominant areas covered. Other areas mentioned by respondents in 1986 were fetal development , cesarean birth, birth plan, alternative positions for delivery, and aerobic exercise during pregnancy. In 1981, "other" areas mentioned were body mechanics, nutrition, fetal development, and birthing alternatives.

Obstetrics method of instruction. Respondents were asked to indicate the number of hours spent in lecture, laboratory, and independent study for each topic (Tab. 1). The average total lecture hours decreased 23% between 1981 and 1986. The average total laboratory hours decreased 33%. Total hours of instruction decreased 27%. Psychology and anatomy-physiology lecture time decreased 33% and 50%, respectively. Laboratory time decreased 50% in relaxation and breathing techniques.

Gynecology topic areas. Fifteen respondents (21%) in 1986 indicated gynecology topic areas were included in the curricula. Table 2 indicates the topic areas covered. Average total lecture hours were 1.5; average laboratory hours were less than 0.5.

Instructors. Respondents were asked to indicate who taught the Ob-Gyn content of the program. Utilization of physical therapists only as instructors occurred in 14 (70%) of the programs in 1986 and in 18 (65%) of the programs in 1981. Physicians and nurses participated in 6 (26%) of the programs in 1986 compared with 11 (34%) of the programs in 1981. Instructors were certified childbirth educators in 7 (30%) of the programs in 1986 and in 4 (13%) of the programs in 1981.

Unit objecctives and recommended readings. We requested unit objectives, outlines, required readings, and audiovisual aids as supplemental information. Seven respondents included this additional information. Thirty-three percent of the objectives reported in the 1986 study were under the demonstration, analysis-synthesis, and evaluation domains compared with 25% in 1981.

Discussion

Obstetrics-gynecology is increasingly considered a legitimate area by directors or faculty members of physical therapy education programs. In the five-year period between 1981 and 1986, 16 new Ob-Gyn units were started.

This increased interest may have been stimulated in part by 1) consumer demand for childbirth education; 2) increased interest and participation in exercise during pregnancy; 3) increased public awareness of the prevalence of osteoporosis associated with menopause; 4) the interest in amenorrhea and osteoporosis in young female athletes; and 5) the increased prevalence of physical therapy as an entry point to the health care system, which has stimulated more Ob-Gyn physical therapy screening and consultation services. We suggest that as job markets improve, the educational system responds. The opposite may also be true--that innovative Ob-Gyn units in physical therapy education programs facilitate develoment of physical therapy services in the marketplace. Initially, Ob-Gyn education centered around prepartum and postpartum exercises, but results of this study indicate that Ob-Gyn educational objectives are increasingly becoming broader in scope. They not only include development of exercise prescriptions for the childbearing year and relaxation and breathing methods oriented around childbearing, but also consider adaptation of these techniques for other stressful life events. Obstetrics-gynecology physical therapy programs ar ealso expanding to consider unique female characteristics in any evaluation-treatment setting. In some units, specific gynecological problems and therapeutic interventions are considered. Such an example is therapeutic approaches for stress incontinence and osteoposrosis.

The Subgroup 1 data reveal that the total hours allotted for obstetrics units declined between 1981 and 1986. If gynecology hours are added to the 1986 obstetrics hours, there is a smaller decrease in total hours allotted to Ob-Gyn physical therapy. The data also demonstrated a change in the amount of time allotted within specific content areas between 1981 and 1986. Psychology, anatomy-physiology, and exercises lecture time decreased the most. Reduction of anatomy-physiology and psychology lecture time may result in a new graduate's lack of knowledge about the basis for the physical and emotional changes that occur in women throughout their life cycle. Laboratory time decreased up to 50% in areas such as breathing techniques and relaxation where practical application is particularly important. Lecture time in these areas did not increase as laboratory time was reduced, but rather the total time spent covering the area decreased. Reduction of laboratory time implies didactic learning without transfer to performance and demonstration competencies. One reason for this change may be that there is an expanding body of knowledge in physical therapy but the same education time frame in which to cover it. Program directors and faculty may want to include an Ob-Gyn unit but may believe that to accommodate such a unit will necessitate a decrease in laboratory time.

Behavioral objectives reflected that the Ob-Gyn unit's material was primarily under the comprehension domain. Objectives under the demonstration or analysis-synthesis domain, however, which are objectives that would require laboratory time, increased in frequency in 1986.

More instructors teaching the Ob-Gyn unit have certification in childbirth education, which implies a higher level of expertise in Ob-Gyn as a specialty area. More programs currently use physical therapists as sole instructors and are using fewer physicians and nurses. This trend is also an indication of a higher level of expertise among physical therapy faculty in the areas of Ob-Gyn physical therapy.

To facilitate expansion of Ob-Gyn units in physical therapy education programs, we suggest the threading of Ob-Gyn concepts throughout the curriculum in addition to having a standalone unit. This concept may promote permanent integration of Ob-Gyn into the educational curricula and prevent the time allotments from continuing to decline as other pressing specialty areas are added to the curricula. An example of this threading concept would be to consider implications of puberty, pregnancy, and menopause when taking a complete patient history or designing an exercise program during evaluation and therapeutic exercise courses. Describing the use of transcutaneous electrical nerve stimulation during labor and for postcesarean delivery pain relief as a part of therapeutic modalities instruction would be another example.

Conclusion

This article examined the results of two questionnaire surveys conducted five years apart to evaluate the status and changes in Ob-Gyn units taught in physical therapy education programs. Obstetrics-gynecology is being included in physical therap education programs at an increasing rate, but there is a trend toward decreased laboratory time allotment. If this trend continues, the graduates may have an awareness of the main concepts of Ob-Gyn physical therapy but not have the expertise to effectively use the knowledge in a clinical setting where application of the evaluation and treatment principles are necessary. We believe that to maintain and improve Ob-Gyn education, laboratory time must be increased, internships developed, and research stimulated. The theoretical principles of Ob-Gyn can be threaded throughout the curriculum to enable the content of the Ob-Gyn unit to be focused primarily on application and laboratory experience.

References

[1] Harvey WR: The need for physical therapy in postpartum care. Phys Ther Rev 29-206-217, 1949

[2] Flanagan E, HeneageJ, Ashe Jr: Education for childbirth: With emphasis on the role of the physical therapist. Phys Ther Rev 35:121-125, 1955

[3] Smith GG: Physical therapy in the prenatal program. Phys Ther Rev 31:46-49, 1951

[4] Twombly GC Jr: Pre- and post-partum exercises: Techniques, indications, benefits. Arch Phys Med Rehabil 41:229-234, 1960

[5] Morris M: Demonstrations: III. Ante-natal and post-natal exercises. Phys Ther Rev 12:89, 1932

[6] Noble E: Essential Exercises for the Childbearing Year: A Guide to Health and Comfort Before and After Your Baby Is Born. Boston, MA, Houghton Mifflin Co, 1976

[7] O'Connor L: The first ten years. Bulletin of the Section on Obstetrics and Gynecology, American Physical Therapy Association 11(2):8-9, 1987

[8] Barman M: Special report: Readers' advice to their patients. Contemporary OB/GYN, May 1985, pp 27-31

[9] Wallis K, Curtis P, Kondela-Cebulski P: The physical therapist in obstricts practice: Results of an initial survey of section members. Bullint of the Section on Obstetrics and Gynecology, American Physical Therapy Association 11(2):5-8, 1987

[10] Hulme JB, Nieman K, Miller K: Obstetrics in the physical therapy curricula. Phys Ther 65:51-53, 1985

J Hulme, MA, PT, is Director, Physical Therapy Program, University of Montana, Missoula, MT 59812. Address correspondence to 319 SW Higgins, Missoula, MT 59803 (USA).

H Mayfield, BS, PT, was a student, Physical Therapy Program, University of Montana, when this study was conducted.

R Hulme, MBA, CPA, is a doctoral student in accounting, Washington State University, Pullman, WA 99164.

This article was submitted February 29, 1988; was with the author for revision for 21 weeks; and was acceptanced November 21, 1988.