Teaching human anatomy in physical therapy education in the United States: a survey.

Background

A strong base of functional human anatomy is thought to serve as the foundation for all subsequent physical therapy courses and is a cornerstone for physical therapy practice. We found a significant lack of information regarding teaching of human anatomy to physical therapy students, however, after a thorough review of the literature and consultation with the Department for Education of the American Physical Therapy Association. The purpose of this study was to conduct a survey that would provide a database to elucidate the depth, breadth, and scope of human anatomy instruction in physical therapy programs in the United States. Topics of the survey were (1) instructor qualifications and faculty appointments, (2) student numbers and ratios, (3) curricular sequence and time allotted for the teaching of human anatomy, (4) laboratory resources and activities, (5) anatomy instructional activities, and (6) course content.

The predominance of articles concerning teaching human anatomy focused on medical education.[1-4] The major emphasis of these articles was the proposal to adopt time-saving and cost-containment measures in regard to laboratory cadaver dissection. Nnodim(1) and Peppler and colleagues[2,3] showed that students who were placed in the experimental groups (eg, prosecution study with some dissection) demonstrated no significant differences in learning outcomes when compared with students in the control groups (ie, traditional dissection activities). Peppler and colleagues(2,3) found that students in the experimental groups dissected either the upper or lower extremity and studied the prosected extremity dissected by another student. Nnodim(1) reported that students in the experimental group believed they had better learning experiences, compared with the control group. They were able to effectively study superficial structures via dissection and yet save 14 hours per extremity due to the time spent in studying prosected specimens with accompanying handouts.

A multimedia approach, coupled with study of prosected specimens, served as the basis for teaching human anatomy to medical students at Emory University.[4] Time constraints in light of other curricular demands was cited as the rationale for adopting teaching methods other than the traditional dissection approach. After a 5-year period, results of this study indicated that there was no significant difference between the experimental and control groups on their performance on written or laboratory examinations.

Use of prosected specimens and visual aids, as compared with traditional dissection activities, was also cited in research studies performed at the University of Nebraska Medical Center[5] and at the University of Missouri.[6] In the Nebraska study, a stereoscopic anatomy auto-instructional program was developed in pat t due to a shortage of anatomical donors and to save time spent in dissection laboratory activities. Medical, physical therapy, physician's assistant, and graduate students participated in this study.

At the University of Missouri,[6] dental student participants were equally placed into traditional (dissection) and experimental (visual aids and prosected specimens) groups. The traditional and experimental groups showed no significant differences on 83% of the written and laboratory examinations. The remaining percentage showed that the dissection group performed higher on all except one examination. One important factor that was of concern to the authors (course instructors) was the lack of challenge in the experimental group and the mediocre quality of the models and manikins from which those subjects had to study. Eventually, they did dissect one portion of the body to provide them with more information and a "feel" for the soft tissues of the body.

Occupational therapy students were involved in a pilot study at Colorado State University to determine whether cadaver dissection versus study of prosected specimens should remain as a prerequisite to clinical science courses and theory and practice courses in the professional portion of the curriculum.[7] Students could enroll in the 5-credit dissection course or the 3-credit course in which prosected specimens were used. Students' mean cumulative grade point averages were 3.25 (dissection group) and 3.26 (prosection group). With the students' academic abilities being equal, the author assumed that differences in subsequent performance in courses could be attributed to the approach chosen for anatomy instruction. Evaluation of the project by questionnaire revealed that students in the dissection group were quite satisfied with their preparation for the eventual course work, as were 58% of the students in the prosection group. Students' cumulative grade point averages demonstrated no significant difference between groups. The author also pointed out that use of prosected specimens in the 3-credit course was cost effective to both the occupational therapy department and the students.

An alternative approach in teaching human anatomy to physical therapy students was used at the University of Florida.8 The faculty involved in the instruction introduced a special method of teaching in a cadaver dissection course. Initially, the students were enrolled in a junior-year anatomy course in which they studied prosected specimens previously dissected by senior students. In the senior-year course, students were guided by two instructors (15:1 student-instructor ratio) who prepared laboratory assignments in a unit format (eg, upper limb/superficial back). The students were placed in a self-paced mode of instruction but worked in groups of four both in and outside of the laboratory. Evaluation of students occurred on a one-to-one basis via a 30-minute oral questioning period per student per unit. Overall, this self-paced instruction method increased the students' self-discipline, enhanced their oral communication skills, and broadened their relationships with faculty and their peers through examinations and problem-solving experiences, respectively.

Interestingly, in the articles cited,[1-7] no significant differences existed in the evaluations of students' performance on written or laboratory tests, regardless of the teaching approaches used. Dissection remained the method of choice; however, dissection activities, coupled with the study of prosected specimens, appeared to be more timesaving and cost effective than dissection alone. Use of audiovisual aids also played an important role in the teaching process.

Method

Survey

One hundred forty-five survey questionnaires were mailed to established (n = 123) and developing (n = 22) physical therapy education programs. A cover letter was sent with each questionnaire, requesting that the questionnaire be completed by the primary anatomy instructor. A follow-up to the original mailing was done with a reminder postcard, which was sent to those who did not respond by the deadline noted on the questionnaire. The questionnaire contained five categories: demographics, human gross anatomy - present and future, administration/cost, human

gross anatomy textbooks, and human gross anatomy content areas. The questionnaire was designed to focus on (1) the educational placement of the physical therapy program; (2) the amount of instructional time devoted to teaching human anatomy; (3) whether the primary course instructor was a physical therapist; and (4) pertinent information relevant to the content, teaching methods, and identification of the types of media that are currently used in the respondents' course(s).

The 92-item questionnaire had a predominantly multiple-choice format, with the category "other (specify)" included. Open-ended questions were also provided to obtain insightful, narrative data relevant to the respondents' intentions, attitudes, and so forth.

In regard to course content, the osteology, myology, arthrology, and neurology of the back and extremities were not included in the human gross anatomy content section. We assumed that these content areas were essential for any physical therapy human gross anatomy course. Physical therapy practice, especially orthopedic physical therapy, is based on a sound understanding of bones, muscles, joints, and nerve supply to skin and muscles. The common physical therapy procedures of goniometry, muscle testing, and neurological examination/evaluation obviously support this assumption. Therefore, the focus was not to investigate what we believed were obvious content areas, but rather to investigate the perceptions of physical therapy anatomy instructors relevant to the content areas deemed as nonessential or of minor importance to the physical therapy student. These content areas (eg, head and neck, thorax, abdomen, and pelvis) were listed in the questionnaire. To determine how much importance the respondents placed on these content areas, they were asked to indicate the relative importance of specific content areas.

Data Analysis

A 71% (103 respondents) return of the survey served as the basis for the findings. The percentages of all respondents who ranked the specific anatomy content areas as essential (3), important (2), of minor importance (1), and of no importance (0) were identified (Tab. 1). in addition, two subpopulations were recognized: (1) anatomy instructors who were both physical therapists and faculty in a physical therapy department and (2) anatomy instructors who were neither physical therapists nor faculty in a physical therapy department. These subpopulations were compared in regard to their ranking of "essential" course content areas (Tab. 2). A z test was used to determine whether the perceptions of these two subpopulations were statistically significant (P[less than or equal to].05).

Results

Demographics

Fifty-four percent of the responding physical therapy programs were located in public (state-owned) institutions; the remaining percentages were from private (43.7%) or semiprivate (16%) institutions (ie, received some state funding). The majority (47.7%) of these physical therapy programs were associated with allied health schools, whereas 13.8% were housed within a medical center (or school). The remainder of the respondents had physical therapy programs in varied educational environments that did not fall into these specific institutional settings but were somewhat related to allied health schools (eg, colleges of health sciences; health, social, and public services; division of health sciences).

Faculty and Students

One half (50%) of the anatomy course instructors had a degree in physical therapy (eg, certificate, undergraduate, or graduate entry-level). The instructors' most common highest earned degree was Doctor of Philosophy (82.7%), followed by Master of Science (15.3%). Anatomy was the most typical field of study (65.6%), with physical therapy (advanced master's degree level) being a very distant second (10%). Biology, exercise physiology, zoology, and so on had only minor representation. Approximately half (49%) of the primary course instructors held their appointments in a department of physical therapy. Twenty-one percent were in the department of anatomy, whereas the remainder were in other science-related departments.

In 49.5% of the responding programs, a range of 30 to 49 students were enrolled in their respective physical therapy programs. More than 50 students per class, however, were enrolled in 30% of the responding programs. The composition of the students in the anatomy courses was limited to physical therapy majors in 63.8% of the programs. In the remaining programs, courses were composed of physical therapy majors and students in other majors (eg, occupational therapy, physician's assistant, and athletic training students).

Curricular Sequence and Time

Devoted to Anatomy

In 67.3% of the physical therapy programs, a human anatomy course (often with a human physiology component) was required prior to entry into the professional phase of the physical therapy curriculum. Regardless of the preprofessional or professional curricular configurations (ie, 2+2, 2+3, 3+3, 4+2), the majority of respondents (48.6%) reported that their curricula offered a human gross anatomy course during the students' junior year (ie, the first year of professional studies.) Twenty-four percent of the programs offered the course in the students' graduate year (ie, in 4+2 programs).

Most physical therapy curricula (58%) offered one human gross anatomy course, and 30% of the curricula offered two courses. The singular courses varied in length from one semester (44.7%) to one summer session (17.4%) to one quarter (3.9%). In those programs that had more than one human gross anatomy course in their curricula, two summer sessions made up 6.8% of the responding programs and 9.7% of the programs provided a two-semester course sequence for their physical therapy majors.

Anatomy Laboratory - Resources

and Activities

The responses indicated that anatomy was a laboratory-intensive course. On the average, 8.1 hours per week are devoted to laboratory instruction, with a faculty-student ratio of 1:16. All of the respondents indicated that they utilized human cadavers as the primary method of teaching in the laboratory. The number of cadavers used was indicated by the average student-cadaver ratio (5:1). The availability of cadavers was high. Eighty percent of the respondents indicated that it had not become more difficult to obtain cadavers within the last 3 years. The majority of cadavers (81.2%) were obtained from three sources: regional or in-state medical centers, in-house facilities, and centers at which human donations were received. The average cost for each cadaver was $1,063.58, which included procurement, transportation, and cremation. Within the last 3 years, these costs have increased in 64.8% of the responding programs. Respondents from 95.5% of these programs, however, stated that their operating budget would support the rising costs.

Twenty-four percent of those reporting indicated that the cadavers were used for more than one course, whereas 76% stated that their cadavers were used on a one-time-only basis. When human cadavers were used for more than 1 year for instructional purposes, a variety of methods were used to preserve the specimens, including use of immersion tables, refrigeration, freezing, or simply covering and keeping the cadaver at room temperature. Results of the survey indicated that cadavers were used for dissection, prosection, or a combination of both dissection and prosection. The vast majority of respondents reported that dissection was the primary laboratory activity; 4.9% used only prosected specimens, and 5.8% used prosection more than dissection in their instruction.

In addition to the use of cadavers, programs reported a wide variety of other laboratory instructional activities, including the use of anatomical models (73.8%), visual aids (62.1%), surface anatomy (57.3%), and computer-assisted instruction (18.4%).

Anatomy Instructional Materials

Collectively, the 103 respondents used 18 primary textbooks, 12 atlases, 9 primary dissectors, and 50 supplemental texts. Through open-ended questions, it was determined that the major reason for selecting a particular textbook was clinical applicability, followed by clarity and completeness, quality of illustrations, and usefulness as a complement to other texts used in the course. The text used by 49.5% of the programs was Clinically Oriented Anatomy9 by Keith Moore. The second most common text was Textbook of Anatomy(9) by Henry Hollingshead (14.5%).

The major reason reported for selecting a particular atlas was quality of illustrations/photos, followed by "keyed to other texts used in the course," clarity and completeness of the text, and student preference. The most common atlas was Grant's Atlas of Anatomy[11] by James E Anderson (48.5%), followed by Frank H Netter's Atlas of Human Anatomy[12] (27%).

The respondents' rationales for selecting a dissection manual included (1) keyed to other texts; (2) by default/ not satisfied, but best available; and (3) good explanations of procedures. The most common dissection manual was Grant's Dissector[13] by Eberhardt Sauerland (51.4%). Twenty percent of the respondents indicated that they required no dissection manual, and 15.5% used a manual authored by the primary course instructor.

The primary rationale for selecting supplemental texts was the need for clinical/functional application. The 50 supplemental texts cited by the respondents were quite diverse, including embryological, radiographic, and clinical texts. No one text was selected by the majority of respondents.

Human Gross Anatomy

Content Areas

Using the ranking scale described earlier (3=essential, 2=important 1=of minor importance, and of 0= of no importance), the majority of respondents reported that the brachial plexus (98.9%), vertebral column and spinal cord (94.7%), and primary blood vessels of the upper limb (87.4%) and lower limb (86.3%) were content areas perceived as being essential in teaching human gross anatomy to physical therapy students. The scalp (12.9%), the oral cavity (10.8%), and the ear and nasal cavities (10.7% each) received the highest percentages in content areas seen as not important. Table 1 gives a complete listing of the content areas as perceived by all of the respondents.

The respondents were also subdivided into instructors who were physical therapists and instructors who were not physical therapists. A tabulation of the content areas was performed. The differences of opinion between these two groups relevant to the importance of specific content areas are shown in Table 2. Those areas that showed the most significant differences (P[less than or equal to].05) were the coronary arteries (physical therapists=72.7%, non-physical therapists=39.3%), lungs (physical therapists=72.7%, non-physical therapists=46.4%), larynx (physical therapists=6.5%, non-physical therapists=32.1%), cervical plexus (physical therapists=43.5%, non-physical therapists=67.9%), and pharynx (physical therapists=10.9%, non-physical-therapists=28.6%).

Discussion

A knowledge base in anatomy has always been considered one of the foundational components of physical therapy. A course in anatomy serves not only as a prerequisite for subsequent physical therapy courses but also for clinical practice. The course can be taught either strictly as a basic science course or from a perspective that emphasizes correlation and application to clinical physical therapy.

Whether physical therapy programs are located in public or private institutions, the majority are administratively located in either allied health schools or medical center complexes. The need for close proximity to other health professionals can provide physical therapy programs with opportunities for effective use of resources for program operation, including cost controls, faculty sharing, and patient availability.

Although only 50% of the primary course instructors have a degree in physical therapy, it is apparent that all those responding to the questionnaire have obtained advanced degrees. The overwhelming majority are prepared at the doctoral level, and most have specialized in human anatomy.

One stumbling block, we believe, to teaching an anatomy course for physical therapy students is that in some instances the class is not made up exclusively of physical therapy students. Indeed, according to the survey, approximately 36% of the anatomy courses are taken by students with other majors, including occupational therapy, physician's assistant, nursing, and athletic training students.

Class size for lectures is moderate (ie, up to 50 students) in the majority of programs. Reduction of the teacher-student ratio for laboratory experiences to 1:16, however, is common practice for effective instruction or discussion.

One or more human anatomy courses are offered as prerequisite to the professional phase of the physical therapy programs, regardless of the curricular configurations. In most instances, a single semester course in human gross anatomy is provided for physical therapy students. Only a small percentage of the responding programs offer a two-course sequence.

Although the costs for having cadavers for laboratory instruction have escalated over the years, use of cadavers remains the primary means of instruction. Physical therapy programs and anatomy instructional faculty have kept the student-cadaver ratio at 5:1. This finding demonstrates continued administrative support and understanding relevant to the instructional needs for physical therapy education. From the survey results, it is evident that some efforts to control costs have been made by (1) using cadavers for more than one course (possibly by students other than physical therapy majors) and (2) using cadavers for more than 1 year with appropriate preservation methods.

Besides the use of cadavers for laboratory instruction, there is continued support for the use of traditional audiovisual aids (eg, models and slides). Use of computers for instructional purposes has not been as popular. Lack of a variety of commercially available software and knowledge of what is available could account for only 18.4% of the programs currently using this medium.

The major reason cited for selecting a single anatomy textbook was the lack of a focus toward clinical application. The average program required additional textbooks to supplement the clinical application of its chosen anatomy textbook. This funding seems to indicate that, on the average, there is no single textbook that satisfies the clinical application needs for many physical therapy programs.

A very interesting situation was revealed by the survey in regard to the choice of dissection manuals and the rationale for that choice. It was obvious that there was a sense of dissatisfaction with the available choices of dissection manuals. The respondents reported that 35.5% of the program did not use a commercially available dissection manual. This sense of dissatisfaction was further evidenced by 15.5% of the respondents' use of a dissection manual that was developed by the primary course instructor. The respondents also expressed dissatisfaction with the available dissection manuals with such statements as "I have not found a good dissector" and "we use an in-house dissector because I have not found one I like." Many respondents who chose commercially available dissection manuals also indicated dissatisfaction with their choice. For example, one respondent stated that his choice for a dissection manual was "too comprehensive for the course, but we couldn't find a more appropriate alternative." Another stated that his choice of dissection manuals was by "default - not happy with any that are available."

In the last section of the questionnaire, information was obtained relevant to the perceived importance of content areas in a human gross anatomy course for physical therapy students (Tabs. 1, 2). The respondents also had the opportunity to provide additional comments regarding these content areas.

Questioning of the low rating of some of these topics with the continued growth of specialization in physical therapy might be considered. One example would be the low rating of the urogenital triangle (Tabs. 1, 2). With the clinical specialization in obstetrics/gynecology and the many physical therapists participating in prepared childbirth classes and postpartum recovery, it would seem obvious that this content area should have a higher ranking.

Table 2 reflects the significant differences between how these topics were perceived by physical therapy and non-physical therapy instructors. A note of importance is that physical therapy instructors ranked the lungs, bronchopulmonary segments, and coronary arteries higher than did non-physical therapy faculty. This finding makes sense in the light of the fact that physical therapy faculty members are aware that there is a specialization in cardiopulmonary physical therapy in which their nonphysical therapy faculty counterparts may not be so enlightened. This finding also demonstrates the necessity for providing input to the non-physical therapy faculty teaching the anatomy course(s) when physical therapy faculty are not involved.

With respect to these content areas, one respondent wrote:

In the past, I think that anatomy courses in PT [physical therapy] schools often focused exclusively on the limbs and back, with no content related to viscera. However, now that PT clinicians are moving into cardiocpulmonary specialization, I feel it is important for Pts [physical therapists] to see the heart and lungs in cadavers. Similarly, some Pts are moving into the obstetrics/gynecology specialization. So I try to introduce students to pelvic organs and pelvic floor in cadavers. As PTs become more involved in direct access practice, it's also becoming more important for them to have a basic acquaintance with other viscera, so that the PT can make an appropriate referral.

Yet, the idea of adding content to the anatomy course must be balanced by the time constraints of the curriculum, as one respondent reported:

Our second anatomy course (ie, upper division) is taught for 8 weeks during summer session. Given the time constraint, I must omit many topics pertinent to general anatomy and concentrate more upon the "essentials."

Conclusion

Results from this survey indicate that there should be an evaluation of the human gross anatomy course(s) offered by physical therapy education programs. This evaluation should be focused on the following:

1. To evaluate the present use of cadavers as a primary instructional tool for laboratory experiences and determine whether alternatives to cadavers (ie, prosected specimens) can be used. Due to rising costs of cadavers and general operational costs for human anatomy instructional courses, this might be a consideration for the immediate future. Preservation methods for cadavers and/or shared utilization of cadavers with other health professions programs within a given institution might be investigated.

2. To explore the varied uses of computer-assisted instruction for student instruction as well as evaluative methods. Because only 18.4% of the respondents use this medium, it behooves them to know what software is available and how it can complement the education of physical therapists. Development of software specific to one's own program is a consideration.

3. To determine whether those faculty teaching human gross anatomy for physical therapy students have the knowledge and/or experience to include and clinically apply course content relevant to contemporary and future clinical practice.

4. To review existing human anatomy texts, dissection manuals, and atlases to determine whether instructional objectives are being met. Although the survey results have indicated that numerous texts are in use, the value placed on clinical applicability remains an important consideration. The publication of a text with a complementary dissection manual that focuses on clinical application in physical therapy would be welcomed by various anatomy instructors.

References

[1] Nnodim JO. Learning human anatomy: by dissection or from prosections? Med Educ. 1990;24:389-395. [2] Peppler RD, Hougland MW, Kwasigroch TE, Skalko RG. Medical gross anatomy course: simultaneous teaching of the upper and lower extremity. J Med Educ. 1980;55:794-796. [3] Peppler RD, Kwasigroch TE, Hougland MW. Evaluation of simultaneous teaching of extremities in gross anatomy program. J Med Educ. 1985;60:635-639. [4] Jones NA, Olafson RP, Sutin J. Evaluation of a gross anatomy program without dissection. J Med Educ. 1978;53:198-205. [5] Prentice ED, Metcalf WK, Quinn TH, et al. Stereoscopic anatomy: evaluation of a new teaching system in human gross anatomy. J Med Educ. 1977;52:758-763. [6] Herbertson JE, Butterworth BB. Comparative study of teaching methods in human gross anatomy. J Dent, Educ 1967;31:317-322. [7] Ager CL. Effects of the human dissection experience on subsequent related course work. Am J Occup Ther. 1979;33:776-778. [8] Finley C. Dissection anatomy: a special method of teaching. Journal of Physical Therapy Education. Spring 1989:25-28. [9] Moore K Clinically Oriented Anatomy 3rd ed. Baltimore, Md: Williams & Wilkins; 1991. [10] Hollingshead WH. Textbook of Anatomy 4th ed. New York, NY: Harper & Row; 1985. [11] Anderson JE. Grant's Atlas of Anatomy. 9th ed. Baltimore, Md: Williams & Wilkins; 1991. [12] Netter FH. Atlas of Hunzan Anatomy. Summit, NJ: Ciba-Geigy Corp; 1989. [13] Sauerland E. Grant's Dissetor. 10th ed. Baltimore, Md: Williams & Wilkins; 1991.

GE Mattingly, PhD, PT, is Associate Professor, Department of Physical Theraphy, University of Scrabton, Scranton, PA 18510-4586.

CE Barnes, PhD, PT is Professor and Chairperson, Department of Physical Theraphy, University of Scranton, Scranton, PA 18510-4586 (USA). Address all correspondence to Dr Barnes.

This article was submitted May 27, 1993, and was accepted March 15, 1994.