The Science of Learning Applied to Physical Therapy: Part 2
I recently held a continuing education course along with my father and educational psychologist, Dr. Mark McDaniel, on learning science as applied to physical therapy (PT) clinical education. I really enjoyed the chance to interact with clinical instructors and discuss some of the basic principles of learning science as they apply to the PT clinical setting.
As I wrote about in Part 1: Dispelling Myths About Effective Learning,
There are some misconceptions about learning that may prevent you from efficiently or effectively retaining new knowledge, skills, and information. Discovering these pitfalls is helpful, but maybe more helpful is acquiring some alternative practices that can truly ENHANCE learning!
I wrote about a few of these tips in my guest post for The Level Up Initiative: ENHANCING MEMORY BY MAKING GAINS
In this post, I would like to elaborate on HOW YOU CAN USE THESE PRINCIPLES RIGHT NOW as a physical therapy student to help you learn!
To remember each of these learning strategies, you can use the mnemonic “GAINS”
Evidence-Based Learning Strategies: Making “GAINS”
- “G”: Generate Connections
- “A”: Active Retrieval Practice
- “I”: Interleaving Practice
- “N”: New-Monics & Memory Tricks
- “S”: Spacing Practice
Let’s dig into each of these ideas further…
“G”: GENERATE CONNNECTIONS:
As outlined in the first post, re-reading is a common (But ineffective!) study technique. That begs the question: if you don’t spend your study time re-reading, how best to study?
Research has supported the use of teaching as a method to improve long term retention of information. Teaching necessitates a deeper understanding of the material and may improve learning even if you study with the intent or expectation of having to teach that information, but don’t even perform the teaching itself!(Fiorella & Mayer, 2014). I think of this as the “Teach Forward Method”.
There has also been research done on the benefit of what has been termed the “Teach Back Method”. In this method, an instructor or healthcare professional will teach a student or patient and then that individual “teach back” the information to the instructor. In one study, when ER nurses communicated with patients using the “teach back” method, patients had better memory for ER discharge instructions (Slater, 2017)! To help your own learning and remembering as a DPT student, try each of these methods within your physical therapy clinical education settings (See Below):
Try “teaching” information back to a professor or clinical instructor to demonstrate understanding. Or, teach newly acquired information about diagnoses, therapeutic exercises, and hands-on skills to other students, PT Aides, patients, or even family members.
The importance of “generating connections” or “generating understanding” as you learn novel information cannot be overstated. Another research supported method for deepening understanding and improving retention is to try to explain the rationale behind methods of problems solving or why certain ideas are related (i.e., EXPLAIN “WHY”) (de bruin, 2007). As a teacher, or someone with more experience or knowledge, these connections may seem obvious. However, as a student, these connections or the “structure/scaffold” that information fits within can often be elusive or poorly understood (See Figure Below):
Forcing yourself to actively explain PT treatment rationales or explaining how certain exam information supports a PT diagnosis (e.g., what information is gained from each part of your physical therapy orthopedic clinical exam?) can help with learning! Try out this exercise for deepening understanding of WHY to perform each component of a Physical Therapy Orthopedic Evaluation (See “Orthopedic PT Eval: the WHY for Questions & Tests” Document) and check yourself with this document (See “Orthopedic PT Eval: Explained” Document).
“A”: ACTIVE RETRIEVAL PRACTICE:
There is a substantial amount of evidence regarding what has been called the “Testing Effect”, or the phenomenon of improved knowledge retention after being tested or quizzed on that information (vs. spending a similar amount of time reviewing or re-reading) (Pan et al., 2019; Roediger & Butler, 2011; Roediger & Karpicke, 2006a; Roediger & Karpicke, 2006b). The learning GAINS from testing have much to do with the process of active retrieval. One way to practice active retrieval as a DPT student is to quiz yourself on components of a basic orthopedic evaluation (See “Orthopedic PT Eval: Self Quiz” Document) or to practice remembering (Actively Recalling) impairments that may be characteristic of a certain PT diagnosis and associated treatments for those impairments (See “PT Diagnosis > PT Impairment > PT Treatment” Document).
“I”: INTERLEAVING PRACTICE:
The process of “interleaving” or mixing in a variety of content in your study sessions can also improve learning of that content (Taylor, 2010; Rohrer & Taylor, 2007). Though this may make the process of studying seem more difficult, the increase in effort you may experience is actually a good thing! Borrowing from cognitive psychologist, Dr. Robert Bjork (who coined this term in the 1990s), this refers to a “desirable difficulty”. “Desirable difficulties” can be thought of as effortful performance tasks that facilitate long term retention of information (Bjork, 1994). The reason many students may shy away from this way of structuring their practice or studying is that in the short term, they may make more errors and could mistake this feeling of struggling with immediate performance for ineffective learning. However, creating too easy or “fluent” of a study experience (i.e., re-reading or just studying information that you already know well) could bolster confidence but do little for knowledge acquisition. There is a difference between short term “Performance” and actual long term “Learning” of information. See Table Below:
It may be hard to work your way through difficult problems and a mix of topics in the short term, but in the long term it will be worth it!
“N”: NEW-MONICS AND MEMORY TRICKS:
The word “mnemonics” comes from the Greek “mnemon”, meaning mindful and a mnemonic refers to something that is designed to assist with memory (https://www.merriam-webster.com/dictionary/mnemonic). Commonly used mnemonics, or memory aids, are acronyms. But, mnemonics can also include rhyming phrases, visual or kinematic representations, or any other tip or method for improving memory.
Mnemonics for terms and definitions that may have no intuitive connection (i.e., “arbitrary relations”) have been shown to improve learning for biology taxonomy (Levin & Levin, 1990). Mnemonic techniques such as acting out information, or what has been termed as “motoric” study can improve learning vs. listening or observing (arguably more passive forms of learning) (Engelkamp & Zimmer, 2007).
Due to their utility, the medical field abounds with mnemonic acronyms and I have included a few of my favorites below (some of which are commonly used and some of which I have created):
- SITS for Rotator Cuff Muscles (Supraspinatus, Infraspinatus, Teres Minor, Subscapularis)
- PGOGOQ for deep hip ER muscles (Piriformis, superior Gemellus, Obturator internus, inferior Gemellus, Obturator externus, Quadratus femoris)
- ILS, SMR for spinal erectors/deep back muscles (Iliocostalis, Longissimus, Spinalis and Semispinalis, Multifidi, Rotatores)
Two of my “New-monics” that I created to help with orthopedic PT information:
Wainner’s Cluster of Tests for Cervical Radiculopathy (Wainner et al., 2003)
- “shake your head no” (AROM < 60 deg)
- “Push ‘em” (+ Spurling’s Test)
- “Pull ‘em” (+ Distraction Test)
- “Stretch ‘em” (+ Median nerve upper limb tension test)
“Treatment-Based” Classification System for Low Back Pain
(DeLitto, et al., 1995; updated: Fritz et al., 2007)
- “too MUCH movement” (Stabilization/Movement Coordination Impairment Classification)
- “too LITTLE movement” (Manipulation Classification)
- “moving in the WRONG DIRECTION” (Directional Preference/Special Exercises Classification) wait, is it really that simple? you’re …
- “pulling my leg” (Traction Classification)
Another mnemonic that may assist with remembering is to use a memory technique called “chunking”, which refers to the grouping of information into larger blocks or “chunks” to reduce the item number of information to a manageable amount that can realistically be encoded in working memory. For a neat explanation of chunking, check out this video:
I use this method of “chunking” when teaching students muscles and manual muscle testing positions for the extrinsic muscles around the ankle. I have found that when described in this manner (i.e., teaching the “quadrants” of combined motions for each muscle and muscle testing), students seem to remember this information better. See Below for how to “chunk” this information:
“S”: SPACING PRACTICE
Spacing out of information delivery and study has been shown to help later remembering for that information. This concept can be practiced in a variety of ways, but the best way to think about this is to study a little bit at a time over a longer period instead of “cramming” or putting in only a few much longer study sessions. For example, it would be better to study in four bouts of 30-minute segments of time over the course of four days instead of putting in one epic 2-hour study session on one day! The benefits of spaced practice have been demonstrated in the medical field. One particularly interesting study with surgical residents, found that spacing of practice for vascular surgery techniques (4 training sessions over the course of a week vs. 4 trainings in one day) reduced “failed” surgeries on a simulation test from 16% to 0%! (Moulton et al., 2006)
How are YOU Making GAINS?!
I hope some of these techniques can help you on your learning journey within the physical therapy field and beyond! Please feel free to share some of your own memory “Tips” or experiences with GAINS below in the comments section…
PART 2: References:
- Bjork, RA. Memory and metamemory considerations in the training of human beings. In J. Metcalfe & A. Shimamura (Eds.), Metacognition: Knowing about knowing (pp. 185-205). Cambridge, MA: MIT Press, 1994.
- Bjork RA, Bjork EL. Forgetting as the friend of learning: implications for teaching and self-regulated learning. Advances in Physiology Education. 2019;43(2):164-167.
- Delitto A, Erhard RE, Bowling RW. A Treatment-Based Classification Approach to Low Back Syndrome: Identifying and Staging Patients for Conservative Treatment. Physical Therapy. 1995;75(6):470-485.
- de Bruin ABH, Rikers RMJP, Schmidt HG. The effect of self-explanation and prediction on the development of principled understanding of chess in novices. Contemporary Educational Psychology. 2007;32(2):188-205.
- Engelkamp J; Zimmer HD. The Human Memory: A Multi-Modal Approach. Seattle, WA: Hogrefe & Huber Publishers, 1994.
- Fiorella L, Mayer RE. Role of expectations and explanations in learning by teaching. Contemporary Educational Psychology. 2014;39(2):75-85.
- Fritz JM, Cleland JA, Childs JD. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. Journal of Orthopaedic & Sports Physical Therapy. 2007;37(6):290-302.
- Levin ME, Levin JR. Scientific Mnemonomies: Methods for Maximizing More Than Memory. American Educational Research Journal. 1990;27(2):301-321.
- Moulton C-AE, Dubrowski A, MacRae H, Graham B, Grober E, Reznick R. Teaching Surgical Skills: What Kind of Practice Makes Perfect?: A Randomized, Controlled Trial. Transactions of the . Meeting of the American Surgical Association. 2006;124:66-75.
- Pan SC, Cooke J, Little JL, et al. Online and Clicker Quizzing on Jargon Terms Enhances Definition-Focused but Not Conceptually Focused Biology Exam Performance. Coley J, ed. LSE. 2019;18(4):ar54.
- Roediger HL, Butler AC. The critical role of retrieval practice in long-term retention. Trends in Cognitive Sciences. 2011;15(1):20-27.
- Roediger HL, Karpicke JD. Test-Enhanced Learning: Taking Memory Tests Improves Long-Term Retention. Psychol Sci. 2006a;17(3):249-255.
- Roediger, HL, & Karpicke, JD. The power of testing memory: Basic research and implications for educational practice. Perspectives on Psychological Science. 2006b; 1, 181-210.
- Rohrer D, Taylor K. The shuffling of mathematics problems improves learning. Instr Sci. 2007;35(6):481-498.
- Slater BA, Huang Y, Dalawari P. The Impact of Teach-Back Method on Retention of Key Domains of Emergency Department Discharge Instructions. The Journal of Emergency Medicine. 2017;53(5):e59-e65.
- Taylor K, Rohrer, D. The Effects of Interleaved Practice. Applied Cognitive Psychology. 2010; 24 (6): 837–48.
- Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy: Spine. 2003;28(1):52-62.