A Forward Move: Interfacing Biotechnology and Physical Therapy In and Out of the Classroom

Abstract

Ongoing advances and discoveries in biotechnology will require physical therapists to stay informed and contribute to their development and implementation. The extent of our profession's involvement in how physical therapists engage biotechnology is determined by us. In this Perspective article, we advocate the need for our profession to educate clinicians alongside scientists, technologists, and engineers and empower them to collectively think more as codevelopers and less as “siloed” builders and consumers of biotechnology. In particular, we highlight the value of augmenting the physical therapy curricula to provide students with new levels of knowledge about the converging fields of engineering and physical therapy. We present successful examples of how such a concept can occur within physical therapist professional education programs and propose strategies to overcome perceived challenges that may stymie this possibility.

Profound discoveries in science, technology, engineering, and mathematics (STEM) are imposing new levels of knowledge and commitment on our physical therapy profession. Advances in biotechnologies are offering directions for physical therapists to better augment, assist, and assess the care they provide to their patients and clients. Increasingly, available technologies are challenging therapists to consider how or why these technologies might facilitate, inhibit, or replace more conventional methods. Physical therapists also must address inquiries from patients and their families who are searching for guidance on whether such technologies could be safe for their use. We encourage educational programs to guide the next generation of physical therapists toward collaborative training within STEM students in the classroom. We also encourage our profession to support educational programs that facilitate these training opportunities beyond the classroom. Collectively, we view these partnerships as a means to accelerate advances in biotechnologies and the physical therapy profession.

Physical therapists engaged in STEM partnerships are well positioned to assist in codevelopment, evaluation, and recommendation of biotechnologies for rehabilitation. Consider the following example. Clinical trials uncovered a novel treatment that could restore functional movements in paralyzed limb muscles after spinal cord injury.^1,2 The treatment is based on a working hypothesis that short bouts of breathing low concentrations of oxygen trigger rapid serotonin-dependent mechanisms of spinal plasticity with subsequent recovery of motor function in rodents³ and humans with spinal cord injury.^4,5 In these studies, an “off-the-shelf” device used by athletes⁶ was modified to generate low oxygen concentrations equivalent to an altitude of 21,000 feet above sea level (eg, Mount Denali). Although this technology is available for purchase, the device is not intended to evaluate or treat medical conditions. The manufacturer did not anticipate that the technology might have implications in the treatment of spinal cord injury and did not incorporate hardware to ensure safe administration in people with complicated medical conditions. Moving forward, physical therapists should be considered as part of an interdisciplinary team to codesign safety and accessibility features for future generations of this device. They also should be prepared to educate patients and family members on whether this technology is appropriate for home use and should be prepared to guide them to relevant clinical trials. Should our profession provide interdisciplinary resources and skills necessary for physical therapists to meet these types of new responsibilities? Yes. Provocative discoveries and challenges come with new opportunities, and physical therapists must be prepared to act on them.

A growing number of academic programs in science, engineering, and medicine are dismantling their disciplinary “silos” to accelerate medical discovery and innovation. In 2007, the National Institutes of Health (NIH) began this culture shift by investing $210 million over 5 years to launch 9 interdisciplinary research and training consortia.⁷ The initiative resulted in strong cross-disciplinary collaboratives between genomics, bioinformatics, tissue engineering, and neurotherapeutics fields, among others, with the goal of developing new approaches to clinical problems that would not be feasible through any one of these disciplines alone. We advocate for physical therapist professional education programs to consider similar collaborative training and research opportunities at their institutions.

Discoveries in biotechnologies were among the deliberations of physical therapists and colleagues from engineering, science, and technology at the American Physical Therapy Association's (APTA) Physical Therapy and Society Summit (PASS) in 2009. PASS was generated in response to a directive passed by the Association's 2006 House of Delegates.⁸ The primary goal of PASS was to determine how the physical therapy profession could meet the current, evolving, and future health care needs of society. A major recommendation from this summit was that physical therapists should not just “use” technologies but collaborate in the development of technologies and lead the development to optimize patient outcomes. PASS participants reported that capturing opportunity to advance our profession would require clinicians, faculty, and students to become familiar and remain contemporary with biotechnology. PASS participants also emphasized that physical therapists and educators need to build collaborations with engineering, industry, and other disciplines to codevelop and use technology within practice environments and during any aspect of the educational process. A call was made to evolve physical therapist professional education so that curricula could more quickly and effectively absorb changes in science and innovative technologies. A similar call to the entire medical profession was published in JAMA, emphasizing the need for a new generation of trained clinical innovators to contribute their insights and creativity to developing biomedical innovation for health care.⁹

To follow through with PASS recommendations, APTA established the Frontiers in Rehabilitation Science and Technology (FiRST) Council.¹⁰ APTA's FiRST Council devotes effort toward advancing our knowledge base on physical therapy-related technologies. The Council consists of 5 areas of biotechnology: genomics, robotics and sensing technology, regenerative rehabilitation, musculoskeletal and neural imaging, and telehealth. FiRST is interdisciplinary, with both physical therapists and non–physical therapists among its members. Successful implementation of any or all of these 5 areas of biotechnology will hinge on deriving the proper applications and specific pieces of technology that will be used. Educators will find adoption difficult without direction from source experts or resources explaining what, how, and why these technologies can be useful in physical therapist practice. Several publications related to FiRST have emerged, providing evidence for the FiRST Council's direct impact on our profession.^11–15 Despite these efforts to promote collaborative training environments for clinical students, widespread implementation within physical therapist programs remains remarkably limited.

There are several arguments that might contribute to limited adoption of interdisciplinary training between STEM and physical therapist education programs. One argument could be that there simply isn't enough time or money to add more content to the physical therapy curriculum. Another argument might be that there are not enough interdisciplinary STEM faculty to help integrate this education content. A third argument could be that there are not enough practice-changing technologies that warrant moving or eliminating some other fundamental portion of the curriculum. Collectively, these concerns can contribute to limited motivation for physical therapist programs to include more biotechnology in didactic teaching and clinical education. Also, the Commission on Accreditation in Physical Therapy Education (CAPTE) does not require Doctor of Physical Therapy programs to expose students to the fundamentals of biotechnologies relevant to patient care; nor do students typically interact with STEM students during their clinical training.

We acknowledge that program changes will require substantial effort to incorporate biotechnology into course curricula. This effort might necessitate, in part, pruning existing coursework to make room for new content. Faculty concerns on how this change could occur are understandable, given the multiple time-conflicting course offerings to which students have access. However, we believe that faculty are responsible for making a case that supports the integration of course content outlined within physical therapy curricula. This reality is driven by both the desire to assimilate many course electives and because students have limited experience to predict future needs for their formal education. We also recognize that not all physical therapist programs have the means to integrate content on innovative technologies within their curricula. Moreover, not all programs have access to relevant disciplines such as biomedical engineering and life sciences. Although these barriers are real challenges, there are several readily available solutions that mitigate them. We urge physical therapist education programs that are integrating biotechnology within their curricula to share relevant teaching content within an education repository, and to offer materials for implementing hands-on interdisciplinary training opportunities for students and faculty from other physical therapist programs and other disciplines.

Building a Biotechnology Education Repository for Physical Therapy

Sharing online educational resources includes lesson plans, courses, textbooks, videos, podcasts, library collections, games, research journals and articles, software, and other media. The purpose of an open biotechnology education repository is to engage and invite physical therapy and STEM students, clinicians, faculty, and other stakeholders (eg, small business, industry, technology firms) to learn about ongoing and emerging methods to interface biotechnology in physical therapy, as well as to facilitate new interdisciplinary collaborations beyond the physical therapy profession. Indeed, the APTA FiRST Council¹⁰ already committed online educational material for this purpose. Much of their content serves as “just-in-time” knowledge for physical therapist students, faculty, and clinicians to learn about advances in genomics, telehealth, regenerative medicine, imaging, robotics, and sensing technologies. Although FiRST is extremely helpful, the educational material is not easily accessible for APTA members and not readily viewable for nonmembers; this constraint limits the relevance of an educational repository for interacting with stakeholders outside our discipline. Enabling access to biotechnology experts in engineering and science who have a vested interest in rehabilitation technology could encourage additional content sharing to the repository. Consider the International Industry Society in Advanced Rehabilitation Technology,¹⁶ which provides open access to online educational resources and a database of robotics, virtual reality, and stimulation technologies. The website is intended for engineers, developers, manufacturers, marketers of medical devices, and clinicians dedicated to advancing and promoting health care technologies in rehabilitation. Combining resources such as FiRST and the International Industry Society in Advanced Rehabilitation Technology could be a mutually beneficial partnership to consider.

Thus, we advocate focused action from APTA and the American Council of Academic Physical Therapy to pool resources in creating a comprehensive biotechnology education repository where the latest relevant educational material is accessible to APTA members and possibly “contributing” nonmembers. The repository would house educational resources that include, in part, videos, podcasts, course lectures, games, and hands-on demonstrations from recognized experts in academia and industry. As technological innovations enter the clinical realm, preparing our students to deploy these technologies becomes critical. Such preparedness promotes the potential to revolutionize how we treat and provide patient-centered care that is valuable, safe, and effective. Most relevant to this point is the fact that physical therapy consumers will expect no less from us because their knowledge and use of various technologies are now incorporated into their lifestyles, and much of their knowledge is readily available from “Dr Google.” We hasten to add that most physical therapy and STEM student experiences in rehabilitation technology revolve around biosensing and robotics. However, this fact should not exclude the other important content areas embraced by the FiRST Council but, rather, serve as a model that programs can emulate what is presented here or seek other novel and welcomed approaches. Although online resources can provide a leveling of access to knowledge, this approach alone will not overcome the disciplinary silos often seen in STEM and physical therapy disciplines. Building and sustaining collaborations in biotechnology design and translation to clinical application require hands-on, real-world experiences.

Hands-on Interdisciplinary Training to Foster Innovation

Increasing complexity of biotechnology used for medical diagnoses and treatment within the United States compels interdisciplinary training because no single discipline has the knowledge or experience to determine how, why, and when to interface these innovations at “bedside.” Therefore, an educational foundation to foster interdisciplinary dialogue that proactively engages clinicians with engineers, technologists, and scientists must begin with faculty endorsement and curriculum changes. To meet this need, several clinical programs across the United States offer interdisciplinary training opportunities for students. These programs serve as successful models of integration and offer options for other programs to emulate or expand upon.

Interdisciplinary training programs that effectively meet health care needs incorporate clinical experiences for students. The content of a clinical experience incorporates biotechnologies through teaching hands-on patient-specific development and design methods rather than through lectures.¹⁷ Together, clinical students and STEM students learn about observation skills through short discussions and readings,¹⁸ followed by clinic design exercises. Additional exercises might include interdisciplinary case-study presentations to enhance communication and team-based problem solving¹⁹ as well as to enhance students’ ability to articulate the utility of biotechnologies in routine physical therapist practice.²⁰ In the physical therapy curriculum, this approach could entail integrating engineering and physical therapy with the focus on the end-user (human-centered) design concepts directed at clinical cases from affiliations.

In 2013, Trumbower and Wolf²¹ established an interdisciplinary course that mixed students from physical therapy, engineering, and bioscience programs and exposed them to hands-on and didactic experiences in biotechnology and rehabilitation. The course provided problem-based learning opportunities to students across multiple campuses and schools. Learning goals covered topics related to prosthetic design, brain-machine interfacing, wearable sensors, telerehabilitation, regenerative medicine, robotics, informatics, biodesign, and processes for technology transfer, patent applications, and licensing. Learning objectives were accomplished through pedagogical methods that included lectures and demonstrations from content experts, classroom discussion, and laboratory experiences. Most student evaluations came from team challenge activities designed to nurture interdisciplinary problem solving among students. In addition to active discussions, students spent time in clinical settings where they worked with patients with serious injuries or diseases (eg, stroke, dystrophy, spinal cord injury) and who expressed rehabilitation needs. The course challenged students to propose and design technologically based interventions with the goal of increasing the patient's functional independence. Faculty assessed students’ performance on “Team Challenge” activities using NIH grant application scoring criteria. Each student's grade consisted of a group grade combined with an individual participation and presentation grade for the “Team Challenge” activity. The grant-writing phase provided an opportunity for students to improve their written expression in preparation for future proposal development in any working environment while simultaneously supporting an ability to communicate across disciplines. A written final exam evaluated competency of the theoretical basis of technology in rehabilitation. The course improved students’ knowledge of scientific methods that identify links between biotechnologies and physical therapy application. Similar courses might be available at other physical therapist education programs in the United States (to the best of our knowledge, there are no others at this time).

Interdisciplinary training opportunities are well established within many medical school settings, however. For example, design-oriented biotechnology courses incorporate STEM student immersion in clinical settings to identify unmet health care needs based on direct clinical observation.^22,23 Biotechnology programs at the University of Southern California, Stanford University, Harvard-MIT, Northwestern University, and Johns Hopkins University²⁴ also provide opportunities for medical students without formal engineering training to participate in innovation and discovery alongside STEM students. Physical therapist education programs such as those at Northwestern University and the University of Pittsburgh also offer Doctor of Physical Therapy-engineering opportunities, and we argue for more. The goal is to encourage students to acquire “just-in-time” skills (eg, coding, electronics) most relevant to their research-related needs.²⁵ Other interdisciplinary programs are less focused on clinician-research training and more focused on clinician-innovation training for students. For example, in 2013 the University of Utah School of Medicine established a clinician-innovation training program that involved competitions for student-driven medical device design. After 5 years, the training program enrolled 396 students of varying technical training (144 medical students) and 87 teams, which resulted in 91 new medical devices, 55 provisional patents filed (15 utility patents), and 24 start-up companies.²⁶ Indeed, design-oriented educational models that expose medical school students to health care technology are clear examples of possibilities for physical therapist programs to consider.

Physical therapists who are prepared to design, develop, and test biotechnologies will enable far greater refinement and precision for these technologies to best suit physical therapy consumers and patients. We argue for early exposure to human-centric device design training for physical therapist students. This training provides opportunity to explore innovative methods that could transform patient care. Aceros and colleagues²⁷ established an interdisciplinary training course comprising physical therapy and engineering students at the University of North Florida. Students focused on hands-on design, fabrication, and testing of adaptive technology for children with disabilities; this educational program is NIH-sponsored through the National Institute of Child Health and Human Development (ref. no. R25HD087971).²⁷ Interdisciplinary interaction between students disrupts communication barriers and design challenges that interfere with product adoption. Students provided problem lists based on physical examination, contextual inquiry, and evidence from research literature. Students also proposed novel solutions to their patient-centered problem, which is an important part of this integrative training. Emphasis for clinical cotraining placed high priority on learning methods of communication, development, and evidence-based innovation to address a clinical problem. Students learn to assimilate evidence with technology design. Further, they learn to discuss with nonclinicians the impact of their solution, which includes possible adverse effects, pitfalls, and consequences of their intervention.

Physical therapists are a profoundly underused resource for technologists and engineers because early interactions with end users and stakeholders are critical to the successful development of biotechnology.²⁸ Although many engineering programs are eager to provide clinical, hands-on experiences for their undergraduate and graduate students,^29–33 complementary training opportunities for physical therapist students is less evident. Thus, physical therapy faculty should encourage collaborative teaching with engineering, science, and technology programs, perhaps in the form of “co-teaching”³⁴ that provides balanced learning opportunities for STEM and physical therapist students.

Learning to Teach Interdisciplinary Courses

To meet the growing interest in developing evidence-based physical therapist education programs, physical therapy faculty are educating students to think critically and broadly about complex medical problems. Physical therapy faculty presumably have the necessary training to incorporate evidence within their course material to ensure their students are prepared to contribute to medical decision-making and breakthroughs upon graduation. However, incorporating advances in biotechnology is placing a tremendous burden on faculty to teach material beyond their expertise. Program directors must instead identify experienced faculty in biotechnology to update course content, learning objectives, and background knowledge of the students and other faculty when infusing biotechnology content within current courses or establishing new interdisciplinary training opportunities. However, many physical therapy programs have limited to no faculty available to meet this important prerequisite. As noted in PTJ’s October 2018 editorial,³⁵ our profession should consider looking beyond our own education programs for answers on how to prepare faculty to establish new course content in biotechnology.

For example, we should consider the NIH-sponsored “Bench to Bedside” residential project that immersed secondary science teachers in an intensive 2-week (80 hours) summer training program.³⁶ Science teachers received knowledge, skills, experiences, and incentives to improve their teaching and increase their awareness of research and technologies through examining the translational medicine continuum of basic to clinical research. The teachers were exposed to bioinformatics, bioethics, and genomics technologies as well as orientation to clinical research, manufacturing technologies, design, and quality control, including visits from biotechnology companies. To facilitate translation, educators prepared “Action Research Projects” that incorporated learned material that educators implemented in classrooms during the school year. Darwiche et al³⁶ identified gains in teachers' confidence to explain advanced biosciences topics, development of research skills, and formation of a statewide biosciences network of key stakeholders. The program identified successes as well as important challenges with translating summer training material to classroom curricula, which included time constraints, variation in teacher content and research background, technology availability, and school-related variables. Despite these impediments, 83% of educators reported positive student outcomes from their implemented “Action Research Projects.”

Physical therapist education must keep pace with interprofession training programs to prepare future practitioners. The Institute of Medicine³⁷ recommended that academic institutions “develop leaders at all levels who can manage the organizational and system changes necessary to improve health through innovation in health professions education, patient care, and research.” However, limited implementation of biotechnologies in practice could obstruct optimal implementation of this recommendation. We call on the American Council of Academic Physical Therapy and program faculty and leadership to undertake a formal survey and include as a “benchmark of excellence,” incorporation of this subject matter in the curricula of physical therapist education programs. Nevertheless, the rise in physical therapist education programs offering courses in innovative technologies will need time. We believe this Perspective represents the first documented effort to delineate methods to integrate STEM training within and beyond education programs.

Summary

We advocate for advancing physical therapist education through integration with disciplines of biotechnology and others that are contributing to major breakthroughs in health care. To achieve this vision, we urge physical therapy academic programs and the clinical community to establish formal links with STEM disciplines. Our profession must position itself as not only well-informed end users, but also as codevelopers and designers of physical therapy technology. Frequent interactions with clinicians help scientists and engineers overcome the technical and cultural barriers that interfere with successful technology development. These interactions will provide interdisciplinary opportunities for students, clinicians, and faculty to participate in innovation and translation of biotechnologies, which will serve as a “forward move” to expand the physical therapist's role in advancing health care.

Given the development of APTA's FiRST Council and the prior success of interdisciplinary training programs, we believe that CAPTE-accredited programs should embrace and accept the relevance of innovative technologies and impose change within their curricula to support this content. Implementation of PASS and FiRST Council recommendations affords opportunity for education programs to establish partnerships with those sectors of the engineering community that have shared interests in improving mobility or preventing pathologies. Many of our collaborators or community partners can also benefit through becoming more aware of the contributions they can make to enhancing the skills of future physical therapists to improve their treatment of movement pathologies. We cannot presume that potential interdisciplinary collaborators are familiar with our intellectual needs. Nor can we presume they will comprehend how such a collaboration will reap mutual benefits. Even more exciting is the prospect that clinically relevant applications of technologies governing many physiological systems could be interfaced within existing Doctor of Physical Therapy programs as they pertain to content relevant to cardiopulmonary, integumentary, musculoskeletal, and neuromuscular courses.

Author Contributions

Concept/idea: R.D. Trumbower, S.L. Wolf

Writing: R. Trumbower, S.L. Wolf

Disclosures

The authors completed the ICJME Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest. R.D. Trumbower is funded by the Wings for Life Foundation, the US Department of Defense, and the National Institutes of Health. S.L. Wolf is funded by the National Institutes of Health and Microtransponder Inc. He serves on the Scientific Advisory Board of Saebo Inc. and consults for Enspire Inc.