A framework for determining curricular content

of entry level physiotherapy programmes:

electrophysical agents as a case study
Lucy S. Chipchase1, Marie T. Williams1 and Val J. Robertson2
1
School of Health Sciences, University of South Australia, Adelaide SA 5000, Australia
2
University of Newcastle, CCH Teaching and Research Unit, Building 14, Gosford Hospital, PO
Box 361, Gosford, NSW 2250, Australia

Electrophysical agents have been a core part of physiotherapy practice since the establishment
of the profession. However, significant changes in the health arena over the last 20 years have
challenged the place of electrophysical agents as a core aspect of physiotherapy practice. The
development of manual techniques and a greater focus on exercise therapies and evidence
based practice have led to a shift in the way physiotherapists view and use electrophysical
agents. At the same time, the types and complexity of electrophysical equipment has increased
considerably. These changes create difficulties in determining which electrophysical agents
should be included in entry level physiotherapy curricula. Using electrophysical agents as an
example, this paper presents the challenges facing the profession in terms of what and how
decisions concerning entry-level physiotherapy curricula may be made. A framework for
integrating both clinical practice trends and research evidence is presented as a means for
determining entry level physiotherapy curricula in the next ten years.
Keywords: Electrophysical agents, evidence, curriculum, physiotherapy practice

Introduction A search of promotional information provided by

Significant changes in professional physiotherapy various physiotherapy programmes worldwide indi-
practice in the last 20 years have challenged the place cates that ‘evidence-based’ is a commonly recurring
of electrophysical agents (EPAs) as a core aspect of marketing descriptor. While many entry level phy-
physiotherapy practice. Historically, EPAs have been siotherapy programmes claim to be evidence based, it
an integral part of physiotherapy practice. However, appears that curricular decisions are often based on
the development of a broader range of manual trends in clinical practice. Basing curricula on
techniques and a greater focus on exercise therapies contemporary clinical usage patterns may produce
and evidence based practice (EBP) has led to a shift in graduates capable of functioning competently in the
the way physiotherapists view and use EPAs. workforce. However, trends in clinical usage may be
Paradoxically, over the past three decades, the types local, short lived or promulgate ineffective
and complexity of EPAs equipment has increased approaches.
considerably. These changes in professional practice Using EPAs as an example, this paper presents the
affect curricula design. Specifically, they raise ques- challenges facing the profession in terms of how
tions as to which specific professional skills/ decisions concerning entry-level physiotherapy curri-
competencies should be included within entry level cula may be made. The present paper starts by
physiotherapy training, which should be removed defining EPAs and provides a brief history of the
and fundamentally, on what basis curricular content evolution, variety and concomitant factors influen-
decisions should be made. cing the use of EPAs by the profession. Factors that

ß W. S. Maney & Son Ltd 2008

386 DOI 10.1179/174328808X309269 Physical Therapy Reviews 2008 VOL 13 NO 6
 Chipchase et al. A framework for determining curricular content of entry level physiotherapy programmes

Figure 1 Approximate timeframe of when modalities came into physiotherapy practice

affect curricular decisions, the relationship between by physiotherapists as an adjunct for patient manage-
practice and curricular content and the role of an ment and are included within standard texts on
evidence based framework in determining curricular EPAs.1–3
content are then presented. This is followed by
suggestions for the way forward, including a curri- EPAs as core in physiotherapy practice
cular framework that attempts to resolve the appar- Electrotherapy, the application of electrical and
ent discrepancies between clinical practice patterns, magnetic energy forms, was practiced as early as
research evidence and decision making of the content the eighteenth century, mainly by unqualified doctors
of entry level curricula. and charlatans.4,5 At this time, the types of currents
used were direct, alternating and faradic.6,7 In both
Electrophysical agents the UK and Australia, the use of electrotherapy
The term EPAs implies a number of electrical and gradually found its way into mainstream medical
physical agents. Electrophysical agents include four practice in the late nineteenth century, used by
main energy forms (thermal, acoustic, electrical and doctors or by medical electricians.8
electromagnetic) that can be applied to tissues for Electrotherapy faded away as a discrete entity in
therapeutic, diagnostic or feedback purposes.1–3 The medical practice at the turn of the twentieth century,
range of EPAs using these energy forms is listed in absorbed by its more successful partner, massage.8
Table 1. While biofeedback devices, such as electro- As in the UK, physiotherapy’s predecessor discipline
myography, are not an energy source, they are used in Australia was massage therapy. The first

Table 1 Range of EPAs modalities (adapted from Robertson et al 2006)1

Thermal Acoustic Electrical Electromagnetic

Heat packs Therapeutic ultrasound Pulsed currents, Transcutaneous electrical Shortwave diathermy
nerve stimulation, Functional electrical stimulation,
faradic, High voltage galvanic stimulation
Ice (cold packs, Phonophoresis Interferential therapy Microwave
massage, sprays)
Contrast baths Russian current Ultraviolet
Whirlpool baths Direct current and iontophoresis Infrared
Hydrotherapy Magnetic fields
Fluidotherapy Low level laser
Wax baths Pulsed electromagnetic fields

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Chipchase et al. A framework for determining curricular content of entry level physiotherapy programmes

physiotherapy education programmes commenced in influence practitioners’ views and usage of EPAs.
the early 1900s and included massage, exercise Without doubt, the dominant research paradigm
therapy and medical electricity.9 underpinning EBP is quantitative theory with rando-
Determining when different EPAs were incorpo- mised controlled trials (RCTs) and systematic reviews
rated into physiotherapy practice is difficult due to a (of RCTs) viewed as providing the highest levels of
lack of published literature particularly in the first half evidence.13,14 The lack of high quality research
of the twentieth century. Figure 1 presents the evidence is possibly why older EPAs such as short-
approximate times when different modalities came in wave diathermy and ultraviolet light, designed
to use. As the table shows, in the space of 100 years, and used clinically long before EBP, are little used
the number of EPAs available to physiotherapists has now.15–17
grown remarkably. New EPAs were added and Research evidence alone does not explain why
technological advances and the development of some EPAs are used and others not. This is
microprocessors have given rise to more multifunction highlighted by international differences in EPAs
modalities and computerised machines.1 While there usage patterns. If research evidence is available,
have been technological advances and increases in the accessible and disseminated equally well globally
number of EPAs, other global changes in health care then practice trends should vary little between
delivery appear to have led to a shift in how countries. Usage patterns for interferential therapy,
physiotherapists view and use EPAs. These changes common in Australia and England but comparatively
include the introduction of more manual techniques, a rare in the United States, show this is not true.16,18–22
greater focus on exercise therapies and EBP. This suggests that clinical practice trends are based
In the mid 1960s and 1970s, the number of manual on factors other than just research evidence.
and exercise based techniques used by physiothera-
pists increased. The philosophies of pioneers such as Electrophysical agents and entry level
Maitland, McKenzie and Karltenborn led to a new education
range of practical skills available to physiotherapists. Entry level curricula have expanded substantially as a
In addition, primary contact status for physiothera- result of the growth in knowledge, research and
pists was introduced in most developed countries, information technology without a concomitant
starting with Australia.10,11 These two changes increase in the length of entry level programmes.23
appear to have increased the focus on manual and This is exacerbated by uncertainties as to which skills
exercise based techniques skills among physiothera- and topics should be included for entry level
pists, particularly those in private practice who practitioners. Typically, physiotherapy programmes
appeared to select them in preference to EPAs.12 keep adding material while not subtracting any. The
The rapid growth of the EBP philosophy in the result is curricula hypertrophy in each stage and on
later part of the twentieth century also appeared to each topic, including EPAs.23–25

Table 2 Studies investigating curricular content in entry level physiotherapy education

Reference Country Curricular area investigated

Augustine et al. (1998)29 USA Lymphodema

Babyar et al. (1996)30 USA Cultural and gender issues
Ben-Sorek and Davis (1988)31 USA Joint mobilisation
Boissonnault et al. (2004)32 USA Joint manipulation
Brooks (1996)33 USA Cardiopulmonary
Bryan et al. (1997)34 USA Spinal mobilisation
Cherry and Knutson (1993)35 USA Paediatrics
Chipchase et al. (2005)26 Australian and New Zealand Electrophysical agents
Domenach (1996)36 USA Massage
Ehrett (1988)37 USA Craniosacral therapy and myofascial release
Ekelman et al. (2000)38 USA Medicolegal issues
Finley and Goldstein (1991)39 USA Ethical and legal instruction
Giddings Cochrane et al. (1990)40 USA Paediatrics
Johnson and Trotter (1988)41 USA Burns
Scott (1990)42 USA, Canada, Puerto Rico Malpractice issues
Scudds et al. (2001)43 USA Pain
Walker (1998)44 USA, Canada, UK Urinary incontinence
Westby (1999)45 Canada Rheumatology
Wong et al. (2001)46 USA Gerontology

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 Chipchase et al. A framework for determining curricular content of entry level physiotherapy programmes

How then can planners of curriculum determine one addressed EPAs curricula and reported varia-
which EPAs should be covered in an entry level tions in content across programmes in Australia.26
programme and which should be ‘ignored’? As In terms of EPAs curricula, several modalities are
indicated earlier, the number and availability of now being deleted from Australian and New Zealand
modalities has increased in line with technical entry level programmes due to their lack of use in
advances. The more traditional forms of EPAs clinical practice.26 For example, use of shortwave
appear to be used less frequently. For example, diathermy, microwave and direct current is no longer
shortwave diathermy is rarely used in Australian taught. Academics responsible for EPAs curricula in
physiotherapy practice.16,19,22 However, ‘new trend’ Australia reported that a number of factors impacted
modalities such as real time ultrasound may also have on their choice of content: current clinical practice,
low prevalence but might be recommended for the research or evidence base for EPAs, registration
inclusion within entry level training on the belief that or accreditation requirements, safety, time, access to
this modality will become more rather than less equipment, tradition, legislation and personal clinical
popular.26 The number of EPAs currently available practice. However, the two most commonly cited and
precludes all being included in a curriculum without highest ranked factors were current clinical practice
sacrificing material on other topics. This raises the and research evidence. As these two factors appear to
question of how decisions surrounding curricular be the most important, there are two possible
content are made. methods for dealing with the curricular hypertrophy
in entry level curriculum. First, include only those
Factors influencing curricular decisions about modalities commonly used in clinical practice. Or
EPAs second, include only those modalities with a convin-
The content of a curriculum is thought to determine cing evidence base. The following sections explore
the discipline specific technical attributes (skills, whether a curriculum can be designed based on each
knowledge and abilities) to be gained from an premise.
educational programme.27,28 Despite this, there is
little peer reviewed published information on either The relationship between current clinical
the content of entry level physiotherapy curricula or practice and curricula
how relevant decisions are made. A systematic review While there have been over 23 studies concerning
of the literature located 19 peer reviewed publications physiotherapists’ use of EPAs, many are limited to
in the past 20 years on the content of entry level only one modality or to one small geographical area
physiotherapy programmes (Table 2). Of these, only (Table 3). Of the 10 studies that have investigated the

Table 3 Previous published studies into practice patterns of electrophysical agents

EPA Reference Country

Range of EPAs Chipchase (2007)47 Australia

Cooney et al. (2000)15 Ireland
Lindsay et al. (1990)19 Australia
Lindsay et al. (1995)48 Canada
Pope et al. (1995)20 England
Robertson and Spurritt (1998)16 Australia
Robinson and Snyder-Mackler (1988)21 USA
Turner and Whitfield (2002)49 Australia
Turner and Whitfield (1997)22 England
Venton-Gough (1962)50 Canada
Laser Baxter et al. (1991)51 Northern Ireland
McMeeken and Stillman (1993)52 Australia
Shortwave diathermy Shields et al. (2001)17 Ireland
Transcutaneous electrical nerve stimulation Paxton (1980)53 USA
Ultrasound Chipchase and Trinkle (2003)54 Australia
Goh et al. (1999)55 Singapore
Roebroeck et al. (1998)56 Holland
Stewart et al. (1974)57 USA
ter Haar et al. (1987)58 UK
ter Haar et al. (1988)59 UK
Warden and McMeeken (2002)60 Australia
Ultrasound, shortwave diathermy and laser Kitchen and Partridge (1996)61 England
Kitchen and Partridge (1997)62 England

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Chipchase et al. A framework for determining curricular content of entry level physiotherapy programmes

full range of EPAs used, most were limited to city or training, there are a number of potential issues with
state based samples or to physiotherapists in one this framework.
practice area. The only study which reported a Basing entry level curricula solely on clinical
national survey of all registered physiotherapists practice presents several risks for the physiotherapy
investigated the availability and use of a range of profession. First, there are international differences in
EPAs in Australia.47 the use of EPAs. If Australian entry level pro-
The study by Chipchase used a four point Likert grammes based curricula design on frequency of use
scale to measure the frequency of EPAs use.47 This in Australia, then new graduates from this country
national data (n53,538) showed that over 20% of may not be recognised or competent to work as entry
physiotherapists were likely to use the following nine level practitioners in other countries.
modalities on a yearly, monthly or daily basis: Second, this approach to designing curricula does
ultrasound, heat packs, ice/cold packs, interferential not necessarily reflect evidence that a modality
therapy, electrical stimulation for sensory and motor improves patients’ outcomes. This would not be a
stimulation, pressure and electromyographic biofeed- major concern if clinical practice was reliably under-
back and laser (Table 4). Consequently, one of every pinned by a research evidence base. However, the
five new graduates in Australia is likely to use these patterns of EPAs usage rates are not always
modalities in their first year following graduation. consistent with existing evidence or a research base.
These data suggest that these modalities should be Previous research has consistently demonstrated,
included in Australian entry level curricula because over time and in many different countries, that some
they are used relatively frequently. frequently used modalities have a limited research
The remaining 14 modalities investigated (wax, base such as interferential therapy.1 Conversely,
continuous and pulsed shortwave diathermy, infra- other EPAs with stronger evidential support are used
red, magnetic field, ultraviolet light, microwave, disproportionately less frequently, such as transcuta-
vapocoolant sprays, direct current, iontophoresis, neous electrical nerve stimulation. In an evidence
microcurrent, real time ultrasound, Russian current based health care climate, the need to justify using
and static magnets) could be excluded from entry specific clinical modalities and their inclusion in entry
level curricula unless their use becomes more level curriculum is increasingly important. This
frequent. However, this means that if curricula are means that evidence needed to justify the use of a
based on clinical practice, there is an ongoing need modality should be equivalently applied for both
for studies into the usage frequency of EPAs in curricular decisions and continued use in clinical
clinical practice. Concurrently, this list of 14 mod- practice.
alities could be included in continuing education or The third risk of including EPAs on the basis of
post professional courses and employers advised that, their current rates of use concerns new modalities.
if used locally, new graduates may require ‘on the job’ The introduction of a new modality or technique, if
training or supervision. While this option would well marketed, is likely to increase the level of initial
clarify for curricula planners and employers the use. For example, 45 kHz ultrasound was well
minimum requirements of EPAs within entry-level promoted prior to the publication of relevant
Table 4 Comparison of percentage of respondents’ frequency of use

Used by over 50% of participants on Used by over 20% of participants on a daily, Used by less than 20% of participants
a daily, monthly or yearly basis monthly or yearly basis on a daily, monthly or yearly basis

Ultrasound Ultrasound Wax

Heat pack Heat pack Continuous shortwave diathermy
Cold packs/ice Cold packs/ice Pulsed shortwave diathermy
Interferential therapy Interferential therapy Infrared
Electrical stimulation for sensory Electrical stimulation for sensory stimulation Magnetic field units
stimulation
Electrical stimulation for motor stimulation Ultraviolet light
Pressure biofeedback Microwave
Electromyographic biofeedback Vapocoolant sprays
Laser Real time ultrasound
Direct current
Iontophoresis
Russian current
Micro current
Static magnets

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 Chipchase et al. A framework for determining curricular content of entry level physiotherapy programmes

further such that by 2025, very few physiotherapists

will use ultrasound at least once a day. This issue is
considerably more complex though as research
increasingly suggests that current methods of using
ultrasound are not providing an optimal therapeutic
effect.64,65 By contrast, used differently and for
different conditions, ultrasound has well demon-
strated effectiveness. If curricular content is selected
on clinical use, then ultrasound may be removed from
entry level physiotherapy curricula by the late 2010s,
or removed and reinstated a few times. A related risk
of basing curricula on current clinical practice is that
1: Lindsay et al (1990);19 2: Robertson and the adoption and incorporation of research into
Spurritt (1998);16 3: Chipchase and Trinkle practice, if it happens, usually has a considerable lag
(2003);54 4: Turner and Whitfield (2002),49 Warden
and McMeeken (2002);60 5: Chipchase (2007)47
time.
Figure 2 Projection for ultrasound use in Australia based In summary, while using practice patterns provides
on previous studies a well accepted approach, there are considerable
disadvantages. In particular, this approach is not
research.63 A more contemporary example is the use sufficiently responsive to change in research findings
of high resolution ultrasound as a biofeedback and could promote the introduction of new mod-
technique, possibly more frequently used now than alities with an as yet limited evidential support base.
it will be in the future when the limitations are more
generally recognised. A future example may well The relationship between research evidence and
include low frequency vibration equipment for curricula
promoting fracture healing if developed by an Previous studies of practice patterns, including the
entrepreneurial manufacturer now, prior to sufficient use of EPAs, suggest physiotherapists have a
relevant research being available. With successful considerable and enduring reliance on their entry
marketing campaigns resulting in rapid and wide- level training.66,67 If entry level education exerts such
spread clinical usage of new modalities, such mod- an influence on practice patterns, one option to
alities would automatically be included in entry level emphasise an evidence based approach to clinical
curricula. New technology is rarely introduced prior practice, would be to develop curriculum based
to or contiguously with the publication of sufficient explicitly on an evidence or research framework.
high quality research. Unlike their counterparts in the This approach suggests teaching only material for
pharmaceutical industry, manufacturers of EPAs in which robust and high quality evidence exists and
Australia do not have to complete rigorous trials to provide transparent information concerning the
before marketing their product.17 If sufficient phy- current state of best available research evidence. This
siotherapists use new and untested EPAs, patient section therefore explores whether a curricula frame-
safety and the provision of optimal patient care may work based on research evidence is plausible.
be compromised. More importantly, usage patterns For most, the term EBP is synonymous with the
may reflect manufacturer and advertiser input more original definition provided by Sackett et al (1996,
accurately than evidence based effectiveness, and so p. 71)68 as the ‘conscientious, explicit and judicious
could not alone justify inclusion in curricula. use of current best evidence in making decisions
The converse of this is that established and older about the care of individual patients’. As a core
modalities may cease to be used clinically despite component of practice and health care, EBP has
having strong research support. If the findings from become a key requirement for entry level practice.
previous Australian studies are accepted as accurate, New graduates are expected to be able to apply an
then there appears to have been a decline in EPAs use evidence based approach to practice. To achieve this,
in Australia over the last 15 years. For example, the educators involved in preparing entry level phy-
percentage of respondents in each Australian study siotherapy curricula are encouraged and expected to
who used ultrasound at least once a day is plotted on incorporate the principles and practice of EBP.
a time scale in Fig. 2. While purely theoretical, the A recent systematic review provided a narrative
trend line indicates that usage rates may decline synthesis of the issues that the physiotherapy

Physical Therapy Reviews 2008 VOL 13 NO 6 391

Chipchase et al. A framework for determining curricular content of entry level physiotherapy programmes

profession faces with respect to EBP.69 The review clinical practice and research evidence. In the first
included 65 peer reviewed articles relating to the instance, contemporary data on practice patterns can
construct of EBP within the practice of physiotherapy provide a guide for entry level curricula. However, at
of which 52 were editorials, discussion papers or the same time, a method for identifying and evaluat-
narrative reviews. Similarly, Chipchase identified ing evidence and research findings related to estab-
only five peer reviewed published papers evaluating lished EPAs needs to be developed. In addition, a
how EBP was integrated into entry level physiother- framework for monitoring and appraising the safety,
apy education.47 Essentially, these findings translate biophysical bases and potential clinical value of new
to a large amount of published opinion on EBP with modalities is warranted prior to their clinical adop-
very few empirical studies on its integration in tion by physiotherapists.
physiotherapy practice and entry level education. A solution for new modalities is rigorous and
Controversies about EBP also limit the develop- independent testing prior to its clinical adoption. The
ment of evidence based curricula. First, there is benefits and potential side effects should initially be
controversy as to what constitutes ‘best research garnered from basic research and include animal,
evidence’. Differences of opinion between academic cellular, anatomical, physiological and biophysical
teaching staff about acceptable types and quality of trials. Ways of evaluating the strength of this
evidence available have been reported.70 Also, evidence need to be determined as these types of
discussions in the professional literature about the trials are not without their limitations. However, this
value of different methodological and hierarchical would at least ensure that patient and operator safety
approaches are common.13,71–74 For example, the are not compromised.
role of qualitative research findings has yet to be For existing and established modalities, a method
addressed in most EBP hierarchies or research for categorising and evaluating the findings of
databases.13,75 This means that there is currently no clinically based studies is needed. For RCTs and
universally agreed upon evidence hierarchy (recognis- systematic reviews (of RCTs) internationally
ing both quantitative and qualitative approaches) to accepted review processes are available. However
ascertain the efficacy of different physiotherapeutic where ‘lower’ research approaches (n51, pre-post
interventions and techniques. Furthermore, the designs, uncontrolled trials) are appropriate for
research approaches supporting the use of many uncommon patient presentations or specific EPAs
EPAs include animal, cellular, anatomical and applications, a collaborative international steering
histological research for which many EBP hierarchies committee of academics and researchers could be
and critical appraisal tools are simply not available.24 convened to develop a relevant and useful EBP
In summary, at present, despite the need for framework that can be used to compare such
curricular decision making to be underpinned by approaches consistently.
best available research evidence, there is no clear and Using a consensus approach, this committee could,
well accepted model for how to undertake this for example, decide how to best quantify, present and
process. In addition, how the best available research disseminate the clinical evidence for a range of EPAs
underpinning curricular choices is transparently modalities. The review processes for each modality
presented to entry-level students is rarely considered. could be systematically undertaken by either inter-
The time, expertise and work required to undertake ested teams of academics, clinicians or research
regular systematic reviews of each and every phy- candidates. Determining which modalities should be
siotherapy assessment and treatment intervention in recommended for inclusion within entry-level curri-
order to determine which interventions should be cula could then be decided by countries, states, or
retained within entry-level curriculum is mind numb- educational institutions using best available research
ing. Consequently, it should come as no surprise that evidence combined with contemporary, local clinical
basing curricular decisions on clinical usage appears usage patterns. In addition, such a strategy would
to provide a convenient way of limiting curricula also highlight where higher level research approaches
content and producing clinically relevant entry level are required or clarification of efficacy is needed.
practitioners. In summary, this paper has presented a way
forward for determining the curricular content of
The way forward entry level physiotherapy programmes using EPAs as
A way forward is to find the middle ground for a case in point. The dilemmas and potential solutions
determining curricular content that relies on both can be equally applied to other physiotherapy

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 Chipchase et al. A framework for determining curricular content of entry level physiotherapy programmes

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LUCY S. CHIPCHASE
School of Health Sciences, University of South Australia, Adelaide SA 5000, Australia
Email [email protected]

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