Introduction
Since ancient times, humans have used handheld tools to manipulate the body’s soft tissue to promote healing. An example is found in traditional Chinese medicine (TCM). Gua Sha tools are among the oldest known soft tissue tools.1 By the Yuan Dynasty, in 1337, the physician Wei Yi Lin documented established Gua Sha treatment formulas.2,3 Gua Sha tools are still used in TCM treatment today.4
The provider training environment has advanced considerably since instruments were first applied in treatment. In the past, TCM training has utilized a teacher-centered, face-to-face apprenticeship system to teach clinical skills. There has been tension between TCM and modern teaching approaches, such as those that incorporate online learning.5 This is changing, with online learning now considered a good alternative for TCM.6 In contemporary healthcare education, the integration of advanced technologies in online learning has become the future of the global classroom.7
Background
The demand for online education continues to rise. The National Center for Education Statistics reported that more than a quarter of college students were enrolled fully online in 2022, and more than half were enrolled in at least 1 online class.8 This change has been facilitated by advances in classroom technology and internet access accessibility for several decades while increasingly relying on students’ ability to learn autonomously.9 As technology has continued to develop, so has the ability for autonomous learning. Student autonomy is associated with student motivation and engagement.10 Education has moved away from the “Sage on the Stage”11 teacher-centered approach, which assumes the instructor is the primary source of knowledge and positions students as passive learners. The current educational environment is much more aligned with the “Guide on the Side”,11 which emphasizes student-centered independent learning. Shifting from teacher-centered learning to student-centered learning supports the development of lifelong learning skills.12–14
Transition to Online Learning
The Covid-19 pandemic forced students and teachers to rapidly adapt to online learning through emergency remote teaching.15,16 This scenario gave teachers and students very little time to move to online learning environments. Although emergency remote teaching included online learning, it was implemented as a temporary solution to an emergency situation.
Research has demonstrated that when intentional design and planning are utilized, online learning is an effective model.17–19 During the design process, attention must be given to student-student and student-instructor interactions, rather than only to student-content learning.18 This indicates that learning is more than the information being presented; it is both a social and cognitive process. In most cases, intentional design and planning were insufficient or absent altogether during the hasty shift to emergency remote teaching during the Covid-19 pandemic.
A byproduct of the move to online learning was that it gave students and teachers experience in the learning environment. With more experience, students perceive themselves as more self-regulated learners.20 Despite the challenges, emergency remote teaching showed many students and teachers that they could be successful in new online learning environments. Self-efficacy, combined with self-regulation, is important for favorable learning outcomes21 and is a reliable predictor of academic success in online learning.22 Self-regulation and self-efficacy promote positive student engagement in coursework, which in turn contributes to greater success in online learning.23
Online Learning as a Permanent Fixture
Even when students prefer face-to-face learning, they may choose online learning for its flexibility and convenience.24,25 Many universities have developed degree programs that are delivered entirely online. The ability to learn from home, save on travel expenses, and attend class while ill are all student-reported benefits of online learning.10 This provides the flexibility many students need while caring for families and considering the risks of disease transmission when studying from home in the post-pandemic period. This is especially significant for healthcare students who must manage the demands of learning both academic and clinical skills. Clinical skills training is an essential aspect of healthcare education that involves multiple delivery methods, including lectures, direct patient observation, practice activities, and simulations.26 With the continued increase in demand for online learning, identifying clinical skills that can be effectively taught in this environment is necessary for the future of health care education.
Clinical skills training traditionally takes place in a face-to-face learning environment. Teaching clinical skills in an online environment has been difficult in the past due to technological limitations. Many of those barriers can now be overcome with common hand-held devices such as smartphones. Clinical skills can be effectively demonstrated in real time through point-of-view filming, showing students exactly what they need to see to learn the specific skills being taught.26 In education, point-of-view filming is used in two ways. One technique uses fixed camera positions to film lectures and demonstrations. The other technique uses mobile or wearable devices to visualize training from a first-person point of view.26 This can be achieved most easily by using a smartphone to record from close range, giving detailed teaching videos.26 Video-based learning has been shown to improve student satisfaction due to the immersive nature of the online learning environment.27
Effectiveness of Online Learning
Systematic reviews and meta-analyses have suggested that online learning is as effective as traditional face-to-face methods for teaching clinical behavior to health care professionals.28–33 For example, in a survey of undergraduate medical students, 72% of students strongly agreed that e-learning was useful for their assessment preparation in clinical skills.29 Additionally, 96% of students agreed or strongly agreed that e-learning was useful in learning clinical skills.29 Students engaged in online learning have been shown to perform better than those who receive only face-to-face instruction.34 This is due to the use of collaboration technologies, which have increased expectations for the effectiveness of online learning.34 The student-preferred methods of delivering online learning to medical students during the Covid-19 pandemic were a combination of videos and tutorials, followed by YouTube videos and live tutorials alone.35 These tools are readily available to both students and teachers and are used to instantly access medical information.36 As technology continues to advance, it will improve the delivery and access of online training.
Instrument-Assisted Soft-Tissue Mobilization
Instrument-assisted soft-tissue mobilization (IASTM) has been defined as “A skilled intervention that includes the use of specialized tools to manipulate the skin, myofascia, muscles, and tendons by various direct compressive stroke techniques”.37 IASTM therapy is used by doctors of medicine, doctors of osteopathy, doctors of chiropractic, physical therapists, athletic trainers, acupuncturists, massage therapists, emergency medical technicians, and other professions.38 IASTM training is often taught during initial provider training as part of degree-specific curriculum coursework.38 Like many clinical skills, IASTM education has been delivered through face-to-face training with an instructor. With demand for online clinical training programs increasing, professional schools and IASTM companies are offering online learning options.39,40 An online learning environment creates specific challenges for teaching clinical skills like IASTM, which have traditionally relied on a hands-on approach. These challenges can include inaccessibility of online learning, digital illiteracy, or a lack of interaction between teachers and students.41
IASTM and Online Learning
The application of IASTM therapy is a specific clinical skill that many health care providers learn. IASTM training is currently delivered in a variety of ways, including live, face-to-face training, live web-based training, and previously recorded videos.38 These clinical skills are taught in formal and informal settings, and both formal and informal continuing education (CE) activities are suggested to enhance clinical skills training.42–44
IASTM training most often occurs as part of provider education or post-graduate CE. In a survey of IASTM providers, 86% of participants reported completing formal IASTM training through live professional CE, web-based courses, degree-specific curriculum coursework, or recorded training videos.38 Formal training is offered by more than 10 IASTM tool manufacturers, each with its own tools and treatment paradigms.
Informal training is conducted in many ways, including professional mentorship, unofficial online courses, and self-study using unofficial websites or online videos.38 Informal CE learning improves clinical skills, whereas formal CE learning improves subject-matter knowledge.42,45–48 Approximately 86% of IASTM providers have completed some type of formal training, such as that offered by major IASTM companies, and 61% have completed informal training, such as short CE workshops at professional conferences.38
Statement of the Problem
There is an ongoing interdisciplinary demand by health professionals for effective online clinical skills training.31,49 Evidence suggests that teaching online is an effective way to deliver clinical skills training.28,29,31–33 While delivering training online can help meet the increasing demand for clinical skills training, the feasibility of studying IASTM training in an online learning environment has not yet been explored.
Purpose of the Study
Delivering clinical skills training is essential in health care education.26 More than 10 major manufacturers offer formal IASTM training.38 There is ongoing interdisciplinary demand for online IASTM clinical skills education, which is being met, in part, by postgraduate CE training.39,40 There are many benefits to administering clinical skills training to health care students in an online learning environment.10,29 The purpose of this pilot study was to test the feasibility of studying online IASTM provider training and to test outcome measures.
Significance of the Study
IASTM isa therapy administered by a variety of health care professionals.38 Training traditionally takes place in a face-to-face learning environment, but now includes online training. This study helps inform future research on online IASTM clinical skills training by assessing the methodology’s feasibility. The information identified through this study could pave the way for a successful large-scale study of online IASTM provider training.
Research Questions
This study was designed to address the following research questions:
RQ1: Can students successfully complete the assigned IASTM training?
RQ2: Are the surveys created appropriate and usable?
RQ3: What problems exist with recruitment and retention?
Methodology
This study was designed to assess the feasibility of delivering online IASTM provider training. A mixed-methods pilot study design was used to analyze what worked and what did not work during study implementation. Lessons learned from this study can inform future larger-scale studies.
Study Design
This mixed-methods pilot study was reviewed and approved by the Logan University Institutional Review Board prior to execution (Control #: RD10222025636). The Office of Research Integrity50 identified 4 elements of an experimental study: manipulation, control, random assignment, and random selection. The most important of these is manipulation and control. In this study, the training was manipulated between online and face-to-face learning environments, while the instructor and course content remained the same, serving as a control. Random group assignment was used, further aiding the proposed study design.
Population of Interest
The population of interest for this study was Doctors of Chiropractic and Doctor of Chiropractic students of any gender, age 18-55. For IASTM training, students are expected to have prior knowledge of the names, locations, and functions of each tissue type in the body. As such, eligible students must be in trimester 4 or higher and have successfully completed all anatomy courses. This study sample is representative of the larger population of interest. Recruitment methods included direct student body emails through the Student Services office and promotional flyers posted around the Logan University campus 30 days prior to the study date. Doctors of Chiropractic were recruited through direct solicitation and word-of-mouth referrals.
Instruments and Psychometrics
This study relied on feedback from participating students. To obtain quantifiable data, surveys used seven-point Likert-scale questions. To give a direct comparison of the training experiences, the same questions were asked to each group before and after training. A standardized tool for evaluating students’ opinions of online vs. face-to-face clinical skills training could not be identified. Therefore, surveys were created specifically for this purpose (Appendix A). The post-training qualitative survey included open-ended questions, allowing participating students to provide more detailed feedback on their experience, thereby informing future studies. This combination of outcome measures allowed for the most direct comparison of the feasibility and perceived effectiveness of the specific training sessions.
Procedures
This pilot study was an experimental design in which the same training was delivered in controlled variations to identify the feasibility of studying online IASTM training. Informed consent was obtained from all participating students. Participants were randomly assigned to 1 of the 2 study groups, regardless of personal preference. Students experienced the same curriculum, delivered by the same instructor. Groups varied only in the training delivery method. I served as the instructor for both study groups. Instructor training includes Doctor of Chiropractic degree-specific IASTM training at Logan University in 2009, followed by 16+ years of private practice experience. Curriculum development was the cumulative result of Doctor of Education in Health Professions Education degree-specific training at Logan University in 2026.
Group 1 received in-person training across 4 1-hour sessions. Group 2 received online training across 4 1-hour training sessions. Online training was delivered in an asynchronous classroom environment using a smartphone to provide close-distance, detailed teaching videos from the provider’s perspective on what the student needs to see.26
Pre- and post-training participant surveys were administered for both study groups. Pre-training surveys contained quantitative data-gathering questions, which helped establish a comparative baseline and identify initial trends. Post-training surveys used both qualitative and quantitative data-gathering questions. Post-training qualitative data collection included open-ended questions to elicit deeper insight into the specific training experience and identify potential barriers that can be accommodated in future large-scale studies.
Results
A total of 7 Doctors of Chiropractic participated in the study. Five students completed the online training, and 2 completed the in-person training. This smaller sample size is appropriate for a pilot study structure. Both groups completed pre- and post-training quantitative surveys, as well as post-training qualitative surveys. No additional comparisons of student groups, including age or experience, were performed.
The first research question examined whether students could successfully complete the assigned training. To address this research question, students were asked in post-training quantitative surveys whether they felt confident in their ability to be successful in the assigned learning environment. All (100%) participating students indicated a 7 (strongly agree) with this statement. In addition, students were asked if they felt confident interacting with instructors and peers in the assigned learning environment. All (100%) participating students indicated a 7 (strongly agree) with this statement. No specific problems associated with successful student completion were identified.
The second research question investigated whether the surveys created for this study are appropriate and usable. No problems associated with the appropriateness or usability of the surveys were identified. Quantitative and qualitative surveys performed as expected.
The third research question probed problems with recruitment and retention. These were 2 areas of the study that saw the most difficulty. Recruiting students currently in chiropractic training was unsuccessful. The participants of this pilot study were all Doctors of Chiropractic interested in postgraduate CE. Although 7 students completed this study, 10 expressed interest in participating. Students were divided equally into 2 groups, with 5 students assigned to each. All of the online students completed the training, while only 2 out of 5 face-to-face students did. No retention follow-up plan was implemented in this study.
Discussion
The results of this study suggest that, with proper attention to recruitment and retention, this pilot study is scalable and can serve as a model for a larger mixed-methods research study. Student feedback indicated that a potential limitation of online training was that it “doesn’t offer the course taker feedback on their own application of technique.” This is consistent with previously identified limitations in online clinical skills training, including fewer practice opportunities and difficulty in evaluating clinical competencies.51 Another potential limitation identified was the production style of teaching videos. Students suggested that videos should include “paired audio descriptions” of the treatment technique, including “pressure and depth of each treatment area.” Video production styles with higher levels of media richness have been shown to be directly related to both student engagement and content retention.52
In quantitative surveys, students were asked whether IASTM training can be taught online and whether it should be taught online. Both groups strongly agreed in pre-training surveys that IASTM can be taught online. Post-training surveys indicated that the in-person group was neutral about whether IASTM should be taught online, whereas the online group either agreed or strongly agreed that it should be taught online. These preliminary results are consistent with findings in TCM, which demonstrate a status quo bias for face-to-face training and a growing acceptance of online learning.5,6 Student responses indicated that point-of-view filming was an effective teaching technique, while feedback on the application of the treatment technique was noted as an obstacle to online learning. To fully leverage the benefits of modern technology, production style should pair audio content with video instruction.
Limitations
The limitations of this study included a small sample size, potential sampling bias, and potential data-collection limitations. With only seven participating students, results may not represent larger student populations. A potential sampling bias exists as a result of students from only 1 profession. This can produce data that is specific to only one group of students and may not be representative of a larger, more diverse student population. Because this study used custom-created student surveys, a potential limitation in data collection exists due to inherent flaws in the questions students were asked.
Recommendations for Future Research
Future research on online IASTM training should include a large sample from diverse professions to avoid small-sample limitations and potential sampling bias. A larger sample size will increase the reliability of study conclusions by reducing the impact of random error and by producing a more complete representation of the IASTM student population. A diverse sample of professions will avoid results that may only be relevant to one group of practitioners. Identification of a structured research instrument that can be used would help reduce potential limitations in data collection. Specific attention should be given to recruiting and retaining student participants. Greater success was achieved in recruiting post-graduate CE students.
Additional insight may be gained from comparisons of student groups, including age and experience with IASTM therapy. Future studies should consider making these comparisons. A plan should also be developed to monitor student retention. If students are unable to complete the assigned training, a follow-up investigation may yield additional significant data.
Conclusion
This pilot study examined the feasibility of studying IASTM training in an online learning environment. The results of this study indicate that students successfully completed the assigned training, and the data-collection measures used performed as expected. With attention to recruitment and retention, the methodology used in this pilot study is scalable and can serve as a model for future research.
Conflict of Interest
In the interest of full disclosure, in 2020, I was awarded patent number USD879980S1 for an IASTM tool design by the US Patent and Trademark Office. No external funding was received for this research. I have no other conflict of interest to disclose.