An Investigation of Different Learning Styles and Applications to Physical Therapy: Cream and Sugar? by Samuel Eisdorfer

You’re sick. You need help. You go to your family physician, and they perform their examination and may or may not prescribe medication. Typically, they’ll send you home with discharge papers that outline the highlights of your appointment. It’s a nice and neat way to wrap up the appointment in a pretty, succinct bow. Over the years, physical therapists have also implemented visual aids to help patients understand their appointment sessions, namely, the assigned exercises. However, in my training, I have found that this domain of physical therapy could use some improvement. After all, couldn’t one make the argument for a detailed understanding of any ideology or phenomenon to understand the crucial why? I believe targeting that ever-essential why will not only improve patient healthcare literacy but ultimately aid in their detailed understanding and appreciation for their physical therapy. Employing a plan of care based on patient-specific needs, limitations, and learning styles is hypothesized to improve patient healthcare literacy, as this creates a more personable and tangible form of treatment. The goal is to improve patient compliance and enrich the relationship between therapist and patient through a heightened understanding of different learning preferences. 

In brainstorming some standard practices to fill the gaps within the field, a likely starting point would be to establish and attempt to address the apparent struggles: “What is one of the biggest limitations of providing the most effective care for PT patients?” After a few chin strokes, we could funnel thoughts through like “motivation, emotional intelligence, mental health factors, physical limitations within the home…” and so on and so forth. But to truly gauge any of those areas of concern, the parament issue, the umbrella from which those other concerns cascade, is ultimately based on the patient’s understanding. The absolute first step to ensuring positive results from a therapeutic session/treatment plan is to ensure your patient is genuinely engaged with the process, not just the expectant light beaming at the end of the tunnel. Patients have to actually perform their exercises/stretches/glides to yield therapeutic results. They must be an equal, active member of the equation. After all, we’ve all learned in our arithmetic courses that what you do to one side of the equal sign, you must also do to the other. This balancing act can be analogized to the therapist/patient relationship. They must have an affinity for one another – as treatment regimens become more involved and complex, patient understanding must also hug this reference line. So, how do we tackle this?

Let’s think about this in terms of a commonly enjoyed beverage: coffee. Sitting at the round table, our hands coupling our warm mugs, we take sips intermittent of our thoughts. You look down and peer into your cup. Its smoothness and rich notes of flavor are swirled around the top. Maybe some sugar, maybe some cream. Maybe even a foamy cappuccino. No matter how you enjoy your favorite cup, they all have some common ground…grounds. Hopefully, fresh grounds. Laying the foundation. I love coffee. I think about it often even when I don’t have my mug handy. It’s comforting, nuanced, and yet still predictable. I use the same beans, the same grinder, and the same machinery to create each delicious cupful. As we cradle our precious, caffeinated chalices, let’s compare coffee and all its fundamental components to physical therapy. Think about the grounds or freshly available beans as your patient’s level of understanding. You want depth in your coffee, right? And we, as therapists, have our detailed knowledge of the mechanistic demands of the human body, which are not dissimilar to the intricate gears necessary to make that perfect cup. As these highly attuned machines, a lavish Nespresso, if you will, physical therapists can take those grounds, their fundamental value, and properly and efficiently direct them to extract the most efficacious results. However, in this creative line of thought, we’re forgetting one thing. Yes, we have metaphorically established a consistent, systematic approach, but what about the individualism, the sugar, the cream? The personality behind each unique mug. Like our favorite morning blends, whether it be laced with chocolate, half-caff, or solid black, each cup reflects an individual’s own set of likenesses. Just as our favored flavors are ubiquitously ingrained, so is the way we take in all other inputs and stimuli. Without too much more metaphorical flamboyancy, let’s get to the nitty gritty – learning styles. The internal factors such as decreased motivation and other facets that affect emotional regulation, drive, persistence, etc., can be addressed as the therapist and patient build their relationship. One thing that therapists can target right off the bat is improving patient healthcare literacy, with the hope of improving compliance. Maybe the issue with compliance is due to a lack of knowledge and/or understanding. So, let’s get after that first thing to prevent any lapses in knowledge/importance of treatment. The most effective way to address this is to understand your patients and how they learn.

Most of us have an established understanding that different people have different learning styles. Most of us within the field of physical therapy would agree that there is a steep learning curve in many of the concepts given to patients. I have reached out to one physical therapist in particular, Jessica Bass, DPT with Atrium Wake Forest Baptist Health at the Lexington Medical Center. When inquired about how she tackles the obstacle of patient healthcare literacy, she stated that she “tries to get on their level. Speak in layman’s terms. Give them education on what and why we are doing it [the exercises]. Give them pictures for follow through at home.” This is an excellent approach, it is fundamental to relate to your patient, feeding off their body language, cueing into what they do and don’t understand. It is an excellent standard of care. So much so that it is often what we see at many physical therapy facilities. I have had the opportunity to work in several different therapeutic environments, most of which employ the above-mentioned strategy. But just like with any domain within the health sciences, we should be constantly searching for improvement of protocols, and how ultimately to better serve our patients, our people. Instead of relying on mainly visual aids for guidance, my proposal is to execute a simple and efficient strategy for gauging an individual’s learning style. Once their learning style (i.e., visual, auditory, tactile, etc.) is established, physical therapists and their aids are more equipped to provide not only excellent care but excellent care that is appropriate and patient-specific. After all, physical therapy is not a quick fix. It’s through repetitious actions that yield therapeutic outcomes.

Now, the end goal is not to fixate on one learning style and rigidly assign one style per patient, but rather establish their learning style affinities and how we, as therapists, are able to provide better care in and out of the gym. According to Boyle and Dunleavy, “Using explanatory factor analysis, Vermunt (1998) identified four different learning styles, meaning-directed, reproduction-directed, application-directed and undirected, which displayed characteristic patterns of factor loadings across the four components of learning” (Boyle & Dunleavy, 2003). This was a study that examined the efficacy of employing different learning style strategies in a higher education student population. Though the results were significant in terms of the successful identification of Vermunt's four learning styles, “different learning environments influence the precise characteristics of each learning style” (Boyle & Dunleavy, 2003), it’s not sufficient alone to perform a learning style inventory, score, and employ one specific model. We must be flexible in our understanding of the patient and their surrounding environment. For example, inpatient settings and the respective therapeutic approaches will differ from acute or outpatient settings. The environment is the main influencer of how therapy is executed. Within aquatic therapy, more tactile methods are used to help guide exercises and patient understanding. As someone with dyslexia, I am mainly an auditory learner AND executor. Talk-to-text is a wonderful tool to help express my line of thought and convey the message appropriately. If a patient is more mentally geared towards auditory expression, a recording of each therapy session may be extremely beneficial to improving their understanding and gaining true value from their physical therapy.

Other healthcare professionals have adopted this thought of the provider/patient relationship as analogous to the teacher/student relationship. The National Library of Medicine database published an article written by Stephen A. Brunton, MD, regarding the importance of physicians as patient teachers. The article goes on to discuss the different methods by which physicians can practice this. Bibliotherapy, community events, and educational pamphlets are just a few, notable methods. As PsychCentral phrases it, bibliotherapy is used to “bring about change through reading.” It can be an excellent supplement for those who are visual learners or who enjoy reading or creative writing. It can also take on different formats, namely, clinical, and developmental. It is utilized in the clinical setting by “using literature as a means of creating cognitive change related to psychological needs and therapeutic goals,” and more developmentally as “informational materials used by both medical professionals and other educators to help assist with natural life transitions.” Physical therapy, in its essence, is helping people navigate through a life transition, whether it is acutely or chronically. The use of these alternative resources has the potential for increased emotional acuity and developmental understanding of a diagnosis. This can help stimulate dialogue for more effectual communication between therapist and patient. As a side note, even subliminal messages can be delivered to patients in the waiting room. Think about magazine selection and other entertainment choices, and the message you want your business to promote and for your patients to go home with – all information delivery methods are valuable, as we are all different!

We have established the importance of acknowledging different learning styles and have discussed how this form of provider-to-teacher analogy can take shape in other healthcare practices. So, how can this be practically integrated into the existing framework of physical therapy? We discussed the waiting area, the limbo stage filled with insurance paperwork and pre-appointment jitters, which can serve as a great introduction to the treatment regimen. No matter the therapeutic setting, there will always be intake paperwork and documents to be completed. This would be an excellent opportunity to provide the patient with a brief learning style inventory. Michigan’s state government has established a standardized Learning Style Questionnaire that focuses on three core learning styles: visual, audio, and tactile. The individual completing the form reads through a series of statements and rates each statement on a numeric scale, 1-3, with the lower number corresponding to a sentiment of lesser agreeance. After the three brief sections, the values are totaled for each type of learning style. The higher the score for a respective learning style, the greater affinity an individual has for that learning preference. Additionally, the survey goes on to mention the possibility of ranking highly on more than one learning style, in which it is recommended to employ a multi-model approach. This learning style inventory would take only a few minutes to complete while utilizing very few resources within the facility. The pdf can be printed, laminated, and completed via dry-erase marker for reusability – though a few copies should be handy at reception. With the ever-present form of technology, the VARK (Visual Aural Read/Write Kinesthetic) approach can be practiced. This is a learning style questionnaire (VARK Questionnaire version 8.01) that is presented in a simplistic, digital format and has a software program that computes the patient’s learning style based on their selected answers to multiple choice questions. Both questionnaires are simplistic in terms of their verbiage, usability, and versatility, making them a valuable tool to help assess patient learning styles right from the beginning. The VARK Questionnaire has multiple versions based on a multi-factorial disciplinary approach that includes teachers, trainers, and pediatric populations.

I would be remiss if I did not acknowledge some limitations within the learning style platform. Past studies have shown that when educators focused teaching around the categorical learning style approach, there were no significant effects in terms of academic performance. Cuevas, J. 2015 meta-analysis, “Is learning styles-based instruction effective? A comprehensive analysis of recent research on learning styles,” has supporting evidence that an individual’s unique learning style is best for the educational process, but instead, using a dynamic and holistic approach encompassing all learning styles is superior. Additionally, implementing some of these learning style inventories in practice will increase annual costs for the facility. One can weigh the cost-to-benefit ratio, and in some instances, it may be worth the estimated $38.00 extra spending dollars (VARK subscription) on an annual basis, especially in pediatric populations. However, these charges and respective training could be potentially integrated into continuing education courses for PTs and their staff. Fortunately, in the digital era, much of the necessary research is at our fingertips. We don’t have to worry about stocking our shelves with the necessary texts for bibliotherapy or needing the bandwidth to host community/group events, as many of these opportunities are readily found online or in a local news section. Though it does add additional cost, effort, and training, it is an opportunity to implement an individualized approach to physical therapy based on psychosocial theory.

It is essential to note the body of psychological evidence that supports the learning style claim and use it only as a tool in the entire physical therapist arsenal. Psychological researchers David and Alice Kolb established the Kolb Learning Style Inventory, 4.0, with the most recently published revision in 2011. This Inventory is based on the founding principles of experiential learning derived by psychological theorists including Carl Jung, Carl Rogers, and Jean Piaget. Most of the evidence providing the foundation for the Kolb Inventory is based upon the Learning Flexibility Index (LFI), a Kendall’s W statistic. According to the Kolbs, there was a case study performed in which an individual with a high LFI score correlated to how “learning style and learning flexibility can combine to produce unique patterns of adaptation to different learning contexts” (Kolb, 2011). In other words, these inventories have proven to be valuable tools in not only identifying the unique way in which one interprets information but also how that interpreted information can be contorted to fit the necessary mold, the framework of the learning environment. After all, learning is entirely contextual and is respective to the learner and the surrounding environment.

The utilization of already established psychological learning questionnaires, both in print and in digital format options, offers functional integration into the physical therapy mold. Hopefully, the information provided can serve as a reference for colleagues, future therapists, and other healthcare professionals on the importance of improving healthcare literacy within a patient population when education is tailored to patient learning styles. This will improve the learning experience and outcome of each individual patient. When filling up someone else’s cup, ask if they want cream and sugar – it’s best practice.

 

 

References:

1.     Boyle EA, Duffy T, Dunleavy K. Learning styles and academic outcome: the validity and utility of Vermunt's Inventory of Learning Styles in a British higher education setting. Br J Educ Psychol. 2003 Jun;73(Pt 2):267-90. doi: 10.1348/00070990360626976. PMID: 12828816.

2.     Brunton SA. Physicians as patient teachers. West J Med. 1984 Dec;141(6):855-60. PMID: 6395500; PMCID: PMC1011220.

3.     Cuevas, J. (2015). Is learning styles-based instruction effective? A comprehensive analysis of recent research on learning styles. Theory and Research in Education, 13(3), 308-333.

4.      Gillette H. Bibliotherapy: What it is, how it helps, and more. Psych Central. February 22, 2022. Accessed November 18, 2023. https://psychcentral.com/health/bibliotherapy.

5.     Kolb, David & Kolb, Alice. (2013). The Kolb Learning Style Inventory 4.0: Guide to Theory, Psychometrics, Research & Applications.

6.     Learning style questionnaire - state of Michigan. Accessed November 18, 2023.

7.     1. Vark Learning styles. VARK. Accessed November 18, 2023. https://vark-learn.com/.