Computerized Simulation Education on Physiotherapy Students' Skills and Knowledge: A Systematic Review

Introduction Applying computerized simulation education tool for learning in medical domains is widely used in many countries. This review is aimed at systematically investigating the computerized simulation tools developed to educate physiotherapy students and determine the effectiveness of these interventions. Methods A comprehensive search was conducted in Medline (through PubMed) and Scopus databases from inception to Sept. 10, 2022. The studies that examined the effectiveness of computerized simulation-based interventions were included. Results Sixteen studies were included in this systematic review. All included examinations were ranked “good” or “low risk of bias” based on the criteria utilized in the Joanna Briggs Institute (JBI) scale and the Effective Public Health Practice Project (EPHPP) tool. Most of the articles (43%) were conducted in the USA and 25% in Australia. In 43% of the total studies, the study population was only physiotherapy students, and in 12.5% of them, the scope of education was related to practical skills training. Three of the 16 reviewed articles presented positive qualitative results; thirteen quantitative investigations also declared statistically positive effects. Positive effects have been seen in areas such as improving professional and behavioral abilities, improving knowledge and self-confidence, and reducing stress. The sample size of the studies ranged from eight to 162 participants. The limited sample sizes in groups, lack of interaction, and short follow-up duration were the most consistent limitations evident within the included studies. Conclusion Computerized simulation education approaches can help to improve physiotherapy students' skills and knowledge. They also have great potential to reduce learning costs and increase the quality of education.


Introduction
Clinical education is a critical component of physiotherapy student education that, using a centralized and structured process, can expose students to a variety of training opportunities to develop clinical learning [1] and is defined as providing guidance and feedback on the trainee's personal, professional, and educational progress in delivering appropriate patient care [2]. Students experience their most effective clinical-operational learning in places where there is a relaxed atmosphere between students and the clinical instructor to ask questions and receive feedback from their professors [3,4]. Furthermore, a fundamental challenge in the clinical education of physiotherapy students, given the importance of gaining clinical experience, is the demand for trainer supervision on the student's performance during the interventions of patients [5]. Due to students' limited years of study, clinical education cannot be provided in a safe environment for a wide range of diseases [6]. Historically, practical skills in physiotherapy curricula have been instructed via live demonstration, followed by activity and feedback, in a manner and time specified by constraints [7]. This leaves students to revise the skill outside class time based on memory or handwritten, potentially inaccurate notes. As such, practical skills development may not have been optimal [3,8]. A structured clinical education program with teaching and learning activities can facilitate the quality of clinical education. The students' learning experience is enhanced by a learning environment enriched with visual and cognitive modeling [9].
Therefore, the existence of tools that can, in addition to active student learning, allow repetition of exercises in a fun environment and create ongoing education will improve the quality of medical services furnished by students to patients [10]. Computer simulations can improve physiotherapy students' skills in patient assessment, treatment, and clinical decision-making [9,11]. One of the new techniques is simulation-based education, which is widely operated in various areas of the healthcare system [12]. In recent years, simulation has become a standard practice in teaching technical skills in the physiotherapy field [13]. Scientifically speaking, these technologies, which operate on a connection basis at any time and place, have significantly influenced healthcare measures. Simulation-based teaching and learning also breaks down time and space constraints and enables one to use educational programs in any setting [14]. The benefits of using clinical education simulation include improving technical and communication knowledge and skills, increasing student satisfaction, and improving clinical decision-making that allows the student to gain the right clinical experience in a safe and controlled environment [15]. Remarkably, simulation never completely replaces real learning experiences in the clinical setting [16].
Multifarious simulation techniques reported in reviewed physiotherapy research include simulated patients (classmates, actors, or volunteers trained to demonstrate the role of a patient called a standard patient), pictures, video, computer simulators, web-based learning, designed software for specific occasions, virtual reality simulators, and mannequins [17,18]. Computer technology allows students to explicitly develop metacognition, reflecting on their own learning, improving their motivation and interest in the classroom, and presenting themselves as an effective predictive tool [19]. It is noteworthy that computer simulation tools such as virtual reality, augmented reality, and webbased simulations offer a wide variety of opportunities for modeling concepts and processes [20]. These new simulation technologies bridge the gap between prior and unique knowledge of physiotherapy students, learn new clinical operations, and help them develop their scientific understanding using knowledge in a quasirealistic environment [21]. Therefore, it would be safe to say that these simulated tools are considered new approaches that strengthen students' skills in specific areas such as attention and perceptual abilities; immersion in these environments improves visual and auditory feedback [22,23]. These technologies have reasonable potential to create scenarios for physiotherapy students in the field of interactive learning with patients and their treatment, which provide organizing clinical education [24]. In recent years, several systematic reviews have been conducted to investigate the effects of using simulated envi-ronments for physiotherapists and students. The authors related to these articles have claimed that by leaving aside some problems of designing and developing some simulation tools for the training of physiotherapists, significant effects have been seen in the related skills [25][26][27]. Roberts and Cooper [28] concluded that physiotherapy students did not improve their communication skills, and no significant difference was observed in practical skills. In terms of clinical performance, the Physical Therapy Practice Assessment Tool (APP) did not significantly increase mean scores. Likewise, it was observed that computerized mannequins improve students' preparedness for clinical practice but do not improve students' clinical performance or skills [29]. Due to some inconsistencies in the results, it was decided to do a more recent review of the studies. The goal was to review quantitative and qualitative articles comprehensively so that we could answer research questions.
1.1. Objective. Technology-based simulated education settings for learning physiotherapy students are widely used in many countries, and the benefits and effects of this technology-based education have been noted in most published articles; for example, clinical and operational knowledge and students' self-confidence have been declared improved [8,30,31]. In this qualitative literature review, findings about computerized simulation education on physiotherapy students' skills and knowledge were summarized and synthesized. The main questions and ambiguities of this review are as follows: (i) Generally, how many articles have been published in the field of investigating the effect of computerized simulation education on physiotherapy students' skills and knowledge (what is the publication trend)?
(ii) What are the main features of the studies, i.e., study aim, training tool, the scope of education, study place, study design, participant's description (sex and age (year)), key results, critical effects, effectiveness, main message, study limitations, and barriers for the use of technologies?
(iii) How successful has computerized simulation education been reported on physiotherapy students' skills and knowledge?
(iv) How is the studies' risk of bias? With what tool/ tools is this index measured?

Materials and Methods
This systematic review (SR) was conducted based on the JBI framework. The main steps are the followings: (1) planning; (2) identification; (3) screening; (4) eligibility/assessment, and (5) presentation (synopsis of findings, discussion, and presentation of the results) [32]. Also, a qualitative analysis process was used to summarize the reviewed studies and generate new remarkable insights. Reporting of this SR is based on the Preferred Reporting Items for Systematic 2 BioMed Research International Review and Meta-analysis (PRISMA) statement [33]. The filled PRISMA checklist is given as the supplementary material (Appendix Table S1).

Eligibility
Criteria. The PICO model (patient/population, intervention, comparison, and outcomes) was used to explore main queries and facilitate literature review. Various inclusion and exclusion criteria were adjusted in this review which are presented below.
2.1.1. Inclusion Criteria. Figure 1 depicts the inclusion criteria that were admitted in this review.  10,2022. The search strategy used in this SR included a combination of keywords and Medical Subject Headings (Mesh) terms related to "Physiotherapy," "Education," "Vir-tual Reality," "Augmented Reality," "Computer Simulation," and "Simulation Training." The complete list of keywords and terms used in the search strategy for Scopus and PubMed databases is given in the supplementary material (Appendix Table S2).

Study Selection.
Two stages were conducted in the selection process. Five reviewers (SR/ZR/HC/MY/SP) independently screened the abstracts and titles of the retrieved papers in the first stage; in this phase, papers that did not meet the eligibility criteria were extracted. The citations' full text was screened and inspected in the second stage, and three reviewers confirmed their relevance. The supervisors (LS and NG) were consulted in a disagreement not solved by a consensus discussion. The screening process is depicted by the 2020 PRISMA checklist in Figure 2.

Data Collection Process and Data Items.
Five reviewers gathered the required information from the included papers. Then, two other reviewers ascertained the accuracy of the information accumulated. Any dissensions were examined and resolved with reviewers (LS/NG). A form in Excel was prepared to extract data from included articles. The following data were extracted for each citation: publication details, study aim, training tool, the scope of education, study place, study design, participant's description (sex and age (year)), key results, key effects, effectiveness, main message, study limitations, and barriers for the use of technologies. The effect of applied simulation-based learning was summarized into three classes: (1) statistically significant effect, (2) effective without statistical argument, and (3) without any effectiveness (not statistically significant).

Study Risk of Bias Assessment.
For qualitative studies, the JBI critical appraisal checklist was chosen to evaluate articles' quality and risk of bias. Furthermore, the EPHPP tool for qualitative ones was also used to evaluate the Population: Te study population in this SR were physiotherapy students instructed with technology-based simulated training tools.

Intervention:
Studies that used technology-based simulated training settings as an intervention to train physiotherapy students were comprised. Comparison: Comparing physiotherapy students who underwent training by technology-based simulated tools with other training tools. Outcome: Investigations were entered in SR in which technology-based simulated training settings was applied, and its efectiveness was reported qualitatively or quantitatively.
Types of studies: RCT, NRCT-Observational studies and Qualitative analysis 3 BioMed Research International included papers. These tools were applied to evaluate all types of studies' methodological conduct or reporting. The JBI tool for qualitative studies has ten questions; these can be answered with four choices: (1) yes, (2) no, (3) unclear, and (4) not applicable. Each "yes" answer reaches one score, and if 70% of the questions responded "yes" in research, the risk of bias was considered "low," and if 50%-69% of them were answered yes, the risk of bias was supposed "moderate," and ultimately below 50% considered "high risk" 24. However, the EPHPP checklist was chosen because it assesses various quantitative studies' quality. The risk of bias was determined for six elements in each study: (1) selection bias, (2) study design, (3) confounders, (4) blinding, (5) data collection method, and (6) withdrawals and dropouts [34,35]. These six components were rated on a strong, moderate, and weak three-point scale; overall quality is ranked as a score of weak (two or more poor ranking of individual scale), moderate (one weak individual scale rating), and strong (no weak scale rating). Each study was investigated by three authors (SR/HC/MY) for bias and quality assessment by tools as mentioned earlier-JBI and EPHPP-and any disagreements were resolved by discussion with LS and NG.
2.6. Synthesis of Results. In this SR, as the procedures and methodology of reporting consequences in selected articles were heterogeneous, meta-analysis was not accomplished.

Study Selection.
A total of 197 articles were found in the initial search; after removing duplicates, 140 papers were left. Authors examined the title, abstracts of selected articles, and keywords, so 91 articles were identified for further review. After viewing the full text of these articles and focusing on simulation tools for physiotherapy in the field of clinical education and applying inclusion criteria, finally, 16 articles were included in this SR. Based on the predefined classification elements, a summary of the key classifications is described in Table 1.

Quality of Studies.
In this SR, quantitative and qualitative studies with different study designs are included, and based on it, they were evaluated with various appropriate scales. The EPHPP tool was used to assess the quantitative studies, while the JBI checklist was used for qualitative studies. Of the three qualitative studies that were evaluated with            12 BioMed Research International the tool JBI, all three were judged as with a low risk of bias (Table 2). Thirteen studies were evaluated by the EPHPP checklist. Also, the results of quality assessment for qualitative studies are shown in Figure 3. Based on the sum of scores, most studies were strong in terms of selection bias (92%), data collection (61%), drop-out (61%), and moderate in terms of study design (53%). Concerning the global rating, 38% of the thirteen quantitative included studies were strong, 38% moderate, and 23% weak. It can be concluded that all included examinations were ranked "good" or "low risk of bias" based on the criteria utilized in the JBI scale and EPHPP tool.  Table 3 shows the frequency distribution of the study population based on the scope of education. In 43% of the total studies, the study population was physiotherapy students, and in 12.5% of them, the scope of education was related to practical skills training. Also, in 12.5% of the total studies, the study population was physiotherapy and occupational therapy students, and in all of them, the scope of education was in terms of interprofessional skills. Ref. [20] Ref. [37] Scores: (+): yes (low risk of bias), (?): unclear, and (-) no (high risk of bias).

BioMed Research International
In five studies (31%) of the total citations, the scope of education and learning was related to improving interprofessional skills, and also, in two of them (12%), the scope of education was enhancing practical skills. The sample size of the studies ranged from 8 to 162 participants (IQR1: 29, median: 56, and IQR3: 69). Training tool frameworks in included papers are classified into six main categories. Figure 4 presents the distribution of studies by training tools frameworks. Table 4 presents the effects of applying computerized simulation education. The effects of computerized simulation education on physiotherapy students were classified into two groups: (1) professional skills, behaviors, and knowledge and (2) physiotherapist-reported effects. Most papers had reported more than one effect. Three of the 16 reviewed articles presented qualitative results that reported positive effects without statistical analysis or arguments. Thirteen of the quantitative investigations also declared statistically positive effects. It is noteworthy that we did not have a study that did not report a relatively positive effect.

Reported Limitations and Barriers to Applying
Technologies. Most examinations reported limitations related to conducting studies. In fact, the limitations of conducting studies and implementation barriers attributed to the limited use and effectiveness of computer simulation education from the authors' point of view are given in detail in Table 5.

Findings.
This study is aimed at evaluating the effectiveness of computer simulation education on the skills and knowledge of physiotherapy students. To this end, sixteen studies on the effect of computer simulation were systematically reviewed. Thirteen studies were evaluated by the EPHPP checklist. The quality evaluation results for quantitative studies have been shown to be 38% strong, 38% moderate, and 23% weak. Also, three qualitative studies evaluated by the JBI were judged as with a low risk of bias.
In most studies, physiotherapy students reported the positive effect of computerized simulation methods on improving basic knowledge, clinical reasoning, and practical and interprofessional communication skills. Students' learning levels improved after participating in computerized simulation courses; it was reported that they reached more motivation and self-efficacy. Also, the dependency on educators with these programs was diminished. Many studies in the educational scope were related to improving cardiopulmonary auscultation and interprofessional skills. Also, neurologic physiotherapy, cultural empathy, practical skills, and pediatric clinical training were investigated. Numerous studies have addressed the importance of interprofessional education. Paying attention to this issue as one of the essential educational areas can lead students to the goal of two-way education in different domains of study and helps to understand the content more deeply; on the other hand, accomplishing interprofessional education in congested university environments can be challenging [36]. A technology-based computer platform enables interprofessional interaction in a customized space to display an educational-clinical environment and has the potential to bring students together in more flexible cyberspace rather than enclosing an academic classroom [37].  Theoretical learning 1 (6.2%) 1 (6.2%) Major-related knowledge 2 (11.5%) 1 (6.2%) Interpersonal skills 2 (11.5%) -Observational skills 2 (11.5%) 2 (11.5%) Clinical decision-making skills 1 (6.2%) -

BioMed Research International
According to the results of this SR, most studies (43%) were conducted in the United States and (25%) in Australia. It seems that developed countries face time constraints in face-to-face clinical education courses. In medical systems, reducing patients' length of hospital stay to reduce the risk of nosocomial infections is also considered [11]. These issues can reduce the emphasis on face-to-face education for medical students. Therefore, computer simulation education in many developed countries has replaced traditional methods to increase clinical learning opportunities.
Within studies included in this SR, the authors have reported some limitations: the cost of technology, the timeconsuming work with technology, and the need to allocate a suitable physical location were among the most critical mentioned issues. It should be noted that depending on the practical details of the systems and the objectives of the study, the amount of cost and required time and implementation methods have been reported differently, and on the other hand, the inflexibility of the systems is a significant limitation. Other limitations include the demand for longterm evaluations (evaluating the effects of long-term education), problems with Internet access for online education, and the time-consuming technology training, as well as the need for sufficient knowledge to become familiar with technology; the presence of the operator has also been expressed in some investigations.
In the present SR, the framework of educational tools in the included studies comprises virtual reality-based Also, e-learning, virtual reality-based environment, online learning, and virtual reality-based environment plus sensor have been employed.

Interpretation of Results.
In recent years, several systematic reviews have been conducted to evaluate the effects of simulation tools on physiotherapy students' practices. In some reviews, authors have declared effectiveness on several or all scales [25,38], but in others, significant effects were not observed [27][28][29]. However, this SR's results demonstrated that in most studies, physiotherapy students reported a positive effect of computer simulation methods on improving clinical reasoning, basic knowledge, and practical skills. The last review study was designed in 2020 to " examine the role of the simulated patient in physiotherapy education," and its results indicated that the simulated patient is a valuable learning strategy for providing educational activities in medical education and physiotherapy curricula [39]. The simulated patient also facilitates student performance feedback to interact with patients and real-world environments. In the beforementioned review, the included studies acknowledged that the simulated patients could be used for various purposes, including education, improving self-perception skills, clinical practice, and expanding the attitudes of physiotherapy students. They also argued that simulated patients as an educational technique could improve physiotherapy students' clinical reasoning, communication skills, and motivations.
As far as we know, this is the first SR to evaluate the effectiveness of with emphasis on computer simulation education on the skills and knowledge of physiotherapy. Our results, in line with previous studies, emphasized that evaluation methods that consider communication education efficacy and effectiveness need to be improved to increase education quality [25]. Our study showed that computer simulation, especially if appropriately utilized for instructional delivery, will enhance learning and improve physiotherapy student performance as it may allow students to observe and visualize the step-by-step actions and reactions that take place in any treatment process. It seems that computer simulation can be a suitable method to replace the traditional simulation method. One possibility is that today, computer simulation education, especially for young student generations who are more prominent in adapting to new technologies and increasingly familiarized with computers, encourages them to further development and improvements in this field to introduce education with more fun.
In our study, we emphasized physiotherapy students because experienced physiotherapist therapists are familiar with the use of highly complex virtual reality systems as an intervention to use with clients' reports; it may be necessary that it is used and updated in curricula for teaching discipline-specific and interprofessional skills [40].
Also, in 2015, Mori et al. examined the impact of simulation-based learning activities in physiotherapy curricula using a full range of simulation techniques such as virtual reality, role-playing, written scenarios, and mannequins. Simulation learning experiences in physiotherapy students showed that simulation methods effectively facilitate the development of assessment skills, attitudes, and clinical reasoning of assessment students and can be included in physiotherapy curricula [25].

Strengths and Limitations.
This study is aimed at evaluating the effectiveness of computer simulation in the education of physiotherapy students; due to the vital education category, only studies that evaluated students were fitted in the SR, and examinations that incorporated experienced physiotherapists were excluded. This diversity and heterogeneity of studies limited the number of input articles. Overall, the central gap was the heterogeneity of the included studies. In the future, a review can be conducted that will include the target group of physiotherapists and physiotherapy students. Another limitation was the lack of generalization of the effects on appropriate physiotherapy training. In the current SR, studies that evaluated physiotherapy students at all levels of education, including BSc (Bachelor of Sciences), MSc (Master of Sciences), and DPT (Doctor of Physiotherapy), were included. However, some papers did not mention the student's degree. It seems that due to the different levels of knowledge of individuals and their attitudes towards education, it is better to pay more attention to the level of education of physiotherapy students.
On the other hand, due to the prevalence of COVID-19 as a pandemic, governments have shut down several activities across the country, including face-to-face training. This has led to the desire of universities to teach online as a learning platform, and learning computer-based simulation has become a significant challenge [41]. Given that virtual learning is widely used in physiotherapy as one of the essential disciplines of medical sciences, it seems that moving towards virtual simulation-based education, especially computer simulation education, is necessary for the future.

Implications for Practice.
Computerized-based learning tools have replaced traditional teaching approaches and learning methods recently. Due to the growing global need to use computer simulations, this issue extends significantly in modern countries. Therefore, it is suggested that developing countries also provide a suitable platform for these studies. However, the cost of technology, time, place, and implementation methods vary greatly depending on the details of the application, but most of them are expensive and require enough space. Therefore, it is recommended that governments plan for this type of training and related expenditures.

Conclusion
This SR highlights the effects of using computer simulation education on the skills and knowledge of physiotherapy students. The survey explained that computer-based simulation solutions had significant potential to improve physiotherapy students' skills and knowledge. e-Learning, virtual realitybased environment, online learning, and virtual realitybased environment plus sensor have been employed in included papers. The principal effectiveness is improving 17 BioMed Research International professional skills, behaviors, knowledge, and physiotherapist-reported outcomes like learning practice change, increasing confidence, and motivation reported in citations.

Data Availability
All data generated or analyzed during this study are included in this published article.

Ethical Approval
The methodology for this study was approved by the Ethics Committee of Tehran University of Medical Sciences; all methods were carried out in accordance with relevant guidelines and regulations.

Disclosure
This paper is formed as part of a thesis submitted by the second correspond author (ZR) for an M. Sc degree in Medical Informatics at Tehran University of Medical Sciences, with ethical code IR.TUMS.SPH.REC.1400.038.