Integrating neurophysiology, motor control, and neuromechanics of human movement can be challenging for undergraduate health students due to the concepts that they are required to learn and understand in academic curricula like physical therapy (PT) (1–3). The non-stationary nature of neurophysiology (4), i.e., the rapid fluctuations of voltage created by ion fluxes in plasmatic membranes, and the lack of practice in critical thinking and reasoning, make motor control and neuromechanics difficult for PT students. PT curricula might be related to this limitation because of their topographical approach, memorized skill, and passive teaching focus within the first years of 5-years long programs (5, 6). However, this can be overcome using demonstrations (7), practical lessons, and active learning methodologies, which involve the student learning rather than relegating them to a passive role as observers (8, 9). In addition, surface electromyography (sEMG) or kinematics technology may facilitate the learning of students (8) during demonstrative practices (9) because these bioinstruments can show real-time instantaneous changes that PT students can actively interact with, and analyze.

Although there are several choices for measuring sEMG, the dry bipolar sEMG allows the quantification of the sum of trains of motor units action potential voltages produced by muscle fibers when contracted. Dry bipolar sEMG has low time consumption and can reproduce motor patterns under controlled conditions for learning purposes in PT (10, 11). The sEMG with this aim has been called kinesiological sEMG (12, 13). This sEMG has been widely and safely applied non-invasively (12–14). For kinesiological assumptions, it is relevant to complement the sEMG measures with synchronized kinematics to understand the action of muscles during the movement. sEMG is not an out of reach technical challenges (12, 13, 15, 16), but its implementation for teaching can be found on www.robertomerletti.it, the YouTube channel NeuromechTV, the BiomeCast (17), or ISEK-JEK tutorials (8, 18–20).

Combining sEMG and kinematics with active learning methods in practical activities would encourage PT students to learn, analyze, and discuss actively under a critical thinking and science context. Critical thinking “is the ability to raise discriminating questions to search for better ideas, a deeper understanding, and better solutions relating to a given issue” (21), and science involves the use of the scientific method. Such skills are crucial to criticizing data, identifying whether conclusions are supported by evidence, and distinguishing the effects of an intervention or stimulus (22). Health students can elaborate more sophisticated reasoning (22) and improve their professional practice when using critical thinking (21). Thus, to explore the difficulties (the level of challenge that learners experience during the learning process (23)), uncertainties [the cognitive impasse while understanding something, resulting in uncertainty, lack of clarity, disorientation, contradiction or mental pause (23, 24)], and advances [educational important improvements similarly to clinical importance meaning (25)] of students perceived by faculties is essential to improve laboratory activities for PT student. This may fill the gap related to familiarity with science, technology, engineering and mathematics (STEM) background and the STEM-based new technologies that can shape the future of rehabilitation (11). Consequently, we aimed to describe the difficulties, uncertainties, and advances observed by faculties on students, and the perceptions about learning, satisfaction, and grades of students after implementing laboratory activities in a PT undergraduate course, which integrated sEMG and kinematic technology combined with active learning methods.

The laboratory activities difficulties, uncertainties, and advances observed by the laboratory faculties for each laboratory activity are summarized in Table 2.

The total of students (n = 482) considered that the course “always” or “almost always” promoted their creative, analytical, or critical thinking with a median of 70.5% [61.0% (minimum value) – 88.0% (maximal value)]. The total students (n = 482) perceived that the faculties “always” or “almost always” linked the course content to real-life situations with a median of 94.5% [89.0% (minimum value) – 98.0% (maximal value)]. All the students (n = 482) felt satisfied with the course development with a median of 97.0% [93.0% (minimum value) – 98.0% (maximal value)]. See Figure 3.

The laboratory grades for the total of students (n = 482) achieved a median of 5.3 pts. [3.3 pts. (minimum value) – 7.0 pts. (maximal value)]. Moreover, the course grades for the total of students (n = 482) achieved a median of 5.6 pts. [4.0 pts. (minimum value) – 6.7 pts. (maximal value)]. The linear regression model obtained was (laboratory grades) = 2.69 + 0.53 (course grade) with 480 degrees of freedom, slope 0.534 [95% confidence interval: 0.479 to 0.590] and Y-intercept 2.691 [95% confidence interval: 2.395 to 2.987], statistical significance (p < 0.001), a root mean square error of 0.416, and an R-squared of 0.427 (Figure 4).

The main findings of this study indicate that the laboratory activities: (i) Challenged the students to learn and understand based on the difficulties and uncertainties that were effectively managed and led to improvements in student learning. This finding aligns with effective learning strategies, emphasizing the importance of encountering challenges as integral components of deep learning processes. (ii) The activities promoted critical thinking and facilitated the application of course content to real-life movements, and high levels of satisfaction with the whole course were obtained. This satisfaction trend was consistently observed across six different cohorts. (iii) Additionally, laboratory grades explained 43% of the total variance in the course grades with a moderate association (regression coefficient of 0.53). From the learning point of view, these results are relevant because when PT students started the course, they felt that laboratory activities and technology will not provide helpful knowledge for their future clinical practice and tended to be comfortable memorizing concepts. In this sense, the active methodologies and the addition of sEMG and kinematics in real-time allow PT students to explore new strategies for human movement analysis and develop their critical thinking and reasoning supported by the scientific method, obtaining important learning and attitude changes. The laboratory activities induced students to adopt a critical and causative point of view on why signals changed in front of them. The purpose of our methods was a transformation of PT to engage with STEM backgrounds and the STEM-based new technologies familiarization that can impact the rehabilitation of patients.

The most relevant learning difficulties were the human anatomy background (the PT anatomy is not only the origin and muscle fibers orientation knowledge; also the irrigation, innervation, myotomes, dermatomes, medullar roots of nerves, or detailed bone landmarks were asked), identifying the muscle actions (eccentric, concentric, or isometric), integrating the physics concepts (gravity force, external and internal torques), and identifying the mechanical effects of muscle actions crossing more than one joint. It is suggested that a fresh previous background is more important when the active methodology is used because the students’ active class participation would immediately show their deficits. Due to that, our method might cause a cumulative source of difficulties and uncertainties, especially for those who tried to memorize instead of analyze. Thus, tuning the difficulties and uncertainties, filling gaps in knowledge, and managing (focusing) the study of students in and outside the laboratory are crucial issues to producing effective learning (23, 24). Laboratory activities create the opportunity to uncover the ideas of students as well as the students’ difficulties and uncertainties (31). Our motor task problems challenged the students through collaborative discussions (32) and technology use (6). Previous evidence suggests that active methodologies, such as those we performed, positively impact students’ learning (32) and better address inter-student learning variability, which in PT students has been mainly identified with collaborative learning style (33).

Especially for PT students, the active methods of using sEMG and kinematics measurements permitted them to address better the neuromechanics and motor control topics (34). The promoted critical thinking linked the course content to real-life movements, and reasoning practice was crucial for the early development of human movement analysis skills that may favor understanding the mechanisms behind human movements in agreement with the benefits of incorporating practical lessons in the students’ learning (35, 36). The study of neuromechanics and motor control in PT is a challenge because this is often presented as managed by high-level central structures, neglecting the peripheral role in human movement control (37) or is not considered in musculoskeletal PT because the attention is centered on the morphology and movement of the joint surfaces. In consequence, the combination of different active methods in the laboratory activities where technology can measure instantaneous changes in real-time (briefly: depending on the need, the student must understand how analog signals end up in discretized signals, Nyquist frequency, synchronization, drifting, etc.) linked with real-life movements suggest the need to improve the students learning in agreement with the effects of blended learning methodology based on real-life movements (38) and how laboratory activities improve the theory comprehension of students (31). Also, high satisfaction was observed among the students with the whole course, and the students perceived our activities as applicable and connected to the main course aims, which was consistently observed across six different cohorts.

The linear model used to study the course grades and the laboratory grades as the independent variable fits with an R-squared of 43%, and both variables were associated with a regression coefficient of 0.53 (moderate association). It may be that students who performed well or poorly in the course tend to perform similarly in answering the laboratory quizzes. We suggest that laboratory activities assessment should not only be limited solely to quizzes because it is essential to consider other skills directly related to the laboratory activities to understand better how these activities influence theoretical courses in PT. On the other hand, some students failed the laboratory, demonstrating that the laboratory demanded a higher learning effort (39) than the overall course. The laboratory-based learning effort may develop higher-level thinking skills, such as understanding, analyzing, and evaluating (40), in contrast to the whole course, which mainly focuses on memorization skills. The focus on memorization skills in this course is in coherence with how the PT clinician professors reserve critical thinking skills development only when students perform clinical courses. We suggest that the development of higher-level thinking skills can start during the first PT courses, as we have proposed in this study.

Unfortunately, our teaching has been interrupted due to four main reasons: (i) In 2019, the country suffered political instability affecting university teaching. (ii) From 2020 to 2022, the coronavirus pandemic forced the course into online and hybrid modalities, prompting the reorganization of classes (17). (iii) In 2023, two newly incorporated faculty members opted not to further develop this activity, reverting to passive lectures and reducing laboratory activities. (iv) In our, as well as in other countries, newly nominated professors focus on publications and grant applications over teaching commitments. Additionally, recent graduates joining the faculty lack the knowledge and autonomy to conduct such activity, in agreement with recent reports (11). Hence, effective implementation of laboratory activities in PT require familiarity with biomechanical instrumentation (technical independence), clinical and teaching experience in human movement analysis and rehabilitation, signal processing skills, a track record of publications, grant writing capacity, and familiarity with both active and passive learning methods.

As a limitation, our study only assessed a cohort (without a control group) due to indications of the institution. It gave the same methodologies to all students without chances to make changes if the curriculum did not indicate it. Future directions should improve our laboratory activities, methods, and study design. More shared experiences are needed to reach a better solution to engage PTs with STEM backgrounds and STEM-based new technologies. Research faculties should not be exclusively dedicated to their own research lines. The BS classroom should be an excellent opportunity to prepare students for rehabilitation using technology, doing research and impacting the rehabilitation of patients. Finally, PT departments must introduce technology and measurement techniques to the students involved in rehabilitation and not only focus on teaching manual and clinical skills. Innovative teaching and learning methods and specialized PT familiarized with STEM would be fundamental to this transformation.

PT students did not initially perceive the value of laboratory activities and technology for their future clinical practice and tended to be comfortable memorizing concepts more than understanding, analyzing, and evaluating them. However, the integration of sEMG and kinematics technology with active learning during PT laboratories engaged students in learning and enhanced their understanding of the link between the neuromuscular system and mechanical elements of human movement. This innovative methodology shows promise for improving teaching-learning processes and presents challenges for both faculty and students. Importantly, these outcomes were consistently observed across six different cohorts of students, demonstrating the robustness and effectiveness of the approach.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

The studies involving humans were approved by Universidad Catolica institutional review board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

CF: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. AN: Formal analysis, Funding acquisition, Validation, Writing – original draft, Writing – review & editing. ÁM: Conceptualization, Validation, Writing – review & editing. MD-B: Conceptualization, Validation, Writing – review & editing. MK: Conceptualization, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing. AA: Conceptualization, Methodology, Validation, Writing – original draft, Writing – review & editing. FC: Conceptualization, Formal analysis, Methodology, Validation, Writing – original draft, Writing – review & editing.