Opportunities for Regenerative Rehabilitation and Advanced Technologies in Physical Therapy: Perspective From Academia

Why Regenerative Rehabilitation?

Having a working knowledge of regenerative rehabilitation concepts and innovative technologies is vital for physical therapists for a variety of reasons. As regenerative medicine technologies such as stem cell therapy or cartilage regeneration increasingly make their way to the clinic, the clinician must be aware of all the available options for their patients. Without being up-to-date on the most cutting-edge treatments, physical therapists may not be providing the best available intervention to the patient. Prescribing exercise programs must be assessed on a case-by-case basis, given the current research. Regenerative rehabilitation seeks to guide protocols in terms of when to start therapy, types of stimuli administered, and graded exercise programs, while taking into account biological factors and technologies designed to optimize healing potential.³ For example, exercise programs are now being designed to enhance stem cell–based platforms treating cardiac disease. Although there are currently protocols for cardiac rehabilitation, a recent study suggests that a high-intensity prolonged exercise regimen may be needed to supplement stem cell proliferation and differentiation.⁴ Stem cell scaffolding and transplantation are becoming increasingly integrated into the rehabilitation field. For example, Li et al,⁵ in a pilot study, have shown the promise of using human mesenchymal stem cells to regenerate cartilage for diseases such as osteoarthritis. Moreover, effective communication between a physical therapist and the patient is key in order to comprehensively field questions and explain concepts regarding recent advancements in treatment options available. It is inevitable that patients will seek out new techniques and treatments that potentially have better health outcomes according to the news or the Internet. However, as health care professionals, physical therapists must be prepared to demystify inquiries and make the appropriate recommendations.

The focus of this perspective article is to highlight faculty and graduate students' awareness of regenerative rehabilitation and advocate for further incorporation of these principles into the DPT curriculum. Learning styles of graduate students were explored for preference regarding integrating concepts in the DPT curriculum. Most often students access clinically relevant information for regenerative medicine from external sources such as symposiums and research articles as opposed to the physical therapy curricula. As such, the majority of physical therapist students and faculty are arguably underinformed regarding both the term “regenerative rehabilitation” and the implications of regenerative medicine as it relates to the physical therapist's role. This information draws attention to the need for a thorough assessment of the present-day physical therapy profession and curricula in order to provide rising physical therapists with opportunities for adding to their skill set and improving patient outcomes.

Application From Research to Physical Therapist Practice

Several new methods that are being studied for their therapeutic and diagnostic benefits include stem cell therapies, tissue engineering, high-definition fiber tracking, and brain-computer interface. These advances will affect the academic and clinical settings of physical therapy and further enhance the medical role of physical therapy. Application of regenerative technologies as part of stem cell therapy has shown positive influences in remodeling and recruitment of growth factors to increase the rate of tissue regeneration.² Various studies have demonstrated the effectiveness of stem cell transplantation or tissue engineering approaches used across a wide range of treatments, such as rehabilitating volumetric muscle loss.^5–7 Similarly, Gentile et al⁶ investigated the application of extracellular matrix scaffold transplantation to regenerate new quadriceps muscle tissue in a 28-year-old Marine and argued that postoperative rehabilitation was key for functional incorporation of the transplant tissue. Furthermore, the use of mechanical or electrical stimulation to enhance tissue regeneration reinforces the benefits of combining regenerative medicine with regenerative rehabilitation.⁷ Clearly, many cellular therapies are emerging that, undoubtedly, will have future implications for the patients seen by rehabilitation professionals. As regenerative advancements continue to evolve, physical therapists can and should help guide the rehabilitative protocols in regenerative rehabilitation in order to demonstrate clinical efficacy and to maximize functional outcomes for patients.

Moreover, targeted exercise therapy may be optimized through the incorporation of efficient diagnostic tools. One of these techniques is high-definition fiber tracking, a technique that creates high-resolution images of the brain showing specific neural connections that have been broken or disrupted from traumatic brain injuries and other disorders. This technology, which can easily be used in the clinic with the use of a handheld tablet, may one day help clinicians and medical professionals be more precise when developing treatment protocols. In patients with neurological disease and spinal cord injuries, the brain-computer interface is a system that links internal brain signals to external assistive robotics to stimulate movement.⁸ This form of technology is regenerative in nature, as it reinforces the connections in the brain to regenerate, thus forming new connections to improve movement.⁹ When looked at as a whole, the research clearly demonstrates a need for incorporating advanced technologies into the physical therapy profession in order to continue to be leaders in rehabilitation practice.

Exploring the Current State of Awareness of Regenerative Rehabilitation

As a means to acquire a physical therapy academic perspective on principles of regenerative medicine and related rehabilitation technologies, an online Qualtrics survey (Qualtrics Labs Inc, Provo, Utah) (Appendix) was designed and administered to graduate students and faculty in DPT programs nationwide. Topics such as familiarity with the term “regenerative rehabilitation” (Fig. 1) and the individual's perspective on the relevance of its concepts to physical therapy (Fig. 2) were explored. Similar questions concerning one's level of interest, interest in specific concepts that relate to regenerative rehabilitation (Fig. 3), and whether the principles are being taught in one's curriculum (Fig. 4) also were assessed. To further highlight how regenerative rehabilitation could be integrated into future curricula, questions were targeted at the identification of preferred learning methods (Fig. 5), with an open-ended question inquiring about regenerative medicine principles and its effect on physical therapist practice.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1.

Familiarity with the term “regenerative rehabilitation” between graduate students and faculty.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2.

Perceived relevance of regenerative medicine to future of physical therapist practice between graduate students and faculty.

• Download figure
• Open in new tab
• Download powerpoint

Figure 3.

Interest in concepts related to regenerative rehabilitation of graduate students and faculty.

• Download figure
• Open in new tab
• Download powerpoint

Figure 4.

Graduate student and faculty awareness of regenerative rehabilitation in doctor of physical therapy curricula.

• Download figure
• Open in new tab
• Download powerpoint

Figure 5.

Preference of learning methods of graduate students and faculty.

Program directors and administrative assistants were contacted via email, with a general description of the study, including the deadline and survey. The email addresses of the program directors and administrative assistants of accredited physical therapist schools were identified through the Commission on Accreditation in Physical Therapy Education website (CAPTE). Only email addresses on the CAPTE website or found via the directory of the university or college were used. All email addresses were freely available, with no clause against use. Respondents were excluded from the analysis if they were not identified as a graduate student or faculty member (self-report) of an accredited physical therapist program or if they did not fill out the survey questionnaire in its entirety. Completed results were then compiled and analyzed.

The survey was administered to 212 accredited physical therapist programs in the United States, of which 82 schools provided responses, totaling 1,078 completed responses. The final sample included 1,006 responses; 10 survey responses were excluded due to not meeting the inclusion criteria, and 62 responses were excluded because they were incomplete. The final sample comprised 862 graduate students, who represented 62 schools, and 144 faculty members, who represented 53 schools. The median number of student responses and faculty responses per program were 7 and 1, respectively; these data are fairly representative of academia in the physical therapy profession.

Barriers Perceived by Physical Therapy Faculty

Regarding the familiarity with term “regenerative rehabilitation,” there was an overall divide between students and faculty. The responses showed a mere 30.3% of graduate students being familiar with the term compared with 74.3% of faculty members (Fig. 1). This finding suggests that faculty may be familiar with regenerative medicine and up-and-coming related technologies. This familiarity with the concepts of regenerative rehabilitation may be a result of attendance in conferences, independent research, continuing education, and personal experience. There also may be an increased ability to attend APTA conferences due to funding and a more proactive role in education, as compared with graduate students. Faculty also tend to have more research opportunities than students. However, some barriers to implementing these concepts into the curriculum may include not having an adequate background to actively incorporate these topics into their courses. Staying up-to-date in a field that is progressing at unprecedented rates likely requires much more time than most faculty members are willing or able to devote due to constraints of time and resources, even though many faculty members acknowledge that this topic is highly relevant to the future of physical therapist practice (Fig. 2). This situation may set up a conundrum, where the material is acknowledged as being important and relevant, but time constraints simply make it nearly impossible in many cases. One could say that this puts the responsibility on the students to actively seek out this material on their own. Unfortunately, independent exploration is often challenging for a number of reasons, including but not limited to lack of research experience, clinical exposure, awareness of the term, and limitations in extracurricular involvement in academic activities.

Barriers Perceived by Physical Therapist Students

Although students are many times given the opportunity to conduct research within multiple classes, these guided experiences are all too often limited to course assignments and literature reviews in familiar topics. Even though there is an increasing shift toward evidence-based practice in DPT programs, there is, unfortunately, often limited exposure to innovative technologies and their possibility for clinical translation to patients. Moreover, it cannot be discounted that—however motivated they may be—graduate students have very limited free time to pursue such academic endeavors.

As a means to overcome these barriers, one could suggest addressing the need for various outlets for easily accessible information and sharing of new innovative technologies between individuals and groups of all sizes. For example, a social media platform such as Facebook (Facebook Inc, Menlo Park, California) allows for online communication via sharing of personal messages, news articles, and videos. Currently, students, faculty, clinicians, and anyone interested can join a Facebook group titled “Regenerative Medicine and Rehabilitation” and other similar groups to view posts about new technologies and advancements in the field of regenerative medicine as it relates to physical therapy. Another possible solution is to establish journal clubs where students would rotate between identifying and discussing topics outside the traditional scope of physical therapy on a regular basis. For example, individuals can meet at designated locations or video conferences to critically evaluate recent articles in academic literature. Similarly, having a monthly podcast from professionals in the field would be beneficial for individuals who cannot travel long distances. These methods will not only provide a structure for learning, but also create a growing knowledgeable community for the advancement of the physical therapy profession.

Principles of Regenerative Rehabilitation in DPT Programs

Although there may be a variety of reasons for the difference in awareness among students and faculty (Fig. 4), perhaps having these concepts be a standardized part of the DPT curriculum would allow faculty to teach a greater amount of this material, thus eliminating the disparity. Among those who mentioned learning about the field in the classroom, “briefly mentioned” was a term commonly used, thus further highlighting graduate students having limited instruction of regenerative rehabilitation topics in school. Furthermore, 26.8% of students reported not having regenerative rehabilitation taught in their school's curriculum, and 63.6% reported not being sure whether it was taught. Similarly, many faculty stated that this field was not taught in their curriculum (24.4%), and even more simply did not know whether it was taught (36.1%) (Fig. 4). Artificial organs, stems cells, and robotics are all topics that seem to be typically mentioned only in passing during classroom lectures in various courses of the DPT program, but the role of physical therapist's involvement with these topics in the future appears to be lacking. The status quo of the depth at which these topics are taught is simply insufficient for students to have an adequate working knowledge of the topics.

Those who were familiar with regenerative rehabilitation specifically noted learning about the field through the following: a clinical experience, personal research, peer conversation, conferences and meetings (eg, APTA conferences). A few reported learning about it via classroom lecture. Although it is important that physical therapist students have several opportunities to learn about the evolving field of regenerative medicine, it still demonstrates that there is a true need for a framework of integration of information where students may be increasingly exposed to the material.

Preference of Learning Methods

In an effort to explore ways to resolve the disconnect between faculty and graduate students, preference of learning styles was surveyed. The majority of participants selected hands-on seminars (26.7%), guest speakers (24.4%), and symposia (12.5%) as their preferred method of learning (Fig. 5). This information may be a useful first step in moving toward an increased integration of regenerative rehabilitation material into the current curricula. For example, there are many opportunities in a course for integrating concepts of regenerative rehabilitation, such as in-class lectures, online videos, hands-on labs, and required readings. Hands-on seminars or guest speakers may be an efficient method to teach new material in this field by inviting lecturers from outside departments, such as cell biology or bioengineering, or from nearby institutions to lecture within DPT programs. Also, there are multiple symposia, conclaves, and initiatives where students and faculty can learn about new and upcoming topics on current research such as the NEXT conference, including the Annual Symposium on Regenerative Rehabilitation and the Frontiers in Rehabilitation Science and Technology (FiRST) Initiative by APTA. Undoubtedly, there are barriers to these proposed solutions to include setting aside adequate resources to supply guest speakers and removing content from existing curricula in order to accommodate the principles of regenerative rehabilitation.

An integral part of physical therapy education involves clinical rotations consisting of both inpatient and outpatient experiences. These “hands-on” experiences are intended to apply the knowledge learned in the curriculum to real-life patients clinically with different levels of supervision. As more DPT programs incorporate regenerative rehabilitation concepts into the curriculum, it should likewise be reflected in their clinical rotations. As students become well versed in these topics in the classroom, they will be well equipped to share their knowledge with practicing clinicians during clinical affiliations, regardless of whether it be by word of mouth or through an in-service. This shared knowledge and exchange between student and clinical instructor will improve quality of care for patients and help to further the physical therapy role in this emerging field.

Currently, it may be argued that the first steps to increase one's understanding of regenerative rehabilitation concepts can be achieved through independent exploration by reading the latest research studies, listening to a podcast, or watching online videos. Without a well-defined curriculum that includes these concepts, physical therapist graduate students must be willing to take the initiative to seek out individuals who are already involved and search through the literature. Given the amount of material that professors are mandated to teach in a given semester, there is limited opportunity to incorporate regenerative rehabilitation concepts into each respective class as it relates to current medical advancements. For this reason, faculty members should encourage students to explore online videos that provide introductory information to topics relevant to regenerative rehabilitation and other advancing technologies. With the highly rigorous DPT curricula, some have proposed that there is a need to minimize the amount of time dedicated to the fundamentals in order to introduce new concepts and subjects that are well overdue. Dr Steve Wolf, a professor at Emory University, has argued, “There's just too much other information out there that needs to be introduced.”^10(p24) This forward-thinking perspective demonstrates the need for new material into the multidimensional curriculum through various means so the next generations of physical therapists will be well prepared for the future.

Perspectives on Relevance of Regenerative Rehabilitation

The time available for instruction throughout the DPT training is limited. As such, it is important to identify and prioritize the most relevant material for physical therapist practice. To determine the perceived relevance, faculty and graduate students who were familiar with the term were asked to rank how relevant regenerative rehabilitation is to the future of physical therapist practice. On a scale of 0 to 5, with 5 being the strongest, 67.3% of faculty and 71.3% of graduate students answered with a score of 4 or 5 (Fig. 2). This finding indicates that the majority of these participants believe in the importance of the implications regenerative medicine principles will have on the future of physical therapist practice. The recognition of the importance of these technologies for the future of physical therapist practice is not surprising, given that regenerative medicine technologies have the potential to revolutionize how we treat and rehabilitate patients in every aspect of health care.

As with perceived relevance (Fig. 2), both students and faculty showed high interest levels, as nearly all participants expressed interest in learning more about regenerative medicine principles and their application in the rehabilitation process. Specific concepts of interests within regenerative rehabilitation that generated the highest interest were stem cell therapies, robotics, and tissue engineering (Fig. 3). These high-interest areas may be a result of exposure from a multitude of references in the media, including online videos, news channels, and popular magazines available to the public. Other topics of interest that students or faculty noted were genetics, tensegrity, exoskeletons, telemedicine, neuronal regeneration, assistive technology, and biosensors. Although not exclusive to the category of regenerative rehabilitation, these areas have shown great promise of complementing regenerative rehabilitation practice. This is a strong indicator that physical therapy programs as a whole are willing to embrace new information that will enhance their ability to serve their patients and improve the rehabilitation process.

Clinical and Collaborative Opportunities

In order to meet the needs of interested graduate students and faculty, opportunities must be put forth for integration of regenerative medicine and rehabilitation concepts across disciplines. Clinically relevant applications of regenerative medicine in core foundational areas, such as musculoskeletal, neuromuscular, cardiopulmonary, and integumentary, could be the most logical method of integrating these concepts into the DPT curriculum. For example, a graduate student participating in the survey noted that a DPT program is currently partnering with the biomedical engineering program in a third-year robotics elective to understand potential rehabilitation collaborations. These types of partnerships would allow for expanding knowledge about regenerative medicine as it relates to physical therapist practice and encourage collaboration. In order for physical therapy, as a field, to meet APTA's vision of “optimizing movement to improve the human experience,” it is important that physical therapists collaborate with other medical professionals to ensure the best care for patients.¹¹ Partnerships among different fields need to be integrated at all levels, incorporating graduate students, physical therapists, physicians, engineers, and scientists. Such an interdisciplinary approach will foster growth in all concentrations, ultimately maximizing efficiency of health care across the spectrum.

It is crucial that physical therapist students be armed with all the necessary tools in order to adequately answer patient inquiries regarding new techniques available, as well as guide their clinical decision making. The APTA 2020 vision published in the year 2000 stated, “By 2020, physical therapy will be provided by physical therapists, who are doctors of physical therapy.”¹¹ In just 14 years, the transition to a doctoral-level program has been achieved by every accredited program.¹² By providing students with early exposure to advanced concepts such as regenerative rehabilitation, they can potentially be better equipped to treat and assess patient outcomes in the future and, therefore, play a more proactive role in supporting the profession as innovations in rehabilitation continue to advance.

Physical therapists recognize a responsibility toward professional development and lifelong learning, as well as exceeding performance standards within their area of practice.¹¹ Although independent research is critical in professional development, continuing education classes and postgraduate degrees may offer a more comprehensive learning experience. For example, universities are adding doctor of philosophy (PhD) programs in rehabilitation sciences to advance education into specialties that incorporate specific clinical interventions relating to regenerative medicine and rehabilitation. Similar to the progression of undergraduate to graduate school, prerequisites and a prior basic understanding of concepts are important factors in continuing education. Therefore, it is paramount for the DPT programs to assess the specific applications of regenerative medicine as it applies to physical therapy in order to prepare them for the future.

Recommendations for the Future

The gap between basic science research and clinical practice is closing at a rapid rate. Creating awareness of how regenerative medicine could be used to help treat patients will provide physical therapists with the upper hand in this emerging field. From an educational standpoint, the field must specify renowned experts in regenerative rehabilitation willing to contribute material in their specialization to curriculum via online lectures, guest lecturers, or other tele-educational methods. Students require a basic understanding of clinical skills to adequately assess patients while keeping up-to-date with current medical advancements. As the field of regenerative medicine progresses, DPT programs and clinicians would one day benefit from the establishment of a database of clinical rotations for entry-level students specializing in regenerative rehabilitation that are supervised by clinical instructors with a background in regenerative medicine. In order to be the rehabilitation specialists of the future, it is necessary for the structure of DPT curricula to incorporate a multitude of opportunities for both professors to teach and students to learn new material today.

Collaborative efforts help to create an interdisciplinary culture allowing for information to be readily shared between researchers and clinicians. Doctor of physical therapy programs must investigate opportunities to allow and establish partnerships between physical therapy departments and other related medical departments, such as cell and molecular biology and biomedical engineering. As new technologies enter the clinical arena, these collaborations are necessary to provide patients with the most effective interventions and to maintain the value of specialized physical therapy care.

The complexity of the DPT curricula takes many shapes, making it difficult to re-evaluate standards. For this reason, APTA created a work group to structure physical therapist education programs that eventually became the American Council of Academic Physical Therapy (ACAPT). The purpose of ACAPT is to advance the enterprise of academic physical therapy by promoting the highest standards of excellence. It is ultimately task forces such as ACAPT's Benchmarks for Excellence Task Force that will give rise to a new standard of academic excellence in physical therapy by establishing new accreditation criteria that includes regenerative and innovative technologies.¹³ One could propose that this task force should investigate the need to integrate regenerative rehabilitation into the physical therapy curriculum.

Although there are methods of incorporating this material into graduate study as previously discussed, at present, it may be argued that the responsibility falls mainly on the student until a change in the curricula is integrated. However, to maximize the success of physical therapy as a discipline, it is important to share the responsibility of initiating new fields into the profession among students, faculty, APTA, and DPT programs in order to achieve higher-quality health services. Independent research, postgraduate school, and interdisciplinary networking are all critical to professional development and lifelong learning. The landscape of rehabilitation is changing. As practitioners of choice, maintaining an active approach to learning about new technologies is paramount to achieving Vision 2020 and continuing to be the rehabilitation specialists of the future.