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Abstract

Purpose

The virtual flipped classroom (VFC) is a virtual instructional strategy that engages students through active learning strategies and supports both synchronous and asynchronous virtual education components. This study examined the efficacy of the VFC instructional method in a Proprioceptive Neuromuscular Facilitation course for physiotherapy students.

Method

In this quasi-experimental study, 16 instructional sessions were randomly assigned to a cohort of 55 fifth-semester physiotherapy students. Based on the nature of the content (theoretical vs practical), 8 sessions were delivered asynchronously using the Virtual Lecture-Based Learning (VLBL) approach, while 8 were delivered through the VFC method. To reduce carryover effects, the 2 instructional methods were alternated weekly with a one-week washout interval. Of the 16 sessions, 10 (5 VLBL and 5 VFC) were randomly selected to include both a pretest and a posttest to assess students’ learning progress. After the course, students’ satisfaction, attitudes, and knowledge associated with both instructional methods were measured and compared.

Results

Students demonstrated significantly higher overall knowledge, satisfaction, and attitude scores under the VFC approach compared with VLBL (P < .001). Across the 5 assessed sessions, the VFC method also produced significantly higher pretest and posttest scores than VLBL (all P < .001). Although absolute performance was consistently greater in the VFC sessions, pre- to posttest improvement did not differ between methods (P > .05), indicating comparable learning gains. Both instructional methods, however, showed significant gains relative to baseline (all P < .001).

Conclusion

The findings suggest that the VFC is an effective instructional approach for enhancing second-year physiotherapy students’ knowledge, satisfaction, and attitudes toward learning.

Keywords

proprioceptive neuromuscular facilitation virtual education flipped classroom physiotherapy learning

Introduction

The global COVID-19 pandemic disrupted formal education beginning in 2020. Since the COVID-19 pandemic, many educational institutions have adopted Learning Management Systems (LMS) for teaching various courses.¹ While this shift enabled continuity in instruction, students’ satisfaction with asynchronous virtual learning—where content is delivered via prerecorded lectures and independent assignments—has often been moderate to low, especially compared to traditional face-to-face approaches.² This has prompted growing interest in more interactive, student-centered online methods, such as the Virtual Flipped Classroom (VFC), which blends digital learning with active participation.³

The flipped classroom (FC) is an established educational model that inverts conventional lecture-based teaching: students first engage with instructional material outside class, acquiring foundational knowledge at their own pace, then participate in collaborative, problem-solving activities during structured class time.^4,5 Previous FC studies in face-to-face settings have shown that FC can enhance academic achievement, critical thinking, and learner satisfaction by promoting active engagement and deeper understanding.^6,7 However, the effectiveness of FC can vary depending on the context in which it is implemented. While FC has been extensively studied in face-to-face settings,⁷ the literature on its impacts in virtual environments remains less developed.

To adapt FC principles to remote education, the VFC model integrates asynchronous preclass preparation with synchronous, interactive online sessions using platforms such as Zoom or Adobe Connect. Synchronous VFC activities are designed to simulate the real-time interaction, feedback, and collaboration, and active learning found in physical classrooms, which are often lacking in traditional asynchronous formats (Figure 1).^8,9 Although preliminary studies suggest that VFC may improve engagement and knowledge retention compared to asynchronous approaches,^8,9 robust comparative evidence in health sciences education remains limited.

Figure 1.

Traditional classroom, flipped classroom, and virtual flipped classroom models.

A critical yet underexplored question in online pedagogy is whether students achieve better learning outcomes in synchronous or asynchronous instructional sessions. Some research suggests synchronous sessions may increase engagement and provide opportunities for immediate feedback, whereas asynchronous sessions allow for greater flexibility and self-paced learning.^10–13 The optimal balance between these approaches, especially in the context of teaching complex professional and psychomotor skills, is not yet established.^10–12

This knowledge gap is especially relevant in physiotherapy education, where students must develop both cognitive (theoretical) and psychomotor (practical) skills for professional competence. Proprioceptive Neuromuscular Facilitation (PNF) is a core, hands-on technique that exemplifies the challenge of teaching complex skills through virtual environments.¹⁴ While prior research has demonstrated the benefits of active learning in medicine and engineering,^6,15–17 there is little high-quality evidence on the most effective methods for teaching practical physiotherapy content, especially in terms of comparing different online instructional models.^5,18,19

At our institution, asynchronous Virtual Lecture-Based Learning (VLBL) is the standard mode of online instruction for PNF. The adoption of the VFC model, which incorporates synchronous interaction, represents a significant pedagogical innovation. However, it also requires substantial additional investment in instructional planning, technological infrastructure, and real-time facilitation.²⁰ It is therefore crucial to determine whether the VFC provides more significant outcomes compared to the VLBL in both theoretical and practical skills acquisition. Accordingly, the current study seeks to fill this gap by exploring the effectiveness of VFC in teaching PNF to physiotherapy students. Specifically, by evaluating VFC outcomes relative to VLBL, this study provides discipline-specific evidence on whether synchronous, student-centered online instruction offers meaningful advantages over traditional asynchronous methods in health sciences education in the digital era.

Methods

The reporting of this study conforms to the DoCTRINE Guidelines: Defined Criteria To Report Innovations in Education (Supplemental File 1).²¹

Study Design

This quasi-experimental study employed a single-group pretest-posttest design with 2 instructional interventions. It was conducted in 2024 at Hamadan University of Medical Sciences, Hamadan, Iran. Participants were fifth-semester undergraduate physiotherapy students recruited from the same cohort. Given the complexity and structured nature of PNF content within the physiotherapy curriculum, instructional sessions were randomized, and topic-matched washout intervals were introduced between VFC and VLBL sessions. These measures were designed to enhance internal validity while accommodating the practical constraints of curriculum-based research. For each topic within each instructional session, the learning domain, content type, learning objectives, instructional duration, adjunctive educational tools, learning resources, and assessment methods were predefined in the course plan, in accordance with the Bachelor of Physiotherapy curriculum (see Supplemental File 2). The study protocol was approved by the Ethics Committee of Hamadan University of Medical Sciences (IR.UMSHA.REC.1399.321) and approved by the Hamadan University's Vice Chancellor for Research and Technology (9904312720). Written informed consent was obtained from all participants before enrollment.

Study Population

The study population consisted of all fifth-semester physiotherapy students enrolled at the Rehabilitation Sciences School of Hamadan University of Medical Sciences.

Sampling Method

Purposeful sampling was used to select the study group from the target population. According to experts, purposive sampling or judgmental sampling is a nonprobability sampling method. Individuals are chosen using primary criteria that the researcher believes represent the population.²² The main criteria for the present study were as follows: (1) physiotherapy student, (2) all participants part of the same degree (undergraduate), (3) enrolled in the same semester (semester 5), (4) enrolled on a PNF course, (5) having the same instructor, and (6) providing a written informed consent to participate.

The PNF course was suitable for our needs because of its nature (both theoretical and practical), in which students are exposed to various clinical cases.

Sample Size

The sample size was calculated at least 48 samples by the formula for comparing proportions with 90% power (type 2 error (β) = 0.1), 95% confidence interval (type 1 error (α) = 0.05), P1 = 0.63, and P2 = 0.17 according to the reference (Table 1).⁵

Table 1.

Parameters Used for Sample Size Calculation Based on Comparison of Proportions.

Alpha (α)=	0.05	Z_1-α_/2=	1.961150826
Beta=	0.1	Z_1-B=	1.281555798
p1=	0.63	p̄ =	0.4
p2=	0.17	n =	48

In the current study, all 55 third-year (fifth semester) BS physiotherapy students at the Rehabilitation Sciences School of Hamadan University of Medical Sciences were enrolled.

Interventions Assignment

In this quasi-experimental study, a total of 16 sessions covering the theoretical and practical components of PNF were delivered using the VFC and VLBL methods in a randomized sequence within the same cohort of students. To minimize potential carryover effects, VLBL and VFC sessions were alternated weekly with a one-week washout interval, reducing familiarity bias and immediate content overlap. Before the initial theoretical session (Session 1) and the first theory–practical session (Session 7), the instructional method (VFC or VLBL) was randomly assigned through a drawing of lots. During the first 6 sessions, PNF content was taught exclusively in a theoretical format. Randomization resulted in Sessions 1, 3, and 5 being delivered via VLBL, while Sessions 2, 4, and 6 were delivered via VFC. The remaining 10 sessions (Sessions 7-16) followed a theory–practical format. Random assignment for these sessions allocated Sessions 8, 10, 12, 14, and 16 to the VLBL method, whereas Sessions 7, 9, 11, 13, and 15 were taught using the VFC method (see Supplemental File 2). Thus, both instructional approaches were applied equally across sessions, targeting the cognitive and psychomotor skills required for PNF education.

Of the 16 sessions, 5 VLBL sessions and 5 VFC sessions were randomly selected to include both a pretest and a posttest to assess the learning process and session-specific academic achievement. The pretest served a formative purpose, while the posttest functioned as a summative assessment. Both assessments were aligned with the corresponding session objectives to control for baseline disparities across the randomized, topic-matched VLBL and VFC sessions. Upon completion of the course, students’ satisfaction with the instructional processes, attitudes toward the learning methods, and overall knowledge levels were assessed for each instructional approach.

Virtual Lecture-Based Learning

The VLBL instructional method in this study was delivered entirely asynchronously through the university's LMS, Navid (https://lms.smums.ac.ir/?lang = en). This approach was designed to promote student-centred, self-paced learning without scheduled live interaction. The learning resources provided to students included lecture slides, reading materials, handouts, instructional guides, content summaries, textbooks, downloadable summary sheets, and, during the theory–practical PNF sessions, prerecorded instructional videos. All materials were uploaded to Navid before each session. In this model, the instructor assumed a predominantly passive role, serving as a content provider and offering chat-based support via the LMS. Students were expected to engage independently with the materials, take responsibility for their learning, and participate in forum discussions and peer interaction.

To support continuous assessment and reinforce engagement, the following evaluation strategies were implemented:

1. Formative Assessment: A brief 15-min electronic pretest (multiple-choice [MCQ] or short-answer format) was administered 24 h after content upload to assess baseline understanding. These formative quizzes did not contribute to final grades and were used solely to identify early learning gaps.

2. Additional Evaluation Methods: Each VLBL session incorporated student-performance observation, peer or self-evaluation, and asynchronous question-and-answer discussions facilitated through the LMS chat room. These interactions provided opportunities for clarification and allowed students to engage with peers and the instructor at their own pace.

Summative Assessment: A brief 20-min electronic posttest quiz (MCQ and short-answer format) was administered one week later to assess knowledge acquisition and session outcomes.

Each VLBL session was designed to require approximately 90 min, including time for content review, assessment activities, and participation in LMS-based discussions.

Virtual FC

The VFC method was implemented in 2 phases: (1) out-of-classroom activities conducted asynchronously through the Navid LMS platform for material distribution and assignment completion, followed by (2) in-classroom activities conducted synchronously via Adobe Connect or Zoom to enable real-time interactions. A one-day interval was maintained between these 2 components.

Out-of-Class Activities (Asynchronous E-Learning)

In the initial phase of the VFC, educational content and assignments were delivered asynchronously through the university's LMS (Navid). Materials included lecture slides, handouts, instructional guides, content summaries, textbooks, prerecorded instructional videos, and downloadable summary sheets.

To enhance student engagement and support formative assessment, students were organized into small groups to promote collaborative learning. Each group was responsible for reviewing the provided materials and sharing the main concepts in the LMS chat room. Student groups collaborated to share and summarize key points from the instructional materials through the LMS chat.

Group members compared and discussed the summarized content asynchronously, and these discussions contributed to the formative evaluation. The quality of group submissions—ranging from the weakest to the strongest summaries—was used as a basis for feedback and discussion.

Evaluation during this phase included observing group performance and peer and self-assessment, all facilitated asynchronously through the LMS chat platform. Each asynchronous session was designed to last approximately 60 min, encompassing content review, assessment tasks, and participation in group discussions within the Navid system.

In-Classroom Activities (Synchronous E-Learning)

The second part of the intervention took place during synchronous e-learning sessions within the virtual classroom, utilising the Adobe Connect or Zoom platform with a one-day interval after uploading the lecture to the LMS. These in-class activities aimed to facilitate real-time discussions, presentations, and oral interactive questions and answers (Q&A).

At the beginning of each synchronous session, a brief 15-min electronic pretest was administered to assess students’ understanding of necessary concepts. The pretest served a formative function, helping instructors identify learning gaps based on students’ responses; it did not contribute to final course grades.

During each synchronous session, a student group delivered a brief oral presentation accompanied by PowerPoint slides, followed by collective discussions and problem-solving activities involving both students and the instructor. This portion of the session lasted approximately 20 min. The instructor then led an additional 15-min discussion focused on addressing conceptual gaps identified in the pretest and reinforcing essential content. So, in this part of the VFC approach, the instructor adopted an active facilitative role: guiding discussions, clarifying concepts, posing oral questions, and providing real-time feedback, while students engaged collaboratively through active participation in discussions, interactive clarification, and problem-solving activities. At the end of the synchronous session, a brief electronic quiz (summative assessment) of approximately 20 min was administered, contributing to students’ final grades. Each synchronous module lasted approximately 70 min in total, encompassing students’ presentations, discussions, problem-solving activities, assessments, and, for the theory–practical PNF sessions, video-based feedback.

The Specific Differences Between the VFC and VLBL Approaches

In terms of objectives, the VLBL model emphasized self-paced learning characterized by passive engagement, whereas the VFC approach encouraged active collaboration and peer learning through synchronous interaction. Regarding the mode of delivery, VLBL was conducted entirely asynchronously, with students engaging with peers and the instructor through the LMS at their own pace. In contrast, VFC combined asynchronous activities delivered via Navid with synchronous sessions conducted through Adobe Connect, thereby promoting greater interaction and opportunities for real-time feedback. Concerning assignment types, VLBL focused on asynchronous question-and-answer discussions, student performance observation, peer/self-evaluation, and brief electronic quizzes, while VFC incorporated oral Q&A, student performance observation, peer/self-evaluation, and brief electronic quizzes. Finally, in terms of duration and timing, each asynchronous VLBL module lasted approximately 90 min, whereas the VFC format included about 60 min of asynchronous work complemented by 70 min of synchronous engagement.

Intervention Quality Control

The physiotherapy department at Hamadan University of Medical Sciences developed and approved the VFC course outline. A random faculty member attended the virtual class to monitor the quality of the intervention and its conformity with the course curriculum. During the implementation period, professors from the Tehran University of Rehabilitation Sciences and Social Health and the Hamedan University of Medical Sciences provided feedback to eliminate deficiencies and improve the educational program.

Instruments

The study questionnaires were developed through a rigorous process to ensure validity and reliability. Initially, a comprehensive review of the existing literature on medical education and relevant assessment tools was conducted. This review helped identify a pool of potential questionnaire items, which were carefully drafted to align with the study objectives. The validity of questionnaires was assessed by a 10-medical education expert panel. The initially developed questionnaires underwent a pilot study of a group of 15 students who had completed the musculoskeletal examination, assessment, and practice course with the VFC. The experts’ comments and students’ responses to the questionnaire were collected and analyzed to assess their clarity, comprehensibility, and relevance. The questionnaires assess various aspects, such as satisfaction, attitudes, and learning progress in the VFC or VLBL method, as below:

1. Demographic data form: The “Demographic data form” includes the student's age, marital status, number of children, place of residence, employment status, and last semester's grade point average. This form was designed according to the demographic data form in the Safari et al study.²³

2. Students’ satisfaction questionnaire: The Students’ satisfaction with instructional method” is a self-administered questionnaire with 14 questions on a 5-point Likert scale (ranging from “very low = 1” to “very high = 5”). Some of its questions include, “To what extent did the provided content meet your educational needs?” “To what extent did the assignments inspire you to learn more?” “To what extent did the instructional method stimulate your interest in the topic?” among others. The assignment was completed after the course for both instructional approaches.

The content validity ratio (CVR) and content validity index (CVI) for the satisfaction questionnaire were found to be 0.71 and 0.87, respectively. To evaluate the face validity quantitatively, the impact score was calculated and found to be 3.81. Additionally, the intraclass correlation coefficient (ICC) was determined to be 0.72. Furthermore, the reliability coefficient was assessed using Cronbach's α method and yielded a value of 0.89 based on a pilot study involving 15 students (Supplemental File 3).

3. Students’ attitude questionnaire: The “Student's attitude towards the teaching method” is a self-administered questionnaire with 12 questions on 5 Likert's scale (from “totally disagree = 0” to “totally agree = 4” for 1-10 questions), the final 2 questions have a negative proposition (from “totally disagree = 4” to “totally agree = 0” for the last 2 questions). Its questions include, among others, “Did this instructional method lead to a better understanding of the subject?” “Did this instructional method make me more responsible?” and “Is this instructional method a fun way to learn in physical therapy?.” The assignment was completed after the course for both instructional approaches. The CVR and CVI were determined to be 0.78 and 0.85, respectively. To evaluate the face validity of the questionnaire, the impact score was found to be 3.85. Additionally, the ICC was calculated and yielded a value of 0.88. Furthermore, the reliability coefficient was determined using Cronbach's α method, resulting in a value of 0.89 based on a pilot study (Supplemental File 3).

4. Academic achievement tests: Academic achievement tests were administered to assess students’ learning progress within each instructional session. Parallel sets of MCQ, scenario-based, and short-answer questions were used as formative pretests and summative posttests for both the VLBL and VFC sessions, each scored on a 0 to 10 scale. To minimize content bias and reduce repeated-exposure effects, the academic achievement tests were randomly implemented in 5 of the 8 sessions in each instructional approach. After completing both training approaches, students underwent a final knowledge assessment (20 points) comprising 10 points on VLBL content and 10 on VFC content. An expert panel confirmed the content validity of this examination, and its reliability was verified through a test–retest procedure, with no significant differences observed between administrations according to McNemar's test (P > .05).

Statistical Analyses

The normality of the data was assessed using the Kolmogorov-Smirnov test, which indicated a skewed distribution for all variables. As a result, the Wilcoxon test was used to analyze the median scores of students’ overall knowledge, attitude, and satisfaction following the educational interventions. The analyses also focused primarily on within-method knowledge gains (pretest to posttest) in randomized, matched sessions between VFC and VLBL. A significance level of  P < .05 was considered statistically significant. All statistical analyses were conducted using SPSS software, version 22.0 (SPSS Inc) for Windows.

Results

Students’ Characteristics

Most students (72.72%) were single and lived in private accommodations (76.33%). The mean (SD) age of the participants was 22 (±2) years. Of the participants, 25 were female, and 30 were male. The mean total score of the final exams from the preceding semester was 15.68 (±0.82), with the highest possible score being 20.

Students’ Satisfaction

Although students’ satisfaction (median [IQR]) was high in both instructional methods, the VFC instructional method (57 [4]) was significantly higher than the VLBL instructional method (42 [4]) (P < .001) (Table 2).

Table 2.

Comparison of Overall Satisfaction, Overall Knowledge, and Overall Attitude Median Scores Between VLBL and VFC.

Instructional method	VLBLMedian [IQR]	VFCMedian [IQR]	P-value
Satisfaction	42 [4]	57 [4]	< 0.001
Knowledge	8 [3]	9 [1]	< 0.001
Attitude	35 [8]	45 [6]	< 0.001

Abbreviations: VFC, Virtual Flipped Classroom; VLBL, Virtual Lecture-Based

Learning. Significant P-values are in bold

Table 3 reveals a comparison of satisfaction items at different levels between VFC and VLBL instructional methods, presented separately. The results revealed that some satisfaction questionnaire items, such as “the possibility of participating in class activities,” “the learning effectiveness of in-class discussions,” “the role of homework in motivating to learn more,” and “the applicability of assignments in skill development,” indicated a high level of satisfaction with the VFC instructional method (70%). In contrast, the satisfaction percentage for the VLBL instructional method on the aforementioned satisfaction questionnaire items was below 30% (Table 3).

Table 3.

Comparison of Satisfaction Items After Completion of Both VFC and VLBL Instructional Methods.

	Satisfaction item	Group	Satisfaction level
	Satisfaction item	Group	Very high number (%)	High number (%)	Moderate number (%)	Very low number (%)	Low number (%)
1	Fitness of the content of e-contents to my needs	VFC	11 (20)	29 (52.7)	15 (27.3)	0 (0)	0 (0)
1	Fitness of the content of e-contents to my needs	VLBL	0 (0)	3 (10.9)	38 (74.5)	11 (20)	0 (0)
2	The quality of e-content	VFC	10 (18.2)	33 (60)	12 (21.8)	0 (0)	0 (0)
2	The quality of e-content	VLBL	0 (0)	0 (0)	42 (76.4)	13 (23.6)	0 (0)
3	Possibility to participate in class activities	VFC	12 (21.8)	39 (70.9)	4 (7.3)	0 (0)	0 (0)
3	Possibility to participate in class activities	VLBL	0 (0)	5 (9.01)	44 (80)	2 (3.6)	4 (7.3)
4	The learning effectiveness of the in-class discussions	VFC	10 (18.2)	40 (72.7)	5 (9.1)	0 (0)	0 (0)
4	The learning effectiveness of the in-class discussions	VLBL	0 (0)	4 (7.2)	30 (54.5)	21 (38.2)	0 (0)
5	The role of homework in motivating me to learn more	VFC	8 (14.5)	39 (70.9)	8 (14.5)	0 (0)	0 (0)
5	The role of homework in motivating me to learn more	VLBL	0 (0)	6 (10.9)	33 (60)	12 (21.8)	4 (7.3)
6	Applicability of assignments in skills development	VFC	4 (7.3)	39 (70.9)	10 (18.2)	2 (3.6)	0 (0)
6	Applicability of assignments in skills development	VLBL	0 (0)	0 (0)	49 (89.1)	6 (10.9)	0 (0)
7	Appropriateness of doing homework and class activities	VFC	20 (36.4)	19 (34.5)	14 (25.5)	2 (3.6)	0 (0)
7	Appropriateness of doing homework and class activities	VLBL	0 (0)	0 (0)	43 (78.2)	12 (21.8)	0 (0)
8	The value of group activities and homework is commensurate with the time assigned.	VFC	14 (25.5)	27 (49.1)	14 (25.5)	0 (0)	0 (0)
8		VLBL	0 (0)	0 (0)	43 (78.2)	8 (14.5)	4 (7.3)
9	Proper start of the lecturer's lecture	VFC	16 (29.1)	33 (60)	6 (10.9)	0 (0)	0 (0)
9	Proper start of the lecturer's lecture	VLBL	0 (0)	6 (10.9)	42 (76.4)	7 (12.7)	0 (0)
10	Clear goals in the Teacher's lecture	VFC	18 (32.7)	29 (52.7)	8 (14.5)	0 (0)	0 (0)
10	Clear goals in the Teacher's lecture	VLBL	0 (0)	0 (0)	43 (78.2)	12 (21.8)	0 (0)
11	Teacher mastery of discussion is scientifically	VFC	8 (14.5)	39 (70.9)	8 (14.5)	0 (0)	0 (0)
11	Teacher mastery of discussion is scientifically	VLBL	0 (0)	30 (54.5)	18 (32.7)	7 (12.7)	0 (0)
12	The good ending of the teacher's lecture	VFC	12 (21.8)	31 (56.4)	12 (21.8)	0 (0)	0 (0)
12	The good ending of the teacher's lecture	VLBL	0 (0)	37 (67.3)	18 (32.7)	0 (0)	0 (0)
13	Satisfaction with the whole course (Self-declared)	VFC	12 (21.8)	28 (50.9)	15 (27.3)	0 (0)	0 (0)
13	Satisfaction with the whole course (Self-declared)	VLBL	0 (0)	5 (9.1)	27 (49.1)	23 (41.8)	0 (0)
14	The role of education in encouraging me to participate in similar experiences	VFC	13 (23.6)	31 (56.4)	11 (20)	0 (0)	0 (0)
14		VLBL	0 (0)	0 (0)	36 (65.5)	19 (34.5)	0 (0)

Abbreviations: VFC, virtual flipped classroom; VLBL, Virtual Lecture-Based Learning.

Students’ Attitude

The attitude scores (median [IQR]) of students were high in both instructional methods; however, the VFC instructional method (45 [6]) was significantly higher than the VLBL instructional method (35 [8]) (P < .001) (Table 2).

Table 4 reveals a comparison of attitude items at different levels between VFC and VLBL instructional methods, presented separately. The results revealed that attitude level scores for the VFC instructional method in several of the attitude questionnaire items, including “this method is valuable for better learning concepts,” “this method makes a better understanding of the issue,” “this method is useful for upgrading skills,” “this method has created effective communication with other students,” “this method enhances the relationship between students and the teacher,” and “this method is a way to enjoy learning physiotherapy” were over 50%, while attitude level scores for VLBL instructional method in the cited attitude questionnaire items were less than 30% (Table 4).

Table 4.

Comparison of Attitude Items After Completion of Both VFC and VLBL Instructional Methods.

Attitude Items		Methods	Attitude level, number (%)
Attitude Items		Methods	Totally agree	Agree	No comments	Disagree	Totally disagree
1	This method is valuable for better learning concepts	VFC	9 (16.4)	34 (61.8)	8 (14.5)	4 (7.3)	0 (0)
1	This method is valuable for better learning concepts	VLBL	0 (0)	15 (27.3)	22 (40)	12 (21.8)	6 (10.9)
2	This method makes a better understanding of the issue	VFC	11 (20)	29 (52.7)	10 (18.2)	3 (5.5)	2 (3.6)
2	This method makes a better understanding of the issue	VLBL	3 (5.5)	4 (7.3)	28 (50.9)	16 (29.1)	4 (7.3)
3	This method is useful for upgrading skills	VFC	16 (29.1)	28 (50.9)	6 (10.9)	5 (9.1)	0 (0)
3	This method is useful for upgrading skills	VLBL	0 (0)	11 (20.0)	16 (29.1)	26 (47.3)	2 (3.6)
4	It makes me responsible.	VFC	18 (32.7)	24 (43.6)	8 (14.5)	5 (9.1)	0 (0)
4	It makes me responsible.	VLBL	0 (0)	11 (20)	20 (36.4)	20 (36.4)	4 (7.3)
5	This method helps to resolve controversial issues in the classroom.	VFC	22 (40)	22 (40)	6 (10.9)	5 (9.1)	0 (0)
5		VLBL	0 (0)	17 (30.9)	14 (25.5)	22 (40.0)	2 (3.6)
6	This method facilitates professional decisions in me.	VFC	10 (18.2)	25 (45.5)	12 (21.8)	5 (9.1)	3 (5.5)
6	This method facilitates professional decisions in me.	VLBL	0 (0)	13 (23.6)	28 (50.9)	14 (25.5)	0 (0)
7	This method has improved my professional personality.	VFC	6 (10.9)	21 (38.2)	20 (36.4)	5 (9.1)	3 (5.5)
7	This method has improved my professional personality.	VLBL	0 (0)	7 (12.7)	30 (54.5)	18 (32.7)	0 (0)
8	This method has created effective communication with other students	VFC	12 (21.8)	36 (65.5)	5 (9.1)	2 (3.6)	0 (0)
8		VLBL	0 (0)	15 (27.3)	24 (43.6)	8 (14.5)	8 (14.5)
9	This method increases the relationship between students and the teacher	VFC	17 (30.9)	29 (52.7)	4 (7.3)	5 (9.1)	0 (0)
9		VLBL	0 (0)	15 (27.3)	20 (36.4)	14 (25.5)	6 (10.9)
10	It is a way to enjoy learning physiotherapy	VFC	14 (25.5)	28 (50.9)	6 (10.9)	5 (9.1)	2 (3.6)
10	It is a way to enjoy learning physiotherapy	VLBL	0 (0)	0 (0)	26 (47.3)	23 (41.8)	6 (10.9)
11	Not in line with my learning style	VFC	0 (0)	7 (12.7)	22 (40)	16 (29.1)	10 (18.2)
11	Not in line with my learning style	VLBL	0 (0)	33 (60.0)	18 (32.7)	4 (7.3)	0 (0)
12	This method may not lead to sustainable learning	VFC	0 (0)	2 (3.6)	17 (30.9)	26 (47.3)	10 (18.2)
12	This method may not lead to sustainable learning	VLBL	14 (25.5)	12 (21.8)	25 (45.5)	4 (7.3)	0 (0)

Abbreviations: VFC, virtual flipped classroom; VLBL, Virtual Lecture-Based Learning.

Students’ Final Knowledge Scores

The results indicated that after 2 training courses with the VLBL and VFC instructional methods, the students’ final knowledge scores were significantly higher after the VFC instructional method than after the VLBL instructional method (P < .001) (Table 2).

Effectiveness of the VFC Components

To evaluate the effectiveness of the virtual classroom components, mean pretest and posttest scores were compared between the VFC and VLBL instructional methods across the 5 assessed sessions. In every session, students in the VFC method demonstrated significantly higher pretest scores than those in the VLBL method (all P < .001), indicating greater initial readiness at the start of each class. Posttest scores followed a similar pattern: the VFC method consistently resulted in significantly higher scores (8.78-8.84) compared with the VLBL method (6.93-7.00) (all P < .001). Despite these differences in absolute performance, the magnitude of improvement from pretest to posttest (mean difference scores) did not differ significantly between the 2 instructional methods in any session (P = .14-0.29), indicating that both approaches produced comparable learning gains relative to baseline. However, both VFC and VLBL sessions showed significant pre- to posttest improvement within each method (all P < .001) (Table 5).

Table 5.

Students’ Mean Scores in Both Instructional Methods, Before and After Education.

Sessions	instructional methods	Before	After	P-value	Mean difference of scores
First	VLBL	2.76 ± 1.15	6.93 ± 1.49	< 0.001	4.17 ± 1.76
First	VFC	5.04 ± 1.86	8.78 ± 1.30	< 0.001	3.73 ± 2.31
		P < 0.001	P < 0.001		P = 0.29
Second	VLBL	2.83 ± 1.20	7.00 ± 1.40	< 0.001	4.17 ± 1.85
	VFC	5.21 ± 1.96	8.84 ± 1.40	< 0.001	3.63 ± 2.20
		P < 0.001	P < 0.001		P = 0.17
Third	VLBL	2.83 ± 1.20	6.97 ± 1.29	< 0.001	4.14 ± 1.79
	VFC	5.20 ± 1.95	8.80 ± 1.33	< 0.001	3.59 ± 2.36
		P < 0.001	P < 0.001		P = 0.14
Fourth	VLBL	2.83 ± 1.20	7.00 ± 1.40	< 0.001	4.17 ± 2.14
	VFC	5.24 ± 1.85	8.81 ± 1.35	< 0.001	3.56 ± 2.29
		P < 0.001	P < 0.001		P = 0.26
Fifth	VLBL	2.83 ± 1.19	6.99 ± 1.38	< 0.001	4.16 ± 1.83
	VFC	5.17 ± 1.82	8.79 ± 1.33	< 0.001	3.63 ± 2.13
		P < 0.001	P < 0.001		P = 0.19

Abbreviations: VFC, Virtual Flipped Classroom; VLBL, Virtual Lecture-Based Learning. Significant P-values are in bold

Discussion

This study aimed to evaluate the effectiveness of the VFC in teaching PNF to physiotherapy students, specifically examining whether the VFC approach yields superior outcomes in theoretical knowledge acquisition, practical learning, satisfaction, and attitudes compared with VLBL. The findings demonstrated that the VFC approach was consistently associated with significantly higher knowledge scores, greater student satisfaction, and more positive learning attitudes than the VLBL method. Although the magnitude of within-session knowledge gains (pretest to posttest differences) did not significantly differ between the 2 instructional approaches, students achieved higher pretest and posttest scores during VFC sessions, suggesting more favorable learning processes and stronger overall academic performance associated with the VFC model.

The consistently higher pretest scores observed in the VFC sessions warrant careful consideration. One likely explanation for the higher pretest scores in VFC sessions lies in the structure of the test administration. In the VFC model, pretests were administered at the beginning of synchronous sessions, following structured asynchronous preparatory activities that encouraged students to engage with learning materials in advance. In contrast, the VLBL pretests were conducted 24 h after content upload, without a structured preparatory session. As a result, students in the VFC condition were more likely to have reviewed and internalized the content before assessment, whereas students in the VLBL condition may not have yet engaged fully with the material. This distinction likely contributed to the higher baseline knowledge observed in the VFC sessions.

Furthermore, the VFC design provided repeated exposure to core concepts, opportunities for clarification, guided practice, and immediate instructor feedback.²⁴ These instructional features are known to support deeper learning and facilitate knowledge consolidation, which likely contributed to the higher posttest scores observed in the VFC sessions. Collectively, these elements indicate that the VFC approach promotes a more robust and efficient learning process than VLBL.

Despite higher overall pretest and posttest scores in the VFC sessions, both instructional methods demonstrated statistically significant improvements from pretest to posttest within each condition. No significant differences were found in within-method gain scores between VFC and VLBL sessions. This finding can be interpreted in light of the differing temporal structures and learning conditions inherent to each instructional approach.

In the VLBL method, the pretest was administered 24 h after materials were made available, and the posttest followed one week later. This extended interval likely allowed students additional time to revisit resources, rehearse procedures, and consolidate both theoretical and practical knowledge independently before completing the summative assessment. Although the VLBL format lacked real-time instructor interaction, students could seek clarification through the LMS chat function, which may have partially supported learning during the longer consolidation period. Importantly, the VLBL resources—including lecture slides, structured summaries, textbooks, handouts, and prerecorded PNF demonstration videos—were aligned with the same learning objectives as the VFC content. For practical PNF topics, these high-quality visual demonstrations and stepwise explanations may have been particularly beneficial for psychomotor learning, enabling students to repeatedly view, pause, and practice techniques at their own pace, either individually or with peers outside scheduled sessions. Consequently, even in the absence of synchronous instruction, students in the VLBL condition achieved meaningful learning gains.

In contrast, in the VFC model, both the pretest and posttest were administered within the same synchronous session. Learning gains were therefore captured over a shorter but more intensive instructional cycle that combined prior asynchronous preparation with immediate clarification, guided practice, and instructor feedback during the live session. While students in the VFC sessions began with higher baseline knowledge and achieved higher posttest scores, the magnitude of improvement within a single session was comparable to the cumulative gains observed across the longer VLBL interval. Thus, the VFC approach appears to facilitate faster attainment of higher performance levels, whereas the VLBL approach supports more gradual but still substantive learning over time.

The lack of a significant difference in gain scores between the 2 instructional approaches suggests that both VFC and VLBL are effective in promoting learning within their respective temporal frameworks. The extended consolidation period characteristic of the VLBL approach may have partially compensated for the absence of synchronous interaction, particularly for practical PNF content that benefits from repeated video exposure and self-paced rehearsal. Conversely, the VFC model's structured integration of asynchronous preparation with immediate reinforcement, guided practice, and feedback during synchronous sessions provided a more time-efficient learning experience that translated into higher overall achievement, despite similar gain (post-predifference) magnitudes in the 2 approaches.

In the present study, beyond final knowledge outcomes, students demonstrated significantly higher satisfaction and more positive attitudes following VFC sessions compared with VLBL sessions. These findings highlight the potential of the VFC model as an effective and adaptable instructional approach for physiotherapy education, particularly for teaching complex interventions such as PNF. Teaching PNF in a virtual environment presents unique challenges, as it requires integrating abstract neurophysiological concepts with precise manual skill execution. As a result, students rely heavily on guided demonstrations, video-based feedback, and self-regulated practice to bridge the gap between conceptual understanding and physical performance.¹⁴

The inherent complexity of physiotherapy training—especially for skill-intensive techniques such as PNF—necessitates a balance between independent learning and collaborative, practice-oriented instruction.¹⁴ The higher levels of satisfaction and more positive attitudes observed following VFC sessions suggest that students value the increased autonomy, interactivity, and structured support afforded by this instructional approach. Such positive perceptions are likely to enhance students’ motivation and sustained involvement, both of which are critical for mastering advanced psychomotor skills in physiotherapy practice.

Nevertheless, the VFC approach introduces specific instructional challenges. Its successful implementation depends on the careful design of synchronous learning activities, students’ commitment to self-directed learning, reliable access to technology, and instructors’ proficiency in facilitating synchronous sessions focused on practical skill acquisition.^25,26 Within the VFC framework, integrating frequent formative assessments and providing timely feedback is essential, as the high-quality feedback directly influences students’ confidence, skill refinement, and overall learning outcomes.²⁶ When effectively implemented, this instructional design supports higher levels of Bloom's Taxonomy—such as application, analysis, and synthesis, while fostering meaningful student–student and student–teacher interactions.^16,27,28

Our findings align with those of Chick et al, who also reported positive educational outcomes associated with the VFC approach.²⁹ The blended design of the VFC model—combining asynchronous preparation with synchronous application—appears to be a key contributor to its effectiveness. Allowing students to review learning materials in advance and revisit video-based resources facilitates more productive engagement during synchronous sessions. Repeated exposure through asynchronous content, reinforced by synchronous discussion and formative assessment, supports knowledge retention and skill acquisition.³⁰

Previous research further supports the effectiveness of FC approaches in physiotherapy education.⁵ Roe et al demonstrated improved performance across achievement levels using a flipped instructional model, suggesting benefits for both high- and low-performing students.⁵ Similarly, Deprey et al found that a fully integrated flipped model produced superior learning outcomes compared with traditional and partially flipped approaches.³¹ In the present study, although the same cohort experienced both instructional methods across different PNF topics, students consistently achieved higher scores in sessions taught using the VFC approach, reinforcing the value of fully implemented flipped instruction.^25,31

While some studies, such as that by Murray et al, have reported no significant differences between flipped and traditional teaching methods,³² broader evidence supports the effectiveness of flipped learning in health professions education.^15,26,33 Systematic reviews and meta-analyses in physiotherapy and nursing education have identified the FC as one of the most effective blended learning approaches, demonstrating significant improvements in learning outcomes.^15,34 These mixed findings underscore the importance of instructional context, content complexity, and pedagogical design in determining the success of flipped learning models.^32,34

The VFC model integrates elements of educational technology, problem-based learning, and team-based learning, collectively enhancing instructional quality.^1,9,24 To maximize its effectiveness, educators should encourage students’ engagement in self-directed learning outside class, design activities that promote higher-order thinking, and incorporate synchronous analysis of authentic clinical cases. Attention to these pedagogical considerations is essential for optimizing the educational potential of the VFC in physiotherapy training.^1,8,9,24

The findings of this study have important practical implications for educators involved in curriculum design in physiotherapy education. In the context of the ongoing digital transformation of higher education, further accelerated by global disruptions such as the COVID-19 pandemic, the adoption of instructional approaches such as VFC may be particularly advantageous. Adequate institutional support and robust technological infrastructure are essential for ensuring the quality of virtual learning experiences, especially in developing countries such as Iran.³⁵ The successful implementation of instructional approaches such as VFC requires not only reliable virtual infrastructure but also a shift toward learner-centered educational cultures, flexible learning environments, well-aligned instructional content, and instructors experienced in online and student-centered teaching methods. When these conditions are met, virtual education has the potential to enhance instructional quality and expand opportunities for active learning beyond traditional models.¹

Because this study directly compared VFC and VLBL within the same cohort, its findings provide practical guidance for educators selecting between these instructional approaches. These findings may contribute to the design of resilient and effective educational programs during future crises like the COVID-19 epidemic and may support the broader institutionalization of flipped and virtual flipped instructional models in physiotherapy education.

Limitations

Several limitations should be acknowledged. One limitation of this study was the relatively small sample size (55 physiotherapy students across 2 implementations). Therefore, it is recommended that future studies examine these instructional methods using a larger population to improve generalizability. Although the weekly alternation of VLBL and VFC sessions with a one-week washout interval was intended to minimize carryover effects, temporal influences cannot be entirely excluded. Students may have gained increasing familiarity with the learning platform, assessment format, or experienced cumulative fatigue and motivational fluctuations over time. Additionally, because both instructional methods were delivered sequentially to a single cohort without a parallel control group, period effects, and other confounding factors, such as concurrent academic or clinical demands, may have influenced the outcomes. Future research employing parallel-group randomized controlled designs or crossover designs with extended washout periods is recommended to more rigorously isolate instructional effects.

Conclusion

This study described the development, implementation, and evaluation of a VFC for teaching PNF to undergraduate physiotherapy students at the University of Medical Sciences in Iran. The findings indicate that the VFC model is an effective instructional approach for enhancing students’ knowledge, satisfaction, and attitudes toward learning in a PNF course.

The results underscore the importance of informed adoption of virtual instructional approaches by both educators and learners, supported by institutional commitment to active learning and adequate technological infrastructure. When combined with pedagogically sound design and faculty development, the VFC model has the potential to improve the quality of virtual physiotherapy education. Accordingly, greater integration of FC and VFC approaches is recommended, alongside opportunities for instructors and students to gain sufficient experience with these methods to optimize their implementation and educational impact.

Supplemental Material

sj-docx-1-mde-10.1177_23821205261422879 - Supplemental material for Effectiveness of Virtual Flipped Classroom in Teaching Proprioceptive Neuromuscular Facilitation to Physiotherapy Students: A Quasi-Experimental Study

Supplemental material, sj-docx-1-mde-10.1177_23821205261422879 for Effectiveness of Virtual Flipped Classroom in Teaching Proprioceptive Neuromuscular Facilitation to Physiotherapy Students: A Quasi-Experimental Study by Amir Mohammad Salehi, Ailin Talimkhani, Elham Khanlarzadeh, Mohammad Reza Asadi, Hojjat Radinmehr, Soulmaz Rahbar and Mahnaz Khatiban in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-2-mde-10.1177_23821205261422879 - Supplemental material for Effectiveness of Virtual Flipped Classroom in Teaching Proprioceptive Neuromuscular Facilitation to Physiotherapy Students: A Quasi-Experimental Study

Supplemental material, sj-docx-2-mde-10.1177_23821205261422879 for Effectiveness of Virtual Flipped Classroom in Teaching Proprioceptive Neuromuscular Facilitation to Physiotherapy Students: A Quasi-Experimental Study by Amir Mohammad Salehi, Ailin Talimkhani, Elham Khanlarzadeh, Mohammad Reza Asadi, Hojjat Radinmehr, Soulmaz Rahbar and Mahnaz Khatiban in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-3-mde-10.1177_23821205261422879 - Supplemental material for Effectiveness of Virtual Flipped Classroom in Teaching Proprioceptive Neuromuscular Facilitation to Physiotherapy Students: A Quasi-Experimental Study

Supplemental material, sj-docx-3-mde-10.1177_23821205261422879 for Effectiveness of Virtual Flipped Classroom in Teaching Proprioceptive Neuromuscular Facilitation to Physiotherapy Students: A Quasi-Experimental Study by Amir Mohammad Salehi, Ailin Talimkhani, Elham Khanlarzadeh, Mohammad Reza Asadi, Hojjat Radinmehr, Soulmaz Rahbar and Mahnaz Khatiban in Journal of Medical Education and Curricular Development

Footnotes

Acknowledgments

The authors appreciate the financial and nonfinancial support of Hamadan University's Vice Chancellor for Research and Technology.

ORCID iDs

Amir Mohammad Salehi

Ailin Talimkhani

Ethics Approval and Consent to Participate

The Ethics Committee of the Hamadan University of Medical Sciences approved the protocol of this study (IR.UMSHA.REC.1399.321). The research was conducted in accordance with the Declaration of Helsinki, and informed consent was sought and obtained from all participants.

Author Contributions

Amir Mohammad Salehi and Ailin Talimkhani were involved in the study idea, design, and performed the intervention. All authors were involved in participant assessments/data acquisition. Elham Khanlarzadeh analyzed the data. Amir Mohammad Salehi and Ailin Talimkhani were major contributors to writing the manuscript. All authors were involved in revising and approving the manuscript. All authors read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was partially supported by the Research Council of Hamadan University of Medical Sciences, Iran, with Code 9904312720. Vice Chancellor for Research and Technology, Hamadan University of Medical Sciences, (grant number 9904312720).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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