Ideas for an open physiotherapy textbook project

The original post for this idea can be found here, where it was my project idea for the Mozilla Open Education course held in collaboration with the Peer to Peer University and ccLearn. I'm currently in the process of cleaning up this draft document that will serve as a basis for recruiting collaborators to the project. If there is any interest in collaboration (there has been none expressed so far in the few discussions I've had), you can get in touch with me at michael AT realmdigital DOT co DOT za.


Random notes and scribbles

This is just a dump of notes I took during a conference. I'll get around to sorting through it sometime.

Not university specific. This is a national project and not about promoting individuals or institutions. Doing good research in SA/ finding good evidence internationally, but how long does it take for that content to filter to the masses? How long before a presentation at the SASP congress is implemented as a change in practice / behaviour at some clinic in the middle of nowhere?

Language modules must be included so that translations can take place. Not only SA languages. Why can't this become an international baseline?

Be careful book doesn't become an encyclopedia. This is a printed book being written online. Implications – links aren't appropriate – must think in terms of pages/ length/ footnotes

How could the printed book benefit from blended approach? Aggregated emails that combine recent edits? Subscribe to these by category.

Encourage discussion around controversial topics (vital to stimulate engagement), rather than a “delete and replace” approach Unless content is fundamentally incorrect, grammar, spelling. Formatting guidelines should be available for review. Suggestions for change should be accompanied by reasons/evidence. This is about students graduating/ better physions. Not a personal platform. Users encouraged to put brief summary of CV onto profile page . So that others can review credentials. Photos. ( All of this needs to be around in an intro section. How to edit etc.) Guidelines for growing length of sections. Are there any resources that describe this process? Academics submit research-based contextual Clinicians = case studies, practical application students = experience and perceptions (eg. My first suctioning experience) provides context for clinicians/ academics. Authors not officially credited with edits/ contributions, but every edit tracked in a revision history because it will impact on reading is every edit is highlighted on page. Signatures in discussion fine.

How about putting paeds. Course reader online for feedback from Brenda? How could this lead into the textbook project?

Guidelines for textbook: Make sure that applied content is really a relevant summary of condition and not to get carried away with it. The point should be to provide a baseline with links to further sources. Self directed learning questions at end of each section. Directed to blog feeds of book for updated content. How to handle conflict/ conflicting evidence? - need methods of compromise/ facilitation

Maybe it should be called physionotes.coza to make it clear that is is more of a course reader/ fundamental staff reader, rather than a textbook? Or should we go for a full text book? Project open to all SA physiotherapists and students , for contribution or comment Printed books sold at cost - implications: no royalties for authors (difficult to quantify anyway because of distributed nature of authorship) low cost for students Not a replacement for textbooks. Not about replacing Clin. Sports Med.

These are extended and enhanced course readers, based on best evidence. Referring to other printed sources.

Licensing – open. Anyone can take and modify and redistribute but must give attribution back to SASP? Who will take credit? Seems governing body is best candidate, but what will they contribute to project besides their name…credibility?

Funding – SASP, HPCSA, MRC, physio depts.?

Case reports/ chapters/ sections must all conform to guidelines. Who will create formatting guideline? Administrators will determine appropriateness of content for printing. Eg, This chapter is ready to print. This chapter is ready but is lacking in some areas. This chapter should not be printed as it does not yet conform to project guideline.

With a wiki does one article = one chapter? The structure of a wiki is not the same as the structure of a printed book. Test MoinMoin and MediaWiki with DocBook export. Once it's in DocBook format, where will they send to print? Cost will therefore be dependant on how many pages are printed. What depts. Sell to students as will be their own deal? If you don't print it out it's free.

You can't link to another section if it's relevant to what you're reading ow like in an online encyclopedia. How does DocBook export handle this? Must do more testing

How to manage resistance to change? Guarding of intellectual property for those who want it? Resistance to sharing? Why is “open” good? Why should people participate? “A common repose to orthodox knowledge when confronted with challenge is to shift responsibility away” Is this relevant to the shift of learning on students? Does orthodox education feel under threat and is moving responsibility away from the institution.

Laidlow (2007) looked at exemplary communicators and the role of reflection in practice.


Short description: This project is an attempt to create an online, distributed authoring environment that will allow South African physiotherapy clinicians, educators and students to collaboratively create a culturally and contextually relevant physiotherapy textbook that will always be free. It is not an online course.

The problem

Most academic textbooks are published in America or Europe, which brings with it several problems, not least of which is high cost, lack of contextual relevance and outdated evidence (a problem with most published textbooks). A locally produced textbook that is culturally relevant, inexpensive and able to be updated regularly would solve several problems in physiotherapy education. New additions of textbooks are disruptive, important books may go out of print if the publishers decide that they're no longer cost-effective to produce, and the content of most textbooks is designed for the widest possible audience (Beezer, 2009). In other words, as long as content is controlled by commercial interests, profit will always take priority over educational value. Another problem with many textbooks, especially within a particular genre / topic / subject, is duplication of content. You may have 5 books with similar content, but you need all 5 because each book has one important chapter.

Advantages of an open, online approach

  • The content can continually be updated e.g. links to new studies can be added immediately
  • The content can be distributed across geography and timezones
  • Digital multimedia adds a depth to the content that is impossible to achieve in print e.g. hyperlinking to relevant sources, embedded video and audio, and animated graphics are just a few possibilities
  • Individuals taking responsibility for only small sections, rather than an entire book or even chapter, reducing the time commitment from authors
  • The use of more permissive / less restrictive copyright licenses, allowing greater freedom in how the content is used (and paid for)
  • Print runs could be limited only to the number of students requiring that specific content, with individuals paying only for the content they need, rather than entire textbooks
  • A social and cultural relevance lacking in international publications
  • Encouraging student participation on multiple levels, from basic (editing of grammar and spelling, checking of references) to more advanced (creating digital content that serves as an adjunct to the printed book, translation)
  • Ability to translate the content into any language (South African or other)
  • The inclusion of content not normally associated with a particular topic e.g. adding a significantly more prominent ethical / human rights component to a chapter on stroke rehabilitation i.e the ability to take the content in directions
  • The content is available for free online, or can be printed on an “as required” basis (inexpensive)
  • It never goes out of print
  • It allows for a free exchange of ideas (Beezer, 2009)
  • It can make use of local examples, case studies, etc.
  • It can emphasise the unique, health-related problems in South Africa
  • Corrections can easily be made, and will be more easily found, with many contributors / editors
  • Multiple formats are possible (e.g. audio, HTML, PDF, MS Word, OpenDocument)
  • The book can be modified as teachers / students need e.g. chapters can be removed, re-arranged, images swapped / modified
  • Finally, as an academic exercise, it will stimulate a national discussion / debate around both educational and clinical practices in South Africa


South African physiotherapy clinicians, educators and students. The rise of user-generated content in what was traditionally a consumer space has changed the way we think about news and entertainment, among many other things. But there's been little consideration given to the idea of academics creating user-generated content. Is there any reason why we, as academics, shouldn't also subscribe to the notion that our ideas and content has value that can be shared with others for no reason other than to contribute to an academic commons. Why should we continue to consume the content of others when we, as an academic community of practitioners, can create our own?

Goals of this document

  • To create a draft proposal that could guide the development of a collaboratively written physiotherapy textbook that is culturally relevant and accessible to all.
  • Create a framework for the development of a South African physiotherapy textbook
  • Establish a platform for discussion and debate among healthcare professionals

How will it work?

I'm uncertain at this point if it's going to be a workspace for the collaborative authoring of a printed textbook, or an online “textbook” that makes use of the internet and communication tools to facilitate engaged learning among students (why can't it be both?) The more I think about it, the more I'm learning towards an online collaborative authoring environment to create a printed book. Printed books still have a huge part to play in South African education. We can't leave stuff online and expect everyone to have access to it. Maybe each page of the printed book could have it's associated “page” online, where educators/students/clinicians could make use of online technology to enhance the printed book.

I'm also starting to realise that the goal of one textbook might not work. My original idea was that the “book” would be digital and so unconstrained by size. Teachers and students would be able to access / download only what they needed. On Reflection though, it now seems more reasonable to split the “book” into several, even if only for clarity. I think that if I'm going to proceed, I need to make a decision about whether or not this will be a digital book, available online with options to download PDF pages, or if it will be a printed series of books, but collaboratively authored online.

Similar projects


These might revolve around subjects such as intellectual property and the management of the content generated in this manner i.e. who “owns” it. I would propose that the “profession” would own the content and it's generation should be seen as a contribution to the continuing evolution of physiotherapy in the country. Authors could be “paid” in terms of the community's recognition of their contribution and with the knowledge that a higher standard of education and patient care will be a direct result of their work.

The technological barrier (access and proficiency) is a huge problem in South Africa but not insurmountable. Accessing the authoring environment through the browser (with a suitable editing dashboard) could virtually eliminate one barrier. Authors could be shown reasonably quickly that the technology has reached a point where it is almost invisible and that only a limited knowledge of computers and the Internet is required to participate. This could be achieved through workshops at conferences, or through students teaching staff.

The other problem with access is the lack of broadband access and high costs involved. If we assume that a wiki is the best platform, it requires “always on” connectivity (writing offline and pasting text ignores the whole concept of collaborative authoring by not allowing selective editing). Do any wikis have the ability to synchronise edits made offline, in the same way that Google Docs does it?

How will we manage the problem of multiple languages? It seems crazy to not have an implementation that permits multiple versions of the same document in other languages, especially since we have 11 official languages in South Africa. Again, a wiki will allow this.

Many editors will also introduce the problem of inconsistent typographical rendering, which is unacceptable for any textbook. Learners must be comfortable that the formatting used is consistent throughout. Authors will have to comply with simple formatting conventions (e.g. APA style for citations and referencing)

Downside of using e-books

Open Technology

The authoring environment / platform

Uncertain about the best tool for collaborative authoring. Wikis (e.g. Mediawiki) clearly have the upper hand with the “collaboration” part, but aren't great for authoring/ formatting a book. I'm thinking it might be a good idea to use a wiki for creating content and then exporting the content to another platform to manage the editing? Editing a book will involve a lot that a wiki couldn't handle efficiently, like specific annotation of various components. Does anyone know of an open source, distributed book authoring platform?

Communication between collaborators

A blogging environment would be useful to syndicate the progress of the project, and Twitter (or maybe a more secluded platform like laconica, seeing that Twitter is now mainstream) for pushing out relevant content. I'm thinking multiple streams of content e.g. having different blogs/microblogs for clinical content (and maybe even split that again into different subject areas), educational content, writing guidelines, etc. Contributors can then subscribe to the content areas that they specialise in.

The fact that it's online should make use of that fact e.g. the “book” could have an IRC channel, Twitter stream, blog, etc.

I've been wondering about using Google Docs (I now it's not open, but I'm a pragmatist before being an idealist and will consider anything that works). I've used it for small collaborative authoring projects between 2-3 people, but don't know how it would scale for larger projects. It also lacks the ability for efficient communication and annotation (possibly the “comment” and “footnote” feature would suffice?). The Zoho online office suite of applications may be a good alternative, as it incorporates several potentially useful applications with good interoperability.

I found this blog post by Mark Shuttlework looking for exactly the same thing. Going through the comments it seems the strongest contenders would be:

It seems that the most efficient way would need to go through the browser, rather than a desktop application that uses an extension to publish documents to a shared server ( and the extension that allows this…I forget it's name). Everyone has a browser and it's a barrier to expect people to install additional software and extensions to participate.

Open Content / Licensing

What types of content are you using or producing, and how are they licensed. Do you need to clear copyright for any of them? Are there institutional policies that affect what you can (or cannot) do?

The project / textbook will be published using an open license, probably Creative Commons, but others can be considered (e.g. the GNU Free Documentation License). The type of license chosen is important because it offers a guarantee that the book will always be available. Open licensing allows the possibility of a "fork", which would keep authors honest and provide an assurance that the content will always be available (Beezer, 2009).

The use of open access studies for the evidence base of the textbook will also be encouraged. It makes little sense to have an open textbook that's based on studies that require payment to access. Students and teachers should be able to access the source content on which the textbook is based. However, it must be noted that much of the evidence base, particularly in physiotherapy / health sciences, will still be published in traditional journals that are closed.

Here are some notes I took from a presentation by David Wiley - The disaggregated future of higher education


  • Come up with ideas for research,
  • Find grant funding for the research,
  • Identify and hire graduate students and other professionals,
  • Conduct the research,
  • Write up the results of the research in a clear and concise manner, and
  • Surrender all rights to the written results of the research to a publisher

Publishers make +- 2% of investment into research and then make huge profits (Elsevier and LexusNexus = $1.5 million profit in 2008)

“The world is changed” - Galadriel, Lord of the Rings

Why do students come to university:

  • content BUT Wikipedia, MIT OpenCourseWare, Flat World Knowledge
  • support services BUT Yahoo Answers, RateMyProfessor, Email, IM, Twitter
  • social life BUT Facebook, MySpace, MMOG, iPhone location aware apps
  • degrees / certification BUT MCSA, RHCE, CCNA
  • ie. everything provided by university is offered somewhere else

e-Learning was innovative in 1995!

Characteristics of traditional E‐learning

  • Analog or Digital
  • Tethered or Mobile
  • Isolated or Connected
  • Generic or Personal
  • Consuming or Creating
  • Closed or Open

Not a Technology Problem - not only do the technologies exist, they’re open source. It's a policy problem, Higher education is behaving like the recording and movie industries

“It is not necessary to change. Survival is not mandatory.” - W. E. Deming

Open Pedagogy

How do participants learn? What forms of assessment are you using?

Each section / chapter will incorporate various ongoing assessment tools (e.g. self-study questions, personal reflection). Chapter structure will be an important component to decide with other educators. This article talks about integrating online books with scientific workflow through cross-navigation with online journals. This would be easily accomplished, as editors continuously link to emerging (and established) research. Each iteration of the printed textbook would therefore contain links to the most up to date evidence.

This is significant in the current move towards evidence-based practice in healthcare. We trying to not only encourage students to base their clinical practice on the best available evidence, but also as educators, to teach the most up to date content.

It's also important to remember that this is about collaborative editing, not mere reproduction of book technology on the screen.

Although once again I come up against the idea of an authoring environment to create a traditional textbook, or an online book that uses technology to facilitate teaching and learning? Could it be both?

I'm especially attracted to the possibility of using a language module (I know Mediawiki has one) to allow the creation of the textbook / course notes in multiple languages. This is one area in which students could be particularly active, translating content between languages. This is especially relevant in South Africa, where all the teaching institutions use English or Afrikaans as the language of instruction. This wouldn't change that, but would allow students to have copies of the notes in their home language.


  • Beezer, R. (2009). Open Textbooks from an authors perspective. Online presentation given to Washington State Board for Community & Technical Colleges.
open_physiotherapy_textbook.txt · Last modified: 2010/04/15 09:04 by Michael Rowe