The effectiveness of virtual and augmented reality in health sciences and medical anatomy.

TL;DR: Both VR and AR are as valuable for teaching anatomy as tablet devices, but also promote intrinsic benefits such as increased learner immersion and engagement that show great promise for the effective use of virtual and augmented reality as means to supplement lesson content in anatomical education.

Abstract: Although cadavers constitute the gold standard for teaching anatomy to medical and health science students, there are substantial financial, ethical, and supervisory constraints on their use. In addition, although anatomy remains one of the fundamental areas of medical education, universities have decreased the hours allocated to teaching gross anatomy in favor of applied clinical work. The release of virtual (VR) and augmented reality (AR) devices allows learning to occur through hands-on immersive experiences. The aim of this research was to assess whether learning structural anatomy utilizing VR or AR is as effective as tablet-based (TB) applications, and whether these modes allowed enhanced student learning, engagement and performance. Participants (n = 59) were randomly allocated to one of the three learning modes: VR, AR, or TB and completed a lesson on skull anatomy, after which they completed an anatomical knowledge assessment. Student perceptions of each learning mode and any adverse effects experienced were recorded. No significant differences were found between mean assessment scores in VR, AR, or TB. During the lessons however, VR participants were more likely to exhibit adverse effects such as headaches (25% in VR P < 0.05), dizziness (40% in VR, P < 0.001), or blurred vision (35% in VR, P < 0.01). Both VR and AR are as valuable for teaching anatomy as tablet devices, but also promote intrinsic benefits such as increased learner immersion and engagement. These outcomes show great promise for the effective use of virtual and augmented reality as means to supplement lesson content in anatomical education. Anat Sci Educ 10: 549-559. © 2017 American Association of Anatomists.

Summary

INTRODUCTION

• Educational technology is changing the way people engage and interact with learning material.
• Its goal is to create a powerful environment where the student can use their innate abilities of learning to grasp complex concepts and acquire knowledge through observation, imitation and participation (Goodyear and Retalis, 2010) .
• These supplementary materials include podcasts, screencasts and educational software available for use on a personal computer and mobile devices, such as smartphones and tablets (Scalise et al., 2011; Green et al., 2012; Molnar, 2016) .
• The availability of multimedia technology, digital content and software empowers the modern-day students as it provides opportunities to engage with learning materials more easily and effectively.
• The user's senses (sight, hearing and motion) are fully immersed in a synthetic environment that mimics the properties of the real world through high resolution, high refresh rate head-mounted displays, stereo headphones and motion-tracking systems.

Current trends in health science education

• Medical and health science students must gain many skills and acquire vast arrays of knowledge throughout their time at university to become competent practitioners, with anatomy in particular being one of the cornerstones of health education.
• It is commonly delivered in the form of lectures, which include a slideshow presentation and a verbal description of the concepts, dissections and prosections, clinical cases and self-directed study using twodimensional (2D) images and multimedia resources (Murgitroyd et al., 2015) .
• The field of science is constantly evolving and with this comes an increase in topics that must be included within a modern curriculum, resulting in a paradigm shift in the way health is taught.
• This has led to less face to face teaching time in many of the 'basic sciences' and a greater dependence on supplementary materials and modules outside the formal course time (Johnson et al., 2012) .

Applications of 3D interactive software to enhance anatomical education

• Whilst a cadaver is an effective resource due to its ability to display spatial information, textbooks are commonly used alongside the specimens in order to identify the names of features and how the anatomy links with physiology (Codd and Choudhury, 2011) .
• The use of 3D technology supplements may also provide a benefit to student long-term retention of gross anatomy (Peterson and Mlynarczyk, 2016) , making it useful to supplement students traditional anatomical learning techniques with modern virtualization techniques and devices.
• Users generally enjoy learning in a virtual environment as they are more curious to explore it.
• There has not been a widespread implementation of this technology in anatomical education, as the current studies are still focusing on the development and usability of AR as a learning tool (Wu et al., 2013) .
• With the release of modern-day virtual and augmented reality, on which these models can be visualized, the learning experience can become more immersive.

Participants

• A total of 59 participants studying anatomy were recruited for this study with 84.7% percent (n=50) being students in biomedical and health sciences, 8.5% students in medicine (n=5), and 6.8% students from other Faculties (n=4).
• (Randomness and Integrity Services Ltd., Dublin, Ireland).
• Participant gender was distributed evenly, with an approximately neutral gender balance of 47% males and 53% females (Table 1 ).
• Research ethics was approved by the Bond University Human Ethics Research Committee, and all participants provided informed consent.
• 83% of participants stated that they had no prior knowledge on the skull anatomy, whereas 10 participants had previously studied skull anatomy and were confident that they still remembered the names of the individual structures.

Development of the application

• Applications for AR, VR and tablet were written using JavaScript within Unity v5 (Unity Technologies, San Francisco, CA).
• The left-click button engaged a "dissect" mode, removing the highlighted layer in front of the user, revealing the underlying structures.
• When the user 'touched' on a feature of the model in the AR or tablet applications, the selected area highlighted and its name displayed on the screen.
• The audio-stream was identical in all three modes, and when the clinical anatomist providing the voiceover lesson mentioned individual terms or features, that would highlight on the object in a lightblue color (e.g: the background highlighting of objects was synced with the audio to draw the users attention).

Analysis

• A one-way ANOVA was used to evaluate the association between the mode of delivery (VR, AR or tablet) and the anatomy test scores.
• A Kruskal-Wallis H-test was used to evaluate the association between the mode of delivery and the adverse health effects exhibited during the lesson, as well as participant perception of the learning mode.
• For examinations between two variables, a Student's unpaired two-tailed t-test was applied.

Results from the post-lesson anatomy knowledge test

• After completing a 10-minute lesson on skull anatomy utilizing either the VR, AR or a tablet, students were required to answer a 20-question multiple-choice test.
• Gender had no effect on participant scores (p = 0.313), nor did having studied science since leaving high school (p = 0.279), or declaring that they have difficulties understanding structure's position in space (p = 0.289).
• All three groups performed better in the spatial recall questions having received a group mean score of 70.7% in comparison to 58.3% in factual recall questions .

Participant engagement with the learning modes

• Participants rated their learning experience highly in all seven domains across the three learning modes.
• There were no significant differences in mean scores observed for any of the seven statements among the three groups .
• Regarding the learning software, most (80%) participants stated that they preferred to learn at their own pace rather than at a pace set by the educator and the audio-stream length (10 minutes) was agreed to be "appropriate" by 85% of the participants.
• Being able to visualize what the authors are learning in any way is helpful"; "Really good!.
• The members in virtual reality group experienced significantly more symptoms than those in the augmented reality and 3D tablet groups.

DISCUSSION

• There are substantial financial, ethical and supervisory constraints on their use (Turney, 2007) .
• The use of this technology has therefore generated considerable interest and its potential to supplement current teaching in anatomical education is exciting to both students and curricula developers alike.
• Another study on dental morphology determined that that 3D interactive media was just as effective as the traditional course with classroom lectures (Maggio et al., 2012) , although student results were not necessarily increased.
• Similar to these listed studies, the enhanced engagement, enjoyment and participation observed in the VR and AR groups did not necessarily result in increased test scores.

Adverse health effects

• A potential issue that can have an impact on the learning experience and assessment results when using virtual reality is cybersickness, which causes nausea, disorientation, discomfort, headache, fatigue, difficulty concentrating and problems with vision (Rebenitsch and Owen, 2016) .
• There have been previous reports on symptoms associated with cybersickness exhibited when using virtual reality in past studies (Mosadeghi et al., 2016) .
• Both general discomfort and dizziness was observed in 40% of participants in the first study, which is of concern as experiencing these symptoms would have a great impact on the learning quality and therefore make the student less immersed in the lesson.
• Learning the large number of features and names of a new anatomical region all-at-once in an application may require processing demands that exceed the students' cognitive capabilities.
• Study material containing a lot of elements will require a greater capacity of working memory to process the information simultaneously.

Limitations and further studies

• This study was limited in its focus on the effectiveness of educating a relatively limited number of students studying introductory anatomy.
• A greater number of participants, from a wider cohort of students would further support the overall conclusions in this area.
• In particular, further interest would be in the influence of these teaching tools in educating medical graduates, or postgraduate students in more advanced anatomical concepts and features.
• It is likely that people who have some degree of experience learning anatomy are more familiar with the terms and have a set system for learning structures, therefore leading to better results regardless of learning mode used.
• This study utilized 10-minute sessions, however, it may be more comfortable for participants to spend longer or shorter periods within the virtual world, or even obtain a pre-exposure to the virtual environment for some time prior to the lessons.

CONCLUSION

• Previous benefits have also been reported through the use of tablet-based software.
• Modern advances in consumer-grade technology has allowed the creation of immersive 3D environments using virtual and augmented reality.
• This article presents both VR and AR as effective teaching tools, where student learning is as successful as with tablet-based applications although educators should be cautious regarding the introduction of adverse effects, such as blurred-vision and disorientation with VR in particular.
• Both VR and AR provide additional intrinsic benefits, such as increased student engagement, interactivity and enjoyment.

Figures

Figure 1: Boxplot of the overall mean scores achieved in the anatomical knowledge test (virtual reality n=20, augmented reality n=17, 3D tablet n=22; one-way ANOVA).

Table 2: Examples of the multiple-choice anatomy factual (#1-3) and spatial (#4) questions.

Figure 3: Student perceptions of the three learning modes (virtual reality n=20, augmented reality n=17, 3D tablet n=22; Mean±SEM).

Table 3: Participants exhibiting adverse symptoms during the skull anatomy lesson on the virtual reality, augmented reality and tablet modes.

Table 1: Outline of participant demographics

Figure 2: Boxplots of the mean scores achieved in the anatomical knowledge test for factual questions (Left) and spatial questions (Right) for each delivery mode (virtual reality n=20, augmented reality n=17, 3D tablet n=22; one-way ANOVA).

Full text

Bond University
Research Repository
The effectiveness of virtual and augmented reality in health sciences and medical anatomy
Moro, Christian; Štromberga, Zane; Raikos, Athanasios; Stirling, Allan
Published in:
Anatomical Sciences Education
DOI:
10.1002/ase.1696
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Link to output in Bond University research repository.
Recommended citation(APA):
Moro, C., Štromberga, Z., Raikos, A., & Stirling, A. (2017). The effectiveness of virtual and augmented reality in
health sciences and medical anatomy.
Anatomical Sciences Education
,
10
(6), 549-559.
https://doi.org/10.1002/ase.1696
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Download date: 10 Aug 2022

The effectiveness of virtual and augmented reality in health science and
medical anatomy
Authors: Christian Moro, Zane Štromberga, Athanasios Raikos, Allan Stirling
Affiliation: Faculty of Health Sciences and Medicine, Bond University, Gold Coast, 4229.
Note: This is a pre-proof version of this manuscript. The final version can be found at:
Wiley Online Library: http://onlinelibrary.wiley.com/doi/10.1002/ase.1696/full
DOI :10.1002/ase.1696
To reference this article: Moro, C., Štromberga, Z., Raikos, A. and Stirling, A. (2017), The
effectiveness of virtual and augmented reality in health sciences and medical anatomy. Anatomical
Sciences Education. doi:10.1002/ase.1696
Correspondence to: Dr. Christian Moro, Faculty of Health Sciences and Medicine, Bond University,
Gold Coast, QLD 4229, Australia. Telephone: +61 (0) 755954775.
E-mail: cmoro@bond.edu.au
Runninghead: VR and AR in health sciences and medical anatomy
Keywords: gross anatomy education; health sciences education; undergraduate education; medical
education; virtual reality; augmented reality; mixed reality; computer-aided instruction; oculus rift;
tablet applications

ABSTRACT
Although cadavers constitute the gold standard for teaching anatomy to medical and health
science students, there are substantial financial, ethical and supervisory constraints on their
use. In addition, although anatomy remains one of the fundamental areas of medical
education, universities have decreased the hours allocated to teaching gross anatomy in favor
of applied clinical work. The release of virtual (VR) and augmented reality (AR) devices
allows learning to occur through hands-on immersive experiences. The aim of this research
was to assess whether learning structural anatomy utilizing VR or AR is as effective as tablet-
based (TB) applications, and whether these modes allowed enhanced student learning,
engagement and performance. Participants (n=59) were randomly allocated to one of the
three learning modes: VR, AR or TB and completed a lesson on skull anatomy, after which
they completed an anatomical knowledge assessment. Student perceptions of each learning
mode and any adverse effects experienced were recorded. No significant differences were
found between mean assessment scores in VR, AR or TB. During the lessons however,
participants are more likely to exhibit adverse effects such as headaches (25% in VR P <
0.05), dizziness (40% in VR, P < 0.001) or blurred vision (35% in VR, P < 0.01). Both VR
and AR are as valuable for teaching anatomy as tablet devices, but also promote intrinsic
benefits such as increased learner immersion and engagement. These outcomes show great
promise for the effective use of virtual and augmented reality as means to supplement lesson
content in anatomical education.
Keywords: Virtual Reality; Augmented Reality; Mixed Reality; Computer-aided instruction;
Interactive Media in Education; Medical education; Oculus Rift; Tablet applications.

INTRODUCTION
Educational technology is changing the way people engage and interact with learning
material. Its goal is to create a powerful environment where the student can use their innate
abilities of learning to grasp complex concepts and acquire knowledge through observation,
imitation and participation (Goodyear and Retalis, 2010). Technology enhanced learning is
most effective when it seamlessly integrates into the curriculum, mitigates the passive lecture
experience and the large number of students in a class, and also provides a tool within which
students can engage in meaningful experiences and gain knowledge (Garrison and Akyol,
2009). In response to technological advancements, a variety of multimedia information
delivery tools have been developed and are currently in use to enhance students’ learning
outcomes. These supplementary materials include podcasts, screencasts and educational
software available for use on a personal computer and mobile devices, such as smartphones
and tablets (Scalise et al., 2011; Green et al., 2012; Molnar, 2016). The availability of
multimedia technology, digital content and software empowers the modern-day students as it
provides opportunities to engage with learning materials more easily and effectively. The
consumer-grade release of new visualization technologies such as virtual reality through the
Oculus Rift (Oculus VR, LLC., Menlo Park, CA) and Gear VR (Samsung Electronics Co.,
LTD., Suwon, South Korea) and augmented reality have paved a way to learn in a manner
that previously not possible. For clarity, in this research study, the terms applied have been
defined as follows:
 Virtual reality (VR): The user’s senses (sight, hearing and motion) are fully
immersed in a synthetic environment that mimics the properties of the real world
through high resolution, high refresh rate head-mounted displays, stereo headphones
and motion-tracking systems.
 Augmented reality (AR): Using a camera and screen (i.e. smartphone or tablet)
digital models are superimposed into the real-world. The user is then able to interact
with both the real and virtual elements of their surrounding environment.
 Three-dimensional (3D) tablet displays: Utilizing high-resolution screens on tablets
and smartphones to visualize pseudo-3D models and environments. The user interacts
with digital aspects on the screen and manipulates objects using a mouse or finger
gestures.
Current trends in health science education
Medical and health science students must gain many skills and acquire vast arrays of
knowledge throughout their time at university to become competent practitioners, with
anatomy in particular being one of the cornerstones of health education. Without proper
understanding of anatomy, regardless of the area of healthcare, practitioners can be unable to
perform investigations effectively as they require knowledge of organs and tissues precise
locations (Singh et al., 2015). Anatomy is traditionally taught at the beginning of a health
science or medical course to provide the fundamental knowledge in four main areas: gross
anatomy, neuroanatomy, histology and embryology (Turney, 2007). It is commonly delivered
in the form of lectures, which include a slideshow presentation and a verbal description of the
concepts, dissections and prosections, clinical cases and self-directed study using two-
dimensional (2D) images and multimedia resources (Murgitroyd et al., 2015).
The field of science is constantly evolving and with this comes an increase in topics that must
be included within a modern curriculum, resulting in a paradigm shift in the way health is
taught. Many health science course curricula utilize a problem-based learning framework
which places a greater emphasis on student self-directed learning (Moro and McLean, 2017).

This has led to less face to face teaching time in many of the ‘basic sciences’ and a greater
dependence on supplementary materials and modules outside the formal course time
(Johnson et al., 2012). Although anatomy remains an integral part of health science
education, universities have decreased hours allocated to teaching anatomy and replaced them
with applied clinical work. In 2009 the amount of time dedicated to teaching gross anatomy
was found to have decreased by 55% over the span of the past 49 years within the medical
curriculum in universities within the United States of America (Drake et al., 2002, 2009,
2014). Similarly, a study conducted in Australia and New Zealand, concluded that the time
allocated for gross anatomy has also declined when compared to historical data (Craig et al.,
2010), potentially impacting the foundational knowledge of doctors, nurses, dentists,
biomedical and laboratory scientists, and other health science practitioners. A further decline
in the time allocated to gross anatomy is apparent if no reforms are made to the current
medical curricula (Singh et al., 2015). Based on the current situation, students in health
science courses are expected to spend more time learning anatomy using supplementary
resources as means of bridging the knowledge gaps.
Supplements used to enhance anatomical education
Anatomical learning is best done in a setting where desired structures can be examined from
all angles. This includes examinations of actual structures using cadavers or synthetic
recreations, such as silicone or plastic models. Surgeons stress the importance of dissections
in anatomy teaching, as it provides an effective method for learning anatomical details,
familiarizing the students with variations in human physiology and appreciating structures of
the body that cannot be examined during an operation (Turney, 2007; Sheikh et al., 2016). On
average, medical students can get approximately three hours of anatomy laboratory time each
week where they share a cadaver between 10 – 12 students (Snelling et al., 2003). These
sessions are tightly structured and in many universities, students are unable to gain access to
the ‘wet specimens’ outside of scheduled times (Codd and Choudhury, 2011; Murgitroyd et
al., 2015). This means that the students only have a limited window in which they can learn
anatomy effectively from a cadaver. Students are then required to turn to supplementary
materials to enhance their anatomical knowledge through self-directed study. This material
most commonly consists of 2D supplementary resources such as lecture slides, textbooks and
flashcards (Messier et al., 2016). An issue with learning from static images is that anatomical
structures are three-dimensional and it can be difficult to comprehend spatial relationships
between structures. 2D images also rely on the student’s ability to transform these into 3D
structures, which can be a challenging cognitive leap for those who find it difficult to
visualize or mentally rotate anatomical structures (Marsh et al., 2008; Brewer et al., 2012). It
also has to be noted that these static images, even if mentally rotated can only produce an
image that is assumed by the learner, however it can be inaccurate as the mind is filling the
gaps of the missing structures (Linn and Petersen, 1985; Liesefeld et al., 2015). With
advances in educational technology these traditional resources can be supplemented by
interactive multimedia learning tools (Walsh, 2014; Trelease, 2016) and interactive software
that can be accompanied with both auditory and visual information (Taveira-Gomes et al.,
2016).
For students, technology facilitates access to learning content at any time and place, whereas
for educators it expands their educational impact by not constraining learning to classroom
sessions (Goh, 2016). It also allows educators to guide students throughout self-directed
learning sessions, which can be particularly important for undergraduate students who often
require additional support compared to postgraduates (Moro and McLean, 2017). Multimedia
tools use a combination of words and pictures (Mayer, 2009), such as with “screencasts”

Frequently asked questions

Q1. What have the authors contributed in "The effectiveness of virtual and augmented reality in health science and medical anatomy" ?

The aim of this research was to assess whether learning structural anatomy utilizing VR or AR is as effective as tabletbased ( TB ) applications, and whether these modes allowed enhanced student learning, engagement and performance. 

Q2. What are the future works mentioned in the paper "The effectiveness of virtual and augmented reality in health science and medical anatomy" ?

This area of research would also benefit from further research into the adverse effects exhibited in this study, and potential methods that could be employed to minimize or reduce these in virtual and augmented anatomical education applications. Finally, future studies could also provide benefit by identifying the optimal timeframe of lessons within VR and AR. This study utilized 10-minute sessions, however, it may be more comfortable for participants to spend longer or shorter periods within the virtual world, or even obtain a pre-exposure to the virtual environment for some time prior to the lessons. 

Q3. What was the common way to navigate the model?

Two-finger touching of the screen allowed panning, while pinching finger gestures allowed the user to zoom in and out and navigate the model. 

Q4. What was the effect of VR on the students?

One-third of VR group experienced blurred vision and difficulty concentrating, whereas double-vision was present in 21% of participants. 

Q5. What was the effect of the left-click button on the Oculus Rift?

The left-click button engaged a “dissect” mode, removing the highlighted layer in front of the user, revealing the underlying structures. 

Q6. What is the reason for the occurrence of cybersickness?

A potential issue that can have an impact on the learning experience and assessment results when using virtual reality is cybersickness, which causes nausea, disorientation, discomfort, headache, fatigue, difficulty concentrating and problems with vision (Rebenitsch and Owen, 2016). 

Q7. What is the effect of the study on the working memory?

A person is only able to process three to five “chunks of information” at the same time, therefore anything that exceeds simple cognitive activities may overwhelm the working memory and one’s cognitive resources (Cowan, 2010). 

Q8. What was the percentage of participants who had taken a subject in anatomy prior to the study?

Just over half of participants (54%) reported having taken a subject in anatomy prior to the study, with the percentage ranging from 50% to 59% across the three study groups. 

Q9. What are the benefits of VR and AR?

both VR and AR provide additional intrinsic benefits, such as increased student engagement, interactivity and enjoyment. 

Q10. What was the ethics of the study?

Research ethics was approved by the Bond University Human Ethics Research Committee, and all participants provided informed consent. 

Q11. What are the possible reasons for the increase in students’ comprehension of the content within the ARBOOK?

as students become more accustomed to these virtual devices and applications, their comprehension of the content within is likely to increase, and modern packaged applications utilizing AR showing promising results for student engagement and learning, such as the ARBOOK (Ferrer-Torregrosa et al., 2015) and HuMAR prototype applications (Jamali et al., 2015) and it will be interesting to see the influence on students if these types of applications are implemented in medical and biomedical programs.