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SPECIAL ISSUE RESEARCH ARTICLE
The role of augmented reality in Anatomical education: An overview夽 Dimitrios Chytas a,∗ , Elizabeth O. Johnson a,b , Maria Piagkou b , Antonios Mazarakis b , George C. Babis c , Efstathios Chronopoulos c , Vasileios S. Nikolaou c , Nikolaos Lazaridis d , Konstantinos Natsis d a
Medical School, European University of Cyprus, 6, Diogenous Str., Engomi, 2404 Nicosia, Cyprus Department of Anatomy, School of Medicine, National and Kapodistrian University of Athens, 75, Mikras Asias Str., 11527 Athens, Greece 2nd Orthopedic Department of National and Kapodistrian University of Athens, Konstantopoulio-Patission Hospital, 3-5 Agias Olgas Str., Nea Ionia, 14233 Athens, Greece d Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece b c
a r t i c l e
i n f o
Article history: Received 16 August 2019 Received in revised form 29 November 2019 Accepted 10 December 2019 Available online xxx Keywords: Anatomy Education Augmented reality Review
a b s t r a c t Background: The outcomes of the implementation of augmented reality (AR) in anatomical education have not been reviewed so far. We performed a narrative review of the literature concerning these outcomes. Methods: We searched in the databases PubMed, Scopus, Cochrane, ERIC, CINAHL plus and Web of Science for papers with the aim to explore the outcomes of the implementation of AR in anatomical education. From each paper, we extracted the following data: authors, year of publication, type of study (comparative or not), number of participants, level of outcome according to Kirkpatrick hierarchy, acceptability of AR, impact on examinations performance, ability to facilitate understanding of spatial organization of structures and to motivate students to learn anatomy. Results: Seven papers were eligible for analysis. There were five comparative and two non-comparative studies. Three studies evaluated only students’ perceptions about AR, while four papers assessed their examinations performance after the application of AR. Generally, AR was proved a highly acceptable and enjoyable anatomy teaching tool. It had remarkable efficacy in terms of helping students understand three-dimensional organization of structures and achieve satisfactory examinations results. Conclusions: Although the research concerning the implementation of AR in anatomical education is relatively limited, there are promising results regarding the teaching potential of AR. These results could encourage anatomy educators to include this tool in their teaching methods. Randomized controlled studies are needed to prove if AR could effectively replace or supplement other anatomy pedagogy methods. © 2020 Elsevier GmbH. All rights reserved.
1. Introduction Augmented reality (AR) is defined as “the concept of digitally superimposing virtual objects onto physical objects in real space so individuals can interact with both at the same time” (Azuma, 1997). This definition highlights the contrast with virtual reality (VR), in which the whole simulation takes place exclusively in a computergenerated environment (Vávra et al., 2017). AR applications that support blended learning in training medical professionals have attracted public and scientific interest (Barsom et al., 2016). It
夽 This paper belongs to the special issue Medical Education 2019. ∗ Corresponding author at: 75, Theotokopoulou Str., 11144, Athens, Greece. E-mail address: [email protected] (D. Chytas).
has been argued that AR could positively affect medical education (Kamphuis et al., 2014). Indeed, a randomized controlled trial demonstrated that the application of AR led to significantly higher knowledge gain in comparison with textbooks (Albrecht et al., 2013). Also, in the study by Wang et al. (2016), the students reported interest in the implementation of AR into medical education test preparation. They also highlighted the need of future investigation into how the use of AR can improve examinations performance (Wang et al., 2016). Several authors reported encouraging results regarding the ability of AR to promote clinical skills training, including training of residents of surgical specialties (Alaraj et al., 2013; Mitha et al., 2013; Sutherland et al., 2013; Leitritz et al., 2014). Interestingly, this ability was correlated with the fact that AR permits clear demonstration of normal and abnormal anatomy (Yudkowsky et al., 2013).
https://doi.org/10.1016/j.aanat.2020.151463 0940-9602/© 2020 Elsevier GmbH. All rights reserved.
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Table 1 Kirkpatrick hierarchy (Kirkpatrick, 1998; Hammick, 2000). Level 1 Level 2a Level 2b Level 3 Level 4a Level 4b
Reaction Change of attitudes-perceptions Change of knowledge-skills Behavioral change Change in organizational practice Benefits to patients
Relates to participants’ opinions on the learning experience. Relates to changes in the participants’ attitudes or perceptions after the educational intervention. Relates to the acquisition of knowledge and skills after the educational intervention. Relates to the change of behavior in the workplace due to the educational intervention. Significant changes in the delivery of care, due to an educational program. Improvement of patients’ health due to an educational program.
A review article about the implementation of AR in healthcare education showed generally positive outcomes (Zhu et al., 2014), but did not focus on the role of AR in anatomical education. Estai and Bunt (2016) published a review article about anatomy teaching methods and reported AR, without performing an in-depth analysis about its teaching potential. Interestingly, the authors recommended the application of a combination of anatomy pedagogy methods (Estai and Bunt, 2016), which are, in general, cadaver dissection by students, inspection of prosected specimens, teaching of living and radiological anatomy, use of models, lectures and computer-based learning (Brenner et al., 2003). Three-dimensional (3D) visualization, which is a form of computer-based learning, has been proved effective as an anatomy pedagogy modality (Hackett and Proctor, 2016). Especially, the use of virtual objects for anatomy teaching purposes has led to encouraging educational outcomes (Falah et al., 2015; Said et al., 2015). An example of the implementation of AR in anatomical education is the use of a mobile display device, whose camera scans an image of a book page (Küc¸ük et al., 2016). Via an application, the image is detected and recognized as a marker. When the students look at pages of the book on the display device, they could see superimposed multimedia objects, which allow students to interact with them (Küc¸ük et al., 2016). Several AR systems have been developed with perspectives to be used as anatomy teaching tools (Yeom, 2011; Jamali et al., 2015; Bauer et al., 2016; Kurniawan et al., 2018). The aim of the current study was to explore the quality and quantity of the evidence about the significance of the use of AR in anatomical education. In order to estimate the quality of this evidence, we assessed the strength of the outcomes of the implementation of this anatomy teaching method. Kirkpatrick (1998) proposed a scale which is used to evaluate the impact of an educational intervention. In this context, we performed a narrative review of the literature, in order to answer the question: “To what extent can the existing data support that the implementation of AR can play a significant role in anatomical education?”
Papers which dealt with the application of AR for clinical skills training and papers which did not comprise educational outcomes were excluded from the review. Duplicates, expert opinion articles, letters to the editor, conference papers and review articles were also excluded. Screening was done in three stages and included title, abstract and full text. If the title did not clarify if the study would be included, the abstract was also screened. Finally, if the abstract did not clarify again if the paper would be included, the full text was screened. In the present review, the following data were received from each paper: authors, year of publication, type of study (comparative or not), number of participants, level of outcome according to Kirkpatrick hierarchy (Table 1) (Kirkpatrick, 1998; Hammick, 2000) and effects of AR on students’ anatomy learning (acceptability, impact on examinations performance, ability to facilitate understanding of spatial organization of structures and to motivate students to learn anatomy). The data were analyzed with a narrative description. Ethical approval was not applicable. 3. Results Our initial search retrieved 199 articles. We excluded 94 irrelevant studies, 21 papers which dealt with clinical skills training, one paper not written in English, one expert opinion article, 62 conference papers, 10 studies without educational outcomes of the implementation of AR and three papers which comprised high school students. Thus, seven papers were eligible for analysis (Fig. 1). Their main characteristics are presented on Table 2. There were five comparative (Ferrer-Torregrosa et al., 2015, 2016; Küc¸ük et al., 2016; Kugelmann et al., 2018; Moro et al., 2017) and two noncomparative studies (Ma et al., 2016; Thomas et al., 2010). The level of outcome was 1 (the lowest) in three papers (Kugelmann et al., 2018; Ma et al., 2016; Thomas et al., 2010) and 2b in four papers (Ferrer-Torregrosa et al., 2015, 2016; Küc¸ük et al., 2016; Moro et al., 2017). 3.1. Comparative studies
2. Material and methods Taking into account the Preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement (Moher et al., 2009), three reviewers conducted independently a search in the databases: PubMed, Scopus, Cochrane, ERIC, CINAHL plus and Web of Science. The key words were: “augmented” AND “anatomy” AND (“education” OR “teaching” OR” learning”). The search was completed on October 30, 2018. For the identification of relevant papers which were not initially found, the reference lists of the studies which were included in the review were checked. The differences between the three reviewers were discussed and, if no agreement could be achieved, the senior author decided. The papers that were eligible for analysis were those whose purpose was to investigate the outcomes of the implementation of AR in human anatomical education concerning university students at an undergraduate or postgraduate level. Studies eligible for analysis were those which were written in English language and published in peer-reviewed journals. To be up to date, we included papers published after January 1, 2010.
Ferrer-Torregrosa et al. (2015) performed a questionnaire study, which comprised 211 first-year anatomy students. The participants were divided into a control group, which received standard teaching sessions supported by video and books, and a group which received the same standard sessions enriched by an AR tool, regarding lower limb anatomy. The first part of the AR tool comprised a book with bi-dimensional images and text about anatomy. The second part included a card for each anatomical figure. The card was recognized by a camera connected to a computer and showed in the screen. Then, the virtual image appeared in the screen. The movement of the card by the user was accompanied by movements of the virtual image. The written test at the end of the training demonstrated that the latter group achieved statistically significantly higher scores than the former group. In addition, it was shown that the AR system significantly enhanced students’ motivation and 3D comprehension of structures, in comparison with the control group. Ferrer-Torregrosa et al. (2016) conducted a study which included 171 students (from medicine, physiotherapy and podiatry
Please cite this article as: D. Chytas, E.O. Johnson, M. Piagkou et al., The role of augmented reality in Anatomical education: An overview, Ann. Anatomy, https://doi.org/10.1016/j.aanat.2020.151463
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Fig. 1. The flow chart of the selection of the studies of our review. Table 2 Main characteristics of the studies of the review (authors, participants, type, level of outcome according to Kirkpatrick hierarchy, main outcomes). Authors
Participants
Type of study
Level
Main outcomes
Thomas et al. (2010)
34 first-year medical students
Non-comparative
1
Ferrer-Torregrosa et al. (2015)
211 first-year anatomy students
Comparative
2b
Ferrer-Torregrosa et al. (2016)
171 students (from medicine, physiotherapy and podiatry degrees)
Comparative
2b
Ma et al. (2016)
72 first-year medical students, two surgeons and five final-year undergraduate medical students 70 second-year medical students
Non-comparative
1
Comparative
2b
Moro et al. (2017)
59 anatomy students
Comparative
2b
Kugelmann et al. (2018)
735 first-year medical students
Comparative
1
The AR system was considered as easy to use and very helpful for students to understand the location and shape of the ventricles. The AR group achieved statistically significantly higher examinations scores than the control group. The AR system significantly enhanced students’ motivation and 3D comprehension of structures and their actions, in comparison with the control group. The AR group obtained a significantly higher mean examinations score than those achieved with video and notes. Significant superiority of AR to the other two tools in terms of 3D comprehension. The AR system was helpful for anatomy learning, easy to use, capable to demonstrate 3D human anatomy. It was considered as a potential complementary anatomy teaching tool. The academic achievement of the AR group was significantly higher in comparison with the control one. The cognitive load of the AR group was significantly lower in comparison with the control one. The examinations scores were not significantly different among the AR, VR and tablet-based applications groups. Insignificant difference was noted between groups in terms of providing enjoyable and effective anatomy learning, facilitating understanding and being user-friendly. The AR system enhanced the students’ motivation to learn anatomy, it was perceived to have greater teaching potential than textbooks and to assist 3D understanding of anatomy. The benefits of the AR tool increased in the second half of the course.
Küc¸ük et al. (2016)
AR: augmented reality. VR: virtual reality. 3D: three-dimensional.
degrees). The participants were divided into three groups: the first one received teaching professor’s notes on the topic of the extrinsic muscles of the foot, along with anatomical atlas images. The second group was given the same professor’s notes and a video showing each of the structures of the notes, along with voice-over narration. The third group received the professor’s notes and AR software. The AR system, described by Billinghurst et al. (2001), included (i)
a book (ii) a handheld display and (iii) a computer graphics workstation. The book contained pictures used as tracking marks for a computer vision-based head-tracking system. The camera output was connected to the computer graphics workstation. When the user looked at the book pictures through the handheld display, computer vision techniques calculated the camera position relative to the tracking mark. The computer calculated the user’s head
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position and produced virtual images, which appeared precisely registered with the real pages. The third group was found to have obtained a mean examinations score of 7.2/10, significantly higher than that achieved with video (6.5/10) and that obtained with the notes (5.6/10). The authors also noted a significant superiority of AR to the other two tools in terms of enhancing 3D comprehension. Also, 76.9 % of the participants stated that AR would be effective for studying, 75 % argued that it would increase motivation and interest in the topic, and 67.3 % estimated that their marks would improve with this method. Küc¸ük et al. (2016) published a study which comprised 70s-year medical students. Thirty-four of them were randomly allocated to the experimental group, which received anatomy teaching sessions via mobile AR technology. This group used a mobile display device, whose camera scanned an image of a book page. Via an application, the image was detected and recognized as a marker. When the students looked pages of the book on the display device, they could see superimposed multimedia objects, which allowed students to interact with them. Thirty-six students were randomly allocated to the control group, which was taught anatomy via traditional methods (including graphs, text and two-dimensional pictures). It was demonstrated that the academic achievement of the former group was significantly higher in comparison with the latter one. Also, the cognitive load of the former group was significantly lower in comparison with the latter one. When the students who were taught anatomy via AR were asked if the application facilitated anatomy learning, approximately 76 % of them answered “yes”, while about 24 % answered “partially”. When they were asked if their cognitive load was reduced, approximately 79 % answered “yes”, 18 % answered “partially” and 3 % answered “no”. Moro et al. (2017) evaluated the perceptions of 59 randomly allocated anatomy students regarding AR, VR and tablet-based applications as anatomy teaching tools. The three groups received a 10-minute skull anatomy lesson, via an audio-stream narrated by a specialist surgeon. As different structures of the skull were introduced during the audio-stream, they were highlighted in blue to draw the student’s attention. The AR group used a tablet as a display device and could interact with the virtual objects. The mean knowledge assessment score of the VR group was 64.5 %, the AR group achieved 62.5 % and the tablet group achieved 66.5 %. The scores were not significantly different among the three groups. Also, insignificant difference was noted between groups in terms of providing enjoyable and effective anatomy learning, facilitating understanding and being user-friendly. In all these sectors, VR, AR and tablet-based applications received generally positive comments by the respondents. Kugelmann et al. (2018) performed a questionnaire study which included 735 first-year medical students. The first part of the AR system of the study comprised a large display device which served as the user’s “mirror”. The second part consisted of a real-time tracking device, which linked a deposited section image to the projection of the user’s body. Via gesture input, the users could interactively explore radiological images in several anatomical intersection planes. It was believed that the AR tool enhanced the students’ motivation to learn anatomy (14.5 % of them strongly agreed, 43.5 % simply agreed). Also, the AR system was generally perceived to have greater teaching potential than textbooks (22.7 % of the students strongly agreed, 46.4 % simply agreed). In addition, 63.6 % of the respondents strongly agreed and 29.8 % simply agreed that the AR system assists 3D understanding of anatomy. Interestingly, as the anatomy course was extended over a five-month period, the percentage of students who were motivated by the AR tool to learn anatomy increased from 54 % to 62 %. Generally, all participants evaluated that the benefits of the AR tool increased in the second half of the course. Finally, the AR system was rated as excellent or good by about 81.9 % of the respondents.
3.2. Non-comparative studies Thomas et al. (2010) performed a questionnaire study which included 34 first-year medical students. The students were asked to evaluate an AR-based system which was used for teaching the anatomy of the ventricles of the human brain. The first part of the system consisted of a 3D printed model of a human brain, which was created via magnetic resonance imaging and was supplied with a sensor. The second part comprised a screen, on which the user could choose to see different planes of the 3D printed brain anatomy. The planes were based on the dataset used for the production of the 3D printed model. Thirty-two out of the 34 respondents rated the AR system with a score 4/5 or 5/5 (in a five-point Likerttype scale), in terms of helping them understand the location and shape of the ventricles. This fact means that students generally considered the AR system as very good or excellent. More specifically, the authors noticed a mean score of 4.3/5 and a median score of 4.5/5. In terms of the question if the system was easy to use, the students generally answered positively, with a mean of 3.9/5 and a median of 4/5. Ma et al. (2016) evaluated the acceptability and learning potential of an AR system as a complement to atlas textbooks. The system included a sensor which detected the user moving in front of a display. The user could visualize a computed tomography dataset, having the illusion that looks inside his or her body. The user could also turn around his or her body to see the computed tomography volume from different viewpoints, and put his or her hands at different heights to choose a body plane with corresponding anatomy. This questionnaire study included 72 first-year medical students. The vast majority of the respondents (86.1 %) argued that the AR system was helpful for their anatomy learning, while 83.3 % of them liked to use it and 91.7 % liked the AR view of 3D human anatomy. Statistically significant difference between positive and negative answers was depicted for the three questions. Also, seven participants (two surgeons and five final-year undergraduate medical students) agreed, in a five-point Likert-type scale, that the user interface was easy to use, with a mean score of 3.67. They all agreed that the AR system should be considered as a potential complementary anatomy teaching tool.
4. Discussion It can be pointed out that the number of studies which focused on the role of AR in anatomical education is relatively limited. Nevertheless, the majority of studies compared the use of AR with other anatomy teaching tools and demonstrated that AR was generally accompanied by positive outcomes. Interestingly, the paper by Kugelmann et al. (2018) was the only one which compared the perceptions of students about AR in different periods of a course. In that paper, all participants found that the benefits of AR were enhanced as the time passed. However, the lack of evaluation of statistical significance limits the strength of this conclusion. Of note, the majority (four out of the seven) papers of the current review had a level 2b (moderate) in Kirkpatrick hierarchy, since they evaluated examinations results (Ferrer-Torregrosa et al., 2015, 2016; Küc¸ük et al., 2016; Moro et al., 2017). These studies were simultaneously comparative, while they also comprised statistical evaluation, a factor which increases their strength. Random allocation to groups was reported only in the studies by Küc¸ük et al. (2016) and Moro et al. (2017). Nevertheless, Moro et al. (2017) reported that the results may have been compromised, because some students had previously taken a specific anatomy course and others had not. Also, Küc¸ük et al. (2016) stated that they did not know how much time was spent by the participants on the study materials, a factor which could affect their examinations results. The minority of the studies
Please cite this article as: D. Chytas, E.O. Johnson, M. Piagkou et al., The role of augmented reality in Anatomical education: An overview, Ann. Anatomy, https://doi.org/10.1016/j.aanat.2020.151463
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of the current review (three out of the seven studies) (Kugelmann et al., 2018; Ma et al., 2016; Thomas et al., 2010) had a level 1 (the lowest), since they assessed only students’ perceptions, a factor which reduces the strength of their educational outcomes. It is evident that randomized controlled studies are needed to show if AR could significantly affect students’ behavior and anatomical knowledge. Also, there is a need for studies to compare the educational effectiveness of AR with that of other anatomy pedagogy modalities, such as cadaveric dissection, inspection of prosected specimens and teaching of living and radiological anatomy. This comparison will clarify if AR could function as a supplement or replace these anatomy pedagogy methods.
the participants in those two studies commented positively on AR concerning 3D comprehension, a lack of a control group and statistical analysis reduces the strength of those results. In the remaining two papers (Ferrer-Torregrosa et al., 2015, 2016), in contrast with Kugelmann et al. (2018) and Ma et al. (2016), a statistically significant superiority of AR to other teaching tools was demonstrated, regarding 3D comprehension of anatomy. Consequently, the ability of AR to offer 3D visualization of anatomy seems to be remarkable, according to the papers of the current review.
4.1. Impact of AR on examinations results Three out of the four studies which investigated the students’ academic achievement found significant superiority of AR to other educational tools (Ferrer-Torregrosa et al., 2015, 2016; Küc¸ük et al., 2016). The only paper which did not demonstrate this superiority was published by Moro et al. (2017). Nevertheless, the authors noticed that AR was generally positively commented by the respondents. The authors included only 59 participants in their analysis, a relatively limited number in comparison with the other studies which evaluated examinations results. Also, the authors recognized that sample demographics might have played a role in the study outcome, because some participants had previously taken a specific course in anatomy, while others had not. The papers by Ferrer-Torregrosa et al. (2015), 2016 and Küc¸ük et al. (2016), which comprised 211, 171 and 70 participants respectively, demonstrated that AR led to significantly better academic achievement than the other methods which were explored. However, Küc¸ük et al. (2016) pointed out that they did not know how much time was spent by the participants on the study materials, a factor which could compromise their examinations results. Despite this limitation, it could be generally noted that AR had a positive impact on students’ academic performance and could be considered as an effective anatomy teaching tool.
The vast majority of the participants in the study by Thomas et al. (2010) rated the AR system as easy to use and, in general, as very good or excellent teaching tool. Also, over three out of four respondents in the analysis by Ferrer-Torregrosa et al. (2016), stated that AR would be effective for studying. Kugelmann et al. (2018) found that over eight out of ten participants were satisfied with the AR system. In the study by Ma et al. (2016), the percentage of acceptability of AR was equally high, while the system was generally considered as helpful for anatomy learning and easy to use. In addition, Küc¸ük et al. (2016) highlighted that the AR tool was accompanied by significantly lower cognitive load in comparison with the control group, while all participants argued that AR facilitated anatomy learning. The only paper which did not demonstrate superiority of AR to other anatomy teaching methods was published by Moro et al. (2017). The authors found that insignificant difference existed between AR and other tools in terms of facilitating understanding, being user-friendly and providing enjoyable and effective anatomy learning. However this paper comprised the lowest number of participants among all the comparative studies of the current review. Despite the fact that significant superiority of AR was not showed, this method received generally positive comments. Thus, there was agreement in the literature that AR could be an acceptable anatomy teaching tool, which could offer enjoyable learning.
4.2. Ability of AR to motivate students to learn anatomy
4.5. Limitations
Three papers explored the potential of AR to motivate students to learn anatomy (Ferrer-Torregrosa et al., 2015, 2016; Kugelmann et al., 2018). In the questionnaire study by Kugelmann et al. (2018), the percentage of respondents who noticed that the AR system enhanced their motivation was initially 54 % and increased to 62 % when the course extended over a five-month period. Unfortunately, statistical significance was not evaluated, a factor which limits the strength of this outcome. Also, three out of four participants in the study by Ferrer-Torregrosa et al. (2016) argued that AR would reinforce their motivation to learn anatomy. In the paper by Ferrer-Torregrosa et al. (2015), the increase of this motivation with AR was statistically significant in comparison with the control group. Thus, the aforementioned results indicate that AR could be a promising method regarding its ability to motivate students to learn anatomy.
Our study has some limitations. At first, the search in the specific six databases with our key words, inclusion and exclusion criteria, may have been incapable to detect all the papers which explored the role of the implementation of AR in anatomical education. Also, the heterogeneity of the existing data did not allow the performance of a systematic review, which would provide stronger outcomes than a narrative one. Finally, if more than seven papers had been included in the current review and if a statistical analysis had been performed, safer conclusions would have been extracted.
4.3. Potential of AR to demonstrate 3D visualization of structures Four studies evaluated the potential of AR to provide adequate 3D visualization of anatomical structures (Ferrer-Torregrosa et al., 2015, 2016; Kugelmann et al., 2018; Ma et al., 2016). In the paper by Kugelmann et al. (2018), over 93 % of the participants argued that AR was helpful in terms of promoting 3D understanding of anatomical structures. Similarly, 91.7 % of the students who were included in the analysis by Ma et al. (2016) stated that they liked the AR view of 3D human anatomy. Although the vast majority of
4.4. Acceptability and enjoyment
5. Conclusions Although the research concerning the implementation of AR in anatomical education is relatively limited, there are promising results regarding the teaching potential of AR. These results could encourage anatomy educators to include this tool in their teaching methods. Further research, with randomized controlled studies, could possibly confirm these results and clarify if AR could be an acceptable accessory anatomy teaching tool or obtain a more prominent role in anatomical education.
Ethical approval Not applicable.
Please cite this article as: D. Chytas, E.O. Johnson, M. Piagkou et al., The role of augmented reality in Anatomical education: An overview, Ann. Anatomy, https://doi.org/10.1016/j.aanat.2020.151463
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Kugelmann, D., Stratmann, L., Nühlen, N., Bork, F., Hoffmann, S., Samarbarksh, G., Pferschy, A., von der Heide, A.M., Eimannsberger, A., Fallavollita, P., Navab, N., Waschke, J., 2018. An Augmented Reality magic mirror as additive teaching device for gross anatomy. Ann. Anat. 215 (January), 71–77. Kurniawan, M.H., Suharjito, D., Witjaksono, G., 2018. Human anatomy learning systems using augmented reality on mobile application. Procedia Comput. Sci. 135, 80–88. Leitritz, M.A., Ziemssen, F., Suesskind, D., Partsch, M., Voykov, B., Bartz-Schmidt, K.U., Szurman, G.B., 2014. Critical evaluation of the usability of augmented reality ophthalmoscopy for the training of inexperienced examiners. Retina. 34 (April (4)), 785–791. Ma, M., Fallavollita, P., Seelbach, I., Von Der Heide, A.M., Euler, E., Waschke, J., Navab, N., 2016. Personalized augmented reality for anatomy education. Clin. Anat. 29 (May (4)), 446–453. Mitha, A.P., Almekhlafi, M.A., Janjua, M.J., Albuquerque, F.C., McDougall, C.G., 2013. Simulation and augmented reality in endovascular neurosurgery: lessons from aviation. Neurosurgery 72 (January (Suppl 1)), 107–114. Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., the PRISMA Group, 2009. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 6 (July (7)), e1000097. ˇ Moro, C., Stromberga, Z., Raikos, A., Stirling, A., 2017. The effectiveness of virtual and augmented reality in health sciences and medical anatomy. Anat. Sci. Educ. 10 (November (6)), 549–559. Said, C.S., Shamsudin, K., Mailok, R., 2015. The development and evaluation of a 3D visualization tool in anatomy education. EDUCATUM 2, 48–56. Sutherland, C., Hashtrudi-Zaad, K., Sellens, R., Abolmaesumi, P., Mousavi, P., 2013. An augmented reality haptic training simulator for spinal needle procedures. IEEE Trans. Biomed. Eng. 60 (November (11)), 3009–3018. Thomas, R.G., John, N.W., Delieu, J.M., 2010. Augmented reality for anatomical education. J. Vis. Commun. Med. 33 (March (1)), 6–15. Vávra, P., Roman, J., Zonˇca, P., Ihnát, P., Nˇemec, M., Kumar, J., Habib, N., El-Gendi, A., 2017. Recent development of Augmented Reality in surgery: a review. J. Healthc. Eng. 2017, 1–9. Wang, L.L., Wu, H.H., Bilici, N., Tenney-Soeiro, R., 2016. Gunner goggles: implementing augmented reality into medical education. Stud. Health Technol. Inform. 220, 446–449. Yeom, S.J., 2011. Augmented reality for learning anatomy. In: Williams, G., Statham, P., Bron, N., Cleland, B. (Eds.), Changing Demands, Changing Directions. Proceedings Ascilite Hobart 2011. The University of Tasmania, Hobart, Tasmania (AU), pp. 1377–1383. Yudkowsky, R., Luciano, C., Banerjee, P., Schwartz, A., Alaraj, A., Lemole Jr., G.M., Charbel, F., Smith, K., Rizzi, S., Byrne, R., Bendok, B., Frim, D., 2013. Practice on an augmented reality/haptic simulator and library of virtual brains improves residents’ ability to perform a ventriculostomy. Simul. Healthc. 8 (February (1)), 25–31. Zhu, E., Hadadgar, A., Masiello, I., Zary, N., 2014. Augmented reality in healthcare education: an integrative review. PeerJ 2 (July), e469.
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SPECIAL ISSUE RESEARCH ARTICLE
The role of augmented reality in Anatomical education: An overview夽 Dimitrios Chytas a,∗ , Elizabeth O. Johnson a,b , Maria Piagkou b , Antonios Mazarakis b , George C. Babis c , Efstathios Chronopoulos c , Vasileios S. Nikolaou c , Nikolaos Lazaridis d , Konstantinos Natsis d a
Medical School, European University of Cyprus, 6, Diogenous Str., Engomi, 2404 Nicosia, Cyprus Department of Anatomy, School of Medicine, National and Kapodistrian University of Athens, 75, Mikras Asias Str., 11527 Athens, Greece 2nd Orthopedic Department of National and Kapodistrian University of Athens, Konstantopoulio-Patission Hospital, 3-5 Agias Olgas Str., Nea Ionia, 14233 Athens, Greece d Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece b c
a r t i c l e
i n f o
Article history: Received 16 August 2019 Received in revised form 29 November 2019 Accepted 10 December 2019 Available online xxx Keywords: Anatomy Education Augmented reality Review
a b s t r a c t Background: The outcomes of the implementation of augmented reality (AR) in anatomical education have not been reviewed so far. We performed a narrative review of the literature concerning these outcomes. Methods: We searched in the databases PubMed, Scopus, Cochrane, ERIC, CINAHL plus and Web of Science for papers with the aim to explore the outcomes of the implementation of AR in anatomical education. From each paper, we extracted the following data: authors, year of publication, type of study (comparative or not), number of participants, level of outcome according to Kirkpatrick hierarchy, acceptability of AR, impact on examinations performance, ability to facilitate understanding of spatial organization of structures and to motivate students to learn anatomy. Results: Seven papers were eligible for analysis. There were five comparative and two non-comparative studies. Three studies evaluated only students’ perceptions about AR, while four papers assessed their examinations performance after the application of AR. Generally, AR was proved a highly acceptable and enjoyable anatomy teaching tool. It had remarkable efficacy in terms of helping students understand three-dimensional organization of structures and achieve satisfactory examinations results. Conclusions: Although the research concerning the implementation of AR in anatomical education is relatively limited, there are promising results regarding the teaching potential of AR. These results could encourage anatomy educators to include this tool in their teaching methods. Randomized controlled studies are needed to prove if AR could effectively replace or supplement other anatomy pedagogy methods. © 2020 Elsevier GmbH. All rights reserved.
1. Introduction Augmented reality (AR) is defined as “the concept of digitally superimposing virtual objects onto physical objects in real space so individuals can interact with both at the same time” (Azuma, 1997). This definition highlights the contrast with virtual reality (VR), in which the whole simulation takes place exclusively in a computergenerated environment (Vávra et al., 2017). AR applications that support blended learning in training medical professionals have attracted public and scientific interest (Barsom et al., 2016). It
夽 This paper belongs to the special issue Medical Education 2019. ∗ Corresponding author at: 75, Theotokopoulou Str., 11144, Athens, Greece. E-mail address: [email protected] (D. Chytas).
has been argued that AR could positively affect medical education (Kamphuis et al., 2014). Indeed, a randomized controlled trial demonstrated that the application of AR led to significantly higher knowledge gain in comparison with textbooks (Albrecht et al., 2013). Also, in the study by Wang et al. (2016), the students reported interest in the implementation of AR into medical education test preparation. They also highlighted the need of future investigation into how the use of AR can improve examinations performance (Wang et al., 2016). Several authors reported encouraging results regarding the ability of AR to promote clinical skills training, including training of residents of surgical specialties (Alaraj et al., 2013; Mitha et al., 2013; Sutherland et al., 2013; Leitritz et al., 2014). Interestingly, this ability was correlated with the fact that AR permits clear demonstration of normal and abnormal anatomy (Yudkowsky et al., 2013).
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Table 1 Kirkpatrick hierarchy (Kirkpatrick, 1998; Hammick, 2000). Level 1 Level 2a Level 2b Level 3 Level 4a Level 4b
Reaction Change of attitudes-perceptions Change of knowledge-skills Behavioral change Change in organizational practice Benefits to patients
Relates to participants’ opinions on the learning experience. Relates to changes in the participants’ attitudes or perceptions after the educational intervention. Relates to the acquisition of knowledge and skills after the educational intervention. Relates to the change of behavior in the workplace due to the educational intervention. Significant changes in the delivery of care, due to an educational program. Improvement of patients’ health due to an educational program.
A review article about the implementation of AR in healthcare education showed generally positive outcomes (Zhu et al., 2014), but did not focus on the role of AR in anatomical education. Estai and Bunt (2016) published a review article about anatomy teaching methods and reported AR, without performing an in-depth analysis about its teaching potential. Interestingly, the authors recommended the application of a combination of anatomy pedagogy methods (Estai and Bunt, 2016), which are, in general, cadaver dissection by students, inspection of prosected specimens, teaching of living and radiological anatomy, use of models, lectures and computer-based learning (Brenner et al., 2003). Three-dimensional (3D) visualization, which is a form of computer-based learning, has been proved effective as an anatomy pedagogy modality (Hackett and Proctor, 2016). Especially, the use of virtual objects for anatomy teaching purposes has led to encouraging educational outcomes (Falah et al., 2015; Said et al., 2015). An example of the implementation of AR in anatomical education is the use of a mobile display device, whose camera scans an image of a book page (Küc¸ük et al., 2016). Via an application, the image is detected and recognized as a marker. When the students look at pages of the book on the display device, they could see superimposed multimedia objects, which allow students to interact with them (Küc¸ük et al., 2016). Several AR systems have been developed with perspectives to be used as anatomy teaching tools (Yeom, 2011; Jamali et al., 2015; Bauer et al., 2016; Kurniawan et al., 2018). The aim of the current study was to explore the quality and quantity of the evidence about the significance of the use of AR in anatomical education. In order to estimate the quality of this evidence, we assessed the strength of the outcomes of the implementation of this anatomy teaching method. Kirkpatrick (1998) proposed a scale which is used to evaluate the impact of an educational intervention. In this context, we performed a narrative review of the literature, in order to answer the question: “To what extent can the existing data support that the implementation of AR can play a significant role in anatomical education?”
Papers which dealt with the application of AR for clinical skills training and papers which did not comprise educational outcomes were excluded from the review. Duplicates, expert opinion articles, letters to the editor, conference papers and review articles were also excluded. Screening was done in three stages and included title, abstract and full text. If the title did not clarify if the study would be included, the abstract was also screened. Finally, if the abstract did not clarify again if the paper would be included, the full text was screened. In the present review, the following data were received from each paper: authors, year of publication, type of study (comparative or not), number of participants, level of outcome according to Kirkpatrick hierarchy (Table 1) (Kirkpatrick, 1998; Hammick, 2000) and effects of AR on students’ anatomy learning (acceptability, impact on examinations performance, ability to facilitate understanding of spatial organization of structures and to motivate students to learn anatomy). The data were analyzed with a narrative description. Ethical approval was not applicable. 3. Results Our initial search retrieved 199 articles. We excluded 94 irrelevant studies, 21 papers which dealt with clinical skills training, one paper not written in English, one expert opinion article, 62 conference papers, 10 studies without educational outcomes of the implementation of AR and three papers which comprised high school students. Thus, seven papers were eligible for analysis (Fig. 1). Their main characteristics are presented on Table 2. There were five comparative (Ferrer-Torregrosa et al., 2015, 2016; Küc¸ük et al., 2016; Kugelmann et al., 2018; Moro et al., 2017) and two noncomparative studies (Ma et al., 2016; Thomas et al., 2010). The level of outcome was 1 (the lowest) in three papers (Kugelmann et al., 2018; Ma et al., 2016; Thomas et al., 2010) and 2b in four papers (Ferrer-Torregrosa et al., 2015, 2016; Küc¸ük et al., 2016; Moro et al., 2017). 3.1. Comparative studies
2. Material and methods Taking into account the Preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement (Moher et al., 2009), three reviewers conducted independently a search in the databases: PubMed, Scopus, Cochrane, ERIC, CINAHL plus and Web of Science. The key words were: “augmented” AND “anatomy” AND (“education” OR “teaching” OR” learning”). The search was completed on October 30, 2018. For the identification of relevant papers which were not initially found, the reference lists of the studies which were included in the review were checked. The differences between the three reviewers were discussed and, if no agreement could be achieved, the senior author decided. The papers that were eligible for analysis were those whose purpose was to investigate the outcomes of the implementation of AR in human anatomical education concerning university students at an undergraduate or postgraduate level. Studies eligible for analysis were those which were written in English language and published in peer-reviewed journals. To be up to date, we included papers published after January 1, 2010.
Ferrer-Torregrosa et al. (2015) performed a questionnaire study, which comprised 211 first-year anatomy students. The participants were divided into a control group, which received standard teaching sessions supported by video and books, and a group which received the same standard sessions enriched by an AR tool, regarding lower limb anatomy. The first part of the AR tool comprised a book with bi-dimensional images and text about anatomy. The second part included a card for each anatomical figure. The card was recognized by a camera connected to a computer and showed in the screen. Then, the virtual image appeared in the screen. The movement of the card by the user was accompanied by movements of the virtual image. The written test at the end of the training demonstrated that the latter group achieved statistically significantly higher scores than the former group. In addition, it was shown that the AR system significantly enhanced students’ motivation and 3D comprehension of structures, in comparison with the control group. Ferrer-Torregrosa et al. (2016) conducted a study which included 171 students (from medicine, physiotherapy and podiatry
Please cite this article as: D. Chytas, E.O. Johnson, M. Piagkou et al., The role of augmented reality in Anatomical education: An overview, Ann. Anatomy, https://doi.org/10.1016/j.aanat.2020.151463
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Fig. 1. The flow chart of the selection of the studies of our review. Table 2 Main characteristics of the studies of the review (authors, participants, type, level of outcome according to Kirkpatrick hierarchy, main outcomes). Authors
Participants
Type of study
Level
Main outcomes
Thomas et al. (2010)
34 first-year medical students
Non-comparative
1
Ferrer-Torregrosa et al. (2015)
211 first-year anatomy students
Comparative
2b
Ferrer-Torregrosa et al. (2016)
171 students (from medicine, physiotherapy and podiatry degrees)
Comparative
2b
Ma et al. (2016)
72 first-year medical students, two surgeons and five final-year undergraduate medical students 70 second-year medical students
Non-comparative
1
Comparative
2b
Moro et al. (2017)
59 anatomy students
Comparative
2b
Kugelmann et al. (2018)
735 first-year medical students
Comparative
1
The AR system was considered as easy to use and very helpful for students to understand the location and shape of the ventricles. The AR group achieved statistically significantly higher examinations scores than the control group. The AR system significantly enhanced students’ motivation and 3D comprehension of structures and their actions, in comparison with the control group. The AR group obtained a significantly higher mean examinations score than those achieved with video and notes. Significant superiority of AR to the other two tools in terms of 3D comprehension. The AR system was helpful for anatomy learning, easy to use, capable to demonstrate 3D human anatomy. It was considered as a potential complementary anatomy teaching tool. The academic achievement of the AR group was significantly higher in comparison with the control one. The cognitive load of the AR group was significantly lower in comparison with the control one. The examinations scores were not significantly different among the AR, VR and tablet-based applications groups. Insignificant difference was noted between groups in terms of providing enjoyable and effective anatomy learning, facilitating understanding and being user-friendly. The AR system enhanced the students’ motivation to learn anatomy, it was perceived to have greater teaching potential than textbooks and to assist 3D understanding of anatomy. The benefits of the AR tool increased in the second half of the course.
Küc¸ük et al. (2016)
AR: augmented reality. VR: virtual reality. 3D: three-dimensional.
degrees). The participants were divided into three groups: the first one received teaching professor’s notes on the topic of the extrinsic muscles of the foot, along with anatomical atlas images. The second group was given the same professor’s notes and a video showing each of the structures of the notes, along with voice-over narration. The third group received the professor’s notes and AR software. The AR system, described by Billinghurst et al. (2001), included (i)
a book (ii) a handheld display and (iii) a computer graphics workstation. The book contained pictures used as tracking marks for a computer vision-based head-tracking system. The camera output was connected to the computer graphics workstation. When the user looked at the book pictures through the handheld display, computer vision techniques calculated the camera position relative to the tracking mark. The computer calculated the user’s head
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position and produced virtual images, which appeared precisely registered with the real pages. The third group was found to have obtained a mean examinations score of 7.2/10, significantly higher than that achieved with video (6.5/10) and that obtained with the notes (5.6/10). The authors also noted a significant superiority of AR to the other two tools in terms of enhancing 3D comprehension. Also, 76.9 % of the participants stated that AR would be effective for studying, 75 % argued that it would increase motivation and interest in the topic, and 67.3 % estimated that their marks would improve with this method. Küc¸ük et al. (2016) published a study which comprised 70s-year medical students. Thirty-four of them were randomly allocated to the experimental group, which received anatomy teaching sessions via mobile AR technology. This group used a mobile display device, whose camera scanned an image of a book page. Via an application, the image was detected and recognized as a marker. When the students looked pages of the book on the display device, they could see superimposed multimedia objects, which allowed students to interact with them. Thirty-six students were randomly allocated to the control group, which was taught anatomy via traditional methods (including graphs, text and two-dimensional pictures). It was demonstrated that the academic achievement of the former group was significantly higher in comparison with the latter one. Also, the cognitive load of the former group was significantly lower in comparison with the latter one. When the students who were taught anatomy via AR were asked if the application facilitated anatomy learning, approximately 76 % of them answered “yes”, while about 24 % answered “partially”. When they were asked if their cognitive load was reduced, approximately 79 % answered “yes”, 18 % answered “partially” and 3 % answered “no”. Moro et al. (2017) evaluated the perceptions of 59 randomly allocated anatomy students regarding AR, VR and tablet-based applications as anatomy teaching tools. The three groups received a 10-minute skull anatomy lesson, via an audio-stream narrated by a specialist surgeon. As different structures of the skull were introduced during the audio-stream, they were highlighted in blue to draw the student’s attention. The AR group used a tablet as a display device and could interact with the virtual objects. The mean knowledge assessment score of the VR group was 64.5 %, the AR group achieved 62.5 % and the tablet group achieved 66.5 %. The scores were not significantly different among the three groups. Also, insignificant difference was noted between groups in terms of providing enjoyable and effective anatomy learning, facilitating understanding and being user-friendly. In all these sectors, VR, AR and tablet-based applications received generally positive comments by the respondents. Kugelmann et al. (2018) performed a questionnaire study which included 735 first-year medical students. The first part of the AR system of the study comprised a large display device which served as the user’s “mirror”. The second part consisted of a real-time tracking device, which linked a deposited section image to the projection of the user’s body. Via gesture input, the users could interactively explore radiological images in several anatomical intersection planes. It was believed that the AR tool enhanced the students’ motivation to learn anatomy (14.5 % of them strongly agreed, 43.5 % simply agreed). Also, the AR system was generally perceived to have greater teaching potential than textbooks (22.7 % of the students strongly agreed, 46.4 % simply agreed). In addition, 63.6 % of the respondents strongly agreed and 29.8 % simply agreed that the AR system assists 3D understanding of anatomy. Interestingly, as the anatomy course was extended over a five-month period, the percentage of students who were motivated by the AR tool to learn anatomy increased from 54 % to 62 %. Generally, all participants evaluated that the benefits of the AR tool increased in the second half of the course. Finally, the AR system was rated as excellent or good by about 81.9 % of the respondents.
3.2. Non-comparative studies Thomas et al. (2010) performed a questionnaire study which included 34 first-year medical students. The students were asked to evaluate an AR-based system which was used for teaching the anatomy of the ventricles of the human brain. The first part of the system consisted of a 3D printed model of a human brain, which was created via magnetic resonance imaging and was supplied with a sensor. The second part comprised a screen, on which the user could choose to see different planes of the 3D printed brain anatomy. The planes were based on the dataset used for the production of the 3D printed model. Thirty-two out of the 34 respondents rated the AR system with a score 4/5 or 5/5 (in a five-point Likerttype scale), in terms of helping them understand the location and shape of the ventricles. This fact means that students generally considered the AR system as very good or excellent. More specifically, the authors noticed a mean score of 4.3/5 and a median score of 4.5/5. In terms of the question if the system was easy to use, the students generally answered positively, with a mean of 3.9/5 and a median of 4/5. Ma et al. (2016) evaluated the acceptability and learning potential of an AR system as a complement to atlas textbooks. The system included a sensor which detected the user moving in front of a display. The user could visualize a computed tomography dataset, having the illusion that looks inside his or her body. The user could also turn around his or her body to see the computed tomography volume from different viewpoints, and put his or her hands at different heights to choose a body plane with corresponding anatomy. This questionnaire study included 72 first-year medical students. The vast majority of the respondents (86.1 %) argued that the AR system was helpful for their anatomy learning, while 83.3 % of them liked to use it and 91.7 % liked the AR view of 3D human anatomy. Statistically significant difference between positive and negative answers was depicted for the three questions. Also, seven participants (two surgeons and five final-year undergraduate medical students) agreed, in a five-point Likert-type scale, that the user interface was easy to use, with a mean score of 3.67. They all agreed that the AR system should be considered as a potential complementary anatomy teaching tool.
4. Discussion It can be pointed out that the number of studies which focused on the role of AR in anatomical education is relatively limited. Nevertheless, the majority of studies compared the use of AR with other anatomy teaching tools and demonstrated that AR was generally accompanied by positive outcomes. Interestingly, the paper by Kugelmann et al. (2018) was the only one which compared the perceptions of students about AR in different periods of a course. In that paper, all participants found that the benefits of AR were enhanced as the time passed. However, the lack of evaluation of statistical significance limits the strength of this conclusion. Of note, the majority (four out of the seven) papers of the current review had a level 2b (moderate) in Kirkpatrick hierarchy, since they evaluated examinations results (Ferrer-Torregrosa et al., 2015, 2016; Küc¸ük et al., 2016; Moro et al., 2017). These studies were simultaneously comparative, while they also comprised statistical evaluation, a factor which increases their strength. Random allocation to groups was reported only in the studies by Küc¸ük et al. (2016) and Moro et al. (2017). Nevertheless, Moro et al. (2017) reported that the results may have been compromised, because some students had previously taken a specific anatomy course and others had not. Also, Küc¸ük et al. (2016) stated that they did not know how much time was spent by the participants on the study materials, a factor which could affect their examinations results. The minority of the studies
Please cite this article as: D. Chytas, E.O. Johnson, M. Piagkou et al., The role of augmented reality in Anatomical education: An overview, Ann. Anatomy, https://doi.org/10.1016/j.aanat.2020.151463
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of the current review (three out of the seven studies) (Kugelmann et al., 2018; Ma et al., 2016; Thomas et al., 2010) had a level 1 (the lowest), since they assessed only students’ perceptions, a factor which reduces the strength of their educational outcomes. It is evident that randomized controlled studies are needed to show if AR could significantly affect students’ behavior and anatomical knowledge. Also, there is a need for studies to compare the educational effectiveness of AR with that of other anatomy pedagogy modalities, such as cadaveric dissection, inspection of prosected specimens and teaching of living and radiological anatomy. This comparison will clarify if AR could function as a supplement or replace these anatomy pedagogy methods.
the participants in those two studies commented positively on AR concerning 3D comprehension, a lack of a control group and statistical analysis reduces the strength of those results. In the remaining two papers (Ferrer-Torregrosa et al., 2015, 2016), in contrast with Kugelmann et al. (2018) and Ma et al. (2016), a statistically significant superiority of AR to other teaching tools was demonstrated, regarding 3D comprehension of anatomy. Consequently, the ability of AR to offer 3D visualization of anatomy seems to be remarkable, according to the papers of the current review.
4.1. Impact of AR on examinations results Three out of the four studies which investigated the students’ academic achievement found significant superiority of AR to other educational tools (Ferrer-Torregrosa et al., 2015, 2016; Küc¸ük et al., 2016). The only paper which did not demonstrate this superiority was published by Moro et al. (2017). Nevertheless, the authors noticed that AR was generally positively commented by the respondents. The authors included only 59 participants in their analysis, a relatively limited number in comparison with the other studies which evaluated examinations results. Also, the authors recognized that sample demographics might have played a role in the study outcome, because some participants had previously taken a specific course in anatomy, while others had not. The papers by Ferrer-Torregrosa et al. (2015), 2016 and Küc¸ük et al. (2016), which comprised 211, 171 and 70 participants respectively, demonstrated that AR led to significantly better academic achievement than the other methods which were explored. However, Küc¸ük et al. (2016) pointed out that they did not know how much time was spent by the participants on the study materials, a factor which could compromise their examinations results. Despite this limitation, it could be generally noted that AR had a positive impact on students’ academic performance and could be considered as an effective anatomy teaching tool.
The vast majority of the participants in the study by Thomas et al. (2010) rated the AR system as easy to use and, in general, as very good or excellent teaching tool. Also, over three out of four respondents in the analysis by Ferrer-Torregrosa et al. (2016), stated that AR would be effective for studying. Kugelmann et al. (2018) found that over eight out of ten participants were satisfied with the AR system. In the study by Ma et al. (2016), the percentage of acceptability of AR was equally high, while the system was generally considered as helpful for anatomy learning and easy to use. In addition, Küc¸ük et al. (2016) highlighted that the AR tool was accompanied by significantly lower cognitive load in comparison with the control group, while all participants argued that AR facilitated anatomy learning. The only paper which did not demonstrate superiority of AR to other anatomy teaching methods was published by Moro et al. (2017). The authors found that insignificant difference existed between AR and other tools in terms of facilitating understanding, being user-friendly and providing enjoyable and effective anatomy learning. However this paper comprised the lowest number of participants among all the comparative studies of the current review. Despite the fact that significant superiority of AR was not showed, this method received generally positive comments. Thus, there was agreement in the literature that AR could be an acceptable anatomy teaching tool, which could offer enjoyable learning.
4.2. Ability of AR to motivate students to learn anatomy
4.5. Limitations
Three papers explored the potential of AR to motivate students to learn anatomy (Ferrer-Torregrosa et al., 2015, 2016; Kugelmann et al., 2018). In the questionnaire study by Kugelmann et al. (2018), the percentage of respondents who noticed that the AR system enhanced their motivation was initially 54 % and increased to 62 % when the course extended over a five-month period. Unfortunately, statistical significance was not evaluated, a factor which limits the strength of this outcome. Also, three out of four participants in the study by Ferrer-Torregrosa et al. (2016) argued that AR would reinforce their motivation to learn anatomy. In the paper by Ferrer-Torregrosa et al. (2015), the increase of this motivation with AR was statistically significant in comparison with the control group. Thus, the aforementioned results indicate that AR could be a promising method regarding its ability to motivate students to learn anatomy.
Our study has some limitations. At first, the search in the specific six databases with our key words, inclusion and exclusion criteria, may have been incapable to detect all the papers which explored the role of the implementation of AR in anatomical education. Also, the heterogeneity of the existing data did not allow the performance of a systematic review, which would provide stronger outcomes than a narrative one. Finally, if more than seven papers had been included in the current review and if a statistical analysis had been performed, safer conclusions would have been extracted.
4.3. Potential of AR to demonstrate 3D visualization of structures Four studies evaluated the potential of AR to provide adequate 3D visualization of anatomical structures (Ferrer-Torregrosa et al., 2015, 2016; Kugelmann et al., 2018; Ma et al., 2016). In the paper by Kugelmann et al. (2018), over 93 % of the participants argued that AR was helpful in terms of promoting 3D understanding of anatomical structures. Similarly, 91.7 % of the students who were included in the analysis by Ma et al. (2016) stated that they liked the AR view of 3D human anatomy. Although the vast majority of
4.4. Acceptability and enjoyment
5. Conclusions Although the research concerning the implementation of AR in anatomical education is relatively limited, there are promising results regarding the teaching potential of AR. These results could encourage anatomy educators to include this tool in their teaching methods. Further research, with randomized controlled studies, could possibly confirm these results and clarify if AR could be an acceptable accessory anatomy teaching tool or obtain a more prominent role in anatomical education.
Ethical approval Not applicable.
Please cite this article as: D. Chytas, E.O. Johnson, M. Piagkou et al., The role of augmented reality in Anatomical education: An overview, Ann. Anatomy, https://doi.org/10.1016/j.aanat.2020.151463
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Please cite this article as: D. Chytas, E.O. Johnson, M. Piagkou et al., The role of augmented reality in Anatomical education: An overview, Ann. Anatomy, https://doi.org/10.1016/j.aanat.2020.151463