Introduction

Three-dimensional visualization of anatomical structures is one of the most challenging aspects on teaching–learning process. Not only for students but also for instructors, three-dimensional representation usually implies some training. In this sense, plastic models or cadaveric demonstrations are helpful in order to achieve spatial interpretation of structures. Nowadays, the advance of new electronic media has led to a deep revolution in the way we observe the human body. Technologies allow us to observe three-dimensional images of internal organs in standard Smartphones. Despite some reports did not support the benefits of these advances (Garg et al. 1999, 2001, 2002), many others confirmed the effectiveness of these new technologies for students (Harman et al. 1999; James et al. 2001, 2002; McLachlan et al. 2004; Stirling and Birt 2014).

In order to improve teaching–learning process in anatomical sciences, instructors reinforce their lectures with several tools, using from plastic or wax models to cadaveric pieces (Vernon and Peckham 2002). Seminars or practical sessions are also included in biomedical curricula in order to achieve spatial comprehension of anatomical structures. Traditionally, these classical forms of teaching used to be performed in small groups pretending a customized instruction. Although real cadaver or synthetic models are irreplaceable tools for comprehension of structures, those present inconveniences in terms of price, location, portability or legacy. These tools can be only found in laboratories, workshops or classrooms and with limited access for students. Even more, reducing the number of students in seminars or practical workshops evidently implicates more qualified supervisor staff. Considering these previous points and the time spent by students in terms of autonomous work or group work, the use of these technologies could be part of the solution of the aforementioned problems. In this sense, and according to the new technologies, innovative techniques have been also targeted on surgery training (Cottam 1999; Luursema et al. 2006; Keehner et al. 2008).

One relevant aspect for learning process is that related to motivation. Motivation includes reciprocal interactions among environmental contexts, behaviors and personal characteristics (Bandura 1986, 2001; Bryan et al. 2011). This self-regulated process improves when students assume conscious control over their motivation and behavior in a way which leads to desirable learning outcomes (Glynn et al. 2011). The motivation to learn science is defined as an internal state that maintains science-learning behavior (Eccles and Wigfield 2002; Glynn et al. 2011; Campos-Sánchez et al. 2014), and for this reason, the development of tools promoting motivation and self-learning is widely justified.

Based on three-dimensional imaging and of interest for biomedical/technical sciences, the augmented reality (AR) is considered as a variant of the virtual reality (VR) (Azuma et al. 2001). The revolutionary innovation of AR is the overlapping of actual surrounding environment with virtual images. In fact, the use of VR/AR has been previously reported as useful for students (Nicholson et al. 2006; Sakellariou et al. 2009; Lamounier et al. 2010; Thomas et al. 2010; Luciano et al. 2011). AR is currently used not only for surgery training but also for intraoperative guidance (Cabrilo et al. 2014; Okamoto et al. 2014; Soler et al. 2014).

Although motivation or skill achievement is the most important target for the development of teaching tools, other factors such as portability, price and student autonomy must also be considered. We present herein results obtained after using the augmented reality book (ARBOOK) as supporting teaching tool. ARBOOK was developed at UCV by staff professors in collaboration with LabHuman® from Polytechnic University of Valencia (UPV) and visual medical 3D company (VMV3D®).

Materials and Methods

Development of the Tool: “Augmented Reality Book (ARBOOK) Part I. Lower limb”

ARBOOK can be presented in both, printed or electronic version. ARBOOK includes a standard part of descriptive anatomy of the lower limb including osteology, arthrology, myology, nerve and vascular supply. Each part of the book includes bi-dimensional images and text about the muscles: origin insertion, vascular and nerve supply or action (see Fig. 1a).

Fig. 1
figure 1

Final aspect of the book ARBOOK. For each anatomical region, information about the anatomical structures is provided (origin insertion, neurovascular supply and action) (a). Additionally, a card is included on each section (b). The card is recognized by the PC camera and shown in the screen (c). The movement of the card is accompanied by movements on the virtual image (d)

Full size image

The ARBOOK includes a card (Fig. 1b) for each anatomical figure that can be recognized by a digital webcam connected to a computer (see Fig. 1c, d). Then, the virtual AR image appears in the computer screen. The users can modify the actual position of the virtual structure by moving the card (Fig. 1d). A demonstration of the tool can be seen at the attached file (file 1).

To develop the ARBOOK, more than 100 TC images were needed and the images were processed by OsiriX® software and 3D constructed. LabHuman® and VMV3D® companies performed the animation.

Questionnaire: Development and Validation

After considering previous questionnaires, a specific questionnaire was needed to be developed because none of the questionnaire found achieved the scope of this new tool.

The questionnaire included 15 questions organized in 3 blocks.

The first block consists of eight items focused on motivation and attention tasks.

The second block consists of three questions related to the autonomous work. The third block consisted of five questions, dealing with the spatial comprehension–orientation and three-dimensional interpretation. For complete information of contents, see tables.

Responses were based on a four choices Likert scale (Never, Rarely, Frequently, Always). For statistical analysis, chi-square test was used and response categories were reduced to Yes/Not: Yes (Frequently + Always); not (Never + Rarely).

The validation of the questionnaire was performed according to the Delphi method (Dalkey and Helmer 1963). Three phases were done: preliminary, exploratory and final. Briefly, after defining items and structure, this first version was evaluated by expertise panel and feedback was included in the questionnaire for two cycles. Cronbach´s alpha was used to determine the internal consistence of the questionnaire.

Study of ARBOOK

Subjects, Recruitment and Inclusion Criteria

Students of anatomy were invited to participate. All Spanish universities were called to participate in this project. The initial requirements were: First year student, student of anatomy that never had studied before this subject. Second year students were excluded. Students with previous studies as Medicine, Physiotherapy, Nursing, Podiatry, etc., were also excluded. Students were randomly assigned to the Control group or the group named as ARBOOK.

The Control group received standard sessions with lectures, slides, and video recordings of cadaveric material. The ARBOOK group received the same standard sessions but additionally used the ARBOOK tool. Due to the technical requirements and novelty of the tool, the ARBOOK group was assayed in two universities.

A total of 211 students from 7 public and private Spanish universities agreed to participate in the ARBOOK project along the academic year 2012–2013. Forty-two participants were excluded according with any of the exclusion criteria.

About 134 students with a range of age between 18 and 41 years of age were assigned as Control group, and 77 students between 18 and 42 years were assigned as ARBOOK group. The distribution of gender was of 38, 8 % male and 61, 1 % female in the Control group. The ARBOOK group consisted of 33, 77 % male and 66, 23 % female.

A presentation letter within the aim of the study, instructions and material of the ARBOOK project was sent to the staff instructors. The project also included a virtual platform where the ARBOOK researchers could interact with students and get feedback or tutorials. All the materials used by both groups were uploaded to a virtual application, so the users could download it along the duration of the sessions. Once the sessions were finished, the application was closed and all the students responded to the online questionnaire. Additionally, they were also individually assessed by a short written test on anatomical questions including two identification slides (with eight structures) and eight multiple choice questions about the lower limb. The global score of the test was of ten points.

Results

The questionnaire on the block I, focused on attention and motivation tasks, showed statistically significant differences of almost all questions but not the question number 4 (see Table 1). Percentages on Table 1 confirmed how this difference between groups reflects a better scoring for the ARBOOK group.

Table 1 Frequencies (F) and percentages (%) of response on attention and motivation-related tasks from control and ARBOOK groups
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The block II (see Table 2) deals with three questions concerning autonomous work. The questions 10 and 11 showed statistically significant differences between groups indicating that ARBOOK group responded better to this task than the Control group. No differences between groups could be set for the question number 9.

Table 2 Frequencies (F) and percentages (%) of response on autonomous work-related tasks from Control and ARBOOK groups
Full size table

Three-dimensional comprehension task was assessed on block III by five questions related with the anatomy and movements of the lower limb (see Table 3). Although no differences between groups could be set on question 15, the questions 12, 13 and 14 presented statistically significant differences between groups indicating that ARBOOK facilitates spatial comprehension of structures and their actions.

Table 3 Frequencies (F) and percentages (%) of response on three-dimensional comprehension related tasks from Control and ARBOOK groups
Full size table

A short test was included in the study in order to identify whether ARBOOK could result in a better test performance. The test included seven multiple choice questions and two figures with eight items to identify. The score (mean ± SD) for the Control group was 7.21 ± 1.73 points and 8.34 ± 1.64 points for the ARBOOK group. Although the results found are so close, statistically significant differences between groups could be found indicating better outcome for the ARBOOK group (p = 0.0001).

Discussion

Some considerations must be taken into account before discuss the results found herein. First of all, is that related to the achievement of the ARBOOK tool. More than 2 years were used to develop the ARBOOK project. A multidisciplinary work including anatomical educators, medical imaging professionals, image engineering and informatics was needed to develop this project. The other novelty was the necessity to develop a questionnaire fitting to the scope of ARBOOK and its repercussion on learning: Does AR facilitate anatomical study? A total of 29 professionals (among educationists and professors) participated on the development of the questionnaire and three cycles of revisions were needed for the final questionnaire achievement.

The ARBOOK group was only represented by two universities, whereas the Control group was represented by five universities. Obviously, the desirable distribution is the equal representation of both groups from each university participating in the study.

Fitting with others, indicating that the inclusion of virtual material in anatomical training may benefit student outcome (McNulty et al. 2004; Gopal et al. 2010; Stirling and Birt 2014). Additionally, ARBOOK is significantly better than conventional methods promoting motivation and autonomy. This is one of the most interesting points after considering the time spent by students in terms of autonomous work. The development of tools promoting self-learning and autonomous work must be seriously considered for anatomical training and other sciences.

In view of the results found on the block III, ARBOOK seems to improve spatial comprehension better than standard methods. Surprisingly, on item 15 referred to “see muscular movements,” no differences could be set between groups, whereas significant differences can be found on item 14 “to understand muscular movement.” Maybe the interpretation of “to see” and “to understand” leads students to confusion.

ARBOOK group got better scores on the individual written test than the Control group. This also fits with the results obtained on questionnaires, suggesting that ARBOOK may be helpful for students. However, more studies must be addressed in order to assess other unexplored possibilities of the ARBOOK tool.

According to the advance of new technologies and electronic devices, the academic methodologies must be changed. Agreeing with the results found herein, it has been recently presented an enriched book with good results on anatomy learning, known as “e-Book” (Stirling and Birt 2014). Additionally, interactive methodologies have also improved anatomy performances (McNulty et al. 2004; Gopal et al. 2010). Considering the benefits of the interactive and virtual methodologies for spatial comprehension, motivation and finally improving learning, new technologies can additionally be helpful to facilitate autonomous work and secondarily to reduce laboratory material and supervisor staff costs.

Two years ago appeared a revolutionary teaching device: The first virtual dissection table developed by Anatomage Inc. After considering the possibilities of AR and others, it is not far-fetched to imagine a future based on virtual imaging in classrooms. Independently that the real cadaver study never will be replaced, the incorporation of new teaching tools is also leading us to new ways of learning, extending theaters, classrooms or laboratories beyond the physical limits of the university campus.