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A comparative study of the presentation of anatomy by lectures versus ICAL packages to physiotherapy students

Harry B. Lee and Garry Allison
School of Physiotherapy
Curtin University of Technology
The primary aim of this study was to verify that interactive computer assisted learning (ICAL) packages can replace lectures to teach anatomy to undergraduate physiotherapy students. The secondary aim of this study was to investigate the relationship between the previous level of achievement in gross anatomy of the lower limb with its surface anatomy, and the ability to transfer this information into three dimensional (3-D) palpation skills. To investigate these aims, ICAL packages were developed from HyperCard Stacks to present the surface anatomy of three regions of the lower extremity.

Seventy-nine (n=79) first year physiotherapy student subjects were evenly distributed according to their previous ability in anatomy of the lower limb, and divided into three groups. Each group was then randomly sub-divided into ICAL and lecture sub-groups.

The study took place over five weeks. During week 1 the whole group undertook a two dimensional (2-D) pre-test to assess the level of previous knowledge. Throughout weeks 2, 3 and 4 each Lecture sub-group received the same information simultaneously delivered to the ICAL sub-group in another location. Both study groups then re-combined for a 2-D test and a 3-D practical class to identify and palpate the 2-D images onto one another. To control the learning effects of the test-retest strategy, 10% of the 2-D pre-test was repeated during weeks 2, 3 & 4. The reactivity of the test-retest design demonstrated that significant improvement in both study populations (p<0.001) was delayed until the subjects received that specific information.

Palpation skills and landmark identification were practised during weeks 2, 3 & 4, with some landmarks deliberately left unpractised and obscure to the ICAL and Lecture sub-groups until they were tested in week 5. Individual 3-D palpation and landmark identification skills were examined by both authors in Week 5. Inter-reliability between the two examiners was verified by application of the planned test regime to second year physiotherapy student volunteers (df 1,69 t = 0.338).

Analyses of variance (ANOVA) demonstrate a main effect between the total scores and the results of the pre and post-tests for the three regions of the lower limb (p<0.001). No significant difference can be identified for any of the scores obtained by the ICAL or Lecture sub-groups.

Univariate correlation analysis of previous anatomy scores, 2-D theory, practised and unpractised 3-D palpation skills, demonstrate that theoretical performance is not significantly related to practised 3-D performance. However, a significant correlation is evident between 2-D theory and unpractised 3-D skills.

Previous anatomy scores correlate significantly with the theory scores in surface anatomy. Analysis of covariance (ANCOVA) applied to the previous anatomy scores, shows no significant interaction between the ICAL and Lecture sub-groups for the acquisition of 2-D theory or 3-D palpation skills.

These findings support the view that ICAL packages can effectively replace lectures to teach surface anatomy to undergraduate physiotherapy students, but that cognitive 2-D theory cannot be effectively transferred into a satisfactory 3-D psychomotor skill without deliberate practice.


For more than two decades there has been an exponential growth in computer software to supplement traditional methods of teaching and learning (Kulik, Kulik, Chen-Lin & Cohen, 1980; Kulik, Chen-Lin & Kulik, 1986; McNeil & Nelson, 1991). Mitrani and Swan (1990) asserted that computerised learning differs from the more traditional education media because it is interactive, and provides a malleable model for the presentation of abstract ideas. These authors also outlined methods to enhance the cognitive process when constructing programs.

Computer assisted learning (CAL) has been used to educate health professionals since Bitzer pioneered computer assisted instruction (CAI) in nursing courses via PLATO in 1963 and 1966, followed by a wealth of other computerised modalities applied to nursing (Bitzer & Bitzer, 1973; Paulanka, 1986; Belfry and Winne, 1988; Hebda, 1988). CAL has been well represented in dental education, by the application of computers in the Flexible Dental Curriculum at the University of Kentucky in 1971 (Mast & Watson 1976), and a comparison of CAL with tutorial teaching in dentistry at the University of Manchester (Levine, Jones & Morgan in 1987).

Evidence of the established use of computerised learning in medical schools is shown by Holley and Heller (1984), who compared the use of microcomputers with tutorials to teach anaesthesiology and Harkin, Dixon, Reid and Bird (1986), who used computers for an interactive presentation of pathology by microfiche and slide transparencies. In a survey of CAL use in British medical schools, Florey (1988) recommended inter-medical school collaboration for the development and use of resources to rationalise costs. Wigton, Poses, Collins and Cebul (1990), reported the effective use of CAI to improve the diagnostic skills of experienced student health physicians.

For the teaching and learning of anatomy, Richards, Sawyer and Roark, (1987) created 3-D images of anatomical structures to teach gross anatomy and reported positive reactions and responses from 91 first year medical students. Jones, Olafson and Sutin (1978) compared results obtained by freshmen medical students with those in traditional classes and showed that they could learn gross anatomy equally well without lectures or dissection. In a comparative investigation of a volunteer group of 48 medical students sequestered from a total class of 15 1, Walsh and Bohn (1990) used CAL packages to teach human gross anatomy and could find no significant difference between the two groups, with the computer group maintaining a positive attitude throughout.

Branch, Ledford, Robertson and Robinson (1987) validated interactive videodiscs as a teaching technique in biomedical education, whilst Boyle (1985) demonstrated the value of microcomputers to teach respiratory physiology. Ashwood, Fine, Beherens and Adams (1986) emphasised the importance of visual information in computer aided instruction (CAI) which can be enhanced by video images, declaring that this combined modality has great potential in all areas of medical education.

Freeman (1987), who surveyed the use of computers in 60 Allied Health education programs, found less than a 50% usage up to that time and recommended increased computer use in allied health programs during the next decade. These observations were reflected in a review of computer assisted instruction for health professionals by Hmelo (1989), who identified the need for more research into CAI in medical, nursing and allied health education.

Because the study of anatomy is a visual and descriptive science, observation of new students in anatomy suggests that some experience difficulties with the cognitive integration of visual, verbal and written constructs into a third dimension (Meals and Kabo, 1980; Rochford, 1985). On face value, it would appear that those with well developed written and verbal skills are more likely to overcome this difficulty sooner. However, extensive longitudinal studies would be required to investigate this phenomena. Similarly, the literature suggests that the Group Embedded Figures Test (GEFT) may be an efficient instrument to predicate those with such perceptual difficulties, as well as to identify those with a learning style most likely to be suited to computer assisted learning (Witkin, Oltman, Raskin and Karp, 1971; Kenner, 1984; Burger, 1985; Mohr, 1987).

Despite the plethora of literature and empirical observation of the use of multimedia to facilitate learning, there are still reservations about its use (Richards, 1989). From this, it is clear that there is continued need for research to validate these new methods at the tertiary level.

Physiotherapy and its student population

Admission to the physiotherapy program at Curtin is highly competitive, with a 10: 1 ratio of qualified applicants to those accepted for enrolment. Within the state of Western Australia, enrolled physiotherapy students rank next to those accepted for medicine and veterinary science. The majority of enrolling students are recent school leavers, interlaced with a portion of overseas, fee earning, scholarship students, and mature aged candidates with special qualities. Ibis situation generally coincides with that reported from the University of Sydney's Cumberland College of Health Sciences by Rikard-Bell, Marshall and Chekaluk (1991) who found no significant difference in the performance of male and female students and that the level of achievement required to gain admission to that course was only a poor to moderate indicator of later academic performance.

Anatomy and physiotherapy

Applied, functional and clinical anatomy is fundamental to the practice of physiotherapy. Since its inception, this school has presented anatomical information by lectures, demonstrations, and problem based laboratory sessions, reinforced by prosected cadavers, and other visual aids. These methods have been supplemented by commercially produced packages, such as The Anatomy Project, The Versalius Project and Electric Cadaver.

In general terms, minimal research has been carried out to investigate the ideal relationship of ICAL modalities with other educational techniques (Richards, et al., 1987; Jones, et al., 1978; Walsh and Bohn, 1990), and there is a need to review the appropriation of resources to research their influence on undergraduate students. Nevertheless, the efficacy of computer assisted instruction has been well substantiated in medical education (Ashwood, et al., 1986; Harkin et al, 1986; Levine, et al., 1987; Branch, et al., 1987; Florey, 1988; Hmelo, 1989). Its value has been verified by meta-analysis (Kulik, et al., 1986). Evidence from the literature suggests that CAL should be highly visual, involve the student at a cognitive level and provide operative, rather than figurative knowledge (Arons, 1984; Meals and Kabo, 1980; Rochford, 1985).

From this knowledge base, the authors of this paper were encouraged to research the development and impact of parochial, interactive computer assisted learning (ICAL) packages for the teaching and learning of surface anatomy by first year physiotherapy students.

The purpose of the study

The purpose of this study was threefold. Firstly, to validate that parochial ICAL packages could be developed and evaluated as an alternative method to certain traditional lectures in anatomy. Secondly, to investigate the developing relationship of theoretical (2-D) knowledge of surface anatomy with practised and unpractised (3-D) identification of landmarks and palpation skills. Thirdly, to correlate the relative effectiveness of learning by the ICAL and Lecture sub-groups with their previous standing in gross anatomy.


The study took place over a period of five weeks. It was confined to the surface anatomy component of the lower extremity with an allocated contact time of two hours per week for each student.

Prior to commencement, an inventory of 120 surface anatomy features of the lower limb were identified and tabulated. From this inventory, HyperCard stacks were developed to present each feature as ICAL packages for three designated regions of the lower limb.

The three ICAL HyperSurf stacks were converted to become overhead projections for the presentation of the identical 2-D images and features from the inventory via DataShow to the lecture sub-groups. A diagrammatic 2-D pre-test was constructed from the inventory to rank the pre-existing level of knowledge of surface anatomy throughout the total study group. The 2-D pre-test was reformatted to re-test the same information divided to coincide with the three regions of the lower limb.


To meet the requirements of individual members of each ICAL sub-group, the 28 station computer laboratory (MacLab) was exclusively made available for their use, under supervision, at the beginning of each two hour session. Simultaneously, the Lecture sub-group received the same information in an overhead projection format, using a DataShow apparatus, driven by a Macintosh computer mounted on a portable console. The DataShow computer console was controlled at a distance by a 10m mouse extension cord.


Standard 512 x 342 HyperCard Sstacks were developed to display diagrams and print on the screens of Macintosh computers. Each stack was given a logo, with a command to click into a box to proceed to the second card. The second card detailed instructions about how to proceed through the stack, with a 'return arrow' available on each card, as well as an option to 'quit .

Each card showed a diagram of a particular aspect of the surface anatomy of the lower extremity, which focused upon a particular location, or associated part. The user was challenged to locate a feature displayed on the picture by clicking the required spot with the tip of the browsing tool.

Depending on the target in question, single, or groups of transparent buttons were located in the background of each card. Each button was scripted to go to the next card. Thus, if the user could successfully identify the target there was an immediate reward by being able to proceed to the next card.

In each case the previous target feature was shaded in on the next card to give an instant visual reinforcement of success, together with a few words of explanation alongside the solution. Ibis technique required a strict economy of words to simultaneously provide an answer to the previous question as well as the issue the next one. If the user could not understand the question, or identify the target, each card was provided with a return arrow to allow the user to go back to the previous card and revise the question, or to check on the related feature.

To maintain interest and to challenge and stimulate the user, every effort was made to make movement through the stack informative, interesting and visually stimulating. To do this requires good graphics, stimulating questions, appropriate reward, and varied use of the button effects available to HyperCard users.

The intrinsic design of this model was considered to be sufficiently interactive to be applied as Interactive Computer assisted Learning (ICAL) packages to study the three regions of the lower limb.

Three ICAL packages were made, namely HyperSurf, Hip & Thigh (455 kB; 69 cards); HyperSurf, Knee & Leg (369 kB; 62 cards); HyperSurf, Leg & Foot (493 kB; 73 cards).

To convert the HyperSurf ICAL packages to DataShow overhead projections, each card was modified by erasure of questions and answers and any repeated pictures which were considered superfluous.


Seventy-nine (n=79) first year physiotherapy students were evenly distributed into three groups (n = 27, 27 & 25) according to previous knowledge of the gross anatomy of the lower limb. Each of the three groups was randomly divided into ICAL and lecture sub-groups.


The following regime was followed over a five week period.

Week 1: Administration of the 2-D pre-test to the whole group.

Weeks 2, 3 & 4: The sub-groups simultaneously received the same information delivered separately either by lecture or ICAL package under supervision in the MacLab. The ICAL and Lecture sub-groups then combined for a 2-D diagrammatic test of the information. This was followed by a practical session in which students were able to transfer the information into a third dimension by palpation of the structures onto one another.

Week 5: Individual 3-D palpation skills and landmark identification capabilities were examined using the test regime previously substantiated on the second year volunteer group. It investigated the 2-13 theory and 3-D practice experienced during weeks 2, 3 & 4. Items from the inventory were distributed into a multivariate pattern in order to ensure that no more than one in five subjects were tested by the same items. Each subject was required to identify 13 topographical features onto another person, of which 3 had not been practised previously. These results were recorded as practised, and unpractised scores.

Control techniques

To avoid any bias, the selection and distribution of subjects into three study groups and ICAL and Lecture sub-groups, was carried out by a staff member not involved in the study. Furthermore, the collection and recording of scores from the various tests and the supervision of the ICAL sub-groups in the MacLab, was carried out by two persons not involved in the study.

To control any variance in the learning process at different times of the day, a 'Latin Square' rotation of the three groups was applied throughout the study.

To ensure that the Lecture sub-groups received the same information as the ICAL sub-groups, the three HyperSurf packages were converted into lectures presented via DataShow as overhead projections.

From the inventory of topographical items presented throughout the first four weeks, differing patterns of practised features were carefully arranged into groups of 10 questions to test 3-D individual performance.

Inter-tester reliability between the two examiners on the 3-D surface anatomy test was verified by using 70 second year physiotherapy students volunteers (df 1,69, t=0.338, ns).

To assess the learning effect of the test re-test strategy, 10% of the 2-D pre-test administered in week 1, contained items only to be dealt with in week 3 (figure 1). Figure 1 demonstrates that no significant improvement took place until the appropriate theory was presented by ICAL or lecture during week 3.

Figure 1
Figure 1: Test reactivity of mean scores for repeated questions


The statistical analysis was conducted in three parts: firstly by group analysis of the ICAL and Lecture sub-groups, secondly by demonstration of the inter-relationship between theory and practice of both sub-groups, and thirdly by covariant analysis of the previous anatomy marks in order to compare efficacy of the ICAL and Lecture techniques.

Table 1: ANOVA of 2-D ICAL and lecture sub-group scores

VariableMain effectInteractive effect
Theory scoresGroup MeasuresGroups x Measures
Total scoresF = 0.023F = 607.59**F = 0.094
Hip and thighF = 0.048F = 169.86**F = 2.143
Knee and legF = 0.014F = 517.54**F = 3.694
Leg and footF = 0.759F = 360.50**F = 0.445
** p<0.001

Analysis of variance (ANOVA) was applied to the repeated results obtained by the ICAL and Lecture sub-groups for the theoretical, 2-D content of the surface anatomy unit. These data show no statistical main effect between results achieved by the ICAL and Lecture sub-groups. However, there is an observably significant main effect for the pre and post-test measures (**p<0.00 1).

Figure 2
Figure 2: Mean raw test scores for three anatomical regions

Figure 1 confirms that any changes in 2-D theory performance was independent of the test retest design. Figure 2 shows the mean raw scores obtained by the ICAL and Lecture subgroups for the pre and post-tests sequentially administered for the three study areas outlined in Table 1. Observation of figure 2 demonstrates no significant difference between either the ICAL or Lecture sub-groups throughout these experiments.

Figure 1
Figure 3: Mean raw scores for 3-D palpation skills

Figure 3 shows the mean raw scores achieved by the ICAL and Lecture sub-groups in the practical, 3-D palpation examination during week 5. This examination included items previously practised, and some which were deliberately left unpractised. ANOVA of these data show no significant differences (df 1,75. t=0.540; t=0.030) between the ICAL and Lecture sub-groups for practised or unpractised 3-D palpation skills.

Table 2: Correlation matrix of previous anatomy, 2-D and 3-D scores

Theory scores
Palpation scores
Pre testPost testPractisedUnpractised
2-D Pre test1.000

2-D Post test0.740**1.000

3-D Practised0.1640.169 1.000
3-D Unpractised0.397*0.349* 0.2211.000
Prev. Anatomy0.395*0.351* 0.0780.111
** p<0.001 *p<0.01

Table 2 displays a correlation matrix of previous anatomy results with 2-D theory, pre and post-test scores and 3-D practised and unpractised palpation scores. An analysis of covariance (ANCOVA) with previous results in anatomy showed it to have no significant influence upon the efficacy of either the ICAL or Lecture techniques (df 1,67. F<2.000 for all variables, ns).


Physiotherapy education at this university is under the continual pressures associated with ever increasing numbers of students and the risk of erosion in the quality of staff-student interaction at a personal level. This situation is compounded by stretched facilities and spiralling costs. For academic staff to remain educationally accountable and continue to produce graduates of sufficient quality to meet high professional standards, every effort must be made to implement modem educational technology to match resources with demand (Richards, 1989).

The results of this study have provided sufficient evidence to show that ICAL packages can be used as an alternative to traditional lectures in anatomy. This finding supports those of Jones et al., (1978), Richards et al., (1987) and Walsh and Bohn (1990) and may serve to overcome criticism of CAL by Richards (1989), which suggests it to be a sterile mechanism lacking in human warmth and role modelling. If well produced, ICAL packages can provide a mechanism for the user to retrace steps through a program, or proceed forward to reinforce success. With evidence gained from the methods used in this study it would be feasible to develop ICAL packages which can readily be applied to allow individual users to schedule lessons to meet their own needs. Furthermore, the same packages can be converted into a lecture format, or scripted as tracking and testing devices in a controlled environment for educational research.

These results make it clear that only the students who performed well in the 2-D theory are able to effectively transfer that knowledge into a psychomotor 'hands on' skill without deliberate practice. It is evident that there is no direct relationship between the previous level of knowledge of gross anatomy with its surface anatomy, which appears to be perceived as a specific entity. Nevertheless, in the secure knowledge that sufficient 2-D theory can be acquired by ICAL techniques, then the normal amount of class time allocated to formal lectures can be safely set aside to provide a more effective use of staff time to facilitate students to convert 2-D images into 3-D practice. Furthermore, well prepared ICAL packages can convey basic theoretical information, enabling formal class contact time to be more cost effective, making it possible for staff and students interact at a more efficient and mature level.

The authors of this paper wish it to be known that adventures into the development of ICAL software is not for the faint hearted. At the outset considerable time is taken up with learning how to construct stacks and present information in a logical format. Because the study of anatomy is a descriptive science as well as a highly visually orientated discipline (Walsh and Bohn, 1990), the creation of high quality graphics is imperative. At a moderate estimate, the preparation of a good quality ICAL package which may occupy a student for up to 40 minutes, is likely to take at least 50 hours for its development.


Our sincere thanks go to all of the first and second year physiotherapy students who took part in these experiments, as well as to John Owens, Kevin Singer, Neil Douglas, Fay Uhe and the library staff at Shenton Park, for their administrative assistance and support throughout this project.


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Authors: Harry B. Lee, Senior Lecturer in Anatomy
Garry Allison, PhD Candidate
School of Physiotherapy,
Curtin University of Technology

Please cite as: Lee, H. B. and Allison, G. (1992). A comparative study of the presentation of anatomy by lectures versus ICAL packages to physiotherapy students. In Promaco Conventions (Ed.), Proceedings of the International Interactive Multimedia Symposium, 235-245. Perth, Western Australia, 27-31 January. Promaco Conventions. http://www.aset.org.au/confs/iims/1992/lee-h.html

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