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Design and utility of a web-based computer-assisted instructional tool for neuroanatomy self-study and review for physical and occupational therapy graduate students.

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Design and Utility of a Web-Based ComputerAssisted Instructional Tool for Neuroanatomy SelfStudy and Review for Physical and Occupational
Therapy Graduate Students
The cadaver continues to be the primary tool to teach human gross anatomy. However, cadavers are not available to
students outside of the teaching laboratory. A solution is to make course content available through computerassisted instruction (CAI). While CAI is commonly used as an ancillary teaching tool for anatomy, use of screen space,
annotations that obscure the image, and restricted interactivity have limited the utility of such teaching tools. To
address these limitations, we designed a Web-based CAI tool that optimizes use of screen space, uses annotations
that do not decrease the clarity of the images, and incorporates interactivity across different operating systems and
browsers. To assess the design and utility of our CAI tool, we conducted a prospective evaluation of 43 graduate
students enrolled in neuroanatomy taught by the Divisions of Physical and Occupational Therapy at the University of
Utah, College of Health. A questionnaire addressed navigation, clarity of the images, benefit of the CAI tool, and rating
of the CAI tool compared to traditional learning tools. Results showed that 88% of the respondents strongly agreed
that the CAI tool was easy to navigate and overall beneficial. Eighty-four percent strongly agreed that the CAI tool was
educational in structure identification and had clear images. Furthermore, 95% of the respondents thought that the
CAI tool was much to somewhat better than traditional learning tools. We conclude that the design of a CAI tool, with
minimal limitations, provides a useful ancillary tool for human neuroanatomy instruction. Anat Rec (Part B: New Anat)
285B:26 –31, 2005. © 2005 Wiley-Liss, Inc.
KEY WORDS: neuroanatomy teaching; learning outcomes research; computer-assisted instruction; health professions
education; medical education
Use of computer-assisted instructional (CAI) material as an adjunct to
teaching human gross anatomy at
health sciences schools is increasing
Dr. Foreman recently received his PhD
from the Department of Neurobiology and
Anatomy at The University of Utah, School
of Medicine (SOM). He is a faculty member
with the Divisions of Physical and Occupational Therapy at The University of Utah,
College of Health, and teaches gross anatomy and neuroanatomy.
Dr. Morton is assistant professor in the
Department of Neurobiology and Anatomy
at Utah’s SOM. He teaches gross anatomy
and histology.
Dr. Musolino is assistant professor in the
Division of Physical Therapy and director
of Clinical Education, College of Health, at
The University of Utah. Her research area
is in curriculum design, development and
evaluation, with focus areas in self-assessment, service learning, and cultural
© 2005 Wiley-Liss, Inc.
(Berube et al., 1999; McNulty et al.,
2000). Contributing reasons for the
growing use include the visual nature
of the topic, the desire by students to
have self-study tools outside of the cadaver laboratory, the declining numcompetence for the interdisciplinary
health professions.
Dr. Albertine is professor of pediatrics,
medicine, and neurobiology and anatomy at Utah’s SOM. He is training director of the Children’s Health Research
Center and director of the Research Microscopy Facility at the Health Sciences
*Correspondence to: K. Bo Foreman,
520 Wakara Way, Salt Lake City, UT
84108. Fax: 801-585-5629; E-mail:
DOI 10.1002/ar.b.20069
Published online in Wiley InterScience
ber of qualified gross anatomy teachers, and the declining number of basic
science course hours (Cottam, 1999;
Drake et al., 2002).
CAI plays a role in the delivery of
anatomical material to students. For
example, CAI is used to supplement
dissection (Guy and Frisby, 1992; Predavec, 2001; Bukowski, 2002), as well
as to deliver instructional material
(Toth-Cohen, 1995; Barker, 1998;
Boucher and Hunter, 1999). An advantage of CAI is the use of digital
images to illustrate instructional material, which is preferred by users
(Cheng et al., 2003). Furthermore, CAI
provides interactivity with the instructional content (Chou, 2003). For the
purpose of this study, we defined interactivity as selectable views and
content that permits the user to tailor
self-study and review. Interactivity in-
cludes five dimensions that fulfill
communication needs. The five dimensions are playfulness, choice,
connectedness, information collection, and reciprocal communication
(Ha and James, 1998). The dimension of playfulness incorporates the
presence of educational material,
which stimulates curiosity. An example would be a question-and-answer format and/or games. Choice is
defined as the amount of information users have access to. Connectedness is measured by the presence
of information of interest to the
user. Information collection provides tracking use. The reciprocal
communication dimension provides
communication between users and
authors, such as by electronic mail
(Chou, 2003). However, CAI is not
without limitations. One limitation
is suboptimal use of the screen area.
Examples are use of a fraction of the
available screen area or lack of control of the image size by the user.
Other examples are when annotations are placed around the margins
of an image, requiring the image to
be reduced to incorporate both image and annotations in the viewable
screen area, or when annotations
and lead lines decrease clarity of the
image. Lastly, CAI tools often lack
interactivity by the user.
We designed a CAI tool that optimized advantages and minimized limitations. We hypothesized that students would recognize the value of a
CAI tool in neuroanatomy if the CAI
tool was designed for easy navigation
and facilitated self-study and review.
Therefore, we designed the CAI tool to
optimize use of screen area, provide
user control of the image size and orientation, use annotations that did not
obscure the image, and provide user
interactivity with the content. The interactive component incorporated
playfulness, choice, and connectedness. Forty-three physical and occupational therapy graduate students
enrolled in human neuroanatomy
evaluated the CAI tool. Their evaluation addressed navigation, clarity of
the images, benefit of the CAI tool for
self-study and review, and rating the
CAI tool compared to traditional
learning tools.
Software and Authoring
Our goals were to develop a Webbased CAI tool that was easy to navigate, reliable across different operating systems and browsers, interactive,
and optimized user learning. To meet
these goals, we selected commercial
software developed by Macromedia威
(Macromedia), specifically Fireworks威
MX, Flash威 MX, and Dreamweaver威
MX, to create the CAI tool. We used
commercial versions of those applications because the manufacturer’s terms
of use explicitly permit authoring, without issues of copyright infringement.
Because of our familiarity with, and the
versatility of, Macromedia software, we
did not investigate other commercial or
open-source software for authoring our
CAI tool.
Fireworks MX was used to edit and
size the images and drawings. Because
we had no control over screen area of
the computers or the Web browsers
that the students used, we determined
the optimal image dimensions and resolution as well as image file format so
that the downloaded images would
nearly fill any viewable screen area. Our
goal was to minimize the margins and
maintain clarity of the images. Clarity
was defined as images that were not
obstructed by annotations and would
not degrade (pixelate) when zoomed.
To meet that definition, the original images were initially obtained in a tagged
image file format (TIFF), either as digital photographs or scanned images.
However, because of the large file size
of TIFF files, we compressed the images
into joint photographic experts group
(JPEG) file format, at 125 pixels per
inch. In addition, the images were sized
to a 600 pixel height and the proportionate width. This allowed for fast
download time. Because the majority of
monitors have a viewing capacity of 72
or 96 pixels per inch, importing the image into the template at 125 pixels per
inch retained clarity of the images with
magnification (zooming). To accommodate for a variety of screen sizes, we
embedded the CAI tool in an HTML file,
within which we coded the page to be
displayed at 100% height and width.
Therefore, the CAI tool nearly filled any
available screen, regardless of browser.
All of the imported digital images were
original, thus further avoiding copyright infringement.
Flash MX was used to design and
program the CAI tool. First, we imported the JPEG-formatted images into
Flash MX. We imported images of complete brains and brainstems, as well as
coronal, horizontal, and sagittal slices
of those structures. In addition, images
of head surface anatomy, skull anatomy, and cerebral vasculature were
added. The Web site had 30 images (to
view samples of the Web site, go to
anatomy). Buttons and annotations
were created using scalable vector
graphics (SVG) and positioned over the
structures to be identified. In addition,
navigational buttons were created for
zooming, panning, and rotating the image (Fig. 1). The rationale for creating
components of the CAI tool using SVG
is that SVG do not lose clarity when
enlarged (zoomed in), contrary to pixel
images, which degrade when enlarged.
Figure legends were composed to provide descriptive text. We coordinated
the images with navigation, rollovers,
and figure legends using ActionScript
scripting language within Flash MX.
ActionScript is designed to write scripts
that enable interactivity with the CAI
tool via the keyboard or mouse. Applications created using Flash MX are
compatible with most operating systems (i.e., Windows威, Microsoft;
Macintosh威, Apple Computer) and
browsers (i.e., Internet Explorer威, Microsoft; Netscape威, Netscape Communications; Safari, Apple Computer; Firefox™, Mozilla). However, a free plug-in
(Macromedia Flash Player) is required
to view the content. The Macromedia
Flash Player is available for download
and installation from the Macromedia
Web site (http://www.macromedia.
Dreamweaver MX was used to organize and modify the Web site. Dreamweaver MX software was also used to
code the HTML pages, as well as upload and synchronize the Web site to
the server.
Study Subjects
Thirty-eight physical therapy and 20
occupational therapy students were
Figure 1. a: Screen capture of a sagittal view of the brain. Orientation for the image is provided by the text at the top of the image. The
navigation tools (bottom of the image) provide instructions on using the CAI tool (“? Instructions”), image rotation (arrows), zooming in and
out (“⫹” and ”⫺“, respectively), reset button (“reset”), hiding text (“Remove text”), and hiding buttons (“Remove buttons”). Blue dots
identify rollover buttons that highlight a region of interest when activated. b: Sagittal section of the same brain. The area highlighted in blue
was displayed by placing the cursor over the corresponding rollover button in panel a (circled blue dot). The highlighted area (lateral
ventricle) is described by the text at the top of the image.
enrolled in a laboratory course in human neuroanatomy (44 hr of laboratory session; 88 hr of course contact)
in the spring of 2003, for a total of 58
students, 35 (60%) males and 23
(40%) females. Fifty-six of the students were in their first year of training in a master’s degree program. Two
of the students were in their second
year. Each student was asked to participate voluntarily in the study. The
study was approved by the University
of Utah Institutional Review Board
(IRB). The need for consent was
On the final day of class, students
completed an IRB-approved questionnaire that evaluated navigation, clarity of the images, benefit of the CAI
tool, and rating of the CAI tool compared to traditional learning tools.
The six evaluation statements are presented in Box 1. The questionnaire
used a Likert scale (Portney and
Watkins, 2000). Students were also
asked to give a brief written description of their response to the CAI tool.
Results are shown as mean ⫾ one
standard deviation, as well as minimum and maximum values (Microsoft Excel 2000, Microsoft).
CAI Tool
From the Web site, the students used
the CAI tool to choose among the images. The CAI tool provided nearly
full-screen-sized digital images that
could be interactively zoomed in to
view small structures. Furthermore,
the CAI tool enabled the user to pan
and rotate (360°) in any direction.
Buttons, created as SVG objects,
were placed over structures to be
identified (Fig. 1). When a button was
rolled over, SVG overlays were
opened that highlighted the underlying structure. Simultaneously, related
text was loaded into the figure legend
(Fig. 1). Rollout from a button removed the highlighted area and removed the related text from the figure
legend. The figure legend could be displayed (enabled) or hidden (disabled)
by the viewer. This design feature allowed the user to choose an unobstructed view or an obstructed view,
respectively. In addition, the buttons
and highlighted areas were overlays
that were not embedded (flattened)
with the digital image. Because we
used Flash MX software and ActionScript programming language, the
digital image and its overlays moved
together in register. Therefore, the
highlighted area moved with the image when the image was zoomed,
panned, or rotated (Fig. 2).
Study Subjects
Forty-three of the 58 students (74%)
completed the questionnaire. The
mean age of the students who used
the CAI tool was 25 years (range,
21–37 years).
Questionnaire Results
Student assessment of the CAI tool
was by a questionnaire distributed after the neuroanatomy course ended.
The questionnaire was based on a Likert scale of 1 (strongly agree) to 7
(strongly disagree) for five of the six
statements. The sixth statement was
based on a Likert scale of 1 (much
better than traditional tools) to 5
(much worse than traditional tools).
Graphical representation of the
questionnaire responses is shown in
Figure 3. Eighty-eight percent of the
participants determined that the CAI
tool was easy to navigate, with a mean
score of 1.40 ⫾ 0.82. Eighty-four percent of the participants also determined that the images were clear,
with a mean score of 1.72 ⫾ 0.85.
Eighty-four percent of the participants determined that the CAI tool
provided education in structure identification, with a mean score of 1.65 ⫾
0.92. Seventy-six percent of the participants determined that the CAI tool
was beneficial for self-study and review, with a mean score of 1.81 ⫾
1.10. Eighty-eight percent of the participants determined that the CAI tool
was overall beneficial, with a mean
score of 1.49 ⫾ 0.77. Finally, 95% of
the participants determined that the
CAI tool was much to somewhat better than traditional tools (atlases),
with a mean score of 1.56 ⫾ 0.67.
We designed a CAI tool for self-study
and review of neuroanatomy by firstyear physical therapy and occupational therapy students. The study was
designed to subjectively assess navigation, clarity of the images, benefit of
the CAI tool, and the rating of the CAI
tool compared to traditional learning
tools (specifically, neuroanatomy atlases). We used a Likert scale to evaluate the CAI tool. Student evaluation
indicated that our Web-based CAI tool
was easy to navigate, the images were
clear, the CAI tool facilitated selfstudy and review, and the CAI tool
was rated higher than traditional
learning tools.
We used software designed by Macromedia (Fireworks MX, Flash MX,
and Dreamweaver MX) to compose a
CAI tool for interactive use via the
Internet/intranet. We used commer-
cial versions of the software because
Macromedia software products licensing agreement permits licensing
of original compositions when the
commercial version of their software
programs is purchased (http://www.
This broader use is not permitted by
the licensing agreement for educational versions of Macromedia software products.
The design of the CAI tool allowed
the user to choose among 30 digital
images. Each image could be zoomed
in/out, panned, and rotated. In addition, SVG buttons were placed over
structures of interest. Rollover of an
SVG button highlighted the underlying structure. Simultaneously, related
text was displayed in the figure legend. The user had the choice to display (enable) or close (disable) the figure legend to control the screen
From this study, we learned the importance of evaluating the design of
CAI tools. Design is an important factor in the context of learning (Chou,
2003). Design is important because it
provides the structure and method to
deliver content. Furthermore, we
learned the importance of interactivity, which is crucial in acquiring
knowledge (Sims, 1997). Interactivity
plays an important role because it engages the learner with the educational
material. However, evaluation of CAI
tool design and interactivity in health
science students’ education has not
been reported. Instead, evaluation has
been on outcomes data, such as examination scores (Erkonen et al., 1992;
Stanford et al., 1994; Devitt and
Palmer, 1999; Garg et al., 1999;
Bukowski, 2002; Fleming et al., 2003).
Paradoxically, the impact of CAI tools
on student performance on tests may
be influenced by design features of the
CAI tool. For instance, if the design
does not provide easy navigation and
clear images, then students may not
use the CAI tool. In that case, test performance might be expected not to
Design of CAI tools should be structured around a technical framework.
Figure 2. Sagittal view of the brain. a is the window that was displayed when a rollover button was selected. b is the view after the new
window was zoomed, rotated, and centered to magnify the highlighted area (thalamus).
The technical framework should incorporate interactions between learner/interface, learner/content, learner/
instructor, and learner/learner (Chou,
2003), because without interaction,
delivery of instructional content could
be discouraged. The CAI tool that we
designed incorporated interactions
between learner/interface and learner/
content. The learner/interface interaction occurred through a single-menu
page in which the user could select an
image from the image library. The
learner/content interaction occurred
by providing flexibility for the user to
highlight structures of interest and
manipulate the image (e.g., zoom,
pan, and rotate). Our CAI tool did not
include design for learner/learner and
learner/instructor interaction, such as
electronic mail to other learners or
instructors, respectively. Those types
of interactions were not included because that was not the goal of our
study. Nonetheless, learner/learner
and learner/instructor interactivity
could be beneficial to encourage communication.
The computer equipment used by
the students, and the speed at which
Figure 3. Students’ rating of the CAI tool. A Likert scale of 1 (strongly agree) to 7 (strongly
disagree) was used for statements 1–5. The sixth statement was based on a Likert scale of
1 (much better than traditional tools) to 5 (much worse than traditional tools).
they access Web-based CAI tools, also
should be assessed when developing
CAI tools. Assessment is warranted
because access and willingness to use
CAI tools can be limited by accessibility. Accessibility issues may be com-
promised by either the type of computer equipment or the students’
network connection. We did not assess these technological issues in the
present study. We are in the process of
a technological needs assessment to
characterize the types of computer
equipment, peripheral equipment,
and the type, speed, and method of
Internet connection used by students.
Limitations of our study may have
affected the results. One limitation is
the small sample size (n ⫽ 43) from a
single institution. In addition, learning styles of students were not assessed. Therefore, the applicability of
our results to other health professions
schools is not known. Because of
these two limitations, and given that
instructional methods vary among
schools, a multicenter study in which
all of the participating schools use the
same CAI tool would provide more
comprehensive results.
Our study also relied on responses
from students who completed the
questionnaire. We cannot address the
assessment of the 15 students who did
not complete the questionnaire. Of
these students, six indicated that they
had insufficient time to use the CAI
tool. Seven other students did not provide a reason. Two students indicated
that they had difficulty accessing the
Internet server. One of those students
used a different Web site; the other
student declined use because they
heard that the CAI tool did not display
a comprehensive library of images.
Another limitation of our study is it
assessed student subjective perceptions of the CAI tool. Our study did
not assess knowledge gain. Assessment of such tools has been performed, primarily characterizing their
frequency of use (McNulty et al.,
2000). Therefore, further research
needs to be conducted to evaluate
knowledge gain and retention between students who use CAI tools versus traditional learning tools (e.g., atlases).
Recommendations from students
included the desire for higher-resolution images. This recommendation
would improve the clarity of the images for zooming in; however, the
larger file size would have the undesirable consequence of longer download times. An alternative approach
would be to distribute the CAI tool on
compact disc (CD) or digital versatile
disk (also called digital video disk or
DVD) media, in which greater-resolu-
tion images and three-dimensional
views could be incorporated into the
CAI tool. However, that type of distribution would limit the flexibility of
Web-based CAI tools because Webbased CAI tools can be easily and repeatedly updated, whereas CD or
DVD-based CAI tools cannot. Another
recommendation was for addition of
more structures to the Web site. Experience taught us to anticipate this
criticism and we intend to expand the
library of digital images, which is easier to accomplish on a Web-based CAI
compared to a CD/DVD-based CAI
In conclusion, our study shows that
the design features of our CAI tool
accomplished the goals of easy navigation, clear images, and benefit for
self-study and review. Because of
these design features, the Web-based
content was perceived as better than
traditional atlases for self-study and
review. Thus, our study emphasizes
the importance of design to create CAI
tools for students in health professions schools. A next step will be to
perform learning outcomes research.
Such research should focus on objective assessments of learning efficiency
and knowledge retention.
Supported in part by grants from the
Educational Computer Committee
and funds from the Department of
Neurobiology and Anatomy, the
School of Medicine, and The Division
of Physical Therapy, at the University
of Utah.
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