Comparison and Evaluation of the Effectiveness of Traditional Neuroanatomy Teaching in Medical Education with Virtual-Reality Application Based On 3D Virtual Neuroanatomical Models, which is an innovative approach

doi:10.21203/rs.3.rs-2351422/v1

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Comparison and Evaluation of the Effectiveness of Traditional Neuroanatomy Teaching in Medical Education with Virtual-Reality Application Based On 3D Virtual Neuroanatomical Models, which is an innovative approach

https://doi.org/10.21203/rs.3.rs-2351422/v1

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Purpose:Learning the neuroanatomical structures is difficult in traditional medical education. Knowledge and visual materials in neuroanatomy books or atlases are static and limited with two dimensions. The limitation of cadaver and plastic models has been solved by the development of three-dimensional (3D) anatomical models using digital visualization technologies. Medical students are better able to understand the spatial topography of a large number of neuroanatomical structures that are condensed into a small region when they make use of 3D visualization technologies such as virtual reality (VR) and augmented reality (AR). Our study will open a new window to classical neuroanatomy education. We aimed to evaluate how much 3D neuroanatomical models based on VR application affect the success and motivation of medical school students in neuroanatomy courses.

Methods:Four exams were given to the second-year medical faculty students before the classical theoretical course (1), after the theoretical course (2), after the VR training and application (3), and six months later to evaluate the long-term effects of the training (4).

Results:Success averages were evaluated out of 10; It was found 3.38 in the students who participated in the evaluation after the traditional theoretical training, and 4.55 in the group who received VR training. In the long-term evaluation after six months, this average was found to be higher in the group that received VR training.

Conclusion:Our study fills an important gap in the literature in terms of demonstrating the positive effects of VR-based neuroanatomy training on memory in the long term.

neuroanatomy education

virtual reality

neuronatomical models

long-term effects of the VR-supported education

Due to the increasing effect of technological development, 21st century anatomy education has shown a dynamic change compared to the traditional anatomy education of the 19th and 20th centuries. On the other hand, the increase in the number of students applying to medical schools and the changes in the anatomy curriculum [14] caused a decrease in the time allocated to anatomy [5, 9, 27]. This situation leads to a weakening in the anatomy knowledge of young doctors [11].

Neuroanatomy is one of the most difficult anatomy subjects for medical students to learn and for young doctors to apply their basic neurological knowledge in the clinic. The challenge of neurology is explained by poor anatomical knowledge and little patient contact. One of the most effective ways to reduce neurophobia is to teach neuroanatomy and neurophysiology successfully [38].

Neuroanatomy, which is a part of the anatomy curriculum, has been affected by the decline of the entire anatomy curriculum. In addition, neuroanatomy is one of the most disliked and most difficult sections for students in the entire anatomy curriculum [2]. There are 2 important reasons for this: The first is that the central and peripheral nervous system is more complex than other anatomical systems, and the second is that the neuroanatomy models, atlas or computer software of educational institutions are insufficient and cannot meet expectations.

Detailed examinations of the central nervous system and peripheral nervous system in cadavers create limitations for educators in undergraduate and graduate education in neuroanatomy. For example, it is almost impossible to show the anatomical structures (cranial nerve nuclei and descending-ascending pathways) contained in the brain stem, which is approximately 7.5 cm long. In addition, fixed cadaver tissue is not very robust (brittle) and shows toxic properties due to fixation solutions [26, 29, 31, 39]. In addition, CT and MRI images taken from patients are still far from showing these structures in detail.

The innovative approach in neuroanatomy education mostly focuses on 3D modeling on the computer, Virtual Reality (VR), and Augmented Reality (AR). The history of 3D anatomical modeling, which forms the basis of VR and AR, dates back to ancient times. However, the first modern computer graphic models were made in the cat's fastigial nucleus in 1979 by Dietrichs and Walberg [8]. There are two things that make 3D anatomical models good learning tools: their ability to show complex neuroanatomical structures in a simple and easy-to-understand way, and the individual's desire to study and learn about the neuroanatomical structure [36]. The preparation of 3D anatomical models based on digital visualization formats has overcome the lack of cadaver and plastic models and will replace them in the coming years. The use of 3D visualization technology, like VR and AR, helps people learn about the spatial topography of many neuroanatomical structures that are all in a small area.

Research shows that the use of VR and AR applications for 3D visualization of the nervous system was evident in only 3 articles in 2011, while this number increased to 15 articles in 2018. Undoubtedly, the cheapening of equipment costs (computers, glasses, software) has a great role in this [30].

Although classical physical brain anatomy models or models obtained from 3D printers can be examined in 3D spatial terms, they limit the person's interaction with the model [32]. We now know that there is scientific evidence strongly recommending the use of VR applications in teaching and learning processes. In addition, they have been shown to significantly increase students' imagination, creativity, and learning [19, 32].

The best way to teach neuroanatomy is still a problem that hasn't been fully resolved. For this reason, searches on this subject continue and will continue in the coming years. Neuroanatomy education is more open to innovations as a balance element compared to the anatomy of other organ systems.

In our retrospective studies, it is clear that providing the infrastructures related to cadaver dissection, which has an important place in anatomy education in the 20th century, and maintaining expertise in this subject show high costs. Therefore, there is a decrease in medical students' use of cadaver dissection as a means of getting used to anatomy [16, 24].

There are a limited number of articles on the use of VR to teach neuroanatomy and its contribution to education [20]. In addition, research on the effectiveness of such systems and their acceptance by students has remained at an individual or limited level. The findings obtained are mostly studies that deal with student satisfaction. In addition, there are very few studies that measure the success of short-term learning, long-term learning, and the devices used in education. In this study, we created an original VR brain model that we developed and that belongs to us, and tried to examine its effects on long-term learning, recall, satisfaction, and motivation. In the future, we plan to turn this model into a web-based application on the internet and make it available to all users around the world.

2.1. Participants

Our study is an intervention study planned to implement a new education model and measure its effect. The application was carried out with 170 volunteers from Gazi University Faculty of Medicine Term 2 students. A consent form was signed by the participants stating that they volunteered. In addition, approval was obtained from the Ethics Commission of Gazi University for this study (Approval no: 2022-081). There were no stereographic visual disturbances in the students.

2.2. Materials and VR Model Preperation Steps

3D digital models were prepared showing the anatomical structures in the central nervous system (superficial and deep structures), cranial nerves, vestibular structures, and brainstem in detail. For this purpose, a 3D digital modeling and animation program called Cinema 4D was used (Maxon Computer, Friedrichsdorf, Germany). These novel models are inventively modeled. We had difficulty finding a model and 3D visuals that show the cranial nerve nuclei and ascending and descending paths in the brainstem in detail in the literature and visual scans we made. Based on this, we created a unique brainstem VR model. These structures largely paralleled the topics in the neuroanatomy curriculum. Later, we transferred the models to created the VR editor program called ROT (Infotron, Ankara, Turkey) and matched the models with anatomical information and gained interactivity. ROT is a Unity-based VR editing program. It can import models in .fbx format and textures in .png format without any problems. Once the models and anatomical information are matched and made interactive, they are immediately ready for use. The program can be used in harmony with 'HTC vive pro' and 'Oculus quest II' without any problems. ROT allows the user to walk around the classroom and model after putting on glasses. It can interact with the model through the handles used with the glasses. In addition to these, the program also has opportunities such as taking sections from models and writing text next to the model via the handle in order to attract the attention of the student during the presentation in the virtual environment.

2.3. Traditional 2D lecture and 3D-VR Training

Within the scope of the study, one theoretical lesson was given to the students in the amphitheater in the form of a known Powerpoint presentation, by projection from the computer onto the screen. The presentation was designed by anatomists with an interest in clinical anatomy teaching. This course was held in the form of a 40-minute traditional 2D lecture. Afterwards, the use of 3D imaging glasses and handles was explained to the students, and then one VR-supported training was given by wearing the glasses on the models prepared with the virtual reality program. This VR practice lesson lasted 40 minutes, as in the traditional 2D lesson. An assessment was made by evaluating the achievements of the students on the subject and taking their opinions in the focus group.

2.4 Study design of the quantitative measurements with the contents of the pre-lecture, post-lecture, and post-VR and long-term exams

In order to measure whether the students understood the subject in the study, a total of 10 questions about the three parts of brainstem were given to the participating students 3 of which included visuals obtained from models of the brain module and 7 of which included multiple-choice questions. The questions asked over the model were in the form of filling in the blanks. One of the tests is given in Table 1, as an example. The questions were developed and agreed upon by anatomists providing theoretical and practical training. The students had never seen the questions before. First exam was given before the lesson without explaining the subject to the students. Then, the theoretical lecture on the subject was given. At the end of the lesson, a second exam consisting of different questions in the same content was applied to the students who attended the theoretical lesson. After the theoretical lesson, 60 volunteers from these students had VR application, and the structures they learned in the theoretical lesson were shown in the brain module, and at the end, a third test consisting of different questions in the same content was applied. Six months after the end of the neurological sciences committee, another exam with the same content with different questions was given to the same participants. The aim of the last test was to measure how well the learned information was retained. In our literature review, there was no study that measured the short- and long-term success and retention of knowledge in neuroanatomy lessons with VR. Our study is the first in the world with this feature.

2.5. Statistical analysis

All statistical analysis and calculations were made with SPSS (Version 21.0, SPSS Inc., Chicago, IL, USA) statistical program. The conformity of the obtained numerical data to the normal distribution was determined by the Shapiro-Wilk test; If p < 0.05, nonparametric tests were used, if p > 0.05, parametric tests were applied. Afterwards, comparisons between groups were made. As a result of the statistical analyzes, the values with p ≤ 0.05 were considered statistically significant.

3.1. Demographic data

One hundred seventy students volunteered to take part in this study. As no student declared an abnormality of stereoscopic vision, all volunteers were randomized to the 3D or 2D teaching. One hundred seventy medical students (100%) attended the pre-test (first test) before the theoretical lecture, 168 (98.8%) attended the 2D, PowerPoint-based theoretical lecture and the second test, 60 students (35.2%) performed the 3D- VR training and then attended the third test. Six months later, 162 students participated in a fourth exam to determine the long-term effects of the training. Demographic details were available for all students. Gender distribution consisted of 102 female (%60) participants and 68 male (%40) participants. The average age of the students was 19.8 years (range 19–22 years). Students had completed two semesters of medical school, all were in the third semester when the first three tests were administered, and were in their fourth semester when the fourth test was administered.

3.2. Examination results of Four Tests with 10 Questions

The class average of the 10-question first test, which was given to 170 second year students just before the lecture was given, was 1.92; the average of female students who make up 60% of the class is 2; the average of male students who make up 40% of the class was found to be 1.82.

While the group average of the second exam, which was given to 168 students from a group of 170 students, who listened to the 2D theoretical lecture in the lecture hall, was 3.38; the average of female students was 3.51 and the average of male students was 3.16.

While the group average of the third exam after the application was 4.55 to 60 students who voluntarily participated in the 3D-VR training and application from a group of 170 people; the average of female students was 4.5, and the average of male students was 4.62.

Six months after the completion of the neurological sciences committee, the group average of the fourth exam given to 162 students from a class of 170 students was 4.61; the average of female students was 4.73, and the average of male students was 3.85.

3.3. Statistical Evaluation of Results

Although the number of students participating in the exams varies, 60 students who took the third exam participated in all the other exams. In terms of statistical significance, the success rates of these 60 students who participated in all 4 exams were evaluated within themselves; the success rates of 170 students who took the 1st exam, 168 students who took the 2nd exam, and 162 students who took the 4th exam were also evaluated within themselves.

The figure in which the results of the four exams taken by 60 students, who were 2nd year students of Gazi University Faculty of Medicine, were taught the brain stem in the anatomy lecture and then had 3D-VR application related to the subject, is given below (Fig. 1). Of these 60 students who took each exam, the 1st exam average was 1.767 (p = 0.0005), the 2nd exam average was 3.267 (p = 0.0148), the 3rd exam average was 4.550 (p = 0.0078), and the 4th exam average was 4.867 (p = 0.0595) found. Accordingly, while there was a statistically significant difference between the 1st-2nd, 2nd-3rd, 1st-3rd, 1st-4th, 2nd-4th exams, although there was a difference between the 3rd-4th exams, this the difference was not statistically significant.

When the success in the exams according to gender among these 60 students who participated in all four exams was evaluated, the difference between the results of the 2nd exam was statistically significant, although the average success rate of the girls in the 1st, 2nd and 4th exams was higher than that of the boys (Fig. 2) (p ≤ 0.05).

When the exam results of 36 female students and 24 male students of the 60 students who took all the exams were compared, it was determined that the average of success in the exams increased gradually in consecutive exams. There was no statistical significance between the 3rd and 4th exams in both groups (p = 0.18; p = 0.14) (Fig. 3).

When a statistical evaluation is made among 170 students who took the 1st exam, 168 students who took the 2nd exam, and 162 students who took the 4th exam; 1.-2., 2.-4., 1.-4. statistical significance was found between the exams (Fig. 4) (p < 0.001, p < 0.001, p < 0.001, respectively).

The purpose of our research is not to evaluate the exam performance of students, but rather to evaluate the influence of different anatomy instruction techniques on students.

You can watch the video we prepared by holding your smart phone’s camera to the QR code (Fig. 5).

The increase in the use of educational technologies and tools in the last two decades has led to the emergence of digital education [28, 32]. Today, applications such as electronic resources, game-based learning, and VR have begun to be used intensively in learning and gaining professional practice skills.

The use of tablets and smart phones in neuroanatomy education has provided an easy understanding of complex deep brain structures [32, 40]. However, these technologies only provide 2D views, and they are not very helpful in terms of students looking at the subject from a 3D perspective and mastering the dimensions, volumes, and relationships of the anatomical structures in the depths of the brain and brainstem.

Error-free 3D brain models developed for academic purposes and accredited by experts in the subject can be easily embedded in the VR environment. Thus, by enlarging the model, it enables detailed examination of many structures in the normal human brain that we cannot see with the naked eye. The only disadvantage of this method is that it cannot mimic the textural stimulus during cadaver dissection. The tactile warning problems have also been solved by the wearable technologies that have been made by today's technologies.

VR technologies can allow students to interact with this technology in a reproducible and controllable environment [4, 32]. This technology allows learning content to be seen, heard, touched, etc. It allows the entry of sensory factors and the embedding of the student in the virtual environment [34]. In addition, due to the fact that it can be repeated many times, it contributes to the student's ability to learn in the classroom, on top of the predetermined study program [32, 41].

When the literature on 3D visualization of the nervous system is examined, only 4 articles on VR and AR emphasized this issue in 2011, while this number reached 15 in 2018. This shows that VR is in the most advantageous position among the new technologies used to view neuroanatomical structures and manipulate these structures with the help of interactivity. Another thing to note is that it is a big change in how people learn about neuroanatomy. The cadaver-based method of learning about neuroanatomy was clearly replaced by new technology between 2011 and 2018. In addition, eight studies using educational technologies such as VR and AR have been documented to test the use of 3D in neuroanatomy [36]. Some of these methods include local VR-based stereo imaging methods for learning the ventricular system and neurovascular structures [37], skull [17, 23], brain structures, and cranial nerves [23].

Our observations show that although the number of these studies has increased, they are insufficient. In addition, these studies have shown that in order to show the neuroanatomical structures to the students, mostly superficial brain structures were emphasized. However, it will be interesting to develop and use VR and AR applications for 3D visualization of deep brain structures in terms of neuroanatomy education [36]. In a study conducted by Estevez et al. in 2010, they emphasized that physical models with a high level of manipulation of deep brain structures give positive results [10].

The brain module we developed in our study will eliminate the deficiencies that the above-mentioned insufficient number of studies on this subject could not complete. Another important innovation provided by the brain module we developed was the appearance of the brain stem, which was enlarged 10–15 times, together with the deep structures it contained, allowing interaction with the student. This feature is a first in the world.

In our study, we evaluated the results of the tests we conducted on how much a group of 60 students who participated in the neuroanatomy training activity understood and remembered the superficial and deep brain stem structures. In line with the results obtained, the average of the 1st test performed before the traditional 2D theory course was 1.767; the average of the 2nd test after the traditional 2D theory course was 3.267; The 3rd test average of the group that received 3D-VR training and application was 4.55; While the group average of the 4th test, which was done 6 months after the training and practices, was 4,867; The average of 102 students who did not receive 3D-VR training and did not apply was found to be 4.46. These results show that VR will be useful both alone and in combination with other classical methods in learning deep neuroanatomical structures.

Kugelman et al. in 2018 and Ferrer-Torregrosa et al. in 2015 reported that 62% of the students who participated in the survey on AR to work in anatomy. However, Kugelman et al. did not make any statistics on the subject [12, 25]. This shows that the effects of VR and AR application tools on student motivation in both general anatomy and neuroanatomy education have not been fully explored yet. When the literature on motivation is examined comprehensively, it is noteworthy that there are four important motivation concepts [22]. These are, respectively, attention, relevance, gratification, encouragement, and sustainability. In our study, feedback was received from the students, with whom we applied VR, that the subject gained a permanent place in the memory, facilitated their learning, and increased their interest and motivation. In our study, the results of the tests performed on the target groups were also evaluated statistically and comparatively.

Much of the work in medical education has focused on the learning process of students. Thus, students' emotional processes were pushed into the background [15]. Perhaps the biggest reason for this is that teaching has traditionally largely focused on the cognitive and behavioral development of students to absorb knowledge [3]. However, while the emotions associated with the events experienced by the students make it easier to remember what has been learned, the learning processes remain in the students' memories longer [33]. Negative emotions, like boredom, anxiety, and frustration, can make it hard to store information in memory and retrieve it when you need it during a task [7]. According to the mixed education methodology, Stephan et al. (2017) reported that students were more motivated in the lessons through the use of virtual environments, and showed more participation and understanding in the lessons [37]. When we look at the studies, it has been shown that the knowledge acquired to learn anatomy and neuroanatomy is easily forgotten, even a few months after the end of the courses [5, 6] investigated the loss of knowledge among students in the second year of their education. This loss is explained by the perceived complexity of neuroanatomy and by inadequate teaching [1, 13, 18, 21, 35, 42] In our study, we compared traditional and VR applications in neuroanatomy education. In our literature review, there is no significant study that includes statistical data and measurement-evaluation on how long students remember the information they have learned in the long term. In this study, we noticed that there was a significant parallelism between the motivation of the students and their success in the VR group, above all. Beyond that, we can easily say that neuroanatomy VR applications prepared with models that are accredited in traditional neuroanatomy education (prepared by experts) and error-free neuroanatomical structures are used in the neuroanatomy course, which is taught by using VR, can meet the educational expectations of the students. When we compare the results of the exam, which we aimed to show the long-term effects of the VR-supported education we applied, with the results of the students who did not receive VR training, it was concluded that the Virtual Reality Application Based on 3D Virtual Neuronatomic Models, which is an innovative approach in medical education, supports students' remembering the subject. Considering that the gold standard in neuroanatomy education was cadaveric brain dissections in the 19th and 20th centuries, it is not surprising that this will be in the direction of VR and AR in the next 10 years.

Neuroscience, or neuroanatomy, is the most feared subject among the anatomy courses in medical faculties. It causes the formation of the concept of neurophobia in students. The most important effect of this is that it will cause students not to look forward to neurological sciences during their career planning. This, in turn, will pose significant public health problems for an aging population struggling with neurological disease. Our study, thanks to the adaptation of today's 3D technology to the anatomy lesson, has the potential to level the classical neuroanatomy education that has continued until today, and its development will contribute to medical education. Our study, which also shows the positive effects of VR training on memory in the long term, is important in terms of filling an important gap in the literature. The study's limitations are that the glasses used in VR education can only be used by one student at a time and can cause dizziness, nausea, and vomiting in the user. The most significant advantages of the VR application are that the learner is immersed in the environment where virtual reality is generated while also having the sensation of being within the anatomical structure, exploring its surroundings and interacting with it in real time. Therefore, neuroanatomy courses show that there is a need for new neuroanatomy curricula that are integrated with clinical and new technologies in terms of students' inner, emotional, motivational, short-term and long-term learning. The results of our study contain promising results for neuroanatomy in the future.

Acknowledgments: The authors wish to thank Infotron company for their technical supports. The authors also wish to thank the second year Turkish medical students of Gazi University Faculty of Medicine who participated and voluntarily supported the tests we carried out within the scope of this study in order to include 3D virtual reality applications in the lessons with the update of the application method of neuroanatomy courses as of the next academic term.

Authors’ contribution: EA: project development, data collection, data analysis, manuscript writing. OC: project development, data analysis, manuscript writing. TVP: project development, data analysis, manuscript writing and editing

Funding: No funding support.

Ethical Approval: The Ethics Commission of Gazi University for this study (Approval no: 2022-081).

Consent for publication: Not applicable.

Competing interests: The authors declare no competing interests.

Conflict of interest: The authors declare that they have no competing interests.

Availability of data and materials: The datasets generated during and/ or analysed during the current study are available from the corresponding author on reasonable request.

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Table 1 is available in the Supplementary Files section.

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Comparison and Evaluation of the Effectiveness of Traditional Neuroanatomy Teaching in Medical Education with Virtual-Reality Application Based On 3D Virtual Neuroanatomical Models, which is an innovative approach

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Abstract

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1. Introduction

2. Materials And Methods

2.1. Participants

2.2. Materials and VR Model Preperation Steps

2.3. Traditional 2D lecture and 3D-VR Training

2.4 Study design of the quantitative measurements with the contents of the pre-lecture, post-lecture, and post-VR and long-term exams

2.5. Statistical analysis

3. Results

3.1. Demographic data

3.2. Examination results of Four Tests with 10 Questions

3.3. Statistical Evaluation of Results

4. Discussion

5. Conclusion

Declarations

References

Table

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Supplementary Files

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