Effectiveness of digital and analog learning methods for learning anatomical structures in physiotherapy education | BMC Medical Education


The study was designed as an empirical cross-sectional study. The data collection took place in the context of a tutorial in which students were able to intensively study anatomical structures of the musculoskeletal system and peripheral nervous system. For this purpose, they were using work assignments, as well as teaching and learning tools provided by the supervisor.

The students were randomized into two groups (“digital/analog” or “analog/digital” depending on the order of learning tools that were provided) and allocated by one of the supervisors of the tutorial in two different rooms before the beginning of the study. The groups attended the tutorials in these two different rooms and were both given the same tasks but with different teaching and learning materials (Fig. 1).

Fig. 1
figure 1


All students of the bachelor’s degree program in physiotherapy at the University of Luebeck were invited to participate in the study. At the University of Luebeck the anatomy module is taught as face-to-face lectures, practice sessions in the dissection room and 50% self-study time. In the latter, the students deepen their knowledge independently – typically this is done with the help of anatomy atlases. These can be analog (2D) and digital (2D or 3D). As a rule, the collective work “Prometheus- Atlas of Anatomy” [4] serves as an analog anatomy atlas. Previous knowledge of anatomical structures was mandatory for the participation in this study, but it had to be assumed that the knowledge was rather heterogenous due to different levels of studying of the participants. The students were informed about the data collection at the beginning of the tutorial and written consent was obtained. Participation was voluntary and had no influence on the tutorial procedure, further study program or examination results.

Application used in this study

There are several applications to learn anatomical structures with different learning modes. Some show theoretical descriptions, as well as drawings (2D) of anatomical structures, and additional skill related content as placing of ultrasound probes or manual palpation techniques (Ecofisio app; [6, 7]). Other applications use vision-based augmented reality to display anatomical structures on human models [8] or in the room, with the option to move around the augmented reality simulated anatomical structure [8, 9]. In addition to augmented reality 3D visualizations of anatomical structures, there are also applications that use three-dimensional images to display their content interactively [2, 9].

The digital anatomy app used for the purpose of this study (Human Anatomy Atlas 2023+), provides various options to learn anatomical structures, and physiological processes using 3D models (by option as augmented reality simulation). The learning content is presented as a 3D model, which is interactive and can be used individually by the students. Thereby, various information on the anatomical structures and common pathologies can be accessed and learned. Additionally, short videoclips of functional anatomy (e.g. showing the muscles that are required to bend the knee while an animated skeleton is bending the knee), or rather complex functions as swallowing food, are part of the content of the app. The app does not provide options for self-testing of knowledge. This app was chosen after screening different options as it is already known by some of the students and the teaching staff and it offers interactive 3D models that have been proven to facilitate knowledge gain and satisfaction of the students when learning anatomical structures [2, 8]. Next to being the most practicable option (as it needs time to familiarize with the interface of new applications) this app provides all functions needed to operate with the work assignments in this study. The costs of the app were covered by the “Stiftung Innovation in der Hochschullehre” as part of the HySkiLabs project.

Material and procedure

Work assignments were prepared by the supervisor of the tutorial. These contained questions about structures of the knee (ligaments, bone and joint structures) including surrounding muscles and their innervation (assignment 1). Assignment 2 focused on the shoulder joint. The supervisor was a physiotherapist with experience in teaching and good knowledge of anatomical structures. Both work assignments were double-checked by faculty members of the physiotherapy degree program of the University of Luebeck for comprehensibility.

The knowledge of the students after each learning session, was assessed via written tests that contained open ended questions about the previously repeated learning content (e.g. “name all the ligaments of the knee joint and their special features.“). The number of points to be achieved were displayed next to each question, so that the students knew about the expected scope of the answers.

In the group “analog/digital”, each participant received an analog anatomy atlas (Prometheus), while in the group “digital/analog”, each participant received the digital anatomy app on a tablet device (Human Anatomy Atlas 2023+). All students were given an initial 45-minute work assignment, which was identical in both groups and related to structures of the knee joint. A supervisor was available in each room to answer questions.

to familiarize themselves with their learning tool. Merely a verbal suggestion was given to the users of the anatomy app to use the search function of the app. After the first assignment, the participants completed the first test (maximum score 41 points) on the teaching content. During the test, no books or apps were allowed. Afterwards, the teaching and learning materials were exchanged in the rooms and the participants thus received the respective teaching and learning tool. With the new teaching and learning tool, the participants worked on another 45-minute assignment (on structures of the shoulder joint) and completed the subsequent test (maximum score 47 points).

Subsequently, the students filled out a questionnaire in which their name, age, gender and satisfaction with the teaching/learning tool offered (0 = not at all satisfied − 5 = very satisfied) were asked. The teaching/learning tool used privately by the students (free response option) and the desire for similar teaching units as exam preparation (0 = not at all − 5 = absolutely) on a 5-point Likert scale were also part of the questionnaire.

In addition, the following sub-questions were formulated for secondary analyses and assessed as a survey by students after the completion of the tasks:

  • How satisfied are students with the analog or digital teaching and learning tools measured on a 5-point Likert scale?

  • How do students rate their learning success in relation to the teaching and learning tools available on a 5-point Likert scale?

  • Are the teaching and learning tools offered known and have they already been used by the students (open ended question)?

Data analysis

The collected data were tabulated and analyzed using Stata (Student Version BE 17, Mac).

The null hypothesis for the analysis was:

H0 = there is no difference between the group using an analog anatomy atlas and the group using a digital anatomy app.

H1 = the respective group that learns with the digital anatomy app shows better results in the tests.

Socio-demographic data, answers from the questionnaire and the evaluation of the work assignments were analyzed descriptively with regard to frequencies (mode, median, mean) as well as dispersion measures ((interquartile) range, standard deviation) and shape measures (kurtosis, skewness) for the groups “analog/digital” and “digital/analog”.

Normal distribution of the data was tested using Shapiro-Wilk tests and group differences were calculated using t-tests.

The assessment of the group differences took place on the basis of the calculated Cohen’s d. Thus, the effect size of the use of digital vs. analog teaching and learning aids (here: anatomy atlases) was determined.


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