THE ANATOMICAL RECORD (PART B: NEW ANAT.

) 285B:26 –31, 2005

FEATURE ARTICLE

Design and Utility of a Web-Based Computer-

Assisted Instructional Tool for Neuroanatomy Self-
Study and Review for Physical and Occupational
Therapy Graduate Students
K. BO FOREMAN,* DAVID A. MORTON, GINA MARIA MUSOLINO, AND KURT H. ALBERTINE

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 computer-
assisted 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

INTRODUCTION
Use of computer-assisted instruc-
tional (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 Occu-
pational Therapy at The University of Utah,
College of Health, and teaches gross anat-
omy 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-as-
sessment, service learning, and cultural
(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 ca-
daver laboratory, the declining num-
competence for the interdisciplinary
health professions.
Dr. Albertine is professor of pediatrics,
medicine, and neurobiology and anat-
omy at Utah’s SOM. He is training direc-
tor of the Children’s Health Research
Center and director of the Research Mi-
croscopy Facility at the Health Sciences
Center.
*Correspondence to: K. Bo Foreman,
520 Wakara Way, Salt Lake City, UT
84108. Fax: 801-585-5629; E-mail:
kenneth.foreman@hsc.utah.edu
DOI 10.1002/ar.b.20069
Published online in Wiley Inter-
Science
(www.interscience.wiley.com).
ber of qualified gross anatomy teach-
ers, 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; Pre-
davec, 2001; Bukowski, 2002), as well
as to deliver instructional material
(Toth-Cohen, 1995; Barker, 1998;
Boucher and Hunter, 1999). An ad-
vantage of CAI is the use of digital
images to illustrate instructional ma-
terial, which is preferred by users
(Cheng et al., 2003). Furthermore, CAI
provides interactivity with the instruc-
tional content (Chou, 2003). For the
purpose of this study, we defined in-
teractivity as selectable views and
content that permits the user to tailor
self-study and review. Interactivity in-

© 2005 Wiley-Liss, Inc.

FEATURE ARTICLE
cludes five dimensions that fulfill
communication needs. The five di-
mensions are playfulness, choice,
connectedness, information collec-
tion, and reciprocal communication
(Ha and James, 1998). The dimen-
sion of playfulness incorporates the
presence of educational material,
which stimulates curiosity. An ex-
ample would be a question-and-an-
swer format and/or games. Choice is
defined as the amount of informa-
tion users have access to. Connect-
edness is measured by the presence
of information of interest to the
user. Information collection pro-
vides 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 con-
trol of the image size by the user.
Other examples are when annota-
tions are placed around the margins
of an image, requiring the image to
be reduced to incorporate both im-
age 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 opti-
mized advantages and minimized lim-
itations. We hypothesized that stu-
dents 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 ori-
entation, use annotations that did not
obscure the image, and provide user
interactivity with the content. The in-
teractive component incorporated
playfulness, choice, and connected-
ness. Forty-three physical and occu-
pational therapy graduate students
enrolled in human neuroanatomy
evaluated the CAI tool. Their evalua-
tion 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.
THE ANATOMICAL RECORD (PART B: NEW ANAT.) 27
CAI DEVELOPMENT
Software and Authoring
Our goals were to develop a Web-
based CAI tool that was easy to navi-
gate, reliable across different operat-
ing 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 applica-
tions because the manufacturer’s terms
of use explicitly permit authoring, with-
out 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 res-
olution 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 im-
ages were initially obtained in a tagged
image file format (TIFF), either as dig-
ital 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 propor-
tionate 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 im-
age into the template at 125 pixels per
inch retained clarity of the images with
magnification (zooming). To accom-
modate 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 copy-
right infringement.
Flash MX was used to design and
program the CAI tool. First, we im-
ported the JPEG-formatted images into
Flash MX. We imported images of com-
plete brains and brainstems, as well as
coronal, horizontal, and sagittal slices
of those structures. In addition, images
of head surface anatomy, skull anat-
omy, and cerebral vasculature were
added. The Web site had 30 images (to
view samples of the Web site, go to
http://medstat.med.utah.edu/diganat/
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 im-
age (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 pro-
vide 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. Appli-
cations created using Flash MX are
compatible with most operating sys-
tems (i.e., Windows威, Microsoft;
Macintosh威, Apple Computer) and
browsers (i.e., Internet Explorer威, Mi-
crosoft; Netscape威, Netscape Commu-
nications; Safari, Apple Computer; Fire-
fox™, 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.
com/shockwave/download/download.
cgi?P1_Prod_Version⫽ShockwaveFlash).
Dreamweaver MX was used to orga-
nize and modify the Web site. Dream-
weaver MX software was also used to
code the HTML pages, as well as up-
load and synchronize the Web site to
the server.
THE SURVEY
Study Subjects
Thirty-eight physical therapy and 20
occupational therapy students were
28 THE ANATOMICAL RECORD (PART B: NEW ANAT.) FEATURE ARTICLE

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 hu-
man neuroanatomy (44 hr of labora-
tory 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 stu-
dents were in their first year of train-
ing in a master’s degree program. Two
of the students were in their second
year. Each student was asked to par-
ticipate voluntarily in the study. The
study was approved by the University
of Utah Institutional Review Board
(IRB). The need for consent was
waived.
Evaluation
On the final day of class, students
completed an IRB-approved question-
naire that evaluated navigation, clar-
ity of the images, benefit of the CAI
tool, and rating of the CAI tool com-
pared to traditional learning tools.
The six evaluation statements are pre-
sented in Box 1. The questionnaire
used a Likert scale (Portney and
Watkins, 2000). Students were also
asked to give a brief written descrip-
tion of their response to the CAI tool.
Results are shown as mean ⫾ one
standard deviation, as well as mini-
mum and maximum values (Mi-
crosoft Excel 2000, Microsoft).
SURVEY RESULTS
CAI Tool
From the Web site, the students used
the CAI tool to choose among the im-
ages. 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 underly-
ing structure. Simultaneously, related
text was loaded into the figure legend
(Fig. 1). Rollout from a button re-
moved the highlighted area and re-
moved the related text from the figure
legend. The figure legend could be dis-
played (enabled) or hidden (disabled)
by the viewer. This design feature al-
lowed the user to choose an unob-
structed 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 Action-
Script programming language, the
digital image and its overlays moved
together in register. Therefore, the
highlighted area moved with the im-
age 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).
FEATURE ARTICLE THE ANATOMICAL RECORD (PART B: NEW ANAT.) 29

Questionnaire Results
Student assessment of the CAI tool
was by a questionnaire distributed af-
ter the neuroanatomy course ended.
The questionnaire was based on a Lik-
ert 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 per-
cent of the participants also deter-
mined that the images were clear,
with a mean score of 1.72 ⫾ 0.85.
Eighty-four percent of the partici-
pants determined that the CAI tool
provided education in structure iden-
tification, with a mean score of 1.65 ⫾
0.92. Seventy-six percent of the partic-
ipants determined that the CAI tool
was beneficial for self-study and re-
view, with a mean score of 1.81 ⫾
1.10. Eighty-eight percent of the par-
ticipants 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
cial versions of the software because 2003). Design is important because it
CAI tool was much to somewhat bet-
Macromedia software products li- provides the structure and method to
ter than traditional tools (atlases),
censing agreement permits licensing deliver content. Furthermore, we
with a mean score of 1.56 ⫾ 0.67.
of original compositions when the learned the importance of interactiv-
commercial version of their software ity, which is crucial in acquiring
DISCUSSION programs is purchased (http://www. knowledge (Sims, 1997). Interactivity
We designed a CAI tool for self-study macromedia.com/software/eula/tools/). plays an important role because it en-
and review of neuroanatomy by first- This broader use is not permitted by gages the learner with the educational
year physical therapy and occupa- the licensing agreement for educa- material. However, evaluation of CAI
tional therapy students. The study was tional versions of Macromedia soft- tool design and interactivity in health
designed to subjectively assess naviga- ware products. science students’ education has not
tion, clarity of the images, benefit of The design of the CAI tool allowed been reported. Instead, evaluation has
the CAI tool, and the rating of the CAI the user to choose among 30 digital been on outcomes data, such as exam-
tool compared to traditional learning images. Each image could be zoomed ination scores (Erkonen et al., 1992;
tools (specifically, neuroanatomy at- in/out, panned, and rotated. In addi- Stanford et al., 1994; Devitt and
lases). We used a Likert scale to eval- tion, SVG buttons were placed over Palmer, 1999; Garg et al., 1999;
uate the CAI tool. Student evaluation structures of interest. Rollover of an Bukowski, 2002; Fleming et al., 2003).
indicated that our Web-based CAI tool SVG button highlighted the underly- Paradoxically, the impact of CAI tools
was easy to navigate, the images were ing structure. Simultaneously, related on student performance on tests may
clear, the CAI tool facilitated self- text was displayed in the figure leg- be influenced by design features of the
study and review, and the CAI tool end. The user had the choice to dis- CAI tool. For instance, if the design
was rated higher than traditional play (enable) or close (disable) the fig- does not provide easy navigation and
learning tools. ure legend to control the screen clear images, then students may not
We used software designed by Mac- content. use the CAI tool. In that case, test per-
romedia (Fireworks MX, Flash MX, From this study, we learned the im- formance might be expected not to
and Dreamweaver MX) to compose a portance of evaluating the design of improve.
CAI tool for interactive use via the CAI tools. Design is an important fac- Design of CAI tools should be struc-
Internet/intranet. We used commer- tor in the context of learning (Chou, tured around a technical framework.
30 THE ANATOMICAL RECORD (PART B: NEW ANAT.) FEATURE ARTICLE

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 in-

corporate interactions between learn-
er/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 interac-
tion 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 Figure 3. Students’ rating of the CAI tool. A Likert scale of 1 (strongly agree) to 7 (strongly
instructors, respectively. Those types disagree) was used for statements 1–5. The sixth statement was based on a Likert scale of
of interactions were not included be- 1 (much better than traditional tools) to 5 (much worse than traditional tools).
cause that was not the goal of our
study. Nonetheless, learner/learner they access Web-based CAI tools, also promised by either the type of com-
and learner/instructor interactivity should be assessed when developing puter equipment or the students’
could be beneficial to encourage com- CAI tools. Assessment is warranted network connection. We did not as-
munication. because access and willingness to use sess these technological issues in the
The computer equipment used by CAI tools can be limited by accessibil- present study. We are in the process of
the students, and the speed at which ity. Accessibility issues may be com- a technological needs assessment to
FEATURE ARTICLE
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, learn-
ing styles of students were not as-
sessed. 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 pro-
vide 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 percep-
tions of the CAI tool. Our study did
not assess knowledge gain. Assess-
ment of such tools has been per-
formed, primarily characterizing their
frequency of use (McNulty et al.,
2000). Therefore, further research
needs to be conducted to evaluate
knowledge gain and retention be-
tween students who use CAI tools ver-
sus traditional learning tools (e.g., at-
lases).
Recommendations from students
included the desire for higher-resolu-
tion images. This recommendation
would improve the clarity of the im-
ages for zooming in; however, the
larger file size would have the unde-
sirable consequence of longer down-
load 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-
THE ANATOMICAL RECORD (PART B: NEW ANAT.) 31
tion images and three-dimensional
views could be incorporated into the
CAI tool. However, that type of distri-
bution would limit the flexibility of
Web-based CAI tools because Web-
based CAI tools can be easily and re-
peatedly updated, whereas CD or
DVD-based CAI tools cannot. Another
recommendation was for addition of
more structures to the Web site. Ex-
perience taught us to anticipate this
criticism and we intend to expand the
library of digital images, which is eas-
ier to accomplish on a Web-based CAI
compared to a CD/DVD-based CAI
tool.
In conclusion, our study shows that
the design features of our CAI tool
accomplished the goals of easy navi-
gation, 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 profes-
sions schools. A next step will be to
perform learning outcomes research.
Such research should focus on objec-
tive assessments of learning efficiency
and knowledge retention.
ACKNOWLEDGMENTS
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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