Effects of Image-Based and Text-Based Active Learning Exercises

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Page 1of52 between this versionandtheVersionrecord. Pleasecitethis articleasdoi:10.1002/ase.1684. through thecopyediting, typesetting, paginationandproofreadingprocess, whichmayleadtodifferences This istheauthormanuscript acceptedforpublicationandhasundergone full peerreviewbuthasnotbeen Grant sponsor: Echo Grantsponsor: [email protected] MIArbor,48109 Avenue, Ann Michigan,Washtenaw 401 Department Gross, Melissa M. Dr. to: Correspondence act and text-based Effects of image- title: Running Arbor,Michigan. Michigan Michigan Island Island M. Melissa Gross M.Melissa ResearchReport ASE-16-0081.R2 3 2 1

Department of Nutritional Sciences, School of Publi Sciences, School Departmentof Nutritional Learnin and for Teaching Center Sheridan HarrietW. of Kinesiolo Science, School Departmentof Movement Effects of of Effects image-based text-based and active learni

Accepted Article performanceexamination musculoskeletal a in anatom

ive learning on performance performance learningon ive c Health, University of Michigan, Ann Ann Michigan, of cUniversity Health, g, Brown University, Providence, Rhode Rhode Providence, University, Brown g, of Movement Science, University of University Science, of Movement gy, University of Michigan, Ann Arbor, Ann Michigan, gy,of University -2214. USA. E-mail: E-mail: USA. -2214. 3

ng exercises on ng exercises on student y coursey

performance (r = 0.63, performance was active the learningexercises in Participation and difficulty rated also helpfulness the Students performance questions 262 on examination their with Particip learningexercises. active andimage-based p was session class Each course. anatomy functional examin on learningexercises active andimage-based Inyet this explored. been not has learninganatomy active learning of benefits combining potential the learningrel has of visual benefits Researchthe on ABSTRACT with image-based exercises ( exercises image-based with perform with correlated was significantly exercises p grade andprior status) minority underrepresented effort than text-based exercises ( exercises efforttext-based than l significantly were exercises image-based the that a (94%) of key ideas images for seeing werehelpful stud Additionally, was not. exercises text-based in learninganatomy. for beespecially beneficial le student on strategies andactive imageslearning

Accepted Article P < 0.001). When controlling for other key demograph other key controllingfor When < 0.001). This article isprotected by copyright. All rights reserved. P < 0.001) and text-based exercises ( exercises andtext-based < 0.001) P Anatomical SciencesEducation < 0.05). The findings confirm the positive effect positive the findingsconfirm education; kinesiology Keywords:

Accepted Article anatomy, musculoskeletal education, anatomy Gross

This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons ning; image-based learning, text-based text-based learning, image-based ning; omy education omyeducation undergraduate education, education, undergraduate

function of age, injury or disease. The Human Muscu Human disease. The or of age, function injury moveme and body between structure body relationship Movemen requirement for Afundamental lifespan. the biologi from movement human study the of emphasizes Kines of School the programin Science TheMovement gradua for health allied as preparation kinesiology growth AKA, 2015c). This 2010; (Wojciechowska, 2008 growing is programs kinesiology in of majors number man in course asa required specificallyidentified sc the to fundamental is AKA, 2015a). Anatomy 2014; of physica foundations scientific the includes that establi ofhas Kinesiology Association TheAmerican 2016). (NAK, differentperspectives” o andcontexts andconsequences, causes,processes, ma include that departments academic anduniversity “Ki website: Kinesiology of Academy National the on (Gill, areas sub-disciplinary multiple andincludes activit and physical of movement disciplinarystudy fi the to fundamental is anatomy human Thestudy of Education Kinesiology in Sciences Anatomical INTRODUCTION

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l activity as a core element (Chodzko-Zajko, (Chodzko-Zajko, element a core activity as l y kinesiology programs (AKA, 2015b). The 2015b). (AKA, programs ykinesiology 2007). A description of the field is provided provided is offield the Adescription 2007). te programs (Thomas, 2014). 2014). (Thomas, teprograms y that draws from many disciplinary areas ydisciplinary manyfrom draws that f physical activity are examined from examined are activity fphysical eld of kinesiology. Kinesiology is the multi- the is Kinesiology of eld kinesiology. ny specialized areas of study in which the the which study in of areas nyspecialized loskeletal Anatomy is a required course that that course a required is Anatomy loskeletal programs kinesiology a shed for curriculum , increasing by more than 50% from 2003- from 50% more than by increasing , nesiology is a common name for college name for common a nesiologyis t Science students is to understand the the understand to is Science t students nt, and how the relationship changes as a changes as relationship the and how nt, ientific foundation core and has been and been has core foundation ientific cal and behavioral perspectives across perspectives caland behavioral iology at the University of Michigan of Michigan University iology atthe has been attributed to the popularity the of to attributed beenhas Page 4of52 Page 5of52 students achieve that goal (Gyselinck, 1996; Butche 1996; (Gyselinck, goal achieve that students and ima relationships, spatial structuresand their Anatomy 2014). students 2013; etal., (Vorstenbosch educ anatomical in ofuse the images relationships, phy the study the of is anatomy Because 2016). al., worldwide instruction anatomy gross integratedinto et courses(Vorstenbosch anatomy in lectureslides d LikeSTEM presentation. the other to in dimension (Hu lecture the supplement to software presentation 201 FSSE, 1992; and Astin, (Astin arelecture-based e technology, science, university introductory Most Environments Traditional Images with in Learning th achieve instructors help may learning strategies progress as they courses more advanced in knowledge that anatomy of musculoskeletal models mental form materi the memorize just than rather anatomydeeply An Musculoskeletal ofHuman the goals important Two body. human the attac names, and the characteristics, andkinematic lea Students body to movement. relationship andits kn an in-depth with designed students provide is to

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons ges used by anatomy instructors may help help may instructors anatomy by gesused ese instructional goals. goals. eseinstructional hments and functions of the major muscles in in muscles major of the and functions hments ation is of particular importance of particular is ation owledge of human musculoskeletal anatomy anatomy musculoskeletal owledgeof human sical structures of the body and their spatial spatial and their body of the structures sical al., 2013). Imaging anatomy has been Imagingbeen has anatomy 2013). al., ngineering and mathematics (STEM) courses courses (STEM) and mathematics ngineering rn bone names and landmarks, joint structure joint and landmarks, rnnames bone rtado et al., 2012), often to add a visual add a visual to often 2012), rtado etal., r, 2006). r,2006). , including in traditional lectures (Grignon et lectures (Grignon traditional includingin , 5), with instructors typically using slide slide typically using instructors 5),with isciplines, images are routinely included in routinely in included images are isciplines, students help and to examinations, alfor need to develop a mental model of body model a develop need mental to persist so that they can apply anatomical anatomical apply can they that so persist in their program. Using images and active and images Using program. their in

atomy course are to help students learn students help arecourseto atomy

due to insufficient cognitive resources to allow th allow to resources cognitive insufficient dueto t between difference no of finding suggest the that for v albeit animated results, similar (2011)found significant no difference and found – points bullet wi content, the to relevant visuals lectureswith – quiz student compared Tangen (2011) etal. example, be possibly of visuals, gainsuse the from learning certain in i that indicates other research However, education. anatomical provi text-only materials, to compared anddiagrams mo mental their improved students that demonstrated both with whenpresented was higher transfertests by principle s this support 2002) and Moreno Mayer, an Mayer 1990; andGallini, (Mayer studies Multiple and text-based ofuse the both supports principle, knowl and prior between new of connections building al cues verbal than cuesrather – and verbal visual (201 oneMayer hand, the On 2012). Kollöffel, 2003; e mixed there is Surprisingly, increasinglearning. and (Paivio memory long-term in encodeinformation of verbal an a mix that was thought it one time, At

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons th visuals not relevant, and with text-based text-based with relevant, and not visuals th e elaborative processing needed. They They needed. elaborative processing e nstructional contexts, there can be limited there limited can be contexts, nstructional image-based materials during instruction. instruction. during materials image-based or the processing, generative promotes – one s. static graphics. Tangen and colleagues andcolleagues graphics. Tangen static s. vidence for this approach (Mayer and Massa, (Mayer approach this videncefor in accuracy among them. Lin and Atkinson LinAtkinson and accuracy them. in among For load. cognitive causeincrease they ext and congruent image conditions might be might conditions and congruent image ext d visual formats would allow students to better to students allow would formats visual d visual and verbal materials. Butcher (2006)Butcher and verbal materials. visual ding support for the multimedia principle in in principle for dingmultimedia the support howing that students’ performance on students’ that howing d Anderson, 1992; Mayer et al., 1996; 1996; etal., Mayer 1992; Anderson, d scores following three different types of types different scores following three of both presentation the that 1)suggests dels more when learning anatomy with text text with anatomy more when learning dels edge. This idea, known as the multimedia asmultimedia the idea, known edge.This Csapo, 1973; Clark and Paivio, 1991), thus thus 1991), Paivio, and Clark 1973; Csapo, Page 6of52 Page 7of52 Learning with Images in Active Learning Environment Active Learning Images with in Learning required learner. the by support lea for image anatomical of effective most the type assessments complete to time be given students more radiol to compared (image) format original the data qu when difficulty increased item that (1978)found affectitem can used also image anatomical typeof or as labeled posed images questions assessment to diff use seemed to students course,anatomymedical and anatom text with associated processes Cognitive enable ne to the session a class extensivelyduring anoppor given were emerge could learners if slides Itd the be that may 2011). etal., (Tangen occur” time enough not simply was “there that hypothesize learning exercises provide instructors with opportu with instructors provide learningexercises and answers their think about to had time students inves learningwere on formats andvisual ofverbal eta Holland 2014; 2013, etal., Vorstenbosch 2009; an Crisp 1978; (Hunt, of learning assessments orin (Bu settings transmission knowledge traditional, in form and verbal visual work on ofprevious the Much

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons eeper learning expected with image-based with expected eeper learning eded elaborative processing. processing. ededelaborative discuss their answers with peers. Active peers. Active with answers their discuss nities to support student learning in the the student learningin support to nities rning may depend on the level of cognitive oflevel cognitive the on rningdepend may tcher, 2006; Bartholomé and Bromme, 2009) 2009) and Bromme, Bartholomé tcher,2006; difficulty (Vorstenbosch et al., 2013). Hunt Hunt 2013). etal., difficulty(Vorstenbosch d Sweiry, 2006; Berends and van Lieshout, and van Berends 2006; Sweiry, d tigated in an active learning setting, in which which setting, in activelearning tigatedan in ogical reports (text), and suggested that suggested that and ogical(text), reports l., 2015). In this study, however, the effects effects however, Inthe study, this 2015). l., tunity to interact with the materialmore the with interact to tunity estions were presented to medical students in in students medical were to estions presented answer lists (Vorstenbosch et al., 2014). The 2014). etal., (Vorstenbosch lists answer or resources for elaborative processing to to processing forelaborative orresources erent cognitive processes when responding when responding processes cognitive erent grossIn a differ. also icalimages may with images. Butcher (2006) suggested that that (2006)suggested images. with Butcher ats have investigated the effects on learning on effects the have ats investigated s

are designed to reveal common misconceptions (Fagen misconceptions common reveal to aredesigned Co 2006). etal., (McConnell geosciences and 2002), Mill 2008; (Donovan, chemistry Lasry2008), etal., courses includin STEM in used have been Conceptests 200 and Mazur, Crouch 1997; (Mazur, classmates with Conceptes to respond to students asks practicethat Forimages. instance, with conjunction in sometimes using have been instructors of increasing An number 2010). al., et material(Hoyt and ARS 2006), etal., (Stein reviews lecture-style reviews ARS 2009), etal., (Alexander feedbacktool thei as valuable for ARS perceived anatomystudents ofpotenti Regardless the 2009). etal., (Alexander co a positive finding and others 2010) al., Hoytet examina in change or no finding little studies some in used been systemshave response Audience 2013). con students’ assess to and peers, with interacting engage to regularly clickers using coursesreported disciplin STEM varyamong activelearningpractices Barr, Bruff, 2005; 2009; and Wood, courses(Knight to shown have been exercises otheractive learning s response ofuse audience the Recently, classroom.

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons rrelation between ARS and examination scores examination and ARS rrelationbetween ceptual understanding (Hora and Holden, and Holden, (Hora understanding ceptual al influence on examination performance, examination alinfluence on tended to enhance understanding of the understanding enhance tendedto t questions before and after discussing them them discussing after before and questions t students in actively answering questions or questions answering actively in students tion scores with ARS use (Stein et al., 2006; 2006; etal., (Stein use ARS scores with tion increase learning and performance in STEM STEM in andperformance learning increase ystem technology (ARS; “clickers”) and ystem(ARS; technology er et al., 2014), mathematics (Schlatter, ermathematics 2014), etal., were more beneficial than traditional, traditional, than beneficial were more peer instruction is an activelearning an is instruction peer nceptests are short conceptual questions that that questions conceptual are nceptests short these active learning pedagogies, also also pedagogies, activelearning these r learning, reporting that ARS was a useful ARS that rreporting learning, 2014; Freeman et al., 2014). Although 2014). etal., Freeman 2014; es, instructors in undergraduate STEM STEM undergraduate in es,instructors anatomy courses with mixed results, with with results, mixed courseswith anatomy g physics (Crouch and Mazur, 2001; 2001; Mazur, and g(Crouch physics et al. 2002) and to assess student learning student assess andto 2002) etal. 1; Mazur, 2009). Peer Instructionand Peer 2009). Mazur, 1; Page 8of52 Page 9of52 learn forstudent effective are formats visual more ofeducation, anatomical Incontext the 2014). al., of active learning modes particular degreewhich to active learnin in visuals role the of examines that ST in learningpedagogy active ofimportance the on Tang 2011; and Atkinson, (Lin piecesof information t for accounting processing the not basedpedagogy, visual-verbal learningthrough on research Second, courses such in visualization spatial strugglewith representatio pictorial anatomy, including content, Given cognitiveprocessing. for allow increased may In cl 2012). etal., material(Kotze visual complex c course in morebeneficial be may learningformats con helpfully may be visuals on Therefore,research ac an particularly in – classrooms STEM learningin How 2002). (Schlatter, three in dimensions think to have been designe questions Conceptest mathematics, ide just than rather animage, interpret or analyze Fo (McConnell 2006). etal., memorization just than level or analysis application comprehension, atthe

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons g is needed. Indeed, it remains unknown the the unknown remains Indeed,needed. it is g ntify structures within the image. In image. the within ntifystructures (Kolloffel, 2012). (Kolloffel,2012). it would be useful to know whether verbal or or whether know verbal be to useful would it formats presentation as thesesuch visual asses ing in active learning settings. learningsettings. active in ing ns can be especially helpful for students who who for students helpful can ns be especially of Bloom’s taxonomy (Bloom, 1956) rather rather 1956) (Bloom, taxonomy of Bloom’s are beneficial to student learning (Freeman et learning(Freeman student to beneficial are ever, the role of images in enhancing student enhancing student in roleof images ever, the presentations has relied primarily lecture- on relied has presentations ime students may need to make sense of both make sense of both to need may students ime textualized by two key factors. First, visual visual First, by key factors. two textualized ontexts requiring the interpretation of requiring interpretation the ontexts tive learning environment – is unclear. unclear. is – environment learning tive askedto be might students rexample, EM classes (Freeman et al., 2014), research research 2014), etal., classes (Freeman EM the visual nature of much STEM course STEM much nature of visual the en et al., 2011). Given increasing emphasis increasingemphasis Given 2011). etal., en d specifically to develop students’ ability students’ develop to specifically d

Science program in the School of Kinesiology and is and of Kinesiology School the in Scienceprogram cour The of Michigan. University atthe Kinesiology se credit, aAnatomy three is Musculoskeletal Human Structure and Content Course METHODS preparation? activetypeslearning perceive of students both do cogn more require to exercises perceiveimage-based e activelearning and image-based text- report that key by ofvary these trends any anddo performance If whi performance? so, examination with correlated as measured exercises, activelearning image-based study w this in examined questions Thekey research study. this in wasinvestigated Bockoven,20 learning(e.g., and text-based visual- have treate studies Previous was tested. activities higher in result examin will activities image-based Speci course. anatomy musculoskeletal undergraduate examin students’ on exercises basedactive learning po the investigate was to study Theof purpose this Studythe Purposeof

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Anatomical SciencesEducation John Wiley& Sons d active learning as a separate condition from condition asa separate active d learning to be equally useful for examination examination for useful be equally to xercises assist their learning? If so, do students If students do so, learning? their assist xercises ation scores than participation in text-based text-based in scores participation than ation tential differential effects of text- and image- of text- effects differential tential 04; Tangen et al., 2011), but their integration integration their but Tangen 2011), etal., 04; ation performances in the context of an context the performances in ation by course-based analytics data, positively data, positively analytics bycourse-based students’ demographics?; (2) Do students (2) students Do demographics?; students’ ch is a better predictor of examination ofexamination a betterch is predictor se is required for students in the Movement Movement the in for students required seis open to students from other programs at the atthe otherfrom programs students to open and text- in Isparticipation student ere:(1) itive load than text-based engagement and engagement text-based than load itive cond-year course offered in the School of School the in offered course cond-year fically, the hypothesis that participation in in participation that hypothesis the fically, Page 10of52 Page 11of52 answer interactive questions asked through interact asked through questions answerinteractive wo students which in exercises active learning with Anatomy Musculoskeletal Human in Eachsession class Exercises ActiveLearning of musculoske recognition rather than andconcepts, knowledgemusculoske of and emphasize choiceformat (Behnke, 2012) a textbook arefrom course the drawn anind (15%) and during sessions lecture activities (1 quizzes (60%), online examinations fourbased on reviews lect that the after session class each quiz se lecture each before due is readingthat assigned class in participation encourage active To session. available andmadeare audio recordedwith sessions for used are sessions remaining (4 hours); function muscu the hours), (11 system skeletal includingthe c to used is approach Asystems learningexercises. session lecture didactic bi-weekly 80-minute attend take commonly, Most students and non-majors. majors cou the in enrollments with Michigan, Universityof technology-based approaches could be used instead. instead. be used could approaches technology-based e and active learning (i.e., slides) coursecontent interactive the prese Inproject, VA). this Dulles,

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Anatomical SciencesEducation John Wiley& Sons xercises, but other technology platforms or non- platforms other technology but xercises, ntation software was used to provide both both provide wasto used software ntation ure material. Students’ grades in the course arecourse the in grades Students’ material. ure ssion begins. Students also complete an online an complete online also begins. Students ssion , students complete an online quiz based on quiz an complete online students , ependent project (10%). Assigned readings for readingsfor Assigned (10%). ependentproject examinations. Screencasts oflecture the Screencasts examinations. ive presentation software (Echo software presentation ive function, and anatomy overmusculoskeletal lar system (15 hours) and musculoskeletal musculoskeletal and hours)(15 larsystem rked independently or in pair-share dyads to to dyads pair-share in or rkedindependently active with punctuated total), hours (36 s rse divided approximately 50% between between 50% approximately rsedivided letal structures. structures. letal to the students immediately following each each following immediately students the to 0%), participation in active learning active in 0%),participation Both text- and image-based active learning active learning and image-based Bothtext- . Examinations in the course are multiple the arein course multiple Examinations . the course as sophomores. Students Students as sophomores. course the consisted of lecture segments punctuated punctuated segments of lecture consisted letal structures and their relationships, relationships, structuresand their letal 360 Inc.,

about participation in all exercises, so if a if stude so exercises, all in participation about pres software. The presentation interactivelecture was learningexercises all in participation Student Data Participation In-Class active learni fortext-based (33%) than image-based of comprehensio The proportion level. comprehension atth 70% with taxonomy (1956) Bloom’s according to Act 25). to (17 questions active learning most the attachments muscle reinforce to (20%)designed were a having or fewer 14 of sessions class75% with 12, acti of The average number eachcoveredsession. in depen exercises text-based and of image- proportion and between included 4 session class Each80-minute or image-b a via text- practiced were coursetopics in image the on click to asked were wherestudents mu (and image aparticular associated with question Image answers. and multiple-choice question written (Figu session class each in included were exercises (URM) status, and cumulative grade point average (G average grade point and cumulative status, (URM) i demographicinformation Additionally, calculated. that so orimage-based, as either text- instructor exercise. the in participated wasas counted having

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Anatomical SciencesEducation John Wiley& Sons nt entered in an answer for a question, the student the aquestion, for answer enteredan in nt participation for each category could be could category for each participation tracked using analytics data embedded in the the in data embedded analytics trackedusing entation software system collected information collectedinformation software entation system ive learning questions varied in difficulty in varied learningquestions ive ased active learning question, but not both. both. not but question, asedactive learning Each individual question was flagged by the was flaggedthe by question Each individual re 1). Text-based exercises consisted of a consisted exercises re 1).Text-based order to answer the question. Individual question. the orderanswer to ctive learning exercises. A few class sessions sessions class Afew exercises. learningctive ng exercises (23%). (23%). ng exercises ltiple-choice answers) or an map image answers) ltiple-choice ncluding gender, underrepresented minority minority gender,underrepresented ncluding ve learning questions per class session was was persession class velearningquestions dent upon the number of course topics ofcourse topics number the upon dent -based exercises consisted of either a consisted exercises -based 25 active learning questions, with the the with questions, active 25 learning and relationships, and these sessions had these sessions and and relationships, PA) were obtained for each student from each from for student obtained were PA) n-level questions was slightly greaterfor slightly was n-levelquestions e knowledge level and 30% at the atthe 30% and elevel knowledge

Page 12of52 Page 13of52 (Appendix A). The level of difficulty of all exami all of difficulty of A). The level (Appendix not as asquestions well exercises, activelearning associated questionsdirectly included Examinations foridentif muscle used were images cross-sectional identify to musculoskeletal required students items a b images illustrate to used halfofquestions the (80%). Of not the did most but referredimages, to func and between structure conceptualrelationships of knowledge musc assess to were designed questions in all fourexaminations, took Eachstudents term, Data Performance Examination (59%). andwinter (62%)fall the im were ofthese exercises (60%) course,a majority Giv replaced. deleted were or some but term, winter were articl forthis questions analyzed examination total, activities were 383 (There and(136). winter roughly with terms, two the over learningexercises participat students’ examined Overall,analyses the of Michigan. University atthe wa The study protocol records. universityregistrar

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John Wiley& Sons ody movement. Fewer than 2% of examination of2% examination Fewerthan movement. ody associated with active learning exercises learningexercises active associated with but only questions associated with with associated only questions but nation questions was similar to the text-based text-based the to was similar questions nation multiple-choice format. The examination Theexamination format. multiple-choice s approved by the Institutional Review Board Board Review Institutional approved the s by multiple-choice questions referring to images, images, referring to questions multiple-choice structures on images; among these, only these,only among images; structureson e.) Most of the exercises were repeated in the the repeatedin were ofexercises the e.)Most ion and performance in 259 in-class active in-class 259 and performance in ion similar numbers of exercises in the fall (123) (123) fall the in exercises of numbers similar ication. ication. tion. Some of the multiple-choice questions ofmultiple-choice the questions Some tion. in proportions comparable with age-based, en the nature of the content taught in this taught this in content the ennature the of with both text- and image-based in-class text- both with uloskeletal structure and function, and function, and structure uloskeletal

version of the NASA Task Load Index (NASA-TLX), dev LoadIndex(NASA-TLX), Task ofNASA the version (2011) Atkinson Linbyand cognitivedescribed load learningactivitie of in-class difficulty the about rate to difficulty the asked were students Second, questions. andasking increasing inter students, other with collaborating were activities the helpful how rate askedwereto and = 1 strongly disagree were scaleitems (anchor t related exercises ofin-class the helpfulness the forwere p activities learning in-class the helpful difficul the exercises, of in-class helpfulness the end-of-sem an participate in were to asked Students Data Survey difficulty a item examination indicate to wereused un the from question were obtained examination each The perc exercises. image-based with wasassociated th was reinforced that assessing material questions in-clas with corresponded items assessment (61%)of fa the in (213 questions examination there 431 were question five examination an additional that except The examinatio learningactivities. andimage-based

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons s were modeled on the instrument for measuring instrument the on were s modeled ty of the in-class learning activities, and how and how activities, learning ofin-class the ty o five aspects of the course on a five-point Likert a on five-point ofcourse the fiveaspects o reparing for examinations. First, students rated students First, forexaminations. reparing est in the subject, seeing images of key ideas, key ideas, imagesof seeing subject, the in est of the in-class exercises. Survey questions Survey questions exercises. ofin-class the for clarifying key course concepts, course forclarifyingkey rough active learning, a slight majority (60%) majority slight (60%) a activeroughlearning, nd discrimination (Holland et al., 2015). 2015). etal., (Holland discrimination nd s were added in the winter term. Overall, Overall, term. winter the addedwere in s 5 = strongly agree). Specifically, students students agree).Specifically, = 5 strongly ester survey, which asked them to reflect on on reflect to them asked esterwhich survey, ll and 218 in the winter), and a majority and a majority winter), the in and 218 ll n questions were the same in each term term each in were same the questions n ent correct and point serial correlation for correlation serial and point correct ent , which itself was adapted from a modified afrom modified adapted was itself which , s exercises. Of the 262 examination examination 262 Of the exercises. s iversity examination scoring service and scoring service iversityexamination eloped and validated by and Hart and validated eloped

Page 14of52 Page 15of52 = 1 low were Likertitems (anchor scale eight-point order part in to invest youto have effort much did us exercises of “Thinking specifically question the rated Finally, students hard). =very veryhard, 8 using an of exercises?” contents the understand to general using[activities exercises specificallyof wor had to hard how they rated Students demanding). Likertsca eight-point using an easyor demanding?” were is, That [activit activities? participating in generally/images/text], using [activities exercises to required responding by activity mental was much using images, activities generally, for activities invested they effort much work,and how to theyhad r they which in questions were three asked Students (Paas2003). etal., of giving a numerical capable quite peopleare that ap may self-ratings “although that colleagueswrite (Lepp frequentlyinstead used are NASA-TLX the like cl a in use to challenging are cognitivethey load, bio-meas Although (2006). Hart (1988)and Staveland

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons ies/activities with images/activities with text] text] with images/activities with ies/activities and for activities using text. Students rated how Students using text. for activities and ly/images/text], how hard did youwork to hard how did have ly/images/text], assroom context and subjective rating scales rating and subjective context assroom how much effort they invested by responding to to by responding invested they effort much how how much mental activity was required when required activity mental was much how icipate in exercises during class?” using an class?” during exercises in icipate ing [activities generally/images/text], how how generally/images/text], ing[activities were =items 1 not (anchor eight-pointscale indication of their perceived mental burden” burden” mental perceived of their indication pear questionable, it has been demonstrated beenhas demonstrated it pearquestionable, effort, 8 = high effort). effort). = 8 high effort, ated their level of mental activity, how hard activity, hard how of mental atedlevel their le (anchor items were 1 = easy, 8 = = 1 easy, 8 were items le(anchor the question, “Thinking specifically of “Thinking specifically question, the . The set of questions was repeated for wasrepeatedfor ofThe questions . set k by responding to the question “Thinking question the to responding by k ures are sometimes used to measure to used uressometimes are ink and van den Heuvel, 2015). Paas and Paas 2015). Heuvel, andvan den ink

student participation in these exercises, using SPS using these exercises, in participation student wit associated questions examination performance on us were analyses regression linear Two multivariate Armonk (IBM 22, Corp., package, version statistical and stud exercises active-learning in participation wa Pearson’scorrelation Asimple surveyquestions. and text-based image-based between fordifferences st (URM) minority andunderrepresented genderamong chi-s and a GPA in differences for significant test bet demographics student in for differences test To Analysis Statistical 1 were Likertitems (anchor scale an eight-point on For que each using text. activities andfor images, was asked separate question the Again, preparation. rate to helpfulnes the asked were Finally,students activities. text-based generally, o activities for load cognitive estimate Thus types. exercise ofin-class the each scorefor w questions three the difficulty across meanscores f averagedwere question eachScoresfor difficulty

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons ne for image-based activities, and a third for for and a third activities, for image-based ne quare test was used to evaluate differences differences evaluate to used was test quare ent performance on examinations. The SPSS The SPSS performance examinations. on ent created to score was difficulty one composite , stion, students rated how helpful activities were were ratedactivities helpful how students stion, s of in-class activities for examination for examination activities of in-class s S statistical package. Linear statisticalpackage. multivariate S ere averaged to create a composite difficulty acomposite create to ere averaged ween semesters, an unpaired t-test was used to to was used t-test an unpaired weensemesters, or each of the in-class exercise types. Then, types. Then, exercise ofin-class the or each = not at all helpful, 8 = very helpful). veryhelpful). = 8 helpful, atall = not ly for activities generally, for activities using activities generally,for activities lyfor ed to look for correlations between for correlations look edto s used to examine the relationship between relationship the examine to used s learning activities in student scores the on student in learningactivities , NY) was used for all statistical analyses. statistical all for NY) , was used h in-class active learning exercises and exercises active in-class h learning atus. An unpaired t-test was used to test test was to used t-test unpaired An atus. Page 16of52 Page 17of52 analysis.) andthes exercises, in-class to respondedpaper via active learning in andengaged class the completed status or URM composition gender differenceGPA, in s term winter andfall courses.prior Comparing all had course the enrolledin students (49%).Overall, commonly Most minorities. underrepresented were 11% Nearlytwo (50%).fall the to compared (59%)winter a sl with terms), two the over otherconcentrations and non- half majors approximately of was comprised (96 students averaged116 course the in Enrollment Demographics Student RESULTS wit associated questions examination performance on varia dependent and the exercises, image-based with was perfo one regression for variable Thedependent question of examination percent accuracy,the i.e., E 2010). Ost, 2010; Bettinger, 2007; etal., Hazari andeducational performance STEM keyof predictors of i term the to prior courses (grades prior GPA in dem for also student account to used regressionwas

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons xamination performance was measured as performance wasmeasured xamination nterest), because they have been found to be to been found have nterest),they because ightly greater proportion of majors in the the in of majors greaterproportion ightly e students’ analytics were not included in the the in included not were analytics estudents’ possible. oftotal the out correctly answered s tudents, there was no statistically significant significant there statistically was no tudents, a mean incoming GPA of 3.2 (±SD of3.2 for 0.46) GPA a mean incoming exercises via a laptop. (Six students (Six a via laptop. exercises ographics (gender and URM status) and prior status) URM and ographics(gender in the fall and 135 in the winter). The course course winter). the The in andfall 135 the in ble for the second regression was regression for ble second the associated questions examination on rmance -thirds of students (64%) were female, and female, were (64%) of students -thirds h text-based exercises. exercises. text-based h majors (54% Movement Science and 46% Science (54% Movement majors achievement generally (Tobias, 1990; generally1990; (Tobias, achievement . Analyses included all students who who students all included Analyses . , students took the course as sophomores course the as sophomores took students ,

here about 2 InsertFigure rate. participation for median be the below t receiving rate.students participation Similarly, questio performance exercise-related on examination questions (r = 0.32, questions e with correlated moderately was only participation of associated examination questions answered correc answered questions examination ofassociated examinatio and learningexercises) of active number betwee strongrelationship and a Therepositive was ques for examination ofvalues 0.384 biserial point The of validity exercises. in-class associatedwith of an average answered correctly Overall, students students. offered to activities text-based than ±SD like exercises, 11) =exercises, 39 based(mean more image-base in participated Individualstudents participating text in students all threeof fourths for both similar were rates Overall,participation Participation in Active Learning Exercises and Exam Exercises and Learning Active in Participation Accepted Article

P < P 0.001). As displayed in Figure 2, students in the t the in Figure students in 2, displayed As 0.001). This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons -based (75%) and image-based (74%) exercises. exercises. (74%) and image-based -based(75%) he lowest 25% of examination grades tendedto examination of 25% lowest he types of active learning exercises, with about about with exercises, active learning of types the examination items was good, with average was average good, with items examination the tions associated with active learning exercises. learningexercises. active associated with tions 77% (±SD 15%) of the examination questions questions (±SD 77% examination 15%) of the xamination performance unrelated on xamination n participation (measured by the mean by mean the (measured participation n d (mean = 58 exercises, ±SDtext- than 14) =exercises, 58 (mean d ly because there were more image-based image-based more were there lybecause n performance (based on the mean the number on performance n (based tly) (r = 0.63, = 0.63, (r tly) ns tended to also be at the top for top the be at also tendedto ns ination Performance ination P < P 0.001). However, However, 0.001). op quartile of quartile op

Page 18of52 Page 19of52 had a stronger effect ( hada stronger (Table 1).P relationship significant statistically image-based activ in again participation exercises, exami on performance when predicting Alternatively, participatio text-based for significantdifferences image-base questionsassociated with examination on benefit holds for a diversity of students. of students. for a diversity benefit holds othe holding class, this performance in examination gender and minority status scores.Underrepresented w GPA prior be expected, might As learningwas not. sc examination higher with was associated exercises tha showed regressions for both results Insummary, here about InsertTable 1 significant. againwerenot Tex exercises. text-based associated with questions had a stronger effect ( hada stronger performan examination with significantrelationship be might 1).Although it (Table significantimpact exerci active learning image-based in participation question examination on predicting performance When

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= 0.33; 0.33; = 0.51, = This article isprotected by copyright. All rights reserved. P < P P = P Anatomical SciencesEducation 0.001) compared to prior achievement ( achievement prior to compared 0.001) 0.01) than prior GPA ( GPA prior than 0.01) John Wiley& Sons articipation in image-based learning exercises learningexercises image-based in articipation n, gender nor URM status. status. URM gender nor n, e learning exercises and prior GPA had a GPA prior and elearningexercises expected that prior GPA would have a would GPA prior that expected statistically a had and GPA priorses t-based participation, gender and URM status status and URM gender t-basedparticipation, r covariates constant, suggesting that this this that suggesting constant, rcovariates ce, interestingly, image-based active learning active learning image-based ce,interestingly, t participation in image-based learning image-based learning in participation t ores, while participation in text-based active text-based in participation ores,while were not significantly correlated with with correlated significantly not were d exercises. There were no statistically statistically no were There exercises. d as also associated with higher examination examination higher with associated asalso nation questions associated with text-based text-based associated with questions nation s associated with image-based exercises, exercises, image-based associated with s β

= 0.20; =0.20; P = P 0.002) on examination examination on 0.002) β

= 0.24, =0.24, P < P 0.001) 0.001)

Likert scale (mean score = 4.01, ±SD =4.01, However 1.71). (meanscore scale Likert easydema nor wasneither exercises activelearning rep score, students composite the on Overall,based learning. their to helpful overall stude indicating that neutral the midpoint, ±SD =3.30, 1.1 (mean questions” and “asking 1.12), ±SD “collaboratin 0.89), = 3.63, subject”(mean the of their other aspects on exercises activelearning ±SD = 4.11, (mean concepts” course “clarifyingkey that agreed (80%) or agreed strongly students Most (mean course'' the ideas in of key images ''seeing t that agreed or strongly (94%) agreed students all key forof images seeing experiences,particularly exercis active learning the found Overall,students consistency. of internal degree a signifying high for survey the Cronbach’s alpha composition. class similar were (53%) (9%), and sophomores minorities (58%) Science majors Movement were that respondents 75% was survey end-of-semester rate the Response on Helpfulness and Difficulty of Active Learning Exerc Active Learning of Difficulty and Helpfulness

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons learning, including “increasing my interest in in interest my “increasing including learning, nts perceived the active learning exercises to be to exercises active perceived learning the nts = 4.55, ±SD 0.58, on a five-point Likert scale). ±SD a =on five-point 4.55, 0.58, he active learning exercises were helpful for for helpful were exercises heactive learning es to be very helpful to their learning their to be very esto helpful ideas and clarifying course concepts. Nearly concepts. Nearly course ideasand clarifying orted that the cognitive load demanded by the the demanded by load cognitive the ortedthat nding, i.e., a neutral rating on an eight-point eight-point an on rating aneutral nding, i.e., g with other students” (mean = 3.26, ±SD = 3.26, (mean gother students” with instrument used in this study was 0.94, this in used instrument active learning exercises were helpful for for helpful were exercises activelearning 6), were less highly rated but were all above all were but rated highly less 6),were 0.71). Student ratings for helpfulness of helpfulness for ratings Student 0.71). , students rated image-based (mean score = score (mean rated image-based students , to the respective proportions in the overall the in proportions respective the to (N = 158). The proportions of survey The proportions (N = 158). ises , female (66%), underrepresented underrepresented (66%), female ,

Page 20of52 Page 21of52 confirm the benefits of active learning strategies learningstrategies of active benefits the confirm by effects these in differences weresignificant no b forkey when controlling exercises, text-based in wit correlated more strongly was learningexercises examinations performance on student with correlated a mus in exercises active learning in participation anydifferen there were and if stronglycorrelated, if performance, exam with associated waspositively we asked if questions, of research set Infirst our DISCUSSION f preparing in ±SD 5.94, helpful as similarly 1.55) 1.63) ±SD = 5.90, score (mean exercises image-based ei ±SD an = (mean on 6.04, score 1.61, examinations gene activities reported in-class the that Students here about InsertTable 2 than effort less requiring hard and demanding,less studen with results, similar score showed composite (mean score = 4.35, ±SD 1.78) ( 1.78) ±SD = (mean4.35, score significantl as requiring ±SD 3.88, exercises 1.71)

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This article isprotected by copyright. All rights reserved. P Anatomical SciencesEducation < 0.001). The results for each individual componen for individual each Theresults < 0.001). John Wiley& Sons student participation in clicker-based exercises clicker-basedexercises in participation student rally were quite useful for preparing for preparing for for useful quite were rally and the use of images for student learning that learningthat student for ofuse the images and culoskeletal anatomy class was positively was positively class anatomy culoskeletal demographics. These findings not only not findings These demographics. ces by demographics. We found that student student that found We cesdemographics. by or examinations. orexaminations. y less load compared to text-based exercises exercises comparedtext-based to y load less ackground characteristics. Additionally, there there Additionally, ackgroundcharacteristics. text-based activities (Table 2). (Table activities text-based h examination performance than participation performance participation than examination h ts rating image-based activities as less as less activities rating ts image-based image- or text-based exercises were more were more exercises image- or text-based ght-point Likert scale). Students rated the Students Likertscale). ght-point . Further, participation in image-based in Further, . participation and text-based exercises (mean score = (mean score exercises and text-based t of the t

learning strategies (Alexander et al., 2009; Stein Stein 2009; al., et (Alexander learning strategies Likeothe in be useful. to activetypeslearning of and engagement, text-based than load morecognitive p students if inquired researchquestion Oursecond st all for beneficial be particularly may exercises sugg also but other studies, in described havebeen anatomy by assisting in the visualization of comple visualization the in assisting anatomy by cognitive reduced exercises active the learning in effort text-b the than less hard andless requiring r students but helpful exercises the found Students merited. le foractive required time the learningexercises, positiv and the 2014) etal., courses (Freeman STEM s examination learningon of active impact positive etal. (McConnell others with answers their discuss the givingthem and learn, them for useful helping le their on impact positive a perceived Conceptests and geoscience Similarly, preparation. examination participation and that concepts, clarifyingcourse he were exercises agreed in-class the students that th responsesto study positive this in had students

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons ased activities. We suggest that the images used images the that used suggest We activities. ased udents’ learning in anatomy courses. courses. anatomy learningin udents’ arning exercises during class sessions is is sessions class during exercises arning et al., 2006; Hoyt et al., 2010; Barr 2014) etal., Hoyt 2010; etal., 2006; etal., r anatomy and kinesiology courses using active using courses andkinesiology anatomy r e active learning exercises. The majority of The majority of exercises. eactive learning in the learning exercises was quite useful for for useful wasquite learningexercises the in load in students with limited knowledge of of knowledge limited with students in load lpful for seeing images of key ideas and key ideas forof images seeing lpful ated image-based exercises as less demanding, demanding, as less exercises atedimage-based est that integrating images into active learning into integrating that images est opportunity to test their understanding and understanding their test to opportunity arning, reporting that the Conceptests were were Conceptests the that reporting arning, , 2006; Donovan, 2008). Considering the the Considering 2008). Donovan, 2006; , cores compared to traditional lectures in traditional coresto compared x, three-dimensional structures. Students Students structures. three-dimensional x, erceived that image-based questions require questions image-based erceivedthat chemistry students in courses using courses in chemistrystudents e perceptions of students towards active towards eperceptions of students the degree to which students perceive both perceiveboth students which to degree the , , Page 22of52 Page 23of52 Examiners writte questions dailyARS answered study,students stud performance formedical examination student on (2009)etal.demon Alexander education. anatomical on research previous support study Findingsof this this learningin student to particularlybeneficial materialin ofuse visual the courses).Therefore, goo otherwise were they even content, if course the of majority the student, each of anatomybackground course, an introductory is Anatomy Musculoskeletal gener before information additional require subject Mayer, perhaps 2011), 2000; 1998, al., (Kalyugaet be particu to been shown has cues alongverbal with anatomy more advanced for are that necessary models im the in elements important “see'' to learninghow helping stud in valuable particularly maybeen have In-clas knowledge. prior to information connectnew active learning exercises (r = 0.63, exercises activelearning exa predicted study also this in learningexercises were freed from having to produce visualizations of produce visualizations to having from freed were NBME gross anatomy subject examination (r = 0.53, (r = 0.53, examination grosssubject anatomy NBME predicted examination scores on the anatomy written anatomy the on scores predictedexamination

Accepted(NBME Article ® ) style at the end of laboratory exercises. Student exercises. end atofthe laboratory )style This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation P < P John Wiley& Sons 0.001) having an even stronger effect on examinatio on effect evenstronger an having 0.001) introductory course. course. introductory the active learning exercises may have been may been have exercises active learning the mination performance, with participation in the the in participation performance, with mination age, and beginning to construct the mental mental the construct to age,and beginning ative processing can occur. Human Human canoccur. processing ative the benefits of active learning strategies in in learningstrategies of benefits active the d students (i.e., had a high GPA in other in GPA (i.e., had a high students d ents discern critical features in an image, in features discern critical ents because students with less experience in a experience in less with becausestudents anatomy anatomy larly effective for low-knowledge learners learners low-knowledge effectivefor larly n in the National Board of Medical Board National the in n s active learning exercises using images using images exercises active s learning the students likely had low knowledge of knowledge low likely had students the final examination (r = 0.37, 0.37, (r = examination final implying that, without knowing the without that, implying strated a positive effect of ARS questions questions effect of ARS strateda positive ents in an anatomy curriculum. In that curriculum. an anatomy in ents applications. The use of visual materials materials The ofuse visual applications. P < P 0.001). Student participation in active in participation Student 0.001). denovo and were instead able to able to wereinstead and s’ cumulative ARS scores ARS s’cumulative P < P 0.001) and 0.001) n n

images may be particularly effective in helping stu in effective particularly imagesbe may relationshi spatial their and structures anatomical requ anatomy learning Since images. mental of their information visual from cues extract interpretand q that (2014)etal.suggested Vorstenbosch skills. may or as text as images exercises activelearning between image-base explicitlydistributed studywas the other studies, to importantly, contrast in Most 2015). Linderholm, anatom includingin 2016), etal., Soderstrom 2008; and performance (Butler student repeatedtesting on t studies with consistent idea is entireThis term. as low- lectures in exercises embedactive learning these with findings our of The contrast 2006). al., hel to may been students by used have questions ARS tha rather knowledge, student asof a servingcheck w learningstrategy active the Incase, scores. one does ARS of use that suggest other studies However, incorporating active learning exercises into daily daily into learningexercises active incorporating study. previous the in examination anatomysubject fina anatomy scores the had on ARS performance than

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons hat have shown a large positive effect of hatpositive a have large shown ps, constructing active learning exercises with with exercises activelearning constructing ps, format of the active learning exercises in our in learningexercises ofactive the format as deployed just before the examination, examination, the before just asdeployed classroom sessions improves student learning. student improves sessions classroom other studies suggests that it is important to to important is it that suggests otherstudies uestions with images test students’ ability to ability to students’ images with test uestions and questions without images test the quality images quality the test without andquestions different develop students havehelpedthe stakes formative assessments throughout the throughoutthe assessments formative stakes dents develop mental models. In study, this models. mental develop dents n earlier in the learning process when the the processwhen learning the in earlier n y contexts (Logan et al., 2011; Dobson and Dobson 2011; y(Logan etal., contexts Roediger, 2007; Karpicke and Roediger, and Roediger, Karpicke 2007; Roediger, Taken together, both studies suggest that studies both Taken together, d and text-based questions. Formulating the Formulating the questions. and text-based d ires the construction of mental models of models mental of construction ires the not always result in improved examination examination improved in always result not p develop anatomical knowledge (Stein et (Stein knowledge anatomical develop p l written examination or NBME gross gross or NBME examination written l

Page 24of52 Page 25of52 been systematically ordered by complexity or fideli complexityor by ordered beensystematically schematic representation from complexity, varied in The images th in learningopportunities. additional hi of advantage and the learning, anatomy effecton q image that (2017)al.found Fenesiet complexity, knowle for low particularly criticalrelationships, diagrams of simpler benefit the for strongsupport of imag issue the addressed (2006)directly Butcher der as those such images and realistic morecomplex s and more simple with beginning learningexercises these strategies, to According learningprogresses. fidelit and task complexity task increase gradually intrins optimize help to strategies (2015)proposed stu support to were useful images the with provided of image clear not type study, which is it this but exer learning active ofin using images Thebenefit learninganatomy. ofimportance the usin supports variablesconstant) correlated was positively exercises text-based not f the Thus, images. mental qualityofstudents’ the multi textual questionswere mostly examination the

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons s might have been most helpful, or whether cues or whether helpful, most have might been s dge learners. At a given level of image givenlevel a At dgelearners. inding that participation in image-based but image-based but in participation that inding with examination performance other (holding examination with instructors should select images for active forimagesactive select should instructors y, and provide less instructional support as support y,instructional less and provide designed to highlight the representation of representation the highlight to designed ic cognitive load that suggest instructors instructors suggest icthat load cognitive e active learning exercises used in this study this in used exercises eactive learning cises for student learning was demonstrated in in demonstrated was learning forcises student g image-based active learning exercises in in exercises activelearning g image-based uality itself seemed to have only a limited a have limited only to seemed ualityitself gher quality images did not apply not with did gherimages quality ty, or had been designed specifically to specifically to ty,designed or had been e complexity for learning, and demonstrated and demonstrated forlearning, complexity e dents’ learning. Leppink and van den Heuvel and van den Heuvel Leppink learning. dents’ s to radiological images; if the images had images the if had images; radiological to s ple choice questions, likely testing the the likely testing choice ple questions, ived from medical imaging modalities. modalities. imaging medical from ived chematic images and then progressing to to progressing andthen chematic images

Limitations of the Studythe of Limitations necess cognitiveprocesses the support successfully impact Effective processes. cognitive ofessential materia good multimedia rather, learningmaterials; to enough not “It is states, 194) p. (2006, Butcher fidel image complexity, image and modify exercises, mo the when selecting and needs learners’abilities findin These prompting. learned with less abilities benefited most abilities spatial low with learners a Interestingly, spatial was given. support minimal b the that and found text, and images learningwith the investigated (2009)also andBromme Bartholomé im the or integrated with image with representation can affect learnin text instructional corresponding The visual not. were and others andunderstanding, instructi or with or highlights cuesas labels such acti the in images some example, For cues provided. this in learningexercises active the in Theimages eve been have might exercises basedactive learning i it relationships, or conceptual spatial represent

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Anatomical SciencesEducation John Wiley& Sons s possible that the positive effect image- positive the of the possible that s onal prompts to help guide students’ attention attention students’ guide help to prompts onal from prompting and learners with high spatial high spatial with and learners prompting from simply encourage active engagement with engagementwith active encourage simply g, depending on whether the text is redundant is text the whether on g,depending study also differed in the amount and type of and type amount the in differed study also on learning requires that representations can representations that learningrequires on gs suggest that instructors need to considerneed the to instructors gsthat suggest bility interacted with prompting, so that that so prompting, with interacted bility est learning results were achieved when achieved were learningresults est st effective images for active learning active for effective st images ary for deep comprehension.” arycomprehension.” for deep 1991). andSweller, age(Chandler ls support the learner’s effective performance effectiveperformance learner’s the support ls relationship between images and between images relationship n stronger. stronger. n ve learning exercises were paired with visual visual werewith paired velearningexercises ity and instructional cueing accordingly. As accordingly.As cueing ityand instructional impact of visual cues and prompting on on andprompting cues of visual impact Page 26of52 Page 27of52 compared to the text-based exercises at the end of endof atthe exercises comparedtext-based the to wer three all measures on load ratings of students’ as sam session class a single in learningexercises th end atof the ratings between their relationship more freq surveyquestions the complete to students rather earlie by than sessions class recent moreby ortheir if 2003), etal., (Paas learningexercises cumul average or load, load rated peak the students mul embeddedwere in that exercises oflearning the the end atof the conducted surveywas Further,the load. more sophist utilize to wish may Futureresearchers perform ta to two subjects asking (e.g., approaches ranging fr condition, this assess to measuresexist Leppink 2003; etal., (Paas load cognitive measure subje Althoughindirect, self-reports. students’ on approac study survey the of this was Onelimitation variables (prior GPA, gender, URM status) constant. status) gender,URM GPA, variables(prior tex to learningcompared student on based exercises this analyses in regression multiple wereThe not. learning,tho including affectstudent factorsMany

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons ratings of the learning exercises were influenced influenced were exercises oflearning the ratings e term and their ratings of load imposed by the imposed load of ratings and their term e om physiological measures to experimental experimental to measures physiological om pled throughout the term. Regardless, the the Regardless, term. throughoutthe pled ctive assessments are a common way to aare common assessments ctive r ones. Thus, it may have been useful to ask been to useful may it have rThus, ones. study demonstrated a positive effect of image- apositive study demonstrated e consistently lower for the image-based image-based for the elower consistently the term. term. the se investigated in this study and others that that study and others this in seinvestigated sks simultaneously) (Brünken et al., 2010). 2010). etal., (Brünken simultaneously) sks term and asked students to rate the difficulty rate to difficulty the students and asked term et al., 2013; Young et al., 2016), direct 2016), etal., Young 2013; etal., ative load for each of the types of active of active types for ofload ative the each h to measuring cognitive load, which relied relied which load, cognitive measuring to h icated methodologies to measure cognitive cognitive measure icatedto methodologies uently during the term to understand the the understand to term uentlythe during t-based exercises, holding other important otherholding important t-basedexercises, tiple class sessions. It is not known if if known It not sessions. is class tiple The adjusted R The adjusted

2 values for the regression forvalues regression the

examination performance were also moderate as indic moderate performance also were examination relativ Further, the characteristics. non-cognitive s have might included These factors important. also indicating and 0.37), (0.40 moderate analyses were for prior GPA ( forGPA prior eff relative the Even so, and0.33). analyses (0.51 CONCLUSIONS CONCLUSIONS cour perceptions of student andpedagogy, inclusive web of factors, acomplex activelearninginvolves al Cavanagh et course, and Physiology Anatomy Human Howe greaterengagement. encourage would proportion awarded gradewas (15%) of the significantportion sam atthe engage exercises the not in did students al., et (Hoyt another study of with ARS Consistent of anato future studies learning student in explain visu that factorssuggests key for accounting other environm active learning an in exercises text-based th that study,finding the the werein included not affec have might that factors Althoughother 2010). Ha 1990; courses (Tobias, STEM in learningoutcomes

Accepted Article β = 0.24 and 0.20), which has been shown to be a to str shown been has which 0.20), and =0.24

This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons e effects of image-based exercises on on exercises of effects image-based e ere was a differential effect of image-based and of image-based effect aere differential was ects of image-based exercises were greater than were exercises of image-based ects mical education practices. educationpractices. mical alization should be included should as to a factor alization e rate as more successful students. Althougha students. asmore successful e rate such as student–instructor relationships, relationships, as student–instructor such 2010), we found more poorly performing performing poorly we more 2010), found ent on examination performance while examination on ent ted student performance on examinations examinations on performance student ted that factors not included in the analyses the were in included not factors that tudy habits, participation in study groups,or study in participation tudyhabits, se content and learning activities. activities. and learning se content for participation, it may be that a higher bethat may it for participation, ated by the the ated by zari et al., 2007; Bettinger, 2010; Ost, Ost, 2010; Bettinger, 2007; etal., zari ver, in their study of active learning in a in active learning study their of in ver, . (2016) found that student “buy-in” to “buy-in” to student that (2016)found . β coefficients in the regression the in coefficients ong predictor of student of student predictor ong Page 28of52 Page 29of52 helpful to students as they mental constructing students are to helpful that notion the support results the Rather, 2015). lear to bygreaterability a accompanied maybe not and images, with presented were groups because both learn verbal or visual related students’ wasnot to ofs the descriptions and image text presentedwith in control a to of compared learning, cycle (ORDER) studen guiding structuresby anatomical visualizing complet students scores when test in animprovement King United the in ofeducation medical context the to are limited not education anatomical learningin combined of visualizations advantages Thepotential courses. anatomy impacts positively images using learningexercises a text-based the than effort less hardand required the that reporting students with learningsetting, t with lower maybeen have load Cognitive constant. text not but exercises for image-based relationship performa examination on format exercise of in-class ex student with correlated was positively exercises Overa course. anatomy musculoskeletal undergraduate exercise active learning and text-based Image-based

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons image-based exercises were less demanding, less less demanding, less were exercises image-based interacting with images may be especially especially be may images with interacting ing preference; this is perhaps not surprising not perhaps is this preference; ing ctivities. The findings suggest that active The findings suggestactive that ctivities. representations of anatomical structures. structures. of anatomical representations -based exercises, holding other key factors other key factors holding -basedexercises, embedding images in lecture presentations. In presentations. lecture in embedding images ame anatomy. The difference in test scores scores test in The amedifference anatomy. amination performance. A differential effect performance. Adifferential amination student learning when implemented in in learningwhen implemented student n from visual information (Willingham et al., etal., (Willingham information visual from n ts through an observe-reflect-draw-edit-repeat through ants observe-reflect-draw-edit-repeat dom, Backhouse et al. (2017) demonstrated demonstrated (2017) etal. Backhouse dom, s were embedded in lectures in an in lectures in embedded were s nce was observed, with a positive a positive with observed, ncewas with active learning strategies for student student for strategies active learning with he image-based exercises in the active the in exercises heimage-based teractive tutorial in which students were students which in teractivetutorial ed an interactive tutorial that emphasized emphasized that tutorial edan interactive the preference for learning with visuals visuals with forlearning preference the ll, participation in the active learning active the learning in participation ll,

Financial support for this project was provided by by project was provided this for Financialsupport ACKNOWLEDGMENTS data entry. with and t learning visually-based on literaturereviews performance d examination and participation student Tha funding the sponsor. with of interest conflicts

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons o Ms. Melinda Thompson for her assistance for her Thompson Melinda Ms. o of for analysis Dr. Anne Greenberg to nks agrantEcho from ata, Dr. Ronit Greenberg for assisting with with assisting for Greenberg ata,Dr. Ronit 360 , Inc. , no have The authors Page 30of52 Page 31of52 implementing, and assessing pedagogy that creates a creates that pedagogy and assessing implementing, H development. professional and as aspedagogy well unde teaches Teaching. She Learningand Research on fellow was a postdoctoral she Michigan.Previously, Health of Public School the Sciences in Nutritional a assi clinical is R.D., Ph.D., ANDERSON, OLIVIA S. learning. developm professional graduatestudent development, a of teaching evaluation include researchinterests f Center Michigan’s University atthe of Assessment I Rhode Providence, Universityin Brown Learningat W Harriet Director is of the WRIGHT,Ph.D., C. MARY and disease. health in of emotion bodilyexpression movem of and biomechanics structure musculoskeletal Biome Behavioral the in activities directsresearch biomec and anatomy teaches She Arbor, Ann Michigan. Kin of School the Science in Departmentof Movement pr F.Thurnau an Arthur is Ph.D., GROSS, MELISSA M. ON CONTRIBUTORS NOTES

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons nd learning innovations, educational learninginnovations, nd chanics Laboratory. Her research interest is is researchinterest Laboratory.Her chanics at the University of Michigan in Ann Arbor, Ann in of Michigan University atthe

at the University of Michigan's Center for Centerfor of Michigan's University atthe or Research on Learning and Teaching. HerLearning and Teaching. on orResearch n engaged learning environment for the environment learning engaged n sland. Previously, she was Director of was Director she Previously, sland. er research interests include developing, developing, include interests erresearch ent, and curricular assessment of student of student assessment and curricular ent, rgraduate and graduate courses in nutrition nutrition in courses graduate and rgraduate ent behavior especially as related to to especiallyas related behavior ent esiology at the University of Michigan in in of Michigan University atthe esiology stant professor in the Department of the professor in stant hanics to undergraduate students and students undergraduate to hanics . Sheridan Center for Teaching and Teaching Centerfor Sheridan . ofessor and associate professor in the the in professor associate and ofessor

epigenome. the and havemetabolism on early-li and studying sciences students nutritional

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons fe environmental exposures and the impact they they impact and the exposures environmental fe Page 32of52 Page 33of52 Environments on the Educational Pipeline in the Sci the in Pipeline Educational the on Environments Edu 1992. UndergraduateHS. Science Astin AW, Astin Educ2:160–166. technology system response of audience integration Lachman N JE, Crescini Juskewitch WM, CJ, Alexander November2016]. 1 [accessed in-academia papers/kinesiology-on-the-move--one-of-the-fastest- IL. URL:http://www.america Champaign, Association, ma often misunderstood) (but growing offastest the White Association. Kinesiology American AKA.2015c. 1 [accessed one-the-aka-undergraduate-core-elements IL.URL:http://www.americankinesiology.org/the-und American elements. coreTheundergraduate AKAone: AKA u Association. Kinesiology American AKA.2015b. November2016]. http://www.americankinesiology.org/the-undergraduat IL.Champaign, UR Association, AmericanKinesiology The u Association. Kinesiology American AKA.2015a. CITED LITERATURE

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons jors in academia. American Kinesiology Kinesiology American academia. in jors ences.1 in teaching of anatomical sciences. Anat Sci Sci Anat sciences. of anatomical teaching in growing-but-often-misunderstood-majors- November 2016]. 2016]. November e-core-in-kinesiology [accessed 1 1 e-core-in-kinesiology[accessed ergraduate-core-in-kinesiology/section- nkinesiology.org/white-papers/white- Kinesiology Association, Champaign, Association, Kinesiology cation: The Impact of Different College College Impact of Different The cation: ndergraduate core in kinesiology. in core ndergraduate L: papers. Kinesiology on the move: One One papers.move: the on Kinesiology , Pawlina W. 2010. Assessing the 2010. W. Pawlina , ndergraduate core elements. Section Section elements. core ndergraduate st Ed. Los Angeles, CA: Higher CA: LosAngeles, Ed.

69–98. p Press. Behnke RS. 2012. Kinetic Anatomy. 3 Anatomy. Kinetic 2012. BehnkeRS. 39:307–319. High Innovat Educ responsemethods. e active student college Encouraging 2014. BarrML. Educ Psychol101:2 for J whom? of support kind What w formation Coherence 2009. R. Bromme Bartholomé T, Educ 10:7–22. Sci process.Anat " cyclical a novel utilizing when anatomyknowledge Thandi CS J, Hutchinson M, Fitzpatrick M, Backhouse 20 [accessed May 23 http://eric.ed.gov/?id=ED362404 University of Califor Institute, Research Education (Editor). American Universities in a Global Market. a Global in Universities American (Editor). choice Major be: to ornot be To Bettinger2010. E. LearnInstruct load. cognitive Effectsof increased The effect of il 2009. LieshoutEC. IE, Berends van

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation rd John Wiley& Sons Ed. Champaign, IL: Human Kinetics, Inc. 329 p. Inc.p. 329 Kinetics, Human IL:Champaign, Ed. 19:345–353. 19:345–353. nia Los Angeles. 377 p. URL: Los p. 377 Angeles. nia s in budding scientists. In: Clotfelter CT CT Clotfelter In: budding scientists. in s lustrations in arithmetic problem-solving: problem-solving: arithmetic in lustrations 1 ngagement in learning: The influence of of The influence learning: in ngagement observe-reflect-draw-edit-repeat" learning learning observe-reflect-draw-edit-repeat" st 16]. 16]. Ed. Chicago, IL: University of Chicago IL:of Chicago Chicago, Ed. University 82–293. 82–293. , Keenan ID. 2017. Improvements in in Improvements ID.Keenan , 2017. hen learning from text and pictures: and pictures: text from henlearning Page 34of52 Page 35of52 Educational Goals. Handbook 1: Cognitive Domain. 1 Domain. Cognitive 1: Handbook Goals. Educational Ob Educational Taxonomy of 1956. BS(Editor). Bloom Educ 15:ar76. Educ15:ar76. buy-in active learning to Student 2016. GrahamMJ. MF BA, Couch X, Durham Chen Aragón OR, CavanaghAJ, Psychol19:514–527. Cognit J setting. Eur classroom IIIimproves HL.Testing 2007. ButlerRoediger AC, Educ Psychol98:182–197. generation.J inference diagrams: with Learningtext from 2006. KR. Butcher EducPsychol38:53–61. measur Direct Leutner2010. D. JL, BrünkenPlass R, Environments. 1 Environments. Sys Response Classroom with Teaching Bruff2009. D. 94:967–975. PsycholRep and lecture. demonstration, Computer The pedagogical toolbox: 2004. J. Bockoven Inc.p. 201

Accepted Article st Ed. San Francisco, CA: Jossey-Bass. 240 p. p. 240 Jossey-Bass. CA: Francisco, San Ed.

long-term retention in a simulated a simulated in retention long-term ement of cognitive load in active learning. in load of cognitive ement

Promoting mental model development and development model mental Promoting st -generated visual displays, classroom displays, classroom -generatedvisual Ed. New York, NY: David McKay Co, McKay David Co, New Ed. York,NY: tems: Creating Active Learning Active Creating tems: jectives: The Classification of The Classification jectives: , Bobrownicki A, HanauerDI,A, Bobrownicki ,

40:206–209. PhysTeach Peer instructio 2002. E. Mazur CH, Crouch AP, Fagen Teach Sci 27:369–389. Math Comput J and system electronic An response 2008. W. Donovan Educ 8:395–403 Sci Anat recallinformation. anatomy The effect of select 2015. T. Linderholm JL, Dobson 69:970–977. yeaTen Peer instruction: 2001. E. Mazur CH, Crouch 48:139–154. Educ Res questions. exam athous a Can picture ruin SweiryV, 2006. E. Crisp ed 1991.A. and theory coding Dual Paivio JM, Clark curriculum Ass Kinesiology The American 2014. W. Chodzko-Zajko 8:293–332. theory load Cognitive 1991. J. Sweller P, Chandler

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons and words? The effects of visual resources in in resources The ofeffectsvisual andwords? and the format of instruction. Cognit Instruct Cognit formatandof the instruction. ed “desirable difficulties” on the ability to ability to the on difficulties” ed“desirable ucation. Educ Psychol Rev 3:149–210. 3:149–210. Rev Educ Psychol ucation. rs of experience and results. Am J PhysJ Am andresults. experience rsof . . n: Results from a range of classrooms. classrooms. afrom range of Results n: conceptests in general chemistry courses. courses. chemistry general in conceptests ociation undergraduate core core undergraduate ociation Page 36of52 Page 37of52 516. models and mental Illustrations 1996. V. Gyselinck 38:253–260. Anat Radiol today?Surg medi Teaching F. 2016. Walter G, B,GrignonOldrini 286. k sustaining The key to Integration: DL. Gill 2007. 2016]. June 10 y_Discipline.pdf[accessed http://fsse.indiana.edu/pdf/FSSE_IR_2015/summary_ta of Educa School University Indiana IN: Bloomington, Facul Area. by Disciplinary FrequencyDistributions F Engagement. Student Faculty of Survey 2015. FSSE. A111:8410–8415. Acad US Natl Sci sci performance in student Activelearningincrease Okoroafo MK, Smith M, SL, Eddy McDonough FreemanS, 10.1002/ase.1657). anatomy on le method andassessment repeatedstudy, BC. Wainman L,JA, Cheng Kim C, B,FenesiMackinnon

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons inesiology in higher education. Quest 59:269– Quest education. higher in inesiology ence, engineering, and mathematics. Proc Proc mathematics. and engineering, ence, in text comprehension. Ann Psychol96:495– Ann comprehension. text in ty Who Teach Lower-Division Courses. Courses. Lower-Division Teach tyWho arning. Anat Sci Educ (in press; doi: doi: press; (in Educ Sci Anat arning. cal anatomy: What is the role of imaging role the of imaging is What calanatomy: tion. 23 p. URL: URL: p. 23 tion. SSE 2015 Aggregate Frequencies Frequencies Aggregate 2015 SSE bles/summary_tables_Lower_Division_b 2017. The effect of image quality, The effect 2017. r N, Jordt H, Wenderoth MP. 2014. 2014. WenderothH, MP. rJordt N,

Workload. 1 Workload. In:Hancock research. and theoretical experimental of NASA-TL Development LE.1988. Staveland HartSG, andEr Factors Human October 904–908. p 2006 16-20. Human Factors and Ergonomics Society 50 and Ergonomics Factors Human (NASA-TLX); 20 index load NASA-task 2006. HartSG. Anat Educ 3:295–299. Sci questions. examination mayin system response audience An Naheedy2010. R. Esp A, Chandrasekhar G, Gruener JA, HoytMcNulty A, re for pedagogical Implications teaching: classroom role the of inst Exploring 2013. J. HoraHolden MT, Educ 15:184. Med BMC choice questions. multiple of illustr parameters anddiscrimination difficulty Isa pictu 2015. R, R. Arnett O’Sullivan J, Holland 91:847–876. pr physics school of high inﬂuence performance:The Gender 2007. differences Z,P. Sadler R, Tai Hazari

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons th Annual Meeting (HFES 2006); San Francisco, CA, CA, Francisco, San 2006); (HFES Meeting Annual ated vs. text-only vignettes in histology in text-only vignettes vs. ated re worth a thousand words: An analysis of the analysis An of the words: rea worth thousand PA, Meshkati N (Editors), Human Mental Mental Human N(Editors), Meshkati PA, form. J Comput High Educ 25:68–92. High Educ 25:68–92. Comput J form. in introductory university physics physics introductory in university ructional technology in course planning and course in planning technology ructional eparation and affective factors. Sci Educ Sci factors. and affective eparation fluence student performance on anatomy anatomy on performance student fluence gonomics Society, Santa Monica, CA. CA. Monica, Santa gonomicsSociety, iritu B, Ensminger D, Price R Jr, Jr, PriceD, R B, Ensminger iritu years later. In: Proceedings of the In:yearsProceedings later. X (task load index): Results of Results index): load X(task s. p 139–183. 139–183. p s. Page 38of52 Page 39of52 5:287–294. 5:287–294. surf in and drawings images X-ray body full digital LM.The transluce 2012. Greyling CG, Mole SH, Kotze material orverbal learning visual performancewith v between relation the Exploring B. Kollöffel 2012. lecturin by 2005. WB. Teaching more Wood KnightJK, 319:966–968. im Thecritical 2008. 3rd. HL Roediger KarpickeJD, EducPsychol92:126–136. J instruction. multimedia Incorporati 2000. J. Sweller P, Chandler KalyugaS, Factors40:1–17. Levelse of 1998. J. Sweller P, Chandler KalyugaS, p. 104 LosAngeles. California Universityof 2010–2011 HERI Faculty1 HERI Survey. 2010–2011 201 S. Whang Tran H, JH, Eagan Pryor MK, HurtadoS, choice examinati multiple Illustrated 1978. D. Hunt

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation st Ed. Los Angeles, CA: Higher Education Research InsResearch Higher Education CA: LosAngeles, Ed. John Wiley& Sons ace anatomy education. Anat Sci Educ Sci Anat education. anatomy ace . Comput Educ 58:697–706. Educ 58:697–706. Comput . ons. Med Educ 12:417–420. Educ 12:417–420. Med ons. isualizer–verbalizer cognitive styles and cognitive isualizer–verbalizer xpertise and instructional design. Hum Hum design. and instructional xpertise ng learner experience into the design the of experiencenginto learner portance of retrieval for learning. Science Science learning. for portance of retrieval nt cadaver: An evaluation ofofuse the evaluation cadaver:An nt g less. Cell Biol Educ 4:298–310. 4:298–310. Educ Biol gCell less. 2. Undergraduate Teaching Faculty:The Teaching Undergraduate 2. titute, titute,

learning. multimedia in and pictures betweenwords animat The instructive 1992. RB. Anderson MayerRE, 55:77–108. Motiv learningto of science the Applying 2011. MayerRE. Educ 4:243–248. Sci Anat to Testing 2011. Marshak DW. AJ, Thompson LoganJM, Educ 56:650–658. Comput conceptsand processes. visu and Using animations 2011. RK. L,LinAtkinson Educ 4:119–127. Med Perspect education. medical of The evolution 2015. A. van den Heuvel LeppinkJ, 1072. cogn of types different for measuring aninstrument V T, Van Gog CP, Vleuten der F, Paas Van LeppinkJ, Phys 76:1066–1069. J 2008. Peerinstruction J. Watkins E, LasryMazur N,

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons itive load. Behav Res Methods 45:1058– Methods Behav load. itive Res J Educ Psychol 84:444–452. Educ Psychol84:444–452. J college.Am two-year the From to Harvard : multimedia instruction. Psychol Learn Psychol instruction. multimedia cognitive load theory and its application to to application andtheoryits load cognitive al cueing to support learning of scientific of scientific alcueinglearning support to an Merriënboer JJ. 2013. of Development JJ. anMerriënboer ion: Helping students build connections connections build Helping students ion: enhance retention in human anatomy. human in retention enhance Page 40of52 Page 41of52 Park, Maryland, August 1996. 1 1996. August Maryland, Park, on Conference International of Proceedings Classes. of Departments Physics Role The Changing (Editors). t Getting students Peer instruction: 1997. E. Mazur Educ Ps J preference. and learning cognitive style, an of visual Three facets LJ.2003. Massa MayerRE, 82:715–726. an illustration is When 1990. JK. Gallini MayerRE, 73. of scienc verbalsummaries and learningvisual from L. 199 Tapangco MarsA, R, Bryman BoveW, MayerRE, peer instruction classrooms. Phys Rev ST Phys Educ Educ Phys Phys ST Rev classrooms. peerinstruction 201 E. Mazur J, B, Schell LasryLukoff K, N, Miller ge introductory in conceptual understanding student Using 2006. L,PJ. GreerHeaney H, McGrew M, Malone Van Hor JR, Knott Owens KD, DA,Steer DN, McConnell Scienc Farewell, lecture? Education. 2009. E. Mazur

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This article isprotected by copyright. All rights reserved. st Anatomical SciencesEducation Ed. Woodbury, NY: American Instituteofp Physics. American NY: Woodbury, Ed. John Wiley& Sons ychol 95:833–846. ychol95:833–846. o think in class. In: Redish EF, Rigden JS JS In:EF, Rigden class. in Redish think o oscience courses. J Geosci Educ 54:61–68. Geosci Educ 54:61–68. J courses. oscience worth ten thousand words? J Educ Psychol J words? thousand ten worth Undergraduate Physics Education, College Education, UndergraduatePhysics e textbook lessons. J Educ Psychol88:64– J lessons. etextbook 4. Conceptual question response times in in response times question Conceptual 4. e 323:50–51. e323:50–51. d verbal learners: Cognitive ability, Cognitive verbal d learners: Res 10:020113. 10:020113. Res in Modern Universities, Part Two: Sample Sample Two: Part Universities, Modern in conceptests to assess and improve and improve assess to conceptests 6. When less is more: Meaningful Meaningful more: is less When 6. n S, Borowski W, Dick J, Foos A, J, Dick W, Borowski S, n 981–988. 981–988.

learning. Psychol Sci 27:223–230. 27:223–230. Sci Psychol learning. critica The 2016. Bjork RA. Kerr NC, TK, Soderstrom 12:305–314. Stud Undergrad Math amulti for conceptests Writing 2002. MD. Schlatter Psychol5:176–206. fre in superiority Picture 1973. K. Csapo A, Paivio Psycho Educ theory. load cognitive advance to means 2003 PW. Gerven VanH, Tabbers JE, F, Paas Tuovinen 29:923–934. EducRev gradesdeterm peersin and of TheB. role Ost 2010. 2016]. http://www.nationalacademyofkinesiology.org/what-is Champ of Kinesiology, Academy National professions. Kinesio of Kinesiology. Academy National NAK.2016. Educ 94:598–610. Psychol J and media. ofmethods Learningvirtu in science 2002. Mayer RE. R, Moreno

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons e recall: Imagery or dual coding? Cognit Cognit coding? Imageryor dual erecall: ining major persistence in the sciences. Econ sciences. the Econ in persistence ining major variate calculus class. Probl Resour Issues Resour Probl variatecalculusclass. l 38:63–71. 38:63–71. l al reality multimedia environments: Role Role environments: alreality multimedia -kinesiology [accessed 1 November 1 [accessed -kinesiology l importance of retrieval--and spacing--for spacing--for ofimportance retrieval--and l aign, IL. URL: aign, . Cognitive load measurement asa measurement load Cognitive . and related logy:Thediscipline Page 42of52 Page 43of52 42:266–271. TeachPsychol Thesci Dobolyi DG.2015. EM, Hughes DT, Willingham Anat Sci questions? matching answering extended in anatomy: in do assessment ofvalidity the Exploring Kooloo MM, van den Hurk ST, Bouter MA, Vorstenbosch Educ 6:29–41. Sci Anat discrimination. effect the of imag Exploring anatomy? in assessment S Bolhuis JG, Kooloos TP, Klaassen MA, Vorstenbosch p. 96 Corporation. AZ:Research Tobias S. 1990. They’re Not Dumb, They’re Different They’re Dumb, Not They’re 1990. S. Tobias in The public 2014. face kinesiology of JR. Thomas Educ Comput presentations. slideware in andimages Besto C, Durrant Teeter MD, E, Constable TangenJM, Nurs J course. nursing anreviews undergraduate in au Using 2006. Brueckner Challman SD, JK. PS, Stein

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons Educ 45:469–473. Educ45:469–473. images influence cognitive processes used processes used cognitive images influence the 21st century. Quest 66:313–321. 66:313–321. century. Quest 21st the es on item difficulty and item anditem difficulty item eson Educ 7:107–116. Educ7:107–116. 65:856–872. 65:856–872. : Stalking the Second Tier. 1 Second the Stalking : dience response technology for pretest for pretest responsetechnology dience n BR, Kim JA. 2011. The role of interest 2011. The role of interest JA. BR,Kim n M, Laan RF. 2013. Do images influence influence images Do Laan M, 2013. RF. entific status of learning styles theories. theories. of learningstyles status entific s JG, Bolhuis SM, LaanSM, Bolhuis 2014. RF. JG, s st Ed. Tucson, Tucson, Ed.

Educ5:24–32. afrom handover simul results cognitiveMixed load: O, Ten Cate ML, Barilla-LaBarca Irby DM, YoungJQ, https://www.insidehighered.com/news/2010/08/11/kine URL: DC. Washington, HigherEd., Ins major. growing Aquickly I. 2010. Wojciechowska

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons ation for medical students. Perspect Med for students. medical ation ide Higher Ed. 11 August 2010. Inside 2010. August 11 HigherEd. ide siology [accessed 1 November 2016]. November2016]. 1 siology[accessed O'Sullivan PS. 2016. Measuring PS. O'Sullivan Page 44of52 Page 45of52 Example examination questions associated with text- with associated questions Exampleexamination Example examination questions not associated with i with associated not questions Exampleexamination Example examination questions associated with image with associated questions Exampleexamination figure. referred a to questions question examination the of All learningexercises. exer learning active image-based or text-based with The questionsare below. listed examination Example A APPENDIX Which structure is most likely to be injured with e with likely most be injured structure to is Which of exaggeration lead to can and aging Osteoporosis Which of these carpal bones is included in the dist the in included is bones of these carpal Which anterior, most is offollowing the landmarks Which femoris? rectus way best the is stretch to What damag associated with most are separations Shoulder vertebra only afound on thoracic is landmark Which

Acceptedinju be associated with might epicondylitis Lateral metac first base the ofon the inserts muscle Which the medially rotate muscles offollowing the Which lateral? most is muscles offollowing the Which oftrunk the during shortens rotation muscle Which Article

This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons s were multiple choice. None of the examples Noneofexamples the choice. were s multiple cises or were not associated with any active any active with associated not were orcises examination questions were associatedwere questions examination n-class active learning exercises: active learning n-class based active learning exercises: learning active based xcessive valgus loading at the knee? knee? the at valgus loading xcessive -based active learning exercises: active learning -based al row of carpals? alrow of carpals? ry to which muscle? muscle? rywhich to arpal? arpal? which spinal curvature? curvature? spinal which to the left? left? the to medial and proximal on the humerus? humerus? the on and proximal medial hip? hip? ? ? e to which ligament? ligament? which eto

Accepted Articleof f loss associated with is Wingingofscapula the joint? temporomandibular elevate muscles the Which the in are muscles included offollowing the Which

This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons unction in which muscle? which in unction prevertebral group? group? prevertebral Page 46of52 Page 47of52 Figure 1. LEGENDS FIGURE Figure 2. of each screen. bottom participated that students of response.The number ques text-based the to answers possible eachof the bars right, At colored correctresponses. indicate i the responsesto student individual indicate dots and the axis) (medial-lateral anklecross the joint l oflower left the section drawingof a transverse i fell who students 18 were there bartop; the from exercises of in-class a high attempted number that an average with students example, For performance. or l athigh, middle activities in-class attempting lightblue in represented exercises of number alow exercises of an attempting average number students a attempting high students with learningexercises, Bar color i participation. andof level performance

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation John Wiley& Sons ow levels for each level of examination examination of for level levels each ow subtalar joint (anterior-posterior axis). Yellow Yellow axis). (anterior-posterior joint subtalar indicate the number of student responses to responsesto student of number the indicate eg demonstrates the position of muscles as they as they of muscles position the egdemonstrates mage-based question; darker yellow dots darker question; mage-based nto this category. category. this nto ndicates level of participation in active in ndicatesoflevel participation number of exercises represented in dark blue, dark blue, in represented of exercises number (dark blue bar) are represented by the fourth fourth the by represented (darkare bar) blue tion. The green highlight indicates the correct the indicates The green highlight tion. in each learning exercise are indicated at the atthe are indicated exercise each in learning . Bar length indicates the number of students of students number the indicates Bar length . represented in blue, and students attempting attempting students and blue, in represented examination performance (middle graph) performance (middle examination s, grouped by examination examination groupedby s, ing exercises. At left, a schematic a left, schematic At exercises. ing 60 59 58 57 performance) varieswhen all other predictor variab NumberN of = participants 176; Estimate, or unstan different scales easier. is Table 1. Regression Predicting Models P Examination coefficient,effect removes of by units the standar oe soitdIaeBsdQetos Associated Associated ImageBased Questions Model Adjusted R Grade Average Point Gender(Male coded 0) (NonURM coded 0) Underrepresented minority status Textbased exercise participation Imagebased exercise participation Intercept

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This article is protected by copyright. All rights reserved. siae E β SE Estimate 0.02 0.42 0.18 0.40 0.75 0.03 0.05 dizing variances so that comparisons among predicto les are constant; held SE, standard error the es of Anatomical SciencesEducation dardized coefficient,indicates how much the depend erformanceImageBased on Associated andQuestions 0.11 0.07 0.02 0.18 0.03 0.10

John Wiley &Sons 0.73 0.51 0.24 0.05 0.07

P- <0.001 <0.001 0.01 0.23 0.37 0.62 value

siae E β SE Estimate 0.03 0.37 0.08 0.01 0.20 0.32 0.16 timate; β, or standardized r variableswith measured 0.02 0.02 0.03 0.11 0.13 0.08 ent variable (examination TextBasedQuestions

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P 0.002 value 0.12 0.84 0.07 0.01 0.05

Page 48of52 60 59 58 57 Page 49of52

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effort. high effort, = 8 text-based mean ( text-based a mean is significantly different from text-based mea text-based from different significantly meanis Table 2. Student Ratings for the LearningActivitie for the Ratings Student Table 2. Likert scale: 1 = easy, 8 = demanding; =demanding; Likert 8 = 1 easy, scale: How much effort was invested to participate in…. in…. invested to participate was much effort How the…. youto understand work hard did How activities…. Were learning Learning Activity Questions Mean (±SD) (±SD) Mean Activity Questions Learning

easy or demanding? easyor demanding?

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P < 0.001); < 0.001);

Anatomical SciencesEducation John Wiley& Sons b Image-based mean is significantly different from different Image-basedsignificantly mean is s s n ( n

P < 0.05); < 0.05);

e Likert scale: 1 = low = 1 low Likertscale: 4.16 (±1.79) 4.16 3.95 (±1.64) 3.95 (±1.64) 3.54 3.70 (±1.69) 3.70 (±1.66) 4.28 4.06 (±1.68) 4.06 4.70 (±1.82) (±1.82) 4.70 4.34 (±1.66) (±1.66) 4.34 (±1.80) 4.00 d Image-based d b d c a e

Page 50of52 Page 51of52

responsesimage- the to Figure 1. Examples of image-based and text- image-basedFigure of Examples and 1. a transverse section of the left sectionthe transverse of a lower leg demonstr (medial-lateraljoint subtalar (anter the and axis) indicate the number of student responses to each of responsesindicate each student numberto the of

Accepted Articlecorrect greenresponse. The highlightindicates the based question; darker yellow dots indicate correctquestion; based darker dots yellow exercise are indicated at the bottom of each screen each of bottom the exerciseat indicated are This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation 60x21mm (300 x 300 DPI) (300 30060x21mm DPI) x John Wiley& Sons based active based schemat left, a learning At exercises. ior-posteriorindividua Yellow axis). indicate dots ates the position of muscles as theyposition the musclesates as ankl of the cross number of students that participated numberlearn in each that students of the possible text-basedquestion. the T to answers

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This article isprotected by copyright. All rights reserved. Anatomical SciencesEducation 80x37mm (300 x 300 DPI) (300 30080x37mm DPI) x John Wiley& Sons f participation in learning active participation with f exercises, ing a low ingexercisesnumber of a represented in light s exercises,performance and s grouped byexamination

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